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Introduction Catheter associated urinary tract infections are widely recognized as the most common health care associated infection in the acute care hospital setting. Methods Experts have reviewed the literature on catheter associated urinary tract infections in urological patients. Where the literature was lacking, expert opinion was used to build recommendations which may be useful to the urological community. Results In this white paper we address limitations surrounding how and when current definitions can be used to detect a catheter associated urinary tract infection in a urological patient, and propose alternative methods for diagnosing catheter associated urinary tract infection in specific populations, including geriatric, neurogenic bladder and lower urinary tract reconstruction. Techniques to avoid catheter associated urinary tract infections through proper urethral catheterization and alternatives to indwelling catheters for urological patients are also discussed. Conclusions Patients with urological disorders have specific concerns relating to catheter associated urinary tract infections. A review of the available literature as well as common clinical practice provides directives for the treatment of these patients in a specific and distinctive fashion to reduce the risk of infection. By understanding the needs and technical modifications necessary in these patients, hospital systems and practitioners can limit patient exposure to catheter associated urinary tract infections.

THE TWO ORGANIZATIONS highlighted in this issue's feature articles are engaged in a journey that many hospitals, health systems, and physician organizations are recognizing is key to the task of transforming the US health system. Palomar Health and ProMedica are developing and deploying physician and other clinical leaders in governance, design, operations, and outcomes. Although each feature article describes a different approach, scope, and scale, the organizations are making good investments that will yield positive results. Without engaged physicians leading healthcare redesign, we are doomed to fail. Organizations must build strong programs to engage and develop physician leaders to succeed in the challenging environment ahead. The question remaining for all of us is how to best accomplish this.Texas Health Resources' approach to welcoming, developing, and deploying physician leaders evolved as it moved from three independent systems in 1997 to one combined organization. Our efforts accelerated five years ago when the system sharpened its focus on its mission of improving the health of people in the communities we serve. Texas Health has transitioned from an acute care hospital system to a healthcare system that includes a physician group with more than 500 physicians and more than 200 physician assistants, nurse practitioners, and extenders; it is the largest health system in North Texas. Some of our approaches are similar to, and some are different from, those demonstrated at Palomar Health and ProMedica. We are similar in recognizing that physicians must be involved in decision making and that our organizational cultures must support a shared vision and mutual trust based on experiences gained by working together. Our priorities align, yet we differ in execution. At Texas Health, we are seeing results and a return on our investment in this important area of transformation. Physician leadership is crucial to developing strategy and designing products and processes that standardize care around evidence-based quality metrics, enhancing service and patient satisfaction, increasing reliability, and, ultimately, improving outcomes.The American Hospital Association (AHA) and American Medical Association (AMA) issued a historic joint position paper in 2015 titled "Integrated Leadership for Hospitals and Health Systems: Principles for Success." The organizations acknowledge that integrated physicianhospital leadership models provide a pathway for delivering greater value to patients and populations.PHYSICIAN LEADERSHIP AND GOVERNANCEOostra describes ProMedica's governance philosophy of maintaining local boards as organizations join its system. Texas Health shares this practice and has held this philosophy since its creation in 1997. As healthcare has evolved and relationships with physicians have grown closer, we have built leadership models that reflect our underlying philosophy.At ProMedica, physician seats have increased to 16 percent of nearly 500 board seats across the system. Both employed and independent physicians hold seats, with six serving on the parent board. At Texas Health, 35 percent of 264 board seats are held by independent and employed physicians. The benefits of this structure include a focus on safety and outcomes, a clear understanding of physicians' motivating factors, and a focus on the patient experience.Oostra notes that, in addition to and because of increased participation in governance, physician leaders have grown in number and been deployed across a wide continuum of settings and businesses. Texas Health has sought to increase the number of clinically trained leaders across the system. Two-thirds of our hospital and physician group leaders are physicians or nurses. Physicians make up one-third of our executive leadership committee membership. Sharing governance with physicians and increasing the number of physicians in the ranks of senior leaders have changed Texas Health's perspective regarding strategy development and deployment. …

Background Most healthcare professionals at some time will experience having a significant other admitted to an acute care hospital. The knowledge and understanding that these individuals possess because of their professional practice can potentially alter this experience. Expectations of staff and other family members (FMs) can potentially increase the burden on these health professionals. All FMs of patients should have their needs and expectations considered; however, this review specifically addresses what may be unique for healthcare professionals. Objectives To synthesize the qualitative evidence on the experiences of healthcare professionals when their significant others are admitted to an acute care hospital. Inclusion criteria types of participants The current review considered studies reporting the experiences of healthcare professionals, specifically registered nurses (RNs) and physicians. Phenomena of interest The experiences of RNs and physicians when a significant other is admitted to an acute care facility. Types of studies Qualitative studies that have examined the phenomenon of interest including, but not limited to, designs such as phenomenology and grounded theory. Search strategy The search strategy aimed to find both published and unpublished studies with no date restrictions. Only studies published in English were considered for inclusion in this review. Methodological quality Qualitative papers selected for retrieval were assessed using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Data extraction Data were extracted from the seven included papers using the standardized data extraction tool from JBI-QARI. Data synthesis The data were synthesized using the JBI approach to meta-synthesis by meta-aggregation using the JBI-QARI software and methods. Results Seven studies of moderate quality were included in the review. Forty findings were extracted and aggregated to create 10 categories, from which five synthesized findings were derived: CONCLUSION: In contrast to "lay" FMs, health professionals possess additional knowledge and understanding that alter their perceptions and expectations, and the expectations others have of them. This knowledge and understanding can be an advantage in navigating a complex health system but may also result in an additional burden such as role conflict.

The organization of the work of nurses, according to recognized models of care, can have a significant impact on the wellbeing and performance of nurses and nursing teams. This review focuses on two models of nursing care delivery, namely, team and total patient care, and their effect on nurses' wellbeing.To examine the effectiveness of team nursing compared to total patient care on staff wellbeing when organizing nursing work in acute care wards.Participants were nurses working on wards in acute care hospitals.The intervention was the use of a team nursing model when organizing nursing work. The comparator was the use of a total patient care model.This review considered quantitative study designs for inclusion in the review.The outcome of interest was staff wellbeing which was measured by staff outcomes in relation to job satisfaction, turnover, absenteeism, stress levels and burnout.The search strategy aimed to find both published and unpublished studies from 1995 to April 21, 2014.Quantitative 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.Data was extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and its specific objectives.Due to the heterogeneity of the included quantitative studies, meta-analysis was not possible. Results have been presented in a narrative form.The database search returned 10,067 records. Forty-three full text titles were assessed, and of these 40 were excluded, resulting in three studies being included in the review. Two of the studies were quasi experimental designs and the other was considered an uncontrolled before and after experimental study. There were no statistically significant differences observed in any study in the overall job satisfaction of nurses using a team nursing model compared with a total patient care model. Some differences in job satisfaction were however observed within different subgroups of nurses. There were no statistically significant differences in either stress or job tension. Within the selected studies, the specific outcomes of absenteeism and burnout were not addressed.Due to the limited number of quantitative studies identified for inclusion in this systematic review it is not possible to determine whether organizing nursing work in a team nursing or total patient care model is more effective in terms of staff wellbeing in acute care settings. Neither a team nursing or total patient care model had a significant influence on nurses' overall job satisfaction, stress levels or staff turnover. This review could not ascertain if the type of model of care affects absenteeism or burnout as these were not addressed in any of the identified studies.Caution should be taken when evaluating which model of care is appropriate and the decision needs to incorporate staff experience levels and staff skill mix. There needs to be clear definition of nursing roles.This review demonstrates the need for further quantitative studies of these models of care that are well designed with sufficient sample sizes to allow for attrition of participants, and that explore the impact each model has on nurse's wellbeing, in particular, studies that address burnout and absenteeism. There is a need for consistent terminology to allow for future comparison and research to occur at an international level. Future studies on models of care should include economic analysis to fully inform policy and practice.

Peer review of the quality of care of the medical staff in a healthcare delivery system, properly executed and utilized, can bring about changes that improve the quality and safety of patient care, enhance clinical performance, and augment physician education. Although all healthcare facilities are mandated to conduct peer reviews, the process of how it is conducted, reported, and utilized varies widely. In 2007, our institution, a large public teaching acute care facility, developed and implemented an electronic Medical Staff Peer Review System (MS-PRS) that replaced the existing paper-based system and created a centralized database for all peer review activities. Despite limited resources and mounting known challenges, we have developed and implemented a system that includes 100% mortality reviews, an ongoing random review for reappointment and operative procedures, and morbidity peer reviews. Parallel to the 4-year implementation of the system, we observed a steady, significant downward trend in the medical malpractice claim rate, which can be attributable in part to the implementation of MS-PRS. In this paper, we share our experiences in the development, outcomes, challenges encountered, and lessons learned from MS-PRS and provide our recommendations to similar institutions for the development of such a system.

Review question/objective The objective of this systematic review is to critically appraise and synthesize the best available evidence on the effectiveness of team nursing compared to total patient care on staff wellbeing when organizing nursing work in acute care ward settings. This review will seek to answer the following question: Is a team nursing or a total patient care approach the most effective model of care when organizing nursing work to achieve desired staff wellbeing (defined by outcomes of staff satisfaction, stress, burnout, absenteeism and turnover) in a general ward setting? Inclusion criteria Types of participants This review will consider studies that include all nurses working on general wards in the acute care hospital sector. This includes registered general nurses or the international equivalent such as staff nurses and professional nurses, enrolled nurses or the international equivalent such as licensed vocational nurses or licensed practical nurses and unlicensed personnel such as nursing assistants or the international equivalent such as nurse’s aides and auxiliary nurses. This will review will exclude: Nursing staff working on specialized wards and areas for example intensive/critical care areas, oncology wards, pediatrics, midwifery, mental health, primary care and aged care sectors, as they utilize specific models of care for their scope of practice. Types of intervention(s) This review will consider studies that investigate the use of a team nursing model when organizing nursing work. The comparator will be utilization of a total patient care model. Types of outcomes The outcome of interest to this review will be staff wellbeing. Methodology for data collection will be grouped from the primary research papers based on the types of outcomes measures or tools that were used to promote homogeneity of pooled data. Data collection tools that have been used in initial searches of papers have included questionnaires for the collection of responses for staff satisfaction. The measurement tools considered for inclusion must be validated and reliable, examples of these tools are the Nursing Work Index tool which measures nursing values in relation to job satisfaction and productivity. This tool has been modified and used in various countries including Australia where it is referred to as the Nursing Work Index – Revised: Australian Tool, (NWI-R:A tool).23 Another reliable tool is the McCloskey/Mueller Satisfaction Scale (MMSS) which is a multidimensional questionnaire designed for hospital staff nurses. There are 31 items; the response format is a five-point Likert scale. The Nurse Satisfaction Scale (NSS) is also a validated tool which measures job satisfaction among nurses. The questionnaire is multidimensional and has 24 items. The response format is a seven-point Likert scale.24 Maslach Burnout Inventory tool has been utilized to measure staff burnout and stress levels other tools that measure staff burnout and stress will be considered for inclusion, providing it is a validated and tested tool for measuring staff burnout and stress levels. Nursing turnover and absenteeism rates will be extracted from included papers. Patient clinical outcomes will be excluded from the review.

BACKGROUND AND PURPOSEIn 2008, the Institute of Medicines (IOM) Committee on the Future Health Care Workforce for Older Americans released its report "Retooling for an Aging America: Building the Health Care Workforce."1 As a call for fundamental reform in the way that the workforce is both trained and utilized in the care of older adults, this report advocated a 3-pronged approach to an aging America: enhancing the geriatric competence of the entire workforce; increasing recruitment and retention of geriatric specialists and caregivers; and improving the way care is delivered to this population. This paper focuses on the third prong, by discussing how potential changes in the delivery and utilization of care to older adults poses both challenges and opportunities for the physical therapy profession, and describing the demographic sociopolitical backdrop for the companion paper by Wong and associates, "Building the Physical Therapy Workforce for an Aging America,"2 that addresses the first 2 components of the IOM report related to the profession of physical therapy, particularly the education of the workforce.Leaders in physical therapy education are committed to preparing physical therapists and physical therapist assistants to provide services to older adults in the United States, therefore must prepare students entering the workforce with the abilities to negotiate a drastically altered heath care landscape, especially when working with older adults. The purposes of this paper are to: (1) inform the physical therapy education community about important age-related population factors that deserve emphasis in physical therapy education curricula; (2) describe the evolving nature of health care financing and service utilization that will effect changes in health care delivery; and (3) identify the challenges and opportunities in the clinical practice of physical therapy that may arise in the profession's efforts to meet societal needs related to our aging population more effectively and efficiently.POSITION AND RATIONALEIt is our position that the profession of physical therapy in the United States (US) needs to be nimble in an evolving environment that will change health care financing and delivery over the next decade. The profession must also continue to exercise sure-footed steps forward in clinical practice and education that can maximize the contributions that the profession can make to our growing population of older adults.The Changing Landscape of Aging in the United StatesIn the past decade alone, the number of persons whose age is 65 years or older in the US grew faster than the rest of the population.3 In 2010, 40.3 million people counted in the US Census were 65 and older, representing 13% of the entire population.3 By 2030, it is estimated that the number of people 65 and older will reach to 72 million.4 By 2050 the number of individuals who are 65 years of age and older should reach 88.5 million, with about 19 million over the age of 85 who will account for over 4% of the population.4With aging comes increased risk of managing one or more chronic diseases, often associated with disabilities. In the United States, over 45% of adults age 65 or over have 2-3 chronic conditions.5 Arthritis, hypertension, diabetes, coronary heart disease, cancer, and chronic obstructive pulmonary disease appear most frequently as various dyads or triads of multiple chronic conditions among men and women in this age group.5 For noninstitutionalized Americans, ambulatory disability (ie, serious difficulty in walking or climbing stairs) affects the highest proportion of the population. Stratified by age, 16% of 65-74-year-olds and 33% of those 75 years of age and older have an ambulatory disability.6 This segment of the population with multiple chronic conditions that impede daily function offers a critical opportunity for the profession, as many of these individuals are living and still working in the community and are not the typical geriatric patients seen in acute care, home care, or nursing home settings. …

Nurses are key players in the effective functioning of complex hospital organizations and their ability to provide good patient care is influenced by the context in which they practice. Hallmarks of successful organizations include flat organizational structure with accessible and informed managers, decentralized decision-making, and the empowerment of front line workers to make decisions.1-2 Managerial strategies that reduce the negative effects of organizational complexity on employee productivity, work quality, and retention have emerged in a variety of industries and settings. The concept of Magnet hospitals—hospitals identified by their reputations for being good places for nurses to work—evolved from observations that hospitals that were successful in attracting and retaining qualified nurses resembled the most highly ranked U.S. corporations.3 In 1994, Medical Care published the first paper on patient outcomes in Magnet hospitals, documenting lower risk-adjusted mortality among Medicare patients in the original Magnet hospitals.4 Magnet hospital designation was formalized with the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program® in the 1990s.5 The voluntary process was subsequently shown to identify hospitals that were as good as the original “reputational” Magnet hospitals of the 1980s in terms of having excellent work environments and nurse outcomes such as lower levels of burnout and higher job satisfaction.6 With few exceptions,7 studies since have shown that care environments in Magnet recognized hospitals are different from non-Magnet hospitals.8-10 These differences are associated with higher levels of nurse satisfaction, less nurse burnout,11-12 lower patient fall rates,13 and lower mortality among very low birth weight infants.14 The number of Magnet recognized hospitals has grown to nearly 400— about 8% of hospitals nationally. The Magnet Recognition Program® has also achieved status and visibility; Magnet recognition is now an indicator for national hospital ranking and quality benchmarking programs like U.S. News and World Report Best Hospitals rankings and the Leapfrog Group hospital ratings.15-17 During the period of evolution and replication of Magnet hospitals, research emerged documenting associations between hospitals with exemplary nurse practice environments and patient outcomes. Lower risk-adjusted mortality and death following complication among surgical patients have been associated with lower patient-to-nurse ratios,18-20 a more educated nurse workforce,21 more specialty-certified nurses,22 and better nurse work environments.12, 23-24 The Magnet Recognition Program® does not specify nurse staffing levels or educational or specialty certification requirements for bedside nurses. Instead, the program requires evidence-based processes aimed at organizational reform of nurses’ work environment in relation to desired patient outcomes. Hospitals are evaluated for evidence of achieving goals in five areas: transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and empirical outcomes. Thus, a follow-up to the 1994 paper must go beyond determining whether a mortality advantage can be documented for formally designated Magnet hospitals. Our inquiry must delve into the possible explanations for such an advantage, if found, because there is now a substantial scientific base documenting the association between nursing and patient outcomes. In the 1994 paper, Magnet designation was used as a proxy for good nursing because details of nurse staffing, education, qualifications, and work environments could not be measured with available data. That is no longer the case. A multi-state survey of nurses in California, Pennsylvania, New Jersey, and Florida provides direct measures of key elements of nursing organization and practice across all general, acute care hospitals in these four large states.23 Additionally, Magnet designation is now a formal process involving evidence-based criteria, on-site evaluations, and re-designation every four years with higher standards required the longer the designation is held.25 We use the data from the four states to examine this new environment and to determine whether Magnet hospitals continue to evince organizational characteristics that differentiate them from other hospitals, and if so, the extent to which these characteristics are associated with lower risk-adjusted mortality and failure-to-rescue. Our hypothesis is that Magnet hospitals should “out-perform” non-Magnet hospitals. Differences in patient outcomes should be associated with the organizational features of nursing that can be measured. However, there may be a Magnet effect above and beyond the effect attributable to the measured nursing features alone.

Aim The aim of this review was to appraise and synthesise the best available evidence on visitation models used in adult intensive care units in acute care hospitals and to explicate their congruence with the core concepts of patient- and family-centred care (PFCC). Methods The review considered both quantitative and qualitative studies on visitation models developed within the PFCC model in adult intensive care units in acute care hospitals. The search strategy sought published and unpublished research papers limited to English for the years 1988 through 2009. An initial search of the Joanna Briggs Institute for Evidence-Based Nursing and Midwifery, the Cochrane Library, and PubMed's Clinical Inquiry/Find Systematic Review database was conducted, followed by an analysis of key words contained in the title, abstract and index terms. Following this, an extensive three-stage search was conducted using PubMed, CINAHL, HealthStar, ScienceDirect, Dissertation Abstracts International, DARE, PsycINFO, BioMedCentral, TRIP, Pre-CINAHL, PsycARTICLES, Psychology and Behavioural Sciences Collection, ISI Current Contents, Science.gov, Web of Science/Web of Knowledge, Scirus.com website. Included was a hand search of reference lists of identified papers to capture all pertinent material as well as a search of relevant worldwide websites and search engines, such as Google Scholar and the Virginia Henderson Library of Sigma Theta Tau International. Each paper was assessed independently by two reviewers for methodological quality prior to inclusion in the review using the appropriate critical appraisal instrument. Results Findings from the qualitative studies were extracted and a synthesis conducted using the QARI (Qualitative Assessment and Review Instrument) software developed by the Joanna Briggs Institute. One synthesis revealed that visiting hours were seen as guidelines for the benefit of nurse and patient, rather than rules or policy. Due to the various types of designs in the available studies, it was not possible to pool quantitative research study results into a statistical meta-analysis. Because statistical pooling was not possible, the findings are presented in a narrative form. Following this, results are presented for their congruence with the principles of PFCC. Conclusion Flexible visiting policies provide the ability to incorporate the concepts of PFCC into practice. However, nurses believe that while visiting is beneficial to patients, open and/or flexible visiting hours are an impediment to practice and increase their workload. Recommendations for best practice were formulated based on the outcomes and include visiting hours should be used as guidelines, not rules, that allow flexibility dependent upon individual patient/family situation. With regard to congruence with PFCC, patient and family requests for information emerged as an unmet need that needs to be addressed.

Protective isolation is one of the precautionary measures put in place for neutropenic cancer patients, where patients will be placed in an isolation room during their medical treatment in the hospital. The purpose of this practice is to minimise neutropenic patients from contracting nosocomial infection and the length of stay in the isolation room varies depending on their medical condition. It has been reported in some literature that this group of patients experience social isolation, a wide range of emotions and psychological burdens such as depression and anxiety as a result of staying in the isolation room. Therefore, a systematic review on neutropenic cancer patients' experience in isolation room will add knowledge to the nursing science of providing high quality care for this particular group of patients.The objectives of this review are to understand neutropenic cancer patients' experiences in the isolation room and their coping mechanisms.The participants of interest were adults neutropenic cancer patients aged 18 years old and above.The phenomenon of interest i was the experience of neutropenic cancer patients who were nursed in an isolation room due to chemotherapy induced neutropenia or during the period of haematopoietic stem cell transplant.The studies of interests were are qualitative studies which focus on adult neutropenic cancer patients' experiences in an isolation room.The outcome of interest wai s patients' self reported experiences.An initial search to identify keywords was undertaken in MEDLINE and CINAHL. A second search using all identified keywords and index terms across the databases was performed subsequently. The final search included reference lists from included papers for additional studies.Six qualitative papers were included in this review. The papers were qualitative descriptive, phenomenological, qualitative exploratory and grounded theory. All the papers used interview as primary method to collect data except one study which had an additional art making directive method.Data were extracted using standardised data extraction tools from JBI-QARI.Categories were formed based on aggregation from the similar findings with like meaning. The categories were then read and reread to develop two synthesised findings that were presented as declamatory and generalisable statements to guide and inform clinical practice.Two syntheses were generated based on the meta-aggregation. The first synthesis was that health care workers need to be aware physical isolation could result in social isolation in patients that made them feel powerless. The second synthesis was that health care workers should encourage patients to use cognitive mechanisms to cope with isolation experiences. Family, friends and nurses should step in to provide help in any form whenever patients need it.Isolation room has a negative impact on the neutropenic cancer patients while they are hospitalised. However, they are coping effectively using cognitive mechanisms and receive adequate support externally.Offering patients more options especially having flexibility in their daily routine such as meal times could be a useful intervention to allow them to take some control. Notifying the patient in advance of their time of treatment and involving patients in their treatment care will promote their autonomy. Tracking the patients' coping mechanisms and offering support when necessary will ease the patients' isolation experience.The psychological effects of being cared for in isolation room may undermine the clinical benefits of infection control. Therefore, future research is needed to evaluate the effectiveness of isolation room in preventing neutropenic cancer patients from infection.

Background Older adults with dementia may have feeding difficulties for several reasons: they may experience deterioration in motor and cognitive skills making eating difficult, they may forget to eat, fail to recognise food or they may suffer from dysphagia. Food intake is often poor and malnutrition is common, leading to adverse health outcomes.This review specifically focussed on how best to promote and achieve 'normal' eating and feeding in older adults with dementia, in order that undernutrition and its consequences could be avoided.Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia.Types of Participants Adults over the age of sixty with dementia in any care setting (who were not living independently). People receiving enteral tube feeding were excluded.Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers, family or volunteers, educational interventions, changes in food service.Types of Outcomes The primary outcomes were improvement in dietary intake and/or nutritional status. Measurements included: dietary intake, anthropometry, clinical outcomes, functional indicators.Types of Studies Randomised controlled trials, controlled trials and quasi-experimental studies with a 'before and after' design.Search Strategy The search strategy aimed to find both published and unpublished studies using a three-step approach. Papers were limited to the English language and a date restriction of 1999 to 2009 was set.Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion.Data Extraction For quantitative studies, data was extracted using a data extraction form developed to include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. This was based on the JBI data extraction tool from MAStARI and 2 reviewers extracted data independently.Data synthesis Heterogeneity in study designs, interventions and outcomes meant meta-analysis was not possible. Findings were discussed in a narrative summary.Results The review included 11 studies. This included one RCT, 1 randomised crossover study, 3 controlled non-randomised trials, 6 quasi-experimental studies. None of the studies provided robust evidence, however there was moderate evidence (Level 3) to support a Grade B recommendation for improvements in dietary intake and/or nutritional status with the following interventions: education of healthcare staff, simple environmental manipulations such as the use of high contrast tableware or small dining rooms, the introduction of something of interest such as an aquarium or background music, or the provision of feeding assistance, provision of enhanced menus, use of a decentralised food service, enhanced nutritional screening combined with increased dietetic time.Conclusion There is moderate (Level 3) evidence to support each of the interventions appraised in this review.Implications for Practice There is moderate support that warrants consideration of the interventions listed above. Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care.Implications for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following: inclusion of reliable outcome measures, full details of interventions, randomisation of participants, inclusion of control groups, adequate sample sizes, longitudinal follow up, consideration of baseline demographics of intervention groups, and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care.

An inter-shift nursing handoff report is the exchange of patient care information for evidence-based nursing and midwifery from one nurse to another, and is a universal procedure used in hospitals to promote continuity of care. The objective of this review was to appraise and synthesize the best available qualitative evidence pertaining to the nursing handoff report at the time of shift change and make recommendations that can enhance the transfer of information between and among nurses, and by extension, improve patient care.The review considered qualitative studies that drew on the experiences of nurses at the time of inter-shift nursing handoff in acute care hospitals, and included designs such as phenomenology, grounded theory, narrative analysis, action research, ethnographic or cultural studies.The search strategy sought to find both published and unpublished research papers. An initial search of the Joanna Briggs Institute for Evidence-Based Nursing and Midwifery, the Cochrane Library, and PubMed's Clinical Inquiry/Find Systematic Review database was conducted. Following this, an extensive three stage search was conducted using PubMed, CINAHL, HealthStar, ScienceDirect, Dissertation Abstracts International, DARE, PsycINFO, BioMedCentral, TRIP, Pre-CINAHL, PsycARTICLES, Psychology and Behavioural Sciences Collection, ISI Current Contents, Science.gov, Web of Science/Web of Knowledge, Scirus.com website. Included was a hand search of reference lists of identified papers to capture all pertinent material as well as a search of relevant world wide websites and search engines, such as Google Scholar and the Virginia Henderson Library of Sigma Theta Tau International.Each paper was assessed independently, by two reviewers for methodological quality prior to inclusion in the review using the critical appraisal instrument QARI (Qualitative Assessment and Review Instrument) developed by the Joanna Briggs Institute for Evidence Based Nursing and Midwifery.A total of 21 qualitative papers were included in the review of the 42 papers retrieved. Twenty-one were excluded as they did not meet the inclusion criteria. Findings were extracted and a meta-synthesis conducted using JBI-QARI. Three syntheses about the process of handoffs at the time of inter-shift nurses' reports in acute care hospitals were derived: 1) An embedded hierarchy exists that influences the conduct of inter-shift nursing handoffs; 2) Participating in inter-shift nursing handoffs are a way of becoming acculturated into the nursing unit's norms, expectations and rituals; 3) The nurse is the gatekeeper of information handed off that is used for subsequent care decisions.There is evidence to support that the current process of inter-shift nurses' reports serves several purposes in addition to transfer of information, including the development of group solidarity. It is apparent from this review that the nurse is the gatekeeper for the flow of information regarding patient care and chooses what information to impart and act upon. Multiple ways of transferring information are recommended for the inter-shift nursing handoff as a way to manage information decay or funneling and to address potential communication gaps due to in congruencies between the medical record, verbal handoff report and actual clinical condition.A consistent guideline is a prerequisite to formulating an optimal shift report given the findings of this review that the quality of information transferred is unpredictable. The guideline needs to take into consideration, not only the exchange of information, but that nurses handle patient information in personal ways. To that end, a one-page report pre-populated with patient demographics, recent vital signs, laboratory results, and other information which can be accessed and printed at point-of-care at the time of change of shift is recommended.As external agencies continue to call for hand-off standardization that may not, in and of itself, reduce risk, further research is needed to determine the associations between inter-shift nursing reports and patient outcomes. Practice model initiatives, such as SBAR (situation-background-assessment-results) need to be investigated to determine if these methods can prevent information loss, particularly in those areas where information decays quickly, such as the Intensive Care Unit. As well, the current shortage of nurses make the composition of the nursing team less stable with more temporary and part-time workers resulting in a decrease in the cohesiveness and social interaction necessary to becoming acculturated in a nursing unit This could present a barrier to communication of important information and contribute to information loss that needs to be investigated.

Background: Violence in healthcare has been widely reported and healthcare workers, particularly nurses in the acute care setting, are ill-equipped to manage patients who exhibit aggressive traits. An initial search of the Cochrane Library and the Joanna Briggs Institute did not reveal any published systematic reviews recommending strategies to manage aggressive and/or violent behaviours in patients admitted to an acute hospital setting.----- Objectives: This systematic review aims to establish best practice in the prevention and management of aggressive behaviours in patients admitted to an acute hospital setting.----- Search strategy: A three-step search strategy was utilised during this review. Major databases searched included: MEDLINE, CINAHL, PsycINFO, Health source, Web of science, EMBASE, the Cochrane library and Database of abstracts of reviews of effects (DARE) as well as PubMed. The search included published and unpublished studies and papers in English from 1990-2007.----- Selection criteria: This review considered any randomised controlled trials (RCT) that evaluated the effectiveness of interventions in the prevention and management of patients who exhibit aggressive behaviours in an acute hospital setting. In the absence of RCT's, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion in the narrative summary to enable the identification of current approaches and possible future strategies for preventing and managing patient aggression in acute care areas.----- Assessment of quality: Each included study was assessed by two independent reviewers using the appropriate appraisal checklist developed by the Joanna Briggs Institute. Data collection and analysis: Data was extracted from the papers included in this review using the standardised data extraction tools from the Joanna Briggs Institute Meta Analysis of Statistics: Assessment and Review Instrument (JBI-MAStARI)package. The studies included in this review were not suitable for meta-analysis and therefore the results are presented in narrative form.----- Results: Twelve studies and one dissertation met the inclusion criteria and were included in the review. The evidence identified includes: the benefit of education and training of acute care nurses in aggression management techniques; the use of “as required” medications to minimise harm to patients and staff; and that specific interventions such as music therapy and physical restraint may play a role in managing aggressive and/or violent behaviours from patients in the acute care setting.----- Conclusion: This review makes several recommendations for clinical practice to prevent and manage aggressive behaviours in acute hospital patients. However due to the lack of high quality intervention studies conducted in the acute care setting there is huge scope for future research in this area.

The overall objective is to examine the current evidence of the impact of Magnet designation on patient and nurse outcomes.This review considered any quantitative or qualitative study comparing organizational, nurse, patient or economic outcomes in Magnet designated hospitals with a comparison to a non-Magnet facility. Studies which used case-controlled, descriptive comparative, descriptive correlational and qualitative designs were considered due to the nature of the question. Participants included nurses in four hospital types: ANCC Magnet, Reputational Magnet, Magnet-Aspiring, and non-Magnet. Interventions included: Magnet hospitals (ANCC), Reputational Magnet; Magnet-Aspiring hospitals and non-Magnet hospitals.The search strategy aimed to find both published and unpublished studies and papers, limited to the English language. An initial search of the Joanna Briggs Institute for Evidence Based Nursing and Midwifery and Cochrane Library databases was conducted. A three-step search strategy was then used. A first-stage, limited search of MEDLINE and CINAHL using preliminary key words was done. In consultation with an information scientist experienced in database searching, a comprehensive search strategy incorporating the key words from the preliminary search was undertaken. The third approach was to review the reference lists from all retrieved papers meeting the inclusion criteria to identify any further research not identified in the first two stages.Each paper was assessed by two independent reviewers for methodological quality prior to inclusion using the appropriate critical appraisal instrument from the Joanna Briggs Institute.A total of 17 papers were included in the review. All were descriptive comparative studies with the majority using a cross sectional survey approach comparing outcomes across either two or three categories of Magnet designation. Comparison across studies using the same instrument was limited as survey instruments were not used in the same manner and studies had different Magnet designation comparison groups. Majority of studies investigated professional nurse practice environment, nurse burnout, nurse satisfaction, perception of quality care, and intent to leave. Limited studies found related to patient outcomes, and no studies met criteria for inclusion for economic review.The investment is worth it. There is evidence to support the positive effect of Magnet designation on the professional nurse practice environment (PNPE). Stronger PNPE and Magnet status are associated with lower levels of nurse burnout, higher levels of nursing satisfaction, higher perceptions of quality of care, and decreased intent to leave. There is a need to further investigate the linkage between PNPE and/or Magnet designation with patient outcomes. Understanding the economic implications of a PNPE requires further study.

Policies concerning restricted or open visiting hours are being challenged in health care institutions internationally, with no apparent consensus on the appropriateness of the visiting hour policies for pediatric and adult patients. The rules that govern practice are often based on the institutional precedent and assumptions of staff, and may have little or no evidence to support them. Policy and practice related to visiting hours is of pressing concern in Canada, and in Ontario specifically, following the reaction to the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 and subsequent changes in visiting policies in most health care settings. A systematic investigation of the impact of hospital visiting hours on visitors (including patients, families, and significant others) would inform decision-makers who are responsible for hospital policies about the best available evidence.The objective of this review was to appraise and synthesize the best available evidence on the impact of hospital visiting hours on patients and their visitors.Types of participants This review considered studies that included both pediatric and adult hospital patients and their visitors. Participants were either patients, visitors, or health care providers in the following hospital settings: medical/surgical units, critical care (ICU, CCU, NICU), pediatrics, maternity, or general hospital wards.Articles were excluded if participants came from the following settings: post-operative and post-anaesthesia care units (PACU), dementia wards, long-term care settings or retirement homes, or delivery rooms. PACUs were excluded because there are aspects of the presence of visitors to these units that are very specific, and differ from the general visits to patients who are not in the immediate post-operative stage. Dementia wards, long-term care settings and retirement homes were excluded because these were considered to be their "home", so visiting would be quite different from that on acute care hospital wards. Finally, delivery rooms were excluded because this review does not evaluate the impact of the outcomes of presence during "delivery" (or other "procedures").Types of interventions Studies were considered for inclusion in this review if they evaluated the effect or impact of visiting policies. This included interventions targeted at limiting or expanding patient visiting. We anticipated a paucity of experimental studies regarding this review question, thus included observational studies where the impact of visiting policy on patients and/or visitors was a focus, but testing intervention(s) may not have been the primary aim. We did not consider observational studies that focused only on the presence of visitors during specific procedures, resuscitation, or childbirth. The reason is that this limited aspect of the presence of a significant other was not considered "visiting" per se, and would be best examined in another systematic review.Types of outcome measures For this review, outcome measures related to both patients and visitors as a result of visiting hour policies were considered, including but not limited to: patient and/or visitor satisfaction; attitudes; beliefs; perceptions; mood; or patient physiological outcomes. These also included health care provider beliefs, perceptions, and attitudes about the impact of visiting policies on patients and/or visitors. Studies were excluded if they examined the trend of current visiting hour policies (with no evaluation of their impact), or if they focused on visitor presence only during emergency procedures, resuscitation, or childbirth.Types of studies Randomized controlled trials (RCTs) or quasi-experimental studies were included. However, given the expected scarcity of these designs relevant to our review question, other quantitative research designs were considered, such as non-randomized controlled trials, before-and-after studies, and descriptive/observational studies.Using a defined search and retrieval method the following databases from 1995-2007 were accessed: Medline, CINAHL, Embase, PsycINFO, HealthSTAR, Cochrane Database of Systematic Reviews, AMED, and ERIC.Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using standardized critical appraisal instruments for evidence of effectiveness, from the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer.Information was extracted from each paper independently by two reviewers using the standardized data extraction tool developed by the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer.Due to type of designs and quality of available studies, it was not possible to pool quantitative research study results in a statistical meta-analysis. Since statistical pooling was not possible, the findings are presented in a descriptive narrative form.Fifteen studies met the inclusion criteria for this review. The study designs were varied, and included one pilot randomized trial, two quasi-experimental studies, eight descriptive studies/cross-sectional surveys, and four pre-post intervention questionnaires. Findings were inconsistent across studies. Nurses inconsistently enforced visiting policies. In ICU settings, liberalized visiting hours did not increase septic complications. One study reinforced the need for increased patient control over visiting (individual visit contracts, devices). Flexible (open) visitation policies increased patient and visitor satisfaction, and sibling visitation was beneficial to the patient and family. In maternity settings, a 'combination policy' was useful (open visiting for partner, more restricted visiting for others).Key recommendations are provided that refer to clinical practice in critical care, maternity, and general ward settings, as well as recommendations for future research. In critical care settings, policy makers/administrators need to be aware of their staff nurses' beliefs and attitudes about visiting policies, educate them about the rationale for these policies and consider program development to assist nurses to work with families. Open visitation, and ways to increase patient control of visiting should be considered. No connection was found between liberal visiting hours and increased infection rates. When facilitating sibling visitation in the NICU, a pre-visit education process is recommended. Maternity settings may wish to consider a 'combination' policy, where the women's partners and/or significant other would have open visiting (all day), with restricted visiting for others. In other general hospital ward settings, open visiting with a 'quiet hour' is suggested.

Background Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin-resistant Staphylococcus aureus (MRSA) transmission continues to rise. The associated costs of increased hospital stay and patient mortality cause considerable burden to the health system. Objectives This review sought to evaluate the role of reservoirs, particularly the environment and equipment commonly found in the clinical area, in the transmission of MRSA within the acute hospital. This review updates a review previously completed by the authors and published by the Joanna Briggs Institute (2002). Search strategy A systematic search for relevant published or unpublished literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included Medline (1966–August Week 1 2005), CINAHL (1982–August Week 1 2005), EMBASE (1996–Week 33), as well as the Cochrane Library (Issue 3, 2005) and the Joanna Briggs Institute Evidence Library (August 2005). Selection criteria All research reports published between 1990 and August 2005 in the English language that focused on the role of the environment and equipment commonly found in the clinical area on the nosocomial MRSA transmission in adult, paediatric or neonatal acute care settings were considered. Data collection and analysis Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Studies that scored less than the mean quality score were excluded from the review. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Results Forty-two papers met the review inclusion criteria, of which 18 obtained a quality score above the threshold and are included in this review. Seven studies reported general investigations of MRSA in the clinical environment and 11 studies explored specific environmental aspects. All studies used exploratory, descriptive or comparative designs. The evidence suggests that MRSA strains within the environment often match those found in patients within that environment. MRSA can be found in the air around MRSA colonised or infected patients. The degree of airborne contamination is significantly increased by activities that promote airflow. Although the site of MRSA colonisation or infection can influence the degree of environmental contamination, these data are inconsistent. Therefore, there is limited evidence for tailoring infection control interventions based on the sites of MRSA colonisation or infection. The evidence suggests that the type of materials used in clinical equipment can influence the effectiveness of cleaning techniques. Current routine cleaning practices, including conventional terminal cleaning, do not necessarily effectively eradicate MRSA from the environment. This review demonstrates that there is a link between the environment and hospital equipment and the transmission of MRSA within the acute hospital setting. Further well-designed research is urgently required to explore the efficacy of specific cleaning and decontamination methods, staff compliance with infection control practices and the range of factors that affect the incidence of MRSA contamination of the environment and equipment commonly found in the clinical area.

EXECUTIVE SUMMARY:Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists.• To systematically review all high-quality studies which have evaluated the impact of care pathway technologies on 'service integration' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support claims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers, users and evaluators.Types of participants The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services - acute care, rehabilitation and long-term support - in hospital and community settings. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care' Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines. Types of outcomes 'Service integration' was the outcome of interest however, this was defined and measured in the selected studies. Types of studies This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available.This review excluded studies that: • focused only on a single aspect of stroke care (e.g. dysphasia) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purposes of the review • focused exclusively on the outcomes of variance analysisIn order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database and the Cochrane Library were searched to establish that no systematic reviews existed and none were in progress. A three-stage search strategy was then used to identify both published and unpublished studies (see Appendix III).Our search strategy located 2123 papers, of which 39 were retrieved for further evaluation. We critically appraised seven papers, representing five studies. These were all evaluation studies and, as is typical in this field, comprised a range of study designs and data collection methods. Owing to the diversity of the study types included in the review, we developed a single-appraisal checklist and data-extraction tool which could be applied to all research designs.(32) The tool drew on the Joanna Briggs Institute (JBI) appraisal checklists for experimental studies and interpretive and critical research, and also incorporated specific information and issues which were relevant for our purposes (see Appendix VI). This extends the thinking outlined in Lyne et al.(31) in which, drawing on Campbell and Stanley's classic paper, the case is made for developing an appraisal tool which is applicable to all types of evaluation, irrespective of study design. In assessing the quality of the papers, we were sympathetic to the methodological challenges of evaluating complex interventions such as ICPs. We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare contexts. In accordance with the aims of this particular review, we have included studies, which are methodologically weaker than is typical of many systematic reviews because, in our view, in the absence of stronger evidence, they yield useful information.Given the heterogeneity of the included studies, meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is presented.1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner, although these improvements may reflect better documentation rather than actual changes in practice. 2 ICPs can be effective in improving the documentation of rehabilitation goals, documentation of communication with patients, carers (diagnosis, prognosis and follow-up arrangements) and documentation of notification of primary care physicians of discharge. However, this can create additional burdens of work for staff. 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination, morbidity or mortality. These effects do not reach statistical significance, however, and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay. While later studies in the acute and rehabilitation contexts do not reveal any significant reduction in length of stay, they do report greater documented use of certain clinical interventions and assessments, suggesting that ICPs can be effective in mobilising hospital resources around the patient. 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections, although we do not know whether this can be attributed to improved service integration. 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life. 6 ICP management may assist in clarifying role boundaries and a shared understanding of the work, but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation. 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement, but in situations in which multidisciplinary working is effective, their positive effects may be limited. Furthermore, it is far from clear what the active ingredients of ICPs actually are. Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20) 8 None of the studies assessed the balance of costs and benefits of ICP use. Therefore, we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits.Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. (ABSTRACT TRUNCATED)

Background Many acute care facilities report endemic methicillin-resistant Staphylococcus aureus (MRSA), while others describe the occurrence of sporadic disease outbreaks. The timely implementation of effective infection control measures is essential to minimise the incidence of MRSA cases and the magnitude of disease outbreaks. Management strategies for the containment and control of MRSA currently vary between facilities and demonstrate varying levels of effectiveness. Objectives This review sought to systematically review the best available research regarding the efficacy of infection control practices in controlling endemic MRSA or MRSA outbreaks in the acute hospital setting. It updates an original review published in 2002. Search strategy A systematic search for relevant published or unpublished English language literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search of the original review. Databases searched included: Medline, CINAHL, EMBASE, Cochrane Library and Joanna Briggs Institute Evidence Library. Selection criteria All research reports published between 1990 and August 2005 in the English language that focused upon the infection control strategies that were implemented in response to either a nosocomial outbreak of MRSA or endemic MRSA within an acute clinical setting were included. Only studies that reported interventions which were implemented following the collection of baseline data were included. Data collection and analysis Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Data extraction was undertaken using a purposely designed tool. Given the heterogeneity of the interventions and outcomes measures, statistical comparisons of findings were not possible, therefore, the findings of this review are presented in a narrative format. Results Fourteen papers met the inclusion criteria for this review. Of these, 11 papers achieved a quality score above the threshold and were included in the review. Of the included papers, five describe MRSA outbreaks, while the remaining six describe endemic MRSA. All included studies used either exploratory descriptive or comparative designs.The varying combinations of interventions described in the included studies make it impossible to differentiate the efficacy of individual or even groups of interventions.The fact that most studies reported positive findings may reflect the bias towards publication of effective interventions. Implications for clinical practice This review provides evidence that the use of multifaceted strategies can reduce nosocomial MRSA transmission in both outbreaks of MRSA and settings where MRSA is endemic. The heterogeneous nature of the topic, combinations of interventions implemented and methodological weaknesses of the studies impairs the ability to aggregate data and develop specific recommendations for practice.

Background Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions,including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness. Objectives This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors. Search Strategy A systematic literature search was performed using Medline (1966 – 2005), CINAHL (1982 −2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials. Selection Criteria This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness. Results Eighteen trials, reported in 33 papers, were included in the review.Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions. Conclusions While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost effectiveness

this issue of Medical Care, Kane and colleagues1 present a meta-analysis of an important subsection of the literature on the relationship between nurse staffing levels and patient outcomes, specifically, papers dealing with registered nurse staffing levels in acute care facilities. Their paper is particularly interesting when considered alongside the Institute of Medicine's report entitled, "Nurse Staffing in Hospitals and Nursing Homes: Is It Adequate?" that was published slightly more than a decade ago.2 The authors of that 1996 report concluded at that time there was little empirical evidence that staffing and safety were tied to each other and strongly recommended further research. Researchers and funding agencies heeded that call. To date, researchers have made innovative use of a variety of data sources on staffing and outcomes and have generated a body of well over 100 papers. Here, the authors reviewed 27 of these reports that dealt with registered nurse to patient staffing ratios and reported associations in a statistical form that allowed direct comparisons. A meta-analysis of this kind is, by necessity, the product of many layers of decisions. However, even if readers question specific details (and different readers may challenge different details), the bottom line from this paper is very similar to that reached by earlier reviews that did not attempt the type of quantitative synthesis that these authors conducted.3"5 Simply put, researchers taking a variety of approaches have found that registered nurse staffing levels are often, but not always, connected to outcomes in acute care hospital patients. A connection between staffing levels and outcomes has now been identified often enough that it is difficult to dismiss out of hand, particularly because the results square with a line of logic that says if staffing levels affect the amount and quality of work that nurses can do, and if nurses' work affects patient welfare, staffing levels should affect patient outcomes, at least at the lowest margins. However, as noted in the paper, there are still a great many unanswered questions about mechanisms and causality in the staffingoutcomes relationship. When staffing levels are higher, are better outcomes generally observed because patients receive more nursing care? Is the nursing care being delivered superior in quality? Or does the relationship when observed actually reflect the operation of external variables not thoroughly accounted for by studies to date? Questions arise not just because of the correlational designs used in the studies, but also from inconsistent results within and across studies. What explains both the inconsistencies and clusters in the types of staffing measures and patient outcomes that have been linked in different studies? Why have researchers seemingly been able to find more associations between nurse staffing and patient outcomes in surgical and intensive care units than in patients admitted for nonsurgical problems or to settings other than acute care? Is this a "real" trend reflecting a greater vulnerability of surgical and intensive care unit patients to aspects of nursing care affected by low staffing, or are acute care patients in other types of units just as vulnerable to poor outcomes, but

BACKGROUND Burnout has been a chronic problem in the workplace, especially in health care. Although the literature has examined many antecedents to burnout, specific workplace practices to reduce burnout remain elusive. Nascent research has begun to examine how health care work places can become more caring for workers. Although psychological safety has been proposed as an important predictor of burnout, relations have not yet been comprehensively examined. PURPOSE Underpinned by conservation of resources theory, we argue that a caring work environment, in which compassion and interpersonal support are key priorities, provides resources for workers, which should increase psychological safety and in turn help reduce emotional exhaustion. METHOD To explore our proposed model, we conducted a paper-and-pencil survey of clinical health care providers working in medical units of a large acute care hospital. Response rate was 44% (n = 631). RESULTS Analysis found support for a moderated-mediation model in which psychological safety partially mediated relations between caring climate and emotional exhaustion, and this effect was stronger for those who were less empowered in their jobs. CONCLUSION Our findings suggest that a caring work environment holds psychological resources that may help buffer against resource losses through increased psychological safety. PRACTICAL IMPLICATIONS Although health care work environments will continue to experience constraints on key resources, worker emotional exhaustion may be mitigated through a focus on systematically increasing caring and compassion in the work environment, as opposed to relying on individual workers to support one another in an uncaring workplace.

Objective The objective of this scoping review is to investigate use of patient reported experience measures and patient reported outcome measures within the acute health care context. Introduction Data from patient reported outcome measures and patient reported experience measures provide important information for health professionals and organizations in order to improve patient-centered care. These two measures have potential to narrow the gap between the clinician's and patient's views and help tailor treatment plans to meet the patient's preferences and needs. Inclusion criteria This scoping review will consider studies that include patients of any age and any condition who have obtained care from any acute health care facility. The concepts of this review are: the types of research studies that have been done using patient reported experience measures and patient reported outcome measures data in acute hospital settings, the geographical contexts of these two measures' studies, the barriers and facilitators that have been identified in studies that use data from the measures, the characteristics of patient reported experience measures and patient reported outcome measures data and the ways in which these types of data have been applied to clinical practice in acute care settings. This review will consider studies that are set in any acute health care setting including inpatient and outpatient areas, emergency departments, and critical care units. Methods This scoping review, utilizing JBI methods, will include an extensive search of the databases for published and unpublished literature. The review will consider any type of quantitative, qualitative, or mixed methods research evidence as well as systematic reviews to understand how hospitals use patient reported experience measures and patient reported outcome measures data in health care. Each included study will be assessed by two independent reviewers and data will be extracted from included papers using a standardized data extraction tool.

PURPOSE OF STUDY The specific aims of this descriptive study were to (1) examine the relationships between individual-level determinants of health using standard care admission assessments of residents admitted to a skilled nursing facility (SNF) and those residents readmitted to the hospital within 30 days from discharge from the same SNF; (2) identify and describe the risk factors of the residents readmitted to the hospital within 30 days; and (3) use the findings to inform and refine current practice to target the mutable risk factors correlated with 30-day hospital readmission. PRIMARY PRACTICE SETTING A 180-bed skilled nursing center in Northeastern Pennsylvania. METHODOLOGY AND SAMPLE A retrospective paper medical record review of patients discharged from an SNF to community living was conducted to examine the relationship between individual determinants of health behaviors and 30-day hospital readmissions. The study sample (N = 221) included adults 65 years and older who were admitted to the SNF from January to December 2014 for subacute physical rehabilitation following an acute care hospital stay with a discharge plan to community living. RESULTS The 30-day readmission rate was 11%. The results of the logistic regression including diagnosis at readmission showed that the odds of readmission before 30 days were nearly three times greater in patients who had congestive heart failure (p < .02). Patients who were at "very high risk" on the Braden Scale were 20 times more likely to be readmitted before 30 days compared with those at low risk. Age and gender were not predictors. None of the other standard screening assessments for delirium, depression, functional status, and fall risk were predictive of 30-day readmission. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE (1) Care coordination and communication with residents, caregivers, and home health can have an impact on 30-day readmissions post-SNF discharge. (2) Chronic respiratory diseases continue to be a challenge in prevention of hospital readmissions.

Prevention of hospital-acquired pressure injuries (HAPIs) remains a crucial clinical challenge especially for those patients undergoing surgery. The purpose of this project was to examine whether a 5-layer silicone foam dressing applied to the sacrum of patients undergoing vascular surgery decreased the occurrence of sacral pressure injuries and to explore participant characteristics associated with the development of operating room (OR)-related pressure injuries. A pre-/postintervention design, quality improvement project in a convenience sample of 81 patients undergoing vascular surgery, in a 700-bed level I trauma acute care setting, in the Northeastern United States. Eighty-one patients undergoing vascular surgery participated in this project. Thirty-seven were in the preintervention group who were identified from the housewide pressure injury prevalence data from May and December 2010 and received standard pressure injury prevention while hospitalized. Forty-four patients in the intervention group were identified from a hospital-based outpatient vascular surgery office and preoperatively received the 5-layer silicone foam dressing in addition to standard care. Data were collected on the third and seventh postoperative days via the electronic medical record and paper medical records. Collected data included age, gender, comorbidities (diabetes, hypertension, peripheral vascular disease and, smoking status), presence of a 5-layer silicone sacral foam dressing, and pressure injury occurrence. Analysis included descriptive statistics, Fisher exact test to compare groups, and logistic regression to identify associated risk factors. More than 50% (n = 19) in the preintervention group developed a hospital-acquired pressure injury while only 1 subject (n = 2%) in the intervention group developed a hospital-acquired pressure injury (P = .000). Findings indicate that, after controlling for age, gender, and other comorbidities, application of a 5-layer silicone sacral foam dressing significantly reduced the likelihood of development of a new pressure injury (OR= 0.04, 95% confidence interval, 0.00-40; P = .006). This pre-/postquality improvement project, using a 5-layer silicone sacral foam dressing in addition to standard operating room pressure injury preventive interventions, for elective vascular surgical cases, resulted in a significant decrease in sacral operating room-related pressure injuries. These findings suggest the effectiveness of a 5-layer silicone foam dressing when added to standard preventive interventions. The findings warrant further investigation of additional preventative interventions in the OR specific to high-risk populations.

Introduction Despite three million adults in the United States (US) being admitted annually for emergency general surgery (EGS) conditions, which disproportionately affect vulnerable populations, we lack an understanding of the barriers to round-the-clock EGS care. Our objective was to measure gaps in round-the-clock EGS care. Methods From August 2015 to December 2015, we surveyed all US-based, adult acute care general hospitals that have an emergency room and ≥1 operating room and provide EGS care, utilizing paper and electronic methods. Surgeons or chief medical officers were queried regarding EGS practices. Results Of 2,811 hospitals, 1,634 (58.1%) responded; 279 (17.1%) were unable to always provide round-the-clock EGS care. Rural location, smaller bed size, and non-teaching status were associated with lack of round-the-clock care. Inconsistent surgeon coverage was the primary reason for lacking round-the-clock EGS care (n=162; 58.1%). However, lack of a tiered system for booking emergency cases, no anesthesia availability overnight, and no stipend for EGS call were also associated with the inability to provide round-the-clock EGS care. Discussion We found significant gaps in access to EGS care, often attributable to workforce deficiencies.

INTRODUCTION: The surge of SARS-CoV-2 patients presenting to New York City (NYC) hospitals quickly overwhelmed and outnumbered the available acute care and intensive care resources in NYC Upon arrival of military medical assets to the Javits Convention Center in New York City, more than 100,000 local residents had already been infected and 5,000 residents had died METHODS: The JNYMS (Javits New York Medical Station) constructed by the Army Corps of Engineers with a capacity to house more than 4,000 patients Healthcare professionals from every branch of the uniformed services, augmented by state and local resources, staffed the JNYMS for April, 2020 All patient demographic data was collected on a computerized registry (maintained by the NY Department of Health) and clinical documentation was done using paper charts RESULTS: During the 28 days of patient intake at the JNYMS, 1,095 SARS-CoV-2 patients were transferred from NYC hospitals At its peak, the JNYMS accepted 119 patients in a single day (Figure 1), had a maximum census of 453, and had a peak ICU census of 35 The median length of stay was 4 6 days [IQR: 3 1-6 9 days] 103 patients [9 4%, 95% CI 7 7-11 3] were transferred back to local hospitals (87) or the USNS Comfort (16) There were 6 deaths, for an overall mortality rate of 0 6% [95% CI 0 3-1 2] however 27 ICU patients were transferred back to NYC hospitals, half were on ventilators and the majority were critically ill CONCLUSIONS: This is the first report of the care provided at the JNYMS Within 2 weeks, this multi-agency effort was able to mobilize to care for over 1000 SARS-CoV-2 patients with varying degrees of illness in a one-month period This large-scale mobilization at the height of the epidemic in NYC saved many more lives, as high-level medical care was afforded patients that would have over-loaded New York hospitals It allowed them to decompress while offering much needed healthcare provider relief In addition to the volume of patients cared for over this short period of time, this circumstance is unique in that this field hospital provided ICU level of care Notably, the JNYMS was able to discharge SARS-CoV-2 patients home in under 5 days, with a full supply of their required medications, thus freeing up NY City case management resources for other patients

PURPOSE The purpose of this study was to identify pressure injury knowledge in critical care nurses related to prevention and staging following multimodal education initiatives. DESIGN Postintervention descriptive study. SETTING AND SAMPLE The sample comprised 32 RNs employed in medical intensive care/coronary intensive care or surgical intensive care units. The study setting was a 237-bed Veterans Affairs acute care hospital in the Midwestern United States. METHODS Critical care RNs were asked to participate in this project over a 3-week period following a multimodal 2-year education initiative. Nurses completed the paper version of the 72-item Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) to determine pressure injury knowledge level. Calculated mean cumulative scores and subscores for items related to prevention and staging, respectively. Pearson correlations were used to examine associations between nursing staff characteristics and the PZ-PUKT prevention and staging scores. RESULTS The cumulative score on the PZ-PUKT was 51.66 (72%); nurses with 5 to 10 years' experience had a higher mean score than nurses with experiences of 20 years or more (mean ± SD = 54.25 ± 4.37 vs 49.5 ± 7.12), but the difference was not statistically significant. Nurses scored higher on the staging system-related items as compared to the prevention-related items (81% vs 70%). Nurses achieved higher staging subscale scores if they were younger (r =-0.41, P < .05), had less experience (r =-0.43, P < .05), and if they worked in the medical intensive care unit (r = 0.37, P < .05). CONCLUSIONS Study findings indicate gaps in knowledge related to pressure injury practice; participants had greater knowledge of staging rather than prevention. Cumulative and subscale findings can be used to direct educational efforts needed to improve and maintain an effective pressure injury prevention program.

Review question/objective What is the experience of partnership between healthcare professionals (doctors and nurses) and consumers/patients in relation to hand hygiene compliance in the acute adult hospital setting? Inclusion criteria Types of participants This review will consider qualitative (critical or interpretive) studies and text or opinion based papers that include in-patients and healthcare professionals (doctors and nurses) in the acute care hospital setting. Types of intervention(s)/phenomena of interest This review will consider studies that investigate the experience of partnership between patients/consumers and healthcare professionals (doctors and nurses) in relation to hand hygiene compliance. This review will investigate the phenomena of partnering from both the perspective of the patient/consumer and the health care professional.

BACKGROUND AND PURPOSE:Todays physical therapists (PTs) are confronted by a complex set of insurance and regulatory requirements. Third parties such as Medicare, Medicaid, and private health insurers pay the majority of claims for physical therapy services. These third-party payers impose restrictions on the provision of physical therapy services in the forms of financial caps, deductibles, copayments, coverage limitations, and benefit restrictions that may change on an annual basis. Restrictions such as these have affected access, frequency, and duration of services provided by a PT. In addition, with the gradual implementation of the Patient Protection and Affordable Care Act (PPACA),1 clinicians have an unprecedented need to understand current health care and insurance policy regulations to provide patients quality care in an efficient manner.There has been a coinciding call for educators in multiple health professional fields to enhance learning experiences on health care policy, health systems, and cost containment strategies2. Patel et al3 studied the responses of 58,294 United States medical graduates and reported that less than half of the respondents believed they had been appropriately educated in the practice of medicine, defined as medical economics, health care systems, managed care, practice management, and medical record keeping. Although there is no existing literature describing PT student perception of their preparation in practice management, it is reasonable to expect that the results would be similar and that increased attention to this area in professional level PT education is warranted. Jette et al4 investigated occupational therapist (OT) and PT clinical decision-making for patient discharge planning from acute care settings and noted that insurance policy and regulations are important factors considered by hospital staff during discharge planning. They suggested that academic programs should consider if students, prior to internships, are sufficiently prepared for clinical decision-making that includes consideration of financial resources and regulations.The authors of this paper believe that practice management content (eg, documentation, insurance policy, and regulations) should be incorporated into the learning process as a component of clinical decisionmaking rather than as an isolated course. As the students learn to develop clinically sound plans of care, they should consider applicable insurance and regulatory policies that directly affect the care as they collaborate with the patient and other health care providers. By threading the material throughout the professional level physical therapy curriculum, students have the opportunity to contextualize this knowledge in the practice area they are studying, incorporate the information into their clinical decision-making and patient management skill set, and create a more realistic plan of care that may lead to improved outcomes.The purpose of this manuscript is to describe a case-based reasoning (CBR) approach to enrich student learning in insurance, regulations, and documentation in a professional level PT education program and assess the outcome of the instruction on student clinical performance. In addition, participating faculty perceptions were assessed to determine the effectiveness of the curricular changes. Specifically, the authors describe a CBR approach that uses active learning methods, progressively complex case studies, and clinical reasoning to integrate insurance, regulatory, and documentation content into a professional level PT education curriculum.Case-Based Reasoning (CBR): An Opportunity for IntegrationContemporary education theorists have shown that learning is most effective when students are involved in real-life, situational learning activities.5,6 Students participating in educational endeavors using problem, project, and CBR methods are more motivated to learn, use information effectively, and develop higher order thinking skills than those that are exposed to teaching methods using rote memory. …

Background: Patients who experience acute stroke often have complex discharge planning needs that impact transitions of care. The hectic acute care hospital environment is not always conducive to addressing these needs in a standardized fashion. Purpose: To improve communication among team members and identify potential post-acute needs early in the hospital stay. Ultimately we hoped to have a positive impact the readmission rate and the patient experience. Methods: We designed a structure for daily rounds, identifying who would attend, setting clear expectations, and having a consistent schedule. We piloted a paper based check list that would serve as a guide to the dialogue during daily rounds to ensure that the team addressed key issues in a step wise, standardized fashion. This process also included the patients and families and their goals of care. Results: Readmissions were reduced from 15.4% to 10.9%. HCAHPS scores improved, specifically "Discharge Information" from 70% to 94% and "Communication with Nurses" from 46% to 83%. Conclusions: For a patient population with complex discharge needs, transitions of care can be improved by implementing a daily rounding checklist. This could positively impact the readmission rate and the patient experience.

INTRODUCTIONThe goal of physical therapist education programs is to prepare practitioners to evaluate and treat movement dysfunction for individuals across the lifespan.1 The US Census Bureau projects that by 2050 the number of persons over age 65 in the United States is expected to reach 88.5 million-nearly double the 40.2 million persons over that age in 2010. 2 In 2008, the Institute of Medicine (IOM) of the National Academies published recommendations for preparing and growing the health care workforce in preparation for a graying America. This report emphasized the need to improve the geriatric-specific competence of health care workers, increase the number of geriatric specialists in all health professions, and develop new models for geriatric care delivery.3As the older segment of the population grows, so too does the proportion of older adults comprising the caseload of the typical physical therapist. The 2006 Practice Profile Survey from the American Physical Therapy Association tracked the mean percentage of patient care time spent with individuals by age group.4 "Older persons" (age 65 and over) comprised a majority of patient care time per week by practice setting, including: approximately 82% in skilled nursing facilities, 60% in home care, 54% in sub-acute rehabilitation hospitals, 52% in acute care hospitals, 31% in hospital-based outpatient clinics, and 27% in private practice. Specialized training is essential in both the academic and clinical environments to prepare physical therapist graduates to meet the needs of the older adult population across health care settings.John Rowe, chairman of the National Academy of Sciences Committee on the Future Healthcare Workforce for Older Americans, emphasized the need for all health care workers to demonstrate basic competence in geriatric care. This competence necessitates "significant enhancements in educational curricula and training programs"3(p xii) available to health care providers.3 A number of curriculum development models for physical therapist professional education have been described in the literature.5"9 These models discuss the development of curriculum on a larger program-level scale, considering factors that extend across academic courses of a given program. Shepard and Jensen discuss a general framework for stand-alone course design through their "preactive teaching grid."7 The grid helps instructors to consider 10 different dimensions of instructional design, such as teaching methods, assessments, student preferences, and learning environment, in preparation for a course or single learning event. Models for content-specific course design in physical therapy, including geriatric physical therapy, are limited.10'13The purpose of this paper is to describe and evaluate a model for the design, development, and implementation of a dedicated course in a Doctor of Physical Therapy (DPT) program on the management of the aging adult. Educational theory that promotes student engagement, reflective practice, clinical decision making, and problem solving will be presented, followed by how these educational principles were incorporated into the course design. Grounded in educational principles, this model optimizes learning and preparedness for geriatric physical therapist clinical practice. The following describes the theoretical framework as the basis for this course design model, application of the design process to a course on the management of the older adult, and evaluation of the course outcomes to determine the efficacy of this model. We apply the model to a geriatrics course, but the model may be used to design or redesign courses related to a broad array of didactic content areas.Theoretical FrameworkCourse development is an iterative process requiring continuous assessment and alignment of objectives, instructional methods, and learner outcomes, incorporation of learner feedback, and integration of current evidence and trends in clinical practice (Figure 1). …

Asymptomatically colonised MRSA carriers serve as a substantial reservoir for person-to-person transmission of MRSA in the acute care setting. Although many studies have evaluated prognostic risk factors for MRSA colonisation on patient admission to an acute care setting, a comprehensive review of all the prognostic risk factors was not identified in a preliminary search of the literature.A systematic review was performed to identify and evaluate the association between risk factors and MRSA colonisation.Studies that included all adult patients on admission in acute care settings were considered in this review.All independent risk factors of MRSA colonisation were analysed in this review.Cohort and case-control studies are main designs associated identifying the independent risk factors for MRSA colonisation.The primary outcome of interest was presence and absence of MRSA on admission, and then independent risk factors associated with MRSA colonisation on admission were identified.MEDLINE, EMABSE, and CINAHL databases were searched for prognostic studies published between 1990 and 2010 that examined the association between risk factors and MRSA colonisation. The search included both published and unpublished studies written in the English language.Included studies were assessed using a standardised critical appraisal instrument that was developed for prognostic studies in infection control field.Data were collected from included papers in the review using the standardised data extraction tool from the JBI SUMARI Program; and the data extraction form was modified based on the characteristics of prognostic studies for infection control.All risk factors in included studies were aggregated depending on their clinical characteristics. Data of any aggregated factors was pooled into meta-analysis based on univariate estimates and multivariate estimates separately when more than two groups of data in selected studies were available.Fifteen prospective studies, including a total 16,467 patients, were eligible for inclusion in the meta-analyses. More than 30 independent risk factors were identified and aggregated. The risk factors associated with MRSA colonisation in the meta-analyses include hospitalisation within the last 24 months, previous admission to a long-term care facility (LTCF) or a rehabilitation facility within the last 18 months, antibiotic use within the past 12 months, the presence of skin lesion, surgical intervention within the last 60 months, indwelling urinary catheter, intensive care unit (ICU) admission in the last 5 years, previous MRSA colonisation, intra-hospital transfer, male sex, comorbidity of chronic health evaluation class C or D, and the presence of fatal illness.The identification of risk factors for MRSA colonisation on admission may contribute to improved effectiveness and efficiency of current MRSA prevention strategies and control MRSA spread and acquisition in acute care settings. The outcomes of this review may facilitate prediction model development to quickly identify potential MRSA carriers before admission.

Information technology to aid reduction in medication errors has been encouraged over the years and one of them is the medication administration technology. It consists of the electronic Medication Administration Record, Bar-Code Medication Administration system and Automated Medication Dispensing system. Studies had examined the effectiveness and impact of this technology to reduce medication error. However, user's acceptance towards this technology has often been neglected. To date, no systematic review has been undertaken to examine the possible factors that affect nurses' use of this technology in the acute care settings.The objective of this systematic review was to explore and determine the factors that affect nurses' use of medication administration technology in the acute care settings.All quantitative studies published in English which examined factors affecting nurses' use of the medication administration technology were considered.Primary focus was on registered nurses with experience of operating medication administration technology in the acute care settings. Other healthcare personnel were excluded.This review considered studies that evaluated factors affecting nurses' use of the medication administration technology.The outcome measures of interest were the factors that affect nurses' use of the medication administration technology in the acute care settings.The search was conducted across published and unpublished databases. A search was conducted in JBI Library of Systematic Reviews, The Cochrane Library, CINAHL, MEDLINE, Scopus, ScienceDirect, Wiley InterScience, SpringerLink, PsycINFO (ovid), Web of science, ProQuest Dissertations and Theses, and MedNar.Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review, using the standardised critical appraisal instruments developed by the Joanna Briggs Institute.Quantitative data were extracted from papers included in the review using a standardised data extraction tool developed by the JBI.Findings were presented in narrative summary due to heterogeneity of the study designs.Six descriptive studies were included in this review. Nurses' use of the technology can be influenced by a combination of complex and inter-related factors, such as organisational factors, and user and system characteristics.In order to successfully implement medication administration technology, system, user and organisational factors have to be collaborated concurrently.Users' needs should be accommodated when designing the system features. Prior to system implementation, institutions should consider the users' demographical characteristics and provide adequate preparations and training. A supportive culture from the institution and colleagues is also important.There is a significant need for further research in this field. Further research to discover potential factors in different settings, locations and countries are suggested. Studies to evaluate nurses' use of the technology at regular intervals are also required.

Physical restraint was introduced as the primary measure to maintain patient safety in preventing falls. However, physical restraints may lead to complications such as functional loss, immobility, delirium, pressure sore, and even falls or injuries. Despite all these negative effects and many alternatives that are available, physical restraint is still commonly used in hospitals and nursing homes. Hence, it is crucial to understand the effectiveness of physical restraints in protecting adult patients from falling.The overall objective was to examine the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes.This review considered quantitative designs, including randomised controlled trials, quasi-experimental studies, cohort studies, case control studies and case series/reports.The participants of this review were male and female adult patients aged 18 years or over who are on authorized physical restraints in acute care hospitals and nursing homes.This review focused on studies that investigated physical restraint as an intervention for reducing falls among adults in acute care hospitals and nursing homes.The outcomes of interest were the number of individuals receiving restraints who fall, or the rate or number of falls in acute hospitals and nursing homes.A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken, followed by a second search using all identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. All searches were limited to English Language studies and there was no limit in the timeframe.The quality of the included studies was subjected to assessment by two independent reviewers using the standardised critical appraisal tools from the Joanna-Briggs Institute from the JBI-MAStARI (Joanna Briggs Institute-Meta-Analysis of Statistics Assessment and Review Instrument).Data was extracted from included papers using the standardised extraction tool from the JBI MASTARI.Due to the heterogeneous nature of the study methods, the findings of this review are presented in a narrative summary.Nine studies were included in the review. The majority of the findings showed that physical restraints were not associated with the reduction in falls and decreased restraint use did not contribute to more falls.From the overall results, physical restraints are not effective in reducing falls or injuries among adults in acute care hospitals and nursing homes.National standards and application guides for physical restraints are recommended. The use of physical restraints should be assessed by trained staff based on individualised need and consideration of patient's autonomy and integrity. The awareness of appropriate physical restraint usage should be enhanced among the healthcare professionals.Large multicentre research to determine the risk and benefit ratio of physical restraints and to examine the effectiveness of alternative measures, different number of bedrails, intermittent restraint use and restraint reduction programs are needed respectively.

Clinical incident reporting is an integral feature of risk management system in the healthcare sector. By reporting clinical incidents, nurses allow for learning from errors, identification of error patterns and development of error preventive strategies. The need to understand attitudes to reporting, perceived barriers and incident reporting patterns by nurses are the core highlights of this review.INCLUSION CRITERIA: This review considered descriptive quantitative studies that examined nurses' attitudes or perceived barriers towards incident reporting.The participants in this review were nurses working in acute care settings or step-down care settings. Studies that included non-nursing healthcare personnel were excluded.This review considered studies which examined nurses' attitudes towards incident reporting, perceived barriers and incident reporting practices.The outcomes of interest were the attitudes that nurses have towards incident reporting, perceived barriers and the types of reported incidents in correlation with nurses' attitudes and barriers.A three-step search strategy was utilised in this review. An initial limited search of CINAHL and MEDLINE was undertaken. Search strategies were then developed using identified keywords and index terms. Lastly, the reference lists of all identified articles were examined. All searches were limited to studies published in English, between 1991 and 2010.The studies were independently assessed by two reviewers using the Joanna Briggs Institute Critical Appraisal Checklist for Descriptive/ Case Series studies.The reviewers extracted data independently from included studies using the Joanna Briggs Institute Data Extraction Form for Descriptive/ Case Series studies.Due to the descriptive nature of the study designs, statistical pooling was not possible. Therefore, the findings of this systematic review are presented in a narrative summary.Fifty-five papers were identified from the searches based on their titles and abstracts. Nine studies were included in this review. Cultural and demographic factors were the most significant factors in affecting nurses' attitudes towards incident reporting. Major perceived barriers included fear, administrative issues, and the reporting process. Also, nurses were more likely to report incidents that caused direct harm, and if reporting was kept anonymous.This review demonstrated that attitudes of nurses towards incident reporting vary across different study settings, with perceived barriers hindering the reporting process. Using the findings, interventions can be customised to increase reporting rates can be developed to curb the problem of underreporting.A non-punitive culture towards incident reporting has to be cultivated, and nursing authorities should provide frequent positive feedback to staff who reported incidents. Investigating system errors should be the focus rather than individual blame.Further research should target the development and evaluation of strategies to increase rates of incident reporting. Any differences between actual and perceived reporting rates should also be explored.

Background and Purpose: The projected increase in persons with advanced heart failure and associated costs warrant the examination of exercise in patients receiving inotropic therapy. Literature supports the use of exercise and inotropic therapy in the treatment of patients with advanced heart failure. The purposes of this paper are to illustrate the use of exercise prescription and outcomes assessment with a 6-minute walk test in a patient with acute decompensated heart failure receiving tailored therapy with dobutamine and to discuss potential relationships resulting in observed improvements. Case Description: A 67-year old man was admitted to an acute care hospital with acute decompensated heart failure for tailored medical therapy including dobutamine. The patient received 14 days of tailored medical therapy, of which 12 days included exercise training by a physical therapist. Outcomes: Functional outcomes showed a clinically significant improvement in distance walked and improvement in the cardiorespiratory response. The improvement in estimated peak oxygen consumption was 7% greater than that predicted to be from tailored medical therapy. Discussion: Exercise was safely provided to a patient hospitalized with advanced heart failure on continuous inotropic therapy. The 6-minute walk test was effectively used to prescribe exercise and examine patient outcomes.

Review Objective The principle objective of this review will be to critically appraise and present the best available evidence for setting different levels of vacuum / suction pressures when patients are receiving endotracheal suctioning. Specifically the review will seek to answer the following questions. What is the best evidence for regulating vacuum pressure in the performance of endotracheal suctioning? What is the best evidence for regulating vacuum pressure for endotracheal suction as opposed to setting no regulated pressure in the performance of endotracheal suctioning? What is the best evidence for a limit to which vacuum should be regulated for endotracheal suction? To what extent does the developed airflow impact on the safety and effectiveness of the suction apparatus? Inclusion Criteria Types of Participants Patients receiving mechanical ventilator support through endotracheal tube or tracheostomy in the acute care setting. Participants may present with a variety of pathologies but studies will not be excluded on the bases of diagnosis. Patients may require intubation and endotracheal suctioning at any age; vacuum applied in the performance of suction may have health implications and be of interest to the clinician. Papers regarding either spontaneously breathing and/or machine ventilated subjects will be also included so long as the participants require endotracheal suctioning in the acute stage of their hospitalisation. Types of intervention / Phenomena of interest The setting of a level of vacuum / suction pressure, taking into account the developed flow, to facilitate safe endotracheal suctioning in the acute care setting of the Intensive Care unit, High Dependency or Emergency Area will be examined. Types of outcomes Outcomes related to mortality, morbidity, and health benefits of regulating suction / vacuum pressure as opposed to having no regulation, i.e. Using the unguarded wall outlet, will be sought. The effects of negative pressure within the tracheo-bronchial tree including Atelectasis; Reported and shown by radiological exam as early as the 1940’s Pulmonary haemorrhage has been seen with rapid decompression of segmental lung, with mechanical trauma from catheter impaction or sudden explosive decompression. TRUNCATED AT 350 WORDS

Background Pressure ulcers remain a serious problem for patients and providers in healthcare. When a pressure ulcer develops, it can inflict pain and cause untoward complications such as severe infections, surgery, prolonged hospital stay and even death. Objective The objective of this review was to establish whether using the Braden subscale mobility assessment is comparable to using the full Braden pressure ulcer risk assessment scale. However, due to lack of research studies, the focus of this review was extended to include the use of other assessment tools for hospital acquired pressure ulcer risk. Inclusion Criteria Types of Studies Quantitative studies that reported data on mobility and pressure ulcer development or preventive interventions, irrespective of their design were included in the review. Types of Participants The review focused on adult patients admitted to an acute care facility, who underwent a pressure ulcer risk assessment, and had no pressure ulcers on admission. Types of Interventions This review considered studies that use Braden mobility subscale assessment Types of Comparator This review compared the use of full Braden risk assessment scale where available only when it was included within the same study, Types of Outcome Measures This review considered: • Incidence of hospital acquired pressure ulcers • Endorsement or initiation of preventive interventions • Reliability of Braden mobility subscale assessment to identify patients at risk of developing pressure ulcer with or without Braden assessment. For the purposes of this systematic review, reliability of the mobility scale means predictive validity. • Frequency of using Braden mobility subscale assessment Search Strategy A search for published and unpublished studies from 2000 to 2010 of major healthcare related electronic databases was conducted. Studies in other languages that were translated into English were included in the review. Assessment of Quality The papers that were selected for possible inclusion were assessed by two independent reviewers for methodological validity using standardised critical appraisal instruments from the Joanna Briggs Institute. Data Collection and Analysis Data from included studies were extracted and analysed using Revman5 software. Results and Conclusions Eighteen studies were included in this review. The findings suggest that the risk of pressure ulcer development was higher when the patient was identified as having impaired mobility, as assessed using the Braden subscale mobility or other similar mobility scales. However, there is little conclusive evidence to indicate that using mobility assessment alone is comparable to using Braden or other risk assessment scales in reducing the incidence of pressure ulcer. Evidence for association between assessment of mobility and endorsement of preventive interventions was significant. However, this finding was based on only one study. No evidence found on the reliability of mobility assessment as a tool to predict pressure ulcer risk. Nor was there evidence on the frequency of assessment using the mobility assessment tool.

Levels of medication administration error have been reported as accounting for 38% of all adverse drug events and have been calculated as occurring in 3-8% of all administrations. The majority of these will occur as part of "routine" administration.To undertake a systematic review of roles and systems for preventing medication error during routine medication administration in hospital-based acute care settings and of perceptions of causes of error.Types of participants- Participants were nurses, pharmacists, pharmacy technicians, medical and surgical staff and adult patients in hospital-based, acute care settings.Types of intervention/Phenomena of interest- Intervention related to administration systems and related to roles of those who administer medicines were considered. The perceptions of causes of error was the phenomena of interest.Types of outcomes- 1) Number of medication administration errors, and 2) Nurses and patients' perceptions of causes of medication errorTypes of studies- Quantitative studies of medication error rates for differing medication systems and roles of those administering medications. Qualitative and descriptive studies of perceived causes of errors.The review sought studies published in English from 1990 to December 2008. 23 databases, websites and search engines were searched.Critical appraisal tools from Joanna Briggs Institute were used. Two reviewers appraised studies independently. 35 studies out of 1004 identified papers were critically appraised. 19 studies met the inclusion criteria.Data were extracted using standardised extraction forms.It was not possible to undertake meta-analysis due to lack of studies in all categories and lack of similarity between studies. Quantitative results were combined in a narrative summary. Qualitative studies were synthesised accordingly using a meta-aggregative approach.Nurses perceptions of medication administration errors suggest that ineligible prescriptions and distractions/interruptions (external factors) are perceived as key causes of error. Limited evidence on patient perceptions, suggest that their inclusion in routine medication administration may reduce errors.Studies related to routine medication administration roles and systems are small and lack power and generalisability to all acute care contexts. What evidence exists suggests routine medication that is individualised to the patient and administered close to the bedside, reduces error.There is equivocal evidence related to differing roles of nurses. The use of dedicated medication nurses and primary administration (nurse administers "own" patient medications) are inconclusive. Equivocal evidence related to three system types was identified: self administration; trolley, bay and bedside systems; individualised and unit dose medications.There is no evidence of effectiveness related to one or two nurse checking or related to the use of devices to reduce distractions, such as signs or tabards.Administration from individually labelled medication, administered close to the patient, appear to be the most significant factors in reducing errors during routine medication rounds. Nurses' perspectives on causes of medication errors, may differ from those recorded. There is no conclusive evidence that manipulating the nursing role has any impact on errors.Implication for practice- Individual or patient dose systems used with administration occurring as close to the patient as possible. Including the patient more fully in the administration process through self administration or involvement in the checking process has some potential for reducing errors.Implication for research- The review identifies the need for rigorous large scale further research.

In September 2008, nurse executives from around the country met in Scottsdale, Ariz, to develop practical tools and recommendations for "Driving Patient Safety Through Transformation," the theme of the fourth annual Nursing Leadership Congress. The Congress was made possible through an educational grant from McKesson and Intel in collaboration with sponsorship from the American Organization of Nurse Executives, Institute for Safe Medication Practices and National Patient Safety Foundation. This paper summarizes the Congress plenary sessions and roundtable discussions. Plenaries included the following: *Transformational Leadership: The Role of Leaders in Managing Complex Problems *Using the Baldrige Business Model as the Infrastructure for Creating a Culture of Patient Safety *Prospects for Structural Reform in Health Care Roundtables included the following: *Joy and Meaning in Work *Managing Chronic Care Across the Continuum *The Future of Acute Care Delivery in Light of Changing Reimbursement* Leveraging Transparency to Drive Patient Safety *Collaborative Partnerships for Driving a Patient Safety Agenda *Innovative Solutions for Patient Safety *Implementing the Fundamentals of the Toyota Production Model forHealthcare

Review Objective The aim of this review is to identify the scope of published qualitative studies on the factors, which influence and shape individual’s lived experience of stroke. By reviewing, appraising, synthesizing the findings in published qualitative literature we aim to develop a greater understanding of the psychological and social phenomena that shape coping and adjustment to living with stroke. It is anticipated that a greater understanding of these phenomena by summarizing the findings from qualitative literature, will inform stroke professionals of some of the key factors influencing transition after stroke. The findings of this review will inform the development and content of rehabilitation programmes and provide greater insights for professionals to be able to address both short term, and long term needs of individuals at different stages post stroke. In summary we aim to provide a critical appraisal and synthesis of existing qualitative evidence on stroke with a focus on the lived experiences of survivors, for a wider audience. This will inform research, clinical practice and policy in stroke and identify potential questions for further research. More specifically, this review question(s) are: • What are individuals lived experiences of stroke? • How do individuals cope after stroke? What are the some of coping strategies used? • What are the key stages of adjustment experienced by individuals after stroke? • What are the common transitions experienced by individuals during the stroke pathway, and how do they influence the lived experience (including hospitalization/acute care phase/rehabilitation phase, discharge and participation in the community phase)? • What factors influence individual motivation following stroke? • What are the enablers and barriers to self-management post stroke? • What are the enablers and barriers to participation post stroke? Inclusion Criteria Types of Participants This component of the review will consider studies that include adult (16 years or older) participants who are stroke survivors. The experiences of the carers will be outside the scope of this systematic review. However, in papers that explore the experiences of both the carer and the patient, the information regarding the patient’s experience will be extracted. Types of TRUNCATED AT 350 WORDS

PURPOSE OF REVIEW: This paper reviews epidemiology, psychiatric comorbidities, risk factors, warning signs, screening measures, and issues related to screening for suicide risk in the pediatric emergency department and acute care settings. RECENT FINDINGS: For the first time in over a decade, rates of adolescent suicide are increasing. A recent review found physician gatekeeper training to be one of only two effective prevention strategies. Limited methods exist to assess for suicide risk in pediatric acute care settings that are able to meet the demands and challenges presented in time-limited medical settings. SUMMARY: Suicide is the third leading cause of death in adolescents. Although a prior suicide attempt is the single most important risk factor, affective, cognitive, family and peer factors also affect risk of completed suicide. Practitioners in the acute care and emergency department setting are well positioned to identify, assess, and appropriately refer these adolescents and their families. Screening instruments in this setting need to be accurate, brief, and relevant to patients, families, and providers. We propose a two-question algorithm that targets imminent risk for a suicide attempt. This type of screening also needs to be accompanied by hospital or community-based support systems for further assessment, intervention and follow-up. Language: en

Review question/objective: This review seeks to establish what is best practice in relation to health care chaplaincy. More specifically, the objectives are to identify: • What behaviours and practices by chaplains are effective in facilitating well being in hospitalised patients and their carers? Other associated review questions are: • Is chaplaincy effective in providing spiritual and religious care for patients,families and staff? • What impact does chaplaincy have on patients and staff and familiesthrough the provision of spiritual and religious care? Inclusion criteria: Types of participants: The review will consider studies that include patients, and/or their carers and families and hospital staff who are exposed to chaplaincy services Types of intervention(s)/phenomena of interest: All studies and papers evaluating the effectiveness and impact of chaplaincy services on the experience of chaplaincy services will be considered for inclusion in this review. Types of outcomes: Quantitative: This component of the review will consider studies that include the following outcome measures based on previous studies that have considered the role of the chaplain: • Measures of physical and mental improvement using measurable criteria such as BP, levels of anxiety and depression; • Measures of well being; • Measures of quality of life; and • Measures of complaints reporting. Qualitative: Experiential accounts of patients, their carers, families and hospital staff. Individuals coming to terms with the realities of their ill health/wellbeing/life situations

The necessary components of an inclusive trauma system were first outlined in the Model Trauma Care Systems Plan published by the U.S. Bureau of Health Resources Development in 1992.1 In an inclusive system, patients with minor to moderate injuries may be treated at nontrauma centers (NTC) with the goal of matching the needs of the patient to the resources of the facility. One of the necessary components of the system is periodic evaluation to assess performance of the system and to determine if modifications are required.2–4 This evaluation may be difficult because of a number of factors. First, accurate data may be difficult to obtain because, while the trauma centers (TC) maintain trauma registries, there are no requirements for nontrauma acute care hospitals to maintain a database of trauma patients.5,6 Second, it may be difficult to demonstrate a survival advantage attributable to treatment at a TC because in a mature trauma system with adequate triage, delivery of seriously injured patients to TCs means that the patients with the largest risk of dying will be clustered in these centers.7 Thus, it would not be unexpected to observe an increased or unchanged mortality risk in TCs in a mature system.8–11 In addition, a “halo effect” may be seen with the maturation of a trauma system. This effect results in improved survival of injured patients regardless of whether they are treated at a TC.12 Shortened EMS response times, improved prehospital medical control, and the performance of airway and resuscitation interventions by emergency medical services personnel have been demonstrated to improve clinical outcomes whether the patient is transported to a TC or a community hospital.13 Finally, the assessment of the cost-effectiveness of a trauma system relies on the return of trauma victims to a productive life. This requires longitudinal follow-up of large groups of patients. This may be difficult to achieve given the limited data sources available. Because of these challenges, few studies have been able to evaluate the effectiveness of mature inclusive trauma systems. The Florida trauma system was established in 1982 when legislation was passed requiring the Florida Department of Health (DOH) to designate individual TCs based on the American College of Surgeons standards. The Roy E. Campbell Trauma Act, passed in 1990, set up a system of state approved trauma centers. In 1998 the DOH's Bureau of Emergency Medical Services (EMS) provided a report to the legislature entitled “Timely Access to Trauma Care,” which examined the feasibility of establishing a prehospital triage plan to ensure that trauma patients were transported to the closest appropriate TC. This report laid the groundwork for Florida to establish an inclusive trauma system in 1999 when legislation was passed directing the DOH to plan, coordinate, and establish a 5-year plan for a statewide trauma system. Despite having a long-standing trauma system, Florida has never provided a durable source of funding to support the system. Cost and manpower concerns have resulted in tensions within the trauma system such that over the life of the system the number of trauma centers has declined from a high of 66 TCs in 1987 to 21 TCs in 2004. During 2003 to 2004, 2 additional trauma centers were threatened with closure. One of these centers was 1 of the 6 level I centers for the state and the only center serving a city with a population of nearly 1 million. This crisis was solved, at least temporarily, by a coalition of local government and hospital leaders who were able to arrange funding for support of trauma patient care. State government support of the Florida trauma system has taken the form of an annual appropriation to each trauma center as well as favorable payment methodologies for trauma centers via the Medicaid insurance system. In May 2004, Governor Bush vetoed the funding bill that would have continued the annual award of grants providing equal amounts of money to each trauma center. In the veto message, the Governor cited the potential inequities of a funding method that awards a set amount to each trauma center regardless of the number of patients served, the absence of a clear plan for the future deployment of trauma system resources, an absence of a clearly articulated plan for consistent local participation in the financial support of the trauma system, and the need to document the effectiveness of the trauma system. Regarding the issue of effectiveness, the Governor stated “Trauma centers save lives, but so do hospitals that are not designated trauma centers. What is the difference derived from adherence to our (trauma system) regulations? If state government is to initiate trauma center unique payments, we must first know we are paying for performance.” The surviving legislation from this bill mandated a study to be funded to ascertain the need for local and state funding for the trauma system, determine the best deployment of the system, and provide outcome data to ensure that the system does confer a survival advantage. The purpose of this paper is to outline the methodology used to evaluate a mature inclusive trauma system such as the one found in the state of Florida and to answer 3 questions: 1) Does treatment at a TC versus a NTC improve survival? 2) Is the system cost-effective? 3) Is access to the system equitable?

Introduction Wound-healing outcomes applying standardized protocols have typically been measured within controlled clinical trials, not natural settings. Standardized protocols of wound care have been validated for clinical use, creating an opportunity to measure the resulting outcomes. Purpose Wound-healing outcomes were explored during clinical use of standardized validated protocols of care based on patient and wound assessments. Design This was a prospective multicenter study of wound-healing outcomes management in real-world clinical practice. Method Healing outcomes from March 26 to October 31, 2001, were recorded on patients in 3 long-term care facilities, 1 long-term acute care hospital, and 12 home care agencies for wounds selected by staff to receive care based on computer-generated validated wound care algorithms. After diagnosis, wound dimensions and status were assessed using a tool adapted from the Pressure Sore Status Toolfor use on all wounds. Wound, ostomy, and continence nursing professionals accessed consistent protocols of care, via telemedicine in home care or paper forms in long-term care. A physician entered assessments into a desktop computer in the wound clinic. Based on evidence that healing proceeds faster with fewer infections in environments without gauze, the protocols generally avoided gauze dressings. Results Most of the 767 wounds selected to receive the standardized-protocols of care were stage III-IV pressure ulcers (n = 373; mean healing time 62 days) or full-thickness venous ulcers (n = 124; mean healing time 57 days). Partial-thickness wounds healed faster than same-etiology full-thickness wounds. Conclusions These results provide benchmarks for natural-setting healing outcomes and help to define and address wound care challenges. Outcomes primarily using nongauze protocols of care matched or surpassed best previously published results on similar wounds using gauze-based protocols of care, including protocols applying gauze impregnated with growth factors or other agents.

Background and Purpose: The purpose of this project was to utilize concurrent chart review with electronic medical record as one method to improve stroke performance measures. In order to standardize and improve stroke care in the acute care setting, stroke performance measures have been set forth by the American Heart Association/American Stroke Association through Get With The Guidelines Registry, and from the Joint Commission. Maintaining stroke measures above goal can present a challenge in the world of paper documentation and chart review after discharge. Electronic medical record (EMR) allows multiple providers, including physicians, nurses, therapists, and stroke coordinator to access the health record concurrently during the patient’s hospital stay. Methods: Guided by a successful program implemented by St Mary’s Health Center in Jefferson City, Missouri, a 2 step concurrent chart review process was initiated for all stroke and transient ischemic attack (TIA) patients admitted to our facility. A stroke coordinator conducted chart review via EMR focusing on 8 of the quality measures (Early Antithrombotics, venous thromboembolism prophylaxis, antithrombotics at discharge, anticoagulation at discharge for atrial fibrillation/atrial flutter, smoking cessation, statin at discharge, dysphagia screen, and stroke education). Chart review was conducted the day after admission and the day of discharge with the goal of correcting potential outliers on the same day of chart review. Monthly performance data was collected over 1 year. Results: Concurrent chart review was conducted on 409 stroke/TIA patients. There was gradual improvement in quality and core stroke measures following implementation with achieving and sustaining 100% in 7 measures by month 6 and acheivement of >90% for dysphagia screen. Conclusions: In conclusion, concurrent chart review with the use of electronic medical record allows the stroke coordinator to focus on core and quality measures, while allowing multiple members of the stroke team (physician, nurse, and therapist) to access the same patient record. This also provides opportunities for collaboration and process improvement within the same stroke team.

Background: Presently, no trauma system exists in Ohio. Since 1993, all hospitals in Cuyahoga County (CUY), northeast Ohio (n = 22) provide data to a trauma registry. In return, each received hospital-specific data, comparison data by trauma care level and a county-wide aggregate summary. This report describes the results of this approach in our region. Methods: All cases were entered by paper abstract or electronic download. Interrater reliability audits and z score analysis was performed by using the Major Trauma Outcome Study and the CUY 1994 baseline groups. Risk adjustment of mortality data was performed using statistical modeling and logistic regression (Trauma and Injury Severity Score, Major Trauma Outcome Study, CUY). Trauma severity measures were defined. Results: In 1995, 3,375 patients were entered. Two hundred ninety-one died (8.6%). Severity measures differed by level of trauma care, indicating differences in case mix. Probability of survival was lowest in the Level I centers, highest in the acute care hospitals. Outcomes z scores demonstrated survival differences for all levels. Conclusions: In a functioning trauma system, the most severely injured patients should be cared for at the trauma centers. A low volume at acute care hospitals is desirable. By using Trauma and Injury Severity Score with community-specific constants, NE Ohio is accomplishing these goals. The Level I performance data are an interesting finding compared with the data from the Level II centers in the region.

To the Editor: We read with interest the paper by Kalra et al recently published in Stroke .1 We would like to contribute to this topic with our experience in 97 patients newly admitted to our Acute Care for the Elderly Medical Unit selected for chronic or recent-onset atrial fibrillation. Seventeen patients had atrial fibrillation of recent onset (>48 hours and 6 months). By strictly following the recommendations of the most commonly cited trials,2 3 all patients potentially needed anticoagulation to prevent thromboembolic strokes. On the contrary, although our hospital guidelines indicate the use of warfarin, the retrospective analysis of our charts revealed that 21 patients (21.6%) had neither anticoagulation nor aspirin, 49 (50.6%) had only aspirin, and 27 had only warfarin (27.8%). Of 21 patients who received neither warfarin nor aspirin, 4 had a diagnosis of active peptic ulcer, 3 severe liver cirrhosis, 3 gastric cancer, 3 cachexia, 3 anemia …