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Academic-practice partnerships provide a model for sharing resources, increasing professional knowledge and skills, improving patient outcomes, and strengthening organizational cultures of quality and safety. This article describes the long-term outcomes of a regional collaborative evidence-based practice fellowship. Results reveal the fellowship had a measurable positive impact on fellows' evidence-based practice knowledge and practice, project outcomes, professional growth, and the culture of excellence within partner organizations.

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Editor's note: The mission of Cochrane Nursing is to provide an international evidence base for nurses involved in delivering, leading, or researching nursing care. Cochrane Corner provides summaries of recent systematic reviews from the Cochrane Library. For more information, see https://nursing.cochrane.org.

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BACKGROUND: Chronic alcohol consumption is a prevalent issue. Healthcare professionals often discover their patient has an alcohol consumption issue when they are admitted to the hospital and no longer have access to alcohol. The global standard for treating alcohol withdrawal syndrome (AWS) symptoms are benzodiazepines; however this therapy is often inadequate to control symptoms of delirium in adult intensive care unit (ICU) patients due to an imbalance of inhibitory and excitatory neurotransmitters. OBJECTIVES: The objective of the systematic review is to examine the clinical effectiveness of dexmedetomidine as an adjuvant to benzodiazepine-based therapy versus benzodiazepine-based therapy alone in decreasing the severity of delirium associated with AWS in adult ICU patients. INCLUSION CRITERIA: This review considered studies that included adult ICU patients over the age of 18 who were experiencing delirium associated with alcohol withdrawal. Patients admitted to the ICU with the diagnosis of AWS were included in the study.This review considered studies that evaluated dexmedetomidine as an adjuvant therapy to benzodiazepine-based therapy, compared to the use of benzodiazepine-based therapy alone in ICU patients experiencing alcohol withdrawal delirium.This review considered randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies, analytical cross sectional studies, case series, individual case reports and descriptive cross sectional studies for inclusion.The systematic review evaluated dexmedetomidine as an adjuvant to benzodiazepine-based therapy to decrease delirium severity in alcohol withdrawal in ICU patients. The general outcome of delirium severity was measured using the Clinical Institute Withdrawal Assessment Score - Revised (CIWA), the Ramsey scale, the Richmond Agitation Sedation Score (RASS) and the Confusion Assessment Method for the ICU (CAM-ICU). SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review and included English language studies published after 1997. A search of Ovid/MEDLINE, EMBASE, Cochrane, Joanna Briggs Institute and nine other databases was conducted. METHODOLOGICAL QUALITY: Two independent reviewers using the Joanna Briggs Institute's standardized appraisal tool critically appraised the studies. A third independent reviewer was available to appraise studies if the two original reviewers disagreed in their assessments. There were no disagreements in findings between the two independent reviewers. DATA COLLECTION: Data was extracted using the standardized Joanna Briggs Institute's data extraction instruments. DATA SYNTHESIS: Statistical pooling was done using meta-analysis and findings are presented using a forest plot and narrative form. RESULTS: Four studies were included in the review, three retrospective case series and one prospective case series with a total sample size of 55 patients. Three studies used the CIWA score as the outcome measure and one study used the RASS score as the outcome measure. A meta-analysis of the three studies using the CIWA demonstrated that adjuvant use of dexmedetomidine with benzodiazepine-based therapy decreased CIWA scores (Weighted Mean Difference [WMD] -5.2, 95% Confidence Interval [CI] -6.24 to -4.16, p <0.0001). The final study using RASS scores reported improvement with adjuvant treatment with dexmedetomidine compared to benzodiazepine-based therapy alone. CONCLUSIONS: The use of dexmedetomidine as an adjuvant to benzodiazepine-based therapy decreased delirium more effectively than benzodiazepine-based therapy alone in adult ICU patients experiencing alcohol withdrawal delirium as evidenced by a decrease in CIWA and RASS scores. IMPLICATIONS FOR PRACTICE: In adult ICU patients who are experiencing alcohol withdrawal delirium that is not controlled with benzodiazepine-based therapy alone, healthcare providers should consider dexmedetomidine as an adjuvant to standard benzodiazepine-based therapy. IMPLICATIONS FOR RESEARCH: The use of dexmedetomidine in the management of delirium associated with alcohol withdrawal in adult ICU patients should be further studied via large scale randomized controlled trials.

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Health practitioners wishing to positively improve health outcomes for their clients have access to a unique set of collated tools to guide their practice. Systematic reviews provide guidance in the form of synthesized evidence that can form the basis of decision making as they provide care for their clients. This article describes systematic reviews as a basis for informed decision making by mental health practitioners. The process of systematic review is discussed, examples of existing systematic review topics relevant to mental health are presented, a sample systematic review is described, and gaps and emerging topics for mental health systematic reviews are addressed.

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Systematic review is an invaluable tool for the practicing clinician. A well-designed systematic review represents the latest and most complete information available on a particular topic or intervention. This article highlights the key elements of systematic review, what it is and is not, and provides an overview of several reputable organizations supporting the methodological development and conduct of systematic review. Important aspects for evaluating the quality of a systematic review are also included.

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AIM: To investigate the impact of nurse practice environment factors, nurse work characteristics, and burnout on nurse reported job outcomes, quality of care, and patient adverse events variables at the nursing unit level. BACKGROUND: Nurse practice environment studies show growing insights and knowledge about determining factors for nurse workforce stability, quality of care, and patient safety. Until now, international studies have primarily focused on variability at the hospital level; however, insights at the nursing unit level can reveal key factors in the nurse practice environment. DESIGN: A cross-sectional design with a survey. METHOD: In a cross-sectional survey, a sample of 1108 nurses assigned to 96 nursing units completed a structured questionnaire composed of various validated instruments measuring nurse practice environment factors, nurse work characteristics, burnout, nurse reported job outcomes, quality of care, and patient adverse events. Associations between the variables were examined using multilevel modelling techniques. RESULTS: Various unit-level associations (simple models) were identified between nurse practice environment factors, nurse work characteristics, burnout dimensions, and nurse reported outcome variables. Multiple multilevel models showed various independent variables such as nursing management at the unit level, social capital, emotional exhaustion, and depersonalization as important predictors of nurse reported outcome variables such job satisfaction, turnover intentions, quality of care (at the unit, the last shift, and in the hospital within the last year), patient and family complaints, patient and family verbal abuse, patient falls, nosocomial infections, and medications errors. CONCLUSION: Results suggested a stable nurse work force, with the capability to achieve superior quality and patient safety outcomes, is associated with unit-level favourable perceptions of nurse work environment factors, workload, decision latitude, and social capital, as well low levels of burnout. Nurses, physicians, nursing leaders, and executives share responsibility to create an environment supportive of interdisciplinary team development.

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Delirium is a frequent, yet often unrecognized, occurrence in elderly hospitalized patients. In patients with hip fracture, the incidence of delirium is reported to be as high as 62% and even greater if over 65 years of age. One approach to the prevention and management of postoperative delirium in elderly patients with hip fracture is the clinical audit. A clinical audit is a retrospective assessment of clinical care of patients and is guided by criteria that are evidence-based statements of best practice. The use of measurable, objective criterion, with an agreed standard of performance is the hallmark of an audit. The clinical audit criteria presented in this article for the prevention and management of delirium in hospitalized elderly with hip fracture were determined by a compilation of systematic reviews and existing evidence-based clinical guidelines. The following 5 audit criteria are discussed: (1) All elderly patients with a hip fracture are assessed for risk factors for developing delirium daily using a valid and reliable tool; (2) the environment of the patient with hip fracture is assessed daily for conduciveness to maintaining sensory orientation; (3) all patients with hip fracture receive essential nursing care; (4) appropriate clinical criteria are applied to confirm a diagnosis of delirium in patients with hip fracture; and (5) nonpharmacologic interventions are employed before pharmacologic interventions in patients with hip fracture with a diagnosis of delirium.

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AIM: To explore the mechanisms through which nurse practice environment dimensions are associated with job outcomes and nurse-assessed quality of care. Mediating variables tested included nurse work characteristics of workload, social capital, decision latitude, as well as burnout dimensions of emotional exhaustion, depersonalization, and personal accomplishment. BACKGROUND: Acute care hospitals face daily challenges to their efforts to achieve nurse workforce stability, safety, and quality of care. A body of knowledge shows a favourably rated nurse practice environment as an important condition for better nurse and patient outcome variables; however, further research initiatives are imperative for a clear understanding to support and guide the practice community. DESIGN: Cross-sectional survey. METHOD: Grounded on previous empirical findings, a structural equation model designed with valid measurement instruments was tested. The study population was registered acute care nurses (N=1201) in two independent hospitals and one hospital group with six hospitals in Belgium. RESULTS: Nurse practice environment dimensions predicted job outcome variables and nurse ratings of quality of care. Analyses were consistent with features of nurses' work characteristics including perceived workload, decision latitude, and social capital, as well as three dimension of burnout playing mediating roles between nurse practice environment and outcomes. A revised model adjusted using various fit measures explained 52% and 47% of job outcomes and nurse-assessed quality of care, respectively. CONCLUSION: The study refines understanding of the relationship between aspects of nursing practice in order to achieve favourable nursing outcomes and offers important concepts for managers to track in their daily work. The findings of this study indicate that it is important for clinicians and leaders to consider how nurses are involved in decision-making about care processes and tracking outcomes of care and whether they are able to work with physicians, superiors, peers, and subordinates in a trusting environment based on shared values. The involvement of nurse managers at the unit level is especially critical because of associations with nurse work characteristics such as decision latitude and social capital and outcome variables. Further practice and research initiatives to support nurses' involvement in decision-making process and interdisciplinary teamwork are recommended.

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BACKGROUND: The role of basic science education in a clinical setting remains unclear. Research to understand how academic clinicians perceive and use this part of their education can aid curricular development. AIMS: To assess physician's attitudes toward the value of science knowledge in their clinical practice. METHODS: Academic physicians from three medical schools completed a questionnaire about the utility of basic science education in core clinical tasks and in practice-based learning and improvement. RESULTS: A total of 109 clinical faculty returned the survey. Overall, 89% of the respondents indicated that basic science education is valuable to their clinical practice. When asked about the utility of basic science information in relation to direct patient care, greater than 50% of the doctors felt they use this when diagnosing and communicating with patients. This rose to greater than 60% when asked about choosing treatment options for their patients. Individuals also responded that basic science knowledge is valuable when developing evidence-based best practices. Specifically, 89% felt that they draw upon this information when training students/residents and 84% use this information when reading journal articles. CONCLUSIONS: This study shows that basic science education is perceived by responding academic physicians to be important to their clinical work.

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REVIEW QUESTION/OBJECTIVE: The objective of this systematic review is to synthesize the best available evidence on the impact of pre-injury anticoagulation therapy in the older adult patient who experiences a traumatic brain injury. BACKGROUND: Trauma in the elderly remains one of the most challenging problems for healthcare providers in the 21 century. The most recent United States (U.S.) census estimates that by the year 2020 more than 52 million Americans will be age 65 years or older, and one million of those will live to be over 100 years of age. In the older adult population, classified as age 65 years or greater, the two leading causes of injury were reported as motor vehicle crashes (MVC) and falls. We have become increasingly aware of the unique physiologic changes in this population that make them more susceptible to succumb to traumatic injuries than their younger counterparts. This is especially true in the anticoagulated patient with a traumatic brain injury.Traumatic brain injury (TBI) is defined as an injury occurring when an external force traumatizes the brain. It may also be known as an intracranial or head injury. TBI is classified depending on the mechanism of injury (blunt or penetrating), severity, and location of the assault. Damage to the brain, skull, and/or scalp transpires. TBI is the leading cause of death and disability in the U.S, and persons of all ages, races, ethnicities, and incomes are affected. In the past five to ten years, trauma services have recorded an increase in major trauma admissions of patients age 65 years and older. In review of the literature to date, it is recognized that outcomes following moderate to severe TBI in older adults are poor, with high rates of significant disability and mortality reported. A recent Australian study reported that 28% of older adults died in the hospital following a TBI and in Finland adults aged 75 years and older had the highest rates of TBI related hospitalizations and death. According to a systematic review of European studies, the overall incidence of hospitalized TBI patients was 235 incidents/per 100,000 individuals, with a mortality rate of 15.4 deaths/per 100,000 of the population.The association between medications that alter a patient's coagulation function and adverse trauma outcome continues to be an important area of interest and study. The percentage of Americans on anticoagulant and antiplatelet agents continues to increase with the long-term trend towards longer life expectancies. Older adults are prescribed anticoagulants and antiplatelet agents to prevent thromboembolic complications of artial fibrillation; prosthetic cardiac valves; cerebral, coronary, and peripheral vascular disease; as well as several other medical conditions. One of the most frequently prescribed anticoagulant medications is warfarin. The prevalence of warfarin use in the Unites States is unknown, but the Food and Drug Administration (FDA) estimates that more than 31 million prescriptions were written in 2004. Newer, more potent antiplatelet medications like clopidogrel (Plavix) pose an even greater risk for uncontrolled bleeding in trauma patients. The uncertainty regarding the impact on trauma outcomes is compounded by the variable response of patients to anticoagulant or antiplatelet medication for an associated comorbidity. Evidence suggests that outcomes for TBI are worse, and there may be delayed intracranial hemorrhage in this population of patients.According to a Western Australian study, trauma patients are theoretically at risk for prolonged major bleeding. Studies of traumatic intracranial hemorrhage (ICH) suggest that patients taking anticoagulants have two to six times greater mortality. Mina et al. noted that the trauma patient with preinjury anticoagulation such as warfarin or even aspirin who had an intracranial injury had a four to five fold higher risk of death than the non-anticoagulated patient. Franko et al. concluded that mortality of patients over age 70 was significantly higher than that of younger patients when taking preinjury anticoagulants. The concern about unfavourable outcomes in the anticoagulated older adult patient presenting with traumatic injury has led many healthcare systems to take action. Ivascu et al. looked at early identification in triage for at- risk patients, and implemented warfarin (coumadin) protocols to assist in promoting improved patient outcomes; however, her research did not demonstrate a positive impact. In an effort to find a relationship between preinjury anticoagulation and outcomes in the older adult trauma patient, the degree of anticoagulation rather than the anticoagulant itself was studied to assist with predicting the severity of the TBI. Pieracci et al. concluded that among older adult patients who have sustained a head injury, warfarin use with an admission International Normalized Ratio (INR) greater than or equal to two was associated with an increase severity of TBI, a trend toward an increased likelihood of intracranial hemorrhage (ICH), increased overall mortality, and increased mortality after ICH.The impact of trauma- related morbidity and mortality in the elderly population is significant. Older adult patients account for 25% of trauma related hospital costs, 25% of trauma-related deaths, have the highest age-specific rate of TBI, and have worse outcomes reported. Fortuna et al. concluded that preinjury anticoagulants and antiplatelet medications used by the older adult patient were not associated with increased mortality, but age was a significant predictor of mortality. Research by Wojcik et al., concluded that preinjury anticoagulation therapy did not adversely impact mortality or length of stay (LOS) outcomes in the head injured patients.The influence of anticoagulation on outcomes in the older adult patient with a head injury has been studied, and has resulted in significant debate. Chronic use of anticoagulants and antiplatelet medications in the management of many medical conditions has increased over the decades. As a consequence, older adults over the age of 65 are at risk for trauma related injuries. Concomitant risks include bleeding after traumatic injury.What is known nationally and internationally is our population is aging. With an aging population comes acute and chronic illness. Anticoagulant medication is frequently prescribed for health conditions to promote positive patient outcomes. We know the impact of anticoagulant and antiplatelet therapy may have detrimental effects; especially when an older adult experiences a traumatic brain injury. What we don't know about the impact of anticoagulant and antiplatelet therapy is how it effects the trauma patient, how to rapidly and successful reverse the detrimental outcomes, and how to prevent mortality in this specific age group. A systematic review of the literature will synthesize the data, identify gaps, and recommend on-going research related to the impact of untoward outcomes in the older adult, anticoagulated, trauma patient.Theoutcome to be studied is mortality prior to discharge from the healthcare system. The gaps in the literature, timeliness of research, and change in demographic data justifies a systematic review of the literature to assist in providing consensus to base practice change, policy advances, and protocol development to promote positive patient outcomesPrior to the commencement of the review, a search of the Cochrane Library of Systematic Reviews, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and MEDLINE was performed. No systematic reviews of the proposed topic were located.

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The authors describe the development of an effort by 21 hospitals and 2 academic institutions in a metropolitan area to strengthen the diffusion of evidence-based practice in their organizations. This has been accomplished by providing collaborative training, mentoring, and support for direct-care RNs through an evidence-based fellowship. The participating direct-care nurses are prepared to take the new knowledge, skills, and abilities they have gained back to the bedside care environment.

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Problems in patient flow persist in practice and seem to defy traditional approaches to resolution. Using concepts from complex adapted systems and diffusion of innovation principles, problems in patient flow are analyzed and possible routes for innovation are identified. Emphasis is on creating a climate receptive to change as the norm, one that values relationships and communication.

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This article describes the development of an evidence-based practice and research collaborative among urban hospitals. The collaborative began as a mechanism to support the incorporation of evidence-based practice and research in the acute care practice setting. This article discusses the development of the collaborative, as well as the challenges, success, and future goals from both the academic and practice perspectives.

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