Jenny Keating

A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome

IntroductionTidal volume and plateau pressure minimisation are the standard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome (ARDS). Open lung strategies, including higher positive end-expiratory pressure (PEEP) and recruitment manoeuvres to date have not proven efficacious. This study examines the effectiveness and safety of a novel open lung strategy, which includes permissive hypercapnia, staircase recruitment manoeuvres (SRM) and low airway pressure with PEEP titration.MethodTwenty ARDS patients were randomised to treatment or ARDSnet control ventilation strategies. The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O. Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1, 3, 5 and 7 (mean ± SE). Duration of ventilation, ICU stay and hospital stay (median and interquartile range) and hospital survival were determined.ResultsThere were significant overall differences between groups when considering plasma IL-8 and TNF-α. For plasma IL-8, the control group was 41% higher than the treatment group over the seven-day period (ratio 1.41 (1.11 to 1.79), P = 0.01), while for TNF-α the control group was 20% higher over the seven-day period (ratio 1.20 (1.01 to 1.42) P = 0.05). PaO2/FIO2 (204 ± 9 versus 165 ± 9 mmHg, P = 0.005) and static lung compliance (49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O, P < 0.001) were higher in the treatment group than the control group over seven days. There was no difference in duration of ventilation (180 (87 to 298) versus 341 (131 to 351) hrs, P = 0.13), duration of ICU stay (9.9 (5.6 to 14.8) versus 16.0 (8.1 to 19.3) days, P = 0.19) and duration of hospital stay (17.9 (13.7 to 34.5) versus 24.7 (20.5 to 39.8) days, P = 0.16) between the treatment and control groups.ConclusionsThis open lung strategy was associated with greater amelioration in some systemic cytokines, improved oxygenation and lung compliance over seven days. A larger trial powered to examine clinically-meaningful outcomes is warranted.Trial registrationACTRN12607000465459

The Assessment of Physiotherapy Practice (APP) is a valid measure of professional competence of physiotherapy students: a cross-sectional study with Rasch analysis

QUESTION Is the Assessment of Physiotherapy Practice (APP) a valid instrument for the assessment of entry-level competence in physiotherapy students? DESIGN Cross-sectional study with Rasch analysis of initial (n=326) and validation samples (n=318). Students were assessed on completion of 4, 5, or 6-week clinical placements across one university semester. PARTICIPANTS 298 clinical educators and 456 physiotherapy students at nine universities in Australia and New Zealand provided 644 completed APP instruments. RESULTS APP data in both samples showed overall fit to a Rasch model of expected item functioning for interval scale measurement. Item 6 (Written communication) exhibited misfit in both samples, but was retained as an important element of competence. The hierarchy of item difficulty was the same in both samples with items related to professional behaviour and communication the easiest to achieve and items related to clinical reasoning the most difficult. Item difficulty was well targeted to person ability. No Differential Item Functioning was identified, indicating that the scale performed in a comparable way regardless of the students age, gender or amount of prior clinical experience, and the educators age, gender, or experience as an educator, or the type of facility, university, or clinical area. The instrument demonstrated unidimensionality confirming the appropriateness of summing the scale scores on each item to provide an overall score of clinical competence and was able to discriminate four levels of professional competence (Person Separation Index=0.96). Person ability and raw APP scores had a linear relationship (r(2)=0.99). CONCLUSION Rasch analysis supports the interpretation that a students APP score is an indication of their underlying level of professional competence in workplace practice.

Breakeven, Cost Benefit, Cost Effectiveness, and Willingness to Pay for Web-Based Versus Face-to-Face Education Delivery for Health Professionals

Background The introduction of Web-based education and open universities has seen an increase in access to professional development within the health professional education marketplace. Economic efficiencies of Web-based education and traditional face-to-face educational approaches have not been compared under randomized controlled trial conditions. Objective To compare costs and effects of Web-based and face-to-face short courses in falls prevention education for health professionals. Methods We designed two short courses to improve the clinical performance of health professionals in exercise prescription for falls prevention. One was developed for delivery in face-to-face mode and the other for online learning. Data were collected on learning outcomes including participation, satisfaction, knowledge acquisition, and change in practice, and combined with costs, savings, and benefits, to enable a break-even analysis from the perspective of the provider, cost-effectiveness analysis from the perspective of the health service, and cost-benefit analysis from the perspective of the participant. Results Face-to-face and Web-based delivery modalities produced comparable outcomes for participation, satisfaction, knowledge acquisition, and change in practice. Break-even analysis identified the Web-based educational approach to be robustly superior to face-to-face education, requiring a lower number of enrollments for the program to reach its break-even point. Cost-effectiveness analyses from the perspective of the health service and cost-benefit analysis from the perspective of the participant favored face-to-face education, although the outcomes were contingent on the sensitivity analysis applied (eg, the fee structure used). Conclusions The Web-based educational approach was clearly more efficient from the perspective of the education provider. In the presence of relatively equivocal results for comparisons from other stakeholder perspectives, it is likely that providers would prefer to deliver education via a Web-based medium. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN): 12610000135011; http://www.anzctr.org.au/trial_view.aspx?id=335135 (Archived by WebCite at http://www.webcitation.org/668POww4L)

A Positive Response to a Recruitment Maneuver With PEEP Titration in Patients With ARDS, Regardless of Transient Oxygen Desaturation During the Maneuver:

Recruitment maneuvers (RMs) can expand collapsed alveoli in ventilated patients. The optimal method for delivering RMs is unknown. Purpose: To evaluate the safety and the respiratory and hemodynamic effects of a staircase recruitment maneuver (SRM) with decremental positive end expiratory pressure (PEEP) titration and the consequences of desaturation during the SRM in patients with early acute lung injury (ALI). Methods: In total, 20 consecutive patients with early ALI were enrolled and received an SRM. Patients were given 15 ± 3 cm H2O pressure-controlled ventilation. Positive end expiratory pressure was increased from baseline (range 10-18) to 20, 30, and 40 cm H2O every 2 minutes to achieve maximum alveolar pressure of 55 ± 3 cm H2O, then decreased at 3-minute intervals to 25, 22.5, 20, 17.5, and 15 cm H2O until a decrease of 1% to 2% oxygen saturation from maximum was detected. Positive end expiratory pressure was left at the level where the fall in oxygen saturation occurred. Standard respiratory and circulatory variables, arterial and central venous gases were measured before, during, and after the SRM. Results: There were significant improvements in shunt fraction (36.3% ± 10% to 26.4% ± 14%, P < .001), oxygen saturation (93.4% ± 2% to 96.8% ± 3%, P = .007), partial pressure of oxygen, arterial (PaO2)/fraction of inspired oxygen ([FIO2]; 150 ± 42 to 227 ± 100, P = .004), lung compliance (33.9 ± 9.1 to 40.1 ± 11.4 mL/cm H2O, P < .01), and chest x-ray (CXR) after the SRM. Briefly, 80% of the patients responded and the response was maintained at 1 hour. In total, 8 patients desaturated 6.1% ± 2.8% in SaO2 during the SRM but 5 of those improved SaO2 relative to baseline by the end of the SRM. Conclusions: In all, 80% of the patients with early ALI responded to the SRM with decremental PEEP titration. Desaturation during the SRM did not indicate a failed response 1 hour later.

Educators and students prefer traditional clinical education to a peer-assisted learning model, despite similar student performance outcomes: a randomised trial

QUESTION What is the efficacy and acceptability of a peer-assisted learning model compared with a traditional model for paired students in physiotherapy clinical education? DESIGN Prospective, assessor-blinded, randomised crossover trial. PARTICIPANTS Twenty-four physiotherapy students in the third year of a 4-year undergraduate degree. INTERVENTION Participants each completed 5 weeks of clinical placement, utilising a peer-assisted learning model (a standardised series of learning activities undertaken by student pairs and educators to facilitate peer interaction using guided strategies) and a traditional model (usual clinical supervision and learning activities led by clinical educators supervising pairs of students). OUTCOME MEASURES The primary outcome measure was student performance, rated on the Assessment of Physiotherapy Practice by a blinded assessor, the supervising clinical educator and by the student in self-assessment. Secondary outcome measures were satisfaction with the teaching and learning experience measured via survey, and statistics on services delivered. RESULTS There were no significant between-group differences in Assessment of Physiotherapy Practice scores as rated by the blinded assessor (p=0.43), the supervising clinical educator (p=0.94) or the students (p=0.99). In peer-assisted learning, clinical educators had an extra 6 minutes/day available for non-student-related quality activities (95% CI 1 to 10) and students received an additional 0.33 entries/day of written feedback from their educator (95% CI 0.06 to 0.61). Clinical educator satisfaction and student satisfaction were higher with the traditional model. CONCLUSION The peer-assisted learning model trialled in the present study produced similar student performance outcomes when compared with a traditional approach. Peer-assisted learning provided some benefits to educator workload and student feedback, but both educators and students were more satisfied with the traditional model. TRIAL REGISTRATION ACTRN12610000859088. [Sevenhuysen S, Skinner EH, Farlie MK, Raitman L, Nickson W, Keating JL, Maloney S, Molloy E, Haines TP (2014) Educators and students prefer traditional clinical education to a peer-assisted learning model, despite similar student performance outcomes: a randomised trial.Journal of Physiotherapy60: 209-216].

Simulated Patients in Physical Therapy Education: Systematic Review and Meta-Analysis

Background Traditional models of physical therapy clinical education are experiencing unprecedented pressures. Simulation-based education with simulated (standardized) patients (SPs) is one alternative that has significant potential value, and implementation is increasing globally. However, no review evaluating the effects of SPs on professional (entry-level) physical therapy education is available. Purpose The purpose of this study was to synthesize and critically appraise the findings of empirical studies evaluating the contribution of SPs to entry-level physical therapy education, compared with no SP interaction or an alternative education strategy, on any outcome relevant to learning. Data Sources A systematic search was conducted of Ovid MEDLINE, PubMed, AMED, ERIC, and CINAHL Plus databases and reference lists of included articles, relevant reviews, and gray literature up to May 2015. Study Selection Articles reporting quantitative or qualitative data evaluating the contribution of SPs to entry-level physical therapy education were included. Data Extraction Two reviewers independently extracted study characteristics, intervention details, and quantitative and qualitative evaluation data from the 14 articles that met the eligibility criteria. Data Synthesis Pooled random-effects meta-analysis indicated that replacing up to 25% of authentic patient–based physical therapist practice with SP-based education results in comparable competency (mean difference=1.55/100; 95% confidence interval=−1.08, 4.18; P=.25). Thematic analysis of qualitative data indicated that students value learning with SPs. Limitations Assumptions were made to enable pooling of data, and the search strategy was limited to English. Conclusion Simulated patients appear to have an effect comparable to that of alternative educational strategies on development of physical therapy clinical practice competencies and serve a valuable role in entry-level physical therapy education. However, available research lacks the rigor required for confidence in findings. Given the potential advantages for students, high-quality studies that include an economic analysis should be conducted.

The Interaction with Disabled Persons scale: Revisiting its internal consistency and factor structure, and examining item-level properties

The Interaction with Disabled Persons scale (IDP) has been used in research into baseline attitudes and to evaluate whether a shift in attitudes towards people with developmental disabilities has occurred following some form of intervention. This research has been conducted on the assumption that the IDP measures attitudes as a multidimensional construct and has good internal consistency. Such assumptions about the IDP appear flawed, particularly in light of failures to replicate its underlying factor structure. The aim of this study was to evaluate the construct validity and dimensionality of the IDP. This study used a prospective survey approach. Participants were recruited from first and second year undergraduate university students enrolled in health sciences, occupational therapy, physiotherapy, community and emergency health, nursing, and combined degrees of nursing and midwifery, and health sciences and social work at a large Australian university (n=373). Students completed the IDP, a 20-item self-report scale of attitudes towards people with disabilities. The IDP data were analysed using a combination of factor analysis (Classical Test Theory approach) and Rasch analysis (Item Response Theory approach). The results indicated that the original IDP 6-factor solution was not supported. Instead, one factor consisting of five IDP items (9, 11, 12, 17, and 18) labelled Discomfort met the four criteria for empirical validation of test quality: interval level scaling (scalability), unidimensionality, lacked of DIF across the two participant groups and data collection occasions, and hierarchical ordering. Researchers should consider using the Discomfort subscale of the IDP in future attitude research since it exhibits sound measurement properties.

How Physically Active Are People Following Stroke? Systematic Review and Quantitative Synthesis

Background Mobility limitations are common following stroke and frequently lead to poor participation in physical activity (PA). Purpose The purpose of this study was to describe PA across the various stages following stroke (acute, subacute, and chronic). Data Sources Searches were conducted in 5 databases. Study Selection Eligible studies included participants with stroke whose PA was quantitatively measured for at least 4 hours in a single session. Two reviewers independently reviewed titles and abstracts. Data Extraction One reviewer extracted data and assessed quality using the Downs and Black checklist. Weighted means were calculated for PA outcomes. Data Synthesis Searches yielded 103 eligible papers including 5306 participants aged 21 to 96 years. Devices (eg, activity monitors) were used in 73 papers, and behavioral mapping (observational monitoring) in 30. Devices show that people with stroke took on average 5535 steps per day (n = 406, 10 studies) in the subacute phase and 4078 steps (n = 1280, 32 studies) in the chronic phase. Average daily walking duration (% measured time) was higher in the chronic phase (9.0%, n = 100) than subacute (1.8%, n = 172), and sedentary time was >78% regardless of time post stroke. Acute data were lacking for these variables. Matched healthy individuals took an average of 8338 steps per day (n = 129). Behavioral mapping showed time in bed was higher in the acute than subacute phase (mean 45.1% versus 23.8%), with similar time spent sitting (mean 37.6% versus 32.6%). Limitations Limitations of this review include not pooling data reported as medians. Conclusions Physical activity levels do not meet guidelines following stroke. Time spent inactive and sedentary is high at all times. Increasing PA and developing standardized activity targets may be important across all stages of stroke recovery.

Management of people with acute low-back pain: a survey of Australian chiropractors

IntroductionChiropractors commonly provide care to people with acute low-back pain (LBP). The aim of this survey was to determine how chiropractors intend to support and manage people with acute LBP and if this management is in accordance with two recommendations from an Australian evidence-based acute LBP guideline. The two recommendations were directed at minimising the use of plain x-ray and encouraging the patient to stay active.MethodsThis is a cross sectional survey of chiropractors in Australia. This paper is part of the ALIGN study in which a targeted implementation strategy was developed to improve the management of acute LBP in a chiropractic setting. This implementation strategy was subsequently tested in a cluster randomised controlled trial. In this survey phase of the ALIGN study we approached a random sample of 880 chiropractors in three States of Australia. The mailed questionnaire consisted of five patient vignettes designed to represent people who would typically present to chiropractors with acute LBP. Four vignettes represented people who, according to the guideline, would not require a plain lumbar x-ray, and one vignette represented a person with a suspected vertebral fracture. Respondents were asked, for each vignette, to indicate which investigation(s) they would order, and which intervention(s) they would recommend or undertake.ResultsOf the 880 chiropractors approached, 137 were deemed ineligible to participate, mostly because they were not currently practising, or mail was returned to sender. We received completed questionnaires from 274 chiropractors (response rate of 37%). Male chiropractors made up 66% of respondents, 75% practised in an urban location and their mean number of years in practice was 15. Across the four vignettes where an x-ray was not indicated 68% (95% Confidence Intervals (CI): 64%, 71%) of chiropractors responded that they would order or take an x-ray. In addition 51% (95%CI: 47%, 56%) indicated they would give advice to stay active when it was indicated. For the vignette where a fracture was suspected, 95% (95% CI: 91%, 97%) of chiropractors would order an x-ray.ConclusionThe intention of chiropractors surveyed in this study shows low adherence to two recommendations from an evidence-based guideline for acute LBP. Quality of care for these patients could be improved through effective implementation of evidence-based guidelines. Further research to find cost-effective methods to increase implementation is warranted.

Targeted Preparation for Clinical Practice

This chapter describes the design and evaluation of a week-long curricular initiative, designed to better prepare physiotherapy students for their transition to clinical practice. Students typically report a lack of preparation and associated anxieties in making the leap from university-based learning to experiential learning in the clinical setting. The transition programme aimed to soften this interface through presenting clear expectations of clinical practice and stakeholder roles, and encouraging students to develop skills in reflection and self-regulation. Despite the transition programme receiving high satisfaction ratings from students, participants reported that their priorities leading into their first clinical placement reflected a ‘survival focus’. That is, they articulated a preoccupation with acquisition and demonstration of technical/procedural skills and viewed metacognitive skill development as ‘peripheral’ to their core business. Incorporating reflective skill development within clinical scenarios, using the advice of older students experienced in clinical education, and leaning on the heuristics and storytelling of clinicians were all viewed as mechanisms to reinforce relevancy and encourage learner engagement in the transition curriculum.