Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: A scoping review.

AIMS: To explore and summarise the literature on the concept of 'clinical deterioration' as a nurse-sensitive indicator of quality of care in the out-of-hospital context. DESIGN: The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review and the JBI best practice guidelines for scoping reviews. METHODS: Studies focusing on clinical deterioration, errors of omission, nurse sensitive indicators and the quality of nursing and midwifery care for all categories of registered, enrolled, or licensed practice nurses and midwives in the out-of-hospital context were included regardless of methodology. Text and opinion papers were also considered. Study protocols were excluded. DATA SOURCES: Data bases were searched from inception to June 2022 and included CINAHL, PsychINFO, MEDLINE, The Allied and Complementary Medicine Database, EmCare, Maternity and Infant Care Database, Australian Indigenous HealthInfoNet, Informit Health and Society Database, JSTOR, Nursing and Allied Health Database, RURAL, Cochrane Library and Joanna Briggs Institute. RESULTS: Thirty-four studies were included. Workloads, education and training opportunities, access to technology, home visits, clinical assessments and use of screening tools or guidelines impacted the ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting. CONCLUSIONS: Little is known about the work of nurses or midwives in out-of-hospital settings and their recognition, reaction to and relay of information about patient deterioration. The complex and subtle nature of non-acute deterioration creates challenges in defining and subsequently evaluating the role and impact of nurses in these settings. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Further research is needed to clarify outcome measures and nurse contribution to the care of the deteriorating patient in the out-of-hospital setting to reduce the rate of avoidable hospitalisation and articulate the contribution of nurses and midwives to patient care. IMPACT: What Problem Did the Study Address? Factors that impact a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting are not examined to date. What Were the Main Findings? A range of factors were identified that impacted a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting including workloads, education and training opportunities, access to technology, home visits, clinical assessments, use of screening tools or guidelines, and avoidable hospitalisation. Where and on whom will the research have an impact? Nurses and nursing management will benefit from understanding the factors that act as barriers and facilitators for effective recognition of, and responding to, a deteriorating patient in the out-of-hospital setting. This in turn will impact patient survival and satisfaction. REPORTING METHOD: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review guidelines guided this review. The PRISMA-Scr Checklist (Tricco et al., 2018) is included as (supplementary file 1).Data sharing is not applicable to this article as no new data were created or analysed in this study." NO PATIENT OR PUBLIC CONTRIBUTION: Not required as the Scoping Review used publicly available information.

Explainable discovery of disease biomarkers: The case of ovarian cancer to illustrate the best practice in machine learning and Shapley analysis.

OBJECTIVE: Ovarian cancer is a significant health issue with lasting impacts on the community. Despite recent advances in surgical, chemotherapeutic and radiotherapeutic interventions, they have had only marginal impacts due to an inability to identify biomarkers at an early stage. Biomarker discovery is challenging, yet essential for improving drug discovery and clinical care. Machine learning (ML) techniques are invaluable for recognising complex patterns in biomarkers compared to conventional methods, yet they can lack physical insights into diagnosis. eXplainable Artificial Intelligence (XAI) is capable of providing deeper insights into the decision-making of complex ML algorithms increasing their applicability. We aim to introduce best practice for combining ML and XAI techniques for biomarker validation tasks. METHODS: We focused on classification tasks and a game theoretic approach based on Shapley values to build and evaluate models and visualise results. We described the workflow and apply the pipeline in a case study using the CDAS PLCO Ovarian Biomarkers dataset to demonstrate the potential for accuracy and utility. RESULTS: The case study results demonstrate the efficacy of the ML pipeline, its consistency, and advantages compared to conventional statistical approaches. CONCLUSION: The resulting guidelines provide a general framework for practical application of XAI in medical research that can inform clinicians and validate and explain cancer biomarkers.

Staff perceptions of the effectiveness of managerial communication during the COVID-19 pandemic: A cross-sectional study.

AIMS: This work aims to explore staff perceptions of (1) the effectiveness of organizational communication during the COVID-19 pandemic and (2) the impact of organizational communication on staff well-being and ability to progress their work and patient care. BACKGROUND: Effective coordination and communication are essential in a pandemic management response. However, the effectiveness of communication strategies used during the COVID-19 pandemic is not well understood. DESIGN: An exploratory cross-sectional research design was used. A 33-item survey tool was created for the study. METHODS: The study was conducted at a tertiary teaching hospital in Western Australia. Convenience sampling was used to recruit participants from nursing, medical, allied health services, administrative and clerical, and personal support services (N = 325). Data were collected between December 2020 and May 2021. RESULTS: Overall, all occupational groups found working during the COVID-19 pandemic stressful, and all groups wanted accessible and accurate communication from management and new policies, procedures, and protocols for future outbreaks. CONCLUSIONS: The use of occupational group-relevant strategies and COVID-19 protocols, as well as the on-going use of email, face-to-face meetings with debrief sessions, are needed to improve communication and support staff to fulfil their roles.

"A spade was called a spade ": Youth and intervention implementers' perceptions of a resilience-based HIV-prevention intervention for youth in South Africa.

The youth (15-24 years old) in South Africa remain at high risk of HIV infection despite varied efforts to control the disease. An understanding of the perspectives of relevant stakeholders of HIV-prevention interventions targeting the youth is important to guide research, policy and practice aimed at improving these interventions. This study explores youth and intervention implementers' perceptions of a resilience-based HIV-prevention intervention (You Only Live Once) aimed at reducing risky sexual behaviours among the youth in South Africa. Semi-structured interviews were conducted with 10 young people who participated in the intervention, and four intervention implementers at a not-for-profit organisation in Maluti-a-Phofung Local Municipality, South Africa. Data were analysed using thematic analysis. Three main themes emerged from the data: (1) Acceptability and impact of the intervention; (2) Factors influencing intervention implementation; and (3) Recommendations to improve intervention implementation. These findings provide insights into the acceptability, impact, barriers and facilitators of resilience-based HIV-prevention interventions for the youth in South Africa and similar contexts, and how implementation of these interventions could be enhanced. The findings can help researchers, policy makers and health care practitioners in the field of HIV prevention to improve interventions targeting young people.

SURVEILLANCE OF BATS IN THE UNITED STATES FOR SARS-COV-2 AND OTHER CORONAVIRUSES.

Bat coronaviruses (CoVs) are extremely prevalent throughout the globe and exhibit a wide range of genetic diversity. Currently, little is known about the susceptibility of New World bats to severe acute respiratory syndrome-2 (SARS-CoV-2), the causative agent of COVID-19. Also, there is limited information about the genetic diversity of other CoVs in the New World bats. The determination of genetic diversity of bat CoVs through continuous surveillance is essential to predict and mitigate the emergence of new CoVs and their impacts on the health of both humans and animals. In this study, 491 guano specimens collected from New World bats and 37 specimens collected from Old World bats during July 2020 to July 2021 were tested for SARS-COV-2 and other CoVs using a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) panel and pan-coronavirus PCR that target a highly conserved region of CoVs. No evidence of SARS-CoV-2 was found in the tested specimens. An alpha CoV was detected in a single specimen from a big brown bat (Eptesicus fuscus). This information was used by wildlife agencies and rehabilitation facilities to permit the release of bats during the pandemic while mitigating the risk of spreading SARS-CoV-2 among North American bats and other wild animal populations.

Barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth worldwide: a systematic review.

BACKGROUND: Interventions aimed at reducing risky sexual behavior are considered an important strategy for averting Human Immunodeficiency Virus (HIV) infection among youth (15-24 years) who continue to be at risk of the disease. Enhancing intervention success requires a comprehensive understanding of the barriers and facilitators to interventions targeting youth. However, there is lack of a systematic review of both quantitative and qualitative studies to comprehensively identify and synthesize barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth worldwide. This review aimed to identify and synthesize barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth globally based on original peer-reviewed studies published in the last decade. METHODS: The Joanna Briggs Institute approach for mixed methods systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to guide this review. Nine electronic databases, Joint United Nations Programme on HIV/AIDS and World Health Organization websites, and reference lists of included studies and systematic reviews on barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth were searched for eligible articles. Studies that met the inclusion criteria underwent quality appraisal and data extraction. Findings were analyzed using thematic synthesis and underpinned by Nilsen, 2015's Determinant Framework. RESULTS: Overall 13 studies comprising of eight qualitative studies, four quantitative studies and one mixed methods study were included in the review. Several barriers and facilitators across the five Determinant Framework domains were identified. Most of the barriers fell under the characteristics of the context domain (e.g., gender-biased norms). The next important group of barriers emerged within the characteristics of the end users domain (e.g., fear of relationship breakdown). In terms of facilitators, the majority fell under the characteristics of the strategy of facilitating implementation domain (e.g., implementation of intervention with fidelity) and characteristics of the end users domain (e.g., fear of pregnancy or sexually transmitted infections). The next common set of facilitators appeared within the characteristics of the context domain (e.g., family support). CONCLUSION: This review identified several multi-level barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth. Multi-level and combination approaches are needed to address these factors and enhance intervention success.

A qualitative systematic review on the experiences of homelessness among older adults.

Adults who experience homelessness for an extended period of time also experience accelerated ageing and other negative impacts on their general health and wellbeing. Homelessness amongst older adults is on the rise, yet there are few systematic reviews investigating their experiences. Thus, this review classifies and synthesises qualitative research findings of studies published between 1990 to 2020 that have examined the needs and challenges of homeless older adults to elucidate their journey of homelessness. Seven papers met the requirements for inclusion. Three main themes were identified in the review: - (1) Pathways to homelessness, (2) Impact of homelessness, and (3) Outcomes and resolutions. This review collates current evidence on what is known about the experience of homelessness among older adults. In this study, homeless older adults identified a wide range of challenges associated with the experience of homelessness.

Residency match interview scheduling: quantifying the applicant experience.

BACKGROUND: The process of offering and scheduling residency interviews varies widely among programmes. Applicants report distress and have advocated for reform. However, there is a paucity of quantitative data to characterise applicant concerns. OBJECTIVE: We quantified the interview scheduling experience for US allopathic medical students in the 2020 main residency match. METHODS: An anonymous, 13 question survey was sent to student representatives from each Association of American Medical Colleges member institution. Recipients were asked to forward the survey to their entire fourth-year class. RESULTS: Of 4314 applicants to whom the survey was sent, 786 (18.2%) responded. Overall, 20.4% reported missing the opportunity to interview at a programme because they did not have adequate time to respond to an invitation; applicants into surgical specialties were significantly more likely than their non-surgical peers to report this experience (26.4% vs 18.4%, p<0.05). Most (57.4%) respondents scheduled an interview knowing they would likely cancel it in the future. The most commonly cited reason for this behaviour was concern that applicants would not receive invitations from other programmes (85.6%). A majority (56.4%) of respondents did not believe the match interview process functions based on equity and merit. CONCLUSIONS: About one in five respondents missed the opportunity to interview at a programme because they did not respond to an invitation in time. Most respondents scheduled interviews knowing that they were likely to cancel them in the future. Standardisation of the interview invitation timeline would address these concerns.

The nursing care of people with class III obesity in an acute care setting: a scoping review.

BACKGROUND: Patients with Class III obesity pose unique challenges to health care staff and organisations. Care requirements of this population are unique and require specialised equipment and knowledge to meet these needs, maintain the quality of care, as well as the safety of patients and staff. AIM: To synthesise the evidence on the nursing care of Class III obese patients in acute care settings. METHODS: A scoping review informed by JBI. CINAHL Plus, Medline, Scopus, Proquest Central, Web of Science and Embase were searched for primary research articles about the nursing management of people classified as Class III obese in acute care. Methodological quality of included studies was assessed; data extracted and synthesised into themes. RESULTS: Fourteen studies were included in the review. The synthesis generated three themes: Access to equipment, knowledge and training, patient care, and opportunities to improve care. CONCLUSIONS: A paucity of high-quality evidence informs the nursing care of people with Class III obesity in acute care. Access to appropriate equipment dominated the findings of this review. Adequate provision of equipment and education on its use are required. Education to promote engagement with patients, adapting clinical practice and promotion of self-care could improve care and outcomes.

The pure and representative types of disordered platinum nanoparticles from machine learning.

The development of interpretable structure/property relationships is a cornerstone of nanoscience, but can be challenging when the structural diversity and complexity exceeds our ability to characterise it. This is often the case for imperfect, disordered and amorphous nanoparticles, where even the nomenclature can be unspecific. Disordered platinum nanoparticles have exhibited superior performance for some reactions, which makes a systematic way of describing them highly desirable. In this study we have used a diverse set of disorder platinum nanoparticles and machine learning to identify the pure and representative structures based on their similarity in 121 dimensions. We identify two prototypes that are representative of separable classes, and seven archetypes that are the pure structures on the convex hull with which all other possibilities can be described. Together these nine nanoparticles can explain all of the variance in the set, and can be described as either single crystal, twinned, spherical or branched; with or without roughened surfaces. This forms a robust sub-set of platinum nanoparticle upon which to base further work, and provides a theoretical basis for discussing structure/property relationships of platinum nanoparticles that are not geometrically ideal.

A delirium prevalence audit and a pre and post evaluation of an interprofessional education intervention to increase staff knowledge about delirium in older adults.

BACKGROUND: Delirium is more prevalent in older people and estimated to occur in up to 50% of the hospital population. Delirium comprises a spectrum of behaviours, including cognitive and attention deficits, and fluctuating levels of consciousness, often associated with an underlying physiological disturbance. Delirium has been increasingly associated with adverse outcomes. Although often preventable or can at least be mitigated, delirium may not be a standard part of assessment and thus may not be recognized in the early stages when it is most likely to be treated successfully. The aim of this study was to evaluate the level of knowledge of delirium amongst clinicians caring for patients at high risk of developing delirium and to determine whether education can improve clinical assessment of delirium. METHODS: Two hundred and forty-six case notes were audited before and 149 were reviewed after the education intervention and implementation of a delirium screening tool. Clinicians at the hospital were invited to complete a questionnaire on knowledge of delirium. The questionnaire was based on a validated tool which contained 39 questions about delirium. The questionnaire also contained 28 questions on delirium knowledge. Additional questions were included to gather demographic information specific to the hospital. Descriptive statistics, chi square and independent t-tests were conducted to test for differences in knowledge between the pre and post periods. The Squire Checklist Reporting Guidelines for Quality Improvement Studies informed the preparation of the manuscript. RESULTS: The audit demonstrated that the use of a cognitive assessment tool overall increased from 8.5% in pre education to 43% in the post education period. One hundred and fifty-nine staff completed the questionnaire in total, 118 the pre and 41 post. The knowledge subscale score was high pre and post education and no statistically significant difference was observed. The greatest increase in knowledge was related to knowledge of the risk factors subscale. The increase in knowledge (6.8%) was statistically significant. CONCLUSION: An interprofessional approach to delirium education was effective in not only increasing awareness of the factors associated with this syndrome but also increased the use of a delirium assessment tool.

Effects of employing primary care doctors in hospital to improve the quality of care and health outcomes of rural patients: A systematic scoping review.

OBJECTIVE: To describe effects of employing primary care doctors in hospital care and their roles in improving the quality of care and health outcomes of rural and remote patients. DESIGN: A systematic scoping review. SETTING: Peer-reviewed publications were sourced from 3 online journal databases (PUBMED, SCOPUS and Web of Science). PARTICIPANTS: All study designs from peer-reviewed journals that discussed effects of employing primary care doctors in hospital care Interventions: employing primary care doctors in hospital care. MAIN OUTCOME MEASURES: Positive and negative consequences of employing primary care doctors in hospital care, and the roles of primary care doctors in improving the quality of care and health outcomes. RESULTS: A total of 12 articles met the inclusion and exclusion criteria. Positive outcomes included improved access to specialised treatment, improved continuity of care, reduced waiting list and admission rates, improved skills, competence and confidence of primary care doctors, and increased satisfaction from both health providers and patients/families. Negative consequences reported included increased prescriptions and poorly documented history and physical examinations. CONCLUSION: Employing primary care doctors in hospital care can fill the gaps in the delivery of acute care, emergency medicine and maternity care. Primary care doctors bring advanced clinical skills and a patient-centred approach to the hospital care. They also improve the quality of referrals leading to freed-up clinical capacity of tertiary hospitals to treat more serious conditions. The provision of acute or emergency care and secondary care in rural and remote areas should be directed towards patient-oriented not provider-oriented policies.

Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia.

OBJECTIVE: To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone-equivalent). DESIGN: Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. PARTICIPANTS, SETTING: People aged 12 years or more treated for asthma during 2014-2018, according to dispensing of controller inhaled corticosteroids (ICS). MAIN OUTCOME MEASURES: Number of people dispensed OCS for managing asthma during 2014-2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone-equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone-equivalent during 2018, stratified by inhaler controller dose and use. RESULTS: 124 011 people had been dispensed at least two prescriptions of ICS during 2014-2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone-equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone-equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone-equivalent or more, for 2316 of whom (50%) controller use was inadequate. CONCLUSIONS: Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one-quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.

The influence of adaptive challenge on engagement of multidisciplinary staff in standardising aseptic technique in an emergency department: A qualitative study.

AIMS AND OBJECTIVES: To explore the challenge of engaging multidisciplinary staff in standardising aseptic technique (AT) in an emergency department (ED) in an Australian tertiary hospital, and to better understand the enablers and barriers to implementing practice change within this setting. BACKGROUND: Healthcare-associated infections are the most common complication for patients in acute care. A clinical practice framework developed in the United Kingdom (UK) standardised AT practice to reduce potential infection risk. One Australian tertiary hospital drew upon this framework to similarly improve clinical practice. It was understood that standardising practice would require some practitioners only to revisit and demonstrate AT principles already embedded in their practice, while others would be challenged to adopt a new approach. DESIGN: Qualitative, descriptive research design. METHODS: Data were collected through focus groups held before and after implementation of the AT programme. Data were analysed using the framework method. The (COREQ) checklist was followed. RESULTS: Four emergent themes described the influence of motivation on individuals' beliefs and attitudes towards practice change, relationships within the ED context, delivery of education and management directives. CONCLUSION: Implementing practice change is more than just providing technical knowledge and includes changing individuals' beliefs and attitudes. An understanding of adaptive challenge can assist in implementing practice change that involves the multidisciplinary team. RELEVANCE TO CLINICAL PRACTICE: Results provide evidence as to how the adaptive challenge framework could be a suitable approach to manage potential enablers and barriers to implementing change within a multidisciplinary team in an acute hospital.

Effects of calcium carbonate, magnesium oxide and encapsulated sodium bicarbonate on measures of post-ruminal fermentation.

Evidence suggests that lipopolysaccharide (LPS) absorbed from the large intestine may contribute to the inflammatory response to high starch feeding in dairy cows. This work evaluated the impact of buffers or alkalinizing agents with expected large intestinal activity on faecal indicators of intestinal fermentation and LPS. Ten late-lactation cows were used in a replicated 5 × 5 Latin square design with 7-day periods. Cows were fed a diet containing 265 g/kg dry matter of starch and were abomasally infused with 1 g/kg body weight cornstarch daily. Treatments were control (CON), ration supplementation with 200 g/day sodium bicarbonate (FSB), 200 g/day calcium carbonate (FCC) or 125 g/day calcium carbonate plus 75 g/day of magnesium oxide (FCCM), or abomasal infusion of a lipid encapsulate providing 200 g/day sodium bicarbonate (ISB). The FCC, FCCM and ISB treatments were hypothesized to have large intestinal buffering effects, and FSB was included as a secondary control. Milk, feed, rumen and faecal samples were collected on day 7 of each period. Treatment did not affect intake, milk yield or milk composition. There were no effects of treatment on ruminal measures except that ISB tended to reduce and the post-ruminal treatments as a whole (FCC, FCCM and ISB) reduced rumen butyrate compared with CON. Faecal pH was greater for FCCM compared with all other treatments. Total faecal VFA tended to increase with FCC and FCCM compared with CON and was increased by the post-ruminal treatments as a whole compared with CON. Treatment did not affect faecal dry matter, lactate or LPS or apparent total tract nutrient digestibility. Although some treatments altered fermentation as evidenced by the change in faecal VFA, this was not accompanied by a decrease in faecal LPS. The strategies employed in this study had limited effects on large intestinal fermentation.

Foot Problems in Patients in Acute Care: A Point-Prevalence Survey.

PURPOSE: Determine the prevalence of foot problems in an inpatient population and to describe demographic data, comorbid conditions, and type of footwear worn. DESIGN: Observational point-prevalence cross-sectional design. SUBJECTS AND SETTING: The study setting was a 722-bed licensed hospital in Western Australia. A convenience sampling was used to include adults hospitalized in the study setting during the period of data collection. METHODS: A subset of foot questions, guided by a literature review, and input from foot, wound, diabetes, and psychometric researchers and clinicians, was incorporated into the hospital point-prevalence survey conducted annually for nursing safety and quality. Trained nurses collected data during the 1-day survey. Data were analyzed using descriptive statistics and 2-tailed tests; associations between study variables were analyzed. RESULTS: Two hundred twenty-one patients participated in the survey; a majority (n = 193, 87%) self-reported at least 1 foot problem. More than half (n = 124) reported 3 foot problems and nearly one-third (n = 67) had 5 or more foot problems. Thick nails, damaged nails, and calluses and corns were the most frequently occurring foot problems. Older participants were more likely to have certain foot problems such as calluses and thick nails. Eleven (5%) participants were admitted to the hospital for a foot-related condition. CONCLUSION: The majority of foot problems in our study were found to be minor and not the primary admitting diagnosis. However, even minor foot problems can pose a risk of worsening, especially in high-risk populations such as those with diabetes. Thus, detection is critical in overall patient assessment, and nurses play a critical role in assessment and management of minor foot problems through the delivery of skin and nail care and through collaboration with other professionals who provide specialized foot care.

Variables associated with successful vascular access cannulation in hemodialysis patients: a prospective cohort study.

BACKGROUND: Successful vascular access (VA) cannulation is integral to the delivery of adequate dialysis, highlighting the importance of ensuring the viability of arteriovenous access in hemodialysis (HD) patients. Missed VA cannulation can lead to infection, infiltration, hematoma or aneurysm formation resulting in the need for access revision, central venous catheter (CVC) placement, or permanent loss of VA. Cannulation-related complications can also negatively impact on a patient's dialysis experience and quality of life. This study aimed to identify patient, VA and nurse factors associated with unsuccessful VA cannulations. METHODS: A prospective cohort study was conducted in HD patients with a permanent VA from three HD units. Data on patient, VA and nurse characteristics, plus, cannulation technique were collected for each episode of cannulation. General Estimating Equation was used to fit a repeated measures logistic regression to determine the odds of cannulation success. RESULTS: We collected data on 1946 episodes of cannulation (83.9% fistula) in 149 patients by 63 nurses. Cannulation included use of tourniquet (62.9%), ultrasound (4.1%) and was by rope ladder (73.8%) or area (24.7%) technique. The miscannulation rate was 4.4% (n = 85) with a third of patients (n = 47) having at least one episode of miscannulation. Extravasation (n = 17, 0.9%) and use of an existing CVC (n = 6, 0.6%) were rare. Multivariable characteristics of successful cannulation included fistula compared with graft [OR 4.38; 95%CI, 1.89-10.1]; older access [OR 1.68; 95%CI, 1.32-2.14]; absence of stent [OR 3.37; 95%CI, 1.39-8.19]; no ultrasound [OR 13.7; 95%CI, 6.52-28.6]; no tourniquet [OR 2.32; 95%CI, 1.15-4.66]; and lack of post graduate certificate in renal nursing [OR 2.27; 95%CI, 1.31-3.93]. CONCLUSION: This study demonstrated a low rate of miscannulation. Further research is required on ultrasound-guided cannulation. Identifying variables associated with successful cannulation may be used to develop a VA cannulation complexity instrument that could be utilised to match to the cannulation skill of a competency-assessed nurse, thereby minimising the risk of missed cannulation and trauma.

Does the intravascular volume status in haemodialysis patients measured by inferior vena cava ultrasound correlate with bioimpedance spectroscopy?

AIMS AND OBJECTIVES: To evaluate the accuracy of traditional clinical predialytic fluid assessment by renal nurses and the efficacy of 2 additional fluid assessment methods focussing on the potential preventative effect for intradialytic hypotension (IDH). BACKGROUND: Predialytic fluid assessment remains a daily challenge for renal nurses, when aiming for adverse event free haemodialysis treatments. Adding further objective parameters obtained through noninvasive methods into pre- and intradialytic fluid assessment could potentially improve health outcomes for haemodialysis patients. DESIGN: Comparative, observational study of three fluid assessment methods on their reliability on volume status and correlation to clinical outcomes. METHODS: Clinical predialytic nursing fluid assessments in 30 haemodialysis patients were compared with additional initial bioimpedance spectroscopy (BIS) measurements, and 3 serial intradialytic ultrasound scans of the inferior vena cava (IVC-US) performed by a second renal nurse concurrently during the same session. A retrospective data analysis compared all measurements in each individual for the predictive value for IDH. A STROBE checklist for observational cohort studies was used for the reporting of results. RESULTS: Seven subjects experienced episodes of symptomatic intradialytic hypotension (S-IDH), which would have been anticipated by IVC-US or by BIS in 5 patients (71%). Using an algorithm to predict IDH would have provided a sensitivity of 100% and specificity of 95%. CONCLUSION: Both additional fluid assessment methods would have provided critical information before and during each haemodialysis session. Therefore, we consider them as being potentially effective for the prevention of intradialytic hypotension, with IVC-US being similar to BIS. RELEVANCE TO CLINICAL PRACTICE: Traditional clinical nursing fluid assessment methods in haemodialysis patients do not provide sufficient information to prevent episodes of IDH. Additional objective fluid assessment methods are useful and likely to lead to improved health outcomes in HD patients when applied by renal nurses. A combination of IVC-US, MAP and BIS has potential to reduce the risk of IDH events in HD patients significantly.

The Australian Rural Clinical School (RCS) program supports rural medical workforce: evidence from a cross-sectional study of 12 RCSs.

INTRODUCTION: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs' 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background. METHODS: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2-5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a 'rural' area (ASGC categories RA2-5 or MMM categories 3-7) or 'metropolitan' area. Pearson's χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated. RESULTS: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3-76.6% and the proportion who had participated in extended RCS placement had a range of 13.7-74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8-55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3-7), range 4.5-29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2-2.1, p=0.004) using ASGC criteria. Using the MMM 3-7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8-3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system (ASGC, MMM) used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally. CONCLUSION: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

Three-Dimensional Branched and Faceted Gold-Ruthenium Nanoparticles: Using Nanostructure to Improve Stability in Oxygen Evolution Electrocatalysis.

Achieving stability with highly active Ru nanoparticles for electrocatalysis is a major challenge for the oxygen evolution reaction. As improved stability of Ru catalysts has been shown for bulk surfaces with low-index facets, there is an opportunity to incorporate these stable facets into Ru nanoparticles. Now, a new solution synthesis is presented in which hexagonal close-packed structured Ru is grown on Au to form nanoparticles with 3D branches. Exposing low-index facets on these 3D branches creates stable reaction kinetics to achieve high activity and the highest stability observed for Ru nanoparticle oxygen evolution reaction catalysts. These design principles provide a synthetic strategy to achieve stable and active electrocatalysts.