A randomised controlled phase II trial to examine the feasibility of using hyper-oxygenated fatty acids (HOFA) to prevent facial pressure injuries from medical devices among adults admitted to intensive care-A research protocol.

One in three patients admitted to intensive care will sustain a pressure injury (PI) from a medical device. These injuries are painful and when on the face, head or neck they can result in permanent disfigurement. Preliminary evidence of the efficacy of hyper-oxygenated fatty acids (HOFAs) to prevent facial pressure injuries from medical devices is promising; however, the feasibility of incorporating HOFAs into current standard care to prevent PI from a medical device of the face, head and neck has not been extensively explored. It is intended that the findings from this phase II feasibility study will inform the design of a larger phase III trial, by addressing two primary aims: (1) to assess the feasibility of incorporating HOFAs into standard care to prevent device-related pressure ulcers of the skin associated with the face, head and neck assess the feasibility and (2) efficacy preliminary effectiveness of HOFA. This feasibility study is an investigator-initiated mixed method study incorporating a multi-centre randomised controlled trial of using HOFAs as an adjunct to standard pressure injury prevention and care, compared with standard care alone to prevent facial, head or neck from medical devices among adults admitted to intensive care. The primary outcome of interest is the incidence of facial, head or neck pressure injuries during the first 14 days in intensive care. Secondary outcomes include PI staging, medical device exposure and intensive care and hospital outcomes. The primary analysis will be undertaken using Cox's Proportional Hazards model, and due to the exploratory nature of this phase II trial, efficacy will be based on a one-sided p-value for superiority set at 0.10. Type I and Type II error rates are set at 20%; therefore, a total sample size of 196 study participants is planned. To explore the feasibility of incorporating HOFA into usual care and to design a larger phase III trial, we will aim to interview between 10 and 20 nurses across participating intensive care unit sites. Pressure injuries of the face, head or neck from medical devices, among adults admitted to intensive care, are considered preventable. This phase II study will investigate the feasibility and efficacy of HOFAs as an adjunct to standard care. Importantly, we aim to inform the development of a larger phase III trial.

The likelihood of hospital-acquired complications in older people with dementia: a matched cohort study.

OBJECTIVES: To investigate whether the likelihood of hospital-acquired complications for older people in Australia differs by whether they have dementia. STUDY DESIGN: Matched cohort study. SETTING, PARTICIPANTS: People aged 60 years or older with dementia who were admitted to five public hospitals in the South Western Sydney Local Health District, New South Wales, 1 January 2010 to 31 December 2020, and people without dementia admitted during the same period, matched by age, sex, number of medical conditions, and presence of selected specific medical conditions, emergency admission status, history of falls, and admission from a nursing home. MAIN OUTCOME MEASURES: Hospital-acquired complications (falls, pressure injuries, delirium, pneumonia, venous thromboembolism, new incontinence, malnutrition, in-hospital death), by dementia status. RESULTS: A total of 217 459 people aged 60 years or older were admitted to the five hospitals during the study period. The mean age of the 11 393 patients with dementia (83 years; standard deviation [SD], 7.5 years) was higher than that of the 206 065 patients without dementia (73 years; SD, 8.9 years), and the proportion of women slightly larger (55% v 50%). Median hospital length of stay was longer for people with dementia (nine days; interquartile range [IQR], 4-19 days) than for people without dementia (three days; IQR, 1-9 days), and the number of in-hospital deaths higher (768, 7% v 584, 5%). After propensity score-based matching, the risks of falls (odds ratio [OR], 4.7; 95% confidence interval [CI], 3.8-5.7), pressure injury (OR, 1.4; 95% CI, 1.1-1.8), delirium (OR, 2.4; 95% CI, 2.0-3.0), and pneumonia (OR, 1.3; 95% CI, 1.01-1.7) were higher for people with dementia than for those without dementia; differences between the two groups in the risks of venous thromboembolism, malnutrition, and incontinence were not statistically significant. CONCLUSIONS: Given the greater risk of many hospital-acquired complications for people with dementia, targeted models of person-centred care are needed to ensure the best outcomes for these patients.

Comparison of outcomes from tunnelled femorally inserted central catheters and peripherally inserted central catheters: a propensity score-matched cohort study.

OBJECTIVES: To compare catheter-related outcomes of individuals who received a tunnelled femorally inserted central catheter (tFICC) with those who received a peripherally inserted central catheter (PICC) in the upper extremities. DESIGN: A propensity-score matched cohort study. SETTING: A 980-bed tertiary referral hospital in South West Sydney, Australia. PARTICIPANTS: In-patients referred to the hospital central venous access service for the insertion of a central venous access device. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome of interest was the incidence of all-cause catheter failure. Secondary outcomes included the rates of catheters removed because of suspected or confirmed catheter-associated infection, catheter dwell and confirmed upper or lower extremity deep vein thrombosis (DVT). RESULTS: The overall rate of all-cause catheter failure in the matched tFICC and PICC cohort was 2.4/1000 catheter days (95% CI 1.1 to 4.4) and 3.0/1000 catheter days (95% CI 2.3 to 3.9), respectively, and when compared, no difference was observed (difference -0.63/1000 catheter days, 95% CI -2.32 to 1.06). We found no differences in catheter dwell (mean difference of 14.2 days, 95% CI -6.6 to 35.0, p=0.910); or in the cumulative probability of failure between the two groups within the first month of dwell (p=0.358). No significant differences were observed in the rate of catheters requiring removal for confirmed central line-associated bloodstream infection (difference 0.13/1000 catheter day, 95% CI -0.36 to 0.63, p=0.896). Similarly, no significant differences were found between the groups for confirmed catheter-related DVT (difference -0.11 per 1000 catheter days, 95% CI -0.26 to 0.04, p=1.00). CONCLUSION: There were no differences in catheter-related outcomes between the matched cohort of tFICC and PICC patients, suggesting that tFICCs are a possible alternative for vascular access when the veins of the upper extremities or thoracic region are not viable for catheterisation.

Structured interactions between nurses and patients through intentional rounding: A scoping review.

AIM: To synthesize existing literature describing the impact of intentional rounding on patient outcomes among hospitalized adults. BACKGROUND: Intentional rounding has been described as purposeful therapeutic communication between nurses and patients during regular checks with patients using standardized protocols. Despite the widespread adoption of intentional rounding, the current understanding of the benefits of these structured interactions between nurses and patients is limited. INTRODUCTION: The critical role of nurses in ensuring high-quality and safe care in acute hospitals is often noted only when things go wrong. This was highlighted by investigations into the reasons for the failures in patient care at the Mid Staffordshire National Health Services. METHODS: A scoping review was performed and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review guidelines. FINDINGS: Sixteen studies were included in the final review. Various rounding models were noted among different clinical settings; four studies reported a significant reduction in falls, and a further three reported a decrease in pressure injuries. Two studies reported a reduction in call bell usage. Significant improvements in patients' satisfaction with intentional rounding were reported in three studies. DISCUSSION: Promoting intentional rounding without solid evidence of its acceptability, feasibility, and suitability in different clinical settings could compromise nurses' ability to provide safe care. CONCLUSION AND IMPLICATIONS FOR NURSING: There is weak evidence of the effectiveness of intentional rounding on patient outcomes because of the diversity of methods employed and methodological limitations in many studies. Our findings identify the need for robust studies to explore the acceptability and feasibility of a rounding protocol that can be implemented in different clinical settings.

Do they stay, or do they go? Children presenting to five emergency departments across New South Wales, Australia with acute burn injuries: a retrospective review.

OBJECTIVE: The overall objective of the study was to describe the disposition status of children presenting with a burn injury to five emergency departments (ED) across New South Wales (NSW), Australia. DESIGN: A retrospective study design was used to review routinely collected ED data. SETTING: Study sites included five acute hospitals across NSW, Australia. PARTICIPANTS: During the 5-year study period between 1 January 2015 to 31 December 2020, there were 5213 paediatric burn injury presentations. RESULTS: The mean age of burn injury presentations was 24 months (Inter-Quartile-Range (IQR) 12-84), of which 57% (2951/5213) were males. The most common presentation time was between 16:00 and 23:59 hours (63%, 3297/5213), and the median time spent in the ED was 3 hours (IQR 1-4). The majority (80%, 4196/5213) of the burn injuries presentations did not require hospital admission. The most common principal diagnoses were 'Burn body region unspecified' (n=1916) and 'Burn of wrist and hand' (n=1060). CONCLUSION: Most children who presented to the hospital with a burn injury were not admitted. Often the details of these burns were poorly recorded and a complete picture of the true burden of burn injury in children, especially the ongoing care given outside the acute hospital setting, is missing. This information is crucial, as it would inform future models of care as the paradigm shifts rapidly towards primary, ambulatory and outpatient models of care.

Frailty in the prediction of delirium in the intensive care unit: A secondary analysis of the Deli study.

BACKGROUND: Delirium is an acute disorder of attention and cognition with an incidence of up to 70% in the adult intensive care setting. Due to the association with significantly increased morbidity and mortality, it is important to identify who is at the greatest risk of an acute episode of delirium while being cared for in the intensive care. The objective of this study was to determine the ability of the cumulative deficit frailty index and clinical frailty scale to predict an acute episode of delirium among adults admitted to the intensive care. METHODS: This study is a secondary analysis of the Deli intervention study, a hybrid stepped-wedge cluster randomized controlled trial to assess the effectiveness of a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adult intensive care units in the south-west of Sydney, Australia. Important predictors of delirium were identified using a bootstrap approach and the absolute risks, based on the cumulative deficit frailty index and the clinical frailty scale are presented. RESULTS: During the 10-mth data collection period (May 2019 and February 2020) 2566 patients were included in the study. Both the cumulative deficit frailty index and the clinical frailty scale on admission, plus age, sex, and APACHE III (AP III) score were able to discriminate between patients who did and did not experience an acute episode of delirium while in the intensive care, with AUC of 0.701 and 0.703 (moderate discriminatory ability), respectively. The addition of a frailty index to a prediction model based on age, sex, and APACHE III score, resulted in net reclassified of risk. Nomograms to individualize the absolute risk of delirium using these predictors are also presented. CONCLUSION: We have been able to show that both the cumulative deficits frailty index and clinical frailty scale predict an acute episode of delirium among adults admitted to intensive care.

Study protocol for Care cOORDInatioN And sympTom managEment (COORDINATE) programme: a feasibility study.

INTRODUCTION: Sustainable approaches to support care coordination and symptom management needs of critically ill adults living with multimorbidity are needed to combat the challenges and complexity that multimorbidity presents. The study aims to test the feasibility of the Care cOORDInatioN And sympTom managEment (COORDINATE) intervention to improve health outcomes of adults living with multimorbidity. METHODS AND ANALYSIS: A multicomponent nurse-driven intervention was developed using experience-based co-design and human-centred design. Inclusion criteria include (1) age 55 years and older, (2) admitted to an intermediate care unit, (3) presence of two or more chronic health conditions and (4) signed informed consent. Data collection will occur at baseline (time of recruitment predischarge) and 6 weeks and 3 months following hospital discharge. Outcome of interest from this feasibility study is to evaluate the financial, technical and logistic feasibility of a full-scale study including data collection and protocol adherence. Additionally, Cohen's d effect sizes for the change in outcomes over time will be computed to establish power calculations required for a full-scale study. The protocol was prepared in accordance with Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Institutional Review Board of Johns Hopkins Medical Institutions. Given the success of this feasibility study, the potential for the COORDINATE intervention to decrease the symptom burden and improve participant quality of life among critically ill people with multimorbidity will be tested in a full-scale study, and findings will be actively disseminated. TRIAL REGISTRATION NUMBER: NCT05985044.

Facilitators and barriers of appropriate and timely initiation of intravenous fluids in patients with sepsis in emergency departments: a consensus development Delphi study.

BACKGROUND: Sepsis is a life-threatening medical emergency in which appropriate and timely administration of intravenous fluids to patients with features of hypotension is critical to prevent multi-organ failure and subsequent death. However, compliance with recommended fluid administration is reported to be poor. There is a lack of consensus among emergency clinicians on some of the determinant factors influencing fluid administration in sepsis. Thus, the aim of this study was to identify the level of consensus among key stakeholders in emergency departments regarding the facilitators, barriers, and strategies to improve fluid administration. METHODS: The modified Delphi questionnaire with 23 statements exploring barriers, facilitators, and strategies to improve fluid administration was developed from the integration of findings from previous phases of the study involving emergency department clinicians. A two-round modified Delphi survey was conducted among key stakeholders with managerial, educational, supervision and leadership responsibilities using a "Reactive Delphi technique" from March 2023 to June 2023. The statements were rated for importance on a 9-point Likert scale. The RAND/UCLA Appropriateness Method (RAM) was used to identify the level of consensus (agreement/disagreement). RESULTS: Of the 21 panellists who completed Round 1 survey, 18 (86%) also completed Round 2. The panellists rated 9 out of 10 (90%) barriers, 3 out of 4 (75%) facilitators and all 9 (100%) improvement strategies as important. Out of the total 23 statements, 18 (78%) had agreement among the panellists. Incomplete vital signs at triage (Median = 9, IQR 7.25 to 9.00) as a barrier, awareness of importance of fluid administration in sepsis (Median = 9, IQR 8.00 to 9.00) as facilitator and provision of nurse-initiated intravenous fluids (Median = 9, IQR 8.00 to 9.00) as an improvement strategy were the highest rated statements. CONCLUSION: This is the first Delphi study identifying consensus on facilitators, barriers, and strategies to specifically improve intravenous fluid administration in sepsis in Australia. We identified 18 consensus-based factors associated with appropriate and timely administration of intravenous fluids in sepsis. This study offers empirical evidence to support the implementation of the identified strategies to improve patient outcomes.

The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation.

BACKGROUND: Nurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients' bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost-benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries. METHODS: A stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses' education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and 'Code Blue' calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses' perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses' and medical officers' perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost-benefit analysis and post-trial process evaluation will also be undertaken. DISCUSSION: If effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022.

Self-efficacy, resilience and healthy ageing among older people who have an acute hospital admission: A cross-sectional study.

AIM: To examine the associations between self-efficacy, resilience and healthy ageing among older people who have an acute hospital admission. DESIGN: A cross-sectional study. METHODS: Survey and medical record data were collected from older people on discharge from hospital. The survey measured self-efficacy with the 6-item General Self-Efficacy scale (GSE-6), resilience with the Brief Resilience Scale (BRS), and healthy ageing with the Selfie Ageing Index (SAI). Medical record data included potential confounders: co-morbidities, frailty items, previous falls and previous admission in the last 28 days. Multi-linear regression and Spearman's rank correlation coefficient were used to examine the independent associations between self-efficacy, resilience and healthy ageing. RESULTS: Responses were received from 143 older people (mean age 79). After adjusting for potential confounders, co-morbidities (ß = -0.08, p = 0.001) remained negatively associated with healthy ageing, while self-efficacy (ß = 0.03, p = 0.005) and resilience (ß = 0.05, p < 0.001) remained positively associated with healthy ageing (R2 = 0.243). Positive correlations were found between self-efficacy (ρ = 0.33, p < 0.01), resilience (ρ = 0.38, p < 0.001) and healthy ageing. Positive correlations were also found between self-efficacy and resilience (ρ = 0.38, p < 0.01). Those with lower self-efficacy and resilience were more likely to report reduced activities of daily living, mobility, physical activity and mood. CONCLUSION: Findings indicate that while the number of co-morbidities have negative consequences for healthy ageing among older people who are hospitalised, the promotion of self-efficacy and resilience can potentially contribute to healthy ageing within the physical and psychological domains. IMPLICATIONS FOR PATIENT CARE: Nurses can promote self-efficacy, which can potentially increase resilience and help to improve self-management of chronic conditions, functional ability in daily activities, mobility and physical activity and reduce both anxiety and depressive symptoms. PATIENT CONTRIBUTION: Participant feedback throughout the data collection process assisted in the evaluation of study methods and data interpretation. This included processes such as assessing selected tools and clarifying the meanings of healthy ageing factors.

Facilitators and barriers of appropriate and timely initial fluid administration in sepsis: A qualitative study.

BACKGROUND: Sepsis is a medical emergency requiring prompt recognition, and early administration of intravenous fluids and antibiotics. While compliance with appropriate and timely administration of intravenous fluids has been found to be poor, the reasons are not well understood. Therefore, we have explored the experiences and perceptions of emergency nurses and medical officers from four hospitals to identify the associated facilitators and barriers. METHODS: Qualitative design incorporating six focus group discussions and thematic analysis of data. A hybrid approach using both inductive and deductive reasoning was used. FINDINGS: Four key themes were developed: 1. Overcrowding and understaffing threaten appropriate fluid management in sepsis; 2. Variations in clinical practice results in suboptimal fluid management; 3. Challenges with clinical recognition of sepsis impedes timely fluid administration; 4. Top-down approach is necessary to improve fluid management. CONCLUSION: Themes highlighted the specific challenges associated with fluid administration in sepsis in the emergency department setting providing potential strategies to be implemented to improve practice and ultimately patient outcomes.

Delirium in the intensive care unit and its importance in the post-operative context: A review.

The burden of delirium in the intensive care setting is a global priority. Delirium affects up to 80% of patients in intensive care units; an episode of delirium is often distressing to patients and their families, and delirium in patients within, or outside of, the intensive care unit (ICU) setting is associated with poor outcomes. In the short term, such poor outcomes include longer stay in intensive care, longer hospital stay, increased risk of other hospital-acquired complications, and increased risk of hospital mortality. Longer term sequelae include cognitive impairment and functional dependency. While medical category of admission may be a risk factor for poor outcomes in critical care populations, outcomes for surgical ICU admissions are also poor, with dependency at hospital discharge exceeding 30% and increased risk of in-hospital mortality, particularly in vulnerable groups, with high-risk procedures, and resource-scarce settings. A practical approach to delirium prevention and management in the ICU setting is likely to require a multi-faceted approach. Given the good evidence for the prevention of delirium among older post-operative outside of the intensive care setting, simple non-pharmacological interventions should be effective among older adults post-operatively who are cared for in the intensive care setting. In response to this, the future ICU environment will have a range of organizational and distinct environmental characteristics that are directly targeted at preventing delirium.

The burden of peripheral intravenous catheters in older hospital inpatients: A national cross-sectional study part of the ONE MILLION GLOBAL PERIPHERAL INTRAVENOUS CATHETERS COLLABORATION.

OBJECTIVES: To investigate the burden of peripheral intravenous catheters (PIVCs) in older hospitalised patients. METHODS: A cross-sectional prospective observational study (2014/2015) to describe the characteristics, indications and outcomes of PIVCs among patients aged ≥65 from 65 Australian hospitals. RESULTS: Amongst 2179 individual PIVCs (in 2041 patients, mean age 77.6 years, 45% female, 58% in NSW), 43% were inserted by doctors and 74% used that day, meaning 25% were 'idle'. Overall, 18% (393/2179) exhibited signs of PIVC-related complications. Most commonly exhibited PIVC-related complications were tenderness (4.1%) and local redness (1.8%). Nearly one in three (29.1%) dressings was soiled, loosened or had come off, and only 36.8% had the time and date documented on the dressing. Both infusing IV medications (aOR 1.74, 95% CI 1.28-2.38, p < 0.001) and inserting the PIVC in a non-upper limb vein (aOR 3.40 compared to forearm [reference site], 95% CI 1.62-7.17, p < 0.001) were independently associated with PIVC failure. Phlebitis was exhibited in 7% (154) of the patients. Only infusing intravenous medications increased the likelihood of developing symptoms of phlebitis (aOR 1.61, 95% CI 1.01-2.57, p = 0.05). Increasing age was inversely associated with symptoms of phlebitis. Among the 1575 patients (79%) who rated their PIVC experience using the Likert scale 0-10 (where 10 = 'best possible'), the median score was 8 (IQR 6-10). Age in highest quartile (>84 years) was independently associated with lower likelihood of a high score (aOR 0.71, 95% CI 0.54-0.94, p = 0.02). CONCLUSIONS: Given 1 in 5 PIVCs were identified with having complications, further research should focus on optimising PIVC use in older patients.

A randomised trial of intracavitary electrocardiography versus surface landmark measurement for central venous access device placement.

BACKGROUND: Malpositioned central venous access devices (CVADs) can lead to significant patient injury including central vein thrombosis and dysrhythmias. Intra-cavitary electrocardiography (IC ECG) has been recommended by peak professional bodies as an accurate alternative for bedside CVAD insertion, to reduce risk of malposition and allowing immediate use of the device. Our objective was to compare the effect of IC ECG on CVAD malposition compared to traditional institutional practice for CVAD placement. METHODS: Randomised controlled trial of IC ECG CVAD insertion verses traditional CVAD insertion (surface landmark measurement with post insertion x ray). Patient recruitment was from December 2016 to July 2018. The setting was a 900-bed tertiary referral hospital based in South Western Sydney, Australia. Three hundred and forty-four adult patients requiring CVAD insertion for intravenous therapy, were enrolled and randomly allocated (1:1 ratio) to either IC-ECG (n = 172) or traditional (n = 172) CVAD insertion. Our primary outcome of interest was the rate of catheters not requiring repositioning after insertion (ready for use). Secondary outcomes were comparison of procedure time and cost. RESULTS: Of the 172 patients allocated to the IC ECG method, 170 (99%) were ready for use immediately compared to 139 of the 172 (81%) in the traditional insertion group (difference, 95% confidence interval (CI): 18%, 11.9-24.1%). The total procedure time was mean 15 min (SD 8 min) for IC ECG and mean 36 min (SD 17 min) for traditional CVAD insertion (difference-19.9 min (95% CI-14.6 to -34.4). IC ECG guided CVAD insertion had a cost reduction of AUD $62.00 per procedure. CONCLUSIONS: Using IC-ECG resulted in nearly no requirement for post-insertion repositioning of CVADs resulting in savings in time and cost and virtually eliminating the need for radiographic confirmation. TRIAL REGISTRATION: This trial is registered at the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au). The registration number is ACTRN12620000919910.

Frailty among older surgical patients and risk of hospital acquired adverse events: The South-Western Sydney frailty and nurse sensitive indicators study.

BACKGROUND: While advances in healthcare mean people are living longer, increasing frailty is a potential consequence of this. The relationship between frailty among older surgical patients and hospital acquired adverse events has not been extensively explored. We sought to describe the relationship between increasing frailty among older surgical patients and the risk of hospital acquired adverse events. METHODS: We included consecutive surgical admissions among patients aged 70 years or more across the SWSLHD between January 2010 and December 2020. This study used routinely collected ICD-10-AM data, obtained from the government maintained Admitted Patient Data Collection. The relationships between cumulative frailty deficit items and risk of hospital acquired adverse events were assessed using Poisson regression modelling. This study followed the RECORD/STROBE guidelines. RESULTS: During the study period, 44,721 (57% women) older adults were admitted, and 41% (25,306) were planned surgical admissions. The risk of all adverse events increased with increasing number of frailty deficit items, the highest deficit items group (4-12 deficit items) compared with the lowest deficit items group (0 or 1 deficit item): falls adjusted rate ratio (adj RR) = 15.3, (95% confidence interval (CI) 12.1, 19.42); pressure injury adj RR = 21.3 (95% CI 12.53, 36.16); delirium adj RR = 40.9 (95% CI 31.21, 53.55); pneumonia adj RR = 16.5 (95% CI 12.74, 21.27); thromboembolism adj RR = 17.3 (95% CI 4.4, 11.92); and hospital mortality adj RR = 6.2 (95% CI 5.18, 7.37). CONCLUSION: The increase in number of cumulative frailty deficit items among older surgical patients was associated with a higher risk of adverse hospital events. The link offers an opportunity to clinical nursing professionals in the surgical setting, to develop and implement targeted models of care and ensure the best outcomes for frail older adults and their families.

A nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to intensive care: A stepped-wedge cluster randomised trial.

BACKGROUND: Delirium is an acute change in behaviour, characterised by a fluctuating course, inattention, and disorganised thinking. For critically ill adults in the intensive care, the incidence of delirium has been reported to be at least 30% and is associated with both short-term and long-term complications, longer hospital stay, increased risk of mortality, and long-term cognitive problems. AIM: The objective of this study was to determine the effectiveness of a nurse-led delirium-prevention protocol in reducing the incidence and duration of delirium among adults admitted to intensive care. METHODS: A hybrid stepped-wedge cluster randomised controlled trial was conducted to assess the effectiveness of the implementation and dissemination of the nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adults intensive care units in the southwest of Sydney, Australia. RESULTS: Between May 2019 and February 2020, over a 10-month period, 2618 admissions, among 2566 patients, were included in the study. After an initial 3-month baseline period, each month there was a random crossover to the nurse-led intervention in one of the four intensive care units, and by the 7th month of the trial, all units were exposed to the intervention for at least 3 months. The incidence of acute delirium was observed to be 10.7% (95% confidence interval [CI] = 9.1-12.4%), compared to 14.1% (95% CI = 12.2-16.2%) during the preintervention (baseline) period (adjusted rate ratio [adjRR] = 0.78, 95% CI = 0.57-1.08, p = 0.134). The average delirium-free-days for these preintervention and postintervention periods were 4.1 days (95% CI = 3.9-4.3) and 4.4 days (95% CI = 4.2-4.5), respectively (adjusted difference = 0.24 days [95% CI = -0.12 to 0.60], p = 0.199). CONCLUSION: Following the introduction of a nurse-led, nonpharmacological intervention to reduce the burden of delirium, among adults admitted to intensive care, we observed no statistically significant decrease in the incidence of delirium or the duration of delirium.

Frailty and risk of subsequent fracture among older adults presenting to hospital with a minimal trauma fracture.

We investigated frailty and refracture risk among older adults with a minimal trauma fracture. After adjusting for age, sex, and site of initial fracture, increasing frailty was associated with an increased risk subsequent fracture. These results indicate the need to routinely screen for frailty following an initial fracture among older adults. INTRODUCTION: Minimal trauma fractures are common among older adults, and frailty increases risk of an initial minimal trauma fracture. This study was undertaken to estimate the risk of subsequent fracture based on frailty status at the time of an initial fracture. METHODS: The study population was older adults presenting to hospital, aged 60 years or more, with a minimal trauma fracture. Frailty was estimated using a cumulative deficit approach. The risk of subsequent fracture based on increasing cumulative frailty deficit item group, adjusted for sex, age, and site of initial fracture, was estimated using Cox's proportional hazard model. RESULTS: Between January 2014 and December 2020, 12,115 older adults presented to hospital (8371 women [69%]), with an initial minimal trauma fracture. The average age was 80 years (SD 9.5). Subsequent fractures identified during the follow-up period occurred in 1137 (9.4%) of study participants. The incidence of subsequent fracture ranged from 25.0 per 1000 older adults (95% confidence interval (CI) 22.4 to 27.8) among the lowest frailty deficit group (1 deficit item) to 31.8 per 1000 (95% CI 28.0 to 35.8) among the highest frailty deficit group (4 to 12 deficit items). After adjusting for age, sex, and site of initial fracture, an increasing number of frailty deficit items was associated with increased risk subsequent fracture (p-value for trend = 0.008). CONCLUSION: Our results indicate that following an initial minimal trauma fracture, frailty independently increases the risk of a subsequent fracture. Therefore, it is important at the time of an initial fracture that older women and men are screened for the presence of frailty, and models of care are implemented to reduce the risk of subsequent fracture among this vulnerable group of older adults.