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Background: Nurses comprise the largest component of the health workforce worldwide and numerous models of workforce allocation and profile have been implemented. These include changes in skill mix, grade mix or qualification mix, staff‐allocation models, staffing levels, nursing shifts, or nurses’ work patterns. This is the first update of our review published in 2011. Objectives: The purpose of this review was to explore the effect of hospital nurse‐staffing models on patient and staff‐related outcomes in the hospital setting, specifically to identify which staffing model(s) are associated with: 1) better outcomes for patients, 2) better staff‐related outcomes, and, 3) the impact of staffing model(s) on cost outcomes. Search methods: CENTRAL, MEDLINE, Embase, two other databases and two trials registers were searched on 22 March 2018 together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria: We included randomised trials, non‐randomised trials, controlled before‐after studies and interrupted‐time‐series or repeated‐measures studies of interventions relating to hospital nurse‐staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective reported measure of patient‐, staff‐related, or economic outcome. The most important outcomes included in this review were: nursing‐staff turnover, patient mortality, patient readmissions, patient attendances at the emergency department (ED), length of stay, patients with pressure ulcers, and costs. Data collection and analysis: We worked independently in pairs to extract data from each potentially relevant study and to assess risk of bias and the certainty of the evidence. Main results: We included 19 studies, 17 of which were included in the analysis and eight of which we identified for this update. We identified four types of interventions relating to hospital nurse‐staffing models: introduction of advanced or specialist nurses to the nursing workforce; introduction of nursing assistive personnel to the hospital workforce; primary nursing; and staffing models. The studies were conducted in the USA, the Netherlands, UK, Australia, and Canada and included patients with cancer, asthma, diabetes and chronic illness, on medical, acute care, intensive care and long‐stay psychiatric units. The risk of bias across studies was high, with limitations mainly related to blinding of patients and personnel, allocation concealment, sequence generation, and blinding of outcome assessment. The addition of advanced or specialist nurses to hospital nurse staffing may lead to little or no difference in patient mortality (3 studies, 1358 participants). It is uncertain whether this intervention reduces patient readmissions (7 studies, 2995 participants), patient attendances at the ED (6 studies, 2274 participants), length of stay (3 studies, 907 participants), number of patients with pressure ulcers (1 study, 753 participants), or costs (3 studies, 617 participants), as we assessed the evidence for these outcomes as being of very low certainty. It is uncertain whether adding nursing assistive personnel to the hospital workforce reduces costs (1 study, 6769 participants), as we assessed the evidence for this outcome to be of very low certainty. It is uncertain whether primary nursing (3 studies, > 464 participants) or staffing models (1 study, 647 participants) reduces nursing‐staff turnover, or if primary nursing (2 studies, > 138 participants) reduces costs, as we assessed the evidence for these outcomes to be of very low certainty. Authors' conclusions: The findings of this review should be treated with caution due to the limited amount and quality of the published research that was included. We have most confidence in our finding that the introduction of advanced or specialist nurses may lead to little or no difference in one patient outcome (i.e. mortality) with greater uncertainty about other patient outcomes (i.e. readmissions, ED attendance, length of stay and pressure ulcer rates). The evidence is of insufficient certainty to draw conclusions about the effectiveness of other types of interventions, including new nurse‐staffing models and introduction of nursing assistive personnel, on patient, staff and cost outcomes. Although it has been seven years since the original review was published, the certainty of the evidence about hospital nurse staffing still remains very low.

Table S1. Disposition for 4900 randomly selected numbers used in sampling. Table S2 Rotation matrix for the first two components of the self-monitoring/info-seeking PCA analysis. Magnitudes greater than 0.3 are highlighted. Table S3 Demographics. Table S4 Multivariable associations with the info-seeking and self-monitoring principal components. Table S5 Multivariable associations with the total delay/avoidance score. Table S6 Linear regressions of likelihood of attending a DMHS in men reporting delays/avoidance in seeking health advice. (PDF 284 kb)

Craniosynostosis is a condition characterized by the premature closure of one or more of the cranial vault sutures. It can occur alone or in association with other congenital defects and may be part of a syndrome. The sagittal suture is most commonly affected, comprising 40-60% of cases. Premature fusion of the sagittal suture can cause scaphocephaly due to compensatory anterior-posterior growth of the skull. This is morphologically considered as a narrow elongated skull with a decreased cephalic index, and is diagnosed clinically and/or radiologically. Both the indications for surgery and the techniques used have varied with time and location. Surgical techniques have evolved, from limited craniectomy to calvarial remodeling. In recent times a return to craniectomy methods has occurred with the more recent introduction of endoscopic methods.The objectives of this review were to identify and synthesize the best available evidence on the morphological, functional and neurological outcomes of craniectomy compared to cranial vault remodeling.This review considered studies of infants with primary isolated sagittal synostosis operated on or before the mean age of 24 months. The intervention of interest was local craniectomy and this was compared to cranial vault remodeling. Morphological (primary), functional and neurological (secondary) outcomes were included. Mortality, complications and aesthetic outcome were included as tertiary outcomes.A comprehensive search was undertaken across major databases. The retrieved studies were assessed by two independent reviewers for methodological validity prior to inclusion. Data was then extracted and, where possible, pooled in statistical meta-analysis. For descriptive studies, where statistical pooling was not possible, the findings are presented in narrative form.Search and retrieval: Based on critical appraisal, 27 studies were considered to be suitable for this review. These studies were all descriptive in nature. Meta-analysis was only possible for the primary morphological outcome (post-operative cephalic index).Morphological (cephalic index):At one year follow-up, post-operatively remodeling offers an advantage over craniectomy (Z = 4.16, P0.0001)Morphological:Improvements of the cephalic index to varying degrees were seen in patients receiving either procedure and there is not enough evidence to suggest that either treatment group had greater improvement over the other.Functional and neurological:Although their global scores may be comparable to an age-matched population, patients with sagittal synostosis who have undergone a surgical repair of any type may have discrepancies in specific domains and may be at risk of developing learning disorders. There is insufficient primary research with inter-procedure comparisons of preoperative and postoperative cognitive and neurological outcomes.Tertiary outcomes:There is not enough evidence to comment on mortality or postoperative infection in either treatment group. Patients undergoing cranial vault remodeling have a higher rate of transfusion compared to those undergoing craniectomy; however, it is likely that this difference relates to elective transfusion based on hospital-specific protocols. It remains unknown whether there is an inherently higher need for transfusion in patients undergoing remodeling procedures. Delaying surgery however may increase the risk of raised intracranial pressure (ICP) and its associated complications. Whilst there is no evidence for raised ICP post-craniectomy, a few studies have shown raised ICP in patients post-remodeling. There is not enough evidence to establish a relationship between both procedures and raised ICP. Aesthetic outcome appears to be "better" in patients who undergo remodeling; however, there is little rigorous evidence to support this hypothesis.Conclusions were drawn from both the meta-analysis and the narrative results.When comparing the mean change in cephalic index one year after surgery, remodeling was shown to be superior to limited craniectomy in patients with isolated synostosis of the sagittal suture. However both procedures were seen to give improvements at short, medium and longer term time points. Improvements in cephalic index may be sustained, deteriorate or improve over time; based on the current data neither procedure offers a clear long-term advantage over the other. Longer follow-up is required to compare outcomes at different time points.Patients who have surgery (any type) for isolated sagittal synostosis may have deficiencies in different subdomains at later school-age testing, whilst maintaining an age-appropriate global intelligence quotient (IQ) and school performance. There is no evidence to suggest that surgery of either type imparts any benefit in terms of functional or neurological outcomes.There is no evidence to suggest that surgery of either type imparts any benefit in terms of functional or neurological outcomes. While school performance and general IQ may be comparable to age-matched controls, patients with sagittal synostosis who have undergone surgical repair of any type may be at risk of deficiencies in sub-areas of testing and be at risk of learning disorders.There is insufficient evidence regarding mortality, infection, postoperative ICP and aesthetic outcome. While transfusion rates were greater in the remodeling group, this may be due to higher rates of elective transfusion.The inconclusive findings indicate an ongoing need for higher quality primary research comparing the morphological and functional outcomes of craniectomy and cranial vault remodeling in primary sagittal synostosis. Outcomes should be measured in both the short and long term.

Background Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital. Methods/Design A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool. Discussion Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions. Trial registration ACTRN12611000020987

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the effectiveness of asthma self management education, self monitoring and either: (1) regular review by a health care provider, or (2) use of a written action plan, or (3) both on patient outcomes. The specific questions addressed are: 1. Do asthma self management education, self monitoring and either regular review by a healthcare provider or use of a written action plan, or both, lead to improved outcomes in asthma? 2. What are the characteristics of those programmes that lead to measurable changes in health outcomes?