Client and stakeholder perceptions of a novel, nurse practitioner-led alcohol and other drug ambulatory withdrawal service.

INTRODUCTION: Despite recommendations for ambulatory withdrawal programs appearing in many contemporary alcohol and other drug treatment guidelines, to date there have been few studies exploring such programs from client and service stakeholder perspectives. The aim of this study was to explore both individual and service stakeholder perceptions of a nurse practitioner-led ambulatory withdrawal service on the Gold Coast, Queensland, Australia. METHODS: Data were obtained from three groups: clinicians with knowledge of the service (n = 6); relatives of clients who had used the service (n = 2); and clients who had used the service (n = 10) using a Qualitative Descriptive design. Saldaña's (Saldaña, The coding manual for qualitative researchers. 2013) structural coding framework was used to analyse and code data into themes, with the study reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al. Int J Qual Health Care 2017;19:349-57). RESULTS: Participants noted advantages of the nurse practitioner-led ambulatory withdrawal service, including rapid availability of admission to the service and a person-centred approach. Compared with other ambulatory withdrawal options, clients valued the ability to remain in their own environment, however participants suggested greater follow-up after withdrawal, with the potential of a home visiting service for greater client engagement and treatment retention. DISCUSSION AND CONCLUSIONS: Findings provide evidence to suggest that nurse practitioner-led ambulatory withdrawal services are an acceptable option for a proportion of clients who need rapid access to services when they wish to make changes to their alcohol and/or other drug use. Furthermore, they can provide person-centred care for comorbid physical and mental ill health occurring in addition to psychosocial issues associated with alcohol and/or other drug use.

Child health nurses' perceptions of the Family Community-based Assistance Resourcing and Education program in contemporary practice: a qualitative study.

BACKGROUND: The Family Community-based Assistance Resourcing and Education Program (FCP) is a nurse home visiting program that was introduced in Queensland two decades ago to redress health inequalities for infants from families experiencing specific social stressors. Locally adapted versions of this home visiting program are still in use, but have not been evaluated. This study examined child health nurse perceptions of the adapted FCP in one regional Queensland health service. METHODS: A qualitative descriptive exploratory study using two focus groups (conducted May 2019) with Child Health Nurses who delivered the FCP was conducted. Transcripts of digital recordings were analysed using Braun and Clarke's (2006) six-step framework for guided thematic analysis. RESULTS: A total of 16 Child Health Nurses participated in the study, with a mean of 10years' experience with the program. Data analysis generated 12 themes organised under three domains: 'Establishing the relationship with families', 'What works in practice' and 'We could do it better'. Participants cited flexibility, expert input and in-home delivery as key program benefits. However, narrow eligibility criteria, poor screening for perinatal anxiety and resourcing constraints were identified as limitations. CONCLUSIONS: This study is the first to measure Child Health Nurses' perceptions of an adapted FCP. It sheds light on their 'practice wisdom', including the program's ability to meet the needs of families with social vulnerabilities. The study supports prior calls for home visiting programs to be evaluated against clearly stated program intentions. Participant insights have been shared to inform practice and program implementation both locally and as part of Queensland's First 2000Days health service delivery reform agenda.

Measuring success: program fidelity of Queensland's child health home visiting services. A document analysis.

BACKGROUND: The Family CA.R.E. (Community-based Assistance Resourcing and Education) program was introduced in Queensland two decades ago. It aimed to redress health inequalities for infants from families experiencing specific social stressors. The program has been locally adapted over time and has not been evaluated against the original program. This study assessed the extent to which selected hospital and health services in Queensland, Australia have modified the original Family C.A.R.E. METHODS: Altheide's model was used to facilitate a critical document analysis of policies and guidelines for adapted Family C.A.R.E. home visiting programs in use by hospital and health services (target n =7). RESULTS: Five of seven eligible services provided service model documentation. There was low alignment with the original Family C.A.R.E. program across four of the five participating services. While the program delivered within Service 4 was highly aligned to the structure and intent of the original model, variation to the program was still evident. Importantly, four of the five participating programs were not collecting evaluation measures. CONCLUSIONS: Health services have adapted the original Family C.A.R.E program format to 'fit' the local service environment but have largely failed to collect data to facilitate evaluation. Inability to evaluate the program leads to uncertainty about program success and benefits as well as any unintended consequences for families engaging in unevaluated home visiting programs. This study highlights the importance of monitoring program fidelity and evaluating success given the potential ramifications for this vulnerable cohort and for health service delivery.

Factors that may threaten or protect the wellbeing of staff working in paediatric intensive care environments.

OBJECTIVE: This study explored the risk and protective factors for wellbeing from the perspectives of multidisciplinary paediatric intensive care unit staff. DESIGN: Using a qualitative, descriptive study design we purposively recruited a sample of nurses, physicians, and allied health professionals to participate in semi-structured interviews which explored staff perceptions of risk and protective factors relating to their daily paediatric intensive care roles. Data was analysed using thematic analysis. SETTING: Four paediatric intensive care units in Australia. FINDINGS: Twenty staff were recruited. Braun and Clarke's thematic analysis approach identified perceived risks for wellbeing included a lack of preparation for the role, and clinical situations that contributed to psychological distress, including perceived worst shift, moral distress, non-accidental injuries, and isolation. Themes perceived as protective to wellbeing included: finding the work stimulating and meaningful, belonging to the team, and using humour. CONCLUSION: Staff perceptions of wellbeing in the paediatric intensive care unit suggested that risk factors often co-existed simultaneously with protective factors. These results are not consistent with the notion that wellbeing as a phenomenon can be considered on a risk-protection continuum. Strategies that enhance this work as meaningful and stimulating, promote a sense of belonging to the team, and support the use of humour, may assist health professionals to achieve a balance between risk and protective factors for wellbeing. IMPLICATIONS FOR CLINICAL PRACTICE: Education and training on end-of-life care, and how to have difficult conversations and manage the consistent psychological distress of intensive care work, is essential at orientation and requires regular formal interventions. Experiencing the work as stimulating highlights the need for advanced scope of practice work. Opportunities for individual and team reflection about the meaning and purpose of their work, and ensuring staff feel valued and experience a sense of belonging to the team, are critical to the intensive care context.

Evaluation of the CARES Skills Framework as a Peer Support Model in the Paramedic Undergraduate Curriculum: Facilitating Challenging Discussions in a Safe Environment.

OBJECTIVE: Infant or child death is reported as being the most distressing type of case paramedics attend. Student paramedics also identify supporting bereaved families as an area associated with low confidence. This study evaluated the CARES skills framework (Connect to emotion, Attention training, Reflective listening, Empathy, Support help seeking) as a peer support model to encourage student paramedics to talk about grief and death related to infants and children. METHOD: A convenience sample of first-year paramedic students (target n = 154) was recruited from a single Australian regional university. A modified nominal group technique method was used following a student debriefing session designed to identify problems, generate solutions, and make decisions regarding the efficacy of the CARES skills framework. RESULTS: Of 154 eligible participants, 141 participated (92% response rate). Peer social support normalized students' emotions related to death and dying. Although naming emotions was challenging, students reported that the CARES model facilitated a safe environment to talk about death and dying. Students reported feeling heard and connected to their peers during the exercise and an enhanced sense of belonging after the exercise. CONCLUSIONS: Findings contribute to evidence that suggests the CARES model is a useful mechanism to enhance peer social support in paramedic students.

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

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

Infant Care Practices, Caregiver Awareness of Safe Sleep Advice and Barriers to Implementation: A Scoping Review.

Modifiable infant sleep and care practices are recognised as the most important factors parents and health practitioners can influence to reduce the risk of sleep-related infant mortality. Understanding caregiver awareness of, and perceptions relating to, public health messages and identifying trends in contemporary infant care practices are essential to appropriately inform and refine future infant safe sleep advice. This scoping review sought to examine the extent and nature of empirical literature concerning infant caregiver engagement with, and implementation of, safe sleep risk-reduction advice relating to Sudden Unexpected Deaths in Infancy (SUDI). Databases including PubMed, CINAHL, Scopus, Medline, EMBASE and Ovid were searched for relevant peer reviewed publications with publication dates set between January 2000-May 2021. A total of 137 articles met eligibility criteria. Review results map current infant sleeping and care practices that families adopt, primary infant caregivers' awareness of safe infant sleep advice and the challenges that families encounter implementing safe sleep recommendations when caring for their infant. Findings demonstrate a need for ongoing monitoring of infant sleep practices and family engagement with safe sleep advice so that potential disparities and population groups at greater risk can be identified, with focused support strategies applied.

Interventions for interpersonal communication about end of life care between health practitioners and affected people.

BACKGROUND: Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes. OBJECTIVES: To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing. SELECTION CRITERIA: This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes. DATA COLLECTION AND ANALYSIS: Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies. MAIN RESULTS: Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear. AUTHORS' CONCLUSIONS: Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Women's use of non-conventional herbal uterotonic in pregnancy and labour: evidence from birth attendants.

BACKGROUND: Over the years, governments and stakeholders have implemented various policies/programmes to improve maternal health outcomes in low-middle-income countries. In Ghana, Community Health Officers were trained as midwives to increase access to skilled maternal healthcare. The government subsequently banned traditional birth attendants from providing direct maternal healthcare in 2000. Despite these, there is an unprecedented utilisation of TBAs' services, including herbal uterotonics. This has attempted to defeat stakeholders' campaigns to improve maternal health outcomes. Thus, we explored and highlighted herbal uterotonic consumption in pregnancy and birth and the implications on maternal and newborn health outcomes in North-Western Ghana. METHODS: This was an exploratory qualitative study that investigated traditional birth attendants (n = 17) and healthcare providers' (n = 26) perspectives on the intake of herbal uterotonics in pregnancy and childbirth in rural Ghana, using in-depth interviews. A combination of convenience, purposive and snowball sampling procedures were employed in selecting participants. RESULTS: Findings were captured in two domains: (1) perceived rationale for herbal uterotonic intake, and (2) potential adverse impacts of herbal uterotonic intake in pregnancy and labour, and nine topics: (i) confidence in unskilled attendance at birth, (ii) cost and a shortage of essential medicines, (iii) herbal uterotonics as a remedy for obstetric problems, (iv) herbal uterotonics facilitate birth, (v) attraction of home birth for cultural reasons, (vi) affordability of herbal uterotonics, (vii) unintended consequences and adverse outcomes, (viii) risks using herbal uterotonics to manage fertility and (ix) risks using herbal uterotonics to facilitate home birth. CONCLUSION: The findings have suggested that the intake of non-conventional herbal uterotonic is widespread in the study area, although the constituents of the herb are unknown. However, complex and multiple factors of healthcare cost, desire for homebirth, unawareness of the negative effects of such substances, perceived way of addressing obstetric problems and cultural undertones, among others, accounted for herbal uterotonics consumption. We also encourage research into the constituents of 'mansugo' and the potential benefits and adverse effects. We recommend qualitative studies involving previous users of this herbal uterotonic to inform policy and healthcare provision.

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

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

What is the prevalence and risk factors of burnout among pediatric intensive care staff (PICU)? A review.

Staff in the paediatric intensive care unit work with children and their families in an area of high acuity, mortality, and morbidity. There is complexity due to technological advancements and confronting psychosocial situations. With increasing reports of the threat of burnout to healthcare professionals it is imperative to understand the prevalence of burnout and the determinants of risk factors for staff to work in the paediatric intensive care unit (PICU) in order to inform interventions that reduce risk and support growth and wellbeing of this specialised workforce. We conducted electronic searches of PUBMED, Medline, CINAHL and PsychINFO. Studies meeting eligibility inclusion criteria comprised English text, publication dates 1995 to 2019, use of standardized measures to assess prevalence and risk factors for burnout where the PICU staff data was reported separately and contained sample sizes ≥10 PICU staff. Two reviewers independently identified and extracted citations and assessed the quality of papers using two standardised reporting tools. Twenty studies were included in the final review. Due to the heterogeneity of the included studies a descriptive account of the studies was developed. Outcomes reported included prevalence and levels of burnout reported across professional disciplines, reported scoring criteria for burnout, risk and protective factors for burnout, comparative populations, systems and social context associated with burnout and study strengths and limitations. Most studies were cross-sectional, used a single measure of burnout and focussed on either physicians or nurses. Of the 20 studies reported 62% reported high burnout, 19% moderate burnout, and 19% reported low levels of burnout. Inconsistency was identified in adherence to recommended cut-off scores or reporting for the categorisation of burnout, which contributed to a lack of clarity in the interpretation of prevalence and severity. Reports of factors associated with increased risk and likely protective factors for burnout were often contradictory suggesting that burnout may be situational; dependent upon personal, environmental, leadership, cultural and patient factors within the PICU. This review revealed that determining levels and risk of burnout in PICU staff remains problematic. Further research which examines the experiences of all members of the multidisciplinary team and identification of factors that affect the development of burnout, including those which are protective, is required.

Challenges parents encounter when implementing infant safe sleep advice.

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

Effect of infusion set replacement intervals on catheter-related bloodstream infections (RSVP): a randomised, controlled, equivalence (central venous access device)-non-inferiority (peripheral arterial catheter) trial.

BACKGROUND: The optimal duration of infusion set use to prevent life-threatening catheter-related bloodstream infection (CRBSI) is unclear. We aimed to compare the effectiveness and costs of 7-day (intervention) versus 4-day (control) infusion set replacement to prevent CRBSI in patients with central venous access devices (tunnelled cuffed, non-tunnelled, peripherally inserted, and totally implanted) and peripheral arterial catheters. METHODS: We did a randomised, controlled, assessor-masked trial at ten Australian hospitals. Our hypothesis was CRBSI equivalence for central venous access devices and non-inferiority for peripheral arterial catheters (both 2% margin). Adults and children with expected greater than 24 h central venous access device-peripheral arterial catheter use were randomly assigned (1:1; stratified by hospital, catheter type, and intensive care unit or ward) by a centralised, web-based service (concealed before allocation) to infusion set replacement every 7 days, or 4 days. This included crystalloids, non-lipid parenteral nutrition, and medication infusions. Patients and clinicians were not masked, but the primary outcome (CRBSI) was adjudicated by masked infectious diseases physicians. The analysis was modified intention to treat (mITT). This study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12610000505000 and is complete. FINDINGS: Between May 30, 2011, and Dec, 9, 2016, from 6007 patients assessed, we assigned 2944 patients to 7-day (n=1463) or 4-day (n=1481) infusion set replacement, with 2941 in the mITT analysis. For central venous access devices, 20 (1·78%) of 1124 patients (7-day group) and 16 (1·46%) of 1097 patients (4-day group) had CRBSI (absolute risk difference [ARD] 0·32%, 95% CI -0·73 to 1·37). For peripheral arterial catheters, one (0·28%) of 357 patients in the 7-day group and none of 363 patients in the 4-day group had CRBSI (ARD 0·28%, -0·27% to 0·83%). There were no treatment-related adverse events. INTERPRETATION: Infusion set use can be safely extended to 7 days with resultant cost and workload reductions. FUNDING: Australian National Health and Medical Research Council.

Awareness of infant safe sleep messages and associated care practices: findings from an Australian cohort of families with young infants.

Objective: To investigate primary infant caregiver awareness of the current national public health safe sleep messages and the associations of awareness with care practices. Design and setting: A cross-sectional survey in Queensland, Australia. All families with live babies birthed during April-May 2017 were eligible. Questionnaires were distributed when infants were approximately 3 months old. Participants: Of the 10 200 eligible families, 3341 (33%) primary caregivers participated. Main outcome measures: Participants were asked: to recall key safe sleeping messages they were aware of (unprompted); questions about their infant care practices; and to select the current, national six safe sleeping messages (prompted multi-choice). Results: Overall, the majority of families are aware of sleep-related infant mortality and sudden infant death (3178/3317, 96%); however, approximately one in four caregivers (867/3292, 26%) could not identify the current six messages to promote safer infant sleep in a multi-choice question. Despite being aware of the six key messages, some caregiver practices did not always align with advice (336/2423, 14% were not smoke-free; 349/2423, 14% were not usually supine for sleep; 649/2339, 28% employed practices which may increase risk of head or face covering; 426/2423, 18% were not receiving breastmilk). Conclusions: There is considerable scope for improvement in parent awareness and ability to recall key safe sleep messages. Awareness of advice does not always translate into safe infant care. Health promotion messaging to encourage safer infant sleep, ultimately aimed at reducing sudden unexpected infant deaths, needs more effective supportive strategies and dissemination if future campaigns are to be successful.

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

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

Australian maternity healthcare professionals' knowledge, attitudes and practices relevant to cord blood banking, donation and clamp timing: A cross-sectional survey.

PROBLEM: Australian health professionals' knowledge and attitudes towards third stage labour options of cord clamp timing, cord blood banking and donation and their practice of informing parents of these options is unknown. BACKGROUND: Parents have several options for the management of their infant' cord blood during the third stage of labour. Early or deferred cord clamping practices may affect parent choices about physiological transfusion to the neonate and/or cord blood collection for private or public banking or donation. AIM: To identify health professionals' knowledge and attitudes towards third stage labour options of cord clamp timing, cord blood banking and donation and their practice of informing parents of these options. METHODS: A total of 129 Australian maternity healthcare professionals responded to the self-administered survey between December 2017 and June 2018. FINDINGS: Occupational differences were revealed in regard to cord clamp timing, cord blood banking and donation knowledge, attitudes and practices. Midwives were more likely to discuss cord clamp timing with parents and to clamp the cord later than obstetricians. Obstetricians were more knowledgeable of cord blood banking and donation options than midwives. Cord blood banking and donation options were discussed by both groups if parents asked. DISCUSSION: Identification of gaps in knowledge should guide future maternity health professional education that is inclusive of all third stage labour options to ensure that open discussion and informing parents of options is consistent, contemporary and evidence-based. CONCLUSION: To make informed decisions, parents need evidence-based information on all third stage labour options.

Applying a Social Exclusion Framework to Explore the Relationship Between Sudden Unexpected Deaths in Infancy (SUDI) and Social Vulnerability.

Background: Sudden Unexpected Death in Infancy (SUDI) is a leading cause of preventable infant mortality and strongly associated with social adversity. While this has been noted over many decades, most previous studies have used single economic markers in social disadvantage analyses. To date there have been no previous attempts to analyze the cumulative effect of multiple adversities in combination on SUDI risk. Methods: Based on sociological theories of social exclusion, a multidimensional framework capable of producing an overall measure of family-level social vulnerability was developed, accounting for both increasing disadvantage with increasing prevalence among family members and effect of family structures. This framework was applied retrospectively to all cases of SUDI that occurred in Queensland between 2010 and 2014. Additionally, an exploratory factor analysis was performed to investigate whether differing "types" of vulnerability could be identified. Results: Increased family vulnerability was associated with four major known risk factors for sudden infant death: smoking, surface sharing, not-breastfeeding and use of excess bedding. However, families with lower levels of social vulnerability were more likely to display two major risk factors: prone infant sleep position and not room-sharing. There was a significant positive relationship between family vulnerability and the cumulative total of risk factors. Exploratory factor analysis identified three distinct vulnerability types (chaotic lifestyle, socioeconomic and psychosocial); the first two were associated with presence of major SUDI risk factors. Indigenous infants had significantly higher family vulnerability scores than non-Indigenous families. Conclusion: A multidimensional measure that captures adversity across a range of indicators highlights the need for proportionate universalism to reduce the stalled rates of sudden infant death. In addition to information campaigns continuing to promote the importance of the back-sleeping position and close infant-caregiver proximity, socially vulnerable families should be a priority population for individually tailored or community based multi-model approaches.

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

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

Prevalence of risk factors for sudden infant death among Indigenous and non-Indigenous people in Australia.

AIM: To examine differences in the prevalence of risk factors for sudden unexpected death in infancy (SUDI) between Aboriginal and Torres Strait Islander and non-Indigenous infants. METHODS: A retrospective cohort study of SUDI in Queensland during 2010-2014 examined exposure to SUDI risk factors, to identify factors accounting for higher SUDI mortality among Indigenous infants. A multistage algorithm was applied to linked data to determine Indigenous status. RESULTS: There were 228 SUDI, of which Indigenous infants comprised 26.8%. The Indigenous SUDI rate was 2.13/1000 live births compared to 0.72/1000 for non-Indigenous. The disparity between Indigenous and non-Indigenous SUDI was accounted for by surface sharing (OR = 2.93 95% CI = 1.41, 6.07), smoking (OR = 2.49, 95% CI = 1.13, 5.52), and a combination of background antenatal and sociodemographic factors (inadequate antenatal care [OR = 6.93, 95% CI = 2.20, 21.86], young maternal age at first birth [OR = 4.02, 95% CI = 1.49, 10.80] and outer regional [OR = 3.03, 95% CI = 1.37, 6.72] and remote locations [OR = 11.31, 95% CI = 3.47, 36.83]). CONCLUSION: Culturally responsive prevention efforts, including wrap-around maternity care and strategies that reduce maternal smoking and promote safer yet culturally acceptable ways of surface sharing, may reduce Indigenous SUDI mortality.

Infant care practices and parent uptake of safe sleep messages: a cross-sectional survey in Queensland, Australia.

BACKGROUND: Globally, the incidence of sleep-related infant mortality declined dramatically following the first public health campaigns seen internationally in the 1990s to reduce the risks of sudden infant death. However, Australian Sudden Unexpected Death in Infancy (SUDI) rates have plateaued with little change in incidence since 2004 despite two further public health safe sleep campaigns. This study aims to describe contemporary infant care practices employed by families related to the current public health SUDI prevention program. METHODS: A cross-sectional survey of 3341 Queensland primary caregivers with infants approximately 3-months of age was conducted using the Queensland Registry of Births, Deaths and Marriages as a sampling frame. Surveys were returned either via reply-paid mail or online. Questionnaires explored prevalence of infant care practices and awareness of safe sleep recommendations. Univariable analysis was used to generate descriptive statistics for key variables. RESULTS: Overall, only 13% of families routinely practised all six 'Safe Sleeping' program messages. More than one third (1118, 34%) of infants had slept in a non-supine sleep position at some time. Potentially hazardous sleep environments were common, with 38% of infants sleeping with soft items or bulky bedding, or on soft surfaces. Nearly half, for either day- or night-time sleeps, were routinely placed in a sleep environment that was not designed or recommended for safe infant sleep (i.e. a bouncer, pram, beanbag). Most babies (84%) were reportedly smoke free before and after birth. Sleeping in the same room as their caregiver for night-time sleeps was usual practice for 75% of babies. Half (1600, 50%) of all babies shared a sleep surface in the last two-weeks. At 8-weeks, 17% of infants were no longer receiving any breastmilk. CONCLUSIONS: The prevalence rates of infant care practices among this Australian population demonstrate many families continue to employ suboptimal practices despite Australia's current safe sleep campaign. Strategic approaches together with informed decisions about pertinent messages to feature within future public health campaigns and government policies are required so targeted support can be provided to families with young infants to aid the translation of safe sleep evidence into safe sleeping practices.