Does an evidence-based sedation protocol improve practice and patient outcomes in critical care?

Learning Objective 1: compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care.

Learning Objective 2: explain the contrasting international research findings on sedation protocol implementation.
Minimization of sedation in critical care patients has recently received widespread support. Professional organizations internationally have published sedation management guidelines for critically ill patients to improve the use of research in practice, decrease practice variability and shorten mechanical ventilation duration. Innovations in practice have included the introduction of decision making protocols, daily sedation interruptions and new drugs and monitoring technologies. The aim of this study was to compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care setting.

A randomized, controlled trial design was used to study 312 mechanically ventilated adult patients in a general critical care unit at an Australian metropolitan teaching hospital. Patients were randomly assigned to receive protocol directed sedation management developed from evidence based guidelines (n=153) or usual clinical practice (n=159).

The median (95% CI) duration of ventilation was 58 hrs (44–78 hrs) for patients in the non-protocol group and 79 hrs (56–93) for those patients in the protocol group (p=0.20). Results were not significant for length of stay in critical care or hospital, the frequency of tracheostomies, and unplanned extubations. A Cox proportional hazards model estimated that protocol directed sedation management was associated with a 22% decrease (95% CI: 40% decrease to 2% increase, p=0.07) in the occurrence of successful weaning from mechanical ventilation.

Few randomized controlled trials have evaluated the effectiveness of protocol-directed sedation outside of North America. This study highlights the lack of transferability between different settings and different models of care. Qualified, high intensity nursing in the Australian critical care setting facilitates rapid, responsive decisions for sedation management and an increased success rate for weaning from mechanical ventilation.

The Health Education Impact Questionnaire (heiQ): An outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions

Objective: This paper describes the development and validation of the Health Education Impact Questionnaire (heiQ). The aim was to develop a user-friendly, relevant, and psychometrically sound instrument for the comprehensive evaluation of patient education programs, which can be applied across a broad range of chronic conditions.

Methods: Item development for the heiQ was guided by a Program Logic Model, Concept Mapping, interviews with stakeholders and psychometric analyses. Construction (N = 591) and confirmatory (N = 598) samples were drawn from consumers of patient education programs and hospital outpatients. The properties of the heiQ were investigated using item response theory and structural equation modeling.

Results: Over 90 candidate items were generated, with 42 items selected for inclusion in the final scale. Eight independent dimensions were derived: Positive and Active Engagement in Life (five items, Cronbach's alpha (α) = 0.86); Health Directed Behavior (four items, α = 0.80); Skill and Technique Acquisition (five items, α = 0.81); Constructive Attitudes and Approaches (five items, α = 0.81); Self-Monitoring and Insight (seven items, α = 0.70); Health Service Navigation (five items, α = 0.82); Social Integration and Support (five items, α = 0.86); and Emotional Wellbeing (six items, α = 0.89).

Conclusion:The heiQ has high construct validity and is a reliable measure of a broad range of patient education program benefits.

Practice Implications: The heiQ will provide valuable information to clinicians, researchers, policymakers and other stakeholders about the value of patient education programs in chronic disease management.

Enhancing patient engagement in chronic disease self-management support initiatives in Australia : the need for an integrated approach

♦ Although emphasis on the prevention of chronic disease is important, governments in Australia need to balance this with continued assistance to the 77% of Australians reported to have at least one long-term medical condition.

♦ Self-management support is provided by health care and community services to enhance patients’ ability to care for their chronic conditions in a cooperative framework.

♦ In Australia, there is a range of self-management support initiatives that have targeted patients (most notably, chronic disease self-management education programs) and health professionals (financial incentives, education and training).

♦ To date, there has been little coordination or integration of these self-management initiatives to enhance the patient–health professional clinical encounter.

♦ If self-management support is to work, there is a need to better understand the infrastructure, systems and training that are required to engage the key stakeholders — patients, carers, health professionals, and health care organisations.

♦ A coordinated approach is required in implementing these elements within existing and new health service models to enhance uptake and sustainability.

Patient outcomes in the acute revovery phase following robotic-assisted prostate surgery : a prospective study

Background: Robotic-assisted minimally invasive urologic surgery was developed to minimise surgical trauma resulting in quicker recovery. It has many potential benefits for patients with localised prostate cancer over traditional surgical techniques without taking a risk with the oncological result.

Objectives: To report the specific surgical outcomes for the first Australian cohort of patients with localised prostate cancer that had undergone robotic-assisted radical prostatectomy (RARP) surgery. The outcomes represent the acute (in-hospital) recovery phase and include pain, length of stay (LOS), urinary catheter management and wound management.

Methods: Prospective descriptive survey of 214 consecutive patients admitted to a large metropolitan private hospital in Melbourne, Australia between December 2003 and June 2005. Patients had undergone RARP surgery for localised prostate cancer. Data were collected from the medical records and through interview at the time of discharge. Descriptive statistics were used to describe the frequency and proportion of outcomes. Patient characteristics were tabulated using cross tabulation frequency distribution and measures of central tendency.

Results: The findings from this study are highly encouraging when compared to outcomes associated with traditional surgical techniques. Transurethral catheter duration (median 7 days (IQ range 2)) and LOS (median 3 days (IQ range 2)) were considerably reduced. While operation time (median 3.30 h (IQ range 1.07)) was marginally reduced we would expect a further reduction as the surgical team becomes more skilled.

Conclusion: The findings from this study contribute to building a comprehensive picture of patient outcomes in the acute (in-hospital) recovery phase for a cohort of Australian patients who have undergone RARP surgery for localised prostate cancer. As such, these findings will provide valuable information with which to plan care for patients’ who undergo robotic-assisted surgery.

Game-centred models and teaching in culturally diverse settings

This presentation draws on the observations and experiences that we, as teacher educators, have had using Teaching Games for Understanding (TGfU) as a pedagogical tool with generalist pre-service teachers in two different sites: Malaysia and Australia. TGfU is a game-centred pedagogy in which students learn the „Why‟ of game playing before the „How‟ of the skills associated with the game. This concept is based on a student-centred approach to learning. The benefit of this pedagogy to generalist teachers is the notion that they are not required to be a master of many sports. This narrative relates the observations and experiences of teacher educators of Malaysian and Australian generalist pre-service teachers confronted with teaching and learning TGfU for the first time in their culturally specific contexts. The two key issues arising from teaching the TGfU model were: the disparity in the cohorts‟ experiences arising from institutionalised conceptions by the pre-service teachers of what and how learning occurs in physical education; and the pre-service teachers‟ difficulty with implementing the TGfU model in a practical situation. Crossing the cultural divide for the Malaysian and Australian pre-service teachers required them to explore more fully the range of approaches to teaching and to recognise a more student-centred approach as a valid and authentic tool. As both teachers and observers of this process, our intention was to examine the two cohorts‟ learning and subsequent teaching with the aim of developing better understandings of the challenges when teaching TGfU in tertiary settings.

Responding to the ageing profile of emergency department patients

Background
Older people with acute superimposed on chronic health problems are becoming a core aspect of emergency department (ED) caseload. This project explored the ED experience from the perspective of older patients and their carers.

Method
A convenience sample of thirty participants was recruited across three participating EDs: tw o metropolitan and one regional. The project utilised two approaches to data collection: 1) an observation approach where a project officer observed participants from the time of ED presentation until discharge, or for up to six hours; and 2) a subsequent interview was conducted with the participant and their carer within a week of the ED presentation. Data from both sources were integrated, and independently thematically analysed by two members of the team.

Results
Thirty participants aged over 65 were recruited. Their average age was 77.1 (sd=6.7) years, 59% w ere female, and 74% were triage category 1- 3 (indicating moderate/high acuity). Participants spent on average 7 hours 47 minutes in the ED, with 50% discharged home, 43% admitted to general wards or MAPU, and 7% discharged to residential care/hospice. Key themes in the factors influencing the patient experience and examples of quality care were identified, along with opportunities to improve the capacity for EDs to be “older person friendly”, and “person-centred.” Challenges include improving the effectiveness of communication between staff and patients/carers (including issues around people from culturally and linguistically diverse backgrounds), availability of allied health professionals to assist with discharge planning, and a tendency for older people not to seek ED care until the health problem was severe. Patient exemplars highlight key themes.

Discussion and implications
Results of the project highlight positive aspects of emergency department care for older people and inform targets for improvement strategies. These can be used to drive ongoing improvements in care for older people presenting to EDs.

The impact of patient sex on paramedic pain management in the prehospital setting

Objective: The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting.
Methods: This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, χ2 test, and logistic regression.
Results: Of the 3357 patients transported in the study period, 1766 (53%) reported pain; this forms the study sample. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84).
Conclusion: Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.

Culture, language, and patient safety : making the link

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a ‘resident pathogen’ within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture–language–patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

The moral imperative of designating patient safety and quality care as a national nursing research priority

Since the early 1990s, research studies conducted respectively in the USA, UK and Australia have found that between 4 and 16.6 per cent of patients suffer from some kind of harm (including permanent disability and death) as a result of human errors and adverse events while in hospital. It has been further estimated that approximately 50 per cent of these human errors/adverse events resulting in harm could have been prevented. In response to the significant financial, social, and political implications of these figures, a range of processes have been put in place in an attempt to improve patient safety and quality care in Australia. Nonetheless, it is evident that more can be done to improve the status quo. One process that warrants consideration is that of peak health professional groups and organisations providing active leadership in the promotion of patient safety, such as by making a visible and recognisable commitment to patient safety as a strategic research priority area. In this paper it is contended that, given the moral importance of patient safety and quality care in nursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focussed public attention to patient safety and quality care as a national research priority.

Patient safety ethics and human error management in ED contexts part I : development of the global patient safety movement

In recent years there has been increasing recognition internationally that health care is not as safe as it ought to be and that patient safety outcomes need to be improved. To this end patient safety has become the focus of a world-wide endeavour aimed at reducing the incidence and impact of preventable human errors and related adverse events in health care domains. The emergency department has been identified as a significant site of preventable human errors and adverse events in the health care system, raising important questions about the nature of human error management and patient safety ethics in rapidly changing environments. In this article (the first of a two-part discussion on the subject) an overview of the incidence and impact of preventable adverse events in ED contexts is explored. The development of a ‘culture of safety’ in other hazardous industries and the ‘lessons learned’ and applied to the health care industry are also briefly examined. In a second article (to be presented as Part II), some of the ethical tensions that have arisen in the context of implementing patient safety processes and their possible implications for ED contexts are explored.