Alison Short

A randomised controlled trial of intramuscular vs. intravenous antivenom for latrodectism—the RAVE study

BACKGROUND Widow spider-bite causes latrodectism and is associated with significant morbidity worldwide. Antivenom is given by both the intravenous (IV) and intramuscular (IM) routes and it is unclear which is more effective. AIM To compare the effectiveness of IV vs. IM redback spider antivenom. DESIGN Randomized controlled trial. METHODS Patients with latrodectism were given either IV or IM antivenom according to a randomized double-dummy, double-blind protocol. The first antivenom treatment was followed by another identical treatment after two hours if required. The primary outcome was a clinically significant reduction in pain two hours after the last treatment. A fully Bayesian analysis was used to estimate the probability of the desired treatment effect, predetermined as an absolute difference of 20%. RESULTS We randomly allocated 126 patients to receive antivenom IV (64) and IM (62). After antivenom treatment pain improved in 40/64(62%) in the IV group vs. 33/62(53%) in the IM group (+9%; 95% Credible Interval [CrI]: -8% to +26%). The probability of a difference greater than zero (IV superior) was 85% but the probability of a difference >20% was only 10%. In 55 patients with systemic effects, these improved in 58% after IV antivenom vs. 65% after IM antivenom (-8%; 95% CrI: -32% to +17%). Twenty-four hours after antivenom pain had improved in 84% in the IV group vs. 71% in the IM group (+13%; 95% CrI: -2% to +27%). A meta-analysis including data from a previous trial found no difference in the primary outcome between IV and IM administration. DISCUSSION The difference between IV and IM routes of administration of widow spider antivenom is, at best, small and does not justify routinely choosing one route over the other. Furthermore, antivenom may provide no benefit over placebo.

Expanding clinical research capacity through a community of practice (CoPER)

PURPOSE The proposed CoPER project (Community of Practice for Engaging in Research) responds to a need for increased research capacity in a clinical setting. We put forward an argument and a design for a prospective action research project to extend research capacity via an integrated academic and practitioner community of practice in an Emergency Department (ED). PROCEDURES This paper explores the research needs of clinicians, articulates the concept of community of practice in light of these needs, and outlines the rationale for considering communities of practice as a potential contributor to building research capacity in a clinical setting. FINDINGS A potential methodology is suggested to test the linkage between research needs, the concept of a community of practice model in a clinical setting, and the contribution of such a model to building research capacity in a clinical setting via the CoPER framework. CONCLUSIONS Combined data from this proposed mixed method action research (survey, focus groups, interviews, observation) are expected to enable the production of a set of facilitators and enablers with a view to building a community of research practice which make the case study transferable to other clinical and non-clinical work settings.

Enhancing research interest and collaboration in the interdisciplinary context of emergency care.

The interdisciplinary context of the emergency department encompasses diverse clinical presentations requiring teamwork by doctors, nurses and allied health workers to achieve optimal patient care. This interdisciplinary focus is extended by adding a research perspective. This project sought to systematically examine the current research capacity of emergency department staff at a major Australian tertiary urban hospital and to derive information about further research-related needs with a view to enhancing research capacity. The mixed method project utilized a department-wide staff survey followed by focus groups and individual interviews. Adequate response rates to the two phases were achieved (n = 67, n = 17 respectively). Not surprisingly, 89% of participants reported that they needed help with developing their research skills. Clinicians reported little or no experience with (i) finding literature (35%) and critical review (50%), (ii) research skills and techniques, both qualitative (72%) and quantitative (63%), and (iii) research output: publishing (68%), writing & presenting (34%). Data from focus groups and individual interviews yielded themes around developing research skills, communication, meaningfulness, team work and interdisciplinary strategies, forming part of the Dimensional Enhancing Research Capacity (DERC) model. This project highlighted not only interdisciplinary needs for research but also the way that research may additionally assist with building interprofessional linkage.

Using Music to Reduce Noise Stress for Patients in the Emergency Department: A Pilot Study

High noise levels in the emergency department (ED) affect patient care and cause noise annoyance (stress) to patients. This pilot project aimed to reduce noise stress by offering patients in the ED a coping strategy: headphones and music. In this randomized controlled study, 30 patients meeting study criteria were recruited, with half undergoing the music intervention. This involved listening to music via headphones and an MP3 player from preloaded playlists in four relevant genres. All participants completed a pre- and post-self-report stress tool, a self-report noise disturbance scale, and visual analogue scales related to stress and music. Results showed a trend toward decreased negative affect scores in the intervention group. Positive affect scores remained constant or increased. Individual comments suggested participants’ enjoyment, distraction, and ‘‘escape’’ from the environment. Results suggested that music may be a beneficial intervention to reduce ED noise stress; however, further exploration is needed.

Achieving patient‐centred care: the potential and challenge of the patient‐as‐professional role

The patient‐as‐professional concept acknowledges the expert participation of patients in interprofessional teams, including their contributions to managing and coordinating their care. However, little is known about experiences and perspectives of these teams.

Exploring the role of music therapy in cardiac rehabilitation after cardiothoracic surgery: a qualitative study using the Bonny Method of Guided Imagery and Music

Background:Cardiac rehabilitation integrates physical, psychological, and vocational strategies to restore and sustain optimal health. Objective:An innovative study using music therapy (Bonny Method of Guided Imagery and Music [BMGIM]) explored the experiences of cardiac rehabilitation participants in an outpatient setting at 2 major metropolitan teaching hospitals. Methods:Commencing 6 to 15 weeks after cardiothoracic surgery, 6 study participants were recruited for 6 weekly music therapy (BMGIM) sessions. Qualitative analysis of the patient narrative within a semiotic framework demonstrated that patients used music therapy to spontaneously explore their recovery process. Results:Five grand themes emerged: (1) looking through the frame, (2) feeling the impact, (3) spiralling into the unexpected, (4) sublime plateau, and (5) rehearsing new steps. The themes related to physical changes, adjustment after surgery, and anticipated lifestyle. Conclusions:This study demonstrates that music therapy (BMGIM) may be used to access and understand the internal recovery process of postcardiothoracic surgical patients, providing an additional clinical tool to augment the external rehabilitation process.

The inaccuracy of automatic devices taking postural measurements in the emergency department

Automatic devices are used to take postural blood pressures in the emergency department despite research proving their inaccuracy in taking single blood pressures. This study assessed the accuracy of an automatic device compared with a manual aneroid reference standard for determining orthostatic hypotension and postural drops at triage. Supine and standing blood pressures were taken with an automatic and a manual device in a sequential and random order, and postural drops were calculated. The manual device indicated 10/150 emergency department patients had orthostatic hypotension (7%) and the automatic device detected this with a sensitivity of 30% and a specificity of 91%. The automatic-manual differences were clinically significant in 13% of systolic drops and 37% of diastolic drops. Findings suggest that automatic devices cannot reliably detect or rule out orthostatic hypotension, indicating that triage nurses need to use manual devices to take accurate postural blood pressures for optimal patient care.

Developing an inter-organizational community-based health network: an Australian investigation

Networks in health care typically involve services delivered by a defined set of organizations. However, networked associations between the healthcare system and consumers or consumer organizations tend to be open, fragmented and are fraught with difficulties. Understanding the role and activities of consumers and consumer groups in a formally initiated inter-organizational health network, and the impacts of the network, is a timely endeavour. This study addresses this aim in three ways. First, the Unbounded Network Inter-organizational Collaborative Impact Model, a purpose-designed framework developed from existing literature, is used to investigate the process and products of inter-organizational network development. Second, the impact of a network artefact is explored. Third, the lessons learned in inter-organizational network development are considered. Data collection methods were: 16 h of ethnographic observation; 10 h of document analysis; six interviews with key informants and a survey (n = 60). Findings suggested that in developing the network, members used common aims, inter-professional collaboration, the power and trust engendered by their participation, and their leadership and management structures in a positive manner. These elements and activities underpinned the inter-organizational network to collaboratively produce the Health Expo network artefact. This event brought together healthcare providers, community groups and consumers to share information. The Health Expo demonstrated and reinforced inter-organizational working and community outreach, providing consumers with community-based information and linkages. Support and resources need to be offered for developing community inter-organizational networks, thereby building consumer capacity for self-management in the community.

The sound of urgency : understanding noise in the emergency department

Hospital noise is a worldwide issue, with detrimental effects on health and healing. The busy emergency department (ED) typically generates excess noise. Few studies have investigated noise levels within the Australian ED. This study examines noise in this setting, in turn suggesting how noise levels may be reduced. Noise level measurements occurred in 4 locations within the ED during peak staff and patient flow times over selected 7-hour periods. These were compared to the available standards and guidelines and supplemented by regular staff surveys documenting perceived noise. Findings indicated that all 4 locations exceeded the maximum recommended levels by up to 20 dB. Staff perception surveys suggested that most noise was created by people (conversations). Reducing noise in the ED may be achieved by (1) decreasing the generation of noise and (2) reviewing building layout and introducing physical noise controls such as noise-absorbing ceiling tiles and acoustic barriers/curtains.

Teaching cultural sensitivity in music therapy : reporting on an international professional development program

Background: In the context of multicultural communities worldwide, culturally diverse clients seek music therapy sessions. Cultural sensitivity is needed in practising the specialist Bonny Method of Guided Imagery and Music (GIM); therefore, GIM therapists need to be well prepared to understand their cultural needs. Beyond an often-applied “trial and error” authentic approach, relevant frameworks exist and music therapists can be trained in how to effectively apply these with a view to assessment of cultural needs in relation to GIM practice.Objective: This presentation reviews and reports on a culture-focused professional development program specifically devised for GIM therapists.Methods: The program was applied internationally to 57 participants across two locations within existing professional development trainings. Post-training responses were gained from participants via a self-report questionnaire, leading to both qualitative and quantitative analysis.Discussion: This presentation reports on the re...