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Year of Publication
1.  Knowledge, attitudes, beliefs and behaviour intentions for three bowel management practices in intensive care: effects of a targeted protocol implementation for nursing and medical staff 
BMC Nursing  2015;14:6.
Background
Bowel management protocols have the potential to minimize complications for critically ill patients. Targeted implementation can increase the uptake of protocols by clinicians into practice. The theory of planned behaviour offers a framework in which to investigate clinicians’ intention to perform the behaviour of interest. This study aimed to evaluate the effect of implementing a bowel management protocol on intensive care nursing and medical staffs’ knowledge, attitude, subjective norms, perceived behavioural control, behaviour intentions, role perceptions and past behaviours in relation to three bowel management practices.
Methods
A descriptive before and after survey using a self-administered questionnaire sent to nursing and medical staff working within three intensive care units before and after implementation of our bowel management protocol (pre: May – June 2008; post: Feb – May 2009).
Results
Participants had significantly higher knowledge scores post-implementation of our protocol (pre mean score 17.6; post mean score 19.3; p = 0.004). Post-implementation there was a significant increase in: self-reported past behaviour (pre mean score 5.38; post mean score 7.11; p = 0.002) and subjective norms scores (pre mean score 3.62; post mean score 4.18; p = 0.016) for bowel assessment; and behaviour intention (pre mean score 5.22; post mean score 5.65; p = 0.048) for administration of enema.
Conclusion
This evaluation, informed by the theory of planned behaviour, has provided useful insights into factors that influence clinician intentions to perform evidence-based bowel management practices in intensive care. Addressing factors such as knowledge, attitudes and beliefs can assist in targeting implementation strategies to positively affect clinician behaviour change. Despite an increase in clinicians’ knowledge scores, our implementation strategy did not, however, significantly change clinician behaviour intentions for all three bowel management practices. Further research is required to explore the influence of opinion leaders and organizational culture on clinicians’ behaviour intentions related to bowel management for intensive care patients.
Electronic supplementary material
The online version of this article (doi:10.1186/s12912-015-0056-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12912-015-0056-z
PMCID: PMC4320841  PMID: 25663819
Bowel management; Intensive care; Nursing; Theory of planned behaviour; Questionnaire
2.  A qualitative study of senior hospital managers’ views on current and innovative strategies to improve hand hygiene 
BMC Infectious Diseases  2014;14(1):611.
Background
Despite universal recognition of the importance of hand hygiene in reducing the incidence of healthcare associated infections, health care workers’ compliance with best practice has been sub-optimal. Senior hospital managers have responsibilities for implementing patient safety initiatives and are therefore ideally placed to provide suggestions for improving strategies to increase hand hygiene compliance. This is an under-researched area, accordingly the aim of this study was to identify senior hospital managers’ views on current and innovative strategies to improve hand hygiene compliance.
Methods
Qualitative design comprising face-to-face interviews with thirteen purposively sampled senior managers at a major teaching and referral hospital in Sydney, Australia. Data were analysed thematically.
Results
Seven themes emerged: culture change starts with leaders, refresh and renew the message, connect the five moments to the whole patient journey, actionable audit results, empower patients, reconceptualising non-compliance and start using the hammer.
Conclusions
To strengthen hand hygiene programmes, strategies based on the five moments of hand hygiene should be tailored to specific roles and settings and take into account the whole patient journey including patient interactions with clinical and non-clinical staff. Senior clinical and non-clinical leaders should visibly champion and mandate best practice initiatives and articulate that hand hygiene non-compliance is culturally and professionally unacceptable to the organization. Strategies that included a disciplinary component and which conceptualise hand hygiene non-compliance as a patient safety error may be worth evaluating in terms of staff acceptability and effectiveness.
doi:10.1186/s12879-014-0611-3
PMCID: PMC4237732  PMID: 25407783
Hand hygiene; Qualitative interviews; Compliance; Hospital managers; Patient safety; Innovative strategies
3.  Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care 
Background
Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.
Objectives
To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.
Methods and design
A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks.
Discussion
TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not.
Trial registration
Australian New Zealand Clinical Trials Registry: ACTRN12613000939796
doi:10.1186/1748-5908-9-38
PMCID: PMC4016636  PMID: 24666591
Collaborative intervention; Thrombolysis; Acute stroke; Evidence-based practice; Quality improvement; Cluster randomised controlled trial; Multidisciplinary approach
4.  Educational outreach visits to improve venous thromboembolism prevention in hospitalised medical patients: a prospective before-and-after intervention study 
Background
Despite the availability of evidence-based guidelines on venous thromboembolism (VTE) prevention clinical audit and research reveals that hospitalised medical patients frequently receive suboptimal prophylaxis. The aim of this study was to evaluate the acceptability, utility and clinical impact of an educational outreach visit (EOV) on the provision of VTE prophylaxis to hospitalised medical patients in a 270 bed acute care private hospital in metropolitan Australia.
Methods
The study used an uncontrolled before-and-after design with accompanying process evaluation. The acceptability of the intervention to participants was measured with a post intervention survey; descriptive data on resource use was collected as a measure of utility; and clinical impact (prophylaxis rate) was assessed by pre and post intervention clinical audits. Doctors who admit >40 medical patients each year were targeted to receive the intervention which consisted of a one-to-one educational visit on VTE prevention from a trained peer facilitator. The EOV protocol was designed by a multidisciplinary group of healthcare professionals using social marketing theory.
Results
Nineteen (73%) of 26 eligible participants received an EOV. The majority (n = 16, 85%) felt the EOV was effective or extremely effective at increasing their knowledge about VTE prophylaxis and 15 (78%) gave a verbal commitment to provide evidence-based prophylaxis. The average length of each visit was 15 minutes (IQ range 15 to 20) and the average time spent arranging and conducting each visit was 92 minutes (IQ range 78 to 129). There was a significant improvement in the proportion of medical patients receiving appropriate pharmacological VTE prophylaxis following the intervention (54% to 70%, 16% improvement, 95% CI 5 to 26, p = 0.004).
Conclusions
EOV is effective at improving doctors’ provision of pharmacological VTE prophylaxis to hospitalised medical patients. It was also found to be an acceptable implementation strategy by the majority of participants; however, it was resource intensive requiring on average 92 minutes per visit.
doi:10.1186/1472-6963-13-398
PMCID: PMC3852069  PMID: 24103108
Educational outreach visit; Implementation science; Venous thromboembolism prevention
5.  Atrial fibrillation and thromboprophylaxis in heart failure: the need for patient-centered approaches to address adherence 
Atrial fibrillation is a common arrhythmia in heart failure and a risk factor for stroke. Risk assessment tools can assist clinicians with decision making in the allocation of thromboprophylaxis. This review provides an overview of current validated risk assessment tools for atrial fibrillation and emphasizes the importance of tailoring individual risk and the importance of weighing the benefits of treatment. Further, this review provides details of innovative and patient-centered methods for ensuring optimal adherence to prescribed therapy. Prior to initiating oral anticoagulant therapy, a comprehensive risk assessment should include evaluation of associated cardiogeriatric conditions, potential for adherence to prescribed therapy, frailty, and functional and cognitive ability.
doi:10.2147/VHRM.S39571
PMCID: PMC3551455  PMID: 23345982
stroke risk; heart failure; atrial fibrillation; anticoagulation; risk stratification; medication adherence
6.  Peri-operative nurses’ knowledge and reported practice of pressure injury risk assessment and prevention: A before-after intervention study 
BMC Nursing  2012;11:25.
Background
Patients are at risk of developing pressure injuries in the peri-operative setting. Studies evaluating the impact of educational interventions on peri-operative nurses’ knowledge and reported practice are scarce. The purpose of this study was to evaluate the effect of a multifaceted intervention on peri-operative nurses’ (a) knowledge of pressure injury risks, risk assessment and prevention strategies for patients in the operating suite; and (b) reported practice relating to risk assessment practices and implementation of prevention strategies for patients in the operating suite.
Methods
A before-after research design was used. A convenience sample of all registered and enrolled nurses employed in two hospitals’ operating suites was recruited. A multifaceted intervention was delivered which comprised a short presentation, educational materials and reminder posters. A 48-item survey tool was completed pre-and post-intervention to measure self-reported knowledge and practice.
Results
70 eligible peri-operative nurses completed both surveys. Post-intervention, statistically significant improvements were seen in knowledge of correct descriptions of pressure injury stages (p=0.001); appropriate reassessment for patients with a new pressure injury (p=0.05); appropriate actions for patients with an existing stage 1 (p=0.02) and stage 2 pressure injury (p=0.04). Statistical improvements were also seen in reported practice relating to an increase in the use of a risk assessment tool in conjunction with clinical judgement (p=0.0008); verbal handover of patients’ pressure injury risk status from the operating room nurse to the recovery room (p=0.023) and from the recovery room nurse to the postoperative ward nurse (p=0.045). The number of participants reporting use of non-recommended and recommended pressure-relieving strategies was unchanged.
Conclusion
A multi-faceted educational intervention can improve some aspects of perioperative nurses’ knowledge and reported practice such as risk assessment practices but not others such as use of recommended pressure-relieving devices. Further research is required to ascertain effective interventions which improve all areas of practice and knowledge, particularly in the use of appropriate pressure-relieving devices in order to prevent pressure injuries in surgical patients.
doi:10.1186/1472-6955-11-25
PMCID: PMC3573907  PMID: 23176368
Pressure injury; Peri-operative; Nurses; Educational intervention; Prevention; Risk assessment
7.  A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams: Study Protocol 
Background
Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care.
Design
A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD.
The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities.
The primary outcome measure is health-related quality of life, assessed with the St George’s Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients’ randomization groups.
Discussion
This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care.
Trial registration
ACTRN12610000592044\
doi:10.1186/1748-5908-7-83
PMCID: PMC3457839  PMID: 22958678
8.  Preventing hypothermia in elective arthroscopic shoulder surgery patients: a protocol for a randomised controlled trial 
BMC Surgery  2012;12:14.
Background
Patients having arthroscopic shoulder surgery frequently experience periods of inadvertent hypothermia. This common perioperative problem has been linked to adverse patient outcomes such as myocardial ischaemia, surgical site infection and coagulopathy. International perioperative guidelines recommend patient warming, using a forced air warming device, and the use of warmed intraoperative irrigation solutions for the prevention of hypothermia in at-risk patient groups. This trial will investigate the effect of these interventions on patients’ temperature, thermal comfort, and total recovery time.
Method/Design
The trial will employ a randomised 2 x 2 factorial design. Eligible patients will be stratified by anaesthetist and block randomised into one of four groups: Group one will receive preoperative warming with a forced air warming device; group two will receive warmed intraoperative irrigation solutions; group three will receive both preoperative warming and warmed intraoperative irrigation solutions; and group four will receive neither intervention. Participants in all four groups will receive active intraoperative warming with a forced air warming device. The primary outcome measures are postoperative temperature, thermal comfort, and total recovery time. Primary outcomes will undergo a two-way analysis of variance controlling for covariants such as operating room ambient temperature and volume of intraoperative irrigation solution.
Discussion
This trial is designed to confirm the effectiveness of these interventions at maintaining perioperative normothermia and to evaluate if this translates into improved patient outcomes.
Australian New Zealand Clinical Trials Registry number
ACTRN12610000591055
doi:10.1186/1471-2482-12-14
PMCID: PMC3411492  PMID: 22817672
9.  Determinants of successful clinical networks: the conceptual framework and study protocol 
Background
Clinical networks are increasingly being viewed as an important strategy for increasing evidence-based practice and improving models of care, but success is variable and characteristics of networks with high impact are uncertain. This study takes advantage of the variability in the functioning and outcomes of networks supported by the Australian New South Wales (NSW) Agency for Clinical Innovation's non-mandatory model of clinical networks to investigate the factors that contribute to the success of clinical networks.
Methods/Design
The objective of this retrospective study is to examine the association between external support, organisational and program factors, and indicators of success among 19 clinical networks over a three-year period (2006-2008). The outcomes (health impact, system impact, programs implemented, engagement, user perception, and financial leverage) and explanatory factors will be collected using a web-based survey, interviews, and record review. An independent expert panel will provide judgements about the impact or extent of each network's initiatives on health and system impacts. The ratings of the expert panel will be the outcome used in multivariable analyses. Following the rating of network success, a qualitative study will be conducted to provide a more in-depth examination of the most successful networks.
Discussion
This is the first study to combine quantitative and qualitative methods to examine the factors that contribute to the success of clinical networks and, more generally, is the largest study of clinical networks undertaken. The adaptation of expert panel methods to rate the impacts of networks is the methodological innovation of this study. The proposed project will identify the conditions that should be established or encouraged by agencies developing clinical networks and will be of immediate use in forming strategies and programs to maximise the effectiveness of such networks.
doi:10.1186/1748-5908-7-16
PMCID: PMC3328243  PMID: 22414246
10.  A qualitative study of stakeholder views of the conditions for and outcomes of successful clinical networks 
Background
Clinical networks have been established to improve health outcomes and processes of care by implementing a range of innovations and undertaking projects based on perceived local need. Limited research exists on the necessary conditions required to bring about successful network outcomes and what characterises network success from the perspective of those involved in network initiatives. This qualitative study identified stakeholder views on i) the conditions for effective clinical networks; and ii) desirable outcomes of successful clinical networks.
Methods
Twenty-seven participants were interviewed using face-to-face audio-recorded semi-structured interviews. Transcribed data were coded and analysed to generate themes relating to the study aims.
Results
Five key factors represented as sub-themes were identified as important conditions for the establishment of successful clinical networks under the main theme of effective network structure, organisation and governance. These were: building relationships; effective leadership; strategic evidence-based workplans; adequate resources; and ability to implement and evaluate network initiatives. Two major themes encapsulated views on desirable outcomes of successful clinical networks: connecting and engaging which represented the outcomes of interdisciplinary and consumer collaboration and, partnerships with state health and local health services, and changing the landscape of care, which represented the importance of outcomes associated with improving services, care and patient health outcomes and implementing evidence-based practice.
Conclusions
This study provides new knowledge on the conditions needed to establish successful clinical networks and on desirable outcomes arising from network projects and initiatives that are considered to be valuable by those working in or associated with clinical networks. This provides health services with information on what needs to be in place for successful networks and on the types of outcomes that can be considered for assessing network effectiveness.
doi:10.1186/1472-6963-12-49
PMCID: PMC3325167  PMID: 22373078
11.  Increasing delivery of an outdoor journey intervention to people with stroke: A feasibility study involving five community rehabilitation teams 
Background
Contrary to recommendations in a national clinical guideline, baseline audits from five community-based stroke rehabilitation teams demonstrated an evidence-practice gap; only 17% of eligible people with stroke were receiving targeted rehabilitation by occupational therapists and physiotherapists to increase outdoor journeys. The primary aim of this feasibility study was to design, test, and evaluate the impact of an implementation program intended to change the behaviour of community rehabilitation teams. A secondary aim was to measure the impact of this change on client outcomes.
Methods
A before-and-after study design was used. The primary data collection method was a medical record audit. Five community rehabilitation teams and a total of 12 professionals were recruited, including occupational therapists, physiotherapists, and a therapy assistant. A medical record audit was conducted twice over 12 months (total of 77 records pre-intervention, 53 records post-intervention) against a guideline recommendation about delivering outdoor journey sessions to people with stroke. A behavioural intervention (the 'Out-and-About Implementation Program') was used to help change team practice. Active components of the intervention included feedback about the audit, barrier identification, and tailored education to target known barriers. The primary outcome measure was the proportion of medical records containing evidence of multiple outdoor journey sessions. Other outcomes of interest included the proportion of medical records that contained evidence of screening for outdoor journeys and driving by team members, and changes in patient outcomes. A small sample of community-dwelling people with stroke (n = 23) provided pre-post outcome data over three months. Data were analysed using descriptive statistics and t-tests.
Results
Medical record audits found that teams were delivering six or more outdoor journeys to 17% of people with stroke pre-intervention, rising to 32% by 12 months post-intervention. This change represents a modest increase in practice behaviour (15%) across teams. More people with stroke (57%) reported getting out of the house as often as they wanted after receiving the outdoor journey intervention compared to 35% one year earlier; other quality of life outcomes also improved.
Conclusions
The 'Out-and-About Implementation Program' helped rehabilitation teams to change their practice, implement evidence, and improve client outcomes. This behavioural intervention requires more rigorous evaluation using a cluster randomised trial design.
doi:10.1186/1748-5908-5-59
PMCID: PMC2917396  PMID: 20670402
12.  Delivering an evidence-based outdoor journey intervention to people with stroke: Barriers and enablers experienced by community rehabilitation teams 
Background
Transferring knowledge from research into practice can be challenging, partly because the process involves a change in attitudes, roles and behaviour by individuals and teams. Helping teams to identify then target potential barriers may aid the knowledge transfer process. The aim of this study was to identify barriers and enablers, as perceived by allied health professionals, to delivering an evidence-based (Level 1) outdoor journey intervention for people with stroke.
Methods
A qualitative design and semi-structured interviews were used. Allied health professionals (n = 13) from two community rehabilitation teams were interviewed, before and after receiving feedback from a medical record audit and attending a training workshop. Interviews allowed participants to identify potential and actual barriers, as well as enablers to delivering the intervention. Qualitative data were analysed using theoretical domains described by Michie and colleagues.
Results
Two barriers to delivery of the intervention were the social influence of people with stroke and their family, and professionals' beliefs about their capabilities. Other barriers included professionals' knowledge and skills, their role identity, availability of resources, whether professionals remembered to provide the intervention, and how they felt about delivering the intervention. Enablers to delivering the intervention included a belief that they could deliver the intervention, a willingness to expand and share professional roles, procedures that reminded them what to do, and feeling good about helping people with stroke to participate.
Conclusions
This study represents one step in the quality improvement process. The interviews encouraged reflection by staff. We obtained valuable data which have been used to plan behaviour change interventions addressing identified barriers. Our methods may assist other researchers who need to design similar behaviour change interventions.
doi:10.1186/1472-6963-10-18
PMCID: PMC2821384  PMID: 20082725
13.  Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: A cluster randomised controlled trial of knowledge transfer 
Background
Hyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke.
Methods and design
Metropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control.
Discussion
This is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services.
Trial Registration
Australia New Zealand Clinical Trial Registry (ANZCTR) No: ACTRN12608000563369
doi:10.1186/1748-5908-4-16
PMCID: PMC2663544  PMID: 19291323
14.  The management of non-valvular atrial fibrillation (NVAF) in Australian general practice: bridging the evidence-practice gap. A national, representative postal survey 
BMC Family Practice  2008;9:62.
Background
General practitioners (GPs) are ideally placed to bridge the widely noted evidence-practice gap between current management of NVAF and the need to increase anticoagulant use to reduce the risk of fatal and disabling stroke in NVAF. We aimed to identify gaps in current care, and asked GPs to identify potentially useful strategies to overcome barriers to best practice.
Methods
We obtained contact details for a random sample of 1000 GPs from a national commercial data-base. Randomly selected GPs were mailed a questionnaire after an advance letter. Standardised reminders were administered to enhance response rates. As part of a larger survey assessing GP management of NVAF, we included questions to explore GPs' risk assessment, estimates of stroke risk and GPs' perceptions of the risks and benefits of anticoagulation with warfarin. In addition, we explored GPs' perceived barriers to the wider uptake of anticoagulation, quality control of anticoagulation and their assessment of strategies to assist in managing NVAF.
Results
596 out of 924 eligible GPs responded (64.4% response rate). The majority of GPs recognised that the benefits of warfarin outweighed the risks for three case scenarios in which warfarin is recommended according to Australian guidelines. In response to a hypothetical case scenario describing a patient with a supratherapeutic INR level of 5, 41.4% of the 596 GPs (n = 247) and 22.0% (n = 131) would be "highly likely" or "likely", respectively, to cease warfarin therapy and resume at a lower dose when INR levels are within therapeutic range. Only 27.9% (n = 166/596) would reassess the patient's INR levels within one day of recording the supratherapeutic INR. Patient contraindications to warfarin was reported to "usually" or "always" apply to the patients of 40.6% (n = 242/596) of GPs when considering whether or not to prescribe warfarin. Patient refusal to take warfarin "usually" or "always" applied to the patients of 22.3% (n = 133/596) of GPs. When asked to indicate the usefulness of strategies to assist in managing NVAF, the majority of GPs (89.1%, n = 531/596) reported that they would find patient educational resources outlining the benefits and risks of available treatments "quite useful" or "very useful". Just under two-thirds (65.2%; n = 389/596) reported that they would find point of care INR testing "quite" or "very" useful. An outreach specialist service and training to enable GPs to practice stroke medicine as a special interest were also considered to be "quite" or "very useful" by 61.9% (n = 369/596) GPs.
Conclusion
This survey identified gaps, based on GP self-report, in the current care of NVAF. GPs themselves have provided guidance on the selection of implementation strategies to bridge these gaps. These results may inform future initiatives designed to reduce the risk of fatal and disabling stroke in NVAF.
doi:10.1186/1471-2296-9-62
PMCID: PMC2611987  PMID: 19014560
15.  A cluster randomised controlled trial of nurse and GP partnership for care of Chronic Obstructive Pulmonary Disease 
Background
Chronic obstructive pulmonary disease (COPD) is a significant health problem worldwide. This randomised controlled trial aims at testing a new approach that involves a registered nurse working in partnership with patients, general practitioners (GPs) and other health professionals to provide care to patients according to the evidence-based clinical practice guidelines. The aim is to determine the impact of this partnership on the quality of care and patient outcomes.
Methods
A cluster randomised control trial design was chosen for this study. Randomisation occurred at practice level. GPs practising in South Western Sydney, Australia and their COPD patients were recruited for the study.
The intervention was implemented by nurses specifically recruited and trained for this study. Nurses, working in partnership with GPs, developed care plans for patients based on the Australian COPDX guidelines. The aim was to optimise patient management, improve function, prevent deterioration and enhance patient knowledge and skills. Control group patients received 'usual' care from their GPs.
Data collection includes patient demographic profiles and their co-morbidities. Spirometry is being performed to assess patients' COPD status and CO analyser to validate their smoking status. Patients' quality of life and overall health status are being measured by St George's Respiratory Questionnaire and SF-12 respectively. Other patient measures being recorded include health service use, immunisation status, and knowledge of COPD. Qualitative methods will be used to explore participants' satisfaction with the intervention and their opinion about the value of the partnership.
Analysis
Analysis will be by intention to treat. Intra-cluster (practice) correlation coefficients will be determined and published for all primary outcome variables to assist future research. The effect of the intervention on outcomes measured on a continuous scale will be estimated and tested using mixed model analysis of variance in which time and treatment group will be fixed effects and GP practice and subject nested within practice will be random effects. The effect of the intervention on the dichotomous variables (such as smoking status, patient knowledge) will be analysed using generalised estimating equations with a logistic link and a model structure that is analogous to that described above.
Trial registration
ACTRN012606000304538
doi:10.1186/1471-2466-8-8
PMCID: PMC2442044  PMID: 18519003

Results 1-16 (16)