Ultrasound-Guided Axillary Brachial Plexus Block for the Management of Graft Site Pain During Dressing Change in the Burn-Injured Patient: A Randomized Control Trial.

Burn injuries requiring split-thickness skin grafting procedures often require ongoing wound aggravation in the form of dressing changes. These dressing changes may cause significant pain due to stimulation of damaged nerve endings in the epidermal layer. A randomized control trial, pilot study, was undertaken to evaluate the impact of ultrasound-guided regional nerve block on the outcome of patient reported pain scores by inpatients requiring dressing changes for hand and upper limb burn injuries. Twenty participants aged >18 years, requiring split-skin grafting for burn injuries of <15% total body surface area were enrolled from a tertiary burns unit between August 2018 and September 2020. Participants were randomized to control (10 participants) or intervention group (10 participants). All participants received analgesia as per their treating team, the intervention group received the addition of an ultrasound-guided axillary brachial plexus block prior to their dressing change procedure. The primary outcome was to assess perceived pain at the graft site as measured by the Numeric Pain Rating Scale (0-10) before, during, and after dressing change procedure. There was strong evidence of a difference in the adjusted mean change score between groups, with a mean reduction of 4.3 in the intervention group, indicating reduced pain, and a mean increase of 1.2 in the control group (P < .001). No adverse events occurred in either group, and the addition of ultrasound-guided regional anesthesia (RA) for the treatment of dressing pain was determined to be a safe and effective intervention.

Ultrasound-Guided Fascia Iliaca Plane Block for the Treatment of Donor Site Pain in the Burn-Injured Patient: A Randomized Control Trial.

Burn injuries requiring surgical intervention often result in split-thickness skin grafting procedures, with donor skin frequently harvested from the patient's anterolateral thigh. The donor site is often reported as the primary site of postoperative pain due to the damage sustained to localized nociceptors. A randomized control trial was undertaken to evaluate the impact an ultrasound-guided regional nerve block would have on patient-reported pain scores in donor site wounds, and associated rescue analgesia consumption. Twenty participants requiring split-skin grafting for burn injuries of <15% total body surface area were enrolled from a tertiary burns unit and randomized to control (10 participants) or intervention group (10 participants). The intervention group received the addition of an ultrasound-guided facia iliaca plane block prior to their surgery. Primary outcome was pain score in the donor site during the postoperative phase while secondary outcome was pain on day 1 post-surgery as measured by the numeric pain score (0-10). During the postoperative phase, the intervention group had a significantly lower median donor site pain score of 0 (interquartile range [IQR] 0-0), compared to the control group median 6 (IQR 4-7) (P < .001). Day 1 post-surgery the intervention group had a median pain score of 0 (IQR 0-4) compared to control group median 4.5 (IQR 2-6) (P = .043). The study findings demonstrated that regional anesthesia was an effective way to reduce pain scores and requirement for additional analgesics during the postoperative phase.

Effectiveness of the Non-Medical Surgical Assistant measured by patient outcome assessment.

AIMS: To investigate effectiveness of the nurse clinician as a Non-Medical Surgical Assistant compared with the Medical Surgical Assistant. BACKGROUND: Non-Medical Surgical Assistants are clinicians who are not medical practitioners. The surgical assistant works directly with the primary surgeon intraoperatively. DESIGN: A pragmatic, retrospective, observational study on patients undergoing Laparoscopic Inguinal Hernia Repair or Primary Unilateral Total Hip Arthroplasty. Each patient received intraoperative care from a consultant surgeon and a Medical Surgical Assistant or Non-Medical Surgical Assistant. All surgical assistants were registered with the Australian Health Practitioner Regulation Agency. METHODS: Data were collected between 01/07/2014 and 30/06/2017. The effect that surgical assistant choice had on patient outcomes was estimated using regression statistical models. Six dependent variables, including length of stay, for clinical outcome assessment were specified. RESULTS/FINDINGS: The groups were equivalent in age, gender, and American Society of Anaesthesiologists scores. There were more emergency procedures in the Medical Surgical Assistant group and more hip surgery in the Non-Medical Surgical Assistant group. Patient outcome assessment showed no statistically significant differences for surgical assistant types. CONCLUSION: The nurse clinician in the role of Non-Medical Surgical Assistant was shown to be effective with equivalent patient outcomes compared with the Medical Surgical Assistant.

Exploring the Role of Regional Anesthesia in the Treatment of the Burn-injured Patient: A Narrative Review of Current Literature.

OBJECTIVES: The review article was designed to assess the effectiveness of regional anesthesia (RA), specifically peripheral nerve blocks, in the treatment of burn pain; with noting of clinical indications and contraindications for peripheral nerve block application, along with discussion of evidence-based analgesic strategies for providing improved, comprehensive burn pain management. MATERIALS AND METHODS: A search of relevant literature was performed using CINAHL, PubMed, EMBASE, Web of Science, and SCOPUS with a publication date between January 2005 and December 2017. RESULTS: The search yielded 10 results that met criteria. Two randomized control trials were included, though they focused on analgesia for donor-site pain only, 1 clinical trial, 2 case series, 2 retrospective audit, 1 burn protocol, and 2 review articles. DISCUSSION: RA techniques are an adjunct therapy currently used worldwide to improve patient pain outcomes and reduce the adverse effects associated with general anesthetic. RA presents a safe and effective intervention for acute pain resulting from burn-acquired injury. This review of current literature supports the use of RA as a treatment to manage pain associated with burn-related care procedures as an addition to multimodal pain treatment. To date there is limited evidence showing the use of RA in the burns' patient population. In addition, there appear to be no particular risks to using the technique of RA in this group. Further prospective studies are required to provide information about the benefits and limitations of RA.

Practice audit of the role of the Non-medical surgical assistant in Australia, an online survey.

The term Non-Medical Surgical Assistant (NMSA) encompasses all roles where healthcare clinicians without a medical degree provide clinical services during the perioperative cycle. The role of NMSA is gaining momentum within Australia. It is timely to ascertain who is preforming the role and quantify the practice setting and scope of practice to enable a nationally recognised platform for role evolution. For two months in 2015 a NMSA Practice Audit was available online. Sampling was initially of a convenience modality. A total of 83 clinicians responded. The majority of NMSAs were experienced RNs [>11yrs]; held post-graduate qualifications [80%], practiced predominantly in metropolitan areas [65%] and had been performing the role for 8 years or less. The specialty with the highest uptake of the NMSAs is orthopaedic surgery. This paper provides an overview of NMSAs practicing in Australia and provides cost effective evidence of the need for this service in Australian healthcare.

Association between left ventricular global longitudinal strain, health-related quality of life and functional capacity in chronic kidney disease patients with preserved ejection fraction.

AIM: Patients with chronic kidney disease (CKD) have a significant burden of dyspnoea and fatigue in spite having normal left ventricular (LV) ejection fraction (EF). Global longitudinal strain (GLS) can detect subtle changes in LV function. This study aimed to evaluate the relationship between LV function, functional capacity and quality of life (QOL) in CKD patients with preserved EF. METHODS: A cross-sectional study of patients with stage 3/4 CKD (n = 108). Clinical characteristics, biochemical data, functional capacity (6-min walk test (6MWT), timed up and go (TUG) test) and QOL (short form-12 (SF-12v2™) ) were measured. Echocardiogram was used to assess GLS, EF and diastolic function (E/A, e' and E/e'). RESULTS: The mean age was 58.1 ± 9.9 years, 55.6% were men, estimated glomerular filtration rate was 44.8 ± 10.6 mL/min/1.73 m(2), GLS was -18.5 ± 3.6% and 19.4% had impaired GLS (>-16%). Patients with impaired GLS had a significantly shorter 6MWT and slower TUG test compared with patients with preserved GLS. Bivariate analysis showed GLS and E/e' correlated with distance walked in 6MWT (GLS (r = -0.24, P = 0.02); E/e'(r = -0.38, P = 0.002) ). Following adjustment for potential confounders, GLS remained independently associated with 6MWT (model R(2) = 0.37, P < 0.001). Mean physical component summary scores (PCS) and mental component summary scores (MCS) were 43.0 ± 10.2 and 50.9 ± 9.5. There was no cardiac parameter that was independently associated with PCS. However women, lower systolic blood pressure and GLS was associated with lower MCS (model R(2) = 0.30, P < 0.001). CONCLUSION: GLS was associated with measures of functional capacity and QOL in CKD patients with preserved EF.

Exercise training in CKD: efficacy, adherence, and safety.

BACKGROUND: Exercise training increasingly is recommended as an important part of the management of cardiovascular disease. However, few studies have evaluated the effectiveness of exercise training in patients with chronic kidney disease (CKD), and those that have included very selective populations. STUDY DESIGN: Analysis of secondary outcomes of a randomized controlled trial, with participants randomly assigned to either lifestyle intervention or usual care (control). SETTING & PARTICIPANTS: Patients with CKD stages 3 to 4 and one or more uncontrolled cardiovascular risk factor were recruited from an outpatient clinic at a large tertiary hospital. INTERVENTION: Lifestyle intervention included access to multidisciplinary care through a nurse practitioner-led CKD clinic, exercise training, and a lifestyle program. The exercise training was a 2-phased program in which participants received 8 weeks of supervised training before commencing 10 months of home-based training. OUTCOMES & MEASUREMENTS: Efficacy, as assessed by metabolic equivalent tasks (METs), 6-minute walk distance, Timed Get-Up-and-Go test, grip strength, and anthropomorphic measures; adherence, as assessed by self-reported physical activity; and safety, as assessed by reported serious adverse events, were recorded. RESULTS: 83 patients were randomly assigned and 72 patients completed follow-up testing (intervention, n=36; control, n=36). The intervention resulted in a significant improvement in METs (pre, 7.2±3.3; post, 9.7±3.6), 6-minute walk distance (pre, 485±110m; post, 539±82m), and body mass index (pre, 32.5±6.7kg/m(2); post, 31.9±7.3kg/m(2)). Reported physical activity levels significantly increased in the intervention group at 6 months, but decreased at 12 months. There were no serious adverse events related to the exercise training. LIMITATIONS: This study was not powered to evaluate the safety of exercise training on serious adverse events. CONCLUSIONS: The findings from the present study suggest that an exercise program that includes a supervised and home-based training phase is effective, adhered to, and safe in patients with CKD.

Effect of a dedicated osteoporosis health professional on screening and treatment in outpatients presenting with acute low trauma non-hip fracture: a systematic review.

UNLABELLED: The aim of this study was to identify the effect a dedicated osteoporosis health professional on screening and treatment in outpatients presenting with acute low trauma fracture. A dedicated osteoporosis health professional improved investigation and management of osteoporosis. Osteoporosis management was enhanced, leading to the potential for future fracture prevention. PURPOSE: This study aimed to review the effect a dedicated osteoporosis health professional on screening and treatment in outpatients presenting with acute low trauma fracture. METHODS: We searched the electronic databases of Medline, EMBASE, CINAHL, Current Contents Connect, Joanna Briggs Institute EBP, and Cochrane from database development to April 2013, examined grey literature, and completed manual searches of reference lists to identify English language research that examined the effect that dedicated health professional input had on osteoporosis management with acute low trauma non-hip fracture in the outpatient setting. Outcomes were defined as the proportion of patients with investigation (bone mineral density (BMD) or blood screen); treated with vitamin D supplementation or antiresorptive agent; documented BMD reading change; recurrent fracture occurrence; or referral to specialist bone (osteoporosis) clinic. RESULTS: All studies with a suitable control group showed an increase in BMD screening in the intervention group (odds ratio (OR) 5.4, 95% confidence interval (CI) 4.3-6.9, P<0.0001). The effect on treatment initiation showed a significantly increased rate of antiresorptive±vitamin D therapy (OR 5.3, 95% CI 4.1-6.8, P<0.0001). No studies examined improvement or decline in BMD guiding clinical practice as an outcome. Two studies showed reduced fracture recurrence. The osteoporosis health professional significantly increased referrals to a specialist bone clinic (OR 9.6, 95% CI 6.2-14.6, P<0.0001). CONCLUSIONS: The presence of a dedicated osteoporosis health professional coordinating a targeted intervention for outpatients with low trauma non-hip fracture improves investigation and management of osteoporosis, resulting in the potential for future fracture prevention.

A pilot project in distance education: nurse practitioner students' experience of personal video capture technology as an assessment method of clinical skills.

This paper reports on a pilot project aimed at exploring postgraduate distance students' experiences using personal video capture technology to complete competency assessments in physical examination. A pre-intervention survey gathered demographic data from nurse practitioner students (n=31) and measured their information communication technology fluency. Subsequently, thirteen (13) students were allocated a hand held video camera to use in their clinical setting. Those participating in the trial completed a post-intervention survey and further data were gathered using semi-structured interviews. Data were analysed by descriptive statistics and deductive content analysis, and the Unified Theory of Acceptance and Use of Technology (Venkatesh et al., 2003) were used to guide the project. Uptake of the intervention was high (93%) as students recognised the potential benefit. Students were video recorded while performing physical examinations. They described high level of stress and some anxiety, which decreased rapidly while assessment was underway. Barriers experienced were in the areas of facilitating conditions (technical character e.g. upload of files) and social influence (e.g. local ethical approval). Students valued the opportunity to reflect on their recorded performance with their clinical mentors and by themselves. This project highlights the demands and difficulties of introducing technology to support work-based learning.

Effects of multidisciplinary models of care for adult pre-dialysis patients with chronic kidney disease: a systematic review.

AIM: To compare the effectiveness of multidisciplinary care with traditional medical care on the progression of chronic kidney disease (CKD) in adult pre-dialysis patients (stages 3-5). METHODS: Eleven databases were searched for articles published between January 1990 and July 2009. The Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument was used to assess the methodological quality of retrieved articles and extract data. RESULTS: Only four articles out of 927 were included in the systematic review. Two reported the results of randomised controlled trials and two reported observational studies. The data were not presented in a format that allowed a meta-analysis to be performed and therefore a narrative summary of these articles is presented. CONCLUSION: Multidisciplinary care is deemed to be effective in delaying the progression of CKD in adults who are in the pre-dialysis phase of this condition. Education that aims to increase the knowledge and understanding of the causes of CKD is an important component of the care. IMPLICATIONS FOR PRACTICE: Members of the multidisciplinary team should draw on their specific expertise to educate the patient about CKD. The nephrologist or a nurse practitioner should devise a management plan jointly with the patient and provide regular reviews.

Effectiveness of medical compared to multidisciplinary models of care for adult persons with pre-dialysis chronic kidney disease: a systematic review.

AIM: Multidisciplinary care is a model of care that has increased in popularity. It offers opportunities for different ways of providing care. The objective of this systematic review was to compare the effectiveness of multidisciplinary care on the progression of chronic kidney disease by adult pre-dialysis patients in comparison to traditional medical care. METHODS: Eleven databases were searched for material published between January 1990 to July 2009 and 37 search terms were used in different combinations. In addition, suitable journals and websites were searched as well as a hand search of reference lists in the retrieved hits from the database searches was used as well. Management tools from the Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument were used to assess the methodological quality of each of the retrieved articles that met the criteria for the review. Data extraction and synthesis was performed using the appropriate tool. RESULTS: From 927 hits only four articles were finally deemed suitable for inclusion in the systematic review. Two reported the results of randomised controlled trials and the remaining two were observational studies. The data was not presented in a format that allowed a meta-analysis to be performed. One article (from 1998) argued that multidisciplinary care was not cost effective and in this study there was no difference in outcomes between multidisciplinary care and traditional care. The other three articles showed a positive impact on patient wellbeing and outcomes for those receiving multidisciplinary care, such as delay in the progression of their chronic kidney disease. Education of patients was shown to have a significant effect on the delay in time for patients initiating renal replacement therapy whether as peritoneal-dialysis, haemo-dialysis or transplantation. None of the articles reported negative effects, reduced safety or poor outcomes for the patients receiving multidisciplinary care. Well controlled blood pressure, within treatment targets, appears to be an important factor in delaying the progression of their chronic kidney disease, although this did not reach statistical significance. CONCLUSION: Multidisciplinary care is deemed to be effective for adults with pre-dialysis chronic kidney disease. The effectiveness is shown as a delay in time to initiation of renal replacement therapy. Education is an important component that should be included in a multidisciplinary model of care. The education should in particular aim to increase the knowledge and understanding of the causes of ill health for people with chronic kidney disease. IMPLICATIONS FOR PRACTICE: The results from the systematic review support the implementation of multidisciplinary clinics like chronic kidney disease clinics as a way to delay progression of chronic kidney disease. This model of care often includes each member of the multidisciplinary team educating the patient in their area of expertise while the nephrologists or a nurse practitioner regularly reviews and creates a management plan jointly with the patient. IMPLICATIONS FOR RESEARCH: Further research needs to be conducted on the best models of education for this population, including who is ideally suited to provide the education. As none of the studies reviewed multidisciplinary care in Australian chronic kidney disease clinics, this needs to be further assessed regarding patient outcomes and wellbeing. Other outcomes of interest that require further research are the safety and cost effectiveness of multidisciplinary care as well as patients' experiences of the care and possible impacts on their independence. At present there is limited research published in this area, particularly in an Australian context.