Kasia Bail

Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study

Objectives To identify rates of potentially preventable complications for dementia patients compared with non-dementia patients. Design Retrospective cohort design using hospital discharge data for dementia patients, case matched on sex, age, comorbidity and surgical status on a 1 : 4 ratio to non-dementia patients. Setting Public hospital discharge data from the state of New South Wales, Australia for 2006/2007. Participants 426 276 overnight hospital episodes for patients aged 50 and above (census sample). Main outcome measures Rates of preventable complications, with episode-level risk adjustment for 12 complications that are known to be sensitive to nursing care. Results Controlling for age and comorbidities, surgical dementia patients had higher rates than non-dementia patients in seven of the 12 complications: urinary tract infections, pressure ulcers, delirium, pneumonia, physiological and metabolic derangement (all at p<0.0001), sepsis and failure to rescue (at p<0.05). Medical dementia patients also had higher rates of these complications than did non-dementia patients. The highest rates and highest relative risk for dementia patients compared with non-dementia patients, in both medical and surgical populations, were found in four common complications: urinary tract infections, pressure areas, pneumonia and delirium. Conclusions Compared with non-dementia patients, hospitalised dementia patients have higher rates of potentially preventable complications that might be responsive to nursing interventions.

Reporting a research project on the potential of aged care nurse practitioners in the Australian Capital Territory

AIM This paper reports a project investigating the potential role of the nurse practitioner in aged care across residential, community and acute care venues in the Australian Capital Territory. BACKGROUND Australia, like many other countries, faces unprecedented challenges in the provision of health care. Escalating health care costs, an ageing population, increasing prevalence of comorbidities and chronic illnesses, inefficient health care delivery, changing models of health care and shifting professional role boundaries are factors that have contributed to the development of advanced practice roles for nursing. DESIGN This was a mixed methods study using multiple data sources. METHODS Student aged care nurse practitioners were examined across the continuum of care in the acute, community and residential aged care settings. The potential role of the nurse practitioner in these areas was evaluated qualitatively and quantitatively to identify a model of care to enhance the delivery of efficient and effective health care. RESULTS The project findings have demonstrated that there is potential for significant improvement in client outcomes arising from a transboundary aged care nurse practitioner model. The improved outcomes are associated with a decrease in acute hospital admissions for residential care clients, timely intervention for a range of common conditions and strengthened multidisciplinary approaches to care provision for older people. CONCLUSIONS Overall the project findings strongly support the potential of a transboundary aged care nurse practitioner role. This role would focus on skilled assessment, timely assessment and intervention, brokering around access to care and clinical leadership and education for nurses. RELEVANCE TO CLINICAL PRACTICE This paper offers further evidence of support for the role of nurse practitioners in complementing existing health services and improving delivery of care.

Characteristics of rural hospital services for people with dementia: Findings from the Hospital Dementia Services Project

OBJECTIVE To obtain information about aged care services in rural New South Wales public hospitals, and to describe key operational aspects of their service delivery models. DESIGN A mixed methods design was used to combine data collected from: (i) a survey of public hospitals and (ii) qualitative site visits in a sample of eleven rural sites. SETTING Rural public hospitals in NSW, Australia. PARTICIPANTS Qualitative data were collected from multidisciplinary clinicians, managers and community service providers who participated in site visits in 2010 and from surveys of NSW public hospitals in 2009/10 about aged care and dementia services. RESULTS Survey and site visit findings demonstrated that rural hospitals have fewer secure beds for managing patients with disturbed behaviour due to dementia and delirium and fewer speciality aged care staff than metropolitan hospitals. Site visit participants also described how secure environments can aid care for people with dementia even in the absence of clinical specialists. CONCLUSION The care of people with dementia in rural hospitals is constrained by access to specialist aged care staff and the physical environment of the hospital. Clinicians are adept at maximising resources to manage diagnosis and transitions for people with dementia. Further understanding of how key operational aspects of clinical leadership and environmental modifications impact on a range of patient outcomes would be valuable.

Engaging nurses in patient care: clinical reflection by a student nurse.

I stood by, the endless student nurse observer, as a woman (let’s call her Joan) was transferred by trolley from the helicopter into emergency following an acute period of respiratory distress. Two nurses from the department were present for hand-over, and three ambulance persons brought her in. Joan’s condition appeared stable, as far as I could tell; her bed was at a ninety-degree angle and her oxygen-assisted breathing was very laboured, but she seemed aware of her immediate surroundings. Joan traveled on the helicopter trolley into the emergency ward, was transferred to an emergency bed, the necessary tubes and wires were re-organised, her hand-over was verbalised and the personal weekends of the treating team were discussed amongst themselves. To my increasing frustration, not one staff member looked Joan in the eye, said hello, or did anything to acknowledge her presence as anything other than another technical detail. This paper was inspired by the above incident, viewed as a nursing student in the emergency department. The clinical reflection that developed around this particular incident was how easily care by nurses could be limited to the physical needs of the patient. This paper is premised on the clinical reflection that engagement by nurses with patients is necessary for optimal patient care. The literature was reviewed, and the concept of ‘engagement’ was used to refer to the actual connection of one person to another via honest care and dedicated communication. I suggest, with literary support, that this lack of engagement extends from the inability of the nurse to provide sufficient care to fulfill the needs of the patient. The current mismatch between duty and ability for nurses is cited as being due to an increasing number of stressors. Major stressors include a lack of support from senior staff; insufficient staff; having too much work and too little time, and the inability to meet patients’ needs (McNeely 1996). Accumulated stress has detrimental effects on nursing care, namely the nurse’s lack of energy and emotional resources due to the stress. These stressors result in coping mechanisms that can additionally affect the manner in which nurses engage their patients. Nursing is an emotional art form, and factors affecting the creation of such an art form are potentially debilitating to nurses and patients alike. This paper will clinically reflect on the implications of such a lack of engagement to both the patient and the nurse, and on the opportunity for individuals and organisations to realise their responsibility in the promotion of nurse–patient engagement.

Potential scope and impact of a transboundary model of nurse practitioners in aged care

Aged care is a growing issue in Australia and other countries. There are significant barriers to meeting the health needs of this population. Current services have gaps between care and lack communication and integration between care providers. Research was conducted in the Australian Capital Territory to investigate the potential role of the aged care nurse practitioner in health service delivery in aged care settings. A multimethod case study design was utilised, with three student nurse practitioners (SNP) providing care to aged care clients across three sectors of health service delivery (residential aged care facilities, general medical practices and acute care). Data collection consisted of in-depth interviews and journal entries of the SNP, as well as focus groups and surveys of multidisciplinary staff and patients over the age of 65 years in the settings frequented by the SNP. The aged care SNP were found to cross professional and organisational boundaries, cross intra- as well as interorganisational boundaries and to contribute to more seamless patient care as members of a multidisciplinary aged care team. The aged care nurse practitioner role consequently has the potential to function in a networked rather than a hierarchical manner, and this could be a key element in addressing gaps in care across care locales and between disciplines.

The Canberra Dedicated Education Unit

This chapter describes the uptake of the Dedicated Education Unit in Canberra, Australia, based on the Flinders University model. The authors provide brief background information about Canberra and the University of Canberra undergraduate nursing curriculum before describing the curriculum redesign required for uptake of the Dedicated Education Unit, key Dedicated Education Unit roles and responsibilities, key assumptions about students in the Dedicated Education Unit context, supports for student learning, engaging clinicians in the learning culture, activities used to promote learning, assessment strategies and different clinical settings for specific Dedicated Education Units. They then shift the focus to evaluation of current Canberra Dedicated Education Units and reflect on the challenges facing Dedicated Education Units, such as the need for ongoing revision of, and engagement with, this clinical education model, and administration. The chapter ends with considerations about the further development of Dedicated Education Units and research possibilities within them.

Feasibility of integrating residential care pharmacists into aged care homes to improve quality use of medicines: Study protocol for a non-randomised controlled pilot trial

Older adults are particularly susceptible to iatrogenic disease and communicable diseases, such as influenza. Prescribing in the residential aged care population is complex, and requires ongoing review to prevent medication misadventure. Pharmacist-led medication review is effective in reducing medication-related problems; however, current funding arrangements specifically exclude pharmacists from routinely participating in resident care. Integrating an on-site clinical pharmacist into residential care teams is an unexplored opportunity to improve quality use of medicines in this setting. The primary objective of this pilot study is to investigate the feasibility of integrating a residential care pharmacist into the existing care team. Secondary outcomes include incidence of pharmacist-led medication review, and incidence of potential medication problems based on validated prescribing measures. This is a cross-sectional, non-randomised controlled trial with a residential care pharmacist trialled at a single facility, and a parallel control site receiving usual care and services only. The results of this hypothesis-generating pilot study will be used to identify clinical outcomes and direct future larger scale investigations into the implementation of the novel residential care pharmacist model to optimise quality use of medicines in a population at high risk of medication misadventure.

A Comparison of Open Access in Exercise Science Journals: 2010 to 2012

The aim of this study was to complete an audit on the number of open access journals within the discipline of Exercise Science. Publishing in open access journals results in wide dissemination of material in a very short period of time compared with the more traditional way of publishing in a subscription journal. The 2010 ERA journal list, category Human Movement and Sport Science, was initially utilised and then compared with the openness of the same journals in 2012. In this study journals were audited for their degree of open access, open licensing and open format. Open access relates to the free online availability of research results and hence research publications and in the discipline of exercise science relates to the concept of an idealised level playing field. Open licensing relates to the ability of the consumers to replicate and share those publications freely whilst open format relates to the use of open and transferrable format types. Open access increased (p=0.014) as did our measurement of open licensing (p=0.000) and open formats (p=0.021) between the 2010 and 2012 reviews of the journals in 1106 For code. This study reveals an increase in the number of Exercise Science journals that have full or partial open access over the two year period and suggests that authors are increasingly adopting peer reviewed open access journal publications. It is evident from this study that the impact of open access journals be assessed and further research into the feasibility of such a rating is imperative.

Patient and Professional Dissatisfaction: A Literature Review of Prognosis Communication Related to Hospital Settings

An essential element of health care decision making is related to ‘what is going to happen next’ (or prognosis). Patients are often dissatisfied with prognosis communication (Chan & Woodruff 1997; Kirk, Kirk & Kristjanson 2004). Yet there is a paucity of literature on the contributing factors and resulting consequences of prognosis communication. A thematic analysis on prognosis communication applicable to hospital wards was employed. The thematic analysis revealed that patients are dissatisfied with prognosis communication, and this dissatisfaction is related to information giving, understanding, and decision making. There is also evidence to suggest that health care professionals are also distressed and dissatisfied with the current use of prognosis in health care delivery, and this relates to hope, role discrepancies, and emotional labour. Factors identified in the literature as contributing to the current use of prognosis included difficulty with the definition, estimation and communication of prognosis. The contributing factor of the medical model upon prognosis communication is discussed. The suggestion is made that if both consumers and providers are dissatisfied with current prognosis communication, then there should be sufficient relevant research funded, undertaken and utilised to inform training, policy changes and individual clinical practice reflection in the movement towards more patient-focussed, sustainable health care.

Predicting excess cost for older inpatients with clinical complexity: A retrospective cohort study examining cognition, comorbidities and complications

Background Hospital-acquired complications increase length of stay and contribute to poorer patient outcomes. Older adults are known to be at risk for four key hospital-acquired complications (pressure injuries, pneumonia, urinary tract infections and delirium). These complications have been identified as sensitive to nursing characteristics such as staffing levels and level of education. The cost of these complications compared to the cost of admission severity, dementia, other comorbidities or age has not been established. Method To investigate costs associated with nurse-sensitive hospital-acquired complications in an older patient population 157,178 overnight public hospital episodes for all patients over age 50 from one Australian state, 2006/07 were examined. A retrospective cohort study design with linear regression analysis provided modelling of length-of-stay costs. Explanatory variables included patient age, sex, comorbidities, admission severity, dementia status, surgical status and four complications. Extra costs were based on above-average length-of-stay for each patient’s Diagnosis Related Group from hospital discharge data. Results For adults over 50 who have length of stay longer than average for their diagnostic condition, comorbid dementia predicts an extra cost of A