Quality Indicators of End-of-Life Cancer Care from the Bereaved Family Members' Perspective in Japan

Although several studies about quality indicators (QIs) in end-of-life (EOL) cancer care have been conducted, the bereaved family members’ perspective of QIs has not been investigated in Japan. The primary aim of this study was to rate QIs for EOL cancer care from the bereaved family members’ perspective in Japan. A cross-sectional anonymous questionnaire was administered to bereaved family members of cancer patients who had died in an inpatient palliative care unit. We mailed questionnaires to potential respondents in March 2007. Of 160 questionnaires sent, 109 responses were analyzed (effective response rate, 76%). Eighty-eight percent of participants rated the medical examination by the palliative care team or specialist positively, 80% rated the availability of emergency room (ER) services or after-hour examinations positively, and 77% agreed that medical orders to alleviate pain or suffering were documented in the chart. Only 15% of the respondents agreed that it was preferable to die at home. Additionally, 59% and 46% of participants agreed that the occurrence of a fall or pressure ulcer and death by an adverse event from surgery or chemotherapy were poor QIs, respectively. Moreover, only 17% and 14% rated the short interval from chemotherapy to dying and frequent visits to the ER or after-hour examination as poor QIs, respectively. In Japan, it would be appropriate to extract QIs from medical charts. However, many items suggested as QIs in a previous study were found to be different from the opinions expressed by bereaved family members in this study.     

ECG Interpretation Part 1: Understanding Mean Electrical Axis

We have provided a concise overview of the knowledge required to interpret the mean electrical axis on the 12-lead ECG. In essence, the QRS electrical axis is useful because it helps determine the position of the heart in the chest, patency of electrical pathways, and integrity of muscle mass. By itself, it is not diagnostic, but it does lend support to the observant clinician’s suspicions for each of these anomalies. The ability to determine the mean electrical axis provides the emergency nurse with an additional readily available clinical tool to assist in the early and rapid detection of potentially life-threatening changes in the patient’s cardiovascular status.     

The effects of an exercise program on fall risk factors in people with Parkinson's disease: A randomized controlled trial

This randomized controlled trial with blinded assessment aimed to determine the effect of a 6‐month minimally supervised exercise program on fall risk factors in people with Parkinson's disease (PD). Forty‐eight participants with PD who had fallen or were at risk of falling were randomized into exercise or control groups. The exercise group attended a monthly exercise class and exercised at home three times weekly. The intervention targeted leg muscle strength, balance, and freezing. The primary outcome measure was a PD falls risk score. The exercise group had no major adverse events and showed a greater improvement than the control group in the falls risk score, which was not statistically significant (between group mean difference = ?7%, 95% CI ?20 to 5, P = 0.26). There were statistically significant improvements in the exercise group compared with the control group for two secondary outcomes: Freezing of Gait Questionnaire (P = 0.03) and timed sit‐to‐stand (P = 0.03). There were statistically nonsignificant trends toward greater improvements in the exercise group for measures of muscle strength, walking, and fear of falling, but not for the measures of standing balance. Further investigation of theimpact of exercise on falls in people with PD is warranted. © 2010 Movement Disorder Society     

Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study

Objectives

The objective was to examine cannulation practice and effectiveness of a multimodal intervention to reduce peripheral intravenous cannula (PIVC) insertion in emergency department (ED) patients.

Methods

A prospective before and after study and cost analysis was conducted at a single tertiary ED in Australia. Data were collected 24 hours a day for 2 weeks pre‐ and post implementation of a multimodal intervention. PIVC placement and utilization within 24 hours were evaluated in all eligible patients.

Results

A total of 4,173 participants were included in the analysis. PIVCs were placed in 42.1% of patients' pre intervention and 32.4% post intervention, a reduction of 9.8% (95% confidence interval [CI] = 6.8 to –12.72%). PIVC usage within 24 hours of admission was 70.5% pre intervention and 83.4% post intervention, an increase of 12.9% (95% CI = 8.8% to 17.0%). Sixty‐six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI = 12.6 to 17.9) minutes. PIVC insertion cost, including staff time and consumables per participant, was A$22.79 (95% CI = A$19.35 to A$26.23).

Conclusions

The intervention reduced PIVC placement in the ED and increased the percentage of PIVCs placed that were used. This program benefits patients and health services alike, with potential for large cost savings.

     

Late Referrals to Palliative Care Units in Japan: Nationwide Follow-Up Survey and Effects of Palliative Care Team Involvement After the Cancer Control Act

Referral to palliative care units tends to be delayed. In Japan, the Cancer Control Act was established in 2006 to improve the quality of life of cancer patients by facilitating greater access to specialized palliative care services. The primary aims of this study were to clarify the family-perceived appropriateness of the timing of referral to palliative care units after the Cancer Control Act, and to determine the effects of the involvement of the palliative care team on the family-perceived referral timing. An additional aim of this study was to clarify the family-perceived usefulness of the palliative care team. A multicenter questionnaire survey was conducted on a sample of 661 bereaved family members of cancer patents who were admitted to palliative care units in Japan. A total of 451 responses were analyzed (response rate: 68%). Half of the bereaved family members regarded the timing of referrals to palliative care units as late or too late: too late (25%, n = 114), late (22%, n = 97), appropriate (47%, n = 212), early (2.4%, n = 11), and very early (1.8%, n = 8). Among 228 families who reported that patients had commented on the timing of referrals, about half reported that the patients said the timing of referral was late or too late: too late (23%, n = 52), late (21%, n = 49), appropriate (48%, n = 110), early (4.4%, n = 10), and very early (3.1%, n = 7). The families of patients with a palliative care team (n = 191) tended to report less frequently that they believed the referral timing to be late or too late (43% vs. 51%, P = 0.073); they also reported significantly less frequently that the patients said that the referral timing was late or too late (36% vs. 52%, P = 0.037). The percentages of families who evaluated the palliative care team as useful or very useful were: 93% (symptom control), 90% (emotional support), 92% (family support), and 87% (care coordination). Half of the Japanese bereaved families of patients admitted to palliative care units regarded the timing of referrals as late or too late, and the rates identified in the survey were similar to those recorded before the Cancer Control Act. Involvement of the palliative care team, however, significantly correlated with lower family- and patient-perceived late referrals, and palliative care team activity was generally perceived as useful by the bereaved family members. Further dissemination of palliative care teams could contribute to better access to palliative care units and quality palliative care throughout the country.