Adaptación cultural y validación de la escala de valoración de riesgo de desarrollar úlceras por presión en neonatos hospitalizados (Neonatal Skin Risk Assessment Scale)

Los estudios epidemiológicos realizados hasta la fecha en neonatos hospitalizados son escasos. En España en las unidades neonatales las cifras de prevalencia se mueven entre un 50% en unidades de cuidados intensivos (UCIN) y un 12,5% en unidades de hospitalización. Desde todas las organizaciones de salud, nacionales (GNEAUPP) e internacionales (EPUAP, EWMA, NPUAP) relacionadas con las heridas, se promociona y potencia la seguridad del paciente mediante la prevención de los efectos adversos hospitalarios. Para conseguirlo es necesario dotar a los profesionales sanitarios de herramientas validadas y adaptadas a la edad neonatal que permitan valorar el riesgo de la población hospitalizada. De esta forma los profesionales sanitarios podrán gestionar de forma eficiente los recursos preventivos y trazar planes de cuidados centrados en el neonato. En la actualidad, en España no existe ninguna escala validada específicamente para neonatos. Por tanto, el objetivo principal de nuestro equipo de investigación fue adaptar transculturalmente al contexto español la escala NSRAS original y evaluar la validez y la fiabilidad de la versión en español. En esta ponencia se presentarán los resultados preliminares de la tesis. Método. El estudio se subdividió en tres fases. En la primera fase se realizó la adaptación transcultural de la escala NSRAS original mediante el método de traducción con retrotraducción. Posteriormente entre un grupo de expertos se calculó la validez de contenido mediante el IVC. La versión de la escala adaptada fue evaluada mediante dos fases de estudio multicéntrico observacional analítico en las unidades neonatales de 10 hospitales públicos del Sistema Nacional de Salud. Se evaluó la fiabilidad interobservadores e intraobservadores, la validez de constructo en la segunda fase y en una tercera fase se evaluó la capacidad predictiva y el punto de corte de la versión en español de la escala NSRAS. Resultados. En la primera fase la validez de contenido evaluada obtuvo un IVC de 0,926 [IC95%0,777-0,978]. En la segunda fase, la muestra evaluada fue de 336 neonatos. La consistencia interna mostró un Alfa de Cronbach de 0,794. Y la fiabilidad intraobservadores fue de 0,932 y la fiabilidad interobservadores fue de 0,969. En la tercera fase la muestra evaluada fue de 268 neonatos. El análisis multivariante de la relación entre los factores de riesgo, las medidas preventivas y la presencia de UPP mostró que 3 variables eran significativas: la puntuación NSRAS, la duración del ingreso y el uso de VMNI. Siendo de esta forma la puntuación NSRAS (debido a que activa las medidas preventivas) un factor protector frente a UPP. Es decir, a mayor puntuación de NSRAS, menor riesgo de UPP. La valoración clinicométrica de la puntuación 17 mostró una sensibilidad del 91,18%, una especificidad de 76,5%, un VPN de 36,05% y un VPP de 98,35%. El área bajo la curva ROC fue de 0,8384 en la puntuación 17. Conclusiones. La versión en español de la escala NSRAS es una herramienta válida y fiable para medir el riesgo de UPP en la población neonatal hospitalizada en el contexto español. Los neonatos hospitalizados con una puntuación igual o menor a 17 están en riesgo desarrollar UPP.

When non-significance may be significant : lessons learned from a study of the development, implementation and evaluation of a fleet risk assessment tool

This paper reports on the development and implementation of a self-report risk assessment tool that was developed in an attempt to increase the efficacy of crash prediction within Australian fleet settings. This study forms a part of a broader program of research into work related road safety and identification of driving risk. The first phase of the study involved a series of focus groups being conducted with 217 professional drivers which revealed that the following factors were proposed to influence driving performance: Fatigue, Knowledge of risk, Mood, Impatience and frustration, Speed limits, Experience, Other road users, Passengers, Health, and Culture. The second phase of the study involved piloting the newly developed 38 item Driving Risk Assessment Scale - Work Version (DRAS-WV) with 546 professional drivers. Factor analytic techniques identified a 9 factor solution that was comprised of speeding, aggression, time pressure, distraction, casualness, awareness, maintenance, fatigue and minor damage. Speeding and aggressive driving manoeuvres were identified to be the most frequent aberrant driving behaviours engaged in by the sample. However, a series of logistic regression analyses undertaken to determine the DRAS-WV scale’s ability to predict self-reported crashes revealed limited predictive efficacy e.g., 10% of crashes. This paper outlines proposed reasons for this limited predictive ability of the DRAS-WV as well as provides suggestions regarding the future of research that aims to develop methods to identify “at risk” drivers.

Pressure ulcers in the adult intensive care unit : a literature review of patient risk factors and risk assessment scales

Background: Critically ill patients are at high risk for pressure ulcer (PrU) development due to their high acuity and the invasive nature of the multiple interventions and therapies they receive. With reported incidence rates of PrU development in the adult critical care population as high as 56%, the identification of patients at high risk of PrU development is essential. This paper will explore the association between PrU development and risk factors. It will also explore PrU development and the use of risk assessment scales for critically ill patients in adult intensive care units. Method: A literature search from 2000 to 2012 using the CINHAL, Cochrane Library, EBSCOHost, Medline (via EBSCOHost), PubMed, ProQuest and Google Scholar databases was conducted. Key words used were: pressure ulcer/s; pressure sore/s; decubitus ulcer/s; bed sore/s; critical care; intensive care; critical illness; prevalence; incidence; prevention; management; risk factor; risk assessment scale. Results: Nineteen articles were included in this review; eight studies addressing PrU risk factors, eight studies addressing risk assessment scales and three studies overlapping both. Results from the studies reviewed identified 28 intrinsic and extrinsic risk factors which may lead to PrU development. Development of a risk factor prediction model in this patient population, although beneficial, appears problematic due to many issues such as diverse diagnoses and subsequent patient needs. Additionally, several risk assessment instruments have been developed for early screening of patients at higher risk of developing PrU in the ICU. No existing risk assessment scales are valid for identification high risk critically ill patient,with the majority of scales potentially over-predicting patients at risk for PrU development. Conclusion: Research studies to inform the risk factors for potential pressure ulcer development are inconsistent. Additionally, there is no consistent or clear evidence which demonstrates any scale to better or more effective than another when used to identify the patients at risk for PrU development. Furthermore robust research is needed to identify the risk factors and develop valid scales for measuring the risk of PrU development in ICU.

Ten Years of the Relative Risk Model and Regional Scale Ecological Risk Assessment

It has been 10 years since the publication of the relative risk model (RRM) for regional scale ecological risk assessment. The approach has since been used successfully for a variety of freshwater, marine, and terrestrial environments in North America, South America, and Australia. During this period the types of stressors have been expanded to include more than contaminants. Invasive species, habitat loss, stream alteration and blockage, temperature, change in land use, and climate have been incorporated into the assessments. Major developments in the RRM have included the extensive use of geographical information systems, uncertainty analysis using Monte Carlo techniques, and its application to retrospective assessments to determine causation. The future uses of the RRM include assessments for forestry and conservation management, an increasing use in invasive species evaluation, and in sustainability. Developments in risk communication, the use of Bayesian approaches, and in uncertainty analyses are on the horizon.

Failure of a numerical quality assessment scale to identify potential risk of bias in a systematic review: a comparison study

BACKGROUND: Assessing methodological quality of primary studies is an essential component of systematic reviews. Following a systematic review which used a domain based system [United States Preventative Services Task Force (USPSTF)] to assess methodological quality, a commonly used numerical rating scale (Downs and Black) was also used to evaluate the included studies and comparisons were made between quality ratings assigned using the two different methods. Both tools were used to assess the 20 randomized and quasi-randomized controlled trials examining an exercise intervention for chronic musculoskeletal pain which were included in the review. Inter-rater reliability and levels of agreement were determined using intraclass correlation coefficients (ICC). Influence of quality on pooled effect size was examined by calculating the between group standardized mean difference (SMD).

RESULTS: Inter-rater reliability indicated at least substantial levels of agreement for the USPSTF system (ICC 0.85; 95% CI 0.66, 0.94) and Downs and Black scale (ICC 0.94; 95% CI 0.84, 0.97). Overall level of agreement between tools (ICC 0.80; 95% CI 0.57, 0.92) was also good. However, the USPSTF system identified a number of studies (n = 3/20) as "poor" due to potential risks of bias. Analysis revealed substantially greater pooled effect sizes in these studies (SMD -2.51; 95% CI -4.21, -0.82) compared to those rated as "fair" (SMD -0.45; 95% CI -0.65, -0.25) or "good" (SMD -0.38; 95% CI -0.69, -0.08).

CONCLUSIONS: In this example, use of a numerical rating scale failed to identify studies at increased risk of bias, and could have potentially led to imprecise estimates of treatment effect. Although based on a small number of included studies within an existing systematic review, we found the domain based system provided a more structured framework by which qualitative decisions concerning overall quality could be made, and was useful for detecting potential sources of bias in the available evidence.

When non-significance maybe significant: lessons learned from a study into the development, implementation and evaluation of a risk assessment tool for fleet settings

Introduction This study reports on the development of a self report assessment tool to increase the efficacy of crash prediction within Australian Fleet settings Over last 20 years an array of measures have been produced (Driver anger scale, Driving Skill Inventory, Manchester Driver Behaviour Questionnaire, Driver Attitude Questionnaire, Driver Stress Inventory, Safety Climate Questionnaire) While these tools are useful, research has demonstrated limited ability to accurately identify individuals most likely to be involved in a crash. Reasons cited include; - Crashes are relatively rare - Other competing factors may influence crash event - Ongoing questions regarding the validity of self report measures (common method variance etc) - Lack of contemporary issues relating to fleet driving performance

Indoor aerosols : from personal exposure to risk assessment

Motivated by growing considerations of the scale, severity and risks associated with human exposure to indoor particulate matter, this work reviewed existing literature to: (i) identify state-of-the-art experimental techniques used for personal exposure assessment; (ii) compare exposure levels reported for domestic/school settings in different countries (excluding exposure to environmental tobacco smoke and particulate matter from biomass cooking in developing countries); (iii) assess the contribution of outdoor background vs indoor sources to personal exposure; and (iv) examine scientific understanding of the risks posed by personal exposure to indoor aerosols. Limited studies assessing integrated daily residential exposure to just one particle size fraction, ultrafine particles, show that the contribution of indoor sources ranged from 19-76%. This indicates a strong dependence on resident activities, source events and site specificity, and highlights the importance of indoor sources for total personal exposure. Further, it was assessed that 10-30% of the total burden-of-disease from particulate matter exposure was due to indoor generated particles, signifying that indoor environments are likely to be a dominant environmental factor affecting human health. However, due to challenges associated with conducting epidemiological assessments, the role of indoor generated particles has not been fully acknowledged, and improved exposure/risk assessment methods are still needed, together with a serious focus on exposure control.

What factors influence nurses’ assessment practices? Development of the Barriers to Nurses’ use of Physical Assessment Scale

Aim To develop and psychometrically test the Barriers to Nurses’ use of Physical Assessment Scale. Background There is growing evidence of failure to recognise hospitalised patients at risk of clinical deterioration, in part due to inadequate physical assessment by nurses. Yet, little is known about the barriers to nurses’ use of physical assessment in the acute hospital setting and no validated scales have been published. Design Instrument development study. Method Scale development was based on a comprehensive literature review, focus groups, expert review and psychometric evaluation. The scale was administered to 434 acute care registered nurses working at a large Australian teaching hospital between June and July 2013. Psychometric analysis included factor analysis, model fit statistics and reliability testing. Results The final scale was reduced to 38 items representing seven factors, together accounting for 57.7% of the variance: (1) reliance on others and technology, (2) lack of time and interruptions, (3) ward culture, (4) lack of confidence, (5) lack of nursing role models, (6) lack of influence on patient care, and; (7) specialty area. Internal reliability ranged from .70 to .86. Conclusion Findings provide initial evidence for the validity and reliability of the Barriers to Nurses’ use of Physical Assessment Scale and point to the importance of understanding the organisational determinants of nurses’ assessment practices. The new scale has potential clinical and research applications to support nursing assessment in acute care settings.

Bioeconomic modelling and risk assessment of tiger prawn (Penaeus esculentus) stock enhancement in Exmouth Gulf, Australia

A bioeconomic model was developed to evaluate the potential performance of brown tiger prawn stock enhancement in Exmouth Gulf, Australia. This paper presents the framework for the bioeconomic model and risk assessment for all components of a stock enhancement operation, i.e. hatchery, grow-out, releasing, population dynamics, fishery, and monitoring, for a commercial scale enhancement of about 100 metric tonnes, a 25% increase in average annual catch in Exmouth Gulf. The model incorporates uncertainty in estimates of parameters by using a distribution for the parameter over a certain range, based on experiments, published data, or similar studies. Monte Carlo simulation was then used to quantify the effects of these uncertainties on the model-output and on the economic potential of a particular production target. The model incorporates density-dependent effects in the nursery grounds of brown tiger prawns. The results predict that a release of 21 million 1 g prawns would produce an estimated enhanced prawn catch of about 100 t. This scale of enhancement has a 66.5% chance of making a profit. The largest contributor to the overall uncertainty of the enhanced prawn catch was the post-release mortality, followed by the density-dependent mortality caused by released prawns. These two mortality rates are most difficult to estimate in practice and are much under-researched in stock enhancement.

Mobile medical applications for melanoma risk assessment: False assurance or valuable tool?

With the smartphone revolution, consumer-focused mobile medical applications (apps) have flooded the market without restriction. We searched the market for commercially available apps on all mobile platforms that could provide automated risk analysis of the most serious skin cancer, melanoma. We tested 5 relevant apps against 15 images of previously excised skin lesions and compared the apps' risk grades to the known histopathologic diagnosis of the lesions. Two of the apps did not identify any of the melanomas. The remaining 3 apps obtained 80% sensitivity for melanoma risk identification; specificities for the 5 apps ranged from 20%-100%. Each app provided its own grading and recommendation scale and included a disclaimer recommending regular dermatologist evaluation regardless of the analysis outcome. The results indicate that autonomous lesion analysis is not yet ready for use as a triage tool. More concerning is the lack of restrictions and regulations for these applications.

Risk assessment of wandering behavior in mild dementia

Objective This prospective longitudinal study aims to determine the risk factors of wandering-related adverse consequences in community-dwelling persons with mild dementia. These adverse consequences include negative outcomes of wandering (falls, fractures, and injuries) and eloping behavior. Methods We recruited 143 dyads of persons with mild dementia and their caregivers from a veteran's hospital and memory clinic in Florida. Wandering-related adverse consequences were measured using the Revised Algase Wandering Scale – Community Version. Variables such as personality (Big Five Inventory), behavioral response to stress, gait, and balance (Tinetti Gait and Balance), wayfinding ability (Wayfinding Effectiveness Scale), and neurocognitive abilities (attention, cognition, memory, language/verbal skills, and executive functioning) were also measured. Bivariate and logistic regression analyses were performed to assess the predictors of these wandering-related adverse consequences. Results A total of 49% of the study participants had falls, fractures, and injuries due to wandering behavior, and 43.7% demonstrated eloping behaviors. Persistent walking (OR = 2.6) and poor gait (OR = 0.9) were significant predictors of negative outcomes of wandering, while persistent walking (OR = 13.2) and passivity (OR = 2.55) predicted eloping behavior. However, there were no correlations between wandering-related adverse consequences and participants' characteristics (age, gender, race, ethnicity, and education), health status (Charlson comorbidity index), or neurocognitive abilities. Conclusion Our results highlight the importance of identifying at-risk individuals so that effective interventions can be developed to reduce or prevent the adverse consequences of wandering.

Gene flow from transgenic plant populations: models and applications for risk assessment

The future use of genetically modified (GM) plants in food, feed and biomass production requires a careful consideration of possible risks related to the unintended spread of trangenes into new habitats. This may occur via introgression of the transgene to conventional genotypes, due to cross-pollination, and via the invasion of GM plants to new habitats. Assessment of possible environmental impacts of GM plants requires estimation of the level of gene flow from a GM population. Furthermore, management measures for reducing gene flow from GM populations are needed in order to prevent possible unwanted effects of transgenes on ecosystems. This work develops modeling tools for estimating gene flow from GM plant populations in boreal environments and for investigating the mechanisms of the gene flow process. To describe spatial dimensions of the gene flow, dispersal models are developed for the local and regional scale spread of pollen grains and seeds, with special emphasis on wind dispersal. This study provides tools for describing cross-pollination between GM and conventional populations and for estimating the levels of transgenic contamination of the conventional crops. For perennial populations, a modeling framework describing the dynamics of plants and genotypes is developed, in order to estimate the gene flow process over a sequence of years. The dispersal of airborne pollen and seeds cannot be easily controlled, and small amounts of these particles are likely to disperse over long distances. Wind dispersal processes are highly stochastic due to variation in atmospheric conditions, so that there may be considerable variation between individual dispersal patterns. This, in turn, is reflected to the large amount of variation in annual levels of cross-pollination between GM and conventional populations. Even though land-use practices have effects on the average levels of cross-pollination between GM and conventional fields, the level of transgenic contamination of a conventional crop remains highly stochastic. The demographic effects of a transgene have impacts on the establishment of trangenic plants amongst conventional genotypes of the same species. If the transgene gives a plant a considerable fitness advantage in comparison to conventional genotypes, the spread of transgenes to conventional population can be strongly increased. In such cases, dominance of the transgene considerably increases gene flow from GM to conventional populations, due to the enhanced fitness of heterozygous hybrids. The fitness of GM plants in conventional populations can be reduced by linking the selectively favoured primary transgene to a disfavoured mitigation transgene. Recombination between these transgenes is a major risk related to this technique, especially because it tends to take place amongst the conventional genotypes and thus promotes the establishment of invasive transgenic plants in conventional populations.

The effects of time pressure and experience on nurses' risk assessment decisions : a signal detection analysis

Background: Time pressure and, occasionally, suboptimal assessment decisions are features of nursing in acute care.

Objectives: To explore the effect of generic and specialist clinical experience on the ability to detect the need to take action in acute care and the impact of time pressure on nurses' decision-making performance.

Methods: Experienced acute care registered nurses (n = 241) were presented with 50 vignettes of real clinical risk assessments. Each vignette contained seven information cues. In response to these vignettes, nurses had to decide whether to intervene or not. The 26 vignettes were time limited and mixed randomly into the 50 cases. Signal detection analysis was used to establish nurses' performance, personal decision thresholds ([beta]), and their abilities (d') to distinguish a signal of clinical risk from the clinical noise of noncontributory information.

Results: Nurses had significantly lower d' and were significantly less likely to indicate intervening under time pressure. For ability-but not threshold-there was a significant interaction of time pressure and years of experience in acute care. With no time pressure, d' increased in line with years of experience. Under time pressure, there was no effect.

Discussion: Time pressure reduced nurses' ability to detect the need and the tendency to report intervening. Thus, there were more failures to report appropriate intervention under time pressure, and the positive effects of clinical experience were negated under time pressure. More and larger scale research on the effect on clinical outcomes of time pressured nursing choices is required.

Risk assessment of child-victim sex offenders for extended supervision in New Zealand

Recently enacted legislation in New Zealand, the Parole (Extended Supervision) Amendment Act 2004, allows for the imposition of up to 10 years of supervision in the community for child-victim sex offenders following their release from prison. The Act requires reports to be written specifically assessing the risk of sexual re-offending against children. This study examined the application of actuarial measures used by the New Zealand Department of Corrections in these assessments, including a computer-scored instrument based on static factors (the Automated Sexual Recidivism Scale; ASRS) and a clinically-based judgement of dynamic risk factors (the SONAR). It was expected that a conservative approach would be taken in making recommendations for or against extended periods of supervision, such that a high score on either measure would predict a recommendation for extended supervision. It was found, however, that a more individualized approach was often taken, whereby a baseline assessment of risk as predicted by the ASRS was adjusted by clinicians based on SONAR ratings. Implications for the practice of risk assessment in sexual re-offending are discussed.