The provision of patient personal hygiene in the intensive care unit : a descriptive exploratory study of bed-bathing practice

Background/objectives The provision of the patient bed-bath is a fundamental nursing care activity yet few quantitative data and no qualitative data are available on registered nurses’ (RNs) clinical practice in this domain in the intensive care unit (ICU). The aim of this study was to describe ICU RNs current practice with respect to the timing, frequency and duration of the patient bed-bath and the cleansing and emollient agents used. Methods The study utilised a two-phase sequential explanatory mixed method design. Phase one used a questionnaire to survey RNs and phase two employed semi-structured focus group (FG) interviews with RNs. Data was collected over 28 days across four Australian metropolitan ICUs. Ethical approval was granted from the relevant hospital and university human research ethics committees. RNs were asked to complete a questionnaire following each episode of care (i.e. bed-bath) and then to attend one of three FG interviews: RNs with less than 2 years ICU experience; RNs with 2–5 years ICU experience; and RNs with greater than 5 years ICU experience. Results During the 28-day study period the four ICUs had 77.25 beds open. In phase one a total of 539 questionnaires were returned, representing 30.5% of episodes of patient bed-baths (based on 1767 bed occupancy and one bed-bath per patient per day). In 349 bed-bath episodes 54.7% patients were mechanically ventilated. The bed-bath was given between 02.00 and 06.00 h in 161 episodes (30%), took 15–30 min to complete (n = 195, 36.2%) and was completed within the last 8 h in 304 episodes (56.8%). Cleansing agents used were predominantly pH balanced soap or liquid soap and water (n = 379, 71%) in comparison to chlorhexidine impregnated sponges/cloths (n = 86, 16.1%) or other agents such as pre-packaged washcloths (n = 65, 12.2%). In 347 episodes (64.4%) emollients were not applied after the bed-bath. In phase two 12 FGs were conducted (three FGs at each ICU) with a total of 42 RN participants. Thematic analysis of FG transcripts across the three levels of RN ICU experience highlighted a transition of patient hygiene practice philosophy from shades of grey – falling in line for inexperienced clinicians to experienced clinicians concrete beliefs about patient bed-bath needs. Conclusions This study identified variation in process and products used in patient hygiene practices in four ICUs. Further study to improve patient outcomes is required to determine the appropriate timing of patient hygiene activities and cleansing agents used to improve skin integrity.

Knowledge transfer in project-based organisations : the need for a unique approach

Effective knowledge transfer between infrastructure projects plays a significant role in organisational success and discovery of new technologies, helping to achieve and maintain competitive advantage and, in effect, sustainable infrastructure development. Knowledge is recognised as an important organisational asset that adds value while being shared. To date, research on knowledge transfer has focused on traditional (functional) types of organisations. However, existing knowledge transfer approaches fail to address the issue of unique characteristics of project-based organisations, and the fact that functional and project-based organisations significantly differ in terms of structure, processes, and characteristics. Therefore, there is a need for a different, separate approach for managing knowledge in the project environment. The aim of this chapter is to highlight this need. An extensive literature review is provided on the areas of project management, knowledge management, and organisational structure; this is further supported by empirical evidence from interviews with project management practitioners. Conducting a ‘cross-field’ literature review provides a better understanding of the knowledge transfer mechanisms and its application to projects, and of the importance of knowledge transfer across projects. This research is crucial to gaining a better understanding of knowledge transfer in the project environment. It stresses that there are dissimilarities between project-based organisations and functional organisations in terms of organisational structure, duration of processes, viewpoint of time, response to change, and mobility of people, and that there is a need for a unique strategic approach in order to achieve effective transfer of knowledge. Furthermore, findings presented in this chapter reveal key elements that play an important role in across project knowledge transfer. These elements include: social communication, lessons learned databases, and project management offices.

Copyright law in the United Arab Emirates in the digital age

This article gives an overview of copyright law in the United Arab Emirates (UAE) and critically evaluates its operation in the digital era, providing suggestions for reform.

Development of a 3-dimensional human skin equivalent wound model for investigating novel wound healing therapies

Numerous difficulties are associated with the conduct of preclinical studies related to skin and wound repair. Use of small animal models such as rodents is not optimal because of their physiological differences to human skin and mode of wound healing. Although pigs have previously been used because of their human-like mode of healing, the expense and logistics related to their use also renders them suboptimal. In view of this, alternatives are urgently required to advance the field. The experiments reported herein were aimed at developing and validating a simple, reproducible, three-dimensional ex vivo de-epidermised dermis human skin equivalent wound model for the preclinical evaluation of novel wound therapies. Having established that the human skin equivalent wound model does in fact “heal," we tested the effect of two novel wound healing therapies. We also examined the utility of the model for studies exploring the mechanisms underpinning these therapies. Taken together the data demonstrate that these new models will have wide-spread application for the generation of fundamental new information on wound healing processes and also hold potential in facilitating preclinical optimization of dosage, duration of therapies, and treatment strategies prior to clinical trials.

The Early Prevention of Obesity in CHildren (EPOCH) collaboration : an individual patient data prospective meta-analysis

Background: Efforts to prevent the development of overweight and obesity have increasingly focused early in the life course as we recognise that both metabolic and behavioural patterns are often established within the first few years of life. Randomised controlled trials (RCTs) of interventions are even more powerful when, with forethought, they are synthesised into an individual patient data (IPD) prospective meta-analysis (PMA). An IPD PMA is a unique research design where several trials are identified for inclusion in an analysis before any of the individual trial results become known and the data are provided for each randomised patient. This methodology minimises the publication and selection bias often associated with a retrospective meta-analysis by allowing hypotheses, analysis methods and selection criteria to be specified a priori. Methods/Design: The Early Prevention of Obesity in CHildren (EPOCH) Collaboration was formed in 2009. The main objective of the EPOCH Collaboration is to determine if early intervention for childhood obesity impacts on body mass index (BMI) z scores at age 18-24 months. Additional research questions will focus on whether early intervention has an impact on children’s dietary quality, TV viewing time, duration of breastfeeding and parenting styles. This protocol includes the hypotheses, inclusion criteria and outcome measures to be used in the IPD PMA. The sample size of the combined dataset at final outcome assessment (approximately 1800 infants) will allow greater precision when exploring differences in the effect of early intervention with respect to pre-specified participant- and intervention-level characteristics. Discussion: Finalisation of the data collection procedures and analysis plans will be complete by the end of 2010. Data collection and analysis will occur during 2011-2012 and results should be available by 2013. Trial registration number: ACTRN12610000789066

Channel-aware routing in MANETs with route handoff

In wireless mobile ad hoc networks (MANETs), packet transmission is impaired by radio link fluctuations. This paper proposes a novel channel adaptive routing protocol which extends the Ad-hoc On-Demand Multipath Distance Vector routing protocol (AOMDV) to accommodate channel fading. Specifically, the proposed Channel Aware AOMDV (CA-AOMDV) uses the channel average non-fading duration as a routing metric to select stable links for path discovery, and applies a preemptive handoff strategy to maintain reliable connections by exploiting channel state information. Using the same information, paths can be reused when they become available again, rather than being discarded. We provide new theoretical results for the downtime and lifetime of a live-die-live multiple path system, as well as detailed theoretical expressions for common network performance measures, providing useful insights into the differences in performance between CA-AOMDV and AOMDV. Simulation and theoretical results show that CA-AOMDV has greatly improved network performance over AOMDV.

Availability of advance visual information constrains association-football goalkeeping performance during penalty kicks

A pressing concern within the literature on anticipatory perceptual-motor behaviour is the lack of clarity on the applicability of data, observed under video-simulation task constraints, to actual performance in which actions are coupled to perception, as captured during in-situ experimental conditions. We developed an in-situ experimental paradigm which manipulated the duration of anticipatory visual information from a penalty taker’s actions to examine experienced goalkeepers’ vulnerability to deception for the penalty kick in association football. Irrespective of the penalty taker’s kick strategy, goalkeepers initiated movement responses earlier across consecutively earlier presentation points. Overall goalkeeping performance was better in non-deception trials than in deception conditions. In deception trials, the kinematic information presented up until the penalty taker initiated his/her kicking action had a negative effect on goalkeepers’ performance. It is concluded that goalkeepers are likely to benefit from not anticipating a penalty taker’s performance outcome based on information from the run-up, in preference to later information that emerges just before the initiation of the penalty taker’s kicking action.

Corneal sensitivity as an ophthalmic marker of diabetic neuropathy

Purpose. The objective of this study was to explore the discriminative capacity of non-contact corneal esthesiometry (NCCE) when compared with the neuropathy disability score (NDS) score—a validated, standard method of diagnosing clinically significant diabetic neuropathy. Methods. Eighty-one participants with type 2 diabetes, no history of ocular disease, trauma, or surgery and no history of systemic disease that may affect the cornea were enrolled. Participants were ineligible if there was history of neuropathy due to non-diabetic cause or current diabetic foot ulcer or infection. Corneal sensitivity threshold was measured on the eye of dominant hand side at a distance of 10 mm from the center of the cornea using a stimulus duration of 0.9 s. The NDS was measured producing a score ranging from 0 to 10. To determine the optimal cutoff point of corneal sensitivity that identified the presence of neuropathy (diagnosed by NDS), the Youden index and “closest-to-(0,1)” criteria were used. Results. The receiver-operator characteristic curve for NCCE for the presence of neuropathy (NDS ≥3) had an area under the curve of 0.73 (p = 0.001) and, for the presence of moderate neuropathy (NDS ≥6), area of 0.71 (p = 0.003). By using the Youden index, for an NDS ≥3, the sensitivity of NCCE was 70% and specificity was 75%, and a corneal sensitivity threshold of 0.66 mbar or higher indicated the presence of neuropathy. When NDS ≥6 (indicating risk of foot ulceration) was applied, the sensitivity was 52% with a specificity of 85%. Conclusions. NCCE is a sensitive test for the diagnosis of minimal and more advanced diabetic neuropathy and may serve as a useful surrogate marker for diabetic and perhaps other neuropathies.

Response shift, recall bias and their effect on measuring change in health-related quality of life amongst older hospital patients

Background: Assessments of change in subjective patient reported outcomes such as health-related quality of life (HRQoL) are a key component of many clinical and research evaluations. However, conventional longitudinal evaluation of change may not agree with patient perceived change if patients' understanding of the subjective construct under evaluation changes over time (response shift) or if patients' have inaccurate recollection (recall bias). This study examined whether older adults' perception of change is in agreement with conventional longitudinal evaluation of change in their HRQoL over the duration of their hospital stay. It also investigated this level of agreement after adjusting patient perceived change for recall bias that patients may have experienced. Methods: A prospective longitudinal cohort design nested within a larger randomised controlled trial was implemented. 103 hospitalised older adults participated in this investigation at a tertiary hospital facility. The EQ-5D utility and Visual Analogue Scale (VAS) scores were used to evaluate HRQoL. Participants completed EQ-5D reports as soon as they were medically stable (within three days of admission) then again immediately prior to discharge. Three methods of change score calculation were used (conventional change, patient perceived change and patient perceived change adjusted for recall bias). Agreement was primarily investigated using intraclass correlation coefficients (ICC) and limits of agreement. Results: Overall 101 (98%) participants completed both admission and discharge assessments. The mean (SD) age was 73.3 (11.2). The median (IQR) length of stay was 38 (20-60) days. For agreement between conventional longitudinal change and patient perceived change: ICCs were 0.34 and 0.40 for EQ-5D utility and VAS respectively. For agreement between conventional longitudinal change and patient perceived change adjusted for recall bias: ICCs were 0.98 and 0.90 respectively. Discrepancy between conventional longitudinal change and patient perceived change was considered clinically meaningful for 84 (83.2%) of participants, after adjusting for recall bias this reduced to 8 (7.9%). Conclusions: Agreement between conventional change and patient perceived change was not strong. A large proportion of this disagreement could be attributed to recall bias. To overcome the invalidating effect of response shift (on conventional change) and recall bias (on patient perceived change) a method of adjusting patient perceived change for recall bias has been described.

Increasing underwater vehicle autonomy by reducing energy consumption

In this paper, we concern ourselves with finding a control strategy that minimizes energy consumption along a trajectory connecting two given configurations. We develop an algorithm, based on our previous work with the time optimal problem, which provides implementable control strategies that are energy efficient. We find an interesting correlation between the duration of these trajectories and the optimal duration. We present the algorithm, control strategy and experimental results from our test-bed vehicle.

Autonomous underwater vehicles: development and implementation of time and energy efficient trajectories

Autonomous underwater vehicles (AUVs) are increasingly used, both in military and civilian applications. These vehicles are limited mainly by the intelligence we give them and the life of their batteries. Research is active to extend vehicle autonomy in both aspects. Our intent is to give the vehicle the ability to adapt its behavior under different mission scenarios (emergency maneuvers versus long duration monitoring). This involves a search for optimal trajectories minimizing time, energy or a combination of both. Despite some success stories in AUV control, optimal control is still a very underdeveloped area. Adaptive control research has contributed to cost minimization problems, but vehicle design has been the driving force for advancement in optimal control research. We look to advance the development of optimal control theory by expanding the motions along which AUVs travel. Traditionally, AUVs have taken the role of performing the long data gathering mission in the open ocean with little to no interaction with their surroundings, MacIver et al. (2004). The AUV is used to find the shipwreck, and the remotely operated vehicle (ROV) handles the exploration up close. AUV mission profiles of this sort are best suited through the use of a torpedo shaped AUV, Bertram and Alvarez (2006), since straight lines and minimal (0 deg - 30 deg) angular displacements are all that are necessary to perform the transects and grid lines for these applications. However, the torpedo shape AUV lacks the ability to perform low-speed maneuvers in cluttered environments, such as autonomous exploration close to the seabed and around obstacles, MacIver et al. (2004). Thus, we consider an agile vehicle capable of movement in six degrees of freedom without any preference of direction.

The largest volcanic eruptions on Earth

Large igneous provinces (LIPs) are sites of the most frequently recurring, largest volume basaltic and silicic eruptions in Earth history. These large-volume (N1000 km3 dense rock equivalent) and large-magnitude (NM8) eruptions produce areally extensive (104–105 km2) basaltic lava flow fields and silicic ignimbrites that are the main building blocks of LIPs. Available information on the largest eruptive units are primarily from the Columbia River and Deccan provinces for the dimensions of flood basalt eruptions, and the Paraná–Etendeka and Afro-Arabian provinces for the silicic ignimbrite eruptions. In addition, three large-volume (675– 2000 km3) silicic lava flows have also been mapped out in the Proterozoic Gawler Range province (Australia), an interpreted LIP remnant. Magma volumes of N1000 km3 have also been emplaced as high-level basaltic and rhyolitic sills in LIPs. The data sets indicate comparable eruption magnitudes between the basaltic and silicic eruptions, but due to considerable volumes residing as co-ignimbrite ash deposits, the current volume constraints for the silicic ignimbrite eruptions may be considerably underestimated. Magma composition thus appears to be no barrier to the volume of magma emitted during an individual eruption. Despite this general similarity in magnitude, flood basaltic and silicic eruptions are very different in terms of eruption style, duration, intensity, vent configuration, and emplacement style. Flood basaltic eruptions are dominantly effusive and Hawaiian–Strombolian in style, with magma discharge rates of ~106–108 kg s−1 and eruption durations estimated at years to tens of years that emplace dominantly compound pahoehoe lava flow fields. Effusive and fissural eruptions have also emplaced some large-volume silicic lavas, but discharge rates are unknown, and may be up to an order of magnitude greater than those of flood basalt lava eruptions for emplacement to be on realistic time scales (b10 years). Most silicic eruptions, however, are moderately to highly explosive, producing co-current pyroclastic fountains (rarely Plinian) with discharge rates of 109– 1011 kg s−1 that emplace welded to rheomorphic ignimbrites. At present, durations for the large-magnitude silicic eruptions are unconstrained; at discharge rates of 109 kg s−1, equivalent to the peak of the 1991 Mt Pinatubo eruption, the largest silicic eruptions would take many months to evacuate N5000 km3 of magma. The generally simple deposit structure is more suggestive of short-duration (hours to days) and high intensity (~1011 kg s−1) eruptions, perhaps with hiatuses in some cases. These extreme discharge rates would be facilitated by multiple point, fissure and/or ring fracture venting of magma. Eruption frequencies are much elevated for large-magnitude eruptions of both magma types during LIP-forming episodes. However, in basaltdominated provinces (continental and ocean basin flood basalt provinces, oceanic plateaus, volcanic rifted margins), large magnitude (NM8) basaltic eruptions have much shorter recurrence intervals of 103–104 years, whereas similar magnitude silicic eruptions may have recurrence intervals of up to 105 years. The Paraná– Etendeka province was the site of at least nine NM8 silicic eruptions over an ~1 Myr period at ~132 Ma; a similar eruption frequency, although with a fewer number of silicic eruptions is also observed for the Afro- Arabian Province. The huge volumes of basaltic and silicic magma erupted in quick succession during LIP events raises several unresolved issues in terms of locus of magma generation and storage (if any) in the crust prior to eruption, and paths and rates of ascent from magma reservoirs to the surface.

Low intensity CBT by mail

Introduction: There are many low intensity (LI) cognitive behavoural therapy (CBT) solutions to the problem of limited service access. In this chapter, we aim to discuss a relatively low-technology approach to access using standard postal services-CBT by mail, or M-CBT. Bibliotherapies including M-CBT teach key concepts and self-management techniques, together with screening tools and forms to structure home practice. M-CBT differs from other bibliotherapies by segmenting interventions and mailing them at regular intervals. Most involve participants returning copies of monitoring forms or completed handouts. Therapist feedback is provided, often in personal letters that accompany the printed materials. Participants may also be given access to telephone or email support. ----- ----- M-CBT clearly fulfills criteria for an LI CBT (see Bennett-Levy et al., Chapter 1, for a definition of LI interventions). Once written, they involve little therapist time and rely heavily on self-management. However, content and overall treatment duration need not be compromised. Long-term interventions with multiple components can be delivered via this method, provided their content can be communicated in letters and engagement is maintained.

Brief motivational interviewing for depression and anxiety

Motivational interviewing (MI)can be applied as a brief, low intensity (LI) intervention of 1-4 individualised sessions (typically 45-60 minutes in duration), including screening, assessment feedback, and psycho-education. MI is a client-centred, directive therapeutic style that enhances readiness for change by helping clients explore and resolve ambivalence (Miller and Rollnick 2002). A summary of the key components of brief MI interventions is provided in Table 16.1. There is a well-established evidence base for MI in the treatment of substance misuse (particularly alcohol misuse; Moyer et al. 2002), as well as a growing evidence for the use of MI in the treatment of other mental disorders (e.g. depression, PTSD, OCD), as well as suicidality and physical health problems (Hettema et al. 2005). Brief MI intervention can be delivered as a standalone treatment or as a motivational prelude to pharmacological and/or other psychological treatments (Hettema et al. 2005). MI has been used as an accompaniment to cognitive behavioural therapy (CBT) in the treatment of both depression and anxiety for resolving ambivalence about change and developing strategies for responding to resistance (e.g. treatment attendance, homework/medication compliance; Arkowitz et al. 2008a, 2008b). This chapter will describe how to apply brief MI interventions to the treatment of depression and anxiety as applied to the case of Megan (see Box 16.1) along with some of the challenges and potential solutions to applying MI in practice.

The impact of changes to the graduated driver licensing program in Queensland, Australia on the experiences of learner drivers

Purpose: Graduated driver licensing (GDL) has been introduced in numerous jurisdictions in Australia and internationally in an attempt to ameliorate the significantly greater risk of death and injury for young novice drivers arising from road crashes. The GDL program in Queensland, Australia, was extensively modified in July 2007. This paper reports the driving and licensing experiences of Learner drivers progressing through the current-GDL program, and compares them to the experiences of Learners who progressed through the former-GDL program. ----- ----- Method: Young drivers (n = 1032, 609 females, 423 males) aged 17 to 19 years (M = 17.43, SD = 0.67) were recruited as they progressed from a Learner to a Provisional driver’s licence. They completed a survey exploring their sociodemographic characteristics, driving and licensing experiences as a Learner. Key measures for a subsample (n = 183) of the current-GDL drivers were compared with the former-GDL drivers (n = 149) via t-tests and chi-square analyses. ----- ----- Results: As expected, Learner drivers progressing through the current-GDL program gained significantly more driving practice than those in the former program, which was more likely to be provided by mothers than in the past. Female learners in the current-GDL program reported less difficulty obtaining supervision than those in the former program. The number of attempts needed to pass the practical driving assessment did not change, nor did the amount of professional supervision. The current-GDL Learners held their licence for a significantly longer duration than those in the former program, with the majority reporting that their Logbook entries were accurate on the whole. Compared to those in the former program, a significantly smaller proportion of male current-GDL Learners reported being detected for a driving offence while the females reported significantly lower crash involvement. Most current-GDL drivers reported undertaking their supervised practice at the end of the Learner period. ----- ----- Conclusions: The enhancements to the GDL program in Queensland appear to have achieved many of their intended results. The current-GDL learners participating in the study reported obtaining a significantly greater amount of supervised driving experience compared to former-GDL learners. Encouragingly, the current-GDL Learners did not report any greater difficulty in obtaining supervised driving practice, and there was a decline in the proportion of current-GDL Learners engaging in unsupervised driving. In addition, the majority of Learners do not appear to be attempting to subvert logbook recording requirements, as evidenced by high rates of self-reported logbook accuracy. The results have implications for the development and the evaluation of GDL programs in Australia and around the world.