Encouraging, assisting, and time to eat : comparison of mealtime assistance interventions in elderly medical inpatients

BACKGROUND: The prevalence of protein-energy malnutrition in older adults is reported to be as high as 60% and is associated with poor health outcomes. Inadequate feeding assistance and mealtime interruptions may contribute to malnutrition and poor nutritional intake during hospitalisation. Despite being widely implemented in practice in the United Kingdom and increasingly in Australia, there have been few studies examining the impact of strategies such as Protected Mealtimes and dedicated feeding assistant roles on nutritional outcomes of elderly inpatients. AIMS: The aim of this research was to implement and compare three system-level interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years. This research also aimed to evaluate the sustainability of any changes to mealtime routines six months post-intervention and to gain an understanding of staff perceptions of the post-intervention mealtime experience. METHODS: Three mealtime assistance interventions were implemented in three medical wards at Royal Brisbane and Women's Hospital: AIN-only: Additional assistant-in-nursing (AIN) with dedicated nutrition role. PM-only: Multidisciplinary approach to meals, including Protected Mealtimes. PM+AIN: Combined intervention: AIN + multidisciplinary approach to meals. An action research approach was used to carefully design and implement the three interventions in partnership with ward staff and managers. Significant time was spent in consultation with staff throughout the implementation period to facilitate ownership of the interventions and increase likelihood of successful implementation. A pre-post design was used to compare the implementation and nutritional outcomes of each intervention to a pre-intervention group. Using the same wards, eligible participants (medical inpatients aged ≥65 years) were recruited to the preintervention group between November 2007 and March 2008 and to the intervention groups between January and June 2009. The primary nutritional outcome was daily energy and protein intake, which was determined by visually estimating plate waste at each meal and mid-meal on Day 4 of admission. Energy and protein intakes were compared between the pre and post intervention groups. Data were collected on a range of covariates (demographics, nutritional status and known risk factors for poor food intake), which allowed for multivariate analysis of the impact of the interventions on nutritional intake. The provision of mealtime assistance to participants and activities of ward staff (including mealtime interruptions) were observed in the pre-intervention and intervention groups, with staff observations repeated six months post-intervention. Focus groups were conducted with nursing and allied health staff in June 2009 to explore their attitudes and behaviours in response to the three mealtime interventions. These focus group discussions were analysed using thematic analysis. RESULTS: A total of 254 participants were recruited to the study (pre-intervention: n=115, AIN-only: n=58, PM-only: n=39, PM+AIN: n=42). Participants had a mean age of 80 years (SD 8), and 40% (n=101) were malnourished on hospital admission, 50% (n=108) had anorexia and 38% (n=97) required some assistance at mealtimes. Occasions of mealtime assistance significantly increased in all interventions (p<0.01). However, no change was seen in mealtime interruptions. No significant difference was seen in mean total energy and protein intake between the preintervention and intervention groups. However, when total kilojoule intake was compared with estimated requirements at the individual level, participants in the intervention groups were more likely to achieve adequate energy intake (OR=3.4, p=0.01), with no difference noted between interventions (p=0.29). Despite small improvements in nutritional adequacy, the majority of participants in the intervention groups (76%, n=103) had inadequate energy intakes to meet their estimated energy requirements. Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. The increase in occasions of mealtime assistance by nursing staff during the intervention period was maintained six-months post-intervention. Staff focus groups highlighted the importance of clearly designating and defining mealtime responsibilities in order to provide adequate mealtime care. While the purpose of the dedicated feeding assistant was to increase levels of mealtime assistance, staff indicated that responsibility for mealtime duties may have merely shifted from nursing staff to the assistant. Implementing the multidisciplinary interventions empowered nursing staff to "protect" the mealtime from external interruptions, but further work is required to empower nurses to prioritise mealtime activities within their own work schedules. Staff reported an increase in the profile of nutritional care on all wards, with additional non-nutritional benefits noted including improved mobility and functional independence, and better identification of swallowing difficulties. IMPLICATIONS: The PhD research provides clinicians with practical strategies to immediately introduce change to deliver better mealtime care in the hospital setting, and, as such, has initiated local and state-wide roll-out of mealtime assistance programs. Improved nutritional intakes of elderly inpatients was observed; however given the modest effect size and reducing lengths of hospital stays, better nutritional outcomes may be achieved by targeting the hospital-to-home transition period. Findings from this study suggest that mealtime assistance interventions for elderly inpatients with cognitive impairment and/or functional dependency show promise.

Blast response and failure analysis of pile foundations subjected to surface explosion

This paper presents the response of pile foundations to ground shocks induced by surface explosion using fully coupled and non-linear dynamic computer simulation techniques together with different material models for the explosive, air, soil and pile. It uses the Arbitrary Lagrange Euler coupling formulation with proper state material parameters and equations. Blast wave propagation in soil, horizontal pile deformation and pile damage are presented to facilitate failure evaluation of piles. Effects of end restraint of pile head and the number and spacing of piles within a group on their blast response and potential failure are investigated. The techniques developed and applied in this paper and its findings provide valuable information on the blast response and failure evaluation of piles and will provide guidance in their future analysis and design.

Limitation of actions - medical negligence

In Christensen v Salter [2002] QDC 082 the District Court of Queensland considered some issues on the limitation period applying to claims arising out of a failed sterilisation procedure

Children and consent to medical treatment

This chapter provides a comprehensive and up-to-date treatment of legislative provisions and common law principles regarding children and the law of consent to medical treatment. When can children provide their own consent? Can parents consent on behalf of their children, and if so, under what circumstances and why? Is court authority ever required, and if so, when, and why? What new contexts are providing fresh challenges to legal principles, parents, medical practitioners, and most importantly, children?

Numerical investigation of deformation and failure mechanisms of osteopontin-hydroxyapatite interfaces and mineralized collagen fibril arrays

This thesis is a comprehensive study of deformation and failure mechanisms in bone at nano- and micro-scale levels. It explores the mechanical behaviour of osteopontin-hydroxyapatite interfaces and mineralized collagen fibril arrays, through atomistic molecular dynamics and finite element simulations. This thesis shows some main factors contributing to the excellent material properties of bone and provides some guidelines for development of new artificial biological materials and medical implants.

Comprehensive contribution of filament thickness and crosslinker failure to the rheological property of F-actin cytoskeleton

Rheological property of F-actin cytoskeleton is significant to the restructuring of cytoskeleton under a variety of cell activities. This study numerically validates the rheological property of F-actin cytoskeleton is not only a result of kinetic energy dissipation of F-actin, but also greatly depends on the configuration remodeling of networks structure. Both filament geometry and crosslinker properties can affect the remodeling of F-actin cytoskeleton. The crosslinker unbinding is found to dissipate energy and induce prominent stress relaxation in the F-actin adjacent to cross-linkages. Coupled with F-actin elasticity, the energy dissipation and stress relaxation are more significant in bundled F-actin networks than in single F-actin networks.

Predicting people’s intention to donate their body to medical science and research

Predictors of people’s intention to register with a body bequest program for donating their deceased body to medical science and research were examined using standard theory of planned behavior (TPB) predictors (attitude, subjective norm, perceived behavioral control) and adding moral norm, altruism, and knowledge. Australian students (N = 221) at a university with a recently established body bequest program completed measures of the TPB’s underlying beliefs (behavioral, normative, and control beliefs) and standard and extended TPB predictors, with a sub-sample reporting their registration-related behavior 2 months later. The standard TPB accounted for 43.6%, and the extended predictors an additional 15.1% of variance in intention. The significant predictors were attitude, subjective norm, and moral norm, partially supporting an extended TPB in understanding people’s body donation intentions. Further, important underlying beliefs can inform strategies to target prospective donors.

Reduced withdrawal and failure rates of accelerated nursing students enrolled in pharmacology is associated with a supportive intervention

Background To reduce nursing shortages, accelerated nursing programs are available for domestic and international students. However, the withdrawal and failure rates from these programs may be different than for the traditional programs. The main aim of our study was to improve the retention and experience of accelerated nursing students. Methods The academic background, age, withdrawal and failure rates of the accelerated and traditional students were determined. Data from 2009 and 2010 were collected prior to intervention. In an attempt to reduce the withdrawal of accelerated students, we set up an intervention, which was available to all students. The assessment of the intervention was a pre-post-test design with non-equivalent groups (the traditional and the accelerated students). The elements of the intervention were a) a formative website activity of some basic concepts in anatomy, physiology and pharmacology, b) a workshop addressing study skills and online resources, and c) resource lectures in anatomy/physiology and microbiology. The formative website and workshop was evaluated using questionnaires. Results The accelerated nursing students were five years older than the traditional students (p < 0.0001). The withdrawal rates from a pharmacology course are higher for accelerated nursing students, than for traditional students who have undertaken first year courses in anatomy and physiology (p = 0.04 in 2010). The withdrawing students were predominantly the domestic students with non-university qualifications or equivalent experience. The failure rates were also higher for this group, compared to the traditional students (p = 0.05 in 2009 and 0.03 in 2010). In contrast, the withdrawal rates for the international and domestic graduate accelerated students were very low. After the intervention, the withdrawal and failure rates in pharmacology for domestic accelerated students with non-university qualifications were not significantly different than those of traditional students. Conclusions The accelerated international and domestic graduate nursing students have low withdrawal rates and high success rates in a pharmacology course. However, domestic students with non-university qualifications have higher withdrawal and failure rates than other nursing students and may be underprepared for university study in pharmacology in nursing programs. The introduction of an intervention was associated with reduced withdrawal and failure rates for these students in the pharmacology course.

Deformation and failure of a film/substrate system subjected to spherical indentation: Part 1. Experimental validation of stresses and strains derived using Hankel transform technique in an elastic film/substrate system

Our concern here is to rationalize experimental observations of failure modes brought about by indentation of hard thin ceramic films deposited on metallic substrates. By undertaking this exercise, we would like to evolve an analytical framework that can be used for designs of coatings. In Part I of the paper we develop an algorithm and test it for a model system. Using this analytical framework we address the issue of failure of columnar TiN films in Part II [J. Mater. Res. 21, 783 (2006)] of the paper. In this part, we used a previously derived Hankel transform procedure to derive stress and strain in a birefringent polymer film glued to a strong substrate and subjected to spherical indentation. We measure surface radial strains using strain gauges and bulk film stresses using photo elastic technique (stress freezing). For a boundary condition based on Hertzian traction with no film interface constraint and assuming the substrate constraint to be a function of the imposed strain, the theory describes the stress distributions well. The variation in peak stresses also demonstrates the usefulness of depositing even a soft film to protect an underlying substrate.

Damage evolution, localization and failure of solids subjected to impact loading

In order to reveal the underlying mesoscopic mechanism governing the experimentally observed failure in solids subjected to impact loading, this paper presents a model of statistical microdamage evolution to macroscopic failure, in particular to spallation. Based on statistical microdamage mechanics and experimental measurement of nucleation and growth of microcracks in an Al alloy subjected to plate impact loading, the evolution law of damage and the dynamical function of damage are obtained. Then, a lower bound to damage localization can be derived. It is found that the damage evolution beyond the threshold of damage localization is extremely fast. So, damage localization can serve as a precursor to failure. This is supported by experimental observations. On the other hand, the prediction of failure becomes more accurate, when the dynamic function of damage is fitted with longer experimental observations. We also looked at the failure in creep with the same idea. Still, damage localization is a nice precursor to failure in creep rupture.

Physicians in leadership: the association between medical director involvement and staff-to-patient ratios

In a hospital environment that demands a careful balance between commercial and clinical interests, the extent to which physicians are involved in hospital leadership varies greatly. This paper assesses the influence of the extent of this involvement on staff-to-patient ratios. Using data gathered from 604 hospitals across Germany, this study evidences the positive relationship between a full-time medical director (MD) or heavily involved part-time MD and a higher staff-to-patient ratio. The data allows us to control for a range of confounding variables, such as size, rural/urban location, ownership structure, and case-mix. The results contribute to the sparse body of empirical research on the effect of clinical leadership on organizational outcomes.

Identification and doing without it, V: A formal mathematical analysis for a case of mix-up of individuals, and of recovery from failure to attain identification

Identification, when sought, is not necessarily obtained. Operational guidance that is normatively acceptable may be necessary for such cases. We proceed to formalize and illustrate modes of exchanges of individual identity, and provide procedures of recovery strategies in specific prescriptions from an ancient body of law for such situations when, for given types of purposes, individuals of some relevant kind had become intermixed and were undistinguishable. Rules were devised, in a variety of domains, for coping with situations that occur if and when the goal of identification was frustrated. We propose or discuss mathematical representations of such recovery procedures.

Failure to Achieve PSA Level ≤I ng/ml Following Neo-Adjuvant LHRHa Therapy Predicts for a Lower Biochemical Control Rate and Overall Survival in Localized Prostate Cancer Treated with Radiotherapy

PURPOSE: To investigate whether failure to suppress the prostate-specific antigen (PSA) level to /=2 months of neoadjuvant luteinizing hormone-releasing hormone agonist therapy in patients scheduled to undergo external beam radiotherapy for localized prostate carcinoma is associated with reduced biochemical failure-free survival. METHODS AND MATERIALS: A retrospective case note review of consecutive patients with intermediate- or high-risk localized prostate cancer treated between January 2001 and December 2002 with neoadjuvant hormonal deprivation therapy, followed by concurrent hormonal therapy and radiotherapy was performed. Patient data were divided for analysis according to whether the PSA level in Week 1 of radiotherapy was 1 ng/mL in 52. At a median follow-up of 49 months, the 4-year actuarial biochemical failure-free survival rate was 84% vs. 60% (p = 0.0016) in favor of the patients with a PSA level after neoadjuvant hormonal deprivation therapy of 1 ng/mL at the beginning of external beam radiotherapy after >/=2 months of neoadjuvant luteinizing hormone-releasing hormone agonist therapy have a significantly greater rate of biochemical failure and lower survival rate compared with those with a PSA level of