Potentially preventable hospitalisations in rural community-dwelling patients.

BACKGROUND: Potentially preventable hospitalisations (PPH) are a common occurrence. Knowing the factors associated with PPH may allow high-risk patients to be identified and healthcare resources to be better allocated, and these factors may differ between urban and rural locations. AIM: To determine factors associated with PPH in an Australian rural population. METHODS: A retrospective review of admitted patients' demographic and clinical data was used to describe and model the factors associated with PPH, using an age- and sex-matched control group of non-admitted patients. This study is based in a multi-site rural general practice, Tasmania. The study included patients aged ≥18 years residing in the Huon-Bruny Island region of Tasmania, who were active patients at a rural general practice and were admitted to a public hospital for a PPH between 1 July 2016 and 30 June 2019. Main outcome measure is overnight admission to hospital for a PPH. RESULTS: Predictors with a significant odds ratio (OR) in the final model were being single/unmarried (OR 2.43; 95% confidence interval (CI) 1.38-4.28), higher Charlson Comorbidity Index score (OR 1.40; 95% CI 1.13-1.74) and the number of general practice visits in the preceding 12 months (OR 1.09; 95% CI 1.05-1.14). CONCLUSIONS: This study found that being single and having a higher comorbidity burden were the strongest independent risk factors for PPH in a rural population. Demographic and socioeconomic factors appeared to be as, if not more, important than medical factors and warrant attention when considering the design of programmes to reduce PPH risk in rural communities.

Rural Patients' Perceptions of Their Potentially Preventable Hospitalisation: A Qualitative Study.

Potentially preventable hospitalisations (PPHs) occur when patients receive hospital care for a condition that could have been more appropriately managed in the primary healthcare setting. It is anticipated that the causes of PPHs in rural populations may differ from those in urban populations; however, this is understudied. Semi-structured interviews with 10 rural Australian patients enabled them to describe their recent PPH experience. Reflexive thematic analysis was used to identify the common factors that may have led to their PPH. The analysis revealed that most participants had challenges associated with their health and its optimal self-management. Self-referral to hospital with the belief that this was the only treatment option available was also common. Most participants had limited social networks to call on in times of need or ill health. Finally, difficulty in accessing primary healthcare, especially urgently or after-hours, was described as a frequent cause of PPH. These qualitative accounts revealed that patients describe nonclinical risk factors as contributing to their recent PPH and reinforces that the views of patients should be included when designing interventions to reduce PPHs.

Healthcare Providers' Perceptions of Potentially Preventable Rural Hospitalisations: A Qualitative Study.

Potentially preventable hospitalisations (PPHs) are common in rural communities in Australia and around the world. Healthcare providers have a perspective on PPHs that may not be accessible by analysing routine patient data. This study explores the factors that healthcare providers believe cause PPHs and seeks to identify strategies for preventing them. Physicians, nurses, paramedics, and health administrators with experience in managing rural patients with PPHs were recruited from southern Tasmania, Australia. Semi-structured telephone interviews were conducted, and reflexive thematic analysis was used to analyse the data. Participants linked health literacy, limited access to primary care, and perceptions of primary care services with PPH risk. The belief that patients did not have a good understanding of where, when, and how to manage their health was perceived to be linked to patient-specific health literacy challenges. Access to primary healthcare was impacted by appointment availability, transport, and financial constraints. In contrast, it was felt that the prompt, comprehensive, and free healthcare delivered in hospitals appealed to patients and influenced their decision to bypass rural primary healthcare services. Strategies to reduce PPHs in rural Australian communities may include promoting health literacy, optimising the delivery of existing services, and improving social support structures.

A case study - Implementing a registered nurse professional recognition program across a Queensland hospital and health service.

Ongoing advancement and documentation of professional development is required to maintain nursing registration and competency to practise in Australia and many other countries. All Australian registered nurses are required to undertake a minimum of 20 h of continuing professional development annually and demonstrate competence to practice; this is a criterion for nursing registration. Many health care organisations nationally and internationally develop programs to support such processes, assisting nurses to formally document their ongoing education and commitment to best practice, and clearly demonstrate their ongoing continuing professional development. Such programs align with the MAGNET ® principles of providing structural empowerment, exemplary professional practice and new knowledge, innovations and improvements. This study describes the implementation, evaluation and impact of the registered nurse professional recognition program undertaken by one Hospital and Health Service in South East Queensland using Donabedian's structure, process outcome framework. The registered nurse professional recognition program was implemented to invest in and develop the nursing workforce by providing an opportunity for registered nurses to assess and document their professional skills, knowledge and expertise that are critical to the provision of safe and cost-effective patient and family-centred care.

Impact of MAGNET hospital designation on nursing culture: an integrative review.

BACKGROUND: Organisational culture is a critical part of a positive and productive working environment and often presents as an area of ongoing development. The MAGNET recognition program awards recognition to organisations that have positive organisational cultures that meet the standards and criteria. However, the broad impact of MAGNET on hospital culture outside of America remains unclear. OBJECTIVE: In this study, we explore the impact of MAGNET designation on organisational culture within the nursing context. METHODS: An integrative literature review was performed using a systematic search of Medline (Ovid), Embase (Elsevier) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL Ebsco) databases and a combination of subject headings and key words for organizational culture, organizational change and MAGNET hospital, as well as reference chaining was conducted. Using a constant comparative process key categories, themes and subthemes emerged. RESULTS: Twenty-nine key studies were identified and were evaluated utilising two study quality appraisal tools; National Health and Medical Research Council (NH&MRC) levels of evidence and the Polit and Beck critical appraisal tool. Three key categories emerged from the data: (1) nurse practice environment; (2) structure and process models; (3) measurement scales. A key finding was that MAGNET designation appears to enhance organisational culture for nurses and the framework used to introduce MAGNET helps to empower nurses to direct organisational culture in their facility. Conclusion and Implications for Nursing and Health Policy: MAGNET appears to have a positive impact on organisational culture, particularly for nurses. However, lack of standardised evaluation tools used to assess organisational culture associated with MAGNET designation limits comparability of the studies. Generally, the quality of evidence used to develop recommendations was poor to very poor. More, well designed studies undertaken outside of the USA are required. Impact Statement: An in-depth integrative review exploring the impact of MAGNET designation on organisational culture has not been undertaken. In this paper, we have used an integrative review methodology to identify, examine, thematically group and critically evaluate published literature around the impact of MAGNET designation on organisational culture within designated hospitals.

What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature.

AIM: In this integrative review, we aimed to: first, identify and summarize published studies relating to ward nurses' recognition of and response to patient deterioration; second, to critically evaluate studies that described or appraised the practice of ward nurses in recognizing and responding to patient deterioration; and third, identify gaps in the literature for further research. DESIGN: An integrative review. METHODS: The Cumulative Index to Nursing and Allied Health Literature (CINAHL) Ovid Medline, Informit and Google Scholar databases were accessed for the years 1990-2014. Data were extracted and summarized in tables and then appraised using the Mixed Method Appraisal Tool. Data were grouped into two domains; recognizing and responding to deterioration and then thematic analysis was used to identify the emerging themes. RESULTS: Seventeen studies were reviewed and appraised. Recognizing patient deterioration was encapsulated in four themes: (1) assessing the patient; (2) knowing the patient; (3) education and (4) environmental factors. Responding to patient deterioration was encapsulated in three themes; (1) non-technical skills; (2) access to support and (3) negative emotional responses. CONCLUSION: Issues involved in timely recognition of and response to clinical deterioration remain complex, yet patient safety relies on nurses' timely assessments and actions.

Cost-effectiveness analysis alongside a pilot study of prophylactic negative pressure wound therapy.

BACKGROUND: Negative pressure wound therapy (NPWT) is increasingly used prophylactically following surgery despite limited evidence of clinical or cost-effectiveness. OBJECTIVE: To evaluate whether NPWT is cost-effective compared to standard care, for the prevention of surgical site infection (SSI) in obese women undergoing elective caesarean section, and inform development of a larger trial. METHODS: An economic evaluation was conducted alongside a pilot randomised controlled trial at one Australian hospital, in which women were randomised to NPWT (n = 44) or standard care (n = 43). A public health care provider perspective and time horizon to four weeks post-discharge was adopted. Cost-effectiveness assessment was based on incremental cost per SSI prevented and per quality-adjusted life year (QALY) gained. RESULTS: Patients receiving NPWT each received health care costing AU$5887 (±1038) and reported 0.069 (±0.010) QALYs compared to AU$5754 (±1484) and 0.066 (±0.010) QALYs for patients receiving standard care. NPWT may be slightly more costly and more effective than standard care, with estimated incremental cost-effectiveness ratios (ICERs) of AU$1347 (95%CI dominant- $41,873) per SSI prevented and AU$42,340 (95%CI dominant- $884,019) per QALY gained. However, there was considerable uncertainty around these estimates. CONCLUSIONS: NPWT may be cost-effective in the prophylactic treatment of surgical wounds following elective caesarean section in obese women. Larger trials could clarify the cost-effectiveness of NPWT as a prophylactic treatment for SSI. Sensitive capture of QALYs and cost offsets will be important given the high level of uncertainty around the point estimate cost-effectiveness ratio which was close to conventional thresholds. AUSTRALIAN AND NEW ZEALAND TRIAL REGISTRATION NUMBER: ACTRN12612000171819.

Negative Pressure Wound Therapy on Surgical Site Infections in Women Undergoing Elective Caesarean Sections: A Pilot RCT.

Obese women undergoing caesarean section (CS) are at increased risk of surgical site infection (SSI). Negative Pressure Wound Therapy (NPWT) is growing in use as a prophylactic approach to prevent wound complications such as SSI, yet there is little evidence of its benefits. This pilot randomized controlled trial (RCT) assessed the effect of NPWT on SSI and other wound complications in obese women undergoing elective caesarean sections (CS) and also the feasibility of conducting a definitive trial. Ninety-two obese women undergoing elective CS were randomized in theatre via a central web based system using a parallel 1:1 process to two groups i.e., 46 women received the intervention (NPWT PICO™ dressing) and 46 women received standard care (Comfeel Plus(®) dressing). All women received the intended dressing following wound closure. The relative risk of SSI in the intervention group was 0.81 (95% CI 0.38-1.68); for the number of complications excluding SSI it was 0.98 (95% CI 0.34-2.79). A sample size of 784 (392 per group) would be required to find a statistically significant difference in SSI between the two groups with 90% power. These results demonstrate that a larger definitive trial is feasible and that careful planning and site selection is critical to the success of the overall study.

The relationship between obesity and surgical site infections in women undergoing caesarean sections: an integrative review.

OBJECTIVE: to provide a critical evaluation of published research on the relationship between obesity and surgical site infection (SSI) in obese women undergoing caesarean section. METHOD: an integrative literature review was conducted using five databases (CINAHL, PUBMED, Cochrane, and EBSCO host) for 2002-2012. Inclusion criteria were: (1) wound infection as an outcome measure for obstetric/maternal complications; (2) obesity assessed as an independent risk factor for wound infection in women undergoing caesarean section; (3) research undertaken in the past 10 years; and (4) full text articles available in English with abstract. A two point assessment score was used to evaluate the included studies in relation to representativeness of sample; accuracy of measures in data collection; and appropriateness of analytic techniques; (5) Databases where accessed including PubMed and MedLine. an intergrative literature review was conducted using four databases. FINDINGS: thirteen research-based papers met the inclusion criteria, and the selected papers used various designs and methods. Five out of 13 studies scored highly in all three quality domains. All 13 studies supported a relationship between obesity and SSI and caesarean section was more common in obese women. CONCLUSION: obesity is a global priority health concern affecting all ages and as demonstrated in this review, can result in serious postoperative complications for child bearing women undergoing caesarean section such as SSI. Further research is required into wound management practices of the obese women following caesarean section as this is an area currently lacking high quality research. IMPLICATIONS FOR PRACTICE: community midwives are well positioned to implement wound assessments in this cohort of women post-discharge, when SSI is often detected.

Independent contribution of plaque complexity to myocardial ischemia during dobutamine stress echocardiography.

The influence of complex plaque morphology on the extent of demand-induced ischemia in unselected patients is not well defined. We sought to investigate the functional significance of lesion morphology in patients who underwent coronary angiography and dobutamine stress echocardiography (DSE). Angiography and DSE were performed within a 6-month period (mean 1 +/- 1 month) in 196 patients. Angiographic assessments involved quantification of stenosis severity, assessment of the extent of jeopardized myocardium, and categorization of plaque morphology according to the Ambrose classification. DSE was interpreted by separate investigators with respect to wall motion score index (WMSI) and number of coronary territories involved. A general linear model was constructed to assess the independent contribution of patient characteristics and angiographic and DSE results with respect to extent of ischemic myocardium. Complex lesion morphology was seen in 62 patients (32%). Patients with complex lesions were more likely to have had prior myocardial infarction (p <0.001) and be current smokers (p = 0.03). During angiography, they exhibited a trend toward a greater number of diseased vessels, had a greater coronary jeopardy score (p <0.001) and more frequent collateral flow (p = 0.03). During echocardiography, patients had a higher stress WMSI (p <0.001) and were more likely to show ischemia in all 3 arterial territories (p <0.01). On multivariate regression, the coronary artery jeopardy score and the presence of complex plaque morphology were independent predictors of the extent of ischemic myocardium (R(2) = 34%, p <0.001). Thus, patients with complex plaque morphology are older, more likely to smoke, and more likely to have had prior myocardial infarction. They exhibit more extensive disease with higher coronary jeopardy scores and a higher resting and peak stress WMSI. Despite these differences, complex plaque morphology remains an independent predictor of the extent of ischemia during stress.

Echocardiographic detection of early diabetic myocardial disease.

OBJECTIVES: We sought to determine whether disturbances of myocardial contractility and reflectivity could be detected in diabetic patients without overt heart disease and whether these changes were independent and incremental to left ventricular hypertrophy (LVH). BACKGROUND: Left ventricular (LV) dysfunction is associated with diabetes mellitus, but LVH is common in this population and the relationship between diabetic LV dysfunction and LVH is unclear. METHODS: We studied 186 patients with normal ejection fraction and no evidence of CAD: 48 with diabetes mellitus only (DM group), 45 with LVH only (LVH group), 45 with both diabetes and LVH (DH group), and 48 normal controls. Peak strain and strain rate of six walls in apical four-chamber, long-axis, and two-chamber views were evaluated and averaged for each patient. Calibrated integrated backscatter (IB) was assessed by comparison of the septal or posterior wall with pericardial IB intensity. RESULTS: All patient groups (DM, DH, LVH) showed reduced systolic function compared with controls, evidenced by lower peak strain (p < 0.001) and strain rate (p = 0.005). Calibrated IB, signifying myocardial reflectivity, was greater in each patient group than in controls (p < 0.05). Peak strain and strain rate were significantly lower in the DH group than in those in the DM alone (p < 0.03) or LVH alone (p = 0.01) groups. CONCLUSIONS: Diabetic patients without overt heart disease demonstrate evidence of systolic dysfunction and increased myocardial reflectivity. Although these changes are similar to those caused by LVH, they are independent and incremental to the effects of LVH.