The Delirium Puzzle: Piecing best practice to clinical care

Background: Delirium is a significant and distressing illness with a high morbidity and mortality. Early detection and management of the underlying cause of delirium are vital to reduce its severity, duration, and complications. Despite the growing focus nationally and internationally to recognise delirium, it is often under-detected. To address the barriers to under-detection and translate the Delirium Clinical Care Standard into practice, education and training have been ranked as the most important intervention. Objective structured clinical examinations (OSCEs) are a potential educational intervention to enhance healthcare practitioners’ self-efficacy, knowledge, and delirium care clinical practice. Aim: The Delirium Puzzle Project aimed to develop and evaluate delirium educational interventions, using OSCEs, to enhance the self-efficacy, knowledge, and clinical practice of undergraduate medical students and post-registration healthcare practitioners, with a focus on nurses. Methods: Following the Medical Research Council framework for developing and evaluating complex interventions, the Delirium Puzzle Project had six discrete yet interrelated studies conducted in three phases. Stakeholder consultation and engagement activities were undertaken prior to each phase. Phase 1 (development) involved two literature reviews to identify existing literature on the use and value of OSCEs in undergraduate geriatric medicine education (a scoping review) and postregistration nurse education (an integrative review) (Chapter 2). Phase 1 included the development of a conceptual framework to better understand how OSCEs transfer delirium knowledge and skills into clinical practice (Chapter 3). Phase 2 (pilot studies) (Chapter 4) included: (i) a pre-post survey pilot study designed to evaluate The Delirium group-OSCE Education Package on self-perceived confidence and competence in delirium assessment tools and delirium knowledge; delirium knowledge scores; planned practice change; and perceived usefulness of the education for third-year medical students during their aged care clinical placement; and (ii) a quasi-experimental study with follow-up qualitative methods to evaluate the effects of The Delirium OSCE Education Package on self-perceived confidence and competence in delirium assessment tools and delirium knowledge; delirium knowledge score; clinical practice; planned practice change; and perceived usefulness of the education for registered healthcare practitioners. Phases 1 and 2 informed Phase 3. Phase 3 (controlled trials) included: (i) a non-randomised, clustered, controlled study to compare The Delirium group-OSCE Education Package to standard delirium education for medical students during clinical placement (Chapter 5), and (ii) a multisite randomised controlled trial (RCT) comparing The Delirium OSCE Education Package to standard professional development education for registered healthcare practitioners (specifically nurses) (Chapter 6). Results from Phases 2 and 3 were synthesised to answer the overarching research questions of the Delirium Puzzle Project (Chapter 7). Results: Phase 1 demonstrated that OSCEs have evolved into educational interventions to improve self-efficacy and drive learning. Bandura’s Self-Efficacy Theory was explored as the conceptual framework to explain how OSCEs could lead to heightened self-efficacy that results in increased competence in delirium care. The two pilot studies in Phase 2 demonstrated significant improvements in self-efficacy and delirium knowledge scores following the educational intervention. The medical student cohort in Phase 3 demonstrated a significant difference in mock OSCE exam scores in favour of medical students who completed The Delirium group-OSCE Education Package. While there was a broad spread in the raw practice scores, Phase 3 for the post-registration nursing cohort demonstrated the intervention group were 10.1 times more likely to achieve a satisfactory score in delirium practice (p=0.009). Conclusion: The Delirium Puzzle Project demonstrated that delirium educational OSCEs are effective in enhancing undergraduate medical students and post-registration healthcare practitioners’ self-efficacy, delirium knowledge, and delirium detection and care. However, delirium educational OSCEs, are just one piece of the delirium care puzzle. The Delirium Puzzle Project identified a range of recommendations at the micro (clinician), meso (ward), and macro (organisational) levels to ensure that the Delirium Clinical Care Standard is translated into clinical practice. Implementing the Delirium Puzzle Project recommendations will improve delirium care in Australia

Intentions For Having Sex: What Matters

The intentions of 614 adolescents to have sex were examined in conjunction with their participation in risky behaviors (hard drugs, violence and suicide, alcohol and marijuana use) and protective factors (community connected and against teen sex, educational aspirations, emotional support from family, friends and girlfriend/boyfriend or sexual partner). Key findings from bivariate and linear regression analyses revealed that alcohol and marijuana use were correlated with intention to have sex among adolescents, as was emotional support from a boyfriend/girlfriend or sexual partner. This study offers insights regarding intentions to have sex among adolescents, pointing particularly to the issue of emotional support in a dating relationship as a motivation for having sex. Findings from this study can be used to develop health education and promotion programs focusing on delaying sexual intercourse

Ultrasound-Assisted Extraction of Polyphenols from Ginger (Zingiber officinale) and Evaluation of its Antioxidant and Antimicrobial Properties

In this present study, ultrasound-assisted solvent extraction conditions were optimized to develop a more efficient method that would result in maximum extraction of polyphenols from ginger. To achieve this optimal extraction process, a central composite design of response surface methodology was applied. A second-order polynomial equation was developed, indicating the effect of ginger concentration (400-1,200 mg/20mL solvent), solvent mixture composition (20-100%), temperature (30-70°C) and treatment time (10-30 min) on polyphenols extraction. The optimum parameters were found to be 1200mg of ginger prepared with 86% ethanol and sonication for 11 minutes at 65°C. The total phenolic and flavonoid content of ginger was found to be 1039.64 mg Gallic acid equivalent (GAE)/g and 492.57±3.5 mg Quercetin equivalent (QE)/g of ginger extract (dry weight), respectively. The ginger extract proved to have significant antioxidant capacity with a DPPH radical scavenging activity of 54.5% noted and further proved to have strong antimicrobial effects against Escherichia coli, Salmonella typhimurium, Bacillus cereus and Staphylococcus aureus with diameter of inhibition zone (DIZ) values of 14.49mm, 15.10mm, 16.74mm and 13.88mm recorded respectively, MIC values ranging from 3.75 – 7.5mg/ml and an extract concentration of 7.5mg/ml required to exert bactericidal effects against B.cereus and 15mg/ml for all other strains. All values obtained were comparable to that of synthetic preservatives sodium nitrite and sodium benzoate thus demonstrating the superior potential of this spice for future application as a natural food preservative

Effect of an evidence based quality improvement framework on patient safety

Objectives To investigate the impact of the introduction of The Productive Ward Program™ on two patient safety indicators; patient falls and medication errors. Design Retrospective quantitative study. Setting The study was conducted at a major metropolitan acute care hospital in Sydney, Australia. Subjects This study was conducted in a medical, surgical and two aged care wards, with a combined total of 120 inpatient beds over a 32 month time period. Main Outcome Measures The number of patient falls and medication errors for each of the participating wards. Results The implementation of The Productive Ward Program™, did not have an overall significant statistical reduction in the number of falls and medication incidents. Aged Care 1, had a reduction of 13 falls between intervention and post intervention phase, these results were not statistically significant (OR 1.17; 95% CI 0.86, 1.59). For Aged Care 1 ward there was a statistically significant reduction in medication errors from 66 errors pre intervention to 27 medication errors post intervention (OR 2.73;95% CI 1.71, 4.38). Conclusion The results of this small study indicate that the implementation of The Productive Ward Program™, did not have an overall significant statistical reduction in the number of falls and medication errors. This paper highlights the need for future research on the impact of the Productive Ward Program on patient safety

Diagnostic Accuracy of Delirium Assessment Tools in Critical Ill Patients: A Systematic Review and Meta-analysis

Abstract presented at The Australian and New Zealand Society for Geriatric Medicine Annual Scientific Meeting, 13-15 May 2019, Adelaide, Australi

Understanding Household Behavioral Risk Factors for Diarrheal Disease in Dar es Salaam: A Photovoice Community Assessment

Whereas Tanzania has seen considerable improvements in water and sanitation infrastructure over the past 20 years, the country still faces high rates of childhood morbidity from diarrheal diseases. This study utilized a qualitative, cross-sectional, modified Photovoice method to capture daily activities of Dar es Salaam mothers. A total of 127 photographs from 13 households were examined, and 13 interviews were conducted with household mothers. The photographs and interviews revealed insufficient hand washing procedures, unsafe disposal of wastewater, uncovered household drinking water containers, a lack of water treatment prior to consumption, and inappropriate toilets for use by small children. The interviews revealed that mothers were aware and knowledgeable of the risks of certain household practices and understood safer alternatives, yet were restricted by the perceived impracticality and financial constraints to make changes. The results draw attention to the real economic and behavioral challenges faced in reducing the spread of disease

Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis

Background Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use. Methods National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public\u27s KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model. Results Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden. Conclusions Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use

Spatial variation in leopard (Panthera pardus) site use across a gradient of anthropogenic pressure in Tanzania's Ruaha landscape

Understanding large carnivore occurrence patterns in anthropogenic landscapes adjacent to protected areas is central to developing actions for species conservation in an increasingly human-dominated world. Among large carnivores, leopards (Panthera pardus) are the most widely distributed felid. Leopards occupying anthropogenic landscapes frequently come into conflict with humans, which often results in leopard mortality. Leopards’ use of anthropogenic landscapes, and their frequent involvement with conflict, make them an insightful species for understanding the determinants of carnivore occurrence across human-dominated habitats. We evaluated the spatial variation in leopard site use across a multiple-use landscape in Tanzania’s Ruaha landscape. Our study region encompassed i) Ruaha National Park, where human activities were restricted and sport hunting was prohibited; ii) the Pawaga-Idodi Wildlife Management Area, where wildlife sport hunting, wildlife poaching, and illegal pastoralism all occurred at relatively low levels; and iii) surrounding village lands where carnivores and other wildlife were frequently exposed to human-carnivore conflict related-killings and agricultural habitat conversion and development. We investigated leopard occurrence across the study region via an extensive camera trapping network. We estimated site use as a function of environmental (i.e. habitat and anthropogenic) variables using occupancy models within a Bayesian framework. We observed a steady decline in leopard site use with downgrading protected area status from the national park to the Wildlife Management Area and village lands. Our findings suggest that human-related activities such as increased livestock presence and proximity to human households exerted stronger influence than prey availability on leopard site use, and were the major limiting factors of leopard distribution across the gradient of human pressure, especially in the village lands outside Ruaha National Park. Overall, our study provides valuable information about the determinants of spatial distribution of leopards in human-dominated landscapes that can help inform conservation strategies in the borderlands adjacent to protected areas

The Vehicle, Spring 1989

Table of Contents Home MoviesBob Zordanipage 4 Mummy BreathMichael Salempage 5 Pop ArtMonica Grothpage 6 Grey Haze and MoonAllison Stroudpage 7 The State of Being at a Soap & SudsDenise Santorpage 9 Letter HomeJim Reedpage 10 Thursday Afternoon in the StacksRebecca Dickenspage 11 Sizing DownMichael Salempage 12 Intellectual AnatomyMonica Grothpage 13 Grandmother PoemAmy Sparkspage 14 Blues of the BrothermanAlma Watsonpage 15 MigrationPatrick Peterspage 17 RidingBob Zordanipage 18 All Hallow\u27s EveErik Hansonpage 19 Waiting RoomAmy Sparkspage 20 Father, Forgive HerMonica Grothpage 21 Silent ReplyTom Caldwellpage 22 PhotographRobb Montgomerypage 24 WashdayAnn Moutraypage 25 PhotographDiane Atkinspage 26 Uptown FogRobb Montgomerypage 27 Shinbones and SkullsJennifer Berkshirepage 29 Sudden Small PhrasesPatrick Peterspage 31https://thekeep.eiu.edu/vehicle/1053/thumbnail.jp