Frailty in the prediction of delirium in the intensive care unit: A secondary analysis of the Deli study.

BACKGROUND: Delirium is an acute disorder of attention and cognition with an incidence of up to 70% in the adult intensive care setting. Due to the association with significantly increased morbidity and mortality, it is important to identify who is at the greatest risk of an acute episode of delirium while being cared for in the intensive care. The objective of this study was to determine the ability of the cumulative deficit frailty index and clinical frailty scale to predict an acute episode of delirium among adults admitted to the intensive care. METHODS: This study is a secondary analysis of the Deli intervention study, a hybrid stepped-wedge cluster randomized controlled trial to assess the effectiveness of a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adult intensive care units in the south-west of Sydney, Australia. Important predictors of delirium were identified using a bootstrap approach and the absolute risks, based on the cumulative deficit frailty index and the clinical frailty scale are presented. RESULTS: During the 10-mth data collection period (May 2019 and February 2020) 2566 patients were included in the study. Both the cumulative deficit frailty index and the clinical frailty scale on admission, plus age, sex, and APACHE III (AP III) score were able to discriminate between patients who did and did not experience an acute episode of delirium while in the intensive care, with AUC of 0.701 and 0.703 (moderate discriminatory ability), respectively. The addition of a frailty index to a prediction model based on age, sex, and APACHE III score, resulted in net reclassified of risk. Nomograms to individualize the absolute risk of delirium using these predictors are also presented. CONCLUSION: We have been able to show that both the cumulative deficits frailty index and clinical frailty scale predict an acute episode of delirium among adults admitted to intensive care.

A nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to intensive care: A stepped-wedge cluster randomised trial.

BACKGROUND: Delirium is an acute change in behaviour, characterised by a fluctuating course, inattention, and disorganised thinking. For critically ill adults in the intensive care, the incidence of delirium has been reported to be at least 30% and is associated with both short-term and long-term complications, longer hospital stay, increased risk of mortality, and long-term cognitive problems. AIM: The objective of this study was to determine the effectiveness of a nurse-led delirium-prevention protocol in reducing the incidence and duration of delirium among adults admitted to intensive care. METHODS: A hybrid stepped-wedge cluster randomised controlled trial was conducted to assess the effectiveness of the implementation and dissemination of the nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adults intensive care units in the southwest of Sydney, Australia. RESULTS: Between May 2019 and February 2020, over a 10-month period, 2618 admissions, among 2566 patients, were included in the study. After an initial 3-month baseline period, each month there was a random crossover to the nurse-led intervention in one of the four intensive care units, and by the 7th month of the trial, all units were exposed to the intervention for at least 3 months. The incidence of acute delirium was observed to be 10.7% (95% confidence interval [CI] = 9.1-12.4%), compared to 14.1% (95% CI = 12.2-16.2%) during the preintervention (baseline) period (adjusted rate ratio [adjRR] = 0.78, 95% CI = 0.57-1.08, p = 0.134). The average delirium-free-days for these preintervention and postintervention periods were 4.1 days (95% CI = 3.9-4.3) and 4.4 days (95% CI = 4.2-4.5), respectively (adjusted difference = 0.24 days [95% CI = -0.12 to 0.60], p = 0.199). CONCLUSION: Following the introduction of a nurse-led, nonpharmacological intervention to reduce the burden of delirium, among adults admitted to intensive care, we observed no statistically significant decrease in the incidence of delirium or the duration of delirium.

'Statistical significance' in research: wider strategies to meaningfully interpret findings.

BACKGROUND: The P -value is frequently used in research to determine the probability that the results of a study are chance findings. A value less than 0.05 was once typically considered only to mean that results are 'statistically significant', as it indicates the chance they are false positives is less than one in 20 (5%). However, P<0.05 has transcended into meaning a study has had positive findings and its results are true and meaningful, increasing the likelihood it will be published. This has led to researchers over-emphasising the importance of the P-value, which may lead to a wrong conclusion and unethical research practices. AIM: To explain what the P -value means and explore its role in determining results and conclusions in quantitative research. DISCUSSION: Some researchers are calling for a move away from using statistical significance towards meaningful interpretation of findings. This would require all researchers to consider the magnitude of the effect of their findings, contemplate findings with less certainty, and place a greater emphasis on logic to support or refute findings - as well as to have the courage to consider findings from multiple perspectives. CONCLUSION: The authors argue that researchers should not abandon P -values but should move away from compartmentalising research findings into two mutually exclusive categories: 'statistically significant' and 'statistically insignificant'. They also recommend that researchers consider the magnitudes of their results and report whether findings are meaningful, rather than simply focusing on P -values. IMPLICATIONS FOR PRACTICE: Lessening the importance of statistical significance will improve the accuracy of the reporting of results and see research disseminated based on its clinical importance rather than statistical significance. This will reduce the reporting of false positives and the overstatement of effects.

Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study.

BACKGROUND: Clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care. METHODS: This study is part of a Delirium in Intensive Care (Deli) Study. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50 years or more; acute episodes of delirium; and the outcomes of intensive care and hospital stay were explored. RESULTS: During the 6-month baseline period, 997 patients, aged 50 years or more, were included in this study. The average age was 71 years (IQR, 63-79); 55% were male (n = 537). Among these patients, 39.2% (95% CI 36.1-42.3%, n = 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (n = 127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted rate ratio (adjRR) = 1.71, 95% confidence interval (CI) 1.20-2.43, p = 0.003), had a longer hospital stay (2.6 days, 95% CI 1-7 days, p = 0.009) and had a higher risk of hospital mortality (19% versus 7%, adjRR = 2.54, 95% CI 1.72-3.75, p < 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality versus 10% among non-frail patients who also experienced delirium in the ICU. CONCLUSION: Frailty and delirium significantly increase the risk of hospital mortality. Therefore, it is important to identify patients who are frail and institute measures to reduce the risk of adverse events in the ICU such as delirium and, importantly, to discuss these issues in an open and empathetic way with the patient and their families.

How to embed a conceptual or theoretical framework into a dissertation study design.

BACKGROUND: Using a theoretical framework is often viewed as laborious or unnecessary for higher degree research projects. However, considering research problems through the lens of a theoretical framework can provide a structure for students to focus their research questions and produce findings that are more likely to address the research problem. AIM: To explain the utility of a theoretical framework and demonstrate the inclusion of a theoretical framework - deterrence theory - in a research project exploring plagiarism in nursing education. DISCUSSION: The experiences of a higher degree research student provided insight into the inclusion of a theoretical framework in a research plan. The benefits of this process are highlighted so other students can appreciate the importance of this process to their research plan and findings. CONCLUSION: A framework can add value to the overall research plan, from developing the research question through to the analysis and presentation of research findings. Fundamentally, frameworks provide a map for a study, providing a rationale for the development of the research questions or research hypothesis. A theoretical framework brings cohesion to the research project by linking the research questions and providing 'intellectual bins' for data analysis and presentation of research findings. IMPLICATIONS FOR PRACTICE: This article may assist higher degree research students in recognising the benefits of using a theoretical framework and provides an example of a 'real-life' application in a research project. The authors argue that theoretical frameworks can strengthen the likelihood that the research has produced meaningful findings that have addressed the research problem.

Delirium in intensive care: A stepped-wedge cluster randomised controlled trial for a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the intensive care unit (protocol).

BACKGROUND: Delirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU). OBJECTIVES: This study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium. STUDY PLAN: A stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): (ACTRN12618000411246p).

Supporting student learning through the use of a sequential case study workbook: An inductive content analysis of student feedback.

BACKGROUND: The use of workbooks to support nursing student learning are not new. Used in a variety of guises and differing delivery formats from printed to electronic, enables nursing students to engage in specific complex patient conditions with the view to enhancing and support learning. However, evaluating the effectiveness of the workbook itself is often overlooked, instead value is expressed in academic success. AIM: The aim of this study was to evaluate the effectiveness of a sequential based workbook to support student learning. METHOD: Inductive content analysis was used to identify text patterns from end of semester student feedback. In all, three generic themes were identified - Usability, Knowledge and Content and Workload to create a main theme - The Living Workbook. RESULTS: On the whole students found the workbook a user-friendly medium to support learning and importantly being able to apply the knowledge into the practice setting. There were a number of students who disliked the workbook because of the complexity of the case studies being presented and for being content heavy. CONCLUSIONS: Despite the challenges of passing the unit, the use of a sequential workbook to enhance the reality of providing nursing care to complex and challenging patient conditions was seen favourably.

Language support improves oral communication skills of undergraduate nursing students: A 6-month follow-up survey.

BACKGROUND: With the widening of participation in higher education, it is essential in the discipline of nursing that students are able to communicate proficiently to deliver quality patient care. However, undergraduate students can experience significant difficulties with spoken communication critical to professional nursing, which places them 'at risk' of failure during the nursing course. OBJECTIVES: To examine the relationship between students' use of academic literacy support and oral communication skills. DESIGN: Prospective, correlational survey design. SETTING: A large multi-campus university in Western Sydney, Australia. PARTICIPANTS: A total of 1699 assessment ratings of first and second year nursing students were completed at both baseline and at the 6-month follow-up in 2015. METHODS: The CLIP index was embedded as an assessment requirement in four clinical skills-based units and assessed at the end of each semester in the first two years of the Bachelor of Nursing program. In this study, first and second year students were assessed in Semester 1 at baseline and also six months later in Semester 2. RESULTS: From Semester 1 to Semester 2, the mean CLIP scores improved from 15.8 (SD: 3.7) to 17.2 (SD: 3.3) and all four components of the mean CLIP index improved. The smallest improvement was in the area of pronunciation while the lexical component had the greatest improvement. In addition, students who attended an academic literacy consultation or workshop for oral language support were over 1.5 times more likely to achieve an improvement in CLIP score (AOR: 1.58, 95% CI: 1.26 to 1.98). CONCLUSION: The CLIP tool can be used to track and monitor students' oral language skills over the course of their study, and identify 'at risk' students requiring additional support through on-campus language support programs.

Spontaneous Breathing in Early Acute Respiratory Distress Syndrome: Insights From the Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study.

OBJECTIVES: To describe the characteristics and outcomes of patients with acute respiratory distress syndrome with or without spontaneous breathing and to investigate whether the effects of spontaneous breathing on outcome depend on acute respiratory distress syndrome severity. DESIGN: Planned secondary analysis of a prospective, observational, multicentre cohort study. SETTING: International sample of 459 ICUs from 50 countries. PATIENTS: Patients with acute respiratory distress syndrome and at least 2 days of invasive mechanical ventilation and available data for the mode of mechanical ventilation and respiratory rate for the 2 first days. INTERVENTIONS: Analysis of patients with and without spontaneous breathing, defined by the mode of mechanical ventilation and by actual respiratory rate compared with set respiratory rate during the first 48 hours of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Spontaneous breathing was present in 67% of patients with mild acute respiratory distress syndrome, 58% of patients with moderate acute respiratory distress syndrome, and 46% of patients with severe acute respiratory distress syndrome. Patients with spontaneous breathing were older and had lower acute respiratory distress syndrome severity, Sequential Organ Failure Assessment scores, ICU and hospital mortality, and were less likely to be diagnosed with acute respiratory distress syndrome by clinicians. In adjusted analysis, spontaneous breathing during the first 2 days was not associated with an effect on ICU or hospital mortality (33% vs 37%; odds ratio, 1.18 [0.92-1.51]; p = 0.19 and 37% vs 41%; odds ratio, 1.18 [0.93-1.50]; p = 0.196, respectively ). Spontaneous breathing was associated with increased ventilator-free days (13 [0-22] vs 8 [0-20]; p = 0.014) and shorter duration of ICU stay (11 [6-20] vs 12 [7-22]; p = 0.04). CONCLUSIONS: Spontaneous breathing is common in patients with acute respiratory distress syndrome during the first 48 hours of mechanical ventilation. Spontaneous breathing is not associated with worse outcomes and may hasten liberation from the ventilator and from ICU. Although these results support the use of spontaneous breathing in patients with acute respiratory distress syndrome independent of acute respiratory distress syndrome severity, the use of controlled ventilation indicates a bias toward use in patients with higher disease severity. In addition, because the lack of reliable data on inspiratory effort in our study, prospective studies incorporating the magnitude of inspiratory effort and adjusting for all potential severity confounders are required.

Evidence for the effectiveness of chlorhexidine bathing and health care-associated infections among adult intensive care patients: a trial sequential meta-analysis.

BACKGROUND: Health care associated infections (HAI) among adults admitted to the intensive care unit (ICU) have been shown to increase length of stay, the cost of care, and in some cases increased the risk of hospital death (Kaye et al., J Am Geriatr Soc 62:306-11, 2014; Roberts et al., Med Care 48:1026-35, 2010; Warren et al., Crit Care Med 34:2084-9, 2006; Zimlichman et al., JAMA Intern Med 173:2039-46, 2013). Daily bathing with chlorhexidine gluconate (CHG) has been shown to decrease the risk of infection in the ICU (Loveday et al., J Hosp Infect 86:S1-S70, 2014). However, due to varying quality of published studies, and varying estimates of effectiveness, CHG bathing is not universally practiced. As a result, current opinion of the merit of CHG bathing to reduce hospital acquired infections in the ICU, is divergent, suggesting a state of 'clinical equipoise'. This trial sequential meta-analysis aims to explore the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections, and address the question: do we need more trials? METHODS: A systematic literature search was undertaken to identify trials assessing the effectiveness of chlorhexidine bathing to reduce risk of infection, among adult intensive care patients. With particular focus on: (1) Blood stream infections (BSI); (2) Central Line Associated Blood Stream Infections (CLABSI); (3) Multi-Resistant Drug Organism (MRDO); (4) Ventilator Associated Pneumonia; and, Catheter Associated Urinary Tract Infections (CAUTI). Only randomised-control or cluster randomised cross-over trials, were include in our analysis. A Trial Sequential Analysis (TSA) was used to describe the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections. RESULTS: Five trials were included in our final analysis - two trials were individual patient randomised-controlled, and the remaining cluster-randomised-crossover trials. Daily bathing with CHG was estimated to reduce BSI in the ICU by approximately 29% (Der-Simonian and Laird, Random-Effects. (DL-RE) Incidence Rate Ratio (IRR) = 0.71, 95% confidence interval (CI) 0.51, 0.98); reduce CLABSI in the ICU by approximately 40% (DL-RE IRR = 0.60, 95% CI 0.34, 1.04); reduce MDRO in the ICU by approximately 18% (DL-RE IRR = 0.82, 95% CI 0.69, 0.98); no effect in reducing VAP in the ICU (DL-RE IRR = 1.33, 95% CI 0.81, 2.18); and, no effect in reducing CAUTI in the ICU (DL-RE IRR = 0.77, 95% CI 0.52, 1.15). Upper (superiority) monitoring boundaries from TSA were not crossed for all five specific infections in the ICU. CONCLUSION: Routine bathing with CHG does not occur in the ICU setting, and TSA suggests that more trials are needed to address the current state of 'clinical equipoise'. Ideally these studies would be conducted among a diverse group of ICU patients, and to the highest standard to ensure generalisability of results.

Exploring nursing students' experiences of a drop-in support-centre: A mixed-methods study.

BACKGROUND: The increased use of blended learning approaches in undergraduate nursing programs has resulted in reduced on-campus contact with academic staff and other students. OBJECTIVES: To explore student's experiences of a Drop-In-Support-Centre and assess the impact of attendance on academic performance. DESIGN: Concurrent mixed-methods. SETTING: A large metropolitan, multi-campus university in Sydney, Australia. PARTICIPANTS: Undergraduate nursing students enrolled in a 3-year Bachelor of Nursing program. METHODS: In March 2016, to support students' learning, a weekly Drop-In-Support-Centre (DISC) initiative was piloted. The DISC provided an informal, learning space one day a week for students to access academic support. Baseline quantitative data was extracted from the University administrative dataset with a 12-month follow-up Grade Point Average (GPA) in January 2017. Attendance at the DISC was collected progressively throughout 2016. Qualitative data were collected using semi-structured interviews. RESULTS: Of 1016 undergraduate nursing students enrolled on the campus, 163 (16%) attended DISC at least once. Attendees were older, more likely to be Overseas-born (74% versus 45% native-born, p < 0.001). Sub-group analysis of first year students revealed attendees had a higher grade point average than non-attendees (4.20 versus 3.85, p = 0.005). Controlling for demographic factors, they were over three times more likely (Adjusted Odds Ratio: 3.75, 95% CI: 1.44-9.78) to achieve a higher GPA (>4.0) compared to non-attendees. Thirteen students were interviewed. Two main themes emerged; 1) 'Home away from home' and 2) 'A sense of community: Everyone supports each other' with three accompanying sub-themes. CONCLUSIONS: This study supports the usefulness of a Drop-In-Support-Centre in enhancing students' learning experiences and outcomes. The success of the program is highlighted by an improvement in academic performance of students who attended the DISC.

The price of journeying towards the prize-Commencing nursing students' experiences of working and studying: A qualitative study.

AIMS AND OBJECTIVES: To explore the experiences of commencing first-year undergraduate nursing students who were studying full time while engaging in 20 or more hours of paid work each week. METHOD: Using a qualitative exploratory design, commencing full-time nursing students who were employed in paid work for at least 20 hr per week were interviewed between May-June 2016. Data were thematically analysed using the following approach: data familiarisation, generating initial codes independently, searching and reviewing themes and subthemes, and defining and naming these themes and subthemes. RESULTS: Four main themes were identified which illustrated students' experiences of working and studying: (a) "Work is a necessity…not a choice" identified how students relied heavily on the financial income from paid work to support themselves and others during their studies, (b) "Something's got to give" highlighted the sacrifices that needed to be made to avoid negative effects on their studies, (c) "It's a balancing act!" demonstrated how students studied strategically and balanced their workload despite challenges, and lastly (d) "Being supported to work and study" described the overwhelming support from others for students to succeed academically. CONCLUSIONS: Despite support, working 20 hr or more per week while studying full time often overwhelmed students' personal resources and negatively impacted on course grades. Inflexible University timetables compounded the challenges experienced by students who struggled to balance work and study commitments. RELEVANCE TO CLINICAL PRACTICE: Nursing employers play a pivotal role in enabling students to juggle effectively their work-study commitments, through providing work flexibility. Students may also benefit if the nursing workforce advocates that they be awarded exclusion from selected clinical placement requirements, particularly if the clinical placement focus is closely related to their current nursing employment.

Students' experiences of embedded academic literacy support in a graduate entry nursing program: A qualitative study.

Graduate entry nursing (GEN) programs were designed to address the predicted nursing shortfall. In Australia, although these programs attract students from culturally and linguistically diverse (CALD) backgrounds, the workload is compounded by cultural differences and a new academic learning environment which presents additional challenges. This qualitative descriptive study explored the experiences of GEN students enrolled in the introductory unit of their nursing program with embedded academic literacy support in Sydney, Australia. Twenty-four commencing GEN students were interviewed in January 2016. Interviews were transcribed verbatim and thematically analysed. Three main themes emerged which illustrated that GEN students were 'diamonds in the rough'. They possessed a raw natural beauty that required some shaping and polishing to ensure academic needs were met. To ensure retention is high, institutions need to evaluate how best to support and harness the potential of these unique students.

Plagiarism in nursing education: an integrative review.

AIMS AND OBJECTIVES: To identify the prevalence and antecedents of plagiarism within nursing education and approaches to prevention and management. BACKGROUND: There has been growing media attention highlighting the prevalence of plagiarism in universities, including the academic integrity of undergraduate nursing students. A breach of academic integrity among nursing students also raises further concern with the potential transfer of this dishonest behaviour to the clinical setting. DESIGN: Integrative review. METHODS: A systematic search of five electronic databases including CINAHL, MEDLINE, SCOPUS, ProQuest Nursing & Allied Health Source, and ERIC was undertaken. Only primary studies related to plagiarism and nursing students (undergraduate or postgraduate) studying at a tertiary education institution or nursing faculty were included. Both qualitative and quantitative study designs were included. RESULTS: Twenty studies were included in this review with six key themes identified: (1) prevalence; (2) knowledge, understanding and attitudes; (3) types of plagiarism; (4) antecedents to plagiarism; (5) interventions to reduce or prevent plagiarism; and (6) the relationship between academic honesty and professional integrity. Plagiarism is common among university nursing students, with a difference in perception of this behaviour between students and academics. The review also highlighted the importance of distinguishing between inadvertent and deliberate plagiarism, with differing strategies suggested to address this behaviour. Nevertheless, interventions to reduce plagiarism have not been shown to be effective. CONCLUSIONS: The current punitive approach to plagiarism within nursing faculties has not reduced its occurrence. There is a need to promote awareness, knowledge and provide students with the appropriate referencing skills, to reduce the significant amount of inadvertent plagiarism. RELEVANCE TO CLINICAL PRACTICE: The importance of promoting honesty and academic integrity in nursing education is highlighted. Cheating within the academic setting has been associated with dishonesty in the clinical setting, which highlights the importance of nurturing a culture of honesty and integrity at university.

Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis.

BACKGROUND: Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths (Kaye and Marchaim, J Am Geriatr Soc 62(2):306-11, 2014; Roberts and Scott, Med Care 48(11):1026-35, 2010; Warren and Quadir, Crit Care Med 34(8):2084-9, 2006; Zimlichman and Henderson, JAMA Intern Med 173(22):2039-46, 2013). Importantly, infections acquired during a hospital stay have been shown to be preventable (Loveday and Wilson, J Hosp Infect 86:S1-70, 2014). In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes. This meta-analysis aims to summarise the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce infection. METHODS: A systematic literature search was undertaken to identify trials assessing the effectiveness of CHG bathing to reduce risk of infection, among adult intensive care patients. Infections included were: bloodstream infections; central line-associated bloodstream infections (CLABSI); catheter-associated urinary tract infections; ventilator-associated pneumonia; methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus; and Clostridium difficile. Summary estimates were calculated as incidence rate ratios (IRRs) and 95% confidence/credible intervals. Variation in study designs was addressed using hierarchical Bayesian random-effects models. RESULTS: Seventeen trials were included in our final analysis: seven of the studies were cluster-randomised crossover trials, and the remaining studies were before-and-after trials. CHG bathing was estimated to reduce the risk of CLABSI by 56% (Bayesian random effects IRR = 0.44 (95% credible interval (CrI), 0.26, 0.75)), and MRSA colonisation and bacteraemia in the ICU by 41% and 36%, respectively (IRR = 0.59 (95% CrI, 0.36, 0.94); and IRR = 0.64 (95% CrI, 0.43, 0.91)). The numbers needed to treat for these specific ICU infections ranged from 360 (CLABSI) to 2780 (MRSA bacteraemia). CONCLUSION: This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.

Osteoporosis education improves osteoporosis knowledge and dietary calcium: comparison of a 4 week and a one-session education course.

BACKGROUND: Education is ideal for osteoporosis because many risk factors are modifiable. However, the efficacy of shortened education courses compared to a standard 4 week course for improving osteoporosis knowledge and healthy behaviours is not known. This study aimed to assess whether education changed knowledge and healthy behaviours over 3 months of follow-up; and whether changes in these outcomes were different between participants receiving the different education courses. METHODS: Adults aged ≥ 50 years presenting to Emergency with mild to moderate trauma fractures received either the Osteoporosis Prevention and Self-Management Course (OPSMC) (4 × 2.5 h) (n = 75) or a one-session course (1 × 2.5 h) (n = 71) in a non-randomised prospective study with single-blinded allocation. Participants completed questionnaires measuring osteoporosis knowledge, dietary calcium, physical activity, calcium and exercise self-efficacy, and osteoporosis medications at baseline and 3 months. Data were analysed using mixed models and GEE regression models. RESULTS: Osteoporosis knowledge and calcium from food (% of RDI) increased from baseline to 3 months in both groups (P < 0.01). Use of osteoporosis medications increased between baseline and 3 months in the OPSMC group while decreasing in the one-session group (P = 0.039). There were no differences between the groups or over time in physical activity, calcium or exercise self-efficacy. CONCLUSIONS: Osteoporosis education (either the OPSMC or the one-session course) improved osteoporosis knowledge and calcium intake after 3 months. Participants attending the OPSMC maintained medication compliance. We were unable to determine other differences between the courses. This study confirms the value of osteoporosis education for improving osteoporosis knowledge.

Clinical practice guidelines for the management of acute limb compartment syndrome following trauma.

BACKGROUND: Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management of acute limb compartment syndrome in Australia. METHODS: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines were based on critically appraised literature evidence and the consensus opinion of a multidisciplinary team involved in trauma management who met in a nominal panel process. RESULTS: Recommendations were developed for key decision nodes in the patient care pathway, including methods of diagnosis in alert and unconscious patients, appropriate assessment of compartment pressure, timing and technique of fasciotomy, fasciotomy wound management, and prevention of compartment syndrome in patients with limb injuries. The recommendations were largely consensus based in the absence of well-designed clinical trial evidence. CONCLUSIONS: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma have been developed that will support consistency in management and optimize patient health outcomes.

Survey of management of acute, traumatic compartment syndrome of the leg in Australia.

BACKGROUND: Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency and is associated with significant morbidity if not diagnosed promptly and treated effectively. Despite the urgency of effective management to minimize the risk of adverse outcomes, there is currently little consensus in the published reports as to what constitutes best practice in the management of acute limb compartment syndrome. METHODS: A structured survey was sent to all currently practising orthopaedic surgeons and accredited orthopaedic registrars in Australia to assess their current practice in the management of acute, traumatic compartment syndrome of the leg. Questions were related to key decision nodes in the management process, as identified in a literature review. These included identification of patients at high risk, diagnosis of the condition in alert and unconscious patients, optimal timeframe and technique for carrying out a fasciotomy and management of fasciotomy wounds. RESULTS: A total of 264 valid responses were received, a response rate of 29% of all eligible respondents. The results indicated considerable variation in management of acute compartment syndrome of the leg, in particular in the utilization of compartment pressure measurement and the appropriate pressure threshold for fasciotomy. Of the 78% of respondents who regularly measured compartment pressure, 33% used an absolute pressure threshold, 28% used a differential pressure threshold and 39% took both into consideration. CONCLUSIONS: There is variation in the management of acute, traumatic compartment syndrome of the leg in Australia. The development of evidence-based clinical practice guidelines may be beneficial.

Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen.

Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence-based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on-call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on-call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence-based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non-therapeutic laparotomy rates.