In-hospital airway management of COVID-19 patients.

Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.

Ischaemia reperfusion injury in liver transplantation: Cellular and molecular mechanisms.

Liver disease causing end organ failure is a growing cause of mortality. In most cases, the only therapy is liver transplantation. However, liver transplantation is a complex undertaking and its success is dependent on a number of factors. In particular, liver transplantation is subject to the risks of ischaemia-reperfusion injury (IRI). Liver IRI has significant effects on the function of a liver after transplantation. The cellular and molecular mechanisms governing IRI in liver transplantation are numerous. They involve multiple cells types such as liver sinusoidal endothelial cells, hepatocytes, Kupffer cells, neutrophils and platelets acting via an interconnected network of molecular pathways such as activation of toll-like receptor signalling, alterations in micro-RNA expression, production of ROS, regulation of autophagy and activation of hypoxia-inducible factors. Interestingly, the cellular and molecular events in liver IRI can be correlated with clinical risk factors for IRI in liver transplantation such as donor organ steatosis, ischaemic times, donor age, and donor and recipient coagulopathy. Thus, understanding the relationship of the clinical risk factors for liver IRI to the cellular and molecular mechanisms that govern it is critical to higher levels of success after liver transplantation. This in turn will help in the discovery of therapeutics for IRI in liver transplantation - a process that will lead to improved outcomes for patients suffering from end-stage liver disease.

An action research approach to practice, service and legislative change.

AIMS: To describe the action research approach taken to engage a multidisciplinary group of health professionals and managers from five rural health services with government officers in redesigning their emergency care services and informing legislative change. BACKGROUND: The diminishing size of the medical workforce across rural Victoria in Australia captured the Victorian state government's attention when this threatened the sustainability of emergency care services in rural and remote hospitals in 2006. The government funded the collaborative practice model pilot between 2006 and 2008 to develop and test an alternative model of emergency care service in which nurses practised at a more advanced and autonomous level. DATA SOURCES: Data were sourced from a combination of interviews, focus groups and patient records. REVIEW METHODS: Qualitative data were analysed using convergent interview and thematic analysis. Quantitative data were analysed using frequencies and cross tabulations. DISCUSSION: The three critical success factors owing to action research are presented. It provided a politically safe approach to service, policy and legislative change, ensured collaboration permeated the endeavour and helped to shift the focus from a technical to an emancipatory approach to action research. CONCLUSION: Action research was key to the success achieved by the participants in changing clinical practice, service delivery and the Victorian Drugs Poisons and Controlled Substances Act (1981) to authorise registered nurses to supply medicines. IMPLICATIONS FOR PRACTICE: This paper offers an approach that nurses in practice, management and government can take to drive changes at practice, service and legislative levels in advanced nursing practice.

Victorian rural emergency care--a case for advancing nursing practice.

The aim of this paper is to profile the emergency care patients seen by a selection of rural health services in Victoria, and show how advancing nursing practice could contribute to a more sustainable model of care. Quantitative patient data extracted from five rural health services across Victoria ranging in size, were analysed using descriptive statistic techniques. Most patients who attended for emergency care did not require urgent or immediate medical attention (70%), many had minor injuries (over 30%) and did not need medicines (57%) but were attended by a doctor either directly or via telephone (over 74%). If emergency care services in rural Victoria are to be sustained in the face of severe medical workforce shortages, registered nurses will need to be enabled through professional development, legislation and organisation policy to manage autonomously a larger proportion of the non-urgent, less complex patients who present to these emergency services.

Triage, treat and transfer: reconceptualising a rural practice model.

AIM: This article argues that the current model of emergency practice in rural Victorian hospitals, which relies heavily on visiting medical officers, needs to be reconceptualised if emergency services are to be supplied to rural communities. BACKGROUND: Medical workforce shortages are manifesting in Victoria as a reduction in emergency care services from rural hospitals. The suggested alternative model of emergency care involves advancing nursing practice to enable a redistribution of clinical capacity across the health care team. Clinicians will need to work collaboratively and continuously negotiate their roles to meet the patient's and the clinical team's needs. DESIGN: Systematic review. METHODS: This article is based on a review of the Victorian and Australian literature on the subject of Victorian health services and policy, emergency care, collaboration, communication and rural nurse scope of practice and roles. Emergency care activity was drawn from data held in the Victorian Emergency Management Dataset and personal communications between one of the authors and hospital executives in a small selection of rural hospitals in Victoria. RESULTS: The evidence reviewed suggests that the current emergency practice profile of rural hospitals in Victoria does not reflect the reconceptualised model of rural emergency practice. Instead, only a small proportion of non-urgent presentations is managed by nurses without medical support, and the data suggest that metropolitan nurses are more likely to manage without medical support than rural nurses. CONCLUSION: Reconceptualising rural emergency care in Victoria will require significantly greater investment in rural nurses' knowledge and skills to enable them to operate confidently at a more advanced level. Clinical teams that deliver emergency service in rural hospitals will be expected increasingly to work collaboratively and interprofessionally. RELEVANCE TO CLINICAL PRACTICE: This article offers some directions for advancing nursing practice and strategies for improving interprofessional collaboration in the delivery of rural emergency care.

Review of small rural health services in Victoria: how does the nursing-medical division of labour affect access to emergency care?

AIMS: This paper is based on a review of the Australian and International literature relating to the nursing-medical division of labour. It also explores how the division of labour affects patient access to emergency care in small rural health services in Victoria, Australia. BACKGROUND: The paper describes the future Australian health workforce and the implications for rural Victoria. The concept of division of labour and how it relates to nursing and medicine is critically reviewed. Two forms of division of labour emerge - traditional and negotiated division of labour. Key themes are drawn from the literature that describes the impact of a traditional form of division of labour in a rural context. METHODS: This paper is based on a review of the Australian and international literature, including grey literature, on the subject of rural emergency services, professional boundaries and roles, division of labour, professional relationships and power and the Australian health workforce. RESULTS: In Australia, the contracting workforce means that traditional divisions of labour between health professionals cannot be sustained without reducing access to emergency care in rural Victoria. A traditional division of labour results in rural health services that are vulnerable to slight shifts in the medical workforce, unsafe services and recruitment and retention problems. A negotiated form of division of labour provides a practical alternative. CONCLUSION: A division of labour that is negotiated between doctors and nurses and supported by a legal and clinical governance framework, is needed to support rural emergency services. The published evidence suggests that this situation currently does not exist in Victoria. Strategies are offered for creating and supporting a negotiated division of labour. RELEVANCE TO CLINICAL PRACTICE: This paper offers some strategies for establishing a negotiated division of labour between doctors and nurses in rural emergency care.

Purification and properties of the extracellular lipase, LipA, of Acinetobacter sp. RAG-1.

An extracellular lipase, LipA, extracted from Acinetobacter sp. RAG-1 grown on hexadecane was purified and properties of the enzyme investigated. The enzyme is released into the growth medium during the transition to stationary phase. The lipase was harvested from cells grown to stationary phase, and purified with 22% yield and > 10-fold purification. The protein demonstrates little affinity for anion exchange resins, with contaminating proteins removed by passing crude supernatants over a Mono Q column. The lipase was bound to a butyl Sepharose column and eluted in a Triton X-100 gradient. The molecular mass (33 kDa) was determined employing SDS/PAGE. LipA was found to be stable at pH 5.8-9.0, with optimal activity at 9.0. The lipase remained active at temperatures up to 70 degrees C, with maximal activity observed at 55 degrees C. LipA is active against a wide range of fatty acid esters of p-nitrophenyl, but preferentially attacks medium length acyl chains (C6, C8). The enzyme demonstrates hydrolytic activity in emulsions of both medium and long chain triglycerides, as demonstrated by zymogram analysis. RAG-1 lipase is stabilized by Ca2+, with no loss in activity observed in preparations containing the cation, compared to a 70% loss over 30 h without Ca2+. The lipase is strongly inhibited by EDTA, Hg2+, and Cu2+, but shows no loss in activity after incubation with other metals or inhibitors examined in this study. The protein retains more than 75% of its initial activity after exposure to organic solvents, but is rapidly deactivated by pyridine. RAG-1 lipase offers potential for use as a biocatalyst.