Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Background Acute kidney injury is common in critically ill patients with detrimental effects on mortality, length of stay and post-discharge outcomes. The Acute Kidney Injury Network developed guidelines based on urine output and serum creatinine to classify patients into stages of acute kidney injury. Methods In this analysis we utilize the Acute Kidney Injury Network guidelines to evaluate the acute kidney injury stage in patients admitted to general and cardiac intensive care units over a period of 18 months. Acute kidney injury stage was calculated in real time hourly based on the guidelines and using these temporal stage scores calculated for the population; the prevalence and progression of acute kidney injury stage was compared between the two units. We hypothesized that the prevalence and progression of acute kidney injury stage between the two units may be different. Results More cardiac intensive care unit patients had no acute kidney injury (stage <1) during their intensive care unit stay but more cardiac intensive care unit patients developed acute kidney injury (stage >1), compared to the General Intensive Care Unit. Both at intensive care unit admission and discharge, more General Intensive Care Unit patients had acute kidney injury; however, the number of cardiac intensive care unit patients with acute kidney injury was three times higher at discharge than admission. Acute kidney injury developed in a different pattern in the two intensive care units over five days of intensive care unit stay. In the General Intensive Care Unit, acute kidney injury was most prevalent on second day of intensive care unit stay and in cardiac intensive care unit acute kidney injury was most prevalent on the third day of intensive care unit stay. We observed the biggest increase in new acute kidney injury in the first day of General Intensive Care Unit and second day of the cardiac intensive care unit stay. Conclusions The study demonstrates the different trends of acute kidney injury pattern in general and cardiac intensive care unit patient populations highlighting the earlier development of acute kidney injury on General Intensive Care Unit and more prevalence of acute kidney injury on discharge from cardiac intensive care unit.

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high‐ (HICs) and low‐ and middle‐income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7‐day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.

Background Critically ill children presenting to district general hospitals (DGH) are admitted to adult intensive care units (AICUs) for stabilisation prior to transfer to paediatric intensive care units (PICUs). Current training in PICU for adult intensive care physicians is only three months. This single centre retrospective case series examines the case mix of children presenting to a DGH AICU and a multidisciplinary survey assesses confidence and previous experience, highlighting continued training needs for DGH AICU staff. Methods all paediatric admissions to AICU and paediatric retrievals were reviewed over a 6-year period (2014-2019). Cases were identified from the Electronic Patient Record (EPR) and from data provided by the regional paediatric retrieval service. A questionnaire survey was sent to AICU doctors and nurses to assess confidence and competence in paediatric critical care. Results Between 2014-2019, 284 children were managed by AICU. In total 35% of cases were <1 y, 48% of cases were <2 y and 64% of cases were <5 y, and 166/284 (58%) children were retrieved. Retrieval reduced with increasing age (OR 0.49 [0.40-0.60], p < 0.0001). The survey had an 82% response rate, and highlighted that only 13% of AICU nurses and 50% of doctors had received prior PICU training. Conclusion At least one critically unwell child presents to the AICU each week. Assessment, stabilisation and management of critically unwell children are vital skills for DGH AICU staff, but confidence and competence are lacking. Formalised strategies are required to develop and maintain paediatric competencies for AICU doctors and nurses.

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