Agitation during anaesthetic emergence: An observational study of adult cardiac surgery patients in two Australian intensive care units.

BACKGROUND: Anaesthetic emergence agitation among adult patients being recovered after open cardiac and/or thoracic aorta surgery has not been described. OBJECTIVES: The objective of this study was to characterise emergence agitation in terms of incidence, clinical features, and consequences in a cohort of cardiac surgery patients being recovered in the intensive care unit (ICU). METHODS: A prospective, observational pilot study was implemented. Over a 5-week period, the study was conducted in two metropolitan hospitals in Victoria, Australia. The cohort comprised all patients admitted to the ICUs aged ≥18 years, who had undergone cardiac surgery via an open sternotomy with general anaesthetic, and whose emergence was directly observed. Emergence agitation was defined as a Richmond Agitation and Sedation Scale score of ≥+2. RESULTS: Fifty patients were observed. Emergence agitation occurred in 24/50 (48%) of patients. Patients with emergence agitation experienced more clinical consequences than patients with calm emergence, including a significantly greater number of episodes of airway compromise (12/24, 50%, p < 0.001); ventilator dyssynchrony (23/24, 96%, p = 0.004); and hypertension (13/24, 54%, p = 0.004). Significant treatment interference (potentially dangerous patient movements such as pulling tubes) occurred with 23/24 patients (96%, p < 0.0001). Patients who underwent emergence agitation required significantly more interventions during anaesthetic emergence than patients who underwent a calm emergence. Interventions included extra nursing measures (16/24, 67%, p = 0.001) administration of sedative and/or opioid intravenous boluses (22/24, 92%, p = 0.001) and vasoactive agents (15/24, 63%, p = 0.05). CONCLUSIONS: In patients recovering from cardiac surgery in the ICU, emergence agitation was clinically important. Immediate interventions were required to prevent and manage complications.

The concept of holism applied in recent palliative care practice: A scoping review.

BACKGROUND: Whilst there is a sense of holism existing within palliative care practice, what is not clear is the extent to which holism, as applied in recent palliative care practice, has been adequately researched. Currently, no reviews on this topic were identified through systematic and scoping review registries. AIM: To identify and describe the available published evidence on the key features of holism and the core domains underpinning the application of holism in relation to recent palliative care practice. DESIGN: Scoping review using the Johanna Briggs Institute design. DATA SOURCES: MEDLINE, EMCARE, and CINAHL (Ovid), PsycINFO, SocINDEX, SCOPUS and Web of Science. (International, peer-reviewed, published papers in the English language from January 2010to December 2020). RESULTS: Five studies met inclusion criteria. Two studies used qualitative methods, one used mixed-methods, and two were randomised controlled trials. The research investigated (1) frameworks for holistic care and (2) assessment tools applied in palliative care settings. CONCLUSIONS: The results from the review led to identifying key features of palliative care that were presented as interconnected aspects of holistic care domains in both assessments and interventions. The literature revealed a focus on curative and biomedical approaches to disease management with holistic aspects acknowledged, but not in the forefront of core service delivery. Holism was generally conceptualised as an overarching theoretical framework to palliative care service provision and positioned as an adjunct to palliative models of care. These findings point to a gap in research that links the concept of holism to applied palliative care practices.

Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review.

BACKGROUND: Cognitive and implicit biases negatively impact clinicians' decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain. METHODS: This scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary. RESULTS: Of the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4). CONCLUSIONS: A range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.

The clinical and cost effectiveness of remote expert wound nurse consultation for healing of pressure injuries among residential aged care patients: A protocol for a prospective pilot parallel cluster randomised controlled trial.

Pressure injuries affect 1 to 46% of residents in aged care (long term) facilities and cause a substantial economic burden on health care systems. Remote expert wound nurse consultation has the potential to improve pressure injury outcomes; however, the clinical and cost effectiveness of this intervention for healing of pressure injuries in residential aged care require further investigation. We describe the remote expert wound nurse consultation intervention and the method of a prospective, pilot, cluster randomised controlled trial. The primary outcome is number of wounds healed. Secondary outcomes are wound healing rate, time to healing, wound infection, satisfaction, quality of life, cost of treatment and care, hospitalisations, and deaths. Intervention group participants receive the intervention over a 12-week period and all participants are monitored for 24 weeks. A wound imaging and measurement system is used to analyse pressure injury images. A feasibility and fidelity evaluation will be concurrently conducted. The results of the trial will inform the merit of and justification for a future definitive trial to evaluate the clinical and cost effectiveness of remote expert wound nurse consultation for the healing of pressure injuries in residential aged care.

Clinical and cost effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for the prevention of hospital-acquired pressure injuries. A randomised controlled trial.

Pressure injuries affect 13.1% to 45.5% of patients in the intensive care unit and lead to pain and discomfort for patients, burden on healthcare providers, and unnecessary cost to the health system. Turning and positioning systems offer improvements on usual care devices, however the evidence of the effectiveness of such systems is still emerging. We conducted an investigator initiated, prospective, single centre, two group, non-blinded, randomised controlled trial to determine the effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for preventing PIs. The trial was prematurely discontinued after enrolment of 78 participants due to COVID-19 pandemic related challenges and lower than expected enrolment rate. The study groups were comparable on baseline characteristics and adherence to the interventions was high. Four participants developed a PI (in the sacral, ischial tuberosity or buttock region), n = 2 each in the intervention and control group. Each participant developed one PI. As the trial is underpowered, these findings do not provide an indication of the clinical effectiveness of the interventions. There was no participant drop-out or withdrawal and there were no adverse events, device deficiencies, or adverse device effects identified or reported. The results of our study (in particular those pertaining to enrolment, intervention adherence and safety) provide considerations for future trials that seek to investigate how to prevent PIs among ICU patients.

Anaesthetic emergence agitation after cardiac surgery: An intensive care staff survey.

BACKGROUND: Anecdotal reports suggest that during emergence from anaesthesia, some post-cardiac surgery patients exhibit signs of agitation with concerning clinical features, including hypoxaemia, ventilation dysynchrony, and haemodynamic instability. This clinical phenomenon has not been described in the published literature. OBJECTIVE: We aimed to investigate the perceptions and practice of intensive care unit staff members who have managed adult patients after cardiac surgery regarding emergence agitation, its clinical features, and treatment. METHODS: A descriptive survey was conducted from December 2020 to January 2021 in two metropolitan hospitals. Items included Likert scale, multiple-item selection, and free-text responses. RESULTS: There were 144 respondents (response rate: 55%). Post-cardiac surgery emergence agitation was witnessed by 143 respondents (99%). Fifty-seven (40%) reported encountering this clinical problem often. Clinical concerns included instabilities with airway or ventilation (347 items selected), cardiovascular system (189 items selected), and patient treatment interference, such as pulling tubes (229 items selected). Overall, 143 (99%) respondents re-sedated patients with emergence agitation, 138 (96%) added a narcotic bolus, and 121 respondents reported use of mechanical restraints (84%). Twenty-four respondents (2%) recalled receiving any formal anaesthetic emergence education, including after cardiac surgery. CONCLUSION: Anaesthetic emergence agitation following cardiac surgery is a concerning clinical problem. Clinical management of emergence agitation was influenced more by clinical experience than research evidence. Further observational research is required to investigate clinical characteristics and inform evidence-based management practices and education.

Organizational strategies to optimize women's safety during labor and birth: A scoping review.

BACKGROUND: Safety is a priority for organizations that provide maternity care, however, preventable harm and errors in maternity care remain. Maternity care is considered a high risk and high litigation area of health care. To mitigate risk and litigation, organizations have implemented strategies to optimize women's safety. Our objectives were to identify the strategies implemented by organizations to optimize women's safety during labor and birth, and to consider how the concept of safety is operationalized to measure and evaluate outcomes of these strategies. METHOD: This scoping review was conducted using the Joanna Briggs Institute Scoping Review Methodology. Published peer-reviewed literature indexed in CINAHL, Medline, and Embase, databases from 2010 to 2020, were reviewed for inclusion. Fifty studies were included. Data were extracted and thematically analyzed. RESULTS: Three categories of organizational strategies were identified to optimize women's safety during labor and birth: clinical governance, models of care, and staff education. Clinical governance programs (n = 30 studies), specifically implementing checklists and audits, models of care, such as midwifery led-care (n = 11 studies), and staff training programs (n = 9 studies), were predominately for the management of obstetric emergencies. Outcome measures included morbidity and mortality for woman and newborns. Three studies discussed women's perceptions of safety during labor and birth as an outcome measure. CONCLUSIONS: Organizations utilize a range of strategies to optimize women's safety during labor and birth. The main outcome measure used to evaluate strategies was focused on clinical outcomes for the mother and newborn.

Registered Nurses' experiences of psychological well-being and ill-being in their first year of practice: A qualitative meta-synthesis.

AIM: To synthesize Registered Nurses' self-reported perceptions and experiences of psychological well-being and ill-being during their first year of practice. DESIGN: Qualitative meta-synthesis. DATA SOURCES: Databases included Cumulative Index of Nursing and Allied Health Literature, Excerpta Medica database, Medical Literature Analysis and Retrieval System Online and Psychological Information. Qualitative studies were considered for inclusion if published in English, from 2009-2019, reporting primary data analysis including psychological well-being and ill-being experiences of graduate nurses in first year of practice. REVIEW METHODS: Qualitative studies were systematically identified and critically appraised. A meta-synthesis was applied using an open card sort technique to organize empirical data into a matrix of graduate nurses' voices of psychological well-being and ill-being. RESULTS: Twenty-two studies were included. Analysis revealed patterns of positive experiences and emotions. These included feeling valued and part of the team and learning from and feeling supported by other nurses. Negative experiences and emotions such as feeling overwhelmed, stressed, alone and inadequately prepared were also identified. CONCLUSION: Graduate nurses' perceptions and experiences of their psychological well-being and ill-being revealed both positive and negative dimensions during this transition period. Specific examples of strategies that may promote transition nurses' well-being and prevent ill-being were identified such as social connection and support. IMPACT: Increasing the numbers of new nursing graduates world-wide is required to strengthen health systems. Developing strategies to retain these graduates in the workforce is paramount. This review found some graduate nurses experience the transition period as a time of personal growth and fulfilment, for others this period was a stressor. These findings were illustrated in a model of 'ways to well-being'. The potential for knowledge translation of this model extends from graduate nurses as individuals, to nurse entry to practice programs and graduate nurse programs, to organizational policy targeting future health workforce. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42020148812.

Nurse wellbeing during the coronavirus (2019) pandemic: A qualitative descriptive study.

BACKGROUND: The wellbeing of individuals influences organisational outcomes. Insight into nurses' wellbeing is crucial to a sustaining a high-quality workforce. AIM: To describe nurses' perceptions and experiences of wellbeing, work wellbeing, and mental health. METHOD: Using a qualitative descriptive design, semi-structured interviews were conducted, transcribed verbatim, analysed inductively and thematically, and reported per consolidated criteria for reporting qualitative research. FINDINGS: Nine Australian nurses were interviewed in 2020, each for 60 to 90 minutes. These nurses had a broad range of clinical roles and years of experience in metropolitan healthcare organisations. Six themes, each related to nurse wellbeing, depicted: (i) value and sense of purpose from nursing, yet also negative consequences of losing sight of oneself within the nursing role; (ii) work nurses did to disengage from their job and create a balance within their life; (iii) significance of the team and senior team as a source of both strength and opportunity for wellbeing; (iv) a range of wellbeing initiatives with a perception these were often developed, and for use, in response to crisis as opposed to preventative or proactive measures; (v) value of additional nurse wellbeing education and promotion of available support; and (vi) novel challenges and ways to wellbeing during times where resources were stretched and usual support systems impacted. DISCUSSION: Identified positive and negative consequences of nursing must be addressed when developing targeted wellbeing interventions. CONCLUSION: New ways of working and supporting individual, team and organisational wellbeing are needed for flourishing working environments. Potential strategies to either leverage or mitigate the positive and negative consequences of nursing are offered.

Socio-demographic and disease related characteristics associated with unplanned emergency department visits by cancer patients: a retrospective cohort study.

BACKGROUND: Emergency department (ED) presentations made by patients having cancer treatment are associated with worth outcomes. This study aimed to explore the socio-demographic and disease related characteristics associated with ED presentation, frequent ED presentations, and place of discharge for cancer patients receiving systemic cancer therapies in the ambulatory setting. METHODS: This was a single site, retrospective observational cohort design. Hospital data for patients treated in the Day Oncology Unit of a large public tertiary hospital in Melbourne, Australia between December 2014 and November 2017 were extracted from clinical databases and retrospectively matched to ED attendance records. Andersen's Behavioral Model of Health Service Utilisation provided the conceptual framework for exploring associations between socio-demographic and disease characteristics and ED use. RESULTS: A total of 2638 individuals were treated in the Day Oncology Unit over the study dates. Of these, 1182 (45%) made an unplanned ED presentation within 28 days of receiving systemic cancer therapy. One hundred and twenty-two (12%) patients attended the ED on two or more occasions within 28 days; while 112 (10%) patients attended the ED four or more times (within 28 days of receiving systemic cancer therapy) within any given 12 month period. Being born outside of Australia was independently related to making an unplanned ED presentation within 28 days of receiving anti-cancer therapy (p < .01) as was being diagnosed with head and neck (p = .03), upper gastrointestinal (p < .001), colorectal (p < .001), lung (p < .001), skin (p < .001) or breast cancer (p = .01). CONCLUSIONS: This study identified a subgroup of cancer patients for whom an ED presentation is more likely. Better understanding of socio-demographic and disease related characteristics associated with the risk of an ED presentation may help inform targeted follow up of patients, to mitigate potentially avoidable ED presentation and optimize outcomes of care.

An observational study of the maintenance of the 30°â€Šside-lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose-designed positioning device.

The aim of the study was to evaluate the maintenance of the 30° side-lying lateral tilt position among aged care residents at the risk of developing pressure injuries when using the standard care pillow and a purpose-designed positioning device. An observational study was conducted. Participants were monitored during positioning under two conditions, with pillows and with a fluidised positioner. Body angle measurements were taken at three time points (baseline, 1 hour, and 2 hours) on 10 occasions. Repeated-measures analysis assessed the difference in the degree of the angle of the body. The sample (n = 12) had an average age of 83 years, and the participants were immobile when in bed. The average angle with the pillow condition was 26.7° at baseline, 21.5° at 1 hour, and 16.6° at 2 hours. The average angle with the fluidised positioner condition was 30.7° at baseline, 29.3° at 1 hour, and 26.8° at 2 hours. The main effects of Condition and Time were significant: Condition: F(1,11) = 14.378, P < .001, Time: F(2,22) = 45.858, P < .001. There was a statistically significant interaction between the effects of Condition and Time on the average lateral tilt position, F(2,22) = 15.574, P < .001. The lateral tilt body position was better maintained with the positioning device than the pillow. Further research is required to determine the effectiveness of the fluidised positioner for pressure injury prevention.

A randomised controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: The Border III Trial.

Pressure injuries are prevalent in highly dependent aged care residents. This study investigated the clinical effectiveness of the application of the Mepilex Border Sacrum and Mepilex Heel dressings to prevent the development of facility-acquired pressure injuries. A total of 288 recently admitted residents were enrolled from 40 Australian nursing homes into a randomised controlled trial. Residents randomised to standard care (n = 150) received pressure injury prevention as recommended by international guidelines. Residents randomised to the intervention (n = 138) received standard pressure injury prevention care and had dressings applied to their sacrum and heels. Participants were comparable on demographic and physiological parameters. More residents in the control group developed pressure injuries than in the intervention group (16 vs 3, P = 0.004), and they developed more pressure injuries in total than residents in the intervention group. The results represent a relative risk reduction of 80% for residents treated with the dressings and for every 12 patients that we treated we prevented one pressure injury. Based on our findings, we conclude that the use of the Mölnlycke Mepilex Border Sacrum and Mepilex Heel dressings confers a significant additional protective benefit to nursing home residents with a high risk of developing a facility-acquired pressure injury.

Alcohol and Other Drug (AOD) Education for Hospital Staff: An Integrative Literature Review.

Alcohol and Other Drug (AOD) education amongst hospital staff is often inadequate. This leads to suboptimal care of patients and is a missed opportunity for early identification and treatment. This integrative review evaluates the core features of current education for hospital-based doctors and nurses in AOD, including country of origin, content, duration, and pedagogy. The majority of included studies were conducted in the USA (72%), target alcohol rather than AOD in general (72%), adopted a purely medical model of treatment (94%), and utilised a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model (94%). The overall quality of the studies was weak-moderate, which led to small effect sizes in most studies and limits the generalizability of any conclusions. More high quality research trials are needed to establish the core features of effective AOD education for hospital staff. Future research should include a focus on the psychosocial context of addiction, other drug use and the impact of negative attitudes on care delivery.

Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

AIMS AND OBJECTIVES: This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. BACKGROUND: Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. DESIGN: A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. METHODS: A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. FINDINGS: Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. CONCLUSIONS: The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication management in an acute hospital setting. Language discourses shaped and were shaped by complex power relations between patients and clinicians and among clinicians themselves. RELEVANCE TO CLINICAL PRACTICE: Clinicians need to be encouraged to have regular conversations to talk about and challenge each other's practices. More emphasis should be placed on ensuring that patients are given opportunities to voice their concerns about how their medications are managed.

Feasibility and need for violence risk screening at triage: an exploration of clinical processes and public perceptions in one Australian emergency department.

BACKGROUND: Research on patient aggression in hospital emergency departments supports the development of a systematic process for identifying individuals at risk of becoming violent. The feasibility and community acceptance of this approach is unknown. In this study, we determine the feasibility and explore the need for a violence risk screening process in one Australian emergency department. METHOD: We used a descriptive exploratory design that involved semistructured interviews and observations of practice. The setting was an adult tertiary referral hospital and major trauma centre located in Melbourne, Australia. A convenience sample of nine triage nurses were observed assessing patients to explore how risk screening was undertaken in practice. Semistructured interviews were conducted with emergency department (ED) service users (N=19) to explore community perspectives on the process of violence risk screening. RESULTS: Observations of practice revealed that nurses used observed and reported information to screen for potential risk of violence rather than employing a direct questioning approach. Interviews with community members in the emergency department waiting room highlighted a public expectation that nurses screen and accurately identify patients at risk of violence on arrival to the ED. CONCLUSIONS: Consistent with local prevalence data, public expectations of emergency care supported the need to adopt a uniform approach to identifying people at risk of becoming violent on arrival to hospital. Observations of triage nurses interactions with patients revealed that the existing violence risk screening approach was not being consistently used by triage nurses. An integrated approach to determining violence risk during triage assessment is recommended.

Challenges and opportunities of undertaking a video ethnographic study to understand medication communication.

AIMS AND OBJECTIVES: To examine the challenges and opportunities of undertaking a video ethnographic study on medication communication among nurses, doctors, pharmacists and patients. BACKGROUND: Video ethnography has proved to be a dynamic and useful method to explore clinical communication activities. This approach involves filming actual behaviours and activities of clinicians to develop new knowledge and to stimulate reflections of clinicians on their behaviours and activities. However, there is limited information about the complex negotiations required to use video ethnography in actual clinical practice. DESIGN: Discursive paper. METHOD: A video ethnographic approach was used to gain better understanding of medication communication processes in two general medical wards of a metropolitan hospital in Melbourne, Australia. This paper presents the arduous and delicate process of gaining access into hospital wards to video-record actual clinical practice and the methodological and ethical issues associated with video-recording. CONCLUSIONS: Obtaining access to clinical settings and clinician consent are the first hurdles of conducting a video ethnographic study. Clinicians may still feel intimidated or self-conscious in being video recorded about their medication communication practices, which they could perceive as judgements being passed about their clinical competence. By thoughtful and strategic planning, video ethnography can provide in-depth understandings of medication communication in acute care hospital settings. Ethical issues of informed consent, patient safety and respect for the confidentiality of patients and clinicians need to be carefully addressed to build up and maintain trusting relationships between researchers and participants in the clinical environment. RELEVANCE TO CLINICAL PRACTICE: By prudently considering the complex ethical and methodological concerns of using video ethnography, this approach can help to reveal the unpredictability and messiness of clinical practice. The visual data generated can stimulate clinicians' reflexivity about their norms of practice and bring about improved communication about managing medications.

Complexities of medicines safety: communicating about managing medicines at transition points of care across emergency departments and medical wards.

AIMS AND OBJECTIVES: To explore how health professionals, patients and family members communicate about managing medicines across transition points of care in two Australian public hospitals. BACKGROUND: Medicines errors are common at transition points of care. Little qualitative work has targeted communicating about medicines management across patients' journeys from admission through to discharge. DESIGN: A qualitative descriptive study was undertaken. METHODS: In-depth, semi-structured interviews were conducted with patients and family members, and focus groups and interviews were undertaken with doctors, nurses and pharmacists (n = 103). These individuals were situated in emergency departments and general medical wards. Data were analysed using thematic analysis. RESULTS: Four themes were identified: contextual environment of care, competing responsibilities of care, awareness of responsibility for safety, and interprofessional communication. Contextual environment of care was affected by time pressure and efficiency, and an overriding priority to move patients out of emergency departments. In competing responsibilities of care, a reactive focus was displayed in emergency departments while a proactive stance was demonstrated in medical wards. There was an awareness of responsibility for safety, whereby key stakeholders appreciated the chain of events involved, interpersonal communication affected patients and carers, and consequences existed for patient education related to lack of information. Interdisciplinary communication was associated with communication modalities used in encounters, compartmentalised thinking, and medicines changes relayed to external providers. CONCLUSIONS: Medicines management at transition points involved a complex interplay of dynamic features. This interplay infiltrated across diverse environments, affecting patient care within and outside hospitals. RELEVANCE TO CLINICAL PRACTICE: Health professionals require greater appreciation of each other's roles at transition points of care. Prioritisation of high-risk patients is needed, such as those with cognitive impairment and multiple co-morbidities. Establishing workable protocols of communication etiquette and a structured approach to medicines activities may assist in pre-empting problems before they occur.

The cost-benefit of using soft silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: a within-trial analysis of the Border Trial.

Little is known about the cost-benefit of soft silicone foam dressings in pressure ulcer (PU) prevention among critically ill patients in the emergency department (ED) and intensive care unit (ICU). A randomised controlled trial to assess the efficacy of soft silicone foam dressings in preventing sacral and heel PUs was undertaken among 440 critically ill patients in an acute care hospital. Participants were randomly allocated either to an intervention group with prophylactic dressings applied to the sacrum and heels in the ED and changed every 3 days in the ICU or to a control group with standard PU prevention care provided during their ED and ICU stay. The results showed a significant reduction of PU incidence rates in the intervention group (P = 0·001). The intervention cost was estimated to be AU$36·61 per person based on an intention-to-treat analysis, but this was offset by lower downstream costs associated with PU treatment (AU$1103·52). Therefore, the average net cost of the intervention was lower than that of the control (AU$70·82 versus AU$144·56). We conclude that the use of soft silicone multilayered foam dressings to prevent sacral and heel PUs among critically ill patients results in cost savings in the acute care hospital.

A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial.

The prevention of hospital acquired pressure ulcers in critically ill patients remains a significant clinical challenge. The aim of this trial was to investigate the effectiveness of multi-layered soft silicone foam dressings in preventing intensive care unit (ICU) pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients. Intervention group patients (n = 219) had Mepilex(®) Border Sacrum and Mepilex(®) Heel dressings applied in the emergency department and maintained throughout their ICU stay. Results revealed that there were significantly fewer patients with pressure ulcers in the intervention group compared to the control group (5 versus 20, P = 0·001). This represented a 10% difference in incidence between the groups (3·1% versus 13·1%) and a number needed to treat of ten patients to prevent one pressure ulcer. Overall there were fewer sacral (2 versus 8, P = 0·05) and heel pressure ulcers (5 versus 19, P = 0·002) and pressure injuries overall (7 versus 27, P = 0·002) in interventions than in controls. The time to injury survival analysis indicated that intervention group patients had a hazard ratio of 0·19 (P = 0·002) compared to control group patients. We conclude that multi-layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer.

Medication communication through documentation in medical wards: knowledge and power relations.

Health professionals communicate with each other about medication information using different forms of documentation. This article explores knowledge and power relations surrounding medication information exchanged through documentation among nurses, doctors and pharmacists. Ethnographic fieldwork was conducted in 2010 in two medical wards of a metropolitan hospital in Australia. Data collection methods included participant observations, field interviews, video-recordings, document retrieval and video reflexive focus groups. A critical discourse analytic framework was used to guide data analysis. The written medication chart was the main means of communicating medication decisions from doctors to nurses as compared to verbal communication. Nurses positioned themselves as auditors of the medication chart and scrutinised medical prescribing to maintain the discourse of patient safety. Pharmacists utilised the discourse of scientific judgement to guide their decision-making on the necessity of verbal communication with nurses and doctors. Targeted interdisciplinary meetings involving nurses, doctors and pharmacists should be organised in ward settings to discuss the importance of having documented medication information conveyed verbally across different disciplines. Health professionals should be encouraged to proactively seek out each other to relay changes in medication regimens and treatment goals.