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OBJECTIVE To determine the feasibility of an adequately powered trial testing a long-acting cyanoacrylate skin protectant to prevent incontinence-associated dermatitis in critically ill patients. METHODS This open-label pilot randomized controlled feasibility study was conducted in the adult ICU of an Australian quaternary referral hospital. Patients were allocated to either an intervention group or a control group (usual care). The intervention was the application of a skin protectant (a durable, ultra-thin, transparent, waterproof, no-removal barrier film). Data collected by trained research nurses included demographic and clinical variables, skin assessment, and incontinence-associated dermatitis presence and severity. Data were analyzed using descriptive and inferential statistics. RESULTS Of the 799 patients screened, 85% were eliminated because of a short ICU stay or other exclusion criteria. The mean proportion of patients not meeting any of the exclusion criteria was 22% on each screening day. Protocol fidelity was followed for 90% of intervention participant study days. Retention of participants was 86% (31 participants out of 36), 15 in the intervention group and 16 in the control group. Enrolled patients had a mean age of 59 years, 50% were obese, 67% were male, and 36% were smokers. Two patients (11%) in the intervention group developed incontinence-associated dermatitis, compared with three (17%) in the control group. CONCLUSIONS This study reports no significant findings between the two groups. Difficulty in recruitment and feasibility issues might be overcome with changes to inclusion criteria and study design.

Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C‐collar) device in situ and are subsequently exposed to device‐related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C‐collar‐related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C‐collar were retrieved over a 9‐year period. Chi square and t‐tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine‐year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C‐collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024‐1.723, P = .033). Time in the C‐collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P

OBJECTIVES To report longitudinal prevalence rates of device-related pressure injuries in critically ill adult patients in the intensive care unit and to explore the patient characteristics associated with the development of device related pressure injuries. RESEARCH DESIGN A prospective observational design where observations of patients' skin integrity were conducted on one day each week for 52 weeks. SETTING The study was conducted in the 36-bed ICU of a major metropolitan tertiary referral hospital in Queensland, Australia. The sample included all patients aged 18 years or older admitted to the intensive care unit before midnight on the day preceding the observation, with a medical device in situ. MAIN OUTCOME MEASURES The primary outcome measure was device related pressure injuries identified at the weekly observations and defined as a pressure injury found on the skin or mucous membrane with a history of medical device in use at the location of the injury. Patient demographic and clinical characteristics were recorded. RESULTS Over the study period, 11.3% (71/631) of patients developed at least one hospital-acquired DRPI. The most common devices associated with injury were nasogastric/nasojejunal tubes (41%) and endotracheal tubes (27%). Significant predictors of device related pressure injuries were the total number of devices (OR 1.230, 95% CI 1.09-1.38, p

Aim To explore the extent of Australian nurse managers' engagement in clinical care activities. Background Hybrid nurse manager roles lack clarity in the optimal balance between the clinical and other activities, resulting in stress and challenges in recruiting and retaining nurse managers. Methods In a national survey using the Advanced Practice Role Delineation tool, Australian nurses self-assessed their level of engagement in activities across five domains of nursing practice. The subset sample analysed comprised 2,758 registered nurses, 390 clinical (front-line) nurse managers and 43 organisational (middle) nurse managers. Median domain scores were compared with non-parametric tests of difference. Results Clinical nurse managers were in a hybrid role, reporting high levels of engagement across the domains. Lower scores observed for organisational nurse managers highlight the shift to strategy-focussed activities that occurs as nurses up the management hierarchy. Conclusions By indicating their engagement in the clinical care domain, respondents demonstrated that clinically focused activities were not entirely lost from either front-line or middle-management roles. Implications for nursing management Nurse managers equipped with clinical and management skills, and allowed time to remain engage in clinical care activities are critical for patient-centred and cost-effective care in today's complex health care environments.

© 2017 International Council of Nurses Aim: To identify the practice patterns of the Australian registered nurse workforce according to position title and to map these disparate titles across all jurisdictions of the country. Introduction: Effective nursing workforce planning can contribute to improved patient care and increased effectiveness and efficiency of healthcare systems. Background: The prevailing approach to nursing workforce planning focuses on number of nursing staff needed in relation to the number of patients. The level of expertise and skill mix of registered nurses as a variable in workforce planning is rarely considered. Methods: A national cross-sectional electronic survey of registered nurses in Australia was conducted using the validated Advanced Practice Role Delineation tool developed from the Strong Model of Advanced Practice. The study involved a sample of 5599 registered nurses. Results: Sixty-six nursing position titles nationally were mapped using cluster analysis technique and gave rise to seven clusters of equivalent Australian jurisdictional nursing position titles and practice profiles. Discussion: Effective workforce policy and planning is reliant upon access to reliable evidence. This research is an international first in that it has provided comprehensive knowledge of the clinical level and practice profiles of a national nursing workforce. Implications for nursing policy: Effective, patient-centred workforce planning must consider both the numerical and expertise mix of a nursing workforce. This research provides Australian health service and policy planners with evidence-base knowledge of the nursing workforce. Internationally, this research establishes a platform from which to develop validated tools and established processes to support replication of this research.

Purpose: The purpose of this study was to provide longitudinal prevalence rates of incontinence-associated dermatitis (IAD) in patients in an intensive care unit (ICU) and to identify patient characteristics associated with IAD development. Design: Prospective observational. Subjects and Setting: The sample comprised 351 patients aged 18 years and older in a major metropolitan public hospital ICU in Queensland, Australia. Methods: All consenting, eligible participants at risk of developing IAD underwent weekly skin inspections to determine the presence of IAD. Data were collected weekly for 52 consecutive weeks. Descriptive statistics described the study sample and logistic regression analysis was used to identify patient characteristics associated with development of IAD. Results: The weekly IAD prevalence ranged between 0% and 70%, with IAD developing in 17% (n = 59/351) of ICU patients. The odds of IAD developing increased statistically significantly with increasing age (odds ratio [OR]: 1.029, 95% confidence interval [CI]: 1.005-1.054, P =.016), time in the ICU (OR = 1.104; 95% CI: 1.063-1.147, P

ObjectivesTo evaluate the impact of nurse practitioner (NP) service in Australian public hospital emergency departments (EDs) on service and patient safety and quality indicators.Design and settingCohort study comprising ED presentations (July 2013–June 2014) for a random sample of hospitals, stratified by state/territory and metropolitan versus non-metropolitan location; and a retrospective medical record audit of ED re-presentations.MethodsService indicator data (patient waiting times for Australasian Triage Scale categories 2, 3, 4 and 5; number of patients who did not-wait; length of ED stay for non-admitted patients) were compared between EDs with and without NPs using logistic regression and Cox proportional hazards regression, adjusting for hospital and patient characteristics and correlation of outcomes within hospitals. Safety and quality indicator data (rates of ED unplanned re-presentations) for a random subset of re-presentations were compared using Poisson regression.ResultsOf 66 EDs, 55 (83%) provided service indicator data on 2 463 543 ED patient episodes while 58 (88%) provided safety and quality indicator data on 2853 ED re-presentations. EDs with NPs had significantly (pConclusionsEDs with NPs had statistically significantly lower performance for service indicators. However, these findings should be treated with caution. NPs are relatively new in the ED workforce and low NP numbers, staffing patterns and still-evolving roles may limit their impact on service indicators. Further research is needed to explain the dichotomy between the benefits of NPs demonstrated in individual clinical outcomes research and these macro system-wide observations.

Background Skin integrity management is often a low clinical priority in the intensive care environment, possibly resulting in high pressure injury (PI) prevalence. This article reports the results of the first phase of a multiphased project, “Translating evidence-based pressure injury prevention strategies to the intensive care environment (SUSTAIN study)”. The SUSTAIN study used a research translation framework to guide the assessment of research uptake, development, and monitoring of translational strategies to reduce PIs. Objective The objective was to assess the enablers and barriers to research translation of evidence-based skin integrity management in one Australian tertiary referral intensive care unit (ICU). Methods This exploratory study was conducted in an Australian metropolitan tertiary ICU on a sample of 204 registered nurses. Data were collected using (i) a descriptive cross-sectional cohort survey of barriers, enablers, and attitudes to PI prevention, (ii) a cross-sectional survey of PI knowledge, and (iii) focus groups to understand the local contextual factors impacting registered nurses' PI prevention practice. Results Participants reported a moderate to high ability to rise above barriers in PI prevention, a positive attitude towards PI prevention, and considered this a priority in their care of patients. High patient acuity emerged as a barrier to implementing timely PI prevention strategies. In the knowledge, test participants with postgraduate qualifications answered more statements correctly. Focus group data revealed four themes: (i) team ICU, (ii) processes of care, (iii) education for consistency, and (iv) the patient. Conclusions It is essential that evidence-based PI prevention strategies are provided in the intensive care environment. Our findings indicate that despite positive attitudes and sound knowledge levels, high patient acuity is a significant barrier to evidence implementation.

Summary Aim This study aimed to test the effectiveness of a bundle combining best available evidence to reduce the incidence of incontinence-associated dermatitis occurrences in critically ill patients. Methods The study used a before and after design and was conducted in an adult intensive care unit of an Australian quartenary referral hospital. Data, collected by trained research nurses, included demographic and clinical variables, skin assessment, incontinence-associated dermatitis presence and severity. Data were analysed using descriptive and inferential statistics. Results Of the 207 patients enrolled, 146 patients were mechanically ventilated and incontinent thus eligible for analysis, 80 with 768 days of observation in the after/intervention group and 66 with 733 days of observation in the before group. Most patients were men, mean age 53 years. Groups were similar on demographic variables. Incontinence-associated dermatitis incidence was lower in the intervention group (15%; 12/80) compared to the control group (32%; 21/66) (p = 0.016). Incontinence-associated dermatitis events developed later in the intensive care unit stay in the intervention group (Logrank = 5.2, p = Conclusion This study demonstrated that the use of a bundle combining best available evidence reduced the incidence and delayed the development of incontinence-associated dermatitis occurrences in critically ill patients. Systematic ongoing patient assessments, combined with tailored prevention measures are central to preventing incontinence-associated dermatitis in this vulnerable patient group.

Background The use of fine needle biopsy (FNB) for the diagnosis of metastatic melanoma can lead to the early removal and treatment of metastases, reduce the frequency of unnecessary surgery, and facilitate the staging of patients enrolled in clinical trials of adjuvant therapies. In this study, the accuracy of FNB for the diagnosis of metastatic melanoma was investigated. Methods A retrospective cohort study was performed with 2204 consecutive FNBs performed on 1416 patients known or suspected to have metastatic melanoma. Almost three-quarters (1582) of these FNBs were verified by either histopathologic diagnosis following surgical resection or clinical follow-up. Results FNB for metastatic melanoma was found to have an overall sensitivity of 92.1% and a specificity of 99.2%, with 69 false-negative and 5 false-positive findings identified. The sensitivity of the procedure was found to be influenced by six factors. The use of immunostains, reporting of the specimen by a cytopathologist who had reported >500 cases, lesions located in the skin and subcutis, and patients with ulcerated primary melanomas were factors associated with a significant improvement in the sensitivity of the test. However, FNBs performed in masses located in lymph nodes of the axilla and FNBs that required more than one needle pass to obtain a sample were far more likely to result in false-negative results. Conclusions FNB is a rapid, accurate, and clinically useful technique for the assessment of disease status in patients with suspected metastatic melanoma.

Fine-needle biopsy (FNB) has been reported as a rapid, minimally invasive technique for the diagnosis of metastatic melanoma. The diagnostic accuracy of FNB was assessed in a consecutive series of 2,204 FNBs of clinically suspicious lesions from patients with previous primary melanomas treated at the Sydney Melanoma Unit, Sydney, Australia, between January 1992 and December 2002. The sensitivity and specificity of FNB were 96.3% and 98.9%, respectively. There were 5 false-positive cases (0.6%), which were verified as metastatic adenocarcinoma (3 cases) or reactive processes (organizing hematoma and chronic osteomyelitis, 1 each). False-negative diagnoses (6.7% of cases) were associated with a variety of clinicopathologic factors, including difficult-to-access anatomic sites (eg, high axilla or deep inguinal), small lesions, and lesional characteristics such as fibrosis, necrosis, or cystic change. FNB is a highly accurate, rapid, and cost-effective procedure for the diagnosis of metastatic melanoma and should be considered as the initial diagnostic procedure of choice in patients with melanoma with clinically suspected metastases. Melanoma is a common tumor, accounting for approximately 3% of all cancers. 1 It is a major cause of mortality and has a major impact on the most productive years of life because it is often diagnosed in relatively young people. 2 Survival in patients with melanoma is related to the stage of the disease at diagnosis, and patients with metastatic melanoma have much poorer survival than those without metastases. 3-7 Melanoma

Purpose To test an interventional patient skin integrity bundle, the InSPiRE protocol, for reducing pressure injuries in critically ill patients in an Australian adult intensive care unit. Methods Before and after design: patients receiving the intervention (InSPiRE protocol) were compared with a similar control group who received standard care. Data collected included demographic and clinical variables, skin assessment, presence and stage of pressure injuries, and score on the Sequential Organ Failure Assessment (SOFA). Results Overall, 207 patients were enrolled, 105 in the intervention group and 102 in the control group. Most patients were men (mean age, 55 years). The groups were similar on major demographic variables (age, SOFA scores, intensive care unit stay). Cumulative incidence of pressure injuries was significantly lower in the intervention group (18.1%) than in the control group (30.4%) for skin injuries ( [Formula: see text], P = .04) and mucous injuries (t = 3.27, P ≤ .001). Significantly fewer pressure injuries developed over time in the intervention group (log rank = 11.842, df = 1, P ≤ .001) and intervention patients had fewer skin injuries (> 3 pressure injuries/patient = 1/105) than did control patients (> 3 pressure injuries/patient = 10/102; P = .02). Conclusion The intervention group, receiving the InSPiRE protocol, had a lower cumulative incidence of pressure injuries, and fewer and less severe pressure injuries that developed over time. Systematic and ongoing assessment of the patient's skin and risk for pressure injuries as well as implementation of tailored prevention measures are central to preventing pressure injuries.

Isolated limb perfusion (ILP) with cytotoxic agents is a remarkably effective but complex technique used to treat locally recurrent and metastatic melanoma confined to a limb. Isolated limb infusion (ILI), essentially a low-flow ILP performed without oxygenation via percutaneous catheters, has been developed as a simpler alternative.The outcome in 135 patients treated by ILI was reviewed.The overall response rate in the treated limb was 85% (complete response [CR] rate 41%, partial response rate 44%). Median response duration response was 16 months (24 months for patients with CR). Median patient survival was 34 months. In those with a CR, the median survival was 42 months. CR rate and survival time decreased with increasing disease stage. Patients aged70 years had a better overall response than younger patients. On multivariate analysis, factors associated with an improved outcome were a lower stage of disease, a final limb temperature37.8 degrees C, and a tourniquet time40 minutes.The frequency and duration of responses after ILI were comparable to those achieved by conventional ILP. The ILI technique is particularly useful for older patients who might not be considered suitable for conventional ILP.

Postburn itch is reported to affect up to 87% of the burn population. Although treatments for postburn itch are multimodal, they remain consistently ineffective. However, recent anecdotal evidence from several outpatients at a tertiary referral hospital suggests that a cream combining beeswax and several herbal oils may be effective in the minimization of postburn itch. The aim of this study was to test the efficacy of beeswax and herbal oil cream against the standard treatment of aqueous cream in the provision of relief from the symptoms of postburn itch. A randomized controlled trial compared two groups using a visual analog scale, frequency of cream application, itch recurrence after cream application, use of antipruritic medications, and sleep disturbance to determine the effect of itch severity and duration. Fifty-two participants were enrolled in the study (84% male) with a mean age of 35 years (SD = 16) and mean burn TBSA of 7.2% (SD = 7.7). Study results found that the beeswax and herbal oil cream reduce itch after application more frequently than aqueous cream (P = .001). In addition, when managed with beeswax and herbal oil cream, participants found that their itch recurred later (P

Fine-needle biopsy (FNB) is commonly used in the investigation of patients with a history of melanoma who present with possible metastatic disease. Non-melanoma malignancies (NMM) are common in the general population and not infrequent in patients with melanoma. Such tumors may be difficult to distinguish from metastatic melanoma on FNB. We sought to determine the types of NMMs that occur in melanoma patients, to document the frequency with which they were diagnosed by FNB, and to highlight potential pitfalls in cytologic diagnosis. NMMs occurring in 1416 consecutive melanoma patients who underwent FNB of 2204 clinically suspicious lesions between 1992 and 2002 at a single center were reviewed and analyzed. The sites of FNB included lymph nodes (36.9%), skin and subcutis (25.1%), visceral locations (17.9%), and other sites (20.0%). Of the 1416 melanoma patients investigated by FNB, 116 (8.2%) had a metachronous or synchronous NMM; the NMM was diagnosed by the FNB in 17 (14.7%) patients. The most common NMMs were epithelial tumors (69.4%, most commonly carcinomas of large bowel, breast and prostate) and hematologic malignancies (21.8%). As NMMs are not infrequent in patients with melanoma, they should always be considered in the differential diagnosis of clinically suspicious masses in patients with a history of melanoma, as well as in patients at high risk of melanoma. Careful assessment of the FNB cytologic features and directed use of ancillary studies should enable accurate diagnosis in most cases and facilitate appropriate patient management.

Background: In most major melanoma treatment centers, sentinel node biopsy (SNB), with complete regional lymph node dissection when a positive sentinel node is found, has now replaced elective lymph node dissection (ELND) for patients with primary cutaneous melanomas who are considered to be at moderate to high risk of nodal recurrence. As for ELND, however, no overall survival benefit for the SNB procedure has yet been demonstrated. The objective of this study was to compare the nodal staging accuracy and duration of survival for SNB and ELND. Methods: A retrospective cohort study was conducted among patients with American Joint Committee on Cancer (AJCC) stage II disease treated at a single center between 1983 and 2000 with either SNB (n = 672) or ELND (n = 793). Multivariate analyses were performed using the logistic regression model for nodal staging accuracy and Cox’s proportional hazards regression model for survival. Results: Patient factors that influenced nodal positivity included age, Breslow thickness, ulceration, head or neck primary, and operation type (SNB or ELND). SNB was superior to ELND in the detection of micrometastases (odds ratio 1.23, 95% CI, 1.06 – 1.43) but operation type did not influence survival (P = .24). Conclusions: Sentinel node biopsy identified more nodal micrometastases than ELND but did not influence survival, although complete regional node dissection was performed in all patients who were SNB positive. This increase in staging accuracy likely results from the reliable identification of the appropriate lymph node field by preoperative lymphoscintigraphy, along with more detailed pathologic examination of the nodes removed by SNB.

Objective To calculate survival probabilities of patients with 3 or more multiple primary melanomas. Design Retrospective cohort study of patients with primary melanoma. Setting Patients treated at a tertiary center (Sydney Melanoma Unit, Sydney, Australia) for stage I or II melanoma between 1983 and 1999. Patients From 5250 patients with primary melanoma, 264 (5.0%) had double and 34 (0.6%) had 3 or more primary melanoma lesions. Results The estimated 10-year risk for developing a second primary melanoma in these patients was 12.7% (95% confidence interval [CI], 10.5%-14.9%). For those patients who had 2 primary melanomas, the estimated 10-year risk of developing a third lesion was 27.7% (95% CI, 14.7%-36.7%). When controlling for known prognostic factors in a proportional hazards regression model, the number of primary melanomas was a significant favorable survival predictor when the thickest or the first tumor was modeled. In patients with 3 or more primary melanomas, 31 survived when 25 (95% CI, 22-27) were expected to survive. Patients who survive longer may have the opportunity to develop multiple primary melanomas. Patients who encountered all their primary lesions within 2 years may not be subject to this bias. Within the 3 or more melanoma set, 11 patients had all primary melanomas within 2 years. All survived, whereas 9 (95% CI, 8-10) were expected to survive. Conclusions Patients with 3 or more primary melanoma lesions survive longer than anticipated. Such enhanced survival in patients with 3 or more primary melanomas may be consistent with observations of an "immunization effect" in animals inoculated with multiple tumors.