Chlorhexidine for meatal cleaning in reducing catheter-associated urinary tract infections : A multicentre stepped-wedge randomised controlled trial

Journal article


Fasugba, Oyebola, Cheng, Allen C., Gregory, Victoria, Graves, Nicholas, Koerner, Jane, Collignon, Peter, Gardner, Anne and Mitchell, Brett G.. (2019). Chlorhexidine for meatal cleaning in reducing catheter-associated urinary tract infections : A multicentre stepped-wedge randomised controlled trial. The Lancet Infectious diseases. 19(6), pp. 611-619. https://doi.org/10.1016/S1473-3099(18)30736-9
AuthorsFasugba, Oyebola, Cheng, Allen C., Gregory, Victoria, Graves, Nicholas, Koerner, Jane, Collignon, Peter, Gardner, Anne and Mitchell, Brett G.
Abstract

Background
Evidence for the benefits of antiseptic meatal cleaning in reducing catheter-associated urinary tract infection (UTI) is inconclusive. We assessed the efficacy of 0·1% chlorhexidine solution compared with normal saline for meatal cleaning before urinary catheter insertion in reducing the incidence of catheter-associated asymptomatic bacteriuria and UTI.

Methods
A cross-sectional, stepped-wedge, open-label, randomised controlled trial was undertaken in Australian hospitals. Eligible hospitals were Australian public and private hospitals, with an intensive care unit and more than 30 000 hospital admissions per year. Hospitals were randomly assigned to an intervention crossover date using a computer-generated randomisation system. Crossover dates occurred every 8 weeks; during the first 8 weeks of the study, no hospitals were exposed to the intervention (control phase), after which each hospital sequentially crossed over from the control to the intervention every 8 weeks. Patients requiring a urinary cathetwer were potentially eligible for inclusion in this hospital-wide study. Participants were excluded if they were younger than 2 years, had a medical reason preventing the use of the chlorhexidine, had the catheter inserted in theatre, did not have the catheter insertion date documented, required in-and-out or suprapubic catheterisation, had symptoms and signs suggestive of UTI at the time of catheter insertion, or were currently undergoing treatment for UTI. The intervention was the use of 0·1% chlorhexidine solution for meatal cleaning before urinary catheterisation with 0·9% normal saline used in the control phase. Masking of hospitals was not possible because it was not feasible to mask staff administering the intervention. The co-primary outcomes were the number of cases of catheter-associated asymptomatic bacteriuria and UTI per 100 catheter-days and were assessed within 7 days of catheter insertion in the intention-to-treat population. This trial is registered with Australian New Zealand Clinical Trials Registry, number ACTRN12617000373370.

Findings
21 hospitals were assessed for eligibility between Jan 5, 2017, and May 1, 2017; of these, three were successfully enrolled and randomised to one of three intervention crossover dates. 1642 participants in these hospitals were included in the study between Aug 1, 2017, and March 12, 2018, 697 (42%) in the control phase and 945 (58%) in the intervention period. In the control period, 13 catheter-associated UTI and 29 catheter-associated asymptomatic bacteriuria events in 2889 catheter-days (0·45 catheter-associated UTI cases and 1·00 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) were recorded compared with four catheter-associated UTI and 16 catheter-associated asymptomatic bacteriuria events in 2338 catheter-days (0·17 catheter-associated UTI cases and 0·68 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) during the intervention period. The intervention was associated with a 74% reduction in the incidence of catheter-associated asymptomatic bacteriuria (incident rate ratio 0·26, 95% CI 0·08–0·86, p=0·026), and a 94% decrease in the incidence of catheter-associated UTI (0·06, 95% CI 0·01–0·32, p=0·00080). There were no reported adverse events.

Interpretation
The use of chlorhexidine solution for meatal cleaning before catheter insertion decreased the incidence of catheter-associated asymptomatic bacteriuria and UTI and has the potential to improve patient safety.

Year2019
JournalThe Lancet Infectious diseases
Journal citation19 (6), pp. 611-619
PublisherThe Lancet Publishing Group
ISSN1473-3099
Digital Object Identifier (DOI)https://doi.org/10.1016/S1473-3099(18)30736-9
Scopus EID2-s2.0-85065862696
Research or scholarlyResearch
Page range611-619
Publisher's version
License
All rights reserved
File Access Level
Controlled
Output statusPublished
Publication dates
Online12 Apr 2019
Publication process dates
Deposited02 Jun 2021
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Mitchell, Brett, Gardner, Anne and Hiller, Janet. (2014). The prolongation of length of stay because of clostridium difficile infection. American Journal of Infection Control. 42(2), pp. 164 - 167. https://doi.org/10.1016/j.ajic.2013.07.006
A point prevalence cross-sectional study of healthcare-associated urinary tract infections in six Australian hospitals
Gardner, Anne, Mitchell, Brett, Beckingham, Wendy and Fasugba, Oyebola. (2014). A point prevalence cross-sectional study of healthcare-associated urinary tract infections in six Australian hospitals. BMJ Open. 4(7), pp. 1 - 9. https://doi.org/10.1136/bmjopen-2014-005099
Using the Donabedian framework to examine the quality and safety of nursing service innovation
Gardner, Glenn, Gardner, Anne and O'Connell, Jane. (2014). Using the Donabedian framework to examine the quality and safety of nursing service innovation. Journal of Clinical Nursing. 23(1-2), pp. 145 - 155. https://doi.org/10.1111/jocn.12146
Surveillance to reduce urinary tract infections: the STRUTI project
Bola, Fasugba,, Gardner, Anne, Mitchell, Brett, Beckingham, Wendy and Bennett, Noleen. (2014). Surveillance to reduce urinary tract infections: the STRUTI project. Australian Nursing and Midwifery Journal. 22(3), pp. 34 - 35.
Healthcare associated urinary tract infections : A protocol for a national point prevalence study
Mitchell, Brett, Gardner, Anne, Beckingham, Wendy and Fasugba, Oyebola. (2014). Healthcare associated urinary tract infections : A protocol for a national point prevalence study. Healthcare Infection. 19(1), pp. 26 - 31. https://doi.org/10.1071/HI13037
Addressing the need for an infection prevention and control framework that incorporates the role of surveillance: A discussion paper
Mitchell, Brett and Gardner, Anne. (2014). Addressing the need for an infection prevention and control framework that incorporates the role of surveillance: A discussion paper. Journal of Advanced Nursing. 70(3), pp. 533 - 542. https://doi.org/10.1111/jan.12193
The Fitzpatrick Skin Type Scale : A reliability and validity study in women undergoing radiation therapy for breast cancer
Fasugba, Oyebola, Gardner, Anne and Smyth, Wendy. (2014). The Fitzpatrick Skin Type Scale : A reliability and validity study in women undergoing radiation therapy for breast cancer. Journal of Wound Care. 23(7), pp. 358 - 368. https://doi.org/10.12968/jowc.2014.23.7.358
Mortality and clostridium difficile infection in an Australian setting
Mitchell, Brett, Gardner, Anne and Hiller, Janet. (2013). Mortality and clostridium difficile infection in an Australian setting. Journal of Advanced Nursing. https://doi.org/10.1111/jan.12078
A survey-based study of knowledge of Alzheimer's disease among health care staff
Smyth, Wendy, Fielding, Elaine, Beattie, Elizabeth, Gardner, Anne, Moyle, Wendy, Franklin, Sara, Hines, Sonia and MacAndrew, Margaret. (2013). A survey-based study of knowledge of Alzheimer's disease among health care staff. BMC Geriatrics. 13(2), pp. 1 - 8. https://doi.org/10.1186/1471-2318-13-2
Views and experiences of nurse practitioners and medical practitioners with collaborative practice in primary health care: An integrative review
Schadewaldt, Verena, McInnes, Elizabeth, Hiller, Janet and Gardner, Anne. (2013). Views and experiences of nurse practitioners and medical practitioners with collaborative practice in primary health care: An integrative review. BMC Family Practice. 14(132), pp. 1 - 11. https://doi.org/10.1186/1471-2296-14-132
Development and interrater reliability testing of a telephone interview training programme for Australian nurse interviewers
Ahern, Tracey, Gardner, Anne, Gardner, Glenn, Middleton, Sandy and Della, Phillip. (2013). Development and interrater reliability testing of a telephone interview training programme for Australian nurse interviewers. Nurse Education Today. 33(5), pp. 470-474. https://doi.org/10.1016/j.nedt.2012.05.001
Centrelink: An innovative urban intervention for improving adult Aboriginal and Torres Strait Islander access to vaccination
Thomsen, Rosie, Smyth, Wendy, Gardner, Anne and Ketchell, Jennifer. (2012). Centrelink: An innovative urban intervention for improving adult Aboriginal and Torres Strait Islander access to vaccination. Infection, Disease and Health. 17(4), pp. 136 - 141. https://doi.org/10.1071/HI12035
Report of a case of neonatal malaria (Plasmodium falciparum) in Nigeria
Fasugba, Oyebola. (2012). Report of a case of neonatal malaria (Plasmodium falciparum) in Nigeria. Healthcare Infection. 17(4), pp. 122 - 126. https://doi.org/10.1071/HI12024
Supporting rural and remote area nurses to utilise and conduct research : An intervention study
Gardner, Anne, Smyth, Wendy, Renison, Bronia, Cann, Tina and Vicary, Mary. (2012). Supporting rural and remote area nurses to utilise and conduct research : An intervention study. Collegian. 19(2), pp. 97 - 105. https://doi.org/10.1016/j.colegn.2011.09.005
Anatomical location of injury in Stage I and Stage II heel pressure injuries : a pilot study
Dunk, Ann Marie, Gardner, Anne and Waddington, Gordon. (2012). Anatomical location of injury in Stage I and Stage II heel pressure injuries : a pilot study. Wound Practice & Research. 20(3), pp. 130 - 141.
Mortality and Clostridium difficile infection : a review
Mitchell, Brett G. and Gardner, Anne. (2012). Mortality and Clostridium difficile infection : a review. Antimicrobial Resistance and Infection Control. 1(20). https://doi.org/10.1186/2047-2994-1-20
Change for the better : An innovative model of care delivering positive patient and workforce outcomes
Cann, Tina and Gardner, Anne. (2012). Change for the better : An innovative model of care delivering positive patient and workforce outcomes. Collegian. 19(2), pp. 107 - 113. https://doi.org/10.1016/j.colegn.2011.09.002
Healthcare-associated infections: Getting the balance right in safety and quality v. public reporting (Review)
Mitchell, Brett, Gardner, Anne and McGregor, Alistair. (2012). Healthcare-associated infections: Getting the balance right in safety and quality v. public reporting (Review). Australian Health Review. 36(4), pp. 365 - 366. https://doi.org/10.1071/AH11200
The epidemiology of Staphylococcus aureus bacteraemia in Tasmania
Mitchell, Brett, Gardner, Anne and Stewart, Lee. (2012). The epidemiology of Staphylococcus aureus bacteraemia in Tasmania. Healthcare Infection. 17(3), pp. 98 - 103. https://doi.org/10.1071/HI12020
Prolongation of length of stay and Clostridium difficile infection : A review of the methods used to examine length of stay due to healthcare associated infections
Mitchell, Brett and Gardner, Anne. (2012). Prolongation of length of stay and Clostridium difficile infection : A review of the methods used to examine length of stay due to healthcare associated infections. Antimicrobial Resistance and Infection Control. 1(14), pp. 1 - 6. https://doi.org/10.1186/2047-2994-1-14
The prevalence of urinary distress in male and female adults with diabetes mellitus attending a Northern Australian endocrine centre
Chadwick, Robyn, Corstiaans, Audrey, Gardner, Anne, Crook, Sandra, Tan, Yong Mong, Rane, Ajay and Millar, Lynne. (2012). The prevalence of urinary distress in male and female adults with diabetes mellitus attending a Northern Australian endocrine centre. Australian and New Zealand Continence Journal. 18(3), pp. 80 - 86.
Irritability :an underappreciated side effect of interferon treatment for chronic hepatitis C?
Blacklaws, Helen, Gardner, Anne and Usher, Kim. (2011). Irritability :an underappreciated side effect of interferon treatment for chronic hepatitis C? Journal of Clinical Nursing. 20, pp. 1215 - 1224. https://doi.org/10.1111/j.1365-2702.2010.03494.x
Audit of factors associated with the intactness of central venous catheter exit site dressings for northern Australian haemodialysis patients
Hughes, K., Gardner, Anne and McArdle, J.. (2011). Audit of factors associated with the intactness of central venous catheter exit site dressings for northern Australian haemodialysis patients. Renal Society of Australasia Journal. 7(3), pp. 108 - 114.
The status of Australian nurse practitioners: The second national census
Middleton, Sandy, Gardner, Anne, Gardner, G. and Della, P R.. (2011). The status of Australian nurse practitioners: The second national census. Australian Health Review. 35(4), pp. 448 - 454. https://doi.org/10.1071/AH10987
A snapshot of Australian nurse practitioners' extended practice activities
Gardner, Glenn, Gardner, Anne, Middleton, Sandy, Della, Phillip and Doubrovsky, Anna. (2010). A snapshot of Australian nurse practitioners' extended practice activities. The Nurse Practitioner Series. 3(1), pp. 8-15.
A literature review supporting the proposed national Australian definition for Staphylococcus aureus bacteraemia
Mitchell, Brett, Gardner, Anne, Collignon, Peter, Stewart, Lee and Cruickshank, Marilyn. (2010). A literature review supporting the proposed national Australian definition for Staphylococcus aureus bacteraemia. Healthcare Infection. 15(4), pp. 105 - 113. https://doi.org/10.1071/HI10030
The work of nurse practitioners
Gardner, Glenn, Gardner, Anne, Middleton, Sandy, Della, Phillip, Kain, Victoria and Doubrovsky, Anna. (2010). The work of nurse practitioners. Journal of Advanced Nursing. 66(10), pp. 2160-2169. https://doi.org/10.1111/j.1365-2648.2010.05379.x
The first Australian nurse practitioner census : A protocol to guide standardized collection of information about an emergent professional group
Middleton, Sandy, Gardner, Glenn, Gardner, Anne, Della, Phillip, Gibb, Michelle and Millar, Lynne. (2010). The first Australian nurse practitioner census : A protocol to guide standardized collection of information about an emergent professional group. International Journal of Nursing Practice. 16(5), pp. 517-524. https://doi.org/10.1111/j.1440-172X.2010.01877.x
Development and validation of a novel approach to work sampling : A study of work practitioner work patterns
Gardner, Glenn, Gardner, Anne, Middleton, Sandy, Gibb, Michelle, Della, Phillip and Duffield, Christine. (2010). Development and validation of a novel approach to work sampling : A study of work practitioner work patterns. Australian Journal of Advanced Nursing. 27(4), pp. 4-12.
Clients' understanding of the role of nurse practitioners
Susan, Allnutt,, Allnutt, Nissa, McMaster, Rose, O'Connell, Jane, Middleton, Sandy, Hillege, Sharon, Della, Phillip R., Gardner, Glenn E. and Gardner, Anne. (2010). Clients' understanding of the role of nurse practitioners. Australian Health Review. 34(1), pp. 59-65. https://doi.org/10.1071/AH09688
The status of Australian nurse practitioners : The first national census
Gardner, Anne, Della, Phillip R., Middleton, Sandy and Gardner, Glenn. (2009). The status of Australian nurse practitioners : The first national census. Australian Health Review. 33(4), pp. 679-689. https://doi.org/10.1071/AH090679
Pressure injury prevalence in a private health service: Risks and recommendations
Gardner, Anne, Millar, Lynne, Legg, Sandra, Gomez, Yvette, McGillion, Tony and Mulcahy, Aidan. (2009). Pressure injury prevalence in a private health service: Risks and recommendations. Wound Practice & Research. 17(3), pp. 134 - 145.
Absolutely fabulous - but are we? Carers' perspectives on satisfaction with a palliative homecare service
O'Connor, Lera, Gardner, Anne, Millar, Lynne and Bennett, Peter. (2009). Absolutely fabulous - but are we? Carers' perspectives on satisfaction with a palliative homecare service. Collegian. 16(4), pp. 201 - 209. https://doi.org/10.1016/j.colegn.2009.04.005
Implementing a journal club in a palliative care setting: A link in the chain of evidence-based practice
O'Connor, Lera, Bennett, Peter, Gardner, Anne, Hawkins, Mary and Wellman, David. (2009). Implementing a journal club in a palliative care setting: A link in the chain of evidence-based practice. Collegian. 16(3), pp. 147 - 152. https://doi.org/10.1016/j.colegn.2008.12.006
A literature review of central venous catheter dressings: Implications for haemodialysis in the tropics
McArdle, Joleen and Gardner, Anne. (2009). A literature review of central venous catheter dressings: Implications for haemodialysis in the tropics. Infection, Disease and Health. 14(4), pp. 139 - 146. https://doi.org/10.1071/HI09014
Excellence in regional stroke care: An evaluation of the implementation of a stroke care unit in regional Australia
McCann, Leanne, Groot, Patrick, Charnley, Chris and Gardner, Anne. (2009). Excellence in regional stroke care: An evaluation of the implementation of a stroke care unit in regional Australia. Australian Journal of Rural Health. 17(5), pp. 273 - 278. https://doi.org/10.1111/j.1440-1584.2009.01098.x
Writing ourselves into a web of obedience: A nursing policy analysis
Bail, Kasia, Cook, Robert, Gardner, Anne and Grealish, Laurie. (2009). Writing ourselves into a web of obedience: A nursing policy analysis. International Journal of Nursing Studies. 46(11), pp. 1457 - 1466. https://doi.org/10.1016/j.ijnurstu.2009.04.005
Potential scope and impact of a transboundary model of nurse practitioners in aged care
Bail, Kasia, Arbon, Paul, Eggert, Marlene, Gardner, Anne, Hogan, Sonia, Phillips, Christine, van Dieman, Nicole and Waddington, Gordon. (2009). Potential scope and impact of a transboundary model of nurse practitioners in aged care. Australian Journal of Primary Health. 15(3), pp. 232 - 237. https://doi.org/10.1071/PY09009
Patients' and nurses' perspectives on oxygen therapy: A qualitative study
Eastwood, Glenn, O'Connell, Beverley, Gardner, Anne and Considine, Julie. (2009). Patients' and nurses' perspectives on oxygen therapy: A qualitative study. Journal of Advanced Nursing. 65(3), pp. 634 - 641. https://doi.org/10.1111/j.1365-2648.2008.04933.x
Reporting a research project on the potential of aged care nurse practitioners in the Australian capital territory
Arbon, Paul, Bail, Kasia, Eggert, Marlene, Gardner, Anne, Hogan, Sonia, Phillips, Christine, van Dieman, Nicole and Waddington, Gordon. (2009). Reporting a research project on the potential of aged care nurse practitioners in the Australian capital territory. Journal of Clinical Nursing. 18(2), pp. 255 - 262. https://doi.org/10.1111/j.1365-2702.2008.02452.x
Selecting the right integration of research into practice strategy
Eastwood, Glenn, O'Connell, Beverley and Gardner, Anne. (2008). Selecting the right integration of research into practice strategy. Journal of Nursing Care Quality. 23(3), pp. 258 - 264. https://doi.org/10.1097/01.NCQ.0000324591.76590.e9
From competence to capability: A study of nurse practitioners in clinical practice
Gardner, Anne, Hase, Stewart, Gardner, Glenn, Dunn, Sandra and Carryer, Jenny. (2008). From competence to capability: A study of nurse practitioners in clinical practice. Journal of Clinical Nursing. 17(2), pp. 250 - 258. https://doi.org/10.1111/j.1365-2702.2006.01880.x
Evaluation of nasopharyngeal oxygen, nasal prongs and facemask oxygen therapy devices in adult patients: A randomised crossover trial
Eastwood, Glenn, O'Connell, Beverley, Gardner, Anne and Considine, Julie. (2008). Evaluation of nasopharyngeal oxygen, nasal prongs and facemask oxygen therapy devices in adult patients: A randomised crossover trial. Anaesthesia and Intensive Care. 36(5), pp. 691 - 694.
The core role of the nurse practitioner: practice, professionalism and clinical leadership
Carryer, Jenny, Gardner, Glenn, Dunn, Sandra and Gardner, Anne. (2007). The core role of the nurse practitioner: practice, professionalism and clinical leadership. Journal of Clinical Nursing. 16(10), pp. 1818 - 1825. https://doi.org/10.1111/j.1365-2702.2007.01823.x
Living with chronic illness
Gardner, Glenn and Gardner, Anne. (2007). Living with chronic illness. In In McAllister, Margaret (Ed.). Solution focused nursing : Rethinking practice pp. 143-153 Palgrave Macmillan.
Dealing with data: optimising data consistency to demonstrate the value of nurse practitioner service
Gardner, Anne, Millar, Lynne and Driscoll, Andrea. (2007). Dealing with data: optimising data consistency to demonstrate the value of nurse practitioner service. The Nurse Practitioner Series. 2(1), pp. 19 - 25.
Intravascular catheter bloodstream infections: An effective and sustained hospital-wide prevention program over 8 years
Collignon, Peter J., eimanis, Dianne E., Beckingham, Wendy D., Roberts, Jan L. and Gardner, Anne. (2007). Intravascular catheter bloodstream infections: An effective and sustained hospital-wide prevention program over 8 years. Medical Journal of Australia. 187(10), pp. 551 - 554.
The capability of nurse practitioners may be diminished by controlling protocols
Carryer, Jenny, Gardner, Glenn, Dunn, Sandra and Gardner, Anne. (2007). The capability of nurse practitioners may be diminished by controlling protocols. Australian Health Review. 31(1), pp. 108 - 115. https://doi.org/10.1071/AH070108
Clinical usefulness and feasibility of using Reality Orientation with patients who have dementia in acute care settings
O'Connell, Beverley, Gardner, Anne, Takase, Miyuki, Hawkins, Mary, Ostaszkiewicz, Joan, Ski, Chantal and Josipovic, Patricia. (2007). Clinical usefulness and feasibility of using Reality Orientation with patients who have dementia in acute care settings. International Journal of Nursing Practice. 13(3), pp. 182 - 192. https://doi.org/10.1111/j.1440-172X.2007.00624.x
Prevalence of genital human papillomavirus DNA in a sample of senior school-aged women in the Australian Capital Territory
O'Keefe, Elissa, Gardner, Anne, Currie, Marian, Garland, Suzanne, Tabrizi, Sepehr and Bowden, Francis. (2006). Prevalence of genital human papillomavirus DNA in a sample of senior school-aged women in the Australian Capital Territory. Sexual Health. 3(2), pp. 91 - 94. https://doi.org/10.1071/SH05047
Competency and capability: imperative for nurse practitioner education
Gardner, Glenn, Carryer, Jenny, Dunn, Sandra and Gardner, Anne. (2006). Competency and capability: imperative for nurse practitioner education. Australian Journal of Advanced Nursing. 24(1), pp. 8 - 14.
Using a monitored sip test to assess risk of aspiration in postoperative patients
Osborne, Sonya, Gardner, Glenn, Gardner, Anne, Franklin, Susan, Tuohy, Elizabeth and Fisher, Alex. (2006). Using a monitored sip test to assess risk of aspiration in postoperative patients. AORN Journal. 83(4), pp. 908 - 928. https://doi.org/10.1016/S0001-2092(06)60010-0
Sedation and analgesia management for mechanically ventilated adults: literature review, case study and recommendations for practice
Feeley, Kathy and Gardner, Anne. (2006). Sedation and analgesia management for mechanically ventilated adults: literature review, case study and recommendations for practice. Australian Critical Care. 19(2), pp. 73 - 77. https://doi.org/10.1016/S1036-7314(06)80012-3
How ophthalmic day surgery patients convalesce at home: an exploration of the salient issues
Ryan, Fiona, O'Connell, Beverley and Gardner, Anne. (2006). How ophthalmic day surgery patients convalesce at home: an exploration of the salient issues. Day Surgery Australia. 5(3), pp. 11 - 16.
Pressure injury: an exploration of the relationship between risk factors and interface pressure
Gardner, Anne, Dunk, Ann Marie, Eggert, Marlene, Gardner, Glenn and Wellman, David. (2006). Pressure injury: an exploration of the relationship between risk factors and interface pressure. Wound Practice & Research. 14(4), pp. 140 - 149.
Nurse Practitioner competency standards: Findings from collaborative Australian and New Zealand research
Gardner, Glenn, Carryer, Jenny, Gardner, Anne and Dunn, Sandra. (2006). Nurse Practitioner competency standards: Findings from collaborative Australian and New Zealand research. International Journal of Nursing Studies. 43(5), pp. 601 - 610. https://doi.org/10.1016/j.ijnurstu.2005.09.002
A trial of nurse practitioner scope of practice
Gardner, Anne and Gardner, Glenn. (2005). A trial of nurse practitioner scope of practice. Journal of Advanced Nursing. 49(2), pp. 135 - 145. https://doi.org/10.1111/j.1365-2648.2004.03273.x
Best practice in stabilisation of oral endotracheal tubes: a systematic review
Gardner, Anne, Hughes, Dot, Cook, Robert, Henson, Rachael, Osborne, Sonya and Gardner, Glenn. (2005). Best practice in stabilisation of oral endotracheal tubes: a systematic review. Australian Critical Care. 18(4), pp. 158 - 165. https://doi.org/10.1016/S1036-7314(05)80029-3
Parenting a preterm infant: Experiences in a regional neonatal health services programme
Rowe, Jennifer, Gardner, Glenn and Gardner, Anne. (2005). Parenting a preterm infant: Experiences in a regional neonatal health services programme. Neonatal, Paediatric and Child Health Nursing. 8(1), pp. 17 - 23.