Economic evaluations in medical technological innovations a mapping review of methodologies.

RATIONALE: Economic evaluations play an important role in the development and implementation of healthcare innovations. For pharmaceutical products, the methodologies used are laid down in guidelines, whereas for medical technologies the guidelines are not as strenuous. The aim of this review was therefore to analyze what types of methodologies are used in economic evaluations of medical technologies. METHODS: We performed a mapping review to identify economic evaluations for medical technologies. We decided to limit our search to one year (2022) and included cost utility and cost effectiveness analyses in which health technologies were evaluated. For each included study we identified the main methodological characteristics. RESULTS: A total of 364 papers were included in the analysis, 268 (74%) contained cost-utility analyses and 91 (25%) cost-effectiveness analyses. A model was used in 236 (64%) analyses, 117 analyses were trial based evaluations. Probabilistic sensitivity analyses and/or bootstrapping was performed in 266 (73%) analyses. Deterministic sensitivity analyses were used in 306 (84%). Time horizon and perspective were underreported in 15-25% of the included studies. CONCLUSIONS: This review shows the wide range of methodologies used in economic evaluations as well as the extent and rigor in which these methodologies are used. Many of the included papers did no use or did not sufficiently report the use of appropriate standard methods. This may lead to research waste, a delay in successful implementation of valuable innovations and in the end may delay improvement patient outcomes.

The experiences of doctorally prepared nurses and doctoral nursing students with being mentored in the Nurse-Lead programme: A focus group study.

AIM: to explore experiences of being mentored and the contribution of the mentoring to leadership and professional development of doctorally prepared nurses and doctoral nursing students participating in the Nurse-Lead programme. BACKGROUND: Mentoring is considered important for career development of academic nurses. Doctorally prepared nurses need a wide range of professional competences to develop sustainable careers. Therefore, they may benefit from a larger network of mentors, outside their own organization, to support their professional development. Therefore, a web-based leadership and mentoring programme was developed - the Nurse Lead programme. DESIGN: A descriptive study with semi-structured focus groups. METHOD: Three focus groups were conducted during an on-site programme meeting in 2019 with twenty-one doctorally prepared nurses and doctoral nursing students. The interview guide included questions about mentoring relationships and meaning of mentoring for leadership and professional development. The interviews were thematically analysed. RESULTS: Five themes were identified: "Preferred characteristics of mentors", "Developing trusting relationships", "Engagement of the mentors", "Becoming a proficient researcher and team leader" and "Becoming an empowered and confident professional". CONCLUSION: Mentoring supported the leadership and professional development of doctorally prepared nurses and doctoral nursing students. Participants were engaged in rewarding mentoring trajectories. The results indicate that a similar approach could be followed when developing mentoring programmes in the future.

Surgical nurses' responses to worry: A qualitative focus-group study in the Netherlands.

BACKGROUND: Hospital nurses observe and respond to deterioration using the 'National Early Warning Score 2'. Surgical nurses are highly engaged in the early recognition of and response to deterioration. Responses to deterioration are based on deviating vital signs, while nurses also act on subjective indicators like worry. Scientific literature and (inter)national guidelines do not mention any information about acting upon worry. OBJECTIVE: To gain an in-depth understanding of the actions nurses on surgical wards undertake to generate an appropriate response to nurses' worry when the 'National Early Warning Score 2' does not indicate deterioration. METHOD: A qualitative focus-group study with surgical nurses working at a hospital in the Netherlands. Data was collected by focus-group interviews supported by vignettes and analysed thematically. FINDINGS: Four focus-group interviews with a total of 20 participants were conducted between February and April 2020. Two sequential themes emerged: 'Searching for explanation and confirmation' and 'Responding by actively applying nursing interventions'. Nurses gathered additional information about the patient and searched for a reference point to place this information in perspective. Nurses also approached others for co-assessment and verification. However, nurses faced barriers in calling for medical assistance. They felt physicians did not take them seriously. After gathering additional information, nurses responded by applying nursing interventions to comfort the patient. CONCLUSION: Nurses mainly try to formalise an in-depth understanding of their feeling of worry to convince a physician to accurately treat the patient. Spending much time on a search to this understanding leads to delays in escalating care.

Nurses' experiences with continuous vital sign monitoring on the general surgical ward: a qualitative study based on the Behaviour Change Wheel.

BACKGROUND: To support early recognition of clinical deterioration on a general ward continuous vital signs monitoring (CMVS) systems using wearable devices are increasingly being investigated. Although nurses play a crucial role in successful implementation, reported nurse adoption and acceptance scores vary significantly. In-depth insight into the perspectives of nurses regarding CMVS is lacking. To this end, we applied a theoretical approach for behaviour change derived from the Behaviour Change Wheel (BCW). AIM: To provide insight in the capability, opportunity and motivation of nurses working with CMVS, in order to inform future implementation efforts. METHODS: A qualitative study was conducted, including twelve nurses of a surgical ward in a tertiary teaching hospital with previous experience of working with CMVS. Semi-structured interviews were audiotaped, transcribed verbatim, and analysed using thematic analysis. The results were mapped onto the Capability, Opportunity, Motivation - Behaviour (COM-B) model of the BCW. RESULTS: Five key themes emerged. The theme 'Learning and coaching on the job' linked to Capability. Nurses favoured learning about CVSM by dealing with it in daily practice. Receiving bedside guidance and coaching was perceived as important. The theme 'interpretation of vital sign trends' also linked to Capability. Nurses mentioned the novelty of monitoring vital sign trends of patients on wards. The theme 'Management of alarms' linked to Opportunity. Nurses perceived the (false) alarms generated by the system as excessive resulting in feelings of irritation and uncertainty. The theme 'Integration and compatibility with clinical workflow' linked to Opportunity. CVSM was experienced as helpful and easy to use, although integration in mobile devices and the EMR was highly favoured and the management of clinical workflows would need improvement. The theme 'Added value for nursing care' linked to Motivation. All nurses recognized the potential added value of CVSM for postoperative care. CONCLUSION: Our findings suggest all parts of the COM-B model should be considered when implementing CVSM on general wards. When the themes in Capability and Opportunity are not properly addressed by selecting interventions and policy categories, this may negatively influence the Motivation and may compromise successful implementation.

The Ambassador Project: Evaluating a Five-Year Nationwide Leadership Program to Bridge the gap Between Policy and District Nursing Practice.

District nurses have a crucial position in healthcare provision and are expected to use leadership practices to ensure optimal quality patient care. To better equip them, a leadership program named the ambassador project was developed to support the development of a liaison role between policy and district nursing practice. This research aims to evaluate from different perspectives the impact of this nationwide, five-year leadership program for district nurses at the organizational, regional, and societal levels. A mixed-methods study was conducted using two focus groups based on peer-to-peer shadowing (n = 14), semistructured interviews (n = 13), and an online questionnaire (n = 45). The analysis shows that the impact of a nationwide leadership program for district nurses was perceived as predominantly positive, and nurses experienced an increase in courage, assertiveness, professional pride, and leadership skills. They obtained confidence in representing the group of district nurses at the organizational, regional, and societal levels when speaking with various key stakeholders from the healthcare system. They were able to bridge the gaps among daily practice, policymaking, and politics by using translations and shaping actions and information into terms suiting the needs of those involved.

Can continuous remote vital sign monitoring reduce the number of room visits to patients suspected of COVID-19: A quasi-experimental study.

BACKGROUND: Continuous remote monitoring of vital signs on the hospital ward gained popularity during the Severe Acute Respiratory Syndrome coronavirus 2 pandemic due to its ability to support early detection of respiratory failure, and the possibility to do so without physical contact between patient and clinician. The effect of continuous monitoring on patient room visits has not been established yet. OBJECTIVES: To assess the impact of continuous monitoring on the number of patient room visits for patients suspected of Corona Virus Disease 2019 (COVID-19) and the use of personal protection equipment. DESIGN AND METHODS: We performed a before-after study at a ward with private rooms for patients suspected of COVID-19 at a tertiary hospital in Nijmegen, The Netherlands. Non-participant observers observed hospital staff during day, evening and night shifts to record patient room visits and personal protection equipment usage. After eleven days, wearable continuous vital sign monitoring was introduced. An interrupted time series analysis was applied to evaluate the effect of continuous monitoring on the number of patient room visits, visits for obtaining vital signs (Modified Early Warning Score visits) and the amount of personal protection equipment used. RESULTS: During the 45 day study period, 86 shifts were observed. During each shift, approximately six rooms were included. A total of 2347 patient room visits were recorded. The slope coefficient for the number of patient room visits did not change after introducing continuous vital sign monitoring (B -0.003, 95% confidence interval -0.022/0.016). The slope coefficients of the number of Modified Early Warning Score visits and the amount of personal protection equipment used did not change either (B -0.002, 95% confidence interval -0.021/0.017 and B 0.046, 95% confidence interval -0.008/0.099). The number of Modified Early Warning Score visits did show a decline over the entire study period, however this decline was not influenced by the intervention. Evening and night shifts were associated with fewer patient room visits compared to day shifts. CONCLUSION: Introduction of continuous vital sign monitoring at a general ward for patients with suspected COVID-19 did not reduce the number of patient room visits or the usage of personal protection equipment by hospital staff. The number of Modified Early Warning Score visits declined over time, but this was not related to the introduction of continuous monitoring. Detailed analysis of the influence of continuous monitoring on the workflow of hospital staff reveals key points to increase efficacy of this intervention.

A scoping review on Chronic Venous Disease and the development of a Venous Leg Ulcer: The role of obesity and mobility.

OBJECTIVE: The risk factors obesity and reduced mobility are not well known in the development of a Venous Leg Ulcer (VLU). The aim of this scoping review is to explore the mechanisms by which obesity and reduced mobility contribute the development of a VLU in patients with Chronic Venous Disease (CVD). METHODS: For this scoping review a search was performed in May 2019 in the Cochrane Library and Pubmed to identify studies on the working mechanisms of obesity and mobility in developing a VLU. Hand searches were performed to find additional studies explaining the working mechanisms (indirectly related to the VLU). Two reviewers independently reviewed the abstracts and full-text articles. RESULTS: Twenty-eight studies met our eligibility criteria. Disturbed range of ankle motion and gait can lead to a reduced Calf Muscle Pump (CMP) function which leading to a venous outflow disorder. Increased abdominal pressure due to obesity can lead to a venous outflow obstruction and increased adipose tissue mass results in an increase in adipokine secretion. The venous outflow disorder, outflow obstruction and increased adipokine secretion can all lead to chronic systemic inflammation, increased endothelial permeability and hence microcirculatory dysfunction. This alone can result in a VLU. CONCLUSION: Obesity and reduced mobility can lead to a reduction of the CMP function, an increase in abdominal pressure and an increase in adipose tissue mass. This can simultaneously lead to haemodynamic changes in the macro- and microcirculation of the lower extremities and eventually in a VLU. In patients with obesity and reduced mobility the microcirculation alone can lead to skin changes and eventually a VLU. Therefore, early recognition of CVD symptoms in patients with obesity and reduced mobility is crucial to diagnose and treat CVD to prevent a VLU.

A qualitative study on the patient's narrative in the progression of chronic venous disease into a first venous leg ulcer: a series of events.

BACKGROUND: A venous leg ulcer (VLU) has a significant negative impact on quality of life. Prevention of a VLU is not yet imbedded in clinical practice because risk factors for developing a first VLU are not well known. OBJECTIVES: To explore further the progression of chronic venous disease (CVD) into a first VLU from the patient's perspective. METHODS: A qualitative study using semistructured interviews was conducted among male and female patients with a VLU. Patients from primary and secondary care, under and over 50 years of age, and with first and recurrent VLUs were included. The interviews were transcribed and analysed using a narrative approach to a thematic analysis. Transcripts were organized in chronological order and an iterative process was used to code the transcripts. RESULTS: Four key themes and the connections made between them emerged from the 11 narratives on the progression of CVD towards a first VLU: 'comorbidity', 'mobility', 'work and lifestyle' and 'acknowledgment of CVD'. Comorbidity was linked to reduced mobility and late acknowledgment of CVD. Comorbidity also affected work and lifestyle and vice versa. Work and lifestyle affected mobility and was linked to the acknowledgment of CVD. CONCLUSIONS: A reduction in mobility as a result of comorbidity and work and lifestyle occurred before the VLU developed. Patients did not recognize symptoms of CVD and did not acknowledge the chronicity of CVD. Healthcare professionals should be aware of reductions in mobility and the knowledge deficit in patients with CVD. What's already known about this topic? Not all patients with chronic venous disease (CVD) develop a venous leg ulcer (VLU). A patient's quality of life decreases significantly when a VLU develops. Risk factors for the development of a first VLU in patients with CVD are not well known, unlike risk factors for other chronic wounds like diabetic foot ulcer and pressure ulcers. What does this study add? The patient's narrative towards the development of a first VLU, a series of events. Insight into the events (comorbidity, mobility, work and lifestyle) that patients themselves link to the development of a VLU. Insight into the patients' acknowledgment of CVD in the progression of CVD towards a first VLU. What are the clinical implications of this work? More awareness is needed of CVD symptoms among patients and healthcare providers, as well as more awareness for prevention of a VLU in clinical practice. New insights (for further studies) are needed into the concept of mobility and the development of a VLU. Improved patient education and follow-up are needed for patients with CVD.

Self-Management Education for Bipolar Disorders: A Hermeneutic-Phenomenological Study on the Tacit Knowledge of Mental Health Nurses.

Background: Self-management of bipolar disorder (BD) education is a complex nursing intervention in which patients and informal caregivers are taught to be actively involved in self-monitoring and self-regulating activities. Some studies question if nurses are sufficiently equipped to deliver these educational tasks. Other studies suggest that nurses have gathered their knowledge implicitly by experience, but to date, this tacit knowledge is not described from the experiences of mental health nurses (MHNs) in ambulant BD care. Objective: To detect the tacit knowledge used by MHNs by interpreting their experiences in delivering self-management education to people with BD and their informal caregivers. Methods: A phenomenological-hermeneutical study amongst MHNs (N = 9) from three ambulant BD care clinics in the Netherlands. Face-to-face, open, in-depth interviews guided by a topic list, were conducted and transcribed verbatim prior to the hermeneutical analysis. Findings: We found five categories resembling the complex character of self-management interventions provided by MHNs: Building a trustful collaboration, Starting a dialogue about needs and responsibilities, Explaining BD, Utilizing mood monitoring instruments, and Conceptualizing self-management of BD. Conclusion: Eventually MHNs use tacit knowledge to cope with situations that demand an outside-the-box approach. Self-management education is partially trained and partially mastered through experience. Practice implications: In order to facilitate long-term self-management of BD, the collaboration of a supporting network is essential.

Towards an international language for incontinence-associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries.

BACKGROUND: Incontinence-associated dermatitis (IAD) is a specific type of irritant contact dermatitis with different severity levels. An internationally accepted instrument to assess the severity of IAD in adults, with established diagnostic accuracy, agreement and reliability, is needed to support clinical practice and research. OBJECTIVES: To design the Ghent Global IAD Categorization Tool (GLOBIAD) and evaluate its psychometric properties. METHODS: The design was based on expert consultation using a three-round Delphi procedure with 34 experts from 13 countries. The instrument was tested using IAD photographs, which reflected different severity levels, in a sample of 823 healthcare professionals from 30 countries. Measures for diagnostic accuracy (sensitivity and specificity), agreement, interrater reliability (multirater Fleiss kappa) and intrarater reliability (Cohen's kappa) were assessed. RESULTS: The GLOBIAD consists of two categories based on the presence of persistent redness (category 1) and skin loss (category 2), both of which are subdivided based on the presence of clinical signs of infection. The agreement for differentiating between category 1 and category 2 was 0·86 [95% confidence interval (CI) 0·86-0·87], with a sensitivity of 90% and a specificity of 84%. The overall agreement was 0·55 (95% CI 0·55-0·56). The Fleiss kappa for differentiating between category 1 and category 2 was 0·65 (95% CI 0·65-0·65). The overall Fleiss kappa was 0·41 (95% CI 0·41-0·41). The Cohen's kappa for differentiating between category 1 and category 2 was 0·76 (95% CI 0·75-0·77). The overall Cohen's kappa was 0·61 (95% CI 0·59-0·62). CONCLUSIONS: The development of the GLOBIAD is a major step towards a better systematic assessment of IAD in clinical practice and research worldwide. However, further validation is needed.

Pressure ulcer development in trauma patients with suspected spinal injury; the influence of risk factors present in the Emergency Department.

OBJECTIVES: To explore the influence of risk factors present at Emergency Department admission on pressure ulcer development in trauma patients with suspected spinal injury, admitted to the hospital for evaluation and treatment of acute traumatic injuries. DESIGN: Prospective cohort study setting level one trauma center in the Netherlands participants adult trauma patients transported to the Emergency Department on a backboard, with extrication collar and headblocks and admitted to the hospital for treatment or evaluation of their injuries. METHODS: Between January and December 2013, 254 trauma patients were included. The following dependent variables were collected: Age, Skin color and Body Mass Index, and Time in Emergency Department, Injury Severity Score, Mean Arterial Pressure, hemoglobin level, Glasgow Coma Score, and admission ward after Emergency Department. RESULTS: Pressure ulcer development during admission was associated with a higher age (p 0.00, OR 1.05) and a lower Glasgow Coma Scale score (p 0.00, OR 1.21) and higher Injury Severity Scores (p 0.03, OR 1.05). Extra nutrition decreases the probability of PU development during admission (p 0.04, OR 0.20). Pressure ulcer development within the first 48h of admission was positively associated with a higher age (p 0.01, OR 1.03) and a lower Glasgow Coma Scale score (p 0.01, OR 1.16). The proportion of patients admitted to the Intensive Care Unit and Medium Care Unit was higher in patients with pressure ulcers. CONCLUSIONS: The pressure ulcer risk during admission is high in patients with an increased age, lower Glasgow Coma Scale and higher Injury Severity Score in the Emergency Department. Pressure ulcer risk should be assessed in the Emergency Department to apply preventive interventions in time.

Nursing staff stress from challenging behaviour of residents with dementia: a concept analysis.

AIM: Provide insight into the concept of stress in the context of challenging behaviour of nursing home residents with dementia and its causes and consequences. BACKGROUND: Challenging behaviour is frequent in residents with dementia, but consequences for nursing staff are unclear. INTRODUCTION: Challenging behaviour of residents can be enervating for nurses and may lead to stress. Although stress in general is associated with negative outcomes, an overview of stress in this context would be a welcome addition to the field. METHOD: Concept analysis according to Walker and Avant. RESULTS: Identified antecedents of stress: physical and verbal aggression, conflicts, excessive demands and being unresponsive (residents), age, experience, tenure, nursing level and training (nursing staff). Defining attributes: disturbed homoeostasis and the personal appraisal of the situation. Identified consequences regard health, psychological aspects and behaviour. DISCUSSION: Intervening in the identified factors may contribute to prevention of stress in nursing staff. LIMITATIONS: Given a lack of strong empirical studies, our analysis is not based on a high level of evidence and needs to be tested. Papers from before 1990 might have been missed. CONCLUSION: The concept analysis revealed that nursing staff stress in the context of challenging behaviour may result from resident and nursing staff factors. Besides health and psychological consequences, behavioural consequences can enormously impact the well-being of residents. IMPLICATIONS: Application in daily care to support teams in influencing resident and nursing staff factors could prevent stress, for instance using behavioural management training or recruiting higher educated nursing staff. Given the increasing complexity of care, creating specialized units with specifically trained staff for different groups of people with dementia may be desirable.

[Pressure ulcers in trauma patients with suspected spine injury: a prospective cohort study with emphasis on device-related pressure ulcers]. / Decubitus bij traumapatiënten met een verdenking op wervelletsel.

Of all patients in a hospital environment, trauma patients may be particularly at risk for developing (device-related) pressure ulcers (PUs), because of their traumatic injuries, immobility, and exposure to immobilizing and medical devices. Studies on device-related PUs are scarce. With this study, the incidence and characteristics of PUs and the proportion of PUs that are related to devices in adult trauma patients with suspected spinal injury were described. From January-December 2013, 254 trauma patients were visited every 2 days for skin assessment. The overall incidence of PUs was 28·3% (n = 72/254 patients). The incidence of device-related PUs was 20.1% (n = 51), and 13% (n = 33) developed solely device-related PUs. We observed 145 PUs in total of which 60·7% were related to devices (88/145). Device-related PUs were detected 16 different locations on the front and back of the body. These results show that the incidence of PUs and the proportion of device-related PUs is very high in trauma patients.

Improving the effect of shear on skin viability with wound dressings.

BACKGROUND: Pressure ulcers are a major healthcare problem and caused by pressure and shear-forces. Although shear-force is understood to be a major contributing factor, no preventive interventions are specifically aimed at relieving the effect of shear on skin to improve skin viability. METHODS: A physical model was used to apply a combined loading of 2.4kPa pressure and 14.5N shear-force on skin in humans. Loading was applied on the volar aspect of both forearms for 30min in ten healthy volunteers. One arm received loading on skin with a wound dressing, the other arm (control) received loading directly on skin. The following parameters were determined before and after loading: IL-1α/Total Protein-ratio (used as a measure of skin damage); Cutaneous blood cell flux ((CBF) measure of reactive hyperaemia); Lactate concentration (measure of tissue ischemia). Three different dressings were tested on three different days. The order of dressing application, dressing arm and start of the intervention were randomized. RESULTS: Participants mean age was 22.5±1.6 year with a BMI of 22.3±2.4kg/m(2). IL-1α/Total Protein-ratio of the skin was significantly lower after the application of pressure and shear when the Mepilex® (P<0.01), Allevyn (P<0.05) or Aquacel(TM) dressing (P<0.01) was used compared with the control measurement. The Mepilex® dressing was more effective in reducing post-load IL-1α/Total Protein-ratio compared to the Allevyn dressing (P<0.01). Post-load CBF was significantly lower when the Mepilex® or Aquacel dressing was used (P<0.001). Both dressings induced significantly less post-load CBF than the Allevyn dressing (P<0.01 and P<0.001, respectively). The concentration of lactate was not significantly increased after the application of pressure and shear and could not be used as a measure with this model. CONCLUSION: This is the first in vivo study to demonstrate that the effects of pressure in combination with shear on skin viability can be improved with foam dressings. In this study, the multi-layered dressings perform better than the single-layered dressing.

Identifying and describing patients' learning experiences towards self-management of bipolar disorders: a phenomenological study.

ACCESSIBLE SUMMARY: Existing evidence suggest that patient education in promoting self-management strategies of bipolar disorder (BD) is effective. However, results across the full range of service users with BD vary. Learning experiences of service users look to be a crucial factor to take into account when designing, delivering, and evaluating effective interventions that promote self-management in chronic illness. What learning activities service users actually undertake themselves when self-managing BD that might explain varying success rates, and guide future self-management educational programmes has not been examined. Unlike previous studies that suggest that outcomes in self-management depend on individual learning activities, the current study found that learning to self-manage BD takes place in a social network that functions as a learning environment in which it is saved for service users to make mistakes and to learn from these mistakes. Especially, coping with the dormant fear of a recurrent episode and acknowledging the limitations of an individual approach are important factors that facilitate this learning process. Practitioners who provide patient education in order to promote self-management of BD should tailor future interventions that facilitate learning by reflecting on the own experiences of service users. Community psychiatric nurses should keep an open discussion with service users and caregivers, facilitate the use of a network, and re-label problems into learning situations where both play an active role in building mutual trust, thereby enhancing self-management of BD. ABSTRACT: Existing evidence suggest that self-management education of bipolar disorder (BD) is effective. However, why outcomes differ across the full range of service users has not been examined. This study describes learning experiences of service users in self-managing BD that provide a possible explanation for this varying effectiveness. We have conducted a phenomenological study via face-to-face, in-depth interviews, guided by a topic list, along service users with BD I or II (n = 16) in three specialised community care clinics across the Netherlands. Interviews were digitally recorded and transcribed verbatim prior to analysis in Atlas.ti 7. Unlike existing studies, which suggest that individual abilities of service users determine outcomes in self-management of BD, the current study found that self-management of BD is a learning process that takes place in a collaborative network. We identified five categories: acknowledgment of having BD, processing the information load, illness management, reflecting on living with BD, and self-management of BD. The success of self-management depends on the acknowledgment of individual limitations in learning to cope with BD and willingness to use a social network as a back-up instead. Especially, the dormant fear of a recurrent episode is a hampering factor in this learning process.

Multinational development and validation of an early prediction model for delirium in ICU patients.

RATIONALE: Delirium incidence in intensive care unit (ICU) patients is high and associated with poor outcome. Identification of high-risk patients may facilitate its prevention. PURPOSE: To develop and validate a model based on data available at ICU admission to predict delirium development during a patient's complete ICU stay and to determine the predictive value of this model in relation to the time of delirium development. METHODS: Prospective cohort study in 13 ICUs from seven countries. Multiple logistic regression analysis was used to develop the early prediction (E-PRE-DELIRIC) model on data of the first two-thirds and validated on data of the last one-third of the patients from every participating ICU. RESULTS: In total, 2914 patients were included. Delirium incidence was 23.6%. The E-PRE-DELIRIC model consists of nine predictors assessed at ICU admission: age, history of cognitive impairment, history of alcohol abuse, blood urea nitrogen, admission category, urgent admission, mean arterial blood pressure, use of corticosteroids, and respiratory failure. The area under the receiver operating characteristic curve (AUROC) was 0.76 [95% confidence interval (CI) 0.73-0.77] in the development dataset and 0.75 (95% CI 0.71-0.79) in the validation dataset. The model was well calibrated. AUROC increased from 0.70 (95% CI 0.67-0.74), for delirium that developed <2 days, to 0.81 (95% CI 0.78-0.84), for delirium that developed >6 days. CONCLUSION: Patients' delirium risk for the complete ICU length of stay can be predicted at admission using the E-PRE-DELIRIC model, allowing early preventive interventions aimed to reduce incidence and severity of ICU delirium.

Pain management in trauma patients in (pre)hospital based emergency care: current practice versus new guideline.

INTRODUCTION: Acute pain in trauma patients in emergency care is still undertreated. Early pain treatment is assumed to effectively reduce pain in patients and improve long-term outcomes. In order to improve pain management in the chain of emergency care, a national evidence-based guideline was developed. The aim of this study was to assess whether current practice is in compliance with the guideline 'Pain management for trauma patients in the chain of emergency care' from the Netherlands Association for Emergency Nurses (in Dutch NVSHV), and to evaluate early and initial pain management for adult trauma patients in emergency care. METHODS: Chart reviews were conducted in three regions of the Netherlands using electronic patient files of trauma patients from the chain of emergency care. We included one after-hours General Practitioner Co-operation (GPC), one ambulance Emergency Medical Services (EMS), two Helicopter Emergency Medical Services (HEMS), and three Emergency Departments (EDs). Organisation of pain management, pain assessment, and pain treatment was examined and compared with national guideline recommendations, including quality indicators. RESULTS: We assessed a random sample of 1066 electronic patient files. The use of standardised tools to assess pain was registered in zero to 52% of the electronic patient files per organisation. Registration of (non-)pharmacological pain treatment was found in less than half of the files. According to the files, pharmacological pain treatment deviated from the guideline in 73-99% of the files. Time of administration of medication was missing in 73-100%. Reassessment of pain following pain medication was recorded in half of the files by the HEMS, but not in files of the other organisations. CONCLUSIONS: The (registration of) current pain management in trauma patients in the chain of emergency care varies widely between healthcare organisation, and deviates from national guideline recommendations. Although guideline compliance differs across groups of healthcare professionals, maximum compliance rate with indicators registered is 52%. In order to improve pain management and evaluate its effectiveness, we recommend to improve pain registration in patient files. Furthermore, we advise to identify barriers and facilitators related to the implementation of the national guideline in all emergency care organisations.

Cervical collar-related pressure ulcers in trauma patients in intensive care unit.

INTRODUCTION: The application of a cervical collar (C-collar) in trauma patients can be life-saving. Previous studies, however, describe development of pressure ulcers related to C-collars. OBJECTIVE: To retrospectively compare collar-related pressure ulcers (CRPUs) occurring in trauma patients admitted to the intensive care unit wearing a C-collar before and after implementation of preventive interventions and to identify risk factors for CRPU development. METHODS: Retrospective chart review of 88 trauma patients admitted to the intensive care unit before (2006) and after (2008) implementation of preventive interventions; early C-collar removal (<24 hours) and an occipital foam ring. Data were collected in the first 14 days of admission on pressure ulcer incidence, risk factors, and preventive interventions. RESULTS: The incidence of CRPUs was 1.1%. Although risk factors were present in the sample, it was impossible to identify significant risk factors for CRPU development and explore the effect of preventive interventions. CONCLUSION: The incidence of CRPUs in this study was low. CRPUs, however, should never be accepted as an inevitable complication of cervical immobilization. To identify trauma patients at risk and to apply effective preventive interventions for CRPU development, further research is needed.

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study.

PURPOSE: Recalibration and determining discriminative power, internationally, of the existing delirium prediction model (PRE-DELIRIC) for intensive care patients. METHODS: A prospective multicenter cohort study was performed in eight intensive care units (ICUs) in six countries. The ten predictors (age, APACHE-II, urgent and admission category, infection, coma, sedation, morphine use, urea level, metabolic acidosis) were collected within 24 h after ICU admission. The confusion assessment method for the intensive care unit (CAM-ICU) was used to identify ICU delirium. CAM-ICU screening compliance and inter-rater reliability measurements were used to secure the quality of the data. RESULTS: A total of 2,852 adult ICU patients were screened of which 1,824 (64%) were eligible for the study. Main reasons for exclusion were length of stay <1 day (19.1%) and sustained coma (4.1%). CAM-ICU compliance was mean (SD) 82 ± 16% and inter-rater reliability 0.87 ± 0.17. The median delirium incidence was 22.5% (IQR 12.8-36.6%). Although the incidence of all ten predictors differed significantly between centers, the area under the receiver operating characteristic (AUROC) curve of the eight participating centers remained good: 0.77 (95% CI 0.74-0.79). The linear predictor and intercept of the prediction rule were adjusted and resulted in improved re-calibration of the PRE-DELIRIC model. CONCLUSIONS: In this multinational study, we recalibrated the PRE-DELIRIC model. Despite differences in the incidence of predictors between the centers in the different countries, the performance of the PRE-DELIRIC-model remained good. Following validation of the PRE-DELIRIC model, it may facilitate implementation of strategies to prevent delirium and aid improvements in delirium management of ICU patients.

Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands.

Pain is one of the main complaints of trauma patients in (pre-hospital) emergency medicine. Significant deficiencies in pain management in emergency medicine have been identified. No evidence-based protocols or guidelines have been developed so far, addressing effectiveness and safety issues, taking the specific circumstances of pain management of trauma patients in the chain of emergency care into account. The aim of this systematic review was to identify effective and safe initial pharmacological pain interventions, available in the Netherlands, for trauma patients with acute pain in the chain of emergency care. Up to December 2011, a systematic search strategy was performed with MeSH terms and free text words, using the bibliographic databases CINAHL, PubMed and Embase. Methodological quality of the articles was assessed using standardized evaluation forms. Of a total of 2328 studies, 25 relevant studies were identified. Paracetamol (both orally and intravenously) and intravenous opioids (morphine and fentanyl) proved to be effective. Non-steroidal anti-inflammatory drugs (NSAIDs) showed mixed results and are not recommended for use in pre-hospital ambulance or (helicopter) emergency medical services [(H)EMS]. These results could be used for the development of recommendations on evidence-based pharmacological pain management and an algorithm to support the provision of adequate (pre-hospital) pain management. Future studies should address analgesic effectiveness and safety of various drugs in (pre-hospital) emergency care. Furthermore, potential innovative routes of administration (e.g., intranasal opioids in adults) need further exploration.