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Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System

imageThe purpose of this study was to demonstrate nursing documentation variation based on electronic health record design and its relationship with different levels of care by reviewing how various flowsheet measures, within the same electronic health record across an integrated healthcare system, are documented in different types of medical facilities. Flowsheet data with information on patients who were admitted to academic medical centers, community hospitals, and rehabilitation centers were used to calculate the frequency of flowsheet entries documented. We then compared the distinct flowsheet measures documented in five flowsheet templates across the different facilities. We observed that each type of healthcare facility appeared to have distinct clinical care foci and flowsheet measures documented differed within the same template based on facility type. Designing flowsheets tailored to study settings can meet the needs of end users and increase documentation efficiency by reducing time spent on unrelated flowsheet measures. Furthermore, this process can save nurses time for direct patient care.

Defining CD4 T helper and T regulatory cell endotypes of progressive and remitting pulmonary sarcoidosis (BRITE): protocol for a US-based, multicentre, longitudinal observational bronchoscopy study

Por: Koth · L. L. · Harmacek · L. D. · White · E. K. · Arger · N. K. · Powers · L. · Werner · B. R. · Magallon · R. E. · Grewal · P. · Barkes · B. Q. · Li · L. · Gillespie · M. · Collins · S. E. · Cardenas · J. · Chen · E. S. · Maier · L. A. · Leach · S. M. · OConnor · B. P. · Hamzeh · N. Y.

Sarcoidosis is a multiorgan granulomatous disorder thought to be triggered and influenced by gene–environment interactions. Sarcoidosis affects 45–300/100 000 individuals in the USA and has an increasing mortality rate. The greatest gap in knowledge about sarcoidosis pathobiology is a lack of understanding about the underlying immunological mechanisms driving progressive pulmonary disease. The objective of this study is to define the lung-specific and blood-specific longitudinal changes in the adaptive immune response and their relationship to progressive and non-progressive pulmonary outcomes in patients with recently diagnosed sarcoidosis.

Methods and analysis

The BRonchoscopy at Initial sarcoidosis diagnosis Targeting longitudinal Endpoints study is a US-based, NIH-sponsored longitudinal blood and bronchoscopy study. Enrolment will occur over four centres with a target sample size of 80 eligible participants within 18 months of tissue diagnosis. Participants will undergo six study visits over 18 months. In addition to serial measurement of lung function, symptom surveys and chest X-rays, participants will undergo collection of blood and two bronchoscopies with bronchoalveolar lavage separated by 6 months. Freshly processed samples will be stained and flow-sorted for isolation of CD4 +T helper (Th1, Th17.0 and Th17.1) and T regulatory cell immune populations, followed by next-generation RNA sequencing. We will construct bioinformatic tools using this gene expression to define sarcoidosis endotypes that associate with progressive and non-progressive pulmonary disease outcomes and validate the tools using an independent cohort.

Ethics and dissemination

The study protocol has been approved by the Institutional Review Boards at National Jewish Hospital (IRB# HS-3118), University of Iowa (IRB# 201801750), Johns Hopkins University (IRB# 00149513) and University of California, San Francisco (IRB# 17-23432). All participants will be required to provide written informed consent. Findings will be disseminated via journal publications, scientific conferences, patient advocacy group online content and social media platforms.

Buteyko method for people with asthma: a protocol for a systematic review and meta-analysis

Por: Mendonca · K. M. P. P. d. · Collins · S. · Santos · T. Z. · Chaves · G. · Leite · S. · Santino · T. A. · Monteiro · K. S.

Buteyko method is recommended as a non-pharmacological treatment for people with asthma. Although the worldwide interest in the Buteyko method, there is a paucity of studies gathering evidence to support its use. Therefore, we aim to conduct a systematic review and meta-analysis to assess the effects of the Buteyko method in children and adults with asthma.

Methods and analysis

We will search on Cochrane Central Register of Controlled Trials, MEDLINE, Embase, US National Institutes of Health Ongoing Trials Register and WHO International Clinical Trials Registry Platform for studies focusing on the Buteyko method for children and adults with asthma. The searches will be carried out in September 2021 from database’s inception to the present. We will include randomised controlled trials comparing Buteyko method alone with asthma education or inactive control intervention. There will be no restriction on language. Primary outcomes include quality of life, asthma symptoms and adverse events/side effects. Two review authors will independently screen the studies for inclusion and extract data. We will assess the quality of the included studies using the ‘Risk of Bias’ tool. The certainty of the evidence will be assessed using the GRADE approach. Data synthesis will be conducted using Review Manager software. Reporting of the review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance and the Cochrane Handbook for Systematic Reviews of Interventions.

Ethics and dissemination

This study will assess and provide evidence for the use of the Buteyko method in people with asthma. We will analyse secondary data and this does not require ethics approval. The findings will be published in peer-reviewed journals, at relevant conferences and will be shared in plain language in social media. Moreover, the findings of this review could guide the direction of healthcare practice and research.

PROSPERO registration number


Preliminary evidence for the impact of digital life stories about aged care residents on staff knowledge and understanding regarding those residents; A single arm trial


Aims and objectives

This study aimed to examine the impact of digital stories about aged care residents on staff knowledge and understanding regarding those residents.


More than a quarter of a million older Australians live in residential aged care facilities. This living arrangement can inhibit the expression of a person's sense of identity. Without objects and cues that reflect the person's selfhood, it can be difficult for a person to express their uniqueness. Staff may not sufficiently appreciate the resident's individuality and therefore may not be able to customise care for the resident.


This study used a single-arm trial design.


The study was conducted in four residential aged care facilities. Short digital life stories (3–4 min) of eight residents were constructed by student volunteers over 6 months. Participants (n = 53 care staff) completed a self-report measure of their knowledge and understanding of a resident before and after watching the resident's story. The study adhered to guidelines for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (see Appendix S1).


Pre- and post-test scores of the measure were compared using paired samples t-tests. These scores changed significantly, showing an improvement of knowledge and understanding regarding residents.


Watching digital life stories were associated with improvements in knowledge and understanding by staff, and hence have the potential to foster a greater level of understanding of residents by such staff, and more person-centred care practices within residential aged care facilities.

Relevance to clinical practice

Digital stories about aged care residents are quick and efficient methods for improving aged care staff members' knowledge and understanding of the residents under their care. With such understanding, staff may be able to better customise care for residents, thereby validating residents' sense of identity and elevating residents' quality of life.

“I felt like it would’ve been perfect, if they hadn’t been rushing”: Black women’s childbirth experiences with medical providers when accompanied by perinatal support professionals



This study examined the nature and characteristics of Black women's interactions with medical providers during childbirth when accompanied by a perinatal support professional (PSP; similar to a doula).


The design was qualitative, and a phenomenological approach was employed to examine the meaning of women's experiences.


We conducted in-depth interviews with 25 Black women enrolled in a perinatal support program in Cleveland, Ohio, in late 2017 and early 2018, exploring their interactions with medical providers, the meaning of their experiences, and the roles their PSPs played.


Clients broadly categorized experiences as positive or negative. When medical providers respected them, their birth plans and/or collaborated with PSPs, women reported more positive experiences. They associated negative experiences with providers having their own timelines and agendas, and women perceiving their needs were unheard and/or disrespected.


The findings emphasize the need for medical providers to be patient-centred, set aside assumptions, treat their patients as experts, value women's knowledge and voice, and treat patients and their supports as part of the team.


Findings support the importance of having a knowledgeable but non-medical support person present during birth. We discuss implications for how empowerment may be a tool to achieving better birth outcomes.

Information Needs and the Use of Documentation to Support Collaborative Decision-Making: Implications for the Reduction of Central Line–Associated Blood Stream Infections

imageIt is clear that interdisciplinary communication and collaboration have the potential to mitigate healthcare-associated harm, yet there is limited research on how communication through documentation in the patient record can support collaborative decision making. Understanding what information is needed to support collaborative decision making is necessary to design electronic health information systems that facilitate effective communication and, ultimately, safe care. To explore this issue, we focused on information needs related to central venous catheter management and the prevention of central line–associated blood stream infections. Semistructured interviews were conducted with nurses working in an intensive care unit. Interview transcripts were analyzed using inductive thematic analysis. Three themes were identified: (1) challenges managing documentation in multiple places in the absence of formal documentation processes for central venous catheter management; (2) lack of standardized decision-making processes for managing central venous catheters; and (3) oral communication holds it together. Our findings provide a foundation for the development of EHR functional requirements that enhance communication regarding the management of central venous catheters and facilitate the prompt removal of unnecessary lines.

Suicide Risk Management Protocol for a Randomized Controlled Trial of Cardiac Patients Reporting Hopelessness

imageBackground Investigators conducting studies that include potentially suicidal individuals are obligated to develop a suicide risk management (SRM) protocol. There is little available in the literature to guide researchers in SRM protocol development. Objectives The aim of the study was to describe an SRM protocol developed for a randomized controlled trial (RCT) currently enrolling cardiac patients who report moderate to severe levels of hopelessness. Methods The SRM protocol identifies suicidal ideation and measures ideation severity through use of the Columbia-Suicide Severity Rating Scale risk factor questions. Based on responses, study participants are deemed safe or at low, moderate, or high risk for suicide. The SRM protocol guides research staff through a plan of action based on risk level. The protocol further guides staff through a plan over the course of this prospective study—from hospital enrollment to home-based visits. Results Research staff are well trained to identify suicidal ideation risk factors, initiate specific questioning about suicidal intent, determine level of risk, identify protective factors and a safe environment, and make referrals if needed. Of the 51 patients hospitalized with cardiac disease who reported moderate to severe hopelessness, 43 scored at a safe suicide risk level and 8 scored at low risk. Thirty-five of the 51 patients enrolled in the RCT. Of the 35 participants who received home visits to date, there have been three instances of low and one instance of moderate suicide risk. The SRM protocol has been consistently and accurately used by research personnel in both hospital and home settings. One modification has been made to the protocol since study activation, namely, the addition of an assessment of counseling history and encouragement of continued counseling. Booster training sessions of research staff will continue throughout the course of the RCT. Discussion Use of the SRM protocol identifies study participants who are safe or at risk for suicide in both hospital and home settings, and research staff can refer participants accordingly. Conclusion The SRM protocol developed for this RCT can serve as a model in the development of SRM protocols for future research in acute care, community, or home-based settings.

Cost of managing patients with venous leg ulcers


The aim of this study was to estimate costs associated with the management of patients with venous leg ulcers (VLUs) from the perspective of the UK National Health Service (NHS). The analysis was undertaken through the Secure Anonymised Information Linkage Databank which brings together and anonymously links a wide range of person‐based data from around 75% of general practitioner (GP) practices within Wales (population coverage ~2.5 million). The data covered an 11‐year period from 2007 to 2017. All patients linked to the relevant codes were tracked through primary care settings, recording the number of GP practice visits (number of days with an event recorded), and wound treatment utilisation (eg, dressings, bandages, etc.) Resources were valued in monetary terms (£ sterling) and the costs were determined from national published sources of unit costs. This is the first attempt to estimate the costs of managing of VLUs using routine data sources. The direct costs to the Welsh NHS are considerable and represent 1.2% of the annual budget. Nurse visits are the main cost driver with annual estimates of £67.8 million. At a UK level, these costs amount to £1.98 billion. Dressings and compression bandages are also major cost drivers with annual Welsh estimates of £828 790. The direct cost of managing patients with VLUs is £7706 per patient per annum, which translates to an annual cost of over £2 billion, when extrapolated to the UK population. The primary cost driver is the number of district nurse visits. Initiatives to reduce healing times through improving accuracy of initial diagnosis, and improved evidence‐based treatment pathways would result in major financial savings.

Role of gender in perspectives of discrimination, stigma, and attitudes relative to cervical cancer in rural Sénégal

by Natalia Ongtengco, Hamidou Thiam, Zola Collins, Elly Lou De Jesus, Caryn E. Peterson, Tianxiu Wang, Ellen Hendrix, Youssoupha Ndiaye, Babacar Gueye, Omar Gassama, Abdoul Aziz Kasse, Adama Faye, Jennifer S. Smith, Marian Fitzgibbon, Jon Andrew Dykens

Cervical cancer is the leading cause of female cancer deaths in Sénégal which is ranked 17th in incidence globally, however, the screening rate there is very low. Nuanced gendered perceptions and health behaviors of both women and men play a significant role in women’s health. Our study analyzed gender differences on perceptions of gender roles, discrimination, cancer attitudes, cancer stigma, and influences in healthcare decision making within our study population to inform ongoing cervical cancer prevention work in the rural region of Kédougou, Sénégal. We conducted a cross-sectional survey of 158 participants, 101 women and 57 men (ages 30–59) across nine non-probability-sampled communities from October 2018 through February 2019. Bivariate analysis was conducted to assess gender differences across all variables. We also conducted analyses to determine whether there were significant differences in beliefs and attitudes, by screening behavior and by education. We found significant gender differences regarding the perception of a woman’s role (P

Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study


Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C‐collar) device in situ and are subsequently exposed to device‐related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C‐collar‐related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C‐collar were retrieved over a 9‐year period. Chi square and t‐tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine‐year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C‐collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024‐1.723, P = .033). Time in the C‐collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P < .001) were associated with pressure injury development. Patients with C‐collar devices are a vulnerable group at risk for pressure injury development because of their immobility and length of ICU stay.

Genomic characterisation of <i>Salmonella enterica</i> serovar Wangata isolates obtained from different sources reveals low genomic diversity

by Kelly M. J. Simpson, Siobhan M. Mor, Michael P. Ward, Julie Collins, James Flint, Grant A. Hill-Cawthorne, Moataz Abd El Ghany

Salmonella enterica serovar Wangata is an important pathogen in New South Wales (NSW), Australia. The incidence of S. Wangata is increasing and transmission is suspected to be via a non-food source. A recent outbreak investigation of sources of S. Wangata recovered isolates from humans, domestic animals, wildlife and the environment. Here, we extend that investigation by characterising and describing the genomic determinates of these isolates. We found that Australian S. Wangata isolates from different sources exhibited similar virulence and antimicrobial resistance gene profiles. There were no major genomic differences between isolates obtained from different geographical regions within Australia or from different host species. In addition, we found evidence (low number of SNPs and identical virulence gene profiles) suggestive of an international transmission event between Australia and the United Kingdom. This study supports the hypothesis that S. Wangata is shared between different hosts in NSW, Australia and provides strong justification for the continued use of genomic surveillance of Salmonella.

Lack of an association between clinical INSTI-related body weight gain and direct interference with MC4 receptor (MC4R), a key central regulator of body weight

by Carrie McMahon, James L. Trevaskis, Christoph Carter, Kevin Holsapple, Kirsten White, Moupali Das, Sean Collins, Hal Martin, Leigh Ann Burns-Naas

An increasing prevalence of overweight and obesity in people living with HIV has been associated with initiation of antiretroviral therapy with integrase strand transfer inhibitors (INSTIs). An off-target inhibition of the endogenous ligand binding to the human melanocortin 4 receptor (MC4R) has been suggested as a potential mechanism for clinical body weight gain following initiation of dolutegravir, an INSTI. In this study, we interrogated several INSTIs for their capacity for antagonism or agonism of MC4R in an in vitro cell-based assays including at concentrations far exceeding plasma concentrations reached at the recommended dosages. Our results indicate that while INSTIs do exhibit the capacity to antagonize MC4R, this occurs at concentrations well above predicted clinical exposure and is thus an implausible explanation for INSTI-associated weight gain.

The impact of human trafficking in relation to maternity care: A literature review

Human trafficking is an international crime and violation of human rights defined as the recruitment and movement of people for the purposes of exploitation – using coercion, deception, and abuse of vulnerability (PROTECT Report for the Department of Health Policy Research Programme, 2015). Trafficking falls under the umbrella term of ‘Modern Slavery’ which additionally encompasses slavery, servitude and forced or compulsory labour (Department of Justice, 2019). In 2013, there were an estimated 10,000–13,000 potential victims of modern slavery in the UK (Department of Justice, 2019); its scale is gradually increasing due a number of social and economic factors (Wheaton et al., 2010).

The association of malnutrition with falls and harm from falls in hospital inpatients: Findings from a 5‐year observational study



Inpatient falls continue to be a significant clinical issue, and while malnutrition is a known risk factors for falls, few studies have investigated its association with inpatient falls. This study aimed to explore the independent association between malnutrition and fall risk as well as harm from falls in hospital inpatients.


Malnutrition identified in annual malnutrition audits was combined with inpatient fall data captured through the electronic patient incident reporting system in the 12 months following audit days. Audit data were available for 1,849 inpatients across 2011–2015, and covariate associations between age, gender, BMI, malnutrition, falls and harmful falls were analysed. The reporting of this paper is in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations (see Appendix S1).


The prevalence of malnutrition was 32.4% (n = 543), and 171 (9.2%) inpatients experienced a fall with 0.7% (n = 13) categorised as harmful. In bivariate analysis, patients who fell were more likely to be older (median 79.0 vs. 70.0 years; p < .0001) or malnourished (40.9% vs. 31.5%; p = .021). Malnutrition (p < .0001) and having a lower BMI (p = .026) were significant predictors of harmful falls. Regression modelling demonstrated that only increasing age increased the likelihood of having an inpatient fall (OR 1.022 95% CI 1.021–1.046; p < .0001). Malnourished inpatients were almost 8 times more likely to have a harmful fall than those not malnourished (OR 7.94 95% CI 1.457–43.338; p = .017), independent of age and BMI.


Malnourished patients are more likely to experience a harmful fall. Assessment of malnutrition should be incorporated into fall risk assessments as a way of highlighting those patients at greater risk and to link to nutritional care pathways.

Comparing the Effects of Single‐ and Multiple‐Component Therapies for Insomnia on Sleep Outcomes



Single‐ and multiple‐component therapies are recommended in professional guidelines for managing chronic insomnia. Systematic reviews point to insufficient evidence of the comparative effectiveness of these therapies, which is required for treatment decision making.


To compare the effectiveness of three single‐component and one multiple‐component therapies on short‐term sleep outcomes.


The data were obtained from 517 persons with chronic insomnia, enrolled in a partially randomized preference trial. They were allocated to the single‐component therapies: sleep education and hygiene (SEH), stimulus control therapy (SCT), and sleep restriction therapy (SRT), or the multiple‐component therapy (MCT). The outcomes, perceived insomnia severity and sleep parameters, were assessed with established measures at pre and posttest. Repeated measure analysis of variance was used to compare the outcomes across therapy groups over time. The clinical relevance of the therapies’ effects was evaluated by examining the effect size and remission rate.


The four therapies differed in their effectiveness in reducing perceived insomnia severity and improving sleep outcomes. SEH was least effective. SCT, SRT, and MCT were moderately effective. SCT and SRT demonstrated slightly higher remission rates than MCT for perceived insomnia severity and some sleep parameters.

Linking Evidence to Action

SCT and SRT are viable single‐component therapies that produce clinical benefits. Single‐component insomnia treatment may be more convenient to implement in the primary care setting due to the reduced number of treatment recommendations compared to MCT.