Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals.

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a "Reduced" (<3%) or "Eliminated" (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Surveillance of hospital-acquired infections in Australia--One Nation, Many States.

Surveillance programmes for hospital-acquired infections differ amongst the Australian states. Victoria, New South Wales, Queensland and South Australia have recent substantial initiatives in development of statewide programmes. Whilst the definitions for surgical site infections (SSIs) and bloodstream infections (BSI) developed by the Australian Infection Control Association (AICA) do not differ from the US National Nosocomial Infection Surveillance (NNIS) programme definitions for SSI and intensive care unit (ICU) acquired central line-associated BSI, only two states use NNIS risk adjustment methods in reporting infection rates. Differences exist in the surgical procedures under surveillance, ICU surveillance, hospital-wide BSI surveillance, staff health immunization surveillance, process measures such us surgical antibiotic prophylaxis and small hospital programmes. Only in the area of antibiotic use surveillance has national consensus been reached. In Victoria, NNIS risk adjustment had limited usefulness in predicting SSIs, especially after coronary artery bypass graft (CABG) surgery. Ventilator-associated pneumonia (VAP) surveillance had limited acceptance, and is not undertaken in other states. Regular reporting of surgical antibiotic prophylaxis data has been followed by improvement in choice of antibiotic in some procedures. The South Australian programme for the surveillance of multiresistant organisms (MROs) has documented substantial improvement in meticillin-resistant Staphylococcus aureus (MRSA) morbidity over time coincident with the introduction of hand hygiene programmes and other measures. In Queensland, statewide monitoring of needlestick injuries is established. In Victoria, the small hospital programme concentrated on process measures, and in Queensland with a standardized investigation pathways for "signal" events. Data quality presented substantial challenges in small Victorian hospitals. Whilst state-based programmes have facilitated communication between hospitals and their coordinating centre, Australia still lacks national coordination and a national database on hospital infections. The differing approaches of the states illustrate many of the fundamental questions facing hospital infection surveillance today.

Clostridium difficile infection: nursing considerations.

Clostridium difficile is a bacterium which commonly causes diarrhoea in inpatients. C. difficile affects hospitalised patients worldwide and can pose a significant risk to patients. This article explores the transmission and risk factors for C. difficile infection (CDI). There are many aspects to the prevention and control of CDI: appropriate antibiotic use, early instigation and maintenance of prevention and control strategies, and high standards of environmental cleanliness, education, and surveillance. This article discusses the role of the nurse in each of these prevention and control activities.