The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: A systematic review and meta-analysis

BACKGROUND

Central venous catheters are commonly used in healthcare, but they come with a range of potential complications. Over the last 15 years, an influx of securement and dressing products has been released, with unknown overall effectiveness to prevent these complications.

OBJECTIVE

To compare the effects of dressings and securement devices for central venous catheters on a range of common complications including catheter-related bloodstream infection, catheter tip colonisation, entry/exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing durability and mortality.

DESIGN

Systematic review with meta-analysis.

METHODS

Following standard Cochrane methods, a systematic search of Cochrane Wounds Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, EBSCO CINAHL, and multiple clinical trial registries was completed in November 2022. Randomised controlled trials evaluating the effectiveness of dressing and securement devices for all CVC types were included. A random-effects model was used during the meta-analysis. Results were expressed using risk ratio (RR), rate ratio, or mean difference (MD), with 95 % confidence intervals (CIs). Methodological quality and bias were assessed.

RESULTS

We included 46 studies involving 10,054 participants. All studies had either an unclear or high-performance bias. The blinding of outcome assessment was unclear in most studies. Chlorhexidine gluconate-impregnated dressings, compared with standard polyurethane dressings, may reduce the incidence (7 studies; N = 5816; RR 0.60, 95 % CI 0.44-0.83; low certainty evidence) and rate (4 studies; N = 4447; RR 0.51, 95 % CI 0.32-0.79; moderate certainty evidence) of catheter-related bloodstream infection and catheter tip colonisation (8 studies; N = 4788; RR 0.70, 95 % CI 0.52-0.95; very low certainty evidence). Medication-impregnated dressings may reduce the incidence of catheter-related bloodstream infection (6 studies; N = 5687; RR 0.60, 95 % CI 0.39-0.93; low certainty evidence) and catheter-tip colonisation (7 studies; N = 4769; RR 0.60, 95 % CI 0.47-0.76; low certainty evidence) relative to non-impregnated dressing types. Tissue adhesive may increase the risk of skin irritation or damage compared with integrated securement dressings (3 studies; N = 166; RR 1.88, 95 % CI 1.09-3.24; low certainty evidence) or sutureless securement devices (4 studies; N = 241; RR 1.64, 95 % CI 1.10-2.44; moderate certainty evidence). Tissue adhesive increased dressing durability compared with integrated securement dressings (MD 43.03 h, 95 % CI 4.88-81.18; moderate certainty evidence) and sutureless securement devices (MD 42.90 h, 4.64-81.16; moderate certainty evidence). Tissue adhesive increased failed catheter securement rate compared with suture (2 studies; N = 103; RR 9.33, 95 % CI 1.10-79.21; moderate certainty evidence).

CONCLUSIONS

The findings of the review provide insights and guidance for clinicians in selecting the appropriate dressings and securements for catheters. Findings should be interpreted with caution due to heterogeneity in catheters and patient types.

REGISTRATION

#CD010367.

TWEETABLE ABSTRACT

Time to implement chlorhexidine gluconate-impregnated dressings to prevent catheter-related bloodstream infections; a meta-analysis by @GraceNP and team.

The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: A multicenter, interrupted time-series study

BACKGROUND

Peripheral intravenous catheters are the most widely used invasive device in hospitals but have serious risks.

OBJECTIVE

To determine if a structured assessment and decision tool (I-DECIDED®) improves daily peripheral intravenous catheter assessment and care decisions.

DESIGN

Prospective, interrupted time-series study.

SETTINGS

Seven adult inpatient wards in three Australian hospitals.

PARTICIPANTS

825 adults with 867 peripheral intravenous catheters.

METHODS

Between August 2017 and December 2018, peripheral intravenous catheter assessments and chart audits were undertaken with informed patient consent. Following a 4-month pre-intervention period (with 2-weekly measures), the I-DECIDED® tool was implemented over 3 months (no data collection) using multiple strategies (stakeholder meetings, vascular access device form, education sessions, ward champions, lanyard cards, and posters), followed by a 4-month post-intervention period (with 2-weekly measures). Primary outcomes were device utilization (number of peripheral intravenous catheters per total number of patients screened); idle/unused catheters; insertion site complications, substandard dressing quality; and primary bloodstream infections.

RESULTS

Of 2055 patients screened, 1175 (57.2%) had a peripheral intravenous catheter, and 825 patients (867 catheters) consented and were included in the final analysis. Device utilization increased from 42.0% of catheters at baseline to 49.6% post-intervention (absolute risk difference [ARD] 7.5%, 95% confidence interval [CI] 4.8, 10.3; relative risk [RR] 1.18, 95% CI 1.11, 1.25; p < 0.001). The proportion of idle catheters reduced from 12.7% to 8.3% (ARD -4.4%, 95% CI -8.5, -0.3; RR 0.66, 95% CI 0.44, 0.97; p = 0.035). Peripheral intravenous catheter complications reduced from 16.1% to 10.9% (ARD -5.2%, 95% CI -9.7, -0.6; RR 0.68, 95% CI 0.48, 0.96; p = 0.026). Substandard dressings reduced from 24.6% to 19.5% (ARD -5.2%, 95% CI -10.7, 0.4; RR 0.79, 95% CI 0.61, 1.02; p = 0.067). Only one primary bloodstream infection occurred (post-intervention).

CONCLUSIONS

Implementation of a comprehensive device assessment and decision tool (I-DECIDED®) reduced idle catheters and catheter complications, despite higher device utilization. Dressing quality improved but was not statistically significant. Further implementation of the tool could improve hospital safety for patients with an intravenous catheter.

ANZCTR TRIAL REGISTRATION

ACTRN12617000067370. Date of registration 13 January 2017. Date of first data collection 3rd August 2017.

TWEETABLE ABSTRACT

#IDECIDEDassessment reduces prevalence of idle peripheral catheters and device complications.

Long-Term Effectiveness of a Nonsurgical BPH Treatment System in Prostate Radiation Patients with Medication-Refractory Lower Urinary Tract Symptoms

PURPOSE/OBJECTIVE(S)

To evaluate the long-term outcomes and toxicity of a nonsurgical prostatic urethral lift system in patients with prior prostate cancer radiation therapy (RT).

MATERIALS/METHODS

From 2018 to 2020, nineteen patients with a history of prior prostate RT underwent a nonsurgical prostatic urethral lift (PUL) procedure for lower urinary track symptoms (LUTS) refractory to alpha blocker medications. Prostate cancer RT was completed a median of 17.8 months (IQR 13.4-27.4) prior to PUL procedure. All patients were assessed with IPSS/quality of life (QOL) scores and urinary post void residual (PVR) ultrasound before and after PUL. Patients were also assessed for ability to discontinue alpha blockade medications for their LUTS and any post PUL toxicity based on CTCAE v5.0 criteria.

RESULTS

All patients underwent successful placement of the PUL implants. Median pre-PUL IPSS score was 20 (IOR 17.5-22.5) and the median prostate volume was 41cc (IQR 33-49). Median follow up was 22 months (IQR 5-30). The average improvement in IPSS score was 8.5 points (IRQ 5.5-11) at 3 months and 7.5 points (IQR 6-10) at last follow-up. Two patients (10%) initially had improvement in IPSS score at 3 months with subsequent significant increase in IPSS (>5 points) at last follow-up. Overall, there was minimal change in reported QOL scores (median 0, IQR 0-1.75). The average reduction in PVR was 90cc. The percentage of patients able to discontinue alpha blockade at last follow-up was 68%. There was no grade 3 or higher GU toxicity in either group.

CONCLUSION

Use of a nonsurgical prostatic urethral lift system in patients with prior prostate RT refractory to alpha blocker medications results in significant long-term improvement of LUTS after radiation therapy for the majority of patients with minimal toxicity.

Public engagement with genomics

As detailed in its flagship report, Genome UK, the UK government recognises the vital role that broad public engagement across whole populations plays in the field of genomics. However, there is limited evidence about how to do this at scale. Most public audiences do not feel actively connected to science, are oftenunsure of the relevance to their lives and rarely talk to their family and friends about; we term this dis-connection a 'disengaged public audience'. We use a narrative review to explore: (i) UK attitudes towards genetics and genomics and what may influence reluctance to engage with these topics; (ii) innovative public engagement approaches that have been used to bring diverse public audiences into conversations about the technology. Whilst we have found some novel engagement methods that have used participatory arts, film, social media and deliberative methods, there is no clear agreement on best practice. We did not find a consistently used, evidence-based strategy for delivering public engagement about genomics across diverse and broad populations, nor a specific method that is known to encourage engagement from groups that have historically felt (in terms of perception) and been (in reality) excluded from genomic research. We argue there is a need for well-defined, tailor-made engagement strategies that clearly articulate the audience, the purpose and the proposed impact of the engagement intervention. This needs to be coupled with robust evaluation frameworks to build the evidence-base for population-level engagement strategies.

Improving the handover of complex trauma patients by implementing a standardised process

BACKGROUND

Patient handover continues to be an international health priority in the prevention of patient harm. Transitioning patients from the intensive care unit (ICU) to the ward is complex, particularly for trauma patients, due to the multifaceted aspects of their care requirements as a result of multiple injuries and different speciality teams.

OBJECTIVES/AIM

To design, implement, and evaluate the efficacy of a standardised handover process and tool for the transfer of ICU trauma patients.

METHODS

A multimethod before/after study design was used. This included observations before and after an implemented transfer process and semistructured interviews with ICU and ward nurses caring for trauma patients. Comparisons were made of data before and after the intervention.

RESULTS

Eleven patient handovers were observed, and 21 nurses (11 from the ICU and 10 from the ward) were interviewed. Patients and family members were included during the handover following the intervention (n = 0/10 [0%] vs n = 4/11 [36%]) and the ward nurses were asked if they had any concerns (n = 5/10 [50%] vs n = 10/11 [91%]). Improvements in patient observations handed over were reported following the intervention. However, omissions remained in some key areas including patient introduction, patient identity, fluid balance, and allergies/alerts. Thematic analysis of interviews revealed that the new handover process was perceived advantageous by both ICU and ward nurses because of its structured and comprehensive approach. Identified future improvements included the need for hospital service managers to ensure integration of ICU and ward electronic health record systems.

CONCLUSION

Precise, accurate, and complete handover remains a patient safety concern. Improvements were achieved using a standardised process and handover tool for the transfer of complex trauma patients. Further improvements are required to reduce the failure to hand over essential patient information.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

An investigation into the clinical scope of practice of MRI reporting radiographers within the United Kingdom

INTRODUCTION

Radiographers have been reporting Magnetic Resonance Imaging (MRI) examinations for over ten years, and there is an increasing body of evidence confirming the efficacy of this role expansion. However, little is known about the clinical scope of practice of radiographers undertaking this enhanced level of practice. The aim of this study was to investigate the clinical scope of practice of MRI reporting radiographers within the United Kingdom (UK).

METHODS

MRI reporting radiographers who are actively reporting within the UK were invited to participate in a short online survey investigating the anatomical areas reported, clinical referral pathways and onward referral practices they routinely undertake. The survey was distributed via social media channels with snowball sampling encouraged.

RESULTS

There were n = 14 responses received, with an estimated response rate of 21.5%. The majority (93% n = 13/14) practised in England, with one response from Scotland. All participants (n = 14/14) undertook reporting of general practitioner (GP) and community healthcare practitioner's referrals, with 93% reporting for outpatient referrers. There was statistically significant variation in the anatomical areas reported when compared against those qualified less than two years and those qualified over ten years (p = 0.003). No other statistically significant variation was seen.

CONCLUSION

There was no statistical difference in the implementation of MRI reporting by radiographers identified. All participants indicated reporting for GP and community healthcare practitioner referrers which align well with the implementation of community diagnostic centre rollout across the UK.

IMPLICATION FOR PRACTICE

This is believed to be the first study of its kind in the realm of MRI reporting. The study has suggested that MRI reporting radiographers are well placed to contribute to the rollout of community diagnostic centres within the UK.

Measuring changes in nursing students' workplace performance following feedback encounters: A quasi-experimental study

BACKGROUND

Work-integrated learning and performance is intimately linked with assessment and feedback; however, empirical evidence concerning the impact of feedback on student performance in workplace settings is limited. A novel practice-based feedback intervention-the REMARK (nuRse fEedback iMplementAtion frameworRK) program-was developed and implemented. Sustainable feedback processes that involve both learners and learning partners can ultimately maximise learning outcomes, optimise self-regulation, and impact performance.

OBJECTIVES

To determine the impact of implementing an educational intervention based on best practice principles of feedback on undergraduate nursing student performance during clinical placements in acute healthcare settings.

METHODS

A non-equivalent, quasi-experimental design was used. A pre- and post-assessment strategy for both control and intervention groups was employed. The REMARK program was based on known attributes of effective feedback critiqued in the literature that foster interactions between a learner and learning partner and, hence, support dialogic feedback.

RESULTS

Clinical assessment data of 214 final-year nursing students collected at three time points were analysed. Using multivariate modelling, the results indicated that students participating in the REMARK programme (intervention group) had statistically higher performance scores than students in the control group when time and placement setting were controlled.

CONCLUSIONS

This research provides evidence that engagement with an intervention based on attributes of effective feedback improves nursing students' workplace performance during clinical placement. To achieve the greatest advantage, incorporating strategies that encourage students to adopt an active role in feedback conversations that relate to the student's learning goals are recommended.

The effect of the ABCDE/ABCDEF bundle on delirium, functional outcomes, and quality of life in critically ill patients: A systematic review and meta-analysis

BACKGROUND

The effect of the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment) on patient outcomes such as delirium is potentially optimised when the bundle is implemented in its entirety.

OBJECTIVE

To systematically synthesise the evidence on the effectiveness of the ABCDEF bundle delivered in its entirety on delirium, function, and quality of life in adult intensive care unit patients.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Electronic databases including MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Joanna Briggs Institute's Evidence Based Practice, Australian New Zealand Clinical Trials Registry, and Embase were searched from 2000 until December 2021.

REVIEW METHODS

Inclusion criteria included (1) adult intensive care unit patients (2) studies that described the ABCDE or ABCDEF bundle in its entirety (3) studies that evaluated delirium, functional outcomes, or quality of life. Studies were excluded if they investigated long-term intensive care unit rehabilitation patients. Two reviewers independently screened records and full text, extracted data, and undertook quality appraisals with discrepancies discussed until consensus was reached. Random effects meta-analyses were conducted for delirium but was not possible for other outcomes. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess the certainty of the synthesised findings of the body of evidence. The study protocol was registered on PROSPERO (CRD 42019126407).

RESULTS

A total of 18 studies (29,576 patients) were included in the descriptive synthesis. Meta-analysis of six studies (2000 patients) identified decreased delirium incidence following implementation of the ABCDEF bundle when compared with standard practice, (risk ratio = 0.57; CI, 0.36-0.90 p = 0.02) although heterogeneity was high (I² = 92%). When compared with standard practice, a meta-analysis of five studies (3418 patients) showed the ABCDEF bundle statistically significantly reduced the duration of intensive care unit delirium (mean difference (days) - 1.37, 95% CI -2.61 to -0.13 p = 0.03; I² 96%). Valid functional assessments were included in two studies, and quality of life assessment in one.

CONCLUSIONS

Although the evidence on the effect of the ABCDEF bundle delivered in its entirety is limited, positive patient delirium outcomes have been shown in this meta-analysis. As this meta-analysis was based on only 4736 patients in eight studies, further evidence is required to support its use in the adult intensive care unit.

REGISTRATION DETAILS

PROSPERO (CRD 42019126407).

Fostering positive emotions, psychological well-being, and productive relationships in the intensive care unit: A before-and-after study

BACKGROUND

Intensive care units (ICUs) are emotionally demanding workplaces. Exposure to stress can negatively impact ICU staff members' emotional resilience, health, and capacity to provide care. Despite recognition of the benefits of promoting "healthy workplaces", there are limited interventional studies aimed at improving the well-being of ICU staff.

AIM

The aim of this study was to assess the effectiveness of a multifaceted intervention for improving well-being of staff working in a tertiary ICU.

METHODS

A before-and-after interventional study was conducted over a 2-year period, between 2019 and 2021. Interventions included social activities, fitness, nutrition, and emotional support. An electronic version of the PERMA-Profiler questionnaire was used to assess the well-being of a convenience sample of ICU staff before (n = 96) and after (n = 137) the intervention. Ten focus groups (each involving 12-18 nurses) were held to explore nurses' perceptions of the intervention's effectiveness.

RESULTS

After the intervention, a significantly greater proportion of participants described their work week as draining (32% vs 19%, χ² = 4.4 df + 1, P = 0.03) and at least a bit harder than normal (38% vs 22%, χ² = 6.4 df + 1, p = 0.01) compared to baseline surveys. However, well-being scores after the intervention (mean = 6.95, standard deviation = 1.28) were not statistically different (p = 0.68) from baseline scores (mean = 7.02, standard deviation = 1.29). Analysis of focus groups data revealed three key categories: boosting morale and fostering togetherness, supporting staff, and barriers to well-being.

CONCLUSIONS

After the intervention, there was a preserved level of well-being from baseline despite a statistically significant increase in staff reporting the work week as draining and at least a little bit harder than normal. These findings must be considered in light of the COVID-19 pandemic, which started after baseline data collection and continues to impact the community, including staff workload and pressures in intensive care. The study findings may inform strategies for improving ICU staff members' well-being.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

37 RE-AUDIT OF VITAMIN D SUPPLEMENTATION IN FRAIL OLDER ADULTS PRESENTING TO AN IRISH LEVEL 5 EMERGENCY DEPARTMENT

Background

The Department of Health published new guidance in November 2020 “Vitamin D advice for people aged 65 and older” which recommended that all adults ≥65 years should be supplemented with 15micrograms of Vitamin D daily. 55.5% of adults ≥65 years have insufficient/deficient vitamin D levels in winter (TILDA 2020). The Frailty Intervention Team (FIT) assess frail adults ≥65 years in the Emergency Department using medication review and Comprehensive Geriatric Assessment to identify vitamin D supplementation. The audit aim was to determine if compliance with the new guideline improved since the initial audit in January 2021.

Methods

All patients who had a medicine reconciliation completed by the FIT Pharmacist in January 2022 were included in a retrospective audit. Patients were identified from the pharmacist’s worklist. Data was collected from a Hospital Clinical System using a Microsoft Excel®. The data recorded included: Age, Sex, Rockwood Clinical Frailty Score (CFS) and vitamin D supplementation.

Results

The FIT Pharmacist completed 66 medicine reconciliations in January 2022. The mean age (+/-SD) was 82.4 (+/-7.6) years.The male to female ratio was 1:1.75The median CFS was 5 (mildly/moderately frail) with an IQR of 1.

68% (n=45) were prescribed vitamin D. Of those 89% (n=40) were prescribed a supplement containing at least 15micrograms of vitamin D. 32% (n=21) were not prescribed any vitamin D supplementation. 8% (n=5) were prescribed doses lower than 15micrograms of vitamin D.

Conclusion

Compliance with the new guideline was 61% (n=40) in comparison to 65% (n=39) in the initial audit. The results are reflective of adherence to the new guideline in the community. The policy update and education provided post the initial audit has possibly influenced the prescribing of vitamin D in the acute setting which unless patients are re-presenting will not have been captured in the outcome of this re-audit.

306 GERIATRICIAN-LED COMPREHENSIVE GERIATRIC ASSESSMENT IN THE EMERGENCY DEPARTMENT: A COST-EFFECTIVE SERVICE APPROVED BY PATIENTS

Background

Many older people are brought to the Emergency Department (ED) who do not require acute hospital admission but there are risks to these patients if this occurs. The Frailty Intervention Team (FIT) are an interdisciplinary team based in the ED including physiotherapy, occupational therapy, speech and language therapy, dietetics, pharmacy, advanced nurse practitioners, and a geriatric registrar and consultant. They assess frail older patients and suggest alternative care pathways to admission. We aimed to investigate the impact of FIT on admission avoidance, bed days saved and to obtain patient feedback on their experience.

Methods

Routinely collected data from May 2021 to April 2022 was reviewed retrospectively. An anonymous patient feedback questionnaire was posted to 40 patients randomised from the FIT worklist between January to May 2022.

Results

2,025 Comprehensive Geriatric Assessments (CGA) were completed between May 2021 and April 2022. 38% percent of patients were discharged home, 45% of this number had follow-up arranged. 104 patients were transferred directly to an offsite bed, mostly rehabilitation. We estimate we avoided 51 admissions to the acute hospital per month, almost half of these were patients admitted to the hospital and, who we discharged to alternative care pathways or home. The average length of stay in April 2022 was 22 days – by avoiding 615 admissions between May 2021 and April 2022 we have saved 13,530 bed days at an estimated cost saving of almost €11 million. 15 completed questionnaires were returned. 73% were very satisfied with their experience. 87% felt the FIT team helped facilitate their discharge from ED. The main themes identified from open ended questions included thorough assessment, patient centred care and satisfaction with early intervention and discharge.

Conclusion

A Frailty Intervention Team is a cost effective and patient centred way of avoiding unnecessary admissions for older people presenting to the ED.

269 PHARMACIST INTERVENTIONS WITHIN A MULTIDISCIPLINARY CARE TEAM FOR FRAIL OLDER ADULTS PRESENTING TO A LEVEL 4 EMERGENCY DEPARTMENT

Background

Inappropriate polypharmacy and ‘Potentially Inappropriate Prescriptions’ (PIP) are associated with increased morbidity and hospitalisation, in particular among frail older persons. A structured medication review, in conjunction with a Comprehensive Geriatric Assessment (CGA), can address PIP. The aim of the study was to review Frail Intervention Team (FIT) pharmacist interventions for frail, older adults presenting to the Emergency Department (ED) and experiencing medication compliance difficulties, polypharmacy and PIP.

Methods

Patients identified for medication review included those experiencing polypharmacy or medication compliance issues, presenting with a fall, delirium and/or frailty syndromes or complex comorbidities. The medication review process involved completion of medicines reconciliation and medication appropriateness review in accordance with the 7-Steps Medication Review Model (Scottish Government Polypharmacy Model of Care Group, 2018). Pharmacist optimisation recommendations were reviewed by a Consultant Geriatrician or Registrar and discussed with the patient prior to implementation.

Results

The FIT Pharmacist completed medication reviews for 765 patients between May 2021 and April 2022. The mean age (+/-SD) was 83.1 (+/-7.0) years with a median Clinical Frailty Score (CFS) of 5 (mildly/moderately frail). Medication Optimisation recommendations were actioned in 63% (n=483) of patients reviewed. The most commonly encountered PIP’s included: excessive anti-hypertensive/diuretic therapy, long-term acid-suppression therapy, anticholinergics and long-term prophylactic antimicrobials. Prescribing opportunities identified included: bone protection, laxatives and pain management.

Conclusion

FIT pharmacist review, in conjunction with the CGA, led to medication optimisation interventions in the frail older adult cohort presenting to the ED. Future studies should examine the impact of medication review on patient outcomes post-discharge.

Dying in intensive care: An analysis of the perspectives of families and clinicians on end-of-life care

BACKGROUND

Despite a growing body of research into end-of-life care (EOLC) in intensive care units (ICUs), few studies have concurrently explored the perspectives of families and clinicians.

OBJECTIVE

The objective of this study was to identify the characteristics of high-quality EOLC in the ICU from family and clinician perspectives and by examining the care documented in medical records.

METHODS

A convergent mixed-methods study incorporating electronic health record audits (n = 20), structured interview surveys with families (n = 20), clinician surveys (n = 189), and focus groups (n = 10) was undertaken at a 30-bed, level 3 ICU at a metropolitan public adult teaching hospital in Australia. Descriptive statistics were calculated from quantitative data, and inductive thematic analysis was used to analyse qualitative data.

RESULTS

Overall, families were very satisfied with EOLC and the quality of communication yet, felt that earlier, clearer communication that the patient was dying was required. Families spoke of the attentiveness, or lack thereof, by ICU clinicians and the opportunity to be present for the patient's death. The majority of ICU clinicians felt EOLC could be improved. Nurses highlighted communication challenges when family meetings were delayed. Some nurses expressed a lack of clarity of how to withdraw care, resulting in hesitancy to cease potentially inappropriate care, and to provide EOLC outside ICU practice norms. In many instances, observations, invasive monitoring, and interventions were documented after EOLC commenced. A lack of documented personal cares was also noted.

CONCLUSIONS

This study provides new insights into EOLC from the dual perspectives of families and clinicians. There is a need for institutional guidelines to support ICU clinicians' EOLC practices and education to improve clinician confidence with communication.

941 The Effect of COVID-19 on Orthopaedic Trauma Theatre Efficiency and Surgical Training in the North and East of Scotland Major Trauma Centres – a Year On

Aim

To determine the orthopaedic trauma theatre efficiency in two large major trauma centres (MTCs) in Scotland before and after the outbreak of Coronavirus disease (COVID-19) pandemic.

Method

All trauma patients presented to the North and East of Scotland's MTCs prior to the outbreak of COVID-19 (7th May to 7th June 2019), during the first peak of COVID-19 (7th May to 7th June 2020), after Aerosol Generating Procedures updates (7th November to 7th December 2020) and the ‘new normal’ (7th May to 7th June 2021) were retrospectively reviewed. Training opportunities and theatre time were compared. The Kruskall-Wallis test was used.

Results

There were no significant differences in the length of hospital stay (p=0.117, 0.065) and time from injuries and surgery within groups in both MTCs (p=0.508, 0.384). The pandemic has negatively affected the anaesthetic and surgical preparation time, time between end of procedure and send for next case, and turnover time, with more profound effect on the North of Scotland's MTC. The trainee's involvement as main surgeon had decreased with the outbreak of the pandemic, with the junior trainees being affected most severely in North of Scotland. The time taken for patient to arrive to theatre after sending and total downtime were twice as long in the North of Scotland.

Conclusion

The COVID-19 pandemic has negatively impacted the orthopaedic trauma theatre efficiency and training opportunities. Actions should be taken to improve the turnover time to maximise theatre efficiency while prioritizing training opportunities.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

The Successful Implementation of Day Case Tonsillectomy

Objective Day case tonsillectomy is standard practice in many international centres, and is widespread across the UK. In Ireland, implementation has been slow for multiple reasons. Our unit aimed to introduce day case tonsillectomy, following a pilot programme. Following a year of implementation we have reaudited our practice. We hypothesised that day case tonsillectomy is a practical and favourable solution to facilitate access to surgery in the context of long waiting times for ENT surgery. Methods This was a prospective audit collecting data on day case tonsillectomy. All patients for day case tonsillectomy were selected in OPD according to our inclusion criteria. We recorded demographical data, surgical technique, length of stay, failed discharges, bleeding rate and readmission rate. Results There was one primary haemorrhage within 24 hours of surgery (0.08%). There were 16 secondary bleeds, giving a rate of 13.9%. Of these, four patients required a return to theatre for the cessation of bleeding (3.5%). There was no statistical significance in bleed rate between surgical technique. Failed discharge rate was 6%. The average time from extubation to discharge was 6 hours and 53 minutes. Conclusions Our experience of day case tonsillectomy is that it is safe, feasible and efficient in a selected group of patients. This can expedite long waiting times for tonsillectomy, and improve access to overnight beds for other cases. Our numbers represent the first unit in Ireland to have 2 year of experience with data showing successful implementation.

Developing intersubjectivity and teamwork skills through learning circles on clinical placement: A mixed methods study

AIM

To determine the efficacy of learning circles on developing intersubjectivity and teamwork skills and determine barriers to and facilitators of, learning circles as a learning tool.

BACKGROUND

Teamwork skills are vital for safe, effective nursing care and are dependent on individual team members' shared understandings or intersubjectivity. Work-based learning circles offer a potential pedagogic strategy to promote teamwork.

METHODS

In work-based learning circles conducted in 2018, students drew a concept map based on a clinical case and discussed an element of it with the group. Using a convergent parallel mixed methods design, a cross-sectional survey of students using a student clinical experience questionnaire and a qualitative descriptive approach for interviews with clinical facilitators was conducted.

RESULTS

Overall, 128 Bachelor of Nursing students (88.9% response) completed the survey and five facilitators (50%) attended group interviews. Students agreed that core teamwork skills were developed during their placement and clinical facilitators reported (1) student engagement in the learning circle processes; (2) learning much about students' abilities; and (3) developing subtle teaching skills to enhance discussion. Sharing experiences from different wards and clinical experiences was a platform for developing intersubjectivity.

CONCLUSIONS

To promote intra-professional teamwork skills, conducting learning circles with students from different disciplines may further enhance intersubjectivity and is an area for further research.

Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment

Background

To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient.

Methods

Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care.

Results

A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves.

Conclusion

The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03712-4.

Poroid hidradenoma of the scalp in a US Veteran's Administration (VA) patient

Poroid hidradenomas are a rare subtype of hidradenoma. A Veteran’s Administration patient presented with a mobile, cystic scalp lesion. Intraoperatively the mass spontaneously ruptured. We hope clinicians will consider this entity on their differential when treating patients presenting with similar scalp lesions and intraoperative findings.

Effectiveness of the ABCDEF bundle on delirium, functional outcomes and quality of life in intensive care patients: a study protocol for a randomised controlled trial with embedded process evaluation

INTRODUCTION

Hospital mortality for critically ill patients has decreased significantly throughout the developed world over the past two decades, attributable to improvements in the quality of intensive care, advances in critical care medicine and technologies that provide long-term multiorgan support. However, the long-term outcomes of intensive care unit (ICU) survivors is emerging as a real issue. Cognitive and physical impairments suffered by ICU survivors are common including profound weakness, pain and delirium which are inextricably linked. This study aims to determine the effectiveness of the Assess, prevent and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of sedation and analgesia; Delirium: assess, prevent and manage; Early mobility and exercise; Family engagement and empowerment (ABCDEF) bundle in reducing ICU-related short-term and long-term consequences of critical illness through a randomised controlled trial (RCT).

METHODS AND ANALYSIS

The study will be a single-centre, prospective RCT. A total of 150 participants will be recruited and randomised to either receive the ABCDEF bundle protocol or non-protocolised standard care for the duration of the participant's admission in the ICU. The primary outcome is delirium status measured using the Confusion Assessment Measure for ICU (CAM-ICU). Secondary outcomes include physical function measured by the Functional Independence Measure and quality of life measured by the European Quality of Life five dimensions, five-level questionnaire. A mixed-method process evaluation will contribute to understanding the experience of health teams who implement the ABCDEF bundle into practice.

ETHICS AND DISSEMINATION

Ethics approval was provided by the Metro South Health Human Research Ethics Committee (HREC) (EC00167) and the Griffith University's HREC prior to study commencement.Study results will be disseminated by presentations at conferences and via publications to peer-review journals.

TRIAL REGISTRATION NUMBER

ACTRN12620000736943; Pre-results.

The intensive care unit visiting study: A multisite survey of visitors

BACKGROUND

Being able to visit a critically ill relative provides comfort to family members and has recognised benefits to the patient. Limited research has been conducted on demographic characteristics and visiting behaviours of family members with a relative in the intensive care unit (ICU).

OBJECTIVES

The objective was to provide an overview of local ICU visitor behaviours and practices across four metropolitan units in Australia.

METHODS

A convenience sample of 440 participants from four ICUs across a metropolitan city in eastern Australia was required for the study. A descriptive 22-item self-report survey was used. Data were collected from four ICUs in a metropolitan city in eastern Australia. Sample characteristics and other variables were analysed using descriptive statistics.

RESULTS

Data collection was undertaken from April 2018 to May 2019. Four hundred sixty-two (n = 462) ICU visitors responded. There were no significant differences between visitor characteristics across the four hospitals. The mean age of the respondents was 49 years, the youngest participant being 18 years and the oldest being 93 years, with most visitors being women (n = 312, 68%). The participants were more likely to be close relatives such as spouses (n = 117, 25%), parents (n = 113, 24%), or children (n = 79, 17%). Visitors reported different methods by which they received information about visiting policies across units and indicated that they would have visited more frequently if able. Although most respondents rated their ICU visiting experience favourably, some reported being frequently asked to leave the patient's bedside impacted their experience.

CONCLUSIONS

This study has highlighted that families want to remain in close proximity when they have a relative in the ICU. Despite visiting hours being flexible, most families visit midmorning so that they can talk with staff. Data captured in this study can be used toward improving the ICU visiting experience for family members.

The use of factor analysis and abductive inference to explore students' and practitioners' perspectives of feedback: divergent or congruent understanding?

BACKGROUND

The importance of feedback in workplace-based settings cannot be underestimated. Approaches that evaluate feedback reflect either the sender's or receiver's viewpoint in isolation of each other. This study investigated prevailing student and practitioner views of feedback resulting from development and testing of a survey about feedback.

METHOD

This study used a cross-sectional design, incorporating use of expert consultation and factor analysis of surveys. Fifty-two items based on identified attributes for effective feedback from current research were developed and reviewed through expert consultation. Surveys developed from the items were completed by students (n = 209) and practitioners (n = 145). The juxtaposition of items based on students' and practitioners' responses to the surveys were examined through use of exploratory factor analysis.

RESULTS

Separate student and practitioner surveys resulted. Each survey contained 23 items that clustered into factors. The item statements were different across practitioner and student groups Only nine items were shared across factors identified for both groups. The resulting factors represented different notions of feedback-namely, practitioners had a process-oriented focus in comparison with students' outcome focus.

CONCLUSION

While students and practitioners view feedback differently this does not necessarily mean they are incongruous.

Concordance between a neuroradiologist, a consultant radiologist and trained reporting radiographers interpreting MRI head examinations: An empirical study

INTRODUCTION

This study assessed agreement between MRI reporting radiographers and a consultant radiologist compared with an index neuroradiologist when reporting MRI head (brain/internal auditory meati [IAMs]) examinations. The effect on patient management of any discordant reports was also examined.

METHODS

Two trained MRI reporting radiographers (RRs), a consultant radiologist (CR) and an index neuroradiologist (INR) reported on a random sample of 210 MRI examinations. The radiographers reported during clinical practice and the radiologists in clinical practice conditions. Two independent consultant physicians (neuro-rehabilitation and neuropsychiatry) compared these reports with the index neuroradiologist report for agreement and the clinical importance of discrepant reports.

RESULTS

Overall observer agreement between the RRs and CR was comparable in relation to agreement with the INR: RR; 93/210 (44.3%); and the CR; 83/210 (39.4%) for all head MRI examinations (p = 0.32). For brain examinations the difference was similar: RR; 64/180 (35.6%); and CR; 54/190 (30.0%), p = 0.26. Agreement rates for the IAMs examinations were identical, 29/30 (97.7%). For all head MRI examinations (n = 210) there was a very small observed difference of <0.5% in mean agreement between the reporting radiographers and the consultant radiologist (p = 0.92) for examinations where a major disagreement would have been likely to have led to a change in patient management.

CONCLUSION

MRI reporting radiographers reported during clinical practice on MRI head examinations to a level of agreement comparable with a consultant radiologist.

IMPLICATIONS FOR PRACTICE

This is an area in which radiographers could provide additional reporting roles to the reporting service to increase capacity. Wider potential benefits include cost-effectiveness and role development/retention of radiographers.

Application of the READY framework supports effective communication between health care providers and family members in intensive care

Effective communication between intensive care health care providers and family is crucial to support surrogate or shared decision-making and to individualise care. Despite its importance in health care standards and policy, the quality of communication with families in intensive care is regarded as suboptimal. Furthermore, an intensive care admission is an extremely stressful event for families, which may impact their understanding and subsequent decision-making. Communicating with family members is a routine practice in intensive care; however, health care providers often receive no formal communication training. To date, family-focused communication interventions in intensive care have targeted end-of-life care and are not generalisable across all types of family–health care provider communication interactions. Mugweni et al. recently reported the results of a multiprofessional training intervention involving 26 health care professionals to improve the delivery of different news to families during pregnancy and at birth. A critique of this article has been undertaken to inform routine communication with critically ill family members and optimise the delivery of care in intensive care units.

Family ward rounds in intensive care: An integrative review of the literature

BACKGROUND

The involvement of family members in the ward rounds is a novel but under-researched family-centered care intervention in adult intensive care units, with limited evidence on the impact it has on patient and family-centered outcomes.

OBJECTIVES

This integrative review aimed to understand how family rounds are implemented in critical care and to appraise the evidence on outcomes for patients, family members, and healthcare professionals.

DESIGN

An integrative review methodological framework permitted the inclusion of all research designs.

DATA SOURCES

MEDLINE; CINAHL; PsycINFO; Cochrane Library; Web of Science Current Contents Connect; Web of Science-Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global, Embase were systematically searched.

REVIEW METHODS

We reviewed studies that referred to or used as an intervention the involvement of family members in daily critical care team rounds. We included primary research in adult intensive care units regardless of patients' length of stay. We excluded patients receiving end-of-life care. We considered any outcome related to the critically ill patient and/or their family member, outcomes related to the healthcare professionals, and outcomes related to clinical and/or nursing treatment. The Mixed Methods Appraisal Tool was used to appraise the quality of the studies. The review was registered in the Prospero database.

RESULTS

From the 541 articles initially retrieved, 15 studies met the inclusion criteria and were included in the review. Studies originated from the United States of America and Canada since 2003, and a variety of designs were used. Four before and after studies and a non-randomized experimental study explored the impact of structured family rounds on family and staff satisfaction, showing limited improvement in satisfaction. Six cross-sectional survey studies explored family members' and clinicians' perceptions and demonstrated a positive attitude towards family-centered rounds, but some concerns were raised from the nursing staff. Three qualitative studies and a mixed-methods study identified structural and cultural factors influencing healthcare professionals' and families' acceptance of family rounds. Most studies were of poor to moderate quality, with limited confidence in the outcomes reported.

CONCLUSIONS

Most studies reported improved family satisfaction as the main outcome. Future research should focus on longitudinal patient and family-centered outcomes, including mental health outcomes, and on qualitative data to understand the processes, barriers, and facilitators to implement family-centered rounds in intensive care units.

Factors affecting medication assisted treatment success for opioid use disorder

Background

In the United States (US) when opioid use disorder (OUD) is treated with medication assisted treatment (MAT), many patients in MAT will relapse into active opioid use during the recovery process. About 23% drop out of treatment within 3 months, and 40-50% drop out within 6 months of MAT start. Using the Anderson and Newman (2005) Framework for Health Services Utilization, 27 variables reflecting predisposing, enabling, and need factors were used to examine the impact on the number of days patients were retained in treatment.

Methods

One MAT clinic in rural Michigan used random sample of archival records (n = 390) OUD patients (DSM-V-TR code 304.00, ICD-10 code F11.20) between Jan. 1, 2014 and Nov. 21, 2018 with prescribed buprenorphine as part of MAT program. The first set of linear regressions (backward elimination) defined significant variables for each factor, and the final model included significant variables to predict length of retention in MAT.

Results

The first step identified legal issues (predisposing), MSHN insurance, distance to clinic, ability to drive, mental health diagnosis, and homelessness (enabling factors); Zung self-reporting depression score, starting dose, past suicide attempt, Hep-C status, and method of use (needs factor) as statistically significant to be used in the final model, controlling for age and gender. Starting dose (unstandardized b = 136.8, 95%CI 98.0, 175.6), driving license (b = 68.3, CI 13.2, 123.4), distance to clinic (b=-1.1, CI -2.2, -0.5) had statistical impact on the length of stay in MAT.

Discussion

This case study identified enabling factors (starting dose and access to clinic) affecting length of participation in MAT. Other factors warranting provider attention were identified for rural OUD patients.

Conclusions

Evidence based guidelines for starting doses are needed to increase MAT effectiveness. MAT services should consider distance to clinic as a factor of successful treatment.

Key messages

Evidence based guidelines for starting doses are needed to increase MAT effectiveness. Opiood treatment services should consider distance to clinic as a factor of successful treatment.

Impact of a work-based feedback intervention on student performance during clinical placements in acute-care healthcare settings: a quasi-experimental protocol for the REMARK programme

INTRODUCTION

Current perspectives present feedback as a dynamic, dialogic process. It is widely accepted that feedback can have an impact on workplace performance, however, how dialogic feedback is enacted with the learner in authentic healthcare settings is less apparent. This paper seeks to describe the design and development of an implementation study to promote the learner voice in the feedback process and improve feedback encounters between learners and learning partners in healthcare settings.

METHODS AND ANALYSIS

A quasi-experimental study design will be used to evaluate whether implementation of a work-based intervention to improve feedback impacts student performance during clinical placements in healthcare settings. Student performance will be measured at three time points: baseline (pre), mid-placement (post-test 1) and end-placement (post-test 2) in keeping with standard assessment processes of the participating university. The intervention is underpinned by Normalisation Process Theory and involves a layered design that targets learners and learning partners using best-practice education strategies. Data regarding participants' engagement with feedback during clinical placements and participants' level of adoption of the intervention will be collected at the completion of the clinical placement period.

ETHICS AND DISSEMINATION

This study has ethics approval from both Griffith University and Metro South Health Human Research and Ethics committees. Dissemination of results will be local, national and international through forums, seminars, conferences and publications.

0467 Benefits of CBT-I for Women Veterans with and without PTSD

Introduction

A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD.

Methods

This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD.

Results

There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93).

Conclusion

CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied.

Support

VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health

Effectiveness of complementary and alternative medicine interventions for sleep quality in adult intensive care patients: A systematic review

BACKGROUND

Pharmacological interventions for sleep (analgesic, sedative and hypnotic agents) can both disrupt and induce sleep and have many negative side effects within the intensive care population. The use of complementary and alternative medicine therapies to assist with sleep has been studied but given the variety of modalities and methodological limitations no reliable conclusions have been drawn.

OBJECTIVE

To synthesise research findings regarding the effectiveness of using complementary and alternative medicine interventions within the domains of mind and body practices (relaxation techniques, acupuncture) and natural biologically based products (herbs, vitamins, minerals, probiotics) on sleep quality and quantity in adult intensive care patients.

REVIEW METHOD USED

Systematic review.

DATA SOURCES

Five databases were searched in August 2018 and updated in February 2019 and 2020.

REVIEW METHODS

Searches were limited to peer reviewed randomised controlled trials, published in English involving adult populations in intensive care units. Interventions were related to the complementary and alternative medicine domains of mind and body practices and natural products. Included studies were assessed using Cochrane's risk of bias tool.

RESULTS

Seventeen studies were included. The interventions used varied: 4 investigated melatonin; 4 music +/- another therapy; 3 acupressure; 2 aromatherapy and 1 each for relaxation and imagery, reflexology, bright light exposure and inspiratory muscle training. Measurement of sleep quantity and quality was also varied: 5 studies used objective measures such as Polysomnography and Bispectral index with the remaining using subjective patient or clinician assessment (for example, Richards-Campbell Sleep Questionnaire, Pittsburgh Sleep Quality Index, observation). Given the different interventions, outcomes and measures used in the studies a meta-analysis was not possible. Generally, the results support the use of complementary and alternative medicine for assisting with sleep with 11 out of 17 trials reporting significant results for the interventions examined.

CONCLUSIONS

Complementary and alternative medicine interventions, in particular, melatonin and music, have shown promise for improving sleep in adults with critical conditions; however, further research that addresses the limitations of small sample sizes and improved techniques for measuring sleep is needed.

Exploring the meaning of undergraduate nursing students' experiences and confidence in clinical skills using video

BACKGROUND

Students and health care faculty staff report a lack of confidence in graduating nurses' clinical skills practice. Traditional approaches to support nursing students' clinical skills development have relied on small group, face-to-face, practice-based learning in clinical laboratories. However, with changing curricula, increased numbers of students, and pressure on laboratory timetables and availability, alternate methods of delivery are necessary to ensure students gain confidence in the development of their clinical skills. Video podcasting is an innovative approach that is being used to stimulate active and ongoing learning of clinical skills.

DESIGN

A hermeneutic phenomenological approach.

METHOD

Data were collected through in-depth interviews with 10 second-year, undergraduate nursing students about their experiences using three clinical skills video podcasts and their perceptions of how this impacted on their learning of these clinical skills and confidence in practice.

FINDINGS

Three themes emerged from the data: 'Accessibility for learning the skill'; 'Preparation for learning and practice'; and 'Student-directed learning'. These themes provided an insight into the students' engagement with video podcasts, demonstrating their sense of confidence was increased in clinical skills development.

CONCLUSION

The findings of this study provide an insight into the students' engagement with video podcasts in relation to their confidence in clinical skills development, and indicate that undergraduate nursing students value the use of video podcasts in their learning of clinical skills. However, it was evident that students still value face-to-face delivery to guide their study, which suggests that video podcasts could be used as an adjunct to teaching to support learning.

Feasibility and acceptability of conducting a partially randomised controlled trial examining interventions to improve psychological health after discharge from the intensive care unit

BACKGROUND

Interventions to support psychological recovery after critical illness, including information provision via an intensive care unit (ICU) diary or discharge summary, have been widely adopted in some regions, albeit without strong empirical evidence.

OBJECTIVE

The objective of this study was to examine the feasibility and acceptability, for patients, family members, and clinicians, of information provision via an ICU diary or discharge summary to support psychological recovery for critical illness survivors.

METHODS

This was a pilot, partially randomised patient preference study in a mixed ICU in a tertiary hospital in Australia. Eligible patients were those in the ICU for >24 h and who were able to converse in English. Interventions were ICU diary or discharge summary compared with usual care. Feasibility was assessed throughout the study process, and acceptability assessed 3 and 6 months after hospital discharge, with data analysed descriptively and thematically.

RESULTS

Sixty-one patients were recruited; 45 completed 3-month follow-up (74%), and 37 (61%), 6-month follow-up. Participants were medical (39%), surgical (30%), and trauma (31%) patients; aged 55 [interquartile range (IQR): 36-67] years; and stayed in the ICU for 7 [IQR: 3-13] days and hospital for 23 [IQR: 14-32] days. Within the partially randomised framework, 34 patients chose their intervention - four chose usual care, 10 ICU diary, and 20 discharge summary. The remaining 27 patients were randomised - nine usual care, 10 ICU diary, and seven discharge summary. The majority (>90%) considered each intervention helpful during recovery; however, a significant proportion of patients reported distress associated with reading the ICU diary (42%) or discharge summary (15%). Clinicians reported they were hesitant to make diary entries.

CONCLUSIONS

When given a choice, more patients chose a discharge summary over the ICU diary or usual care. Participants considered both interventions acceptable. Given the reports of distress associated with information provision, clear empirical evidence is required to determine effectiveness, optimal timing, support needed, and for whom they should be used.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12615001079538.

The I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: a clinimetric evaluation

OBJECTIVE

To describe the clinimetric validation of the I-DECIDED tool for peripheral intravenous catheter assessment and decision-making.

DESIGN AND SETTING

I-DECIDED is an eight-step tool derived from international vascular access guidelines into a structured mnemonic for device assessment and decision-making. The clinimetric evaluation process was conducted in three distinct phases.

METHODS

Initial face validity was confirmed with a vascular access working group. Next, content validity testing was conducted via online survey with vascular access experts and clinicians from Australia, the UK, the USA and Canada. Finally, inter-rater reliability was conducted between 34 pairs of assessors for a total of 68 peripheral intravenous catheter (PIVC) assessments. Assessments were timed to ensure feasibility, and the second rater was blinded to the first's findings. Content validity index (CVI), mean item-level CVI (I-CVI), internal consistency, mean proportion of agreement, observed and expected inter-rater agreements, and prevalence-adjusted bias-adjusted kappas (PABAK) were calculated. Ethics approvals were obtained from university and hospital ethics committees.

RESULTS

The I-DECIDED tool demonstrated strong content validity among international vascular access experts (n=7; mean I-CVI=0.91; mean proportion of agreement=0.91) and clinicians (n=11; mean I-CVI=0.93; mean proportion of agreement=0.94), and high inter-rater reliability in seven adult medical-surgical wards of three Australian hospitals. Overall, inter-rater reliability was 87.13%, with PABAK for each principle ranging from 0.5882 ('patient education') to 1.0000 ('document the decision'). Time to complete assessments averaged 2 min, and nurse-reported acceptability was high.

CONCLUSION

This is the first comprehensive, evidence-based, valid and reliable PIVC assessment and decision tool. We recommend studies to evaluate the outcome of implementing this tool in clinical practice.

TRIAL REGISTRATION NUMBER

12617000067370.