The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): a cluster randomised trial

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 ≥48 h 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

Primers used for molecular analysis for identification of bee populations, pathogens and parasites.

<p>Abbreviations: Israeli acute paralysis virus (IAPV), acute bee paralysis virus (ABPV), black queen cell virus, (BQCV), chronic bee paralysis virus (CBPV), deformed wing virus (DWV), kashmir bee virus (KBV), and sacbrood virus (SBV). References: Arias MC and WS Sheppard WS (1996) <i>Molecular Phylogenetics and Evolution</i> 5: 557–566; Benjeddou et al. (2001) <i>Applied and Environmental Microbiol</i>ogy 67:2384–2387; Chen et al. (2005) <i>Applied and Environmental Microbiol</i>ogy 71(1):436–441; Di Prisco et. al. (2011) <i>Journal of General Virology</i> 92: 151–15; Klee et al. (2007). Journal of Invertabrate Pathology 96: 1–10. Ribiere et al. (2002) <i>Apidologie</i> 33: 339–351; Stoltz et al. (1995) <i>Journal of Apicultural Research</i> 34: 153–160.</p

Geographic location of surveyed apiaries.

<p>Twenty-four apiaries were surveyed throughout Kenya with an additional three apiaries (25–27), see supplemenatry material, surveyed for ecological effects on colony health. The location and numerical designation of the apiaries is indicated on the map.</p

Association of viral diversity with colony size and <i>Varroa</i>.

<p><b>A</b>. Colony size (the number of frames of bees) was not affected by viral diversity (the number of viruses in a colony), H(2) = 2.74, p = 0.254. <b>B</b>. However, colonies with different number of viruses had significantly different numbers of <i>Varroa</i> (H(2) = 13.10; p = 0.0014). Colonies with 1 or 2 viruses had significantly higher <i>Varroa</i> loads than colonies that had no viruses (p<0.05, Wilcoxon pairwise tests, different letters denote significant differences). The number of colonies in each group is indicated at the bottom of each bar. <i>Varroa</i> counts were converted to logarithmic scale.</p

Association of <i>Varroa</i> infestation with elevation and colony size.

<p><b>A</b>. Levels of <i>Varroa</i> mites were positively correlated with elevation, with colonies at higher elevations having significantly higher average numbers of <i>Varroa</i> (r(53) = 0.44, p = 0.001). <b>B</b>. Levels were also positively correlated with colony size ((48) = 0.35, p = 0.013). <i>Varroa</i> counts were converted to logarithmic scale.</p