Acute Care Hospitals In Australia Research Articles

Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial

The benefit of combined treatment with intravenous thrombolysis before endovascular thrombectomy in patients with acute ischaemic stroke caused by large vessel occlusion remains unclear. We hypothesised that the clinical outcomes of patients with stroke with large vessel occlusion treated with direct endovascular thrombectomy within 4·5 h would be non-inferior compared with the outcomes of those treated with standard bridging therapy (intravenous thrombolysis before endovascular thrombectomy). DIRECT-SAFE was an international, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Adult patients with stroke and large vessel occlusion in the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or basilar artery, confirmed by non-contrast CT and vascular imaging, and who presented within 4·5 h of stroke onset were recruited from 25 acute-care hospitals in Australia, New Zealand, China, and Vietnam. Eligible patients were randomly assigned (1:1) via a web-based, computer-generated randomisation procedure stratified by site of baseline arterial occlusion and by geographic region to direct endovascular thrombectomy or bridging therapy. Patients assigned to bridging therapy received intravenous thrombolytic (alteplase or tenecteplase) as per standard care at each site; endovascular thrombectomy was also per standard of care, using the Trevo device (Stryker Neurovascular, Fremont, CA, USA) as first-line intervention. Personnel assessing outcomes were masked to group allocation; patients and treating physicians were not. The primary efficacy endpoint was functional independence defined as modified Rankin Scale score 0-2 or return to baseline at 90 days, with a non-inferiority margin of -0·1, analysed by intention to treat (including all randomly assigned and consenting patients) and per protocol. The intention-to-treat population was included in the safety analyses. The trial is registered with ClinicalTrials.gov, NCT03494920, and is closed to new participants. Between June 2, 2018, and July 8, 2021, 295 patients were randomly assigned to direct endovascular thrombectomy (n=148) or bridging therapy (n=147). Functional independence occurred in 80 (55%) of 146 patients in the direct thrombectomy group and 89 (61%) of 147 patients in the bridging therapy group (intention-to-treat risk difference -0·051, two-sided 95% CI -0·160 to 0·059; per-protocol risk difference -0·062, two-sided 95% CI -0·173 to 0·049). Safety outcomes were similar between groups, with symptomatic intracerebral haemorrhage occurring in two (1%) of 146 patients in the direct group and one (1%) of 147 patients in the bridging group (adjusted odds ratio 1·70, 95% CI 0·22-13·04) and death in 22 (15%) of 146 patients in the direct group and 24 (16%) of 147 patients in the bridging group (adjusted odds ratio 0·92, 95% CI 0·46-1·84). We did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment. Australian National Health and Medical Research Council and Stryker USA.

Regional differences in the care and outcomes of acute stroke patients in Australia: an observational study using evidence from the Australian Stroke Clinical Registry (AuSCR)

ObjectiveTo compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia.DesignObservational study using data from a multicentre national registry.SettingData...

Implementation of a multifaceted nurse‐led intervention to reduce indwelling urinary catheter use in four Australian hospitals: A pre‐ and postintervention study

This study aimed to reduce indwelling urinary catheter (IDC) use and duration through implementation of a multifaceted "bundled" care intervention. Indwelling urinary catheters present a risk for patients through the potential development of catheter-associated urinary tract infection (CAUTI), with duration of IDC a key risk factor. Catheter-associated urinary tract infection is considered preventable yet accounts for over a third of all hospital-acquired infections. The most effective CAUTI reduction strategy is to avoid IDC use where ever possible and to remove the IDC as early as appropriate. A cluster-controlled pre- and poststudy at a facility level with a phased intervention implementation approach. A multifaceted intervention involving a "No CAUTI" catheter care bundle was implemented, in 4 acute-care hospitals, 2 in metropolitan and 2 in rural locations, in New South Wales, Australia. Indwelling urinary catheter point prevalence and duration data were collected at the bedside on 1,630 adult inpatients at preintervention and 1,677 and 1,551 at 4 and 9months postintervention. This study is presented in line with the StaRI checklist (see Appendix S1). A nonsignificant trend towards reduction in IDC prevalence was identified, from 12% preintervention to 10% of all inpatients at 4 and 9months. Variability in preintervention IDC prevalence existed across hospitals (8%-16%). Variability in reduction was evident across hospitals at 4months (between -2% and 4%) and 9months (between 0%-8%). Hospitals with higher preintervention prevalence showed larger decreases, up to 50% when preintervention prevalence was 16%. Indwelling urinary catheter duration increased as more of the short-term IDC placements were avoided. Implementation of a multifaceted intervention resulted in reduced IDC use in four acute-care hospitals in Australia. This result was not statistically significant but did reflect a positive trend of reduction. There was a significant reduction in short-term IDC use at 9months postintervention. Clinical nurse leaders can effectively implement change strategies that influence patient outcomes. Implementation of the evidence-based "No CAUTI" bundle increased awareness of appropriate indications and provided nurses with the tools to inform decision-making related to insertion and removal of IDCs in acute inpatient settings. Working in partnership with inpatients and the multidisciplinary team is essential in minimising acute-care IDC use.

An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial

The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals. The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureus bacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505. Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3 534 439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureus bacteraemia, and 278 C difficile infections, for 1 267 134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0·35 to 0·22 per 10 000 occupied bed-days (relative risk 0·63, 95% CI 0·41-0·97, p=0·0340). The incidences of S aureus bacteraemia (0·97 to 0·80 per 10 000 occupied bed-days; 0·82, 0·60-1·12, p=0·2180) and C difficile infections (2·34 to 2·52 per 10 000 occupied bed-days; 1·07, 0·88-1·30, p=0·4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2·07, 1·83-2·34, p<0·0001) and bedrooms from 64% to 86% (1·87, 1·68-2·09, p<0·0001). The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice. National Health and Medical Research Council (Australia).

Differences in the characteristics, treatment, and outcomes of patient groups reviewed by intensive care liaison nurses in Australia: A multicentre prospective study

BackgroundThere is a lack of knowledge about tasks intensive care unit liaison nurses (ICU LNs) perform during patient review, despite this role operating in at least 31 acute care hospitals in Australia. ObjectivesTo evaluate the tasks that ICU LNs perform during patient review in the following referral subcategories: review after ICU discharge, rapid response team (RRT) review, and ward referral. MethodsA 2-month prospective observational study using standardised case report forms to collect data on patients reviewed by ICU LNs in 20 Australian hospitals was conducted. ResultsFrom 3799 patients screened, 3542 were included, among whom 1933 (54.6%) were men, and the mean (standard deviation) age was 63 (19.4) years. The admitting units were surgical 1765 (49.8%) and medical 1696 (47.9%), and the breakdown of referral types were routine review after ICU discharge (1732; 47.9%), RRT review (1208; 34.1%), and ward referral (602; 17.0%). Patients subject to ward and RRT reviews were older, more likely to be medical admissions with less favourable vital signs on the initial review, and less likely to have repeat reviews. Of note, ward reviews were more likely to receive palliative care. Intensive care liaison nurse–initiated medication prescription and investigation ordering was uncommon. The most common interventions included consultation with medical staff, bedside education, adjusting oxygen flow and patient position, and directing the change in frequency of vital sign measurement. In-hospital mortality was lower in patients reviewed after ICU discharge (2.3%), compared with those after RRT review (2.8%) and ward referral (4.4%). ConclusionsMost patients were reviewed after ICU discharge or in the context of the RRT. RRT and ward patients were less physiologically stable and more likely to die in hospital. The most common interventions performed by the ICU LN were nontechnical skills including clinical education, consultation with medical staff, and changes to vital sign frequency. Finally, the most common medication therapies administered related to intravenous therapy and electrolyte administration.

Validation of a Falls Risk Screening Tool Derived From InterRAI Acute Care Assessment.

This study aimed to develop and validate a falls risk screening tool derived from interRAI Acute Care (AC) Assessment. For derivation and validation, two prospective cohorts were recruited from AC hospitals in Australia. The derivation cohort comprised 1418 patients from 11 hospitals. In the validation cohort, 393 patients were recruited from four hospitals. The interRAI AC tool was used to collect comprehensive geriatric assessment data at admission. In-hospital falls were documented from medical records. A falls risk score was calculated using logistic regression. Predictive ability was compared with St. Thomas Risk Assessment Tool In Falling elderlY (STRATIFY), using area under curve (AUC). The validation cohort provided external validity. Complete data in the derivation cohort were available for 1288 patients (91%), with 75 (5.8%) having an in-hospital fall. The derived interRAI AC falls risk score (range = 0-6) had significantly better predictive ability (AUC = 0.70, 95% confidence interval [CI] = 0.63-0.76) compared with St. Thomas Risk Assessment Tool In Falling elderlY (AUC = 0.64, 95% CI = 0.58-0.70) (P = 0.033). At a cut point of three, 54 of 75 falls were correctly predicted by the falls risk score derived from interRAI AC (sensitivity = 0.72 [95% CI = 0.60-0.82] and specificity = 0.60 [95% CI = 0.57-0.62]). The falls risk score performed similarly in the validation cohort. The falls risk tool developed from interRAI AC is a valid measure to screen for in-hospital falls. Reduction in assessment burden without loss of fidelity can be achieved through integrating the risk screener within the interRAI hospital system, which automatically triggers protocols for falls prevention based on identified risk.

Nurse educators in Australia: High job satisfaction despite role ambiguity

Purpose: The purpose of this study was to describe the nurse educator role in Australian hospitals, including their practice and performance standards. Methods: A cross-sectional, online survey of nurse educators employed in acute care hospitals in Australia was administered over a three-month period. The survey comprised established and researcher-developed scales, and a single open-ended question. Quantitative data was analysed using descriptive statistics. Qualitative data was analysed using a general inductive approach. Results: Nurse educators who were more likely to fulfil nurse educator competency practice domains had master’s degrees in education, defined professional development needs, and met regularly with their managers. These educators also had higher levels of job satisfaction. Participants identified that role ambiguity and role confusion adversely impacted nurse educator role expectations, responsibilities, and job satisfaction. Despite this, the majority of educators intended to stay in their role for the foreseeable future. Conclusions: Role ambiguity influenced professional identity and job satisfaction, highlighting the need for clarification of nurse educator roles. These findings suggest the need for review of the nurse educator role and incorporation of professional and educational requirements and practice competencies. Ongoing role monitoring is recommended to identify the effects of role change.

Prescribing for older people discharged from the acute sector to residential aged-care facilities.

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper-polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk-benefit ratio.

Predictors of use of infection control precautions for multiresistant gram-negative bacilli in Australian hospitals: Analysis of a national survey

Despite the global expansion of extended spectrum β-lactamase-harboring Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE), only limited research on the infection control management of patients with these organisms is available. We present a national survey of infection control practices amongst adult acute-care hospitals in Australia, for ESBL-E, CRE, and the emerging threat of patients with overseas health care contact. In total, 97 health services responded, representing 9% of all eligible hospitals. The proportion of hospitals that reported use of contact precautions (CP) was 96% (93 out of 97) for ESBL-E, 81% (79 out of 97) for CRE, and 72% (48 out of 67) for patients transferred from an international hospital. For ESBL-E hospitals frequently employed risk-stratification to limit the use of CP (40 out of 97; 41%). On multivariate analysis predictors of a strategy to limit use of CP for ESBL-E were government funding (odds ratio, 4.8; P = .003) and a metropolitan location (odds ratio, 3.2; P = .014); predictors of any use of CP for CRE were location in an Australian state with a specific legislation on CRE (P = .030) and the presence of a written policy on CRE (P = .011). Infection control management of multiresistant gram-negative bacilli varied considerably across the Australian hospitals surveyed. A lower rate of reported CP use for CRE than for ESBL-E was unexpected and indicates a vulnerability in some Australian hospitals. Multivariate analysis revealed various drivers influencing infection control practice in Australia.

Use of Benzodiazepines and Association with Falls in Older People Admitted to Hospital: A Prospective Cohort Study

Hypnosedatives are commonly prescribed for anxiety and sleep problems. Changes in pharmacokinetics and pharmacodynamics of benzodiazepines (BZDs) during ageing may increase their potential to cause adverse outcomes. This study aimed to investigate the use of BZDs in acute care settings and explore their association with falls. A prospective cohort study was undertaken of patients aged over 70years consecutively admitted to 11 acute care hospitals in Australia. Data were collected using the interRAI Acute Care assessment tool. Falls were recorded prospectively (in hospital) and retrospectively (in the 90days prior to admission). Of 1,412 patients, 146 (10.3%) were taking BZDs at admission and 155 (11.3%) at discharge. Incidence rates of in-hospital fallers for users and non-users of BZDs were not statistically different [incidence rate ratio 1.03, 95% confidence interval (CI) 0.58-1.82]. There was also no significant association between benzodiazepine use at admission and history of falls in the previous 90days compared with non-users. However, patients on diazepam were significantly more likely to have a history of falls than all other benzodiazepine users (70.8 vs. 36.1%; p=0.002), particularly when compared with oxazepam users (70.8 vs. 25.0%; p<0.001). Adjusting for confounders, use of diazepam at admission was positively associated with a history of falls compared with all other benzodiazepine users (odds ratio 3.0; 95% CI 1.1-8.5; p=0.036). Different BZDs may vary in their propensity to predispose to falls, with diazepam having the strongest association. The selection of particular BZDs for older patients should be carefully evaluated.

Scope of practice conflict in nursing: A new war or just the same battle?

The changing roles within health care teams reflect the rapid pace of change in contemporary health care environments. Traditional nursing roles and responsibilities are being challenged as fi scal constraints drive health reform. How nursing teams are configured in the future and the scope of practice of the individuals within those teams will require clear and unambiguous boundaries.This study explores the relationships in and between scope of practice and communication amongst teams of nurses. Six focus groups with both Registered and Enrolled Nurses were undertaken in three Sydney metropolitan hospitals in New South Wales. Nurses report that confusion surrounding scope of practice particularly in the areas of medication administration, patient allocation and workload are resulting in situations whereby nurses are feeling bullied, stressed and harassed.With the imminent widespread introduction of a third tier of nursing into acute care hospitals in Australia the findings of this study are timely and suggest that unless nursing team members clearly understand their roles and scope of practice there is potential for intra-professional workplace conflict. Furthermore the impact of the conflict may have consequences for both the individual nurse and their patients.

Economic rationale for infection control in Australian hospitals

The objective of the present study was to predict the economic consequences of healthcare-acquired infections arising among admissions to Australian acute care hospitals. A quantitative algorithm informed by epidemiological and economic data was developed. All acute care hospitals in Australia were included in the study and the participants included all admissions to general medical and general surgical specialties. The main outcome measures were the numbers of cases of healthcare-acquired infection and bed days lost annually. It was estimated that there are 175 153 (95% credible interval 155 911 : 195 168) cases of healthcare-acquired infection among admissions to Australian hospitals annually, and the extra stay in hospital to treat symptoms accounts for 854 289 bed days (95% credible interval 645 091 : 1 096 244). If rates were reduced by 1%, then 150 158 bed days would be released for alternative uses. This would allow ~38 500 new admissions. Healthcare-acquired infections in patients cause bed blocks in Australian hospitals. The cost-effectiveness of hospital services might be improved by allocating more resources to infection control, releasing beds and allowing new admissions. There exists an opportunity to improve the efficiency of the Australian health care system.

Rasch Analysis of the Barthel Index in the Assessment of Hospitalized Older Patients After Admission for an Acute Medical Condition

de Morton NA, Keating JL, Davidson M. Rasch analysis of the Barthel Index in the assessment of hospitalized older patients after admission for an acute medical condition. Objective To investigate the validity of item score summation for the original and modified versions of the Barthel Index. Design Rasch analysis of Barthel Index data. Setting General medical wards at 2 acute care hospitals in Australia. Participants Consecutive older medical patients (N=396). Interventions Not applicable. Main Outcome Measures Activity limitation was assessed by using the Barthel Index at hospital admission and discharge. At 1 hospital site, the original Barthel Index was used, and at the other hospital site the Modified Barthel Index (MBI) was used. Results More than half of the items showed misfit to the Rasch model for both versions of the Barthel Index. The continence items appear to measure a different construct to the other items. After the removal of the continence items, data for the remaining items still did not fit the Rasch model. Neither the original nor the MBI are unidimensional scales. An exception to this occurred when the original Barthel Index was rescored and only then for discharge and not for admission Barthel Index data. Conclusions Because clinicians do not typically rescore outcomes obtained by using the Barthel Index, these findings, combined with unacceptable ceiling effects, render the Barthel Index an assessment tool with limited validity for measuring and monitoring the health of older medical patients.

Nurse‐initiated defibrillation? Reality or rhetoric

Evidence indicates that hospital nurse-initiated defibrillation improves survival following cardiac arrest. Accordingly, hospitals are changing their policies to permit nurses to initiate defibrillation. However, if nurse-initiated defibrillation is to be successful implemented, nurses' beliefs about this practice need to be understood. Therefore, the aim of this study was to explore the attitudes of rural nurses towards defibrillation to assist in the development of nurse-initiated defibrillation programmes. This cross-sectional study examined the defibrillation beliefs of registered nurses in rural areas. A proportionally stratified sample of registered nurses (n = 436) were drawn from 51 rural acute care hospitals in Australia. Most (n = 224; 52%) of the participants were not permitted to initiate defibrillation. A one-way between-groups multivariate analysis of variance showed that nurses who were permitted to initiate defibrillation held stronger positive beliefs towards defibrillation than nurses not permitted (10,410) = 13.88, p < 0.001. Nurses not permitted were more concerned about the challenge of learning rhythms, incurring litigation and harming the patient or themselves. If it is accepted that defibrillation will become an essential part of all nurses' roles, these beliefs should be explored and integrated into educational programmes as inappropriate beliefs about defibrillation may impede implementation and skills development.

Establishing thresholds for adverse patient outcomes.

To establish thresholds for adverse patient outcomes in the absence of knowledge of patient illness severity indices. Pulmonary embolism, unplanned return to operating rooms, unplanned readmissions, clean and contaminated wound infections, and hospital-acquired bacteraemia. Analysis of results of surveys of hospitals in Australia by the Australian Council on Healthcare Standards following the introduction of clinical performance measures into the Accreditation process. Acute care hospitals in Australia undergoing Accreditation surveys in 1993 and 1994. Stratification of hospitals into small (1-99 beds), medium (100-199 beds), and large (> or = 200 beds), calculation of mean rates for the above outcomes in each group, and establishment of thresholds based on two standard errors from the mean. The mean rate of occurrence of incidents was higher for larger hospitals. Thresholds were generally lower for smaller and higher for larger hospitals. Bed-size is a useful index for "flagging" peer group variation. The methodological issues in establishing thresholds and their implications in monitoring the quality of care in hospitals are discussed.