Understanding the provision of goal-concordant care in the intensive care unit: A sequential two-phase qualitative descriptive study.

BACKGROUND: Goal-concordant care in intensive care is care that aligns with the patient's expressed goals, values, preferences and beliefs. Communication and shared decision-making are key to ensuring goal-concordant care. AIMS: The aims of his study were to explore (i) critical care clinicians' perspectives on how patient goals of care were communicated between clinicians, patients, and family in the intensive care unit; (ii) critical care nurses' role in this process; and (iii) how goals of care were used to guide care. METHOD: Sequential two-phase qualitative descriptive design. Data were collected from February to June 2022 in a level-3 intensive care unit in a private hospital in Melbourne, Australia. In Phase One, individual interviews were conducted with critical care nurse participants (n = 11). In Phase Two, the findings were presented to senior clinical leaders (n = 2) to build a more comprehensive understanding. Data were analysed using Braun and Clarke's six step reflexive thematic analysis. FINDINGS: There was poor consensus on the term 'goals of care', with some participants referring to daily treatment goals or treatment limitations and others to patients' wishes and expectations beyond the ICU. Critical care nurses perceived themselves as information brokers and patient advocates responsible for ensuring patient goals of care were respected, but engaging in goals-of-care conversations was challenging. A lack of role clarity, poor team communication, and inadequate processes to communicate patient goals impeded goal-concordant care. Senior clinical leaders affirmed these views, emphasising the need to utilise critical care nurses' insight for practical solutions to improve patient care. CONCLUSIONS: Clarity in both, the term 'goals of care' and the critical care nurses' role in these conversations, are the essential first steps to ensuring patients' values, preferences, and beliefs to guide shared-decision-making and goal-concordant care. Improved verbal and written communication that is inclusive of all members of the treating team is key to addressing these issues.

Use of Wearable Devices to Monitor Postoperative Activity following Cardiac Surgery. A Systematic Scoping Review.

AIM: There is an emerging trend of using wearable digital technology to monitor patient activity levels in acute care contexts. However, the overall extent and quality of evidence for their use in acute cardiac surgery care is unclear. The purpose of this systematic scoping review was to evaluate current literature regarding the use of wearable activity trackers/accelerometers to monitor patient activity levels in the first 30-days following cardiac surgery. METHOD: A systematic scoping review was conducted. A search of CINAHL and MEDLINE Complete databases identified all peer reviewed research evidence published in English between 2010 and 2023. Studies evaluating the use of wearable, technology in adults who had undergone coronary bypass graft surgery (CAGS), and/valve replacement (VR) were included. Study data was summarised thematically. RESULTS: A total of 853 citations were identified. Once duplicates were removed, 816 studies were screened by title and abstract, 54 full-text studies were assessed for eligibility and 11 studies included. Accelerometers were able to capture changing exercise and physical activity levels over an acute care admission. Device use was acceptable to clinicians and patients. Low activity levels in the early postoperative period were associated with longer length of stay and higher 30-day readmissions. CONCLUSION: Wearable devices are acceptable and feasible to use in acute care. Use of wearable activity trackers by acute cardiac patients may increase patient participation in exercise and identify more sedentary patients who are a greater risk of increased length of stay and hospital readmission.

Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: a cluster randomised controlled trial.

BACKGROUND: People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care. OBJECTIVE: The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia. DESIGN: Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside. SUBJECTS & SETTING: One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff. METHODS: Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence. Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes. RESULTS: At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified. CONCLUSION: This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257 . Registered 14 December 2018.

Impact of Pain on Postoperative Recovery and Participation in Care Following Knee Arthroplasty Surgery: A Qualitative Descriptive Study.

BACKGROUND: Patient participation in care is key to optimising postsurgical outcomes and the quality of acute care delivery. AIMS: This study explored patient perceptions of the impact of pain on acute recovery following Total Knee Arthroplasty (TKA), and barriers and facilitators to participating in pain management. DESIGN: An exploratory-descriptive qualitative study involving semi-structured interviews. SETTINGS: A private-sector health service. PARTICIPANTS/SUBJECTS: Participants were adults undergoing TKA allocated to the control ward of a cluster randomised controlled trial who received standard care. METHODS: To allow adequate opportunity for participation in their care, interview and pain data were collected on postoperative Day 3. Acute pain was assessed using an 11-point Numerical Rating Scale (NRS). Interviews were analysed using combined qualitative thematic analysis and quantitative content analysis. RESULTS: Overall, 120 patients, 69 females (50.4%) and 68 males, were interviewed (mean age = 66.8 years, stadard deviation [SD] = 8.5). Most reported severe (NRS 7-10), day 3 pain (n = 76, 63.3%). Two themes emerged from interviews: (1) participants' postoperative pain experience; and (2) participation in postoperative pain management was limited. Pain experience was characterised by variation in pain and its qualities, having uncontrolled pain and distress, and influence from preoperative expectations. Patient participation was characterized by reliance upon prior staff instruction, barriers from limited knowledge, inconsistent promotion of non-pharmacologic strategies, and suboptimal clinician-patient communication. Regular analgesia was identified to facilitate participation. CONCLUSIONS: Despite the known benefits of patient participation in pain management, gaps remain in providing patients with the knowledge and opportunity to take an active role in their recovery. Interventions to overcome identified barriers need to be developed and evaluated.

Australian and Danish nurses' and midwives' wellbeing during COVID-19: A comparison study.

Background: Most investigations of nurses' and midwives' psychological wellbeing during the COVID-19 pandemic have been conducted in a single setting. Aim: To assess and compare the psychological wellbeing of nurses and midwives in Australia and Denmark during the COVID-19 pandemic. Methods: Nurses and midwives employed at four metropolitan health services in Australia and one in Denmark completed an anonymous online survey, which assessed depression, anxiety, and stress symptoms (The Depression, Anxiety and Stress Scale - 21 Items (DASS-21)), and sociodemographic and employment factors. Findings: Completed surveys were received from 3001 nurses and midwives (1611 Australian and 1390 Danish). Overall, approximately one in seven of the nurses and midwives surveyed reported moderate to extremely severe levels of depression (n = 399, 13.5%), anxiety (n = 381, 12.9%) and stress (n = 394, 13.4%). Australian nurses' and midwives' scores on all DASS-21 subscales were significantly higher (representing higher levels of depression, anxiety and stress) than the scores for the Danish nurses and midwives. Fewer years of clinical experience, living in Australia and being employed on a part-time basis were significantly associated with higher levels of psychological distress. Discussion: A considerable proportion of nurses and midwives experienced distress during the COVID-19 pandemic; however, the proportion and severity varied by country. Australian nurses and midwives experienced higher levels of distress than their Danish colleagues. Conclusion: Nurses and midwives working in countries with relatively low numbers of COVID-19 cases and deaths are also likely to experience psychological distress. Nurses and midwives would benefit from targeted country-specific support and wellbeing initiatives.

Inter-rater reliability and predictive accuracy of the Shkuratova Assessment of Falls-risk in Rehabilitation (SAFER) tool.

Despite the recognised importance of falls prevention in rehabilitation settings, there is limited research focusing on falls risk assessment tools designed to guide both patient screening and therapy. This study evaluated the predictive accuracy and inter-rater reliability of the Shkuratova Assessment of Falls-risk in Rehabilitation settings (SAFER) tool. The study was conducted at a subacute rehabilitation facility in Australia. Patient assessments were performed on admission to subacute care by trained physiotherapists, and the incidence of falls was documented prospectively. Of the 147 patients, 45 had at least one fall and were compared to 102 who had no falls. The inter-rater reliability of the SAFER tool when used by trained physiotherapists was high with the level of agreement for individual items ranging from 74 to 99%. Thirty-two (76%) patients who experienced a fall during their admission and 46 (44%) who did not fall were identified as having a high falls-risk. Using a SAFER tool cut-off of 12/26: sensitivity is 69%, specificity is 66%, area under the curve 0.71 (95% confidence interval: 0.62-0.80). The high negative predictive values at a range of cut-offs provided strong evidence that patients identified as having a low falls-risk were unlikely to experience a fall. Performing a comprehensive assessment of specific deficits in gait, balance and mobility on admission provided a streamlined approach to identification of patients who would benefit from tailored falls prevention interventions.

Nursing students' awareness and perceptions of nurses' role in antimicrobial stewardship.

Antimicrobial resistance is a major threat to public health worldwide. Antimicrobial stewardship programs and interventions aiming to optimise the use of antibiotics, are increasingly used to ensure judicious use of antibiotics and limit the emergence of antimicrobial resistance. Nurses are pivotal in antimicrobial stewardship however nursing students' awareness of such programs has not been investigated. This study aimed to elicit nursing students' perspectives and perceptions of the nurse's role in antimicrobial stewardship. A cross-sectional design was utilised to survey pre-registration nursing students. A total of 321 nursing students enrolled in an Australian university participated. The survey comprised questions on knowledge and opinions regarding the nurse's role in AMS and on a range of topics relating to antimicrobial stewardship and antimicrobial resistance, through closed and open-ended questions. While 44.5% of participants indicated they were familiar with the term Antimicrobial Stewardship, 70.7% believed they had very little or no knowledge of the principles. Completion of subjects with a focus on quality and safety in nursing practice and quality use of medications was associated with greater awareness. Findings underscore the need to engage nursing students in discussions exploring the problem of antimicrobial resistance and the important role nurses play in Antimicrobial Stewardship programs.

The relationship between the undergraduate clinical learning environment and work readiness in new graduate nurses: A pre-post survey study.

BACKGROUND: Due to projected nurse shortages, it is necessary that undergraduate programs optimise work readiness outcomes in new graduate nurses. Research that quantitatively evaluates characteristics of clinical nursing programs that predict increased work readiness is required. OBJECTIVES: To explore the relationship between the undergraduate clinical learning environment and nurse perceptions of work readiness prior to and following, commencement as a new graduate nurse. DESIGN: A pre-post follow-up study. Undergraduates were surveyed at the end of their Bachelor's degree (baseline) and at 8-10 weeks after commencement as a graduate nurse (Time 1). SETTING: A multi-site, metropolitan private hospital in Victoria, Australia. PARTICIPANTS: Nursing graduates who completed a university fellowship program (n = 26), or were undertaking their graduate year and had completed placement blocks within (n = 18) or outside (n = 31) the healthcare organisation. METHODS: Participants self-completed the Clinical Learning Environment Inventory (CLEI) and Work Readiness Scale for Graduate Nurses (WRS-GN) at baseline and Time 1. Multiple regression analyses were performed. RESULTS: CLEI scores significantly predicted work readiness outcomes (all p-values<.05), accounting for 16-36% and 17-28% of the variance of WRS-GN scores at baseline and Time 1, respectively. After adjusting for clustering due to clinical placement groups, CLEI Individualisation (p = .023) and Valuing Nurses Work (p = .01) predicted improved Time 1 WRS-GN Organisational Acumen. CLEI Innovative and Adaptive Culture scores predicted poorer Time 1 Organisational Acumen (p = .001). CONCLUSIONS: Learning environments that offered high levels of individualised attention and valued nurses' work appeared to facilitate post-graduation engagement and identification with nursing practice. However, highly innovative and adaptive education may detract from optimal work readiness. Findings revealed that while important, the clinical learning environment only accounted for a small-to-moderate degree of nursing graduates' work readiness. To facilitate robust evidence-based improvement of clinical nursing education, future research should attempt to empirically establish the value of additional facilitators of work readiness.

Effectiveness of strategies to increase uptake of pertussis vaccination by new parents and family caregivers: A systematic review.

OBJECTIVES: Cocoon immunisation strategies involve administration of Bordetella pertussis containing vaccines to parents and family members who are in close contact with newborns. The objective of this systematic review was to evaluate the effectiveness of strategies to increase uptake of vaccination against Bordetella pertussis infection by parents and family caregivers of newborn children (< 3 months of age). DESIGN: A protocol driven systematic review was conducted between 2005 and February 2020. CINAHL, Medline, and Google Scholar databases were searched. SETTING: Inpatient maternity care units, ante-natal and post-natal clinics based in acute care or primary/community care contexts. PARTICIPANTS: (i) mothers, (ii) fathers and (iii) family caregivers or other regular household contacts of infants < 3 months of age. INTERVENTIONS: Health promotion interventions and immunisation clinics designed to promote "cocoon immunisation" against Bordetella pertussis infections of the newborn. MEASUREMENTS: Change in uptake of adult vaccination with a pertussis containing vaccine (dTpa or Tdap) by new parents and family caregivers. FINDINGS: Eight studies were included in this review. Strategies used to promote vaccination included: written and verbal education, promotional videos, provision of vaccine prescriptions and financial incentives, opportunistic vaccination of family members and population-based health promotional messaging. Six of the eight studies reported positive impacts on vaccination uptake. Four studies evaluating providing opportunistic immunisation during the obstetric admission reported statistically significant increases in maternal (+39% to +57%), paternal (+21% to +52%) and household members (+32%) vaccination rates. Targeted public health campaigns were also found to increase vaccination uptake but in isolation were insufficient to achieve vaccination of all household contacts. CONCLUSION: Promotion of pertussis vaccination to new parents and the provision of opportunistic vaccination during the obstetric admission or post-natal visit, was the most successful strategy to increase uptake of pertussis vaccination by family caregivers.

Analgesic Outcomes in a Danish Acute Care Hospital Following Electronic Prescribing and Analgesic Self-Administration.

BACKGROUND: Despite the long-term consequences of poorly controlled postoperative pain, inadequate pain control remains a problem. AIMS: To improve the quality of postoperative pain management, the study site, an acute care hospital in Denmark, introduced electronic prescribing with standard order-sets, and allowed patients to self-administer analgesia. This study aimed to describe analgesic prescribing, prescriptions for multimodal analgesia, analgesic administration, and patients' pain experience, in this context. DESIGN: Point-prevalence survey. SETTINGS: One Danish regional hospital. PARTICIPANTS: Consecutive sample of 286 surgical inpatients comprising 65 orthopaedic, 41 gynaecological, 57 urology and 123 gastrointestinal patients. METHODS: We evaluated the quality of postoperative pain management on four postoperative surgical wards using: (1) the Revised American Pain Society Patient Outcome Questionnaire; and (2) patient chart audit. RESULTS: Overall, 89.2% of patients were prescribed a fixed analgesic and 71.7% were prescribed fixed analgesics in multimodal combination. Patterns of multimodal prescribing and administration varied significantly across surgical groups. Patients received 87.7% of available fixed prescriptions and 22.5% of available analgesics prescribed 'as needed'. However, patients' worst pain intensity was high (mean = 5.8/10, SD = 2) and 73.4% reported moderate-to-severe worst pain during the previous 24-hours. Patients who self-administered medications used significantly more fixed-schedule paracetamol (p = .018), non-steroidal anti-inflammatory drugs (p = .001), weak (p = .035) and strong (p < .001) opioids. CONCLUSIONS: The availability of multimodal analgesia was high following the introduction of electronic prescribing. However, gaps remain in the administration of both fixed and 'as needed' analgesics for postoperative patients. Findings suggested that allowing patients to self-administer analgesia may increase compliance with fixed schedule prescriptions.

Use of excessive supplemental oxygen in mechanically ventilated patients is based on unit culture. A multiple-methods study in a regional intensive care unit.

BACKGROUND: Administration of supplemental oxygen is widely used in the management of critically ill patients; however, there is evidence that excessive supplemental oxygen exposure is associated with increased mortality. There is limited research evaluating what factors clinicians take into consideration when managing oxygenation in critically ill adults. OBJECTIVES: The purpose of this study was to explore intensive care unit (ICU) clinicians' experience and decision-making when managing supplemental oxygen therapy in mechanically ventilated patients in a regional intensive care unit. METHODS: A multiple-methods observational study that included (i) a cross-sectional ICU staff survey and (ii) focus group discussions with critical care nurses was conducted. Descriptive statistics were used to summarise the key outcomes of the staff survey. Thematic analysis was used to analyse the focus group discussions and open-ended questions on the staff survey. The staff survey was completed by 49 ICU clinicians, and 11 critical care nurses participated in the two focus group discussions. RESULTS: Survey data showed that staff acknowledged the problem of excessive oxygen exposure; 79.6% (n = 39) reported that the minimum acceptable fraction of inspired oxygen for mechanically ventilated patients was 0.3. The majority (89.8%, n = 44) reported that there was an interdisciplinary approach to decision-making in the unit. Two major themes were chosen from the focus group discussions and staff survey data: (i) Decision-making is based on unit culture rather than evidence and (ii) the process of weaning is driven by interdisciplinary team collaboration. Participants acknowledged that there needed to be a culture change from a liberal approach to oxygen therapy. CONCLUSIONS: Although participants acknowledged the adverse consequences of excessive oxygen use, achieving oxygenation targets with the minimum level of supplemental oxygen was not a key focus of care. The findings highlight the need to develop and evaluate evidence-based protocols to support a conservative approach to supplemental oxygen management.

Resuscitation status and characteristics and outcomes of patients transferred from subacute care to acute care hospitals: A multi-site prospective cohort study.

AIMS AND OBJECTIVES: To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital. BACKGROUND: Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%). DESIGN: This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. METHODS: Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect. FINDINGS: Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care. CONCLUSIONS: Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients. RELEVANCE TO CLINICAL PRACTICE: As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.

Usability and feasibility of multimedia interventions for engaging patients in their care in the context of acute recovery: A narrative review.

PURPOSE: The purpose of this narrative review was to examine the usability and feasibility of multimedia intervention as a platform to enable patient participation in the context of acute recovery and to discover what outcomes have been measured. DATA SOURCES: A narrative review of primary research articles identified through a search of four electronic databases (MEDLINE, CINAHL, EMBASE and PsycInfo) identified peer-reviewed research evidence published in English language with no limitation placed on time period or publication type. Two authors independently assessed articles for inclusion. From the 277 articles identified through the search, 10 papers reporting the outcomes of seven studies were included in this review. REVIEW METHODS: Articles were independently assessed for quality and relevance by two authors. The most appropriate method for data synthesis for this review was a narrative synthesis. RESULTS: From the narrative synthesis of study outcomes, two findings emerged as follows: (a) multimedia interventions are feasible and usable in the context of acute care, and (b) multimedia interventions can improve patients' perception of care-related knowledge. Identified gaps included a lack of evidence in relation to the effect of interventions on enhancing patients' ability to participate in their care and the impact on patients' health-related outcomes. CONCLUSIONS: In conclusion, there is some evidence of the feasibility and usability of multimedia interventions in acute care. That is, patients can use these types of platforms in this context and are satisfied with doing so. Multimedia platforms have a role in the delivery of information for patients during acute recovery; however, the effectiveness of these platforms to engage and enhance patients' capability to participate in their recovery and the impact on outcomes needs to be rigorously evaluated.

A screen-based simulation training program to improve palliative care of people with advanced dementia living in residential aged care facilities and reduce hospital transfers: study protocol for the IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) cluster randomised controlled trial.

BACKGROUND: Many people with advanced dementia live in residential aged care homes. Care home staff need the knowledge and skills to provide high-quality end-of-life (EOL) dementia care. However, several studies have found EOL dementia care to be suboptimal, and care staff have reported they would benefit from training in palliative care and dementia. Simulation offers an immersive learning environment and has been shown to improve learners' knowledge and skills. However, there is little research on simulation training for residential care staff. This article presents the development and evaluation protocol of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) - a screen-based simulation training program on palliative dementia care, targeted at residential care staff. IMPETUS-D aims to improve the quality of palliative care provided to people living with dementia in residential care homes, including avoiding unnecessary transfers to hospital. METHODS: A cluster RCT will assess the effect of IMPETUS-D. Twenty-four care homes (clusters) in three Australian cities will be randomised to receive either the IMPETUS-D intervention or usual training opportunities (control). The primary outcome is to reduce transfers to hospital and deaths in hospital by 20% over 6-months in the intervention compared to the control group. Secondary outcomes include uptake of goals of care plans over 6 and 12 months, change in staff knowledge and attitudes towards palliative dementia care over 6 months, change in transfers to hospital and deaths in hospital over 12 months. For the primary analysis logistic regression models will be used with standard errors weighted by the cluster effects. A mixed methods process evaluation will be conducted alongside the cluster RCT to assess the mechanisms of impact, the implementation processes and contextual factors that may influence the delivery and effects of the intervention. DISCUSSION: In Australia, the need for high-quality advanced dementia care delivered in residential aged care is growing. This study will assess the effect of IMPETUS-D a new simulation-based training program on dementia palliative and EOL care. This large multisite trial will provide robust evidence about the impact of the intervention. If successful, it will be distributed to the broader residential care sector. TRIAL REGISTRATION: ANZCTR, ACTRN12618002012257 . Registered 14 December 2018.

Patient activation intervention to facilitate participation in recovery after total knee replacement (MIME): a cluster randomised cross-over trial.

BACKGROUND: Patient participation in care is a fundamental element of safe and high-quality healthcare with the potential to enhance health outcomes and improve patient satisfaction. OBJECTIVES: To test the efficacy of a clinician-facilitated, bedside multimedia (MyStay) intervention designed to support patient participation in their recovery after total knee replacement surgery. The primary outcome was patients' reported worst pain intensity on postoperative day 3. Secondary outcomes were patient activation, length of hospital stay, knee function and satisfaction with care. METHODS: Unmasked, cluster randomised, four-period cross-over trial with a simultaneous process evaluation within in a large private, not-for-profit, metropolitan teaching hospital. Statistical analyses used linear mixed models with random effects for wards, cohorts within wards and patients within cohorts and fixed effects for treatment and period. RESULTS: 241 patients were recruited between March 2014 and June 2015. Patients were admitted to intervention (104) or control (137) clusters. Intervention group patients reported significantly lower mean pain intensity scores on postoperative day 3 (6.1 vs 7.1, 95% CI -1.94 to -0.08, p=0.04). The percentages of patients who reported severe pain (score ≥7) were 43.7% and 64.2% in the intervention and control groups, respectively (χ2 9.89, p=0.002; generalised linear mixed model Wald test, p=0.05). Intervention group patients on average stayed in hospital one less day (5.3 vs 6.3, 95% CI 0.05 to 1.94, p=0.04), reported higher activation (45.1% vs 27.1% at level 4 activation) (p=0.04) and higher overall satisfaction with care (9.3 vs 8.6, 95% CI 1.09 to 0.219, p=0.01), and were more likely to refer family or friends to the health service (9.3 vs 8.7, 95% CI 1.07 to 0.13, p=0.02). CONCLUSION: The clinician-facilitated, MyStay bedside multimedia intervention enhanced patients' activation and participation in their care after surgery; pain intensity and length of stay in hospital were reduced and patients were more satisfied with their care. TRIAL REGISTRATION: ACTRN12614000340639 (http://www.anzctr.org.au/default.aspx).

STOPDVTs: Development and testing of a clinical assessment tool to guide nursing assessment of postoperative patients for Deep Vein Thrombosis.

AIMS AND OBJECTIVES: To develop and test a clinical tool to guide nurses' assessment of postoperative patients for Deep Vein Thrombosis. BACKGROUND: Preventing venous thromboembolism in hospitalised patients is an international patient safety priority. Despite high-level evidence for optimal venous thromboembolism prophylaxis, implementation is inconsistent and the incidence of Deep Vein Thrombosis remains high. METHODS: A two-stage sequential multi-method design was used. In stage 1, the STOPDVTs tool was developed using a review of the literature and focus groups with local clinical experts. Stage 2 involved pilot testing the tool with 38 surgical nurses who conducted repeated assessments on a prospective sample of 50 postoperative orthopaedic patients. RESULTS: Stage 1: The focus group members who were members of the nursing leadership team agreed on eight local and systemic signs and symptoms that should be included in a nursing patient assessment tool for early Deep Vein Thrombosis. Local symptoms were pain in the limbs, calf swelling and tightness, changes in the affected limb's skin temperature. Systemic signs included in the tool were as follows: increased shortness of breath, increased respiratory and heart rates, and decreased oxygen saturation. Stage 2: The STOPDVTs tool had acceptable face and content validity, the agreement between the expert nurse and surgical nurses on assessments of individual signs and symptoms varied between 44%-94%. Surgical nurses were less likely than the expert nurse to identify signs indicative of Deep Vein Thrombosis. CONCLUSION: Despite finding the STOPDVTs clinical assessment tool was a useful guide for nursing assessment, surgical nurses often underestimated the potential importance of clinical signs. The findings reveal a gap in nursing knowledge and skill in assessing for Deep Vein Thrombosis in postoperative orthopaedic patients. RELEVANCE TO CLINICAL PRACTICE: This study identified a possible risk to patient safety related to under-recognition of the signs and symptoms of possible Deep Vein Thrombosis (DVT) in postoperative orthopaedic patients. The findings demonstrate the feasibility of developing and implementing a protocol for consistent screening by nurses for possible DVT in the postoperative period.

COPD: Health Care Utilisation Patterns with Different Disease Management Interventions.

PURPOSE: The management of COPD is a significant and costly issue worldwide, with acute healthcare utilisation consisting of admissions and outpatient attendances being a major contributor to the cost. Pulmonary rehabilitation (PR) and integrated disease management (IDM) are often offered. Whilst there is strong evidence of physical and quality of life outcomes following IDM and PR, few studies have looked into healthcare utilisation. The aims of this study were to confirm whether IDM and PR reduce acute healthcare utilisation and to identify factors which contribute to acute health care utilisation or increased mortality. METHODS: This was a retrospective cohort study of patients with COPD who were referred to IDM over a 10-year period. Patients were also offered an 8-week PR program. Data collected were matched with the hospital dataset to obtain information on inpatient, ED and outpatient attendances. RESULTS: 517 patients were enrolled to IDM. 315 (61%) also commenced PR and 220 (43%) completed PR. Patients who were referred to PR were younger and had less comorbidities (p < 0.001). Both groups (IDM only and IDM + PR referred) had reductions in healthcare utilisation but the IDM-only group had greater reductions. A survival benefit (HR 0.68, 95% CI 0.50-0.92) was seen in those who were PR completers compared to patients who received IDM only. CONCLUSIONS: Patients with COPD who successfully complete PR in addition to participating in IDM have improved survival. IDM alone was effective in the reduction of healthcare utilisation; however, the addition of PR did not reduce healthcare usage further.

Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions.

BACKGROUND: There is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation. METHODS: A prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007-2009 and follow-up data until 2012. Administrative data was used to classify patients' primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm. RESULTS: There were 1999 participants (54 % male) with a mean age of 63 years (range 18-101), enrolled in the study. Participants' primary health conditions at enrolment were: diabetes 915 (46 %), chronic respiratory disease 463 (23 %), cardiac disease 260 (13 %), peripheral vascular disease, and 181 (9 %) and aged care 180 (9 %). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95 % CI, 1.16-2.13, p = 0.003) and admissions (OR 1.67, 95 % CI.1.21 to 2.30, p = 0.002) after adjusting for differences in age and comorbidities. CONCLUSION: This study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.

Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial.

OBJECTIVES: To determine whether outcomes for patients with cellulitis treated with oral antimicrobials are as good as for those who are treated with parenteral antimicrobials. METHODS: A prospective randomized non-inferiority trial was conducted at a tertiary teaching hospital in Melbourne, Australia. Participants were patients referred by the emergency department for treatment of uncomplicated cellulitis with parenteral antimicrobials. Patients were randomized to receive either oral cefalexin or parenteral cefazolin. Parenteral antimicrobials were changed to oral after the area of cellulitis ceased progressing. The primary outcome was days until no advancement of the area of cellulitis. A non-inferiority margin of 15% was set for the oral arm compared with the parenteral arm. Secondary outcomes were failure of treatment, pain, complications and satisfaction with care. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000685910). RESULTS: Twenty-four patients were randomized to oral antimicrobials and 23 to parenteral antimicrobials. Mean days to no advancement of cellulitis was 1.29 (SD 0.62) for the oral arm and 1.78 (SD 1.13) for the parenteral arm, with a mean difference of -0.49 (95% CI: -1.02 to +0.04). The upper limit of the 95% CI of the difference in means of +0.04 was below the 15% non-inferiority margin of +0.27 days, indicating non-inferiority. More patients failed treatment in the parenteral arm (5 of 23, 22%) compared with the oral arm (1 of 24, 4%), although this difference was not statistically significant (P=0.10). Pain, complications and satisfaction with care were similar for both groups. CONCLUSIONS: Oral antimicrobials are as effective as parenteral antimicrobials for the treatment of uncomplicated cellulitis.

Effect of a chronic disease management service for patients with diabetes on hospitalisation and acute care costs.

OBJECTIVE: To evaluate the effect of a diabetes-management program for patients with type 2 diabetes and related comorbidities on acute healthcare utilisation and costs. METHODS: This was a retrospective administrative dataset analysis using data for patients enrolled from 2007 to 2008. Inpatient admissions for diabetes-related conditions were compared before, during and following enrolment. Costs per episode were estimated from Weighted Inlier Equivalent Separations (WIES) funding. A cost model was then developed based on admission rates per 100 patients. RESULTS: Data were retrieved for 357 patients; 49% males, mean age 62 years. The mean per-patient cost of the program was AU$524 (s.d. $213). The mean cost of an inpatient admission was $4357(95% CI 2743-5971) pre-enrolment and $4396 (95% CI 2888-5904) post-enrolment. Following program completion the annual costs (per 100 patients) for managing 'diabetes with multiple complications' and hypoglycaemia decreased from $10181 to $1710 and $9947 to $7800. In contrast, the annual cost of cardiovascular disorders increased from $14485 to $40071 per 100 patients. CONCLUSIONS: In the short-term diabetes-management programs for patients with comorbid vascular disease may reduce hospital utilisation for diabetes but not for cardiovascular disease. Longer-term follow-up is needed to determine whether intensive management of vascular complications can reduce costs.