Perioperative antimicrobial decision making: Focused ethnography study in orthopedic and cardiothoracic surgeries in an Australian hospital

Objective:Antimicrobial use in the surgical setting is common and frequently inappropriate. Understanding the behavioral context of antimicrobial use is a critical step to developing stewardship programs.Design:In this study, we employed qualitative methodologies to describe the phenomenon of antimicrobial use in 2 surgical units: orthopedic surgery and cardiothoracic surgery.Setting:This study was conducted at a public, quaternary, university-affiliated hospital.Participants:Healthcare professionals from the 2 surgical unit teams participated in the study.Methods:We used focused ethnographic and face-to-face semi-structured interviews to observe antimicrobial decision-making behaviors across the patient’s journey from the preadmission clinic to the operating room to the postoperative ward.Results:We identified 4 key themes influencing decision making in the surgical setting. Compartmentalized communication (theme 1) was observed with demarcated roles and defined pathways for communication (theme 2). Antimicrobial decisions in the operating room were driven by the most senior members of the team. These decisions, however, were delegated to more junior members of staff in the ward and clinic environment (theme 3). Throughout the patient’s journey, communication with the patient about antimicrobial use was limited (theme 4).Conclusions:Approaches to decision making in surgery are highly structured. Although this structure appears to facilitate smooth flow of responsibility, more junior members of the staff may be disempowered. In addition, opportunities for shared decision making with patients were limited. Antimicrobial stewardship programs need to recognize the hierarchal structure as well as opportunities to engage the patient in shared decision making.

“Why and how did this happen?”: development and evaluation of an information resource for parents of children with CHD

Background:The causes of CHD are complex and often unknown, leading parents to ask how and why this has happened. Genetic counselling has been shown to benefit these parents by providing information and support; however, most parents currently do not receive this service. This study aimed to develop a brochure to determine whether an information resource could improve parents’ knowledge about CHD causation and inheritance and increase psychosocial functioning.Methods:In development, the resource was assessed against several readability scales and piloted. Parents of children attending preadmission clinic for surgery were included. Assessments occurred pre- and post-receiving the information resource using a purpose-designed knowledge measure and validated psychological measures.Results:Participant’s (n = 52) knowledge scores increased significantly from the pre-questionnaire ( ${\overline x}\, = \,5/10$ , sd = 2.086) to post-questionnaire ( $\overline x\, = \,7.88/10$ , sd = 2.094, p < 0.001), with all aware that CHD can be caused by genetic factors after reading the brochure. Perceived personal control also increased from pre- ( $\overline x\, = \,11.856/18$ , sd = 4.339) to post-brochure ( $\overline x\, = \,14.644/18$ , sd = 3.733, p < 0.001), and many reported reduced feelings of guilt. No negative emotional response to the brochure was reported. The information provided was considered relevant (88%), reassuring (86%), and 88% would recommend the brochure to other parents. However, some wanted more emotional support and assistance in what to tell their child.Conclusions:Use of the information resource significantly enhanced parents’ knowledge of CHD causation and increased their psychosocial functioning. It is a valuable resource in the absence of genetic counselling; however, it should not replace formal genetic counselling when required.

Knowledge of and Willingness to Try Acupuncture for Postoperative Nausea and Vomiting: An Australian Survey of Surgical Patients

Introduction Level 1 evidence supports the use of acupuncture as a safe and effective treatment for postoperative nausea and vomiting (PONV). However, to date, very few hospitals in Western countries have incorporated this technique into their management strategies. Objective To conduct a survey to establish patients’ knowledge and opinions of acupuncture as a treatment option for the management of PONV in a large Western teaching hospital that did not offer acupuncture. Methods Over a 4-week period, a self-completed, anonymous questionnaire survey was distributed to 171 consecutive patients attending the preadmission clinic pending surgery. Results Overall, 161 participants met the selection criteria and completed the survey (100%). The majority of them had a European background (88.8%) and were over 40 years old (87.6%). Seventy-eight participants (48%) had a history of nausea and vomiting and 39 (24%) had suffered from PONV. One hundred and four (65%) and 110 (68%) patients, respectively, stated that they would be willing to try acupuncture in hospital or at home following surgery to prevent or reduce PONV. Only 25 (15.5%) participants knew that acupuncture could be used to treat nausea and vomiting; however, 140 (87%) indicated that they would be willing to try the therapy after being informed of the potential benefit of acupuncture for PONV prevention/reduction. Those with previous experience of acupuncture were ~3.9 times more likely to be willing to use acupuncture for PONV than those without. Conclusion Patients attending an Australian tertiary hospital showed an overwhelming interest in acupuncture to manage PONV. This provides strong support for the potential implementation of acupuncture in an acute hospital setting.

Measuring Height in Recumbent Critical Care Patients

Background Estimates of the height of patients in the intensive care unit are required to adhere to clinical guidelines for drug dosages, ventilatory support, and nutrition. The gold standard of standing height cannot be used because these patients are often unconscious and recumbent. The ability of physiotherapists or dietitians to measure height in unconscious, recumbent patients has not been evaluated. Objectives To compare the accuracy of physicians, physiotherapists, and dietitians in estimating the height of recumbent critical care patients by using existing practice methods. Methods A total of 35 patients were recruited from the cardiothoracic preadmission clinic, where standing height is routinely measured by a physiotherapist. After surgery, in the intensive care unit, 1 physician, 2 physiotherapists, and 2 dietitians measured each recumbent patient’s height. Three methods were used: observation, whole-body measurement, and height estimated by using length of the forearm and the British Association for Parenteral and Enteral Nutrition normative chart. Difference from standing height was measured from zero and was compared across professions and methods, with zero indicating no difference. Results Overall, 17 physicians, 4 dietitians, and 9 physiotherapists consented to measure patients. After adjustments for method, measurements by physiotherapists did not differ significantly from the gold standard (P = .59), whereas those of physicians (P = .02) and dietitians (P &lt; .001) did. Conclusions Physiotherapists’ measurements of supine height of recumbent critical care patients, obtained by using a nonrigid measuring tape, are more accurate than measurements obtained by physicians and dietitians.

Abstract P126: Can a Structured Quality Improvement Initiative Reduce Elective Cardioversion Patient Waiting Times?

Background: Current guidelines recommend anticoagulation with a documented international normalised ratio of 2-3 for 3 weeks prior to an elective cardioversion (ECV). At Western Health multiple stakeholders were involved in the pre-procedural care of the ECV patient (cardiologists, general physicians, outpatient clinics and pathology service providers) with varying adherence to the anticoagulation guidelines. Inadequate patient anticoagulation identified at the time of procedure or inadequate hospital resources (CCU bed or anaesthetic personnel) led to cancellations and re-booking of the procedure. ECV cancellations led to prolonged waiting times to the procedure and consequently patients remaining in atrial fibrillation longer. Objective: Decrease waiting times from referral to the ECV procedure by improving guideline compliance. Method: The ECV procedure was re-designed by incorporating the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation into the written clinical procedure and clinical pathway. Coordination of the ECV was assigned to the cardiology preadmission clinic (PAC) and all patients attend a PAC appointment prior to ECV being scheduled. The role of PAC was to manage clinical risk factors and patient preparation. Resource alignment and bed modelling resulted in structured twice-weekly ECV sessions. A combined transoesophageal echocardiogram /ECV procedure was introduced as per guideline recommendations to specifically manage the ‘difficult to anticoagulate’ patient subgroup. Effectiveness of the process improvement was performed by comparing mean waiting time from referral to ECV before the change (2008) and after (2009). Results: Following process improvement, mean waiting times to ECV procedure decreased from 12 weeks to 5 weeks (p < 0.001). The patient subgroup ‘difficult to anticoagulate’ achieved the greatest reduction in mean waiting time, from 22 weeks to 8 weeks (p < 0.001). Conclusion: Introducing a guideline driven policy and procedure for ECV has led to a significant reduction in waiting times from referral to ECV. Goals of anticoagulation therapy are clearly articulated and the preadmission clinic provides a coordinating role amongst the multiple stakeholders involved.