Good nutrition for good surgery: clinical and quality of life outcomes

Undernutrition is common in patients admitted for surgery and is often unrecognised, untreated and worsens in hospital. The complex synergistic relationship between nutritional status and the physiological responses to surgery puts patients at high nutritional risk. There are clear prospective associations between inadequate nutritional status and the risk of poorer outcomes for surgical patients, including infection, complications and length of stay. However, practically and ethically evidence that nutritional interventions can significantly reduce these poor outcomes is difficult to obtain. Nevertheless health professionals have a duty of care to ensure our patients are properly fed, by whatever means, to meet their physiological requirements.

Evaluating the effect of a patient education brochure on patients’ expectations and satisfaction with emergency department service

Introduction: The purpose of this study was to assess the capacity of a written intervention, in this case a patient information brochure, to improve patient satisfaction during an Emergency Department (ED) visit. For the purpose of measuring the effect of the intervention the ED journey was conceptualised as a series of distinct areas of service comprising waiting time, service by the triage nurse, care from doctors and nurses and information giving Background of study: Research into patient satisfaction has become a widespread activity endorsed by both governments and hospital administrations. The literature on ED patient satisfaction has consistently indicated three primary areas of patient dissatisfaction: waiting time, nursing care and communication. Recent developments in the literature on patient satisfaction studies however have highlighted the relationship between patients. expectations of a service encounter and their consequent assessment of the experience as dissatisfying or satisfying. Disconfirmation theory posits that the degree to which expectations are confirmed will affect subsequent levels of satisfaction. The conceptual framework utilised in this study is Coye.s (2004) model of disconfirmation. Coye while reiterating satisfaction is a consequence of the degree expectations are either confirmed or disconfirmed also posits that expectations can be modified by interventions. Coye.s work conceptualises these interventions as intra encounter experiences (cues) which function to adjust expectations. Coye suggests some cues are unintended and may have a negative impact which also reinforces the value of planned cues intended to meet or exceed consumer expectations. Consequently the brochure can be characterized as a potentially positive cue, encouraging the patient to understand processes and to orient them in what can be a confronting environment. Only a limited number of studies have examined the effect of written interventions within an ED. No studies could be located which have tested the effect of ED interventions using a conceptual framework which relates the effect of the degree to which expectations are confirmed or disconfirmed in terms of satisfaction with services. Method: Two studies were conducted. Study One used qualitative methods to explore patients. expectations of the ED from the perspective of both patients and health care professionals. Study One was used in part to direct the development of the intervention (brochure) in Study Two. The brochure was an intervention designed to modify patients. expectations thus increasing their satisfaction with the provision of ED service. As there was no existing tools to measure ED patients. expectations and satisfaction a new tool was also developed based on the findings and the literature of Study One. Study Two used a non-randomised, quasi-experimental approach using a non-equivalent post-test only comparison group design used to investigate the effect of the patient education brochure (Stommel and Wills, 2004). The brochure was disseminated to one of two study groups (the intervention group). The effect of the brochure was assessed by comparing the data obtained from both the intervention and control group. These two groups consisted of 150 participants each. It was expected that any differences in the relevant domains selected for examination would indicate the effect of the brochure both on expectation and potentially satisfaction. Results: Study One revealed several areas of common ground between patients and nurses in terms of relevant content for the written intervention, including the need for information on the triage system and waiting times. Areas of difference were also found with patients emphasizing communication issues, whereas focus group members expressed concern that patients were often unable to assimilate verbal information. The findings suggested the potential utility of written material to reinforce verbal communication particularly in terms of the triage process and other ED protocols. This material was synthesized within the final version of the written intervention. Overall the results of Study Two indicated no significant differences between the two groups. The intervention group did indicate a significant number of participants who viewed the brochure of having changed their expectations. The effect of the brochure may have been obscured by a lack of parity between the two groups as the control group presented with statistically significantly higher levels of acuity and experienced significantly shorter waiting times. In terms of disconfirmation theory this would suggest expectations that had been met or exceeded. The results confirmed the correlation of expectations with satisfaction. Several domains also indicated age as a significant predictor with older patients tending to score higher satisfaction results. Other significant predictors of satisfaction established were waiting time and care from nurses, reinforcing the combination of efficient service and positive interpersonal experiences as being valued by patients. Conclusions: Information presented in written form appears to benefit a significant number of ED users in terms of orientation and explaining systems and procedures. The degree to which these effects may interact with other dimensions of satisfaction however is likely to be limited. Waiting time and interpersonal behaviours from staff also provide influential cues in determining satisfaction. Written material is likely to be one element in a series of coordinated strategies to improve patient satisfaction during periods of peak demand.

Implementation and evaluation of a new model of nursing practice in radiation oncology

Patients undergoing radiation therapy for cancer face a series of challenges that require support from a multidisciplinary team which includes radiation oncology nurses. However, the specific contribution of nursing, and the models of care that best support the delivery of nursing interventions in the radiotherapy setting, is not well described. In this case study, the Interaction Model of Client Health Behaviour and the associated principles of person-centred care were incorporated into a new model of care that was implemented in one radiation oncology setting in Brisbane, Australia. The new model of care was operationalised through a Primary Nursing/Collaborative Practice framework. To evaluate the impact of the new model for patients and health professionals, multiple sources of data were collected from patients and clinical staff prior to, during, and 18 months following introduction of the practice redesign. One cohort of patients and clinical staff completed surveys incorporating measures of key outcomes immediately prior to implementation of the model, while a second cohort of patients and clinical staff completed these same surveys 18 months following introduction of the model. In-depth interviews were also conducted with nursing, medical and allied health staff throughout the implementation phase to obtain a more comprehensive account of the processes and outcomes associated with implementing such a model. From the patients’ perspectives, this study demonstrated that, although adverse effects of radiotherapy continue to affect patient well-being, patients continue to be satisfied with nursing care in this specialty, and that they generally reported high levels of functioning despite undergoing a curative course of radiotherapy. From the health professionals’ perspective, there was evidence of attitudinal change by nursing staff within the radiotherapy department which reflected a greater understanding and appreciation of a more person-centred approach to care. Importantly, this case study has also confirmed that a range of factors need to be considered when redesigning nursing practice in the radiotherapy setting, as the challenges associated with changing traditional practices, ensuring multidisciplinary approaches to care, and resourcing a new model were experienced. The findings from this study suggest that the move from a relatively functional approach to a person-centred approach in the radiotherapy setting has contributed to some improvements in the provision of individualised and coordinated patient care. However, this study has also highlighted that primary nursing may be limited in its approach as a framework for patient care unless it is supported by a whole team approach, an appropriate supportive governance model, and sufficient resourcing. Introducing such a model thus requires effective education, preparation and ongoing support for the whole team. The challenges of providing care in the context of complex interdisciplinary relationships have been highlighted by this study. Aspects of this study may assist in planning further nursing interventions for patients undergoing radiotherapy for cancer, and continue to enhance the contribution of the radiation oncology nurse to improved patient outcomes.

Infant wrapping as an evidence-based strategy to encourage settling and the utilisation of the supine sleep position

Objective: To identify knowledge, attitudes and practices of child health nurses relating to infant wrapping as an effective settling/sleep strategy. Methods: A pre-test/post-test intervention design was used to explore knowledge, attitudes and practices relating to wrapping in a sample of child health nurses (n=182): a) pre-test survey; b) educational intervention incorporating evidence relating to infant wrapping; SIDS&KIDS endorsed infant wrapping pamphlet; Safe Sleeping recommendations. Emphasis was placed on infant wrapping as an effective settling strategy for parents to use as an alternative to prone positioning; c) post-test survey to evaluate intervention effectiveness. Results: Pretest results identified wide variation in nurses’ knowledge, attitudes and practices of infant wrapping as a settling/sleep strategy. The intervention increased awareness of wrapping guidelines and self-reported practices relating to parent advice. Significant positive changes in nurses’ awareness of wrapping guidelines (p<0.001); to wrap in supine position only (p<0.001); and parental advice to use wrapping as an alternative strategy to prone positioning to assist settling/sleep (p<0.01), were achieved post-test. Conclusions: Managing unsettled infants and promoting safe sleeping practices are issues routinely addressed by child health nurses working with parents of young infants. Queensland has a high incidence of prone sleeping. Infant wrapping is an evidence-based strategy to improve settling and promote supine sleep consistent with public health recommendations. Infant wrapping guidelines are now included in Queensland Health’s state policy and Australian SIDSandKids information relating to safe infant sleeping. In communicating complex health messages to parents, health professionals have a key role in reinforcing safe sleeping recommendations and offering safe, effective settling/sleep strategies to address the non-recommended use of prone positioning for unsettled infants.

Implementing value management as a decision-making tool in the design stages of design and build construction projects : a methodology for improved cost optimization

Value Management (VM) has been proven to provide a structured framework, together with other supporting tools and techniques, that facilitate effective decision-making in many types of projects, thus achieving ‘best value’ for clients. One of the major success factors of VM in achieving better project objectives for clients is through the provision of beneficial input by multi-disciplinary team members being involved in critical decision-making discussions during the early stage of construction projects. This paper describes a doctoral research proposal based on the application of VM in design and build construction projects, especially focusing on the design stage. The research aims to study the effects of implementing VM in design and build construction projects, in particular how well the methodology addresses issues related to cost overruns resulting from poor coordination and overlooking of critical constructability issues amongst team members in construction projects in Malaysia. It is proposed that through contractors’ early involvement during the design stage, combined with the use of the VM methodology, particularly as a decision-making tool, better optimization of construction cost can be achieved, thus promoting more efficient and effective constructability. The main methods used in this research involve a thorough literature study, semi-structured interviews, and a survey of major stakeholders, a detailed case study and a VM workshop and focus group discussions involving construction professionals in order to explore and possibly develop a framework and a specific methodology for the facilitating successful application of VM within design and build construction projects.

Compliance, normality and the patient on peritoneal dialysis

Monitoring and enhancing patient compliance with peritoneal dialysis (PD) is a recurring and problematic theme in the renal literature. A growing body of literature also argues that a failure to understand the patient's perspective of compliance may be contributing to these problems. The aim of this study was to understand the concept of compliance with PD from the patient's perspective. Using the case study approach recommended by Stake (1995), five patients on PD consented to in-depth interviews that explored the meaning of compliance in the context of PD treatment and lifestyle regimens recommended by health professionals. Participants also discussed factors that influenced their choices to follow, disregard, or refine these regimens. Results indicate that health professionals acting in alignment with individual patient needs and wishes, and demonstrating an awareness of the constraints under which patients operate and the strengths they bring to their treatment, may be the most significant issues to consider with respect to definitions of PD compliance and the development of related compliance interventions. Aspects of compliance that promoted relative normality were also important to the participants in this study and tended to result in greater concordance with health professionals' advice.

New criteria for evaluating methods of identifying hot spots

Identification of hot spots, also known as the sites with promise, black spots, accident-prone locations, or priority investigation locations, is an important and routine activity for improving the overall safety of roadway networks. Extensive literature focuses on methods for hot spot identification (HSID). A subset of this considerable literature is dedicated to conducting performance assessments of various HSID methods. A central issue in comparing HSID methods is the development and selection of quantitative and qualitative performance measures or criteria. The authors contend that currently employed HSID assessment criteria—namely false positives and false negatives—are necessary but not sufficient, and additional criteria are needed to exploit the ordinal nature of site ranking data. With the intent to equip road safety professionals and researchers with more useful tools to compare the performances of various HSID methods and to improve the level of HSID assessments, this paper proposes four quantitative HSID evaluation tests that are, to the authors’ knowledge, new and unique. These tests evaluate different aspects of HSID method performance, including reliability of results, ranking consistency, and false identification consistency and reliability. It is intended that road safety professionals apply these different evaluation tests in addition to existing tests to compare the performances of various HSID methods, and then select the most appropriate HSID method to screen road networks to identify sites that require further analysis. This work demonstrates four new criteria using 3 years of Arizona road section accident data and four commonly applied HSID methods [accident frequency ranking, accident rate ranking, accident reduction potential, and empirical Bayes (EB)]. The EB HSID method reveals itself as the superior method in most of the evaluation tests. In contrast, identifying hot spots using accident rate rankings performs the least well among the tests. The accident frequency and accident reduction potential methods perform similarly, with slight differences explained. The authors believe that the four new evaluation tests offer insight into HSID performance heretofore unavailable to analysts and researchers.

Incorporating weather into regionwide safety planning prediction models

Predicting safety on roadways is standard practice for road safety professionals and has a corresponding extensive literature. The majority of safety prediction models are estimated using roadway segment and intersection (microscale) data, while more recently efforts have been undertaken to predict safety at the planning level (macroscale). Safety prediction models typically include roadway, operations, and exposure variables—factors known to affect safety in fundamental ways. Environmental variables, in particular variables attempting to capture the effect of rain on road safety, are difficult to obtain and have rarely been considered. In the few cases weather variables have been included, historical averages rather than actual weather conditions during which crashes are observed have been used. Without the inclusion of weather related variables researchers have had difficulty explaining regional differences in the safety performance of various entities (e.g. intersections, road segments, highways, etc.) As part of the NCHRP 8-44 research effort, researchers developed PLANSAFE, or planning level safety prediction models. These models make use of socio-economic, demographic, and roadway variables for predicting planning level safety. Accounting for regional differences - similar to the experience for microscale safety models - has been problematic during the development of planning level safety prediction models. More specifically, without weather related variables there is an insufficient set of variables for explaining safety differences across regions and states. Furthermore, omitted variable bias resulting from excluding these important variables may adversely impact the coefficients of included variables, thus contributing to difficulty in model interpretation and accuracy. This paper summarizes the results of an effort to include weather related variables, particularly various measures of rainfall, into accident frequency prediction and the prediction of the frequency of fatal and/or injury degree of severity crash models. The purpose of the study was to determine whether these variables do in fact improve overall goodness of fit of the models, whether these variables may explain some or all of observed regional differences, and identifying the estimated effects of rainfall on safety. The models are based on Traffic Analysis Zone level datasets from Michigan, and Pima and Maricopa Counties in Arizona. Numerous rain-related variables were found to be statistically significant, selected rain related variables improved the overall goodness of fit, and inclusion of these variables reduced the portion of the model explained by the constant in the base models without weather variables. Rain tends to diminish safety, as expected, in fairly complex ways, depending on rain frequency and intensity.

A simultaneous equations model of crash frequency by collision type for rural intersections

Safety at roadway intersections is of significant interest to transportation professionals due to the large number of intersections in transportation networks, the complexity of traffic movements at these locations that leads to large numbers of conflicts, and the wide variety of geometric and operational features that define them. A variety of collision types including head-on, sideswipe, rear-end, and angle crashes occur at intersections. While intersection crash totals may not reveal a site deficiency, over exposure of a specific crash type may reveal otherwise undetected deficiencies. Thus, there is a need to be able to model the expected frequency of crashes by collision type at intersections to enable the detection of problems and the implementation of effective design strategies and countermeasures. Statistically, it is important to consider modeling collision type frequencies simultaneously to account for the possibility of common unobserved factors affecting crash frequencies across crash types. In this paper, a simultaneous equations model of crash frequencies by collision type is developed and presented using crash data for rural intersections in Georgia. The model estimation results support the notion of the presence of significant common unobserved factors across crash types, although the impact of these factors on parameter estimates is found to be rather modest.

Use of expert panels in highway safety: A critique

Expert panels have been used extensively in the development of the "Highway Safety Manual" to extract research information from highway safety experts. While the panels have been used to recommend agendas for new and continuing research, their primary role has been to develop accident modification factors—quantitative relationships between highway safety and various highway safety treatments. Because the expert panels derive quantitative information in a “qualitative” environment and because their findings can have significant impacts on highway safety investment decisions, the expert panel process should be described and critiqued. This paper is the first known written description and critique of the expert panel process and is intended to serve professionals wishing to conduct such panels.

Quality of child abuse information in emergency department injury surveillance data : linking hospital and child welfare data

Emergency departments (EDs) are often the first point of contact with an abused child. Despite legal mandate, the reporting of definite or suspected abusive injury to child safety authorities by ED clinicians varies due to a number of factors including training, access to child safety professionals, departmental culture and a fear of ‘getting it wrong’. This study examined the quality of documentation and coding of child abuse captured by ED based injury surveillance data and ED medical records in the state of Queensland and the concordance of these data with child welfare records. A retrospective medical record review was used to examine the clinical documentation of almost 1000 injured children included in the Queensland Injury Surveillance Unit database (QISU) from 10 hospitals in urban and rural centres. Independent experts re-coded the records based on their review of the notes. A data linkage methodology was then used to link these records with records in the state government’s child welfare database. Cases were sampled from three sub-groups according to the surveillance intent codes: Maltreatment by parent, Undetermined and Unintentional injury. Only 0.1% of cases coded as unintentional injury were recoded to maltreatment by parent, while 1.2% of cases coded as maltreatment by parent were reclassified as unintentional and 5% of cases where the intent was undetermined by the triage nurse were recoded as maltreatment by parent. Quality of documentation varied across type of hospital (tertiary referral centre, children’s, urban, regional and remote). Concordance of health data with child welfare data varied across patient subgroups. Outcomes from this research will guide initiatives to improve the quality of intentional child injury surveillance systems.

Food literacy : time for a new term or just another buzzword?

Eating is an essential everyday life activity that has fascinated, captivated and defined society since time began. We currently exist in a society where over-consumption of food is an established risk factor chronic disease, the rate of which is increasing alarmingly. 'Food literacy' is an emerging term used to describe what we, as individuals and as a community know and understand about food and how to use it to meet our need, and thus potentially support and empower citizens to make healthy food choices. What exactly the components of food literacy are and how they influence food choice are poorly defined and understood, but increasingly gaining interest among health professionals, policy makers, community workers, educators and members of the public. This paper will build the argument for why concepts of 'food literacy' need to extend beyond existing terms and measures used in the literature to describe the food skills and knowledge needed to make use of public health nutrition messages.

Secure tracking using trusted GNSS receivers and Galileo authentication services

This paper describes a secure framework for tracking applications that use the Galileo signal authentication services. First a number of limitations that affect the trust of critical tracking applications, even in presence of authenticated GNSS signals, are detailed. Requirements for secure tracking are then introduced; detailing how the integrity characteristics of the Galileo authentication could enhance the security of active tracking applications. This paper concludes with a discussion of our existing tracking technology using a Siemens TC45 GSM/GPRS module and future development utilizing our previously proposed trusted GNSS receiver.

The Eat Smart Study : a randomised controlled trial of a reduced carbohydrate versus a low fat diet for weight loss in obese adolescents

Background Despite the recognition of obesity in young people as a key health issue, there is limited evidence to inform health professionals regarding the most appropriate treatment options. The Eat Smart study aims to contribute to the knowledge base of effective dietary strategies for the clinical management of the obese adolescent and examine the cardiometablic effects of a reduced carbohydrate diet versus a low fat diet. Methods and design Eat Smart is a randomised controlled trial and aims to recruit 100 adolescents over a 2½ year period. Families will be invited to participate following referral by their health professional who has recommended weight management. Participants will be overweight as defined by a body mass index (BMI) greater than the 90th percentile, using CDC 2000 growth charts. An accredited 6-week psychological life skills program ‘FRIENDS for Life’, which is designed to provide behaviour change and coping skills will be undertaken prior to volunteers being randomised to group. The intervention arms include a structured reduced carbohydrate or a structured low fat dietary program based on an individualised energy prescription. The intervention will involve a series of dietetic appointments over 24 weeks. The control group will commence the dietary program of their choice after a 12 week period. Outcome measures will be assessed at baseline, week 12 and week 24. The primary outcome measure will be change in BMI z-score. A range of secondary outcome measures including body composition, lipid fractions, inflammatory markers, social and psychological measures will be measured. Discussion The chronic and difficult nature of treating the obese adolescent is increasingly recognised by clinicians and has highlighted the need for research aimed at providing effective intervention strategies, particularly for use in the tertiary setting. A structured reduced carbohydrate approach may provide a dietary pattern that some families will find more sustainable and effective than the conventional low fat dietary approach currently advocated. This study aims to investigate the acceptability and effectiveness of a structured reduced dietary carbohydrate intervention and will compare the outcomes of this approach with a structured low fat eating plan. Trial Registration: The protocol for this study is registered with the International Clinical Trials Registry (ISRCTN49438757).

Understanding the optimal learning environment in palliative care

The learning experiences of student nurses undertaking clinical placement are reported widely, however little is known about the learning experiences of health professionals undertaking continuing professional development (CPD) in a clinical setting, especially in palliative care. The aim of this study, which was conducted as part of the national evaluation of a professional development program involving clinical attachments with palliative care services (The Program of Experience in the Palliative Approach [PEPA]), was to explore factors influencing the learning experiences of participants over time. Thirteen semi-structured, one-to-one telephone interviews were conducted with five participants throughout their PEPA experience. The analysis was informed by the traditions of adult, social and psychological learning theories and relevant literature. The participants' learning was enhanced by engaging interactively with host site staff and patients, and by the validation of their personal and professional life experiences together with the reciprocation of their knowledge with host site staff. Self-directed learning strategies maximised the participants' learning outcomes. Inclusion in team activities aided the participants to feel accepted within the host site. Personal interactions with host site staff and patients shaped this social/cultural environment of the host site. Optimal learning was promoted when participants were actively engaged, felt accepted and supported by, and experienced positive interpersonal interactions with, the host site staff.