A randomized controlled trial of a community nurse-supported hospital discharge programme in older patients with chronic heart failure

Aims and objectives. To evaluate the effectiveness and cost‐effectiveness of a community nurse‐supported hospital discharge programme in preventing hospital re‐admissions, improving functional status and handicap of older patients with chronic heart failure. Design. Randomized controlled trial; 105 hospitalized patients aged 60 years or over with chronic heart failure and history of hospital admission(s) in previous year were randomly assigned into intervention group (n = 49) and control group (n = 56) for six months. Intervention group subjects received community nurse visits before discharge, within seven days of discharge, weekly for four weeks, then monthly. Community nurse liaised closely with a designated specialist in hospital and were accessible to subjects during normal working hours. Control and intervention group subjects were followed up in the same specialist medical clinics. Primary outcome was the rate of unplanned re‐admission at six months. Secondary outcomes were number of unplanned re‐admissions, six‐minute walking distance, London Handicap Scale and public health care and personal care costs. Results. At sixth months, the re‐admission rates were not significantly different (46 vs. 57% in control subjects, p = 0·233, Chi‐square test). But the median number of re‐admissions tended to lower in the intervention group (0 vs. 1 in control group, p = 0·057, Mann Whitney test). Intervention group subjects had less handicap in independence (median change 0 vs. 0·5 in control subjects, p = 0·002, Mann Whitney test), but there was no difference in six‐minute walking distance. There was no significant group difference in median total public health care and personal care costs. Conclusion. Community nurse‐supported post‐discharge programme was effective in preserving independence and was probably effective in reducing the number of unplanned re‐admissions. The cost benefits to public health care were not significant. Relevance to clinical practice. Older chronic heart failure patients are likely to benefit from post‐discharge community nurse intervention programmes. More comprehensive health economic evaluation needs to be undertaken.     

Predictors of Emergency Department Observation Unit Outcomes

Background: Acute decompensated heart failure (adHF) is the cause of approximately 1 million annual hospital admissions. In some of these, the use of a short‐stay emergency department observation unit (EDOU) decreases 90‐day ED revisits and 90‐day rehospitalizations and, if subsequent hospitalization is required, results in shorter stays. Objectives: To determine whether laboratory and clinical parameters, available at ED arrival, predict successful EDOU discharge. Methods: This was a 19‐month retrospective analysis of adHF EDOU admissions. Details of medical history, clinical course, patient management, laboratory data, and disposition destination were gathered through review of electronic medical records. Recorded laboratory data included measurements of sodium, creatinine, blood urea nitrogen (BUN), hemoglobin, b‐type natriuretic peptide, and initial ED systolic blood pressure. Data were analyzed for ability to predict the requirement of hospital admission after EDOU management. Results: There were 385 patients were enrolled. The mean (± standard deviation) age was 69.7 (± 13.6) years, and 50.1% were female. On ED admission chest radiograph, 69.0% had evidence of pulmonary edema. Elevations in creatinine and BUN levels had statistically significant associations with admission; however, on multivariable analysis, only a BUN value >30 mg/dL significantly predicted EDOU management failure, and subsequent inpatient admission. Conclusions: These results demonstrate that a BUN level >30 mg/dL is associated with an increased likelihood of admission in patients with adHF. This provides the emergency physician with a practical prognostic tool for disposition planning in congestive heart failure patients.     

To evaluate the effectiveness of a discharge‐planning programme for hip fracture patients

Aims and objectives. This study aimed to evaluate the effectiveness of a comprehensive discharge‐planning service for hip fracture patients, including length of stay, functional status, self‐care knowledge and quality of life (QOL). Background. Hip fractures are the most devastating result of osteoporosis. Care of these patients from the moment they enter the hospital until discharge and postdischarge is a challenging task, requiring a coordinated approach by an interdisciplinary team. Design. An experimental design was used. Methods. Fifty hip fracture patients were recruited from a medical centre in Taipei, Taiwan and randomly divided into two groups. The control group received routine discharge nursing care and the experimental group received comprehensive discharge planning. After patient admission, researchers assessed discharge‐planning needs, provided discharge nursing instruction, coordinated services and determined discharge placement based on assessment results. Results. (i) Mean age of 50 hip fracture patients was 78·75 (SD 6·99) years. Mean length of stay was 6·04 (SD 2·41) days for the experimental group and 6·29 (SD 2·17) for the control group. Difference between groups was not significant (t = ?0·394, p = 0·696). (ii) The self‐care knowledge of the experimental group was higher than that of the control group (F = 11·569, p = 0·001). (iii) Significant improvements were observed in functional status of both groups at three months postdischarge, with no significant differences observed between groups. However, the functional status of experimental group patients showed a slightly better trend than that of the control group. (iv) At three months postdischarge, QOL of experimental group patients was better than control group patients. Conclusions. A comprehensive discharge‐planning service can improve hip fracture patients’ self‐care knowledge and QOL. Relevance to clinical practice. Results of this study can be used clinically as a basis for practical implementation of discharge‐planning services in fracture patients.     

Doxycycline vs. levofloxacin in the treatment of community‐acquired pneumonia

Background: Community‐acquired pneumonia (CAP) affects 5–10 million adults annually in the United States with approximately 1·1 million hospitalizations. Current guidelines recommend fluoroquinolones as monotherapy for treatment of CAP in general medical wards and doxycycline monotherapy for outpatient therapy only. Fluoroquinolones are expensive and development of bacterial resistance to them has become a concern. Therefore, we studied whether doxycycline is as efficacious as levofloxacin in treatment of CAP in general medical wards. Methods: In this prospective double‐blinded trial, non‐pregnant adults with clinical and radiological evidence of pneumonia requiring hospitalization were enrolled. Patients who were septic, hypoxic requiring intubations, nursing home residents, diagnosed with severe hepatic or renal dysfunction, recently hospitalized or immunocompromised were excluded from the study. Subjects were randomly assigned to either i.v. levofloxacin 500 mg daily or doxycycline 100 mg twice daily. After discharge, patients were followed for 2 months. Results: There were 30 patients in the levofloxacin group and 35 patients in the doxycycline group. Groups were comparable in both clinical and laboratory profiles. Additionally, efficacy of treatment was not significantly different between the two groups (P = 0·844). Length of stay was 5·7 ± 2·05 days in the levofloxacin group and 4·0 ± 1·82 days in the doxycycline group (P < 0·0012). Failure rate was similar in both groups (P = 0·893). Total antibiotic cost was $122·07 ± 15·84 for levofloxacin and $64·98 ± 24·4 for doxycycline (P < 0·0001). Conclusions: Our study supports doxycycline as an effective and economical alternative therapy for levofloxacin in the empirical treatment of CAP in general medical wards.     

The sustainability of a community pharmacy intervention to improve the quality use of asthma medication

What is known and Objective: A previously published asthma intervention used a software application to data mine pharmacy dispensing records and generate a list of patients with potentially suboptimal management of their asthma; in particular, a high rate of provision of reliever medication. These patients were sent educational material from their community pharmacists and advised to seek a review of their asthma management from their general practitioner. The intervention resulted in a 3‐fold improvement in the ratio of dispensed preventer medication (inhaled corticosteroids) to reliever medication (short‐acting beta‐2 agonists). This follow‐up study aimed to determine the long‐term effects of the intervention programme on the preventer‐to‐reliever (P:R) ratio. Methods: The same data mining software was modified so that it could re‐identify patients who were originally targeted for the intervention. Community pharmacists who participated in the previous intervention installed the modified version of the software. The dispensing data were then de‐identified, encrypted and transferred via the Internet to a secure server. The follow‐up dispensing data for all patients were compared with their pre‐ and post‐intervention data collected originally. Results and Discussion: Of the 1551 patients who were included in the original study, 718 (46·3%) were eligible to be included in the follow‐up study. The improved P:R ratio was sustained for at least 12 months following the intervention (P < 0·01). The sustained increase in the P:R ratio was attributed to significant decreases in the average daily usage of reliever medication (P < 0·0001). What is new and Conclusion: The follow‐up study demonstrated a sustained improvement in the ratio of dispensed preventer medication to reliever medication for asthma. The intervention has the potential to show long‐lasting and widespread improvements in asthma management, improved health outcomes for patients, and ultimately, a reduced burden on the health system.     

Commentary: Knowles RE, Tarrier N (2009). Evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: a randomized control trial

Objective: To evaluate the effect of a prospective diary intervention on levels of anxiety and depression in a group of intensive care unit (ICU) survivors. Design: Pragmatic randomized controlled trial. Setting: Adult ICU, medical/surgical wards of a district general hospital and community bases. Patients: A total of 36 patients who were admitted to the ICU between March 2006 and March 2007 for a minimum of 48 h. Interventions: Prospective diary kept by nursing staff for the duration of the patient’s stay on ICU, containing daily information about their physical condition, procedures and treatments, events occurring on the unit, and significant events from outside the unit. Measurement and main results: At initial assessment, almost half of patients fell into the ‘disorder likely’ category on the Hospital Anxiety and Depression Scale (44% for anxiety and 47·2% for depression). Paired samples Student’s t‐tests to compare the Hospital Anxiety and Depression Scale scores at time 1 and time 2 in the two participant groups revealed that the experimental group displayed statistically significant decreases in both anxiety [t(1, 17) = 2·65, p < 0·05) and depression [t (1, 17) = 3·33, p < 0·005] scores, while the control group did not, a difference attributed to the diary intervention. Conclusions: Survivors of critical illnesses are likely to experience clinically significant symptoms of anxiety and depression following their discharge from hospital. The prospective diary intervention was designed to help patients understand what happened to them in intensive care, and it has a significant positive impact on anxiety and depression scores almost 2 months after patients’ discharge from ICU. Attempts to replicate these results using larger samples are therefore encouraged, with the aim of informing best practice guidelines. Abstract reprinted from the Critical Care Medicine, volume 37, Knowles and Tarrier, ‘(2009) Evaluation of the effect of prospective patient diaries on emotional well‐being in intensive care unit survivors: A randomized control trial’, pages 184–191. © 2009, reproduced with permission from Lippincott Williams & Wilkins.     

Development and implementation of a noise reduction intervention programme: a pre‐ and postaudit of three hospital wards

Aims. By developing, implementing and delivering a noise reduction intervention programme, we aimed to attempt to reduce the high noise levels on inpatient wards. Background. Sleep is essential for human survival and sleep deprivation is detrimental to health and well being. Exposure to noise has been found to disrupt sleep in hospitalised patients which is to be expected as noise levels have been measured and reported as high. Design. A primarily nursing focused, multi‐method approach, involving development of clinical guidelines, ward environment review and a staff noise awareness and education programme, was used to target mainly nursing staff plus other healthcare staff on three wards within one hospital. Methods. This practice development initiative was carried out in three key phases (1) Preaudit of ward noise levels, (2) The development, implementation and delivery of a noise reduction intervention programme, (3) Postaudit of ward noise levels. Results. Preintervention average peak decibel levels over 24 hours were found to be 96·48 dB(A) and postintervention average peak decibel levels were measured at 77·52 dB(A), representing an overall significant reduction in noise levels (p < 0·001). Conclusions. This study describes one way to reduce peak noise levels on inpatient hospital wards. Relevance to clinical practice. Sleep deprivation is detrimental to patients with acute illness, so any developments to improve patients’ sleep are important. Nurses have a key role in leading, developing and implementing changes to reduce peak noise levels on inpatient wards in hospitals. This nurse‐led practice development programme has demonstrated how improvements can be achieved by significantly reducing peak noise levels using simple multi‐method change strategies.     

Non‐therapeutic omission of medications in acutely ill patients

Aims and objectives: To examine documentation of medication administration in medical and surgical patients. Study objectives: (1) Determine the point prevalence of non‐therapeutic medication omissions; (2) identify documented reasons for non‐therapeutic medication omissions; (3) examine the relationship between length of stay and medication omissions; and (4) explore the impact of outlier status (e.g. medical patients managed on surgical wards) on medication administration. Background: Acutely ill patients are particularly sensitive to health care errors. We previously identified a 26% rate of non‐therapeutic medication omissions in patients admitted unexpectedly to intensive care unit (ICU) from medical and surgical wards. Design: A point prevalence survey of 162 medical and surgical patients across four sites in the South West of England. Method: Data collected included: all instances of, and reasons for, non‐therapeutic medication omission. We also recorded whether the patient was an ‘outlier’ and examined nursing documentation where no reason for medication omission was given on the drug chart. Results: The number of patients who missed at least one medication was high across all sites (n = 129/162; 79.6%, range 60–88%), with a total of 1077 doses omitted. Patients who were outliers (e.g. surgical patients on a medical ward) were more likely to miss medications (100% versus 74%, p < 0.001). The most common missed medications were analgesia and anti‐inflammatory drugs (28%, 299/1077); 203 of these were due to patient refusal. Conclusions: The extent of medications omitted for non‐therapeutic reasons in medical and surgical patients is of concern. None were recorded as an adverse drug event; however, the extent of omitted or refused medications suggests the need for a review of prescribing and drug administration processes. These findings have important implications for the role of ICU outreach and liaison services, for example, including medication management in the monitoring of patients pre/post‐ICU admission and support/education provided for ward staff. Relevance to clinical practice: Detailed analysis of medication records suggests a number of areas of medication administration that would benefit from review.     

An intervention to encourage ambulance paramedics to bring patients' own medications to the ED: Impact on medications brought in and prescribing errors

Objective: To undertake and evaluate a multifaceted intervention to encourage paramedics to bring patients' own medications (POM) to the ED. Method: Adult patients were enrolled in each of the pre‐intervention (March 2006) and post‐intervention (December 2006) periods if they were brought to ED by ambulance, taking four or more medications, admitted to hospital and were not referred to a pharmacist prior to the admission medication chart being written. ED pharmacists determined patients' regular medication and details of medications brought in by ambulance. Medication charts were assessed for discrepancies related to medications taken prior to presentation. These were recorded as errors if a change was made to the medication chart after discussion with the prescriber. The intervention, conducted in October and November 2006, involved meetings with Metropolitan Ambulance Service * team managers and dissemination of promotional material. Paramedics of the Metropolitan Ambulance Service were participants for the intervention. Main outcome measures were: percentage of regular medications incorrectly prescribed; and percentage of POM brought to ED by paramedics. Results: One hundred patients were enrolled in each of the pre‐ and post‐intervention periods. The percentage of regular medications incorrectly prescribed significantly decreased from 18.9% (151/800, 95% CI 16–22%) to 8.8% (73/834, 95% CI 7–11%) in the pre‐ and post‐intervention periods, respectively (P < 0.001). Pre‐intervention, paramedics brought some or all POM to ED in 67.0% (67/100, 95% CI 57–76%) of cases compared with 87.0% (87/100, 95% CI 78–93%) of cases, post‐intervention. Conclusion: The multifaceted intervention encouraging paramedics to bring POM to ED was effective. POM were brought into ED more frequently and prescribing errors reduced.     

Comparison of SSRIs and SNRIs in major depressive disorder: a meta‐analysis of head‐to‐head randomized clinical trials

Context: Controversy exists whether serotonin–norepinephrine reuptake inhibitors (SNRIs) have improved efficacy compared with selective serotonin reuptake inhibitors (SSRIs). Objective: To compare clinical outcomes of adults treated with SSRIs or SNRIs for major depressive disorder (MDD) under ideal clinical condition, research design, and outcome measure. Data sources: Electronic databases searched were Medline, Embase and Cochrane Library from inception to July 2007. Study selection: Included studies were those head‐to‐head randomized trials comparing remission (HAMD‐17 ≤7–8, MADRS ≤10–12) after 8–12 weeks of therapeutic doses of SSRIs or SNRIs in patients diagnosed with MDD were targeted for analysis. Reviews, letters, commentaries, economic studies, etc. were excluded. Studies were reviewed by two independent researchers. Where disagreements occurred in study selection, a consensus approach was used. Data extraction and analysis: Targeted outcome data included number of patients achieving remission, withdrawing from therapy due to lack of efficacy (LoE) and/or adverse drug reactions (ADRs), and total patients in trial. A random effects model combined intent‐to‐treat (ITT) and per‐protocol (PP) odds ratio (OR), and remission and dropout rates. Chi‐square assessed heterogeneity. Quality assessment was done using Downs‐Black checklist. Results: Thirty‐three studies were identified; 18 were rejected (patients had co‐morbidities in 7, outcomes differed in 5, different follow‐up in 3, and three reviews). Fifteen head‐to‐head trials of 3094 patients, average age was 41·9 ± 11·9 years (for SNRIs) and 41·6 ± 12·1 years (for SSRIs), P = 0·941. All analyses displayed non‐heterogeneity (P > 0·05). The OR (under ITT) was 1·27 (1·06–1·52 95% CI) favoring SNRIs. Meta‐analytic remission rates were 48·5 ± 3·2% and 41·9 ± 4·2% for SNRIs and SSRIs, respectively. The meta‐analytic difference in remission rates between drugs was 5·7% (P = 0·007). Dropout rates due to ADRs were higher with SNRIs than SSRIs (3·2% difference, P < 0·001). Dropout rates due to LoE were non‐significant between studied groups (P > 0·05). Conclusions: Serotonin and norepinephrine reuptake inhibitors showed statistical but not clinical significance when compared with SSRIs in treating MDD.     

Effectiveness of a community pharmacist intervention in diabetes care: a randomized controlled trial

What is known and Objective: There is little evidence from well‐designed randomized controlled trials of the impact of community pharmacist intervention on the clinical management of patients with type 2 diabetes. It is also not known how sustainable any observed effects on glycaemic control are, over time. This study was initiated to address both these issues. Methods: A 6‐month, randomized, controlled parallel‐group trial in 66 community pharmacies was conducted in Belgium. Patients were randomly assigned to receive usual pharmacist care (n = 135) or a predefined pharmacist intervention (n = 153). The intervention mainly focused on correct medication use, medication adherence and healthy lifestyle promotion. Primary outcome was glycaemic control, as measured by fasting plasma glucose and HbA1c. Sustainability of changes in glycaemic control was assessed by additional glucose measurements 18 months after the end of the study. Results and Discussion: The intervention significantly reduced HbA1c (between‐group difference: 0·5%, P = 0.009). The largest impact on HbA1c was observed when pharmacotherapy changes (i.e., type and/or dose of hypoglycaemic agents) initiated by the physician were sustained with pharmaceutical care: HbA1c was reduced by 1·05% in the intervention group, whose medication was changed, compared with a reduction of 0·02% in the therapy‐modification only, group. It was also found that the diabetes education program resulted in improved self‐management and better knowledge of diabetes. Eighteen months after the end of the formal study period, the mean HbA1c of the intervention group did not differ significantly from the control group (7·4% vs. 7·2%). What is new and Conclusion: This study provides new evidence, from a randomized controlled trial, of the beneficial effect of community pharmacist intervention in the clinical management of type 2 diabetic patients. However, questions remain about the sustainability of the observed improvements.     

Evaluation of contextual influences on the medication administration practice of paediatric nurses

Title. Evaluation of contextual influences on the medication administration practice of paediatric nurses. Aim. This paper is a report of a study conducted to explore the impact of preidentified contextual themes (related to work environment and socialization) on nursing medication practice. Background. Medication administration is a complex aspect of paediatric nursing and an important component of day‐to‐day nursing practice. Many attempts are being made to improve patient safety, but many errors remain. Identifying and understanding factors that influence medication administration errors are of utmost importance. Method. A cross‐sectional survey was conducted with a sample of 278 paediatric nurses from the emergency department, intensive care unit and medical and surgical wards of an Australian tertiary paediatric hospital in 2004. The response rate was 67%. Result. Contextual influences were important in determining how closely medication policy was followed. Completed questionnaires were returned by 185 nurses (67%). Younger nurses aged <34 years thought that their medication administration practice could be influenced by the person with whom they checked the drugs (P = 0·001), and that there were daily circumstances when it was acceptable not to adhere strictly to medication policy (P < 0·001), including choosing between following policy and acting in the best interests of the child (P = 0·002). Senior nurses agreed that senior staff dictate acceptable levels of medication policy adherence through role modelling (P = 0·01). Less experienced nurses reported greater confidence with computer literacy (P < 0·001). Conclusions. Organizations need to employ multidisciplinary education programmes to promote universal understanding of, and adherence to, medication policies. Skill mix should be closely monitored to ensure adequate support for new and junior staff.