Aportación de la consulta de enfermería en el manejo del paciente con artritis reumatoide

The goal of a nurse-led clinic in the management of rheumatoid arthritis patients is to promote patient independence. Patient education and empowerment are efficacious tools for achieving this. The main nursing care roles are vigilance of physical symptoms, drug toxicity and co-morbidities; management of physical and psychological symptoms; to provide continuity of care. There is evidence supporting the effectiveness of nurse-led clinics and the economic benefits related to it.     

Does everybody need a team?

Multidisciplinary team care, defined as care provided by a group of health professionals from various disciplines, has been widely used in arthritis management since the 1950s. Its effectiveness in comparison with regular outpatient care has mainly been established in patients with rheumatoid arthritis (RA). Recent studies have shown that similar outcomes can be achieved in patients with RA at lower costs using care provided by a clinical nurse specialist. These latter findings suggest that the active components of the multidisciplinary team care model may not be related to the number or professional backgrounds of the health professionals involved, nor with their physical proximity, but rather to the provider's skills in rheumatology and the coordination of services. Because many patients with arthritis have healthcare needs that are not met through treatment by the rheumatologist alone and since traditional multidisciplinary team care in many countries is unavailable or may be undesirable in specific situations, the development and evaluation of alternative, comprehensive models of care delivery is recommended.     

Current topics on models of care in the management of inflammatory arthritis

While there is strong evidence supporting a multidisciplinary team approach in arthritis management, access and use are hindered by limited human and financial resources. To safeguard the provision of comprehensive care throughout the disease trajectory, alternative care models are being developed. Three promising arthritis care models include the use of information technology and telemedicine, patient initiated care, and extended roles of health professionals. Future research projects should focus on: (1) the cost-effectiveness of information technology for exchange of patient-based data and education and management support; (2) the characteristics and needs of patients who can versus those who cannot self-manage; (3) strategies to improve access to care for patients with early arthritis, such as extending roles of health professionals to include triage; and (4) further structuring and standardizing rheumatology training of nursing and allied health professionals.     

Multidisciplinary team approach for elderly patients

The multidisciplinary team approach plays an increasingly important role in the management and care of elderly patients, providing support to patients and families and helping them adapt to illness and treatment plans – it offers psychosocial counseling, patient and family education, discharge planning and post hospital care planning. Multidisciplinary team assessment and intervention strategies are also essential in preventing injuries such as falls and delirium as well as in end of life care. Moreover, teaching hospitals are expected to provide team training for medical, nursing and social work students to promote early exposure to interdisciplinary teamwork.     

Disease‐specific knowledge and clinical skills required by community‐based physiotherapists to co‐manage patients with rheumatoid arthritis

Objective

While strong evidence supports the role of physiotherapy in the co‐management of patients with rheumatoid arthritis (RA), it remains unclear what constitutes the essential disease‐specific knowledge and clinical skills required by community‐based physiotherapists to effectively and safely deliver recommended care. This study aimed to identify essential disease‐specific knowledge and skills, link these with evidence from clinical guidelines, and broadly determine the professional development (PD) needs and confidence related to the management of RA among physiotherapists.

Methods

An international Delphi panel of rheumatologists, physiotherapists, and consumers (n = 27) identified essential disease‐specific knowledge and clinical skills over 3 rounds. Physiotherapy‐relevant recommendations from high‐quality, contemporary clinical guidelines were linked to Delphi responses. Finally, an e‐survey of PD needs among registered physiotherapists (n = 285) was undertaken.

Results

Overarching themes identified by the Delphi panel across the RA disease stages included the need for excellent communication, the importance of a multidisciplinary team and early referral, adoption of chronic disease management principles, and disease monitoring. Of the essential Delphi themes, 86.7% aligned with clinical guideline recommendations. Up to 77.5% of physiotherapists reported not being confident in managing patients with RA. Across the range of essential knowledge and skills themes, 45.1–93.5% and 71.1–95.2% of respondents, respectively, indicated they would benefit from or definitely need PD.

Conclusion

To effectively manage RA, community‐based physiotherapists require excellent communication skills and disease‐specific knowledge, including understanding the role of the multidisciplinary team and the principles of early referral, chronic disease management, and monitoring. Physiotherapists identified a need for PD to develop these skills.     

Rheumatology nurse practitioners' perceptions of their role

Objectives: To identify the current practices of rheumatology nurse practitioners and ascertain their perceptions of how their role could be enhanced. Method: A cross‐sectional questionnaire study of currently employed nurse practitioners in rheumatology in the United Kingdom (UK) was undertaken. Results: 200 questionnaires were distributed and 118 nurses responded. Ninety‐five respondents met the inclusion criteria for undertaking an advanced nursing role. Typical conditions dealt with included: rheumatoid arthritis (96.8%); psoriatic arthritis (95.8%); osteoarthritis (63.2%); ankylosing spondylitis (62.8%); systemic lupus erythematosus (51.6%); and scleroderma (34.7%). Drug monitoring, education, counselling of patients and arranging basic investigations were routinely performed by more than 80% of respondents. A smaller proportion performed an extended role that included dealing with referrals, research and audit, the administration of intra‐articular injections, and admission of patients. Specific attributes identified as being necessary for competence were: knowledge and understanding of rheumatic diseases (48.4%); drug therapy (33.7%); good communication skills (35.8%); understanding of the roles of the team (27.4%); working effectively (23.2%) as part of a multidisciplinary team; assessment of patients by physical examination (28.4%); teaching (26.3%), research (17.9%); organizational skills (14.7%); and the interpretation of investigations (9.5%). Factors that could enhance their role included: attendance at postgraduate courses (30.5%); obtaining further qualifications (13.7%); active participation in the delivery of medical education (41.1%); training in practical procedures (31.6%); protected time and resources for audit and research (11.6%); formal training in counselling (11.6%); and implementation of nurse prescribing (10.5%). Conclusion: Nurse practitioners already have a wide remit and play an invaluable part in the delivery of modern rheumatology services. An extended role could improve patient care and enhance nursing career pathways in rheumatology. Copyright © 2006 John Wiley & Sons, Ltd.     

Evaluation of a continuing education program in rheumatoid arthritis

A continuing medical education (CME) program in rheumatoid arthritis was implemented and evaluated in six community hospitals. It was targeted at primary care physicians and utilized physicians identified by their peers as being educationally influential for the dissemination of content knowledge. Although inpatient and outpatient audits of physician records demonstrated little change in three control communities, substantial improvement in the utilization of diagnostic procedures and patient management was documented in the three intervention communities utilizing the influential physicians. CME delivered through community-based educationally influential physicians is an effective way to change physician behavior in small communities with no prior ongoing educational programs. This approach should improve the primary care given to patients with rheumatoid arthritis and reduce the need for participation of academic faculty in traditional CME programs.     

Team management of rheumatoid arthritis

The main objectives of team management of rheumatoid arthritis are to stop structural damage of joints and to reduce functional, psychological, socioprofessional and economic consequences. Team management requires the collaboration, around the patient, of a rheumatologist, a nurse, a psychologist, a physiotherapist, an occupational therapist, an orthopaedic surgeon at the same time, in the same place. More and more patients wish to manage their disease by themselves. Team care should not be proposed to every patient; it must be reserved to patients whose condition required such an approach because of the severity of the disease, comorbidity, psychological or socioprofessionnal difficulties. Team management should be personalized. Utility of team management is now accepted; out-patient administration is as effective as in-patient one. A good educational program is very important. However, search is still needed to define optimal modalities of team management and tools to measure the efficiency of this approach.     

The intensive insulin therapy team

The use of a team approach to the management of patients using intensive insulin therapy (IIT) has been supported by policy/position statements of both the American Association of Diabetes Educators and the American Diabetes Association. A course designed and taught by a health care team within the Washington University Diabetes Research and Training Center was offered to 18 multidisciplinary health care teams desiring information about initiating IIT programs. Course outcomes demonstrated positive responses to the team approach to team education but raised questions about the actual composition and functioning of the health care "team." While a well-defined team with IIT knowledge and skills is essential for the development of a comprehensive and safe approach to IIT programs, it is not clear who should be offering these programs.     

Neonatal physiology of the functionally univentricular heart

The neonate with functionally univentricular physiology presents unique challenges to the cardiac team. An integrated approach that applies working knowledge of cardiac anatomy, cardiopulmonary physiology, and basic principles of intensive care is essential to guide management of each individual patient. This requires cooperative and constructive involvement of a surgical, medical, nursing and respiratory care team experienced in the management of such patients. In the neonate with this physiology, systemic oxygen delivery is optimized by manipulating pulmonary and systemic resistances, augmenting total cardiac output, and utilizing strategies for ventilation that preserve optimal pulmonary recruitment.     

Evaluation of interprofessional health care team communication simulation in geriatric palliative care

ABSTRACT

An interprofessional education (IPE) simulation-based geriatric palliative care training was developed to educate health professions students in team communication. In health care, interprofessional communication is critical to team collaboration and patient and family caregiver outcomes. Studies suggest that acquiring skills to work on health care teams and communicate with team members should occur during the early stage of professional education. The Interprofessional Education Collaborative (IPEC®) competency-based framework was used to inform the training. An evaluation examined attitudes toward health care teams, self-efficacy in communication skills, interprofessional collaboration, and participant satisfaction with the training experience. One-hundred and eleven participants completed pre- and post-training surveys. Overall, a majority of participants (97.3%) were satisfied with the training and reported more positive attitudes toward health care teams and greater self-efficacy in team communication skills. IPE participants had higher collaboration scores compared to observer learners. Further research is needed to explore long-term effects of IPE in clinical practice.     

From confusion to consensus: Need for multi disciplinary team approach in rheumatology: An orthopaedic surgeons's perpective

Aim of joint surgeries in rheumatoid arthritis is to restore function and quality of life, prevent joint deterioration, relieve pain and correct deformity in patients afflicted with rheumatoid disorders With advent of newer therapeutic modalities, the need for joint surgeries in cases of rheumatoid disorders has drastically reduced over the past two decades. Decision-making and timing for orthopaedic intervention are complex issues because of polyarticular involvement in rheumatoid disorder. Optimal results from the surgery demands close team work between the rheumatologists and the orthopaedic surgeon. However, as studies, have indicated, there appears to be divergent views amongst rheumatologist and the orthopaedic surgeon as regards indications, timing and effectiveness of rheumatoid joint surgery. This is to the detriment of the patient's best interest. Therefore, it is imperative that a multidisciplinary team approach be adopted towards managing each patient. The need of the hour is evolution of integrated Rheumatology Team comprising of rheumatologist, orthopaedic surgeon, pain care specialist, physiotherapist and nurse, a close synergy of interests to provide holistic care to patients of inflammatory joint disorders.     

Patient adherence to tyrosine kinase inhibitor therapy in chronic myeloid leukemia

Dramatically improved survival associated with tyrosine kinase inhibitor (TKI) therapy has transformed the disease model for chronic myeloid leukemia (CML) to one of long-term management, but treatment success is challenged with poor medication adherence. Many risk factors associated with poor adherence can be ameliorated by close monitoring, dose modification, and supportive care. Controlling risk factors for poor adherence in combination with patient education that includes direct communication between the health care team and the patient are essential components for maximizing the benefits of TKI therapy.     

Nurse developments in neuroendocrine tumour management

Nurse developments in the management of neuroendocrine tumours have changed significantly over the past three years. At the Royal Free Hospital we set up the nurse specialist role due to the expansion of patients being referred to the specialist unit, and the obvious need for a nursing input into their care. The nurse specialist can make a significant contribution within the context of a multidisciplinary team especially in the production of guidelines and policies to ensure and maintain high standards of practice, education for the patient, and the provision of expertise and security that the patient requires when diagnosed with a rare disease.     

Lessons to be learned: review of a multidisciplinary foot clinic in rheumatology

SIR, Foot problems in rheumatoid arthritis are common, under-researchedand frequently neglected [1]. Although evidence-based multidisciplinaryclinics are well established in the care of people with diabetes[2], the case for dedicated podiatry care as part of the serviceprovided by a multidisciplinary team in rheumatology has yetto be made. Traditionally, patients with foot problems are referredto an orthotist in an appliance department, where stock or bespokefootwear together with an insole (either ready-made or manufacturedto a cast of the foot) are provided. Communication between doctorand orthotist is minimal and the patient may never see a podiatrist,as specialist podiatry is generally only     

Sulphasalazine in rheumatoid arthritis: desensitising the patient with a skin rash.

Sulphasalazine has been shown to be useful in the management of rheumatoid arthritis. However, its use may be complicated by a skin rash. Eight patients with a rash have undergone desensitisation, the aim of which was to achieve a daily dose of 2 g sulphasalazine. This was successful in five patients, partially successful in two, and failed in one patient. Desensitisation to sulphasalazine is a simple outpatient procedure, which subsequently allows the majority of patients developing a skin rash to continue treatment.     

Cognitive-behavioral approaches to pain management in rheumatoid arthritis

The purpose of this article is to review the literature on the topic of cognitive-behavioral approaches to pain management for persons with rheumatoid arthritis. Existing studies offer support for the usefulness of cognitive-behavioral techniques, but methodologic limitations were identified. Although the core element in rheumatoid arthritis pain management is optimal rheumatologic care, an important role also exists for strategies that seek to reduce the cognitive-evaluative aspects of arthritis pain.     

A randomized comparison of care provided by a clinical nurse specialist,an inpatient team,and a day patient team in rheumatoid arthritis

OBJECTIVES: To compare in a randomized, controlled trial the clinical effectiveness of care delivered by a clinical nurse specialist, inpatient team care, and day patient team care in patients with rheumatoid arthritis (RA) who have increasing functional limitations. METHODS: Between December 1996 and January 1999, 210 patients with RA were recruited in the outpatient clinic of the rheumatology department of 6 academic and nonacademic hospitals. Clinical assessments recorded on study entry and weeks 6, 12, 26, and 52 included the Health Assessment Questionnaire (HAQ) and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire as primary outcome measures, and the RAND-36 Item Health Survey, the Rheumatoid Arthritis Quality of Life questionnaire, the Health Utility Rating Scale, and the Disease Activity Score as secondary outcome measures. Patient satisfaction with care was measured on a visual analog scale in week 6 in all 3 groups and again in week 12 in the nurse specialist group. RESULTS: Within all 3 groups, functional status, quality of life, health utility, and disease activity improved significantly over time (P < 0.05). However, a comparison of clinical outcome among the 3 groups and a comparison between the nurse specialist group and the inpatient and day patient care groups together did not show any sustained significant differences. Subgroup analysis showed that age had a significant impact on differences between the 3 treatment groups with respect to functional outcome as measured with the HAQ (P < 0.001). With increasing age, the most favorable outcome shifted from care provided by a clinical nurse specialist and inpatient care to day patient care. Patients' satisfaction with care was significantly lower in the nurse specialist group than in the inpatient and day patient care groups (P < 0.001). CONCLUSION: Care provided by a clinical nurse specialist appears to have a similar clinical outcome in comparison with inpatient and day patient team care. Although all patients were highly satisfied with multidisciplinary care, patients who received care provided by a clinical nurse specialist were slightly less satisfied than those who received inpatient or day patient team care. Age appeared to be the only factor related to differences in functional outcome between the 3 treatment groups. The choice of management strategy may, apart from age, further be dependent on the availability of facilities, the preferences of patients and health care providers, and economic considerations.