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Jennifer A Whitty - One of the best experts on this subject based on the ideXlab platform.
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the cost effectiveness of a patient centred pressure ulcer prevention Care Bundle findings from the intact cluster randomised trial
International Journal of Nursing Studies, 2017Co-Authors: Elizabeth Mcinnes, Tracey Bucknall, Brigid M. Gillespie, Jennifer A Whitty, Joan Webster, Merrilyn BanksAbstract:Abstract Background Pressure ulcers are serious, avoidable, costly and common adverse outcomes of healthCare. Objectives To evaluate the cost-effectiveness of a patient-centred pressure ulcer prevention Care Bundle compared to standard Care. Design Cost-effectiveness and cost-benefit analyses of pressure ulcer prevention performed from the health system perspective using data collected alongside a cluster-randomised trial. Settings Eight tertiary hospitals in Australia. Participants Adult patients receiving either a patient-centred pressure ulcer prevention Care Bundle (n=799) or standard Care (n=799). Methods Direct costs related to the intervention and preventative strategies were collected from trial data and supplemented by micro-costing data on patient turning and skin Care from a 4-week substudy (n=317). The time horizon for the economic evaluation matched the trial duration, with the endpoint being diagnosis of a new pressure ulcer, hospital discharge/transfer or 28days; whichever occurred first. For the cost-effectiveness analysis, the primary outcome was the incremental costs of prevention per additional hospital acquired pressure ulcer case avoided, estimated using a two-stage cluster-adjusted non-parametric bootstrap method. The cost-benefit analysis estimated net monetary benefit, which considered both the costs of prevention and any difference in length of stay. All costs are reported in AU$(2015). Results The Care Bundle cost AU$144.91 (95%CI: $74.96 to $246.08) more per patient than standard Care. The largest contributors to cost were clinical nurse time for repositioning and skin inspection. In the cost-effectiveness analysis, the Care Bundle was estimated to cost an additional $3296 (95%CI: dominant to $144,525) per pressure ulcer avoided. This estimate is highly uncertain. Length of stay was unexpectedly higher in the Care Bundle group. In a cost-benefit analysis which considered length of stay, the net monetary benefit for the Care Bundle was estimated to be −$2320 (95%CI −$3900, −$1175) per patient, suggesting the Care Bundle was not a cost-effective use of resources. Conclusions A pressure ulcer prevention Care Bundle consisting of multicomponent nurse training and patient education may promote best practice nursing Care but may not be cost-effective in preventing hospital acquired pressure ulcer.
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the effect of a patient centred Care Bundle intervention on pressure ulcer incidence intact a cluster randomised trial
International Journal of Nursing Studies, 2016Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Shelley Roberts, Tracey Bucknall, Brigid M. Gillespie, Jennifer A Whitty, Joan Webster, Lukman Thalib, Mandy TallottAbstract:Abstract Background Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthCare costs. They are also viewed as an indicator of nursing Care quality. Objective To evaluate the effectiveness of a pressure ulcer prevention Care Bundle in preventing hospital-acquired pressure ulcers among at risk patients. Design Pragmatic cluster randomised trial. Setting Eight tertiary referral hospitals with >200 beds each in three Australian states. Participants 1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. Methods Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention Care Bundle or standard Care. The Care Bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention Care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention Care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. Results Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention Care Bundle relative to standard Care) was 0.58 (95% CI: 0.25, 1.33; p =0.198). No adverse events or harms were reported. Conclusions Although the pressure ulcer prevention Care Bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention Care Bundle was effective but the sample size too small to detect this.
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introducing a Care Bundle to prevent pressure injury intact in at risk patients a protocol for a cluster randomised trial
International Journal of Nursing Studies, 2015Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Marianne Wallis, Tracey Bucknall, Brigid M. Gillespie, Joan Webster, Jennifer A WhittyAbstract:Abstract Background Pressure injuries are a significant clinical and economic issue, affecting both patients and the health Care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals. Objectives This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention Care Bundle on the development of hospital acquired pressure injury in at-risk patients. Design This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation. Methods Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention Care Bundle or standard Care. The Care Bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical Care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in Care and health Care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported. Discussion To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a Care Bundle focusing on patient participation and nurse–patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed Care Bundle, it could have a significant impact on clinical practice worldwide. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.
Wendy Chaboyer - One of the best experts on this subject based on the ideXlab platform.
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the effect of a patient centred Care Bundle intervention on pressure ulcer incidence intact a cluster randomised trial
International Journal of Nursing Studies, 2016Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Shelley Roberts, Tracey Bucknall, Brigid M. Gillespie, Jennifer A Whitty, Joan Webster, Lukman Thalib, Mandy TallottAbstract:Abstract Background Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthCare costs. They are also viewed as an indicator of nursing Care quality. Objective To evaluate the effectiveness of a pressure ulcer prevention Care Bundle in preventing hospital-acquired pressure ulcers among at risk patients. Design Pragmatic cluster randomised trial. Setting Eight tertiary referral hospitals with >200 beds each in three Australian states. Participants 1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. Methods Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention Care Bundle or standard Care. The Care Bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention Care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention Care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. Results Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention Care Bundle relative to standard Care) was 0.58 (95% CI: 0.25, 1.33; p =0.198). No adverse events or harms were reported. Conclusions Although the pressure ulcer prevention Care Bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention Care Bundle was effective but the sample size too small to detect this.
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nurses perceptions of a pressure ulcer prevention Care Bundle a qualitative descriptive study
BMC Nursing, 2016Co-Authors: Shelley Roberts, Elizabeth Mcinnes, Merrilyn Banks, Marianne Wallis, Tracey Bucknall, Wendy ChaboyerAbstract:Pressure ulcer prevention is a critical patient safety indicator for acute Care hospitals. An innovative pressure ulcer prevention Care Bundle targeting patient participation in their Care was recently tested in a cluster randomised trial in eight Australian hospitals. Understanding nurses’ perspectives of such an intervention is imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the main trial, this study assessed nurses’ perceptions of the usefulness and impact of a pressure ulcer prevention Care Bundle intervention on clinical practice. This qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention Care Bundle. Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured interview guide to question participants about their perceptions of the Care Bundle. Interviews were digitally recorded, transcribed and analysed using thematic analysis. Eighteen nurses from four hospitals participated in the study. Nurses’ perceptions of the intervention are described in five themes: 1) Awareness of the pressure ulcer prevention Care Bundle and its similarity to current practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention Care Bundle; 3) Appreciating the positive aspects of patient participation in Care; 4) Perceived barriers to engaging patients in the pressure ulcer prevention Care Bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer prevention Care Bundle implementation. Overall, nurses found the Care Bundle feasible and acceptable. They identified a number of benefits from the Bundle, including improved communication, awareness and participation in pressure ulcer prevention Care among patients and staff. However, nurses thought the Care Bundle was not appropriate or effective for all patients, such as those who were cognitively impaired. Perceived enablers to implementation of the Bundle included facilitation through effective communication and dissemination of evidence about the Care Bundle; strong leadership and ability to influence staff behaviour; and simplicity of the Care Bundle.
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introducing a Care Bundle to prevent pressure injury intact in at risk patients a protocol for a cluster randomised trial
International Journal of Nursing Studies, 2015Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Marianne Wallis, Tracey Bucknall, Brigid M. Gillespie, Joan Webster, Jennifer A WhittyAbstract:Abstract Background Pressure injuries are a significant clinical and economic issue, affecting both patients and the health Care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals. Objectives This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention Care Bundle on the development of hospital acquired pressure injury in at-risk patients. Design This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation. Methods Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention Care Bundle or standard Care. The Care Bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical Care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in Care and health Care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported. Discussion To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a Care Bundle focusing on patient participation and nurse–patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed Care Bundle, it could have a significant impact on clinical practice worldwide. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.
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Development and pilot testing of a patient-participatory pressure ulcer prevention Care Bundle.
Journal of nursing care quality, 2014Co-Authors: Brigid M. Gillespie, Wendy Chaboyer, Mark Sykes, Jennifer O'brien, Susan BrandisAbstract:This study developed and piloted a patient-centered pressure ulcer prevention Care Bundle for adult hospitalized patients to promote patient participation in prevention. The Care Bundle had 3 core messages: (1) keep moving, (2) Care for your skin, and (3) ensure a good diet. A brief video, combined brochure/checklist, and poster were developed as training resources. Patient evaluation identified benefits of the Care Bundle; however, the combined checklist/brochure was rarely used.
Merrilyn Banks - One of the best experts on this subject based on the ideXlab platform.
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the cost effectiveness of a patient centred pressure ulcer prevention Care Bundle findings from the intact cluster randomised trial
International Journal of Nursing Studies, 2017Co-Authors: Elizabeth Mcinnes, Tracey Bucknall, Brigid M. Gillespie, Jennifer A Whitty, Joan Webster, Merrilyn BanksAbstract:Abstract Background Pressure ulcers are serious, avoidable, costly and common adverse outcomes of healthCare. Objectives To evaluate the cost-effectiveness of a patient-centred pressure ulcer prevention Care Bundle compared to standard Care. Design Cost-effectiveness and cost-benefit analyses of pressure ulcer prevention performed from the health system perspective using data collected alongside a cluster-randomised trial. Settings Eight tertiary hospitals in Australia. Participants Adult patients receiving either a patient-centred pressure ulcer prevention Care Bundle (n=799) or standard Care (n=799). Methods Direct costs related to the intervention and preventative strategies were collected from trial data and supplemented by micro-costing data on patient turning and skin Care from a 4-week substudy (n=317). The time horizon for the economic evaluation matched the trial duration, with the endpoint being diagnosis of a new pressure ulcer, hospital discharge/transfer or 28days; whichever occurred first. For the cost-effectiveness analysis, the primary outcome was the incremental costs of prevention per additional hospital acquired pressure ulcer case avoided, estimated using a two-stage cluster-adjusted non-parametric bootstrap method. The cost-benefit analysis estimated net monetary benefit, which considered both the costs of prevention and any difference in length of stay. All costs are reported in AU$(2015). Results The Care Bundle cost AU$144.91 (95%CI: $74.96 to $246.08) more per patient than standard Care. The largest contributors to cost were clinical nurse time for repositioning and skin inspection. In the cost-effectiveness analysis, the Care Bundle was estimated to cost an additional $3296 (95%CI: dominant to $144,525) per pressure ulcer avoided. This estimate is highly uncertain. Length of stay was unexpectedly higher in the Care Bundle group. In a cost-benefit analysis which considered length of stay, the net monetary benefit for the Care Bundle was estimated to be −$2320 (95%CI −$3900, −$1175) per patient, suggesting the Care Bundle was not a cost-effective use of resources. Conclusions A pressure ulcer prevention Care Bundle consisting of multicomponent nurse training and patient education may promote best practice nursing Care but may not be cost-effective in preventing hospital acquired pressure ulcer.
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the effect of a patient centred Care Bundle intervention on pressure ulcer incidence intact a cluster randomised trial
International Journal of Nursing Studies, 2016Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Shelley Roberts, Tracey Bucknall, Brigid M. Gillespie, Jennifer A Whitty, Joan Webster, Lukman Thalib, Mandy TallottAbstract:Abstract Background Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthCare costs. They are also viewed as an indicator of nursing Care quality. Objective To evaluate the effectiveness of a pressure ulcer prevention Care Bundle in preventing hospital-acquired pressure ulcers among at risk patients. Design Pragmatic cluster randomised trial. Setting Eight tertiary referral hospitals with >200 beds each in three Australian states. Participants 1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. Methods Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention Care Bundle or standard Care. The Care Bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention Care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention Care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. Results Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention Care Bundle relative to standard Care) was 0.58 (95% CI: 0.25, 1.33; p =0.198). No adverse events or harms were reported. Conclusions Although the pressure ulcer prevention Care Bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention Care Bundle was effective but the sample size too small to detect this.
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nurses perceptions of a pressure ulcer prevention Care Bundle a qualitative descriptive study
BMC Nursing, 2016Co-Authors: Shelley Roberts, Elizabeth Mcinnes, Merrilyn Banks, Marianne Wallis, Tracey Bucknall, Wendy ChaboyerAbstract:Pressure ulcer prevention is a critical patient safety indicator for acute Care hospitals. An innovative pressure ulcer prevention Care Bundle targeting patient participation in their Care was recently tested in a cluster randomised trial in eight Australian hospitals. Understanding nurses’ perspectives of such an intervention is imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the main trial, this study assessed nurses’ perceptions of the usefulness and impact of a pressure ulcer prevention Care Bundle intervention on clinical practice. This qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention Care Bundle. Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured interview guide to question participants about their perceptions of the Care Bundle. Interviews were digitally recorded, transcribed and analysed using thematic analysis. Eighteen nurses from four hospitals participated in the study. Nurses’ perceptions of the intervention are described in five themes: 1) Awareness of the pressure ulcer prevention Care Bundle and its similarity to current practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention Care Bundle; 3) Appreciating the positive aspects of patient participation in Care; 4) Perceived barriers to engaging patients in the pressure ulcer prevention Care Bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer prevention Care Bundle implementation. Overall, nurses found the Care Bundle feasible and acceptable. They identified a number of benefits from the Bundle, including improved communication, awareness and participation in pressure ulcer prevention Care among patients and staff. However, nurses thought the Care Bundle was not appropriate or effective for all patients, such as those who were cognitively impaired. Perceived enablers to implementation of the Bundle included facilitation through effective communication and dissemination of evidence about the Care Bundle; strong leadership and ability to influence staff behaviour; and simplicity of the Care Bundle.
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introducing a Care Bundle to prevent pressure injury intact in at risk patients a protocol for a cluster randomised trial
International Journal of Nursing Studies, 2015Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Marianne Wallis, Tracey Bucknall, Brigid M. Gillespie, Joan Webster, Jennifer A WhittyAbstract:Abstract Background Pressure injuries are a significant clinical and economic issue, affecting both patients and the health Care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals. Objectives This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention Care Bundle on the development of hospital acquired pressure injury in at-risk patients. Design This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation. Methods Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention Care Bundle or standard Care. The Care Bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical Care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in Care and health Care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported. Discussion To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a Care Bundle focusing on patient participation and nurse–patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed Care Bundle, it could have a significant impact on clinical practice worldwide. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.
Tracey Bucknall - One of the best experts on this subject based on the ideXlab platform.
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the cost effectiveness of a patient centred pressure ulcer prevention Care Bundle findings from the intact cluster randomised trial
International Journal of Nursing Studies, 2017Co-Authors: Elizabeth Mcinnes, Tracey Bucknall, Brigid M. Gillespie, Jennifer A Whitty, Joan Webster, Merrilyn BanksAbstract:Abstract Background Pressure ulcers are serious, avoidable, costly and common adverse outcomes of healthCare. Objectives To evaluate the cost-effectiveness of a patient-centred pressure ulcer prevention Care Bundle compared to standard Care. Design Cost-effectiveness and cost-benefit analyses of pressure ulcer prevention performed from the health system perspective using data collected alongside a cluster-randomised trial. Settings Eight tertiary hospitals in Australia. Participants Adult patients receiving either a patient-centred pressure ulcer prevention Care Bundle (n=799) or standard Care (n=799). Methods Direct costs related to the intervention and preventative strategies were collected from trial data and supplemented by micro-costing data on patient turning and skin Care from a 4-week substudy (n=317). The time horizon for the economic evaluation matched the trial duration, with the endpoint being diagnosis of a new pressure ulcer, hospital discharge/transfer or 28days; whichever occurred first. For the cost-effectiveness analysis, the primary outcome was the incremental costs of prevention per additional hospital acquired pressure ulcer case avoided, estimated using a two-stage cluster-adjusted non-parametric bootstrap method. The cost-benefit analysis estimated net monetary benefit, which considered both the costs of prevention and any difference in length of stay. All costs are reported in AU$(2015). Results The Care Bundle cost AU$144.91 (95%CI: $74.96 to $246.08) more per patient than standard Care. The largest contributors to cost were clinical nurse time for repositioning and skin inspection. In the cost-effectiveness analysis, the Care Bundle was estimated to cost an additional $3296 (95%CI: dominant to $144,525) per pressure ulcer avoided. This estimate is highly uncertain. Length of stay was unexpectedly higher in the Care Bundle group. In a cost-benefit analysis which considered length of stay, the net monetary benefit for the Care Bundle was estimated to be −$2320 (95%CI −$3900, −$1175) per patient, suggesting the Care Bundle was not a cost-effective use of resources. Conclusions A pressure ulcer prevention Care Bundle consisting of multicomponent nurse training and patient education may promote best practice nursing Care but may not be cost-effective in preventing hospital acquired pressure ulcer.
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the effect of a patient centred Care Bundle intervention on pressure ulcer incidence intact a cluster randomised trial
International Journal of Nursing Studies, 2016Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Shelley Roberts, Tracey Bucknall, Brigid M. Gillespie, Jennifer A Whitty, Joan Webster, Lukman Thalib, Mandy TallottAbstract:Abstract Background Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthCare costs. They are also viewed as an indicator of nursing Care quality. Objective To evaluate the effectiveness of a pressure ulcer prevention Care Bundle in preventing hospital-acquired pressure ulcers among at risk patients. Design Pragmatic cluster randomised trial. Setting Eight tertiary referral hospitals with >200 beds each in three Australian states. Participants 1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. Methods Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention Care Bundle or standard Care. The Care Bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention Care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention Care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. Results Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention Care Bundle relative to standard Care) was 0.58 (95% CI: 0.25, 1.33; p =0.198). No adverse events or harms were reported. Conclusions Although the pressure ulcer prevention Care Bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention Care Bundle was effective but the sample size too small to detect this.
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nurses perceptions of a pressure ulcer prevention Care Bundle a qualitative descriptive study
BMC Nursing, 2016Co-Authors: Shelley Roberts, Elizabeth Mcinnes, Merrilyn Banks, Marianne Wallis, Tracey Bucknall, Wendy ChaboyerAbstract:Pressure ulcer prevention is a critical patient safety indicator for acute Care hospitals. An innovative pressure ulcer prevention Care Bundle targeting patient participation in their Care was recently tested in a cluster randomised trial in eight Australian hospitals. Understanding nurses’ perspectives of such an intervention is imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the main trial, this study assessed nurses’ perceptions of the usefulness and impact of a pressure ulcer prevention Care Bundle intervention on clinical practice. This qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention Care Bundle. Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured interview guide to question participants about their perceptions of the Care Bundle. Interviews were digitally recorded, transcribed and analysed using thematic analysis. Eighteen nurses from four hospitals participated in the study. Nurses’ perceptions of the intervention are described in five themes: 1) Awareness of the pressure ulcer prevention Care Bundle and its similarity to current practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention Care Bundle; 3) Appreciating the positive aspects of patient participation in Care; 4) Perceived barriers to engaging patients in the pressure ulcer prevention Care Bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer prevention Care Bundle implementation. Overall, nurses found the Care Bundle feasible and acceptable. They identified a number of benefits from the Bundle, including improved communication, awareness and participation in pressure ulcer prevention Care among patients and staff. However, nurses thought the Care Bundle was not appropriate or effective for all patients, such as those who were cognitively impaired. Perceived enablers to implementation of the Bundle included facilitation through effective communication and dissemination of evidence about the Care Bundle; strong leadership and ability to influence staff behaviour; and simplicity of the Care Bundle.
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introducing a Care Bundle to prevent pressure injury intact in at risk patients a protocol for a cluster randomised trial
International Journal of Nursing Studies, 2015Co-Authors: Wendy Chaboyer, Elizabeth Mcinnes, Merrilyn Banks, Marianne Wallis, Tracey Bucknall, Brigid M. Gillespie, Joan Webster, Jennifer A WhittyAbstract:Abstract Background Pressure injuries are a significant clinical and economic issue, affecting both patients and the health Care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals. Objectives This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention Care Bundle on the development of hospital acquired pressure injury in at-risk patients. Design This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation. Methods Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention Care Bundle or standard Care. The Care Bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical Care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in Care and health Care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported. Discussion To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a Care Bundle focusing on patient participation and nurse–patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed Care Bundle, it could have a significant impact on clinical practice worldwide. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.
Jonathan Koffman - One of the best experts on this subject based on the ideXlab platform.
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the amber Care Bundle for hospital inpatients with uncertain recovery nearing the end of life the improveCare feasibility cluster rct
Health Technology Assessment, 2019Co-Authors: Jonathan Koffman, Irene J Higginson, Emel Yorganci, Wei Gao, Fliss E M Murtagh, Andrew Pickles, Stephen Barclay, Halle Johnson, Rebecca L Wilson, Sylvia BaileyAbstract:Background Patients admitted to hospital with a terminal illness and uncertain recovery often receive inconsistent Care and do not have the opportunity to die in their preferred place of death. Previous end-of-life Care packages, such as the Liverpool Care Pathway for the Dying Patient, have sometimes been badly implemented. The AMBER (Assessment; Management; Best practice; Engagement; Recovery uncertain) Care Bundle was developed to remedy this. It has not been evaluated in a randomised trial, but a definitive trial would face many hurdles. Objective To optimise the design of and determine the feasibility of a pragmatic, multicentre, cluster randomised controlled trial of the AMBER Care Bundle compared with best standard Care. Design A feasibility cluster randomised controlled trial including semistructured interviews with patients and relatives, focus groups with health-Care professionals, non-participant observations of multidisciplinary team meetings, a standard Care survey, heat maps and case note reviews. Retrospective data were collected from the family or close friends of deceased patients via a bereavement survey. Setting Four general medical wards at district general hospitals in England. Participants There were 65 participants (control, n = 36; intervention, n = 29). There were 24 interviews, four focus groups, 15 non-participant meeting observations, six case note reviews and three heat maps, and 15 of out 23 bereavement, standard Care surveys were completed. Intervention The AMBER Care Bundle is implemented by a nurse facilitator. It includes the development and documentation of a medical plan, consideration of outcomes, resuscitation and escalation status and daily plan revisiting. The AMBER Care Bundle encourages staff, patients and families to talk openly about their preferences and priorities should the worst happen. Main outcome measures Two 'candidate' primary outcomes were selected to be evaluated for a future definitive trial: Integrated Palliative Care Outcome Scale patient/family anxiety and communication subscale and 'howRwe'. The secondary outcome measures were Integrated Palliative Care Outcome Scale symptoms, Australian-modified Karnofsky Performance Status scale, EuroQol-5 Dimensions, five-level version, Client Service Receipt Inventory, recruitment rate, intervention fidelity and intervention acceptability. Results Data were collected for 65 patients. This trial was not powered to measure clinical effectiveness, but variance and changes observed in the Integrated Palliative Care Outcome Scale subscale indicated that this measure would probably detect differences within a definitive trial. It was feasible to collect data on health, social and informal Care service use and on quality of life at two time points. The AMBER Care Bundle was broadly acceptable to all stakeholders and was delivered as planned. The emphasis on 'clinical uncertainty' prompted health-Care professional awareness of often-overlooked patients. Reviewing patients' AMBER Care Bundle status was integrated into routine practice. Refinements included simplifying the inclusion criteria and improving health-Care professional communication training. Improvements to trial procedures included extending the time devoted to recruitment and simplifying consent procedures. There was also a recommendation to reduce data collected from patients and relatives to minimise burden. Limitations The recruitment rate was lower than anticipated. The inclusion criteria for the trial were difficult to interpret. Information sheets and consent procedures were too detailed and lengthy for the target population. Health-Care professionals' enthusiasm and specialty were not considered while picking trial wards. Participant recruitment took place later during hospital admission and the majority of participants were lost to follow-up because they had been discharged. Those who participated may have different characteristics from those who did not. Conclusions This feasibility trial has demonstrated that an evaluation of the AMBER Care Bundle among an acutely unwell patient population, although technically possible, is not practical or feasible. The intervention requires optimisation. Trial registration Current Controlled Trials ISRCTN36040085. National Institute for Health Research (NIHR) Portfolio registration number 32682. Funding This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 55. See the NIHR Journals Library website for further project information.
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managing uncertain recovery for patients nearing the end of life in hospital a mixed methods feasibility cluster randomised controlled trial of the amber Care Bundle
Trials, 2019Co-Authors: Jonathan Koffman, Emel Yorganci, Wei Gao, Fliss E M Murtagh, Andrew Pickles, Stephen Barclay, Halle Johnson, Rebecca L Wilson, L Sampson, Joanne DroneyAbstract:Background The AMBER (Assessment, Management, Best Practice, Engagement, Recovery Uncertain) Care Bundle is a complex intervention used in UK hospitals to support patients with uncertain recovery. However, it has yet to be evaluated in a randomised controlled trial (RCT) to identify potential benefits or harms. The aim of this trial was to investigate the feasibility of a cluster RCT of the AMBER Care Bundle.
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Improving Care for patients whose recovery is uncertain. The AMBER Care Bundle: design and implementation.
BMJ supportive & palliative care, 2015Co-Authors: Irene Carey, Susanna Shouls, Katherine Bristowe, Ruth Caulkin, Michelle Morris., Linda Briant, Mathew Griffiths, Kieron Clark, Carole Robinson, Jonathan KoffmanAbstract:Despite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1-2 months. This paper suggests an approach to improve this Care. A Care Bundle (the AMBER Care Bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The Care Bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up. This paper describes the development and implementation of a Care Bundle. From August 2011 to July 2012, 638 patients received Care supported by the AMBER Care Bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development. It has been possible to develop a Care Bundle addressing a complex area of Care which can be a lever for cultural change. The implementation of the AMBER Care Bundle has the potential to improve Care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
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Patient and Carer experiences of clinical uncertainty and deterioration, in the face of limited reversibility: A comparative observational study of the AMBER Care Bundle
Palliative medicine, 2015Co-Authors: Katherine Bristowe, Susanna Shouls, Irene Carey, Adrian Hopper, Wendy Prentice, Ruth Caulkin, Irene J Higginson, Jonathan KoffmanAbstract:Background: Clinical uncertainty is emotionally challenging for patients and Carers and creates additional pressures for those clinicians in acute hospitals. The AMBER Care Bundle was designed to improve Care for patients identified as clinically unstable, deteriorating, with limited reversibility and at risk of dying in the next 1–2 months. Aim: To examine the experience of Care supported by the AMBER Care Bundle compared to standard Care in the context of clinical uncertainty, deterioration and limited reversibility. Design: A comparative observational mixed-methods study using semi-structured qualitative interviews and a followback survey. Setting/participants: Three large London acute tertiary National Health Service hospitals. Nineteen interviews with 23 patients and Carers (10 supported by AMBER Care Bundle and 9 standard Care). Surveys completed by next of kin of 95 deceased patients (59 AMBER Care Bundle and 36 standard Care). Results: The AMBER Care Bundle was associated with increased frequency of discussions about prognosis between clinicians and patients (χ2 = 4.09, p = 0.04), higher awareness of their prognosis by patients (χ2 = 4.29, p = 0.04) and lower clarity in the information received about their condition (χ2 = 6.26, p = 0.04). Although the consistency and quality of communication were not different between the two groups, those supported by the AMBER Care Bundle described more unresolved concerns about caring for someone at home. Conclusion: Awareness of prognosis appears to be higher among patients supported by the AMBER Care Bundle, but in this small study this was not translated into higher quality communication, and information was judged less easy to understand. Adequately powered comparative evaluation is urgently needed.
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Improving Care for patients whose recovery is uncertain. The AMBER Care Bundle: design and implementation
BMJ supportive & palliative care, 2014Co-Authors: Irene Carey, Susanna Shouls, Katherine Bristowe, Ruth Caulkin, Michelle Morris., Linda Briant, Carole A. Robinson, Mathew Griffiths, Kieron Clark, Jonathan KoffmanAbstract:Introduction Despite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1–2 months. This paper suggests an approach to improve this Care. Intervention A Care Bundle (the AMBER Care Bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The Care Bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up. Clinical impact This paper describes the development and implementation of a Care Bundle. From August 2011 to July 2012, 638 patients received Care supported by the AMBER Care Bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development. Conclusions It has been possible to develop a Care Bundle addressing a complex area of Care which can be a lever for cultural change. The implementation of the AMBER Care Bundle has the potential to improve Care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated.