Development and use of clinical guidelines

The purpose of this chapter is to provide an overview of the development and use of clinical guidelines as a tool for decision making in clinical practice. Nurses have always developed and used tools to guide clinical decision making related to interventions in practice. Since Florence Nightingale (Nightingale 1860) gave us ‘notes’ on nursing in the late 1800s, nurses have continued to use tools, such as standards, policies and procedures, protocols, algorithms, clinical pathways and clinical guidelines, to assist them in making appropriate decisions about patient care that eventuate in the best desired patient outcomes. Clinical guidelines have enjoyed growing popularity as a comprehensive tool for synthesising clinical evidence and information into user-friendly recommendations for practice. Historically, clinical guidelines were developed by individual experts or groups of experts by consensus, with no transparent process for the user to determine the validity and reliability of the recommendations. The acceptance of the evidence-based practice (EBP) movement as a paradigm for clinical decision making underscores the imperative for clinical guidelines to be systematically developed and based on the best available research evidence. Clinicians are faced with the dilemma of choosing from an abundance of guidelines of variable quality, or developing new guidelines. Where do you start? How do you find an existing guideline to fit your practice? How do you know if a guideline is evidence-based, valid and reliable? Should you apply an existing guideline in your practice or develop a new guideline? How do you get clinicians to use the guidelines? How do you know if using the guideline will make any difference in care delivery or patient outcomes? Whatever the choice, the challenge lies in choosing or developing a clinical guideline that is credible as a decision-making tool for the delivery of quality, efficient and effective care. This chapter will address the posed questions through an exploration of the ins and outs of clinical guidelines, from development to application to evaluation.

Telephone reliability of the Frenchay Activity Index and EQ-5D amongst older adults

Background Older adults may find it problematic to attend hospital appointments due to the difficulty associated with travelling to, within and from a hospital facility for the purpose of a face-to-face assessment. This study aims to investigate equivalence between telephone and face-to-face administration for the Frenchay Activities Index (FAI) and the Euroqol-5D (EQ-5D) generic health-related quality of life instrument amongst an older adult population. Methods Patients aged >65 (n = 53) who had been discharged to the community following an acute hospital admission underwent telephone administration of the FAI and EQ-5D instruments seven days prior to attending a hospital outpatient appointment where they completed a face-to-face administration of these instruments. Results Overall, 40 subjects' datasets were complete for both assessments and included in analysis. The FAI items had high levels of agreement between the two modes of administration (item kappa's ranged 0.73 to 1.00) as did the EQ-5D (item kappa's ranged 0.67–0.83). For the FAI, EQ-5D VAS and EQ-5D utility score, intraclass correlation coefficients were 0.94, 0.58 and 0.82 respectively with paired t-tests indicating no significant systematic difference (p = 0.100, p = 0.690 and p = 0.290 respectively). Conclusion Telephone administration of the FAI and EQ-5D instruments provides comparable results to face-to-face administration amongst older adults deemed to have cognitive functioning intact at a basic level, indicating that this is a suitable alternate approach for collection of this information.

Optical absorption near infrared and EPR studies of mottramite

Mottramite mineral originated from Tsumeb Corporation Mine, Tsumeb, Otavi, Namibia, is used in the present work. The mineral contains of vanadium and copper to the extent of 22.73% and 16.84% by weight respectively as V2O5 and CuO. An EPR study of sample confirms the presence of Cu(II) with g = 2.2. Optical absorption spectrum of mottramite indicates that Cu(II) is present in rhombic environment. NIR results are due to water fundamentals.

Survey of eResearch practices and skills at QUT, Australia

Queensland University of Technology (QUT) is a multidisciplinary university in Brisbane, Queensland, Australia, and has 40,000 students and 1,700 researchers. Notable eResearch infrastructure includes the QUT ePrints repository, Microsoft QUT Research Centre, the OAK (Open Access to Knowledge) Law Project, Cambia and leading research institutes. ---------- The Australian Government, via the Australian National Data Service (ANDS), is funding institutions to identify and describe their research datasets, to develop and populate data repositories and collaborative infrastructure, and to seed the Australian Research Data Commons. QUT is currently broadening its range of research support services, including those to support the management of research data, in recognition of the value of these datasets as products of the research process, and in order to maximize the potential for reuse. QUT is integrating Library and High Performance Computing (HPC) services to achieve its research support goals. ---------- The Library and HPC released an online survey using Key Survey to 1,700 researchers in September 2009. A comprehensive range of eResearch practices and skills was presented for response, and grouped into areas of scholarly communication and open access publishing, using collaborative technologies, data management, data collection and management, computation and visualization tools. Researchers were asked to rate their skill level on each practice. 254 responses were received over two weeks. Eight focus groups were also held with 35 higher degree research (HDR) students and staff to provide additional qualitative feedback. A similar survey was released to 100 support staff and 73 responses were received.---------- Preliminary results from the researcher survey and focus groups indicate a gap between current eResearch practices, and the potential for researchers to engage in eResearch practices. Researchers are more likely to seek advice from their peers, than from support staff. HDR students are more positive about eResearch practices and are more willing to learn new ways of conducting research. An account of the survey methodology, the results obtained, and proposed strategies to embed eResearch practices and skills across and within the research disciplines will be provided.

Osteoarthritis Index delivered by mobile phone (m-WOMAC) is valid, reliable, and responsive

Objectives: To evaluate the validity, reliability and responsiveness of EDC using the WOMAC® NRS 3.1 Index on Motorola V3 mobile phones. ---------- Methods: Patients with osteoarthritis (OA) undergoing primary unilateral hip or knee joint replacement surgery were assessed pre-operatively and 3-4 months post-operatively. Patients completed the WOMAC® Index in paper (p-WOMAC®) and electronic (m-WOMAC®) format in random order. ---------- Results: 24 men and 38 women with hip and knee OA participated and successfully completed the m-WOMAC® questionnaire. Pearson correlations between the summated total index scores for the p-WOMAC® and m-WOMAC® pre- and post-surgery were 0.98 and 0.99 (p<0.0001). There was no clinically important or statistically significant between-method difference in the adjusted total summated scores, pre- and post-surgery (adjusted mean difference = 4.44, p = 0.474 and 1.73, p = 0.781). Internal consistency estimates of m-WOMAC® reliability were 0.87 – 0.98. The m-WOMAC® detected clinically important, statistically significant (p<0.0001) improvements in pain, stiffness, function and total index score. ---------- Conclusions: Sixty-two patients with hip and knee OA successfully completed EDC by Motorola V3 mobile phone using the m-WOMAC® NRS3.1 Index; completion times averaging only 1-1.5 minutes longer than the p-WOMAC® Index. Data were successfully and securely transmitted from patients in Australia to a server in the USA. There was close agreement and no significant differences between m-WOMAC® and p-WOMAC® scores. This study confirms the validity, reliability and responsiveness of the Exco InTouch engineered, Java-based m-WOMAC® Index application. EDC with the m-WOMAC® Index provides unique opportunities for using quantitative measurement in clinical research and practice.

Employer branding : strategic implications for staff recruitment

In many developed economies, changing demographics and economic conditions have given rise to increasingly competitive labour markets, where competition for good employees is strong. Consequently, strategic investments in attracting suitably qualified and skilled employees are recommended. One such strategy is employer branding. Employer branding in the context of recruitment is the package of psychological, economic, and functional benefits that potential employees associate with employment with a particular company. Knowledge of these perceptions can help organisations to create an attractive and competitive employer brand. Utilising information economics and signalling theory, we examine the nature and consequences of employer branding. Depth interviews reveal that job seekers evaluate: the attractiveness of employers based on any previous direct work experiences with the employer or in the sector; the clarity, credibility, and consistency of the potential employers’ brand signals; perceptions of the employers’ brand investments; and perceptions of the employers’ product or service brand portfolio.

Schizophrenia Housing and Supportive Relationships

Schizophrenia can be a very disabling illness that affects between 0.5% and 1% of the population. This illness has a great personal impact on the individual sufferer, their family and friends. In addition, it makes significant demands on health services and the community in general. This paper reviews the literature on housing and supportive relationships for people with schizophrenia. The literature reports that people's experience of their schizophrenia is that it not only causes symptoms, but often impacts on their ability to maintain the basic resources in life. These resources include the ability to maintain reasonable quality housing, which seems to further impact negatively on their illness and their ability to maintain supportive social relationships. People with schizophrenia (and people in general) rely on their social relationships and family to maintain their mental health. The loss of social relationships and inability to maintain quality housing seem to be related - if people cannot maintain quality housing, they find it difficult to maintain supportive social relationships.

Cholecystokinin and leptin: their influence upon the eating behaviour and nutrient intake of dialysis patients

Background We have used serial visual analogue scores to demonstrate disturbances of the appetite profile in dialysis patients. This is potentially important as dialysis patients are prone to malnutrition yet have a lower nutrient intake than controls. Appetite disturbance may be influenced by accumulation of appetite inhibitors such as leptin and cholecystokinin (CCK) in dialysis patients. Methods Fasting blood samples were drawn from 43 controls, 50 haemodialysis (HD) and 39 peritoneal dialysis (PD) patients to measure leptin and CCK. Hunger and fullness scores were derived from profiles compiled using hourly visual analogue scores. Nutrient intake was derived from 3 day dietary records. Results Fasting CCK was elevated for PD (6.73 ± 4.42 ng/l vs control 4.99 ± 2.23 ng/l, P < 0.05; vs HD 4.43 ± 2.15 ng/l, P < 0.01). Fasting CCK correlated with the variability of the hunger (r = 0.426, P = 0.01) and fullness (r = 0.52, P = 0.002) scores for PD. There was a notable relationship with the increase in fullness after lunch for PD (r = 0.455, P = 0.006). When well nourished PD patients were compared with their malnourished counterparts, CCK was higher in the malnourished group (P = 0.004). Leptin levels were higher for the dialysis patients than controls (HD and PD, P < 0.001) with pronounced hyperleptinaemia evident in some PD patients. Control leptin levels demonstrated correlation with fullness scores (e.g. peak fullness, r = 0.45, P = 0.007) but the dialysis patients did not. PD nutrient intake (energy and protein intake, r = -0.56, P < 0.0001) demonstrated significant negative correlation with leptin. Conclusion Increased CCK levels appear to influence fullness and hunger perception in PD patients and thus may contribute to malnutrition. Leptin does not appear to affect perceived appetite in dialysis patients but it may influence nutrient intake in PD patients via central feeding centres.

Validity of the Waterlow screening tool and risks for pressure injury in acute care

Objectives: To assess the validity of the Waterlow screening tool in a cohort of internal medicine patients and to identify factors contributing to pressure injury. Design: Longitudinal cohort study Setting: A tertiary hospital in Brisbane, Australia Participants: 274 patients admitted through the Emergency Department or outpatient clinics and expected to remain in hospital for at least three days were included in the study. The mean age was 65.3 years. Interventions: Patients were screened on admission using the Waterlow screening tool. Every second day, their pressure ulcer status was monitored and recorded. Main outcome measures: Pressure ulcer incidence Results: Fifteen participants (5.5%) had an existing pressure ulcer and a further 12 (4.4%) developed a pressure ulcer during their hospital stay. Sensitivity of the Waterlow scale was 0.67, (95% CI: 0.35 to 0.88); specificity 0.79, (95% CI: 0.73 to 0.85); PPV 0.13, (95% CI: 0.07 to 0.24); NPV 0.98, (95% CI: 0.94 to 0.99). Conclusion: This study provides further evidence of the poor predictive validity of the Waterlow scale. A suitably powered randomised controlled trial is urgently needed to provide definitive evidence about the usefulness of the Waterlow scale compared with other screening tools and with clinical judgement.

Advice-implicative interrogatives : building 'client-centered" support in a children's helpline

Interactional research on advice giving has described advice as normative and asymmetric. In this paper we examine how these dimensions of advice are softened by counselors on a helpline for children and young people through the use of questions. Through what we term ‘‘adviceimplicative interrogatives,’’ counselors ask clients about the relevance or applicability of a possible future course of action. The allusion to this possible action by the counselor identifies it as normatively relevant, and displays the counselor’s epistemic authority in relation to dealing with a client’s problems. However, the interrogative format mitigates the normative and asymmetric dimensions typical of advice sequences by orienting to the client’s epistemic authority in relation to their own lives, and delivering advice in a way that is contingent upon the client’s accounts of their experiences, capacities, and understandings. The demonstration of the use of questions in advice sequences offers an interactional specification of the ‘‘client-centered’’ support that is characteristic of prevailing counseling practice. More specifically, it shows how the values of empowerment and child-centered practice, which underpin services such as Kids Helpline, are embodied in specific interactional devices. Detailed descriptions of this interactional practice offer fresh insights into the use of interrogatives in counseling contexts, and provide practitioners with new ways of thinking about, and discussing, their current practices.

Molecular epidemiology of respiratory viruses in a paediatric cohort from Indonesia

Acute lower respiratory tract infections (ALRTIs) are a common cause of morbidity and mortality among children under 5 years of age and are found worldwide, with pneumonia as the most severe manifestation. Although the incidence of severe disease varies both between individuals and countries, there is still no clear understanding of what causes this variation. Studies of community-acquired pneumonia (CAP) have traditionally not focused on viral causes of disease due to a paucity of diagnostic tools. However, with the emergence of molecular techniques, it is now known that viruses outnumber bacteria as the etiological agents of childhood CAP, especially in children under 2 years of age. The main objective of this study was to investigate viruses contributing to disease severity in cases of childhood ALRTI, using a two year cohort study following 2014 infants and children enrolled in Bandung, Indonesia. A total of 352 nasopharyngeal washes collected from 256 paediatric ALRTI patients were used for analysis. A subset of samples was screened using a novel microarray pathogen detection method that identified respiratory syncytial virus (RSV), human metapneumovirus (hMPV) and human rhinovirus (HRV) in the samples. Real-time RT-PCR was used both for confirming and quantifying viruses found in the nasopharyngeal samples. Viral copy numbers were determined and normalised to the numbers of human cells collected with the use of 18S rRNA. Molecular epidemiology was performed for RSV A and hMPV using sequences to the glycoprotein gene and nucleoprotein gene respectively, to determine genotypes circulating in this Indonesian paediatric cohort. This study found that HRV (119/352; 33.8%) was the most common virus detected as the cause of respiratory tract infections in this cohort, followed by the viral pathogens RSV A (73/352; 20.7%), hMPV (30/352; 8.5%) and RSV B (12/352; 3.4%). Co-infections of more than two viruses were detected in 31 episodes (defined as an infection which occurred more than two weeks apart), accounting for 8.8% of the 352 samples tested or 15.4% of the 201 episodes with at least one virus detected. RSV A genotypes circulating in this population were predominantly GA2, GA5 and GA7, while hMPV genotypes circulating were mainly A2a (27/30; 90.0%), B2 (2/30; 6.7%) and A1 (1/30; 3.3%). This study found no evidence of disease severity associated either with a specific virus or viral strain, or with viral load. However, this study did find a significant association with co-infection of RSV A and HRV with severe disease (P = 0.006), suggesting that this may be a novel cause of severe disease.

Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression

Objective: To determine whether bifocal and prismatic bifocal spectacles could control myopia in children with high rates of myopic progression. ---------- Methods: This was a randomized controlled clinical trial. One hundred thirty-five (73 girls and 62 boys) myopic Chinese Canadian children (myopia of 1.00 diopters [D]) with myopic progression of at least 0.50 D in the preceding year were randomly assigned to 1 of 3 treatments: (1) single-vision lenses (n = 41), (2) +1.50-D executive bifocals (n = 48), or (3) +1.50-D executive bifocals with a 3–prism diopters base-in prism in the near segment of each lens (n = 46). ---------- Main Outcome Measures: Myopic progression measured by an automated refractor under cycloplegia and increase in axial length (secondary) measured by ultrasonography at 6-month intervals for 24 months. Only the data of the right eye were used. ---------- Results: Of the 135 children (mean age, 10.29 years [SE, 0.15 years]; mean visual acuity, –3.08 D [SE, 0.10 D]), 131 (97%) completed the trial after 24 months. Myopic progression averaged –1.55 D (SE, 0.12 D) for those who wore single-vision lenses, –0.96 D (SE, 0.09 D) for those who wore bifocals, and –0.70 D (SE, 0.10 D) for those who wore prismatic bifocals. Axial length increased an average of 0.62 mm (SE, 0.04 mm), 0.41 mm (SE, 0.04 mm), and 0.41 mm (SE, 0.05 mm), respectively. The treatment effect of bifocals (0.59 D) and prismatic bifocals (0.85 D) was significant (P < .001) and both bifocal groups had less axial elongation (0.21 mm) than the single-vision lens group (P < .001). ---------- Conclusions: Bifocal lenses can moderately slow myopic progression in children with high rates of progression after 24 months.

Human and bovine adenoviruses for the detection of source-specific fecal pollution in coastal waters in Australia

In this study, the host-specificity and -sensitivity of human- and bovine-specific adenoviruses (HS-AVs and BS-AVs) were evaluated by testing wastewater/fecal samples from various animal species in Southeast, Queensland, Australia. The overall specificity and sensitivity of the HS-AVs marker were 1.0 and 0.78, respectively. These figures for the BS-AVs were 1.0 and 0.73, respectively. Twenty environmental water samples were colleted during wet conditions and 20 samples were colleted during dry conditions from the Maroochy Coastal River and tested for the presence of fecal indicator bacteria (FIB), host-specific viral markers, zoonotic bacterial and protozoan pathogens using PCR/qPCR. The concentrations of FIB in water samples collected after wet conditions were generally higher compared to dry conditions. HS-AVs was detected in 20% water samples colleted during wet conditions and whereas BS-AVs was detected in both wet (i.e., 10%) and dry (i.e., 10%) conditions. Both, C. jejuni mapA and Salmonella invA genes were detected in 10% and 10% of samples, respectively collected during dry conditions. The concentrations of Salmonella invA ranged between 3.5 × 102 to 4.3 × 102 genomic copies per 500 ml of water G. lamblia β-giardin gene was detected only in one sample (5%) collected during the dry conditions. Weak or significant correlations were observed between FIB with viral markers and zoonotic pathogens. However, during dry conditions, no significant correlations were observed between FIB concentrations with viral markers and zoonotic pathogens. The prevalence of HS-AVs in samples collected from the study river suggests that the quality of water is affected by human fecal pollution and as well as bovine fecal pollution. The results suggest that HS-AVs and BS-AVs detection using PCR could be a useful tool for the identification of human sourced fecal pollution in coastal waters.