Matthew Robertson

There's no place like home: boarding surgical ICU patients in other ICUs and the effect of distances from the home unit.

BACKGROUND Intensive care units (ICUs) function frequently at capacity, requiring incoming critically ill patients to be placed in alternate geographically distinct ICUs. In some medical ICU populations, “boarding” in an overflow ICU has been associated with increased mortality. We hypothesized that surgical ICU patients experience more complications when boarding in an overflow ICU and that the frequency of these complications are greatest in boarders farthest from the home unit (HU). METHODS A 5-year (June 2005 to June 2010) retrospective review of a prospectively maintained ICU database was performed, and demographics, severity of illness, length of stay, and incidence of ICU complications were extracted. Distances between boarding patients’ rooms and the HU were measured. Complications occurring in patients located in the same floor (BUSF) and different floor (BUDF) boarding units were compared and stratified by distance from HU to the patient room. Logistic regression was used to develop control for known confounders. RESULTS A total of 7,793 patients were admitted to the HU and 833 to a boarding unit (BUSF, n = 712; BUDF, n = 121). Boarders were younger, had a lower length of stay, and Acute Physiology and Chronic Health Evaluation II and were more often trauma/emergency surgery patients. Compared with in-HU patients, the incidence of aspiration pneumonia (2.2% vs. 3.6%, p < 0.01) was greater in BUSF patients and highest in those farthest from the HU (odds ratio [OR], 2.39; p = 0.01). Delirium occurred less often in HU than in BUDF patients (3.3% vs. 8.3 %, p < 0.01), and both delirium (OR, 6.09, p < 0.01) and ventilator-associated pneumonia (OR, 4.49, p < 0.05) were more frequent in patients farther from the HU. CONCLUSION Certain ICU complications occur more frequently in boarding patients particularly if they are located on a different floor or far from the HU. When surgical ICU bed availability forces overflow admissions to non–home ICUs, greater interdisciplinary awareness, education, and training may be needed to ensure equivalent care and outcomes. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

Telemedicine coverage for post-operative ICU patients:

Introduction There is an increased demand for intensive care unit (ICU) beds. We sought to determine if we could create a safe surge capacity model to increase ICU capacity by treating ICU patients in the post-anaesthesia care unit (PACU) utilizing a collaborative model between an ICU service and a telemedicine service during peak ICU bed demand. Methods We evaluated patients managed by the surgical critical care service in the surgical intensive care unit (SICU) compared to patients managed in the virtual intensive care unit (VICU) located within the PACU. A retrospective review of all patients seen by the surgical critical care service from January 1st 2008 to July 31st 2011 was conducted at an urban, academic, tertiary centre and level 1 trauma centre. Results Compared to the SICU group (n = 6652), patients in the VICU group (n = 1037) were slightly older (median age 60 (IQR 47–69) versus 58 (IQR 44–70) years, p = 0.002) and had lower acute physiology and chronic health evaluation (APACHE) II scores (median 10 (IQR 7–14) versus 15 (IQR 11–21), p < 0.001). The average amount of time patients spent in the VICU was 13.7 + /–9.6 hours. In the VICU group, 750 (72%) of patients were able to be transferred directly to the floor; 287 (28%) required subsequent admission to the surgical intensive care unit. All patients in the VICU group were alive upon transfer out of the PACU while mortality in the surgical intensive unit cohort was 5.5%. Discussion A collaborative care model between a surgical critical care service and a telemedicine ICU service may safely provide surge capacity during peak periods of ICU bed demand. The specific patient populations for which this approach is most appropriate merits further investigation.

Veloce Rosso: Australia's new precision radial velocity spectrograph

Veloce is an ultra-stable fibre-fed R4 echelle spectrograph for the 3.9 m Anglo-Australian Telescope. The first channel to be commissioned, Veloce ‘Rosso’, utilises multiple low-cost design innovations to obtain Doppler velocities for sun-like and M-dwarf stars at <1 ms -1 precision. The spectrograph has an asymmetric white-pupil format with a 100-mm beam diameter, delivering R>75,000 spectra over a 580-930 nm range for the Rosso channel. Simultaneous calibration is provided by a single-mode pulsed laser frequency comb in tandem with a traditional arc lamp. A bundle of 19 object fibres ensures full sampling of stellar targets from the AAT site. Veloce is housed in dual environmental enclosures that maintain positive air pressure at a stability of ±0.3 mbar, with a thermal stability of ±0.01 K on the optical bench. We present a technical overview and early performance data from Australias next major spectroscopic machine.

Veloce environmental control system

Veloce is an ultra-stabilized Echelle spectrograph for precision radial velocity measurements of stars. In order to maximize the grating performance, the air temperature as well as the air pressure surrounding it must be maintained within tight tolerances. The control goal was set at +/-10 mK and +/-1 mbar for air temperature and pressure respectively. The strategy developed by the design team resulted in separate approaches for each of the two requirements. A constrained budget early in the concept phase quickly ruled out building a large vacuum vessel to achieve stable air pressure. Instead, a simplified approach making use of a slightly over pressurized enclosure containing the whole spectrograph was selected in conjunction with a commercially available pressure controller. The temperature stability of Veloce is maintained through a custom array of PID controlled heaters placed on the outer skin of the internal spectrograph enclosure. This enclosure is also fully lined with 19 mm thick insulating panels to minimize the thermal fluctuations. A second insulated enclosure, built around the internal one, adds a layer of conditioned air to further shield Veloce from the ambient thermal changes. Early success of the environment control system has already been demonstrated in the integration laboratory, achieving results that amply exceed the goals set forth. Results presented show the long term stability of operation under varying barometric conditions. This paper details the various challenges encountered during the implementation of the stated designs, with an emphasis on the control strategy and the mechanical constraints to implement the solutions.

Advanced practitioner-driven critical care outreach to reduce intensive care unit readmission mortality

Objectives: Intensive care unit (ICU) readmission is associated with poorer outcomes as compared to primary admissions. Recognizing new or recurrent critical care issues on the wards postICU discharge may improve outcomes, especially in those subsequently requiring readmission. Herein, we describe and evaluate a pilot surgical critical care outreach initiative to reduce mortality in patients ultimately requiring ICU readmission. Methods: Each patient discharged from the ICU was visited within 48 h by a Critical Care Advanced practitioner who examined the patient, reviewed the chart, recent laboratory results, and orders, and then communicated any concerns to the primary service. Patient demographics, outreach issues identified, and severity of issues were recorded prospectively. Retrospectively, patient outcomes were assessed including the need and timing of any ICU readmission and mortality both before and after outreach implementation. Results: Pre and postoutreach readmission rates were 2.41% (37/1534) versus 3.54% (54/1524), respectively (P = 0.07). Mortality rates before and after outreach were 5.08% (n = 78) versus 5.64% (n = 86) overall (P = 0.052) and 18.9% (n = 7) versus 9.25% (n = 5) for readmissions (P = 0.21), respectively. Conclusions: Critical care outreach postICU discharge did not decrease readmission mortality in this pilot study. Further studies are required to evaluate its effects on not only readmission mortality but also readmission rates and timing along with the incident of subsequent ICU complications. The following core competencies are addressed in this article: Patient care, Systems based practice, Communication.