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Background Various solutions have been recommended for cleansing wounds, however, normal saline is favoured as it is an isotonic solution and is less likely to interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost-effective; however, there is an unresolved debate about its use. Objectives The objective of this review was to assess the effects of water compared with other solutions for wound cleansing. Search strategy Randomised and quasi-randomised controlled trials were identified by electronic searches of Cochrane Wounds Group Specialised Register (June 2004), MEDLINE (1996–2004), EMBASE (1980–2004), CINAHL (1982–2004), and the Cochrane Controlled Trials Register (Issue 2, 2004). Primary authors, company representatives and content experts were contacted to identify eligible studies. Reference lists from included trials were also searched. Selection criteria Randomised and quasi-randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing. Data collection and analysis Trial selection, data extraction and quality assessment were carried out independently by two reviewers and checked by a third reviewer. Differences in opinion were settled by discussion. Some data were pooled using a fixed effects model. Main results Five trials were identified that compared rates of infection and healing in wounds cleansed with water and normal saline; three compared cleansing with no cleansing and one compared cleansing with procaine spirit with water. There were no standard criteria for the assessment of wound infection across the trials which limited the ability to pool the data. The major comparisons were water versus normal saline, and tap water versus no cleansing. For chronic wounds, the relative risk of developing an infection when cleansed with tap water compared with normal saline was 0.16 (95% CI 0.01–2.96). Use of tap water to cleanse acute wounds in adults was associated with a lower rate of infection than saline (RR 0.55, 95% CI 0.31–0.97). The use of tap water to cleanse acute wounds in children was not associated with a statistically significant difference in infection, when compared with saline (RR 1.07, 95% CI 0.43–2.64). Similarly, no statistically significant differences in infection rates were seen when wounds were cleansed with tap water versus not cleansed at all (RR 0.81, 95% CI 0.31–2.12). Likewise, there was no difference in the infection rate in episiotomy wounds cleansed with water or procaine spirit. The use of isotonic saline, distilled water and boiled water for cleansing open fractures also did not demonstrate a statistically significant difference in the number of fractures that were infected. Conclusions Although the evidence is limited one trial has suggested that the use of tap water to cleanse acute wounds reduces the infection rate and other trials conclude that there is no difference in the infection and healing rates between wounds that were not cleansed and those cleansed with tap water and other solutions. In the absence of drinkable tap water, boiled and cooled water as well as distilled water can be used as cleansing agents.

Background Poorly controlled diabetes leads to multiple complications including oral health problems. General practitioners (GPs) are at the forefront of management of chronic diseases in primary health care. Diabetes guidelines encourage a proactive role for GPs in oral health complications management in people with diabetes, yet little is known about this area of care. This study aimed to explore current practices, perceptions and barriers of GPs towards oral health care for people with diabetes. Methods We employed a qualitative research method utilising telephone interviews. Purposive and snowball sampling were used to recruit 12 GPs from Greater Sydney region. A thematic analysis involving an inductive approach was used to identify and analyse contextual patterns and themes. Results A majority of participants were males (n = 10), working in group practices (n = 11) with a mean ± SD age of 55 ± 11.4 years and 25 ± 13.6 years work experience. Three major themes emerged: oral health care practices in general practice settings; barriers and enablers to oral health care; and role of diabetes care providers in promoting oral health. Most GPs acknowledged the importance of oral health care for people with diabetes, identifying their compromised immune capacity and greater risks of infections as risk factors. GPs reported 20–30% of their patients having oral health problems, however their current oral health care practices relating to education, risk assessment and referrals were reported as very limited. GPs identified several barriers including time constraints, absence of referral pathways, and limited knowledge and training in promoting oral health care. They also reported patient barriers including oral health care costs and lower oral health awareness. GPs perceived that resources such as education/training, a standardised assessment tool and patient education materials could support them in promoting oral health care. GPs also perceived that other diabetes care providers such as diabetes educators could play an important role in promoting oral health. Conclusions Despite current recommendations, GPs’ current oral health care practices among people with diabetes are limited. Further strategies including capacity building GPs by developing appropriate oral health training programs and simple risk assessment tools along with accessible referral pathways are needed to address the current barriers.

Background Diabetes increases the risk of periodontal disease, which in turn negatively impact on diabetes control and complications. Therefore, awareness about the diabetes-oral health link and dental problems is important for people with diabetes. This study aimed to assess self-reported oral health status and knowledge of people living with diabetes. Methods A survey was conducted among patients who attended four public diabetes clinics in Sydney, Australia. The questionnaire included 10 knowledge items and a validated Oral Health Impact Profile (OHIP-14) scale. A convenience sample of 200 patients were recruited. The data were analysed using SPSS software with descriptive and Pearson's Chi-Squared tests reported. Results The mean age of participants was 62.4(±13.5) years. More than half were males (54.5%), born overseas (64%), not working (73%) and had type 2 diabetes (88%). More than half (55.1%) of the patients reported having one or more dental problems and this was negatively associated with their oral health-related quality of life (p the mean correct score 5.2 (±2.6). The main areas with poor knowledge were around the impact of gum disease on blood glucose levels (29.6%), effects of dry mouth on tooth decay (33.8%) and the link between diabetes and teeth and gums (44.5%). Only 13% of the patients reported receiving oral health information from diabetes care providers (diabetes educator, general practitioner/diabetes specialist and dietitian/nutritionist). Receiving oral health information was found to be significantly associated with higher oral health knowledge scores (p Conclusions Considering that a majority of patients with diabetes have dental problems and inadequate oral health knowledge, diabetes care providers should take the opportunity to educate patients about oral health risks. Key messages People living with diabetes found to have dental problems and inadequate oral health knowledge. Considering that diabetes and dental problems adversely affect each other, it is crucial to educate patients about good oral hygiene and regular dental visit.

Background People with uncontrolled diabetes are at greater risk for several oral health problems, particularly periodontal (gum) disease. Periodontal disease also impacts diabetes control. Good oral hygiene and regular dental visits are recommended to prevent and manage oral health problems. Several studies have been conducted to assess the oral health knowledge, attitudes, and practices of people with diabetes yet a review of these findings has not yet been undertaken. The aim of this systematic review was to synthesize current evidence on the knowledge, attitudes and practices of people with diabetes in relation to their oral health care. Methods A systematic search of all literature was carried out in five databases using key search terms. The inclusion criteria were: 1) published in the English language; 2) from 2000 to November, 2017; 3) conducted on persons with any type of diabetes and of all ages; 4) explored at least one study outcome (knowledge or attitude or practices toward oral health care); and 5) used quantitative methods of data collection. No restrictions were placed on the quality and setting of the study. Results A total of 28 studies met the inclusion criteria. The studies included a total of 27,894 people with diabetes and were conducted in 14 countries. The review found that people with diabetes have inadequate oral health knowledge, poor oral health attitudes, and fewer dental visits. They rarely receive oral health education and dental referrals from their care providers. Provision of oral health education by diabetes care providers and referral to dentists when required, was associated with improved oral health behaviours among patients. Conclusions Overall, people with diabetes have limited oral health knowledge and poor oral health behaviours. It is therefore essential to educate patients about their increased risk for oral health problems, motivate them for good oral health behaviours and facilitate access to dental care. Electronic supplementary material The online version of this article (10.1186/s12889-018-5485-7) contains supplementary material, which is available to authorized users.

Patient: Male, 65-year-old Final Diagnosis: Mycobacterium avium intracellulare epidural abscess Symptoms: Back pain • flank pain Medication: — Clinical Procedure: Debridement • evacuation of epidural abscess • laminectomy Specialty: Infectious Diseases • Neurosurgery Objective: Unusual clinical course Background: Mycobacterium avium intracellulare complex (MAI) is a member of the non-tuberculous mycobacteria family, which can cause both pulmonary and non-pulmonary disease. In patients with advanced HIV, it is known to cause disseminated disease. We present a case of a 65-year-old man who has sex with men (MSM) with AIDS, found to have spondylodiscitis and an epidural abscess, who had recently completed treatment for disseminated MAI. Case Report: The patient was a 65-year-old with AIDS secondary to HIV and a prior history of disseminated MAI, who presented with severe back pain. Upon presentation to the hospital, an MRI was performed, which was suggestive of spondylodiscitis and an epidural abscess. He was taken to surgery for a minimally invasive T12-L1 laminectomy and evacuation of the epidural abscess. Both traditional cultures and acid-fast bacillus (AFB) cultures were negative. Due to worsening pain, he was taken back to surgery for a repeat debridement and biopsy. Repeat cultures were positive for MAI. He was started on rifabutin, ethambutol, azithromycin, and moxifloxacin. Moxifloxacin was subsequently discontinued. He has had problems tolerating the treatment regimen, but is planned to complete an 18–24-month course. Conclusions: For patients with AIDS who have a diagnosis of spondylodiscitis and an epidural abscess, an opportunistic infection such as MAI should be considered. A repeat biopsy should be considered if suspicion is still high, even despite initially negative cultures. Treatment regimens should be prolonged, despite difficulty with medication compliance.

Aims and Objectives: The aim of this paper was to evaluate the impact of phone support on sick day management of young people with type 1 diabetes.Method: Qualitative exploratory study to understan...

Aim: To explore how intensive insulin therapy is integrated into the primary school setting, to identify support strategies in order to inform policy and practice.Data sources: Articles between 2005 and 2015, children aged 4–12 years.Review methods: A meta-ethnographic comparative approach, using reciprocal translation and line of argument synthesis.Findings: Fourteen studies with qualitative data were included. Seven major metaphors were identified: Oh, it's needles, cover your back, worried about safety, great expectations, I'm not a diabetes expert, like everyone else and working together.Conclusion: A line of argument and conceptual model was developed from the metaphors and identified; competent diabetes care, risk management and a sense of normality and understanding as key areas that required addressing to improve integration of intensive insulin therapy. Collaboration and planning between the home, health, education and legal systems is also essential.

Purpose The purpose of this study was to explore the current perceptions and practices of diabetes educators (DEs) in providing oral health care to people with diabetes. Methods A qualitative study design involving focus groups was used to gather data. Purposive sampling was used to recruit DEs working across 3 metropolitan hospitals in South Western Sydney, Australia. Results Fourteen DEs participated in 3 focus groups. Participants had a mean ± SD age of 44.4 ± 9.2 years and 5.2 ± 5.3 years of work experience in diabetes care. Four main themes were identified: perceptions about oral health care and diabetes current oral health care practices, perceptions on incorporating oral health, and suggested model of care. DEs agreed that promoting oral health in diabetes clinics is important, and they reported seeing patients frequently with oral health problems. However, the majority do not include oral health care in consultations, primarily because they have limited knowledge in this area and have not received any formal oral health education or training. Additional barriers were the lack of referral pathways and resources for patient education. DEs were receptive to incorporating oral health provided that the current barriers were addressed. DEs also suggested a multidisciplinary team care approach to promote oral health. Conclusions Current practices of DEs in oral health care are limited, but they are willing to address oral health. A suggested model of oral health care should include capacity building of diabetes care providers, appropriate dental referral pathways, and a team approach within multidisciplinary diabetes care.

Background The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia. Aim To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers. Methods Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke champions from intervention sites was conducted. Results A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical champions, medical staff, nursing management and allied health staff; easy adaptation of current protocols, care-plans, and local policies; and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions; hyperglycaemic protocols could not be commenced without written orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor level of engagement of medical staff; and doctors' unawareness of the trial. Linking Evidence to Action The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers.

Research Question: What factors determine diabetes care outcomes for young adults with type 1 diabetes after transition from paediatric to adult health care services? Criteria for considering studies for this review: Types of participants: People aged 15-19 years inclusive with diagnosis of type 1 diabetes who have been transitioned from paediatric to adult health care services. Types of outcome measures: The primary outcomes are: Diabetes control as measured by HbA1c at follow-up Loss to follow-up Adherence to insulin therapy Incidence of hospital admission for acute complications Frequency and regularity of clinic attendance Secondary outcomes: Uptake of screening for long term diabetes complications Cost effectiveness of intervention Health related quality of life Patient satisfaction

Aim Oral health complications are common in people with diabetes yet very little is reported about the oral health care provided in diabetes care setting. This study reviewed global evidence on the oral health care knowledge and practices of diabetes care providers and the role of non-dental health professionals in oral health promotion. Methods A systematic search of five databases was undertaken with key search terms using a scoping review framework. Relevant studies published till October 2016 in the English language were included (n = 30) and no restrictions were placed on the study design, quality or setting. Results Most diabetes care providers are not addressing oral health care with the main barriers being time constraints and limited oral health knowledge. Diabetes educators (DEs) could engage in oral health promotion with few studies showing this model of care can translate into improved patient outcomes. However, no appropriate oral health training programs and assessment tools exist for DEs. With proper training, non-dental professionals like nurses have successfully incorporated oral healthcare in other settings. Conclusions DEs are well placed to promote oral health in diabetes care setting. Further research is needed to identify barriers and oral health resources to support DEs in this role.

BACKGROUND This paper is a reflection by a PhD candidate on her qualitative study involving parents, diabetes educators and school teachers who were caring for a child with type 1 diabetes using intensive insulin therapy in primary school. AIM To reflect on a novice researcher's experience of recruiting research participants from community, health and education settings in Australia. DISCUSSION Participants were successfully recruited for the study using internet communication tools: Facebook support groups; the Australian Diabetes Educators Association (ADEA) e-newsletter; and emails sent to school principals. These methods were successful as Facebook and online support groups are popular, the study topic was of interest, the ADEA has many members, and numerous emails were sent to schools. Potential barriers to recruitment were a lack of access to those who did not use Facebook or the internet, gatekeepers, the high workloads of diabetes educators and teachers, and the time needed to obtain ethics approval and send a large number of emails to schools. CONCLUSION Internet communication tools were successful in recruiting participants from community, health and education settings. However, different approaches were required for each type of participant. Lessons learned from this experience were: the importance of taking time to plan recruitment, including an in-depth understanding of potential participants and recruitment tools, the benefit of being an insider, and the need to work closely with gatekeepers. IMPLICATIONS FOR PRACTICE An understanding of recruitment is essential for ensuring access to appropriate participants and timely collection of data. The experience of the novice researcher may provide insight to others planning to use internet communication tools for recruitment.

Background Nasogastric tubes are frequently used in the clinical setting for the management of patients who require decompression of the gastrointestinal tract, diagnosis and assessment, nutritional support and medication administration. A variety of bedside methods have been used either individually or in combination to assess NG tube placement. Objectives The objective of this review is to present the best available evidence to support decisions pertaining to methods for determining the correct nasogastric tube placement after insertion. Search strategy A literature search was performed using the following databases MEDLINE (1950 to Sept 2008), CINAHL (1982 to Sept 2008), EMBASE (1980 to Sept 2008) and All EBM Reviews (up to 3rd Quarter 2008). Chinese databases searched included WanFang Data (1998 to Sept 2008), China Journal Net (1994 to Sept 2008), Chinese Medical Current Contents (1994 to Sept 2008), Index to Chinese Periodical Literature (1970 to Sept 2008), and the Chinese Biomedical Literature Database (1980 to Sept 2008). In addition the reference lists of relevant trials and conference proceedings were also scrutinised. Investigators were contacted to elicit further information. Selection criteria Clinical trials, prospective studies, observational studies, case reports, and evaluation studies assessing the diagnostic accuracy of methods for determining the correct placement of nasogastric tube after insertion were considered for inclusion in the meta-analysis. Data collection and analysis Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Since not all trials reported true positive, true negative, false positive and false negative rates, these rates were calculated based on the data in the published papers. The two by two tables were reconstructed for each study, and sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were calculated for each study. Diagnostic studies presenting insufficient data forconstruction of a two by two table were excluded from statistical analysis, but were included in the narrative part of the review. Main results Twenty-six trials were included in this meta-analysis: three trials investigated the effectiveness of colorimetric capnometry in detecting inadvertent airway intubation; three trials reported the use of capnography to verify tube placement in airway and to differentiate between respiratory and GI tube placement; one trial compared the use of a portable capnograph with a disposable colorimetric CO2 indicator in detecting inadvertent respiratory intubation. There were nine trials made use of a variety of cut-off points based on the biochemical measurement parameters of feeding tube aspirates (pH, bilirubin, pepsin and trypsin) in differentiating gastric from respiratory and intestinal placement of feeding tubes; one trial evaluated the accuracy of six pH test-strips. There were nine trials investigated the effectiveness of using various methods to differentiate between respiratory and GI feeding tube placement which included the use of: spring gauge pressure manometer, magnetic detection, sonography, auscultation and visual inspection of aspirates. Authors’ conclusion The limited evidence obtained from the meta-analysis does not provide a substantial base for the development of practice guidelines. However, based on the trials undertaken to date, there is strong evidence to support the use of capnography or colorimetric capnometry for identification of feeding tube placement in mechanically ventilated patients. Until stronger evidence becomes available practice related to the diagnostic tests used within the clinical setting will continue to be dictated by local preferences and cost factors.

Errors and adverse events have major impact on elderly patients due to their recurrent hospitalisation and particularly as they move between settings to receive care for comorbid chronic conditions. A range of strategies such as discharge planners, use of patients transfer sheet, medications reconciliation and patients education have been implemented to improve care transition. However, there have been no systematic reviews undertaken to evaluate the effectiveness of these strategies in a concise format for the development of evidence-based guidelines. Therefore, a systematic review is urgently needed to support clinicians in implementing safe quality care transition and also use as a front line to improve patient safety.The objective of this review is to appraise and synthesise the best available evidence in promoting a safer transfer of elderly patients across care settings.Types of studies Only randomised controlled trials (RCTs) evaluating the effectiveness of strategies to promote safe transfer of elderly patients across care settings were eligible for inclusion in this review.Types of participants The review included studies undertaken in participants aged65 years who have been transferred between care settings.The review focused on any interventions that were undertaken to reduce or minimise errors and adverse events and promote safe transition of the elderly patients from one setting to another.The primary outcome of interest was the effect of the interventions on the use of health care resources.A comprehensive search of the literature published in the English language was undertaken using all major electronic databases ranging from 1966 to 2008. Reference lists and bibliographies of all possible trials and reviews of studies were searched. Relevant conference proceedings were searched; experts in the field were also contacted to identify further trials.12 studies were included in the review. The results indicated that comprehensive plan of care and well-trained healthcare practitioners such as nurses or pharmacists, who have current information about the patient's clinical status and care plan, ensured smoother transition from hospital to home. The use of multi-faceted interventions such as elderly patient education and collaborative team approach reduce the incidence of errors and adverse events during care transition.There is evidence of benefits to demonstrate:1. Strategies that involve structured communication improve outcomes for elderly patients during care transition.2. Nurse-led interventions and multidisciplinary team interventions were effective in reducing readmission to hospital at one to nine months.3. Pharmacist-led interventions and multidisciplinary team led interventions reduced frequency of hospital services utilisation such as emergency visits, long-term institutions and rehabilitation clinics.4. Pharmacist-led interventions were effective in improving quality of medications prescribed by physician. In addition, significantly reduced non-adherence in patients taking four or more medication at three months.5. Nurse-led interventions effectively improved quality of life in patients receiving the interventions.6. Nurse-led and multidisciplinary team led interventions reduced costs associated with the interventions.The review has provided a guide for future research priorities which involves larger randomised controlled trials assessing transitions between hospital and in-patient settings; comprehensive standardised method to assess outcomes such as medication adherence and studies to clearly demonstrate the association between adverse events and transfer.

Aims and objectives. To examine the association between trait emotional intelligence and learning strategies and their influence on academic performance among first-year accelerated nursing students. Design. The study used a prospective survey design. Methods. A sample size of 81 students (100% response rate) who undertook the accelerated nursing course at a large university in Sydney participated in the study. Emotional intelligence was measured using the adapted version of the 144-item Trait Emotional Intelligence Questionnaire. Four subscales of the Motivated Strategies for Learning Questionnaire were used to measure extrinsic goal motivation, peer learning, help seeking and critical thinking among the students. The grade point average score obtained at the end of six months was used to measure academic achievement. Results. The results demonstrated a statistically significant correlation between emotional intelligence scores and critical thinking (r = 0.41; p

SALAMONSON Y., RAMJAN L., LOMBARDO L., LANSER L.H., FERNANDEZ R. & GRIFFITHS R. (2011) Diversity and demographic heterogeneity of Australian nursing students: a closer look. International Nursing Review59, 59–65 Background: In the last decade, there has been a rapid growth of international students undertaking nursing studies in Australian universities. At the same time, nursing courses continue to attract local students from a diversity of backgrounds. Aim: The aim of this study is to examine first year nursing students by enrolment classification and country of birth: i) international; ii) local, overseas-born; and iii) local, Australian-born student, and demographic differences of academic performance at the 12-month follow-up. Methods: A prospective, correlational design was used to identify nursing student characteristics as predictors of academic performance in a large university in the western region of Sydney. Results: Of the 806 students enrolled in the course, 540 (67%) completed the survey and consented to data linkage. Fifty-six per cent of the 540 participants were born overseas, of which 38% were local and 18% were international students. Local, overseas-born students originated from 55 different countries, in contrast to international students who were representative of only 16 different countries. International students were younger, spent less time in paid work and were more likely to have a close friend in the same course. Although age was positively related to academic performance, local, overseas-born and international enrolment classifications, and hours in paid work during semester were negatively associated to academic performance. Conclusion: This study has taken a closer look at an important issue that requires further examination, given that international and local, overseas-born students were two distinctive groups. Although both groups underperformed academically compared with Australian-born students, the differences in characteristics between local, overseas-born students and international students suggest that these two student groups are likely to experience different challenges during their nursing studies in Australia.

Summary Background We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs). Methods In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. Findings 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8–25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2–5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44). Interpretation Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. Funding National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

Aims and objectives. To explore current practice and opportunities to improve practice in decision-making about transfer of nursing home residents to hospital. Background. Nursing home staff are often faced with the decision of whether to send a resident to hospital for medical treatment. While many residents will benefit from going to hospital, there are also several risks associated with this. This study sought to add to the existing body of research on this issue by seeking the views of nursing home managers, who are the persons most frequently involved in making these decisions. Design. Qualitative design using purposive, quota sampling. Method. Qualitative interviews with 41 nursing home managers from south-western Sydney, Australia. Results. Factors affecting the decision to transfer a resident to hospital include acuteness of their condition; level and style of medical care available; role of family members; numbers, qualifications and skills mix of staff; and concern about criticism for not transferring to hospital. Two factors that have not featured as strongly in previous research are the roles of advance care planning and support from local hospital and community health services. Conclusion. While transferring a nursing home resident to hospital is often necessary, there are many situations where they could be cared for in the nursing home; therefore, avoid complications associated with being in hospital. Apart from a range of factors already identified in the literature, this study has highlighted the important role that advance care planning and support from local health services can play in reducing unnecessary transfers to hospital. Relevance to clinical practice. There are several strategies that nursing homes and local health authorities can adopt to promote advance care planning and build better support systems between the two sectors, thereby reducing the numbers of residents who need to be transferred to hospital for their health care.

Objective To review the diagnostic accuracy of end-tidal carbon dioxide detection in detecting inadvertent airway intubation and verifying correct placement of nasogastric tubes. Design We undertook a meta-analysis of diagnostic studies. Study selection All clinical trials that evaluated the diagnostic accuracy of the colorimetric capnometry or capnography in detecting inadvertent airway intubation and differentiating between respiratory and gastrointestinal tube placement in adults were included. Electronic databases including MEDLINE, CINAHL, EMBASE, All EBM Reviews, WanFang Data, China Journal Net, Chinese Medical Current Contents, and Index to Chinese Periodical Literature were searched from inception to July 2009. Data extraction and quality assessment Data were extracted using a form piloted prior to use. Two reviewers independently extracted data relating to purpose of the trial, sample, measurements used, index test results and reference standard. Methodological quality of eligible trials was assessed independently by two reviewers using a modified version of the Quality Assessment of Diagnostic Accuracy Studies for assessing studies of diagnostic accuracy. The accuracy of diagnostic tests is presented in terms of sensitivity, specificity, predictive values, and likelihood ratios. Data synthesis Nine clinical trials were eligible for inclusion in the meta-analysis. Eight trials were undertaken in intubated and mechanically ventilated patients and two trials also involved participants who were alert or awake. Eight involving a total of 456 nasogastric feeding tube placements investigated the diagnostic accuracy of either colorimetric capnometry or capnography to detect feeding tube placement. One trial involving 195 gastric tube insertions compared the diagnostic accuracy of simultaneous use of a colorimetric carbon dioxide detector and capnography to detect feeding tube placement. The use of colorimetric capnometry or capnography had a sensitivity ranging from 0.88 to 1.00, specificity 0.95 to 1.00, positive likelihood ratio 15.22 to 283.35, negative likelihood ratio 0.01 to 0.25. A summary receiver operator characteristics (SROC) curve was constructed and showed an area under the curve was 0.9959. Three trials reported significant cost savings using end-tidal carbon dioxide detectors. Conclusions There is evidence to support the use of capnography or colorimetric capnometry for the identification of nasogastric feeding tube placement in mechanically ventilated patients.

The purpose of this study was to describe the demographic and employment characteristics of Australian occupational therapists working in youth mental health and explore the relationship between these characteristics and the occupational therapist's role. Sixty-three occupational therapists completed a postal survey during 2006–2007. Numerical data were analyzed using descriptive statistics and qualitative data were analyzed using thematic analysis. The majority (86%) of participants were female, with a mean age of 31.8 years. Over half of the participants were employed as occupational therapists (60%). While most participants reported less than five years experience working with young people (92.5%), thirty-nine participants (61.9%) expressed optimism about the future of occupational therapy in youth mental health. Factors such as funding, staff retention, support, training, and attitudes surrounding professional roles were identified as barriers to role expansion. Occupational therapists work in a range...

Palliative care clients often have a reduced quality of life (QOL). The purpose of this study was to explore the QOL trajectory of clients and carers newly referred to a community palliative care service. A total of 49 clients and 43 carers respectively completed the McGill QOL scale (MQOL) and the caregiver QOL cancer scale (CQOLC) questionnaires. Baseline data relating to demographics, health status, and QOL are presented for the 49 participants and their 43 carers, and these are compared with follow-up data from 22 clients and 13 carers (matched pairs). On average, there were no significant differences between baseline and follow-up QOL scores in any respects for either clients or carers, including measures of burden, disruptiveness, positive adaptation, and financial concerns. Whether this indicates that the care administered succeeded in cancelling out the worsening of the clients' conditions or whether it indicates a shortcoming of the care was not assessed. Refereed/Peer-reviewed

Background: Stroke is an Australian health priority area causing considerable levels of disability. We report 90-day outcomes for a cohort of acute stroke patients in New South Wales (NSW), Australia prior to randomization to a large cluster randomized controlled trial (CRCT), the Quality in Acute Stroke Care (QASC) trial. Aims: This paper describes prospectively collected, 90-day outcome data for a cohort of NSW stroke patients, providing pre-intervention data for the QASC trial. Methods: A consecutive sample of patients from acute stroke units in NSW was recruited. We measured patient death, disability (modified Rankin Score (mRS)), dependency (Barthel Index (BI)) and Health Status (Medical Outcomes Short-Form Health Survey (SF-36)) 90 days post-hospital admission. We also collected self-reported healthcare utilization and patient satisfaction with health professionals' advice and management to reduce risk of subsequent stroke. Results: Ninety-day outcome data were obtained for 687 patients, of which, 335 (49%) had an mRS ≥2; 44 patients (6.4%) had died. For the 643 surviving patients, the mean BI was 87.2 (SD 21.9) and the mean scores for SF-36 Physical Component Summary score and Mental Component Summary score were 46.2 (SD 10.1) and 46.3 (SD 12.6) respectively. Conclusions: In this pre-intervention cohort of selected acute stroke inpatients, stroke severity was mild to moderate and subsequent clinical outcomes were favourable in the majority. The findings from this study provide a comprehensive description of 90-day health outcomes of patients who have experienced a mild–moderate stroke managed in stroke care units across metropolitan NSW and provide valuable data to inform the subsequent cluster trial.

A wide range of services are provided to palliative care clients to alleviate pain and improve their quality of life. The purpose of this study was to explore the perceptions of clients and their carers regarding palliative care services in New South Wales, Austalia. Ten patients and their carers (n=7) were randomly selected from a sample of palliative care clients and were informed of the study and interviewed. Interview data were coded independently by three researchers and thematic analysis was undertaken. The themes identified were similar for both clients and carers and included: access to services; service provision; impact on way of life; usefulness of services; and staffing. An additional theme identified by clients was the burden of caregiving on carers. Knowledge of perceptions and concerns of client and carers is important to consider when planning palliative care services.

Risk-factor modification after an acute coronary event is imperative, and intervention strategies are continuously being developed to assist patients with behavioral change and, consequently, decreasing the risk of further coronary episodes. This article describes the development of the health-related lifestyle self-management (HeLM) intervention, which is a brief structured intervention embedded within the transtheoretical model of behavioral change. The HeLM intervention was developed by undertaking three discrete yet interrelated studies and consisted of the following components: goal-setting, the HeLM booklet, feedback regarding personal risk, team-building and communication with the patient's family physician, three supportive telephone calls, trained interviewers, a refrigerator magnet, and a health diary for self-monitoring. The HeLM intervention has been successfully implemented in 50 patients with acute coronary syndrome after discharge from hospital and has been demonstrated to be feasible and practical and could easily be delivered by health care professionals. © 2009 Mosby, Inc. All rights reserved.

Individual and community health outcomes are strengthened by friendships and social support networks. Community interventions aimed at improving the social factors that influence the health of individuals and communities increasingly include strategies to develop resilience through building networks and social capital. The study reported here used a cross-sectional survey design, administered at two time points, to measure the effect of a community capacity-building programme implemented by Women's Health Nurses. Data described and where possible measured women's perceptions of their physical and mental well-being, friendships and support networks, community connectedness and participation, safety, and knowledge of and access to local community services. The follow-up survey also measured the impact of specific community development initiatives. Overall, findings of both surveys were consistent, with some notable exceptions. For example, at follow up there was a significant improvement in mental health indicators and fewer women believed their physical or emotional problems imposed a considerable burden on their daily activities. They also believed people from other cultures were more likely to be accepted by neighbours and reported increased involvement in community activities as a direct result of the Villawood Icebreakers Project.

Agitation is a common symptom of dementia which becomes exacerbated in the advanced stages of the disease. The negative effects of this symptom are numerous and often result in institutionalisation. Given it is the registered nurse, with the cooperation of the enrolled nurse/ assistant in nursing, who provide the majority of face-to-face care in residential aged care facilities, there is a clear need to identify effective management strategies for agitated behaviours which nursing staff can easily access and implement.This review identifies the best available evidence regarding the efficacy of nurse implemented non-pharmacological strategies for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities METHOD: A systematic literature search of MEDLINE, CINAHL, PsycINFO, Cochrane Library, SCOPUS, EMBASE, and AgeLine databases was undertaken. Additionally, the reference lists of relevant papers were examined for additional trials.This review considered any English language randomised trial that investigated strategies implemented by a nurse for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities. Outcomes measured included frequency and severity of agitation.Seven trials were included in this review. Five of the seven strategies investigated were shown to be effective in the symptom management of agitation when compared to alternate strategies. Effective strategies include: behavioural therapy, balancing arousal states, therapeutic touch, multi-sensory stimulation and person-centred bathing.The heterogeneity of the included trials made it difficult to draw definitive conclusion. However, the results of this systematic review reveal that some non-pharmacological strategies are effective when implemented by a nurse for the symptom management of agitation in pesons with advanced dementia living in residential aged care facilities. Despite this finding, there is currently insufficient evidence to develop practice guidelines.

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.

Review Objectives: The aim of this systematic review [SR] is to examine whether the context of diabetes education effects psychosocial outcomes in adults with type 2 diabetes mellitus. Review question: This SR will be undertaken to answer the following research questions: Is there a difference in psychosocial outcomes for adults with type 2 diabetes who participate in: 1. group versus individual diabetes education; 2. group versus other diabetes education; or 3. Individual versus other diabetes education? Criteria for considering studies for this review: Types of participants: This review will consider all studies that report relevant interventions involving individuals aged 18 years and over who have been diagnosed with type 2 diabetes. Given the changes in classification and diagnostic criteria for type 2 diabetes over the years, the diagnosis should have been based on standard criteria, such as the WHO criteria, that were current at the time of the trial (16). Ideally, this information should be included in the study report. Studies involving only participants with type 1 or gestational diabetes will not be included. Studies that include participants with both type 1 and type 2 diabetes will be included provided data from participants with type 2 diabetes is analysed separately. Types of interventions: Trials will be considered for inclusion in the review if they report on any kind of group or individual diabetes education intervention, conducted in all settings, and delivered by any provider type. The interventions of interest are related to lifestyle modification and instruction on self-management behaviours, such as diet and exercise counselling, medication adherence, and blood glucose monitoring, as well as psychosocial counselling such as coping skills training, empowerment, and motivational interviewing. Interventions that specifically address insulin initiation will be excluded, as will those that involve specialised psychological therapies such as cognitive behavioural therapy, psychotherapy, and others. Studies with multiple component interventions will be included only if the effects of the educational component can be examined separately. Types of outcome measures: The primary outcomes of interest will include: Quality of life Wellbeing Empowerment Self-efficacy Patient satisfaction Attitudes Health/illness beliefs and perceptions Anxiety Depression Stress Motivation Psychological adjustment

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 The physical and psychosocial benefits of participation in cardiac rehabilitation following a coronary event have well been established. Despite these benefits there is strong evidence that participation in traditional cardiac rehabilitation programs remains low. Various models of cardiac rehabilitation have been implemented including the use of brief structured interventions to enable modification of coronary risk factors. Objectives The objective of this review was to determine the effect of brief structured interventions on risk factor modification in patients with coronary heart disease. Search strategy A literature search was performed using the following databases MEDLINE (1966-2006), CINAHL (1982-2006), EMBASE (1980-current) and up to the Cochrane Controlled Trials Register (Issue 2, 2006 of Cochrane Library). In addition, the reference lists of relevant trials and conference proceedings were also scrutinised. Company representatives, experts and investigators were contacted to elicit further information. Selection criteria All randomised and quasi-randomised controlled trials that compared the effects of brief structured interventions on risk factor modification in patients with coronary heart disease were considered for inclusion in the review. Data collection and analysis Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals. Where synthesis was inappropriate, trials were considered separately. Main results Seventeen trials involving a total of 4725 participants were included in the final review: three trials compared the effects of brief structured interventions on diet modification; seven on smoking cessation; and seven on multiple risk factors. Two trials involving 76 patients compared brief structured intervention versus usual care for dietary modification. Although there was a tendency for more participants in the intervention arm to lose weight at the 12-week follow up and achieve target cholesterol levels at the 6-month follow up, these results were not statistically significant. Only one small trial involving 36 patients compared brief structured intervention and extensive intervention for dietary modification and demonstrated a significant reduction in the percentage of energy obtained from fat and saturated fat intake among participants receiving extensive intervention. However, no difference in fish, fruit and vegetable intake between the groups was evident. Six trials involving 2020 patients compared brief structured intervention versus usual care for smoking cessation. There was no difference in the smoking cessation rates at the 3- and 6-week follow up, however, there was evidence of a benefit of brief structured interventions for smoking cessation at the 3-, 6- and 12-month follow up. In the only trial that and compared brief structured intervention and extensive intervention for smoking cessation in 254 participants there was no clear difference of a likelihood of smoking cessation between the two groups. In the seven trials that compared brief structured intervention and usual care for multiple risk factor modification there was evidence of a benefit of the intervention on behavioural changes such as fat intake, weight loss and consequently on reduction in the body mass index, smoking cessation and physical activity among the participants. The findings concerning the effect on blood pressure, blood glucose levels and the lipid profile, however, remain inconclusive. Conclusions There is suggestive but inconclusive evidence from the trials of a benefit in the use of brief interventions for risk factor modification in patients with coronary heart disease. This review, however, supports the concept that brief interventions for patients with coronary heart disease can have beneficial effects on risk factor modification and consequently on progression of coronary heart disease. Further trials using larger sample sizes need to be undertaken to demonstrate the benefits of brief structured intervention targeted at the modification of single or multiple risk factors.

Digital technology has provided a new way of recording qualitative interviews, surpassing the clarity, usability and storage capabilities of conventional tape recorders. Ritin Fernandez and Rhonda Griffiths examine a technological resource that pervades modern social life and which can be used effectively for digitally recording interviews for qualitative research.

PURPOSE The purpose of this study was to describe the trajectory of cardiac patient's perceptions of health-related quality of life (HRQoL) during a 24-month period in a community-based population. METHODS After obtaining informed consent, a self-administered questionnaire was mailed to participants. Using the MacNew questionnaire, which assesses the emotional, physical, social, and global domains, HRQoL outcomes were assessed. RESULTS Completed questionnaires were received from 202 participants (75%). Improvements in the emotional, physical, social, and global HRQoL scores were observed until 15 to 17 months after the index percutaneous coronary intervention, after which a decline was observed. However, the scores in all HRQoL domains remained high when compared with the scores at 12 months. No clinical or sociodemographic predictors for HRQoL were identified. CONCLUSIONS The information obtained from this study will enable clinicians to further understand the process of recovery and adjustment of patients after percutaneous coronary intervention and the development of tailored strategies for patient management.

Objective to explore the effect of volitional food consumption by women during labour on labour and birth outcomes. Design a comparative design using concurrent controls. Setting four public hospitals in Sydney, Australia. Participants 217 English-speaking, nulliparous women with low-risk pregnancies. The sample was divided into four sub-groups identified post hoc from reported behaviour: (1) 82 women who chose to eat food during early labour only; (2) 10 who ate during established labour only; (3) 31 who ate during early and established labour and (4) 94 who chose to consume clear fluids only during early and established labour. Interventions voluntarily eating food during labour compared with voluntarily consuming clear fluids only. Measurements differences between the four eating groups were examined for labour progress using one-way analysis of variance (ANOVA). A hierarchical multiple regression tested the association between eating during labour and labour duration. The relationship between food intake and the incidence of medical interventions was tested using χ 2 tests. Findings eating during the early phase of the first stage of labour was associated with M=2.16hrs longer labour ( p 0.01 ). When women ate food during both their early and established phases of labour, M=3.5hrs was added to their labour ( p 0.01 ). The incidence of vomiting, medical interventions during labour or adverse birth outcomes were unaffected by food intake. Conclusion the findings suggest that women should be informed that labour may take longer when they eat food. However, eating does not seem to affect other labour or birth outcomes. Implication for practice the findings challenge the belief among many midwives that food intake is beneficial to labour progress. However, women should not be denied food for fear of vomiting or because it may make labour longer. Women with low-risk labours should be informed of the risk, although rare, of aspiration if general anaesthesia is required, and be allowed to respond to their natural desires for oral intake during labour.

This article discusses the influence that professional socialisation can have on midwifery practice. Differences in beliefs and practices regarding the oral intake of labouring women were the basis for this paper's discussion. Midwives should be aware of the problems that may be caused by the socialisation processes experienced during the training and subsequent working life of a midwife which aim to procure obedience and unquestioning conformity. These attributes diminish the ability of midwives to challenge traditional practices and to make decisions based on the available research evidence and the preferences of women in their care. Basing practice on tradition or practice conventions rather than a formal guideline or an evidence-based policy may expose a midwife to potential litigation should there be an adverse event.

Strengthening the physical and social environment has been shown to support health and strengthen community action for health. In an attempt to improve the social factors that influence the health of individuals and the community, community interventions increasingly include strategies to build networks and social capital and develop resilience. This study was undertaken to identify the most appropriate strategies to strengthen friendships and the social support networks for women aged 18-39 years living in Villawood, an area of high disadvantage in South Western Sydney, Australia. Although the majority reported positively on their health, one-third reported feeling isolated, experienced low energy levels and felt unhappy and anxious over the past month. Women who described themselves as unemployed felt more isolated than women in home duties. Women who were employed or engaged in home duties had more contact with neighbours, and had more in common with their neighbours. Those who reported more contact with their neighbours perceived their mental health level as being higher. These results indicate that community development initiatives should include consultation with the community and consider the needs of socially isolated groups and those with the poorest health status.

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

Review Questions: a) What is the effectiveness of interventions to reduce cardiovascular risk factors delivered by the general practice nurse in adult patients with CVD, patients with known cardiac risk factors and the general population? b) What is the effect of multifaceted compared to targeted interventions for the reduction of cardiovascular risk factors in adult patients with CVD, patients with known cardiac risk factors and the general population? Inclusion Criteria: Types of Participants This review will consider all studies that report relevant interventions involving individuals aged 18 years and older. Types of Interventions: Trials will be considered for inclusion in the review if they report any kind of intervention delivered by the practice nurse related to CVD management or cardiovascular risk factor reduction. The interventions of interest are related to: health assessment; lifestyle modification; counselling; referral; and, support. Types of Outcomes: The primary outcomes of interest are either objective or subjective measures of cardiac risk factors. These measures include: adverse events (e.g. hospital admission, death, myocardial infarction), smoking cessation, body weight, blood pressure, cholesterol level, physical activity, dietary intake, and alcohol consumption. The secondary outcomes of interest are the cost-effectiveness of the intervention and clinician / consumer satisfaction.

It is only recently that recognition of the serious and debilitating sequelae of trauma has prompted exploration of outcomes beyond survival, such as disability, health status and quality of life. This paper aims to review the literature describing outcomes following severe traumatic injury to provide clinicians with a greater understanding of the recovery trajectory following severe trauma and highlight the issues faced by those recovering from such injury. Electronic databases, published reference lists and the Internet were searched to identify relevant literature. The heterogeneous nature of published literature in this area prohibited a systematic approach to inclusion of papers in this review. Trauma survivors report significant sequelae that influence functional status, psychological wellbeing, quality of life and return to productivity following severe injury. Key themes that emerge from the review include: current trauma systems which provide inadequate support along the recovery trajectory; rehabilitation referral which is affected by geographical location and provider preferences; a long-term loss of productivity in both society and the workplace; a high incidence of psychological sequelae; a link between poor recovery and increased drug and alcohol consumption; and valued social support which can augment recovery. Future research to evaluate interventions which target the recovery needs of the severely injured patients is recommended. Particular emphasis is required to develop systematic, sustainable and cost-effective follow-up to augment the successes of existing acute trauma services in providing high quality acute resuscitation and definitive trauma management. © 2005 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd.).

Question/Objectives This systematic review will be undertaken to answer the following question. For patients with CHD what is the effect of brief structured interventions for the modification of the following risk factors: smoking; physical inactivity, lipid profile, high blood pressure, high fat diet and diabetes? The objective of this review is to determine the effect of brief intervention on risk factor modification in patients with CHD. The following comparisons will be made: 1) Brief intervention versus usual care for single risk factor modification 2) Brief intervention versus extensive interventions for single risk factor modification. 3) Brief intervention versus usual care for multiple risk factor modification 4) Brief intervention versus extended intervention for multiple risk factor modification. Criteria for considering studies for this review Types of participants Adults (age >18years) with CHD and known risk factors will be included. Trials undertaken in children to promote healthy lifestyle will be excluded. Types of interventions The following comparisons will be made: 1) Brief intervention versus usual care for single risk factor modification 2) Brief intervention versus extensive interventions for single risk factor modification. 3) Brief intervention versus usual care for multiple risk factor modification 4) Brief intervention versus extensive interventions for multiple risk factor modification Trials that include the following methods for delivery of the brief intervention will be included: face to face interview; telephone; electronic and postal. Trials that included brief intervention as part of an extended program will be excluded. In addition trials that compare types of diets or exercises will be excluded. Population based trials and those undertaken for health promotion will also be excluded. Types of outcome measures The primary outcomes of interest will include a) Changes in self-monitoring or other-reports of smoking b) Changes in self- monitoring or other-reports of cholesterol level c) Changes in self- monitoring or other-reports of physical activity d) Changes in self- monitoring or other-reports of dietary habits including fat and fish intake e) Changes in self- monitoring or other-reports of blood sugar levels f) Changes in self- monitoring or other-reports of blood pressure levels g) Changes in BMI TRUNCATED AT 350 WORDS

OBJECTIVE The objective of this systematic review was to determine the effect of the timing of removal of indwelling urethral catheters (IUCs) on the duration to and volume of first void, length of hospitalization, number of patients developing urinary retention and requiring recatheterization, patient satisfaction, and the percentage of IUCs removed according to the scheduled time for removal. MATERIALS AND METHODS Published and unpublished literature in English and other languages between January 1966 and June 2002, which compared the effects of the timing of removal of short-term indwelling urethral catheters on patient outcomes, was systematically reviewed using multiple electronic databases. To determine eligibility of the trials for inclusion in the review, assessment of methodologic quality and data extraction was undertaken independently by 2 reviewers and verified by a third reviewer. Odds ratio (OR) for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, a narrative overview has been undertaken. RESULTS Eight randomized controlled trials were eligible for this review. When IUCs were removed at midnight, the time to first void was significantly shorter (P = .012) after gynecologic surgery and significantly longer in patients after urologic surgery and procedures. Seven trials reported that the volume of the first void was greater in patients whose IUCs were removed late at night, and this was statistically significant in 4 trials. Patients who had their IUC removed at midnight were discharged from the hospital significantly (P < .00001) earlier than those who had their IUC removed in the morning, a finding that could result in potential cost savings for hospitals. CONCLUSION Based on the limited available evidence, this article suggests benefits in terms of patient outcomes and reduction in the length of hospitalization after midnight removal of the IUCs. Further trials should be undertaken in wider settings and on specific groups of patients to enhance generalizability.

This article explores factors influencing the sustained use of Peer Assisted Learning Strategies (PALS) in math in one elementary school. General education teachers participating in research studies implemented PALS twice a week to the full class, including students both with and without disabilities. The authors examined whether teachers maintained their use of PALS after the research studies ended. They also studied how PALS was used in each classroom and assessed teachers' perceptions of its utility, their understanding of its underlying principles, and their reasons for continuing use. The continued use and fidelity of implementation remained extremely high several years after the original research projects ended. Factors influencing continued use include the high quality of professional development and support provided during the research project, the solid alignment of PALS with district and state mandates, the autonomy in teaching math that PALS allowed teachers on the days they were not using PALS, and the fact that the computer-based system for monitoring student progress allowed teachers to easily see improvement in their students' math proficiency.

Background This systematic review updates a previous review published in 2001. Cleansing is a vital component of wound management; however; little attention has been give to the solutions and techniques used for cleansing purposes. The objective of this review was to assess the effectiveness of different solutions, pressures and techniques used for wound cleansing to prevent infection and promote wound healing. Search strategy Randomised and clinical controlled trials were identified using the Cochrane Central Register of Controlled Trials (CENTRAL). Additional searches of other databases and hand searches of journals and bibliographies was undertaken to identify further trials. Selection criteria All randomised and clinical controlled trials involving adults and/or children whose wounds were cleaned with commercial cleansers, normal saline, water, chlorhexidine, hydrogen peroxide or povidone-iodine were eligible for inclusion. Studies that utilised solutions for preoperative skin cleansing, compared solutions for burns or dental procedures, and those that compared dressings for patients with ulcers were excluded from this review. Outcomes included rate of healing, incidence of infections or levels of bacterial count. Selection of potential articles, assessment of methodological quality and data abstraction was conducted independently by two reviewers. Trials with similar patients, comparisons, and outcomes were pooled. The data were analysed using Cochrane Review Manager 4.2. Where pooling was inappropriate, trials are discussed in a narrative review. Results Fourteen randomised controlled trials were included that compared various solutions for wound cleansing. The evidence indicates that there is no difference in the infection and healing rates in acute and chronic wounds cleansed with either tap water or normal saline. An irrigation pressure of 13 psi is effective for cleansing wounds and reducing infection without causing tissue trauma. There were no studies comparing common techniques for wound cleansing such as swabbing or scrubbing. Showering postoperative wounds did not demonstrate any difference in infection rates; however, it increased the morale of the patient. Whirlpool therapy was effective in reducing inflammation and pain in surgical wounds. Conclusions These conclusions are based on the best available clinical evidence. However, there is an urgent need to support these findings with rigorous research as some of the conclusions are based on single studies with limited sample sizes. Solutions for wound cleansing: • The evidence supports the use of potable tap water for cleansing lacerations in both adults and children and postoperative wounds in adults only. • Potable tap water as well as boiled and cooled water is also an effective wound cleansing solution. This finding, however, is based on a trial that had a small sample size. • The evidence to support the use of potable tap water is limited (only one study with low power); therefore, further studies are required to confirm that assumption. • Povidone-iodine is an effective cleansing solution for contaminated wounds. Pressure for wound cleansing: • A pressure of 13 psi is effective in reducing infection and inflammation in both adults and children with lacerations and traumatic wounds. Techniques for wound cleansing: • Evidence to support or refute swabbing and scrubbing to cleanse wounds is lacking. • The review demonstrated no evidence of a difference in the wound infection and healing rates between wounds that were showered and those that were not. • The evidence for showering ulcers and other chronic wounds is lacking; therefore, this technique of wound cleansing should be undertaken with caution. • Whirlpool therapy is effective to reduce pain and inflammation in surgical wounds and improve the healing rate in pressure ulcers. • The evidence to support the use of Sitz bath for patients following episiotomy is limited.

Total parenteral nutrition (TPN) is a form of nutritional support that has become an essential adjunct to the management of patients who are unable to obtain adequate nutrition either via the oral or enteral route. Previous studies indicate that TPN can be administered safely and effectively to patients; however, there are associated risks with this form of nutritional support. Researchers have indicated that due to the complexity of TPN therapy a high level of knowledge and expertise is required in the management of these patients. The multidisciplinary team approach has been supported for its ability to assess the patients' nutritional status, prescribe the nutritional requirements, and reduce the incidence of metabolic complications through regular monitoring. However, contradictory views on the effectiveness of multidisciplinary TPN teams in health-care facilities have also been reported.The aim of this review was to critically analyse the literature and present the best available evidence that investigated the effectiveness of multidisciplinary TPN teams in the provision of TPN to adult hospitalised patients. The primary outcomes included: incidence of catheter-related complications, types of catheter-related complications, incidence of metabolic and electrolyte abnormalities, provision of nutritional requirements, estimated nutritional requirements, number of patients whose nutritional goals were met and the amount of energy and protein provided. Secondary outcomes included cost effectiveness of nutritional support teams and physician compliance with team recommendations.The literature search sought to identify both published and unpublished studies utilising various search strategies and the Internet. The Cochrane Library (2001, Issue 4) was initially searched to identify randomised controlled trials. The other electronic databases searched included CINAHL, Complete Medline, Complete Biomedical Collection, Complete Nursing Collection, and EMBASE. Experts and company representatives were contacted to identify published reports as well as research in progress relevant to this review. Professional bodies were contacted and included the British Association for Parenteral and Enteral Nutrition (BAPEN) and the Australasian Society for Parenteral and Enteral Nutrition (AuSPEN).All randomised and non-randomised controlled trials comparing the effectiveness of multidisciplinary TPN teams, in the provision of TPN to adult hospitalised patients, were considered for inclusion in this review. Trials were included if they reported objective or subjective measures of nutritional, metabolic and catheter-related complications and cost effectiveness. To minimise publication bias studies reported in other languages were also considered for inclusion in the review.The eligibility of studies for inclusion, the methodological quality and data extraction were undertaken independently by two reviewers and cross-checked by a third reviewer. The studies included in the review have been synthesised as a narrative overview.Eleven studies comparing the effectiveness of a multidisciplinary TPN team in the hospital setting were analysed in this review. Six studies that investigated the incidence of total mechanical complications reported a higher incidence of these complications in patients who were managed by their physician. Catheter-related sepsis was investigated in seven studies of which five reported a reduction and two reported an increase in catheter-related sepsis in patients managed by the team. One study reported no statistically significant difference in the total metabolic and electrolyte abnormalities and four studies reported fewer of these abnormalities in patients cared for by the nutrition team. Overfeeding and underfeeding in patients not managed by the TPN team were reported in five studies. The most appropriate route of feeding was investigated in four studies. Two of the four studies reported that patients managed by the team were more likely to be fed by the most appropriate route and the findings from the remaining two studies were unclear. Cost effectiveness of the TPN team was reported in two studies and a reduction in costs was demonstrated in both studies when the patients were managed by the TPN team. Compliance by physicians to recommendations made by the TPN team was investigated in two studies, and both reported that physicians complied with at least 50% of the recommendations.The general effectiveness of the TPN team has not been conclusively demonstrated. There is evidence that patients managed by TPN teams have a reduced incidence of total mechanical complications; however, it is unclear if there is a reduction in catheter-related sepsis. The conflicting results relating to the benefit of the TPN teams in the reduction of electrolyte and metabolic abnormalities indicate that further research is needed to clarify the impact of TPN teams on this outcome. The provision of the patients estimated energy requirements are positively influenced when managed by the TPN team; however, the evidence relating to the effectiveness of the TPN team in the provision of protein requirements remains unclear. From this review it is unclear if management of the patients by the TPN team prevented the inappropriate use of TPN. The limited data obtained from the studies provide evidence of a clinically important difference between groups in terms of cost effectiveness.

Indwelling urethral catheters (IUCs) are inserted in approximately 15-25% of all hospitalised patients mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention and for investigative purposes. However, this procedure is associated with significant morbidity. Although research has focused on the type and maintenance of urinary catheters and techniques for insertion, limited attention has been given to the procedures for their removal, in particular whether the time of day the IUC is removed influences patient outcomes. There is no consensus among clinicians about the optimal time for removal of IUCs, rather practices tend to be based on personal preference and tradition rather than on evidence from research.The objective of this review was to determine whether the timing of the removal of IUCs influences patient outcomes. The primary outcomes of interest included duration to and volume of first void; length of hospitalisation; number of patients developing urinary retention and number requiring recatheterisation. Secondary outcome measures included patient satisfaction and the percentage of IUCs removed according to the scheduled time for removal.A literature search was performed using the following databases Medline (1966-2000), CINAHL (1982-2002), Nursing Collection (1995-2002), EMBASE (1980-current) and the Cochrane Controlled Trials Register (Issue 2, 2002 of Cochrane Library). In addition, the reference lists of relevant trials and conference proceedings were also scrutinised. No language restrictions were applied. Company representatives, experts and investigators were contacted to elicit further information.All published and unpublished randomised and quasi-randomised controlled trials that compared the effects of the timing of removal of short-term IUC on patient outcomes were considered for inclusion in the review. Trials were included if they reported objective measures of time to and volume of the first void, length of hospital stay (number of hours from removal of the IUC to discharge), the number of patients who developed urinary retention following the removal of the IUC and the incidence of recatheterisation. Trials that included subjective measures of patient satisfaction were also considered for inclusion in the review.Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials was assessed independently by two reviewers. All information was verified by a third reviewer. Odds ratios for dichotomous data and weighted mean differences for continuous data were calculated with 95% confidence intervals. Where synthesis was inappropriate a narrative overview was undertaken. Trials were grouped according to the types of operation.Eight randomised controlled trials comparing the effectiveness of early morning versus late night removal of IUCs were eligible for this review. Four trials (three following urological surgery and procedures and one involving patients following gynaecological surgery) demonstrated a statistically significant increase in the volume of the first void in patients whose IUCs were removed late at night compared to those removed in the morning. In the two trials on patients following transurethral resection of the prostate (TURP) there was no statistically significant difference in the volume of the first void.One trial that involved patients having gynaecological surgery reported that the time to first void was shorter when the IUC was removed at midnight (median 3 h 20 min) compared to early morning (median 5 h) (P = 0.012). Three trials undertaken on patients following urological surgery and procedures reported the time to first void was longer in patients whose IUCs were removed at midnight compared to those removed in the morning with all three trials demonstrating a statistically significant difference. The time to first void was shorter following TURP when IUCs were removed in the morning, although these results were not statistically significant. Patients who had their IUC removed at midnight were discharged from hospital significantly earlier (P0.00001) than those who had their IUC removed in the morning, which would result in potential cost savings for the hospitals.Based on the limited available evidence, this review suggests a benefit in terms of patient outcomes and reduction in the length of hospitalisation following midnight removal of the IUCs. Further trials should be undertaken in wider settings and on specific groups of patients to enhance generalisability. The trials should also examine the efficacy of midnight or early morning IUC removal compared to removal at any time of the day.

Nurses played a significant role in providing care to Kosovar and East Timorese refugees at the East Hills Reception Centre in Sydney, Australia, during Operation Safe Haven in 1999-2000. To ascertain the needs of nurses in this setting, 13 nurses participated in two focus group interviews, and two in-depth interviews were conducted with nursing managers. Qualitative thematic analysis was conducted on the resulting transcripts. Nurses reported that, overall, they had the necessary clinical skills but needed specific refugee health profiles and training in culturally competent and trauma-sensitive care. The nurses experienced trauma-related, cultural, environmental and role-related stressors. They used a variety of informal psychosocial supports but reported the need for ongoing counselling and debriefing. While clinical skills were considered important, nurses identified other factors as having more impact on their ability to provide comprehensive care for traumatized refugees, particularly their role as client advocates.

The aim of this systematic review (SR) was to identify and critically appraise the best available research evidence regarding the infection control strategies used to manage nosocomial outbreaks and endemic methicillin resistant Staphylococcus aureus (MRSA) within the acute hospital setting. A thorough search of the literature identified 60 potential papers; however, only 33 studies met the quality criteria and were therefore considered the best evidence for inclusion in the review. Various strategies such as staff, patient and environmental surveillance, patient isolation, flagging of medical records, use of protective apparel, education programmes for staff and monitoring of compliance with infection control practices, have been adopted to control transmission of infection during an epidemic. Medical staff, nurses and respiratory therapists were identified as sources of transmission during outbreaks. Researchers have demonstrated that between 1-20% of staff screened during an epidemic and up to 44% of staff working in areas where MRSA is endemic were colonised. Prospective patient surveillance indicated that a large number of patients were colonised without the symptomatic presentation of clinical illness. This SR indicates that, in an attempt to curtail the spread of MRSA, various combinations of strategies have been beneficial. However, the effectiveness of the strategies used will depend on the patient demographics, acuity and size of the institution and the resources available.