Tackling Guideline Non-concordance: Primary Care Barriers to Incorporating Life Expectancy into Lung Cancer Screening Decision-Making-A Qualitative Study.

BACKGROUND: Primary care providers (PCPs) are often the first point of contact for discussing lung cancer screening (LCS) with patients. While guidelines recommend against screening people with limited life expectancy (LLE) who are less likely to benefit, these patients are regularly referred for LCS. OBJECTIVE: We sought to understand barriers PCPs face to incorporating life expectancy into LCS decision-making for patients who otherwise meet eligibility criteria, and how a hypothetical point-of-care tool could support patient selection. DESIGN: Qualitative study based on semi-structured telephone interviews. PARTICIPANTS: Thirty-one PCPs who refer patients for LCS, from six Veterans Health Administration facilities. APPROACH: We thematically analyzed interviews to understand how PCPs incorporated life expectancy into LCS decision-making and PCPs' receptivity to a point-of-care tool to support patient selection. Final themes were organized according to the Cabana et al. framework Why Don't Physicians Follow Clinical Practice Guidelines, capturing the influence of clinician knowledge, attitudes, and behavior on LCS appropriateness determinations. KEY RESULTS: PCP referrals to LCS for patients with LLE were influenced by limited knowledge of the life expectancy threshold at which patients are less likely to benefit from LCS, discomfort estimating life expectancy, fear of missing cancer at the point of early detection, and prioritization of factors such as quality of life, patient values, clinician-patient relationship, and family support. PCPs were receptive to a decision support tool to inform and communicate LCS appropriateness decisions if easy to use and integrated into clinical workflows. CONCLUSIONS: Our study suggests knowledge gaps and attitudes may drive decisions to offer screening despite LLE, a behavior counter to guideline recommendations. Integrating a LCS decision support tool that incorporates life expectancy within the electronic medical record and existing clinical workflows may be one acceptable solution to improve guideline concordance and increase confidence in selecting high benefit patients for LCS.

Disparities across the continuum of lung cancer care: a review of recent literature.

PURPOSE OF REVIEW: Lung cancer remains the leading cause of cancer mortality worldwide. Health disparities have long been noted in lung cancer incidence and survival and persist across the continuum of care. Understanding the gaps in care that arise from disparities in lung cancer risk, screening, treatment, and survivorship are essential to guiding efforts to achieve equitable care. RECENT FINDINGS: Recent literature continues to show that Black people, women, and people who experience socioeconomic disadvantage or live in rural areas experience disparities throughout the spectrum of lung cancer care. Contributing factors include structural racism, lower education level and health literacy, insurance type, healthcare facility accessibility, inhaled carcinogen exposure, and unmet social needs. Promising strategies to improve lung cancer care equity include policy to reduce exposure to tobacco smoke and harmful pollutants, more inclusive lung cancer screening eligibility criteria, improved access and patient navigation in lung cancer screening, diagnosis and treatment, more deliberate offering of appropriate surgical and medical treatments, and improved availability of survivorship and palliative care. SUMMARY: Given ongoing disparities in lung cancer care, research to determine best practices for narrowing these gaps and to guide policy change are an essential focus of future lung cancer research.

"It Can't Hurt!": Why Many Patients With Limited Life Expectancy Decide to Accept Lung Cancer Screening.

PURPOSE: Lung cancer screening (LCS) has less benefit and greater potential for iatrogenic harm among people with multiple comorbidities and limited life expectancy. Yet, such individuals are more likely to undergo screening than healthier LCS-eligible people. We sought to understand how patients with marginal LCS benefit conceptualize their health and make decisions regarding LCS. METHODS: We interviewed 40 people with multimorbidity and limited life expectancy, as determined by high Care Assessment Need scores, which predict 1-year risk of hospitalization or death. Patients were recruited from 6 Veterans Health Administration facilities after discussing LCS with their clinician. We conducted a thematic analysis using constant comparison to explore factors that influence LCS decision making. RESULTS: Patients commonly held positive beliefs about screening and perceived LCS to be noninvasive. When posed with hypothetical scenarios of limited benefit, patients emphasized the nonlongevity benefits of LCS (eg, peace of mind, planning for the future) and generally did not consider their health status or life expectancy when making decisions regarding LCS. Most patients were unaware of possible additional evaluations or treatment of screen-detected findings, but when probed further, many expressed concerns about the potential need for multiple evaluations, referrals, or invasive procedures. CONCLUSIONS: Patients in this study with multimorbidity and limited life expectancy were unaware of their greater risk of potential harm when accepting LCS. Given patient trust in clinician recommendations, it is important that clinicians engage patients with marginal LCS benefit in shared decision making, ensuring that their values of desiring more information about their health are weighed against potential harms from further evaluations.

The effects of intravenous hydration regimens in nulliparous women undergoing induction of labor: A systematic review and meta-analysis.

INTRODUCTION: Labor is both a physiological and physical activity that requires energy expenditure by the woman. Despite this, women are often fasted in labor, with hydration requirements addressed predominantly by intravenous therapy. Little is known about how best to manage this in nulliparous women undergoing induction of labor, who can be prone to lengthy labors. Therefore, we undertook a systematic review and meta-analysis to determine the effects of intravenous hydration regimens on nulliparous women undergoing induction of labor. MATERIAL AND METHODS: A systematic review and meta-analysis were conducted. Databases searched were PubMed, CINAHL, Embase, Cochrane, Scopus, and Web of Science using the search strategy combination of associated key concepts for intravenous therapy and nulliparous laboring women. The primary outcome was excessive neonatal weight loss. Meta-analyses for categorical outcomes included estimates of odds ratio (OR) and their 95% confidence intervals (CI) calculated; and for continuous outcomes the standardized mean difference, each with its 95% CI. Heterogeneity was assessed visually and by using the χ2 statistic and I2 with significance being set at p < 0.10. RESULTS: A total of 1512 studies were located and following screening, three studies met the eligibility criteria. No studies reported excessive neonatal weight loss. Increased rates of intravenous therapy (250 mL/h vs. 125 mL/h) during labor were not found to reduce the overall length of labor (mean difference -0.07 h, 95% CI -0.27 to 0.13 h) or reduce cesarean sections (OR 0.74, 95% CI 0.45-1.23), when women were not routinely fasted. CONCLUSIONS: Our review found no significant improvements for nulliparous women who received higher intravenous fluid volumes when undergoing induction of labor and were not routinely fasted. However, data are limited, and further research is needed.

Designing a behaviour change intervention using COM-B and the Behaviour Change Wheel: Co-designing the Healthy Gut Diet for preventing gestational diabetes.

BACKGROUND: Evidence suggests that modulating the gut microbiota during pregnancy may help prevent gestational diabetes mellitus (GDM). The Healthy Gut Diet study is a complex behaviour change intervention co-designed with women who have a lived experience of GDM. The aim of the study was to describe the development of the behaviour change dietary intervention, the Healthy Gut Diet. METHODS: This study followed the process for designing behaviour change interventions using the Behaviour Change Wheel. Six researchers and 12 women with lived experience participated in online workshops to co-design the Healthy Gut Diet intervention. This included "diagnosing" the barriers and enablers to two target behaviours: eating more plant foods and eating less ultra processed/saturated fat containing foods. Content analysis of the workshop transcripts and activities was undertaken, underpinned by the Capability, Opportunity, Motivation and Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). RESULTS: Barriers and enablers to the target behaviours were described across all six COM-B components and 10 TDF domains. The intervention functions for the Healthy Gut Diet were education, enablement, environmental restructuring, persuasion and incentivisation. Forty behaviour change techniques were integrated into five modes of delivery for the Healthy Gut Diet intervention. The feasibility, acceptability and effectiveness of the Healthy Gut Diet is being tested within a randomised controlled trial. CONCLUSIONS: Using the Behaviour Change Wheel process in partnership with consumers resulted in a clearly described complex intervention targeting barriers and enablers of dietary behaviour change to improve the gut microbiota diversity in pregnant women.

Co-designing The Healthy Gut Diet for Preventing Gestational Diabetes: Co-design methods and process outcomes.

BACKGROUND: Gestational diabetes mellitus (GDM) is a common and costly condition of pregnancy. The Healthy Gut Diet for Preventing Gestational Diabetes study is a novel randomised controlled trial that aims to prevent GDM through a diet that modulates the gut microbiota for pregnant women with GDM risk factors. Despite increasing interest in co-designing interventions with consumers (lived experience experts), co-design methods and outcomes are often poorly reported. The present study aims to report on the co-design process used to develop The Healthy Gut Diet intervention. METHODS: Co-design occurred across three online workshops with consumer participants (women with a lived experience of GDM, n = 11), researchers (n = 6) and workshop co-facilitators (including a consumer co-facilitator, n = 2). The workshops explored women's preferences for the mode and length of education sessions, as well as the types of information and supportive resources women wanted to receive, and undertook a "behaviour diagnosis" to understand barriers and enablers to the target behaviours (eating for gut health). The final intervention is reported according to the Template for Intervention Description and Replication. RESULTS: A co-designed dietary intervention (The Healthy Gut Diet), delivered via telehealth, with a suite of educational and supportive resources that integrates published behaviour change techniques, was developed. Generally, the co-design process was reported as a positive experience based on participant feedback and evidenced by no participant dropouts over the 3-month study period. CONCLUSIONS: Co-design is recognised as a process that creates a partnership between lived experience experts and researchers who can engage and empower research recipients and improve health behaviours.

Being a First Nations baby is not independently associated with low birthweight in a large metropolitan health service.

AIM: To examine low birth weight (LBW) in First Nations babies born in a large metropolitan health service in Queensland, Australia. MATERIALS AND METHODS: A retrospective population-based study using routinely collected data from administrative data sources. All singleton births in metropolitan health services, Queensland, Australia of ≥20 weeks gestation or at least 400 g birthweight and had information on First Nations status and born between 2019 and 2021 were included. The study measured birthweight and birthweight z-score, and also identified the predictors of LBW. Multivariate regression models were adjusted by demographic, socioeconomic and perinatal factors. RESULTS: First Nations babies had higher rates of LBW (11.4% vs 6.9%, P < 0.001), with higher rates of preterm birth (13.9% vs 8.8%, P < 0.001). In all babies, the most important factors contributing to LBW were: maternal smoking after 20 weeks of gestation; maternal pre-pregnancy underweight (body mass index <18.5 kg/m2); nulliparity; socioeconomic disadvantage; geographical remoteness; less frequent antenatal care; history of cannabis use; pre-existing cardiovascular disease; pre-eclampsia; antepartum haemorrhage; and birth outcomes including prematurity and female baby. After adjusting for all contributing factors, no difference in odds of LBW was observed between First Nations and non-First Nation babies. CONCLUSIONS: First Nations status was not an independent factor influencing LBW in this cohort, after adjustment for identifiable factors. The disparity in LBW relates to modifiable risk factors, socioeconomic disadvantage, and prematurity. Upscaling culturally safe maternity care, focusing on modifiable risk factors is required to address LBW in Australian women.

Evidence-based guidelines for intrapartum maternal hydration assessment and management: A scoping review.

PROBLEM: Inconsistent practice relating to intrapartum hydration assessment and management is reported, and potential harm exists for laboring women and birthing persons. BACKGROUND: Labor and birth are physically demanding, and adequate nutrition and hydration are essential for labor progress. A lack of clear consensus on intrapartum hydration assessment and management during labor and birth currently exists. In addition, there is an inconsistent approach to managing hydration, often including a mixture of intravenous and oral fluids that are poorly monitored. AIM: The aim of this scoping review was to identify and collate evidence-based guidelines for intrapartum hydration assessment and management of maternal hydration during labor and birth. METHODS: PubMed, Embase, and CINAHL databases were searched, in addition to professional college association websites. Inclusion criteria were intrapartum clinical guidelines in English, published in the last 10 years. FINDINGS: Despite searching all appropriate databases in maternity care, we were unable to identify evidence-based guidelines specific to hydration assessment and management, therefore resulting in an "empty review." A subsequent review of general intrapartum care guidelines was undertaken. Our adapted review identified 12 guidelines, seven of which referenced the assessment and management of maternal hydration during labor and birth. Three guidelines recommend that "low-risk" women in spontaneous labor at term should hold determination over what they ingest in labor. No recommendations with respect to assessment and management of hydration for women undergoing induction of labor were found. DISCUSSION: Despite the increasing use of intravenous fluid as an adjunct to oral intake to maintain maternal intrapartum hydration, there is limited evidence and, subsequently, guidelines to determine best practice in this area. How hydration is assessed was also largely absent from general intrapartum care guidelines, further perpetuating potential clinical variation in this area. CONCLUSION: There is an absence of guidelines specific to the assessment and management of maternal hydration during labor and birth, despite its importance in ensuring labor progress and safe care.

A prospective cohort study comparing neonatal outcomes of waterbirth and land birth in an Australian tertiary maternity unit.

BACKGROUND: Maternal preference for warm water immersion (WWI) and waterbirth is increasing, but adoption into obstetric guidelines and clinical practice remains limited. Concerns regarding safety and a paucity of evidence have been cited as reasons for the limited adoption and uptake. AIM: The aim was to investigate maternal and neonatal outcomes after WWI and/or waterbirth compared with land birth. MATERIALS AND METHODS: A prospective cohort study was conducted in an Australian public maternity hospital between 2019 and 2020. Maternal and neonatal outcomes for 1665 women who had a vaginal birth were studied. Primary outcome was admission to the neonatal unit (NNU). Secondary outcomes included neonatal antibiotic administration, maternal intrapartum fever, epidural use and perineal injury. Multivariate logistical regression analyses compared the outcomes between three groups: waterbirth, WWI only and land birth. RESULTS: NNU admissions for a suspected infectious condition were significantly higher in the land birth group (P = 0.035). After accounting for labour duration, epidural use and previous birth mode, no significant difference was detected between groups in the odds of NNU admission (P = 0.167). No babies were admitted to NNU with water inhalation or drowning. Women birthing on land were more likely to be febrile (2 vs 0%; P = 0.007); obstetric anal sphincter injury and postpartum haemorrhage were similar between groups. Regional analgesia use was significantly lower in the WWI group compared to the land birth group (21.02 vs 38.58%; P = <0.001). There was one cord avulsion in the waterbirth group (0.41%). CONCLUSION: Maternal and neonatal outcomes were similar between groups, with no increased risk evident in the waterbirth and WWI groups.

The effectiveness of continuous positive airway pressure for treating obstructive sleep apnoea in pregnancy: A systematic review.

BACKGROUND: Obstructive sleep apnoea (OSA) occurs in 15-20% of pregnant women living with obesity. As global obesity prevalence increases, OSA in pregnancy is concurrently increasing, yet remains under-diagnosed. The effects of treating OSA in pregnancy are under-investigated. AIM: A systematic review was conducted to determine whether treating pregnant women with OSA using continuous positive airway pressure (CPAP) will improve maternal or fetal outcomes, compared with no treatment or delayed treatment. MATERIALS AND METHODS: Original studies in English published until May 2022 were included. Searches were conducted in Medline, PubMed, Scopus, the Cochrane Library and clinicaltrials.org. Maternal and neonatal outcome data were extracted, and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach (PROSPERO registration: CRD42019127754). RESULTS: Seven trials met inclusion criteria. Use of CPAP in pregnancy appears to be well tolerated with reasonable adherence. Use of CPAP in pregnancy may be associated with both a reduction in blood pressure and pre-eclampsia. Birthweight may be increased by maternal CPAP treatment, and preterm birth may be reduced by treatment with CPAP in pregnancy. CONCLUSION: Treatment of OSA with CPAP in pregnancy may reduce hypertension and, preterm birth, and may increase neonatal birthweight. However, more rigorous definitive trial evidence is required to adequately assess the indication, efficacy, and applications of CPAP treatment in pregnancy.

The impact of an autonomous nurse-led high-flow nasal cannula oxygen protocol on clinical outcomes of infants with bronchiolitis.

OBJECTIVE: To investigate the relationship of the implementation of a nurse-led high-flow nasal cannula oxygen protocol on the clinical outcomes of infants with bronchiolitis in a regional paediatric unit. BACKGROUND: Bronchiolitis is a common lower respiratory illness and is the leading cause for hospitalisation of infants globally. Standard care involves the provision of supportive measures. Historically, supplemental oxygen was provided by low-flow nasal cannula. High-flow nasal cannula oxygen has been increasingly adopted despite limited evidence of its efficacy. METHODS: This study employed non-equivalent, post-implementation only design to explore clinical outcomes of infants with bronchiolitis admitted for high-flow nasal cannula oxygen therapy. The study compared infants in the 24 months before and after the initiation of a high-flow nasal cannula protocol. The primary clinical outcome was length of stay, secondary outcomes included time on high flow, weaning time, escalation of care and time outside of physiological parameters. Implementation strategy evaluation was measured by compliance with applying the protocol, reported as episodes of variance, and duration of variance. The StaRI checklist was selected as the most appropriate reporting guideline. RESULTS: A total of 80 patients were admitted with bronchiolitis and received high-flow nasal cannula oxygen therapy during a 48-month period; 37 patients were prior, and 43 after, the introduction of a nurse-led high-flow nasal cannula protocol. Length of stay was significantly reduced in the post-implementation group compared to the historical control group (83.8 vs. 61.3 h). Time on high flow and weaning time was decreased in the post-implementation group compared to the control group (33.5 vs. 26.7 h and 26 vs.12.25 h, respectively); however, these did not reach statistical significance. There was varied application of the HFNC protocol. CONCLUSIONS: The implementation of a nurse-led high-flow nasal cannula protocol was associated with a reduced length of stay. RELEVANCE TO CLINICAL PRACTICE: This study demonstrated that infants with bronchiolitis that were treated with a nurse-led high-flow nasal cannula (HFNC) therapy protocol had positive effects on clinical outcomes including a shorter length of stay than compared with those with physician-directed care in a regional paediatric unit. A weight-based (2 L/kg) HFNC therapy was safely administered to infants with bronchiolitis in a regional hospital paediatric ward with no paediatric intensive care unit (PICU).

Ligand-Structure Effects on N-Heterocyclic Carbene Rhenium Photo- and Electrocatalysts of CO2 Reduction.

Three novel rhenium N-heterocyclic carbene complexes, [Re]-NHC-1-3 ([Re] = fac-Re(CO)3Br), were synthesized and characterized using a range of spectroscopic techniques. Photophysical, electrochemical and spectroelectrochemical studies were carried out to probe the properties of these organometallic compounds. Re-NHC-1 and Re-NHC-2 bear a phenanthrene backbone on an imidazole (NHC) ring, coordinating to Re by both the carbene C and a pyridyl group attached to one of the imidazole nitrogen atoms. Re-NHC-2 differs from Re-NHC-1 by replacing N-H with an N-benzyl group as the second substituent on imidazole. The replacement of the phenanthrene backbone in Re-NHC-2 with the larger pyrene gives Re-NHC-3. The two-electron electrochemical reductions of Re-NHC-2 and Re-NHC-3 result in the formation of the five-coordinate anions that are capable of electrocatalytic CO2 reduction. These catalysts are formed first at the initial cathodic wave R1, and then, ultimately, via the reduction of Re-Re bound dimer intermediates at the second cathodic wave R2. All three Re-NHC-1-3 complexes are active photocatalysts for the transformation of CO2 to CO, with the most photostable complex, Re-NHC-3, being the most effective for this conversion. Re-NHC-1 and Re-NHC-2 afforded modest CO turnover numbers (TONs), following irradiation at 355 nm, but were inactive at the longer irradiation wavelength of 470 nm. In contrast, Re-NHC-3, when photoexcited at 470 nm, yielded the highest TON in this study, but remained inactive at 355 nm. The luminescence spectrum of Re-NHC-3 is red-shifted compared to those of Re-NHC-1 and Re-NHC-2, and previously reported similar [Re]-NHC complexes. This observation, together with TD-DFT calculations, suggests that the nature of the lowest-energy optical excitation for Re-NHC-3 has π→π*(NHC-pyrene) and dπ(Re)→π*(pyridine) (IL/MLCT) character. The stability and superior photocatalytic performance of Re-NHC-3 are attributed to the extended conjugation of the π-electron system, leading to the beneficial modulation of the strongly electron-donating tendency of the NHC group.

Nonurgent Pediatric Interhospital Transfers: A Narrative Enquiry of Nurses' Experiences in Australia.

INTRODUCTION: This study aimed to explore nonurgent pediatric interhospital transfers through the lens of nurses' experiences and perceptions when undertaking these transfers. METHODS: Using a narrative inquiry approach, data were collected via semistructured interviews with registered nurses (N = 7) who had experience undertaking patient transfers between nonurgent low-acuity and urgent high-acuity hospital settings. RESULTS: Findings established the following 8 themes: ensuring transfer preparation for risk mitigation, practicing confident advocacy, being accountable for risk mitigation of the deteriorating patient during transfer, maintaining standardized procedure, using training and mentorship to support confidence, maintaining interhospital and intrahospital relationships, recognizing the significance of transfer on families, and acknowledging the burden of transfer and delay. DISCUSSION: By exploring the stories and experiences of emergency nurses who undertake pediatric interhospital transfers, a deep investigation of the risks and challenges has been described, an area often underrepresented in the literature. Findings from this study highlight important learnings for pediatric interhospital transfer that add value to the wider body of evidence.

Integrated review of the knowledge, attitudes, and practices of maternity health care professionals concerning umbilical cord clamping.

BACKGROUND: Umbilical cord clamp timing has implications for newborn health, which include increased iron stores up to 6 months of age. National and International cord clamping guidelines differ as do health professionals' practices. The rationale for differences in cord clamping practice is unclear. AIMS AND OBJECTIVE: Studies on the knowledge, attitudes, and practices of maternity health care professionals about cord clamp timing were synthesized. Similarities and differences between professional groups and understanding of the optimal timing of cord clamp timing for term newborns were compared. METHODS: An integrative review was undertaken. PubMed, Scopus, MIDIRS, CINAHL, and Google Scholar were searched. Publication date limits were set between January 2007 and December 2020. Quality appraisal was undertaken using the Critical Appraisal Skills Program (CASP) tools. RESULTS: Eighteen studies met inclusion criteria, as they included primary research studies that investigated maternity health care professionals' knowledge, attitudes, and practices about umbilical cord clamping, and were written in English. Four main subject areas were identified: a) knowledge of optimal cord clamp timing; b) attitudes and perceptions of early vs deferred cord clamping; c) cord clamping practice; and d) rationale for cord clamping practice. CONCLUSIONS: Different attitudes and practices were identified between midwifery and medical professionals in relation to cord clamp timing together with health professional knowledge and practice gaps pertaining to optimal cord clamp timing. Contemporary evidence should inform guidelines for clinical practice and be embedded into maternity health professional curricula and professional development programs.

A mixed methods study to inform and evaluate a longitudinal nurse practitioner/community health worker intervention to address social determinants of health and chronic obstructive pulmonary disease self-management.

BACKGROUND: Individuals with low socioeconomic status experience higher prevalence and worse outcomes of chronic obstructive pulmonary disease (COPD). We undertook a quality improvement initiative at our safety net hospital in which a nurse practitioner (NP)/community health worker (CHW) team followed patients with COPD, frequent admissions, and unmet SDOH needs from hospitalization through one month post-discharge. We report our mixed methods approach to inform development and preliminary evaluation of this intervention. METHODS: We first assessed characteristics of patients admitted with COPD in 2018 (n = 1811), performing multivariable logistic regression to identify factors associated with ≥ 2 admissions per year. We then tested a standardized tool to screen for unmet SDOH needs in a convenience sample of 51 frequently hospitalized patients with COPD. From January-July 2019, we pilot tested the NP/CHW intervention with 57 patients, reviewed NP/CHW logs, and conducted qualitative interviews with 16 patient participants to explore impressions of the intervention. RESULTS: Patients with Medicaid insurance, mental health disorders, cardiac disease, and substance use disorder had increased odds of having ≥ 2 admissions. COPD severity, comorbidities, and unmet SDOH needs made COPD self-management challenging. Seventy-four percent of frequently admitted patients with COPD completing SDOH screening had unmet SDOH needs. Patients perceived that the NP/CHW intervention addressed these barriers by connecting them to resources and providing emotional support. CONCLUSIONS: Many patients with COPD admitted at our safety-net hospital experience unmet SDOH needs that impede COPD self-management. A longitudinal NP/CHW intervention to address unmet SDOH needs following discharge appears feasible and acceptable.

Challenges parents encounter when implementing infant safe sleep advice.

AIM: To understand which safe sleep recommendations parents find most challenging to implement, identifying common barriers encountered; and investigate whether challenges are associated with practices employed. METHODS: A cross-sectional survey of 3341 Australian families with young infants who birthed a live baby during April-May 2017. Caregivers were asked about infant care practices and family characteristics. Qualitative free-text items explored challenges faced with current safe sleep recommendations. RESULTS: Nearly one-third (n = 1033, 31%) of caregivers reported difficulty with at least one safe sleep recommendation. Infant sleep position and avoiding bed-sharing were identified as the most challenging recommendations. Caregivers described barriers which influenced consistency in uptake of advice. Families who described difficulty with a recommendation were significantly less likely to consistently employ that advice compared to those who did not report difficulty (sleep position: 198/473,42% vs 2548/2837,90% [p < 0.0001]; own sleep space: (269/344,78% vs 1331/2884,46% [p < 0.0001]). When families encountered challenges, they often proposed alternate strategies with an inference their substitute action compensated potential increased risk. CONCLUSION: Many families encounter difficulties implementing safe sleep advice; these challenges negatively impact care practices. Effective interventions meeting individual family needs, to provide safe sleep environments consistently, are necessary to improve sleep-related infant care and further reduce infant mortality.

Priority setting: Consensus for Australia's infant safe sleeping public health promotion programme.

AIM: To develop focused priorities to inform the revision of Australia's Sudden Unexpected Death in Infancy (SUDI) risk reduction public health programme. METHODS: A content expert consensus research activity was designed using two consensus techniques. The two-phase study employed a Delphi process (phase 1) and a Nominal Group workshop technique (phase 2). The Delphi invited 56 national and international content experts. The Nominal Group comprised 17 Australasian experts and stakeholders to ensure priority setting was relevant to the Australian context. RESULTS: Phase 1 established a ranked thematic list of 10 key SUDI risk reduction themes. Phase 2 addressed three nominal questions producing prioritised lists for: key-message wording; contextual information and strategies to support caregiver implementation of key messages; and considerations in redesigning and dissemination of a safe sleep campaign. The top four priority themes were: sleep position, sleep space, smoking and surface-sharing. CONCLUSION: This two-phase priority setting was successful in establishing clearly defined infant safe sleep priorities. International content expert participation in phase 1 strengthened priority setting outcomes while phase 2 ensured final outcomes provided a strong national focus reflective of identified needs of Australian families. Findings provide a foundation from which important components can be considered when revising and developing future SUDI risk reduction programmes.

Peripheral intravenous catheter management in childbirth (PICMIC): A multi-centre, prospective cohort study.

BACKGROUND: Childbirth is a normal, physiological process, yet intervention is common. Arguably the most common intervention is the insertion of a peripheral intravenous catheter; however, there are few studies guiding best practice. This study aimed to describe current intravenous catheter insertion practice, explore clinician decision-making during insertion and perceptions of women. METHODS: This prospective, observational cohort study recruited 101 women and clinicians from two Australian regional hospitals. Data collection incorporated non-participant observation, brief interview and chart review. Variables measured included pain score, insertion attempts, catheter gauge and dwell time. RESULTS: Childbearing women were, on average, aged 31 with body mass index (BMI) above 28. Women reported a mean pain score of 3.3/10 at 24 h for catheter insertion and 12% reported bruising. An 18-gauge catheter was considered more painful than a 16-gauge, and multiple attempts did not increase perceived average pain score. Association between failed first attempts and higher BMI was not established. Participant clinicians were predominantly midwives, who selected and placed 18-gauge catheters mostly in hand or wrist (66%). Decision-making about site, catheter gauge, dressing and attempts varied. Thirty-four per cent attempted two to three times, despite regular practise. Confidence to reliably insert determined catheter gauge and almost half clinician participants cited hospital policy and preferred non-dominant arm as key reasons for the location of PIVC. CONCLUSIONS: Regular use of a large-gauge catheter is counter intuitive when placed in the small veins of the hand with extension tubing. More research is needed to promote best practice around gauge selection, site and women's experience.

Implementation of a guideline of early administration of tranexamic acid for severe primary postpartum haemorrhage: a retrospective comparative study.

BACKGROUND: Since the WOMAN trial, intravenous tranexamic acid (TXA) has been increasingly used in severe postpartum haemorrhage (PPH) but research evaluating use in high-income settings is limited. AIMS: To assess whether implementation of a new guideline involving early administration of 1 g intravenous TXA in active PPH with blood loss ≥ 1000 mL, was associated with a change in maternal morbidity. MATERIALS AND METHODS: Retrospective study of all singleton, term, vaginal births from November 2016 to June 2019 with a PPH of ≥1000 mL, before and after hospital adoption of a guideline recommending early (within three hours of birth) administration of TXA for women with active PPH ≥ 1000 mL. Univariate analysis assessed the impact of this guideline implementation on a primary outcome of maternal morbidity, defined as one or more of haemoglobin < 90 g/L, administration of blood products, hysterectomy or intensive care admission. Secondary outcomes were adverse events related to administration of TXA, use of an intrauterine balloon or postpartum iron infusion. RESULTS: There was no difference in morbidity (odds ratio (OR) 0.86, 95% CI 0.57-1.29, P = 0.46) or postpartum iron infusion (OR 1.44, 95% CI 0.92-2.27, P = 0.11), but there was a reduction in the use of intrauterine balloon tamponade after the implementation of the TXA guideline (OR 0.33, 95% CI 0.16-0.67, P < 0.01). CONCLUSIONS: This retrospective analysis showed a reduced use of intrauterine balloon but failed to show a benefit in maternal morbidity with early administration of TXA for severe postpartum haemorrhage in a high-income setting.

Maternity health professionals' perspectives of cord clamp timing, cord blood banking and cord blood donation: a qualitative study.

BACKGROUND: Parents today have several options for the management of their infant's cord blood during the third stage of labour. Parents can choose to have their infant's cord clamped early or to have deferred cord clamping. If the cord is clamped early, cord blood can be collected for private cord blood banking or public cord blood donation for use later if needed. If cord clamping is deferred, the placental blood physiologically transfuses to the neonate and there are physiological advantages to this. These benefits include a smoother cardiovascular transition and increased haemoglobin levels while not interfering with the practice of collecting cord blood for gases if needed. The aim of this study is to explore Australian maternity health professionals' perspectives towards cord clamp timing, cord blood banking and cord blood donation. METHODS: Fourteen maternity health professionals (midwives and obstetricians) from both private and public practice settings in Australia participated in semi-structured interviews either in person or by telephone. Interviews were transcribed and data analysed using thematic analysis. RESULTS: Overall there was strong support for deferred cord clamping, and this was seen as important and routinely discussed with parents as part of antenatal care. However, support did not extend to the options of cord blood banking and donation and to routinely informing parents of these options even when these were available at their birthing location. CONCLUSION: Formalised education for maternity health professionals is needed about the benefits and implications of cord blood banking and cord blood donation so that they have the confidence to openly discuss all options of cord clamp timing, cord blood banking and cord blood donation to facilitate informed decision-making by parents.