Alison Craswell

Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis

BACKGROUND Guidelines for patient blood management recommend restrictive transfusion practice for most adult patients. These guidelines are supported by evidence from randomised controlled trials (RCTs); however, one of the patient groups not explicitly examined in these studies is the geriatric population. We examined RCTs relevant to transfusion outcomes in older patients. Our aim was to determine whether special guidelines are warranted for geriatric patients, recognising the different pathophysiological characteristics of this group. METHODS For this systematic review and meta-analysis, we searched PubMed, Scopus, and the Cochrane Library databases from their inception to May 5, 2017, for evidence relating to transfusion outcomes in adults aged 65 years and older. This criterion was widened to include RCTs where a substantial proportion of the study population was older than 65 years. We also included study populations of all clinical settings, and did not limit the search by date, language, or study type. For articles not in English, only available translations of the abstracts were reviewed. Studies were excluded if they did not specify age. Observational studies and duplicate patient and outcome data from studies that generated multiple publications were also excluded. We screened bibliographies of retrieved articles for additional publications. We analysed data extracted from published RCTs comparing restrictive and liberal transfusion strategies in older adults. We generated fixed effects risk ratios (RR) for pooled study data using the Mantel-Haenszel method. Primary outcomes were 30-day and 90-day mortality events for patients enrolled in restrictive and liberal transfusion study groups. We included intention-to-treat outcome data in the meta-analysis when available, otherwise we used per-protocol outcome data. FINDINGS 686 articles were identified by the search, and a further 37 by the snowball approach. Of these articles, 13 eligible papers described findings from nine RCTs (five trials investigating orthopaedic surgery, three cardiac surgery, and one oncology surgery; including 5780 patients). The risk of 30-day mortality was higher in older patients who followed a restrictive transfusion strategy than in those who followed a liberal transfusion strategy (risk ratio [RR] 1·36, 95% CI 1·05-1·74; p=0·017). The risk of 90-day mortality was also higher in those who followed a restrictive transfusion strategy than in those who followed a liberal transfusion strategy (RR 1·45, 95% CI 1·05-1·98; p=0·022). INTERPRETATION Liberal transfusion strategies might produce better outcomes in geriatric patients than restrictive transfusion strategies. This outcome contradicts current restrictive transfusion approaches. Population ageing will challenge resources globally, and this finding has implications for blood supply and demand, and optimal care of older adults. Further research is needed to formulate evidence-based transfusion practice across clinical specialties specific to the geriatric population, and to examine resource effects. FUNDING Australias National Blood Authority.

Perinatal data collection: current practice in the Australian nursing and midwifery healthcare context

The collection of perinatal data within Queensland, Australia, has traditionally been achieved via a paper form completed by midwives after each birth. Recently, with an increase in the use of e-health systems in healthcare, perinatal data collection has migrated to an online system. It is suggested that this move from paper to an e-health platform has resulted in improvement to error rates, completion levels, timeliness of data transfer from healthcare institutions to the perinatal data collection and subsequent publication of data items. Worldwide, perinatal data are collected utilising a variety of methods, but essentially data are used for similar purposes: to monitor outcome patterns within obstetrics and midwifery. This paper discusses current practice in relation to perinatal data collection worldwide and within Australia, with a specific focus on Queensland, highlights relevant issues for midwives, and points to the need for further research into the efficient use of an e-health platform for perinatal data collection.

Authors' reply to comment Blood transfusion strategies in elderly patients

1 Murphy MF, Estcourt L, Goodnough LT. Blood transfusion strategies in elderly patients. Lancet Haematol 2017; published online September 11. http://dx.doi.org/10.1016/ S2352-3026(17)30173-4. 2 Simon GI, Craswell A, Thom O, Fung YL. Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis. Lancet Haematol 2017; published online September 11. http://dx.doi.org/10.1016/ S2352-3026(17)30141-2 3 Carson JL, Stanworth SJ, Roubinian N, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10: CD002042. Authors’ reply to comment “Blood transfusion strategies in elderly patients”

Shared responsibility for electronic records: governance in perinatal data entry.

This paper presents research undertaken as part of a larger research project to examine the factors that influence midwives when entering perinatal data. A grounded theory methodology was used to undertake qualitative interviews with 15 participants from 12 different hospitals across Queensland, Australia using three different systems for perinatal data collection. The findings surrounding accountability are presented revealing that a shift in governance relating to responsibility and accountability is not occurring in midwifery units across Queensland. Without assignation of responsibility for entries and accountability for mistakes or omissions, perinatal data records can be left incomplete or inaccurate. Increasing use of electronic health records and creation of digital hospitals indicates these issues are highly relevant in planning for these services.

Questioning the benefit of restrictive transfusion practice in older adults

Restrictive transfusion practice is widely promoted, with many international guidelines recommending haemoglobin thresholds of 70 to 80 g/l for adult patients who are asymptomatic. Randomized controlled trials comparing outcomes associated with liberal and restrictive transfusion strategies underpin this approach. Meta‐analyses including trials of adult patients >18 years of age have concluded that restrictive practice is noninferior to liberal transfusion approaches. A restrictive approach to transfusion reduces resource consumption and cost, as well as the hazards associated with unnecessary exposure to blood products. Although adults aged ≥65 years consume over half of the blood supply, there are few randomized controlled transfusion trials exclusive to this cohort. Our 2017 meta‐analysis of a small number of trials focussed on older adults found that higher transfusion haemoglobin thresholds were associated with lower mortality and fewer cardiac complications in this age group. Other studies have also shown that higher transfusion haemoglobin thresholds are beneficial in older adults. This paper presents recent evidence regarding transfusion outcomes in older adults and discusses aspects of the pathophysiology of ageing that impact on the reduced resilience of older patients to anaemic states. This evidence challenges the use of Hb thresholds that apply across the adult lifespan, regardless of age. It proposes that older age be considered as a risk factor in assessing transfusion requirements, and that transfusion practice in older adults may require higher haemoglobin thresholds than for younger adults.

Nurse-led multidisciplinary initiatives to improve outcomes and reduce hospital admissions for older adults: The Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration project

This article describes the Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration (CEDRiC) project.

The relationship between midwife-led group-based versus conventional antenatal care and mode of birth: a matched cohort study

BackgroundMidwife facilitated, group models of antenatal care have emerged as an alternative to conventional care both within Australia and internationally. Group antenatal care can be offered in a number of different ways, however usually constitutes a series of sessions co-ordinated by a midwife combining physical assessment, antenatal education and peer support in a group setting. Midwife-led group antenatal care is viewed positively by expectant mothers, with no associated adverse outcomes identified in the published literature for women or their babies when compared with conventional care. Evidence of an improvement in outcomes is limited. The aim of this study was to compare mode of birth (any vaginal birth with caesarean birth) between pregnant women accessing midwife-led group antenatal care and conventional individual antenatal care, in Queensland, Australia.MethodsThis was a retrospective matched cohort study, set within a collaborative antenatal clinic between the local university and regional public health service in Queensland, Australia. Midwife-led group antenatal care (n = 110) participants were compared with controls enrolled in conventional antenatal care (n = 330). Groups were matched by parity, maternal age and gestation to form comparable groups, selecting a homogeneous sample with respect to confounding variables likely to affect outcomes.ResultsThere was no evidence that group care resulted in a greater number of caesarean births. The largest increase in the odds of caesarean birth was associated with a previous caesarean birth (p < 0.001), no previous birth (compared with previous vaginal birth) (p < 0.003), and conventional antenatal care (p < 0.073). The secondary outcomes (breastfeeding and infant birth weight) which were examined between the matched cohorts were comparable between groups.ConclusionsThere is no evidence arising from this study that there was a significant difference in mode of birth (caesarean or vaginal) between group and conventional care. Group care was associated with a lower risk of caesarean birth after controlling for previous births, with the highest chance for a vaginal birth being a woman who has had a previous vaginal birth and was in group care. Conversely, the highest risk of caesarean birth was for women who have had a previous caesarean birth and conventional care.

Evaluation of an aged care nurse practitioner service: quality of care within a residential aged care facility hospital avoidance service

BackgroundReducing avoidable hospitialisation of aged care facility (ACF) residents can improve the resident experience and their health outcomes. Consequently many variations of hospital avoidance (HA) programs continue to evolve. Nurse practitioners (NP) with expertise in aged care have the potential to make a unique contribution to hospital avoidance programs. However, little attention has been dedicated to service evaluation of this model and the quality of care provided. The purpose of this study was to evaluate the quality of an aged care NP model of care situated within a HA service in a regional area of Australia.MethodsDonabedian’s structure, process and outcome framework was applied to evaluate the quality of the NP model of care. The Australian Nurse Practitioner Study standardised interview schedules for evaluating NP models of care guided the semi-structured interviews of nine health professionals (including ACF nurses, medical doctors and allied health professionals), four ACF residents and their families and two NPs. Theory driven coding consistent with the Donabedian framework guided analysis of interview data and presentation of findings.ResultsStructural dimensions identified included the ‘in-reach’ nature of the HA service, distance, limitations of professional regulation and the residential care model. These dimensions influenced the process of referring the resident to the NP, the NPs timely response and interactions with other professionals. The processes where the NPs take time connecting with residents, initiating collaborative care plans, up-skilling aged care staff and function as intra and interprofessional boundary spanners all contributed to quality outcomes. Quality outcomes in this study were about timely intervention, HA, timely return home, partnering with residents and family (knowing what they want) and resident and health professional satisfaction.ConclusionsThis study provides valuable insights into the contribution of the NP model of care within an aged care, HA service and how staff manipulated the process dimensions to improve referral to the NPs. NP service in this study was dynamic, flexible and responsive to both patient and organisational demands.

Does use of computer technology for perinatal data collection influence data quality

Population health data, collected worldwide in an effort to monitor mortality and morbidity of mothers and babies, namely, perinatal data, are mandated at a federal level within Australia. The data are used to monitor patterns in midwifery, obstetric and neonatal practice, health outcomes, used for research purposes, funding allocation and education. Accuracy in perinatal data is most often reported via quantitative validation studies of perinatal data collections both internationally and in Australia. These studies report varying levels of accuracy and suggest researchers need to be more aware of the quality of data they use. This article presents findings regarding issues of concern identified by midwives relating to their perceptions of how technology affects the accuracy of perinatal data records. Perinatal data records are perceived to be more complete when completed electronically. However, issues regarding system functionality, the inconsistent use of terminology, lack of data standards and the absence of clear, written records contribute to midwives’ perceptions of the negative influence of technology on the quality of perinatal data.

Midwives and the Computerization of Perinatal Data Entry: The Theory of Beneficial Engagement

Theory building in nursing and midwifery both to explain and inform practice is important to advance these professions via provision of a theoretical foundation. This research explored the process of perinatal data entry undertaken by midwives to explore the impact of the movement from paper to computer collection of data. Use of grounded theory methodology enabled theory building, leading to a theoretical understanding of the phenomenon and development of the Theory of Beneficial Engagement grounded in the data. Methods involved in-depth semistructured interviews with 15 users of perinatal data systems. Participants were recruited from 12 different healthcare locations and were utilizing three different electronic systems for data entry. The research question that guided the study focused on examining the influences of using the computer for perinatal data entry. Findings indicated that qualities particular to some midwives denoted engagement with perinatal data entry, suggesting a strong desire to enter complete, timely, and accurate data. The Theory of Beneficial Engagement provides a model of user engagement with systems for perinatal data entry consistent with other theories of engagement. The theory developed describes this phenomenon in a simple, elegant manner that can be applied to other areas where mandatory data entry is undertaken.