Family experiences and perceptions of intensive care unit care and communication during the COVID-19 pandemic.

INTRODUCTION: In 2020, during the first wave of the COVID-19 pandemic in Melbourne, visitor access to acute hospitals including intensive care units (ICUs) was initially barred, followed by a limit of one person per patient for one hour per day. This study explores the care and communication experienced by family members of ICU patients during this time. METHODS: This qualitative descriptive study was conducted at an Australian quaternary hospital. Semistructured phone interviews were conducted using an aide-memoire designed to understand participants' experiences as family of a patient during this time. Interviews were recorded, transcribed, and thematically analysed. FINDINGS: Twenty family members of patients in the ICU participated. Three major themes were identified: 'impact of restricting visiting procedures', 'family experiences of communication', and 'care and support'. Inflexible visiting restrictions had a momentous impact on families. Participants objected to having to nominate only two people to visit during the admission and the short visiting time limit. Some family members suffered extreme stress and anxiety during their absence from the bedside. Additional challenges were experienced by rural families, visitors with disabilities, and the young children of patients who were excluded. Communication with clinicians varied. Telehealth was valued by some but not universally embraced. The relationship between staff members and families and involvement in decision-making were unaffected. CONCLUSION: Families experienced significant psychological distress from being separated from their critically ill relatives. Patient care and involvement in decision-making appeared to be unchanged, but communication with staff felt to be lacking. Better alternatives to face-to-face communication must be sought to limit the impact of family separation on mental health. Families are a key link between the patient and clinicians and often play a major role in patient support and recovery after discharge. There is an urgent need to support them and facilitate meaningful engagement despite the obstacles.

Comparison of an algorithm, and coding data, with traditional surveillance to identify surgical site infections in Australia: a retrospective multi-centred cohort study.

BACKGROUND: Surveillance of healthcare-associated infections (HAIs) in Australia is disparate, resource intensive, unsustainable, and provides limited information. Traditional HAI surveillance is time intensive and agreement levels between clinicians have been shown to be variable. AIM: To compare two methods: a semi-automated algorithm, and coding data, against traditional surgical site infection (SSI) surveillance methods. METHODS: This retrospective multi-centre cohort study included all patients undergoing a hip (HPRO) or knee (KPRO) prosthesis and coronary artery bypass graft (CABG) surgery during a two-year period at two large metropolitan hospitals. Routine SSI data were obtained via the infection prevention and control (IPC) team, a previously developed algorithm was applied to all patient records, and the ICD-10-AM data were searched for those categorized as having an SSI. FINDINGS: Overall, 1447, 1416, and 1026 patients who underwent HPRO, KPRO, and CABG, respectively, were included. The highest sensitivity values were generated by the algorithm: HPRO deep or organ-space (D/O) 0.87 (95% confidence interval: 0.66-0.96), CABG 0.86 (0.64-0.96), and HPRO all SSI 0.77 (0.57-89); the lowest sensitivity was Code CABG D/O 0.03 (0.00-0.21). The highest PPV values were generated by the algorithm: HPRO D/O 0.97 (0.77-0.99), CABG D/O 0.97 (0.76-0.99), and the Code HPRO D/O 0.9 (0.66-0.99). Both the algorithm and coding data resulted in a substantial reduction in the number of medical records required to review. CONCLUSION: The application of algorithms to enhance SSI surveillance demonstrates high accuracy in identifying patient records that require review by IPC teams to determine the presence of an SSI. Coding data alone should not be used to identify SSIs.

Using machine learning models to predict falls in hospitalised adults.

BACKGROUND: Identifying patients at high risk of falling is crucial in implementing effective fall prevention programs. While the integration of information systems is becoming more widespread in the healthcare industry, it poses a significant challenge in analysing vast amounts of data to identify factors that could enhance patient safety. OBJECTIVE: To determine fall-associated factors and develop high-performance prediction tools for at-risk patients in acute and sub-acute care services in Australia. METHODS: A retrospective study of 672,400 patients admitted to acute and sub-acute care services within a large metropolitan tertiary health service in Victoria, Australia, between January 1, 2019, and December 31, 2021. Data were obtained from four sources: the Department of Health Victorian Admitted Episodes Dataset, RiskManTM, electronic health records, and the health workforce dataset. Machine learning techniques, including Random Forest and Deep Neural Network models, were used to analyse the data, predict patient falls, and identify the most important risk factors for falls in this population. Model performance was evaluated using accuracy, F1-score, precision, recall, specificity, Matthew's correlation coefficient, and the area under the receiver operating characteristic curve (AUC). RESULTS: The deep neural network and random forest models were highly accurate in predicting hospital patient falls. The deep neural network model achieved an accuracy of 0.988 and a specificity of 0.999, while the RF achieved an accuracy of 0.989 and a specificity of 1.000. The top 20 variables impacting falls were compared across both models, and 12 common factors were identified. These factors can be broadly classified into three categories: patient-related factors, staffing-related factors, and admission-related factors. Although not all factors are modifiable, they must be considered when planning fall prevention interventions. CONCLUSION: The study demonstrated machine learning's potential to predict falls and identify key risk factors. Further validation across diverse populations and settings is essential for broader applicability.

Burden of five healthcare associated infections in Australia.

BACKGROUND: Healthcare associated infections are of significant burden in Australia and globally. Previous estimates in Australia have relied on single-site studies, or combinations thereof, which have suggested the burden of these infections is high in Australia. Here, we estimate the burden of five healthcare associated infections (HAIs) in Australian public hospitals using a standard international framework, and compare these estimates to those observed in Europe. METHODS: We used data from an Australian point prevalence survey to estimate the burden of HAIs amongst adults in Australian public hospitals using an incidence-based approach, introduced by the ECDC Burden of Communicable Diseases in Europe. RESULTS: We estimate that 170,574 HAIs occur in adults admitted to public hospitals in Australia annually, resulting in 7583 deaths. Hospital acquired pneumonia is the most frequent HAI, followed by surgical site infections, and urinary tract infections. We find that blood stream infections contribute a small percentage of HAIs, but contribute the highest number of deaths (3207), more than twice that of the second largest, while pneumonia has the higher impact on years lived with disability. CONCLUSION: This study is the first time the national burden of HAIs has been estimated for Australia from point prevalence data collected using validated surveillance definitions. Per-capita, estimates are similar to that observed in Europe, but with significantly higher occurrences of bloodstream infections and healthcare-associated pneumonia, primarily amongst women. Overall, the estimated burden is high and highlights the need for continued investment in HAI prevention.

Predicting medical emergency team calls, cardiac arrest calls and re-admission after intensive care discharge: creation of a tool to identify at-risk patients.

We aimed to develop a predictive model for intensive care unit (ICU)-discharged patients at risk of post-ICU deterioration. We performed a retrospective, single-centre cohort observational study by linking the hospital admission, patient pathology, ICU, and medical emergency team (MET) databases. All patients discharged from the Alfred Hospital ICU to wards between July 2012 and June 2014 were included. The primary outcome was a composite endpoint of any MET call, cardiac arrest call or ICU re-admission. Multivariable logistic regression analysis was used to identify predictors of outcome and develop a risk-stratification model. Four thousand, six hundred and thirty-two patients were included in the study. Of these, 878 (19%) patients had a MET call, 51 (1.1%) patients had cardiac arrest calls, 304 (6.5%) were re-admitted to ICU during the same hospital stay, and 964 (21%) had MET calls, cardiac arrest calls or ICU re-admission. A discriminatory predictive model was developed (area under the receiver operating characteristic curve 0.72 [95% confidence intervals {CI} 0.70 to 0.73]) which identified the following factors: increasing age (odds ratio [OR] 1.012 [95% CI 1.007 to 1.017] P <0.001), ICU admission with subarachnoid haemorrhage (OR 2.26 [95% CI 1.22 to 4.16] P=0.009), admission to ICU from a ward (OR 1.67 [95% CI 1.31 to 2.13] P <0.001), Acute Physiology and Chronic Health Evaluation (APACHE) III score without the age component (OR 1.005 [95% CI 1.001 to 1.010] P=0.025), tracheostomy on ICU discharge (OR 4.32 [95% CI 2.9 to 6.42] P <0.001) and discharge to cardiothoracic (OR 2.43 [95%CI 1.49 to 3.96] P <0.001) or oncology wards (OR 2.27 [95% CI 1.05 to 4.89] P=0.036). Over the two-year period, 361 patients were identified as having a greater than 50% chance of having post-ICU deterioration. Factors are identifiable to predict patients at risk of post-ICU deterioration. This knowledge could be used to guide patient follow-up after ICU discharge, optimise healthcare resources, and improve patient outcomes and service delivery.

Orgaran (Org 10172) or heparin for preventing venous thrombosis after elective surgery for malignant disease? A double-blind, randomised, multicentre comparison. ANZ-Organon Investigators' Group.

This double-blind, randomised, multicentre trial in 513 patients having elective surgery for intra-abdominal or intrathoracic malignancy compared the efficacy and safety of venous thrombosis (VT) prophylaxis using 750 anti-factor Xa units of Orgaran (a mixture of low molecular weight heparinoids) given subcutaneously (sc) twice-daily with that of twice-daily injections of 5,000 units standard heparin. The main study endpoints were the development of postoperative VT detected by 125I-fibrinogen leg scanning, and the onset of clinically significant venous thromboembolism or bleeding. "Intent to treat" analysis showed a statistically non-significant trend towards less VT during Orgaran prophylaxis (10.4%) than after heparin (14.9%) and there was no difference in bleeding complications between the two study groups. Results remained similar if only patients who completed the intended course of therapy ("compliant patients") were analysed. Other trials have shown that Orgaran prevents VT after hip surgery and stroke. We now show it is also safe and effective in patients having major surgery for cancer.

Abdominal wound closure--a comparison of monofilament nylon and polyglycolic acid.

The incidence of burst abdomen, incisional herniation, and sinus formation after a vertical abdominal incision was studied in a prospective randomized trial that compared two suture materials--monofilament nylon and polyglycolic acid. Laparotomy wounds were closed with a continuous mass suture technique. Of the 210 patients studied, 15 died between 10 days and 6 months postoperatively with their wounds intact. The remaining patients were followed up for 6 months or longer. The two groups were well matched for known risk factors. The 104 patients in the polyglycolic acid group had a 12.5% wound failure rate (1 burst abdomen and 12 hernias), but the 106 patients in the nylon group had only a 4.7% wound failure rate (1 burst abdomen and 4 hernias) (P = 0.04). There was a significant association between the rate of infection and sinus formation, but there was no difference between the incidence of these complications between the two groups. Closure of abdominal wounds with absorbable sutures does not appear to be justified, and we suggest that nylon and the mass closure technique be used for all abdominal wound closures. Other etiologic factors significantly associated with wound failure include male sex and postoperative chest complications. However, infection remains the most significant postoperative complication because the incidence of incisional hernias and sinus formation would be reduced by the elimination of wound sepsis.

Cutaneous ectopic breast calcification in a haemodialysis patient.

This case report details the unique breast calcification and swellings of a 61-year-old lady. The ectopic breast calcification was a result of chronic renal failure and hyperparathyroidism secondary to vesiculo-ureteric reflux nephropathy. Subcutaneous nodules were also noted around her ileostomy (from surgery due to Crohn's disease) and abdominal wall. Mammogram revealed calcified breast discs and lobules with extensive vascular calcification. Histological biopsies revealed extensive calcium deposition (benign). Cutaneous deposition of calcium oxalate has been described in 13 patients world wide, usually involving fingers, ears, or nose. Two of these report breast involvement, but this is described as less extensive and more focal calcification on clinical findings and mammography. This case report describes a rare condition with extraordinary mammographic images.

Modern trends in breast cancer therapy: towards less lymphoedema?

AIMS: To review from the evidence, with special reference to axillary node management, whether the incidence of lymphoedema following breast cancer treatment is falling in modern breast practice. CONCLUSIONS: The incidence of lymphoedema does seem to be reducing with modern approaches to breast cancer management. Axillary treatment seems to determine its development but more studies looking specifically at this problem are needed.

Factors influencing wound complications: a clinical and experimental study.

Burst abdomen, incisional herniation, sinus formation and post-operative wound infection continue to bedevil the surgeon. A prospective study of 1129 laparotomy wounds defined the extent of the problem; 1.7% incidence of dehiscence, 7.4% herniation and 6.7% sinus formation, all significantly associated with wound infection. Mass closure reduced the dehiscence rate from 3.8% to 0.76%. Infection reduced wound strength in a rat laparotomy model due to a decrease in fibroblast concentration and activity. A monofilament non-absorbable suture was shown experimentally to be the most suitable suture for closing infected abdominal wounds. Electron microscopy demonstrated bacteria in the interstices of infected multifilament sutures. A randomised clinical trial comparing polyglycolic acid and monofilament nylon in the closure of abdominal wounds confirmed the experimental findings; polyglycolic acid resulted in a significantly higher wound failure rate with no decrease in sinus formation. A mass closure technique using monofilament nylon is recommended for laparatomy closure and efforts should continue to reduce wound sepsis.

Argon beam coagulation as an adjunct in breast-conserving surgery.

The development of a haematoma after wide excision of breast tumours is not uncommon. Suction drainage is commonly used to prevent this but often increases the hospital stay and can create unsightly wounds. Argon beam coagulation is a new technique which permits large 'raw' areas to be coagulated with minimal tissue damage. We believe that this technique may reduce the development of haematomas and seromas after breast surgery. We present our initial results using argon beam coagulation after wide excision of breast tumours in 80 patients without suction drainage. One patient required a single aspiration of a seroma at the site of breast lump excision and none required surgical drainage. Argon beam coagulation appears a useful adjunct in breast surgery and may help reduce hospital stay.

Removal of skin staples in an emergency.

We have highlighted this problem as there are situations where skin staples have to be removed rapidly, for example where bleeding and subsequent respiratory distress develop following neck surgery. A survey of junior hospital staff showed that many doctors had never removed skin staples nor were aware how best to remove them in the event of an emergency. Using skin simulation we compared the time to remove sutures and staples, and found it takes 55% longer to remove skin staples. Where the standard staple remover is not immediately available, an artery forceps, correctly applied, is just as quick.

Abdominal wound closure: choice of suture.

Experiments were designed to test suture materials for their use in potentially infected abdominal wound closure. The nearest to the ideal, at present available, is a monofilament nonabsorbable suture, the one tested being monofilament nylon. The suture retained adequate strength in the infected and noninfected state over a 70-day period. This is particularly important as infection has been shown to result in low wound strength in the early phases of healing. The monofilamentous nature of this suture represented an advantage when sutures were examined electronmicroscopically. Infected, braided sutures viewed for the first time by electronmicroscopy were shown to contain bacteria and polymorphonuclear cells, even after 70 days implantation. The normal absorption and encapsulation of these sutures was delayed by the presence of infection. Polyglycolic acid had marked strength when new but rapidly weakened after implantation. This together with slowed absorption in the infected state is a disturbing feature in terms of wound failure and sinus formation respectively.

Assessment of sutures for use in colonic surgery: an experimental study.

Following injury, normal colon takes approximately 30 days to regain full breaking strength. This healing period can be lengthened by local infection. Colonic anastomoses are likely to be contaminated by intraluminal organisms, and suture material in such a situation is known to potentiate the development of sepsis. Experiments were designed to evaluate six suture materials used in colonic surgery to determine which retained adequate tensile strength and which excited least inflammatory response. The results indicate that absorbable sutures, with the exception of polydioxanone, lose strength too rapidly for use alone. Braided materials, notably silk, produce a prolonged tissue response and harbour bacteria. Monofilament materials are unreactive and appear least likely to delay healing. Polydioxanone, which is monofilament and absorbable, is recommended for use in the colon.

Why we do the things we do: applying clinical decision-making frameworks to triage practice.

This paper discusses major themes presented in the published literature concerning clinical decision making and links these to the practice of emergency department nurse triage. Themes discussed include: approaches to decision research in nursing and medicine; decision autonomy in nursing practice and clinical decision making under conditions of uncertainty. Some assumptions underpinning clinical decision-making frameworks are explored and the use of triage scales, algorithms and intuitive thought processes are discussed in terms of clinical practice. In addition, the strengths and limitations of each approach are outlined. It is argued that naturalistic research methods are necessary in order to describe the often uncertain and frequently chaotic environment in which triage decisions are made. This research must occur in order to evaluate and improve both the triage process and the outcomes of these decisions in practice.

From abstract to acclaim.

Increasing specialisation in the health-care sector requires nurses to be proficient communicators both within their own profession and among other health-care disciplines. Although the work environment provides numerous opportunities for oral communication, traditionally we have been taught written communication. Like scientific writing, an oral presentation demands a sense of planning, audience awareness and attention to detail. Yet, because of the different medium, other important factors must also be considered. While a reader may select passages or reread a report, the audience must listen in a linear way. Your voice and body, aided by visual displays, will have a different effect on the listener than the printed pages have on the reader. Therefore, it is important to concentrate on both the content and the method of presentation if the audience is to be left feeling inspired. This article outlines the planning of a presentation, development of visual aids and delivery of a polished performance.

Evidence based practice: are critical care nurses ready for it?

In the emergence of the evidence based practice movement, critical care nurses have struggled to identify scientific evidence on which to base their clinical practice. While the lack of critical care nursing research is a major concern, other important issues have significantly stalled the implementation of evidence even when it is available. A descriptive study of 274 critical care nurses was undertaken to examine nursing research activity in Victorian critical care units. The study aimed to identify critical care nurses' research skills, the barriers encountered in participation and implementation and the current availability of resources. Results revealed that 42 per cent of the nurses who participated in the study believed that they were not prepared adequately to evaluate research, and less than a third believed they were sufficiently skilled to conduct valid scientific studies. An association was found between nurses' ability to confidently perform research activities and higher academic qualifications. The study found that there is a lack of organisational support and management commitment for the development of evidence based nursing. In order to facilitate the implementation of evidence based practice, clinicians must be made aware of the available resources, be educated and mentored when carrying out and using clinical research, and be supported in professional initiatives that promote evidence based practice. It is argued that this will have positive implications for patient outcomes in the critical care environment.

A clinical trial of tissue adhesive (histoacryl) in skin closure of groin wounds.

The use of tissue adhesives has been widely studied since the 1960s. Since then they have found use in specialties like plastic surgery, neurosurgery, ENT surgery and dental surgery. Several papers have reported their safe use, both clinically and experimentally, particularly of the newer homologue n-butyl/2-cyanoacrylate (Histoacryl). In this study 43 patients (46 wounds) whose operations involved a groin incision were randomised into two groups for skin closure either with Dexon subcuticular suture (23 wounds) or Histoacryl glue (23 wounds). We found that both sets of wounds healed well with no wound infections or excessive inflammation when assessed at one week and four weeks. However the glued wounds had consistently better cosmesis scores (mean score 4.71 at four weeks) compared to the subcuticular Dexon wounds (mean score 4.00 at four weeks) and P value of less than 0.05. We feel that there is a place for tissue adhesives in skin closure for some general surgical wounds.