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NEWSLETTER

ISSUE 08MAY 2016

Professor Tracey Bucknall and her team have been awarded an NHMRC Partnership Project grant for their study ‘PRONTO - Prioritising responses of nurses to deteriorating patient observations’, with generous contributions from Alfred Health, Monash Health, Eastern Health, SA Health, and the Australian Commission on Safety and Quality in Health Care. Total funding will come to $972, 213.

Professor Alison Hutchinson and her team have been awarded $197,025 from the Dementia Collaborative Research Centres for their project ‘Reducing harm, in the acute hospital setting, to people displaying symptoms associated with a neurocognitive disorders’.

Professor Alison Hutchinson and Professor Bodil Rasmussen have both been awarded Nurses Board of Victoria Legacy Limited (NBVLL) grants for projects in 2016. Professor Hutchinson received a Mona Menzies grant of $49,985 for her project ‘Partnering with patients in medication administration’. Professor Rasmussen received an Ella Lowe grant of $49,985 for her project ‘Physical, social, psychological and cultural factors influencing breastfeeding intention, initiation and duration among women with Type 1 and Type 2 Diabetes living in Victoria’.

GRANTS SUCCESS FOR QPS

Alfred Deakin Professor Mari Botti AM, Executive Member of QPS and Chair in Nursing at the Epworth Deakin Centre for Clinical Nursing Research, has been made a Member of the Order of Australia in the 2016 Australia Day Honours. The award recognised Professor Botti’s significant service to nursing and medical education, as an academic and author, and to pain management research.

AUSTRALIA DAY HONOURS FOR QPS STAFF

QPS has a new Twitter account! We will be using this outlet to showcase our research, including new projects, recent publications, grant successes, seminars and other events.

Follow us: @DeakinQPS.

MORE WAYS TO CONNECT WITH USSAVE THE DATE

Professor Trisha Dunning will conduct a webinar as part of the Alumni series, titled:

Ah! Language: Today a person – Tomorrow a DIABETIC.

The webinar will be held on June 7, 2016, from 12:30-1:30pm. To register, go to http://www.deakin.edu.au/alumni and click on ‘Events and Webinars’.

CONTACT USCentre for Quality and Patient Safety Research

Deakin University 221 Burwood Highway

Burwood VIC 3125

Telephone: +61 3 9244 6578 Email: maxine.duke@deakin.edu.au

Twitter: @DeakinQPS

Deakin University CRICOS Provider Code: 00113B

The risk of comorbid illness, frailty, and dependency sharply increases after 75 years of age. Chronic diseases have the greatest effect of any disease type in older adults. Diabetes is one of the most prevalent chronic diseases in care home residents.

Recent research shows that diabetes lowers the chances of successful ageing, increases functional limitations and impairs quality of life. Diabetes diagnosed at age 60 reduces quality of life years by 11.1 years in men and 13.8 years in women. Older people with diabetes are at higher risk of diseases such as stroke, heart failure, kidney disease, and are more likely to develop delirium during acute medical illnesses, surgical procedures, and palliative care scenarios. Long-duration of diabetes increases the loss of skeletal muscle mass and function, which contributes to reduced mobility and increases the risk of falls, frailty and disability.

Diabetes is often detected in old people presenting for other health concerns. For example, the disease may present as urinary incontinence, falls, or cognitive and behavioural disturbances. Diabetes frequently co-exists with dementia, and is associated with mild cognitive impairment that can cause difficulties performing instrumental daily tasks. Diabetes is also associated with a two-fold increase in the risk of depression: more than a quarter of older people with diabetes have mood disturbances.

Diabetes management strategies are often based on evidence from younger populations and on a single disease and do not adequately address the complexity of illness in older people. The treatment

goals and plan for older people with diabetes need to be individualised and reviewed regularly. Clinicians need to understand age-related physiological and metabolic changes to appreciate the need to focus on safety and quality of life rather than ‘tight blood glucose control’ to prevent long term diabetes complications and implement individualised care.

Older people on insulin and sulphonylurea regimens need regular blood glucose monitoring because of the increased risk of hypoglycaemia associated with these medicines. Hypoglycaemia accounts for up to one in five hospital admissions in older people. Physical activity should be incorporated into the care plan where possible to preserve muscle mass, promote strength and balance, contribute to glycaemic control and improve mobility.

An algorithm was proposed that places an obligation on the clinician to tailor treatment to characteristics of the individual, their risk of hypoglycaemia, the degree of frailty, and their life expectancy. The focus of care needs to move from a focus on managing the diabetes to managing the individual and recognising diabetes as a model of pre-disability.

Reference Sinclair, A., Dunning, T. & Rodriguez-Mañas, L. (2015). Diabetes in older people: New insights and remaining challenges. The Lancet Diabetes & Endocrinology, 3, 275-285. doi:10.1016/S2213-8587(14)70176-7.

DIABETES IN OLDER PEOPLE: NEW INSIGHTS AND REMAINING CHALLENGES

Vital signs are the primary indicator of physiological status and the most common assessment technique employed in healthcare. If physiological signs of deterioration are missed, misinterpreted or mismanaged, then critical illness, cardiac arrest, unplanned intensive care admissions and death may result. Early detection requires frequent and accurate measurement of vital signs by nurses and escalation to appropriate clinicians to prevent adverse events. However we have shown this is not always the case and that the activation response ranges from 3-53% despite the release of national guidelines and the prioritisation of Standard 9 (recognition and response to clinical deterioration in acute health care) as one of ten National Quality and Safety Health Service Standards required for hospital accreditation from 2011. A significant gap between current policy and practice exists.

The PRONTO knowledge translation study is a 2 year cluster randomised controlled trial that will measure the effectiveness of a facilitation intervention to improve nurses’ vital signs measurement, treatment and escalation of patients with abnormal vital signs. Alongside the trial, an economic evaluation will evaluate the cost effectiveness of the intervention from the perspective of the hospital and a process evaluation will determine if and how the intervention reached the target audience. The research will investigate the relationship between facilitation and the impact on evidence use, contextual change and patient outcomes.

The PRONTO study is funded by an NHMRC Partnership Grant and generous contributions from Alfred Health, Monash Health, Eastern Health, SA Health, and the Australian Commission on Safety and Quality in Health Care, for total funding of $972, 213.

PRONTO - PRIORITISING RESPONSES OF NURSES TO DETERIORATING PATIENT OBSERVATIONS

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Heart failure has a high rate of hospitalisations and mortality. Large clinical trials have shown that the prescribing of beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) will improve these outcomes. These medications are recommended as first-line therapy in the treatment of heart failure. Also, there is a dose response, so the higher the dose of these medications, the greater the improvement in patient outcomes. However, general practitioners are often reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration is one such strategy.

A literature search was undertaken for articles published up to 31st December 2014. We conducted a meta-analysis of seven randomised controlled trials of 1684 participants, comparing nurse-led titration of beta-adrenergic blocking agents, ACEIs, and ARBs with titration of these medications by a general practitioner. The aim of the meta-analysis was to assess the effects of nurse-led titration of beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) in patients with heart failure in terms of safety and patient outcomes.

Results showed that the demographic characteristics of participants within each study were similar. All participants had been diagnosed with heart failure. The mean age of participants ranged from 59 to 81 years of age. Participants in the nurse-led titration group had a 20% reduction in risk for all-cause hospital admission and 49% reduction in risk for a hospital admission related to heart failure compared to the usual-care group.

Participants in the nurse-led titration group were 34% less likely to die compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving nurse-led titration of beta-adrenergic blocking agents, ACEIs, and ARBs. Participants in the nurse-led titration group were also 40% more likely to survive and have no hospital readmissions compared to participants in the usual-care group. Participants in the nurse-led titration group were twice more likely to reach maximal dose of beta-adrenergic blocking agents and in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event.

In summary, participants in the nurse-led titration group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting nurse-led titration as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions and mortality. Despite evidence of a dose dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving patient outcomes, translation of this evidence into clinical practice is poor. Nurse-led titration is one strategy that facilitates the implementation of this evidence into practice

Reference Driscoll A, Currey J, Tonkin A, Krum H. Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD009889. doi:10.1002/14651858.CD009889.pub2.

Key message

Heart failure is associated with a high burden of disease and poor patient outcomes. It has no cure, so strategies aimed at improving patient outcomes are warranted.

Nurse-led titration has been shown to be a safe and effective strategy to improve patient outcomes through the optimisation of key medications in heart failure resulting in a reduction in hospital readmissions and mortality.

Funding acknowledgement

Andrea Driscoll was supported by an Early Career Training Fellowship 546250 from the National Health and Medical Research Council of Australia and a Heart Foundation Future Leader fellowship 100472 from the National Heart Foundation of Australia.

NURSE-LED OPTIMISATION OF MEDICATIONS IN HEART FAILURE: A META-ANALYSIS

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During this time, Melissa enjoyed working in clinical and education roles but a desire to improve nursing care, patient outcomes and the family’s experience, led to Melissa’s interest in pursuing research. Working with a team of ICU clinicians, Melissa first got involved with research in 2007 examining End-of-Life management practices in the ICU.

Since then, Melissa has passionately pursued research, completing a PhD in 2013 with the support of 4 scholarships. Her ongoing commitment to research has resulted in more than 40 peer-reviewed research publications, $135,000 in research funding and a growing local and international research profile in the fields of End-of-Life Care and Intensive Care.

Current research interests

Melissa’s PhD utilised a mixed methods approach to explore the registered nurse’s recognition of and responsiveness to the dying patient in acute hospital (non-palliative care) wards. Melissa has also undertaken research focusing on End-of-Life care in adult, paediatric and neonatal ICU settings, sub-acute care and rehabilitation. Her research work focusses primarily on care and management practices, communication between clinicians and with family members, decision making and the preparedness of nurses to deal with preparing for death, death and grieving.

Melissa is a Research Fellow for the INACTIC project, funded by the European Society of Intensive Care Medicine, exploring the educational preparation of advanced practice roles in critical care across Europe. Melissa has also been involved in work around cultural competent care and as a result of this work, Melissa will be participating in the development of the ‘Brisbane Declaration’ at the upcoming World Federation of Critical Care Nurses International Congress, an international collaboration designed to inform culturally competent care in critical care.

With skills in qualitative and mixed methods research, Melissa is keen to continue researching by developing new research collaborations and higher degree supervision opportunities within the School.

Recent key publications

Bloomer, M. J., Endacott, R., Copnell, B., & O’Connor, M. (2016). ‘Something normal in a very, very abnormal environment’–Nursing work to honour the life of dying infants and children in neonatal and paediatric intensive care in Australia. Intensive and Critical Care Nursing, 33, 5-11. doi:10.1016/j.iccn.2015.09.001

Endacott, R., Jones, C., Bloomer, M. J., Boulanger, C., Ben Nun, M., Iliopoulou, K. K., . . . Blot, S. (2015). The state of critical care nursing education in Europe: an international survey. Intensive Care Medicine, 41(12), 2237-2240. doi:10.1007/s00134-015-4072-y

Bloomer, M. J., O’Connor, M., Copnell, B., & Endacott, R. (2015). Nursing care for the families of the dying child/infant in paediatric and neonatal ICU: Nurses’ emotional talk and sources of discomfort. A mixed methods study. Australian Critical Care, 28(2), 87-92. doi:10.1016/j.aucc.2015.01.002

Bloomer, M. J., Endacott, R., O’Connor, M., & Cross, W. (2013). The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study. Palliative Medicine, 27(8), 757-764. doi:10.1177/0269216313477176

RESEARCHER PROFILE: DR MELISSA BLOOMERDr Melissa Bloomer joined the School of Nursing and Midwifery at Deakin University in February, 2016 after eight years at Monash University. Melissa has more than 20 years experience as a registered nurse in intensive care (ICU), general acute and sub-acute care settings across four states of Australia.

Emily has worked as a Registered Nurse since completing her Bachelor in 2008 and has experience in both general acute and sub-acute care settings. While Emily loves to work in the clinical setting and engaging with patients, she strongly felt that her passion for learning, teaching and research should be perused.

Working in a busy acute general medical ward, Emily still remembers the patient she cared for that made her want to do more for patients who develop delirium while in hospital. After having only recently completed her honours, her wonderful supervisors convinced her to continue on with a PhD. Emily was awarded a Babe Norman Scholarship through the Nurses Memorial Centre to undertake her PhD. Emily graduated in April 2016.

Emily’s PhD work titled “Incident Delirium in the Acute General Medical Setting” focused on investigating the risk factors, outcomes and management of patients who develop incident delirium in an acute medical setting. She conducted a systematic review on risk factors for delirium that was published in the JBI library of systematic reviews. The research undertaken for her PhD also involved conducting a case-control study, reviewing medical records of patients with delirium. A number of interesting findings have come out of this research, including aligning research findings from international settings with a population in Australia. The work will be an excellent stepping stone for

further research into cognitive impairment and delirium in the future.

Current research interests

Emily’s current research interests are to extend the work of her PhD. Emily is keen to continue focusing on improving the quality of care and safety of patients who are at risk of developing delirium in hospital settings. There is still a lot of work that needs to be continued in this field and Emily is excited by what the future may hold.

Emily is also working collaboratively with Dr Joan O who was a previous post-doctoral research fellow within QPS. Emily is involved in a number of projects with Joan regarding continence in residential aged care settings, as well as investigating the role of the continence nurse in implementing interventions for incontinence.

Emily is also keen to be involved in other research projects and is looking forward to working collaboratively with other researchers within the School of Nursing and Midwifery and QPS.

Recent publications

Tomlinson, E., Phillips, N., Mohebbi, M and Hutchinson, A. Risk Factors for Incident

Delirium in an Acute General Medical Setting: A Retrospective Case – Control Study. 2016. Unpublished manuscript [In draft]

Cull, E., Kent, B., Phillips, N. and Mistarz, R. (2012) Risk factors for incident delirium in acute medical in-patients. A systematic review, JBI library of systematic reviews, vol. 10, no. 56, pp. 1-12, University of Adelaide, Faculty of Health Sciences, Adelaide, S. Aust.

RESEARCHER PROFILE: DR EMILY TOMLINSON (NEE CULL)Dr Emily Tomlinson joined the School of Nursing and Midwifery at Deakin University as a Lecturer in February 2016 after six years working as a sessional within the school. Emily has an extensive history with Deakin University having completed her Bachelor of Nursing and Honours and more recently a PhD.