Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9-year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual-care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital-acquired pressure ulcers decreased following implementation of an evidence-based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual-care nurses under-estimated patients' risk of pressure ulcer development and under-utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital-acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.

Clinical practice recommendations for depression

Objective:  To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.Method:  A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.Results:  The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.Conclusion:  These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

Clinical practice recommendations for bipolar disorder

Objective:  To provide clinically relevant evidence-based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision-making.Method:  A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. These preliminary recommendations underwent extensive consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.Results:  The clinical practice recommendations for bipolar disorder (bipolar CPR) summarise evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.Conclusion:  These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of bipolar disorder. Further, the novel style and practical approach should promote their uptake and implementation.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies.

INTRODUCTION: Low back pain is the highest ranked condition contributing to years lived with disability, and is a significant economic and societal burden. Evidence-based clinical practice guidelines are designed to improve quality of care and reduce practice variation by providing graded recommendations based on the best available evidence. Studies of low back pain guideline implementation have shown no or modest effects at changing clinical practice. OBJECTIVES: To identify enablers and barriers to adherence to clinical practice guidelines for the management of low back pain. METHODS AND ANALYSIS: A systematic review and meta-synthesis of qualitative studies that will be conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Eight databases will be searched using a priori inclusion/exclusion criteria. Two independent reviewers will conduct a structured review and meta-synthesis, and a third reviewer will arbitrate where there is disagreement. This protocol has been registered on PROSPERO 2014. ETHICS AND DISSEMINATION: Ethical approval is not required. The systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically, in print and at conferences. Updates of the review will be conducted to inform and guide healthcare translation into practice. TRIAL REGISTRATION NUMBER: PROSPERO 2014:CRD42014012961. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014012961.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and meta-synthesis of qualitative studies

INTRODUCTION: Despite the availability of evidence-based guidelines for the management of low back pain that contain consistent messages, large evidence-practice gaps in primary care remain.

OBJECTIVES: To perform a systematic review and meta-synthesis of qualitative studies that have explored primary care clinicians' perceptions and beliefs about guidelines for low back pain, including perceived enablers and barriers to guideline adherence.

METHODS: Studies investigatingperceptions and beliefs about low back pain guidelines were included if participants were primary care clinicians and qualitative methods had been used for both data collection and analysis. We searched major databases up to July 2014. Pairs of reviewers independently screened titles and abstracts, extracted data, appraised method quality using the CASP checklist, conducted thematic analysis and synthesized the results in narrative format.

RESULTS: Seventeen studies, with a total of 705 participants, were included. We identified three key emergent themes and eight subthemes: (1) guideline implementation and adherence beliefs and perceptions; (2) maintaining the patient-clinician relationship with imaging referrals; (3) barriers to guideline implementation. Clinicians believed that guidelines were categorical, prescriptive and constrained professional practice; however popular clinical practices superseded the guidelines. Imaging referrals were used to manage consultations and to obtain definitive diagnoses. Clinicians' perceptions reflected a lack of content knowledge and understanding of how guidelines are developed.

DISCUSSION: Addressing misconceptions and other barriers to uptake of evidence-based guidelines for managing low back pain is needed to improve knowledge transfer and close the evidence-practice gap in the treatment of this common condition.

The diagnosis of attention-deficit/hyperactivity disorder in Australian children: current paediatric practice and parent perspective

Aims In a sample of newly diagnosed children with attention-deficit/hyperactivity disorder (ADHD), the aims were to examine (1) paediatrician assessment and management practices; (2) previous assessments and interventions; (3) correspondence between parent-report and paediatrician identification of comorbidities; and (4) parent agreement with diagnosis of ADHD. Methods Design: cross-sectional, multi-site practice audit with questionnaires completed by paediatricians and parents at the point of ADHD diagnosis. Setting: private/public paediatric practices in Western Australia and Victoria, Australia. Main outcome measures: paediatricians: elements of assessment and management were indicated on a study-designed data form. Parents: ADHD symptoms and comorbidities were measured using the Conners 3 ADHD Index and Strengths and Difficulties Questionnaire, respectively. Sleep problems, previous assessments and interventions, and agreement with ADHD diagnosis were measured by questionnaire. Results Twenty-four paediatricians participated, providing data on 137 patients (77% men, mean age 8.1 years). Parent and teacher questionnaires were used in 88% and 85% of assessments, respectively. Medication was prescribed in 75% of cases. Comorbidities were commonly diagnosed (70%); however, the proportion of patients identified by paediatricians with internalising problems (18%), externalising problems (15%) and sleep problems (4%) was less than by parent report (51%, 66% and 39%). One in seven parents did not agree with the diagnosis of ADHD. Conclusions Australian paediatric practice in relation to ADHD assessment is generally consistent with best practice guidelines; however, improvements are needed in relation to the routine use of questionnaires and the identification of comorbidities. A proportion of parents do not agree with the diagnosis of ADHD made by their paediatrician.

Physical activity guidelines and cardiovascular risk in children: a cross sectional analysis to determine whether 60 minutes is enough

BACKGROUND: Physical activity reduces cardiovascular mortality and morbidity. The World Health Organisation (WHO) recommends children engage in 60 min daily moderate-to-vigorous physical activity (MVPA). The effect of compliance with this recommendation on childhood cardiovascular risk has not been empirically tested. To evaluate whether achieving recommendations results in reduced composite-cardiovascular risk score (CCVR) in children, and to examine if vigorous PA (VPA) has independent risk-reduction effects.

METHODS: PA was measured using accelerometry in 182 children (9-11 years). Subjects were grouped according to achievement of 60 min daily MVPA (active) or not (inactive). CCVR was calculated (sum of z-scores: DXA body fat %, blood pressure, VO2peak, flow mediated dilation, left ventricular diastolic function; CVR score ≥ 1SD indicated 'higher risk'). The cohort was further split into quintiles for VPA and odds ratios (OR) calculated for each quintile.

RESULTS: Active children (92 (53 boys)) undertook more MVPA (38 ± 11 min, P < 0.001), had greater VO2peak (4.5 ± 0.8 ml/kg/min P < 0.001), and lower fat % (3.9 ± 1.1 %, P < 0.001) than inactive. No difference were observed between active and inactive for CCVR or OR (P > 0.05). CCVR in the lowest VPA quintile was significantly greater than the highest quintile (3.9 ± 0.6, P < 0.05), and the OR was 4.7 times higher.

CONCLUSION: Achievement of current guidelines has positive effects on body composition and cardiorespiratory fitness, but not CCVR. Vigorous physical activity appears to have beneficial effects on CVD risk, independent of moderate PA, implying a more prescriptive approach may be needed for future VPA guidelines.

Investigative interviewers' perceptions of their difficulty in adhering to open-ended questions with child witnesses

Best practice guidelines for conducting investigative interviews of children emphasise the importance of obtaining free narrative accounts with the use of open-ended questions. However, research indicates that most investigative interviewers underutilise open-ended questions, even following intensive training in their use. The aim of the current study was to explore investigative interviewers' perceptions of their difficulty in asking open-ended questions. During a training course on how to use open-ended questions, eight child abuse investigators were individually interviewed about why they had asked specific questions in a 10-minute mock interview conducted immediately earlier with a school child. Overall, three reasons were identified. These related to: 1. the specificity of the information required from children; 2. the unfamiliar nature of the open-ended discourse style; and 3. the complex distinction between open-ended versus specific questions. Each of these themes is discussed, along with the implications for trainers and researchers in child investigative interviewing.

Barriers in providing psychosocial support for patients with cancer

There is sound evidence to support the notion that the provision of effective psychosocial care improves the outcomes of patients with cancer. Central to the implementation of this care is that health professionals have the necessary communication and assessment skills. This study aimed to identify key issues related to providing effective psychosocial care for adult patients admitted with hematological cancer, as perceived by registered nurses with 3 or more years of clinical experience. An exploratory qualitative design was used for this study. Two focus group interviews were conducted with 15 experienced cancer nurses. The provision of psychosocial care for patients with cancer is a dynamic process that has a professional and personal impact on the nurse. The 5 analytic themes to emerge from the data were as follows: When is it a good time to talk? Building relationships; Being drawn into the emotional world; Providing support throughout the patient's journey; and Breakdown in communication processes. The findings from this study indicate an urgent need to develop a framework to provide nurses with both skill development and ongoing support in order to improve nurses' ability to integrate psychosocial aspects of care and optimize patient outcomes.

Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive–behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness – Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression.

Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods.

Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold.

Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Effectiveness of pain management in hospital in the home programs

Alternative health care delivery models such as HITH facilitate the care of patients requiring acute treatments in their own homes. There are over 570 Diagnostic Related Groups managed in HITH programs and many of these are known to have associated physical pain. The impact of the home environment on patients’ experience of pain or how pain is managed is poorly understood. The purpose of this presentation is to
present the background and preliminary findings of a study that aims to increase our understanding of the issues related to providing optimal pain management for acute care patients who are transferred to Hospital in the Home. This knowledge will enable the development of effective practice guidelines to improve patient outcomes. More specifically, the aims are:
• To identify whether patients are transferred to HITH in pain or develop
   significant pain while in the program
• To identify the frequency and intensity of pain experienced by patients in 3      HITH programs.
• To describe patients’ experience of pain in the home environment.
• To investigate whether patients receive adequate pain relief once                      transferred to HITH.
• To explore the strategies patients use to manage pain at home.

The study will be carried out over 12 months in three HITH units in Victoria: Box Hill Hospital, Alfred Hospital and Epworth Hospital. The design is a descriptive survey of patients’ experience of pain and pain management using a modified version of The American Pain Society’s Patient Outcome Questionnaire. 360 consecutive surgical patients transferred to HITH care in the three participating programs will be interviewed by telephone between 48 and 72 hours of admission to the program.

The findings of this study will identify issues in providing optimum pain management for patients receiving acute care in non-traditional treatment environments.

An exploratory study on internal audit independence in Australia

This study draws on agency and institutional theory to examine the issue of internal audit’s independence through its relationship with components of corporate governance.

The internal audit function is actively considered as one of the four components of corporate governance, along with the board, management and external auditors. It serves this purpose by providing a range of services in its capacity of monitoring and consulting which is actively sought by the other components of corporate governance to satisfy their extended accountability requirements. The integrity of these services is, however, only assured if internal audit maintains its independent status. As such there is a “tension” resulting from the pressure to provide these value added services as perceived by the parties involved and maintaining its independence status.

Based on an extended survey with organisations in the Australian corporate sector, this study critically examines the results of the survey against existing literature and best practice guidelines to determine if internal audit functions operating under this tense environment are operating independently.

The results indicate an interesting analysis. While it indicates a somewhat trend in complying with best practice guidelines for maintaining independence, it also indicates that this is not consistently adhered to as organisations are able to operate in an environment that compromises internal audit independence. A main reason for this appears to be a mix of internal audit structural set ups brought about by a lack of statutory backing to provide for consistency in implementation of best practice guidelines for maintaining independence. This is exacerbated by internal audit being viewed as partner by these parties thus widening the “tension” gap between its advisory role and its independent status. A wider question emerges which questions the ability to maintain this independence concept under a partnership management environment. The concept of internal audit being an independent function as promulgated by the Institute of Internal Auditors through its definition of internal audit is seriously questioned under the totality of this environment.

An examination of the limitations in investigative interviewer's use of open-ended questions

Best-practice guidelines in the area of investigative interviewing of children specify the importance of using open-ended questions. However, use of open-ended questions per se does not maximise interview outcome; open-ended questions can vary markedly in quality. The aim of this study was to identify the nature of investigative interviewers' limitations when using open-ended questions, and to compare how representative these limitations are in three distinct interview paradigms. These interview paradigms include: (a) interviews in which trained actors played the role of a 5-6-year-old child; (b) interviews where 5-6-year-old children recalled an innocuous event that was staged in their school; and (c) actual field interviews where child witnesses aged 5 to 7 years recalled an abusive event. Overall, several common problems that would restrict children's opportunity to provide elaborate and accurate narrative accounts of events were identified and described. Our identification of these problems (using a dichotomous rating scale) was found to be consistent with an independent expert, and their presence was not limited to those interviewers who used a low frequency of open-ended questions. The implications of the findings for researchers and trainers in the area of investigative interviewing of children are discussed.

Designing effective training programs for investigative interviewers of children

'Best-practice' guidelines for conducting investigative interviews with children are well established in the literature, yet few investigative interviewers actually adhere to such guidelines in the field. One of the problems is that little discussion has focused on how such guidelines are learned and sustained by professionals. To address this concern, the current article reviews the key elements of interview training programs that are known to promote competent interviewing. These elements include: (i) the establishment of key principles or beliefs that underpin effective interviewing, (ii) the adoption of an interview framework that maximises narrative detail, (iii) clear instruction in relation to the application of the interview framework, (iv) effective ongoing practice, (v) expert feedback and (vi) regular evaluation of interviewer performance. A description and justification of each element is provided, followed by broad recommendations regarding how these elements can be implemented by police and human service organisations in a cost-effective manner.

Prevalence, detection and drug treatment of hypertension in a rural Australian population : the Greater Green Triangle Risk Factor Study 2004

Background: Hypertension is an important risk factor for cardiovascular disease; however, limited findings are available on its detection and management in rural Australia.

Aim: To assess the prevalence, awareness and treatment of hypertension in a rural South-East Australian population.

Methods: Three cross-sectional surveys in Limestone Coast, Corangamite Shire and Wimmera regions during 2004–2006 using a random population sample (n = 3320, participation rate 49%) aged 25–74 years. Blood pressure was measured by trained nurses. Information on history of hypertension and medication was obtained by questionnaires. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and/or on antihypertensive drug treatment.

Results: Overall, one-third of participants had hypertension; of these, two-thirds, 54% (95% confidence interval (CI) 47–60) of men and 71% (95% CI 65–77) of women, were aware of their condition. Half of the participants with hypertension were treated and nearly half of these were controlled. Both treatment and control were more common in women (60%, 95% CI 54–67 and 55%, 95% CI 47–64) compared with men (42%, 95% CI 36–49 and 35%, 95% CI 26–44). Monotherapy was used by 55% (95% CI 48–61) of treated hypertensives. Angiotensin-converting enzyme inhibitors were the most frequently used class of antihypertensive drugs in men, whereas angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and diuretics were all widely used among women.

Conclusion: This study emphasizes suboptimal detection and treatment of hypertension, especially in men, in rural Australia.