A nurse-led comprehensive geriatric assessment intervention in primary care: A feasibility cluster randomized controlled trial.

AIM: To determine the feasibility of a nurse-led, primary care-based comprehensive geriatric assessment (CGA) intervention. DESIGN: A feasibility cluster randomized controlled trial. METHODS: The trial was conducted in six general practices in the United Kingdom from May 2018 to April 2020. Participants were moderately/severely frail people aged 65 years and older living at home. Clusters were randomly assigned to the intervention arm control arms. A CGA was delivered to the intervention participants, with control participants receiving usual care. Study outcomes related to feasibility of the intervention and of conducting the trial including recruitment and retention. A range of outcome measures of quality of life, function, loneliness, self-determination, mortality, hospital admission/readmission and number of prescribed medications were evaluated. RESULTS: All pre-specified feasibility criteria relating to recruitment and retention were met with 56 participants recruited in total (30 intervention and 26 control). Retention was high with 94.6% of participants completing 13-week follow-up and 87.5% (n = 49) completing 26-week follow-up. All outcome measures instruments met feasibility criteria relating to completeness and responsiveness over time. Quality of life was recommended as the primary outcome for a definitive trial with numbers of prescribed medications as a secondary outcome measure. CONCLUSION: It is feasible to implement and conduct a randomized controlled trial of a nurse-led, primary care-based CGA intervention. IMPACT: The study provided evidence on the feasibility of a CGA intervention for older people delivered in primary care. It provides information to maximize the success of a definitive trial of the clinical effectiveness of the intervention. PATIENT OR PUBLIC CONTRIBUTION: Patient and public representatives were involved in the study design including intervention development and production of participant-facing documentation. Representatives served on the trial management and steering committees and, as part of this role, interpreted feasibility data. ISRCTN Number: 74345449.

The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis.

OBJECTIVES: Penicillin allergy records are often incorrect and may result in harm. We aimed to systematically review the effectiveness and safety of nonallergist health care worker delivery of penicillin allergy delabeling. METHODS: We searched EMBASE/MEDLINE/CINAHL (Ovid), PsycInfo, Web of Science, and Cochrane CENTRAL from inception to January 21, 2022 and unpublished studies and gray literature. The proportion of patients allergic to penicillin delabeled and harmed was calculated using random-effects models. RESULTS: Overall, 5019 patients were delabeled. Using allergy history alone, 14% (95% confidence interval [CI], 9-21%) of 4350 assessed patients were delabeled without reported harm. Direct drug provocation testing resulted in delabeling in 27% (95% CI, 18-37%) of 4207 assessed patients. Of the 1373 patients tested, 98% were delabeled (95% CI, 97-99%), and nonserious harm was reported in 1% (95% CI, 0-2%). Using skin testing, followed by drug provocation testing, 41% (95% CI, 24-59%) of 2890 assessed patients were delabeled. Of the 1294 tested patients, 95.0% (95% CI, 90-99%) were delabeled, and the reported harm was low (0%; (95% CI 0-1%). CONCLUSION: Penicillin allergy delabeling by nonallergists is efficacious and safe. The proportion of assessed patients who can be delabeled increases with the complexity of testing method, but substantial numbers can be delabeled without skin testing.

Effectiveness of interventions that support penicillin allergy assessment and de-labeling of patients by non-allergy specialists: a systematic review protocol.

OBJECTIVE: This review will systematically examine and synthesize the evidence evaluating the effectiveness and safety of interventions that enable non-allergy specialist health care workers to assess allergy risk in patients with reported penicillin allergies and subsequently remove erroneous allergy records. INTRODUCTION: The potential benefits of removing erroneous penicillin allergy labels (de-labeling) are wide-ranging. Penicillin allergy assessment and de-labeling is an antibiotic stewardship priority. Delivery of such assessment and de-labeling by non-allergy specialists has been reported in several studies, but the effectiveness and safety have not been formally synthesized. This is a necessary step in the upscaling of penicillin allergy assessment services. INCLUSION CRITERIA: This review will consider quantitative studies using appropriate designs. The studies will include adults and pediatric patients who have undergone penicillin allergy assessment and de-labeling by non-allergy specialists in any health care setting. METHODS: A range of databases will be searched to identify studies published in English, with no date limit applied. Unpublished studies and gray literature will also be searched. Title and abstract screening, and assessment of selected full texts against the inclusion criteria will be conducted by at least two independent reviewers. Identified studies will be assessed for methodological quality using standardized critical appraisal instruments. Data will be extracted and categorized using the EPOC taxonomy, and the effectiveness and safety of the intervention will be determined. Where possible, data will be pooled to facilitate meta-analysis. Data from heterogeneous studies will be reported narratively. The GRADE approach for grading the certainty of evidence will be followed. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020219044.

Designing a nurse-led assessment and care planning intervention to support frail older people in primary care: An e-Delphi study.

AIM: To identify and establish expert consensus on important and feasible components of a nurse-led, comprehensive geriatric assessment (CGA)-based intervention for community-dwelling older people who live with frailty. DESIGN: A three-round modified e-Delphi survey. METHODS: An expert panel of 33 UK specialist older people's, primary and community care nurses participated in the three-round e-Delphi survey over a 12-month period in 2017-2018. Data from round 1 were analysed using content analysis. Descriptive statistics were used in the subsequent two rounds to demonstrate convergence of panel opinion and consensus. RESULTS: In round 1, experts proposed 30 CGA components that were combined with six additional components from a literature review and clustered into six domains. In round 2, components were rated for importance and feasibility. Rating scores for importance were high across all domains, with lower scores for feasibility. Round 3 revealed that 36 components achieved consensus on importance and 11 out of 36 components reached consensus on feasibility. CONCLUSION: Based on expert panel opinion, the content of a nurse-led CGA-based intervention was established, with the aim of future feasibility testing in a randomized controlled trial. IMPACT: This study provides feasible components of a CGA-based intervention that can be implemented in clinical practice by nurses in partnership with older people who live with frailty. Following further testing and evaluation, the components have the potential to improve clinical outcomes, maximize independence and improve the quality of life for community-dwelling frail older people.

Return on investment of a model of access combining triage with initial management: an economic analysis.

OBJECTIVES: Timely access to outpatient services is a major issue for public health systems. To address this issue, we aimed to establish the return on investment to the health system of the implementation of an alternative model for access and triage (Specific Timely Appointments for Triage: STAT) compared with a traditional waitlist model. DESIGN: Using a prospective pre-post design, an economic analysis was completed comparing the health system costs for participants who were referred for community outpatient services post-implementation of STAT with a traditional waitlist comparison group. SETTING: Eight community outpatient services of a health network in Melbourne, Australia. PARTICIPANTS: Adults and children referred to community outpatient services. INTERVENTIONS: STAT combined targeted activities to reduce the existing waiting list and direct booking of patients into protected assessment appointments. STAT was compared with usual care, in which new patients were placed on a waiting list and offered appointments as space became available. OUTCOMES: Health system costs included STAT implementation costs, outpatient health service use, emergency department presentations and hospital admissions 3 months before and after initial outpatient appointment. Waiting time was the primary outcome. Incremental cost-effectiveness ratios (ICERs) were estimated from the health system perspective. RESULTS: Data from 557 participants showed a 16.9 days or 29% (p<0.001) reduction in waiting time for first appointment with STAT compared with traditional waitlist. The ICER showed a cost of $A10 (95% CI -19 to 39) per day reduction in waiting time with STAT compared with traditional waitlist. Modelling showed the cost reduced to $A4 (95% CI -25 to 32) per day of reduction in waiting, if reduction in waiting times is sustained for 12 months. CONCLUSIONS: There was a significant reduction in waiting time with the introduction of STAT at minimal cost to the health system. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12615001016527).

Identifying the health care-initiated and self-initiated interventions used by women for the management of rectal emptying difficulty secondary to obstructive defecation: a scoping review protocol.

OBJECTIVE: This scoping review aims to identify interventions used by women for the management of rectal emptying difficulty secondary to obstructive defecation. INTRODUCTION: Rectal emptying difficulty is typically a symptom of obstructive defecation syndrome. Even though a range of interventions are already available for this condition, this review is necessary to increase understanding of what interventions women find useful and are acceptable for them. This depth of understanding will facilitate the development of a specific care pathway to support women living with rectal emptying difficulty secondary to obstructive defecation syndrome. INCLUSION CRITERIA: This review will consider studies that include adult women (over 18 years of age) living in the community who have experienced difficulty with rectal emptying secondary to obstructive defecation and who have not had surgical intervention. Exclusion criteria include prolapse surgery and surgical techniques, oral laxatives, vaginal pessaries, cognitive impairment, pregnancy, and those residing in care homes. METHODS: The databases to be searched include MEDLINE, Embase, CINAHL, PsycINFO, Emcare, AMED, Web of Science, Scopus, PROSPERO, Open Grey, ClinicalTrials.gov, International Clinical Trials Registry Platform Search Portal, UK Clinical Trials Gateway, International Standard Randomised Controlled Trial Number Registry, JBI Evidence Synthesis, Epistemonikos, Cochrane Library, and gray literature. Studies conducted in English from any time period will be considered for inclusion. The titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review.

Sustainable waiting time reductions after introducing the STAT model for access and triage: 12-month follow up of a stepped wedge cluster randomised controlled trial.

BACKGROUND: Timely access is a challenge for providers of outpatient and community-based health services, as seen by the often lengthy waiting lists to manage demand. The Specific Timely Appointments for Triage (STAT) model, an alternative approach for managing access and triage, reduced waiting time by 34% in a stepped wedge cluster randomised controlled trial involving 8 services and more than 3000 participants. Follow up periods ranged from 3 to 10 months across the participating services in accordance with the stepped wedge design. This study aimed to determine whether outcomes were sustained for a full 12 months after implementation of the STAT model at each site. METHODS: Routinely collected service data were obtained for a total of 12 months following implementation of the STAT model at each of the 8 services that participated in a stepped wedge cluster randomised controlled trial. The primary outcome was time to first appointment. Secondary outcomes included non-attendance rates, time to second appointment and service use over 12 weeks. Outcomes were compared to pre-intervention data from the original trial, modelled using generalised linear mixed effects models accounting for clustering of sites. RESULTS: A 29% reduction in waiting time could be attributed to STAT over 12 months, compared to 34% in the original trial. A reduction in variability in waiting time was sustained. There were no significant changes in time to second appointment or in the number of missed appointments in the extended follow up period. CONCLUSIONS: STAT is an effective strategy for reducing waiting time in community-based outpatient services. At 12 months, small reductions in the overall effect are apparent, but reductions in variability are sustained, suggesting that people who previously waited the longest benefit most from the STAT model. TRIAL REGISTRATION: This is a 12-month follow up of a stepped wedge cluster randomised controlled trial that was registered with the Australia and New Zealand Clinical Trials Registry ( ACTRN12615001016527 ).

Effectiveness of nurse-coordinated, person-centered comprehensive assessment on improving quality of life of community-dwelling, frail older people: a systematic review protocol.

OBJECTIVE: The objective of this systematic review is to determine the effectiveness of nurse-coordinated, person-centered comprehensive assessment on improving quality of life of community-dwelling, frail older people. INTRODUCTION: There is a growing need to meet the challenges of the increasingly frail and older population, and to provide proactive, holistic care close to home. A standardized assessment and care planning intervention could be implemented in primary care, which could be delivered by a primary or community healthcare nurse to address these challenges. However, it is not yet clear if an assessment and care planning intervention will improve outcomes for patients, such as quality of life. INCLUSION CRITERIA: This review will consider studies that evaluate nurse-coordinated, person-centered, comprehensive assessment delivered in partnership with community-dwelling, frail older people, and will compare the intervention to usual care. Studies that include people aged 60 years and older living at home or in supported living accommodation with a recognized level of frailty as assessed by use of frailty screening or assessment tools, will be considered. Studies that include outcomes of health-related quality of life, social functioning, and well-being will also be considered. METHODS: An initial limited search of PubMed and CINAHL has been undertaken to identify articles on the topic. The following sources will be searched for eligible papers: PubMED, CINAHL, Embase, PsycINFO, BNI, AMED, and OpenGrey. Retrieval of full-text studies, assessment of methodological quality, and data extraction will be performed independently by two reviewers. Meta-analysis will be performed, if possible, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings presented. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019137886.

The holistic assessment and care planning in partnership intervention study (HAPPI): A protocol for a feasibility, cluster randomized controlled trial.

AIM: During an initial phase of this research, an e-Delphi survey was conducted to gain consensus among stakeholders on the components of a nurse-led assessment and care planning intervention for older people who live with frailty in primary care. This feasibility randomized controlled trial (fRCT) will test the proposed intervention and its implementation and determine methods for the design of a conclusive randomized controlled trial. METHODS: The fRCT, with embedded qualitative study, aims to recruit 60 participants. Moderately and severely frail older people will be identified using the electronic frailty index (eFI) and the intervention will be delivered by senior community nurses. The control participants will receive usual primary care for frailty. The study is funded by the National Institute of Health Research (NIHR; funding granted in May 2016, ref: ICA-CDRF-2016-02-018) and received NHS and University Research Ethics Committee approval in 2018. DISCUSSION: There is evidence that the delivery of complex interventions for community-dwelling older people can reduce care home and hospital admissions and falls, there is less evidence for the benefit of any specific type or intensity of intervention or the additional benefits of targeting the frail population. This trial will determine feasibility of the intervention, define recruitment and retention parameters and trial logistics, and decide outcome measures. IMPACT: This study aims to address the limitations of current research by using a systematic method of frailty diagnosis and participant identification, trialling implementation of a person-centred intervention, and testing of feasibility parameters. TRIAL REGISTRATION NUMBER: ISRCTN: 74345449.

Refining nursing assessment and management with a new postanaesthetic care discharge tool to minimize surgical patient risk.

AIMS: To evaluate use of an evidence-based discharge tool, the Post-Anaesthetic Care Tool and its impact on nursing assessment, communication, and management of patients in the postanaesthetic care unit. BACKGROUND: Postanaesthetic care unit nurses manage patients immediately after surgery and make clinical decisions on discharge readiness. There is a lack of evidence-based guidance on assessing, documenting, and communicating the patient's postoperative experience. The Post-Anaesthetic Care Tool, which includes instructions for assessing discharge readiness and incorporates the ISOBAR acronym, was developed following a comprehensive systematic review and expert consultation. DESIGN AND METHODS: This quasiexperimental, multicentre, nonrandomized study was conducted in three postanaesthetic care units in Australia. Participants were nurses providing care to adults postgeneral anaesthesia. Episodes of care were observed before (N = 723) and after (N = 694) introduction of the evidence-based tool. Statistical methods (Chi-Square and Mann-Whitney U-Tests) were undertaken to analyse nursing assessment, communication, and management outcomes before and after implementation of the Post-Anaesthetic Care Tool. RESULTS: The Post-Anaesthetic Care Tool was associated with statistically significant improvements in the frequency of nursing assessment and responsiveness to complications including pain, nausea/vomiting and hypothermia. After the tool's introduction, nurses requested more medical reviews. This was associated with increased recognition of clinical deterioration and significant improvements in clarity of handover from the postanaesthetic care unit to the ward. CONCLUSIONS: The structured discharge tool, Post-Anaesthetic Care Tool, was associated with improved nursing management of patients in the postanaesthetic care unit and enabled early identification and response to clinical concerns.

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial.

BACKGROUND: Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional "waitlist and triage" model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction. METHODS/DESIGN: A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12 weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial. DISCUSSION: This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12615001016527 . Approved 15/9/2015.

Health coaching to prevent excessive gestational weight gain: A randomized-controlled trial.

OBJECTIVES: The objectives of this study were to evaluate the efficacy of a health coaching (HC) intervention designed to prevent excessive gestational weight gain (GWG), and promote positive psychosocial and motivational outcomes in comparison with an Education Alone (EA) group. DESIGN: Randomized-controlled trial. METHODS: Two hundred and sixty-one women who were <18 weeks pregnant consented to take part. Those allocated to the HC group received a tailored HC intervention delivered by a Health Coach, whilst those in the EA group attended two education sessions. Women completed measures, including motivation, psychosocial variables, sleep quality, and knowledge, beliefs and expectations concerning GWG, at 15 weeks of gestation (Time 1) and 33 weeks of gestation (Time 2). Post-birth data were also collected at 2 months post-partum (Time 3). RESULTS: There was no intervention effect in relation to weight gained during pregnancy, rate of excessive GWG or birth outcomes. The only differences between HC and EA women were higher readiness (b = 0.29, 95% CIs = 0.03-0.55, p < .05) and the importance to achieve a healthy GWG (b = 0.27, 95% CIs = 0.02-0.52, p < .05), improved sleep quality (b = -0.22, 95% CIs = -0.44 to -0.03, p < .05), and increased knowledge for an appropriate amount of GWG that would be best for their baby's health (b = -1.75, 95% CI = -3.26 to -0.24, p < .05) reported by the HC at Time 2. CONCLUSIONS: Whilst the HC intervention was not successful in preventing excessive GWG, several implications for the design of future GWG interventions were identified, including the burden of the intervention commitment and the use of weight monitoring. STATEMENT OF CONTRIBUTION: What is already known on the subject? Designing interventions to address gestational weight gain (GWG) continues to be a challenge. To date, health behaviour change factors have not been the focus of GWG interventions. What does this study add? Our health coaching (HC) intervention did not reduce GWG more so than education alone (EA). There was an intervention effect on readiness and importance to achieve healthy GWG. Yet there were no group differences regarding confidence to achieve healthy GWG post-intervention.

Minimising post-operative risk using a Post-Anaesthetic Care Tool (PACT): protocol for a prospective observational study and cost-effectiveness analysis.

INTRODUCTION: While the risk of adverse events following surgery has been identified, the impact of nursing care on early detection of these events is not well established. A systematic review of the evidence and an expert consensus study in post-anaesthetic care identified essential criteria for nursing assessment of patient readiness for discharge from the post-anaesthetic care unit (PACU). These criteria were included in a new nursing assessment tool, the Post-Anaesthetic Care Tool (PACT), and incorporated into the post-anaesthetic documentation at a large health service. The aim of this study is to test the clinical reliability of the PACT and evaluate whether the use of PACT will (1) enhance the recognition and response to patients at risk of deterioration in PACU; (2) improve documentation for handover from PACU nurse to ward nurse; (3) result in improved patient outcomes and (4) reduce healthcare costs. METHODS AND ANALYSIS: A prospective, non-randomised, pre-implementation and post-implementation design comparing: (1) patients (n=750) who have surgery prior to the implementation of the PACT and (2) patients (n=750) who have surgery after PACT. The study will examine the use of the tool through the observation of patient care and nursing handover. Patient outcomes and cost-effectiveness will be determined from health service data and medical record audit. Descriptive statistics will be used to describe the sample and compare the two patient groups (pre-intervention and post-intervention). Differences in patient outcomes between the two groups will be compared using the Cochran-Mantel-Haenszel test and regression analyses and reported as ORs with the corresponding 95% CIs. CONCLUSIONS: This study will test the clinical reliability and cost-effectiveness of the PACT. It is hypothesised that the PACT will enable nurses to recognise and respond to patients at risk of deterioration, improve handover to ward nurses, improve patient outcomes, and reduce healthcare costs.

Implementation science: a reappraisal of our journal mission and scope.

The implementation of research findings into healthcare practice has become increasingly recognised as a major priority for researchers, service providers, research funders and policymakers over the past decade. Nine years after its establishment, Implementation Science, an international online open access journal, currently publishes over 150 articles each year. This is fewer than 30% of those submitted for publication. The majority of manuscript rejections occur at the point of initial editorial screening, frequently because we judge them to fall outside of journal scope. There are a number of common reasons as to why manuscripts are rejected on grounds of scope. Furthermore, as the field of implementation research has evolved and our journal submissions have risen, we have, out of necessity, had to become more selective in what we publish. We have also expanded our scope, particularly around patient-mediated and population health interventions, and will monitor the impact of such changes. We hope this editorial on our evolving priorities and common reasons for rejection without peer review will help authors to better judge the relevance of their papers to Implementation Science.

In-reach nursing services improve older patient outcomes and access to emergency care.

AIMS: To identify the impact of in-reach services providing specialist nursing care on outcomes for older people presenting to the emergency department from residential aged care. METHODS: Retrospective cohort study compared clinical outcomes of 2278 presentations from 2009 with 2051 presentations from 2011 before and after the implementation of in-reach services. RESULTS: Median emergency department length of stay decreased by 24 minutes (7.0 vs 6.6 hours, P < 0.001) and admission rates decreased by 23% (68 vs 45%, P < 0.001). The proportion of people with repeat emergency department visits within six months decreased by 12% (27 vs 15%). The proportion of admitted patients who were discharged with an end of life palliative care plan increased by 13% (8 vs 21%, P = 0.007). CONCLUSIONS: There was a significant reduction in the median length of stay, fewer hospital admissions and fewer repeat visits for people from residential aged care following implementation of in-reach services.

Repositioning for pressure ulcer prevention in adults.

BACKGROUND: A pressure ulcer (PU), also referred to as a 'pressure injury', 'pressure sore', or 'bedsore' is defined as an area of localised tissue damage that is caused by unrelieved pressure, friction or shearing forces on any part of the body. PUs commonly occur in patients who are elderly and less mobile, and carry significant human and economic impacts. Immobility and physical inactivity are considered to be major risk factors for PU development and the manual repositioning of patients in hospital or long-term care is a common pressure ulcer prevention strategy. OBJECTIVES: The objectives of this review were to:1) assess the effects of repositioning on the prevention of PUs in adults, regardless of risk or in-patient setting;2) ascertain the most effective repositioning schedules for preventing PUs in adults; and3) ascertain the incremental resource consequences and costs associated with implementing different repositioning regimens compared with alternate schedules or standard practice. SEARCH METHODS: We searched the following electronic databases to identify reports of the relevant randomised controlled trials: the Cochrane Wounds Group Specialised Register (searched 06 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); Ovid MEDLINE (1948 to August, Week 4, 2013); Ovid EMBASE (1974 to 2013, Week 35); EBESCO CINAHL (1982 to 30 August 2013); and the reference sections of studies that were included in the review. SELECTION CRITERIA: Randomised controlled trials (RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different patient positions and measured PU incidence in adults in any setting. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS: We included three RCTs and one economic study representing a total of 502 randomised participants from acute and long-term care settings. Two trials compared the 30º and 90º tilt positions using similar repositioning frequencies (there was a small difference in frequency of overnight repositioning in the 90º tilt groups between the trials). The third RCT compared alternative repositioning frequencies.All three studies reported the proportion of patients developing PU of any grade, stage or category. None of the trials reported on pain, or quality of life, and only one reported on cost. All three trials were at high risk of bias.The two trials of 30º tilt vs. 90º were pooled using a random effects model (I² = 69%) (252 participants). The risk ratio for developing a PU in the 30º tilt and the standard 90º position was very imprecise (pooled RR 0.62, 95% CI 0.10 to 3.97, P=0.62, very low quality evidence). This comparison is underpowered and at risk of a Type 2 error (only 21 events).In the third study, a cluster randomised trial, participants were randomised between 2-hourly and 3-hourly repositioning on standard hospital mattresses and 4 hourly and 6 hourly repositioning on viscoelastic foam mattresses. This study was also underpowered and at high risk of bias. The risk ratio for pressure ulcers (any category) with 2-hourly repositioning compared with 3-hourly repositioning on a standard mattress was imprecise (RR 0.90, 95% CI 0.69 to 1.16, very low quality evidence). The risk ratio for pressure ulcers (any category) was compatible with a large reduction and no difference between 4-hourly repositioning and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02, very low quality evidence).A cost-effectiveness analysis based on data derived from one of the included parallel RCTs compared 3-hourly repositioning using the 30º tilt overnight with standard care consisting of 6-hourly repositioning using the 90º lateral rotation overnight. In this evaluation the only included cost was nursing time. The intervention was reported to be cost saving compared with standard care (nurse time cost per patient €206.6 vs €253.1, incremental difference €-46.5; 95%CI: €-1.25 to €-74.60). AUTHORS' CONCLUSIONS: Repositioning is an integral component of pressure ulcer prevention and treatment; it has a sound theoretical rationale, and is widely recommended and used in practice. The lack of robust evaluations of repositioning frequency and position for pressure ulcer prevention mean that great uncertainty remains but it does not mean these interventions are ineffective since all comparisons are grossly underpowered. Current evidence is small in volume and at risk of bias and there is currently no strong evidence of a reduction in pressure ulcers with the 30° tilt compared with the standard 90º position or good evidence of an effect of repositioning frequency. There is a clear need for high-quality, adequately-powered trials to assess the effects of position and optimal frequency of repositioning on pressure ulcer incidence.The limited data derived from one economic evaluation means it remains unclear whether repositioning every 3 hours using the 30º tilt is less costly in terms of nursing time and more effective than standard care involving repositioning every 6 hours using a 90º tilt.

A conceptual model of psychosocial risk and protective factors for excessive gestational weight gain.

OBJECTIVE: nearly half of all women exceed the guideline recommended pregnancy weight gain for their Body Mass Index (BMI) category. Excessive gestational weight gain (GWG) is correlated positively with postpartum weight retention and is a predictor of long-term, higher BMI in mothers and their children. Psychosocial factors are generally not targeted in GWG behaviour change interventions, however, multifactorial, conceptual models that include these factors, may be useful in determining the pathways that contribute to excessive GWG. We propose a conceptual model, underpinned by health behaviour change theory, which outlines the psychosocial determinants of GWG, including the role of motivation and self-efficacy towards healthy behaviours. This model is based on a review of the existing literature in this area. ASSESSMENT AND CONCLUSION: there is increasing evidence to show that psychosocial factors, such as increased depressive symptoms, anxiety, lower self-esteem and body image dissatisfaction, are associated with excessive GWG. What is less known is how these factors might lead to excessive GWG. Our conceptual model proposes a pathway of factors that affect GWG, and may be useful for understanding the mechanisms by which interventions impact on weight management during pregnancy. This involves tracking the relationships among maternal psychosocial factors, including body image concerns, motivation to adopt healthy lifestyle behaviours, confidence in adopting healthy lifestyle behaviours for the purposes of weight management, and actual behaviour changes. IMPLICATIONS FOR PRACTICE: health-care providers may improve weight gain outcomes in pregnancy if they assess and address psychosocial factors in pregnancy.

Telephone pre-operative assessment for adults: a comprehensive systematic review.

BACKGROUND: The preparation of the patient for surgery is an extremely important stage of the elective perioperative process. Telephone preoperative assessment is being used internationally as a tool to perform health screening. The evidence around the effectiveness of such an intervention and the patient's experience of preoperative screening has not, however, been examined. OBJECTIVES: Is telephone preoperative assessment as effective as face-to-face preadmission clinic visits on adult patient preparedness for elective surgery?What are the perioperative experiences of adult patients who have received telephone- based preoperative preparation for elective surgery? INCLUSION CRITERIA: This review considered quantitative and qualitative studies that examined the effectiveness of telephone preoperative assessment and the experiences of adult elective ambulatory and inpatient surgery patients receiving this intervention.The participants in the review were adult patients, having elective surgery in a hospital setting, and who had experienced a telephone preoperative consultation.Studies that examined the effectiveness and meaningfulness of telephone preoperative assessment for adults were considered for inclusion in this systematic review.The review explored evidence on outcome measures related to the patient preparation for surgery and also to the experiences of patients who have had telephone preoperative assessment. SEARCH STRATEGY: A three phase search strategy was utilised. A limited search of systematic reviews and PubMed database was conducted. Search strategies were developed using identified key words and index terms across multiple databases and grey literature and reference lists of identified articles were examined. Searches were limited to studies published in English between 2000 and May 2011. METHODOLOGICAL QUALITY: The studies were independently assessed by two reviewers using standardised critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION: Quantitative data were extracted using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument data extraction tool. Qualitative data were extracted using the Joanna Briggs Institute Qualitative Assessment Review Instrument data extraction tool. DATA SYNTHESIS: Statistical pooling was not possible due to the nature of the quantitative study designs, therefore the findings of this review are presented in narrative form. Only one qualitative paper was included therefore findings are presented in narrative form. RESULTS: Twelve studies were included in the review. From the available evidence it was found that telephone assessment may be as effective as face-to-face preadmission clinic visits in terms of preparing the patient for elective surgery, reducing the rate of last minute theatre cancellations and in the reduction of anxiety levels. Only one study reported the patient experiences of this intervention. CONCLUSIONS: This review demonstrated that telephone preoperative assessment may be a viable option for practice in terms of effectiveness. There is a paucity of literature regarding the patient experiences of the intervention. IMPLICATIONS FOR PRACTICE: Telephone preoperative assessment may be an effective alternative to face-to-face assessment, resulting in reduction of cancellations and postponements and reduction of anxiety in preoperative patients. IMPLICATION FOR RESEARCH: Currently the overall level of evidence regarding telephone-based preoperative assessment is low; more rigorous studies are required for all of the examined outcomes.

Use of mobility subscale for risk assessment of pressure ulcer incidence and preventive interventions: A systematic review.

BACKGROUND: Pressure ulcers remain a serious problem for patients and providers in healthcare. When a pressure ulcer develops, it can inflict pain and cause untoward complications such as severe infections, surgery, prolonged hospital stay and even death. OBJECTIVE: The objective of this review was to establish whether using the Braden subscale mobility assessment is comparable to using the full Braden pressure ulcer risk assessment scale. However, due to lack of research studies, the focus of this review was extended to include the use of other assessment tools for hospital acquired pressure ulcer risk. INCLUSION CRITERIA: Quantitative studies that reported data on mobility and pressure ulcer development or preventive interventions, irrespective of their design were included in the review.The review focused on adult patients admitted to an acute care facility, who underwent a pressure ulcer risk assessment, and had no pressure ulcers on admission.This review considered studies that use Braden mobility subscale assessmentThis review compared the use of full Braden risk assessment scale where available only when it was included within the same study,This review considered: SEARCH STRATEGY: A search for published and unpublished studies from 2000 to 2010 of major healthcare related electronic databases was conducted. Studies in other languages that were translated into English were included in the review. ASSESSMENT OF QUALITY: The papers that were selected for possible inclusion were assessed by two independent reviewers for methodological validity using standardised critical appraisal instruments from the Joanna Briggs Institute. DATA COLLECTION AND ANALYSIS: Data from included studies were extracted and analysed using Revman5 software. RESULTS AND CONCLUSIONS: Eighteen studies were included in this review. The findings suggest that the risk of pressure ulcer development was higher when the patient was identified as having impaired mobility, as assessed using the Braden subscale mobility or other similar mobility scales. However, there is little conclusive evidence to indicate that using mobility assessment alone is comparable to using Braden or other risk assessment scales in reducing the incidence of pressure ulcer. Evidence for association between assessment of mobility and endorsement of preventive interventions was significant. However, this finding was based on only one study. No evidence found on the reliability of mobility assessment as a tool to predict pressure ulcer risk. Nor was there evidence on the frequency of assessment using the mobility assessment tool. IMPLICATIONS FOR PRACTICE: Assessment of mobility may be a useful measure in an acute care setting in relation to assessing the risk of developing pressure ulcer. However, there is not enough evidence to conclude that mobility assessment alone can replace the more common risk assessment scales such as Braden scale in predicting incidence of pressure ulcer. IMPLICATIONS FOR RESEARCH: Further research is required to.