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Sandy Middleton

Publications and source records attributed to Sandy Middleton.

14 recordsLinked to original sources
PubMed2026

Assessment and CommuniCation ExcelLEnce foR sAfe paTient outcomEs (ACCELERATE): A stepped-wedge cluster randomised trial evaluating the effectiveness of a nurse-led assessment and handover communication intervention on patient adverse events.

BACKGROUND: Patients continue to experience harm from undetected deterioration, falls and pressure injuries. We aimed to implement and evaluate an organisational, ward-level nurse-led assessment and communication intervention to proactively reduce patient adverse events. METHODS: A stepped-wedge cluster randomised Trial over 12-months was conducted at three metropolitan hospitals. Our intervention comprised a comprehensive, systematic patient assessment at shift commencement; a structured patient-centred bedside nurse-to-nurse clinical handover; and multidisciplinary communication consisting of nurse participation in medical ward rounds. Evidence-based implementation strategies informed intervention delivery to nine clusters (20-35 bed-wards with &#x2265;70% permanent nurses) over three sequential 14-week steps. Routinely collected patient-level data were used to measure intervention effect. The primary outcome was a composite measure of medical emergency team calls, unplanned intensive care unit admissions, in-hospital falls; and stage 2-4 pressure injuries. Secondary outcomes were: individual measures of the primary outcome; nurse-reported perceptions of safety culture; organisational readiness to change; barriers to physical assessment; staff engagement; and patient-reported experience measures of safety and overall hospital experience. Analyses were adjusted for age, sex, hospital, pre/post intervention, and Trial step (fortnight), with random effects for ward and patient. RESULTS: There were 13,753 eligible admissions. No change was observed in the primary composite outcome measure (odds ratio (OR) [95% confidence interval (CI)]: 0.99 [0.77, 1.28]; p&#xa0;=&#xa0;0.95). There was no significant difference in medical emergency team calls (OR [95% CI]: 1.02 [0.75, 1.39]; p&#xa0;=&#xa0;0.91); unplanned intensive care unit admissions (OR [95% CI]: 1.35 [0.57, 3.20]; p&#xa0;=&#xa0;0.50) and falls (OR [95% CI]: 1.53 [0.96, 2.45]; p&#xa0;=&#xa0;0.07). However, stage 2-4 pressure injuries significantly decreased by 41% (OR [95% CI]: 0.59 [0.38, 0.93]; p&#xa0;=&#xa0;0.02); a significant absolute effect improvement of 0.8% ([95% CI: 0.3%-1.3%], p&#xa0;<&#xa0;0.01). There were statistically significant improvements in nurses' overall perceptions of Safety Attitudes (Pre: 74.6, Post: 79.7; p&#xa0;=&#xa0;0.02), and the Organisational Readiness to Change subscales of, leader culture (Pre: 3.73, Post 3.91; p&#xa0;=&#xa0;0.02), leadership behaviour (Pre: 3.85, Post: 4.11; p&#xa0;=&#xa0;0.03), and general resources (Pre: 3.06, Post: 3.30; p&#xa0;=&#xa0;0.03). A statistically significant decrease in Barriers to Physical Assessment (Pre: 2.48, Post: 2.24; p&#xa0;<0.001) and in six of seven sub-scales was observed. Patients' overall Measure of Safety remained high, but unchanged (Pre: 3.94 Post: 3.92; p&#xa0;=&#xa0;0.07). CONCLUSION: The ACCELERATE Trial demonstrated that nurse-driven initiatives, emphasising structured physical assessments by nurses, patient-centred clinical handovers, and multidisciplinary communication, significantly: reduced pressure injuries; decreased nurses' perceived barriers to performing physical assessments; and improved leadership behaviour, communication, and ward safety culture perceptions. Results highlight the transformative potential of this approach, which now warrants testing at scale for broader implementation. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ID: ACTRN12621000265875.

Humans↗
PubMed2006

Assessing surgeons' disclosure of risk information before carotid endarterectomy.

BACKGROUND: To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and 'non-treatment' options. A survey was conducted to determine patients' recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA). METHODS: A self-administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self-assessed estimates of stroke risk with and without surgery and receipt of written information before CEA. RESULTS: A significantly higher proportion of patients recalled that their surgeon discussed the short-term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short-term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long-term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P < 0.0001). CONCLUSIONS: Patients recalled discussions with their surgeon about short-term stroke risk. Only a minority, however, accurately quantified their postoperative stroke risk. In view of variable patient recall, decision aids could assist.

Aged↗
PubMed2005

Implementing root cause analysis in an area health service: views of the participants.

PURPOSE: This study identifies the attitudes of participants in the root cause analysis (RCA) process and barriers to it's implementation within one New South Wales area health service. METHOD: Employees and consumer representatives of the former South Western Sydney Area Health Service who participated in an RCA as either a team member or a team leader between December 2002 and October 2003 completed a self-administered survey. RESULTS: Thirty seven of 39 eligible participants completed the survey (response rate 95%). The respondents identified formulation of causal statements, ensuring the causal statements met the "rules of causality" outlined by New South Wales Health, and arranging times for interviews as most difficult. Team leader respondents (n = 7) ranked keeping the team focused, organising the first meeting within 7 days of the incident, and completing the RCA in three 2-hour meetings as barriers to the process. CONCLUSIONS: Training was valued by participants, however greater emphasis on the development of causal statements could be beneficial. Team leaders expressed difficulty in keeping the team focused and meeting the stipulated RCA timeframes, suggesting that additional support for RCA participants may be warranted.

Attitude of Health Personnel↗
PubMed2005

Nursing intervention after carotid endarterectomy: a randomized trial of Co-ordinated Care Post-Discharge (CCPD).

AIM: This paper reports a study evaluating the short-term impact of nursing-led, co-ordinated care after discharge following carotid endarterectomy. BACKGROUND: Patient education about stroke risk factors, combined systematically with carotid endarterectomy, holds unrealized potential to improve patient outcomes. Nurses are well-placed in the healthcare system to co-ordinate this type of education. METHODS: A randomized controlled trial was conducted between October 2001 and October 2002. Patients having carotid endarterectomy (n = 133) were randomized to either the intervention (n = 66) or control group (n = 67). The intervention consisted of telephone liaison with the patient by a Registered Nurse at 2, 6 and 12 weeks following carotid endarterectomy, combined with education about stroke risk factor management and structured liaison with the patient's surgeon and referring general practitioner. While patients allocated to the control group did not receive any postoperative telephone contact directly from the Registered Nurse during the study, their general practitioners received structured postoperative liaison. RESULTS: The co-ordinated care postdischarge intervention had a statistically significant positive effect on patient knowledge of stroke warning signs (P = 0.002), patient self-reported changes to improve lifestyle (P = 0.006) and diet modification (P < 0.001). Statistically significant improvements from baseline to follow-up were detected in both groups for other outcomes. CONCLUSIONS: While nursing-led, co-ordinated care after discharge achieves important improvements for short-term outcomes, carotid endarterectomy itself may have been a catalyst for improved patient outcomes. Further research of nursing-led co-ordinated care initiatives for vascular surgery patients is needed.

Aged↗
PubMed2004

Effective discharge policy: are we getting there?

PURPOSE: To determine patients' knowledge before admission about how many days they were likely to be hospitalised and, after discharge, to determine patients' perceptions of their 'readiness' to leave hospital following carotid endarterectomy. Usefulness of discharge communications to patients' GPs also was ascertained. METHODS: Pre- and post-operative self-administered questionnaires to 133 patients and a follow-up telephone survey of GPs providing primary care to 118 of these patients. RESULTS: Pre-operatively, the majority (84.2%) of patients recalled being told how many days they were likely to be hospitalised. Univariate analysis did not demonstrate any factors predicting positive recall. The majority (87.0%) of patients perceived themselves 'ready to go home' at discharge. Twenty-eight GPs (23.7%) had received both a discharge summary from the hospital and a personalized letter from the patient's surgeon. GP's rated the surgeons' letters as significantly more useful than discharge summaries (P = 0.01). CONCLUSIONS: Although hospitals are required by NSW Health's Effective Discharge Policy to inform patients about their likely length of stay in hospital, not all patients recalled whether they were so informed pre-operatively. Barriers impeding realisation of the NSW Health policy remain.

Chi-Square Distribution↗
PubMed2003

Case scenarios to assess Australian general practitioners' understanding of stroke diagnosis, management, and prevention.

BACKGROUND AND PURPOSE: Stroke represents the third-leading cause of death in Western society. Prompt and appropriate intervention for those with stroke or at risk of stroke is highly dependent on general practitioners' (GPs') knowledge and referral practices. METHODS: We randomly selected 490 eligible GPs from New South Wales, Australia, to complete our self-administered questionnaire. Case scenarios were used to assess GPs' knowledge of transient ischemic attack/ stroke risk factors, stroke prevention strategies, and management of asymptomatic and symptomatic patients. RESULTS: We received 296 completed questionnaires (60% response rate). Nearly all GPs (286, 96.6%) strongly agreed or agreed that stroke is a medical emergency. Most were aware that management by multidisciplinary teams improves outcomes (strongly agree or agree, 279; 94.3%). GPs endorsed the effectiveness of aspirin and warfarin in reducing stroke morbidity. GPs also were aware of the benefit of carotid endarterectomy (CEA) for symptomatic patients with >80% carotid stenosis but were less aware of the value of CEA for symptomatic patients with moderate stenosis. Vascular surgeon was the specialist of choice for referral of patients with high-grade carotid stenosis. Few GPs reported having seen the Cochrane Collaboration reviews of CEA for symptomatic (3.0%) and asymptomatic (1.7%) patients. CONCLUSIONS: GPs were well apprised of the evidence to support CEA for symptomatic patients with high-grade carotid stenosis. Our findings, however, invite more purposeful and effective education of GPs about stroke prevention, diagnosis, and management if optimal outcomes are to be realized.

Adult↗
PubMed2003

Vascular disease risk factor management 4 years after carotid endarterectomy: are opportunities missed?

BACKGROUND: Because a large percentage of patients surviving carotid endarterectomy (CEA) subsequently die from a vascular cause, the aim of the present paper was to determine risk factor management for a cohort of patients 4 years after their CEA. METHODS: Surviving patients who had a CEA within the region administered by the Central Sydney Area Health Service in 1995 were asked to complete a self-administered questionnaire to determine vascular risk factors. RESULTS: Of the 181 patients eligible to participate, 162 returned questionnaires (response rate: 90%). While 106 (65.4%) patients recalled that they had been diagnosed with high blood pressure either before or after their CEA, only 79.2% recalled that their latest blood pressure reading was 'about right for my age'. Nearly one in five (16.7%) who had had their cholesterol level checked in the last 12 months (n = 120) indicated that the reading was 'too high'. Only 76.5% reported taking medications to 'thin the blood'. Almost one-fifth of patients (17.3%) were current smokers. Only 35.2% of patients participated in a level of physical activity sufficient to confer a health benefit. Further, 30.2% of patients were overweight and 14.8% were obese. The majority of patients (98.1%) reported having a regular general practitioner (GP). Of these, 98.7% had visited their GP at least once within the previous 6 months. CONCLUSIONS: Vascular risk factor management following CEA is suboptimal, inviting the implementation and evaluation of strategies to improve outcomes.

Aged↗
PubMed2003

GPs' views of quality initiatives to improve stroke outcomes following carotid endarterectomy.

BACKGROUND: General practitioners' satisfaction with previous referral of patients may influence their future specialist referral patterns. METHOD: A postal survey of 123 GPs assessing satisfaction with discharge planning and communication from operating surgeons for patients following carotid endarterectomy. General practitioners' views of quality indicators for patient referral also were assessed. RESULTS: General practitioners were significantly more likely to be 'very satisfied' with the level of communication from the operating surgeon (83%) than the discharge planning (65%), (p < 0.001). The most highly ranked quality indicator for use in referring a patient for carotid endarterectomy was the 30 day postoperative complication rate per surgeon (n = 69, 56% 'very useful'). Over one-third (35%) remembered seeing the relevant guidelines for GPs. DISCUSSION: General practitioners value information about surgeon performance when making referral decisions. They are less satisfied with discharge planning than other aspects of care.

Attitude of Health Personnel↗
PubMed2002

Are there commonalities among audit tools used to measure carotid endarterectomy outcomes in New South Wales?

BACKGROUND: To prepare for a state-wide audit of carotid endarterectomy (CEA), we sought to ascertain pre-existing practices and identify common process and outcome measures among audits tools used by NSW vascular surgeons. METHOD: Telephone survey comprising five questions about CEA audit practices. RESULTS: Of 37 known vascular surgeons in NSW, all performed CEA and agreed to participate in our telephone survey (response rate 100%). All but one reported collecting CEA data (97%). Two thirds of these collected data prospectively. From those 19 surgeons (51%) who stated that they used standard tools for audit, we received five CEA-specific tools. Process measures common to all five were: side of CEA, date of operation, sex, past history of hypertension, history of diabetes, use of shunt, use of patch. There were only three outcome measures common to all five CEA-specific tools: postoperative transient ischaemic attack (TIA), postoperative stroke, and postoperative death. Data about outcomes beyond discharge were inconsistently collected. CONCLUSIONS: While most vascular surgeons in NSW report collecting information about CEA outcomes, not all do so prospectively. Only three outcomes (postoperative TIA, postoperative stroke and death) were common to all tools, inviting the development and use of a comprehensive and standard tool.

Endarterectomy, Carotid↗
PubMed2002

Outcomes of carotid endarterectomy: how does the Australian state of New South Wales compare with international benchmarks?

OBJECTIVES: The objective of this study was to determine the outcomes of carotid endarterectomy (CEA) in New South Wales, Australia. METHODS: This state-wide prospective audit of all public and private hospitals during a 6-month period had main outcome measures of 30-day mortality, 30-day fatal stroke, 30-day nonfatal stroke, and 30-day combined stroke and mortality. RESULTS: Fifty-three of 54 eligible surgeons participated (response rate, 98%). The audit obtained inpatient data for 689 internal CEA procedures performed on 666 patients. Of 666 first or only procedures, 462 (69.4%) were performed on patients who were symptomatic and 204 (30.6%) on patients who were asymptomatic. After adjustment for cluster by surgeon, we determined a state-wide 30-day death rate of 1.2% (95% CI, 0.3% to 2.1%), a 30-day fatal or nonfatal stroke rate of 3.0% (95% CI, 1.6% to 4.4%; ipsilateral stroke, 2.6%), a 30-day nonfatal stroke rate of 2.3% (95% CI, 1.1% to 3.4%; ipsilateral stroke, 2.0%), and a 30-day combined stroke and death rate of 3.5% (95% CI, 2.1% to 4.9%). A significant linear relationship was found between patient preoperative hypertensive status and the combined 30-day stroke and death rate (trend odds ratio, 3.5; 95% CI, 1.6 to 7.7). No association was seen between any main outcome measures and hospital volume (<10 CEAs versus > or = 10 CEAs). Four patients underwent surgery outside guideline recommendations (CEA performed for either < or = 30% stenosis or occluded carotid artery). CONCLUSION: This first comprehensive state-wide audit confirms that Australian surgeons achieve 30-day outcomes comparable with international benchmarks.

Age Factors↗
PubMed2002

Audit of long-term mortality and morbidity outcomes for carotid endarterectomy.

There have been no Australian studies of long-term mortality status and cause of death after carotid endarterectomy (CEA) or, for survivors, quality-of-life. We first determined rate and cause of death for a cohort of patients four years after CEA. Surviving patients were surveyed to ascertain health status, using MOS SF-36. Of 238 patients who underwent CEA in our health service in 1995, 44 (18.5%) had died within four years. The majority of deaths (61.4%) were attributable to vascular causes. Of the surviving 162 patients (survey response fraction 90%), 10 (6.2%) subsequently had suffered a non-fatal stroke in the four years following their CEA. With respect to health status, Physical Functioning scores differed significantly by age (t = 2.65, df = 149, P = 0.01) as did Role Physical scores (t = 2.10, df = 142, P = 0.04). We conclude that patients undergoing CEA are at high risk of dying from vascular causes, inviting concerted efforts in discharge planning to co-ordinate optimal vascular risk factor management.

Aged↗
PubMedDate not supplied

Contamination of interventional research is possible through GP membership of more than one division.

INTRODUCTION: General practice divisions were promoted in the 1990s to provide support for general practitioners. Membership patterns are not well understood and may have implications for research and health services development. METHODS: Within a postal questionnaire conducted in 1999, we determined self reported membership of divisions. RESULTS: We obtained a 60% response rate (n = 296) from a random sample drawn from all New South Wales GPs. The majority of GPs (n = 204, 69%) belonged to one division. Thirty respondents (10%) did not belong to any division. Fifty-nine GPs (20%) belonged to two or more divisions, women GPs (n = 27, 31%) significantly more than men (n = 32, 16%) (P = 0.002), and GPs with city or metropolitan area practices (n = 52, 24%) were significantly more likely than rural or remote GPs (n = 7, 9%) (P = 0.005) to belong to two or more divisions. DISCUSSION: If divisions are used as the unit of randomisation for interventional research, there is risk of contamination in study design. Articles reporting such trials should acknowledge this.

Adult↗