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Purpose To examine nursing knowledge and confidence of peripheral intravenous catheter insertion and maintenance in pediatric patients. Design and methods An online survey using validated questionnaires was conducted in ten (tertiary and district) hospitals in Indonesia from May to September 2020. Multivariable general linear models were used to investigate associations between nurses' characteristics and knowledge and confidence on the catheter insertion and maintenance score. Results A total of 413 out of 458 pediatric nurses completed the survey (a response rate of 90%). The mean score of the nurse knowledge on insertion was 18.9(±3.3) (maximum score: 21), and the maintenance score was 6.5(±2.0) (maximum score: 12). The median score of the nurse insertion and maintenance confidence was quite high: 44 (IQR = 7) out of 50 and 37 (IQR = 4) out of 45, respectively. Initial patient assessment, catheter securement, site assessment and management of complications are areas where nurse knowledge and confidence are still lacking. Adjusted analysis indicates that training and work experience were significantly associated with the knowledge and confidence score (p Conclusion Pediatric nurses were largely confident in their skills but this was not reflected in their knowledge scores. Training and experience were important predictors for nursing knowledge and confidence in catheter insertion and maintenance. Practice implications The results provide nursing and hospital managers and educational institutions to understand areas of intravenous catheter insertion and maintenance in which nurses lack of knowledge and confidence as well as to formulate tailored and ongoing training to improve nurse knowledge, confidence, practices and optimize patients' care.

Background Continuous body temperature monitoring during perioperative care is enabled by using a non-invasive “zero-heat-flux” (ZHF) device. However, rigorous evaluation of whether continuous monitoring capability improves process of care and patient outcomes is lacking. This study assessed the feasibility of a large-scale trial on the impact of continuous ZHF monitoring on perioperative temperature management practices and hypothermia prevention. Methods A feasibility study was conducted at a tertiary hospital. Participants included patients undergoing elective surgery under neuraxial or general anesthesia, and perioperative nurses and anesthetists caring for patient participants. Eighty-two patients pre and post introduction of the ZHF device were enrolled. Feasibility outcomes included recruitment and retention, protocol adherence, missing data or device failure, and staff evaluation of intervention feasibility and acceptability. Process of care outcomes included temperature monitoring practices, warming interventions and perioperative hypothermia. Results There were no adverse events related to the device and feasibility of recruitment was high (60%). Treatment adherence varied across the perioperative pathway (43 to 93%) and missing data due to electronic transfer issues were identified. Provision of ZHF monitoring had most impact on monitoring practices in the Post Anesthetic Care Unit; the impact on intraoperative monitoring practices was minimal. Conclusions Enhancements to the design of the ZHF device, particularly for improved data retention and transfer, would be beneficial prior to a large-scale evaluation of whether continuous temperature monitoring will improve patient outcomes. Implementation research designs are needed for future work to improve the complex area of temperature monitoring during surgery. Trial registration Prospective registration prior to patient enrolment was obtained from the Australian and New Zealand Clinical Trials Registry (ANZCTR) on 16th April 2021 (Registration number: ACTRN12621000438853).

Judy Munday,1,2 Niall Higgins,1,3 Lee Jones,1,4 Dimitrios Vagenas,4 André Van Zundert,1,5,6 Samantha Keogh1,3 1School of Nursing & Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD, Australia; 2Department of Health and Nursing Science, Faculty of Health and Sports Sciences, University of Agder, Grimstad, Norway; 3Royal Brisbane and Women’s Hospital, Herston, QLD, Australia; 4Research Methods Group, Institute of Health and Biomedical Innovation (IHBI), Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD, Australia; 5Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia; 6School of Medicine, The University of Queensland, Brisbane, Australia & Queensland University of Technology, Brisbane, QLD, AustraliaCorrespondence: Judy MundaySchool of Nursing & Centre for Healthcare Transformation, Queensland University of Technology, Rm 529, Level 5, N Block, Kelvin Grove, QLD, 4059, AustraliaTel +61 73138 8209Fax +61 3138 3814Email judy.munday@qut.edu.auPurpose: Perioperative hypothermia prevention requires regular, accurate, and consistent temperature monitoring. Zero-heat-flux (ZHF) thermometry offers a non-invasive, measurement method that can be applied across all surgical phases. The purpose of this study was to measure agreement between the zero-heat-flux device and esophageal monitoring, sensitivity, and specificity to detect hypothermia and patient acceptability amongst patients undergoing upper and lower limb orthopedic surgery.Patients and Methods: This prospective, observational study utilized Bland–Altman analysis and Lin’s concordance coefficient to measure agreement between devices, sensitivity and specificity to detect hypothermia and assessed patient acceptability amongst 30 patients between December 2018 and June 2019.Results: Bias was observed between devices via Bland Altman, with bias dependent on actual temperature. The mean difference ranged from − 0.16°C at 34.9°C (where the mean of ZHF was lower than the esophageal device) to 0.46°C at 37.25°C (where the mean of ZHF was higher than esophageal device), with 95% limits of agreement (max) upper LOA = 0.80 to 1.41, lower LOA = − 1.12 to − 0.50. Seventy-five percentage of zero-heat-flux measurements were within 0.5°C of esophageal readings. Patient acceptability was high; 96% (n=27) stated that the device was comfortable.Conclusion: ZHF device achieved lesser measurement accuracy with core (esophageal) temperature compared to earlier findings. Nonetheless, due to continuous capability, non-invasiveness and patient reported acceptability, the device warrants further evaluation.Title Registration: The study was registered at www.ANZCTR.org.au (reference: ACTRN12619000842167).Keywords: perioperative, thermoregulation, thermometry, sensitivity, specificity

Alana Delaforce,1– 3 Jed Duff,1,4 Judy Munday,3– 5 Shannon Farmer,6,7 Kristin Miller,2 Lynne Glover,2 Christopher Corney,2 Cameron Hurst,8 Gareth Ansell,2,9 Naadir Gutta,2,9 Haitham Tuffaha,10 Janet Hardy2,3 1School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia; 2Mater Health Services, South Brisbane, QLD, Australia; 3Mater Research Institute-UQ, South Brisbane, QLD, Australia; 4Centre for Healthcare Transformation/School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia; 5Faculty of Health and Sport Science, The University of Agder, Kristiansand, Norway; 6Department of Haematology, Royal Perth Hospital, Perth, Western Australia, Australia; 7Medical School and Division of Surgery, The University of Western Australia, Perth, Western Australia, Australia; 8QIMR Berghoffer Medical Research Institute, Brisbane, QLD, Australia; 9School of Clinical Medicine - Mater Clinical Unit, The University of Queensland, St Lucia, QLD, Australia; 10Centre for the Business and Economics of Health, The University of Queensland, St Lucia, QLD, AustraliaCorrespondence: Alana Delaforce Level 6, Duncombe Building, Mater Hospital Brisbane, South Brisbane, QLD, 4101, AustraliaTel +61 7 3163 2853Email alana.delaforce@mater.org.auIntroduction: Blood transfusions are a risk factor for increased morbidity, mortality, and length of hospital stay. Patient blood management guidelines provide guidance to reduce risk and improve patient outcomes. They outline steps to help prevent transfusions and considerations for when deciding to transfuse. One recommendation to prevent unnecessary transfusion is to optimize patients using Pre-operative Anemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P). The uptake of these recommendations is highly variable, and an effective approach to implementing them in a tailored and context-specific manner remains elusive.Method and Design: A mixed-methods, interventional study, using a type two-hybrid effectiveness-implementation design, will evaluate the impact of a change package to improve the uptake of PAIDSEM-P. The change package consists of the intervention (PAIDSEM-P) supported by theoretically informed implementation strategies. Pre- and post-implementation, retrospective health record reviews will determine the effect of the change package on provider outcomes, including compliance with guideline recommendations as measured by the proportion of patients who have the appropriate tests performed, and, if required, appropriate treatment and/or referrals. Patient outcomes will be measured by checking for any difference in the proportion of patients with anemia on the day of surgery and the proportion of patients who receive a blood transfusion during the peri-operative period. An economic evaluation will be conducted to compare health outcomes and costs. The feasibility, acceptability and appropriateness of the PAIDSEM-P will be assessed using a quantitative, validated survey to measure implementation outcomes.Discussion: Testing of implementation theory is required to advance understanding of what works, in what context, and the impact on implementation success. This study aims to evaluate the impact of a theoretically informed change package on improving the uptake of PAIDSEM-P. If successful, it will also provide a framework for health care facilities to follow when addressing other evidence-practice gaps.Keywords: patient blood management, implementation, anemia, iron deficiency, surgery

Introduction and aims: Patients undergoing major surgery risk significant blood loss and transfusion, which increases substantially if they have pre-existing anemia. Preoperative Anemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P) outline recommended blood tests and treatment to optimize patients before surgery. Documented success using PAIDSEM-P to reduce transfusions and improve patient outcomes exists, but the reporting quality of such studies is suboptimal. It remains unclear what implementation strategies best support the implementation of PAIDSEM-P. Method: Maximum variation, purposive sampling was used to recruit a total of 15 partici-pants, including a range of health professionals and patients for semi-structured interviews. Data analysis utilized a deductive approach informed by the Consolidated Framework for Implementation Research (CFIR) for barrier identification and the Expert Recommendations for Implementing Change (ERIC) for reporting recommended implementation strategies. A modified version of the Action, Actor, Context, Target and Time (AACTT) framework assisted with conceptualisation and targeted strategy selection. Results: The analysis revealed five barriers: access to knowledge and information, patient needs and resources, knowledge and beliefs about the intervention, available resources, and networks and communications, which had strong ERIC recommendations, including conduct educational meetings, develop educational materials, distribute educational materials, obtain and use patients/consumers family feedback, involve patients/consumers/family members, conduct a local needs assessment, access new funding, promote network weaving, and organize clinician implementation team meetings. Conclusions: Mapping the barriers and strategies using the ERIC framework on the basis of individual actor categories proved to be useful in identifying a pragmatic number of implementation strategies that may help in supporting the utilisation of the PAIDSEM-P and other evidence-based healthcare implementation problems more broadly.

Background: Surgical patients with preoperative anemia are more likely to experience adverse outcomes. Patient blood management (PBM) guidelines recommend screening and treating patients for anemia preoperatively to enable optimisation before surgery. This study investigates compliance with PBM guidelines and reports the association between length of stay and transfusion risk in patients with preoperative anemia. Study Design and Methods: A retrospective, observational, chart audit that included all patients having primary, total hip and knee replacement surgery between July–December 2018 at a tertiary, metropolitan healthcare facility. Results: Six hundred and seven patients patients were included, 96% (n = 583) patients had blood tests available (full blood count), and 8.1% (n = 49) had iron studies. Most patients 53% (n = 324) were screened between 2 and 6 days before surgery; 14.6% (n = 85) were anaemic preoperatively and only 5.9% (n = 5) of anaemic patients received treatment. Patients who had anemia preoperatively were more likely to receive a blood transfusion (odds ratio 8.65 [95% CI 3.98– 18.76]) and stayed longer in hospital (median difference = 1, χ2 LR = 17.2, df=1, p< 0.007). Conclusion: Tests ordered for patients having major surgery should include iron studies, renal function, CRP and full blood count to enable detection and classification of preoperative anemia. Timing of screening relative to surgery needs to be sufficient to allow patient optimisation to occur. Appropriate treatment should be provided to anaemic patients to prevent unnecessary blood transfusions and reduce the length of stay. A standardised preoperative anemia pathway may assist in improving practice.

Purpose : Nurses provide care at each phase of the complex, perioperative pathway and are well placed to identify areas of care requiring investigation in randomized controlled trials. Yet, currently, the scope of nurse-led randomized controlled trials conducted within the perioperative setting are unknown. This scoping review aims to identify areas of perioperative care in which nurse-led randomized controlled trials have been conducted, to identify issues impacting upon the quality of these trials and identify gaps for future investigation. Methods : This scoping review was conducted in reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Searches were conducted in PubMed, Embase, Cumulative Index for Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials, with a date range of 2014– 19. Sources of unpublished literature included Open Grey, and ProQuest Dissertation and Theses, Clinical Trials.gov and the Australian and New Zealand Clinical Trials Registry. After title and abstract checking, full-text retrieval and data extraction, studies were appraised using the Joanna Briggs Institute Critical Appraisal Checklists for randomized controlled trials. Data were synthesized according to the main objectives. Key information was tabulated. Results : From the 86 included studies, key areas where nurses have led randomized controlled trials include patient or caregiver anxiety; postoperative pain relief; surgical site infection prevention: patient and caregiver knowledge; perioperative hypothermia prevention; postoperative nausea and vomiting; in addition to other diverse outcomes. Issues impacting upon quality (including poorly reported randomization), and gaps for future investigation (including a focus on vulnerable populations), are evident. Conclusion : Nurse-led randomized controlled trials in the perioperative setting have focused on key areas of perioperative care. Yet, opportunities exist for nurses to lead experimental research in other perioperative priority areas and within different populations that have been neglected, such as in the population of older adults undergoing surgery.

This study aimed to describe the translation process and establish the validity of the three instruments in Indonesian to assess pediatric peripheral intravenous catheter (PIVC) insertion and care practices.The six-step forward and backward translation method was used to translate the adapted questionnaires. The English version questionnaires included the point prevalence audit checklist, the nurse survey consisting of the nurse PIVC knowledge questionnaire and the nurse PIVC confidence questionnaire, plus a Patient/parent Experience Survey. Data collection was conducted in Indonesia between October 2019 and February 2020. In total, there were six translators (two for each instrument), nine-panel vascular access experts (three for each instrument), and 30 participants (ten for each instrument) of the target population involved in the translation and validation of the three instruments. Three-panel experts rated the content relevance of each instrument using a four-point rating scale. Item level and scale level content validity index and kappa index were calculated. Ten-panel members of the target population evaluated each questionnaire regarding feasibility, clarity, logical sequence, and formatting. Qualitative comments from the panel were also reviewed.The translation process indicated relatively low discrepancies between translators except for semantic equivalence. There were nine, eight, and one semantic discrepancies found in the forward translation of the point prevalence audit checklist, nurse survey, and patient/parent experience survey. The semantic discrepancies were less prevalent in the backward translation, with only one, three, and two items reported during the process. The item validity index for all of the three instruments showed relatively high agreement between experts (I-CVI0.78, S-CVI/Ave0.90, S-CVI/UA 0.70, and kappa index0.74). The face validity was established with the panel reporting that the three instruments were easy to understand and presented logically. However, some re-formatting of the nurse survey and patient/parent experience survey were needed to avoid ambiguity and confusion for the participants.The results indicate that the translated three survey instruments that had been widely used in other developed countries show good content validity in the Indonesian context. They can be used as a reference for further testing in different countries and contribute to understanding the pediatric PIVC audit tools used in future clinical research.

AIM This study aimed to investigate workplace bullying and explore correlations between bullying, burnout and resilience amongst perioperative nurses in Australia. BACKGROUND Workplace bullying in perioperative nursing involves verbal, physical and psychological violence. However, no prior studies have measured Australian perioperative nurses' experiences of workplace bullying nor sought to understand if there is a relationship with burnout and resilience. METHODS A descriptive correlational study was conducted utilizing an online survey incorporating four validated instruments. Descriptive statistics and regression models analysed workplace bullying, burnout and resilience. RESULTS Over half of perioperative nurses (n = 158/257, 61%) were exposed to workplace bullying. Consequences included fatigue and exhaustion (n = 129/192, 67%), anxiety (n = 123/192, 64%) and sleeplessness (n = 121/192, 63%). Organisational processes (r = .458, p

Background Active warming reduces risk of surgical complications. Implementation of a perioperative thermal care bundle increased use of active warming for surgical patients. Objective This study aimed to determine if implementing a thermal care bundle to prevent inadvertent perioperative hypothermia is cost-effective. Design A model-based cost-effectiveness analysis was undertaken using Monte Carlo simulations from input distributions to estimate costs and effects. Setting Hospitals undertaking between 5,000 and 40,000 surgeries per year, which either implemented or did not implement the thermal care bundle, were modelled. Participants The decision tree guiding the structure of the model was populated with clinical outcomes (surgical site infection, blood transfusion requirement and morbid cardiac events) of a hypothetical cohort of surgical patients. Interventions Implementation or non-implementation of the thermal care bundle. Main outcome measures Net monetary benefit was calculated by multiplying the health benefits (quality-adjusted life years) by the willingness-to-pay threshold minus the cost. We tested a range of values for willingness to pay per quality-adjusted life year thresholds and plotted results for expected incremental benefits and probability of cost-effectiveness. The incremental cost-effectiveness ratio was also calculated. Results Thermal care bundle implementation simultaneously reduced costs and increased quality-adjusted life years in the majority of simulations (88.1%). The average cost reduction was $689,659 (95% credible intervals spanned from a $2,718,364 decrease in costs to $379,826 increase in costs) and average difference in quality-adjusted life years was 54 (95% CI = 0.4 less to 176 more). This equated to an incremental cost-effectiveness ratio of $12747 saved per quality-adjusted life year gained. Conclusions It is likely that increasing use of active warming by implementing the thermal care bundle would generate cost-savings and improve the quality of life for surgical patients. It would be good value for hospitals with similar characteristics to those included in our model to allocate the extra resources required for implementation.

Judy Munday,1,2 Alana Delaforce,1,3 Gillian Forbes,4 Samantha Keogh11School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia; 2Department of Health and Nursing Science, University of Agder, Grimstad, Norway; 3Clinical Governance Unit, Mater Health, South Brisbane, QLD 4101, Australia; 4Department of Clinical, Educational and Health Psychology, UCL Centre for Behaviour Change, London WC1E 6BT, UKPurpose: Inadvertent perioperative hypothermia is a significant problem for surgical patients globally, and is associated with many detrimental side-effects. Despite the availability of rigorously developed international evidence-based guidelines for prevention, a high incidence of this complication persists. This qualitative study aims to identify and examine the domains which act as barriers and enablers to perioperative hypothermia prevention practices, from the perspectives of the key healthcare professionals involved with perioperative temperature management.Methods: A qualitative study employing semi-structured interviews was utilized. A purposive sample of key stakeholders involved in perioperative temperature management, including perioperative nurses, anesthetists, surgeons, and perioperative managers, were recruited via email. The interview guide was developed in reference to the Theoretical Domains Framework. All interviews were recorded, de-identified, transcribed, and coded. Belief statements were generated within each domain, and a frequency score generated for each belief. Finally, the domains were mapped to the COM-B model of the Behavior Change Wheel to develop recommendations for future interventions.Results: Twelve participants were included including eight nurses, two surgeons, and two anesthetists. Eleven key theoretical domains that influence the uptake of perioperative hypothermia practices were identified: knowledge; skills; social/professional role and identity; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; goals; memory, attention, and decision processes; environmental context and resources; social influence. Suggested intervention strategies include training, reminder systems, audit, and feedback, organizational support to resolve lack of control of ambient temperature, as well as provision of accurate temperature measurement devices.Conclusion: Future interventions to address the key behavioral domains and improve perioperative hypothermia prevention need to be evaluated in the context of feasibility, effectiveness, safety, acceptability, and cost by the target users. All suggested intervention strategies need to take a team-based, multi-modal approach, as this is most likely to facilitate improvements in perioperative hypothermia prevention.Keywords: perioperative hypothermia, temperature management, Theoretical Domains Framework, multidisciplinary, COM-B, behaviour change wheel

Background: Patients undergoing major surgery are at risk of significant blood loss and subsequent transfusion, which increases substantially if the patient has pre-existing anaemia. Preoperative anaemia screening and treatment pathways (PAST-P) outline recommended blood tests and treatment to ensure patient optimisation before surgery. Although documented success in using PAST-P to reduce transfusions and improve patient outcomes exists, the reporting quality of such studies is suboptimal, and it remains unclear what implementation strategies best support the implementation of PAST-P. This study uses qualitative methods to identify local barriers and maps them to recommended implementation strategies.Method: Maximum variation, purposive sampling was used to recruit a total of 15 participants, including a range of health professionals and patients. Qualitative data was collected using semi-structured interviews. Data analysis utilised a deductive approach informed by the Consolidated Framework for Implementation Research (CFIR) for barrier identification and the Expert Recommendations for Implementing Change (ERIC) for reporting recommended implementation strategies. The Action, Actor, Context, Target and Time (AACTT) framework assisted with conceptualisation and targeted strategy selection.Results: The analysis revealed ten barriers: external policy and incentives, patient needs and resources, structural characteristics, networks and communications, relative priority, available resources, access to knowledge and information, knowledge and beliefs about the intervention, self-efficacy and executing. ERIC strategies recommended to mitigate barriers are: conduct educational meetings, develop educational materials, distribute educational materials, access new funding, promote network weaving, organise clinician implementation team meetings, obtain and use patients/consumers/family feedback, involve patients/consumers/family members and conduct a local needs assessment.Conclusion: Five of ten identified barriers had strong recommendations, and nine implementation strategies were identified as being suitable to address them. Mapping the barriers and strategies using the ERIC framework on the basis of individual actor categories proved to be useful in identifying a pragmatic number of implementation strategies that may help in supporting the utilisation of the PAST-P, once it is launched at the study hospital.

Aim: To explore perioperative nursing students' experiences of interprofessional simulation-based learning to gain a deeper understanding of how this educational tool can be used to support students' learning and enable them to achieve the intended learning outcomes. Background: Despite extensive research, it remains unclear what and how participants learn from interprofessional simulation-based learning. There is a need to specify how interprofessional simulation-based learning should be organised to support and promote learning processes, especially for postgraduate learners. In particular, there seems to be little evidence in the existing literature in the field of educating perioperative nurses, where advanced technical skills and high-quality nursing care are required. Design: The study's qualitative and explorative design is reported in accordance with the COREQ guideline. Method: Between May–October 2019, thirty-four perioperative nursing students from four educational institutions participated in six focus group interviews, with four to eight students in each. All participants had previous experience of interprofessional simulation-based learning in acute settings. Data were transcribed verbatim and were then subjected to phenomenological hermeneutical analysis involving three steps: naive reading, structural analysis and comprehensive understanding. Results: Three themes were identified the following: customised interprofessional simulation-based learning; reality of the experience of interprofessional simulation-based learning; and preparedness for clinical practice. Conclusion: Customised interprofessional simulation-based learning was found to be of value to the participants and reflected their feeling of mental preparedness entering interprofessional simulation-based learning. Furthermore, participants' experience of reality when using the tool was a key theme that also impacted how prepared participants felt for clinical practice. Relevance to clinical practice: The study findings contribute to the further expansion of interprofessional simulation-based learning in perioperative nursing education as a means of developing students' professional competence. This is essential knowledge, as professional practitioners must reflect on practice to further enhance that practice and patient safety.

Access to palliative care is recognised internationally as a basic human right. Ensuring adequate clinical knowledge and communication skills to achieve this outside of specialist palliative care settings is therefore essential. Take, for instance, the example of perioperative care...

Background Surgical patients with preoperative anemia are more likely to experience adverse outcomes. Patient blood management (PBM) guidelines recommend screening and treating patients for anemia preoperatively to enable optimisation before surgery. This study investigates compliance with PBM guidelines and reports the association between length of stay and transfusion risk in patients with preoperative anemia. Study Design and Methods A retrospective, observational, chart audit that included all patients having primary, total hip and knee replacement surgery between July–December 2018 at a tertiary, metropolitan healthcare facility. Results Six hundred and seven patients patients were included, 96% (n = 583) patients had blood tests available (full blood count), and 8.1% (n = 49) had iron studies. Most patients 53% (n = 324) were screened between 2 and 6 days before surgery; 14.6% (n = 85) were anaemic preoperatively and only 5.9% (n = 5) of anaemic patients received treatment. Patients who had anemia preoperatively were more likely to receive a blood transfusion (odds ratio 8.65 [95% CI 3.98–18.76]) and stayed longer in hospital (median difference = 1, χ2 LR = 17.2, df=1, p

Purpose Rates of inadvertent perioperative hypothermia among women undergoing spinal anesthesia for cesarean delivery are reported to be high. Intrathecal morphine has been noted to have a potentially potent effect on thermoregulation. This retrospective case-control study sought to investigate the incidence of perioperative hypothermia in women undergoing cesarean delivery with and without intrathecal morphine and to describe any clinical factors associated with the condition, the identification of which would provide direction for nursing priorities in the care of the condition. Design A retrospective case-controlled study design was used. Methods The charts of 358 women who had undergone emergency or elective cesarean delivery under spinal anesthesia were reviewed: 179 having received intrathecal morphine and 179 having received spinal anesthesia without intrathecal morphine (control group). SPSS (IBM, Armonk, New York), version 22, was used for data analysis, including logistic regression to predict the outcome of hypothermia across the study population. Findings There was no significant difference ( P = .62; 95% confidence interval, −0.09 to 0.15) in mean postoperative temperature for the morphine group (mean postanesthesia care unit arrival temperature, 35.91°C; standard deviation, 0.59) and the no morphine group (mean postanesthesia care unit arrival temperature, 35.88°C; standard deviation, 0.52). However, within groups, the temperature decline preoperatively to postoperatively was statistically (and clinically) significant. Conclusions The results refute the suggestion that intrathecal morphine contributes to greater core temperature decline in this population; however, it does confirm that perioperative hypothermia is a prevalent concern for women undergoing cesarean delivery and that pre-emptive measures should be routinely considered by health care providers.

Background Rates of hypothermia for women undergoing spinal anesthesia for cesarean delivery are high and prevention is desirable. This trial compared the effectiveness of preoperative warming versus usual care among women receiving intrathecal morphine, which is thought to exacerbate perioperative heat loss. Methods A prospective, single-blinded, randomized controlled trial compared 20 minutes of forced air warming (plus intravenous fluid warming) versus no active preoperative warming (plus intravenous fluid warming) in 50 healthy American Society of Anesthesiologists graded II women receiving intrathecal morphine as part of spinal anesthesia for elective cesarean delivery. The primary outcome of maternal temperature change was assessed via aural canal and bladder temperature measurements at regular intervals. Secondary outcomes included maternal thermal comfort, shivering, mean arterial pressure, agreement between aural temperature, and neonatal outcomes (axillary temperature at birth, Apgar scores, breastfeeding, and skin-to-skin contact). The intention-to-treat population was analyzed with descriptive statistics, general linear model analysis, linear mixed-model analysis, X2 test of independence, Mann-Whitney, and Bland-Altman analysis. Full ethical approval was obtained, and the study was registered on the Australia and New Zealand Clinical Trials Registry (Trial No: 367160, registered at http://www.ANZCTR.org.au/). Results Intention-to-treat analysis (n = 50) revealed no significant difference in aural temperature change from baseline to the end of the procedure between groups: F (1, 47) = 1.2, P = .28. There were no other statistically significant differences between groups in any of the secondary outcomes. Conclusions A short period of preoperative warming is not effective in preventing intraoperative temperature decline for women receiving intrathecal morphine. A combination of preoperative and intraoperative warming modalities may be required for this population.

Background: Evidence-based practice (EBP) education is important to overcome barriers to evidence use in practice. Method: The authors conducted a cross-sectional study to evaluate the EBP knowledge, attitudes, and practices (KAP) of RNs and midwives who had participated in an EBP workshop and compared their results with those of nonparticipants. Results: A total of 198 nurses and midwives responded to the survey, 91 who had received EBP education and 107 who had not. There was a significant difference in terms of mean total KAP score which was significantly higher in the education group, indicating greater KAP in those respondents than those who had not received education ( p = .004). Conclusion: This study has shown that participation in a single day of EBP education covering the basic steps of EBP results in nurses who have more positive attitudes, and greater knowledge and practice abilities in EBP than those who had not participated. J Contin Educ Nurs . 2017;48(6):256–262.

Background: Most paediatric patients have at least one peripheral intravenous catheter insertion during their hospitalisation. Despite the important function of peripheral intravenous catheters for delivery of intravenous therapy, failure and complications rates are widely reported; however these results have not been synthesised. Objective: To provide an overall estimate of peripheral intravenous catheter failure and related complications in the paediatric population. Design: Systematic review and meta-analysis Data sources: The electronic databases, Cochrane Central Register of Controlled Trials, US National Library of Medicine National Institutes of Health, Cumulative Index of Nursing and Allied Health, Embase, Joanna Briggs Institute databases and ProQuest Dissertations and Theses, from January 2000 to January 2019 was conducted. Review methods: Observational studies and randomised controlled trials were independently screened by paired reviewers, and then eligible studies had data extracted and assessed for quality. Key outcomes of interest were any peripheral intravenous catheter complication, either as a composite measure or individually reported, including infiltration, extravasation, phlebitis, accidental removal, occlusion, leakage, local or catheter-associated infection. Results were pooled for analysis or summarised in a narrative synthesis. Results: Thirty-two studies met the inclusion criteria. Overall, the pooled incidence of peripheral intravenous catheter failure as a composite measure was 38% (n = 6,492; 95% CI 0.32 – 0.45) by device and 34% (n = 3,654, 95% CI 0.29 – 0.39) by patients. Infiltration was the most common individual reason for failure with 10% pooled incidence (95% CI 0.07 – 0.14) followed by accidental removal, occlusion, and leakage. Incidence of total phlebitis (any symptoms) was 5% (95% CI 0.02 – 0.10), with extravasation at 1% (95% CI 0.00 – 0.02). Studies ranged in methodological quality as appraised by the relevant tool. Conclusions: Peripheral intravenous catheter failure and complications in paediatrics patients are a significant problem globally. Therefore, continued efforts from health care providers are required to decrease the incidence of these complications.

Background Undergraduate students across health professions are required to be capable users of evidence in their clinical practice after graduation. Gaining the essential knowledge and clinical behaviors for evidence-based practice can be enhanced by theory-based strategies. Limited evidence exists on the effect of underpinning undergraduate EBP curricula with a theoretical framework to support EBP competence. A systematic review was conducted to determine the effectiveness of EBP teaching strategies for undergraduate students, with specific focus on efficacy of theory-based strategies. Methods This review critically appraised and synthesized evidence on the effectiveness of EBP theory-based teaching strategies specifically for undergraduate health students on long or short-term change in multiple outcomes, including but not limited to, EBP knowledge and attitudes. PubMed, CINAHL, Scopus, ProQuest Health, ERIC, The Campbell Collaboration, PsycINFO were searched for published studies and The New York Academy of Medicine, ProQuest Dissertations and Mednar were searched for unpublished studies. Two independent reviewers assessed studies using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. Results Twenty-eight studies reporting EBP teaching strategies were initially selected for review with methodological quality ranging from low to high. Studies varied in course duration, timing of delivery, population and course content. Only five included papers reported alignment with, and detail of, one or more theoretical frameworks. Theories reported included Social Cognitive Theory (one study), Roger’s Diffusion of Innovation Theory (two studies) and Cognitive Apprenticeship Theory (one study). Cognitive Flexibility Theory and Cognitive Load Theory were discussed in two separate papers by the same authors. All but one study measured EBP knowledge. Mixed results were reported on EBP knowledge, attitudes and skills across the five studies. Conclusions EBP programs for undergraduate health students require consideration of multiple domains, including clinical behaviors, attitudes and cognitive learning processes; Interventions grounded in theory were found to have a small but positive effect on EBP attitudes. The most effective theory for developing and supporting EBP capability is not able to be determined by this review therefore additional rigorous research is required. Electronic supplementary material The online version of this article (10.1186/s12909-019-1698-4) contains supplementary material, which is available to authorized users.

The prevention of perioperative hypothermia is a responsibility of all members of the perioperative team. Nurses are well placed to have a central role in implementing strategies to reduce perioperative heat loss, which is associated with a host of adverse outcomes (National Collaborating Centre for Nursing and Supportive Care 2008).

Background: Patient advocacy is central to nursing practice; acting as a patient advocate in the perioperative environment requires the care of patients that are highly vulnerable and unable to speak up for themselves, in a busy and often highly pressurized environment involving multiple professional groups providing care simultaneously. This can present particular challenges for nurses, particularly those unfamiliar with the expectations of being a patient advocate. Objectives: The objective of this review was to identify the meaningfulness of perioperative nurses' experiences of advocacy. The specific objectives were to explore the following questions: * What are perioperative nurses' experiences as patient advocates? * How do perioperative nurses define advocacy? * What are the barriers to and strategies for promoting advocacy in the perioperative environment? Inclusion criteria: Types of participants Registered nurses, enrolled nurses, licensed practical nurses, licensed vocational nurses, and midwives working in the perioperative department, including anesthetic, scrub/scout and post‐anesthetic care room nurses, were eligible for inclusion. Phenomena of interest Perioperative nurses' experiences of acting as patient advocates were the phenomena of interest in this review. This includes experiences of the barriers to nursing advocacy, strategies used, and explorations of how nursing advocacy benefits perioperative patients. Context The perioperative department, including preoperative, intraoperative and postoperative recovery areas, was of interest in this review. Types of studies This review aimed to consider all qualitative studies that sought to examine perioperative nurses' experiences of advocacy including but not limited to phenomenology, ethnography, hermeneutics, action research, grounded theory, feminist research and naturalistic inquiry. Search strategy: Searches were conducted across 13 databases, including four for unpublished studies, with no language restriction, and with the date range of 1985 to April 2014. Studies were assessed for relevance to the review using a Verification of Relevance form developed by the reviewers and based on the recommendations of the Cochrane Collaboration. Methodological quality: Papers selected for retrieval were assessed by two independent reviewers for methodological validity using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI‐QARI). A third reviewer was used to assess three papers where disagreements between the first two reviewers could not be resolved through discussion. Data extraction: Data were extracted from papers included in the review using the standardized data extraction tool from JBI‐QARI. Data synthesis: Findings were pooled using JBI‐QARI. Findings were assembled and rated according to their quality, and categorized on the basis of similarity in meaning. These categories were then subjected to a meta‐synthesis in order to produce a single comprehensive set of synthesized findings. The ConQual approach for grading the synthesized findings was used. Results: Nine studies were included in the review. From these, 31 findings were aggregated into five categories, which were then meta‐synthesized into two synthesized findings which provide evidence for nursing practice. The two synthesized findings are:safeguarding from harm ‐ being the patient's voice; and challenges of patient advocacy can be alleviated by experience and training. Conclusions: Perioperative nurses identify being a voice, communicating with, and safeguarding the patient as key advocacy activities that they undertake within their roles. Establishing trust between the nurse and patient is an important aspect of patient advocacy in this environment. Acting as a patient advocate can expose perioperative nurses to workplace conflict and cause them distress. While professional experience prepares nurses to be patient advocates, less experience in the perioperative environment and time pressures were reported as barriers to the role.

Major surgery can induce functional decline and pain, which can also have negative implications on health care utilization and quality of life. Prehabilitation is the process of optimizing physical functionality preoperatively to enable the individual to maintain a normal level of function during and after surgery. Prehabilitation training can be a combination of aerobic exercises, strength training, and functional task training to suit individual needs.To evaluate the impact of prehabilitation on physical functional status, health care utilization, quality of life, and pain after surgery.Studies of adult surgical patients, excluding day surgery patients.Any preoperative exercise interventions identified in the study as part of a prehabilitation or preoperative exercise program, versus usual care.Randomized controlled trials.Functional status, health care utilization, quality of life and pain.Published (CINAHL, CENTRAL, EMBASE, MEDLINE, PEDro) and unpublished studies between 1996 and March 2013 were searched extensively.All studies were assessed independently by two reviewers for relevance, eligibility and methodological quality.Data from included papers were extracted using a modified data extraction tool.Where possible, study results were pooled in statistical meta-analysis. Alternatively, results are presented in narrative and table form.A total of 3167 citations were identified; after removal of duplicates, assessment for relevance and eligibility, 33 studies underwent critical appraisal. Seventeen studies met the quality criteria and were included in quantitative synthesis. Thirteen studies were conducted in orthopedics (mainly knee or hip arthroplasty for osteoarthritis), one in colorectal, two in cardiac and one in upper gastrointestinal/hepatobiliary. Function, pain and quality of life were quantified according to prehabilitation dose and postoperative months. Prehabilitation, at any dose, did not demonstrate benefits in objective and self-reported function at any of the postoperative time points. Prehabilitation did not demonstrate benefits in quality of life or pain; however, there was significant evidence that prehabilitation doses of more than 500 minutes reduced the need for postoperative rehabilitation, but no significant reduction was found in readmissions or nursing home placement.Results from this review reveal that prehabilitation has no significant postoperative benefits in function, quality of life and pain in patients who have had knee or hip arthroplasty for osteoarthritis; however, there is evidence that prehabilitation may reduce admission to rehabilitation in this population. The evidence on postoperative benefits of prehabilitation in other surgical populations is limited; however, preliminary evidence does not demonstrate better outcomes.There is no evidence that prehabilitation provides benefits in function, pain or quality of life in patients who have had arthroplasty for osteoarthritis; however prehabilitation doses of more than 500 minutes might reduce acute rehabilitation admissions. The evidence is insufficient to provide recommendations on the benefits of prehabilitation in other surgical populations.Future prehabilitation studies are not recommended in patients with osteoarthritis for whom arthroplasty is planned. However, should prehabilitation be tested in other surgical populations, programs must consider patient suitability, setting, delivery of intervention and clinical effectiveness. It is also recommended that the exercises prescribed should be maintained and adhered to after surgery. Most importantly, prehabilitation studies must have adequately powered sample sizes.

Perioperative nurses recognise that family members experience increased levels of anxiety during the wait for a relative undergoing a surgical procedure. It is often during this time that little or no meaningful communication occurs between family members and health professionals. It has been suggested that a structured information intervention has the potential to increase communication between families and health care professionals as well as decrease family members' anxiety.

Women undergoing cesarean section are vulnerable to adverse effects associated with inadvertent perioperative hypothermia, but there has been a lack of synthesized evidence for temperature management in this population. This systematic review aimed to synthesize the best available evidence in relation to preventing hypothermia in mothers undergoing cesarean section surgery.

Background: Dysphagia, or difficulty swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurological impairment, largely from stroke. Objectives: To find the best available evidence regarding: • The nursing role in the recognition and management of dysphagia in adults with acute neurological impairment. • The evidence on the effectiveness of nursing interventions in the recognition and management of dysphagia. Inclusion criteria: This review considered any quantitative studies that evaluated interventions which focused on the nursing role in the recognition and screening for dysphagia in adults over the age of 18 years with neurogenic dysphagia. Other interventions concerned with the nursing management of dysphagia were also of interest to the review. Outcomes of interest were: • Early recognition by nurses of those with difficulty swallowing • Clinical screening by nurses of any patient with suspected swallowing difficulties • Timely referral by nurses to speech-language pathologists for formal assessment Search strategy: The databases searched included CINAHL, MEDLINE, Cochrane CENTRAL, Web of Science, Embase and Mednar. The search for unpublished studies included OpenSIGLE, New York Academy of Medicine Library, Gray Literature Report and Dissertations Abstracts International. Methodological quality: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data collection: Data were extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI. Data synthesis: Quantitative data was, where possible, pooled in statistical meta-analysis using RevMan 5.0. Effect sizes are expressed as odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed statistically using the standard Chi-square and I-squared tests. Where statistical pooling was not possible, the findings are presented in narrative form including tables and figures to aid in data presentation where appropriate. Results: Four new studies were added by this update; data from which enabled a number of new analyses providing stronger evidence that dysphagia screening by nurses significantly reduces the number of chest infections in patients with stroke (OR 0.45, 95% CI 0.33-0.62, p

Background Whilst waiting for patients undergoing surgery, a lack of information regarding the patient’s status and the outcome of surgery, can contribute to the anxiety experienced by family members. Effective strategies for providing information to families are therefore required. Objectives To synthesize the best available evidence in relation to the most effective information-sharing interventions to reduce anxiety for families waiting for patients undergoing an elective surgical procedure. Inclusion criteria Types of participants All studies of family members over 18 years of age waiting for patients undergoing an elective surgical procedure were included, including those waiting for both adult and pediatric patients. Types of intervention All information-sharing interventions for families of patients undergoing an elective surgical procedure were eligible for inclusion in the review. Types of studies All randomized controlled trials (RCTs) quasi-experimental studies, case-controlled and descriptive studies, comparing one information-sharing intervention to another or to usual care were eligible for inclusion in the review. Types of outcomes Primary outcome: The level of anxiety amongst family members or close relatives whilst waiting for patients undergoing surgery, as measured by a validated instrument such as the S-Anxiety portion of the State-Trait Anxiety Inventory (STAI). Secondary outcomes: Family satisfaction and other measurements that may be considered indicators of stress and anxiety, such as mean arterial pressure (MAP) and heart rate. Search strategy A comprehensive search, restricted to English language only, was undertaken of the following databases from 1990 to May 2013: Medline, CINAHL, EMBASE, ProQuest, Web of Science, PsycINFO, Scopus, Dissertation and Theses PQDT (via ProQuest), Current Contents, CENTRAL, Google Scholar, OpenGrey, Clinical Trials, Science.gov, Current Controlled Trials and National Institute for Clinical Studies (NHMRC). Methodological quality Two independent reviewers critically appraised retrieved papers for methodological quality using the standardized critical appraisal instruments for randomized controlled trials and descriptive studies from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instruments (JBI-MAStARI). Data extraction Two independent reviewers extracted data from included papers using a customized data extraction form. Data synthesis Statistical pooling was not possible, mainly due to issues with data reporting in two of the studies, therefore the results are presented in narrative form. Results Three studies with a total of 357 participants were included in the review. In-person reporting to family members was found to be effective in comparison with usual care in which no reports were provided. Telephone reporting was also found to be effective at reducing anxiety, in comparison with usual care, although not as effective as in-person reporting. The use of paging devices to keep family members informed were found to increase, rather than decrease anxiety. Conclusions Due to the lack of high quality research in this area, the strength of the conclusions are limited. It appears that in-person and telephone reporting to family members decreases anxiety, however the use of paging devices increases anxiety.

Background Women undergoing Cesarean Section (CS) are vulnerable to the adverse effects associated with perioperative core temperature drop, in part due to the tendency for CS to be performed under neuraxial anesthesia, blood and fluid loss, and vasodilation. Inadvertent perioperative hypothermia (IPH) is a common condition that affects patients undergoing surgery of all specialties and is detrimental to all age groups, including neonates. Previous systematic reviews on IPH prevention largely focus on either adult or all ages populations, and have mainly overlooked pregnant or CS patients as a distinct group. Not all recommendations made by systematic reviews targeting all adult patients may be transferable to CS patients. Alternative, effective methods for preventing or managing hypothermia in this group would be valuable. Objectives To synthesize the best available evidence in relation to preventing and/or treating hypothermia in mothers after CS surgery. Types of participants Adult patients over the age of 18 years, of any ethnic background, with or without co-morbidities, undergoing any mode of anesthesia for any type of CS (emergency or planned) at healthcare facilities who have received interventions to limit or manage perioperative core heat loss were included. Types of intervention(s) Active or passive warming methods versus usual care or placebo, that aim to limit or manage core heat loss as applied to women undergoing CS were included. Types of studies Randomized controlled trials (RCTs) that met the inclusion criteria, with reduction of perioperative hypothermia a primary or secondary outcome were considered. Types of outcomes Primary outcome: maternal core temperature measured during the preoperative, intraoperative and postoperative phases of care Secondary outcomes: newborn core temperature at birth, umbilical pH obtained immediately after birth, Apgar scores, length of Post Anesthetic Care Unit (PACU) stay, maternal thermal comfort. Search strategy A comprehensive search was undertaken of the following databases from their inception until May 2012: ProQuest, Web of Science, Scopus, Dissertation and Theses PQDT (via ProQuest), Current Contents, CENTRAL, Mednar, OpenGrey, Clinical Trials. There were no language restrictions. Methodological quality Retrieved papers were assessed for methodological quality by two independent reviewers prior to inclusion using JBI software. Disagreements were resolved via consultation with the third reviewer. An assessment of quality of the included papers was also made in relation to five key quality factors. Data collection Two independent reviewers extracted data from the included papers using a previously piloted customized data extraction tool. Results 12 studies with a combined total of 719 participants were included. Three broad intervention groups were identified; intravenous (IV) fluid warming, warming devices, leg wrapping. IV fluid warming, whether administered intraoperatively or preoperatively, was found to be effective at maintaining maternal (but not neonatal) temperature and preventing shivering, but does not improve thermal comfort. The effectiveness of IV fluid warming on Apgar scores and umbilical pH remains unclear. Warming devices, including forced air warming and under body carbon polymer mattresses, were effective at preventing hypothermia and reduced shivering, however were most effective if applied preoperatively. The effectiveness of warming devices to improve thermal comfort remains unclear. Preoperative forced air warming appears to aid maintenance of neonatal temperature, while intraoperative forced air warming does not. Forced air warming was not effective at improving Apgar scores and the effects for umbilical pH remain unclear. Conclusions Intravenous fluid warming, by any method, improves maternal temperature and reduces shivering for women undergoing CS. Preoperative body warming devices also improve maternal temperature, in addition to reducing shivering.

Review question/objective What are the most effective information sharing strategies used to reduce anxiety in families of patients undergoing elective surgery? This review seeks to synthesize the best available evidence in relation to the most effective information-sharing intervention to reduce anxiety for families waiting for patients undergoing an elective surgical procedure. The specific objectives are to review the effectiveness of evidence of interventions designed to reduce the anxiety of families waiting whilst their loved one undergoes a surgical intervention. A variety of interventions exist and include surgical nurse liaison services, intraoperative reporting either by face-to-face or telephone delivery, informational cards, visual information screens, and intraoperative paging devices for families. Inclusion criteria Types of participants All studies of family members over 18 years of age waiting for patients undergoing an elective surgical procedure will be included, including those waiting for both adult and paediatric patients. Studies of families waiting for other patient populations, eg emergency surgery, chemotherapy or intensive care patients will be excluded. Types of intervention(s)/phenomena of interest All information-sharing Interventions for families of patients undergoing an elective surgical procedure will be included, including but not limited to: surgical nurse liaison services, in-person intraoperative reporting, visual information screens, paging devices, informational cards and telephone delivery of intraoperative progress reports. Interventions that take place during the intraoperative phase of care only will be included in the review. Preadmission information sharing interventions will be excluded. Types of outcomes The outcomes of interest include: Primary outcome: the level of anxiety amongst family members or close relatives whilst waiting for patients undergoing surgery, as measured by a validated instrument (such as the S-Anxiety portion of the State-Trait Anxiety Inventory).4 Secondary outcomes: family satisfaction and other measurements that may be considered indicators of stress and anxiety, such as mean arterial pressure (MAP) and heart rate.

Background: Dysphagia, or difficulty in swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurological impairment, largely from stroke. Dysphagia is not generally considered a major cause of mortality; however, the complications that result from this medical condition, namely, aspiration pneumonia and malnutrition, are among the most common causes of death in the older adults. Methods : This is an update of an existing systematic review. The standard systematic review methods of the Joanna Briggs Institute were used. Methods were specified in advance in a published protocol. Awide range of databases were searched for quantitative research articles examining the effectiveness of nursing interventions to identify and manage dysphagia in adult patients with acute neurological dysfunction, published between 2008 and 2013. Results : Four new studies were added in this update, for a total of 15 included studies. Strong evidence was found to show that nurse-initiated dysphagia screening is effective for reducing chest infections in patients with dysphagia (odds ratio [OR] = 0.45, 95% CI [0.33, 0.62], p > .00001). Nurse-initiated dysphagia screening by trained nurses may be effective for detection of dysphagia, and training nurses in dysphagia screening improves the number and accuracy of screens conducted. The presence of formal dysphagia guidelines in a health facility is likely to reduce inpatient deaths (OR = 0.60, 95% CI [0.43, 0.84], p = .003) and chest infections (OR = 0.68, 95% CI [0.51, 0.90], p = .008); however, it does not appear that formal guidelines have an effect on length of stay. Conclusions : Nurse-initiated dysphagia screening for patients with acute neurological dysfunction is effective for a range of important patient outcomes. The presence of formal guidelines for the identification and management of dysphagia may have a significant effect on serious adverse outcomes such as chest infections and death. Training nurses to conduct dysphagia screening will improve patient outcomes.

Background Rates of hypothermia for women undergoing spinal anesthesia for cesarean delivery are high and prevention is desirable. This trial compared the effectiveness of preoperative warming versus usual care among women receiving intrathecal morphine, which is thought to exacerbate perioperative heat loss. Methods A prospective, single-blinded, randomized controlled trial compared 20 minutes of forced air warming (plus intravenous fluid warming) versus no active preoperative warming (plus intravenous fluid warming) in 50 healthy American Society of Anesthesiologists graded II women receiving intrathecal morphine as part of spinal anesthesia for elective cesarean delivery. The primary outcome of maternal temperature change was assessed via aural canal and bladder temperature measurements at regular intervals. Secondary outcomes included maternal thermal comfort, shivering, mean arterial pressure, agreement between aural temperature, and neonatal outcomes (axillary temperature at birth, Apgar scores, breastfeeding, and skin-to-skin contact). The intention-to-treat population was analyzed with descriptive statistics, general linear model analysis, linear mixed-model analysis, X2 test of independence, Mann-Whitney, and Bland-Altman analysis. Full ethical approval was obtained, and the study was registered on the Australia and New Zealand Clinical Trials Registry (Trial No: 367160, registered at http://www.ANZCTR.org.au/). Results Intention-to-treat analysis (n = 50) revealed no significant difference in aural temperature change from baseline to the end of the procedure between groups: F (1, 47) = 1.2, P = .28. There were no other statistically significant differences between groups in any of the secondary outcomes. Conclusions A short period of preoperative warming is not effective in preventing intraoperative temperature decline for women receiving intrathecal morphine. A combination of preoperative and intraoperative warming modalities may be required for this population.

Nurse-led preadmission clinics or services have been implemented in many health services as a strategy to facilitate the admission and assessment of booked surgical cases. In order to provide the most recent available evidence, this systematic review is an update of our previous review published in 2010.The objective of this review was to integrate recent research with a previously published systematic review on the effectiveness of nurse-led elective surgery preoperative assessment clinics or services on patient outcomes.The review considered studies that included adult or pediatric patients who were undergoing any type of elective surgical procedure, either as a day-only case or as an inpatient.The review considered studies that evaluated the effect of attending or receiving the services of a nurse-led elective surgery outpatient preadmission or preoperative assessment clinic. TYPES OF OUTCOMES: This review considered studies that included the following outcome measures: length of stay, cancellation of surgery, incidence of non-attendance for scheduled surgery, mortality, morbidity, adverse surgical events, preoperative preparation, recognition and fulfilment of postoperative care needs, patient anxiety and patient or parent satisfaction. TYPES OF STUDIES: The review update considered any randomized controlled trials published after 2009; in the absence of randomized controlled trials other research designs, such as non-randomized controlled trials and before and after studies, were considered for inclusion in a narrative summary to enable the identification of current best evidence regarding the effectiveness of nurse-led preoperative assessment services.The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in each component of this review.Methodological validity was assessed by two reviewers prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.Data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.Due to the clinical heterogeneity of the included studies, no statistical pooling was possible and all results are presented narratively.Four new studies were identified from searches and added to the 19 studies from the previous review for a total of 23 studies. There is weak evidence to suggest nurse-led preadmission services may be an effective strategy for reducing procedural cancellations, failure to attend for procedures, length of stay, adverse surgical events and morbidity. Similarly weak evidence suggests nurse-led preadmission services may improve patient preparation, recognition of postoperative needs and patient/parent satisfaction.While all included studies reported evidence of effectiveness for nurse-led preadmission services on a wide range of outcomes for elective surgery patients, the lack of experimental trials means that the level of evidence is low.

Women undergoing cesarean section are vulnerable to adverse effects associated with inadvertent perioperative hypothermia, but there has been a lack of synthesized evidence for temperature management in this population. This systematic review aimed to synthesize the best available evidence in relation to preventing hypothermia in mothers undergoing cesarean section surgery.Randomized controlled trials meeting the inclusion criteria (adult patients of any ethnic background, with or without comorbidities, undergoing any mode of anesthesia for any type of cesarean section) were eligible for consideration. Active or passive warming interventions versus usual care or placebo, aiming to limit or manage core heat loss in women undergoing cesarean section were considered. The primary outcome was maternal core temperature. A comprehensive search with no language restrictions was undertaken of multiple databases from their inception until May 2012. Two independent reviewers using the standardized critical appraisal instrument for randomized controlled trials from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments (JBI-MASTARI) assessed retrieved papers for methodological quality and conducted data collection. Where possible, results were combined in a fixed effects meta-analysis using the Cochrane Collaboration Review Manager software. Due to heterogeneity for one outcome, random effects meta-analysis was also used.A combined total of 719 participants from 12 studies were included. Intravenous fluid warming was found to be effective at maintaining maternal temperature and preventing shivering. Warming devices, including forced air warming and under-body carbon polymer mattresses, were effective at preventing hypothermia. However, effectiveness increased if the devices were applied preoperatively. Preoperative warming devices reduced shivering and improved neonatal temperatures at birth. Intravenous fluid warming did not improve neonatal temperature, and the effectiveness of warming interventions on umbilical pH remains unclear.Intravenous fluid warming by any method improves maternal temperature and reduces shivering during and after cesarean section, as does preoperative body warming. Preoperative warming strategies should be utilized where possible. Preoperative or intraoperative warmed IV fluids should be standard practice. Warming strategies are less effective when intrathecal opioids are administered. Further research is needed to investigate interventions in emergency cesarean section surgery. Larger scale studies using standardized, clinically meaningful temperature measurement time points are required.

Aims: The prevention of inadvertent perioperative hypothermia (IPH) remains an important issue in perioperative healthcare. The aims of this project were to: (i) assess current clinical practice in the management of IPH and (ii) promote best practice in the management of IPH in adult operating theatres. Methods: This project from August 2010 to March 2012 utilised a system of audit and feedback to implement best practice recommendations. Data were collected via chart audits against criteria developed from best practice recommendations for managing IPH. Evidence-based best practices, such as consistent temperature monitoring and patient warming, were implemented using multifaceted interventions. Results: Perioperative records for 73 patients (baseline) and 72 patients (post-implementation) were audited. Post-implementation audit showed an increase in patients with temperatures >36°C admitted to the post-anaesthetic care unit (PACU) (8%) and discharged from PACU (28%). The percentage of patients receiving preoperative temperature monitoring increased (38%); however, low levels of intraoperative monitoring remained (31% of patients with surgery of 30min or longer duration). Small increases were found in patient warming of 5% intraoperatively and 8% postoperatively. Preoperative warming was not successfully implemented during this phase of the project. Conclusion: Temperature monitoring, warming and rates of normothermia improved; however, barriers to best practice of IPH management were experienced, which negatively impacted on the project. Further stages of implementation and audit were added to further address IPH management in this department. © 2013 The Authors International Journal of Evidence-Based Healthcare

Objectives This evidence based quality improvement project sought to measure current practice during the peri operative journey against recommendations from the evidence-based literature and guidelines, followed by the implementation of key strategies to reduce and manage IPH. Methods This project utilised a process of audit and feedback to measure current practice, implement recommended strategies and assess practice change in line with the evidence. Audits utilised eighteen criteria developed from three systematic reviews and four clinical guidelines. The inclusion criteria were adult patients over 18 years of age, undergoing general, local or regional anaesthesia. Patients less than 18 years of age, undergoing local anaesthesia only or sedation, or placed in induced hypothermia were excluded, as were any patients bypassing PACU after surgery. Sample size for the audits was 73 charts pre-implementation and 72 charts post-implementation. Strategies implemented to change practice included - consistent measurement of temperature, pre-warming prior to surgery and postoperative warming. Additional strategies included patient information and the maintenance of normothermia prior to surgery. Results Results were disseminated to staff after each audit via email, paper and oral presentation. Champions and opinion leaders were essential to drive change. Prior to the implementation of strategies the opportunity was given for staff to give feedback on the proposed changes. Post-implementation there was an 8% reduction in the number of hypothermic patients on arrival to PACU. Temperature measurement was introduced in the Pre Op Holding Bay. An increase in discharge temperature from 35.5°C to 36°C was adhered to, thereby increasing the number of normothermic patients returning to ward areas. Discussion The project has been successful in increasing an awareness of IPH as a problem that needs to be prevented and managed. Difficulties were experienced in the introduction of pre-warming and with implementing changes within such a complex work area with a high number of multidisciplinary working groups. Issues with the reliability and accuracy of temperature measurement devices were highlighted after the second audit and have ensured greater scrutiny of the measurement devices used in Operating Theatres. Conclusion Management of IPH has improved in line with best practice guidelines within this area of practice. However work is ongoing and, in particular, consideration is needed regarding temperature measurement devices and techniques to ensure consistency and accuracy. Further audits will be required in the future to ensure this practice is sustained.