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.

A novel device using the Nordic hamstring exercise to assess eccentric knee flexors strength : a reliability and retrospective injury study

STUDY DESIGN: Reliability and case-control injury study. OBJECTIVES: 1) To determine if a novel device, designed to measure eccentric knee flexors strength via the Nordic hamstring exercise (NHE), displays acceptable test-retest reliability; 2) to determine normative values for eccentric knee flexors strength derived from the device in individuals without a history of hamstring strain injury (HSI) and; 3) to determine if the device could detect weakness in elite athletes with a previous history of unilateral HSI. BACKGROUND: HSIs and reinjuries are the most common cause of lost playing time in a number of sports. Eccentric knee flexors weakness is a major modifiable risk factor for future HSIs, however there is a lack of easily accessible equipment to assess this strength quality. METHODS: Thirty recreationally active males without a history of HSI completed NHEs on the device on 2 separate occasions. Intraclass correlation coefficients (ICCs), typical error (TE), typical error as a co-efficient of variation (%TE), and minimum detectable change at a 95% confidence interval (MDC95) were calculated. Normative strength data were determined using the most reliable measurement. An additional 20 elite athletes with a unilateral history of HSI within the previous 12 months performed NHEs on the device to determine if residual eccentric muscle weakness existed in the previously injured limb. RESULTS: The device displayed high to moderate reliability (ICC = 0.83 to 0.90; TE = 21.7 N to 27.5 N; %TE = 5.8 to 8.5; MDC95 = 76.2 to 60.1 N). Mean±SD normative eccentric flexors strength, based on the uninjured group, was 344.7 ± 61.1 N for the left and 361.2 ± 65.1 N for the right side. The previously injured limbs were 15% weaker than the contralateral uninjured limbs (mean difference = 50.3 N; 95% CI = 25.7 to 74.9N; P < .01), 15% weaker than the normative left limb data (mean difference = 50.0 N; 95% CI = 1.4 to 98.5 N; P = .04) and 18% weaker than the normative right limb data (mean difference = 66.5 N; 95% CI = 18.0 to 115.1 N; P < .01). CONCLUSIONS: The experimental device offers a reliable method to determine eccentric knee flexors strength and strength asymmetry and revealed residual weakness in previously injured elite athletes.

Intelligent reliability analysis with incomplete covariates

The reliability analysis is crucial to reducing unexpected down time, severe failures and ever tightened maintenance budget of engineering assets. Hazard based reliability methods are of particular interest as hazard reflects the current health status of engineering assets and their imminent failure risks. Most existing hazard models were constructed using the statistical methods. However, these methods were established largely based on two assumptions: one is the assumption of baseline failure distributions being accurate to the population concerned and the other is the assumption of effects of covariates on hazards. These two assumptions may be difficult to achieve and therefore compromise the effectiveness of hazard models in the application. To address this issue, a non-linear hazard modelling approach is developed in this research using neural networks (NNs), resulting in neural network hazard models (NNHMs), to deal with limitations due to the two assumptions for statistical models. With the success of failure prevention effort, less failure history becomes available for reliability analysis. Involving condition data or covariates is a natural solution to this challenge. A critical issue for involving covariates in reliability analysis is that complete and consistent covariate data are often unavailable in reality due to inconsistent measuring frequencies of multiple covariates, sensor failure, and sparse intrusive measurements. This problem has not been studied adequately in current reliability applications. This research thus investigates such incomplete covariates problem in reliability analysis. Typical approaches to handling incomplete covariates have been studied to investigate their performance and effects on the reliability analysis results. Since these existing approaches could underestimate the variance in regressions and introduce extra uncertainties to reliability analysis, the developed NNHMs are extended to include handling incomplete covariates as an integral part. The extended versions of NNHMs have been validated using simulated bearing data and real data from a liquefied natural gas pump. The results demonstrate the new approach outperforms the typical incomplete covariates handling approaches. Another problem in reliability analysis is that future covariates of engineering assets are generally unavailable. In existing practices for multi-step reliability analysis, historical covariates were used to estimate the future covariates. Covariates of engineering assets, however, are often subject to substantial fluctuation due to the influence of both engineering degradation and changes in environmental settings. The commonly used covariate extrapolation methods thus would not be suitable because of the error accumulation and uncertainty propagation. To overcome this difficulty, instead of directly extrapolating covariate values, projection of covariate states is conducted in this research. The estimated covariate states and unknown covariate values in future running steps of assets constitute an incomplete covariate set which is then analysed by the extended NNHMs. A new assessment function is also proposed to evaluate risks of underestimated and overestimated reliability analysis results. A case study using field data from a paper and pulp mill has been conducted and it demonstrates that this new multi-step reliability analysis procedure is able to generate more accurate analysis results.

Development of the palliative care needs assessment tool (PC-NAT) for use by multi-disciplinary health professionals

Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.

Exploring dependencies of 5.9 GHz DSRC throughput and reliability on safety applications

Dedicated Short Range Communication (DSRC) is the emerging key technology supporting cooperative road safety systems within Intelligent Transportation Systems (ITS). The DSRC protocol stack includes a variety of standards such as IEEE 802.11p and SAE J2735. The effectiveness of the DSRC technology depends on not only the interoperable cooperation of these standards, but also on the interoperability of DSRC devices manufactured by various manufacturers. To address the second constraint, the SAE defines a message set dictionary under the J2735 standard for construction of device independent messages. This paper focuses on the deficiencies of the SAE J2735 standard being developed for deployment in Vehicular Ad-hoc Networks (VANET). In this regard, the paper discusses the way how a Basic Safety Message (BSM) as the fundamental message type defined in SAE J2735 is constructed, sent and received by safety communication platforms to provide a comprehensive device independent solution for Cooperative ITS (C-ITS). This provides some insight into the technical knowledge behind the construction and exchange of BSMs within VANET. A series of real-world DSRC data collection experiments was conducted. The results demonstrate that the reliability and throughput of DSRC highly depend on the applications utilizing the medium. Therefore, an active application-dependent medium control measure, using a novel message-dissemination frequency controller, is introduced. This application level message handler improves the reliability of both BSM transmissions/receptions and the Application layer error handling which is extremely vital to decentralized congestion control (DCC) mechanisms.

Mechanical testing and modelling of a bone-implant construct

Finite Element modelling of bone fracture fixation systems allows computational investigation of the deformation response of the bone to load. Once validated, these models can be easily adapted to explore changes in design or configuration of a fixator. The deformation of the tissue within the fracture gap determines its healing and is often summarised as the stiffness of the construct. FE models capable of reproducing this behaviour would provide valuable insight into the healing potential of different fixation systems. Current model validation techniques lack depth in 6D load and deformation measurements. Other aspects of the FE model creation such as the definition of interfaces between components have also not been explored. This project investigated the mechanical testing and FE modelling of a bone– plate construct for the determination of stiffness. In depth 6D measurement and analysis of the generated forces, moments and movements showed large out of plane behaviours which had not previously been characterised. Stiffness calculated from the interfragmentary movement was found to be an unsuitable summary parameter as the error propagation is too large. Current FE modelling techniques were applied in compression and torsion mimicking the experimental setup. Compressive stiffness was well replicated, though torsional stiffness was not. The out of plane behaviours prevalent in the experimental work were not replicated in the model. The interfaces between the components were investigated experimentally and through modification to the FE model. Incorporation of the interface modelling techniques into the full construct models had no effect in compression but did act to reduce torsional stiffness bringing it closer to that of the experiment. The interface definitions had no effect on out of plane behaviours, which were still not replicated. Neither current nor novel FE modelling techniques were able to replicate the out of plane behaviours evident in the experimental work. New techniques for modelling loads and boundary conditions need to be developed to mimic the effects of the entire experimental system.

Rethinking the literacy capabilities of pre-service primary teachers in testing times

As a group of committed literacy teacher educators from five universities across three Australian states, the authors bring professional critique to the problematic issue of what counts in current and possible future measures of pre-service teachers’ literacy capacity. In times when normalising models of literacy assessment ignore innovative developments in technologies, we provide an example of what is happening at the ‘chalk-face’ of literacy teacher education. This paper describes a study that demonstrates how responsible alignment of teacher accreditation requirements with a scholarly impetus to incorporate digital literacies to prepare pre-service teachers will help address changing educational needs and practices (AITSL 2012; Gillen & Barton 2010; Hattie 2003; Johnson, Smith, Willis, Levine & Haywood 2011; Klein 2006; Masny & Cole 2012; OECD 2011).

Random Breath Testing in Australia: Is there an Optimum Level of Intensity?

Background: Random Breath Testing (RBT) is the main drink driving law enforcement tool used throughout Australia. International comparative research considers Australia to have the most successful RBT program compared to other countries in terms of crash reductions (Erke, Goldenbeld, & Vaa, 2009). This success is attributed to the programs high intensity (Erke et al., 2009). Our review of the extant literature suggests that there is no research evidence that indicates an optimal level of alcohol breath testing. That is, we suggest that no research exists to guide policy regarding whether or not there is a point at which alcohol related crashes reach a point of diminishing returns as a result of either saturated or targeted RBT testing. Aims: In this paper we first provide an examination of RBTs and alcohol related crashes across Australian jurisdictions. We then address the question of whether or not an optimal level of random breath testing exists by examining the relationship between the number of RBTs conducted and the occurrence of alcohol-related crashes over time, across all Australian states. Method: To examine the association between RBT rates and alcohol related crashes and to assess whether an optimal ratio of RBT tests per licenced drivers can be determined we draw on three administrative data sources form each jurisdiction. Where possible data collected spans January 1st 2000 to September 30th 2012. The RBT administrative dataset includes the number of Random Breath Tests (RBTs) conducted per month. The traffic crash administrative dataset contains aggregated monthly count of the number of traffic crashes where an individual’s recorded BAC reaches or exceeds 0.05g/ml of alcohol in blood. The licenced driver data were the monthly number of registered licenced drivers spanning January 2000 to December 2011. Results: The data highlights that the Australian story does not reflective of all States and territories. The stable RBT to licenced driver ratio in Queensland (of 1:1) suggests a stable rate of alcohol related crash data of 5.5 per 100,000 licenced drivers. Yet, in South Australia were a relative stable rate of RBT to licenced driver ratio of 1:2 is maintained the rate of alcohol related traffic crashes is substantially less at 3.7 per 100,000. We use joinpoint regression techniques and varying regression models to fit the data and compare the different patterns between jurisdictions. Discussion: The results of this study provide an updated review and evaluation of RBTs conducted in Australia and examines the association between RBTs and alcohol related traffic crashes. We also present an evidence base to guide policy decisions for RBT operations.

Reliability and validity of conjunctival ultraviolet autofluorescence measurement

BACKGROUND: Conjunctival ultraviolet autofluorescence (UVAF) photography was developed to detect and characterise pre-clinical sunlight-induced UV damage. The reliability of this measurement and its relationship to outdoor activity are currently unknown. METHODS: 599 people aged 16-85 years in the cross-sectional Norfolk Island Eye Study were included in the validation study. 196 UVAF individual photographs (49 people) and 60 UVAF photographs (15 people) of Norfolk Island Eye Study participants were used for intra- and inter-observer reliability assessment, respectively. Conjunctival UVAF was measured using UV photography. UVAF area was calculated using computerised methods by one grader on two occasions (intra-observer analysis) or two graders (inter-observer analysis). Outdoor activity category, during summer and winter separately, was determined with a UV questionnaire. Total UVAF equalled the area measured in four conjunctival areas (nasal/temporal conjunctiva of right and left eyes). RESULTS: Intra-observer (ρ_c=0.988, 95% CI 0.967 to 0.996, p<0.001), and inter-observer concordance correlation coefficients (ρ_c=0.924, 95% CI 0.870 to 0.956, p<0.001) of total UVAF exceeded 0.900. When grouped according to 10 mm(2) total UVAF increments, intra- and inter-observer reliability was very good (κ=0.81) and good (κ=0.71), respectively. Increasing time outdoors was strongly with increasing total UVAF in summer and winter (p(trend) <0.001). CONCLUSION: Intra- and inter-observer reliability of conjunctival UVAF is high. In this population, UVAF correlates strongly with the authors' survey-based assessment of time spent outdoors.

Homeostatic epistemology : reliability, coherence and coordination in a Bayesian virtue epistemology

How do agents with limited cognitive capacities flourish in informationally impoverished or unexpected circumstances? Aristotle argued that human flourishing emerged from knowing about the world and our place within it. If he is right, then the virtuous processes that produce knowledge, best explain flourishing. Influenced by Aristotle, virtue epistemology defends an analysis of knowledge where beliefs are evaluated for their truth and the intellectual virtue or competences relied on in their creation. However, human flourishing may emerge from how degrees of ignorance are managed in an uncertain world. Perhaps decision-making in the shadow of knowledge best explains human wellbeing—a Bayesian approach? In this dissertation I argue that a hybrid of virtue and Bayesian epistemologies explains human flourishing—what I term homeostatic epistemology. Homeostatic epistemology supposes that an agent has a rational credence p when p is the product of reliable processes aligned with the norms of probability theory; whereas an agent knows that p when a rational credence p is the product of reliable processes such that: 1) p meets some relevant threshold for belief (such that the agent acts as though p were true and indeed p is true), 2) p coheres with a satisficing set of relevant beliefs and, 3) the relevant set of beliefs is coordinated appropriately to meet the integrated aims of the agent. Homeostatic epistemology recognizes that justificatory relationships between beliefs are constantly changing to combat uncertainties and to take advantage of predictable circumstances. Contrary to holism, justification is built up and broken down across limited sets like the anabolic and catabolic processes that maintain homeostasis in the cells, organs and systems of the body. It is the coordination of choristic sets of reliably produced beliefs that create the greatest flourishing given the limitations inherent in the situated agent.

Are more city dwellers caught drink driving than country folk? An analysis by random breath testing apprehension rates

Background Random Breath Testing (RBT) remains a central enforcement strategy to deter and apprehend drink drivers in Queensland (Australia). Despite this, there is little published research regarding the exact drink driving apprehension rates across the state as measured through RBT activities. Aims The aim of the current study was to examine the prevalence of apprehending drink drivers in urban versus rural areas. Methods The Queensland Police Service provided data relating to the number of RBT conducted and apprehensions for the period 1 January 2000 to 31 December 2011. Results In the period, 35,082,386 random breath tests (both mobile and stationary) were conducted in Queensland which resulted in 248,173 individuals being apprehended for drink driving offences. Overall drink driving apprehension rates appear to have decreased across time. Close examination of the data revealed that the highest proportion of drink driving apprehensions (when compared with RBT testing rates) was in the Northern and Far Northern regions of Queensland (e.g., rural areas). In contrast, the lowest proportions were observed within the two Brisbane metropolitan regions (e.g., urban areas). However, differences in enforcement styles across the urban and rural regions need to be considered. Discussion and conclusions The research presentation will further outline the major findings of the study in regards to maximising the efficiency of RBT operations both within urban and rural areas of Queensland, Australia.

Tensile properties of pumpkin peel and flesh tissue and review of current testing methods

In South and Southeast Asia, postharvest loss causes material waste of up to 66% in fruits and vegetables, 30% in oilseeds and pulses, and 49% in roots and tubers. The efficiency of postharvest equipment directly affects industrial-scale food production. To enhance current processing methods and devices, it is essential to analyze the responses of food materials under loading operations. Food materials undergo different types of mechanical loading during postharvest and processing stages. Therefore, it is important to determine the properties of these materials under different types of loads, such as tensile, compression, and indentation. This study presents a comprehensive analysis of the available literature on the tensile properties of different food samples. The aim of this review was to categorize the available methods of tensile testing for agricultural crops and food materials to investigate an appropriate sample size and tensile test method. The results were then applied to perform tensile tests on pumpkin flesh and peel samples, in particular on arc-sided samples at a constant loading rate of 20 mm min-1. The results showed the maximum tensile stress of pumpkin flesh and peel samples to be 0.535 and 1.45 MPa, respectively. The elastic modulus of the flesh and peel samples was 6.82 and 25.2 MPa, respectively, while the failure modulus values were 14.51 and 30.88 MPa, respectively. The results of the tensile tests were also used to develop a finite element model of mechanical peeling of tough-skinned vegetables. However, to study the effects of deformation rate, moisture content, and texture of the tissue on the tensile responses of food materials, more investigation needs to be done in the future.

Discriminative ability of functional loading tests for adolescent jumper's knee

Objective. To investigate the reliability and validity of five squat-based loading tests that are clinically appropriate for jumper's knee. The loading tests were step up, double leg squat, double leg squat on a 25-degree decline (decline squat), single leg decline squat, and decline hop. Design. Cross-sectional controlled cohort. Subjects without knee pain comprised controls, those with extensor tendon pain comprised the jumper's knee group. Setting. Institutional athlete study group in Australia Participants. Fifty-six elite adolescent basketball players participated in this study, thirteen comprised the jumper's knee group, fifteen athletes formed a control group. Intervention. Each subject performed each loading test for baseline and reliability data on the first testing day. Subjects then performed three days of intensive (6 h daily) basketball training, after which each loading test was reexamined. Main outcome measures. Eleven point interval scale for pain. Results. The tests that best detected a change in pain due to intensive workload were the single leg decline squat and single leg decline hop. This study found that decline tests have better discriminative ability than the standard squat to detect change in jumper's knee pain due to intensive training. The typical error for these tests ranged from 0.3 to 0.5, however, caution should be exercised in the interpretation of these reliability figures due to relatively low scores. Conclusions. The single leg decline squat is recommended in the physical assessment of adolescent jumper's knee. The decline squat was selected as the best clinical test over the decline hop because it was easier to standardise performance.

Econometric Modelling with Time Series : Specification, Estimation and Testing

This book provides a general framework for specifying, estimating, and testing time series econometric models. Special emphasis is given to estimation by maximum likelihood, but other methods are also discussed, including quasi-maximum likelihood estimation, generalized method of moments estimation, nonparametric estimation, and estimation by simulation. An important advantage of adopting the principle of maximum likelihood as the unifying framework for the book is that many of the estimators and test statistics proposed in econometrics can be derived within a likelihood framework, thereby providing a coherent vehicle for understanding their properties and interrelationships. In contrast to many existing econometric textbooks, which deal mainly with the theoretical properties of estimators and test statistics through a theorem-proof presentation, this book squarely addresses implementation to provide direct conduits between the theory and applied work.