INTroducing a care bundle to prevent pressure injury (INTACT) in at-risk patients: a protocol for a cluster randomised trial

BACKGROUND: Pressure injuries are a significant clinical and economic issue, affecting both patients and the health care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals. OBJECTIVES: This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention care bundle on the development of hospital acquired pressure injury in at-risk patients. DESIGN: This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation. METHODS: Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention care bundle or standard care. The care bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in care and health care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported. DISCUSSION: To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a care bundle focusing on patient participation and nurse-patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed care bundle, it could have a significant impact on clinical practice worldwide. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.

Using an evidence-based care bundle to improve initial emergency nursing management of patients with severe traumatic brain injury

AIMS AND OBJECTIVES: To test the feasibility of an evidence-based care bundle in a Thai emergency department. The specific objective of this study was to examine the impact of the implementation of the care bundle on the initial emergency nursing management of patients with severe traumatic brain injury. BACKGROUND: A care bundle approach is one strategy used to improve the consistency, quality and safety of emergency care for different patients groups, however, has not been tested in patients with severe traumatic brain injury. DESIGN: A pretest/post-test design was used. The study intervention was an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury. METHODS: Nonparticipant observations were conducted between October 2012-June 2013 at an emergency department of a 640 bed regional hospital in Southern Thailand. The initial emergency nursing care was observed in 45 patients with severe traumatic brain injury: 20 patients in the pretest period and 25 patients in the post-test period. RESULTS: There were significant improvements in clinical care of patients with severe traumatic brain injury after implementation of the care bundle: (1) use of end-tidal carbon dioxide monitoring, (2) frequency of respiratory rate assessment, (3) frequency of pulse rate and blood pressure assessment, and (4) patient positioning. CONCLUSION: This study demonstrated that implementation of an evidence-based care bundle improved specific elements of emergency nurses' clinical management of patients with severe traumatic brain injury. RELEVANCE TO CLINICAL PRACTICE: The study suggests that a care bundle approach can be used as a strategy to improve emergency nursing care of patients with severe traumatic brain injury.

Use of an evidence-based care bundle by Thai emergency nurses.

 Implementation of a care bundle for nursing management of patients with severe traumatic brain injury was feasible in the Thai context. Use of an evidence-based care bundle increased emergency nurses’ knowledge regarding severe TBI management and improved the care delivered during the initial emergency nursing management of these patients.

Modeling the tensile behavior of fiber bundles with irregular constituent fibers

In this paper, the effect of fiber dimensional irregularities on the tensile behavior of fiber bundles is modeled, using the finite element method (FEM). Fiber dimensional irregularities are simulated with sine waves of different magnitude. The specific stress-strain curves of fiber bundles and the constituent single fibers are obtained and compared. The results indicate that fiber diameter irregularity along fiber length has a significant effect on the tensile behavior of the fiber bundle. For a bundle of uniform fibers of different diameters, all constituent fibers will break simultaneously regardless of the fiber diameter. Similarly, if fibers within a bundle have the same pattern and level of diameter irregularity along fiber length, the fibers will break at the same time also regardless of the difference in average diameter of each fiber. In these cases, the specific stress and strain curve for the bundle overlaps with that of the constituent fibers. When the fiber bundle consists of single fibers with different levels of diameter irregularity, the specific stress-strain and load-elongation curves of the fiber bundle exhibit a stepped or “ladder” shape. The fiber with the highest irregularity breaks first, even when the thinnest section of the fiber is still coarser than the diameter of a very thin but uniform fiber in the bundle. This study suggests that fiber diameter irregularity along fiber length is a more important factor than the fiber diameter itself in determining the tensile behavior of a fiber bundle consisting of irregular fibers.

The softness of alpaca fibres

Softness is a unique selling point for luxury fibres such as alpaca. However, there is very little objective data on the softness of animal fibres. This study first establishes that the resistance to compression (RtC) behaviour of alpaca and wool fibres is quite different, and that the RtC method can not be used to examine the softness of different animal fibres. It then reports a new method for evaluating fibre softness. This method is based on the measurement of the force required to pull a fibre bundle through a series of parallel pins. This force, reflecting the combined effect of fibre surface properties, fibre diameter and rigidity, can achieve reasonable discrimination between fibres of varying levels of softness, such as alpaca and wool. Mechanisms responsible for the superior softness of alpaca fibres are discussed also.

Initial emergency nursing management of patients with severe traumatic brain injury : development of an evidence-based care bundle for the Thai emergency department context.

Thai emergency nurses play a vital role in caring for patients with severe TBI, and are an important part of the healthcare team throughout the resuscitation phase. They are also responsible for continuous physiological monitoring, and detecting deterioration associated with increased intracranial pressure and preventing secondary brain injury. However, there is known variation in Thai nurses' knowledge and care practices for patients with severe TBI. In addition, there are no specific evidence-based practice guidelines available for emergency nursing management of patients with severe TBI.

Nurses' perceptions of using an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury: A qualitative study.

Evidence to guide initial emergency nursing care of patients with severe traumatic brain injury (TBI) in Thailand is currently not available in a useable form. A care bundle was used to summarise an evidence-based approach to the initial emergency nursing management of patients with severe TBI and was implemented in one Thai emergency department. The aim of this study was to describe Thai emergency nurses' perceptions of care bundle use. A descriptive qualitative study was used to describe emergency nurses' perceptions of care bundle use during the implementation phase (Phase-One) and then post-implementation (Phase-Two). Ten emergency nurses participated in Phase-One, while 12 nurses participated in Phase-Two. In Phase-One, there were five important factors identified in relation to use of the care bundle including quality of care, competing priorities, inadequate equipment, agitated patients, and teamwork. In Phase Two, participants perceived that using the care bundle helped them to improve quality of care, increased nurses' knowledge, skills, and confidence. Care bundles are one strategy to increase integration of research evidence into clinical practice and facilitate healthcare providers to deliver optimal patient care in busy environments with limited resources.

Using an evidence-based care bundle to improve Thai emergency nurses' knowledge of care for patients with severe traumatic brain injury

There is known variation in Thai nurses' knowledge regarding the best available evidence for care of patients with severe traumatic brain injury. The purpose of this study was to examine the impact of an evidence-based care bundle on Thai emergency nurses' knowledge regarding management of patients with severe traumatic brain injury. A pre-test/post-test design was used. The study intervention was an evidence-based care bundle for initial nursing management of patients with severe traumatic brain injury. Data were collected from 31 Registered Nurses using multiple choice questions. Results revealed a statistically significant improvement in overall knowledge scores after care bundle implementation (p < 0.001). There were statistically significant improvements in five areas of knowledge: understanding of target end-tidal carbon dioxide levels (p < 0.001), implications of hypocapnia in severe traumatic brain injury (p = 0.01), implications of hypercapnia in severe traumatic brain injury (p = 0.02), importance of maintaining head and neck in neutral position (p = 0.05), and administration of sedatives and analgesics in severe traumatic brain injury (p = 0.01). This study suggested that implementation of an evidence-based care bundle improved emergency nurses' knowledge regarding management of patients with severe traumatic brain injury.

High breakdown bundle adjustment

Identifying the parameters of a model such that it best fits an observed set of data points is fundamental to the majority of problems in computer vision. This task is particularly demanding when portions of the data has been corrupted by gross outliers, measurements that are not explained by the assumed distributions. In this paper we present a novel method that uses the Least Quantile of Squares (LQS) estimator, a well known but computationally demanding high-breakdown estimator with several appealing theoretical properties. The proposed method is a meta-algorithm, based on the well established principles of proximal splitting, that allows for the use of LQS estimators while still retaining computational efficiency. Implementing the method is straight-forward as the majority of the resulting sub-problems can be solved using existing standard bundle-adjustment packages. Preliminary experiments on synthetic and real image data demonstrate the impressive practical performance of our method as compared to existing robust estimators used in computer vision.

Effectiveness of a care bundle to reduce central line-associated bloodstream infections

OBJECTIVE: To determine the effectiveness of a care bundle, with a novel line maintenance procedure, in reducing the rate of central line-associated bloodstream infection (CLABSI) in the intensive care unit (ICU).

DESIGN, PARTICIPANTS AND SETTING: Before-and-after study using CLABSI data reported to the Victorian Healthcare Associated Infection Surveillance System (VICNISS), in adult patients admitted to a tertiary adult ICU in regional Victoria between 1 July 2006 and 30 June 2014. VICNISS-reported CLABSI cases were reviewed for verification. An intervention was implemented in 2009.

INTERVENTION: The care bundle introduced in 2009 included a previously established line insertion procedure and a novel line maintenance procedure comprising Biopatch, daily 2% chlorhexidine body wash, daily ICU central line review, and liaison nurse follow-up of central lines.

MAIN OUTCOME MEASURES: CLABSI rate (cases per 1000 central line days). RESULTS: The average CLABSI rate fell from 2.2/1000 central line days (peak of 5.2/1000 central line days in quarter 4, 2008) during the pre-intervention period to 0.5/1000 central line days (0/1000 central line days from July 2012 to July 2014) during the post-intervention period.

CONCLUSION: Our study suggests that this care bundle, using a novel maintenance procedure, can effectively reduce the CLABSI rate and maintain it at zero out to 2 years.

Comparative analysis of two selective bleaching methods on alpaca fibers

Dark brown Alpaca fiber was reduced in shade via selective bleaching with peroxide. Two selective oxidative bleaching methods were tested on alpaca top to assess their effectiveness for color removal and fiber quality properties. Color change, bundle strength, weight loss, fiber diameter, surface modification, dye-ability and dye wash fastness were assessed for both methods and compared with the original brown top. Bleach method 1 (BL-I) showed little surface modification, 5.8 % weight loss and 2.4 % strength loss. D1925 yellowness index was reduced to 74.3 from 83.1 and provided a good base for the dyeing of medium to deep shades. Bleach method 2 (BL-II) displayed considerable surface modification, 7.8 % weight loss and 18 % strength loss. BL-II also resulted in a mean diameter reduction of 1.9 micron during bleaching. Yellow-ness was reduced to 64.5 from 83.1 and provided a very good base for the dyeing of medium to deep shades. BL-I showed better exhaustion of the pre-metallised dye Lanaset Violet B than BL-II. Wash fastness for BL-II was 1 grey scale unit poorer than BL-I. BL-II showed far better color clarity at pale depths however the wash fastness of the finished product was not good enough to maintain the depth or clarity of the color. BL-I showed poorer clarity of color but exhibited better wash fastness results.

Evaluating the softness of animal fibers

Softness is an important property of textile fibers, and animal fibers in particular. At present, there is no reliable method for objectively evaluating fiber softness. This paper examines a simple technique of such evaluations by pulling a bundle of parallel fibers through a series of pins. Softer fibers with lower bending rigidities and smoother surfaces should have lower pulling forces. Alpaca and wool fibers are used in this study to validate this technique, and the results suggest that pulling force measurements can reflect differences in fiber softness.

Internal structure and pigment granules in colored alpaca fibers

Alpaca fibers have some distinct properties such as softness and warmth, which have not been fully understood in combination with the fiber internal structures. In the present investigation, the internal structures of alpaca fibers have been closely examined under the scanning electron microscope (SEM), especially in the longitudinal direction. The results showed that numerous pigment granules reside loosely inside pockets in brown and dark-brown alpaca fibers. These pigment granules were mainly distributed inside the cortical cells, the medullation regions as well as underneath the cuticles. Their size in the brown alpaca fibers was smaller and more uniformly round than in the dark-brown fibers. These granules in colored alpaca fibers loosen the bundle of cortical cells, providing many crannies in the fibers which may contribute to the superior flexibility, warmth and softness of the fibers. Moreover, there are no heavy metal elements found in the granules. The mordant hydrogen peroxide bleaching employed could eliminate the pigment granules and create many nano-volumes for further dyeing of fibers into more attractive colors.