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Objective: To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end‐of‐life decision‐making in Queensland, Australia. Methods: An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. Results: The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end‐of‐life decision‐making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. Conclusions: The legal framework that supports end‐of‐life decision‐making for adults who lack decision‐making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted. [ABSTRACT FROM AUTHOR]

Background: Critical illness significantly impacts the well‐being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families. Aim: In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature. Study Design: In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA‐ScR guidelines were adhered to for reporting. Results: Thirty‐three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies. Conclusions: There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions. Relevance to Clinical Practice: Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic has been associated with detrimental effects on mental health and psychological well‐being. Although multiple studies have shown decreases in mental health‐related Emergency Department (ED) presentations early in the COVID‐19 pandemic, the medium‐term effects on mental health‐related ED presentations have remained less clear. This study aimed to evaluate the effect of the pandemic on mental health ED presentations by comparing observed presentation numbers to predictions from pre‐pandemic data. Methods: This retrospective cohort study tallied weekly ED presentations associated with mental health disorders from a state‐wide minimum dataset. Three time periods were identified: Pre‐Pandemic (January 1, 2018–March 8, 2020), Statewide Lockdown (March 9, 2020–June 28, 2020), and Restrictions Easing (June 29, 2020–June 27, 2021). Time series analysis was used to generate weekly presentation forecasts using pre‐pandemic data. Observed presentation numbers were compared to these forecasts. Results: Weekly presentation numbers were lower than predicted in 11 out of 16 weeks in the Statewide Lockdown period and 52 out of 52 weeks in the Restrictions Easing period. The largest decrease was seen for anxiety disorders (Statewide Lockdown: 76.8% of forecast; Restrictions Easing: 36.4% of forecast), while an increase was seen in presentations for eating disorders (Statewide Lockdown: 139.5% of forecast; Restrictions Easing: 194.4% of forecast). Conclusions: Overall weekly mental health‐related presentations across Queensland public EDs were lower than expected for the first 16 months of the COVID‐19 pandemic. These findings underline the limitations of emergency department provision of mental health care and the importance of alternate care modalities in the pandemic context. [ABSTRACT FROM AUTHOR]

Objectives: To assess emergency department (ED) presentation numbers in Queensland during the coronavirus disease 2019 (COVID‐19) pandemic to mid‐2021, a period of relatively low COVID‐19 case numbers. Design: Interrupted time series analysis. Setting: All 105 Queensland public hospital EDs. Main outcome measures: Numbers of ED presentations during the COVID‐19 lockdown period (11 March 2020 – 30 June 2020) and the period of easing restrictions (1 July 2020 – 30 June 2021), compared with pre‐pandemic period (1 January 2018 – 10 March 2020), overall (daily numbers) and by Australasian Triage Scale (ATS; daily numbers) and selected diagnostic categories (cardiac, respiratory, mental health, injury‐related conditions) and conditions (stroke, sepsis) (weekly numbers). Results: During the lockdown period, the mean number of ED presentations was 19.4% lower (95% confidence interval, –20.9% to –17.9%) than during the pre‐pandemic period (predicted mean number: 5935; actual number: 4786 presentations). The magnitudes of the decline and the time to return to predicted levels varied by ATS category and diagnostic group; changes in presentation numbers were least marked for ATS 1 and 2 (most urgent) presentations, and for presentations with cardiac conditions or stroke. Numbers remained below predicted levels during the 12‐month post‐lockdown period for ATS 5 (least urgent) presentations and presentations with mental health problems, respiratory conditions, or sepsis. Conclusions: The COVID‐19 pandemic and related public restrictions were associated with profound changes in health care use. Pandemic plans should include advice about continuing to seek care for serious health conditions and health emergencies, and support alternative sources of care for less urgent health care needs. [ABSTRACT FROM AUTHOR]

Introduction: When handover is conducted at the patient's bedside, active patient participation can be encouraged, which may improve the safety and quality of care. There is a need for valid and reliable tools to measure patient perceptions of participation in bedside handover, to ensure the rising number of implementation and improvement efforts are consistently and effectively evaluated. The aim of this study is to systematically develop and evaluate the psychometric properties of a self‐report survey to measure patients' perceptions of participation in bedside handover. Methods: In Phase 1, our team developed a conceptual framework and item pool (n = 130). In Phase 2, content validity was assessed with four health consumers, four nurses and four researchers. Next, 10 current hospital inpatients tested the survey for end‐user satisfaction. In Phase 3, 326 inpatients completed the survey, allowing exploratory factor analysis, reliability analyses and convergent/divergent validity analyses to occur. Results: Phase 1 and 2 resulted in a 42‐item survey. In Phase 3, 321 surveys were available for analysis. Exploratory factor analysis revealed a three‐factor solution, with 24 items, which matched our conceptual framework. The three factors were: 'Conditions for patient participation in bedside handover', 'Level of patient participation in bedside handover' and 'Evaluation of patient participation in bedside handover'. There was strong evidence for factor reliability and validity. Additionally, the correlation between factors was strong. Conclusion: This study furthers our conceptual understanding by showing that nurse facilitating behaviours are a strong precursor for patient participation and perceived handover outcomes, justifying the need for nursing training. A robust survey has been developed to measure patient perceptions of participation in bedside handover, which can effectively evaluate this approach to care. Engaging consumers and nurses as research team members was invaluable in ensuring that the survey is acceptable for end‐users. Patient or Public Contribution: A health consumer and nurse partnered as members of the research team from study inception to dissemination. [ABSTRACT FROM AUTHOR]

Pressure injuries are frequently occurring adverse events in hospitals, negatively impacting patient safety and quality of care. Most pressure injuries are avoidable if effective prevention strategies are used. However, the extent to which various settings influence their use of prevention strategies is unknown. The aim of this study was to describe and compare pressure injury prevention strategies used by medical and surgical nurses in the Chinese context. In this observational study, we used semi‐structured observations with chart audits to collect data in two medical and two surgical wards in a tertiary hospital from June to December 2020. Observations were patient‐focused; any prevention practices the patient received were recorded, and a chart audit was used to identify documented prevention strategies. The frequency of each prevention strategy was reported, and differences between medical and surgical wards were analysed using independent t‐test or χ2 test. A total of 577 patients (n = 294, 50.9% medical; n = 283, 49.1% surgical) were observed and their charts audited. Risk assessment was completed on admission for all patients. Repositioning was the most frequently used strategy, with about 84% (n = 486) patients being repositioned regularly. However, skin care, nutritional risk screening and the use of support surfaces were suboptimal. Patient education was not commonly observed but was documented in 75% (n = 433) of audited charts. More medical patients' skin was kept clean and hydrated, but more surgical patients received barrier creams, had a support surface and received more nutrition support and if a prone position was used, they were more likely to be turned after 2 hr and to be repositioned after sitting in a chair for an hour. Prevention strategies were more likely to be documented in surgical patients' charts. Despite pressure injury prevention guideline recommendations provided various prevention strategies for nurses to apply, the observed use of some strategies such as nutrition, skin care and support surfaces was not ideal. Nurses relied heavily on repositioning for pressure injury prevention. Most pressure injury prevention practices need improvement although surgical patients generally received better preventative care. These findings can facilitate clinicians and nurse managers when tailoring future pressure injury prevention work. [ABSTRACT FROM AUTHOR]

Aim: To identify, synthesize and appraise the systematic reviews of ERAS for patients undergoing pancreatic surgery and facilitate ERAS implementation. Design: An umbrella review was used to identify systematic reviews. Methods: A systematic search following the PRISMA guidelines was used to search databases including PubMed, Embase, Cochrane Library, CINAHL, CNKI, WanFang and VJIP. AMSTAR 2 was used to appraise the quality of included reviews. Results: Ten systematic reviews were included. The quality of all included systematic reviews was rated as "critically low." The most frequently reported ERAS elements were epidurals analgesia/PCA (9/10), goal‐directed mobilization (9/10) and early removal of drains (9/10). Only one review mentioned audit protocol compliance. None of the included reviews reported discharge standards. Ten reviews reported decreased length of stay, seven reviews reported lower hospital costs, and six reviews reported decreased total complications rate. There were no adverse effects reported. [ABSTRACT FROM AUTHOR]

Evidence on sepsis screening and care in developing nations is insufficient to inform implementation practices in hospital wards. The aim of this multi‐method study was to describe and evaluate the implementation of a three‐step intervention (sepsis screening, alert activation, care) in five wards in Argentina in 2017. The implementation involved three stages: (1) context assessment, (2) development/participation in implementation strategies, and (3) evaluation of intervention adherence. Results were variable. The context assessment (Stage 1) demonstrated the value of education, proactivity towards care and team structures. Strategies developed (Stage 2) included sepsis screening and response guide, education, team rounding, posters, champions, audit/feedback and knowledge brokering. In Stage 3, staff screened 92% patients (506/547) for sepsis at ≥60% of set times; only 33% (21/64) patients had a sepsis alert activated when needed. A similar proportion of patients who had alerts activated (n = 16, 76%) or not (n = 32, 74%) received at least one element of care. The use of implementation strategies resulted in adherence to some aspects of the intervention. Future research is needed to improve sepsis screening and alert activation and care in this setting. [ABSTRACT FROM AUTHOR]

Background: Conceptual clarity for the term patient engagement is growing. However, there is variability in patient engagement in healthcare, which could be due to the absence of models to guide practice or a myriad of organisational, nurse and patient factors. The recently developed 'Interactive Care Model' provides guidance on how to genuinely promote individualised patient engagement. An understanding of how to action this model in nursing is required. Aims: The aim of this scoping review was to examine actions in the published scientific literature that align with the Interactive Care Model, in the context of nursing care of hospitalised patients. Data sources: In 2018, searches of CINAHL, Cochrane Library, MEDLINE and PsycInfo were undertaken, for literature published between 2008 and 2018. This was followed by citation tracking. Review methods: Two researchers screened and selected studies using prespecified criteria. Data were charted into a pre‐established tool and collated and summarised using numerical summaries and deductive content analysis. For content analysis, categories were generated from the 'Interactive Care Model'. Findings: Forty‐three studies were included in the review, 33 noninterventional and 10 interventional studies. Publications on the topic are increasing in number over time, with most conducted in Europe with patient or nurse participants. Forty‐two actions were found in the literature that aligned with the 'Interactive Care Model'. The actions uncovered differed between intervention and noninterventional studies; in interventional studies actions were formalised. Conclusions: This review provides an overview of actions that promote patient engagement and could inform implementation of the Interactive Care Model and the design and testing of patient engagement interventions to support the model. There are opportunities to explore latter phases of the Interactive Care Model to foster patient engagement in self‐management and to motivate patients' management of healthcare beyond hospitalisation. Further, there is a need to rigorously evaluate patient engagement interventions. [ABSTRACT FROM AUTHOR]

Purpose: Patient participation is characterized by dyadic patient–nurse interactions that enable patients to passively or actively participate in communicative and physical care activities. Less research has been conducted on nonparticipation. Examining this phenomenon may highlight issues to address and identify strategies that may ultimately promote patient participation and move the rhetoric of patient participation to a reality. The aim of this secondary analysis was to explore hospital patients' and nurses' perceptions of nonparticipation in nursing care specifically focused on communication and self‐care. Design: Secondary supplementary analysis of qualitative data. We collated original transcripts from one dataset that included 20 patient and 20 nurse interviews conducted at two hospitals in Australia, in November 2013 to March 2014. Methods: Interviews were arranged into units of analysis dependent on group (patient/nurse) and setting (public/private hospital) and were reanalyzed using manifest, inductive content analysis. Findings: Two categories were found: (a) nurses impeding two‐way clinical communication; and (b) patients and nurses disregarding patients' self‐care efforts. These categories describe that nonparticipation occurred when nurses inhibited communication, and when patients were not involved in self‐care while hospitalized or during discharge planning. Conclusions: Perceptions of nonparticipation differ across settings, having implications for how patient participation recommendations are enacted in different contexts. Clinical Relevance: There is no one‐size‐fits‐all approach; nurses need to identify common instances of nonparticipation within their setting and develop and implement strategies to promote patient participation that are suited to their context. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID‐19) results from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID‐19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID‐19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID‐19 and general nutrition and intensive care. Patients hospitalised with COVID‐19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower‐nutritional‐risk patients and individualised care for high‐nutritional‐risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume‐controlled, higher‐protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS‐CoV‐2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS‐CoV‐2 pandemic. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition. Design: Mixed‐methods health‐care improvement approach guided by the Theoretical Domains Framework. Methods: Implementation of the 'Calling for Help' (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups. Setting: Australian specialist paediatric hospital. Participants: Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses. Main outcome measures: Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation. Results: Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time‐consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review. Conclusions: There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers. [ABSTRACT FROM AUTHOR]

Background: Hospital leaders, policymakers and healthcare professionals are realising the benefits of delivering care that promotes family participation because it is known to enhance the quality of care, and improve patient satisfaction. Aim: The aim of this study was to explore, from the perspective of patients and family members within an adult acute care ward: (a) their beliefs and attitudes towards family participation in patient care and (b) staff behaviours that support or hinder family participation in patient care. Design and methods: A naturalistic approach with an exploratory sequential design was used in a medical assessment and planning unit of a regional referral hospital in Australia. Purposeful maximum variation sampling was used to recruit patients and family members who differed in age, ethnicity, relationship to patient and gender. Observer‐as‐participant observation data and semi‐structured interviews were undertaken. Following separate inductive content analysis, data were triangulated. Results: Thirty‐two patients and 26 family members were recruited. Thirty hours of observational data were gathered. Eighteen patients and 15 family members were interviewed. Analysis uncovered two contrasting categories: (a) disconnected communication and (b) family influence quality. Conclusion: The findings of our study demonstrated that most patients and families perceived staff communication as disconnected and inadequate, which constrained them from engaging in care processes or decision‐making. However, when family felt empowered and participated in patient care, the quality of health care was enhanced. Healthcare professionals can use these findings to make informed evidence‐based changes to the way they practice and communicate to ensure family participation in patient care is optimised in the acute care setting. [ABSTRACT FROM AUTHOR]

Objective: Timely and appropriate assessment and management within the ED impacts patient outcomes including in‐hospital mortality and length of stay (LOS). Within the ED, several processes facilitate timely recognition of the need for intensive care unit (ICU) admission. This study describes characteristics and outcomes for patient presentations admitted to ICU from ED, categorised by Australasian Triage Score (ATS), ICU admission time and ICU admission source. Methods: A retrospective observational cohort study with linked health data of adult ICU admissions during 2012. Outcomes measured included: ED, ICU and hospital LOS, time to see ED clinician, ICU readmission and ICU and hospital mortality rates. Results: In total, 423 ICU admissions occurred within 24 h of ED arrival; 395 were admitted directly to ICU; 28 were admitted to the ward before ICU admission. ATS 3/4/5 patients comprised 26.7% of ICU admissions and experienced longer waits to be seen, longer total ED LOS, shorter ICU LOS and a lower mortality rate than those triaged ATS 1/2. Compared to ICU admissions during business hours, admissions outside hours did not differ significantly for any outcome measured. Patients admitted to the ward before ICU experienced longer waits to be seen and longer ED LOS. Conclusion: Most patients are appropriately identified in ED as requiring ICU admission, although around one in four were triaged ATS 3/4. Patients admitted to the ward first tended to have poorer outcomes than those directly admitted to ICU. Factors predicting the need for ICU admission should be identified to support clinical decision‐making. [ABSTRACT FROM AUTHOR]

Objective: To identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H). Design: Audits, semi‐structured interviews and focus groups guided by the Theoretical Domains Framework. Setting: Australian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months. Participants: Four children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members. Main outcome measures: Parent awareness and involvement in escalating care and factors impacting implementation of C4H. Results: Two audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents' information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent‐staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture. Conclusions: Although there was a low level of awareness about C4H in practice, there was in‐principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation. [ABSTRACT FROM AUTHOR]

Aim: Evidence‐based guidelines recommend early oral feeding (EOF) as prescription of an unrestricted diet within 24 hours after colorectal surgery. The present study aimed to understand local postoperative feeding practices after colorectal surgery; identify barriers to EOF implementation; select, tailor and implement stakeholder engagement strategies to facilitate EOF uptake; and evaluate changes to practice. Methods: A longitudinal, mixed methods study was undertaken, guided by the knowledge‐to‐action framework. Phase 1 assessed the nature of the problem using postoperative diet Audits 1 and 2. In Phase 2, staff interviews identified barriers to EOF implementation. Results from Phases 1 and 2 were fed back to inform Phase 3 strategies. Knowledge uptake was monitored in Audits 3 and 4. Phase 4 evaluated outcomes from Audit 5. Results: In Phase 1, median time to commencement of full diet was postoperative Days 4 and 3 in Audits 1 and 2, respectively. Phase 2 identified EOF barriers, including disparities in diet upgrade practices and variable understanding of hospital diets. In Phase 3, planned strategies were implemented to improve EOF (i) educational session describing local hospital diets; (ii) consultant decision to prescribe a full diet on operation notes; and (iii) educational sessions with nursing staff describing changes to EOF practice. In Phase 4, median time to commencement of full diet improved to postoperative Day 0. Patients prescribed a full diet on operation notes increased from 0% to 82%. Conclusions: The present study successfully identified and overcame local barriers to improve EOF practices to align with guideline recommendations. [ABSTRACT FROM AUTHOR]

Background Regardless of the benefits associated of the Surgical Safety Checklist, adherence across its three phases remains inconsistent. The aim of this study was to systematically identify issues around workflow that impact on surgical teams' ability to use the Surgical Safety Checklist in a large tertiary facility in Queensland, Australia. Method Observational audit of 10 surgical teams and 33 semi-structured interviews with 70 participants from nursing, medicine and the community were conducted. Data were collected during 2014-2015. Inductive and deductive approaches were used to analyse field observations and interview transcripts. Results The domain, impact of workflow on checklist utilization, was identified. Within this domain, seven categories illustrated the causal conditions which determined the ways in which workflow influenced checklist use. These categories included: 'busy doing the task'; 'clashing task priorities'; 'being pressured, running out of time'; 'adapting processes to work patterns'; 'doubling up on work'; 'a domino effect, leading to delays' and 'reality of the workflow'. Conclusions One of the greatest systemic challenges to checklist use in surgery is workflow. Process changes in the way that surgical safety checklists are used need to incorporate the temporal demands of the workflow. Any changes made must ensure the process is reliable, is easily embedded into existing work routines and is not disruptive. [ABSTRACT FROM AUTHOR]

Objectives Behaviour change interventions often target 'important' beliefs. The literature proposes four methods for assessing importance of attitudinal beliefs: elicitation frequency, importance ratings, and strength of prediction (bivariate and multivariate). We tested congruence between these methods in a Delphi study about selective decontamination of the digestive tract ( SDD). SDD improves infection rates among critically ill patients, yet uptake in intensive care units is low internationally. Methods A Delphi study involved three iterations ('rounds'). Participants were 105 intensive care clinicians in the United Kingdom, Canada, and Australia/ New Zealand. In Round 1, semi-structured interviews were conducted to elicit beliefs about delivering SDD. In Rounds 2 and 3, participants completed questionnaires, rating agreement and importance for each belief-statement (9-point Likert scales). Belief importance was assessed using elicitation frequency, mean importance ratings, and prediction of global attitude ( Pearson's correlations; beta-weights). Correlations between indices were computed. Results Participants generated 14 attitudinal beliefs. Indices had adequate variation (frequencies: 4-94, mean importance ratings: 4.93-8.00, Pearson's correlations: ±0.09 to ±0.54, beta-weights: ±0.01 to ±0.30). SDD increases antibiotic resistance was the most important belief according to three methods and was ranked second by beta-weights (behind Overall, SDD benefits patients to whom it is delivered). Spearman's correlations were significant for importance ratings with frequencies and correlations. However, other indices were unrelated. The top four beliefs differed according to the measure used. Conclusions Results provided evidence of congruence across three methods for assessing belief importance. Beta-weights were unrelated to other indices, suggesting that they may not be appropriate as the sole method. Statement of contribution What is already known on this subject? Attitudinal beliefs (specific beliefs about the consequences of performing an action) are key to designing interventions to change intentions and behaviour., The literature reports four methods for assessing the importance of attitudinal beliefs: frequency of elicitation in interviews, importance ratings in questionnaires, and strength of prediction (bivariate and multivariate) of global attitude scores., The congruence between these measures of importance is not known., What does this study add? Four indices of importance were examined in a multi-professional, international study about the use of selective digestive decontamination to prevent infection in intensive care settings., Three indices were correlated with one another., Each method used to assess importance produced a different subset of the most important beliefs. Selection of the most important beliefs should use multiple assessment methods., This evidence suggests that multiple regression approaches may not be appropriate as the sole method for assessing belief importance. [ABSTRACT FROM AUTHOR]

To report time from the onset of symptoms to hospital presentation in Australian and New Zealand patients with subsequently confirmed acute coronary syndrome, and to identify factors associated with prehospital delay time in these patients. Patients with coronary artery disease enrolled in a randomized clinical trial testing an intervention to reduce delay in responding to acute coronary syndrome symptoms had been followed for 24 months. In cases of admission to the ED for possible acute coronary syndrome, medical records were reviewed to determine the diagnosis, prehospital delay time, mode of transport to the hospital and aspirin use before admission. Clinical and demographic data were taken from the trial database. Patients ( n= 140) had an average (SD) age of 67.3 (11.5) years; 36% were female. Two-thirds of patients went to hospital by ambulance and 89.3% had a final diagnosis of unstable angina. The median time from onset of symptoms to arrival at the ED was 2 h and 25 min (interquartile range 1:25-4:59); 12.1% arrived ≤ 1 h and 66% within 4 h. Multiple linear regression analysis showed that use of ambulance (Beta = 0.247, P= 0.012) and younger age (Beta = 0.198, P= 0.043) were independent predictors of shorter delay times. The time from the onset of symptoms to hospital presentation was too long for maximal benefit from treatment in most patients. Further efforts are needed to reduce treatment-seeking delay in response to symptoms of acute coronary syndrome. [ABSTRACT FROM AUTHOR]

Aims. This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes. Background. Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients’ sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Design. Observational study. Methods. Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Results. Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Conclusions. Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Relevance to clinical practice. Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions. [ABSTRACT FROM AUTHOR]

Purpose: International collaboration in research is essential in order to improve worldwide health. The purpose of this paper is to describe strategies used to administer an international multicenter trial to assess the effectiveness of a nursing educational intervention. Design: The study design was a two-group randomized multicenter international clinical trial conducted to determine whether a brief education and counselling intervention delivered by a nurse could reduce prehospital delay in the event of symptoms suggestive of acute coronary syndrome (ACS) in patients previously diagnosed with cardiovascular disease. Method: A flexible but well-defined project structure showed intervention consistency in five sites among three countries and included experienced project coordinators, multidimensional communication methods, strategies to optimize intervention fidelity, site-specific recruitment and retention techniques, centralized data management, and consideration of ethical and budgetary requirements. Findings: Staff at five sites enrolled 3,522 participants from three countries and achieved 80% follow-up obtained at both 12 and 24 months. Conclusion: Multidimensional approaches to maintain consistency across study sites, while allowing flexibility to meet local expectations and needs, contributed to the success of this trial. Clinical Relevance: In order to support appropriate development of an evidence base for practice, nursing interventions should be tested in multiple settings. A range of strategies is described in this paper that proved effective in conducting a multicenter international trial. [ABSTRACT FROM AUTHOR]

• The principles and physiological underpinnings of gastric tonometry are reviewed • Tonometric variables, including the PtCO2, pHi and CO2 gap, are described and critiqued as measurements of gastrointestinal perfusion • Increases in gastrointestinal CO2 unrelated to gastrointestinal hypoperfusion are discussed within different clinical contexts • The technical limitations of gastric tonometry, including procedural errors and PtCO2 measurement are discussed in relation to the accuracy of tonometric measurements • Tonometric measurement using semi-continuous air tonometry is introduced as a strategy to minimize technical limitations [ABSTRACT FROM AUTHOR]

The cover image is based on the Original Research Paper Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital, by Fenella J. Gill PhD, RN, FACCCN et al., DOI 10.1111/hex.12806. [ABSTRACT FROM AUTHOR]