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Rationale: Defensive caesarean section (CS) has become one of the most common medical procedure worldwide. Additionally, performing CS in accordance with the patient's choice is an appropriate professional practice. Aims and Objective: This paper reports a prospective, observational, multicenter study to quantify the use of this type of practice that is performed by obstetricians to avoid medico‐legal complaints and decrease the frequency of malpractice litigations. Methods: We interviewed 73 obstetricians from three distinct units of obstetrics and gynaecology, to assess their opinion regarding defensive caesarean delivery and caesarean delivery performed upon maternal request. We conducted an opinion‐based survey using questionnaires based on nine, close‐ended questions. Results: Out of 73 respondents, 51 (69.9%) stated that they perform defensive CS; 63 (86.3%) declared that their choice of birth delivery is influenced by the risk of being accused of malpractice; 60 (82.2%) indicated that it is normal for the patient to be able to decide on the type of delivery; and 63 (86.3%) declared that they consult their patients regarding their delivery preferences. We found statistically significant differences between the respondents who declare that they perform defensive CS (69.9%) and those who said that they are influenced by the risk of malpractice when they choose the method of delivery for their patients (86.3%) (P < .001; McNemar Test). Conclusions: The results of our study indicate that defensive caesarean section is a widespread practice among obstetrics practitioners in Romania. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality. Methods: We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis. Results: The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA. Conclusions: We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The shortage of kidney donors and benefits of kidney transplantation make graft success imperative. Medication adherence is critical to prevent the risk of graft rejection. This paper examines how adults are prepared and supported by renal transplant co-ordinators and pharmacists to take their medications as prescribed in kidney transplantation. Methods Renal transplant co-ordinators and pharmacists of all five hospitals offering adult kidney transplantation in Victoria, Australia, were interviewed between November 2013 and February 2014. All data underwent qualitative descriptive analysis. Results Nine renal transplant co-ordinators and six pharmacists were interviewed. Although there was no standardized approach to education or other evidence-based strategies to facilitate medication adherence, there were similarities between sites. These similarities included printed information, pre-transplant education sessions, the use of medication lists and medication administration aids, intensive education in hospital and ensuring an adequate supply of medications post-discharge. Conclusions Renal transplant co-ordinators and pharmacists recognized the importance of early patient education concerning immunosuppressant medication. However, each site had developed their own way of preparing a patient for kidney transplantation and follow-up in the acute hospital setting based on experience and practice. Other non-educational strategies involving behavioural and emotional aspects were less common. Differences in usual care reinforce the necessity for evidence-based health care for best patient outcomes. [ABSTRACT FROM AUTHOR]

Rationale This paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia. Aim and objectives The aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers. Method In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client profile (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted. Results Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. The pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk. Conclusion Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well-adopted practice. Success continued following organizational wide implementation. Pilot study findings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group. [ABSTRACT FROM AUTHOR]

Rationale Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person. Method Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study. Results The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year). Conclusions This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use. [ABSTRACT FROM AUTHOR]

The aim of this paper was to compare selected indication parameters for patients scheduled for hip and knee replacement at orthopaedic units in Sweden. Swedish orthopaedic clinics performing joint replacement were invited to enrol in the study. The study time was set to 2 years (from June 2006 to June 2008). The study subjects were patients undergoing hip or knee replacement for osteoarthritis (OA). For data collection, we used a Swedish priority criteria tool based on a translation from a form used in Canada with minor changes. The reliability and validity of the Swedish tool were investigated, with good reproducibility. The questionnaires (one for the doctor and one for the patient) were completed during decision making for surgery. Eleven hospitals enrolled in the study. In total, 2961 patients were included during the study period. Among these, 1662 were hip replacement patients and 1299 were knee replacement patients. The vast majority of patients undergoing hip or knee replacement had findings indicating severe OA, both clinically and radiologically according to the clinical priority tool. Statistically significant self-reported problems with pain at rest, walking and impaired activities of daily living were also observed. There were statistically significant differences in reported indications between the hospitals, both for hip OA patients and for knee OA patients. A clinical priority criteria tool is a useful means of following changes in indications for certain procedures. It could also contribute to explaining differences in case mix when evaluating clinical outcome and patient satisfaction. [ABSTRACT FROM AUTHOR]