Care complexity, perceptions of complexity and preferences for interprofessional collaboration: an analysis of relationships and social networks in paediatrics

BACKGROUND

In the context of increasingly intricate healthcare systems, professionals are compelled to collaborate within dynamically changing interprofessional teams. Moreover, they must adapt these collaborative processes to effectively and efficiently manage the evolving complexity of care needs. It remains unclear how professionals determine care complexity and relate this complexity to their preferences for interprofessional collaboration (IPC). This study investigated the relationships between care complexity, professionals' perceived complexity and IPC preferences, and examined the variation in individual and team characteristics of IPC-practices across different levels of complexity in paediatric care.

METHODS

In an online questionnaire, 123 healthcare professionals working at an academic tertiary children's hospital scored their perceptions of complexity and preferences for IPC. They also selected family and various professions as members of the interprofessional (IP-) team based on thirteen patient cases. We employed conjoint analysis to systematically model the complexity of case descriptions across the five domains of the International Classification of Functioning, Disability and Health (ICF). Additionally, we applied social network analysis to identify important professions, crucial connectors and influential professions in the IP-team, and to describe the cohesiveness of IP-teams.

RESULTS

Modelled case complexity, professionals' perceived complexity and IPC preferences were positively associated. We found large inter-individual variations in the degree of these associations. Social network analysis revealed that the importance and influence of professions was more equally distributed when case complexity increased. Depending on the context and complexity of the case, different professions (e.g. medical doctors, social professionals, extramural professionals) were considered to be more crucial connectors within the IP-team. Furthermore, team cohesion was positively associated with modelled and perceived care complexity.

CONCLUSIONS

In conclusion, our study contributes to the existing knowledge by integrating task-specific insights and broadening the use of conjoint and social network analysis in the context of IPC. The findings substantiate the contingency theory that relates characteristics of IPC to care complexity, offering quantified insights into how IP-teams adapt to situational needs. This understanding of relationships and variations within IPC holds crucial implications for designing targeted interventions in both clinical and health profession education contexts. Consequently, it contributes to advancements in healthcare systems.

Opening the black box of team-based learning (TBL): A study of verbal interactions in online application sessions

CONTEXT

In team-based learning (TBL), an instructional strategy that encourages in-depth team discussion and deep learning, interactions in terms of sharing, co-construction, constructive conflict and procedural interactions are important. Since TBL has also been applied online in recent years, the question is whether these interactions are sufficiently present in an online setting.

AIM

Gain insight into the nature and extent of these types of interactions in online TBL application sessions and to what extent these vary between teams and sessions.

METHODS

We made audiovisual recordings of 12 TBL teams in two online application sessions during assignments. Transcripts were coded and analyzed using a framework derived.

RESULTS

Teams spent more than 85% of their time on all four types of interactions in both sessions. The largest proportion of time was spent on sharing and co-construction. Constructive conflict occurred to a limited extent. We observed variation in proportion of time spent on and the distribution of the four types of interactions between teams and sessions.

DISCUSSION

All interactions important for achieving deep learning occurred in online TBL application sessions. However, the effective use of these types of interaction should not be left to chance.

Perception of oral health related quality of life and orofacial aesthetics following restorative treatment of tooth wear: A five-year follow-up

OBJECTIVES

Non-carious tooth wear often has a multifactorial etiology and may lead to functional or aesthetically related problems. The most common complaints associated with tooth wear are dissatisfaction with dental appearance and a negative impact on the experienced Oral Health Related Quality of Life (OHRQoL). The aim of this study was to investigate the change in OHRQoL and the perception of aesthetics, following restorative treatment of moderate to severe tooth wear patients, with a five-year follow-up.

METHODS

An explorative study, based on prospective data, was performed. OHRQoL and the perception of aesthetics were measured with the OHIP-NL and OES-NL. These questionnaires were completed before treatment, one month after treatment, and at 1-, 3- and 5-years post-treatment. Treatment involved full mouth reconstruction with composite resin restorations. The data was analysed as repeated measures by using a linear mixed-effects model.

RESULTS

One hundred and twenty-three tooth wear patients that received restorative rehabilitation were included (97 males, 26 females, 37.5 ± 8.8 years-old). Data showed a statistically significant increase in both experienced OHRQoL and orofacial appearance after restorative treatment. The OHIP-scores remained stable over time, while the OES-scores slightly decreased during the years after treatment. Regarding the seven domains of the OHIP, the largest difference in OHIP-score was found in the domain of 'Psychological Discomfort'. The mean overall OHIP-score was 1.8 at baseline and 1.3 at the 5-years recall. The mean OES score increased from 41.8 at baseline to 66.1 at the 5-years follow-up.

CONCLUSIONS

Tooth wear patients reported significant improvements in their OHRQoL and their perception of orofacial aesthetics after restorative treatment. This increase remained at least five years post-treatment.

CLINICAL SIGNIFICANCE

The clinical impact of restorative treatment for tooth wear patients is considerable. This paper emphasizes the need to include a discussion of the patient related outcome measures when planning care.

Team-based learning (TBL): Each phase matters! An empirical study to explore the importance of each phase of TBL

CONTEXT

In Team Based Learning (TBL), it is, based on theory, assumed that knowledge development in each phase contributes to the subsequent phase and to learning performance. However, there is no empirical evidence for this assumption.

AIM

In order to find support for the relation between TBL and the underlying theory, we determined to what extent each phase of TBL is associated with the knowledge development in the next phase and with the total learning performance.

METHODS

We measured the scientific concepts recalled by 56 second-year undergraduate medical students before TBL, after each of the three phases and after TBL. We used multivariate regression analysis to determine the statistical association between the phases as well as the total learning performance.

RESULTS

Results showed that in each phase, students produced new concepts in addition to those previously recalled. Regression models showed statistically significant explained variance ranging from 0.19 to 0.26, between the three phases and the total learning performance.

DISCUSSION

Each phase of the TBL is significantly associated with knowledge development in the subsequent phase and with the total learning performance, and therefore matters. This study contributes to the scientific underpinning of TBL and offers leads to more elaborate research and interventions to improve TBL.

Additional preconditioning program for bariatric surgery: Any benefits? A large cohort study

Postbariatric outcomes may improve by providing an additional preconditioning program (APP) in targeted patients. However, APPs are a demand for health resources while only little and inconsistent evidence consists to support their effectiveness. This cohort study aims to evaluate the effectiveness of APP, by comparing outcomes of patients with and without such APP. We carried out a retrospective single-centre cohort study in a before-after design. Patients signing up for primary gastric bypass or sleeve gastrectomy and eligible for surgery were included if screened as vulnerable patients. Vulnerable patients screened between September 2017 and March 2018 followed an APP and formed the APP-group. Due to a policy change, APPs were no longer performed since September 2018. Vulnerable patients screened between September 2018 and March 2019 thus did not receive an APP (comparator-group). Multidisciplinary follow-up remained unchanged. Endpoints included percentage total weight loss (%TWL), bodyweight, evolution of comorbidities, protein intake, and number of no-shows. The APP-group comprised 231 patients and the comparator-group 153. %TWL differed statistically significantly at 7 (Δ1.5%, p = .01) and 12 months postoperative (Δ2.8%, p < .01) in favour of the comparator-group, as did bodyweight 12 months postoperative (Δ1.8 kg, p < .01). Statistically significant differences were also found in the evolution of comorbidities, protein intake, and the number of no-shows, most in favour for the comparator-group. APP proofed not to be superior to Non-App. It is debatable whether statically significant differences are clinically relevant given their small magnitude. A care pathway without an APP seems at least as effective as a care pathway without.

Influencing nursing students' perceptions of community care with curriculum-redesign; a quasi-experimental cohort study

BACKGROUND

The shift in healthcare to extramural leads to more patients with complex health problems receiving nursing care at home. However, the interest of baccalaureate nursing students for community nursing is moderate, which contributes to widespread labour-market shortages. This study investigates the effect of a more 'community-care-oriented' curriculum on nursing students' perceptions of community care.

METHODS

A quasi-experimental quantitative survey study with a historic control group (n = 477; study cohorts graduating in 2015, 2016, and 2017; response rate 90%) and an intervention group (n = 170; graduating in 2018; response rate 93%) was performed in nursing students of a University of Applied Sciences in a large city in the Netherlands. The intervention group underwent a new curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). The control and intervention group were compared on demographics, placement preferences and perceptions with a chi-square or T-test. Multiple regression was used to investigate the effect of the curriculum-redesign on nursing students' perceptions of community care.

RESULTS

The comparison between the control and intervention group on students' perceptions of community care shows no significant differences (mean 6.18 vs 6.21 [range 1-10], respectively), nor does the curriculum-redesign have a positive effect on students' perceptions F (1,635) = .021, p = .884, R² = < .001. The comparison on placement preferences also shows no significant differences and confirms the hospital's popularity (72.7% vs 76.5%, respectively) while community care is less often preferred (9.2% vs 8.2%, respectively). The demographics 'working in community care' and 'belonging to a church/religious group' appear to be significant predictors of more positive perceptions of community care.

CONCLUSIONS

Graduating students who experienced a more 'community-care-oriented' curriculum did not more often prefer community care placement, nor did their perceptions of community care change. Apparently, four years of education and placement experiences have only little impact and students' perceptions are relatively static. It would be worth a try to conduct a large-scale approach in combination with a carefully thought out strategy, based on and tying in with the language and culture of younger people.

Factors underlying perceptions of community care and other healthcare areas in first-year baccalaureate nursing students: A focus group study

BACKGROUND

Despite the increasing labour market shortage of well-educated community nurses, few baccalaureate nursing students choose for a career in community care. Obtaining knowledge of how students perceive healthcare areas early in their education is important to take meaningful steps in counteracting any existing misconceptions with targeted curriculum redesign.

OBJECTIVE

Determination of factors underlying perceptions of healthcare areas in first-year baccalaureate nursing students.

DESIGN

A descriptive qualitative study using focus group inquiry.

METHODS

This study follows up on a large-sample quantitative multicentre survey study. Fourteen first-year nursing students at a university of applied sciences in the Netherlands participated in focus group discussions in October 2014. Transcripts of the discussions were coded by two independent researchers at three levels - open, axial and selective coding - on the basis of two templates. The codes were sorted into categories and assigned to suitable main codes in the templates. The number of sub-codes per category and code were added together.

RESULTS

Eight main themes were formulated, to wit (1) variety and diversity, (2) challenges, (3) improving people's health, (4) collaboration, (5) role models, (6) patient- or environment-based perceptions, (7) self-efficacy and (8) immediate vicinity. Data suggest that first-year students have clear ideas about the characteristics which they consider important in professional practice. Their perceptions do not necessarily reflect the actual situation, as they expect the hospital to possess all desired characteristics while community nursing seems to be undervalued.

CONCLUSION

To remedy students' misperceptions, four recommendations are formulated for curriculum redesign strategies deriving from the eight themes. These recommendations are based on collaboration between school and care organisations as well as on themes related to in-depth knowledge within the educational programme. The interventions will potentially help to strengthen the focus on community care, which will foster a more optimistic and realistic career outlook on this field.

The Scale on COmmunity care PErceptions (SCOPE) for nursing students: A development and psychometric validation study

The aim of this study was to develop a valid instrument to measure student nurses' perceptions of community care (SCOPE). DeVellis' staged model for instrument development and validation was used. Scale construction of SCOPE was based on existing literature. Evaluation of its psychometric properties included exploratory factor analysis and reliability analysis. After pilot-testing, 1062 bachelor nursing students from six institutions in the Netherlands (response rate 81%) took part in the study. SCOPE is a 35-item scale containing: background variables, 11 measuring the affective component, 5 measuring community care perception as a placement, 17 as a future profession, and 2 on the reasons underlying student preference. Principal axis factoring yielded two factors in the affective component scale reflecting 'enjoyment' and 'utility', two in the placement scale reflecting 'learning possibilities' and 'personal satisfaction', and four in the profession scale: 'professional development', 'collaboration', 'caregiving', and 'complexity and workload'. Cronbach's α of the complete scale was 0.892 and of the subscales 0.862, 0.696, and 0.810 respectively. SCOPE is a psychometrically sound instrument for measuring students' perceptions of community care. By determining these perceptions, it becomes possible to positively influence them with targeted curriculum redesign, eventually contributing to decreasing the workforce shortage in community nursing.

Perceptions of community care and placement preferences in first-year nursing students: A multicentre, cross-sectional study

BACKGROUND

Despite increasing shortages of highly educated community nurses, far too few nursing students choose community care. This means that a strong societal problem is emerging that desperately needs resolution.

OBJECTIVES

To acquire a solid understanding of the causes for the low popularity of community care by exploring first-year baccalaureate nursing students' perceptions of community care, their placement preferences, and the assumptions underlying these preferences.

DESIGN

A quantitative cross-sectional design.

SETTINGS

Six universities of applied sciences in the Netherlands.

PARTICIPANTS

Nursing students in the first semester of their 4-year programme (n=1058).

METHODS

Data were collected in September-December 2014. The students completed the 'Scale on Community Care Perceptions' (SCOPE), consisting of demographic data and three subscales measuring the affective component of community care perception, perceptions of a placement and a profession in community care, and students' current placement preferences. Descriptive statistics were used.

RESULTS

For a practice placement, 71.2% of first-year students prefer the general hospital and 5.4% community care, whereas 23.4% opt for another healthcare area. Students consider opportunities for advancement and enjoyable relationships with patients as most important for choosing a placement. Community care is perceived as a 'low-status-field' with many elderly patients, where students expect to find little variety in caregiving and few opportunities for advancement. Students' perceptions of the field are at odds with things they believe to be important for their placement.

CONCLUSION

Due to misconceptions, students perceive community care as offering them few challenges. Strategies to positively influence students' perceptions of community nursing are urgently required to halt the dissonance between students' preference for the hospital and society's need for highly educated community nurses.

Thiamine Levels During Intensive Insulin Therapy in Critically Ill Patients

Introduction:

Thiamine is an essential cofactor in carbohydrate metabolism, and deficiency can therefore cause various organ dysfunctions. Little is known about the prevalence and possible worsening of thiamine deficiency in critically ill patients. In this study, we investigated the prevalence of thiamine deficiency at admission to the intensive care unit (ICU) and hypothesized that intensive insulin therapy, aimed at regulating glucose levels, increases thiamine utilization and therefore might cause or worsen deficiency in patients with limited thiamine stores.

Materials and Methods:

An observational prospective cohort study was carried out in a medical–surgical ICU in a general teaching hospital in Apeldoorn, the Netherlands. All adults who were treated during that time with intensive insulin therapy were included. Deficiency was defined as a thiamine level <100 nmol/L. No thiamine supplementation was administered except for normal amounts present in standard enteral feeding.

Results:

A total of 58 patients were available for analysis. Median thiamine level at admission was 111 nmol/L. Deficiency was present in 39.7% of patients and was significantly associated with the presence of gastrointestinal pathology and with recent surgery. Thiamine levels increased a median of 14 nmol/L in 48 hours. Only 3.4% of patients showed a predefined relevant decline in thiamine levels.

Conclusion:

Intensive insulin therapy does not appear to cause or worsen thiamine deficiency. However, based on the high prevalence of deficiency at admission, it might be warranted to supplement thiamine in all patients admitted to the ICU, especially when there is an underlying gastrointestinal disease or recent surgery.

Practice variation in treatment of suspected asymptomatic bacteriuria prior to cardiac surgery: are there differences in postoperative outcome? A retrospective cohort study

OBJECTIVES

It is unclear whether postoperative infections can be prevented by treating asymptomatic bacteriuria, or whether, on the other hand, such treatment will increase the risk of more serious infection by pathogenic bacteria different from the ones causing bacteriuria. This study aimed to support future treatment decisions for preoperative cardiothoracic surgery patients with asymptomatic bacteriuria, by examining current preoperative practice, in relation to postoperative outcome.

METHODS

A retrospective cohort study was conducted. All patients who underwent cardiothoracic surgery in 2011-2013 using extracorporeal circulation in St. Antonius Hospital Nieuwegein, and who preoperatively had nitrituria and/or leucocyturia were included. Exclusion criteria were C-reactive protein level higher than 10 mg/l, emergency surgery, critical preoperative state and/or antibiotic treatment because of other infections. Outcomes were postoperative infections and length of stay. Furthermore, we compared culture results of preoperative urine with postoperative infection sites in order to study the hypothesis of haematogenous spread.

RESULTS

One thousand and two patients with leucocyturia or nitrituria were eligible, of whom 3.9% had been treated with antibiotics preoperatively (AB+). Of the 96.1% of patients who had not been treated (AB-), 8.3% had an infection postoperatively, compared with 5.1% in the treatment (AB+) group. This was not statistically significant {odds ratio, corrected for EuroSCORE, 0.53 [95% confidence interval (CI) 0.12-2.24, P = 0.39]}. Length of stay, corrected for EuroSCORE, between the treated (AB+) and the non-treated (AB-) group did not differ, with a hazard ratio of 1.05 (95% CI 0.63-1.75, P = 0.85). As regards bacterial culture results, none of patients not treated with antibiotics preoperatively (AB-) seemed to have a postoperative infection due to haematogenous spread of bacteria from the urinary tract present preoperatively.

CONCLUSIONS

The risk of haematogenous spread of bacteria seems to be non-existent in this large cohort of non-treated patients, under our local clinical practice. Based on this current, best available evidence, it seems therefore safe not to treat patients with asymptomatic bacteriuria prior to cardiothoracic surgery. This could also imply that it is safe not to perform routine preoperative urine testing.

Ambulance Transfer in Case of Postpartum Hemorrhage after Birth in Primary Midwifery Care in The Netherlands: A Prospective Cohort Study

BACKGROUND

The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage (PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met.

METHODS

Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions.

RESULTS

Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found (RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met.

CONCLUSIONS

We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings.

Postoperative loss of skeletal muscle mass, complications and quality of life in patients undergoing cardiac surgery

OBJECTIVE

The objective of this study was to describe postoperative undernutrition in terms of postoperative losses of appendicular skeletal muscle mass (ASMM) with respect to complications, quality of life, readmission, and 1-y mortality after cardiac surgery.

METHODS

Patients undergoing cardiac surgery were prospectively followed. ASMM was measured 2 wk before and 2 mo after surgery using dual-energy X-ray absorptiometry. ASMM consists of arm skeletal muscle mass (SMM) and leg SMM. The association between ≥5% of ASMM decrease and postoperative outcome was analyzed using the chi-square test. A similar approach was used to analyze arm SMM and leg SMM decreases separately.

RESULTS

Twenty-nine patients were included (23 male, 34.5% ≥65 y old). Postoperatively, seven patients (24.1%) lost ≥5% ASMM. When analyzed separately, a ≥5% decrease in leg SMM was associated with a decrease in experienced vitality (odds ratio 13.0, 95% confidence interval 1.32-128.11, P = 0.03). In contrast, a ≥5% loss of arm SMM was associated with fewer in-hospital complications (odds ratio 0.20, 95% confidence interval 0.04-0.98, P = 0.04). These patients were characterized by a higher preoperative fat-free mass index (kilograms per meter squared; P = 0.01).

CONCLUSIONS

The results suggest that a preoperatively higher fat-free mass index indicates better ability to cope with operative stress, resulting in fewer complications. In addition, postoperative loss of muscle mass was associated with decreased vitality. We advocate further research investigating the effect of preoperative and postoperative nutritional intervention combined with physical exercise programs to increase lean body mass and thereby improve postoperative recovery after cardiac surgery.

Kashin Beck Disease: more than just osteoarthrosis: a cross-sectional study regarding the influence of body function-structures and activities on level of participation

The purpose of this study was to investigate the influence of body function, activities and pain on the level of activity in adults with Kashin Beck Disease (KBD). Seventy-five KBD patients with a mean age of 54.8 years (SD 11.3) participated. Anthropometrics, range of joint motion (ROM) and muscle strength were measured as well as the time-up-and-go test and functional tests for the lower and upper extremities. Activity was assessed with the participation scale and the WHO DAS II. In the shoulder, elbow, hip and knee joints, a severe decrease in ROM and bilateral pain was noted. A decrease in muscle strength was observed in almost all muscles. The timed-up-and-go test scores decreased. No or mild restriction in activity was found in 35%, and 33% experienced a moderate restriction whereas 32% had severe to extreme restriction. Activities in the lower extremities were mildly to moderately correlated to ROM and muscle strength, whereas in the upper extremities activities were correlated to range of joint motion. Activity was significantly associated with ROM after correction for muscle strength, gender and age. Participation was borderline significantly associated with ROM after correction for muscle strength, gender, age and the activity time-up-and-go. In KBD adults, a severe decrease in activity is primarily caused by decrease in ROM. These findings have strong influence on rehabilitation and surgical intervention.

Safe early discharge for patients undergoing high dose chemotherapy with or without stem cell transplantation: a prospective analysis of clinical variables predictive for complications after treatment

AIM

To identify which patient groups can be safely discharged early after high dose chemotherapy.

BACKGROUND

Until recently, the standard of care for patients with haematological malignancies who have been treated with high dose chemotherapy has been to hospitalise them until neutrophil recovery and clinical improvement. Over the past years, a more liberal approach has resulted in a tendency to discharge patients earlier. However, currently it is unclear which clinical variables are important and which patient groups are most suitable to be discharged early.

DESIGN

Prospective cohort study.

METHODS

The study group of 55 patients underwent 82 admission periods for a total of 2269 patient days, which could be classified into four categories: induction treatment, consolidation treatment and autologous or allogeneic stem cell transplantation. Different clinical variables potentially interfering with early discharge were subsequently analysed for their association with each treatment group.

RESULTS

The median duration of admission was 27 days. The incidence of fever (82.9%) and use of intravenous antibiotics (79.3%) was high in all treatment groups. The only statistically significant differences between groups were found for performance status and mucositis. In the patient group undergoing consolidation chemotherapy for acute myeloid leukaemia, the performance status was better and mucositis was less severe. The decline in performance status and the severity of mucositis were as expected most obvious 10-14 days after the start of chemotherapy.

CONCLUSION

Patients undergoing consolidation chemotherapy appear to be the most suitable candidates for early discharge, especially in the first-week postchemotherapy treatment. Early discharge can also be considered in patients with a good performance status in the autologous stem cell transplantation group, directly after transplantation.

RELEVANCE TO CLINICAL PRACTICE

An important factor in developing an early discharge programme is a good infrastructure, both at home and in the hospital.

Functional outcome in patients with critical illness polyneuropathy

PURPOSE

To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset.

METHODS

DESIGN

A prospective observational cohort study and a cross-sectional study.

SETTING

University hospital in the Netherlands.

PATIENTS

Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study.

MAIN OUTCOME MEASURES

Functional outcome regarding body functions and structure, activities, participation and perceived quality of life.

RESULTS

Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients.

CONCLUSIONS

The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.

Preoperative unintended weight loss and low body mass index in relation to complications and length of stay after cardiac surgery

BACKGROUND

Several studies reported increased adverse outcomes after cardiac surgery in patients with low body mass index (BMI; in kg/m(2)). Little is known yet, however, about the effect of preoperative unintended weight loss (UWL) in cardiac surgery patients.

OBJECTIVE

We explored the prevalence and effect of UWL in view of low BMI and vice versa adjusted for a validated set of preoperative risks, inflammatory activity, and duration of extracorporeal circulation on postoperative adverse outcome.

DESIGN

A prospective cohort study was performed. Nutritional data of cardiac surgery patients were collected within 24 h of admission and linked to the standard postoperative complication registration database.

RESULTS

The cohort consisted of 331 cases. Multivariate logistic regression analyses showed that preoperative UWL of >or=10% in the past 6 mo (>or=10%UWLin6m) was associated with a prolonged length of stay in the hospital independent from low BMI [odds ratio (OR): 7.06; 95% CI: 1.78, 28.04]. Preoperative BMI <or= 21.0 was associated with an increased incidence of postoperative infections and prolonged stay in the intensive care unit independent from >or=10%UWLin6m (OR: 4.62; 95% CI: 1.20, 17.82; and OR: 5.27; 95% CI: 1.28, 21.76, respectively). Preoperative undernutrition in cardiac surgery patients (>or=10%UWLin6m or BMI <or= 21.0 or both) was present in 9.1% of the study population (4.3% and 4.8%, respectively).

CONCLUSIONS

From this study, we recommend special attention for cardiac surgery patients with preoperative >or=10%UWLin6m or BMI <or= 21.0 because both variables are independently related to adverse outcomes. Preoperative referral to a dietitian for further diagnostic assessment and nutritional treatment is strongly recommended.

Decision making in interhospital transport of critically ill patients: national questionnaire survey among critical care physicians

Objective

This study assessed the relative importance of clinical and transport-related factors in physicians' decision-making regarding the interhospital transport of critically ill patients.

Methods

The medical heads of all 95 ICUs in The Netherlands were surveyed with a questionnaire using 16 case vignettes to evaluate preferences for transportability; 78 physicians (82%) participated. The vignettes varied in eight factors with regard to severity of illness and transport conditions. Their relative weights were calculated for each level of the factors by conjoint analysis and expressed in β. The reference value (β = 0) was defined as the optimal conditions for critical care transport; a negative β indicated preference against transportability.

Results

The type of escorting personnel (paramedic only: β = –3.1) and transport facilities (standard ambulance β = –1.21) had the greatest negative effect on preference for transportability. Determinants reflecting severity of illness were of relative minor importance (dose of noradrenaline β = –0.6, arterial oxygenation β = –0.8, level of peep β = –0.6). Age, cardiac arrhythmia, and the indication for transport had no significant effect.

Conclusions

Escorting personnel and transport facilities in interhospital transport were considered as most important by intensive care physicians in determining transportability. When these factors are optimal, even severely critically ill patients are considered able to undergo transport. Further clinical research should tailor transport conditions to optimize the use of expensive resources in those inevitable road trips.

Nurses' critical event risk assessments: a judgement analysis

AIMS

To explore and explain nurses' use of readily available clinical information when deciding whether a patient is at risk of a critical event.

BACKGROUND

Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge 'basics' such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses' responses to abnormal signs result in delays of between one and three hours.

METHODS

A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, 'at-risk' status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients.

RESULTS

Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as 'at risk' and deciding to intervene. Nurses' weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (R(a)) statistics suggests that nurses' assessments of risk were largely inaccurate; these assessments were applied consistently among 'patients' (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene.

CONCLUSION

Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use.

RELEVANCE TO CLINICAL PRACTICE

Practice developers and educators need to pay attention to the quality of nurses' clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes' rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of 'holism' and 'expertise' from the science of predictive validity, accuracy and competence in judgement and decision making.

A method to provide integrated care for complex medically ill patients: The INTERMED

A growing number of nursing subspecializations have been developed in recent decades. Topics of concern are that care is not tailored to cope with the growing number of patients with more than one chronic disease, there is an increase in co-ordination problems in the care that is provided for this group of complex patients, and the care for these complex patients is extremely fragmented. The assessment of health risks resulting in co-ordinated care with effective communication is vital for multimorbid patients. Our aim is to describe a systematic approach (the INTERMED [IM] method) to identify complex patients who are in need of integrated care and its applicability to the nursing process. We demonstrate the ability of the IM method to quantify, weigh, and classify the complexity of problems. The method is applied in Europe and will be started in the USA in a pharmacy program. The IM is presented as a decision-support system for multidisciplinary teams with nurse co-ordinators.

Preferences of patients, doctors, and nurses regarding wound dressing characteristics: A conjoint analysis

The different choices doctors, nurses, and patients make regarding wound dressing materials are generally based on personal preferences, because strong evidence and guidelines on local wound care for open wounds are lacking. We studied which attributes of a wound dressing doctors, nurses, and patients consider the most important. A conjoint analysis questionnaire comprising paper-based descriptions with six attributes, and questions regarding the willingness-to-pay for these attributes were sent out to surgical patients, (assistant)-surgeons and nurses. Preferences for wound dressing attributes were similar for doctors (n=50), nurses (n=150), and patients (n=74). Pain during dressing changes, duration of hospitalization, and wound healing time were ranked highest. Doctors would spend more money on a shorter hospitalization, nurses on pain reduction, and patients on quicker wound healing. Patients were willing to pay a relatively small monthly amount out of pocket for a dressing that would result in a quicker and less-painful wound healing. Doctors, nurses, and patients prefer similar attributes of wound dressing materials, but differ in their willingness-to-pay. To achieve a more consistent local wound care, clinical decision-making should be in accordance with these preferences. These should also be the focus for manufacturers and researchers to obtain more evidence on which materials best match these attributes.

Nurse-led case management for ambulatory complex patients in general health care: a systematic review

OBJECTIVE

The aim of this study was to summarize the available literature on the effectiveness of ambulatory nurse-led case management for complex patients in general health care.

METHOD

We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and Cinahl. We included randomized controlled trials, controlled clinical trials, controlled before/after study, and time series studies; identified references were screened by two reviewers. Two reviewers rated the quality of each article. Data extracted from the selected publications included design, characteristics of the participants, the intervention, type of outcome measures, and results.

RESULTS

We identified 10 relevant publications. Nine studies used readmission rate as primary outcome. Fewer studies investigated duration of hospital readmissions, emergency department (ED) visits, functional status, quality of life, or patient satisfaction. In general, results with regard to the effectiveness of case management were conflicting.

CONCLUSION

There is moderate evidence that case management has a positive effect on patient satisfaction and no effect on ED visits. It was not possible to draw firm conclusions on the other outcomes.

Cost-effectiveness of a nurse-led case management intervention in general medical outpatients compared with usual care: an economic evaluation alongside a randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness of a nurse-led, home-based, case-management intervention (NHI) after hospital discharge in addition to usual care.

METHODS

Economic evaluation alongside a randomized controlled trial after being discharged home with 24 weeks of follow-up. Patients discharged to their home from a general hospital were randomly assigned to NHI or usual care. Clinical outcomes were frequency of emergency readmissions, quality of life, and psychological functioning. Direct costs were measured by means of cost diaries kept by the patients and information obtained from the patients' pharmacists.

RESULTS

A total of 208 patients were randomized, 61 patients dropped out, and 26 had incomplete data, leaving a total of 121 patients included in the final analysis. There were no statistically significant differences in emergency readmissions, quality of life, and psychological functioning. There was a substantial difference in total costs between the NHI group and the control group (4286 Euro; 95% CI, -41; 8026), but this difference was not statistically significant.

CONCLUSION

NHI is not a cost-effective intervention. We do not recommend the implementation of this intervention in populations that do not consist of severely vulnerable and complex patients. Future studies should include complexity assessment on inclusion and evaluate the effectiveness and cost-effectiveness of this intervention in patients with more complex profiles.

The added value of assessing the 'most troublesome' symptom among patients with cancer in the palliative phase

OBJECTIVE

In this study among patients with cancer in the palliative phase, we analysed whether assessing the symptom, which is causing the most trouble in the patient's every day life ('most troublesome' symptom) had added value apart from the presence and severity of symptoms, which are most commonly assessed in clinical practice.

METHODS

Patients with cancer (lung, gastro-intestinal, breast cancer) in the palliative phase from two non-academic hospitals were included in the study. Using the Symptom Monitor tool, 10 physical symptoms were assessed with regard to presence and severity. The Symptom Monitor has an extra added item indicating as the 'most troublesome' symptom. This item was monitored to determine whether it had added value apart from the presence of symptoms and 'most severe' symptom. The severity score on the indicated 'most troublesome' symptom was subtracted from the severity score of the 'most severe' symptom. The generated delta score of 0 indicated no added value, whereas a score of one or more indicated that the 'most troublesome' symptom would have been missed if not specifically asked for by the physician, because its severity was lower that the 'most severe' symptom.

RESULTS

One hundred and forty-six patients reported 590 symptoms to be present. In total, 227 symptoms were reported as 'most severe' symptom (n = 138 patients). Among these, fatigue (n = 52) and pain (n = 24) were reported most frequently as 'most severe' symptom. In total, 134 patients indicated a symptom as 'most troublesome'. Fatigue (n = 33; 25%) and pain (n = 22; 16%) were also indicated by most of these patients as the 'most troublesome' symptom. One hundred and fifty-two comparisons could be made between the 'most severe' and the 'most troublesome' symptom. In 102 (67%) of the comparisons assessing the 'most troublesome' symptom had no added value: the score for 'most severe' symptom did not differ from the score for the 'most troublesome' symptom revealing a delta score of 0. In 23 times (15%) of the 152 comparisons made, the delta score was 1 and in 27 (18%) of the comparisons the delta score was 2 or more indicating that assessing the 'most troublesome' symptom substantially had added value.

CONCLUSION

In patients in the palliative phase of their disease, extra attention for the 'most troublesome' symptom is needed. In our study, in almost 1/3 of the cases, this symptom would have been missed the physicians attention if not specifically asked for.

PRACTICE IMPLICATIONS

We recommend not only to assess the presence and severity of symptoms, but furthermore to assess the patient's 'most troublesome' symptom in addition.

Effectiveness of Post-Discharge Case Management in General-Medical Outpatients: A Randomized, Controlled Trial

This study was initiated to determine the impact of post-discharge, nurse-led, home-based case management intervention on the number of emergency readmissions, level of care utilization, quality of life, and psychological functioning. Patients discharged home from a general hospital (N=147) were randomly assigned to usual care or nurse-led, home-based, case management intervention. During the 24 weeks of follow-up, no difference between the two groups was found for readmission, care utilization, quality of life, or psychological functioning. Patients in the control group tended to move sooner to non-independent living accommodation than patients in the nurse-led, home-based, case management intervention group.

The reliability and validity of a new and simple method to measure sedation levels in intensive care patients: A pilot study

BACKGROUND

Since more sophisticated ventilation techniques have enabled patients to comply with the ventilator with little or no sedation, deep sedation levels can easily be avoided. However, successful ventilation techniques also expanded the treatment possibilities for more severely ill patients who require deeper sedation levels. We developed a new sedation score to improve the prevention of oversedation and to simplify scoring practice in the intensive care unit (ICU).

OBJECTIVE

The study's objective was to establish the validity and reliability of a new sedation score (Sedic score) for critically ill, sedated adult patients.

METHODS

We prospectively evaluated the reliability and validity of the Sedic score. The study took place in a 30-bed ICU in a university teaching hospital. Forty-six consecutive mechanically ventilated and sedated ICU patients were included. The constructed scale consists of five levels of stimuli and five levels of responses. Sedation levels are defined by the sum of stimulus and response. The reliability of the Sedic score was assessed by simultaneous measurement by the research nurse and attending nurse (n=70). VALIDITY was expressed as (1) the hierarchic relation between stimulus and response (n=443), (2) the prediction of wake-up time by the Sedic score (n=46), and (3) the association between the Sedic score and the Ramsay scale (n=88).

RESULTS

The method showed excellent reliability.

VALIDITY

Weighted kappa between stimulus and response was .82. Multivariate analysis: (recovery time as independent variable) regression line (Y=-2.53+ 2.16 * beta; P<.001) (r2=42%). Correlation between the Sedic scores and the Ramsay scores was r(s) .74 (P=.01). Sixty-seven percent of the patients with a maximum Ramsay score of 6 had scores ranging between 6 and 10 on the Sedic scale, indicating that the Ramsay scale has a serious ceiling effect.

CONCLUSION

The Sedic score demonstrates sufficient reliability and validity, and correlates well with wake-up time. It allows for frequent use by nurses to avoid oversedation in patients.

Using the symptom monitor in a randomized controlled trial: the effect on symptom prevalence and severity

This randomized controlled trial investigated the effect of reporting physical symptoms by using a systematic symptom monitoring instrument, the Symptom Monitor, on symptom prevalence and severity among patients with cancer in the palliative phase. The overall objective was to achieve symptom relief through systematic and regular symptom reporting by patients themselves. One hundred forty-six patients with cancer in the palliative phase were randomized to either the intervention group (n = 69 with Symptom Monitor) or the control group (n = 77 without Symptom Monitor). Ten physical symptoms with regard to prevalence and severity were monitored. After 2 months, the prevalence of symptoms was lower in the intervention group compared to the control group (prevalent differences 2.1-24.3%) for 9 out of 10 symptoms (except coughing). The intervention group scored a statistically significantly lower prevalence in constipation and vomiting (prevalence differences 24.3% and 18.0%, respectively). In four symptoms (fatigue, lack of appetite, shortness of breath, and nausea), the intervention group had a lower, although not statistically significant, severity score (median differences 0.5-1). In four symptoms (pain, coughing, sleeplessness, and diarrhea), the severity score was the same in both groups (medians 2-4). In two symptoms (constipation and vomiting), the severity score was lower in the control group (median differences -1 and -2). A comparison between the study groups on improved, deteriorated, or steady-state cases showed that the severity score had deteriorated less for 8 out of 10 symptoms in a larger proportion of patients in the intervention group. Although statistical significance was not reached, the prevalence as well as severity of symptoms in the palliative phase of cancer can be influenced by using the Symptom Monitor.

Prospective Assessment of Interobserver Agreement for Defecography in Fecal Incontinence

OBJECTIVE

The primary aim of our study was to determine the interobserver agreement of defecography in diagnosing enterocele, anterior rectocele, intussusception, and anismus in fecal-incontinent patients. The subsidiary aim was to evaluate the influence of level of experience on interpreting defecography.

SUBJECTS AND METHODS

Defecography was performed in 105 consecutive fecal-incontinent patients. Observers were classified by level of experience and their findings were compared with the findings of an expert radiologist. The quality of the expert radiologist's findings was evaluated by an intraobserver agreement procedure.

RESULTS

Intraobserver agreement was good to very good except for anismus: incomplete evacuation after 30 sec (kappa, 0.55) and puborectalis impression (kappa, 0.54). Interobserver agreement for enterocele and rectocele was good (kappa, 0.66 for both) and for intussusception, fair (kappa, 0.29). Interobserver agreement for anismus: incomplete evacuation after 30 sec was moderate (kappa, 0.47), and for anismus: puborectalis impression was fair (kappa, 0.24). Agreement in grading of enterocele and rectocele was good (kappa, 0.64 and 0.72, respectively) and for intussusception, fair (kappa, 0.39). Agreement separated by experience level was very good for rectocele (kappa, 0.83) and grading of rectoceles (kappa, 0.83) and moderate for intussusception (kappa, 0.44) at the most experienced level. For enterocele and grading, experience level did not influence the reproducibility.

CONCLUSION

Reproducibility for enterocele, anterior rectocele, and severity grading is good, but for intussusception is fair to moderate. For anismus, the diagnosis of incomplete evacuation after 30 sec is more reproducible than puborectalis impression. The level of experience seems to play a role in diagnosing anterior rectocele and its grading and in diagnosing intussusception.

Trained first-responders with an automated external defibrillator: how do they perform in real resuscitation attempts?

INTRODUCTION

The quality of first-responder performance at the end of automated external defibrillator (AED) training may not predict the performance adequately during a real resuscitation attempt.

METHODS

Between January and December 2000, we evaluated 67 resuscitation attempts in Amsterdam and surroundings, where police officers used an AED. We compared their performance with their assessment at the end of their ERC AED training course. One of the main goals of training was to deliver a shock within 90 s after switching the power on in the AED.

RESULTS

We analysed 127 police officers working in 67 police-teams. The police officers had a mean age of 35 years (range 23-54 years), 73% was male. The interval between AED training and the first resuscitation attempt was a median of 4 months (range 1-13). 78% percent of the 67 teams consisted of two police officers who both were qualified as "competent" after the initial training. Successful completion of the course correlated well with good performance during a resuscitation attempt (p = 0.009). When measured switching the power on in the AED, 92% of the victims received a shock within 90 s.

CONCLUSIONS

Successful training correlates well with successful performance in the field. Competence of a team may be better than competence of two separate individuals.

Training of police officers as first responders with an automated external defibrillator

A short and effective training programme is an essential prerequisite for the use of automated external defibrillators (AED) by EMS providers and first responders. We evaluated a 3-h AED course based on the ERC requirements.

METHODS

As part of a study evaluating the effectiveness of AEDs used by first responders (ARREST 4), we trained all police officers in the region of Amsterdam, the Netherlands. By means of a Basic Life Support (BLS) assessment at the beginning of the course and at the end, we evaluated whether BLS can be improved in a 3-h AED course. Through a combined BLS and AED assessment at the end of the course, we evaluated whether AED skills can be acquired sufficiently. BLS skills were measured with the Laerdal SkillMeter in evaluation mode. AED skills were assessed using 13 criteria. By means of logistic regression, we analysed the influence of student characteristics, such as age, gender, previous training, resuscitation experience and motivation for BLS and AED on BLS and AED skills acquisition.

RESULTS

Between September 1999 and June 2000, 823 police officers were trained (76% male, mean age 36 (S.D. 9) years). BLS improved significantly (P < 0.001) in all criteria, except for hypoventilation (P < 0.001). After training, 89% of the students were able to use an AED safely and effectively. Self-confidence and motivation improved from 12 and 73% to 99 and 94% over the course (P < 0.001). Independent student characteristics influencing the success of the AED course were: previous BLS training, motivation before the course for an AED, and resuscitation experience that dated back for more than 12 months.

CONCLUSION

The majority of police officers can be trained to use an AED safely and effectively within a 3-h AED course. During this course, they also improve on their BLS skills. Successful completion of the course depends in part on the student characteristics.

Cognitive impairment in survivors of out-of-hospital cardiac arrest

BACKGROUND

The huge importance of rapid provision of care, especially early defibrillation, for survival of out-of-hospital cardiac arrest (OHCA) is well known. This prospective cohort study investigated cognitive functioning of OHCA survivors in relation to the time-related elements of the resuscitation.

METHODS

Fifty-seven consecutive survivors, from a cohort of 308 witnessed OHCA patients with ventricular fibrillation as the initial rhythm, underwent extensive neuropsychologic examination, including tests of memory, attention, and executive functioning, 6 months after the resuscitation. Time-related aspects of the resuscitation were collected on scene. Cognitive functioning was studied in relation to the administration of cardiopulmonary resuscitation (CPR) prior to ambulance arrival, and time from collapse to start of CPR, defibrillation, and return of spontaneous circulation (ROSC).

RESULTS

Depending of the test, between 11% and 28% of survivors were cognitively impaired, while 58% scored unimpaired for all tests. Daily life activities were limited in 19% of the patients. Patients who received CPR prior to arrival of the ambulance showed a trend towards overall better cognitive functioning and significant better immediate memory and visuomotor tracking (P =.03 and P <.01). We found a weak correlation between the time to CPR, time to defibrillation, or time to ROSC and cognitive functioning.

CONCLUSIONS

The majority of survivors of OHCA with ventricular fibrillation as the initial rhythm are cognitively unimpaired. Long delays to ROSC are compatible with good cognitive outcome. Initiation and cessation of resuscitation efforts should not be based on the duration of circulatory arrest.

Assessment of quality of life and cognitive function after out-of-hospital cardiac arrest with successful resuscitation

This prospective cohort study evaluated the impact of the time-related elements of the "chain of survival" on the quality of life of patients, taking their characteristics into account. Between 1995 and 2002, consecutive, out-of-hospital cardiac arrest patients from Amsterdam and the surrounding areas were included in this study. A total of 227 patients (12%) survived to hospital discharge and 174 were definitive survivors who were available for assessment at 6 months. Quality of life was measured with the 136-item Sickness Impact Profile (SIP); cognitive functioning was assessed through the Mini Mental State Examination. SIP profiles were compared with profiles of an open Dutch population of the elderly and patients who experienced a stroke. Time intervals of the chain of survival were calculated from the estimated moment of collapse and related to outcome using regression analysis. The SIP profile of survivors was a little above the reference profile, indicating a slightly poorer quality of life, and below the profile of patients after stroke, indicating a better quality of life. Impaired cognitive function was associated with delay in the start of cardiopulmonary resuscitation (odds ratio 4.3, 95% confidence interval 1.0 to 19). Absence of the need for advanced cardiopulmonary life support was associated with better cognitive functioning (odds ratio 0.3, 95% confidence interval 0.1 to 0.9). Female gender and older age were associated with impaired physical functioning. Trends were found for better outcomes after early access, immediate resuscitation, early defibrillation, and early advanced care.

Dressings and topical agents for surgical wounds healing by secondary intention

BACKGROUND

Many different wound dressings and topical applications are used to cover surgical wounds healing by secondary intention. It is not known whether these dressings heal wounds at different rates.

OBJECTIVES

To assess the effectiveness of dressings and topical agents on surgical wounds healing by secondary intention

SEARCH STRATEGY

We sought relevant trials from the Cochrane Central Register of Controlled Trials, Cochrane Wounds Group Specialised Trials Register, MEDLINE, EMBASE, and CINAHL databases in March 2002.

SELECTION CRITERIA

All randomised controlled trials (RCTs) evaluating the effectiveness of dressings and topical agents for surgical wounds healing by secondary intention.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two reviewers who independently judged the methodological quality of the trials according to the Dutch Cochrane Centre list of factors relating to internal and external validity. Two reviewers summarised data from eligible studies using a data extraction sheet, any disagreements were referred to a third reviewer.

MAIN RESULTS

Fourteen reports of 13 RCTs on dressings or topical agents for postoperative wounds healing by secondary intention were identified.

WOUND HEALING

Whilst a single small trial of aloe vera supplementation vs gauze suggests delayed healing with aloe vera, the results of this trial are un interpretable since there was a large differential loss to follow up. A plaster cast applied to an amputation stump accelerated wound healing compared with elastic compression, WMD -25.60 days, 95% CI -49.08 to -2.12 days (1 trial). There were no statistically significant differences in healing for other dressing comparisons (e.g. gauze, foam, alginate; 11 trials). PAIN: Gauze was associated with significantly more pain for patients than other dressings (4 trials). PATIENT SATISFACTION: Patients treated with gauze were less satisfied compared with those receiving alternative dressings (3 trials).

COSTS

Gauze is inexpensive but its use is associated with the use of significantly more nursing time than foam (2 trials). LENGTH OF HOSPITAL STAY: Four trials showed no difference in length of hospital stay. One trial found shorter hospital stay in people after amputation when plaster casts were applied compared with elastic compression (WMD -30.10 days; 95% CI -49.82 to -10.38).

REVIEWERS' CONCLUSIONS

We found only small, poor quality trials; the evidence is therefore insufficient to determine whether the choice of dressing or topical agent affects the healing of surgical wounds healing by secondary intention. Foam is best studied as an alternative for gauze and appears to be preferable as to pain reduction, patient satisfaction and nursing time.

Use of automated external defibrillator by first responders in out of hospital cardiac arrest: prospective controlled trial

OBJECTIVE

To test the hypothesis that the use of an automated external defibrillator by police and fire fighters results in higher discharge rates for out of hospital cardiac arrest.

DESIGN

Controlled clinical trial with initial random allocation of automated external defibrillators to first responders in four of the eight participating regions; each region switched from control to experimental, and vice versa, every four months.

SETTING

Amsterdam and surroundings, the Netherlands.

PARTICIPANTS

Patients with witnessed out of hospital cardiac arrests, identified by the emergency medical system between January 2000 and January 2002.

MAIN OUTCOMES MEASURES

Survival to hospital discharge; return of spontaneous circulation; admission to hospital.

RESULTS

243 patients (65% in ventricular fibrillation) were included in the experimental area and 226 patients (67% in ventricular fibrillation) in the control area. The median time interval between collapse and first shock was 668 seconds in the experimental area and 769 seconds in the control area (P < 0.001). 44 (18%) patients in the experimental area versus 33 (15%) patients in the control area were discharged (odds ratio 1.3 (95% confidence interval 0.8 to 2.2), P = 0.33), 139 (57%) experimental versus 108 (48%) control patients had return of spontaneous circulation (1.5 (1.0 to 2.2), P = 0.05), and 103 (42%) experimental versus 74 (33%) control patients were admitted (1.5 (1.1 to 1.6), P = 0.02). The median delay from receipt of call to dispatch of the ambulance was 120 seconds, and the delay to dispatch of the first responder was 180 seconds.

CONCLUSIONS

Use of automated external defibrillators by first responders did not significantly increase survival to discharge from hospital, although it did improve return of spontaneous circulation and admission to hospital. Improved dispatch procedures should increase the success of programmes of first responders using external defibrillators.