The role of additive manufacturing in patient specific solutions

This dissertation investigates de role of the new additive manufacturing techniques in the treatment of pathologies with a patient-specific approach. Throughout this work the development methodology of these said products is explained in order to understand the different stages required to achieve a tailor made solution. The goal is to demonstrate the importance of the manufacturing technique and its capabilities to tailor-fit devices to patients and the adaptability of the process to tackle the most diverse situations. Three real cases are documented in order to prove the viability of the method and to showcase its advantages. Whenever possible patient-specific solutions are compared to their “off-the-shelf” counterparts in order to establish the pros and cons of each one of them. The dissertation is an insight into a possible future for the medical devices industry, where customization is expected to be the standard approach in the treatment of patients.

Effects of fibrosis morphology on reentrant ventricular tachycardia inducibility and simulation fidelity in patient-derived models

Myocardial fibrosis detected via delayed-enhanced magnetic resonance imaging (MRI) has been shown to be a strong indicator for ventricular tachycardia (VT) inducibility. However, little is known regarding how inducibility is affected by the details of the fibrosis extent, morphology, and border zone configuration. The objective of this article is to systematically study the arrhythmogenic effects of fibrosis geometry and extent, specifically on VT inducibility and maintenance. We present a set of methods for constructing patient-specific computational models of human ventricles using in vivo MRI data for patients suffering from hypertension, hypercholesterolemia, and chronic myocardial infarction. Additional synthesized models with morphologically varied extents of fibrosis and gray zone (GZ) distribution were derived to study the alterations in the arrhythmia induction and reentry patterns. Detailed electrophysiological simulations demonstrated that (1) VT morphology was highly dependent on the extent of fibrosis, which acts as a structural substrate, (2) reentry tended to be anchored to the fibrosis edges and showed transmural conduction of activations through narrow channels formed within fibrosis, and (3) increasing the extent of GZ within fibrosis tended to destabilize the structural reentry sites and aggravate the VT as compared to fibrotic regions of the same size and shape but with lower or no GZ. The approach and findings represent a significant step toward patient-specific cardiac modeling as a reliable tool for VT prediction and management of the patient. Sensitivities to approximation nuances in the modeling of structural pathology by image-based reconstruction techniques are also implicated.

Patients' perceptions of seclusion : a qualitative investigation

Twelve patients receiving acute in-patient psychiatric care in Queensland, Australia, participated in semi-structured interviews to elicit their perceptions of seclusion. All respondents had experienced time in seclusion within the 7 days prior to interview. Interviews were audiotaped, transcribed and analysed using content analysis. Five major themes emerged: use of seclusion, emotional impact, sensory deprivation, maintaining control and staff-patient interaction. The prevailing negativity towards seclusion underscores the need for ongoing critical review of its use. In particular, the relationship between patient responses to seclusion and the circumstances in which seclusion takes place requires greater consideration. Interventions such as providing information to patients about seclusion, increased interaction with patients during seclusion, attention to privacy and effective debriefing following seclusion may help to reduce the emotional impact of the practice.

Ocorrência de infecção hospitalar em idosos internados em hospital universitário

OBJETIVO: A infecção hospitalar é uma importante causa de morbidade e mortalidade na população idosa. O estudo realizado teve como objetivo avaliar a ocorrência e os fatores de risco da infecção hospitalar. MÉTODOS: Realizou-se estudo prospectivo em uma amostra de 322 idosos com 60 anos e mais, internados em um hospital universitário, entre setembro de 1999 e fevereiro de 2000. O cálculo da amostra foi feito pela fórmula de Fisher e Belle, com intervalo de confiança de 0,95%, de um total de 760 idosos internados, proporcionalmente ao número de pacientes em cada unidade de internação, no ano de 1997. Os critérios para definição da infecção hospitalar foram os do Center for Diseases and Prevention Control. Para a análise estatística dos dados foram utilizados o odds ratio e regressão logística. RESULTADOS: A taxa de infecção hospitalar encontrada foi de 23,6%. As topografias prevalentes de infecção hospitalar foram infecção respiratória (27,6%), do trato urinário (26,4%) e do sítio cirúrgico (23,6%). O tempo de internação dos pacientes sem infecção hospitalar foi de 6,9 dias e dos com infecção hospitalar foi de 15,9 (p<0,05). A taxa de mortalidade dos pacientes internados foi de 9,6% e a de letalidade dos pacientes com infecção hospitalar de 22,9% (p<0,05). Os fatores de risco encontrados para infecção hospitalar foram colangiografia (odds ratio (OR)=46,4, intervalo de confiança 95% (IC 95%)=4,4-485); diabetes melito (OR=9,9, IC 95%=4,4-22,3); doença pulmonar obstrutiva crônica (OR=8,3, IC 95%=2,9-23,7); cateterismo urinário (OR=5, IC 95%=2,7-11,8); internação com infecção comunitária (OR=3,9, IC 95%=1,7-8,9) e ventilação mecânica (OR=3,8, IC 95%=1,9-6,3). CONCLUSÕES: A infecção hospitalar apresentou incidência e letalidade elevadas e aumentou o tempo de internação dos idosos estudados.

Psychological intervention in an only multifamily session at an Acute Care Unit of a psychiatric clinic

This article provides an overview of the psychological intervention in a Unit Care of Mental Health. The objectives and therapeutic actions to follow are defined through the participation of an interdisciplinary team and networking; it includes support groups and, especially, the families of patients that suffer a severe mental disorder. The materials and resources used were weekly sessions of one hour and forty minutes, for two years of monitoring (2005-2007). The study population consists of families of patients with different pathologies, which are in the Intensive Care Unit. In terms of design, it is made a qualitativeanalysis of 100 field day formats, and fills a matrix of content analysis. It is reviewed the objectives, the approach Multi-Focus, methodology, used techniques, the procedures developed and the feedback given at each session. The findings from this study show that mental disorders are related to the environment in which the patient is developed and complex social process. They also suggest a greater need for psychiatric patient care and its networks, timely and relevantly. By the other hand, it shows the importance of increasing efforts to make available in the field of mental health brief strategic interventions in interdisciplinary teams, it is appropriate a psycho educational and therapeutic approach in which the actions are coordinated at different levels.

The effects of advanced practice nurses (APNs) as intensivists in a surgical intensive care unit (SICU) on patient outcomes, healthcare charges, and apn intensivist services in the SICU

Intensive Care Units (ICUs) account for over 10 percent of all US hospital beds, have over 4.4 million patient admissions yearly, approximately 360,000 deaths, and account for close to 30% of acute care hospital costs. The need for critical care services has increased due to an aging population and medical advances that extend life. The result is efforts to improve patient outcomes, optimize financial performance, and implement models of ICU care that enhance quality of care and reduce health care costs. This retrospective chart review study examined the dose effect of APN Intensivists in a surgical intensive care unit (SICU) on differences in patient outcomes, healthcare charges, SICU length of stay, charges for APN intensivist services, and frequency of APNs special initiatives when the SICU was staffed by differing levels of APN Intensivist staffing over four time periods (T1-T4) between 2009 and 2011. The sample consisted of 816 randomly selected (204 per T1-T4) patient chart data. Study findings indicated reported ventilator associated pneumonia (VAP) rates, ventilator days, catheter days and catheter associated urinary tract infection (CAUTI) rates increased at T4 (when there was the lowest number of APN Intensivists), and there was increased pressure ulcer incidence in first two quarters of T4. There was no statistically significant difference in post-surgical glycemic control (M = 142.84, SD = 40.00), t (223) = 1.40, p = .17, and no statistically significant difference in the SICU length of stay among the time-periods (M = 3.27, SD = 3.32), t (202) = 1.02, p = .31. Charges for APN services increased over the 4 time periods from $11,268 at T1 to $51,727 at T4 when a system to capture APN billing was put into place. The number of new APN initiatives declined in T4 as the number of APN Intensivists declined. Study results suggest a dose effect of APN Intensivists on important patient health outcomes and on the number of APNs initiatives to prevent health complications in the SICU. ^

The Effects of Advanced Practice Nurses (APNs) as Intensivists in a Surgical Intensive Care Unit (SICU) on Patient Outcomes, Healthcare Charges, and APN Intensivist Services in the SICU

Intensive Care Units (ICUs) account for over 10 percent of all US hospital beds, have over 4.4 million patient admissions yearly, approximately 360,000 deaths, and account for close to 30% of acute care hospital costs. The need for critical care services has increased due to an aging population and medical advances that extend life. The result is efforts to improve patient outcomes, optimize financial performance, and implement models of ICU care that enhance quality of care and reduce health care costs. This retrospective chart review study examined the dose effect of APN Intensivists in a surgical intensive care unit (SICU) on differences in patient outcomes, healthcare charges, SICU length of stay, charges for APN intensivist services, and frequency of APNs special initiatives when the SICU was staffed by differing levels of APN Intensivist staffing over four time periods (T1-T4) between 2009 and 2011. The sample consisted of 816 randomly selected (204 per T1-T4) patient chart data. Study findings indicated reported ventilator associated pneumonia (VAP) rates, ventilator days, catheter days and catheter associated urinary tract infection (CAUTI) rates increased at T4 (when there was the lowest number of APN Intensivists), and there was increased pressure ulcer incidence in first two quarters of T4. There was no statistically significant difference in post-surgical glycemic control (M = 142.84, SD= 40.00), t (223) = 1.40, p = .17, and no statistically significant difference in the SICU length of stay among the time-periods (M= 3.27, SD = 3.32), t (202) = 1.02, p= .31. Charges for APN services increased over the 4 time periods from $11,268 at T1 to $51,727 at T4 when a system to capture APN billing was put into place. The number of new APN initiatives declined in T4 as the number of APN Intensivists declined. Study results suggest a dose effect of APN Intensivists on important patient health outcomes and on the number of APNs initiatives to prevent health complications in the SICU.

The provision of patient personal hygiene in the intensive care unit : a descriptive exploratory study of bed-bathing practice

Background/objectives The provision of the patient bed-bath is a fundamental nursing care activity yet few quantitative data and no qualitative data are available on registered nurses’ (RNs) clinical practice in this domain in the intensive care unit (ICU). The aim of this study was to describe ICU RNs current practice with respect to the timing, frequency and duration of the patient bed-bath and the cleansing and emollient agents used. Methods The study utilised a two-phase sequential explanatory mixed method design. Phase one used a questionnaire to survey RNs and phase two employed semi-structured focus group (FG) interviews with RNs. Data was collected over 28 days across four Australian metropolitan ICUs. Ethical approval was granted from the relevant hospital and university human research ethics committees. RNs were asked to complete a questionnaire following each episode of care (i.e. bed-bath) and then to attend one of three FG interviews: RNs with less than 2 years ICU experience; RNs with 2–5 years ICU experience; and RNs with greater than 5 years ICU experience. Results During the 28-day study period the four ICUs had 77.25 beds open. In phase one a total of 539 questionnaires were returned, representing 30.5% of episodes of patient bed-baths (based on 1767 bed occupancy and one bed-bath per patient per day). In 349 bed-bath episodes 54.7% patients were mechanically ventilated. The bed-bath was given between 02.00 and 06.00 h in 161 episodes (30%), took 15–30 min to complete (n = 195, 36.2%) and was completed within the last 8 h in 304 episodes (56.8%). Cleansing agents used were predominantly pH balanced soap or liquid soap and water (n = 379, 71%) in comparison to chlorhexidine impregnated sponges/cloths (n = 86, 16.1%) or other agents such as pre-packaged washcloths (n = 65, 12.2%). In 347 episodes (64.4%) emollients were not applied after the bed-bath. In phase two 12 FGs were conducted (three FGs at each ICU) with a total of 42 RN participants. Thematic analysis of FG transcripts across the three levels of RN ICU experience highlighted a transition of patient hygiene practice philosophy from shades of grey – falling in line for inexperienced clinicians to experienced clinicians concrete beliefs about patient bed-bath needs. Conclusions This study identified variation in process and products used in patient hygiene practices in four ICUs. Further study to improve patient outcomes is required to determine the appropriate timing of patient hygiene activities and cleansing agents used to improve skin integrity.

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.

Risk factors for incident delirium in acute medical in-patients. A systematic review

Review question/objective
What risk factors are associated with incident delirium in adult patients during an acute medical hospitalisation?
More specifically, the objectives are to:
Identify and synthesise the best available evidence on the factors which are associated with delirium in adult patients admitted to acute medical facilities.

Types of participants
This review will consider studies that include adults (defined as 18 years and above) who were admitted to an acute medical setting (e.g. general medical units, stroke units, short stay units and neuromedical units) who were not delirious on admission (in order to differentiate incident delirium) but who developed incident delirium during hospitalisation

The review will exclude patients who were:
- critically ill and admitted to specialist unit e.g. ICU or CCU
- admitted for any type of surgery
- admitted for alcohol related reasons
- admitted to psychiatric facility
These patients will be excluded in order to determine factors that may be exclusive to the medical in patient setting.

Types of intervention(s)/phenomena of interest
This review will consider studies that evaluate any risk factors that may contribute to the development of delirium during in-patient hospitalisation. The review will look at factors present on admission (predisposing) and also factors that may occur during hospitalisation (precipitating) that contribute to incident delirium.

Types of outcomes
This review will consider studies that include the following outcome measures: the incidence of delirium as related to individual risk factors.

Patient participation in treatment in the context of acute care

This mixed methods, case study identified key patient, clinician and environmental factors associated with hospitalised patients’ ability and willingness to participate in their recovery after cardiac surgery. Patient participation is a significant component of the processes for achieving quality and safety outcomes. The findings inform redesign of the care delivery system to facilitate participation within acute care environments.

Organisational and systems factors impacting on patient safety in acute care organisations: lessons from four multi-site research studies

Background Patient safety is concerned with preventable harm in healthcare, a subject that became a focus for study in the UK in the late 1990s. How to improve patient safety, presented both a practical and a research challenge in the early 2000s, leading to the eleven publications presented in this thesis. Research question The overarching research question was: What are the key organisational and systems factors that impact on patient safety, and how can these best be researched? Methods Research was conducted in over 40 acute care organisations in the UK and Europe between 2006 and 2013. The approaches included surveys, interviews, documentary analysis and non-participant observation. Two studies were longitudinal. Results The findings reveal the nature and extent of poor systems reliability and its effect on patient safety; the factors underpinning cases of patient harm; the cultural issues impacting on safety and quality; and the importance of a common language for quality and safety across an organisation. Across the publications, nine key organisational and systems factors emerged as important for patient safety improvement. These include leadership stability; data infrastructure; measurement capability; standardisation of clinical systems; and creating an open and fair collective culture where poor safety is challenged. Conclusions and contribution to knowledge The research presented in the publications has provided a more complete understanding of the organisation and systems factors underpinning safer healthcare. Lessons are drawn to inform methods for future research, including: how to define success in patient safety improvement studies; how to take into account external influences during longitudinal studies; and how to confirm meaning in multi-language research. Finally, recommendations for future research include assessing the support required to maintain a patient safety focus during periods of major change or austerity; the skills needed by healthcare leaders; and the implications of poor data infrastructure.

Delirium in advanced cancer : screening for the incidence on admission to an inpatient hospice unit

Background Delirium is a common underdiagnosed condition in advanced cancer leading to increased distress, morbidity, and mortality. Screening improves detection but there is no consensus as to the best screening tool to use with patients with advanced cancer. Objective To determine the incidence of delirium in patients with advanced cancer within 72 hours of admission to an acute inpatient hospice using clinical judgement and validated screening tools. Method One hundred consecutive patients with advanced cancer were invited to be screened for delirium within 72 hours of admission to an acute inpatient hospice unit. Two validated tools were used, the Delirium Rating Scale-Revised 98 (DRS-R-98) and the Confusion Assessment Method (CAM) shortened diagnostic algorithm. These results were compared with clinical assessment by review of medical charts. Results Of 100 consecutive admissions 51 participated and of these 22 (43.1%) screened positive for delirium with CAM and/or DRS-R-98 compared to 15 (29.4%) by clinical assessment. Eleven (21.6%) were identified as hypoactive delirium and 5 (9.8%) as subsyndromal delirium. Conclusion This study confirms that delirium is a common condition in patients with advanced cancer.While there remains a lack of consensus regarding the choice of delirium screening tool this study supports theCAMas being appropriate. Further research may determine the optimal screening tool for delirium enabling the development of best practice clinical guidelines for routinemedical practice.

Patient group directions : the application and integration of knowledge in advancing nursing practice

Background: The introduction of Patient Group Directions (PGD) has changed significantly the way in which nurses can now administer prescription only medicines as a one-off for patients requiring this level of service. PGD’s are a written authority to administer drugs to patients that are not identified at the time of treatment. Aim: The aim of this project was to develop a PGD for use within an Outreach team to administer colloid boluses to patients presenting with hypovolemia. Method: Using a case exemplar this paper will discuss the development of a PGD using aspects of transitional change theory to highlight the potential barriers that were encountered. Implications for Practice: The implications for this PGD are wide reaching. First it now enables members from the nursing Outreach team to administer colloid fluid boluses to a prescribed patient cohort without the need for prescription. Second, it ensures the deteriorating patient has interventions initiated in a timely and appropriate manner to reduce inadvertent admission to high care areas. Last, it will improve inter-professional team-working and communication so much so that collaborative patient care reduces health costs and identifies earlier those patients requiring substantially greater nursing and medical input. Conclusion: The experience of developing a working PGD for fluid administration has meant that the Outreach team is able to respond to patients in a more effective way. In addition, it is the experience of developing this PGD that has enabled the team to contemplate other PGD’s in the execution of Outreach work.

Nursing physical assessment for patient safety in general wards: Reaching consensus on core skills

Aims and objectives To determine consensus across acute care specialty areas on core physical assessment skills necessary for early recognition of changes in patient status in general wards. Background Current approaches to physical assessment are inconsistent and have not evolved to meet increased patient and system demands. New models of nursing assessment are needed in general wards that ensure a proactive and patient safety approach. Design A modified Delphi study. Methods Focus group interviews with 150 acute care registered nurses (RNs) at a large tertiary referral hospital generated a framework of core skills that were developed into a web-based survey. We then sought consensus with a panel of 35 senior acute care RNs following a classical Delphi approach over three rounds. Consensus was predefined as at least 80% agreement for each skill across specialty areas. Results Content analysis of focus group transcripts identified 40 discrete core physical assessment skills. In the Delphi rounds, 16 of these were consensus validated as core skills and were conceptually aligned with the primary survey: (Airway) Assess airway patency; (Breathing) Measure respiratory rate, Evaluate work of breathing, Measure oxygen saturation; (Circulation) Palpate pulse rate and rhythm, Measure blood pressure by auscultation, Assess urine output; (Disability) Assess level of consciousness, Evaluate speech, Assess for pain; (Exposure) Measure body temperature, Inspect skin integrity, Inspect and palpate skin for signs of pressure injury, Observe any wounds, dressings, drains and invasive lines, Observe ability to transfer and mobilise, Assess bowel movements. Conclusions Among a large and diverse group of experienced acute care RNs consensus was achieved on a structured core physical assessment to detect early changes in patient status. Relevance to clinical practice Although further research is needed to refine the model, clinical application should promote systematic assessment and clinical reasoning at the bedside.