Surgical wound dehiscence in an Australian community nursing service: time and cost to healing

OBJECTIVE

Surgical wound dehiscence (SWD) increases the length of hospital stay and impacts on patient wellbeing and health-care costs. Globally, the health-care costs associated with SWD are poorly reported and those reported are frequently associated with surgical site infection (SSI), rather than dehiscence of non-microbial cause. This retrospective study describes and reports on the costs and time to healing associated with a number of surgical patients who were referred to a community nursing service for treatment of an SWD following discharge from a metropolitan hospital, in Perth, Western Australia.

METHOD

Descriptive statistical analysis was carried out to describe the patient, wound and treatment characteristics. A costing analysis was conducted to investigate the cost of healing these wounds.

RESULTS

Among the 70 patients referred with a SWD, 55% were treated for an infected wound dehiscence which was a significant factor (p=0.001). Overall, the cost of treating the 70 patients with a SWD in a community nursing service was in excess of $56,000 Australian dollars (AUD) (£28,705) and did not include organisational overheads or travel costs for nurse visits. The management of infection contributed to 67% of the overall cost.

CONCLUSION

SWD remains an unquantified aspect of wound care from a prevalence and fiscal point of view. Further work needs to be done in the identification of SWD and which patients may be 'at risk'.

DECLARATION OF INTEREST

The authors declare they have no competing interests.

A retrospective review of fluid balance control in CRRT

INTRODUCTION

An effect of severe acute kidney injury (AKI) is the development of oliguria and subsequent retention of fluid. Recent studies have reported an association between fluid overload and increased mortality in critically ill patients. Achieving fluid balance control through haemofiltration is an important part of dialysis dose delivery in continuous renal replacement therapy (CRRT).

AIMS

(1) Compare the prescribed dose with the delivered dose of dialysis and haemofiltration for CRRT. (2) Identify how interruptions and delays in treatment delivery impact on fluid balance management.

METHOD

A retrospective cohort study was undertaken of daily fluid balance and fluid removal for patients who required CRRT. Each observation chart and prescription order for every treatment day was reviewed. Each patient was exposed to the same treatment mode, predilutional continuous veno-venous haemodiafiltration (CVVHDf). A comparison was made of fluid balance control delivered to the patient over 24h against the dose of fluid removal prescribed.

RESULTS

The observation charts of 46 consecutive patients were reviewed for total of 288 treatment days. Median number of days patients received CRRT was 5 (range 1-31). Median circuit life was 16h (range 0-66). Fluid removal targets did not occur in 75 (26%) treatment days. Median daily fluid removal shortfall was 300mL (range 25-3800mL). Mean number of daily treatment interruptions 1.25, SD±0.49. The most frequent cause of treatment downtime was circuit clotting (45%). Mean length of treatment down time was 3.71, SD±4.36h excluding delays attributed to assessment of renal function.

CONCLUSION

In over a quarter of treatment days prescribed fluid removal was not achieved. Frequency of interruptions and delays in resumption of treatment compromised fluid balance control. Daily targets for fluid removal which are not achieved contribute to fluid overload and may compromise the outcome of patients who require CRRT.

The Impact of Implementation of Family-Initiated Escalation of Care for the Deteriorating Patient in Hospital: A Systematic Review

BACKGROUND

Rapid response systems incorporate concepts of early recognition of patient deterioration, prompt reporting, and response which result in escalation of patient care. The ability to initiate escalation of care is now being extended to families of hospitalized patients.

RESEARCH AIMS

To identify the impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital?

METHODS

A systematic review of peer-reviewed publications was conducted. Databases were searched from January 2005 to May 2015 for articles reporting the implementation and evaluation of family involvement programs. Reference lists of retrieved articles were searched.

RESULTS

Ten articles (all descriptive studies) reported implementation and evaluation of response systems for patients and families to trigger an alert for help; five described a triaged response; five reported systems for families to directly activate the rapid response team. Five articles reported implementation in the pediatric setting. There were a total of 426 family-initiated calls, range 0.17 to 11 per month, with no deaths reported. All calls were deemed to be appropriate and three calls resulted in intensive care unit admissions. The basis of patient- or family-initiated calls stemmed from communication or systems breakdown. The large range in frequency of calls was associated with the process implemented, the strategies used and the calling criteria (up to four). Feedback from families was positive. There appeared to be a level of staff stress associated with introducing this process.

LINKING EVIDENCE TO ACTION

A variety of practice models and calling criteria were reported to either directly activate an existing rapid response team or trigger a separate response to patient- or family-initiated calls. The broader calling criteria and more comprehensive implementation strategies were associated with more patient- and family-initiated escalation of care calls. There is no systematically researched evidence to assess the value of family-initiated calls for deteriorating patients.

Slipping through the net: the paradox of nursing's electronic theses and dissertations

AIM

The study's main aim was to gain in-depth understanding of how nurse scholars engage with electronic theses and dissertations. Through elicitation of opinions about challenges and opportunities, and perceptions of future development, the study also aimed to influence the design of a new international web-based forum for learning and sharing information on this topic.

BACKGROUND

Electronic theses and dissertations provide an opportunity to radically change the way in which graduate student research is presented, disseminated and used internationally. However, as revealed by a multi-national survey in 2011, many nurse scholars in vanguard universities have little awareness of how to find and exploit this ever-expanding global knowledge resource that is increasingly available free in full text format. Within this context more detailed understandings of nurse scholars' thinking and actions are required.

METHODS

A qualitative approach using a semi-structured interview guide was utilized to elicit perceptions from 14 nurse scholars.

RESULTS

Thematic analysis of the interviewees' responses identified six major themes: initial exposure and effect; searching; accessing; handling; using; and evaluation. Insights were gained about the value of these resources and behaviours in using them as exemplars for structure, format and methodology.

CONCLUSION AND IMPLICATIONS FOR NURSING AND NURSING POLICY

Despite the small study size, the findings added valuable new insights to the overview gained from the 2011 survey. These have been used to inform development of a new global initiative: the International Network for Electronic Theses and Dissertations in Nursing. Featuring an educational website (www.inetdin.net), this initiative aims to support and challenge nursing's policy makers, practitioners and especially educators to utilize this neglected but exponentially increasing wellspring of international nursing knowledge.

The development and testing of a skin tear risk assessment tool

The aim of the present study is to develop a reliable and valid skin tear risk assessment tool. The six characteristics identified in a previous case control study as constituting the best risk model for skin tear development were used to construct a risk assessment tool. The ability of the tool to predict skin tear development was then tested in a prospective study. Between August 2012 and September 2013, 1466 tertiary hospital patients were assessed at admission and followed up for 10 days to see if they developed a skin tear. The predictive validity of the tool was assessed using receiver operating characteristic (ROC) analysis. When the tool was found not to have performed as well as hoped, secondary analyses were performed to determine whether a potentially better performing risk model could be identified. The tool was found to have high sensitivity but low specificity and therefore have inadequate predictive validity. Secondary analysis of the combined data from this and the previous case control study identified an alternative better performing risk model. The tool developed and tested in this study was found to have inadequate predictive validity. The predictive validity of an alternative, more parsimonious model now needs to be tested.

Determining risk factors for surgical wound dehiscence: a literature review

Postoperative wound healing plays a significant role in facilitating a patient's recovery and rehabilitation. Surgical wound dehiscence (SWD) impacts on mortality and morbidity rates and significantly contributes to prolonged hospital stays and associated psychosocial stressors on individuals and their families. A narrative review of SWD was undertaken on English-only studies between 1945 and 2012 using three electronic databases Ovid CINHAL, Ovid Medline and Pubmed. The aim of this review was to identify predisposing factors for SWD and assessment tools to assist in the identification of at-risk patients. Key findings from the included 15 papers out of a search of 1045 revealed the most common risk factors associated with SWD including obesity and wound infection, particularly in the case of abdominal surgery. There is limited reporting of variables associated with SWD across other surgical domains and a lack of risk assessment tools. Furthermore, there was a lack of clarity in the definition of SWD in the literature. This review provides an overview of the available research and provides a basis for more rigorous analysis of factors that contribute to SWD.

Developing and Testing the Standard of Practice and Evaluation of Critical-Care-Nursing Tool (SPECT) for Critical Care Nursing Practice

BACKGROUND

Nurses working in critical care often undertake specialty education. There are no uniform practice outcomes for critical care programs, and consumer input to practice standards has been lacking.

METHODS

A structured multiphase project was undertaken to develop practice standards and an assessment tool informed by critical care nursing stakeholders as well as patients and families-the Standards of Practice and Evaluation of Critical-Care-Nursing Tool (SPECT).

RESULTS

Testing of the SPECT revealed adequate content validity index (CVI), domain CVI (range, 0.772 to 0.887), and statement CVI (range, 0.66 to 1.00). Reliability was adequate in terms of internal consistency (Cronbach's α > 0.864) and test-retest Spearman rank correlation (range, 0.772 to 0.887); intra-rater kappa agreement was significant for 102 of 104 statements with moderate agreement for 94.2% of statements.

CONCLUSION

The SPECT appears to have clinical feasibility, preliminary validity and reliability, and provides a clear definition for the expected practice level for graduates of a critical care education program.

Health consumers' experiences in Australian critical care units: postgraduate nurse education implications

AIM

To explore critical care patients and families experiences and seek their input into nurses' postgraduate educational preparation and practice.

BACKGROUND

There is an inconsistency in the expected standard of practice to 'qualify' Australian critical care nurses. There has also been a lack of health consumer input in the development of postgraduate course curriculum and content.

METHOD

Following institutional ethics committee approval, purposive sampling was used to select participants for focus groups and individual interviews who had experienced intensive care or coronary care.

FINDINGS

Seventeen participants provided data which created two main thematic categories; the role of the critical care nurse and; minimum practice standards for postgraduate critical care course graduates. Both physical patient care and socio-emotional support of patients and family were identified as important for the critical care nurse role. The level of socio-emotional support provided by nurses was reported to be inconsistent. Components of socio-emotional support included communication, people skills, facilitating family presence and advocacy. These components were reflected in participants' concepts of minimum practice standards for postgraduate critical care course graduates; talking and listening skills, relating to and dealing with stressed people, individualizing care and patient and family advocacy.

CONCLUSION

Health consumers' views emphasize that socio-emotional skills and behaviours need to be explicitly described in postgraduate critical care nursing course curricula and instruments developed to consistently assess these core competencies.

Using a web-based survey tool to undertake a Delphi study: application for nurse education research

BACKGROUND

The Internet is increasingly being used as a data collection medium to access research participants. This paper reports on the experience and value of using web-survey software to conduct an eDelphi study to develop Australian critical care course graduate practice standards.

METHODS

The eDelphi technique used involved the iterative process of administering three rounds of surveys to a national expert panel. The survey was developed online using SurveyMonkey. Panel members responded to statements using one rating scale for round one and two scales for rounds two and three. Text boxes for panel comments were provided.

COLLECTING DATA AND PROVIDING FEEDBACK

For each round, the SurveyMonkey's email tool was used to distribute an individualized email invitation containing the survey web link. The distribution of panel responses, individual responses and a summary of comments were emailed to panel members. Stacked bar charts representing the distribution of responses were generated using the SurveyMonkey software. Panel response rates remained greater than 85% over all rounds.

DISCUSSION

An online survey provided numerous advantages over traditional survey approaches including high quality data collection, ease and speed of survey administration, direct communication with the panel and rapid collation of feedback allowing data collection to be undertaken in 12 weeks. Only minor challenges were experienced using the technology. Ethical issues, specific to using the Internet to conduct research and external hosting of web-based software, lacked formal guidance.

CONCLUSIONS

High response rates and an increased level of data quality were achieved in this study using web-survey software and the process was efficient and user-friendly. However, when considering online survey software, it is important to match the research design with the computer capabilities of participants and recognize that ethical review guidelines and processes have not yet kept pace with online research practices.

WITHDRAWN: ECG quiz

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Decrease in proven ventriculitis by reducing the frequency of cerebrospinal fluid sampling from extraventricular drains

OBJECT

Ventriculitis associated with extraventricular drains (EVD) increases rates of morbidity and mortality as well as costs. Surveillance samples of CSF are taken routinely from EVD, but there is no consensus on the optimum frequency of sampling. The goal of this study was to assess whether the incidence of ventriculitis changed when CSF sampling frequency was reduced once every 3 days.

METHODS

After receiving institutional ethics committee approval for their project, the authors compared a prospective sample of EVD-treated patients (admitted 2008-2009) and a historical comparison group (admitted 2005-2007) at two tertiary hospital ICUs. A broad definition of ventriculitis included suspected ventriculitis (that is, treated with antibiotics for ventriculitis) and proven ventriculitis (positive CSF culture). Adult ICU patients with no preexisting neurological infection were enrolled in the study. After staff was provided with an education package, sampling of CSF was changed from daily to once every 3 days. All other management of the EVD remained unchanged. More frequent sampling was permitted if clinically indicated during the third daily sampling phase.

RESULTS

Two hundred seven patients were recruited during the daily sampling phase and 176 patients when sampling was reduced to once every 3 days. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was lower for the daily sampling group than for the every-3rd-day group (18.6 vs 20.3, respectively; p < 0.01), but there was no difference in mean age (47 and 45 years, respectively; p = 0.14), male or female sex (61% and 59%, respectively; p = 0.68), or median EVD duration in the ICU (4.9 and 5.8 days, respectively; p = 0.14). Most patients were admitted with subarachnoid hemorrhage (42% in the daily group and 33% in the every-3rd-day group) or traumatic head injuries (29% and 36%, respectively). The incidence of ventriculitis decreased from 17% to 11% overall and for proven ventriculitis from 10% to 3% once sampling frequency was reduced. Sampling of CSF once every 3 days was independently associated with ventriculitis (OR 0.44, 95% CI 0.22-0.88, p = 0.02).

CONCLUSIONS

Reducing the frequency of CSF sampling to once every 3 days was associated with a significant decrease in the incidence of ventriculitis. The authors suggest that CSF sampling should therefore be performed once every 3 days in the absence of clinical indicators of ventriculitis. Reducing frequency of CSF sampling from EVDs decreased proven ventriculitis.

Health-related quality of life and physical recovery after a critical illness: a multi-centre randomised controlled trial of a home-based physical rehabilitation program

INTRODUCTION

Significant physical sequelae exist for some survivors of a critical illness. There are, however, few studies that have examined specific interventions to improve their recovery, and none have tested a home-based physical rehabilitation program incorporating trainer visits to participants' homes. This study was designed to test the effect of an individualised eight-week home-based physical rehabilitation program on recovery.

METHODS

A multi-centre randomised controlled trial design was used. Adult intensive care patients (length of stay of at least 48 hours and mechanically ventilated for 24 hours or more) were recruited from 12 Australian hospitals between 2005 and 2008. Graded, individualised endurance and strength training intervention was prescribed over eight weeks, with three physical trainer home visits, four follow-up phone calls, and supported by a printed exercise manual. The main outcome measures were blinded assessments of physical function; SF-36 physical function (PF) scale and six-minute walk test (6MWT), and health-related quality of life (SF-36) conducted at 1, 8 and 26 weeks after hospital discharge.

RESULTS

Of the 195 participants randomised, 183, 173 and 161 completed the 1, 8 and 26 weeks assessments, respectively. Study groups were similar at Week 1 post-hospital; for the intervention and control groups respectively, mean norm-based PF scores were 27 and 29 and the 6MWT distance was 291 and 324 metres. Both groups experienced significant and clinically important improvements in PF scores and 6MWT distance at 8 weeks, which persisted at 26 weeks. Mixed model analysis showed no significant group effects (P = 0.84) or group by time interactions (P = 0.68) for PF. Similar results were found for 6MWT and the SF-36 summary scores.

CONCLUSIONS

This individualised eight-week home-based physical rehabilitation program did not increase the underlying rate of recovery in this sample, with both groups of critically ill survivors improving their physical function over the 26 weeks of follow-up. Further research should explore improving effectiveness of the intervention by increasing exercise intensity and frequency, and identifying individuals who would benefit most from this intervention.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register ACTRN12605000166673.

Challenges and possible solutions for long-term follow-up of patients surviving critical illness

INTRODUCTION

Surviving critical illness can be life-changing and present new healthcare challenges for patients after discharge from hospital. Optimisation of recovery, rather than mere survival, is an important goal of intensive care. Observational studies have identified decreased quality of life and increased healthcare needs for survivors but loss to follow-up can be high with possible selection bias. Patients in need of support may therefore not be included in study results or allocated appropriate follow up support.

AIM

To examine the frequency and reasons patients admitted to general ICUs who survive critical illness are excluded from study participation or lost to follow-up and consider the possible implications and solutions.

METHOD

The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies (2006-2010) were included if they described follow-up of survivors from general ICUs.

RESULTS

Ten studies were reviewed. Of the 3269 eligible patients, 14% died after hospital discharge, 27% declined, and 22% were lost to follow-up. Reasons for loss to follow-up included no response, inability to contact the patient, too ill or admitted to another facility.

CONCLUSION

The most appropriate method of care follow-up has yet to be established but is likely to involve an eclectic model that tailors service provision to support individual patient needs. Identifying methods to minimise loss to follow-up may enhance interpretation of patients' recovery, lead to improvements in clinical practice and inform healthcare service decisions and policy.

Optimizing seating in the intensive care unit for patients with impaired mobility

BACKGROUND

Having intensive care patients sit out of bed improves their respiration and psyche and reduces complications of immobilization.

OBJECTIVES

To compare seating interface pressures to determine a preferred seating surface for patients sitting out of bed.

METHOD

The study was conducted in 2 phases among intensive care patients with impaired mobility who could sit out of bed. Pressure mapping was used to test seating surfaces in a non-randomized crossover design. In phase 1, three surfaces were compared: (1) regular chair (TotaLift-II), (2) regular chair with gel overlay, and (3) alternative chair (Hausted APC). A new surface, informed from phase 1, was designed and compared with the regular chair surface in phase 2. The number of cells recording pressures of 200 mm Hg or higher (excessive pressure) for 30 minutes was compared between surfaces.

RESULTS

In phase 1, the alternative chair had fewer excessive pressures than did the regular chair in 67% of seating episodes among 18 patients (P < .001), but the alternative chair lacked practical utility. In phase 2, the new seating surface was compared with the regular surface using the regular chair frame for 20 patients. Among patients with excessive pressures, most (93%) had fewer excessive pressures recorded on the new surface than on the regular surface (P < .001).

CONCLUSION

Results from this study provided important data for development of a new seating surface for intensive care patients sitting out of bed. The new surface promotes patients' comfort and probably reduces risk of pressure ulcers.

Early experience with influenza A H1N109 in an Australian intensive care unit

Influenza is a common seasonal viral infection that affects large numbers of people. In early 2009, many people were admitted to hospitals in Mexico with severe respiratory failure following an influenza-like illness, subtyped as H1N1. An increased mortality rate was observed. By June 2009, H1N1 was upgraded to pandemic status. In June–July, Australian ICUs were experiencing increased activity due to the influenza pandemic. While hospitals implemented plans for the pandemic, the particularly heavy demand to provide critical care facilities to accommodate an influx of people with severe respiratory failure became evident and placed a great burden on provision of these services. This paper describes the initial experience (June to mid September) of the pandemic from the nursing perspective in a single Australian ICU. Patients were noted to be younger with a higher proportion of women, two of whom were pregnant. Two patients had APACHE III comorbidity. Of the 31 patients admitted during this period, three patients died in ICU and one patient died in hospital. Aerosol precautions were initiated for all patients. The requirement for single room accommodation placed enormous demands for bed management in ICU. Specific infection control procedures were developed to deal with this new pandemic influenza.