Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor pati... more Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality. To evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients. Pragmatic cluster randomised trial. Eight tertiary referral hospitals with >200 beds each in three Australian states. 1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198). No adverse events or harms were reported. Although the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this.
OBJECTIVE: To evaluate the cost-effectiveness of nutritional support compared with standard care ... more OBJECTIVE: To evaluate the cost-effectiveness of nutritional support compared with standard care in preventing pressure ulcers (PrUs) in high-risk hospitalized patients. DESIGN: An economic model using data from a systematic literature review. A meta-analysis of randomized controlled trials on the efficacy of nutritional support in reducing the incidence of PrUs was conducted. PATIENTS: Modeled cohort of hospitalized patients at high risk of developing PrUs and malnutrition simulated during their hospital stay and up to 1 year. INTERVENTIONS: Standard care included PrU prevention strategies, such as redistribution surfaces, repositioning, and skin protection strategies, along with standard hospital diet. In addition to the standard care, the intervention group received nutritional support comprising patient education, nutrition goal setting, and the consumption of high-protein supplements. MAIN OUTCOMES MEASURES: The analysis was from a healthcare payer perspective. Key outcomes of the model included the average costs and quality-adjusted life years. Model results were tested in univariate sensitivity analyses, and decision uncertainty was characterized using a probabilistic sensitivity analysis. MAIN RESULTS: Compared with standard care, nutritional support was cost saving at AU $425 per patient and marginally more effective with an average 0.005 quality-adjusted life years gained. The probability of nutritional support being cost-effective was 87%. CONCLUSIONS: Nutritional support to prevent PrUs in high-risk hospitalized patients is cost-effective with substantial cost savings predicted. Hospitals should implement the recommendations from the current PrU practice guidelines and offer nutritional support to high-risk patients.
Background: The Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an... more Background: The Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an advanced practice nursing role that emerged in the late 1990s in Australia and the United Kingdom (UK). Little is known about this role in less developed economies. Objective: To describe the activities undertaken by ICULNs in Argentina. Methods: Prospective, descriptive, observational, single site study in an Argentinean metropolitan tertiary referral hospital. Adult patients under ICULN follow up were included in the sample. Data on ICULN activities and patients were collected using an established tool developed by The Australian Intensive Care Unit Liaison Nurse Forum. Descriptive statistics were used to summarise the findings. Results: Two hundred patients were visited by the ICULNs during the study period. The mean age of patients was 52.5 years (SD 17.7). Cardiovascular disease (n = 104, 52%), respiratory disease (n = 90, 45%) and diabetes (n = 40, 20%) were the most common comorbidities. 110 (55%) patients had surgical procedures. The primary reasons for ICULN visit were follow up post ICU discharge (n = 138, 69%) and ward referral (n = 46, 23%). 136 (68%) patients received up to 3 visits; the remaining 64 (32%) patients received ≥4 visits. In those patients in need of ≥4 visits ICULNs initiated more non-medical treatments (100%), referred to escalate treatment (35%) and to a higher level of care (13.8%) than in those who were visited up to 3 times.
Objective: To identify, classify, and describe safety hazards during the process of intrahospital... more Objective: To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. Design: A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. Setting: The study was undertaken at two ICUs in one university hospital. Patients: Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. Interventions: None. Measurements and Main Results: Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4–10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. Conclusions: Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety. (Crit Care Med 2017; 45:e1043–e1049)
The aim of this longitudinal study was to describe adherence to evidence-based pressure injury (P... more The aim of this longitudinal study was to describe adherence to evidence-based pressure injury (PI) prevention guidelines in routine clinical practice in Australian hospitals. Data were analysed from four control sites of a larger-cluster randomised trial of a PI intervention. The sample of 799 included 220 (27⋅5%) Not at risk, 344 (43⋅1%) At risk and 110 (13⋅8%) At high risk patients. A total of 84 (10⋅5%) patients developed a PI during the study: 20 (9⋅0% of 220) in the Not at risk group, 45 (13⋅1% of 344) in the At risk group, 15 (13⋅6% of 110) in the At high risk group and 4 (3⋅2% of 125) patients who did not have a risk assessment completed. Of all patients, 165 (20⋅7%) received only one PI prevention strategy, and 494 (61⋅8%) received ≥2 strategies at some point during the study period. There was no statistical difference in the proportion of time the three risk groups received ≥1 and ≥2 strategies; on average, this was less than half the time they were in the study. Thus, patients were not receiving PI prevention strategies consistently throughout their hospital stay, although it is possible patients' risk changed over the study period.
Aims. The aim of this study was to develop the Patient Participation in Pressure injury Preventio... more Aims. The aim of this study was to develop the Patient Participation in Pressure injury Prevention (PPPIP) scale and undertake initial testing of some of its psychometric properties. Background. Clinical practice guidelines recommend patient involvement in pressure injury prevention. There is some evidence that patients are willing to participate in this activity, but there are currently no instruments to measure this participation. Design. This methodological study used data collected as part of a cluster randomized trial to develop and test the PPPIP scale. Methods. A sample of 688 of patients with complete PPPIP scale data was used. A stratified random subsample, (Subsample A) was created and the remainder became Subsample B. Item analysis, exploratory factor analysis and Cronbach's alpha reliability were undertaken in Subsample A. Confirmatory factor analysis and Cronbach's alpha reliability were undertaken in Subsample B. Data collection occurred between June 2014-May 2015. Results. In Subsample A (n = 320), inter-item correlations, item total correlations met the acceptance criteria and an exploratory factor analysis identified a one factor solution. In Subsample B (n = 368), the confirmatory factor analysis supported this one factor. In both subsamples, the Cronbach's alpha was 0Á86. Conclusion. This study provides preliminary evidence of acceptable reliability and validity of the PPPIP scale in two subsamples of hospitalized patients who had limited mobility. It may be used in research and quality improvement activities. As a better conceptual understanding of patient participation emerges, the PPPIP scale may require refinement.
Please cite this article in press as: Frohmader TJ, et al. Structures, processes and outcomes of ... more Please cite this article in press as: Frohmader TJ, et al. Structures, processes and outcomes of the Aussie Heart Guide Program: A nurse mentor supported, home based cardiac rehabilitation program for rural patients with acute coronary syndrome. Aust Crit Care (2017), a b s t r a c t Background: Cardiac rehabilitation has a number of benefits for patients, yet participation in it is sub-optimal, especially in regional Australia. Innovative models of cardiac rehabilitation are needed to improve participation. Providing nurse mentors to support patients transitioning from hospital to home represents a new model of service delivery in Australia. Objectives: To explore the impact of a home based cardiac rehabilitation program in assisting patients to recover from Acute Coronary Syndrome and meeting the expectations of nurse mentors delivering the program. Methods: This case study was underpinned by the structure, process and outcomes model and occurred in three Australian hospitals 2008–2011. Thirteen patients recovering from acute coronary syndrome were interviewed by telephone and seven nurse mentors completed a survey after completing the program. Findings: Mentor perceptions concerning the structures of the home based CR program included the timely recruitment of patients, mentor training to operationalise the program, commitment to development of the mentor role, and the acquisition of knowledge and skills about cognitive behavioural therapy and patient centred care. Processes included the therapeutic relationship between mentors and patients, suitability of the program and the promotion of healthier lifestyle behaviours. Outcomes identified that patients were satisfied with the program's audiovisual resources, and the level of support and guidance provided by their nurse mentors. Mentors believed that the program was easy to use in terms of its delivery. Discussion and conclusion: Patients believed the program assisted their recovery and were satisfied with the information, guidance and support received from mentors. There were positive signs that the program influenced patients' decisions to change unhealthy lifestyle behaviours. Outcomes highlighted both rewards and barriers associated with mentoring patients in their homes by telephone. Experience gained from developing a therapeutic relationship with patients during their recovery, assisted nurses in developing the mentor role. Crown
Home-based cardiac rehabilitation (CR) programs improve health outcomes for people diagnosed with... more Home-based cardiac rehabilitation (CR) programs improve health outcomes for people diagnosed with heart disease. Mentoring of patients by nurses trained in CR has been proposed as an innovative model of cardiac care. Little is known however, about the experience of mentors facilitating such programs and adapting to this new role. The aim of this qualitative study was to explore nurse mentor perceptions of their role in the delivery of a home-based CR program for rural patients unable to attend a hospital or outpatient CR program. Seven nurses mentored patients by telephone providing patients with education, psychosocial support and lifestyle advice during their recovery. An open-ended survey was administered to mentors by email and findings revealed mentors perceived their role to be integral to the success of the program. Nurses were satisfied with the development of their new role as patient mentors. They believed their collaborative skills, knowledge and experience in coronary care, timely support and guidance of patients during their recovery and use of innovative audiovisual resources improved the health outcomes of patients not able to attend traditional programs. Cardiac nurses in this study perceived that they were able to successfully transition from their normal work practices in hospital to mentoring patients in their homes. Crown
Background: Surgical-site infection (SSI) occurs in 1–10 per cent of all patients undergoing surg... more Background: Surgical-site infection (SSI) occurs in 1–10 per cent of all patients undergoing surgery; rates can be higher depending on the type of surgery. The aim of this review was to establish whether (or not) surgical hand asepsis, intraoperative skin antisepsis and selected surgical dressings are cost-effective in SSI prevention, and to examine the quality of reporting. Methods: The authors searched MEDLINE via Ovid, CINAHL via EBSCO, Cochrane Central and Scopus databases systematically from 1990 to 2016. Included were RCTs and quasi-experimental studies published in English, evaluating the economic impact of interventions to prevent SSI relative to surgical hand and skin antisepsis, and wound dressings. Characteristics and results of included studies were extracted using a standard data collection tool. Study and reporting quality were assessed using SIGN and CHEERS checklists. Results: Across the three areas of SSI prevention, the combined searches identified 1214 articles. Of these, five health economic studies evaluating the cost-effectiveness of selected surgical dressings were eligible. Study authors concluded that the interventions being assessed were cost-effective, or were potentially cost-saving. Still, there is high uncertainty around the decision to adopt these dressings/devices in practice. The studies' reporting quality was reasonable; three reported at least 15 of the 24 CHEERS items appropriately. Assessment of methodological quality found that two studies were considered to be of high quality. Conclusion: With few economic studies undertaken in this area, the cost-effectiveness of these strategies is unclear. Incorporating economic evaluations alongside RCTs will help towards evidence-informed decisions.
Objective. The aim of the present study was to describe process changes in surgical team performa... more Objective. The aim of the present study was to describe process changes in surgical team performance and team members' attitudes to safety culture following hospital relocation and expansion of perioperative services. Methods. The study was a naturalistic study using structured observations and surveys to assess non-technical skills (NTS; i.e. communication, teamwork, situational awareness, decision making and leadership) in surgery. This interrupted time series design used mixed-linear regression models to examine the effect of phase (before and after hospital relocation) on surgical teams' NTS and their processes that may affect performance. Differences in self-reported teamwork and safety climate attitudes were also examined. Results. In all, 186 procedures (100 before and 81 after hospital relocation) were observed across teams working in general, paediatric, orthopaedic and thoracic surgeries. Interobserver agreement ranged from 86% to 95%. An effect of phase was found, indicating that there were significant improvements after relocation in the use of NTS by the teams observed (P = 0.020; 95% confidence interval 1.9–4.7). Conclusions. The improvements seen in surgical teams' NTS performance and safety culture attitudes may be related to the move to a new state-of-the-art perioperative department. What is known about the topic? Patient safety in surgery relies on optimal team performance, underpinned by effective NTS. What does this paper add? The NTS of surgical teams may be improved through ergonomic innovations that promote teams' shared mental models. What are the implications for practitioners? Effective multidisciplinary teamwork relies on a combination of NTS and ergonomic factors, which inherently contribute to team performance and safety climate attitudes.
Background: Communication and teamwork failures have frequently been identified as the root cause... more Background: Communication and teamwork failures have frequently been identified as the root cause of adverse events and complications in surgery. Few studies have examined contextual factors that influence teams' non-technical skills (NTS) in surgery. The purpose of this prospective study was to identify and describe correlates of NTS.
Background: Up to 60% of adverse events in surgery are the result of poor communication and teamw... more Background: Up to 60% of adverse events in surgery are the result of poor communication and teamwork. Nontechnical skills in surgery (NOTSS) are critical to the success of surgery and patient safety. The study aim was to evaluate the effect of a brief team training intervention on teams' observed NOTSS.
The person-centred care of older people with cognitive impairment in acute care (POPAC) scalepsyc... more The person-centred care of older people with cognitive impairment in acute care (POPAC) scalepsychometric evaluation Aim To test the reliability and validity of the Person-centred care of Older People with cognitive impairment in Acute Care scale to determine nurses' perceptions of person-centred care. Background One-third of older adults admitted to hospital are at risk of serious hospital-acquired complications such as falls, infections and pressure injuries because of cognitive impairment. These risks can be reduced through personcentred practices. The Person-centred care of Older People with cognitive impairment in Acute Care scale is a self-report staff instrument to explore the extent to which person-centred practices are undertaken; however psychometric testing is limited. Methods A cross-sectional sample of acute care nurses (n = 240) in Queensland, Australia completing self-report questionnaires. Psychometric analyses of item performance, reliability and validity were conducted. Results Item analysis revealed independent items. One item was removed due to negatively associating with the scale, improving total Cronbach's alpha from 0.76 to 0.84. The three original factors were maintained with regrouping of items. Confirmatory factor analysis confirmed the revised model. Conclusions The revised Person-centred care of Older People with cognitive impairment in Acute Care scale had satisfactory psychometric properties when used as a total scale. Implications for nursing management Scale brevity and simplicity together with rigorous development and testing indicates that the revised Person-centred care of Older People with cognitive impairment in Acute Care may be useful for quality improvement programmes into the care of older people in hospitals.
Background: Negative pressure wound therapy (NPWT) is increasingly used prophylactically followin... more Background: Negative pressure wound therapy (NPWT) is increasingly used prophylactically following surgery despite limited evidence of clinical or cost-effectiveness. Objective: To evaluate whether NPWT is cost-effective compared to standard care, for the prevention of surgical site infection (SSI) in obese women undergoing elective caesarean section, and inform development of a larger trial. Methods: An economic evaluation was conducted alongside a pilot randomised controlled trial at one Australian hospital, in which women were randomised to NPWT (n ¼ 44) or standard care (n ¼ 43). A public health care provider perspective and time horizon to four weeks post-discharge was adopted. Cost-effectiveness assessment was based on incremental cost per SSI prevented and per quality-adjusted life year (QALY) gained. Results: Patients receiving NPWT each received health care costing AU$5887 (±1038) and reported 0.069 (±0.010) QALYs compared to AU$5754 (±1484) and 0.066 (±0.010) QALYs for patients receiving standard care. NPWT may be slightly more costly and more effective than standard care, with estimated incre-mental cost-effectiveness ratios (ICERs) of AU$1347 (95%CI dominant-$41,873) per SSI prevented and AU$42,340 (95%CI dominant-$884,019) per QALY gained. However, there was considerable uncertainty around these estimates. Conclusions: NPWT may be cost-effective in the prophylactic treatment of surgical wounds following elective caesarean section in obese women. Larger trials could clarify the cost-effectiveness of NPWT as a prophylactic treatment for SSI. Sensitive capture of QALYs and cost offsets will be important given the high level of uncertainty around the point estimate cost-effectiveness ratio which was close to conventional thresholds. Australian and New Zealand trial registration number: ACTRN12612000171819.
Aim In this integrative review, we aimed to: first, identify and summarize published studies rela... more Aim In this integrative review, we aimed to: first, identify and summarize published studies relating to ward nurses' recognition of and response to patient deterioration ; second, to critically evaluate studies that described or appraised the practice of ward nurses in recognizing and responding to patient deterioration; and third, identify gaps in the literature for further research.
Background: Patient participation in health care is associated with improved outcomes for patient... more Background: Patient participation in health care is associated with improved outcomes for patients and hospitals. New technologies are creating vast potential for patients to participate in care at the bedside. Several studies have explored patient use, satisfaction and perceptions of health information technology (HIT) interventions in hospital. Understanding what works for whom, under what conditions, is important when considering interventions successfully engaging patients in care. This realist review aimed to determine key features of interventions using bedside technology to engage hospital patients in their care and analyse these in terms of context, mechanisms and outcomes. Methods: A realist review was chosen to explain how and why complex HIT interventions work or fail within certain contexts. The review was guided by Pawson's realist review methodology, involving: clarifying review scope; searching for evidence; data extraction and evidence appraisal; synthesising evidence and drawing conclusions. Author experience and an initial literature scope provided insight and review questions and theories (propositions) around why interventions worked were developed and iteratively refined. A purposive search was conducted to find evidence to support, refute or identify further propositions, which formed an explanatory model. Each study was 'mined' for evidence to further develop the propositions and model.
Background: Advancements in technology are enabling patients to participate in their health care ... more Background: Advancements in technology are enabling patients to participate in their health care through self-monitoring and self-management of diet, exercise and chronic disease. Technologies allowing patients to participate in hospital care are still emerging but show promise. Our team is developing a program by which hospitalised patients can participate in their nutrition care. This study explores hospital staffs' perceptions of using this technology to engage patients in their care.
Background: Active patient involvement in nutrition care may improve dietary intakes in hospital.... more Background: Active patient involvement in nutrition care may improve dietary intakes in hospital. Our team is developing an innovative programme allowing patients to self-assess and self-monitor their nutrition at the bedside. The present study aimed to assess usability and patient perceptions of an electronic foodservice system (EFS) for participating in nutrition care. Methods: This qualitative study was conducted in an Australian tertiary hospital. Participants were sampled purposively and included patients who were able to provide informed consent and communicate in English. Patient interviews were conducted at the bedside and consisted of: (i) usability testing of the EFS using 'Think Aloud' technique and (ii) questioning using a semi-structured interview guide to understand perceptions of the EFS. Interview data were analysed using inductive content analysis. Results: Thirty-two patients were interviewed. Their perceptions of using the EFS to participate in nutrition care were expressed in five categories: (i) Familiarity with technology can affect confidence and ability but is not essential to use EFS; (ii) User interface design significantly impacts EFS usability; (iii) Identifying benefits to technology increases its acceptance; (iv) Technology enables participation, which occurs to varying extents; and (v) Degree of participation depends on perceived importance of nutrition. Conclusions: Patients found the EFS acceptable and acknowledged benefits to its use. Several factors appeared to influence usability, acceptability and willingness to engage with the system, such as user interface design and perceived ease of use, benefits and importance. The present study provides important insights into designing technology-based interventions for engaging inpatients in their nutrition care.
Background: As pressure ulcers contribute to significant patient burden and increased health care... more Background: As pressure ulcers contribute to significant patient burden and increased health care costs, their prevention is a clinical priority. Our team developed and tested a complex intervention, a pressure ulcer prevention care bundle promoting patient participation in care, in a cluster-randomised trial. The UK Medical Research Council recommends process evaluation of complex interventions to provide insight into why they work or fail and how they might be improved. This study aimed to evaluate processes underpinning implementation of the intervention and explore end-users' perceptions of it, in order to give a deeper understanding of its effects. Methods: A pre-specified, mixed-methods process evaluation was conducted as an adjunct to the main trial, guided by a framework for process evaluation of cluster-randomised trials. Data was collected across eight Australian hospitals but mainly focused on the four intervention hospitals. Quantitative and qualitative data were collected across the evaluation domains: recruitment, reach, intervention delivery and response to intervention, at both cluster and individual patient level. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were analysed using thematic analysis.
Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor pati... more Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality. To evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients. Pragmatic cluster randomised trial. Eight tertiary referral hospitals with >200 beds each in three Australian states. 1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198). No adverse events or harms were reported. Although the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this.
OBJECTIVE: To evaluate the cost-effectiveness of nutritional support compared with standard care ... more OBJECTIVE: To evaluate the cost-effectiveness of nutritional support compared with standard care in preventing pressure ulcers (PrUs) in high-risk hospitalized patients. DESIGN: An economic model using data from a systematic literature review. A meta-analysis of randomized controlled trials on the efficacy of nutritional support in reducing the incidence of PrUs was conducted. PATIENTS: Modeled cohort of hospitalized patients at high risk of developing PrUs and malnutrition simulated during their hospital stay and up to 1 year. INTERVENTIONS: Standard care included PrU prevention strategies, such as redistribution surfaces, repositioning, and skin protection strategies, along with standard hospital diet. In addition to the standard care, the intervention group received nutritional support comprising patient education, nutrition goal setting, and the consumption of high-protein supplements. MAIN OUTCOMES MEASURES: The analysis was from a healthcare payer perspective. Key outcomes of the model included the average costs and quality-adjusted life years. Model results were tested in univariate sensitivity analyses, and decision uncertainty was characterized using a probabilistic sensitivity analysis. MAIN RESULTS: Compared with standard care, nutritional support was cost saving at AU $425 per patient and marginally more effective with an average 0.005 quality-adjusted life years gained. The probability of nutritional support being cost-effective was 87%. CONCLUSIONS: Nutritional support to prevent PrUs in high-risk hospitalized patients is cost-effective with substantial cost savings predicted. Hospitals should implement the recommendations from the current PrU practice guidelines and offer nutritional support to high-risk patients.
Background: The Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an... more Background: The Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an advanced practice nursing role that emerged in the late 1990s in Australia and the United Kingdom (UK). Little is known about this role in less developed economies. Objective: To describe the activities undertaken by ICULNs in Argentina. Methods: Prospective, descriptive, observational, single site study in an Argentinean metropolitan tertiary referral hospital. Adult patients under ICULN follow up were included in the sample. Data on ICULN activities and patients were collected using an established tool developed by The Australian Intensive Care Unit Liaison Nurse Forum. Descriptive statistics were used to summarise the findings. Results: Two hundred patients were visited by the ICULNs during the study period. The mean age of patients was 52.5 years (SD 17.7). Cardiovascular disease (n = 104, 52%), respiratory disease (n = 90, 45%) and diabetes (n = 40, 20%) were the most common comorbidities. 110 (55%) patients had surgical procedures. The primary reasons for ICULN visit were follow up post ICU discharge (n = 138, 69%) and ward referral (n = 46, 23%). 136 (68%) patients received up to 3 visits; the remaining 64 (32%) patients received ≥4 visits. In those patients in need of ≥4 visits ICULNs initiated more non-medical treatments (100%), referred to escalate treatment (35%) and to a higher level of care (13.8%) than in those who were visited up to 3 times.
Objective: To identify, classify, and describe safety hazards during the process of intrahospital... more Objective: To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. Design: A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. Setting: The study was undertaken at two ICUs in one university hospital. Patients: Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. Interventions: None. Measurements and Main Results: Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4–10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. Conclusions: Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety. (Crit Care Med 2017; 45:e1043–e1049)
The aim of this longitudinal study was to describe adherence to evidence-based pressure injury (P... more The aim of this longitudinal study was to describe adherence to evidence-based pressure injury (PI) prevention guidelines in routine clinical practice in Australian hospitals. Data were analysed from four control sites of a larger-cluster randomised trial of a PI intervention. The sample of 799 included 220 (27⋅5%) Not at risk, 344 (43⋅1%) At risk and 110 (13⋅8%) At high risk patients. A total of 84 (10⋅5%) patients developed a PI during the study: 20 (9⋅0% of 220) in the Not at risk group, 45 (13⋅1% of 344) in the At risk group, 15 (13⋅6% of 110) in the At high risk group and 4 (3⋅2% of 125) patients who did not have a risk assessment completed. Of all patients, 165 (20⋅7%) received only one PI prevention strategy, and 494 (61⋅8%) received ≥2 strategies at some point during the study period. There was no statistical difference in the proportion of time the three risk groups received ≥1 and ≥2 strategies; on average, this was less than half the time they were in the study. Thus, patients were not receiving PI prevention strategies consistently throughout their hospital stay, although it is possible patients' risk changed over the study period.
Aims. The aim of this study was to develop the Patient Participation in Pressure injury Preventio... more Aims. The aim of this study was to develop the Patient Participation in Pressure injury Prevention (PPPIP) scale and undertake initial testing of some of its psychometric properties. Background. Clinical practice guidelines recommend patient involvement in pressure injury prevention. There is some evidence that patients are willing to participate in this activity, but there are currently no instruments to measure this participation. Design. This methodological study used data collected as part of a cluster randomized trial to develop and test the PPPIP scale. Methods. A sample of 688 of patients with complete PPPIP scale data was used. A stratified random subsample, (Subsample A) was created and the remainder became Subsample B. Item analysis, exploratory factor analysis and Cronbach's alpha reliability were undertaken in Subsample A. Confirmatory factor analysis and Cronbach's alpha reliability were undertaken in Subsample B. Data collection occurred between June 2014-May 2015. Results. In Subsample A (n = 320), inter-item correlations, item total correlations met the acceptance criteria and an exploratory factor analysis identified a one factor solution. In Subsample B (n = 368), the confirmatory factor analysis supported this one factor. In both subsamples, the Cronbach's alpha was 0Á86. Conclusion. This study provides preliminary evidence of acceptable reliability and validity of the PPPIP scale in two subsamples of hospitalized patients who had limited mobility. It may be used in research and quality improvement activities. As a better conceptual understanding of patient participation emerges, the PPPIP scale may require refinement.
Please cite this article in press as: Frohmader TJ, et al. Structures, processes and outcomes of ... more Please cite this article in press as: Frohmader TJ, et al. Structures, processes and outcomes of the Aussie Heart Guide Program: A nurse mentor supported, home based cardiac rehabilitation program for rural patients with acute coronary syndrome. Aust Crit Care (2017), a b s t r a c t Background: Cardiac rehabilitation has a number of benefits for patients, yet participation in it is sub-optimal, especially in regional Australia. Innovative models of cardiac rehabilitation are needed to improve participation. Providing nurse mentors to support patients transitioning from hospital to home represents a new model of service delivery in Australia. Objectives: To explore the impact of a home based cardiac rehabilitation program in assisting patients to recover from Acute Coronary Syndrome and meeting the expectations of nurse mentors delivering the program. Methods: This case study was underpinned by the structure, process and outcomes model and occurred in three Australian hospitals 2008–2011. Thirteen patients recovering from acute coronary syndrome were interviewed by telephone and seven nurse mentors completed a survey after completing the program. Findings: Mentor perceptions concerning the structures of the home based CR program included the timely recruitment of patients, mentor training to operationalise the program, commitment to development of the mentor role, and the acquisition of knowledge and skills about cognitive behavioural therapy and patient centred care. Processes included the therapeutic relationship between mentors and patients, suitability of the program and the promotion of healthier lifestyle behaviours. Outcomes identified that patients were satisfied with the program's audiovisual resources, and the level of support and guidance provided by their nurse mentors. Mentors believed that the program was easy to use in terms of its delivery. Discussion and conclusion: Patients believed the program assisted their recovery and were satisfied with the information, guidance and support received from mentors. There were positive signs that the program influenced patients' decisions to change unhealthy lifestyle behaviours. Outcomes highlighted both rewards and barriers associated with mentoring patients in their homes by telephone. Experience gained from developing a therapeutic relationship with patients during their recovery, assisted nurses in developing the mentor role. Crown
Home-based cardiac rehabilitation (CR) programs improve health outcomes for people diagnosed with... more Home-based cardiac rehabilitation (CR) programs improve health outcomes for people diagnosed with heart disease. Mentoring of patients by nurses trained in CR has been proposed as an innovative model of cardiac care. Little is known however, about the experience of mentors facilitating such programs and adapting to this new role. The aim of this qualitative study was to explore nurse mentor perceptions of their role in the delivery of a home-based CR program for rural patients unable to attend a hospital or outpatient CR program. Seven nurses mentored patients by telephone providing patients with education, psychosocial support and lifestyle advice during their recovery. An open-ended survey was administered to mentors by email and findings revealed mentors perceived their role to be integral to the success of the program. Nurses were satisfied with the development of their new role as patient mentors. They believed their collaborative skills, knowledge and experience in coronary care, timely support and guidance of patients during their recovery and use of innovative audiovisual resources improved the health outcomes of patients not able to attend traditional programs. Cardiac nurses in this study perceived that they were able to successfully transition from their normal work practices in hospital to mentoring patients in their homes. Crown
Background: Surgical-site infection (SSI) occurs in 1–10 per cent of all patients undergoing surg... more Background: Surgical-site infection (SSI) occurs in 1–10 per cent of all patients undergoing surgery; rates can be higher depending on the type of surgery. The aim of this review was to establish whether (or not) surgical hand asepsis, intraoperative skin antisepsis and selected surgical dressings are cost-effective in SSI prevention, and to examine the quality of reporting. Methods: The authors searched MEDLINE via Ovid, CINAHL via EBSCO, Cochrane Central and Scopus databases systematically from 1990 to 2016. Included were RCTs and quasi-experimental studies published in English, evaluating the economic impact of interventions to prevent SSI relative to surgical hand and skin antisepsis, and wound dressings. Characteristics and results of included studies were extracted using a standard data collection tool. Study and reporting quality were assessed using SIGN and CHEERS checklists. Results: Across the three areas of SSI prevention, the combined searches identified 1214 articles. Of these, five health economic studies evaluating the cost-effectiveness of selected surgical dressings were eligible. Study authors concluded that the interventions being assessed were cost-effective, or were potentially cost-saving. Still, there is high uncertainty around the decision to adopt these dressings/devices in practice. The studies' reporting quality was reasonable; three reported at least 15 of the 24 CHEERS items appropriately. Assessment of methodological quality found that two studies were considered to be of high quality. Conclusion: With few economic studies undertaken in this area, the cost-effectiveness of these strategies is unclear. Incorporating economic evaluations alongside RCTs will help towards evidence-informed decisions.
Objective. The aim of the present study was to describe process changes in surgical team performa... more Objective. The aim of the present study was to describe process changes in surgical team performance and team members' attitudes to safety culture following hospital relocation and expansion of perioperative services. Methods. The study was a naturalistic study using structured observations and surveys to assess non-technical skills (NTS; i.e. communication, teamwork, situational awareness, decision making and leadership) in surgery. This interrupted time series design used mixed-linear regression models to examine the effect of phase (before and after hospital relocation) on surgical teams' NTS and their processes that may affect performance. Differences in self-reported teamwork and safety climate attitudes were also examined. Results. In all, 186 procedures (100 before and 81 after hospital relocation) were observed across teams working in general, paediatric, orthopaedic and thoracic surgeries. Interobserver agreement ranged from 86% to 95%. An effect of phase was found, indicating that there were significant improvements after relocation in the use of NTS by the teams observed (P = 0.020; 95% confidence interval 1.9–4.7). Conclusions. The improvements seen in surgical teams' NTS performance and safety culture attitudes may be related to the move to a new state-of-the-art perioperative department. What is known about the topic? Patient safety in surgery relies on optimal team performance, underpinned by effective NTS. What does this paper add? The NTS of surgical teams may be improved through ergonomic innovations that promote teams' shared mental models. What are the implications for practitioners? Effective multidisciplinary teamwork relies on a combination of NTS and ergonomic factors, which inherently contribute to team performance and safety climate attitudes.
Background: Communication and teamwork failures have frequently been identified as the root cause... more Background: Communication and teamwork failures have frequently been identified as the root cause of adverse events and complications in surgery. Few studies have examined contextual factors that influence teams' non-technical skills (NTS) in surgery. The purpose of this prospective study was to identify and describe correlates of NTS.
Background: Up to 60% of adverse events in surgery are the result of poor communication and teamw... more Background: Up to 60% of adverse events in surgery are the result of poor communication and teamwork. Nontechnical skills in surgery (NOTSS) are critical to the success of surgery and patient safety. The study aim was to evaluate the effect of a brief team training intervention on teams' observed NOTSS.
The person-centred care of older people with cognitive impairment in acute care (POPAC) scalepsyc... more The person-centred care of older people with cognitive impairment in acute care (POPAC) scalepsychometric evaluation Aim To test the reliability and validity of the Person-centred care of Older People with cognitive impairment in Acute Care scale to determine nurses' perceptions of person-centred care. Background One-third of older adults admitted to hospital are at risk of serious hospital-acquired complications such as falls, infections and pressure injuries because of cognitive impairment. These risks can be reduced through personcentred practices. The Person-centred care of Older People with cognitive impairment in Acute Care scale is a self-report staff instrument to explore the extent to which person-centred practices are undertaken; however psychometric testing is limited. Methods A cross-sectional sample of acute care nurses (n = 240) in Queensland, Australia completing self-report questionnaires. Psychometric analyses of item performance, reliability and validity were conducted. Results Item analysis revealed independent items. One item was removed due to negatively associating with the scale, improving total Cronbach's alpha from 0.76 to 0.84. The three original factors were maintained with regrouping of items. Confirmatory factor analysis confirmed the revised model. Conclusions The revised Person-centred care of Older People with cognitive impairment in Acute Care scale had satisfactory psychometric properties when used as a total scale. Implications for nursing management Scale brevity and simplicity together with rigorous development and testing indicates that the revised Person-centred care of Older People with cognitive impairment in Acute Care may be useful for quality improvement programmes into the care of older people in hospitals.
Background: Negative pressure wound therapy (NPWT) is increasingly used prophylactically followin... more Background: Negative pressure wound therapy (NPWT) is increasingly used prophylactically following surgery despite limited evidence of clinical or cost-effectiveness. Objective: To evaluate whether NPWT is cost-effective compared to standard care, for the prevention of surgical site infection (SSI) in obese women undergoing elective caesarean section, and inform development of a larger trial. Methods: An economic evaluation was conducted alongside a pilot randomised controlled trial at one Australian hospital, in which women were randomised to NPWT (n ¼ 44) or standard care (n ¼ 43). A public health care provider perspective and time horizon to four weeks post-discharge was adopted. Cost-effectiveness assessment was based on incremental cost per SSI prevented and per quality-adjusted life year (QALY) gained. Results: Patients receiving NPWT each received health care costing AU$5887 (±1038) and reported 0.069 (±0.010) QALYs compared to AU$5754 (±1484) and 0.066 (±0.010) QALYs for patients receiving standard care. NPWT may be slightly more costly and more effective than standard care, with estimated incre-mental cost-effectiveness ratios (ICERs) of AU$1347 (95%CI dominant-$41,873) per SSI prevented and AU$42,340 (95%CI dominant-$884,019) per QALY gained. However, there was considerable uncertainty around these estimates. Conclusions: NPWT may be cost-effective in the prophylactic treatment of surgical wounds following elective caesarean section in obese women. Larger trials could clarify the cost-effectiveness of NPWT as a prophylactic treatment for SSI. Sensitive capture of QALYs and cost offsets will be important given the high level of uncertainty around the point estimate cost-effectiveness ratio which was close to conventional thresholds. Australian and New Zealand trial registration number: ACTRN12612000171819.
Aim In this integrative review, we aimed to: first, identify and summarize published studies rela... more Aim In this integrative review, we aimed to: first, identify and summarize published studies relating to ward nurses' recognition of and response to patient deterioration ; second, to critically evaluate studies that described or appraised the practice of ward nurses in recognizing and responding to patient deterioration; and third, identify gaps in the literature for further research.
Background: Patient participation in health care is associated with improved outcomes for patient... more Background: Patient participation in health care is associated with improved outcomes for patients and hospitals. New technologies are creating vast potential for patients to participate in care at the bedside. Several studies have explored patient use, satisfaction and perceptions of health information technology (HIT) interventions in hospital. Understanding what works for whom, under what conditions, is important when considering interventions successfully engaging patients in care. This realist review aimed to determine key features of interventions using bedside technology to engage hospital patients in their care and analyse these in terms of context, mechanisms and outcomes. Methods: A realist review was chosen to explain how and why complex HIT interventions work or fail within certain contexts. The review was guided by Pawson's realist review methodology, involving: clarifying review scope; searching for evidence; data extraction and evidence appraisal; synthesising evidence and drawing conclusions. Author experience and an initial literature scope provided insight and review questions and theories (propositions) around why interventions worked were developed and iteratively refined. A purposive search was conducted to find evidence to support, refute or identify further propositions, which formed an explanatory model. Each study was 'mined' for evidence to further develop the propositions and model.
Background: Advancements in technology are enabling patients to participate in their health care ... more Background: Advancements in technology are enabling patients to participate in their health care through self-monitoring and self-management of diet, exercise and chronic disease. Technologies allowing patients to participate in hospital care are still emerging but show promise. Our team is developing a program by which hospitalised patients can participate in their nutrition care. This study explores hospital staffs' perceptions of using this technology to engage patients in their care.
Background: Active patient involvement in nutrition care may improve dietary intakes in hospital.... more Background: Active patient involvement in nutrition care may improve dietary intakes in hospital. Our team is developing an innovative programme allowing patients to self-assess and self-monitor their nutrition at the bedside. The present study aimed to assess usability and patient perceptions of an electronic foodservice system (EFS) for participating in nutrition care. Methods: This qualitative study was conducted in an Australian tertiary hospital. Participants were sampled purposively and included patients who were able to provide informed consent and communicate in English. Patient interviews were conducted at the bedside and consisted of: (i) usability testing of the EFS using 'Think Aloud' technique and (ii) questioning using a semi-structured interview guide to understand perceptions of the EFS. Interview data were analysed using inductive content analysis. Results: Thirty-two patients were interviewed. Their perceptions of using the EFS to participate in nutrition care were expressed in five categories: (i) Familiarity with technology can affect confidence and ability but is not essential to use EFS; (ii) User interface design significantly impacts EFS usability; (iii) Identifying benefits to technology increases its acceptance; (iv) Technology enables participation, which occurs to varying extents; and (v) Degree of participation depends on perceived importance of nutrition. Conclusions: Patients found the EFS acceptable and acknowledged benefits to its use. Several factors appeared to influence usability, acceptability and willingness to engage with the system, such as user interface design and perceived ease of use, benefits and importance. The present study provides important insights into designing technology-based interventions for engaging inpatients in their nutrition care.
Background: As pressure ulcers contribute to significant patient burden and increased health care... more Background: As pressure ulcers contribute to significant patient burden and increased health care costs, their prevention is a clinical priority. Our team developed and tested a complex intervention, a pressure ulcer prevention care bundle promoting patient participation in care, in a cluster-randomised trial. The UK Medical Research Council recommends process evaluation of complex interventions to provide insight into why they work or fail and how they might be improved. This study aimed to evaluate processes underpinning implementation of the intervention and explore end-users' perceptions of it, in order to give a deeper understanding of its effects. Methods: A pre-specified, mixed-methods process evaluation was conducted as an adjunct to the main trial, guided by a framework for process evaluation of cluster-randomised trials. Data was collected across eight Australian hospitals but mainly focused on the four intervention hospitals. Quantitative and qualitative data were collected across the evaluation domains: recruitment, reach, intervention delivery and response to intervention, at both cluster and individual patient level. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were analysed using thematic analysis.
There is unprecedented demand for critical care services globally. In our region, there are appro... more There is unprecedented demand for critical care services globally. In our region, there are approximately 119,000 admissions to 141 general intensive care units (ICUs) in Australia per year; this includes 5500 patient readmissions during the same hospital episode. In ...
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Papers by Wendy Chaboyer