Sonya Osborne

Best practice in stabilisation of oral endotracheal tubes: A systematic review

Mechanical ventilation of patients in intensive care units is common practice. Artificial airways are utilised to facilitate ventilation and the endotracheal tube (ETT) is most commonly used for this purpose. The ETT must be stabilised to optimise ventilation and avoid displacement or unplanned extubation. Tube movement is a major factor in causing airway trauma. A destabilised tube can cause fatal complications. A systematic review was conducted to identify and analyse the best available evidence on ETT stabilisation to determine which stabilisation method resulted in reduced tube displacement and the least amount of unplanned or accidental extubations. The types of stabilisations included one or a combination of the following methods: twill or cotton tape, adhesive tape, gauze, or a manufactured device. All relevant randomised controlled and quasi-experimental studies of ETT stabilisation practices, identified through electronic and hand searching, were assessed for inclusion in the study. One published randomised controlled trial and six published quasi-experimental studies met the inclusion and exclusion criteria and were retrieved. Data were extracted independently by two reviewers. Results of the systematic review showed that no single method of ETT stabilisation could be identified as superior for minimising tube displacement and unplanned or accidental extubations. Rigorous randomised controlled trials with clearly identified and described ETT stabilisation methods are required to establish best practice. In addition, comparative research to evaluate cost effectiveness and nursing time requirements would also be of significant benefit to critical care nursing practice.

Reconceptualising the objectives of a pilot study for clinical research

This is a methodological study in which a case report is used to retrospectively analyse the link between a successful pilot study and stalled main study to identify potential methodological weaknesses in the planning process. The analysis identified unanticipated influences related to hospital processes and discipline boundaries that adversely influenced participant recruitment and retention for a clinical trial. The findings of the study demonstrate that, whilst the pilot is an important step in research planning to confirm the design and operational processes for a study, a thorough analysis of the relevant health service environment is an important additional objective for the pilot study.

Meta-analysis of preoperative antiseptic bathing in the prevention of surgical site infection

Preoperative bathing with an antiseptic solution is widely used to prevent surgical site infection, but trial results are conflicting.

Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting.

The purpose of this cross‐sectional study was to identify the prevalence of incontinence and incontinence‐associated dermatitis (IAD) in Australian acute care patients and to describe the products worn to manage incontinence, and those provided at the bedside for perineal skin care. Data on 376 inpatients were collected over 2 days at a major Australian teaching hospital. The mean age of the sample group was 62 years and 52% of the patients were male. The prevalence rate of incontinence was 24% (91/376). Urinary incontinence was significantly more prevalent in females (10%) than males (6%) (χ2 = 4·458, df = 1, P = 0·035). IAD occurred in 10% (38/376) of the sample group, with 42% (38/91) of incontinent patients having IAD. Semi‐formed and liquid stool were associated with IAD (χ2 = 5·520, df = 1, P = 0·027). Clinical indication of fungal infection was present in 32% (12/38) of patients with IAD. Absorbent disposable briefs were the most common incontinence aids used (80%, 70/91), with soap/water and disposable washcloths being the clean‐up products most commonly available (60%, 55/91) at the bedside. Further data are needed to validate this high prevalence. Studies that address prevention of IAD and the effectiveness of management strategies are also needed.

Nursing and medical perceptions of a hospital rapid response system: new process but same old game?

Perhaps no other patient safety intervention depends so acutely on effective interprofessional teamwork for patient survival than the hospital rapid response system. Yet, little is known about nurse-physician relationships when rescuing at-risk patients. This study compared nursing and medical staff perceptions of a mature rapid response system at a large tertiary hospital. Findings indicate that the rapid response system may be failing to address a hierarchical culture and systems-level barriers to early recognition and response to patient deterioration.

The Skin Safety Model: Reconceptualizing Skin Vulnerability in Older Patients

PURPOSE To develop a unique skin safety model (SSM) that offers a new and unified perspective on the diverse yet interconnected antecedents that contribute to a spectrum of potential iatrogenic skin injuries in older hospitalized adults. ORGANIZING CONSTRUCT Discussion paper. METHODS A literature search of electronic databases was conducted for published articles written in English addressing skin integrity and iatrogenic skin injury in elderly hospital patients between 1960 and 2014. FINDINGS There is a multiplicity of literature outlining the etiology, prevention, and management of specific iatrogenic skin injuries. Complex and interrelated factors contribute to iatrogenic skin injury in the older adult, including multiple comorbidities, factors influencing healthcare delivery, and acute situational stressors. A range of injuries can result when these factors are complicated by skin irritants, pressure, shear, or friction; however, despite skin injuries sharing multiple antecedents, no unified overarching skin safety conceptual model has been published. CONCLUSIONS The SSM presented in this article offers a new, unified framework that encompasses the spectrum of antecedents to skin vulnerability as well as the spectrum of iatrogenic skin injuries that may be sustained by older acute care patients. Current skin integrity frameworks address prevention and management of specific skin injuries. In contrast, the SSM recognizes the complex interplay of patient and system factors that may result in a range of iatrogenic skin injuries. Skin safety is reconceptualized into a single model that has the potential for application at the individual patient level, as well as healthcare systems and governance levels. CLINICAL RELEVANCE Skin safety is concerned with keeping skin safe from any iatrogenic skin injury, and remains an ongoing challenge for healthcare providers. A conceptual framework that encompasses all of the factors that may contribute to a range of iatrogenic skin injuries is essential, and guides the clinician in maintaining skin integrity in the vulnerable older patient.

Does evening removal of urinary catheters shorten hospital stay among general hospital patients?: A randomized controlled trial

OBJECTIVE Literature indicates that removing urinary catheters at midnight facilitates earlier discharge among urology patients, but the effect of evening removal on the general patient population is unknown. The objective of this study was to investigate whether removing a urinary catheter at 22.00 hours compared to 06.00 hours among a general hospital population would lead to earlier hospital discharge. DESIGN Randomized controlled trial. SETTING AND SUBJECTS The study was conducted in a large tertiary hospital in Brisbane, Australia. Two hundred and ten general surgical and medical patients who had an indwelling catheter as part of their routine care were included. RESULTS Length of hospital stay after catheter removal was not significantly affected by the timing of its removal among general hospital patients: mean hours morning 186.1; mean evening 209.3, (P = .309). In a cohort of surgical patients, the hospital stay was shorter in the evening removal group (mean hours morning 186.1; mean evening 209.3), but this result was not statistically significant (P = .127). Patients in the evening group were more likely to have a longer time period between catheter removal and the first postcatheter void, mean hours morning, 3.76 vs evening, 4.89 (t = −2.59, CI − 1.99 to −0.27). Timing of removal of the urinary catheter had no effect on the volume of the first void, mean volume morning, 214.7 mL vs evening, 221.4 mL. Twenty-five (12.1%) patients were recatheterized, but the rate of recatheterization between groups was similar. There were no differences in postdischarge problems between groups. CONCLUSION Among general hospital patients, removing an indwelling urinary catheter at 22:00 hours does not shorten the length of stay and is effective in increasing the time to first void.

Candida albicans colonisation, continence status and incontinence-associated dermatitis in the acute care setting: a pilot study.

Candida albicans is the most prevalent human fungal commensal organism and is reported to be the most frequent aetiological organism responsible for infection associated with incontinence‐associated dermatitis. However, it remains unclear whether incontinence predisposes a patient to increased Candida colonisation or whether incontinence acts as a trigger for Candida infection in those already colonised. The purpose of this observational cross‐sectional study was to estimate colonisation rates of C. albicans in continent, compared to incontinent patients, and patients with incontinence‐associated dermatitis. Data were collected on 81 inpatients of a major Australian hospital and included a pelvic skin inspection and microbiological specimens to detect C. Albicans at hospital admission. The mean age of the sample was 76 years (SD = 12.22) with 53% being male. Incontinent participants (n = 53) had a non‐significant trend towards greater Candida colonisation rates at the perianal site (43% versus 28%) χ2(1, N = 81) = 4·453, p = ·638 and the inguinal site (24% versus 14%) χ2(1, N = 81) = 6·868, p = ·258 compared to continent patients (n = 28). The incontinent subgroup with incontinence‐associated dermatitis (n = 22) showed no difference in colonisation rates compared to those without incontinence‐associated dermatitis. Understanding the epidemiology of colonisation may have implications for the prevention of Candida infection in these patients.

Incidence and Predictors of Lower Limb Split-Skin Graft Failure and Primary Closure Dehiscence in Day-Case Surgical Patients.

BACKGROUND After general surgery, the lower limb experiences some of the highest complication rates. However, little is known about contributing factors to surgical site failure in the lower limb dermatological surgery population. OBJECTIVE To determine the incidence of lower limb surgical site failure and to explore the predictors that contribute to surgical site failure. METHODS A prospective observational study design was used to collect data from 73 participants, from July 2010, to March 2012. Incidence was determined as a percentage of surgical site failure from the total population. Predictors were determined by the use of a binary logistic regression model. RESULTS The surgical site failure rate was 53.4%. Split-skin grafting had a higher failure rate than primary closures, 66% versus 26.1%. Predictors of lower limb surgical site failure were identified as increasing age (p = .04) and the presence of postoperative hematoma (p = .01), with all patients who developed surgical site infection experiencing surgical site failure (p = .01). CONCLUSION Findings from this study confirmed that the lower limb is at high risk of surgical site failure. Two predictors of surgical site failure from this cohort were determined. However, to understand this phenomenon and make recommendations to assist and reduce surgical site complications, further research in this field is required.

Does Preoperative Oral Carbohydrate Reduce Hospital Stay? A Randomized Trial

Oral carbohydrate-rich fluids are used preoperatively to improve postoperative recovery, but their effectiveness for reducing length of hospital stay is uncertain. We assessed the effectiveness of preoperative loading with carbohydrates on the postoperative outcomes of 44 patients scheduled for elective colorectal surgery who were randomly allocated to a carbohydrate-rich fluid group or a usual care group during their preadmission clinic visit. Our primary outcome was the time patients required to be ready for discharge. Patients in the control group spent an average of 4.3 days (95% confidence interval [CI], 3.2-5.7) in the hospital and patients in the carbohydrate-rich fluid group spent 4.1 days (95% CI, 3.2-5.4) in the hospital until they met discharge criteria (P = .824). We found that the safety of administering preoperative oral carbohydrate-rich fluids is supported, but we were unable to confirm or refute the benefit of this treatment regimen for contributing to shorter hospital stays after elective colorectal surgery.