Use of low-frequency contact ultrasonic debridement with and without polyhexamethylene biguanide in hard-to-heal leg ulcers: an RCT protocol.

OBJECTIVE: The purpose of this research is to investigate the effect of low-frequency contact ultrasonic debridement therapy (LFCUD) in hard-to-heal wounds with suspected biofilm, and compare the effect with or without a surfactant antimicrobial on bacterial colony counts and wound healing rates. METHOD: A single-blinded randomised controlled trial (RCT) will investigate the combination of LFCUD and the antiseptic polyhexamethylene biguanide with a surfactant betaine (referred to in this paper as PHMB) as a topical solution post-treatment and in a sustained dressing, compared with use of LFCUD alone. Potential participants from a community wound clinic (n=50) will be invited to take part in the 12-week trial. Wound swabs and tissue samples will be analysed for bacterial type and quantity, before and after treatments, using traditional culture techniques and advanced molecular methods. Wound healing, pain, quality of life and biofilm (via a specifically designed tool) will also be measured. DISCUSSION: Bacteria have the potential to cause a hard-to-heal wound, particularly when antibiotics are too frequently and unnecessarily prescribed, resulting in antibiotic-resistant microorganisms. Appropriate care is vital when caring for hard-to-heal wounds to avoid these scenarios. With no simple laboratory method available to identify or treat wound biofilm, clinicians rely on their expertise in wound management. This study aims to provide in vivo evidence on the effectiveness of PHMB, to prevent the reformation of biofilm when applied after LFCUD. The aim is to provide evidence-based and more cost-effective wound care.

The quandary of registered nurses untrained in adult intellectual disability nursing when caring for this diverse patient group in acute care settings: An integrated literature review.

AIMS AND OBJECTIVES: To critically appraise relevant literature on the lived experiences of registered nurses caring for adults with intellectual disability in the acute care setting in Australia to determine current knowledge and gaps in the literature. BACKGROUND: People with intellectual disability have the right to the highest attainable health care the same as everyone else. However, inequities still exist in the delivery of health care across the globe, including Australia that result in poorer health outcomes for this population group. Part of the problem is a lack of understanding of the complexities of ID care due to an absence of ID specific content in undergraduate curricula. DESIGN: Integrative literature review. METHODS: Electronic databases were searched for relevant empirical and theoretical literature. Additional articles were found by reviewing reference lists of selected articles resulting in ten articles for review. Selected articles were critically appraised using JBI critical appraisal tools. Data were analysed using comparative thematic analysis. PRISMA checklist completed the review. RESULTS: Two main themes emerged from the data that informed the gap in knowledge: (a) Defining nursing practice; and (b) Confidence to practice. CONCLUSIONS: There was limited qualitative research published on the topic. International studies revealed that a lack of understanding of the ID condition due to inadequate education left registered nurses feeling underprepared, unsupported and struggling to provide optimal care. No studies were located on the phenomenon within the Australian context. A study exploring the lived experiences of RNs in Australia is needed to offer a deeper understanding of the phenomenon that will help inform practice. RELEVANCE TO PRACTICE: Including ID care in national undergraduate and postgraduate nursing curricula must become a nursing educational and professional priority to support nurses more fully in their practice to ensure patients with ID receive the highest attainable standard of nursing care.

Dose and setting of rehabilitation received after stroke in Queensland, Australia: a prospective cohort study.

OBJECTIVE: The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. DESIGN: This was a prospective observational cohort study. SETTING: A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. SUBJECTS: Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. METHODS: We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. MEASURES: Dose of rehabilitation - time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. RESULTS: We recruited 504 patients, of whom 337 (median age = 73 years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7-7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7-3.8) compared to no rehabilitation, after adjustment for baseline factors. CONCLUSION: Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.

Assessment and selection for rehabilitation following acute stroke: a prospective cohort study in Queensland, Australia.

OBJECTIVE: To describe current practice and investigate factors associated with selection for rehabilitation following acute stroke. DESIGN: Prospective observational cohort study. SETTING: Seven public hospitals in Queensland, Australia. SUBJECTS: Consecutive patients surviving acute stroke. MEASURES: Rehabilitation selection processes are assessment for rehabilitation needs, referral for rehabilitation and receipt of rehabilitation. Functional impairment following stroke is modified Rankin Scale (mRS). RESULTS: We recruited 504 patients, median age 73 years (interquartile range (IQR) = 62-82), between July 2016 and January 2017. Of these, 90% (454/504) were assessed for rehabilitation needs, 76% (381/504) referred for rehabilitation, and 72% (363/504) received any rehabilitation. There was significant variation in all rehabilitation selection processes across sites (P < 0.05). In multivariable analyses, stroke unit care (odds ratio (OR) = 2.7; 95% confidence interval (CI) = 1.1, 6.6) and post stroke functional impairment (severe stroke mRS 4-5: OR = 10.9; 95% CI = 4.9, 24.6) were associated with receiving an assessment for rehabilitation. Receipt of rehabilitation was more likely following assessment (OR = 6.5; 95% CI = 2.9, 14.6) but less likely in patients with dementia (OR = 0.2; 95% CI = 0.1, 0.9), end-stage medical conditions (OR = 0.4; 95% CI = 0.2, 0.8) or ischaemic stroke (OR = 0.4; 95% CI = 0.1, 0.9). The odds of receiving rehabilitation increased with greater impairment: OR = 3.0 (95% CI = 1.5, 4.9) for mRS 2-3 and OR = 12.5 (95% CI = 6.5, 24.3) for mRS 4-5. Among patients with mild-moderate impairment (mRS 2-3), 39/117 (33%) received no rehabilitation. CONCLUSIONS: There was significant inter-site variation in rehabilitation selection processes. The major factors influencing rehabilitation access were assessment for rehabilitation needs, co-morbidities and post-stroke functional impairment. Gaps in access to rehabilitation were found in those with mild to moderate functional impairment.

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis.

Background: Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke. Methods: We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in 2012. Findings: We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference -0.16%/month (95% CI -0.29, -0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality -0.18%, (95% CI -0.34, -0.02). Interpretation: This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design. Funding: Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.

Methods for living guidelines: early guidance based on practical experience. Paper 2: consumer engagement in living guidelines.

OBJECTIVES: To describe and reflect on the consumer engagement approaches used in five living guidelines from the perspectives of consumers (i.e., patients, carers, the public, and their representatives) and guideline developers. STUDY DESIGN AND SETTING: In a descriptive report, we used a template to capture engagement approaches and the experiences of consumers and guideline developers in living guidelines in Australia and the United Kingdom. Responses were summarized using descriptive synthesis. RESULTS: One guideline used a Consumer Panel, three included two to three consumers in the guideline development group, and one did both. Much of our experience was common to all guidelines (e.g., consumers felt welcomed but that their role initially lacked clarity). We identified six challenges and opportunities specific to living guidelines: managing the flow of work; managing engagement in online environments; managing membership of the panel; facilitating more flexibility, variety and depth in engagement; recruiting for specific skills-although these can be built over time; developing living processes to improve; and adapting consumer engagement together. CONCLUSION: Consumer engagement in living guidelines should follow established principles of consumer engagement in guidelines. Conceiving the engagement as living, underpinned by a living process evaluation, allows the approach to be developed with consumers over time.

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline.

WHAT IS THE ROLE OF DUAL ANTIPLATELET THERAPY AFTER HIGH RISK TRANSIENT ISCHAEMIC ATTACK OR MINOR STROKE? SPECIFICALLY, DOES DUAL ANTIPLATELET THERAPY WITH A COMBINATION OF ASPIRIN AND CLOPIDOGREL LEAD TO A GREATER REDUCTION IN RECURRENT STROKE AND DEATH OVER THE USE OF ASPIRIN ALONE WHEN GIVEN IN THE FIRST 24 HOURS AFTER A HIGH RISK TRANSIENT ISCHAEMIC ATTACK OR MINOR ISCHAEMIC STROKE? AN EXPERT PANEL PRODUCED A STRONG RECOMMENDATION FOR INITIATING DUAL ANTIPLATELET THERAPY WITHIN 24 HOURS OF THE ONSET OF SYMPTOMS, AND FOR CONTINUING IT FOR 10-21 DAYS CURRENT PRACTICE IS TYPICALLY TO USE A SINGLE DRUG.

A COLLABORATIVE PROJECT.

The Queensland government Department of Communities, Child Safety and Disability Services has funded Community Resourcing to establish the Community Care Smart Assistive Technology Collaborative (CCSATC) online space.

IMPROVING HEALTH AND SAFETY IN AGED CARE USING GAME BASED SIMULATION.

Australia faces the challenge of supporting a growing ageing population (AIHW, 2012). Health and safety is paramount in ensuring care is economically sustainable. Nurses involved in healthcare have a responsibility to protect themselves and those being cared for against health and safety risk. Training of the workforce is paramount to reducing the chance of injury (Robson et al. 2012).

Improving discharge care: the potential of a new organisational intervention to improve discharge after hospitalisation for acute stroke, a controlled before-after pilot study.

OBJECTIVE: Provision of a discharge care plan and prevention therapies is often suboptimal. Our objective was to design and pilot test an interdisciplinary, organisational intervention to improve discharge care using stroke as the case study using a mixed-methods, controlled before-after observational study design. SETTING: Acute care public hospitals in Queensland, Australia (n=15). The 15 hospitals were ranked against a benchmark based on a composite outcome of three discharge care processes. Clinicians from a 'top-ranked' hospital participated in a focus group to elicit their success factors. Two pilot hospitals then participated in the organisational intervention that was designed with experts and consumers. PARTICIPANTS: Hospital clinicians involved in discharge care for stroke and patients admitted with acute stroke or transient ischaemic attack. INTERVENTION: A four-stage, multifaceted organisational intervention that included data reviews, education and facilitated action planning. PRIMARY AND SECONDARY OUTCOME MEASURES: Three discharge processes collected in Queensland hospitals within the Australian Stroke Clinical Registry were used to select study hospitals: (1) discharge care plan; (2) antihypertensive medication prescription and (3) antiplatelet medication prescription (ischaemic events only). Primary measure: composite outcome. Secondary measures: individual adherence changes for each discharge process; sensitivity analyses. The performance outcomes were compared 3 months before the intervention (preintervention), 3 months postintervention and at 12 months (sustainability). RESULTS: Data from 1289 episodes of care from the two pilot hospitals were analysed. Improvements from preintervention adherence were: antiplatelet therapy (88%vs96%, p=0.02); antihypertensive prescription (61%vs79%, p<0.001); discharge planning (72%vs94%, p<0.001); composite outcome (73%vs89%, p<0.001). There was an insignificant decay effect over the 12-month sustainability period (composite outcome: 89% postintervention vs 85% sustainability period, p=0.08). CONCLUSION: Discharge care in hospitals may be effectively improved and sustained through a staged and peer-informed, organisational intervention. The intervention warrants further application and trialling on a larger scale.