928 resultados para improved outcomes
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Aim. The paper presents a study assessing the rate of adoption of a sedation scoring system and sedation guideline. Background. Clinical practice guidelines including sedation guidelines have been shown to improve patient outcomes by standardizing care. In particular sedation guidelines have been shown to be beneficial for intensive care patients by reducing the duration of ventilation. Despite the acceptance that clinical practice guidelines are beneficial, adoption rates are rarely measured. Adoption data may reveal other factors which contribute to improved outcomes. Therefore, the usefulness of the guideline may be more appropriately assessed by collecting adoption data. Method. A quasi-experimental pre-intervention and postintervention quality improvement design was used. Adoption was operationalized as documentation of sedation score every 4 hours and use of the sedation and analgesic medications suggested in the guideline. Adoption data were collected from patients' charts on a random day of the month; all patients in the intensive care unit on that day were assigned an adoption category. Sedation scoring system adoption data were collected before implementation of a sedation guideline, which was implemented using an intensive information-giving strategy, and guideline adoption data were fed back to bedside nurses. After implementation of the guideline, adoption data were collected for both the sedation scoring system and the guideline. The data were collected in the years 2002-2004. Findings. The sedation scoring system was not used extensively in the pre-intervention phase of the study; however, this improved in the postintervention phase. The findings suggest that the sedation guideline was gradually adopted following implementation in the postintervention phase of the study. Field notes taken during the implementation of the sedation scoring system and the guideline reveal widespread acceptance of both. Conclusion. Measurement of adoption is a complex process. Appropriate operationalization contributes to greater accuracy. Further investigation is warranted to establish the intensity and extent of implementation required to positively affect patient outcomes.
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Objective: To evaluate the effectiveness of a programme of static positional stretches and positioning of the stroke-affected shoulder for maintaining shoulder external rotation and decreasing hemiplegic shoulder pain. Design: Randomized controlled trial with pretest and posttest design. Setting: Inpatient rehabilitation unit. Subjects: Thirty-two participants ( 17 treatment, 15 comparison) with a first time stroke who were admitted for rehabilitation. Interventions: Treatment participants completed a programme of static positional stretches of the stroke-affected shoulder twice daily and positioned the stroke-affected upper limb in an armrest support at all other times when seated. Main measures: The main outcome measures were pain-free range of motion into external rotation, pain in the stroke-affected shoulder at rest and with movement, motor recovery and functional independence. Results: All participants demonstrated a significant loss of external rotation ( P = 0.005) with no significant group differences. All participants demonstrated a significant improvement in motor recovery ( P < 0.01) and functional independence ( P < 0.01) with no significant group differences. There were no significant effects for pain. The comparison group recorded a decrease in mean pain reported with movement from admission to discharge, and the treatment group recorded an increase. Conclusions: Participation in the management programme did not result in improved outcomes. The results of this study do not support the application of the programme of static positional stretches to maintain range of motion in the shoulder. The effect of increasing pain for the treatment group requires further investigation.
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Aim To test whether addition of moderation-orientated cue exposure (CE) or CE after dysphoric mood induction ( emotional CE, ECE) improved outcomes above those from cognitive-behaviour therapy alone (CBT) in people who drank when dysphoric. Design Multi-site randomized controlled trial comparing CBT with CBT + CE and CBT + ECE. Setting Out-patient rooms in academic treatment units in Brisbane and Sydney, Australia. Participants People with alcohol misuse and problems controlling consumption when dysphoric (n = 163). Those with current major depressive episode were excluded. Intervention Eight weekly 75-minute sessions of individual treatment for alcohol problems were given to all participants, with CBT elements held constant across conditions. From session 2, CBT + CE participants resisted drinking while exposed to alcohol cues, with two priming doses of their preferred beverage being given in some sessions. After an initial CE session, CBT + ECE participants recalled negative experiences before undertaking CE, to provide exposure to emotional cues of personal relevance. Measurements Alcohol consumption, related problems, alcohol expectancies, self-efficacy and depression. Results Average improvements were highly significant across conditions, with acceptable maintenance of effects over 12 months. Both treatment retention and effects on alcohol consumption were progressively weaker in CBT + CE and CBT + ECE than in CBT alone. Changes in alcohol dependence and depression did not differ across conditions. Conclusions These data do not indicate that addition of clinic-based CE to standard CBT improves outcomes. A different approach to the management of craving may be required.
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Purpose – This paper describes a “work in progress” research project being carried out with a public health care provider in the UK, a large NHS hospital Trust. Enhanced engagement with patients is one of the Trust’s core principles, but it is recognised that much more needs to be done to achieve this, and that ICT systems may be able to provide some support. The project is intended to find ways to better capture and evaluate the “voice of the patient” in order to lead to improvements in health care quality, safety and effectiveness. Design/methodology/approach – We propose to investigate the use of a patient-orientated knowledge management system (KMS) in managing knowledge about and from patients. The study is a mixed methods (quantitative and qualitative) investigation based on traditional action research, intended to answer the following three research questions: (1) How can a KMS be used as a mechanism to capture and evaluate patient experiences to provoke patient service change (2) How can the KMS assist in providing a mechanism for systematising patient engagement? (3) How can patient feedback be used to stimulate improvements in care, quality and safety? Originality/value –This methodology aims to involve patients at all phases of the study from its initial design onwards, thus leading to an understanding of the issues associated with using a KMS to manage knowledge about and for patients that is driven by the patients themselves. Practical implications – The outcomes of the project for the collaborating hospital will be firstly, a system for capturing and evaluating knowledge about and from patients, and then as a consequence, improved outcomes for both the patients and the service provider. More generally, it will produce a set of guidelines for managing patient knowledge in an NHS hospital that have been tested in one case example.
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A correlation scheme (leading to a special equilibrium called “soft” correlated equilibrium) is applied for two-person finite games in extensive form with perfect information. Randomization by an umpire takes place over the leaves of the game tree. At every decision point players have the choice either to follow the recommendation of the umpire blindly or freely choose any other action except the one suggested. This scheme can lead to Pareto-improved outcomes of other correlated equilibria. Computational issues of maximizing a linear function over the set of soft correlated equilibria are considered and a linear-time algorithm in terms of the number of edges in the game tree is given for a special procedure called “subgame perfect optimization”.
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BACKGROUND: The American College of Cardiology guidelines recommend 3 months of anticoagulation after replacement of the aortic valve with a bioprosthesis. However, there remains great variability in the current clinical practice and conflicting results from clinical studies. To assist clinical decision making, we pooled the existing evidence to assess whether anticoagulation in the setting of a new bioprosthesis was associated with improved outcomes or greater risk of bleeding. METHODS AND RESULTS: We searched the PubMed database from the inception of these databases until April 2015 to identify original studies (observational studies or clinical trials) that assessed anticoagulation with warfarin in comparison with either aspirin or no antiplatelet or anticoagulant therapy. We included the studies if their outcomes included thromboembolism or stroke/transient ischemic attacks and bleeding events. Quality assessment was performed in accordance with the Newland Ottawa Scale, and random effects analysis was used to pool the data from the available studies. I(2) testing was done to assess the heterogeneity of the included studies. After screening through 170 articles, a total of 13 studies (cases=6431; controls=18210) were included in the final analyses. The use of warfarin was associated with a significantly increased risk of overall bleeding (odds ratio, 1.96; 95% confidence interval, 1.25-3.08; P<0.0001) or bleeding risk at 3 months (odds ratio, 1.92; 95% confidence interval, 1.10-3.34; P<0.0001) compared with aspirin or placebo. With regard to composite primary outcome variables (risk of venous thromboembolism, stroke, or transient ischemic attack) at 3 months, no significant difference was seen with warfarin (odds ratio, 1.13; 95% confidence interval, 0.82-1.56; P=0.67). Moreover, anticoagulation was also not shown to improve outcomes at time interval >3 months (odds ratio, 1.12; 95% confidence interval, 0.80-1.58; P=0.79). CONCLUSIONS: Contrary to the current guidelines, a meta-analysis of previous studies suggests that anticoagulation in the setting of an aortic bioprosthesis significantly increases bleeding risk without a favorable effect on thromboembolic events. Larger, randomized controlled studies should be performed to further guide this clinical practice.
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Copyright © 2014 International Anesthesia Research Society.BACKGROUND: Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT. METHODS: One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient's stroke volume was optimized using 250- mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared. RESULTS: Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were -0.96 to +1.95 days (P = 0.5016). CONCLUSIONS: The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.
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Minimally-invasive microsurgery has resulted in improved outcomes for patients. However, operating through a microscope limits depth perception and fixes the visual perspective, which result in a steep learning curve to achieve microsurgical proficiency. We introduce a surgical imaging system employing four-dimensional (live volumetric imaging through time) microscope-integrated optical coherence tomography (4D MIOCT) capable of imaging at up to 10 volumes per second to visualize human microsurgery. A custom stereoscopic heads-up display provides real-time interactive volumetric feedback to the surgeon. We report that 4D MIOCT enhanced suturing accuracy and control of instrument positioning in mock surgical trials involving 17 ophthalmic surgeons. Additionally, 4D MIOCT imaging was performed in 48 human eye surgeries and was demonstrated to successfully visualize the pathology of interest in concordance with preoperative diagnosis in 93% of retinal surgeries and the surgical site of interest in 100% of anterior segment surgeries. In vivo 4D MIOCT imaging revealed sub-surface pathologic structures and instrument-induced lesions that were invisible through the operating microscope during standard surgical maneuvers. In select cases, 4D MIOCT guidance was necessary to resolve such lesions and prevent post-operative complications. Our novel surgical visualization platform achieves surgeon-interactive 4D visualization of live surgery which could expand the surgeon's capabilities.
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Stroke is a prevalent disorder with immense socioeconomic impact. A variety of chronic neurological deficits result from stroke. In particular, sensorimotor deficits are a significant barrier to achieving post-stroke independence. Unfortunately, the majority of pre-clinical studies that show improved outcomes in animal stroke models have failed in clinical trials. Pre-clinical studies using non-human primate (NHP) stroke models prior to initiating human trials are a potential step to improving translation from animal studies to clinical trials. Robotic assessment tools represent a quantitative, reliable, and reproducible means to assess reaching behaviour following stroke in both humans and NHPs. We investigated the use of robotic technology to assess sensorimotor impairments in NHPs following middle cerebral artery occlusion (MCAO). Two cynomolgus macaques underwent transient MCAO for 90 minutes. Approximately 1.5 years following the procedure these NHPs and two non-stroke control monkeys were trained in a reaching task with both arms in the KINARM exoskeleton. This robot permits elbow and shoulder movements in the horizontal plane. The task required NHPs to make reaching movements from a centrally positioned start target to 1 of 8 peripheral targets uniformly distributed around the first target. We analyzed four movement parameters: reaction time, movement time (MT), initial direction error (IDE), and number of speed maxima to characterize sensorimotor deficiencies. We hypothesized reduced performance in these attributes during a neurobehavioural task with the paretic limb of NHPs following MCAO compared to controls. Reaching movements in the non-affected limbs of control and experimental NHPs showed bell-shaped velocity profiles. In contrast, the reaching movements with the affected limbs were highly variable. We found distinctive patterns in MT, IDE, and number of speed peaks between control and experimental monkeys and between limbs of NHPs with MCAO. NHPs with MCAO demonstrated more speed peaks, longer MTs, and greater IDE in their paretic limb compared to controls. These initial results qualitatively match human stroke subjects’ performance, suggesting that robotic neurobehavioural assessment in NHPs with stroke is feasible and could have translational relevance in subsequent human studies. Further studies will be necessary to replicate and expand on these preliminary findings.
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Aim The aim of this study was to explore parental preparedness for discharge and their experiences of going home with their infant after the first-stage surgery for a functionally univentricular heart. Background Technological advances worldwide have improved outcomes for infants with a functionally univentricular heart over the last 3 decades; however, concern remains regarding mortality in the period between the first and second stages of surgery. The implementation of home monitoring programmes for this group of infants has improved this initial inter-stage survival; however, little is known about parents’ experiences of going home, their preparedness for discharge, and parents’ recognition of deterioration in their fragile infant. Method This study was conducted in 2011–2013; eight sets of parents were consulted in the research planning stage in September, 2011, and 22 parents with children aged 0–2 years responded to an online survey during November, 2012–March, 2013. Description of categorical data and deductive thematic analysis of the open-ended questions were undertaken. Results Not all parents were taught signs of deterioration or given written information specific to their baby. The following three themes emerged from the qualitative data: mixed emotions about going home, knowledge and preparedness, and support systems. Conclusions Parents are not adequately prepared for discharge and are not well equipped to recognise deterioration in their child. There is a role for greater parental education through development of an early warning tool to address the gap in parents’ understanding of signs of deterioration, enabling appropriate contact and earlier management by clinicians.
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Background and aims: Advances in modern medicine have led to improved outcomes after stroke, yet an increased treatment burden has been placed on patients. Treatment burden is the workload of health care for people with chronic illness and the impact that this has on functioning and well-being. Those with comorbidities are likely to be particularly burdened. Excessive treatment burden can negatively affect outcomes. Individuals are likely to differ in their ability to manage health problems and follow treatments, defined as patient capacity. The aim of this thesis was to explore the experience of treatment burden for people who have had a stroke and the factors that influence patient capacity. Methods: There were four phases of research. 1) A systematic review of the qualitative literature that explored the experience of treatment burden for those with stroke. Data were analysed using framework synthesis, underpinned by Normalisation Process Theory (NPT). 2) A cross-sectional study of 1,424,378 participants >18 years, demographically representative of the Scottish population. Binary logistic regression was used to analyse the relationship between stroke and the presence of comorbidities and prescribed medications. 3) Interviews with twenty-nine individuals with stroke, fifteen analysed by framework analysis underpinned by NPT and fourteen by thematic analysis. The experience of treatment burden was explored in depth along with factors that influence patient capacity. 4) Integration of findings in order to create a conceptual model of treatment burden and patient capacity in stroke. Results: Phase 1) A taxonomy of treatment burden in stroke was created. The following broad areas of treatment burden were identified: making sense of stroke management and planning care; interacting with others including health professionals, family and other stroke patients; enacting management strategies; and reflecting on management. Phase 2) 35,690 people (2.5%) had a diagnosis of stroke and of the 39 co-morbidities examined, 35 were significantly more common in those with stroke. The proportion of those with stroke that had >1 additional morbidities present (94.2%) was almost twice that of controls (48%) (odds ratio (OR) adjusted for age, gender and socioeconomic deprivation; 95% confidence interval: 5.18; 4.95-5.43) and 34.5% had 4-6 comorbidities compared to 7.2% of controls (8.59; 8.17-9.04). In the stroke group, 12.6% of people had a record of >11 repeat prescriptions compared to only 1.5% of the control group (OR adjusted for age, gender, deprivation and morbidity count: 15.84; 14.86-16.88). Phase 3) The taxonomy of treatment burden from Phase 1 was verified and expanded. Additionally, treatment burdens were identified as arising from either: the workload of healthcare; or the endurance of care deficiencies. A taxonomy of patient capacity was created. Six factors were identified that influence patient capacity: personal attributes and skills; physical and cognitive abilities; support network; financial status; life workload, and environment. A conceptual model of treatment burden was created. Healthcare workload and the presence of care deficiencies can influence and be influenced by patient capacity. The quality and configuration of health and social care services influences healthcare workload, care deficiencies and patient capacity. Conclusions: This thesis provides important insights into the considerable treatment burden experienced by people who have had a stroke and the factors that affect their capacity to manage health. Multimorbidity and polypharmacy are common in those with stroke and levels of these are high. Findings have important implications for the design of clinical guidelines and healthcare delivery, for example co-ordination of care should be improved, shared decision-making enhanced, and patients better supported following discharge from hospital.
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Abstract This study investigated depressive symptom and interpersonal relatedness outcomes from eight sessions of manualized narrative therapy for 47 adults with major depressive disorder. Post-therapy, depressive symptom improvement (d=1.36) and proportions of clients achieving reliable improvement (74%), movement to the functional population (61%), and clinically significant improvement (53%) were comparable to benchmark research outcomes. Post-therapy interpersonal relatedness improvement (d=.62) was less substantial than for symptoms. Three-month follow-up found maintenance of symptom, but not interpersonal gains. Benchmarking and clinical significance analyses mitigated repeated measure design limitations, providing empirical evidence to support narrative therapy for adults with major depressive disorder. RÉSUMÉ Cette étude a investigué les symptômes dépressifs et les relations interpersonnels d'une thérapie narrative en huit séances chez 47 adultes souffrant d'un trouble dépressif majeur. Après la thérapie, l'amélioration des symptômes dépressifs (d=1.36) et la proportion de clients atteignant un changement significatif (74%), le mouvement vers la population fonctionnelle (61%), enfin l'amélioration clinique significative (53%) étaient comparables aux performances des études de résultats. L'amélioration des relations interpersonnelles (d=0.62) était inférieure à l'amélioration symptomatique. Le suivi à trois mois montrait un maintien des gains symptomatiques mais pas pour les relations interpersonnelles. L’évaluation des performances et les analyses de significativité clinique modèrent les limitations du plan de recherche à mesures répétées et apportent une preuve empirique qui étaie l'efficacité des thérapies narratives pour des adultes avec un trouble dépressif majeur. Este estudo investigou sintomas depressivos e resultados interpessoais relacionados em oito sessões de terapia narrativa manualizada para 47 adultos com perturbação depressiva major. No pós terapia, melhoria de sintomas depressivos (d=1,36) e proporção de clientes que alcançam melhoria válida (74%), movimento para a população funcional (61%) e melhoria clinicamente significativa (53%) foram comparáveis com os resultados da investigação reportados. As melhorias pós terapia nos resultados interpessoais relacionados (d=.62) foi menos substancial do que para os sintomas. Aos três meses de seguimento houve a manutenção dos sintomas mas não dos ganhos interpessoais. As análises de benchemarking e de melhoria clinicamente significativas atenuam as limitações de um design de medidas repetidas, fornecendo evidência empírica para a terapia narrativa para adultos com perturbação depressiva major. Questo lavoro ha valutato i sintomi depressivi e gli outcome nella capacità di relazionarsi a livello interpersonale in 8 sedute di psicoterapia narrativa manualizzata in un gruppo di 47 adulti con depressione maggiore. I risultati ottenuti relativamente a: post terapy, miglioramento dei sintomi depressivi (d_1.36), proporzione di pazienti che hanno raggiunto un miglioramento affidabile e consistente (74%), movimento verso il funzionamento atteso nella popolazione (61%) e miglioramento clinicamente significativo (53%) sono paragonabili ai valori di riferimento della ricerca sull'outcome. I miglioramento della capacità di relazionarsi valutata alla fine del trattamento (d_.62) si è rivelata meno sostanziale rispetto ai sintomi. Un follow-up dopo 3 mesi ha dimostrato che il miglioramento sintomatologico è stato mantenuto, ma non quello degli obiettivi interpersonali. Valori di riferimento e analisi della significatività clinica hanno fatto fronte ai limiti del disegno a misure ripetute, offrendo prove empiriche sulla rilevanza della terapia narrativa in pazienti adulti con depressione maggiore
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Quality and equity issues as they relate to assessment practices and policy are becoming increasingly important as Australia introduces a national curriculum and achievement standards. In a context of high-stakes accountability, concerns regarding equity and quality have important implications for teachers‘ practice for the improvement of learner outcomes. This article is based on three research projects that were conducted over the past four years and were funded by the Australian Federal Government. The research focus, emergent questions, the educational contexts, and the rationale for the studies are discussed prior to the presentation of the analysis of the research findings and the implications for teachers‘ practice and policy reform.
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Insulated Rail Joints (IRJs) are safety critical component of the automatic block signalling and broken rail detection systems. IRJs exhibit several failure modes due to complex interaction between the railhead ends and the wheel tread near the gap. These localised zones could not be monitored using automatic sensing devices and hence are resorted to visual inspection only, which is error prone and expensive. In Australia alone currently there are 50,000 IRJs across 80,000 km of rail track. The significance of the problem around the world could thus be realised as there exists one IRJ for each 1.6 km track length. IRJs exhibit extremely low and variable service life; further the track substructure underneath IRJs degrade faster. Thus presence of the IRJs incur significant costs to track maintenance. IRJ failures have also contributed to some train derailments and various traffic disruptions in rail lines. This paper reports a systematic research carried out over seven years on the mechanical behaviour of IRJs for practically relevant outcomes. The research has scientifically established that stiffening the track bed for reduction in impact force is an ill-conceived concept and the most effective method is to reduce the gap size. Further it is established that hardening the railhead ends through laser coating (or other) cannot adequately address the metal flow problem in the long run; modification of the railhead profile is the only appropriate technique to completely eliminate the problem. Part of these outcomes has been adopted by the rail infrastructure owners in Australia.