Resource use, governance and case load of rapid response teams in Australia and New Zealand in 2014

Background: Rapid response teams (RRTs) are a mandatory element of Australian national health care policy. However, the uptake, resourcing, case load and funding of RRTs in Australian and New Zealand hospitals remain unknown.Aim: To assess the clinical activity, funding, staffing and governance of RRTs in Australian and New Zealand hospitals.Methods: Survey of Australian and New Zealand hospitals as part of a biannual audit of intensive care resources and capacity.Results: Of 207 hospitals surveyed, 165 (79.7%) participated, including 22 (13.3%) from New Zealand. RRTs were present in 138/143 (95.5%) Australian and 11/22 (50%) New Zealand hospitals equipped with intensive care units (P < 0.001). Additional funding was provided in 43/146 hospitals (29.4%) but was more likely in tertiary ICUs (P < 0.001) and in New Zealand (P = 0.012). ICU staff participated in 147/148 RRTs (99.3%), which involved medical staff only (10.2%), nursing staff only (6.8%), and both medical and nursing staff (76.2%). Isolated ICU nursing involvement was more common in smaller ICUs (P = 0.005), in rural/regional and metropolitan hospitals (P = 0.04), and in New Zealand (P = 0.006). Dedicated ICU outreach registrars and consultants were present in 19/146 hospitals (13.0%) and 14/145 hospitals (9.7%), respectively. The ICU provided oversight for 122/147 RRTs (83%). In the 2013–14 financial year, there were more than 104 000 RRT calls.Conclusion: In cases where data were known, ICU staff provided staff for most RRTs, and oversight for more than 80% of RRTs. However, additional funding for ICU RRT staff and dedicated doctors was relatively uncommon

Safety, immunogenicity, and reactogenicity of BNT162b2 and mRNA-1273 COVID-19 vaccines given as fourth-dose boosters following two doses of ChAdOx1 nCoV-19 or BNT162b2 and a third dose of BNT162b2 (COV-BOOST): a multicentre, blinded, phase 2, randomised trial

Background Some high-income countries have deployed fourth doses of COVID-19 vaccines, but the clinical need, effectiveness, timing, and dose of a fourth dose remain uncertain. We aimed to investigate the safety, reactogenicity, and immunogenicity of fourth-dose boosters against COVID-19.Methods The COV-BOOST trial is a multicentre, blinded, phase 2, randomised controlled trial of seven COVID-19 vaccines given as third-dose boosters at 18 sites in the UK. This sub-study enrolled participants who had received BNT162b2 (Pfizer-BioNTech) as their third dose in COV-BOOST and randomly assigned them (1:1) to receive a fourth dose of either BNT162b2 (30 µg in 0·30 mL; full dose) or mRNA-1273 (Moderna; 50 µg in 0·25 mL; half dose) via intramuscular injection into the upper arm. The computer-generated randomisation list was created by the study statisticians with random block sizes of two or four. Participants and all study staff not delivering the vaccines were masked to treatment allocation. The coprimary outcomes were safety and reactogenicity, and immunogenicity (antispike protein IgG titres by ELISA and cellular immune response by ELISpot). We compared immunogenicity at 28 days after the third dose versus 14 days after the fourth dose and at day 0 versus day 14 relative to the fourth dose. Safety and reactogenicity were assessed in the per-protocol population, which comprised all participants who received a fourth-dose booster regardless of their SARS-CoV-2 serostatus. Immunogenicity was primarily analysed in a modified intention-to-treat population comprising seronegative participants who had received a fourth-dose booster and had available endpoint data. This trial is registered with ISRCTN, 73765130, and is ongoing.Findings Between Jan 11 and Jan 25, 2022, 166 participants were screened, randomly assigned, and received either full-dose BNT162b2 (n=83) or half-dose mRNA-1273 (n=83) as a fourth dose. The median age of these participants was 70·1 years (IQR 51·6–77·5) and 86 (52%) of 166 participants were female and 80 (48%) were male. The median interval between the third and fourth doses was 208·5 days (IQR 203·3–214·8). Pain was the most common local solicited adverse event and fatigue was the most common systemic solicited adverse event after BNT162b2 or mRNA-1273 booster doses. None of three serious adverse events reported after a fourth dose with BNT162b2 were related to the study vaccine. In the BNT162b2 group, geometric mean anti-spike protein IgG concentration at day 28 after the third dose was 23 325 ELISA laboratory units (ELU)/mL (95% CI 20 030–27 162), which increased to 37 460 ELU/mL (31 996–43 857) at day 14 after the fourth dose, representing a significant fold change (geometric mean 1·59, 95% CI 1·41–1·78). There was a significant increase in geometric mean anti-spike protein IgG concentration from 28 days after the third dose (25 317 ELU/mL, 95% CI 20 996–30 528) to 14 days after a fourth dose of mRNA-1273 (54 936 ELU/mL, 46 826–64 452), with a geometric mean fold change of 2·19 (1·90–2·52). The fold changes in anti-spike protein IgG titres from before (day 0) to after (day 14) the fourth dose were 12·19 (95% CI 10·37–14·32) and 15·90 (12·92–19·58) in the BNT162b2 and mRNA-1273 groups, respectively. T-cell responses were also boosted after the fourth dose (eg, the fold changes for the wild-type variant from before to after the fourth dose were 7·32 [95% CI 3·24–16·54] in the BNT162b2 group and 6·22 [3·90–9·92] in the mRNA-1273 group).Interpretation Fourth-dose COVID-19 mRNA booster vaccines are well tolerated and boost cellular and humoral immunity. Peak responses after the fourth dose were similar to, and possibly better than, peak responses after the third dose

Propofol infusion for the retrieval of the acutely psychotic patient

Case StudyTransporting acutely psychotic patients is hazardous because of the risks they present to themselves, escorting staff, and aircraft. Various strategies have been proposed, usually involving combinations of sedating drugs and physical restraint. Thus far, none guarantees safe retrieval while completely mitigating risks. This case proposes the use of propofol as an alternative to more traditionally used agents. An infusion facilitated the uneventful and safe retrieval of a patient who had demonstrated resistance and tolerance to other drugs. Discussion is also presented on the potential utility of propofol for the retrieval of acutely psychotic patients.Richard Chalwi

Impact of Non-Technical Skills on Performance and Effectiveness of a Rapid Response System

Background The Rapid Response System (RRS) is a globally recognised hospital safety service that recognises and escalates inpatient clinical deterioration for management by a Rapid Response Team (RRT). Successful use of Non-Technical Skills (NTS) during RRT calls may facilitate and expedite resolution of clinical deteriorations. Improving clinicians’ use of NTS typically involves dedicated training which requires considerable time and financial resources, which are commonly not available. Therefore, this research was undertaken, aiming to promote use of NTS during RRT calls using a pragmatic approach with minimal resource requirements. Methods This research, presented herein as a PhD-by-publication, investigated the re-design of an existing RRS on the use of NTS during RRT calls. The re-design had three components: 1) shift-by-shift meetings of the RRT; 2) RRT role badges; and 3) a structured “hand-off” transition-of-care process at the end of calls. A literature review was undertaken on NTS in context of an RRS to inform development of the redesign. Prior to implementation of the re-design (Phase 1), RRT Members and Users (ward staff that called the RRT) were surveyed regarding their experiences of RRT calls, and analysis of an RRS performance indicator: repeat RRT calls to the same patient during an admission, was conducted. Following introduction of the RRS re-design (Phase 2), the survey of RRT Members and Users was repeated, and an interrupted time series analysis was performed to determine the effect of the redesign on the proportion of RRT attended patients going on to have repeat calls. Results Potentially preventable repeat calls (i.e. following an initial call that ended despite an ongoing breach of RRT calling triggers) were associated with increased risk of in-hospital mortality (odds ratio 4.80 [95% confidence interval (CI) 2.96 – 7.81)], by comparison to not having repeat RRT calls. The RRS re-design was associated with improvements in both RRT Members’ and Users’ perceptions of NTS use during RRT calls. There were significant reductions in the proportion of RRT Members and Users reporting inter-personnel conflicts during calls following introduction of the re-design (26% less [95%CI -41% – -11%] and 14% less [95%CI -21% – -7%], respectively). However, there was little evidence of a significant difference in the proportion of RRT-attended patients (per month) going on to have repeat calls (6% fewer [95%CI -15.1% – 3.1%]) or in the mean number of calls per admission for these patients (-0.07 calls [95%CI -0.23 – 0.08]). Conclusions This program of research showed that a pragmatic NTS-based re-design of an existing RRS was associated with statistically significant reductions in RRT Members’ and Users’ perceptions of conflicts during RRT calls; however, this did not extend to a significant reduction in repeat RRT calls. Conflict between staff can exacerbate and/or be symptomatic of burnout. The results suggest that the RRS re-design had some beneficial effects on the working relationship between RRT Members and Users, which is promising as the well-being and resilience of clinicians is vital for sustainability of effective healthcare delivery. This research provides an important precedent for other resource-limited hospitals by demonstrating that a low-cost quality improvement initiative could be implemented for an existing RRS. The RRS redesign has broad applicability, and potential for future iterative refinement.Thesis (Ph.D.) -- University of Adelaide, School of Public Health, 202

Extracorporeal membrane oxygenation (ECMO) reconsidered

The role of extracorporeal membrane oxygenation (ECMO) in the treatment of the acute respiratory distress syndrome (ARDS) is controversial, notwithstanding the recent publication of the results of the CESAR (Conventional Ventilation or ECMO for Severe Adult Respiratory Failure) trial. Using Bayesian meta-analytic methods from three randomised controlled trials (RCTs) of ECMO in ARDS, we estimate the mortality odds ratio to be 0.78 (95% credible interval, 0.25-3.04), P (OR > 1) = 30%. Thus, a null effect of ECMO is not excluded and there appears only weak evidence of efficacy. We survey particular problems associated with the conduct of the "pragmatic" CESAR trial: composite endpoints, sample size estimation under uncertainty of baseline mortality rates, the generation of unbiased treatment comparisons, the impact of treatment non-compliance, and the uncertainty associated with cost-effectiveness and cost-utility analysis. We conclude that the CESAR trial is problematic in terms of both the clinical and economic outcomes, although observational series suggest plausible efficacy. We suggest that ECMO finds rationale as rescue therapy and that the current uncertainty of its role mandates a further RCT.John L. Moran, Richard P. Chalwin and Petra L. Grahamhttp://search.informit.com.au/documentSummary;dn=335916187456850;res=IELHEAhttp://www.ncbi.nlm.nih.gov/pubmed/2051322

The Role of extracorporeal membrane oxygenation for treatment of the adult respiratory distress syndrome : review and quantitative analysis

The role of extracorporeal membrane oxygenation (ECMO) has not been formally validated for patients with adult respiratory distress syndrome. In anticipation of publication of the conventional ventilation versus ECMO in severe adult respiratory failure (CESAR) trial, the role of ECMO in this setting was reviewed. An electronic search for studies reporting the use of ECMO for the treatment of adult respiratory distress syndrome revealed two randomised controlled trials and three non-controlled trials. Bayesian analysis on the two randomised controlled trials produced an odds ratio mortality of 1.28 (credible interval 0.24 to 6.55) demonstrating no significant harm or benefit. Pooling was not possible for the non-controlled studies because of differing admission status and ECMO selection criteria and an inability to control for these differences in the absence of individual patient data. A large number (n=35) of case series have been published with generally more positive results. We also present a comprehensive narrative commentary on the history, current practice and future for ECMO. ECMO, as rescue therapy for adult respiratory distress syndrome, appears to be an unvalidated rescue treatment option. Analysis and review of trial data does not support its application; however the body of reported cases suggests otherwise. Until the CESAR trial provides an authoritative answer ECMO will continue to be offered on a case by case basis.10 page(s

ECMO: expertise and equipoise : in reply

2 page(s