Does implementation of clinical practice guidelines change nurses' screening for alcohol and other substance use?

AIM: To examine the effectiveness of the implementation of a clinical practice guideline on nurses screening patients for alcohol and other substance use, providing brief interventions, and referring patients at risk for treatment. METHOD: Medical record audits were conducted in selected medical and surgical wards of two metropolitan hospitals in Sydney prior to and three months following the guideline implementation. RESULT: Seventy-nine (pre) and 84 (post) patient records were audited. There were no differences in screening rates for alcohol (28% and 29%), tobacco (29% and 23%) and illicit drug use (16% and 8%) before and after implementation of the guideline. PRACTICE IMPLICATION: Factors which may have limited the effectiveness of the clinical practice guideline dissemination included design of the education program, existing level of nurses' knowledge and competence, and strategies in place to ensure sustainability of the program. We also provided suggestions for improvement of screening for alcohol and other substance use.

Changes in general nurses' knowledge of alcohol and substance use and misuse after education.

PURPOSE: This study aims to assess the impact of an education program on Australian general nurses' knowledge and competence in identifying and managing patients with alcohol and substance use and misuse, and compare findings with existing literature on mental health nurses. DESIGN AND METHODS: Pre- and posttest design without a control group. FINDINGS: The nurses' knowledge of safe drinking limits and alcohol withdrawal management improved following the education. Nevertheless, overall the nurses reported a lack of adequate knowledge and competence. Compared to mental health nurses, the nurses in this study had lower levels of knowledge and competence. PRACTICE IMPLICATIONS: We suggest several opportunities for general nurses to strengthen their knowledge and skills and the need for a comprehensive and regular education program.

Duration of short-term indwelling catheters--a systematic review of the evidence.

OBJECTIVE: A systematic review on the effect of duration of catheterization on urinary retention. MATERIALS AND METHODS: Published and unpublished randomized and nonrandomized control trials from January 1966 to July 2004 comparing the effects of duration of catheterization on patient outcomes were systematically reviewed. Relative risks (RR) for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, a narrative overview was undertaken. RESULTS: Eight trials were included. Two trials on patients following urethrotomy demonstrated no statistically significant difference in the number of patients developing restenosis, epididymitis, or urethral pain at any follow-up periods. Two trials comparing removal of the indwelling urethral catheter within 24-48 hours to usual surgical criteria after transurethral surgery demonstrated no statistically significant difference in the number of patients requiring recatheterization. However, significant reduction in the length of hospitalization was reported after removal of the indwelling urethral catheter within 24-48 hours. An increased risk of urinary tract infection was found when the catheter was removed after 48 hours. Catheter removal on day 1 compared to day 3 after vaginal or retropubic surgery demonstrated no statistically significant difference in urinary retention or urinary tract infection. CONCLUSIONS: No significant differences in patient outcome were found, but the timing of catheter removal is a balance between avoiding infection by early removal and circumventing voiding dysfunction by later removal. Shorter catheterizations appear to reduce mean length of hospital stay.

Educational interventions for mental health consumers receiving psychotropic medication: a review of the evidence.

The objective of this systematic review is to investigate the efficacy of educational interventions, relating to psychotropic medications, for consumers with a mental health disorder. This review included only randomized controlled trials that compared the effects of various educational interventions on knowledge retention, compliance to medication and treatment, incidence of relapse, and insight into illness in patients aged 18 years and over with a mental disorder. Twenty-one trials met the quality criteria and were included in the final analysis. Patients who were provided with education demonstrated a significant increase in the level of knowledge and compliance compared with those who were not. However, there was no difference in the incidence of relapse and insight in those who were provided education. A structured education session using both written and verbal methods followed by discussion of the contents is demonstrated to be effective. The evidence suggests that consumers who were provided multiple education sessions had greater knowledge gains in the short term (up to 1 month); however, the effectiveness of multiple sessions in the long term (2 years) is inconclusive. The review provides evidence that multiple education sessions are better than single education sessions in improving knowledge relating to medications and insight into illness. Evidence from the trials demonstrates that structured educational interventions delivered at frequent intervals are useful as part of the treatment programme for people with a mental illness. More well designed and reported randomized studies investigating the efficacy of education are urgently needed.

Clamping short-term indwelling catheters: a systematic review of the evidence.

OBJECTIVE: The objective of this review is to determine the effects of clamping short-term indwelling urethral catheters before removal on the incidence of urinary tract infection, time to first void, voiding dysfunction, incidence of recatheterization, and the length of hospital stay. MATERIALS AND METHODS: Published and unpublished randomized and quasi-randomized controlled trials, completed between January 1966 and July 2004, in English and other languages that compared the effects of clamping short-term indwelling urethral catheters, were systematically reviewed using multiple electronic databases. Determination of eligibility of trials for inclusion in the review, assessment of methodological quality, and data extraction were undertaken independently by 2 reviewers. Relative risks for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals. Where synthesis was inappropriate, a narrative overview has been undertaken. RESULTS: Three trials that investigated the effect of clamping the indwelling urethral catheter compared to free drainage before removal were eligible for inclusion. Two trials reported no significant difference in the incidence of urinary tract infection (UTI), number of patients who developed urinary retention or required recatheterization, and the length of hospital stay between the 2 groups. Another reported that the postvoid residual urine volume for patients who did not receive reconditioning of the bladder increased from 4.25 mL at baseline to 42.25 mL after removal of the indwelling urethral catheter, whereas the residual urine volume for patients who received reconditioning increased from 17.25 mL at baseline to 22 mL at follow-up. CONCLUSIONS: The evidence for clamping indwelling urethral catheters before removal remains equivocal. Given the current state of evidence, procedures relating to clamping of indwelling urinary catheters should not be initiated. Until stronger evidence becomes available, however, practices relating to clamping indwelling urethral catheters will continue to be dictated by local preferences and cost factors.

Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review.

BACKGROUND: Total parenteral nutrition (TPN) is a specialized form of nutrition support. The complexity associated with the management of patients receiving TPN therapy has led to the development of multidisciplinary TPN teams. The purpose of this review was to critically analyze the literature and present the best available evidence that investigated the effectiveness of multidisciplinary TPN teams in the provision of TPN to adult hospitalized patients. METHODS: A systematic review of studies identified from the Cochrane Library (2001, Issue 4), CINAHL, Complete MEDLINE, Complete Biomedical Collection, Complete Nursing Collection, and EMBASE, published in any language. RESULTS: Eleven studies, 4 with concurrent controls and 7 with historical controls, were eligible for inclusion in the review. Results of the studies indicate that the incidence of total mechanical complications is reduced in patients managed by the TPN team. However, the benefit of the TPN team in the reduction of catheter-related sepsis remains inconclusive. Four of the 5 studies reported fewer total metabolic and electrolyte abnormalities in patients cared for by the team, and these patients were more likely to receive their optimal caloric intake. However it was unclear if the management of the patients by the TPN team prevented the inappropriate use of TPN therapy. Although only 2 studies (n = 356) investigated total costs associated with management of patients by the TPN teams, there was evidence that a team approach is a cost-effective strategy. CONCLUSIONS: Overall, the general effectiveness of the TPN team has not been conclusively demonstrated. There is evidence that patients managed by TPN teams have a reduced incidence of total mechanical complications; however, it is unclear if there is a reduction in catheter-related sepsis and metabolic and electrolyte complications. The available evidence, although limited, suggests financial benefits from the introduction of multidisciplinary TPN teams in the hospital setting.

Removal of short-term indwelling urethral catheters: the evidence.

OBJECTIVE: The objective of this systematic review was to determine the effect of the timing of removal of indwelling urethral catheters (IUCs) on the duration to and volume of first void, length of hospitalization, number of patients developing urinary retention and requiring recatheterization, patient satisfaction, and the percentage of IUCs removed according to the scheduled time for removal. MATERIALS AND METHODS: Published and unpublished literature in English and other languages between January 1966 and June 2002, which compared the effects of the timing of removal of short-term indwelling urethral catheters on patient outcomes, was systematically reviewed using multiple electronic databases. To determine eligibility of the trials for inclusion in the review, assessment of methodologic quality and data extraction was undertaken independently by 2 reviewers and verified by a third reviewer. Odds ratio (OR) for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, a narrative overview has been undertaken. RESULTS: Eight randomized controlled trials were eligible for this review. When IUCs were removed at midnight, the time to first void was significantly shorter (P = .012) after gynecologic surgery and significantly longer in patients after urologic surgery and procedures. Seven trials reported that the volume of the first void was greater in patients whose IUCs were removed late at night, and this was statistically significant in 4 trials. Patients who had their IUC removed at midnight were discharged from the hospital significantly (P < .00001) earlier than those who had their IUC removed in the morning, a finding that could result in potential cost savings for hospitals. CONCLUSION: Based on the limited available evidence, this article suggests benefits in terms of patient outcomes and reduction in the length of hospitalization after midnight removal of the IUCs. Further trials should be undertaken in wider settings and on specific groups of patients to enhance generalizability.

Comparison of educational interventions for mental health consumers receiving psychotropic medication.

BACKGROUND: One in four people globally will be affected by mental disorders at some point in their life. Currently approximately 450 million people worldwide suffer from this condition thereby placing mental health disorders among the leading cause of illness. Although treatment with psychotropic medication for specific psychological interventions has been demonstrated to be beneficial, it is also associated with relapse due to non-adherence to the medication regime. Factors associated with non-compliance include inadequate knowledge of the condition and the side-effects of the drugs. However, there is still some debate amongst psychiatrists as to the relative benefits of informing consumers about the side-effects. OBJECTIVES: The objective of this review was to systematically assess the literature and present the best available evidence that investigated the efficacy of educational interventions, relating to psychotropic medications, for consumers with a mental health disorder. SEARCH STRATEGY: A literature search was performed using the following databases Medline (1966-2000), CINAHL (1982-2002), EMBASE (1980-2002) ProQuest, Psychlit and the Cochrane Controlled Trials Register (Issue 2, 2002 of Cochrane Library). In addition, the reference lists of relevant trials and conference proceedings were also scrutinised. No language restrictions were applied. Experts and investigators were contacted to elicit further information. SELECTION CRITERIA: All relevant randomised controlled trials that investigated the effectiveness of providing education and the methods to provide education to adult consumers with a mental illness were eligible for inclusion in the study. DATA COLLECTION AND ANALYSIS: Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials was assessed jointly by two reviewers. All information was verified by a third reviewer. Odds ratio for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals. Where synthesis was inappropriate a narrative overview was undertaken. RESULTS: Twenty-one studies were included in this review. Knowledge was assessed in 15 studies. Compliance was assessed in 13 studies. Relapse was assessed in five studies and insight was assessed in six studies. Those patients who were provided with education demonstrated a significant increase in the level of knowledge and compliance compared to those who were not. However, there was no difference in the incidence of relapse and insight in those who were provided education. A structured education session using both written and verbal methods followed by discussion was demonstrated to be effective. The evidence suggests that consumers who were provided multiple education sessions had greater knowledge gains in the short term (up to 1 month); however, the effectiveness of multiple sessions in the long term (2 years) was inconclusive. The review provides evidence that multiple education sessions are better than single education sessions in improving knowledge relating to medications and insight into illness. CONCLUSIONS: Evidence from the trials demonstrates that structured educational interventions delivered at frequent intervals are useful as part of the treatment program for people with a mental illness. More well-designed and reported randomised studies investigating the efficacy of education are urgently needed.

Peripheral venous catheters: a review of current practices.

Loss of peripheral intravenous (PIV) catheter patency is a common problem in the clinical setting. A survey of all private and public hospitals in a metropolitan city in Australia was conducted to identify practices related to maintaining patency of PIV catheters. Eighty-three hospitals were surveyed and responses were obtained from all of them. Normal saline was the most commonly used solution for flushing. The frequency for flushing ranged from 4 to 12 hours, and the volume of the irrigant used ranged from 2 to 10 mL in those hospitals where flushing is routine practice. Policy documents were available from only a few hospitals to validate the practice reported. Significant diversity in practices was documented among healthcare organizations.