Are clinicians using routinely collected data to drive practice improvement? A cross-sectional survey.

BACKGROUND: Clinical registry participation is a measure of healthcare quality. Limited knowledge exists on Australian hospitals' participation in clinical registries and whether this registry data informs quality improvement initiatives. OBJECTIVE: To identify participation in clinical registries, determine if registry data inform quality improvement initiatives, and identify registry participation enablers and clinicians' educational needs to improve use of registry data to drive practice change. METHODS: A self-administered survey was distributed to staff coordinating registries in seven hospitals in New South Wales, Australia. Eligible registries were international-, national- and state-based clinical, condition-/disease-specific and device/product registries. RESULTS: Response rate was 70% (97/139). Sixty-two (64%) respondents contributed data to 46 eligible registries. Registry reports were most often received by nurses (61%) and infrequently by hospital executives (8.4%). Less than half used registry data 'always' or 'often' to influence practice improvement (48%) and care pathways (49%). Protected time for data collection (87%) and benchmarking (79%) were 'very likely' or 'likely' to promote continued participation. Over half 'strongly agreed' or 'agreed' that clinical practice improvement training (79%) and evidence-practice gap identification (77%) would optimize use of registry data. CONCLUSIONS: Registry data are generally only visible to local speciality units and not routinely used to inform quality improvement. Centralized on-going registry funding, accessible and transparent integrated information systems combined with data informed improvement science education could be first steps to promote quality data-driven clinical improvement initiatives.

Using the trauma patient experience and evaluation of hospital discharge practices to inform practice change: A mixed methods study.

AIMS AND OBJECTIVES: To explore the pain management experiences of recently discharged adult trauma patients and the discharge practices of the treating hospital. BACKGROUND: Adult trauma patients are not always able to manage their pain effectively and as a result often experience intense and enduring injury pain at home. They describe their pain experience as unique and debilitating, and report feeling uninformed at hospital discharge. There is a need to understand what is fundamentally required for this population at hospital discharge, to facilitate competent pain management and promote best possible outcomes. DESIGN: A mixed methods convergent study design. METHODS: The quantitative results (incidence, intensity and impact of injury pain and the barriers to effective pain management) were merged with the qualitative results (patient experiences and beliefs) to produce greater understanding about the reasons behind the pain management practices of participants. RESULTS: Integration of the quantitative and qualitative data produced four new themes. These themes demonstrate that recently discharged adult trauma patients do not have the knowledge or experience to understand or manage their injury pain effectively at home. Inadequate information and education by clinicians, at hospital discharge, contribute to this insufficiency. CONCLUSIONS: Clinicians need to understand the trauma patient pain experience to appreciate the importance of their discharge practices. Increased understanding and implementation of evidence-informed discharge processes would improve current discharge practices and ultimately support and improve the trauma patient's injury pain management practices at home. RELEVANCE TO CLINICAL PRACTICE: By understanding the patient perspective in the pain management of injuries, clinicians are better able to appreciate what hospital discharge practices and information are genuinely required by the trauma patient to manage their pain effectively at home, potentially preventing the long-term consequences of injury pain.

The experience and understanding of pain management in recently discharged adult trauma patients: A qualitative study.

INTRODUCTION: Pain following injury is often intense, prolonged and debilitating. If poorly managed, this acute pain has the potential to delay rehabilitation and lead to chronic pain. Recent quantitative Australian research recommends implementing further information and interventions to improve trauma patient outcomes, however, to ensure effectiveness, exploration of the patient perspective is imperative to ensure the success of future pain management strategies. This study aimed to gain understanding about the experience of pain management using prescribed analgesic regimens of recently discharged adult trauma patients. METHOD: Semi-structured interviews were used to explore the experiences and understandings of trauma patients in managing pain using prescribed analgesic regimens during the initial post-hospital discharge period. Twelve participants were purposively selected over a 6-month period at a level one trauma outpatient clinic based on questionnaire responses indicating pain related concerns. Qualitative data were thematically analysed. RESULTS: The overarching finding was that injuries and inadequate pain management incapacitate the patient at home. Four main themes were developed: injury pain is unique and debilitating; patients are uninformed at hospital discharge; patients have low confidence with pain management at home; and patients make independent decisions about pain management. Patients felt they were not given adequate information at hospital discharge to support them to make effective decisions about their pain management practices at home. CONCLUSION: There is a need for more inclusive and improved hospital discharge processes that includes patient and family education around pain management following injury. To achieve this, clinician education, support and training is essential.

Incidence, Intensity, and Impact of Pain in Recently Discharged Adult Trauma Patients: An Exploratory Study.

The long-term implications of pain following injury are well known; however, the immediate posthospitalization incidence and impact of pain is less understood. Inadequate pain relief during this time can delay return to work, leading to psychological stress and chronic pain. This exploratory study aimed to identify the incidence, intensity, and impact of injury-related pain in recently discharged adult trauma patients. During July to December 2014, 82 recently discharged adult trauma patients completed a questionnaire about their injury-related pain experience approximately 2 weeks posthospital discharge from a Level 1 trauma center. The questionnaire was developed using the Brief Pain Inventory, assessing severity, and impact of pain through a score from 0 to 10. The average age of participants was 52 years, the median Injury Severity Score was 6, and almost all (n = 80, 98%) experienced a blunt injury. The majority of participants reported pain since discharge (n = 80, 98%), with 65 (81%) still experiencing pain on the day of data collection. Normal work was most affected by pain, with an average score of 6.6 of 10, closely followed by effect on general activity (6.1 of 10) and enjoyment of life (5.7 of 10). The highest pain severity was reported by those with injuries from road trauma, with low Injury Severity Scores, who were female, and did not speak English at home. Pain in the recently discharged adult trauma patient is common, intense and interferes with quality of life. Identification of barriers to effective pain management and interventions to address these barriers are required.

Effective pain management in recently discharged adult trauma patients: Identifying patient and system barriers, a prospective exploratory study.

AIMS AND OBJECTIVES: To identify barriers to adherence with prescribed analgesic regimens in recently discharged trauma patients. BACKGROUND: Trauma pain severely interferes with the life of healthy and often working individuals with intense and enduring pain experienced at home following discharge. The reasons for this are unclear considering discharge information (including discharge referral letters and nursing discharge checklists) and analgesics (scripts and/or medication) are routinely provided to patients at hospital discharge. DESIGN: A prospective exploratory study. METHODS: Between July-December 2014, 82 recently discharged adult trauma patients completed a questionnaire about their injury-related pain and pain management experiences posthospital discharge from a level one trauma centre. For 77 of these participants, medical records were reviewed for documentation regarding pain, analgesic consumption and hospital discharge processes. RESULTS: Sixty-five participants (84%) consumed opioids prior to discharge, with two-thirds (65%) of these participants given a script for and/or opioid medication at hospital discharge. Of the 77 participants who took analgesics following discharge, 26 (34%) indicated they had experienced side effects and 16 (21%) used pain medication not prescribed by a doctor. Whilst it was documented that discharge letters were given to 25 participants (32%) at discharge and 13 participants (17%) had completed nursing discharge checklists, these participants reported the lowest pain severity and interference scores postdischarge. CONCLUSIONS: Insufficient information and analgesics given to trauma patients at hospital discharge and inconsistent and incomplete discharge processes fail to equip trauma patients to effectively manage their pain at home. RELEVANCE TO CLINICAL PRACTICE: It is crucial that nurses and other healthcare professionals are aware of and actively contribute to correct and complete discharge processes. Effective patient and hospital facilitators can contribute to good pain management practices amongst recently discharged trauma patients, which will thereby improve the functional outcomes of this patient population.

The Effect of Prehospital Intubation on Treatment Times in Patients With Suspected Traumatic Brain Injury.

OBJECTIVE: This study examines whether, in patients requiring intubation with moderate to severe traumatic brain injury (TBI), prehospital intubation compared with emergency department intubation leads to a reduction in treatment times and time to a computed tomographic (CT) scan. METHODS: A retrospective cohort study compared adult patients with a Glasgow Coma Score of less than 14 with a suspected TBI who underwent intubation, either prehospital or on arrival to the emergency department. RESULTS: Prehospital intubation was associated with a decreased time from emergency department arrival to CT scan compared with emergency department intubation (43 vs. 54 minutes, P < .001). The prehospital intubation group had a longer median scene time (42 vs. 17 minutes, P ≤ .001), longer median transport times (32 vs. 14 minutes, P ≤ .001), and longer total treatment times (90 vs. 73 minutes, P = .007). CONCLUSIONS: Patients intubated in the prehospital setting spend a longer time at the scene but a shorter amount of time in the emergency department before brain imaging. Prehospital intubation may lead to earlier control of airway and ventilation. The minority of intubated TBI patients required urgent neurosurgical intervention. Overall prehospital intubation shows no significant survival advantage for the patients when compared with emergency department intubation.

ChIP: An early activation protocol for isolated blunt chest injury improves outcomes, a retrospective cohort study.

BACKGROUND: Blunt chest injuries not treated in a timely manner with sufficient analgesia, physiotherapy and respiratory support are associated with increased morbidity and mortality. The aim of the study was to determine the impact of a blunt chest injury early activation protocol (ChIP) on patient and hospital outcomes. METHODS: In this pre-post cohort study, the outcomes of patients with blunt chest injury who received ChIP were compared against those who did not. Data including injury severity, patient outcomes, hospital treatments and comorbidites were extracted from medical records. The primary outcome was pneumonia. Secondary outcomes evaluated health service delivery. Logistic and multiple regressions were used to adjust for potential confounding variables. RESULTS: 546 patients were included, 273 in the before-ChIP cohort and 273 in the after-ChIP cohort. The incidence of pneumonia following the introduction of ChIP was reduced by 4.8% (95% CI 0.5-9.2, p=0.03). In the after-ChIP cohort, more patients received a pain team review (32% vs. 13%, p<0.001), physiotherapy (93% vs. 86%, p=0.005) and trauma team review (95% vs. 39%, p<0.001). There was no difference in length of stay (p=0.50). CONCLUSIONS: ChIP improved the delivery of healthcare services and reduced the rate of pneumonia among patients with isolated chest trauma.

Analgesic Adherence in Recently Discharged Trauma Patients: An Integrative Literature Review.

UNLABELLED: Trauma is defined as injuries to tissue and organs resulting from mechanical, thermal, chemical, or electrical mechanisms. There is evidence to suggest that patients admitted to hospital for their injuries do not adhere to prescribed analgesic regimens once discharged; however, the causes and potential solutions of this have not been fully explored. Patients who have inadequate pain relief also experience delayed return to work, psychological stress, disability, and chronic pain. OBJECTIVES: To identify causes of and solutions to analgesic regimen nonadherence in recently discharged trauma patients. DESIGN: Integrative literature review. DATA SOURCES: A systematic search using electronic databases (PsycINFO; Embase; CINAHL; Medline) and hand-searching methods, using the terms "analgesics," "pain," "trauma," and "discharge," was conducted for the period 1990 to 2014. Review/Analysis Methods: Following a systematic screening process, the included articles were analyzed and synthesized to identify patterns, variations, and relationships. RESULTS: Twenty-four primary research articles were examined and three main categories were identified: pain is a common and enduring experience in recently discharged trauma patients, postdischarge analgesics are inadequately prescribed and poorly used, and inadequate discharge information inhibits adequate analgesic use. CONCLUSION: Reasons for poor analgesic adherence in the trauma outpatient population are not well understood and there is a paucity of solutions to address this problem. Research to inform the design of an evidence-based patient discharge process and patient information tools would address this evidence-practice gap.

Implementation and Evaluation of a Ward-Based eLearning Program for Trauma Patient Management.

The majority of trauma nursing education is focused on the emergency phases of care. We describe the development and evaluation of a trauma eLearning module for the ward environment. The module was developed using adult learning principles and implemented in 2 surgical wards. There were 3 phases of evaluation: (1) self-efficacy of nurses; (2) relevance and usability of the module and; (3) application of knowledge learnt. The majority indicated they had applied new knowledge, particularly when performing a physical assessment (85.7%), communicating (91.4%), and identifying risk of serious illness (90.4%). Self-efficacy relating to confidence in caring for patients, communication, and escalating clinical deterioration improved (p = .023). An eLearning trauma patient assessment module for ward nursing staff improves nursing knowledge and self-efficacy.

My work is unique.

I am clinical nurse lead for Local Care Force, an agency that provides nurses to care homes, intermediate care units and private hospitals in Yorkshire.

Interim analysis of toxicity and response in phase 1 trial of systemic targeted alpha therapy for metastatic melanoma.

PURPOSE: The aim is to assess toxicity and response of systemic alpha therapy for metastatic melanoma. EXPERIMENTAL DESIGN: This is an open-labelled Phase 1 dose escalation study to establish the effective dose of the alpha-immunoconjugate (213)Bi-cDTPA-9.2.27 mAb (AIC). Tools used to investigate the effects were physical examination; imaging of tumors; pathology; GFR; CT and changes in tumor marker. Responses were assessed using RECIST criteria. RESULTS AND DISCUSSION: Twenty-two patients with stage IV melanoma/in-transit metastasis were treated with activities of 55-947 MBq. Using RECIST criteria 50% showed stable disease and 14% showed partial response. One patient (6%) showed near complete response and was retreated because of an excellent response to the initial treatment. Another patient showed response in his tumor on mandible and reduction in lung lesions. Overall 30% showed progressive disease. The tumor marker melanoma inhibitory activity protein (MIA) showed reductions over eight weeks in most of the patients. The disparity of dose with responders is discussed. No toxicity was observed over the range of administered activities. CONCLUSION: Observation of responses without any toxicity indicates that targeted alpha therapy has the potential to be a safe and effective therapeutic approach for metastatic melanoma.

Fine structural evaluation of the iris after unilateral treatment with latanoprost in patients undergoing bilateral trabeculectomy (the Mainz II study).

OBJECTIVE: To investigate by masked electron microscopy whether 6 months of topical latanoprost caused pathological changes in the peripheral iris of patients with glaucoma. METHODS: Seventeen patients with bilateral primary open-angle glaucoma requiring trabeculectomy were recruited for this study. The iridectomy taken during surgery on the first eye served as a control. The second test eye was treated topically with latanoprost for 6 months before its trabeculectomy. Fourteen patients completed the treatment arm of the study, and 1 of these underwent marked color change. As a result, 31 iridectomy specimens were fixed, coded, and evaluated. RESULTS: The specimens were evaluated for evidence of stromal inflammation, vascular alterations, and stromal and posterior epithelial degeneration. None of these features was evident in any of the 31 iridectomy specimens. There was evidence of the incidence of free melanin granules in the stroma, melanin turnover, abundance of stromal clump cells, atypical cellular features in melanocytes, and prominence of the anterior border. After code breaking, it was evident that none of these features distinguished the test from the fellow irises in our group. The patient with color change in the test iris did not stand out from the others in this analysis. Qualitative reexamination of further sections after unmasking gave the impression of increased melanin granule numbers in the melanocytes of the anterior border region. CONCLUSIONS: The ultrastructure of the iridectomies from the latanoprost-treated eyes and the fellow eyes conformed to published standards for normal iris. There was no evidence of early ultrastructural changes, which might have been the harbingers of latanoprost-induced iris abnormality.