ORCID Profile
0000-0002-5925-2478
Current Organisation
University of Otago Wellington
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Publisher: Elsevier BV
Date: 12-2016
Publisher: Elsevier BV
Date: 04-2011
Publisher: Cold Spring Harbor Laboratory
Date: 20-09-2019
DOI: 10.1101/19007138
Abstract: To understand patient/family perspective of inappropriate intensive care unit (ICU) admissions and treatment. Rapid literature review of English language articles published between 2001 and 2017 in Medline or PsycInfo. Thirteen articles covering 6,194 elderly patients or surrogate decision-makers from four countries were eligible. Perceived inappropriateness of ICU treatments was mainly expressed as dissatisfaction with clinicians’ as surrogate decision-makers, inconsistency with patient/family values, family distrust of physician’s predictions on poor prognosis, and inadequate communication on over-aggressive treatment causing suffering. Consultation on opinion before ICU admission varied from 1% to 53.6%, and treatment goals from 1.4 to 31.7%. Satisfaction with the decision-making process in ICU was higher for those who had certain level of control and involvement in the process. The patient/family perspective on inappropriateness of ICU treatments involves preferences, values and social constructs beyond medical criteria. Earlier consultation with families before ICU admission, and patient education on outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. The patient/family perspective on inappropriateness of ICU at the end of life often differs from the clinician’s opinion due to the non-medical frame of mind. To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction are a good start to reconcile differences between physician and health service users’ viewpoint.
Publisher: Elsevier BV
Date: 08-2013
DOI: 10.1016/J.RESUSCITATION.2013.01.022
Abstract: To review current systems for recognising and responding to clinically deteriorating patients in all New Zealand public hospitals. A cross-sectional study of recognition and response systems in all New Zealand public hospitals was conducted in October 2011. Copies of all current vital sign charts and/or relevant policies were requested. These were examined for vital sign based recognition and response systems. The charts or policies were also used to determine the type of system in use and the vital sign parameters and trigger thresholds that provoke a call to the rapid response team. All New Zealand District Health Boards (DHBs). Physiological parameters used to trigger rapid response, the weighting of any early warning score assigned to them, type of system used, values of physiological derangement that trigger maximal system response. All DHBs use aggregate scoring systems to assess deterioration and respond. A total of 9 different physiological parameters were scored with most charts (21%) scoring 6 different parameters. All scored respiratory rate, heart rate, systolic blood pressure and conscious level. 86% scored oliguria, 14% polyuria, 33% oxygen saturation and 24% oxygen administration. All systems used either aggregate scores or a single extreme parameter to elicit a maximal system response. The extremes of physiological derangement to which scores were assigned varied greatly with bradypnoea having the greatest range for what was considered grossly abnormal. A large variance exists in the criteria used to detect deteriorating patients within New Zealand hospitals. Standardising both the vital signs chart and escalation criteria is likely to be of significant benefit in the early detection of and response to patient deterioration.
Publisher: Springer Science and Business Media LLC
Date: 05-2021
Abstract: The excess of electron recoil events seen by the XENON1T experiment has been interpreted as a potential signal of axion-like particles (ALPs), either produced in the Sun, or constituting part of the dark matter halo of the Milky Way. It has also been explained as a consequence of trace amounts of tritium in the experiment. We consider the evidence for the solar and dark-matter ALP hypotheses from the combination of XENON1T data and multiple astrophysical probes, including horizontal branch stars, red giants, and white dwarfs. We briefly address the influence of ALP decays and supernova cooling. While the different datasets are in clear tension for the case of solar ALPs, all measurements can be simultaneously accommodated for the case of a sub-dominant fraction of dark-matter ALPs. Nevertheless, this solution requires the tuning of several a priori unknown parameters, such that for our choices of priors a Bayesian analysis shows no strong preference for the ALP interpretation of the XENON1T excess over the background hypothesis.
Publisher: Elsevier BV
Date: 09-2016
Publisher: Elsevier
Date: 2013
Publisher: Elsevier BV
Date: 06-2016
DOI: 10.1016/J.JCRC.2016.02.004
Abstract: Orotracheal intubation is known to impair cough reflex, but the validity of cough reflex testing (CRT) as a screening tool for silent aspiration in this population is unknown. One hundred and six participants in a tertiary-level intensive care unit (ICU) underwent CRT and videoendoscopic evaluation of swallowing (VES) within 24 hours of extubation. Cough reflex threshold was established for each participant using nebulized citric acid. Thirty-nine (37%) participants had an absent cough to CRT. Thirteen (12%) participants aspirated on VES, 9 (69%) without a cough response. Sensitivity of CRT to identify silent aspiration was excellent, but specificity was poor. There was a significant correlation between intubation duration and presence of aspiration on VES (P= .0107). There was no significant correlation between silent aspiration on VES and length of intubation, age, sex, diagnosis at intensive care unit admission, indication for intubation, Acute Physiology and Chronic Health Evaluation III score, morphine equivalent dose, or time of testing postextubation. Intensive care unit patients are at increased risk of aspiration in the 24 hours following extubation, and an impaired cough reflex is common. However, CRT overidentifies risk of silent aspiration in this population.
Publisher: Wiley
Date: 04-07-2023
DOI: 10.1111/ANAE.16093
Publisher: Elsevier BV
Date: 12-2021
Publisher: Elsevier BV
Date: 10-2016
Publisher: Elsevier BV
Date: 10-2012
Publisher: Cold Spring Harbor Laboratory
Date: 23-09-2020
DOI: 10.1101/2020.09.20.20198184
Abstract: As the world struggles with the COVID-19 pandemic, health service demands have increased to a point where healthcare resources may prove inadequate to meet demand. Guidelines and tools on how to best allocate intensive care beds and ventilators developed during previous epidemics can assist clinicians and policy-makers to make consistent, objective and ethically sounds decisions about resource allocation when healthcare rationing is inevitable. This scoping review of 62 published guidelines, triage protocols, consensus statements and prognostic tools from crisis and non-crisis situations sought to identify a multiplicity of objective factors to inform healthcare rationing of critical care and ventilator care. It also took ethical considerations into account. Prognostic indicators and other decision tools presented here can be combined to create locally-relevant triage algorithms for clinical services and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. Community awareness of the triage protocol is recommended to build trust and alleviate anxiety among the public. This review provides a unique resource and is intended as a discussion starter for clinical services and policy makers to consider formalising an objective triage consensus document that fits the local context. An evidence-based catalogue of objective variables from 62 published resources tested in crisis and non-crisis situations can help clinicians make locally relevant triage decisions on ICU and ventilator allocation in inevitable COVID-19 health rationing.
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1053/J.JVCA.2017.04.023
Abstract: To evaluate the effect of Plasma-Lyte 148 (PL-148) compared with 0.9% saline (saline) on blood product use and postoperative bleeding in patients admitted to the intensive care unit (ICU) following cardiac surgery. A post hoc subgroup analysis conducted within a multicenter, double-blind, cluster-randomized, double-crossover study (study 1) and a prospective, single-center nested-cohort study (study 2). Tertiary-care hospitals. Adults admitted to the ICU after cardiac surgery requiring crystalloid fluid therapy as part of the 0.9% saline vs. PL-148 for ICU fluid therapy (SPLIT) trial. Blinded saline or PL-148 for 4 alternating 7-week blocks. 954 patients were included in study 1 475 patients received PL-148, and 479 received saline. 128 of 475 patients (26.9%) in the PL-148 group received blood or a blood product compared with 94 of 479 patients (19.6%) in the saline group (OR [95% confidence interval], 1.51 [1.11-2.05] p = 0.008). In study 2, 131 patients were allocated to PL-148 and 120 patients were allocated to saline. There were no differences between groups in chest drain output from the time of arrival in the ICU until 12 hours postoperatively (geometric mean, 566 mL for the PL-148 group v 547 mL in the saline group p = 0.60). The findings did not support the hypothesis that using PL-148 for fluid therapy in ICU following cardiac surgery reduces transfusion requirements compared to saline. The significantly increased proportion of patients receiving blood or blood product with allocation to PL-148 compared to saline was unexpected and requires verification through further research.
Publisher: Elsevier BV
Date: 2022
Publisher: Elsevier BV
Date: 2012
Publisher: Springer Science and Business Media LLC
Date: 08-03-2016
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.JCRC.2015.03.013
Abstract: This study aims to evaluate the effect of intubation for coronary artery bypass grafting (CABG) on the cough reflex, an important airway protection mechanism. Eighty-six participants (70 males) underwent cough reflex texting (CRT) before intubation for CABG to establish baseline threshold for reflexive cough. Cough reflex texting was repeated within 2 hours of extubation and every morning and evening thereafter until the participant coughed at baseline level, withdrew, or was discharged from hospital. Sixty percent of participants had an absent cough reflex at CRT2 (x = 70 minutes). Participants varied in time to recovery of cough reflex. By CRT6, only 3 remaining participants persisted with an absent cough. Age, sex, or length of intubation had no significant impact on the time to recovery of cough reflex (P > .3). Absent cough reflex persists after CABG and may impact patients' ability to clear their airway in the event of aspiration. These results could contribute to better understanding postextubation dysphagia. More research is needed to determine if cough reflex is affected in the wider intensive care unit population postextubation and if CRT is a valid tool for detecting silent aspiration in this population.
Publisher: Oxford University Press (OUP)
Date: 15-03-2015
DOI: 10.1093/QJMED/HCV059
Abstract: Intensive care units (ICUs) exist to support patients through acute illness that threatens their life. Although ICUs aim to save life, they are also a place where a significant proportion of patients die with international mortality rates ranging from 15% to 24%. To explore the experience of relatives and staff of patients dying in ICU using qualitative approach. Consecutive patients were identified who were dying in the ICU. The researcher met the families prior to the patient's death. The ICU nurse and doctor most involved were interviewed within 48 h of the death. The families were interviewed 2 weeks later. Interviewees described their experience of the patient's dying and death. Recruitment until data saturation and thematic analysis occurred concurrently. Ten families, nurses and doctors were interviewed in relation to 10 patients. In caring for the patients who are dying in the ICU and their families, nurses practice to their satisfaction with creativity and autonomy, although concerned about continuity of care at handover. Families appreciate kindness and regular sensitive communication. Families would like more contact with the ICU doctors. Limiting access to the patient according to ICU protocol is distressing for relatives. Doctors struggle with decision making, determining prognosis and witnessing the grief of relatives. Some doctors wish to have a greater part in care of the dying patient. Distress among nurses reported in the ICU literature and attributed to disenfranchisement by doctors was not evident. In contrast, some doctors struggle to practice what they value. Adherence to ICU protocols needs flexibility when a patient is dying.
Publisher: Wiley
Date: 19-02-2014
DOI: 10.1111/NICC.12080
Abstract: To review clinical models and activities of critical care outreach (CCO) in New Zealand public hospitals. Data were collected using a two-stage process. Stage 1 consisted of a cross-sectional descriptive online survey distributed to nurse managers of all CCO in New Zealand. Stage 2 requested that all respondent sites supply outreach documentation for analysis. Twenty acute care public hospitals replied to the data request (100%). Nine hospitals (45%) had CCO and completed the survey. There was considerable ersity in the models of CCO used. All nine hospitals had CCO that were nurse-led 66% of these had intensive care medical input. There was variation in the size and scope of each CCO with only 4 (44%) sites providing 24-h clinical cover. The majority of referral requests made to CCO were for ward-based reviews (mean: 57%) and intensive care discharge reviews (mean: 31%). The most frequently performed activity was provision of support to ward staff (89%). All CCO routinely collected data on activities across a range of clinical areas. Less than half of the public hospitals in New Zealand have a CCO service despite national recommendations that every hospital utilize one to support deteriorating ward patients. New Zealand hospitals that have critical care outreach have adopted recognized international models and adapted these to meet local demands. Whilst the evidence base demonstrating impact of critical care outreach continues to be established, international support for critical care outreach continues. Given this, critical care outreach should be more widely available 24/7 and activities standardized across New Zealand to align with national recommendations. Critical care outreach service models and activities in New Zealand hospitals continue to be erse. Awareness of these variances will help influence critical care outreach service development and regional integration.
Publisher: Jaypee Brothers Medical Publishing
Date: 2015
Publisher: Springer International Publishing
Date: 2022
Publisher: Wiley
Date: 06-01-2019
DOI: 10.1111/HEX.12860
Publisher: Wiley
Date: 04-2023
DOI: 10.1111/IMJ.16067
Abstract: Rapid reponse teams emerged 27 years ago to identify deteriorating patients and reduce preventable harm. There are concerns that such teams have deskilled hospital staff. However, over the past 20 years, there have been marked changes in hospital care and workplace requirements for hospital staff. In this article, we contend that hospital staff have been reskilled rather than deskilled.
Publisher: Elsevier BV
Date: 08-2012
Publisher: Wiley
Date: 31-03-2023
DOI: 10.1111/IMJ.16046
Abstract: Cardiopulmonary resuscitation (CPR) is internationally defined as chest compressions and rescue breaths, and is a subset of resuscitation. First used for out‐of‐hospital cardiac arrest, CPR is now frequently used for in‐hospital cardiac arrest (IHCA) with different causes and outcomes. This paper aims to describe clinical understanding of the role of in‐hospital CPR and perceived outcomes for IHCA. An online survey of a secondary care staff involved in resuscitation was conducted, focussing on definitions of CPR, features of do‐not‐attempt‐CPR conversations with patients and clinical case scenarios. Data were analysed using a simple descriptive approach. Of 652 responses, 500 were complete and used for analysis. Two hundred eleven respondents were senior medical staff covering acute medical disciplines. Ninety‐one percent of respondents agreed or strongly agreed that defibrillation is part of CPR, and 96% believed CPR for IHCA included defibrillation. Responses to clinical scenarios were dissonant, with nearly half of respondents demonstrating a pattern of underestimating survival and subsequently showing a desire to offer CPR in similar scenarios with poor outcomes. This was unaffected by seniority and level of resuscitation training. The common use of CPR in hospital reflects the broader definition of resuscitation. Recapturing the CPR definition for clinicians and patients as only chest compressions and rescue breaths may allow clinicians to better discuss in idualised resuscitation care to aide meaningful shared decision‐making around patient deterioration. This may involve reframing current in‐hospital algorithms and uncoupling CPR from wider resuscitative measures.
Publisher: Wiley
Date: 29-03-2023
DOI: 10.1111/ANAE.16007
Abstract: Aotearoa New Zealand uses a single early warning score (EWS) across all public and private hospitals to detect adult inpatient physiological deterioration. This combines the aggregate weighted scoring of the UK National Early Warning Score with single parameter activation from Australian medical emergency team systems. We conducted a retrospective analysis of a large vital sign dataset to validate the predictive performance of the New Zealand EWS in discriminating between patients at risk of serious adverse events and compared this with the UK EWS. We also compared predictive performance for patients admitted under medical vs. surgical specialties. A total of 1,738,787 aggregate scores (13,910,296 in idual vital signs) were obtained from 102,394 hospital admissions to six hospitals within the Canterbury District Health Board of New Zealand's South Island. Predictive performance of each scoring system was determined using area under the receiver operating characteristic curve. Analysis showed that the New Zealand EWS is equivalent to the UK EWS in predicting patients at risk of serious adverse events (cardiac arrest, death and/or unanticipated ICU admission). Area under the receiver operating characteristic curve for both EWSs for any adverse outcome was 0.874 (95%CI 0.871–0.878) and 0.874 (95%CI 0.870–0.877), respectively. Both EWSs showed superior predictive value for cardiac arrest and/or death in patients admitted under surgical rather than medical specialties. Our study is the first validation of the New Zealand EWS in predicting serious adverse events in a broad dataset and supports previous work showing the UK EWS has superior predictive performance in surgical rather than medical patients.
Publisher: Wiley
Date: 13-08-2021
DOI: 10.1111/ANAE.15557
Abstract: Strong evidence now demonstrates that recognition and response systems using standardised early warning scores can help prevent harm associated with in‐hospital clinical deterioration in non‐pregnant adult patients. However, a standardised maternity‐specific early warning system has not yet been agreed in the UK. In Aotearoa New Zealand, following the nationwide implementation of the standardised New Zealand Early Warning Score (NZEWS) for adult inpatients, a modified maternity‐specific variation (NZMEWS) was piloted in a major tertiary hospital in Auckland, before national rollout. Following implementation in July 2018, we observed a significant and sustained reduction in severe maternal morbidity as measured by emergency response calls to women who were very unwell (emergency response team call), and a non‐significant reduction in cardiorespiratory arrest team calls. Emergency response team calls to maternity wards fell from a median of 0.8 per 100 births at baseline (January 2017–May 2018) to 0.6 per 100 births monthly (from March 2019 to December 2020) (p 0.0001). Cardiorespiratory arrest team calls to maternity wards fell from 0.14 per 100 births per quarter (quarter 1 2017–quarter 2 2018) to 0.09 calls per 100 births per quarter after NZMEWS was introduced (quarter 3 2018–quarter 4 2020) (p = 0.2593). These early results provide evidence that NZMEWS can detect and prevent deterioration of pregnant women, although there are multiple factors that may have contributed to the reduction in emergency response calls noted.
Publisher: Elsevier BV
Date: 04-2012
Publisher: Elsevier BV
Date: 08-2012
Publisher: Wiley
Date: 13-09-2017
DOI: 10.1111/AAS.12994
Abstract: The relationship between fatigue-related risk and impaired clinical performance is not entirely clear. Non-technical factors represent an important component of clinical performance and may be sensitive to the effects of fatigue. The hypothesis was that the sum score of overall non-technical performance is degraded by fatigue. Nineteen physicians undertook two different simulated air ambulance missions, once when rested, and once when fatigued (randomised crossover design). Trained assessors blinded to participants' fatigue status performed detailed structured assessments based on expected behaviours in four non-technical skills domains: teamwork, situational awareness, task management, and decision making. Participants also provided self-ratings of their performance. The primary endpoint was the sum score of overall non-technical performance. The main finding, the overall non-technical skills performance rating of the clinicians, was better in rested than fatigued states (mean difference with 95% CI, 2.8 [2.2-3.4]). The findings remained consistent across in idual non-technical skills domains also when controlling for an order effect and examining the impact of a number of possible covariates. There was no difference in self-ratings of clinical performance between rested and fatigued states. Non-technical performance of critical care air transfer clinicians is degraded when they are fatigued. Fatigued clinicians may fail to recognise the degree to which their performance is compromised. These findings represent risk to clinical care quality and patient safety in the dynamic and isolated environment of air ambulance transfer.
Publisher: Elsevier BV
Date: 08-2012
Publisher: American Medical Association (AMA)
Date: 27-10-2015
Abstract: Saline (0.9% sodium chloride) is the most commonly administered intravenous fluid however, its use may be associated with acute kidney injury (AKI) and increased mortality. To determine the effect of a buffered crystalloid compared with saline on renal complications in patients admitted to the intensive care unit (ICU). Double-blind, cluster randomized, double-crossover trial conducted in 4 ICUs in New Zealand from April 2014 through October 2014. Three ICUs were general medical and surgical ICUs 1 ICU had a predominance of cardiothoracic and vascular surgical patients. All patients admitted to the ICU requiring crystalloid fluid therapy were eligible for inclusion. Patients with established AKI requiring renal replacement therapy (RRT) were excluded. All 2278 eligible patients were enrolled 1152 of 1162 patients (99.1%) receiving buffered crystalloid and 1110 of 1116 patients (99.5%) receiving saline were analyzed. Participating ICUs were assigned a masked study fluid, either saline or a buffered crystalloid, for alternating 7-week treatment blocks. Two ICUs commenced using 1 fluid and the other 2 commenced using the alternative fluid. Two crossovers occurred so that each ICU used each fluid twice over the 28 weeks of the study. The treating clinician determined the rate and frequency of fluid administration. The primary outcome was proportion of patients with AKI (defined as a rise in serum creatinine level of at least 2-fold or a serum creatinine level of ≥3.96 mg/dL with an increase of ≥0.5 mg/dL) main secondary outcomes were incidence of RRT use and in-hospital mortality. In the buffered crystalloid group, 102 of 1067 patients (9.6%) developed AKI within 90 days after enrollment compared with 94 of 1025 patients (9.2%) in the saline group (absolute difference, 0.4% [95% CI, -2.1% to 2.9%] relative risk [RR], 1.04 [95% CI, 0.80 to 1.36] P = .77). In the buffered crystalloid group, RRT was used in 38 of 1152 patients (3.3%) compared with 38 of 1110 patients (3.4%) in the saline group (absolute difference, -0.1% [95% CI, -1.6% to 1.4%] RR, 0.96 [95% CI, 0.62 to 1.50] P = .91). Overall, 87 of 1152 patients (7.6%) in the buffered crystalloid group and 95 of 1110 patients (8.6%) in the saline group died in the hospital (absolute difference, -1.0% [95% CI, -3.3% to 1.2%] RR, 0.88 [95% CI, 0.67 to 1.17] P = .40). Among patients receiving crystalloid fluid therapy in the ICU, use of a buffered crystalloid compared with saline did not reduce the risk of AKI. Further large randomized clinical trials are needed to assess efficacy in higher-risk populations and to measure clinical outcomes such as mortality. clinicaltrials.gov Identifier: ACTRN12613001370796.
Publisher: Elsevier BV
Date: 05-2014
Publisher: Springer Science and Business Media LLC
Date: 05-2017
Publisher: Elsevier BV
Date: 02-2016
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Alex Psirides.