Challenges in Providing Timely Physiotherapy and Opportunities to Influence Outcomes for Potential Lung Donors.

CONTEXT: There is a critical shortage of donor lungs however, considerable ethical considerations are associated with the conduct of research to optimize care of the potential organ donor. OBJECTIVE: To investigate pathways of consent, respiratory care by physiotherapists and donation rates to contextualize future research on physiotherapy effects on donor lung suitability for procurement. DESIGN: Retrospective audit. SETTING: Australian tertiary hospital. PATIENTS: Potential organ donors (defined as patients who may have been eligible to donate organs for transplantation via either brain death or circulatory death) 75 years or younger presenting to the emergency department or the intensive care unit (ICU) between September 2011 and December 2012. MAIN OUTCOME MEASURES: Donation rates, timing of organ procurement from initial hospital presentation, number of persons designated to make health-care decisions approached for and consenting to donation and clinical research, and number of patients assessed and/or treated by physiotherapists. RESULTS: Records of 65 potentially eligible donors were analyzed. Eighteen (28%) of the 65 became donors. Organ procurement occurred at a median of 48 hours (interquartile range: 34-72 hours) after ICU admission. All decision-makers approached regarding participation in clinical research (4 [6%] of the 65) consented. Physiotherapists assessed 48 (74%) of the 65 patients at least once and provided 28 respiratory treatments to 18 (28%) of the 65 patients, including lung hyperinflation and positioning. Limitations were the retrospective, single-center design and the "potential organ donor" definition. CONCLUSION: Organ procurement occurs early. There is potential for early intervention to improve lung donor rates. Randomized controlled trials investigating protocolized respiratory packages of care may increase the potential donor pool and transplantation rates.

Remote-online case-based learning: A comparison of remote-online and face-to-face, case-based learning - a randomized controlled trial.

BACKGROUND: Case-based learning (CBL) is an educational approach where students work in small, collaborative groups to solve problems. Computer assisted learning (CAL) is the implementation of computer technology in education. The purpose of this study was to compare the effects of a remote-online CBL (RO-CBL) with traditional face-to-face CBL on learning the outcomes of undergraduate physiotherapy students. METHODS: Participants were randomized to either the control (face-to-face CBL) or to the CAL intervention (RO-CBL). The entire 3rd year physiotherapy cohort (n = 41) at Monash University, Victoria, Australia, were invited to participate in the randomized controlled trial. Outcomes included a postintervention multiple-choice test evaluating the knowledge gained from the CBL, a self-assessment of learning based on examinable learning objectives and student satisfaction with the CBL. In addition, a focus group was conducted investigating perceptions and responses to the online format. RESULTS: Thirty-eight students (control n = 19, intervention n = 19) participated in two CBL sessions and completed the outcome assessments. CBL median scores for the postintervention multiple-choice test were comparable (Wilcoxon rank sum P = 0.61) (median/10 [range] intervention group: 9 [8-10] control group: 10 [7-10]). Of the 15 examinable learning objectives, eight were significantly in favor of the control group, suggesting a greater perceived depth of learning. Eighty-four percent of students (16/19) disagreed with the statement "I enjoyed the method of CBL delivery." Key themes identified from the focus group included risks associated with the implementation of, challenges of communicating in, and flexibility offered, by web-based programs. DISCUSSION: RO-CBL appears to provide students with a comparable learning experience to traditional CBL. Procedural and infrastructure factors need to be addressed in future studies to counter student dissatisfaction and decreased perceived depth of learning.

Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals.

BACKGROUND: The introduction of Web-based education and open universities has seen an increase in access to professional development within the health professional education marketplace. Economic efficiencies of Web-based education and traditional face-to-face educational approaches have not been compared under randomized controlled trial conditions. OBJECTIVE: To compare costs and effects of Web-based and face-to-face short courses in falls prevention education for health professionals. METHODS: We designed two short courses to improve the clinical performance of health professionals in exercise prescription for falls prevention. One was developed for delivery in face-to-face mode and the other for online learning. Data were collected on learning outcomes including participation, satisfaction, knowledge acquisition, and change in practice, and combined with costs, savings, and benefits, to enable a break-even analysis from the perspective of the provider, cost-effectiveness analysis from the perspective of the health service, and cost-benefit analysis from the perspective of the participant. RESULTS: Face-to-face and Web-based delivery modalities produced comparable outcomes for participation, satisfaction, knowledge acquisition, and change in practice. Break-even analysis identified the Web-based educational approach to be robustly superior to face-to-face education, requiring a lower number of enrollments for the program to reach its break-even point. Cost-effectiveness analyses from the perspective of the health service and cost-benefit analysis from the perspective of the participant favored face-to-face education, although the outcomes were contingent on the sensitivity analysis applied (eg, the fee structure used). CONCLUSIONS: The Web-based educational approach was clearly more efficient from the perspective of the education provider. In the presence of relatively equivocal results for comparisons from other stakeholder perspectives, it is likely that providers would prefer to deliver education via a Web-based medium. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN): 12610000135011; http://www.anzctr.org.au/trial_view.aspx?id=335135 (Archived by WebCite at http://www.webcitation.org/668POww4L).

A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome.

INTRODUCTION: Tidal volume and plateau pressure minimisation are the standard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome (ARDS). Open lung strategies, including higher positive end-expiratory pressure (PEEP) and recruitment manoeuvres to date have not proven efficacious. This study examines the effectiveness and safety of a novel open lung strategy, which includes permissive hypercapnia, staircase recruitment manoeuvres (SRM) and low airway pressure with PEEP titration. METHOD: Twenty ARDS patients were randomised to treatment or ARDSnet control ventilation strategies. The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O. Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1, 3, 5 and 7 (mean ± SE). Duration of ventilation, ICU stay and hospital stay (median and interquartile range) and hospital survival were determined. RESULTS: There were significant overall differences between groups when considering plasma IL-8 and TNF-α. For plasma IL-8, the control group was 41% higher than the treatment group over the seven-day period (ratio 1.41 (1.11 to 1.79), P = 0.01), while for TNF-α the control group was 20% higher over the seven-day period (ratio 1.20 (1.01 to 1.42) P = 0.05). PaO2/FIO2 (204 ± 9 versus 165 ± 9 mmHg, P = 0.005) and static lung compliance (49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O, P < 0.001) were higher in the treatment group than the control group over seven days. There was no difference in duration of ventilation (180 (87 to 298) versus 341 (131 to 351) hrs, P = 0.13), duration of ICU stay (9.9 (5.6 to 14.8) versus 16.0 (8.1 to 19.3) days, P = 0.19) and duration of hospital stay (17.9 (13.7 to 34.5) versus 24.7 (20.5 to 39.8) days, P = 0.16) between the treatment and control groups. CONCLUSIONS: This open lung strategy was associated with greater amelioration in some systemic cytokines, improved oxygenation and lung compliance over seven days. A larger trial powered to examine clinically-meaningful outcomes is warranted. TRIAL REGISTRATION: ACTRN12607000465459.

A positive response to a recruitment maneuver with PEEP titration in patients with ARDS, regardless of transient oxygen desaturation during the maneuver.

UNLABELLED: Recruitment maneuvers (RMs) can expand collapsed alveoli in ventilated patients. The optimal method for delivering RMs is unknown. PURPOSE: To evaluate the safety and the respiratory and hemodynamic effects of a staircase recruitment maneuver (SRM) with decremental positive end expiratory pressure (PEEP) titration and the consequences of desaturation during the SRM in patients with early acute lung injury (ALI). METHODS: In total, 20 consecutive patients with early ALI were enrolled and received an SRM. Patients were given 15 ± 3 cm H(2)O pressure-controlled ventilation. Positive end expiratory pressure was increased from baseline (range 10-18) to 20, 30, and 40 cm H(2)O every 2 minutes to achieve maximum alveolar pressure of 55 ± 3 cm H(2)O, then decreased at 3-minute intervals to 25, 22.5, 20, 17.5, and 15 cm H(2)O until a decrease of 1% to 2% oxygen saturation from maximum was detected. Positive end expiratory pressure was left at the level where the fall in oxygen saturation occurred. Standard respiratory and circulatory variables, arterial and central venous gases were measured before, during, and after the SRM. RESULTS: There were significant improvements in shunt fraction (36.3% ± 10% to 26.4% ± 14%, P < .001), oxygen saturation (93.4% ± 2% to 96.8% ± 3%, P = .007), partial pressure of oxygen, arterial (PaO(2))/fraction of inspired oxygen ([FIO(2)]; 150 ± 42 to 227 ± 100, P = .004), lung compliance (33.9 ± 9.1 to 40.1 ± 11.4 mL/cm H(2)O, P < .01), and chest x-ray (CXR) after the SRM. Briefly, 80% of the patients responded and the response was maintained at 1 hour. In total, 8 patients desaturated 6.1% ± 2.8% in SaO(2) during the SRM but 5 of those improved SaO(2) relative to baseline by the end of the SRM. CONCLUSIONS: In all, 80% of the patients with early ALI responded to the SRM with decremental PEEP titration. Desaturation during the SRM did not indicate a failed response 1 hour later.

Simulated Patients in Physical Therapy Education: Systematic Review and Meta-Analysis.

BACKGROUND: Traditional models of physical therapy clinical education are experiencing unprecedented pressures. Simulation-based education with simulated (standardized) patients (SPs) is one alternative that has significant potential value, and implementation is increasing globally. However, no review evaluating the effects of SPs on professional (entry-level) physical therapy education is available. PURPOSE: The purpose of this study was to synthesize and critically appraise the findings of empirical studies evaluating the contribution of SPs to entry-level physical therapy education, compared with no SP interaction or an alternative education strategy, on any outcome relevant to learning. DATA SOURCES: A systematic search was conducted of Ovid MEDLINE, PubMed, AMED, ERIC, and CINAHL Plus databases and reference lists of included articles, relevant reviews, and gray literature up to May 2015. STUDY SELECTION: Articles reporting quantitative or qualitative data evaluating the contribution of SPs to entry-level physical therapy education were included. DATA EXTRACTION: Two reviewers independently extracted study characteristics, intervention details, and quantitative and qualitative evaluation data from the 14 articles that met the eligibility criteria. DATA SYNTHESIS: Pooled random-effects meta-analysis indicated that replacing up to 25% of authentic patient-based physical therapist practice with SP-based education results in comparable competency (mean difference=1.55/100; 95% confidence interval=-1.08, 4.18; P=.25). Thematic analysis of qualitative data indicated that students value learning with SPs. LIMITATIONS: Assumptions were made to enable pooling of data, and the search strategy was limited to English. CONCLUSION: Simulated patients appear to have an effect comparable to that of alternative educational strategies on development of physical therapy clinical practice competencies and serve a valuable role in entry-level physical therapy education. However, available research lacks the rigor required for confidence in findings. Given the potential advantages for students, high-quality studies that include an economic analysis should be conducted.

Management of people with acute low-back pain: a survey of Australian chiropractors.

INTRODUCTION: Chiropractors commonly provide care to people with acute low-back pain (LBP). The aim of this survey was to determine how chiropractors intend to support and manage people with acute LBP and if this management is in accordance with two recommendations from an Australian evidence-based acute LBP guideline. The two recommendations were directed at minimising the use of plain x-ray and encouraging the patient to stay active. METHODS: This is a cross sectional survey of chiropractors in Australia. This paper is part of the ALIGN study in which a targeted implementation strategy was developed to improve the management of acute LBP in a chiropractic setting. This implementation strategy was subsequently tested in a cluster randomised controlled trial. In this survey phase of the ALIGN study we approached a random sample of 880 chiropractors in three States of Australia. The mailed questionnaire consisted of five patient vignettes designed to represent people who would typically present to chiropractors with acute LBP. Four vignettes represented people who, according to the guideline, would not require a plain lumbar x-ray, and one vignette represented a person with a suspected vertebral fracture. Respondents were asked, for each vignette, to indicate which investigation(s) they would order, and which intervention(s) they would recommend or undertake. RESULTS: Of the 880 chiropractors approached, 137 were deemed ineligible to participate, mostly because they were not currently practising, or mail was returned to sender. We received completed questionnaires from 274 chiropractors (response rate of 37%). Male chiropractors made up 66% of respondents, 75% practised in an urban location and their mean number of years in practice was 15. Across the four vignettes where an x-ray was not indicated 68% (95% Confidence Intervals (CI): 64%, 71%) of chiropractors responded that they would order or take an x-ray. In addition 51% (95%CI: 47%, 56%) indicated they would give advice to stay active when it was indicated. For the vignette where a fracture was suspected, 95% (95% CI: 91%, 97%) of chiropractors would order an x-ray. CONCLUSION: The intention of chiropractors surveyed in this study shows low adherence to two recommendations from an evidence-based guideline for acute LBP. Quality of care for these patients could be improved through effective implementation of evidence-based guidelines. Further research to find cost-effective methods to increase implementation is warranted.