ORCID Profile
0000-0003-2613-0308
Current Organisations
Gold Coast University Hospital
,
Royal Australasian College of Physicians
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Publisher: Oxford University Press (OUP)
Date: 13-11-2006
DOI: 10.1093/JAC/DKL478
Abstract: To compare the clinical and bacteriological outcome of critically ill patients with sepsis treated by ceftriaxone administered as a once-a-day intermittent bolus dose or by 24 h continuous infusion. We conducted an open-label, randomized controlled pilot study in 57 patients clinically diagnosed with sepsis (suspected roven infection and systemic inflammatory response syndrome) in a tertiary level intensive care unit. Patients were randomized to receive 2 g of ceftriaxone administered by once-daily intermittent bolus dosing or by 24 h continuous infusion. Clinical and bacteriological outcomes were assessed by blinded clinicians. Fifty-seven patients were enrolled in the study, 50 of whom fulfilled the a priori definition of treatment for 4 or more days. The infusion (n = 29) and bolus groups (n = 28) were similar in terms of demographics, although the median age of those receiving the infusion was younger. Intention-to-treat analysis found no statistically significant differences in the primary outcomes for clinical response (P = 0.17), clinical cure [infusion n = 13/29 versus bolus n = 5/28 adjusted odds ratio (AOR) = 3.74 95% confidence interval (95% CI) = 1.11-12.57 P = 0.06], bacteriological response (P = 0.41) and bacteriological cure (infusion n = 18/29 versus bolus 14/28 AOR = 1.64 95% CI = 0.57-4.70 P = 0.52). However, logistic regression in patients that complied with the a priori definitions who received ceftriaxone by continuous infusion (AOR = 22.8 95% CI = 2.24-232.3 P = 0.008) or patients with a low Acute Physiology and Chronic Health Evaluation (APACHE) II score (AOR = 0.70 95% CI = 0.54-0.91 P = 0.008) were associated with an improved clinical outcome when age and Sepsis Organ Failure Assessment (SOFA) score at time of study entry were controlled for. This pilot study suggests clinical and bacteriological advantages of continuous infusion of ceftriaxone over bolus administration in critically ill patients in patients requiring 4 or more days of treatment. This sets the scene for a large multicentre double-blind randomized controlled trial to confirm these findings.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2018
DOI: 10.1097/CCM.0000000000003092
Abstract: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. ICUs. Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo ( n = 45 and n = 60, respectively). IV angiotensin II or placebo. Primary end point: survival through day 28 secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo ( p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo ( p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo ( p = 0.001), respectively. In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.
Publisher: AMPCo
Date: 06-08-2019
DOI: 10.5694/MJA2.50294
Publisher: Elsevier BV
Date: 08-2018
DOI: 10.1016/J.IJANTIMICAG.2018.03.001
Abstract: The aim of this study was to describe the population pharmacokinetics of vancomycin during prolonged intermittent renal replacement therapy (PIRRT) in critically ill patients with acute kidney injury. Critically ill patients prescribed vancomycin across two sites had blood s les collected during one to three dosing intervals during which PIRRT was performed. Plasma s les were assayed with a validated immunoassay method. Population pharmacokinetic analysis and Monte Carlo simulations were performed using Pmetrics Eleven critically ill patients (seven male) were enrolled and contributed 192 plasma s les. The patient's mean ± standard deviation (SD) age, weight and body mass index (BMI) were 57 ± 13 years, 98 ± 43 kg and 31 ± 9 kg/m This is the first population pharmacokinetic study of vancomycin in patients receiving PIRRT and we observed large pharmacokinetic variability. Empirically, weight-based doses that are appropriate for the duration of PIRRT, should be selected and supplemented with therapeutic drug monitoring.
Publisher: Elsevier BV
Date: 09-2019
DOI: 10.1016/J.IJANTIMICAG.2019.06.027
Abstract: The aim of this study was to describe the population pharmacokinetics of ticarcillin during extended daily diafiltration (EDDf) in critically ill patients with acute kidney injury. Blood s les were collected from critically ill patients prescribed ticarcillin during one to two dosing intervals during which EDDf was performed. Plasma s les were measured using a validated ultra high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method. Concentration-time data were analysed using a population pharmacokinetics approach with Pmetrics®. A total of 53 blood s les were collected from six critically ill patients (three male). The mean ± standard deviation patient age, weight and body mass index (BMI) was 43 ± 22 years, 88 ± 14 kg and 31 ± 5 kg/m
Publisher: Elsevier BV
Date: 12-2015
Publisher: Oxford University Press (OUP)
Date: 09-03-2020
DOI: 10.1093/CID/CIAA224
Abstract: The optimal dosing of antibiotics in critically ill patients receiving renal replacement therapy (RRT) remains unclear. In this study, we describe the variability in RRT techniques and antibiotic dosing in critically ill patients receiving RRT and relate observed trough antibiotic concentrations to optimal targets. We performed a prospective, observational, multinational, pharmacokinetic study in 29 intensive care units from 14 countries. We collected demographic, clinical, and RRT data. We measured trough antibiotic concentrations of meropenem, piperacillin-tazobactam, and vancomycin and related them to high- and low-target trough concentrations. We studied 381 patients and obtained 508 trough antibiotic concentrations. There was wide variability (4–8-fold) in antibiotic dosing regimens, RRT prescription, and estimated endogenous renal function. The overall median estimated total renal clearance (eTRCL) was 50 mL/minute (interquartile range [IQR], 35–65) and higher eTRCL was associated with lower trough concentrations for all antibiotics (P & .05). The median (IQR) trough concentration for meropenem was 12.1 mg/L (7.9–18.8), piperacillin was 78.6 mg/L (49.5–127.3), tazobactam was 9.5 mg/L (6.3–14.2), and vancomycin was 14.3 mg/L (11.6–21.8). Trough concentrations failed to meet optimal higher limits in 26%, 36%, and 72% and optimal lower limits in 4%, 4%, and 55% of patients for meropenem, piperacillin, and vancomycin, respectively. In critically ill patients treated with RRT, antibiotic dosing regimens, RRT prescription, and eTRCL varied markedly and resulted in highly variable antibiotic concentrations that failed to meet therapeutic targets in many patients.
Publisher: Wiley
Date: 12-12-2012
DOI: 10.1111/J.1741-6787.2011.00234.X
Abstract: To evaluate the impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge delay, hospital mortality, and ICU readmission within 72 hours. A quality improvement study using a time series design and statistical process control analysis was conducted in one Australian general ICU. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured for 15 months prior to, and for 12 months after the redesigned process was implemented. The redesign process included appointing a change agent to facilitate process improvement, developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time, and designing a daily ICU discharge alert sheet that included an expected date of discharge. A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. There was no difference in in-hospital mortality after discharge from ICU or ICU readmission within 72 hours during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention). Involving both ward and ICU staff in the redesign process may have contributed to a shared situational awareness of the problems, which led to more timely and effective ICU discharge processes. The use of a change agent, whose ongoing role involved follow-up of patients discharged from ICU, may have helped to embed the new process into practice.
Publisher: Elsevier BV
Date: 09-2019
DOI: 10.1016/J.IJMEDINF.2019.07.002
Abstract: Assessment of the performance of Intensive Care Units (ICU) is of vital importance for an effective healthcare system. Such assessment ensures that the limited resources of the healthcare system are allocated where they are most needed. Severity scoring systems are employed for this purpose and improving these systems is a continuing area of research which has focused on the use of more complex techniques and new variables. This paper investigates whether scoring systems could be improved through use of metrics which better summarise the high frequency data collected by automated systems for patients in the ICU. 3128 admissions to the Gold Coast University Hospital ICU are used to construct three logistic regressions based on the most widely used scoring system (APACHE III) to compare performance with and without predictors leveraging available high frequency information. Performance is assessed based on model accuracy, calibration, and discrimination. High frequency information was considered for existing pulse and mean arterial pressure physiology fields and resulting models compared against a baseline logistic regression using only APACHE III physiology variables. Model discrimination and accuracy were better for models which included high frequency predictors, with calibration remaining good in all cases. The most influential high frequency summaries were the number of turning points in a patient's mean arterial pressure or pulse in the first 24 h of ICU admission. The findings indicate that scoring systems can be improved by better accounting for high frequency data.
Publisher: Oxford University Press (OUP)
Date: 12-11-2010
DOI: 10.1093/NDT/GFQ694
Abstract: Prolonged intermittent renal replacement therapy (PIRRT) is a dialysis modality for critically ill patients that in theory combines the superior detoxification and haemodynamic stability of the continuous renal replacement therapy (CRRT) with the operational convenience, reduced haemorrhagic risk and low cost of conventional intermittent haemodialysis. However, the extent to which PIRRT should replace these other modalities is uncertain because comparative studies of mortality are lacking. We retrospectively examined the mortality data from three general intensive care units (ICUs) in different countries that have switched their predominant therapeutic approach from CRRT to PIRRT. We assessed whether this practice change was associated with a change in mortality rate. Data were analysed from ICUs in New Zealand, Australia and Italy. The study population comprised all patients requiring renal replacement therapy from 1 January 1995 to 31 December 2005 (n = 1347), the period of time spanning the change from CRRT to PIRRT in each unit. Poisson regression models were used to estimate the incident rate ratio (IRR) for death, comparing the periods before and after change to PIRRT in each unit. Estimates were adjusted for patient illness severity (APACHE II score) and for the underlying time trend in mortality rate over time. The change from CRRT to PIRRT was not associated with any increase in mortality rate, with an adjusted IRR of 1.02 (0.61-1.71). The IRR was virtually identical in the three ICUs (P-value = 0.63 for the difference in the IRR between ICUs). Switching from CRRT to PIRRT was not associated with a change in mortality rate. Pending the results of a randomized trial, our study provides evidence that PIRRT might be equivalent to CRRT in the general ICU patient.
Publisher: Public Library of Science (PLoS)
Date: 30-11-2018
Publisher: Massachusetts Medical Society
Date: 03-08-2017
Publisher: Wiley
Date: 11-07-2019
Abstract: Timely and appropriate assessment and management within the ED impacts patient outcomes including in-hospital mortality and length of stay (LOS). Within the ED, several processes facilitate timely recognition of the need for intensive care unit (ICU) admission. This study describes characteristics and outcomes for patient presentations admitted to ICU from ED, categorised by Australasian Triage Score (ATS), ICU admission time and ICU admission source. A retrospective observational cohort study with linked health data of adult ICU admissions during 2012. Outcomes measured included: ED, ICU and hospital LOS, time to see ED clinician, ICU readmission and ICU and hospital mortality rates. In total, 423 ICU admissions occurred within 24 h of ED arrival 395 were admitted directly to ICU 28 were admitted to the ward before ICU admission. ATS 3/4/5 patients comprised 26.7% of ICU admissions and experienced longer waits to be seen, longer total ED LOS, shorter ICU LOS and a lower mortality rate than those triaged ATS 1/2. Compared to ICU admissions during business hours, admissions outside hours did not differ significantly for any outcome measured. Patients admitted to the ward before ICU experienced longer waits to be seen and longer ED LOS. Most patients are appropriately identified in ED as requiring ICU admission, although around one in four were triaged ATS 3/4. Patients admitted to the ward first tended to have poorer outcomes than those directly admitted to ICU. Factors predicting the need for ICU admission should be identified to support clinical decision-making.
Publisher: Elsevier BV
Date: 05-2021
Publisher: Elsevier BV
Date: 05-2003
DOI: 10.1016/S0195-6701(03)00071-9
Abstract: This study reports on a block clinical trial of two types of central venous catheters (CVCS): antiseptic-impregnated catheters (AIC) and non-impregnated catheters (non-AIC), on catheter tip colonization and bacteraemia. In total, 500 catheters were inserted in 390 patients over the 18 month study period, 260 (52.0%) AIC and 240 (48.0%) non-AIC. Of these, 460 (92.0%) tips (237 AIC and 223 non-AIC) were collected. While significantly fewer AIC, 14 (5.9%), than non-AIC, 30 (13.5%), catheters were colonized (P<0.01), there was no difference in the rates of bacteraemias in the two groups (0.8% vs. 2.7%, respectively, P=0.16). There were 6.87 (95% CI 3.38-14.26) and 16.92 (95% CI 10.61-27.12) colonized AIC and non-AIC catheters, respectively, per 1000 catheter days, a difference that was significant (P<0.01). However, no difference emerged between bacteraemias in AIC and non-AIC catheters per 1000 catheter days measured at 0.98 (95% CI 0.24-5.54) and 3.38 (95% CI 1.29-9.34), respectively (P=0.10). Of the 444 CVCs that were sited in the subclavian or jugular veins and had tips collected, significantly more catheters were colonized in the jugular group, 19 (20%), compared with the subclavian group, 24 (6.9% P< or =0.01). Overall, the low rates of colonization and bacteraemia may be explained by the population studied, the policies used and the employment of a clinical nurse dedicated to CVC management.
Publisher: Elsevier BV
Date: 09-2020
Publisher: SAGE Publications
Date: 12-1998
DOI: 10.1177/0310057X9802600606
Abstract: A prospective standardized collection of clinical, microbiological and pharmaceutical information on antibiotic use was conducted in Australia and New Zealand intensive care units (ICUs) involving 481 consecutive critically ill patients who were receiving antibiotics for any reason while in ICU. Patients had a mean SAPS II score of 34.1 ±17.8 with an expected mortality of 15.6% (actual mortality 12%). Of these, 292 (60.8%) were admitted to the ICU within 72 hours of surgery. Among such surgical patients, 233 (79.9%) received antibiotics for “surgical prophylaxis” while in ICU (48% of s le population). The second largest group of patients treated with antibiotics in ICU included those with systemic inflammatory response syndrome and clinical suspicion of infection (38%). Antibiotics were prescribed for the treatment of clinically diagnosed infection in 268 patients. Clinical response was apparent in 62.6%) and in most (71%) was achieved in the first 72 hours of treatment. The incidence of antimicrobial-related side-effects was 4%, mostly in the form of diarrhoea or rash (75%o of all side-effects). The most commonly prescribed antimicrobials were gentamicin (n = 146), ceftriaxone (n=98), vancomycin (n = 94) and metronidazole (n = 111). Three times daily prescription of aminoglycosides was uncommon ( %). Forty-one patients had a documented infection (positive culture) with a gram-negative organism. Of these, 17 received therapy with a single antibiotic and 24 received therapy with two antibiotics. Despite similar illness severity, there were six deaths in the former group and only two in the latter.
Publisher: Massachusetts Medical Society
Date: 12-11-2009
Publisher: Georg Thieme Verlag KG
Date: 2018
Abstract: Background Various tasks within health care processes are repetitive and time-consuming, requiring personnel who could be better utilized elsewhere. The task of assigning clinical urgency categories to internal patient referrals is one such case of a time-consuming process, which may be amenable to automation through the application of text mining and natural language processing (NLP) techniques. Objective This article aims to trial and evaluate a pilot study for the first component of the task—determining reasons for referrals. Methods Text is extracted from scanned patient referrals before being processed to remove nonsensical symbols and identify key information. The processed data are compared against a list of conditions that represent possible reasons for referral. Similarity scores are used as a measure of overlap in terms used in the processed data and the condition list. Results This pilot study was successful, and results indicate that it would be valuable for future research to develop a more sophisticated classification model for determining reasons for referrals. Issues encountered in the pilot study and methods of addressing them were outlined and should be of use to researchers working on similar problems. Conclusion This pilot study successfully demonstrated that there is potential for automating the assignment of reasons for referrals and provides a foundation for further work to build on. This study also outlined a potential application of text mining and NLP to automating a manual task in hospitals to save time of human resources.
Publisher: SAGE Publications
Date: 02-2006
DOI: 10.1177/0310057X0603400101
Abstract: The mismatch between intensive care unit (ICU) bed availability and demand may be improved with timely patient discharges, however little is known about the nature and contributing factors of discharge delays. This study investigated the impact of a specific intervention—the ICU liaison nurse role—in reducing ICU discharge delay using a prospective block intervention study. One hundred and eighty-six ICU patients (101 control and 85 liaison nurse intervention) with an ICU length of stay of three days or longer and who survived to ICU discharge were examined. The liaison nurse was involved in assessment of patients for transfer to the ward, with a major focus on coordinating patient transfer including liaison with ward staff prior to and following ICU discharge. Logistic regression was used to quantify the risk of discharge delay associated with the liaison nurse intervention with adjustment for potential confounding variables. While no demographic or clinical variables were significant predictors of ICU discharge delay, those in the liaison nurse group were almost three times less likely to experience a discharge delay of at least two hours and about 2.5 times less likely to experience a delay of four or more hours. The positive effect of the liaison nurse role in reducing the discharge delay remained after adjusting for potential confounders. We conclude that the liaison nurse role is effective in reducing the discharge delay in ICU transfer.
Publisher: Springer Science and Business Media LLC
Date: 27-02-2019
No related grants have been discovered for Brent Richards.