Australian and New Zealand nurses’ perceptions of procedural sedation and analgesia in the cardiac catheterisation laboratory : a qualitative study

Background: Australian and New Zealand College of Anaesthetists’ guidelines for procedural sedation and analgesia (PSA) are intended to apply across all clinical settings. As nurses are frequently responsible for patient care during PSA in the cardiac catheterisation laboratory (CCL), their perspectives can provide insight into the effectiveness of these guidelines within this particular setting. Methods: A cross-sectional sampling design was used to recruit nurses from urban, regional, public and private CCLs across Australia and New Zealand. Semi-structured interviews were conducted, digitally recorded and transcribed. Data were analysed using thematic analysis. Findings: Twenty-three nurses from 16 CCLs across four states in Australia and New Zealand participated. Most held senior positions (managers=14; educators=5) and CCL experience ranged from 4 to 26 years (mean 11). Participants were concerned about the legitimacy of their practice as they administered PSA outside of guideline recommendations and deemed present education and training as deficient. Participants noted also that guideline recommendations were sometimes not adhered to as it was difficult to balance the increasingly complex PSA requirements of their case-mix with limited access to anaesthetists while trying not to delay procedures. Conclusion: Findings suggest that application of current PSA guidelines may be impractical for CCL nurses and, as a consequence, they are often not followed. Participants were concerned about risks to patient safety as they felt education and training was not commensurable with practice requirements. The findings suggest existing guidelines should be reviewed or new guidelines developed which address nursing practice, education and competency standards for PSA in the CCL

Respiratory monitoring practices during procedural sedation and analgesia in the cardiac catheterisation laboratory could be improved by using capnography to assess ventilation

Background: Procedural sedation and analgesia (PSA) administered by nurses in the cardiac catheterisation laboratory (CCL) is unlikely to yield serious complications. However, the safety of this practice is dependent on timely identification and treatment of depressed respiratory function. Aim: Describe respiratory monitoring in the CCL. Methods: Retrospective medical record audit of adult patients who underwent a procedure in the CCLs of one private hospital in Brisbane during May and June 2010. An electronic database was used to identify subjects and an audit tool ensured data collection was standardised. Results: Nurses administered PSA during 172/473 (37%) procedures including coronary angiographies, percutaneous coronary interventions, electrophysiology studies, radiofrequency ablations, cardiac pacemakers, implantable cardioverter defibrillators, temporary pacing leads and peripheral vascular interventions. Oxygen saturations were recorded during 160/172 (23%) procedures, respiration rate was recorded during 17/172 (10%) procedures, use of oxygen supplementation was recorded during 40/172 (23%) procedures and 13/172 (7.5%; 95% CI=3.59–11.41%) patients experienced oxygen desaturation. Conclusion: Although oxygen saturation was routinely documented, nurses did not regularly record respiration observations. It is likely that surgical draping and the requirement to minimise radiation exposure interfered with nurses’ ability to observe respiration. Capnography could overcome these barriers to respiration assessment as its accurate measurement of exhaled carbon dioxide coupled with the easily interpretable waveform output it produces, which displays a breath-by-breath account of ventilation, enables identification of respiratory depression in real-time. Results of this audit emphasise the need to ascertain the clinical benefits associated with using capnography to assess ventilation during PSA in the CCL.

Validation and consistency in the application of a trauma team activation system at a level 1 trauma centre

- The RAH was activated over 2500 trauma calls in 2009. This figure is over twice the number of calls put out by similar services. - Many trauma calls (in particular L2 trauma calls) from the existing system do not warrant activation of the trauma team - Sometimes trauma calls are activated for nontrauma reasons (eg rapid access to radiology, departmental pressures etc) - The excess of trauma calls has several deleterious effects particularly on time management for the trauma service staff: ward rounds/tertiary survey rounds, education, quality improvement, research

Nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a mixed methods study

The cardiac catheterisation laboratory (CCL) is a specialised medical radiology facility where both chronic-stable and life-threatening cardiovascular illness is evaluated and treated. Although there are many potential sources of discomfort and distress associated with procedures performed in the CCL, a general anaesthetic is not usually required. For this reason, an anaesthetist is not routinely assigned to the CCL. Instead, to manage pain, discomfort and anxiety during the procedure, nurses administer a combination of sedative and analgesic medications according to direction from the cardiologist performing the procedure. This practice is referred to as nurse-administered procedural sedation and analgesia (PSA). While anecdotal evidence suggested that nurse-administered PSA was commonly used in the CCL, it was clear from the limited information available that current nurse-led PSA administration and monitoring practices varied and that there was contention around some aspects of practice including the type of medications that were suitable to be used and the depth of sedation that could be safely induced without an anaesthetist present. The overall aim of the program of research presented in this thesis was to establish an evidence base for nurse-led sedation practices in the CCL context. A sequential mixed methods design was used over three phases. The objective of the first phase was to appraise the existing evidence for nurse-administered PSA in the CCL. Two studies were conducted. The first study was an integrative review of empirical research studies and clinical practice guidelines focused on nurse-administered PSA in the CCL as well as in other similar procedural settings. This was the first review to systematically appraise the available evidence supporting the use of nurse-administered PSA in the CCL. A major finding was that, overall, nurse-administered PSA in the CCL was generally deemed to be safe. However, it was concluded from the analysis of the studies and the guidelines that were included in the review, that the management of sedation in the CCL was impacted by a variety of contextual factors including local hospital policy, workforce constraints and cardiologists’ preferences for the type of sedation used. The second study in the first phase was conducted to identify a sedation scale that could be used to monitor level of sedation during nurse-administered PSA in the CCL. It involved a structured literature review and psychometric analysis of scale properties. However, only one scale was found that was developed specifically for the CCL, which had not undergone psychometric testing. Several weaknesses were identified in its item structure. Other sedation scales that were identified were developed for the ICU. Although these scales have demonstrated validity and reliability in the ICU, weaknesses in their item structure precluded their use in the CCL. As findings indicated that no existing sedation scale should be applied to practice in the CCL, recommendations for the development and psychometric testing of a new sedation scale were developed. The objective of the second phase of the program of research was to explore current practice. Three studies were conducted in this phase using both quantitative and qualitative research methods. The first was a qualitative explorative study of nurses’ perceptions of the issues and challenges associated with nurse-administered PSA in the CCL. Major themes emerged from analysis of the qualitative data regarding the lack of access to anaesthetists, the limitations of sedative medications, the barriers to effective patient monitoring and the impact that the increasing complexity of procedures has on patients' sedation requirements. The second study in Phase Two was a cross-sectional survey of nurse-administered PSA practice in Australian and New Zealand CCLs. This was the first study to quantify the frequency that nurse-administered PSA was used in the CCL setting and to characterise associated nursing practices. It was found that nearly all CCLs utilise nurse-administered PSA (94%). Of note, by characterising nurse-administered PSA in Australian and New Zealand CCLs, several strategies to improve practice, such as setting up protocols for patient monitoring and establishing comprehensive PSA education for CCL nurses, were identified. The third study in Phase Two was a matched case-control study of risk factors for impaired respiratory function during nurse-administered PSA in the CCL setting. Patients with acute illness were found to be nearly twice as likely to experience impaired respiratory function during nurse-administered PSA (OR=1.78; 95%CI=1.19-2.67; p=0.005). These significant findings can now be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered PSA in the CCL. The objective of the third and final phase of the program of research was to develop recommendations for practice. To achieve this objective, a synthesis of findings from the previous phases of the program of research informed a modified Delphi study, which was conducted to develop a set of clinical practice guidelines for nurse-administered PSA in the CCL. The clinical practice guidelines that were developed set current best practice standards for pre-procedural patient assessment and risk screening practices as well as the intra and post-procedural patient monitoring practices that nurses who administer PSA in the CCL should undertake in order to deliver safe, evidence-based and consistent care to the many patients who undergo procedures in this setting. In summary, the mixed methods approach that was used clearly enabled the research objectives to be comprehensively addressed in an informed sequential manner, and, as a consequence, this thesis has generated a substantial amount of new knowledge to inform and support nurse-led sedation practice in the CCL context. However, a limitation of the research to note is that the comprehensive appraisal of the evidence conducted, combined with the guideline development process, highlighted that there were numerous deficiencies in the evidence base. As such, rather than being based on high-level evidence, many of the recommendations for practice were produced by consensus. For this reason, further research is required in order to ascertain which specific practices result in the most optimal patient and health service outcomes. Therefore, along with necessary guideline implementation and evaluation projects, post-doctoral research is planned to follow up on the research gaps identified, which are planned to form part of a continuing program of research in this field.

Acute illness is a risk factor for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory

Impaired respiratory function (IRF) during procedural sedation and analgesia (PSA) poses considerable risk to patient safety as it can lead to inadequate oxygenation and ventilation. Risk factors that can be screened prior to the procedure have not been identified for the cardiac catheterization laboratory (CCL).

Sun, sea, sex, sand and conservatism in the Australian television soap opera

A recent issue of Young People Now (November 1995) mentioned the new (UK) television soap opera Hollyoaks by Phil Redmond, which raises the issue of the role of ‘soap operas’ (hereafter referred to as soaps) in the daily lives of young people. The term ‘soap’ originates with the sponsorship of radio and television programmes by companies such as Proctor and Gamble who in America in 1932 used a daytime radio domestic comedy, The Puddle Family to advertise Oxydol, a washing powder. The first British television soap was The Grove Family (BBC 1954-7) was followed by Emergency Ward Ten (ATV 1957-67), Coronation Street (Granada Television 1960-present) and Eastenders (BBC 1985-present). Australian soaps are especially popular in Britain and of potential interest to those who work with young people, because they have a high proportion of youthful looking actors and actresses and frequently depict scenes involving young people and apparent ‘real’ teenage dilemmas. On one level it may be commendable that actors who are young(ish) somewhere between the ages of 14 and 25 play roles that are ostensibly about young people and their alleged problems. However, the casting of young, largely unknown, actors reflects more the political economy of soaps in their relative cheapness and dispensability, rather than any genuine attempt to create an oppositional text for, about and by young people (Paterson 1986).

Justifications and limits in the politically motivated lawbreaking of environmental activist groups

In recent events, notions of political protest, civil disobedience, extremism, and criminal action have become increasingly blurred. The London Riots, the Occupy movement, and the actions of hacking group Anonymous have all sparked heated debate about the limits of legitimate protest, and the distinction between an acceptable action and a criminal offence. Long before these events, environmental activists were challenging convention in protest actions, with several groups engaging in politically motivated law-breaking. The emergence of the term ‘eco-tage’ (the sabotage of equipment in order to protect the environment) signifies the important place environmental activists hold in challenging the traditional boundaries between illegal action and legitimate protest. Many of these groups establish their own boundaries of legitimacy, with some justifying their actions on the basis of civil disobedience or extensional self-defence. This paper examines the statements of environmental activist organisations that have engaged in politically motivated law breaking. It identifies the parameters that these groups set on their illegal actions, as well as the justifications that they provide, with a view to determining where these actions fit in the vast grey area between legal protest and violent extremism.

Academics and activists in the policy process : engagement with Australian media inquiries 2011-13

After its narrow re-election in June 2010, the Australian Labor government undertook a series of public inquiries into reform of Australian media, communications and copyright laws. One important driver of policy reform was the government’s commitment to building a National Broadband Network (NBN), and the implications this had for existing broadcasting and telecommunications policy, as it would constitute a major driver of convergence of media and communications access devices and content platforms. These inquiries included: the Convergence Review of media and communications legislation; the Australian Law Reform Commission (ALRC) review of the National Classification Scheme; the Independent Media Inquiry (Finkelstein Review) into Media and Media Regulation; and the ALRC review of Copyright and the Digital Economy. One unusual feature of this review process, discussed in the paper, was the degree to which academics were involved in the process, not simply as providers of expert opinion, but as review chairs seconded from their universities. This paper considers the role played by activist groups in all of these inquiries and their relationship to the various participants in the inquiries, as well as the implications of academics being engaged in such inquiries, not simply as activist-scholars, but as those primarily responsible for delivering policy review outcomes. The latter brings to the forefront issues arising in from direct engagement with governments and state agencies themselves, which challenges traditional understandings of the academic community as “critical outsiders” towards such policy processes.

Regional contingencies in the relationship between aboveground biomass and litter in the world’s grasslands

Based on regional-scale studies, aboveground production and litter decomposition are thought to positively covary, because they are driven by shared biotic and climatic factors. Until now we have been unable to test whether production and decomposition are generally coupled across climatically dissimilar regions, because we lacked replicated data collected within a single vegetation type across multiple regions, obfuscating the drivers and generality of the association between production and decomposition. Furthermore, our understanding of the relationships between production and decomposition rests heavily on separate meta-analyses of each response, because no studies have simultaneously measured production and the accumulation or decomposition of litter using consistent methods at globally relevant scales. Here, we use a multi-country grassland dataset collected using a standardized protocol to show that live plant biomass (an estimate of aboveground net primary production) and litter disappearance (represented by mass loss of aboveground litter) do not strongly covary. Live biomass and litter disappearance varied at different spatial scales. There was substantial variation in live biomass among continents, sites and plots whereas among continent differences accounted for most of the variation in litter disappearance rates. Although there were strong associations among aboveground biomass, litter disappearance and climatic factors in some regions (e.g. U.S. Great Plains), these relationships were inconsistent within and among the regions represented by this study. These results highlight the importance of replication among regions and continents when characterizing the correlations between ecosystem processes and interpreting their global-scale implications for carbon flux. We must exercise caution in parameterizing litter decomposition and aboveground production in future regional and global carbon models as their relationship is complex.

Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : A modified Delphi study

Aim To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory. Background Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist presents means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances in which nurse-administered procedural sedation and analgesia is used in the cardiac catheterisation laboratory. Methods A sequential mixed methods design was utilised. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised in accordance with responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterisation laboratory nurses. All but one of the draft recommendations met the pre-determined cut-off point for inclusion. There were a total of 59 responses to the second round. Consensus was reached on all recommendations. Implications for nursing The guidelines that were derived from the Delphi study offer twenty four recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Post-procedural patient assessment and monitoring. Conclusion These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterisation laboratory setting.

Validation of a new tool to measure responsiveness and structure in the feeding context : the Authoritative Feeding Practices Questionnaire

How mothers interact with their toddlers around food lays the foundations for healthy eating and healthy weight gain in later life. This research involving 467 Australian first-time mothers of 2-year-old children resulted in the development of a new self-report tool, the Authoritative Feeding Practices Questionnaire, assessing maternal responsive feeding and mealtime structure. Secondary analysis of the NOURISH randomised controlled trial included theory-driven item selection, confirmatory factor analysis, evaluation of psychometric properties and construct validation. The result is a brief, reliable and valid new tool for evaluating the maternal feeding practices that support children to become healthy, independent eaters.

“Who decides?” Security and privacy in the wild

Even though web security protocols are designed to make computer communication secure, it is widely known that there is potential for security breakdowns at the human-machine interface. This paper examines findings from a qualitative study investigating the identification of security decisions used on the web. The study was designed to uncover how security is perceived in an individual user's context. Study participants were tertiary qualified individuals, with a focus on HCI designers, security professionals and the general population. The study identifies that security frameworks for the web are inadequate from an interaction perspective, with even tertiary qualified users having a poor or partial understanding of security, of which they themselves are acutely aware. The result is that individuals feel they must protect themselves on the web. The findings contribute a significant mapping of the ways in which individuals reason and act to protect themselves on the web. We use these findings to highlight the need to design for trust at three levels, and the need to ensure that HCI design does not impact on the users' main identified protection mechanism: separation.

Prospective observational study of dementia and delirium in the acute hospital setting

Background: Dementia and delirium appear to be common among older patients admitted to acute hospitals, although there are few Australian data regarding these important conditions. Aim: The aim of this study was to determine the prevalence and incidence of dementia and delirium among older patients admitted to acute hospitals in Queensland and to profile these patients. Method: Prospective observational cohort study (n = 493) of patients aged 70 years and older admitted to general medical, general surgical and orthopaedic wards of four acute hospitals in Queensland between 2008 and 2010. Trained research nurses completed comprehensive geriatric assessments and obtained detailed information about each patient’s physical, cognitive and psychosocial functioning using the interRAI Acute Care and other standardised instruments. Nurses also visited patients daily to identify incident delirium. Two physicians independently reviewed patients’ medical records and assessments to establish the diagnosis of dementia and/or delirium. Results: Overall, 29.4% of patients (n = 145) were considered to have cognitive impairment, including 102 (20.7% of the total) who were considered to have dementia. This rate increased to 47.4% in the oldest patients (aged 90 years). The overall prevalence of delirium at admission was 9.7% (23.5% in patients with dementia), and the rate of incident delirium was 7.6% (14.7% in patients with dementia). Conclusion: The prevalence of dementia and delirium among older patients admitted to acute hospitals is high and is likely to increase with population aging. It is suggested that hospital design, staffing and processes should be attuned better to meet these patients’ needs.

Phase III trial comparing paclitaxel poliglumex (CT-2103, PPX) in combination with carboplatin versus standard paclitaxel and carboplatin in the treatment of PS 2 patients with chemotherapy-naïve advanced non-small cell lung cancer

INTRODUCTION: Performance status (PS) 2 patients with non-small cell lung cancer (NSCLC) experience more toxicity, lower response rates, and shorter survival times than healthier patients treated with standard chemotherapy. Paclitaxel poliglumex (PPX), a macromolecule drug conjugate of paclitaxel and polyglutamic acid, reduces systemic exposure to peak concentrations of free paclitaxel and may lead to increased concentrations in tumors due to enhanced vascular permeability. METHODS: Chemotherapy-naive PS 2 patients with advanced NSCLC were randomized to receive carboplatin (area under the curve = 6) and either PPX (210 mg/m/10 min without routine steroid premedication) or paclitaxel (225 mg/m/3 h with standard premedication) every 3 weeks. The primary end point was overall survival. RESULTS: A total of 400 patients were enrolled. Alopecia, arthralgias/myalgias, and cardiac events were significantly less frequent with PPX/carboplatin, whereas grade ≥3 neutropenia and grade 3 neuropathy showed a trend of worsening. There was no significant difference in the incidence of hypersensitivity reactions despite the absence of routine premedication in the PPX arm. Overall survival was similar between treatment arms (hazard ratio, 0.97; log rank p = 0.769). Median and 1-year survival rates were 7.9 months and 31%, for PPX versus 8 months and 31% for paclitaxel. Disease control rates were 64% and 69% for PPX and paclitaxel, respectively. Time to progression was similar: 3.9 months for PPX/carboplatin versus 4.6 months for paclitaxel/carboplatin (p = 0.210). CONCLUSION: PPX/carboplatin failed to provide superior survival compared with paclitaxel/carboplatin in the first-line treatment of PS 2 patients with NSCLC, but the results with respect to progression-free survival and overall survival were comparable and the PPX regimen was more convenient. © 2008International Association for the Study of Lung Cancer.

Cisplatin and gemcitabine in the management of metastatic penile cancer

Penile cancer is rare and receives little public attention. There are few treatment options for advanced disease. The most active regimen to date is a combination of bleomycin, methotrexate, and cisplatin. However the treatment-related mortality is 11% and hence this combination has not been adapted as a standard of care. We report two cases of advanced penile cancer where a sustained palliative response was observed with combination chemotherapy using cisplatin and gemcitabine. Our experience demonstrates that this is a well tolerated regimen active in this setting. © 2009 Elsevier Inc. All rights reserved.