Prevention of postsurgical wound dehiscence after abdominal surgery with NPWT: a multicentre randomised controlled trial protocol.

OBJECTIVE: The effectiveness of negative pressure wound therapy (NPWT) in the prevention of postoperative surgical wound dehiscence (SWD) is the subject of much debate and remains to be determined. This study will identify individuals at risk of postoperative SWD and trial the use of NPWT as a prophylactic measure against the occurrence of SWD, compared with a non-NPWT standard surgical dressing (SSD). METHOD: A prospective multicentre randomised controlled trial comparing NPWT dressing against standard surgical dressings (SSD) will be conducted. An intention-to-treat (ITT) approach will be used for the trial. AIMS: The primary outcome is the prevention of postoperative SWD up to and including day 30 postoperative. Secondary outcomes are: prevention of surgical site infection (SSI) and economic analysis of treatment groups. CONCLUSION: This study will determine the effectiveness of NPWT in the prevention of postoperative abdominal SWD in a predefined level of risk population. This level 1 study will provide further data for abdominal SWD risk classification, which is anticipated to inform preventive postoperative management. The study design uses a prospective real-world scenario in order to identify clinically significant differences between the intervention and control groups. TRIAL REGISTRATION: This trial was prospectively registered on 10 December 2012 with Australian and New Zealand Clinical Trials Network (ANZCTR): 12612001275853.

Surgical wound dehiscence in an Australian community nursing service: time and cost to healing.

OBJECTIVE: Surgical wound dehiscence (SWD) increases the length of hospital stay and impacts on patient wellbeing and health-care costs. Globally, the health-care costs associated with SWD are poorly reported and those reported are frequently associated with surgical site infection (SSI), rather than dehiscence of non-microbial cause. This retrospective study describes and reports on the costs and time to healing associated with a number of surgical patients who were referred to a community nursing service for treatment of an SWD following discharge from a metropolitan hospital, in Perth, Western Australia. METHOD: Descriptive statistical analysis was carried out to describe the patient, wound and treatment characteristics. A costing analysis was conducted to investigate the cost of healing these wounds. RESULTS: Among the 70 patients referred with a SWD, 55% were treated for an infected wound dehiscence which was a significant factor (p=0.001). Overall, the cost of treating the 70 patients with a SWD in a community nursing service was in excess of $56,000 Australian dollars (AUD) (£28,705) and did not include organisational overheads or travel costs for nurse visits. The management of infection contributed to 67% of the overall cost. CONCLUSION: SWD remains an unquantified aspect of wound care from a prevalence and fiscal point of view. Further work needs to be done in the identification of SWD and which patients may be 'at risk'. DECLARATION OF INTEREST: The authors declare they have no competing interests.

Slipping through the net: the paradox of nursing's electronic theses and dissertations.

AIM: The study's main aim was to gain in-depth understanding of how nurse scholars engage with electronic theses and dissertations. Through elicitation of opinions about challenges and opportunities, and perceptions of future development, the study also aimed to influence the design of a new international web-based forum for learning and sharing information on this topic. BACKGROUND: Electronic theses and dissertations provide an opportunity to radically change the way in which graduate student research is presented, disseminated and used internationally. However, as revealed by a multi-national survey in 2011, many nurse scholars in vanguard universities have little awareness of how to find and exploit this ever-expanding global knowledge resource that is increasingly available free in full text format. Within this context more detailed understandings of nurse scholars' thinking and actions are required. METHODS: A qualitative approach using a semi-structured interview guide was utilized to elicit perceptions from 14 nurse scholars. RESULTS: Thematic analysis of the interviewees' responses identified six major themes: initial exposure and effect; searching; accessing; handling; using; and evaluation. Insights were gained about the value of these resources and behaviours in using them as exemplars for structure, format and methodology. CONCLUSION AND IMPLICATIONS FOR NURSING AND NURSING POLICY: Despite the small study size, the findings added valuable new insights to the overview gained from the 2011 survey. These have been used to inform development of a new global initiative: the International Network for Electronic Theses and Dissertations in Nursing. Featuring an educational website (www.inetdin.net), this initiative aims to support and challenge nursing's policy makers, practitioners and especially educators to utilize this neglected but exponentially increasing wellspring of international nursing knowledge.

TEMPORARY REMOVAL: ECG quiz.

This article has temporarily being removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Clinical purpura and elastosis and their correlation with skin tears in an aged population.

The previous research reported the results of a prospect cohort study that used logistic regression analysis to construct a risk prediction model for skin tears in individuals aged over 65 years. The model identified three baseline individual characteristics (male gender, history of STs, and history of falls) and two baseline skin manifestations (purpura and elastosis) that predicted the risk of dorsal forearm skin tears. This paper outlines the relationships between baseline skin manifestations and the risk of skin tears. Univariable logistic regression analysis was conducted of all the baseline data collected from the same-study participants to identify variables that significantly predicted purpura and elastosis at baseline. Amongst the 173 participants, 71 (41%) developed one or more skin tears, and in these participants, 52 (73.2%) displayed purpura, 41 (57.8%) had elastosis, and 30 (42.3%) exhibited both manifestations of the dorsal forearm at baseline. Four individual characteristics (age, history of skin tears, history of falls, and antiplatelet therapy) and three skin properties (pH, subepidermal low echogenicity band of the forearms, and skin thickness) were found to predict the risk of purpura. Conversely, three individual variables (age, gender, and smoking), three clinical skin variables (uneven skin pigmentation, cutis rhomboidalis nuchae, and history of actinic keratosis) and one skin property variable (collagen type IV) predicted the risk of skin elastosis. Progressive changes to the skin's structural and mechanical properties from the underlying effects of chronological ageing, and environmental and lifestyle-related influences increased the risk of purpura and elastotic skin manifestations and concomitantly increased risk of skin tears amongst participants.

A comparison of outcomes among hospital survivors with and without severe comorbidity admitted to the intensive care unit.

Little is known about the experiences of patients with severe comorbidity discharged from Intensive Care Units (ICUs). This project aimed to determine the effects of an ICU stay for patients with severe comorbidity by comparing 1) quality of life (QOL), 2) the symptom profile of hospital survivors and 3) health service use after hospital discharge for patients admitted to ICU with and without severe comorbidity. A case-control study was used. Patients with severe comorbidity were matched to a contemporaneous cohort of ICU patients by age and severity of illness. Assessment tools were the Medical Outcome Study 36-item short-form and European Organisation for Research and Treatment of Cancer QLQ-C15-PAL questionnaires for QOL and the Symptom Assessment Scale for symptom distress. A proportional odds assumption was performed using an ordinal regression model. The difference in QOL outcome was the dependent variable for each pair. Health service use after discharge from ICU was monitored with patient diaries. Patients aged 18+ years admitted to an ICU in a metropolitan teaching hospital between 2011 and 2012 were included. We recruited 30 cases and 30 controls. QOL improved over the six months after hospital discharge for patients with and without severe comorbidity (P <0.01) within the groups but there was no difference found between the groups (P >0.3). There was no difference in symptoms or health service use between patients with and without severe comorbidity. ICU admission for people with severe comorbidity can be appropriate to stabilise the patient's condition and is likely to be followed by some overall improvement over the six months after hospital discharge.

Proximally delivered dilute heparin does not improve circuit life in continuous venovenous haemodiafiltration.

OBJECTIVE: To assess the effect on circuit life in continuous venovenous haemodiafiltration (CVVHD) by manipulating heparin dilution and point of administration. DESIGN: Repeated crossover design. Cases were randomised for first circuit and heparin dilution, after which crossovers occurred until treatment was stopped. SETTING: A 24-bed combined general and surgical intensive care unit admitting 1900 patients a year. On average, 54 cases a year receive CVVHD. PATIENTS: 26 critically ill adult patients requiring CVVHD were enrolled, 18 of whom used at least one standard circuit and one modified circuit. INTERVENTIONS: Two circuit configurations and heparin dilutions were compared. In combination A, standard CVVHD blood lines and heparin concentration (100 units/ml) were used. In combination B, heparin was delivered in a more dilute volume (10 units/ml) via a modified circuit design with an administration port immediately adjacent to the venous access. MEASUREMENTS AND RESULTS: 18 randomised crossovers of circuits A and B occurred. Mean/median circuit life for the standard heparin/circuit combination A was 20.1/17.5 (SD 14.6) and for the modified combination B 21.4/15.4 (SD 19.2). There was no significant difference between circuits (paired t-test, p = 0.8175). To identify other factors which could have influenced circuit life (platelet count, heparin dose and pre- and post-filter activated partial thromboplastin time, APTT) all circuits terminated for the reasons identified (n = 105) were analysed using linear modelling. Survival analysis was used to determine the survival function of the circuit. Pre-heparin APTT was the only factor associated with an increase in filter life (p = 0.035). The hazard rate for filter failure was 0.049/h (95% confidence interval 0.04 to 0.06), the range of time until filters failed was 1.8 to 78.5 h. CONCLUSIONS: Proximally administered dilute heparin is not associated with a significant increase in circuit life.

A position statement on resuscitation by all levels of nurse. Confederation of Australian Critical Care Nurses Inc.

As part of its brief, the CACCN Inc. Advanced Life Support (ALS) Subcommittee has been reviewing and compiling a national policy for education in ALS for nurses. We believe this is an appropriate pursuit, since critical care nurses are at the forefront of practice in this area and also care for patients receiving life-saving interventions. One of the Subcommittee's concerns is the lack of a uniform approach to the issue of resuscitation across the nursing community, despite the broad applicability of such skills to many of the diverse settings in which nurses practice. The following is a position statement aimed at setting a precedent for both Basic and Advanced Life Support practice and education in the Australian nursing context. We have distributed the statement widely to stimulate debate and, eventually, a broader acceptance of this competency for nurses. We look forward to your comments.

Healthcare utilisation among patients discharged from hospital after intensive care.

Surviving critical illness can be life-changing and presents new healthcare challenges for patients after hospital discharge. This feasibility study aimed to examine healthcare service utilisation for patients discharged from hospital after intensive care unit stay. Following Ethics Committee approval, patients aged 18 years and older were recruited over three months. Those admitted after cardiac surgery, discharged to another facility or against medical advice were excluded. Patients were informed of the study by post and followed-up by telephone at two and six months after discharge. General practitioners were also contacted (44% responded). Among 187 patients discharged from hospital, 11 died, 25 declined to participate and 39 could not be contacted. For 112 patients (60%) who completed a survey, the majority (82%) went home from hospital and were cared for by their partner (53%). More than half of the patients (58%) reported taking the same number of medications after intensive care unit stay but 30% took more (P = 0.023). While there was no change in the number of visits to the general practitioner for 64% of patients, 29% reported an increase after intensive care unit stay. At six months, 40% of responders who were not retired were unemployed. Discharge summary surveys revealed 39 general practitioners (71%) were satisfied with details of ongoing healthcare needs. Twenty-one general practitioners wrote comments: 10 reported insufficient information about ongoing needs/rehabilitation and two reported no mention of intensive care unit stay. Survivors of critical illness had increased healthcare needs and despite most returning home, had a low workforce participation rate. This requires further investigation to maximise the benefits of survival from critical illness.

Examining the occurrence of adverse events within 72 hours of discharge from the intensive care unit.

Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for re-admission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a 'do-not-resuscitate' order Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.