Mari Botti

Assessment of Patient Pain in the Postoperative Context

Because of its subjective nature, the assessment of pain requires the use of comprehensive practices that accurately reflect a patient’s experiences of pain. The purpose of this study was to determine how nurses make decisions in their assessment of patients’ pain in the postoperative clinical setting. An observational design was chosen as the means of examining pain activities in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were selected. Each 2-hour observation period was examined 12 times thus resulting in 74 observations. In total, 316 pain activities were determined. Five themes relating to assessment were identified from the data analysis: simple questioning, use of a pain scale, complex assessment, the lack of pain assessment, and physical examination for pain. The study identified how nurses’ prioritization of work demands created barriers in conducting timely and comprehensive pain assessment decisions.

A prospective analysis of pain experience, beliefs and attitudes, and pain management of a cohort of Danish surgical patients.

Adequacy of pain management is a process indicator of health care quality with consequences for patient outcomes and satisfaction. The reported incidence of moderate to severe postoperative pain worldwide is between 20% and 80%.

6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial

Objective To evaluate the effect of the 6-PACK programme on falls and fall injuries in acute wards. Design Cluster randomised controlled trial. Setting Six Australian hospitals. Participants All patients admitted to 24 acute wards during the trial period. Interventions Participating wards were randomly assigned to receive either the nurse led 6-PACK programme or usual care over 12 months. The 6-PACK programme included a fall risk tool and individualised use of one or more of six interventions: “falls alert” sign, supervision of patients in the bathroom, ensuring patients’ walking aids are within reach, a toileting regimen, use of a low-low bed, and use of a bed/chair alarm. Main outcome measures The co-primary outcomes were falls and fall injuries per 1000 occupied bed days. Results During the trial, 46 245 admissions to 16 medical and eight surgical wards occurred. As many people were admitted more than once, this represented 31 411 individual patients. Patients’ characteristics and length of stay were similar for intervention and control wards. Use of 6-PACK programme components was higher on intervention wards than on control wards (incidence rate ratio 3.05, 95% confidence interval 2.14 to 4.34; P<0.001). In all, 1831 falls and 613 fall injuries occurred, and the rates of falls (incidence rate ratio 1.04, 0.78 to 1.37; P=0.796) and fall injuries (0.96, 0.72 to 1.27; P=0.766) were similar in intervention and control wards. Conclusions Positive changes in falls prevention practice occurred following the introduction of the 6-PACK programme. However, no difference was seen in falls or fall injuries between groups. High quality evidence showing the effectiveness of falls prevention interventions in acute wards remains absent. Novel solutions to the problem of in-hospital falls are urgently needed. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12611000332921.

Implementation of a management guideline aimed at minimizing the severity of primary graft dysfunction after lung transplant.

OBJECTIVE Primary graft dysfunction, a severe form of lung injury that occurs in the first 72 hours after lung transplant, is associated with morbidity and mortality. We sought to assess the impact of an evidence-based guideline as a protocol for respiratory and hemodynamic management. METHODS Preoperative and postoperative data for patients treated per the guideline (n = 56) were compared with those of a historical control group (n = 53). Patient data such as ratio of arterial Po(2) to inspired oxygen fraction, central venous pressure, cumulative fluid balance, vasopressor dose, and serum urea and creatinine were measured and documented at specific times. Primary outcome was severity of primary graft dysfunction within the first 72 hours. RESULTS Primary graft dysfunction grade was progressively lower in patients treated after introduction of the guideline (P = .01). Lower postoperative fluid balances (P = .01) and vasopressor doses (P = .007) were seen, with no associated renal dysfunction. There were no differences in duration of mechanical ventilation or mortality. Nonadherence to the guideline occurred in 10 cases (18%). CONCLUSIONS Implementation of an evidence-based guideline for managing respiratory and hemodynamic status is feasible and safe and was associated with reduction in severity of primary graft dysfunction. Further studies are required to determine whether such a guideline would lead to a consistent reduction in severity of primary graft dysfunction at other institutions. Creation of a protocol for postoperative care provides a template for further studies of novel therapies or management strategies for primary graft dysfunction.

Effects of a clinician referral and exercise program for men who have completed active treatment for prostate cancer: A multicenter cluster randomized controlled trial (ENGAGE)

BACKGROUND : The purpose of this study was to determine the efficacy of a clinician referral and exercise program in improving exercise levels and quality of life for men with prostate cancer. METHODS : This was a multicenter cluster randomized controlled trial in Melbourne, Australia comprising 15 clinicians: 8 clinicians were randomized to refer eligible participants (n = 54) to a 12-week exercise program comprising 2 supervised gym sessions and 1 home-based session per week, and 7 clinicians were randomized to follow usual care (n = 93). The primary outcome was self-reported physical activity; the secondary outcomes were quality of life, anxiety, and symptoms of depression. RESULTS : A significant intervention effect was observed for vigorous-intensity exercise (effect size: Cohens d, 0.46; 95% confidence interval [CI], 0.09-0.82; P = .010) but not for combined moderate and vigorous exercise levels (effect size: d, 0.08; 95% CI, −0.28 to 0.45; P = .48). Significant intervention effects were also observed for meeting exercise guidelines (≥150 min/wk; odds ratio, 3.9; 95% CI, 1.9-7.8; P = .002); positive intervention effects were observed in the intervention group for cognitive functioning (effect size: d, 0.34; 95% CI, −0.02 to 0.70; P = .06) and depression symptoms (effect size: d, −0.35; 95% CI, −0.71 to 0.02; P = .06). Eighty percent of participants reported that the clinicians referral influenced their decision to participate in the exercise program. CONCLUSIONS : The clinician referral and 12-week exercise program significantly improved vigorous exercise levels and had a positive impact on mental health outcomes for men living with prostate cancer. Further research is needed to determine the sustainability of the exercise program and its generalizability to other cancer populations.The purpose of this study was to determine the efficacy of a clinician referral and exercise program in improving exercise levels and quality of life for men with prostate cancer.

Efficacy of a referral and physical activity program for survivors of prostate cancer [ENGAGE]: Rationale and design for a cluster randomised controlled trial

AbstractBackgroundDespite evidence that physical activity improves the health and well-being of prostate cancer survivors, many men do not engage in sufficient levels of activity. The primary aim of this study (ENGAGE) is to determine the efficacy of a referral and physical activity program among survivors of prostate cancer, in terms of increasing participation in physical activity. Secondary aims are to determine the effects of the physical activity program on psychological well-being, quality of life and objective physical functioning. The influence of individual and environmental mediators on participation in physical activity will also be determined.Methods/DesignThis study is a cluster randomised controlled trial. Clinicians of prostate cancer survivors will be randomised into either the intervention or control condition. Clinicians in the intervention condition will refer eligible patients (n = 110) to participate in an exercise program, comprising 12 weeks of supervised exercise sessions and unsupervised physical activity. Clinicians allocated to the control condition will provide usual care to eligible patients (n = 110), which does not involve the recommendation of the physical activity program. Participants will be assessed at baseline, 12 weeks, 6 months, and 12 months on physical activity, quality of life, anxiety, depression, self-efficacy, outcome expectations, goals, and socio-structural factors.DiscussionThe findings of this study have implications for clinicians and patients with different cancer types or other chronic health conditions. It will contribute to our understanding on the potential impact of clinicians promoting physical activity to patients and the long term health benefits of participating in physical activity programs.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000609055 Deakin University Human Research Ethics Approval 2011-085

Unmet needs and depression among carers of people newly diagnosed with cancer.

AIMS The aims of this analysis were to examine levels of unmet needs and depression among carers of people newly diagnosed with cancer and to identify groups who may be at higher risk, by examining relationships with demographic characteristics. METHODS One hundred and fifty dyads of people newly diagnosed with cancer and their carers, aged 18 years and older, were recruited from four Australian hospitals. People with cancer receiving adjuvant cancer treatment with curative intent, were eligible to participate. Carers completed the Supportive Care Needs Survey-Partners & Caregivers (SCNS-P&C45), and both carers and patients completed the Centre of Epidemiologic-Depression Scale (CES-D). RESULTS Overall, 57% of carers reported at least one, 37% at least three, 31% at least five, and 15% at least 10 unmet needs; the most commonly endorsed unmet needs were in the domains of information and health care service needs. Thirty percent of carers and 36% of patients were at risk of clinical depression. A weak to moderate positive relationship was observed between unmet needs and carer depression (r=0.30, p<0.001). Carer levels of unmet needs were significantly associated with carer age, hospital type, treatment type, cancer type, living situation, relationship status (in both uni- and multi-factor analysis); person with cancer age and carer level of education (in unifactor analysis only); but not with carer gender or patient gender (in both uni- and multi-factor analyses). CONCLUSION Findings highlight the importance of developing tailored programmes to systematically assist carers who are supporting patients through the early stages of cancer treatment.

Psychosocial issues of women with type 1 diabetes transitioning to motherhood: a structured literature review

BackgroundLife transitions often involve complex decisions, challenges and changes that affect diabetes management. Transition to motherhood is a major life event accompanied by increased risk that the pregnancy will lead to or accelerate existing diabetes-related complications, as well as risk of adverse pregnancy outcomes, all of which inevitably increase anxiety. The frequency of hyperglycaemia and hypoglycaemia often increases during pregnancy, which causes concern for the health and physical well-being of the mother and unborn child. This review aimed to examine the experiences of women with T1DM focusing on the pregnancy and postnatal phases of their transition to motherhood.MethodsThe structured literature review comprised a comprehensive search strategy identifying primary studies published in English between 1990–2012. Standard literature databases were searched along with the contents of diabetes-specific journals. Reference lists of included studies were checked. Search terms included: ‘diabetes’, ‘type 1’, ‘pregnancy’, ‘motherhood’, ‘transition’, ‘social support’, ‘quality of life’ and ‘psychological well-being’.ResultOf 112 abstracts returned, 62 articles were reviewed in full-text, and 16 met the inclusion criteria. There was a high level of diversity among these studies but three common key themes were identified. They related to physical (maternal and fetal) well-being, psychological well-being and social environment. The results were synthesized narratively.ConclusionWomen with type 1 diabetes experience a variety of psychosocial issues in their transition to motherhood: increased levels of anxiety, diabetes-related distress, guilt, a sense of disconnectedness from health professionals, and a focus on medicalisation of pregnancy rather than the positive transition to motherhood. A trusting relationship with health professionals, sharing experiences with other women with diabetes, active social support, shared decision and responsibilities for diabetes management assisted the women to make a positive transition. Health professionals can promote a positive transition to motherhood by proactively supporting women with T1DM in informed decision-making, by facilitating communication within the healthcare team and co-ordinating care for women with type 1 diabetes transitioning to motherhood.

The effect of pressure bandaging on complications and comfort in patients undergoing coronary angiography: a multicenter randomized trial

OBJECTIVES To determine the effectiveness of pressure bandaging in reducing bleeding and bruising in patients undergoing coronary angiography and to investigate the contribution that pressure bandages make to patient discomfort after angiography. DESIGN A prospective multicenter, randomized study. SETTING Three university hospitals in Melbourne, Australia. PATIENTS One thousand seventy-five patients undergoing coronary angiography were randomized to receive a pressure bandage (N = 556) or no bandage (N = 519) after manual compression of the right femoral artery puncture site. RESULTS Patients without pressure bandages had a higher incidence of bleeding (P < 0.05) and bled earlier (mean 2.4 hours; SD 3.6 hours) after catheter removal (P < 0.001) than patients with bandages (mean 5.3 hours; SD 3.8 hours). The incidence of bleeding in patients without pressure bandages was 6.7%. The incidence and extent of bruising was the same for both groups. Patients with pressure bandages experienced a higher incidence of back (P < 0.05), groin (P < 0.001), and leg pain (P < 0.001), nausea (P < 0.05) and urinary difficulty (P < 0.01). CONCLUSIONS In view of the associated increase in patient discomfort and the delay in time of onset of bleeding, pressure bandages should not be used routinely in the management of patients after coronary angiography, especially in the context of early discharge from the hospital.

Reported medication errors after introducing an electronic medication management system

AIMS AND OBJECTIVES To explore the effects of introducing an electronic medication management system on reported medication errors. BACKGROUND Computerised medication management systems have been found to improve medication safety; however, introducing medication management system into healthcare environments can create unanticipated or new problems and opportunities for medication error. DESIGN Descriptive analysis of medication error reports. METHODS This was a retrospective analysis of 359 incident reports drawn from the period of 1 May 2005-30 April 2006 across two hospital sites of a single not-for-profit private health service located in metropolitan Melbourne. Site A used a conventional pen and paper system for medication management, and Site B had introduced a computerised medication management system. RESULTS Most medication errors occurred at the nurse administration (71·5%) and prescribing (16·4%) stages of delivery. The most common medication error type reported at Site A was omission (33%), and at Site B was wrong documentation (24·2%). A higher proportion of errors at the prescribing phase, and less nurse administration errors, were detected at Site B where the medication management system was in use. The incidence of other, less frequent errors was similar across the two hospital sites. CONCLUSIONS This examination of medication error reports suggests there are differences in the types of medication errors that are reported in association with the introduction of electronic medication management system compared to pen and paper system systems. The findings provide a new insight into the effects of introducing an electronic medication management system on the types of medication errors reported. RELEVANCE TO CLINICAL PRACTICE The findings provide a new insight into the types of medication errors that are reported during implementation of an electronic medication management system. Extra support for physicians prescribing practices should be considered.