Obstructive sleep apnoea syndrome: a nurse-led domiciliary service

AIM: This paper reports a successful transformation of clinical practice from inpatient diagnosis and initiation of treatment for obstructive sleep apnoea syndrome to a nurse-led domiciliary model increasing patient access and choice. BACKGROUND: Obstructive sleep apnoea syndrome is common, affecting globally 2-4% of the adult population. It is characterized by periodic complete or partial collapse of the upper airway, leading to hypoxaemia and sleep fragmentation, resulting in daytime sleepiness and impaired quality of life. It can be treated successfully with nocturnal continuous positive airway pressure. Strategies for diagnosis and initiation of treatment have traditionally been inpatient-based, but limited facilities and increasing demand in many countries have necessitated alternative strategies. METHODS: As an extension to our current inpatient provision, we have established nurse-led domiciliary investigation and treatment. Patients meeting predefined criteria undergo a limited sleep study followed by therapy initiation at home. Confirmation of investigation findings, evaluation of treatment, education and long-term review are carried out in nurse-led clinics. RESULTS: We evaluated outcome in the first 150 patients managed in this way between August 2002 and December 2003. In our highly selected patient group, 79% of those who undertook a trial of treatment continued at 3 months, with average compliance >5 hours per night, a figure which compares favourably with our overall patient population. Statistically significant sustained improvement in sleepiness was seen. Independent predictors of long-term acceptability of continuous positive airway pressure were disease severity and magnitude of improvement in sleepiness. CONCLUSION: A nurse-led service for domiciliary diagnosis, treatment initiation and on-going management of selected patients with obstructive sleep apnoea syndrome is feasible and cost-effective, with outcomes comparable with conventional inpatient services. This approach is applicable in most countries where increasing demand for investigations greatly exceeds the availability of traditional facilities.     

Follow-up for people with cancer: nurse-led services and telephone interventions

BACKGROUND: Questions about the suitability of traditional outpatient follow-up clinics as a way of providing on-going monitoring for patients following serious illness have led to the development of a range of nurse-led services. However, there has been little attempt to draw some of this knowledge together formally and consider the weight of evidence on the necessity and value of nurse-led follow-up. AIM: To provide a review of literature evaluating the impact of nurse led follow-up in cancer care, with particular focus on the use and value of telephone interventions. METHOD: A literature search was conducted of nursing, medical and social science databases and the following keywords: cancer follow-up, nurse-led follow-up, telephone follow-up, telephone-based interventions and telephone survey. The search yielded over 150 papers, of which 37 were relevant to this review. FINDINGS: The literature suggests that nurse-led follow-up for people with cancer meets their needs for psychological support and information. The telephone is identified as a suitable means of providing this kind of service. CONCLUSION: This review demonstrates that nurse-led follow-up services are acceptable, appropriate and effective. Combined with use of the telephone, such services can be an efficient means of maintaining contact with a large client group, providing vital support to vulnerable patients during their move into aftercare and beyond.     

护理门诊发展现状及展望

介绍了护理门诊的定义、国内外护理门诊发展概况及护理门诊实践效果,同时对国内护理门诊存在的问题及未来发展方向进行了分析及展望,以期为我国护理门诊的发展提供参考。     

国内助产士门诊实践研究现状

介绍国内助产士门诊的实践研究现状,对助产士及助产士门诊发展现状、助产士门诊的准入、实践模式、实践内容及实践效果进行综合梳理及探讨,旨在为后续助产士门诊的发展及改进提供思路和参考依据。     

The quality of oral anticoagulant therapy and recurrent venous thrombotic events in the Leiden Thrombophilia Study

BACKGROUND: The International Normalized Ratio (INR) target range is a relatively narrow range in which the efficacy of oral anticoagulant treatment, i.e. prevention of extension and recurrence of thrombosis, is balanced with the risk of hemorrhagic complications. Over the years, different INR target ranges have been implemented for individual indications, depending on their thrombotic potential. In most of the studies defining these INR targets, the treatment of the patients was aimed at a certain INR range, but in the analysis no account was taken of the time that the patients spent within this range in reality. METHODS: The Leiden Thrombophilia Study (LETS) is a population-based case-control study on risk factors for venous thrombosis, in which many genetic and acquired factors have been investigated. Our aim was to investigate the effect of the quality of the oral anticoagulant therapy for the initial venous thrombosis and its relationship with recurrence of thrombosis. Quality of anticoagulation was defined as the time spent at various INR levels during treatment, and we focused on the effect of sustained intensities above a certain INR in preventing recurrences later on. RESULTS: Two hundred and sixty-six patients with a total follow-up of 2495 patient-years were studied. The mean duration of the initial anticoagulant therapy was 194.5 days (range 48-4671). During follow-up, 58 recurrences were diagnosed (cumulative recurrence rate of 21.8% over 9 years). The mean INR during initial therapy was 2.90, with 90.3% [95% confidence interval (CI) 88.4-92.3%] of the time being spent above an INR of 2.0, and 39.1% (95% CI 35.5-42.7%) above an INR of 3.0. Patients who spent more time below the target range, or who had a shorter duration of anticoagulation, did not experience a higher risk of recurrence after the initial period of anticoagulation had passed. CONCLUSION: Provided that oral anticoagulant treatment is adequately managed, according to international guidelines, recurrent thrombosis cannot be ascribed to variation in the primary treatment. Further attempts to reduce the risk of recurrence should therefore be aimed at identifying other explanatory factors, and subsequently fine-tuning the target ranges.     

护士主导的口服营养补充方法在造血干细胞移植期间的应用研究

目的观察护士主导的口服营养补充方法对造血干细胞移植期间患者营养状态的影响。方法用便利抽样法选择2014年1月至2015年9月行异基因造血干细胞移植的患者75例作为对照组,予以血液洁净病房常规护理及饮食指导;选择2015年10月至2016年9月行异基因造血干细胞移植的患者29例作为观察组,应用护士主导的口服营养补充方法,采用人体测量指标、血生化指标及PG-SGA量表对两组患者进行营养评价,观察护士主导的口服营养补充方法对患者营养状态的影响。结果异基因造血干细胞移植期间两组患者的PG-SGA评分差异具有统计学意义;预处理后第4周观察组患者营养良好的比例高于对照组,发生营养不良的比例要低于对照组。干预后两组患者体质量及BMI指数比较差异无统计学意义,但平均体质量下降幅度观察组较对照组小,且两组预处理后第4周前白蛋白水平比较具有统计学意义(P0.05)。结论护士主导的口服营养补充方法能够降低异基因造血干细胞移植期间患者营养状态下降的程度,对改善及维持患者的营养状态有一定作用。     

Prediction of hemorrhagic and thrombotic events in patients with mechanical heart valve prostheses treated with oral anticoagulants

Summary.  Background:  Variability in the intensity of anticoagulant therapy is considered a risk factor for complications, but it is unclear how best to quantify variability. Objective:  We evaluated the association of three methods to measure variability with complications of oral anticoagulant therapy. Methods:  We conducted a nested case–control study within a cohort of patients with prosthetic heart valves. 210 patients with a first hemorrhagic or thrombotic event during follow-up were selected with two controls per case, matched on age and sex. We calculated the time spent at an International Normalized Ratio below, above, and between 2.5 and 4.0, and the variance growth rate according to three different methods (A, B1, B2); method A combines variability and time in range, and methods B1 and B2 purely look at variability. Results:  Odds ratios of the variance growth rates for thrombotic events for patients in the second and third tertiles varied between 2 and 3, with the highest odds ratio for complications for the method that purely looked at variability. For hemorrhagic complications, the highest odds ratios were found for method A, which also incorporated time in range, with odds ratios of 2.6 (95% CI: 1.3–5.1) and 3.1 (95% CI: 1.6–6.0) for the second and third tertiles as compared to the first. The combination of time spent out of range with the highest tertile of variability increased the risk 2.6-fold (95% CI: 1.6–4.2) as compared to subjects with stable anticoagulation within the target range. Conclusion:  Unstable anticoagulation was associated with hemorrhagic and thrombotic complications. Method A was best associated with complications, but methods B1 and B2, in combination with time spent in range, were equally well associated. As we prefer to disentangle variability and intensity of anticoagulation, we propose to use methods B1 or B2 to reflect pure variability of oral anticoagulant therapy.     

肺栓塞患者抗凝治疗的急救护理

对肺栓塞患者的急救和抗凝治疗的配合及护理特点进行探讨。介绍了肺栓塞的急救护理措施、抗凝治疗的观察要点及护理对策,肯定了密切观察心电图、血压．呼吸及血氧饱和度与抗凝治疗中的护理配合和做好出院指导的重要性。     

QCC在儿童医院特需门诊输液服务流程改进中的应用

目的：探索品管圈活动（QCC）在儿童医院特需门诊输液服务流程改进中的效果与体会。方法：成立“品管圈”组织,通过主题选定、拟定活动计划、目标设定、现状分析,制定输液各环节精细化流程并实施。结果：输液服务流程改进后患儿家长对输液各环节的满意度明显提升,患儿输液等候时间明显缩短,护士综合能力明显提高。结论：将QCC模式用于输液服务流程的改进,可以改善护理服务品质,提升护理工作质量,提高护士工作效率,建立和谐的工作团队,提高患儿及家长的满意度。     

医院门诊志愿服务组织体系的创建与效果

目的 探讨医院门诊开展志愿服务的做法与效果.方法 根据门诊志愿服务的基本原则,建立志愿服务管理体系,招募392名志愿者在门诊开展志愿服务,帮助就诊患者陪检、护送、查询,提供轮椅、平车、健康指导等服务.结果 志愿者服务对象对志愿服务的满意度均高于90.00％,实施志愿服务前后患者满意度由78.10％提高到89.90％,实...     

Evaluation of a nurse-led continence service in the south-west of Glasgow, Scotland

This paper reports the results of a pilot study of a nurse-led continence promotion service in both the community and a local nursing home. Telephone and written referrals were made to the service from 28 primary care teams in Glasgow, Scotland. In the nursing home all patients were assessed and an appropriate management plan implemented. A full assessment was carried out in all community patients, including an appraisal of contributory factors, urinalysis and diaries of food and drink intake. A management plan suited to the patient was then implemented. Patients' levels of incontinence in both arms of the study were assessed objectively using the Lagro-Janssen method. The cost incurred in both arms of the study were measured. There was a 69% improvement in the level of incontinence in the community group compared with 30% in the residents wing and 13% in the hospital wing. The savings in the nursing home amounted to pound;4152 in the residents' wing and £1959 in the hospital wing. In summary, a nurse dedicated to urinary incontinence in the community allows improved management, a greater level of awareness and results in resource savings, whilst increasing patient accessibility to a service.     

上海市社区老年人群心房颤动的流行病学特征及抗凝治疗现状调查

目的:探讨上海市社区老年人群心房颤动(房颤)的患病类型、相关心血管疾病、血栓栓塞风险及抗凝治疗现状。方法:对2015年4月至2016年5月上海市金山区11个社区65岁以上健康体检诊断为房颤的患者进行横断面调查。由调查者对患者进行12导联常规心电图检查并填写"房颤患者特征评估调查表"。结果:房颤患者共1 368例,平均年龄(76.1±6.4)岁,男性患者占50.4%。首诊房颤、阵发性房颤、持续性房颤、永久性房颤及无法确定房颤类型者分别占39.7%、19.2%、8.6%、13.2%、19.3%。合并高血压59.3%、冠心病35.9%、脑血管疾病10.5%、糖尿病9.5%、慢性阻塞性肺病3.3%、窦房结功能不全/病窦综合征2.3%、左心室肥厚2.2%、心肌梗死2.0%、心力衰竭1.9%。CHASD2评分≥2分的房颤患者共239例,其中16例(6.9%)接受抗凝治疗、57例(24.7%)采用抗血小板治疗;CHA2DS2-VASc评分≥2分的房颤患者共471例,29例(6.4%)接受抗凝治疗,96例(21.2%)采用抗血小板治疗。结论:上海市社区老年房颤患者人群中,首诊房颤患者、卒中高危风险者所占比例较大,但接受抗凝治疗比例低。     

改善儿科门诊输液服务质量的做法与效果

目的 探讨改善儿科门诊输液室服务流程的模式,提升护理服务质量.方法 通过分析儿科门诊输液存在的问题,优化服务流程,引进导诊服务,实行预约输液服务,强化查对制度.结果 儿科门诊输液室发生护理不良事件和护理投诉明显减少(P＜0.01),患者家长满意度提高(P＜0.01).结论 优化服务流程、落实查对制度是提升护理服务质量的...     

Development, implementation and evaluation of a new nurse-led continence service: a pilot study

The Leicestershire Medical Research Council (MRC) Incontinence Study is a series of interrelated studies exploring the epidemiology of urinary symptoms, including incontinence, and evaluating service provision and treatment options for these symptoms. This paper describes one aspect of the Leicestershire MRC Incontinence Study, namely the development, implementation and evaluation of a new nurse-led continence service. When developing a new service it is important to determine its acceptability and suitability to the target population. The new mode of service delivery was dependent on specially trained Continence Nurse Practitioners (CNP) delivering predefined evidence-based treatment interventions. Objective and subjective outcome measures were used to evaluate the service. The service was shown to be effective in reducing urinary symptoms and led to high levels of patient satisfaction. This service is currently being evaluated in a randomized controlled trial.     

Patient autonomy in nurse-led shared care: a review of theoretical and empirical literature

AIM: This paper presents a review of the theoretical and empirical literature addressing patient autonomy and how nurses can support patient autonomy. BACKGROUND: Nurse-led, shared care settings provide needs-based care to patients who are encouraged to participate actively in their care. Patient autonomy is a complex ethical concept with many different meanings. As a result, nurses must solve various problems to foster patient autonomy successfully. METHOD: Two methods were used to identify literature for the review: (a) a search of the MEDLINE, Embase, CINAHL and Online Contents databases and the keywords 'patient autonomy' in combination with 'nursing', and the Dutch Central Catalogue for material published from 1966 to 2005; (b) ethical and nursing literature was selected on the basis of its identification of positive and negative freedom. We reviewed qualitative empirical research to explore the patients' views of autonomy. FINDINGS: Negative freedom emphasizes freedom of action and freedom from interference by others. Positive freedom stresses the idea that people should direct their lives according to their personal convictions and individual reasons and goals. The most prominent theories fitting negative freedom are those defining autonomy as self-governance and self-care. Theories fitting positive freedom are those focusing on autonomy in caring, autonomy as identification, autonomy as communication and autonomy as goal achievement. In the empirical literature, two studies centred on patient autonomy in home care, one in nursing home care and three in hospital settings. To achieve autonomy, patients prefer a mixed approach that combines features of negative and positive freedom. CONCLUSION: Nurses cannot rely exclusively on one model of autonomy to foster patient autonomy. Rather, it requires in-depth knowledge of, and interaction with, patients in the context of each particular nursing encounter because people express their autonomy through particular courses of action.     

区域管理结合走动服务模式在门诊一站式服务中的实践与体会

目的探讨在门诊一站式服务中运用区域管理结合走动服务模式的效果。方法根据医院门诊现有工作环境确定区域管理岗位,制订区域管理岗位职责,制订走动服务规范及管理措施。结果实施前后病人满意度得分分别为（88．37±2．89）分和（91．78±2．65）分,差异具有统计学意义（P〈0．01）;导医对区域管理结合走动服务模式实施效果总体满意度为100．00％。结论在门诊一站式服务中运用区域管理结合走动服务模式有利于提高病人满意度,提升导医个人工作能力。     

门诊流程优化的研究与分析

目的分析门诊流程存在的问题,为门诊流程优化的必要性提供依据。方法调查现有门诊流程的现状,抽取500例门诊患者在收费处缴费的相关数据,并对一周内每天的挂号量及收费处打印的发票数按时间段进行分析统计。结果门诊患者就诊需要多次排队等候,高峰期排队等待时间长,门诊挂号的高峰期为每天的7:00～10:00,收费处打印发票的高峰期在每天的8:00～11:00。结论医院制定相应的策略进行门诊流程优化十分必要,基于一卡通平台通过信息化手段进行门诊流程优化是一种有效方式。     

Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire

BACKGROUND: A new model of comprehensive care nurse-led clinics has enabled experienced genitourinary medicine nurses to co-ordinate the first-line, comprehensive care of female patients presenting with sexually transmitted infections and other sexual health conditions and issues. AIM: This paper describes the development of a patient satisfaction questionnaire to compare the satisfaction of women attending nurse-led or doctor-led clinics at a central London genitourinary medicine clinic. METHODS: A previously validated questionnaire was adapted using the findings of qualitative interviews exploring patient expectations of the service. The draft questionnaire was tested for internal consistency, sub-scale homogeneity, construct validity and stability. The final version consisted of a 34 item, five-point Likert scale, which was found to be both reliable (Cronbach's alpha 0.91) and stable (test-retest 0.95). There was some evidence of construct validity. The questionnaire was then distributed to a convenience sample of 132 women attending a nurse-led clinic and 150 seen at a doctor-led clinic. RESULTS: There was a 90% response rate. The median total satisfaction scores, out of a total of five, were 4.47 and 4.30 for the nurse-led and doctor-led groups, respectively (P = 0.05). Significantly higher scores on the sub-scales measuring quality and competence of technical care (P < 0.001), provision of information (P = 0.01) and overall satisfaction (P = 0.01) were seen for the nurse-led group. No significant differences were found in the sub-scales measuring service attributes and specific attributes of interpersonal relationships. CONCLUSION: The rigorous development, piloting and testing phases of this satisfaction questionnaire led to reliable and valid results. This study demonstrated that nurse-led clinics within this service are an acceptable alternative to the existing doctor-led clinics.     

华法林抗凝治疗中药师干预对治疗效果及安全性的影响

目的探讨在华法林抗凝治疗中药师干预对治疗效果及用药安全性的影响。方法选择2017年1月至2017年12月服用华法林进行抗凝治疗的86例患者为对照组,以2018年1月至2018年12月由临床药师参与指导华法林抗凝治疗的86例患者为观察组。比较两组患者的治疗效果。结果观察组达到稳态时间、INR达标时间短于对照组,出院时INR达标率高于对照组(P<0.05)。观察组平均TTR大于对照组,且观察组在TTR<58%范围内的患者占比少于对照组,在TTR>70%范围内患者的占比多于对照组(P<0.05)。观察组血栓及出血总发生率均低于对照组,抗凝知识评分高于对照组(P<0.05)。结论临床药师参与华法林抗凝治疗的指导可以显著提高抗凝质量和安全性,改善患者对抗凝知识的知晓情况。