Prevention of falls in acute hospital settings: a multi-site audit and best practice implementation project.

OBJECTIVE: To assess falls prevention practices in Australian hospitals and implement interventions to promote best practice. DESIGN: A multi-site audit using eight evidence-based audit criteria. Following a baseline audit, barriers to compliance were identified and targeted. Two follow-up audit cycles assessed the sustainability of practice change. SETTING: Nine acute care hospitals around Australia, including a mix of public and private. One medical ward and one surgical ward from each hospital were involved. PARTICIPANTS: A clinical leader from each hospital, trained in evidence implementation, conducted the audits and implementation strategies in their setting. INTERVENTIONS: Multi-component falls prevention interventions were utilized, designed to target specific barriers to compliance identified at each hospital. Common interventions involved staff and patient education. MAIN OUTCOME MEASURE: Percentage compliance with falls prevention audit criteria and change in compliance between baseline and follow-up audits. Fall rate data were also analysed. RESULTS: Mean overall compliance at baseline across all hospitals was 50.4% (range 30.8-76.6%). At the first follow-up, this had increased to 74.5% (range 59.4-87.4%), which was sustained at the second follow-up (74.1%, range 48.6-84.4%). There were no statistically significant differences between compliance rates in medical versus surgical wards or in private versus public hospitals. Despite sustained practice improvement, reported fall rates remained unchanged. The focus on staff education possibly led to improved reporting of falls, which may explain the apparent lack of effect on fall rates. CONCLUSIONS: Clinical audit and feedback is an effective strategy to promote quality improvement in falls prevention practices in acute hospital settings.

Notions of quality and standards for qualitative research reporting.

The utility of qualitative research findings in the health sciences has been the subject of considerable debate, particularly with the advent of qualitative systematic reviews in recent years. There has been a significant investment in the production of guidance to improve the reporting of quantitative research; however, comparatively little time has been spent on developing the same for qualitative research reporting. This paper sets out to examine the possibility of developing a framework for refereed journals to utilize when guiding authors on how to report the results of qualitative studies in the hope that this will improve the quality of reports and subsequently their inclusion in qualitative syntheses and guidelines to inform practice at the point of care.

Improving communication between health-care professionals and patients with limited English proficiency in the general practice setting.

Quality service provision and patient safety and satisfaction in encounters with health-care professionals relies on effective communication between the practitioner and patient. This study aimed to identify effective practices for improving communication between clinical staff in general practice and patients with limited English proficiency, and to promote their implementation in general practice. Effective interventions and strategies were identified from a review of international research. Experiences with their use in practice were explored via focus group discussions with general practitioners and practice nurses. The results suggest that, wherever possible, communication in the patient's primary language is preferable; use of a qualified medical interpreter should be promoted, and practices should have a standardised and documented procedure for accessing interpreter services. General practice staff must increase their awareness about services that are available to facilitate communication with patients with limited English proficiency, and also develop attitudes, both individual and organisational, that will maximise the effectiveness of these strategies. These findings were used to develop brief, evidence-based practice guidelines that were disseminated to focus group participants for evaluation of utility and general feedback. This evidence-based guidance is now available to assist clinical and administrative general practice staff across regional and metropolitan South Australia.

Establishing confidence in the output of qualitative research synthesis: the ConQual approach.

BACKGROUND: The importance of findings derived from syntheses of qualitative research has been increasingly acknowledged. Findings that arise from qualitative syntheses inform questions of practice and policy in their own right and are commonly used to complement findings from quantitative research syntheses. The GRADE approach has been widely adopted by international organisations to rate the quality and confidence of the findings of quantitative systematic reviews. To date, there has been no widely accepted corresponding approach to assist health care professionals and policy makers in establishing confidence in the synthesised findings of qualitative systematic reviews. METHODS: A methodological group was formed develop a process to assess the confidence in synthesised qualitative research findings and develop a Summary of Findings tables for meta-aggregative qualitative systematic reviews. RESULTS: Dependability and credibility are two elements considered by the methodological group to influence the confidence of qualitative synthesised findings. A set of critical appraisal questions are proposed to establish dependability, whilst credibility can be ranked according to the goodness of fit between the author's interpretation and the original data. By following the processes outlined in this article, an overall ranking can be assigned to rate the confidence of synthesised qualitative findings, a system we have labelled ConQual. CONCLUSIONS: The development and use of the ConQual approach will assist users of qualitative systematic reviews to establish confidence in the evidence produced in these types of reviews and can serve as a practical tool to assist in decision making.

Overview of reviews: mechanical interventions for the treatment and management of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is characterized by a progressive and non-reversible airflow limitation and symptoms of breathlessness, sputum production and cough. COPD is the fourth most common cause of mortality worldwide and represents a significant social and economic burden. As such, effective strategies that might be employed to treat COPD and manage symptoms need to be investigated. This overview aimed to summarize the existing evidence available in the Cochrane Library regarding the use of mechanical interventions used for the treatment and management of COPD. Systematic reviews that included adult participants with diagnosed COPD who received a mechanical intervention were included. Five reviews were included, and due to the heterogeneity of these reviews, direct and indirect comparisons of the effects of the intervention were not possible. Instead, data of the effectiveness of each intervention were extracted and summarized in tables and discussed as a narrative summary. Interventions included non-invasive positive pressure ventilation (NPPV), positive airway pressure (PEP) devices and neuromuscular electrical stimulation (NMES). Evidence regarding the effectiveness of NPPV was limited, and available data do not support the use of NPPV for patients with stable COPD. NPPV might, however, be of benefit as a weaning strategy for intubated patients and for patients experiencing respiratory failure; however, more research is required. Although PEP devices are considered as a safe airway clearance technique, data do not reveal a clear clinical benefit to their use. NMES is also regarded as safe for patients with COPD, and might also be beneficial in improving exercise tolerance and improving quality of life for patients with COPD.

Predictors of acute adverse events from rapid rituximab infusion.

PURPOSE: This study aimed to identify the predictors of acute adverse events resulting from rapid rituximab infusion over 90 min. METHOD: It was a retrospective cohort study using medical record review based on a convenience sampling from 2007 till May 2011 in both in-patient and ambulatory setting in Royal Adelaide Hospital. RESULTS: There were a total of 294 patients who received 376 courses and 1,571 cycles of rapid rituximab infusion. Forty-three (14.6 %) patients experienced acute adverse events of hypotension being the most commonly occurring events followed by patients feeling hot and face-flushed. There were 11 predictors analysed, namely age, gender, diagnosis, stage of disease, presence of cardiac or lung morbidities, type of treatment, number of course and cycles, total white blood cells count, lymphocyte counts and lactate dehydrogenase using log generalised estimating equation for univariate and multivariate analysis. The findings successfully demonstrated that high lymphocyte counts were the independent predictor of acute adverse event from rapid rituximab infusion (p = 0.0009). Patient with high lymphocyte counts were 6.9382 times the odd to experience an adverse event as compared to those with normal lymphocyte counts. CONCLUSION: There are no specific patient characteristics to preclude prescribing rapid rituximab infusion following a 90-min regimen for non-Hodgkin lymphoma except a potential for adverse events to occur when patients have abnormally high lymphocyte counts.

Use of focussed beam reflectance measurement (FBRM) for monitoring changes in biomass concentration.

The potential of focussed beam reflectance measurement (FBRM) as a tool to monitor changes in biomass concentration was investigated in a number of biological systems. The measurement technique was applied to two morphologically dissimilar plant cell suspension cultures, Morinda citrifolia and Centaurea calcitrapa, to a filamentous bacteria, Streptomyces natalensis, to high density cultures of Escherichia coli and to a murine Sp2/0 hybridoma suspension cell line, 3-2.19. In all cases, the biomass concentration proved to be correlated with total FBRM counts. The nature of the correlation varied between systems and was influenced by the concentration, nature, size and morphology of the particle under investigation.

Safety of rapid rituximab infusion in adult cancer patients: a systematic review.

The purpose of this study is to critically appraise, synthesize and present the best available evidence related to the safety of rapid rituximab infusion in adult non-Hodgkin lymphoma and chronic lymphocytic leukaemia patients. Data are from published and unpublished studies from electronic databases, grey literature and reference lists. The studies that met the inclusion criteria were critically appraised by two independent reviewers for methodological validity using standardized critical appraisal instruments. Proportional meta-analysis based on DerSimonian-Laird weights using a random effects model was used for statistical pooling through Stats Direct. Heterogeneity is assessed using Cochran Q. When statistical pooling is not possible, the findings were presented in narrative summary. Rapid rituximab infusion is safe for non-Hodgkin lymphoma patients at a 90 min regimen. However, there is insufficient evidence to support rapid rituximab infusions for chronic lymphocytic leukaemia patients.

The "quality" of JBI qualitative research synthesis: a methodological investigation into the adherence of meta-aggregative systematic reviews to reporting standards and methodological guidance.

INTRODUCTION: Approaches to the synthesis of qualitative research have existed for more than 20 years and have evolved significantly during that time. One common approach is meta-aggregation, as advocated by JBI. There is now a considerable number of published reviews that claim to follow the JBI approach to meta-aggregation. This methodological review sought to determine the extent to which a selection of these reviews follow the available guidance, with a view to establishing compliance and identifying potential areas for improvement. METHODS: The JBI Database of Systematic Reviews and Implementation Reports (JBISRIR) was searched from 2015 to 2017 to identify all qualitative systematic reviews following the JBI approach. Citations were screened by two independent reviewers, and data extraction was conducted independently by at least two reviewers. Eligible reviews were then assessed against the JBI methodological guidance and ENTREQ statement to determine compliance. RESULTS: From the search, 33 health care-related reviews that met the inclusion criteria were identified. Several areas were identified where reviewers consistently made errors or did not clearly report their findings, including study screening and selection issues (particularly how this was done and by whom), transparent rationale for study exclusion, who performed data extraction and how, processes for developing synthesized findings, and the development and presentation of recommendations. CONCLUSION: Although qualitative synthesis has come a long way, there are still some areas for improvement in conduct and reporting. This has implications for those who develop guidance and provide education to systematic reviewers.

A comparative analysis of three online appraisal instruments' ability to assess validity in qualitative research.

The concept of validity has been a central component in critical appraisal exercises evaluating the methodological quality of quantitative studies. Reactions by qualitative researchers have been mixed in relation to whether or not validity should be applied to qualitative research and if so, what criteria should be used to distinguish high-quality articles from others. We compared three online critical appraisal instruments' ability to facilitate an assessment of validity. Many reviewers have used the critical appraisal skills program (CASP) tool to complete their critical appraisal exercise; however, CASP appears to be less sensitive to aspects of validity than the evaluation tool for qualitative studies (ETQS) and the Joanna Briggs Institute (JBI) tool. The ETQS provides detailed instructions on how to interpret criteria; however, it is the JBI tool, with its focus on congruity, that appears to be the most coherent.

Caring to death: the murder of patients by nurses.

Beyond the initial 'shock-horror' reaction in the mass media, little attention is paid by nurses or the public to nurses who murder patients. This study used discursive inquiry to uncover social constructions of this phenomenon and their implications for the definition and treatment of such murders. The mass media and professional literature were searched for commentary on cases of nurses who had been convicted of murder between 1980 and 2006. The retrieved texts were subjected to discursive analysis. Discursive constructions included the profile of murderous nurses; types of murders; contexts in which murder occurs; factors that aid detection and apprehension; legal processes and punishment; and reactions of the public, profession, regulators and families. The findings imply that murder of a patient by a nurse might occur in any setting in which nurses care for vulnerable patients--the old, the young, the sick and the disabled. Trust in nurses assists a nurse to murder. Nurses have a responsibility to understand how their workplaces can form crucibles in which murder can take place. The profession needs to acknowledge the possibility of nurses who murder patients and to commence a discussion about what might be done to limit the harm they do.

The ripple effect of evidence implementation: a descriptive evaluation of JBI's Evidence-based Clinical Fellowship Program.

BACKGROUND: Across healthcare there are acknowledged gaps in the translation of evidence into clinical practice. Undertaking a structured implementation program may assist clinicians to achieve this in their clinical practice setting. AIMS/METHODS: The current study descriptively evaluates and analyzes the impact of JBI's (formerly known as the Joanna Briggs Institute) Evidence-based Clinical Fellowship program, since its inception in 2005. RESULTS: Since its inception the JBI Evidence-based Clinical Fellowship Program has trained over 560 Clinical Fellows. The program consists of two 1-week intensive training workshops at JBI, collaborating with a JBI Research Fellow facilitator, with each participant then conducting a workplace evidence implementation project over the intervening 6 months in their own clinical setting. A 'train-the-trainer' program was established to provide accredited trainers to run the program through established JBI Collaborating Entities. CONCLUSION: Implementation of research evidence into the clinical setting is challenging for health professionals. A pragmatic approach adopted through the JBI Evidence-based Clinical Fellowship Program ensures that the Clinical Fellow remains central as the program leader, but has direction and support from their team of various stakeholders, and ongoing collaboration with a JBI facilitator. This ensures increased capacity for engagement and ongoing sustainability of future implementation programs.

Informing and implementing policy to advance mental health and wellbeing through action research in a rural remote community mental health setting.

OBJECTIVES: The aim of this study was to work collaboratively with a rural Community Mental Health Team (CMHT) to examine the issue of workplace stress and address issues specified by the group. METHOD: A five stage action research method following the Susman and Evered Model of Change was implemented for this research with four distinct cycles completed. RESULTS: A cyclic process of action research established that organizational policies, clinical skills and educational levels of staff were inadequate. Two overarching themes drove the research cycles: staff safety and inadequate education of nursing staff to assess and appropriately manage consumers with mental health issues. CONCLUSIONS: This study found that unsafe environmental conditions in the health workplace and limited staff knowledge contributed to workplace stress. Staff identified as vital strategies to manage aggressive or potentially aggressive incidents effectively and ensure staff and client safety. Managers, policy makers and government officials need awareness of the threats to healthy workforces. Tools to guide practice and staff education were implemented to address the identified problems.

Life-changing research.

Landmark nursing research has inspired nurse leaders to take their own pioneering steps.

Adherence of meta-aggregative systematic reviews to reporting standards and methodological guidance: a methodological review protocol.

REVIEW OBJECTIVE: The objective of the review is to examine Joanna Briggs Institute (JBI) qualitative meta-aggregative reviews to determine.

The development of software to support multiple systematic review types: the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).

AIM: Systematic reviews play an important role in ensuring trustworthy recommendations in healthcare. However, systematic reviews can be laborious to undertake and as such software has been developed to assist in the conduct and reporting of systematic reviews. The Joanna Briggs Institute and its collaborating centres consist of thousands of researchers, academics and clinicians across the globe conducting systematic reviews of various types. To support them in their work, modern software and online tools are required. Our aim was to develop a software program to support systematic reviewers across the globe. METHODS: A working party was formed with extensive consultation with members of the Joanna Briggs Collaboration focusing on ideal features of a software program to support systematic reviews. The new systematic review software was built using an agile methodology and designed to be a modern web application. RESULTS: The new systematic review software, the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), was successfully developed through an iterative process of development, feedback, testing and review. The software is now available (https://www.jbisumari.org/) and supports the entire systematic review process for different types of systematic reviews. CONCLUSIONS: An agile software development approach combined with wide consultation and user testing can facilitate systematic review software design and development. This new software can support systematic reviews and guideline developers to create systematic reviews for a diverse range of questions.

The effectiveness of a promotion programme on hand hygiene compliance and nosocomial infections in a neonatal intensive care unit.

This quasi-experimental study aimed to identify the impact of a promotion programme on hand hygiene practices and its effect on nosocomial infection rates in a neonatal intensive care unit of a university hospital in Thailand. The study populations were 26 nursing personnel. After implementing a hand hygiene promotion programme, compliance with hand hygiene among nursing personnel improved significantly from 6.3% before the programme to 81.2% 7 months after the programme. Compliance rate did not correlate with the intensity of patient care. Nosocomial infection rate did not decrease after the intervention, probably because of the multifactorial nature of infections. All participants agreed that promotion programme implemented in this project motivated them to practise better hand hygiene. This study indicated that multiple approaches and persistent encouragement are key factors leading to a sustained high level of appropriate hand hygiene practices among nursing personnel.

The SPOT GRADE: A New Method for Reproducibly Quantifying Surgical Wound Bleeding.

STUDY DESIGN: Benchtop model with prospective surgeon video testing. OBJECTIVE: To create a surface bleeding severity scale, the SPOT GRADE (SG), for quantitative assessment of target bleeding site (TBS) blood loss. This is of particular interest for spinal surgery due to epidural bleeding and an inability to use diathermy and radiofrequency cautery close to nerve roots. SUMMARY OF BACKGROUND DATA: A novel apparatus perfusable at known flow rates and simulating different sized wounds was used to create movies to educate surgeons on specific degrees of bleeding. METHODS: Training (36) and testing (108) videos were created using a benchtop apparatus employing different bleeding severities based on the six-level SG (none, minimal, mild, moderate, severe, and extreme) and TBS sizes (1, 10, and 50 cm). Fourteen surgeons in four specialties (cardiothoracic, abdominal, spine, and orthopedic lower extremity) were trained and tested to evaluate SG characteristics including inter-rater and intrarater reliability. RESULTS: The interclass correlation coefficient was estimated to be 0.89840 (95% confidence interval [CI]: 0.85771, 1), whereas the intraclass correlation coefficient was estimated to be 0.93673 (95% CI: 0.89603, 1). In 98% of cases (95% CI: 0.9736, 0.9927), surgeons correctly identified eligible bleeds for a future clinical trial (scores = 1, 2, or 3) and in 91% of cases (95% CI: 0.8895, 0.9344), surgeons correctly identified noneligible bleeds (scores = 4 or 5). In 98.6% of cases (95% CI: 0.9777, 0.9945), physicians correctly identified true hemostasis (score = 0). Based upon these data the probability of a physician rating a bleed incorrectly as hemostasis (score = 0) is estimated to be 1.51% (95% CI: 0.0061, 0.0363). CONCLUSION: This SG is reproducible and reliable providing a basis for educating surgeons on TBS blood loss. It appears to be a new standard for evaluating wound blood loss. LEVEL OF EVIDENCE: 2.