Enhanced Recovery After Surgery program for elective abdominal surgery at three Victorian hospitals

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.

Assessing risk post intervention for an acute coronary syndrome: a review of the risk assessment tools and their development

Considerable variability in survival rate after an acute myocardial infarction exists and accurate risk stratification is of significant importance. The American College of Cardiology and the American Heart Association has recommended early risk stratification using several clinical risk scoring instruments to identify high risk patients. The aim of this paper is to identify secondary cardiovascular risk scoring instruments that could be utilized at the time of intervention for acute coronary syndromes and compare their psychometric properties as they were developed. A search using Medline, Cumulative Index to Nursing and Allied Health Literature and the Psychology and Behavioral Sciences Collection data-bases identified studies published between January 1990 and January 2010 used to measure risk after intervention for acute coronary syndrome. Four validated secondary risk prediction scoring instruments were identified for comparison.Secondary risk prediction scoring instruments for the acute coronary syndrome patient population are evidence based, valid and reliable. Use of the instruments by cardiac focused clinicians will aid in the determination of treatment strategies, and estimation of short and long term events and mortality.

Measuring self-care in chronic heart failure : a review of the psychometric properties of clinical instruments

<b>Background :</b> Improved self-care skills and behaviors are an important outcome of patient education and counseling. Both researchers and health professionals need to utilize instruments that are reliable and valid at measuring this outcome to advance our understanding as to the efficacy of clinical practice directed toward improving self-care. <br /><br /><b>Objective : </b>The aim of this study was to identify instruments that measure chronic heart failure (CHF) self-care and demonstrate their psychometric properties. <br /><b><br />Methods :</b> A search of Medline, Cumulative Index to Nursing and Allied Health Literature, Medline, PsycArticles, Psychology and Behavioral Sciences Collection, and PsycINFO databases elucidated studies published between January 1980 and February 2009 that measure CHF self-care. The clinical instruments selected were disease-specific measures of CHF self-care behaviors that are promoted in best practice guidelines. Only instruments that reported estimates of reliability and validity were included in this review. Psychometric properties of the instruments were evaluated according to practice guidelines. <br /><b><br />Results :</b> The literature search identified 14 instruments published in peer-reviewed journals that measured constructs that predict or correlate to self-care rather than self-care itself. Only 2 disease-specific measures of self-care were identified (Self-care Heart Failure Index [SCHFI] and European Heart Failure Self-care Behavior Scale [EHFScBS]) that have undergone rigorous psychometric testing in CHF populations. Five aspects of validity had been demonstrated with EHFScBS, and 6 aspects of validity had been demonstrated with SCHFI. Two of 3 aspects of reliability have been demonstrated in both instruments. <br /><br /><b>Conclusion : </b>Only 2 reliable and valid tools have been developed to specifically measure CHF self-care. Further use of these instruments in the research arena may reduce gaps in our understanding of CHF self-care and further shape clinical practice directed at improving it.

An evaluation of the effect of an educational intervention for Australian social workers on competence in delivering brief cognitive behavioural strategies : a randomised controlled trial

Background Broad community access to high quality evidence-based primary mental health care is an ongoing challenge around the world. In Australia one approach has been to broaden access to care by funding psychologists and other allied health care professionals to deliver brief psychological treatments to general practitioners' patients. To date, there has been a scarcity of studies assessing the efficacy of social worker delivered psychological strategies. This study aims to build the evidence base by evaluating the impact of a brief educational intervention on social workers' competence in delivering cognitive behavioural strategies (strategies derived from cognitive behavioural therapy). Methods A randomised controlled trial design was undertaken with baseline and one-week follow-up measurement of both objective and self-perceived competence. Simulated consultations with standardised depressed patients were recorded on videotape and objective competence was assessed by blinded reviewers using the Cognitive Therapy Scale. Questionnaires completed by participants were used to measure self-perceived competence. The training intervention was a 15 hour face-to-face course involving presentations, video example consultations, written materials and rehearsal of skills in pairs. Results 40 Melbourne-based (Australia) social workers enrolled and were randomised and 9 of these withdrew from the study before the pre training simulated consultation. 30 of the remaining 31 social workers (97%) completed all phases of the intervention and evaluation protocol (16 from intervention and 14 from control group). The intervention group showed significantly greater improvements than the control group in objective competence (mean improvement of 14.2 (7.38-21.02) on the 66 point Cognitive Therapy Scale) and in subjective confidence (mean improvement of 1.28 (0.84-1.72) on a 5 point Likert scale). On average, the intervention group improved from below to above the base competency threshold on the Cognitive Therapy Scale whilst the control group remained below. Conclusions Social workers can attain significant improvements in competency in delivering cognitive behavioural strategies from undertaking brief face to face training. This is relevant in the context of health reforms that involve social worker delivery of evidence based psychological care. Further research is required to assess how these improvements in competence translate into performance in practice and clinical outcomes for patients.

Competing ethical paradigms in forensic psychiatry and forensic psychology: commentary for a special section of legal and criminological psychology

In her paper Gwen Adshead (2013) identifies the principle of respect for justice as the foundation for ethical practice in forensic psychiatry. This commentary discusses how forensic psychologists have approached a key aspect of the justice principle, the ethical imperative to promote the welfare of the individual client. The approaches of the psychiatric and psychological professions are compared and the role of psychologists as allied health professionals working in the forensic setting considered.

The impact structured patient assessment frameworks have on patient care: an integrative review

<b>Aims and objectives:<br /></b>To evaluate structured patient assessment frameworks' impact on patient care.<br /><br /><b><span style="font-size: 12px;">Background:</span><br /></b>Accurate patient assessment is imperative to determine the status and needs of the patient and the delivery of appropriate patient care. Nurses must be highly skilled in conducting timely and accurate patient assessments to overcome environmental obstacles and deliver quality and safe patient care. A structured approach to patient assessment is widely accepted in everyday clinical practice, yet little is known about the impact structured patient assessment frameworks have on patient care.<br /><br /><b>Design:<br /></b><span style="font-size: 12px;">Integrative review.</span><br /><br /><b>Methods:<br /></b>An electronic database search was conducted using Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System, PubMed and ProQuest Dissertations and Theses. The reference sections of textbooks and journal articles on patient assessment were manually searched for further studies. A comprehensive peer review screening process was undertaken. Research studies were selected that evaluated the impact structured patient assessment frameworks have on patient care. Studies were included if frameworks were designed for use by paramedics, nurses or medical practitioners working in prehospital or acute in-hospital settings.<br /><br /><b>Results:<br /></b>Twelve studies met the inclusion criteria. There were no studies that evaluate the impact of a generic nursing assessment framework on patient care. The use of a structured patient assessment framework improved clinician performance of patient assessment. Limited evidence was found to support other aspects of patient care including documentation, communication, care implementation, patient and clinician satisfaction, and patient outcomes.<br /><br /><b>Conclusion:<br /></b>Structured patient assessment frameworks enhance clinician performance of patient assessment and hold the potential to improve patient care and outcomes; however, further research is required to address these evidence gaps, particularly in nursing.<br /><br /><b>Relevance to clinical practice:<br /></b><span style="font-size: 12px;">Acute care clinicians should consider using structured patient assessment frameworks in clinical practice to enhance their performance of patient assessment.</span>

A systematic review and meta-analysis of diabetes and risk of physical disability and functional impairment - protocol

<b>Background</b><br />Diabetes and increased age are known risk factors for physical disability. With the increasing prevalence of diabetes within our aging population, the future burden of disability is expected to increase. To date, there has not been a pooled estimate of the risk for disability associated with diabetes or its precursor states, impaired glucose tolerance and impaired fasting glucose. We aim to conduct a systematic review and meta-analysis of the association between prediabetes and diabetes with disability, and quantify the risk of association.<br /><b><br />Methods/design</b><br />We will search for relevant studies in Medline via Pubmed, Embase, Cochrane library and Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as scan reference lists from relevant reviews and publications included in our review. We will review all publications that include studies on human adults (18 years and older) where information is included on diabetes status and at least one measure of disability (Activities of Daily Living (ADL), Instrumental ADL (IADL) or functional/mobility limitation), and where a risk association is available for the relationship between diabetes and/or prediabetes with disability, with reference to those without diabetes.<br /><br />We will further conduct a meta-analysis to pool estimates of the risk of disability associated with prediabetes and diabetes. Sensitivity analysis will be conducted to assess for publication bias and study quality.Findings from this systematic review and meta-analysis will be widely disseminated through discussions with stake-holders, publication in a peer-reviewed journal and conference presentation.<br />

Diabetes and risk of physical disability in adults: a systematic review and meta-analysis

<b>Background</b><br />According to previous reports, the risk of disability as a result of diabetes varies from none to double. Disability is an important measure of health and an estimate of the risk of disability as a result of diabetes is crucial in view of the global diabetes epidemic. We did a systematic review and meta-analysis to estimate this risk.<br /><br /><b>Methods</b><br />We searched Ovid, Medline, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature up to Aug 8, 2012. We included studies of adults that compared the risk of disability&mdash;as measured by activities of daily living (ADL), instrumental activities of daily living (IADL), or mobility&mdash;in people with and without any type of diabetes. We excluded studies of subpopulations with specific illnesses or of people in nursing homes. From the studies, we recorded population characteristics, how diabetes was diagnosed (by doctor or self-reported), domain and definition of disability, and risk estimates for disability. We calculated pooled estimates by disability type and type of risk estimate (odds ratio [OR] or risk ratio [RR]).<br /><br /><b>Results</b><br />Our systematic review returned 3224 results, from which 26 studies were included in our meta-analyses. Diabetes increased the risk of mobility disability (15 studies; OR 1&middot;71, 95% CI 1&middot;53&mdash;1&middot;91; RR 1&middot;51, 95% CI 1&middot;38&mdash;1&middot;64), of IADL disability (ten studies; OR 1&middot;65, 95% CI 1&middot;55&mdash;1&middot;74), and of ADL disability (16 studies; OR 1&middot;82, 95% CI 1&middot;63&mdash;2&middot;04; RR 1&middot;82, 95% CI 1&middot;40&mdash;2&middot;36).<br /><br /><b>Interpretation</b><br />Diabetes is associated with a strong increase in the risk of physical disability. Efforts to promote healthy ageing should account for this risk through prevention and management of diabetes.<br /><br /><b>Funding</b><br />Monash University, Baker IDI Bright Sparks Foundation, Australian Postgraduate Award, VicHealth, National Health and Medical Research Council, Australian Research Council, Victorian Government.

Midwifery work and the making of narrative

This paper draws on a study of birth support conducted across three Melbourne maternity units. Midwife informants were asked to participate in semistructured interviews with two researchers and describe the activity and role of lay birth support people. In the course of the study, the activity of the midwives themselves became a research focus. The study found that one of the key tasks midwives described was assisting birthing women to develop and negotiate satisfactory birth narratives that could encompass the intense and sometimes difficult experience of birth. Midwife informants offered strategies for the development of such narratives as part of their professional and personal labour in the birth room.

Australia's response to sexualised or sexually abusive behaviours in children and young people.

<p style="margin: 0px; font-size: 10.5px; font-family: Helvetica;">Responding to children and young people with sexualised or sexual offending behaviours presents&nbsp;significant challenges across the allied health, child protection, education and juvenile justice sectors.&nbsp;This report maps the specialised therapeutic services designed to effect positive behavioural change&nbsp;and thus divert young people with sexualised behaviours from the juvenile justice system.&nbsp;Accurate numbers on children with sexualised or sexual offending behaviours are difficult to&nbsp;determine.&nbsp;<span style="font-size: 10.5px;">There are several factors&nbsp;</span>contributing to this gap in understanding. These include entrenched ideals about children as inherently&nbsp;innocent, widespread ignorance about developmental sexuality, and the tendency of both young&nbsp;people and parents to deny or minimise incidents when they do occur.</p> <p style="margin: 0px; font-size: 10.5px; font-family: Helvetica;"></p><p style="margin: 0px; font-size: 10.5px; font-family: Helvetica;">In Australia, data on children with sexualised behaviours are not collected uniformly and nondisclosure&nbsp;contributes to what might be large numbers of offences going undetected. Mandatory&nbsp;reporting requirements apply where children display sexualised behaviours and are thought to be at&nbsp;risk of harm. Yet a general lack of knowledge as to what constitutes appropriate behaviour means that&nbsp;many may respond inappropriately to incidents of sexualised behaviours. This context of confusion,&nbsp;denial and non-disclosure creates a hidden population of children that continues to be at risk.&nbsp;Attention to redressing the contexts for non-disclosure is urgently required to ensure that children in&nbsp;need are provided with specialised therapeutic care.<br /><br />This report presents qualitative data from interviews with specialised clinicians as well as submissions&nbsp;from service providers in both community and youth justice settings. In mapping the availability of&nbsp;therapeutic services, this report highlights a number of geographic and demographic gaps in service&nbsp;provision, including difficulties with eligibility criteria, referral pathways, funding arrangements and&nbsp;specialised workforce development.&nbsp;<span style="font-family: Arial, Verdana, sans-serif; font-size: 12px;">There are multiple challenges facing the tertiary services sector, yet the comprehensive provision&nbsp;</span>of specialised services is just one part of the response required. This study emphasises the need for&nbsp;effective primary and secondary prevention to effect a reduction in the numbers of young people&nbsp;requiring counselling in the future. Consistent with the public health model, this report prioritises&nbsp;professional and community education strategies that would ultimately necessitate fewer tertiary&nbsp;services for young people and fewer places in juvenile detention centres.</p>