What influences antibiotic initiation? Developing a scale to measure nursing behaviour in residential aged-care facilities.

AIM: The purpose of the current study was to develop and assess the psychometric properties of a measure that captures nursing behaviours that have the potential to influence the initiation of antibiotics in residential aged-care facilities. DESIGN: Cross-sectional online survey. METHOD: One hundred and fifty-seven nurses completed an online survey. The survey consisted of two clinical vignettes and measures of tolerance of uncertainty and anxiety. The vignettes consisted of the most common presentations (urinary tract infections and upper respiratory tract infections) of two hypothetical residents in aged-care facilities. The vignettes provided participants with incremental information with varying levels of symptoms, input from other people and availability of test results. Both vignettes were subjected to exploratory factor analysis. RESULTS: The results focus on the 16 items in the second vignette which resulted in the extraction of three factors. The derived factors were labelled as follows: (i) Noting and Calling GP, (ii) Consult a Colleague and (iii) Immediate Assessment and Antibiotics. Reliability analysis revealed excellent to satisfactory reliability. All three scales were significantly correlated with measures of clinical tolerance of uncertainty, and the 'noting and calling GP' scale was also negatively correlated with measures of anxiety and general tolerance of uncertainty. The measure showed satisfactory reliability and validity for capturing nursing behaviours that have the potential to influence decisions regarding antibiotics. As such, the current study provides a first step towards addressing the lack of ecologically valid measures that capture the complex and nuanced context of nurses' behaviours in RACF that have the potential to inform future stewardship interventions.

Comparing the delirium objective structured clinical examination (OSCE) education package to standard education for post-registration nurses: A randomised controlled trial.

BACKGROUND: A recent pilot study demonstrated that an interactive delirium educational intervention, The Delirium OSCE Education Package, had a positive impact on self-perceptions of confidence and competence in the use of delirium assessment tools and delirium knowledge; delirium knowledge scores; clinical practice; and planned practice change for participants. However, it is not known if The Delirium OSCE Education Package is superior to standard methods of professional development education. OBJECTIVE: To determine if The Delirium OSCE Education Package is superior to standard methods of professional development education on observations of delirium care in practice scores for post-registration nurses. DESIGN: Clustered randomised, controlled, and observer-blinded, multisite superiority trial with two parallel groups at each site. SETTINGS: Three private hospitals across New South Wales, Australia. PARTICIPANTS: Registered nurses (RNs) (n = 153) or enrolled nurses (ENs) (n = 37) working in the eligible inpatient medical or surgical wards at each site. METHODS: Within each hospital site wards were clusters, with wards rather than individuals being randomised for The Delirium OSCE Education Package or standard professional development education at a ratio of 1:1. The primary outcome was observations of delirium care in practice, 6-weeks post (T1) allocated intervention. Secondary outcomes were self-perceived confidence and competence (self-efficacy) in delirium assessment tools and delirium knowledge; and delirium knowledge scores. RESULTS: A total of 51.3 % (n = 20) in the intervention group obtained a satisfactory observation of delirium care in practice score, compared to 34.9 % (n = 15) in the control group (p = 0.134, χ2). The odds of a satisfactory observation of delirium care in practice score for the intervention group was 10.1 times higher than the control (p = 0.009). The mean MCQ score and perceptions of confidence and competence in the intervention and control group increased from baseline to six-weeks post-intervention, however, there was no significant difference between the groups. CONCLUSION: The Delirium OSCE Education Package provides the foundation for facilitating change in delirium care. It is recommended that The Delirium OSCE Education Package is implemented as part of a multicomponent strategy involving a validation delirium screening and assessment tool, hospital-specific policy, interprofessional education, and delirium champions. Future studies are needed to evaluate the sustainability of the intervention and if there is a positive impact on patient-level outcomes.

Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities.

HIGHLIGHTS: The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.

Paste, aggregate, or air? That is the question.

The Ambassador Bridge between Detroit, Michigan, and Windsor, Ontario, has served for almost 100 years as North America's busiest international border crossing. But in 2025, the Ambassador will be replaced by the new Gordie Howe International Bridge. The Gordie Howe is a cable-stayed bridge, with two massive 220 m tall concrete piers on opposite banks of the St. Claire River, a single clear span of 853 m, and 42 m of clearance over this busy waterway. To ensure durability in this harsh freeze-thaw environment, air-entrained concrete is specified throughout. And, to ensure the quality of air entrainment, the ASTM C 457 Procedure C, Contrast Enhanced Method is employed. While a similar automated microscopic approach has been in use for well over a decade according to EN 480-11 Determination of air void characteristics in hardened concrete, this is the first large-scale application of automated air void assessment in North American infrastructure. According to the ASTM Procedure C, the air void characteristics are determined through digital image processing, while the paste content may be determined by either mix design parameters, manual point count, or 'other means'. Of these three options, point counting is used for Gordie Howe; but in parallel, during each point count, the digital image coordinates and phase identifications for each evaluated stop are recorded. This allows for training of a neural network, for automated determination of paste content, as demonstrated here.

Disparities in Influenza, Pneumococcal, COVID-19 Vaccine Coverage in High-Risk Adults 19 to 64 Years of Age in Southeastern Minnesota, 2010-2021.

BACKGROUND: Despite effective vaccines against influenza, pneumococcus, and COVID-19, uptake has been suboptimal. RESEARCH QUESTION: Although disparities in vaccination by race and ethnicity have been observed, what is the role of other sociodemographic in US vaccine uptake? STUDY DESIGN AND METHODS: We conducted a population-based study using the Rochester Epidemiology Project (REP), a comprehensive medical records linkage system, to assess effects of sociodemographic factors including race, ethnicity, individual-level socioeconomic status (SES) via the housing-based socioeconomic status index, education, population density (urban or nonurban), and marital status with uptake of influenza, pneumococcal, and COVID-19 vaccination in high-risk adults. Adults at high risk of invasive pneumococcal disease residing in four counties in southeastern Minnesota who were 19 to 64 years of age were identified. Vaccination data were obtained from the Minnesota Immunization Information Connection and REP from January 1, 2010, through December 31, 2021. RESULTS: We identified 45,755 residents. Most were White (82%), non-Hispanic (94%), married (56%), and living in an urban setting (81%), with three-quarters obtaining at least some college education (74%). Although 45.1% were up-to-date on pneumococcal vaccines, 60.1% had completed the primary COVID-19 series. For influenza and COVID-19, higher SES, living in an urban setting, older age, and higher education positively correlated with vaccination. Magnitude of differences in race, education, and SES widened with booster vaccines. INTERPRETATION: This high-risk population is undervaccinated against preventable respiratory diseases, especially influenza and pneumococcus. Although national data reported improvement of disparities in COVID-19 vaccination uptake observed early in the pandemic, our data demonstrated gaps related to race, education level, SES, and age that widened with booster vaccines. Communities with high social vulnerabilities often show increased risk of severe disease outcomes, yet demonstrate lower uptake of preventive services. This highlights the need to understand better vaccine compliance and access in rural, lower SES, less-educated, Black, Hispanic, and younger populations, each of which were associated independently with decreased vaccination.

The dam that fly ash built.

When the first concrete was poured in 1949 for the Hungry Horse Dam (Montana, USA), pozzolan cements had already been used in several major North American dams, including Grand Coulee on the Columbia River (diatomaceous earth explored but ultimately not used), Friant on the San Joaquin River and Altus on the North Fork Red River (pumicite) and Bonneville on the Columbia River and Davis on the Colorado River (calcined clay). But Hungry Horse Dam stands out as the first dam constructed using coal combustion fly ash. Utilising 2.4 million cubic metres of concrete, the dam is located on the South Fork Flathead River, one of the tributaries feeding one of the nation's major waterways, the Columbia River, and closely related to the adjacent Glacier National Park. In this respect, Hungry Horse is directly connected to two momentous periods in modern history - the massive adoption in the 1950s of coal as fuel for power plants, and the ongoing threats to fresh water supply and the rapid retreat of alpine glaciers due to global warming. Two concrete cores from this dam, one with fly ash and one without fly ash, are examined microscopically to explore the long-term suppression of alkali-aggregate reaction by fly ash. The core without fly ash exhibits clear evidence of alkali-aggregate reaction, manifested by sandstone coarse aggregate particles with darkened reaction rims. Sandstone coarse aggregate particles of the same lithology in the core with fly ash are without signs of alkali-aggregate reaction. A detailed examination of the darkened rims indicates that alkali-silica reaction products fill the narrow gaps between adjacent sand grains in the sandstone. This alkali-silica gel infilling allows for optical continuity between adjacent sand grains and is responsible for the classic darkened rim associated with the alkali-aggregate reaction.

Gaining consensus on expert rule statements for acute respiratory failure digital twin patient model in intensive care unit using a Delphi method.

Digital twin technology is a virtual depiction of a physical product and has been utilized in many fields. Digital twin patient model in healthcare is a virtual patient that provides opportunities to test the outcomes of various interventions virtually without subjecting an actual patient to possible harm. This can serve as a decision aid in the complex environment of the intensive care unit (ICU). Our objective is to develop consensus among a multidisciplinary expert panel on statements regarding respiratory pathophysiology contributing to respiratory failure in the medical ICU. We convened a panel of 34 international critical care experts. Our group modeled elements of respiratory failure pathophysiology using directed acyclic graphs (DAGs) and derived expert statements describing associated ICU clinical practices. The experts participated in three rounds of modified Delphi to gauge agreement on 78 final questions (13 statements with 6 substatements for each) using a Likert scale. A modified Delphi process achieved agreement for 62 of the final expert rule statements. Statements with the highest degree of agreement included the physiology, and management of airway obstruction decreasing alveolar ventilation and ventilation-perfusion matching. The lowest agreement statements involved the relationship between shock and hypoxemic respiratory failure due to heightened oxygen consumption and dead space. Our study proves the utility of a modified Delphi method to generate consensus to create expert rule statements for further development of a digital twin-patient model with acute respiratory failure. A substantial majority of expert rule statements used in the digital twin design align with expert knowledge of respiratory failure in critically ill patients.

Exploring leadership in health professionals following an industry-based leadership program: A cross-sectional survey.

AIM: To evaluate the self-reported leadership practices and behaviours of health professionals following a leadership program and explore factors that impacted leadership style. DESIGN: An online cross-sectional survey was conducted from August to October 2022. METHODS: The survey was disseminated via email to leadership program graduates. The Multifactor Leadership Questionnaire Form-6S was used to measure leadership style. RESULTS: Eighty completed surveys were included in the analysis. Participants scored highest on transformational leadership and lowest on passive/avoidant leadership style. Participants with higher qualifications scored significantly higher in the inspirational motivation scores (p = 0.03). As years in their profession increased, there was a significant decrease in contingent reward scores (p = 0.04). The younger participants scored significantly higher on the management-by-exception than older participants (p = 0.05). There were no significant associations with the year the leadership program was completed, gender or profession and Multifactor Leadership Questionnaire Form - 6S scores. Most participants (72.5%) strongly agreed that the program enhanced their leadership development and 91.3% strongly agreed or agreed that they routinely apply the skills and knowledge learnt in the program in their workplace. CONCLUSION: Formal leadership education is important in developing a transformational nursing workforce. This study found that program graduates had adopted a transformational leadership style. Education, years of experience and age impacted the specific leadership elements. Future work needs to incorporate longitudinal follow-up to relate changes in leadership with impact on clinical practice. IMPLICATIONS FOR THE PROFESSION: Transformational leadership as a dominant style can contribute to nurses and other disciplines positively contributing to innovative and person-centred approaches to health service delivery. SUMMARY STATEMENT: What already is known-Leadership amongst nurses and other health professionals impacts patients, staff, organizations and ultimately healthcare culture. What this paper adds-Formal leadership education is important in developing a transformational healthcare workforce. Implications for practice/policy-Transformational leadership can enhance nurses and other disciplines commitment to innovative and person-centred approaches. IMPACT STATEMENT: This research identifies that lessons learnt from formal leadership education are retained over time by healthcare providers. This is important for nursing staff, and other healthcare providers, who are leading teams and overseeing care delivery, can ensure leadership behaviours and practices are enacted to influence a transformational workforce and culture. REPORTING METHOD: This study adhered to STROBE guidelines. No Patient or Public Contribution.

Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis.

BACKGROUND: With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over. METHODS: Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed. RESULTS: A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted. LINKING EVIDENCE TO ACTION: This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.

Developing DELPHI expert consensus rules for a digital twin model of acute stroke care in the neuro critical care unit.

INTRODUCTION: Digital twins, a form of artificial intelligence, are virtual representations of the physical world. In the past 20 years, digital twins have been utilized to track wind turbines' operations, monitor spacecraft's status, and even create a model of the Earth for climate research. While digital twins hold much promise for the neurocritical care unit, the question remains on how to best establish the rules that govern these models. This model will expand on our group's existing digital twin model for the treatment of sepsis. METHODS: The authors of this project collaborated to create a Direct Acyclic Graph (DAG) and an initial series of 20 DELPHI statements, each with six accompanying sub-statements that captured the pathophysiology surrounding the management of acute ischemic strokes in the practice of Neurocritical Care (NCC). Agreement from a panel of 18 experts in the field of NCC was collected through a 7-point Likert scale with consensus defined a-priori by ≥ 80% selection of a 6 ("agree") or 7 ("strongly agree"). The endpoint of the study was defined as the completion of three separate rounds of DELPHI consensus. DELPHI statements that had met consensus would not be included in subsequent rounds of DELPHI consensus. The authors refined DELPHI statements that did not reach consensus with the guidance of de-identified expert comments for subsequent rounds of DELPHI. All DELPHI statements that reached consensus by the end of three rounds of DELPHI consensus would go on to be used to inform the construction of the digital twin model. RESULTS: After the completion of three rounds of DELPHI, 93 (77.5%) statements reached consensus, 11 (9.2%) statements were excluded, and 16 (13.3%) statements did not reach a consensus of the original 120 DELPHI statements. CONCLUSION: This descriptive study demonstrates the use of the DELPHI process to generate consensus among experts and establish a set of rules for the development of a digital twin model for use in the neurologic ICU. Compared to associative models of AI, which develop rules based on finding associations in datasets, digital twin AI created by the DELPHI process are easily interpretable models based on a current understanding of underlying physiology.

The dilemmas of antimicrobial stewardship in aged care: The perspectives of the family members of older Australians.

Antimicrobial resistance makes the misuse of antibiotics in residential aged care facilities (RACFs) a significant concern. Family members influence antibiotic prescribing for RACF residents, but there is limited understanding of the beliefs and knowledge that drive their involvement. Drawing on a fictional scenario, forty-six participants with a parent aged 75 or over took part in eight dialogue groups exploring family members' perspectives on antibiotic use and risks in older relatives. Main themes were identified using framework analysis. Participants supported judicious use of antibiotics in RACFs, but perceived vulnerabilities of older people, both structural and physiological prompt family pressure for antibiotics. Empirical antibiotic use became more acceptable when pathways to a prompt diagnosis are not apparent or confidence in RACF monitoring and care is lacking. The role of antibiotics in end-of-life decision-making was significantly under-recognised. Overall, elevation of discussion around antibiotics and end of life care are required.

'REDI TO CHAT?' Evaluating the effect of two structured tools on the confidence of nursing and care staff working in residential aged care facilities in Australia: A pre-post survey design.

OBJECTIVE: The objective of the study was to evaluate the effect of two self-designed structured clinical tools on overall self-perceptions of confidence in the assessment, management and communication of acutely unwell residents in nursing and care staff of residential aged care facilities (RACFs). METHODS: Quasi-experimental pre-post design using surveys in 22 RACFs in Metropolitan Sydney, Australia. A convenience sample of 254 nursing and care staff were recruited. Two structured tools were developed to enhance confidence: (1) RACF Emergency Decision Index (REDI) and (2) Clinical Handover Assessment Tool (CHAT). The REDI is a clinical decision guide for treatment implementation and escalation, and the CHAT is a structured communication aid. Surveys were administered to participating nursing and care staff working within the RACFs prior to the implementation of the two structured tools (T0) and 6 months later (T1). RESULTS: There was a significant increase in reported overall confidence in assessing and managing acutely unwell residents 6 months after the implementation of the REDI and CHAT (p = 0.003 and p = 0.006, respectively). Baseline Confidence in Assessment Scale and Confidence in Management Scale scores differed significantly 6 months following the implementation of the REDI and CHAT tools (p < 0.001). There was improvement across all surveyed communication domains. CONCLUSIONS: Preliminary data suggested that the two structured tools are effective in increasing confidence in the assessment, management and communication of acutely unwell residents for nursing and care staff working in RACFs.

Teaching delirium to undergraduate medical students: Exploring the effects of a cross-professional group objective structured clinical examination compared to standard education.

OBJECTIVES: To compare a cross-professional facilitated delirium group objective structured clinical examination (GOSCE) educational intervention with standard delirium education for medical students during clinical placement, and explore the differences in the examiner's written feedback between the two groups. METHODS: A non-randomised clustered controlled designed study at a single metropolitan university across several campuses in Sydney, Australia. A convenience sample of third-year medical students was recruited. Students' knowledge, communication, and clinical reasoning skills were assessed using a delirium case mock OSCE at the end of the academic year. The OSCE marks and the examiner's feedback for the intervention and control group were compared. RESULTS: The intervention group (n = 41) had a higher total mean OSCE mark compared to the control group (n = 29) (36.5, SD 2.9 vs. 33.7, SD 2.9, p < 0.001). Content analysis of the examiner's feedback showed the intervention group had a greater understanding of the need for forward planning and future cognitive assessments, and the roles of the interdisciplinary team in delirium care. CONCLUSIONS: The innovative cross-professional facilitated delirium GOSCE education was effective in increasing delirium knowledge, communication, and clinical reasoning skills compared to conventional education for medical students during clinical placement. Further studies are needed to investigate how this is translated into practice.

Cannabidiol as a Treatment for Neurobiological, Behavioral, and Psychological Symptoms in Early-Stage Dementia: A Double-Blind, Placebo-Controlled Clinical Trial Protocol.

Rationale: The slowing of disease progression in dementia in the early stages of diagnosis is paramount to improving the quality of life for those diagnosed and their support networks. Accumulating evidence suggests that CBD, a constituent of Cannabis sativa, is associated with neuroprotective, neuroendocrine, and psychotherapeutic effects, suggesting that it may be beneficial to dementia treatment. However, no published human study to date has examined this possibility. This trial aims to determine whether daily treatment with CBD over a 12-week period is associated with improved neurobiological, behavioral, and psychological outcomes in individuals living with early-stage dementia. Methods: Sixty participants with early-stage dementia will be recruited for a randomized, double-blind, placebo-controlled clinical trial. Participants will be randomized into either 99.9% pure CBD or placebo treatment conditions and administered two capsules per day for 12 weeks. Participants will commence a 200 mg/day dose for 2 weeks before escalating to 300 mg/day for the remaining 10 weeks. Neuroimaging and blood-based neuroendocrine profiles will be assessed at baseline and post-treatment. Psychological and behavioral symptoms will be assessed at baseline, 6 weeks, and post-treatment. Monitoring of health and side-effects will be conducted through weekly home visits. Discussion: This study is among the first to investigate the effects of isolated CBD in improving neuroanatomical and neuroendocrine changes, alongside psychological symptoms, during the early stages of dementia diagnosis. The outcomes of this trial have the capacity to inform a potential novel and accessible treatment approach for individuals living with early-stage dementia, and in turn, improve quality of life, prognoses, and treatment outcomes. Trial Registration: This trial has been registered with the Therapeutic Goods Administration (CT-2020-CTN-03849-1v2) and the Australian and New Zealand Clinical Trials Registry (ACTRN12621001364864).

Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review.

BACKGROUND: Infection is more frequent, and serious in people aged > 65 as they experience non-specific signs and symptoms delaying diagnosis and prompt treatment. Monitoring signs and symptoms using decision support tools (DST) is one approach that could help improve early detection ensuring timely treatment and effective care. OBJECTIVE: To identify and analyse decision support tools available to support detection of infection in older people (> 65 years). METHODS: A scoping review of the literature 2010-2021 following Arksey and O'Malley (2005) framework and PRISMA-ScR guidelines. A search of MEDLINE, Cochrane, EMBASE, PubMed, CINAHL, Scopus and PsycINFO using terms to identify decision support tools for detection of infection in people > 65 years was conducted, supplemented with manual searches. RESULTS: Seventeen papers, reporting varying stages of development of different DSTs were analysed. DSTs largely focussed on specific types of infection i.e. urine, respiratory, sepsis and were frequently hospital based (n = 9) for use by physicians. Four DSTs had been developed in nursing homes and one a care home, two of which explored detection of non- specific infection. CONCLUSIONS: DSTs provide an opportunity to ensure a consistent approach to early detection of infection supporting prompt action and treatment, thus avoiding emergency hospital admissions. A lack of consideration regarding their implementation in practice means that any attempt to create an optimal validated and tested DST for infection detection will be impeded. This absence may ultimately affect the ability of the workforce to provide more effective and timely care, particularly during the current covid-19 pandemic.

Dismantling antibiotic infrastructures in residential aged care: The invisible work of antimicrobial stewardship (AMS).

Recent social science scholarship has sought to understand the visible and invisible impacts of how antibiotics are entrenched as infrastructures and put to work as a proxy for higher levels of care (clinical or otherwise) within modern healthcare. Using a qualitative research design, in this paper our aim is to draw attention to less visible aspects of antimicrobial stewardship (AMS) in residential aged care and their implications for nurse-led optimization of antibiotic use in these settings. By developing an account of the perceptions, experiences and practices of staff regarding the 'on the ground' work associated with implementing and upholding AMS objectives our study extends research on attempts to dismantle antibiotic infrastructures in Australian residential aged care facilities (RACF). Drawing on a review of relevant policies, empirical data is presented from fifty-six in-depth interviews conducted in 2021 with staff at 8 different RACFs. Interview participants included managers, nurses, and senior and junior personal care assistants. Our results suggest that registered nurses in residential aged care have been tasked with promoting antibiotic optimization and assigned with AMS responsibilities without sufficient authority and resourcing. A host of hidden care work associated with AMS strategies was evident, reinforcing some staff support for empirical antibiotic prescribing as a 'safety net' in uncertain clinical cases. We argue that this hidden work occurs where AMS strategies displace the infrastructural role previously performed by antibiotics, exposing structural gaps and pressures. The inability of organisational accounting systems and the broader AMS policy agenda to capture hidden AMS workflows in RACFs has consequences for future resourcing and organisational learning in ways that mean AMS gaps may remain unaddressed. These results support findings that AMS interventions might not be easily accepted by aged care staff in view of associated burdens which are under recognised and under supported in this domain.

How do aged-care staff feel about antimicrobial stewardship? A systematic review of staff attitudes in long-term residential aged-care.

BACKGROUND: Antimicrobial resistance (AMR) is a problem in residential aged care facilities (RACF). There is a gap in our understanding of how psychosocial barriers such as risk perceptions shape staff attitudes towards antimicrobial stewardship (AMS). We sought to ascertain the attitudinal domains that have been identified to be of importance to AMS in RACF and comment on how they have been measured empirically. Our aim was to consolidate what is known regarding staff attitudes and perceptions in order to inform future stewardship. METHOD: We searched PsycINFO, PsycARTICLES, CINAHL Plus, MEDLINE, PubMed, Web of Science, Cochrane, and Scopus databases for primary studies of healthcare workers attitudes to AMS in RACF (1990-February 2021). RESULTS: 14 Studies were included in the review, within which 10 domains were identified: attitudes towards antimicrobial prescribing; guidelines; educational interventions; self-confidence regarding clinical assessment and prescribing; awareness of AMR as a problem and stewardship as a priority; self-efficacy; perception of role; perception of risk; team culture and resident/family members expectations. 46 measures were developed across the 14 studies to measure the 10 domains. The variability in the attitudinal domains and how these domains were measured was large. Only 13% included psychometric data regarding reliability and/or internal consistency. CONCLUSIONS: Attitudes are generally defined as having three evaluative bases: cognitive, behavioural, and affective. Findings from the current review suggest that the measures commonly used to capture healthcare staff attitudes to AMS do not sufficiently capture affect; particularly with respect to staff's risk perceptions, perceptions of their role, and family members' expectations. Given that affective processes have been postulated to influence medical decision making, these findings highlight the importance of understanding how staff, especially nurses feel about implementing AMS strategies and other peoples' (e.g. residents and their families) perceptions of stewardship. It is expected that a more nuanced understanding of RACF nurses affective experiences when applying AMS, and their perceptions of the risks entailed, will help in reducing barriers to overprescribing antibiotics.

The DEMS-DOSS study: validating a delirium monitoring tool in hospitalised older adults.

OBJECTIVE: to evaluate the sensitivity, specificity and test-retest reliability of the Delirium Early Monitoring System-Delirium Observation Screening Scale (DEMS-DOSS). DESIGN: prospective diagnostic accuracy study of a convenience sample of admitted older adults with DEMS-DOSS and reference standard assessments. SETTING: 60-bed aged care precinct at a metropolitan hospital in Sydney, Australia. PARTICIPANTS: 156 patients (aged ≥65 years old) were recruited to participate between April 2018 and March 2020. One hundred participants were included in the analysis. MEASUREMENTS: Participants were scored on the DEMS-DOSS. Trained senior aged care nurses conducted a standardised clinical interview based on the Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV delirium criteria, within two hours of DEMS-DOSS completion. The senior aged care nurse undertaking the DSM-IV interview was blinded to the results of the DEMS-DOSS. RESULTS: Participants' mean age was 84 (SD ±7.3) years and 39% (n = 39) had a documented diagnosis of dementia. Delirium was detected in 38% (n = 38) according to the reference standard. The DEMS-DOSS had a sensitivity of 76.3% and a specificity of 75.8% for delirium. The area under the receiver operating characteristics curve for delirium was 0.76. The test-retest reliability of the DEMS-DOSS was found to be high (r = 0.915). CONCLUSION: DEMS-DOSS is a sensitive and specific tool to assist with monitoring new onset and established delirium in hospitalised older adults. Further studies are required to evaluate the impact of the monitoring tool on health outcomes.

Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis.

BACKGROUND: Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use. METHODS: National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public's KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model. RESULTS: Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden. CONCLUSIONS: Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use.