Paul McLiesh

Are we providing the best possible pain management for our elderly patients in the acute-care setting?

BACKGROUND During 2008 seven practice improvement projects were conducted in an acute-care hospital under the banner of The Older Person and Improving Care (TOPIC 7). Each project team examined a discrete aspect of care of the elderly and this project focus was on pain management and in particular assessment of the older person with communication difficulties. AIMS The project intended to assess current practice and implement changes to match best practice in the management of pain in the older person within an acute-care setting. METHODS A multidisciplinary team was recruited to conduct the project. The pain team with the other six TOPIC 7 teams was facilitated by a coordinating team. The project was divided into four phases. Phase one was designated as Describing, where the clinical issue was identified and focused to priority areas. It was decided to focus on the elderly who were unable to verbally communicate their pain management needs. Standards of practice relevant to the area of practice were sourced to guide practice improvement. Phase two was Measuring activity where clinical audits were used to measure current practice and compare this with the appropriate standards. Phase three was Taking action where a range of practice improvement activities were implemented including the introduction of the Abbey Pain Scale. The final phase was designated as Review and share where the impact of the project activities was measured with a follow-up audit and the results were disseminated. RESULTS Initial results showed a need for increased awareness of the difficulties in the pain assessment and management of older persons who cannot verbally communicate their needs. Seventy-eight per cent of patients had a documented pain assessment in the previous 24 h on audit. However, 83% of these assessments were only a general comment in the patient records. No tools were available for completing a systematic assessment that was reliable and reproducible. Sixty-two per cent of patients did not have analgesia administered 1 h before mobilising or having a significant dressing completed. Reaudit, posteducation sessions, showed an increase in the awareness in the complexities involved in caring for this group of patients. An alternate, specific tool (Abbey Pain Scale) was utilised well by staff and acted as a prompt in reminding staff to assess the pain levels of their elderly patients. CONCLUSIONS Globally, pain in the older person is poorly managed. Pain in older persons who are unable to communicate or who have difficulty in communicating their needs is even more poorly managed. However, the availability of an appropriate tool and an increased awareness of this issue can have a significant and real impact on the pain management of this group of patients.

Identifying and reducing the incidence of post discharge Venous Thromboembolism (VTE) in orthopaedic patients: a systematic review

Background The risk of venous thromboembolism for orthopaedic patients is often high due to the length of surgery, damage from trauma to bone and soft tissues and lengthy periods of immobility or reduced mobility. Although venous thromboembolism occurs mainly in inpatients a significant number of patients develop venous thromboembolism post discharge Objectives To synthesise the best available evidence on strategies that effectively reduce post discharge venous thromboembolism in orthopaedic patients. Inclusion criteria Types of participants Patients regardless of age, gender or co‐morbidities that have been admitted with an acute orthopaedic injury (unplanned) or a planned orthopaedic surgery/procedure and then followed up after discharge. Only papers describing the incidence and prophylaxis treatment used in non‐Asian patients were considered for inclusion. Types of interventions Any interventions of combinations of chemoprophylaxis and/or mechanical prophylaxis to prevent venous thromboembolism incidence extending beyond hospital admission. Types of outcomes Outcomes included diagnosis of venous thromboembolism following an orthopaedic admission/surgery for up to 6 months post discharge and the incidence of any significant bleeding or death related to venous thromboembolism or haemorrhage. Types of studies The review considered any randomised controlled trials; in the absence of RCTs other research designs, such as non‐randomised controlled trials and before and after studies, were considered Search strategy Search strategy considered only papers in English from 2000 to March 2012. Methodological quality Papers selected for retrieval were assessed using standardised critical appraisal instruments from the Joanna Briggs Institute. Data collection Data was extracted from the studies using the standardised Johanna Briggs Institute data extraction form. Data synthesis Of the included studies none matched methodology, treatment or comparator that allowed meta‐analysis. The results were therefore presented in a narrative form and were structured using patient population, then intervention and then analysis of results. Results 20 articles were included in the systematic review. The overall incidence of post discharge venous thromboembolism in orthopaedic patients is not possible to determine due to the variability in reporting criteria and poor follow‐up. Use of Low Molecular Weight Heparins was generally shown to be effective in preventing venous thromboembolism. The new generation Factor Xa inhibitors were shown to improve venous thromboembolism prevention however had a slightly higher risk of bleeding. There was limited high level research presented to allow effective assessment of aspirin and/or mechanical compression devices. Conclusions Prevention of post discharge venous thromboembolism is complex due to the number of variables that can influence its occurrence. The risk of post discharge venous thromboembolism varies among different patient populations so consideration must be given to matching the risk for each of those groups with available interventions. Implications for practice For higher risk orthopaedic patient groups such as those with large joint replacements and femoral fractures low molecular weight heparins should be considered and continued where possible post discharge for thirty days however the risk profile for venous thromboembolism and bleeding must be considered for both populations and individuals. Implications for research Consideration in future research design must be given to factors such as: adequate follow‐up time, and standardised criteria to measure the incidence of post discharge venous thromboembolism.

Orthopaedic nursing in developing nations: A collaboration between the Republic of the Union of Myanmar (Burma) and Australia

This paper describes a collaboration between orthopaedic nurses in Myanmar (Burma) and Australia. It aims to explores how that collaboration began and how it can grow and has grown. The unique needs and challenges of healthcare delivery in developing nations are discussed. Understanding these unique needs and challenges is vital in tailoring strategies to provide orthopaedic nurses in those countries with resources that are suitable to assist them in providing the highest level of quality care to their patients. The authors hope that this example may inspire other orthopaedic nurses and organisations around the globe to participate in this type of activity with the understanding that it benefits all those involved, nurses from both developed and developing countries, as well as improving patient care.

Introducing the understanding research series

I am pleased to introduce, in this issue, a series designed to assist readers in understanding research, especially for those who are not familiar with research methodologies (theoretical basis) and language. The series will contain papers dedicated to assisting readers in developing an understanding of research terminology and design. Each paper will focus on different aspects of research design and methodology. This first paper in the series will provide a broad overview of what research is and why it is important; describing good practice in research and providing a brief summary of the different types of research methodologies. My hope is that this series will demystify research and provide the reader with insight into why research is conducted in certain ways as well as identify its usefulness and applicability for practice. Prior to leaving the clinical setting in 2012 and beginning as a lecturer at the University of Adelaide in South Australia, I had only a rudimentary understanding of what research entailed, how and why it was conducted and how to identify well-designed and presented research. I was very comfortable with the notion that there were a wide variety of types of practice, settings, specialities, ways of practicing, levels of expertise and specific ‘language’ used. To a non-healthcare professional that language, and variations in specialities and settings, can be confusing, foreign and challenging to understand. Even in different speciality healthcare settings, there are unique sets of language and ways of communicating. The same is true for research. There are a wide range and diverse types of research designed to focus on different issues and elements of practice. Some may consider the effectiveness of a new medication or treatment type (Parsons et al., 2013) while others may seek to understand the experience of certain phenomena or identify the meaning of why things occur in the world the way they do (Sjøeveian and Leegaard, 2017). Research is conducted to help us better understand our world and the complexity of interactions within it. By knowing these relationships, we can add to our collective knowledge of the world and the clinical setting and use this information to change or refine our practice to provide better care and improve outcomes for all involved. Everything that we may today take for granted in our understanding of healthcare and nursing, has at some point in history been identified, researched and tested by someone. We have benefited from their devotion to knowledge development and investigations because we are now able to use this knowledge as a basis of our practice. Just like in healthcare, research also uses its own unique ‘language’ and this can vary greatly between research methodologies. To the nurse or healthcare professional who has not been exposed to formal research training, this language may seem foreign. Attempting to read a research article that identifies elements such as p-values, confidence intervals, parametric testing, t-tests, fusion of horizons, thematic analysis, heterogeneity, ordinal data, frequency distribution, PICO, Intention to treat and type 1 errors

The value of specialist orthopaedic nurses.

As orthopaedic nurses we believe that we possess specialist orthopaedic knowledge and skills that are used daily to deliver effective care to our patients. In the acute care setting this care has b ...