The two-step Mini Nutritional Assessment procedure in community resident homes

Aims and objectivities. The aims were to test internal consistency and interrater reliability of Mini Nutritional Assessment during implementation of Mini Nutritional Assessment in community residential homes and to test sensitivity, specificity and diagnostic predictivity of Mini Nutritional Assessment-short form vs. Mini Nutritional Assessment. Background. There is a need in clinical practice to assess nutritional status in older people and to identify those who could benefit from early intervention. Methods. The two-step Mini Nutritional Assessment procedure (Mini Nutritional Assessment-short form and Mini Nutritional Assessment) was used in 127 older people admitted to eight residential homes. In three of those homes (A, B and C), registered nurses simultaneously performed the assessment procedure, after receiving education and training. The intention was to offer the registered nurses a tool for independent practice use. Results. Internal consistency was 0·68 (Cronbach's alpha) (n = 127). In residential home A, B and C, the registered nurses carried out Mini Nutritional Assessment in 45 residents out of 68. The agreement level between the author's and the registered nurses’ assessments was 62% (kappa 0·41). In residential home A, B and C, the agreement level was 89%, 89% and 44%, respectively. Sensitivity, specificity and diagnostic predictivity of Mini Nutritional Assessment-short form vs. Mini Nutritional Assessment were 89%, 82% and 92%, respectively. Conclusions. The two-step Mini Nutritional Assessment procedure seems to be a useful tool to identify residents in need of nutritional interventions, despite the registered nurses not carrying out Mini Nutritional Assessment in all residents and the low agreement in residential home C. It indicates that to implement and use Mini Nutritional Assessment in nursing care demands the creating necessary staff resources, such as adequate staffing, sufficient education and continual supervision. Relevance to clinical practice. Because of the high sensitivity of Mini Nutritional Assessment-short form and Mini Nutritional Assessment, Mini Nutritional Assessment-short form alone might be sufficient for practice use, as its simplicity might increase its usefulness.     

Reliability of the European Pressure Ulcer Advisory Panel classification system

AIM: This paper reports a study examining the interrater and intrarater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using photographs of pressure ulcers and incontinence lesions. BACKGROUND: Pressure ulcer classification is an essential tool for assessing ulcers and their severity and determining which preventive or therapeutic action is needed. Many classification systems are described in the literature. There are only a limited number of studies that evaluate the interrater reliability of pressure ulcer grading scales. The intrarater reliability is seldom studied. METHODS: The study consisted of two phases. In the first phase 56 photographs, together with a random selection of nine photographs from the same set, were presented to 473 nurses. In the second phase, the 56 photographs were presented twice to 86 other nurses with an interval of one month and in a different order. All the nurses were familiar with the European Pressure Ulcer Advisory Panel classification. They did not receive any additional training on classification, and were asked to classify the lesions as normal skin, blanchable erythema, pressure ulcers (four grades, European Pressure Ulcer Advisory Panel classification) or incontinence lesions. RESULTS: In the first phase, the multirater-Kappa for the 473 participating nurses was 0.37 (P < 0.001). Non-blanchable erythema was often confused with blanchable erythema and incontinence lesions. Also incontinence lesions were frequently not correctly classified. The intrarater agreement was low (kappa = 0.38). In the second phase, the interrater agreement was not significantly different in both sessions. The intrarater agreement was 0.52. CONCLUSION: Both the interrater and intrarater reliability of the European Pressure Ulcer Advisory Panel classification of lesion photographs by nurses was very low. Differentiation between pressure ulcers and incontinence lesions seems to be difficult.     

A systematic review of interrater reliability of pressure ulcer classification systems

Aims. To review systematically the interrater reliability of pressure ulcer classification systems to find out which classification should be used in daily practice. Background. Pressure ulcer classification systems are important tools in research and practice. They aim at providing accurate and precise communication, documentation and treatment decisions. Pressure ulcer classifications are criticised for their low degree of interrater reliability. Design. Systematic review. Methods. The data bases MEDLINE, EMBASE, CINAHL and the World Wide Web were searched. Original research studies estimating interrater reliability of pressure ulcer classification systems were included. Study selection, data extraction and quality assessment was conducted independently by two reviewers. Results. Twenty‐four out of 339 potentially relevant studies were included in the final data synthesis. Due to the heterogeneity of the studies a meaningful comparison was impossible. Conclusions. There is at present not enough evidence to recommend a specific pressure ulcer classification system for use in daily practice. Interrater reliability studies are required, in which comparable raters apply different pressure ulcer classification systems to comparable samples. Relevance to clinical practice. It is necessary to determine the interrater reliability of pressure ulcer classifications among all users in clinical practice. If interrater reliability is low the use of those systems is questionable. On the basis of this review there are no recommendations as to which system is to be given preference.     

Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness

Objective: To assess the interrater reliability of the Glasgow Coma Scale (GCS) between nurses and senior doctors in the ED. Methods: This was a prospective observational study with a convenience sample of patients aged 18 or above who presented with a decreased level of consciousness to a tertiary hospital ED. A senior ED doctor (emergency physicians and trainees) and registered nurse each independently scored the patient’s GCS in blinded fashion within 15 min of each other. The data were then analysed to determine interrater reliability using the weighted kappa statistic and the size and directions of differences between paired scores were examined. Results: A total of 108 eligible patients were enrolled, with GCS scores ranging from 3 to 14. Interrater agreement was excellent (weighted kappa > 0.75) for verbal scores and total GCS scores, and intermediate (weighted kappa 0.4–0.75) for motor and eye scores. Total GCS scores differed by more than two points in 10 of the 108 patients. Interrater agreement did not vary substantially across the range of actual numeric GCS scores. Conclusions: Although the level of agreement for GCS scores was generally high, a significant proportion of patients had GCS scores which differed by two or more points. This degree of disagreement indicates that clinical decisions should not be based solely on single GCS scores.     

Developing stroke-specific vocational rehabilitation: a soft systems analysis of current service provision

Purpose.?To establish interrater and test–retest reliability of a clinical assessment of motor and sensory upper limb impairments in children with hemiplegic cerebral palsy aged 5–15 years.

Method.?The assessments included passive range of motion (PROM), Modified Ashworth Scale (MAS), manual muscle testing (MMT), grip strength, the House thumb and Zancolli classification and sensory function. Interrater reliability was investigated in 30 children, test–retest reliability in 23 children.

Results.?For PROM, interrater reliability varied from moderate to moderately high (correlation coefficients 0.48–0.73) and test–retest reliability was very high (>0.81). For the MAS and MMT, total score and subscores for shoulder, elbow, and wrist showed a moderately high to very high interrater reliability (0.60–0.91) and coefficients of >0.78 for test–retest reliability. The reliability for the individual muscles varied from moderate to high. The Jamar dynamometer was found to be highly reliable. The House thumb classification showed a substantial reliability and the Zancolli classification an almost perfect reliability. All sensory modalities had a good agreement.

Conclusions.?For all motor and sensory assessments, interrater and test–retest reliability was moderate to very high. Test–retest reliability was clearly higher than interrater reliability. To improve interrater reliability, it was recommended to strictly standardize the test procedure, refine the scoring criteria and provide intensive rater trainings.     

Pressure ulcers in palliative care: development of a hospice pressure ulcer risk assessment scale

The aim of this study was to construct a pressure ulcer risk assessment scale appropriate for palliative care patients. Risk assessments were performed using the modified Norton scale and nine newly constructed scales, consisting of the modified Norton scale with various changes. Data were collected from 98 patients in a Swedish hospice between April 1999 and September 2000. Pressure ulcer occurrence was registered weekly in the patient record. Increasing age, male gender, physical inactivity, immobility, decreasing food and fluid intake, incontinence, poor general physical condition and lean body constitution were shown to be significant risk factors for development of pressure ulcers in terminally ill cancer patients. After further testing of the data, one scale was found to be superior in identifying patients at risk, with higher validity than the modified Norton scale. The assessment items in this new scale, The Hospice Pressure Ulcer Risk Assessment Scale (in Swedish: Hospice Riskbed?ming Trycks?r, (HoRT)), are physical activity, mobility and age.     

Utility of the Emergency Severity Index by Accuracy of Interrater Agreement by Expert Triage Nurses in a Simulated Scenario in Japan: A Randomized Controlled Trial

ObjectiveThe Emergency Severity Index (ESI) is a highly reliable and valid triage scale that is widely used in emergency departments in not only English language regions but also other countries. The Japan Triage and Acuity Scale (JTAS) is frequently used for emergency patients, and the ESI has not been evaluated against the JTAS in Japan. This study aimed to examine the decision accuracy of the ESI for simulated clinical scenarios among nursing specialists in Japan compared with the JTAS.MethodA parallel group randomized trial was conducted. In total, 23 JTAS–trained triage nurses from 10 Japanese emergency departments were randomly assigned to the ESI or the JTAS group. Nurses independently assigned triage categories to 80 emergency cases for the assessment of interrater agreement.ResultsInterrater agreement between the expert and triage nurses was κ = 0.82 (excellent) in the ESI group and κ = 0.74 (substantial) in the JTAS group. In addition, interrater agreement by acuity was level 2 = 0.42 (moderate) in the ESI group and level 2 = 0.31 (fair) in the JTAS group. Interrater agreement for triage decisions was classified in a higher category in the ESI group than in the JTAS Scale group at level 2. Triage decisions based on the ESI in Japan maintained the same level of interrater agreement and sensitivity as those in other countries.ConclusionThese findings suggest that the ESI can be introduced in Japan, despite its different emergency medical background compared with other countries.     

Video education for critical care nurses to assess pain with a behavioural pain assessment tool: A descriptive comparative study

AimTo evaluate the impact of video education on critical care nurses’ knowledge and skills in using a behavioural pain assessment tool for intensive care patients and to explore the nurses’ experiences with video education.MethodsForty-eight nurses in one intensive care unit watched an educational video on the use of the Critical-Care Pain Observation Tool, then assessed pain in two patients with the tool and took a knowledge test. The researcher made parallel pain assessments. Interrater reliability of patients’ pain assessment between nurses and the researcher was determined to examine nurses’ skills in using the tool after education. Twenty nurses were interviewed about their experiences with the video education. Interviews were analysed with deductive thematic analysis.ResultsThe knowledge test scores indicated that the nurses learned the principles of how to use the tool. The interrater reliability of pain assessments reached a moderate level of agreement during the painful procedure, with a weighted kappa coefficient value of 0.48, CL [0.37, 0.58]. The nurses perceived video education positively, but requested additional interaction.ConclusionsVideo education is useful in teaching the principles of using a pain assessment tool. Additional clinical training is required for nurses to reach adequate skills in using the tool.     

Kennedy Axis V: Clinimetric properties assessed by mental health nurses

The Kennedy Axis V is a routine outcome measurement instrument which can assist the assessment of the short‐term risk for violence and other adverse patient outcomes. The purpose of this study was to evaluate the interrater reliability and clinical utility of the instrument when used by mental health nurses in daily care of patients with mental illness. This cross‐sectional study was conducted in inpatient and outpatient adult psychiatric care units and in one adolescent inpatient unit at a university hospital in the Netherlands. Interrater reliability was measured based on the independent scores of two different nurses for the same patients. The clinical utility of the instrument was evaluated by means of a clinical utility questionnaire. To gain a deeper understanding of rating difficulties at the adolescent unit, additional data were collected in two focus group interviews. The overall results revealed a substantial level of agreement between nurses (intraclass correlation coefficient and Pearson 0.79). Some rating challenges were identified, including difficulties with scoring the instrument and using tailor‐made interventions related to the scores. These challenges can be resolved using refined training and implementation strategies. When the Kennedy Axis V is accompanied by a solid implementation strategy in adult mental health care, the instrument can be used for short‐term risk assessment and thereby contribute in efforts to reduce violence, suicide, self‐harm, severe self‐neglect, and enhanced objectivity in clinical decision‐making.     

Interrater reliability of the Modified Modified Ashworth Scale (MMAS) for patients with wrist flexor muscle spasticity

The measurement of spasticity is part of the neurological examination of patients with disorders of the central nervous system. Recently, the Modified Modified Ashworth Scale (MMAS) was developed for the characterization of muscle spasticity. The purpose of this study was to determine the interrater reliability of the MMAS in the assessment of wrist flexor muscle spasticity in adult patients after upper motoneuron lesions resulted in hemiplegia. Thirty hemiplegic patients (17 males and 13 females) with a mean age of 55.6±7.8 years participated in this study. The wrist flexor spasticity was assessed according to MMAS by two female physiotherapists. The raters gave 23 patients the same spasticity score (weighted percentage agreement=97.4%). The most agreement occurred for scores 3 (46.7%) and 0 (16.7%), respectively. The agreement between raters was very good (weighted kappa=0.92, SE=0.03, p<0.0001). In conclusion, the MMAS has very good interrater reliability for the assessment of wrist flexor muscle spasticity.     

Interrater reliability of the Modified Modified Ashworth Scale (MMAS) for patients with wrist flexor muscle spasticity

The measurement of spasticity is part of the neurological examination of patients with disorders of the central nervous system. Recently, the Modified Modified Ashworth Scale (MMAS) was developed for the characterization of muscle spasticity. The purpose of this study was to determine the interrater reliability of the MMAS in the assessment of wrist flexor muscle spasticity in adult patients after upper motoneuron lesions resulted in hemiplegia. Thirty hemiplegic patients (17 males and 13 females) with a mean age of 55.6+/-7.8 years participated in this study. The wrist flexor spasticity was assessed according to MMAS by two female physiotherapists. The raters gave 23 patients the same spasticity score (weighted percentage agreement=97.4%). The most agreement occurred for scores 3 (46.7%) and 0 (16.7%), respectively. The agreement between raters was very good (weighted kappa=0.92, SE=0.03, p<0.0001). In conclusion, the MMAS has very good interrater reliability for the assessment of wrist flexor muscle spasticity.     

A pressure ulcer and fall rate quality composite index for acute care units: A measure development study

BackgroundComposite indices are single measures that combine the strengths of two or more individual measures and provide broader, easy-to-use measures for evaluation of provider performance and comparisons across units and hospitals to support quality improvement.ObjectiveThe study objective was to develop a unit-level inpatient composite nursing care quality performance index—the Pressure Ulcer and Fall Rate Quality Composite Index.DesignTwo-phase measure development study.Settings5144 patient care units in 857 United States hospitals participating in the National Database of Nursing Quality Indictors^® during the year 2013.MethodsThe Pressure Ulcer and Fall Rate Quality Composite Index was developed in two phases. In Phase 1 the formula was generated using a utility function and generalized penalty analysis. Experts with experience in healthcare quality measurement provided the point of indicator equivalence. In Phase 2 initial validity evidence was gathered based on hypothesized relationships between the Pressure Ulcer and Fall Rate Quality Composite Index and other variables using two-level (unit, hospital) hierarchical linear mixed modeling.ResultsThe Pressure Ulcer and Fall Rate Quality Composite Index = 100 − PUR − FR, where PUR is pressure ulcer rate and FR is total fall rate. Higher scores indicate better quality. Bland-Altman plots demonstrated agreement between pairs of experts and provided evidence for inter-rater reliability of the formula. The validation process demonstrated that higher registered nurse skill mix, higher percent of registered nurses with a baccalaureate in nursing or higher degree, higher percent of registered nurses with national specialty certification, and lower percent of hours supplied by agency staff were significantly associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores. Higher percentages of unit patients at risk for a hospital-acquired pressure ulcer and higher unit rates of physical restraint use were not associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores.ConclusionsThe Pressure Ulcer and Fall Rate Quality Composite Index is a step toward providing a more holistic perspective of unit level nursing quality than individual measures and may help nurses nursing administrators obtain a broader view of which patient care units are the higher and lower performers. Further study is needed to examine the usability of the Pressure Ulcer and Fall Rate Quality Composite Index.     

Clinical evaluation of a new pressure ulcer risk assessment instrument,the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T)

Aim

To test the psychometric properties and clinical usability of a new Pressure Ulcer Risk Assessment Instrument including inter‐rater and test–retest reliability, convergent validity and data completeness.

Background

Methodological and practical limitations associated with traditional Pressure Ulcer Risk Assessment Instruments, prompted a programme to work to develop a new instrument, as part of the National Institute for Health Research funded, Pressure UlceR Programme Of reSEarch (RP‐PG‐0407‐10056).

Design

Observational field test.

Method

For this clinical evaluation 230 patients were purposefully sampled across four broad levels of pressure ulcer risk with representation from four secondary care and four community NHS Trusts in England. Blinded and simultaneous paired (ward/community nurse and expert nurse) PURPOSE‐T assessments were undertaken. Follow‐up retest was undertaken by the expert nurse. Field notes of PURPOSE‐T use were collected. Data were collected October 2012–January 2013.

Results

The clinical evaluation demonstrated “very good” (kappa) inter‐rater and test–retest agreement for PURPOSE‐T assessment decision overall. The percentage agreement for “problem/no problem” was over 75% for the main risk factors. Convergent validity demonstrated moderate to high associations with other measures of similar constructs.

Conclusion

The PURPOSE‐T evaluation facilitated the initial validation and clinical usability of the instrument and demonstrated that PURPOSE‐T is suitable of use in clinical practice. Further study is needed to evaluate the impact of using the instrument on care processes and outcomes.     

System-wide Clinical Assessment of Functioning Based on the International Classification of Functioning,Disability and Health in China: Interrater Reliability,Convergent, Known Group,and Predictive Validity of the ICF Generic-6

ObjectiveTo validate the International Classification of Functioning, Disability and Health (ICF) Generic-6 in daily routine clinical practice in Mainland China. Specific objectives were to analyze (1) interrater reliability, (2) convergent validity, (3) known group validity, and (4) predictive validity of the ICF Generic-6.DesignMulticenter prospective cohort study.SettingFifty hospitals from 20 provinces of Mainland China.ParticipantsA total of 4510 patients from departments of rehabilitation, orthopedics, neurology, cardiology, pneumology, and cerebral surgery of the participating hospitals with different health conditions were included in this study.InterventionNot applicable.Main Outcome MeasuresThe assessment was undertaken by nurses with ICF Generic-6 in combination with a numeric rating scale. Interrater reliability was evaluated with intraclass correlation coefficients (ICC). Convergent validity was evaluated with Spearman correlation coefficients between ICF Generic-6 and Medical Outcomes Short Form (SF)-12 items. Known group validity was examined by comparing discharge scores between different discharge destinations. Predictive validity was determined by using ICF Generic-6 baseline scores for estimating length of hospital stay with a loglogistic survival model with gamma shared frailty and cost of in-hospital treatment with a mixed effects generalized linear regression model of the gamma family.ResultsThe interrater reliability of items and score of ICF Generic-6 was good with ICCs ranging from 0.67-0.87. ICF Generic-6 items were further correlated with respective SF-12 items. Discharge scores of patients differed significantly by discharge destination. The ICF Generic-6 admission score was a significant predictor of length of stay and treatment cost.ConclusionsThe ICF Generic-6 administered in combination with a 0-10 numeric rating scale is a reliable and valid tool for the collection of minimal information on functioning across various clinical settings.     

Reliability and validity of the nutritional form for the elderly (NUFFE)

AIM: The aim of this study was to test the reliability and validity of the Nutritional Form for the Elderly (NUFFE). BACKGROUND: The prevalence of undernutrition among older people in nursing homes and hospitals reaches high levels. Assessment of older patients' nutritional status is an important task for nurses in clinical care. To use a simple nutritional assessment instrument for older people is one approach for nurses. Examples of such instruments are the well validated Mini Nutritional Assessment (MNA) and the newly developed NUFFE. METHODS: A total of 114 consecutively chosen, newly admitted older patients in an elder care rehabilitation ward in western Sweden were interviewed using the NUFFE and MNA. Arm and calf circumferences, body mass index (BMI), and presence of pressure sores and skin ulcers were noted as part of the MNA on admission. Weight was monitored and BMI calculated on discharge. Serum albumin levels on admission and discharge were used if these were available in the records. Reliability of the NUFFE was measured as homogeneity. Criterion related validity, concurrent validity, construct validity, and predictive validity were assessed with different statistical methods. The regional research ethics committee approved the study. RESULTS: The results showed that the NUFFE is a fairly reliable and valid instrument for identifying actual and potential undernutrition among older patients. CONCLUSION: The NUFFE is a simple tool for nurses to use to assess older patients with the aim of detecting undernourished individuals and those at risk for undernutrition. When doing a nutritional assessment with the NUFFE, the BMI ought also to be calculated. The assessment could also be combined with food intake recording for a period of time.     

Reliability of measurements obtained with the modified Ashworth scale in the lower extremities of people with stroke.

BACKGROUND AND PURPOSE: Abnormal muscle tone is a common motor disorder following stroke, which may require rehabilitation. The Modified Ashworth Scale is a 6-point rating scale that is used to measure muscle tone. The interrater and intrarater reliability of measurements obtained with the scale remain equivocal. The purpose of this study was to investigate the reliability of measurements obtained with the scale in the lower limb of patients with stroke. SUBJECTS: Twenty patients were tested 2 weeks after their stroke, and 12 patients were tested 12 weeks after their stroke. METHODS: Gastrocnemius, soleus, and quadriceps femoris muscles on the hemiplegic side were tested. RESULTS: Interrater reliability for 2 raters was poor, with a Kendall tau-b correlation for the combined muscle group of.062 (P=.461). For intrarater reliability, the Kendall tau-b correlation was.567 (P<.001). The agreement within one rater occurred mostly on the grade of 0. DISCUSSION AND CONCLUSION: The Modified Ashworth Scale yielded reliable measurements in the lower limb for a single examiner, and agreement was best on the grade of 0. The reliability between examiners was not good, which may bring into question the validity of measurements obtained with the scale.     

Direct observation as a means of assessing frequency of maladaptive behavior in youths with severe emotional and behavioral disorder.

OBJECTIVE. The purpose of this pilot study was to identify the incidence of maladaptive behavior in youths enrolled in community living and support training programs. Direct observation and partial-interval time sampling was used to determine occurrence of behaviors to develop effective strategies for group participation. METHOD. Participants were 30 youths ages 10 to 17 and diagnosed with behavioral disorders. Four observers recorded incidence of eight maladaptive behaviors during three group occupations using direct observation across time and setting, twice per week for 8 weeks. RESULTS. Intraclass correlation coefficients (ICCs) were used to describe the interrater reliability of four observers in recording frequency of maladaptive behaviors. Interrater reliability was high to moderate for the most commonly demonstrated behaviors (ICC = 0.83-0.89). Lower agreement was observed in behaviors that were less frequent, such as violent episodes and sexual inappropriateness (ICC = 0.66-0.68). CONCLUSION. Direct observation across time and setting demonstrated good-to-moderate interrater reliability in identifying frequency of behaviors that may interfere with group participation. Observation provides the opportunity to document occupation-based assessment without having to depend on youths' willingness and ability to answer questions.     

The Swedish version of the PACU‐Behavioural Pain Rating Scale: a reliable method of assessing postoperative pain?

One of the obstacles to effective pain management in the Post-Anaesthesia Care Unit (PACU) is the lack of systematic and comprehensive methods for assessing and treating postoperative pain. Nurses' intuitive knowledge of pain were verbalized and divided into four categories of pain behaviours in the PACU-Behavioural Pain Rating Scale. The aim of the present study was to test the reliability of the Swedish version by performing test-retest and interrater reliability in clinical conditions. Materials for this study were gathered through patient observations. The results showed poor agreement in the item restless, fair agreements in both items tense muscles and frowning and grimacing, while patients' sounds showed moderate agreement. Interrater reliability showed moderate agreement in the item restless, very good agreement in tense muscles and patient sounds, and good agreement in frowning and grimacing. A refined classification of the separate categories and a careful review of the category of behaviours is suggested. A more detailed manual for the categories needs to be developed to establish more acceptable reliability.