The influence of patient complexity and nurses` experience on haemodynamic decision-making following cardiac surgery

Critical care nurses’ haemodynamic decision-making in the immediate postoperative cardiac surgical context is complex. To optimise patient outcomes, nurses of varying levels of experience are required to make complex decisions rapidly and accurately. In a dynamic clinical context such as critical care, the quality of such decision-making is likely to vary considerably. The aim of this study was to describe variability of nurses’ haemodynamic decision-making in the 2-hour period after cardiac surgery as a function of interplay between decision complexity, nurses’ levels of experience, and the support provided. A descriptive study based on naturalistic decision-making was used. Data were collected using continuous non-participant observation of clinical practice for a 2-hour period and follow-up interview. Purposive sampling was used to recruit 38 nurses for inclusion in the study. The quality of nurses’ decision-making was influenced by interplay between the complexity of patients’ haemodynamic presentations, nurses’ levels of cardiac surgical intensive care experience, and the form of decision support provided by nursing colleagues. Two factors specifically influenced decision-making quality: nurses’ utilisation of evidence for practice and the experience levels of both nurses and their colleagues. The findings have implications for staff resourcing decisions and postoperative patient management, and may be used to inform nurses’ professional development and education.

How ophthlamic day surgery patients convalesce at home : an exploration of the salient issues

Cataract surgery is the most commonly performed surgical procedure in Australia. In the next 10-15 years, the number of people needing this surgery is expected to double, This article is based on a study, which explored the types and levels of symptoms experienced by patients post-ophthalmic surgery. Patients were asked to complete two instruments: a 'Postoperative Symptoms Diary' and a follow up 'Telephone Survey Questionnaire'. Eight males and 15 females (n = 23) with a mean age of 80.5 years were recruited. The findings revealed that patients' symptom levels decreased over time, except for tiredness and moving around which increased slightly on Day 4 post-operatively. A carer was required for an average of 2.3 days. This study highlighted the discrepancies in current day surgery literature, which recommend that a carer is needed during only the first 24 hours post-operatively.

Audit of the use of antimicrobial prophylaxis in nasal surgery at a speciali

Background: In 2002−03 a retrospective audit of the use of surgical antimicrobial prophylaxis (AMP) for elective nasal surgery was undertaken at the Royal Victorian Eye and Ear Hospital (RVEEH). The RVEEH is a publicly funded teaching hospital that provides specialist eye, nose and throat medicine in Victoria, Australia. The aim of the audit was to determine the extent to which the use of antimicrobial prophylaxis in the hospital was consistent with Australian and international evidence-based guidelines and if there was a need for the hospital to develop internal guidelines for the use of AMP.

Methods: The histories of 500 consecutive patients who had undergone nasal surgery within the study period of August 2001 and July 2002 were examined. The data collected from these histories included information such as the patients' age, gender, diagnosis, surgical procedure performed, antimicrobial agents used, and the length of follow up and a range of factors shown in previous studies to increase the risk of surgical site infection.

Results: A total of 306 (72.86%) patients were found to have received antimicrobial agents either prior to admission, during admission or on discharge. Only 24 patients (5.71%) were administered antimicrobials immediately prior to surgery and at no other time.

Conclusions: The findings of this study support the need for further research to examine the appropriateness of the use of AMP at the RVEEH and the need for internal guidelines for its use.

Operating a studio within a research culture: the urban heart surgery design research forum

The question of whether or not design can be considered research has perplexed schools of architecture ever since they were first introduced into universities. It was at the center of the Oxbridge union debates in the early 1900s. It formed one of the corner stones of the Oxford conference on education organized by the RIBA in 1958 (Martin 1958) and came under scrutiny again in the UK with the introduction of the Research Assessment Exercise (RAE) in 1992. While the arguments both for and against are considerable1, “in order to understand the questions and the possibilities of architectural research and to respond to the difficulties that confront us now, we have to have a model which acknowledges what schools of architecture really are, and could be, and then work with that” 2.
Drawing on professionally oriented research models, such as qualitative ‘clinical research’, from Medicine and the Health Sciences - where the processes of exploration, observation, investigation, recording and communication are conducted in-situ by the ‘practitioner-as-researcher’ 3 - the following paper outlines an initiative introduced in 1999, referred to as the ‘Urban Heart Surgery’ 4. The program actively integrates students entering their second degree program into a studio based design research culture and allows them to engage in critical discourse by working on high profile strategic design projects in three areas significant to Victoria’s future growth: Metropolitan Urbanism, Urbanism on the Periphery, and Regional Urbanism.
With a growing core of industrial and community based partnerships, including: four regional councils (Bendigo, Ballarat, Geelong and Warrnambool) and three metropolitan municipalities (Melbourne City, Port Phillip and Wyndham), the forum actively facilitates a graduate/practice research agenda through the ARC linkage grant program.

The nature and impact of incontinence in men who have undergone prostate surgery and implications for nursing practice

Aim: The aim of this study was to increase knowledge and understanding of the nature and experiences of incontinence in men one or more years post prostate surgery.

Methods: This descriptive study used a sample of convenience. Two hundred and twelve male participants who had undergone prostate surgery more than a year ago were asked about their experiences of incontinence. Participants were asked to fill in two questionnaires: The Expanded Prostate Cancer Index Composite and the Incontinence Impact Questionnaire. Participants were also asked about their prostate surgery, their health seeking behaviour in relation to incontinence, the type of discharge information they were given, and demographic information.

Results: Sixty-six percent of participants indicated that, in the last four weeks, their overall urinary function had been a problem and 36.3% reported their bowel habits were problematic, which affected the quality of their lives. In addition, 41% of participants reported that they were not given discharge information regarding the possibility of developing urinary incontinence and sexual problems post prostate surgery.

Conclusions: Health care professionals should pay more attention to routinely providing information to all men regarding the possibility of developing incontinence or sexual problems post prostate surgery. This may assist them to better manage these problems.

Issues in the provision of nursing care to people undergoing cardiac surgery who also have type 2 diabetes

There has been little investigation of the issues associated with caring for patients presenting for cardiac surgery with a comorbid diagnosis of diabetes although there is some evidence that the diabetes management is suboptimal. This study aimed to identify issues that patients and cardiac specialist nurses experience with the provision of inpatient services for people undergoing cardiac surgery who also have type 2 diabetes. A qualitative interpretive design, using individual interviews with patients and nurses, provided data about some of these issues. The study found that nurses had high levels of confidence in their cardiac care but little confidence in diabetes management. Patients described concerns about their diabetes care and treatment regimens. A 'typical journey' for a person with diabetes undergoing cardiac surgery was identified. The findings support the need to build increased capacity in specialist nurses to support diabetes care as a secondary diagnosis.

Upregulation of peroxisome proliferator-activated receptor gamma coactivator gene (PGC1A) during weight loss is related to insulin sensitivity but not to energy expenditure

Aims/hypothesis We investigated whether skeletal muscle peroxisome proliferator-activated receptor gamma coactivator-1 (PGC1A; also known as PPARGC1A) and its target mitofusin-2 (MFN2), as well as carnitine palmitoyltransferase-1 (CPT1; also known as carnitine palmitoyltransferase 1A [liver] [CPT1A]) and uncoupling protein (UCP)3, are involved in the improvement of insulin resistance and/or in the modification of energy expenditure during surgically induced massive weight loss.
Materials and methods Seventeen morbidly obese women (mean BMI: 45.9 ± 4 kg/m2) were investigated before, and 3 and 12 months after, Roux-en-Y gastric bypass (RYGB). We evaluated insulin sensitivity by the euglycaemic–hyperinsulinaemic clamp, energy expenditure and substrate oxidation by indirect calorimetry, and muscle mRNA expression by PCR.
Results Post-operatively, PGC1A was enhanced at 3 (p = 0.02) and 12 months (p = 0.03) as was MFN2 (p = 0.008 and p = 0.03 at 3 and 12 months respectively), whereas UCP3 was reduced (p = 0.03) at 12 months. CPT1 did not change. The expression of PGC1A and MFN2 were strongly (p < 0.0001) related. Insulin sensitivity, which increased after surgery (p = 0.002 at 3, p = 0.003 at 12 months), was significantly related to PGC1A and MFN2, but only MFN2 showed an independent influence in a multiple regression analysis. Energy expenditure was reduced at 3 months post-operatively (p = 0.001 vs before RYGB), remaining unchanged thereafter until 12 months. CPT1 and UCP3 were not significantly related to the modifications of energy expenditure or of lipid oxidation rate.
Conclusions/interpretation Weight loss upregulates PGC1A, which in turn stimulates MFN2 expression. MFN2 expression significantly and independently contributes to the improvement of insulin sensitivity. UCP3 and CPT1 do not seem to influence energy expenditure after RYGB.

Assessing patient satisfaction with day surgery at a metropolitan public hospital

With the advances in health care technology, many surgical procedures are performed as day surgery cases. The provision of day surgery is considered to be a cost effective method of utilising resources, but it does challenge nurses to provide optimal patient care during the patient's short stay in hospital. Patient satisfaction is considered to be an important indicator of quality nursing care. This paper reports on an investigation aimed at assessing patient satisfaction with day surgery in an Australian metropolitan public hospital. One hundred and seven patients completed a recently developed survey assessing patient satisfaction with day surgery. The response rate was 41%. Waiting times, communication, pain management and discharge planning were major areas of patient dissatisfaction. Directions for improvement in day surgery services are discussed.

Safety and efficacy of routine postoperative ibuprofen for pain and disability related to ectopic bone formation after hip replacement surgery (HIPAID): a randomised control trial

Objectives To determine the benefits and risks of a non-steroidal anti-inflammatory drug (NSAID) as prophylaxis for ectopic bone formation in patients undergoing total hip replacement (or revision) surgery.
Design Double blind randomised placebo controlled clinical trial, stratified by treatment site and surgery (primary or revision).
Setting 20 orthopaedic surgery centres in Australia and New Zealand.
Participants 902 patients undergoing elective primary or revision total hip replacement surgery.
Intervention 14 days' treatment with ibuprofen (1200 mg daily) or matching placebo started within 24 hours of surgery.
Main outcome measures Changes in self reported hip pain and physical function 6 to 12 months after surgery (Western Ontario and McMaster University Arthritis index).
Results There were no significant differences between the groups for improvements in hip pain (mean difference -0.1, 95% confidence interval -0.4 to 0.2, P = 0.6) or physical function (-0.1, -0.4 to 0.2, P = 0.5), despite a decreased risk of ectopic bone formation (relative risk 0.69, 0.56 to 0.83) associated with ibuprofen. There was a significantly increased risk of major bleeding complications in the ibuprofen group during the admission period (2.09, 1.00 to 4.39).
Conclusions These data do not support the use of routine prophylaxis with NSAIDs in patients undergoing total hip replacement surgery.
Trial registration NCT00145730.

Small diameter Polyurethane vascular graft reinforced by elastic weft-knitted tubular fabric of polyester / spandex

Small diameter vascular grafts were fabricated from pure Polyurethane (PU) as well as PU reinforced with a tubular weft-knitted fabric. The tensile properties of the reinforced composite vascular grafts were compared with that of the tubular fabric itself and the pure PU vascular grafts. The elasticity and strength of the reinforced vascular grafts were improved compared with the tubular fabric. Strength of the reinforced vascular grafts was 5–10 times of the strength of the pure PU vascular grafts. Expanding the tubular fabric to increase the inner diameter of the reinforced vascular graft reduced the graft’s strength and initial modulus, but the difference was reduced as the PU content was increased. For grafts of the same inner diameter, increasing the PU content increased the thickness and strength of the graft wall, which led to a general increase in the strength and initial modulus of the composite vascular grafts.