Small but important errors in cardiovascular risk calculation by practice nurses: A cross-sectional study in randomised trial setting

Background

Practice nurses play an increasingly important role in the prevention of cardiovascular diseases but we do not have evidence about the accuracy of their cardiovascular risk assessments during real practice consultations.

Objectives

To examine how nurses perform with regard to absolute 10-year cardiovascular risk assessment in actual practice.

Design

Cross-sectional study.

Setting

This study was nested in the IMPALA study, a clustered randomised controlled trial involving 24 general practices in The Netherlands.

Participants

24 practice nurses, trained in 10-year cardiovascular risk assessment, calculated the risk of a total of 421 patients without established cardiovascular diseases but eligible for cardiovascular risk assessment.

Methods

The main outcome measure was the accuracy of risk assessments, defined as (1) the difference between the 10-year cardiovascular risk percentage calculated by nurses and an independent assessor, and (2) the agreement between the treatment categories assigned by the nurses (low, moderate or high risk) and those assigned by the independent assessor.

Results

Thirty-one (7.4%) of the calculated risk percentages differed by more than our preset limits, 25 (81%) being underestimations. Elderly patients (OR 1.1, 95% CI 1.0-1.1), male patients (vs. female OR 3.1, 95% CI 1.2-7.3), and smoking patients (vs. non-smoking OR 3.8, 95% CI 1.7-8.9) were more likely to have their cardiovascular risk miscalculated. Ten (28%) of the 36 patients who should be assigned to the high-risk treatment category according to the independent calculation, were missed as high-risk patients by the practice nurses.

Conclusions

The overall standard of accuracy of cardiovascular risk assessment by trained practice nurses in actual practice is high. However, a significant number of high-risk patients were misclassified, with the probability that it led to missed opportunities for risk-reducing interventions. As cardiovascular risk assessments are frequently done by nurses in general practice, further specific training should be considered to prevent undertreatment.     

基于TOPSIS法的四川省市级城市基层公共卫生服务中社区居民感受度的横断面调查

目的了解四川省市级城市基层公共卫生服务中心社区居民感受度,为进一步加强薄弱地区措施提供参考。方法采用分层系统抽样法,借助四川省基本公共卫生服务监管平台,在21个市级的五类重点人群档案中分别等距抽取40份,即每个市级抽取200人作为调查对象。采用电话调查方法,调查居民知晓率、满意度、依从性,应用TOPSIS法综合评价四川省市级城市基层公共卫生服务中社区居民感受度,并通过聚类分档进行评价。结果共调查接受过基层医疗卫生机构健康管理的社区居民4 200人。四川省基层公共卫生服务社区居民服务知晓率为76.31%,健康知识知晓率为69.45%,服务便利性的满意率为69.42%,技术水平的满意率为67.96%,服务态度的满意率为69.74%,服务对改善健康的满意率为69.13%,继续接受服务的意愿率为68.17%,健康生活方式建议依从率为68.31%,服药依从率为85.14%。21个市级的Cj值平均为0.523 6,序号4的市级Cj值最高为0.751 9,序号10的市级Cj值最低为0.276 3。对评价结果进行聚类分档结果显示,不同档次间差异均无统计学意义。结论四川省21个市级基层公共卫生服务中心社区居民感受度各不相同。应加强对薄弱地区的措施,缩小各市级城市间的差距,切实提高社区居民的感受度。     

Outcomes for family carers of a nurse-delivered hospital discharge intervention for older people (the Further Enabling Care at Home Program): Single blind randomised controlled trial

BackgroundHospital discharge of older people receiving care at home offers a salient opportunity to identify and address their family caregivers’ self-identified support needs.ObjectivesThis study tested the hypothesis that the extent to which family caregivers of older people discharged home from hospital felt prepared to provide care at home would be positively influenced by their inclusion in the new Further Enabling Care at Home program.DesignThis single-blind randomised controlled trial compared outcomes from usual care alone with those from usual care plus the new program. The program, delivered by a specially trained nurse over the telephone, included: support to facilitate understanding of the patient’s discharge letter; caregiver support needs assessment; caregiver prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports.Setting and participantsDyads were recruited from the medical assessment unit of a Western Australian metropolitan public hospital. Each dyad comprised a patient aged 70 years or older plus an English speaking family caregiver.MethodsThe primary outcome was the caregiver’s self-reported preparedness to provide care for the patient. Data collection time points were designated as: Time 1, within four days of discharge; Time 2, 15–21 days after discharge; Time 3, six weeks after discharge. Other measures included caregivers’ ratings of: their health, patients’ symptoms and independence, caregiver strain, family well-being, caregiver stress, and positive appraisals of caregiving. Data were collected by telephone.ResultsComplete data sets were obtained from 62 intervention group caregivers and 79 controls. Groups were equivalent at baseline. Needs prioritised most often by caregivers were: to know whom to contact and what to expect in the future and to access practical help at home. Support guidance included how to: access help, information, and resources; develop crisis plans; obtain referrals and services; and organise legal requirements.Compared to controls, preparedness to care improved in the intervention group from Time 1 to Time 2 (effect size = 0.52; p = 0.006) and from Time 1 to Time 3 (effect size = 0.43; p = 0.019). These improvements corresponded to a change of approximately 2 points on the Preparedness for Caregiving instrument. Small but significant positive impacts were also observed in other outcomes, including caregiver strain.ConclusionsThese unequivocal findings provide a basis for considering the Furthering Enabling Care at Home program’s implementation in this and other similar settings. Further testing is required to determine the generalisability of results.     

Adherence to a guideline on cardiovascular prevention: a comparison between general practitioners and practice nurses

Background

Patient non-compliance with prescribed treatment is an important factor in the lack of success in cardiovascular prevention. Another important cause is non-adherence of caregivers to the guidelines. It is not known how doctors and nurses differ in the application of guidelines. Patient compliance to treatment may vary according to the type of caregiver.

Objective

To compare adherence to cardiovascular prevention delivered by practice nurses and by general practitioners.

Setting

Six primary health care centres in the Netherlands (25 general practitioners, six practice nurses).

Methods

701 high risk patients were included in a randomised trial. Half of the patients received nurse-delivered care and half received care by general practitioners. For 91% of the patients treatment concerned secondary prevention. The Dutch guideline on cardiovascular prevention was used as protocol. A structured self-administered questionnaire was sent by post to patients. Data were extracted from the practice database and the questionnaire.

Results

Intervention was received by 77% of respondents who visited the practice nurse compared to 57% from the general practitioner group (OR = 2.56, p < 0.01). More lifestyle intervention was given by the practice nurse; 46% of patients received at least one lifestyle intervention (weight, diet, exercise, and smoking) compared to 13% in general practitioner group (OR = 3.24, p < 0.001). In addition, after one year more patients from the practice nurse group used cardiovascular drugs (OR = 1.9, p = 0.03). Nurses inquired more frequently about patient compliance to medical treatment (OR = 2.1, p < 0.01). Regarding patient compliance, no statistical difference between study groups in this trial was found.

Conclusion

Practice nurses adhered better to the Dutch guideline on cardiovascular prevention than general practitioners did. Lifestyle intervention advice was more frequently given by practice nurses. Improvement of cardiovascular prevention is still necessary. Both caregivers should inquire about patient adherence on a regular basis.     

Prevention of cardiovascular disease within the primary health care system: Feasibility of a prevention programme within the Sollentuna primary health care catchment area

Objective - To integrate prevention of cardiovascular disease within the primary health care.

Design - A prevention programme which combines population and individual high-risk strategy.

Setting - The Primary Health Care in Sollentuna, Stockholm, Sweden.

Main outcome measure - Characteristics of, and risk factor prevalence among, persons registered in the prevention programme.

Results - During the first year more than 2000 persons, representing every tenth visitor and 6% of the population aged 15–60 years, were registered in the prevention programme. 90% were ?60 years and 62% were women. A large proportion (70%) had risk factors that required advice, treatment, and follow up. 24% of the men and 27% of the women were smokers, 68% and 62% respectively, had serum cholesterol ?5.2 mmol/1, and 33% and 22% had a diastolic blood pressure ?90 mmHg.

Conclusion - The present study implies that it is possible to integrate a large scale prevention programme in the existing primary health care organization. The prevalence of risk factors in those who enter the prevention programme is high, which places great demands for treatment and follow up.     

Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: A randomized controlled trial

Background

Many strategies have been evaluated to improve the prevention and control of cardiovascular (CVD) risk factors. Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation. This study tested the efficacy of a nurse-led reminder program through email (NRP-e) to improve CVD risk factors among hypertensive adults.

Methods

All participants received usual CVD prevention and a guideline-based educational program. Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months. Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines. Follow-up visits were scheduled at 1, 3 and 6 months after enrollment; randomization was made centrally and blood samples were evaluated into a single laboratory.

Results

The final sample consisted of 98 (control) and 100 (NRP-e) subjects (mean age 59.0 ± 14.5 years; 51.0% males). After 6 months, the following CVD risk factors significantly improved in both groups: body mass index, alcohol and fruit consumption, cigarette smoking, adherence to therapy hours, systolic and diastolic blood pressure, fasting blood glucose, low-density lipoproteins (LDL) and total cholesterol, triglycerides, and physical activity. In the NRP-e group, however, the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group: obesity (−16%), low fruit consumption (−24%), uncontrolled hypertension (−61%), LDL (−56%), and total cholesterol (−40%).

Conclusions

The NRP-e improved a range of CVD risk factors. The program had low costs, required only an average of <20 min per day in addition to normal practice, and may deserve further evaluation for the inclusion among existing care management approaches.     

The effects of nurse-delivered caregiving in the neonatal setting: An integrative review

Infants hospitalised in neonatal intensive care units require interventions for lifesaving care and to meet basic human needs. Evidence that stress influences neurodevelopment suggests the effects of caregiving in the neonatal intensive care unit (NICU) warrant further investigation to assess links with infant developmental outcomes. This review explores the effects of nurse-delivered caregiving in the NICU on infant physiological and behavioural responses, and longer-term developmental outcomes (behaviour and temperament). CINHAL, MEDLINE and PsychINFO were systematically searched for studies in peer-reviewed journals related to nurse-delivered caregiving and developmental outcomes. Synthesis of the literature identified altered physiological and behavioural responses as immediate effects of caregiving in neonatal settings, and non-optimal developmental outcomes. Results indicate that caregiving is not innocuous. Yet, little is known about nurses’ perceptions of the effects of caregiving. Identifying the care components that influence development is essential to minimise the potentially adverse impact of the NICU experience on infants and families.     

2014年浙江省台州市适龄儿童扩大国家免疫规划疫苗接种率横断面调查

目的 了解浙江省台州市适龄儿童扩大国家免疫规划(national immunization program, NIP)疫苗接种现状。方法 采用分层整群随机抽样方法,对台州市所辖9个县(市、区)随机抽取45个乡镇、90个村和9个流动人口聚集地,采用入户见人查证方法进行疫苗接种情况调查。结果 本次共调查2202名儿童,其中本地儿童1922名,流动儿童280名。本地儿童22剂次NIP疫苗接种率,除A群C群脑膜炎球菌多糖疫苗(MPV-A+C2)外,其余疫苗接种率均95%,含麻类疫苗首针(MCV1)及时接种率89.64%,乙型病毒性肝炎(乙肝)疫苗首针(HepB1)及时接种率98.60%、五苗全程(BCG、OPV1-3、DTP1-3、 HepB1-3、MCV1)接种率96.63%。除(MPV-A+C1)、(MPV-A+C2)和 OPV4外,本地儿童加强免疫疫苗接种率各年龄组之间差异有统计学意义(P0.001);流动儿童除口服脊髓灰质炎减毒活疫苗(OPV)第4剂(OPV4)90.28%、A群C群脑膜炎球菌多糖疫苗第1剂(MPV-A+C1)89.44%、A群C群脑膜炎球菌多糖疫苗第2剂(MPV-A+C2)90.00%、甲型病毒性肝炎疫苗(HepA)91.89%、白破(DT)疫苗94.12%外,22剂次NIP疫苗其余剂次接种率均95%;含麻类疫苗首针(MCV1)及时接种率84.46%、乙肝疫苗首针(HepB1)及时接种率91.79%、五苗全程(BCG、OPV1-3、DTP1-3、 HepB1-3、MCV1)接种率94.64%。流动儿童各年龄组加强免疫疫苗接种率差异无统计学意义(P0.05)。结论 台州本地儿童和流动儿童NIP疫苗接种率均处于较高水平,且A群C群脑膜炎球菌多糖疫苗和白破疫苗接种率较2013年明显提高。     

Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial

Background

In the absence of clear differences in effectiveness and cost-effectiveness between hospital-at-home schemes and usual hospital care, patient preference plays an important role. This study investigates patient preference for treatment place, associated factors and patient satisfaction with a community-based hospital-at-home scheme for COPD exacerbations.

Methods

The study is part of a larger randomised controlled trial. Patients were randomised to usual hospital care or early assisted discharge which incorporated discharge at day 4 and visits by a home care nurse until day 7 of treatment (T + 4 days). The hospital care group received care as usual and was discharged from hospital at day 7. Patients were followed for 90 days (T + 90 days). Patient preference for treatment place and patient satisfaction (overall and per item) were assessed quantitatively and qualitatively using questionnaires at T + 4 days and T + 90 days. Factors associated with patient preference were analysed in the early assisted discharge group.

Results

139 patients were randomised. No difference was found in overall satisfaction. At T + 4 days, patients in the early assisted discharge group were less satisfied with care at night and were less able to resume normal daily activities. At T + 90 days there were no differences for the separate items. Patient preference for home treatment at T + 4 days was 42% in the hospital care group and 86% in the early assisted discharge group and 35% and 59% at T + 90 days. Patients’ mental state was associated with preference.

Conclusion

Results support the wider implementation of early assisted discharge for COPD exacerbations and this treatment option should be offered to selected patients that prefer home treatment.     

浙江省806例急性心肌梗死患者药物治疗状况的调查

目的了解2001~2002年浙江省急性心肌梗死(AMI)患者的药物治疗状况。方法调查浙江省23所医院2001—2002年间出院诊断为AMI的806份病史资料。结果男性占72·2%。平均年龄为67·4岁,从胸痛发生至到达医院平均时间为11h。总静脉溶栓率仅为19·2%,适宜溶栓却未进行溶栓治疗者106例(45·9%)。β受体阻滞剂(BB)和血管紧张素转换酶抑制剂(ACEI)的实际使用率分别为49·4%、65·4%。阿斯匹林、低分子肝素、他汀类使用率较高,分别为88·2%、73·7%、71·5%。结论浙江省的AMI西医药治疗基本上遵循了指南推荐策略,但与指南要求仍存在差距,尤其是静脉溶栓率偏低。     

Patient preference for falls prevention in hospitals revealed through willingness-to-pay, contingent valuation survey

Rationale, aims and objectives Patient preference for interventions aimed at preventing in‐hospital falls has not previously been investigated. This study aims to contrast the amount patients are willing to pay to prevent falls through six intervention approaches. Methods This was a cross‐sectional willingness‐to‐pay (WTP), contingent valuation survey conducted among hospital inpatients (n = 125) during their first week on a geriatric rehabilitation unit in Queensland, Australia. Contingent valuation scenarios were constructed for six falls prevention interventions: a falls consultation, an exercise programme, a face‐to‐face education programme, a booklet and video education programme, hip protectors and a targeted, multifactorial intervention programme. The benefit to participants in terms of reduction in risk of falls was held constant (30% risk reduction) within each scenario. Results Participants valued the targeted, multifactorial intervention programme the highest [mean WTP (95% CI): $(AUD)268 ($240, $296)], followed by the falls consultation [$215 ($196, $234)], exercise [$174 ($156, $191)], face‐to‐face education [$164 ($146, $182)], hip protector [$74 ($62, $87)] and booklet and video education interventions [$68 ($57, $80)]. A ‘cost of provision’ bias was identified, which adversely affected the valuation of the booklet and video education intervention. Conclusion There may be considerable indirect and intangible costs associated with interventions to prevent falls in hospitals that can substantially affect patient preferences. These costs could substantially influence the ability of these interventions to generate a net benefit in a cost–benefit analysis.     

Patient safety culture in out-of-hours primary care services in the Netherlands: a cross-sectional survey

Objective: To examine patient safety culture in Dutch out-of-hours primary care using the safety attitudes questionnaire (SAQ) which includes five factors: teamwork climate, safety climate, job satisfaction, perceptions of management and communication openness.

Design: Cross-sectional observational study using an anonymous web-survey. Setting Sixteen out-of-hours general practitioner (GP) cooperatives and two call centers in the Netherlands. Subjects Primary healthcare providers in out-of-hours services. Main outcome measures Mean scores on patient safety culture factors; association between patient safety culture and profession, gender, age, and working experience.

Results: Overall response rate was 43%. A total of 784 respondents were included; mainly GPs (N?=?470) and triage nurses (N?=?189). The healthcare providers were most positive about teamwork climate and job satisfaction, and less about communication openness and safety climate. The largest variation between clinics was found on safety climate; the lowest on teamwork climate. Triage nurses scored significantly higher than GPs on each of the five patient safety factors. Older healthcare providers scored significantly higher than younger on safety climate and perceptions of management. More working experience was positively related to higher teamwork climate and communication openness. Gender was not associated with any of the patient safety factors.

Conclusions: Our study showed that healthcare providers perceive patient safety culture in Dutch GP cooperatives positively, but there are differences related to the respondents’ profession, age and working experience. Recommendations for future studies are to examine reasons for these differences, to examine the effects of interventions to improve safety culture and to make international comparisons of safety culture.

• Key Points

• Creating a positive patient safety culture is assumed to be a prerequisite for quality and safety. We found that:

• ??healthcare providers in Dutch GP cooperatives perceive patient safety culture positively;

• ??triage nurses scored higher than GPs, and older and more experienced healthcare professionals scored higher than younger and less experienced professionals – on several patient safety culture factors; and

• ??within the GP cooperatives, safety climate and openness of communication had the largest potential for improvement.

     

Patient,family-centred care interventions within the adult ICU setting: An integrative review

ObjectivesPatient, Family-Centred Care (PFCC) is internationally advocated as a way to improve patient care. The aim of this integrative review was to extend the knowledge and understanding by synthesising empirical evidence of PFCC interventions within the adult intensive care unit (ICU) setting.Review method usedAn integrative review methodological framework was employed, permitting the inclusion of all research designs. A comprehensive and systematic search, selection, quality appraisal, and data extraction of research were conducted to synthesise knowledge and identify research gaps.Data sourcesA systematic search of the following databases was conducted: MEDLINE; CINHAL; PsycINFO; Cochrane Library; Web of Science—Current Contents Connect; Web of Science—Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global. Primary research in adult ICUs was included.Review methodsData extracted from the studies included authors, year, country of origin, design, setting, sample, intervention, data collection strategies, main findings and limitations. Study quality was assessed using the Mixed Methods Appraisal Tool.ResultsForty-two articles met the inclusion criteria and were included in the review. Only a third of the papers stated the theory underpinning their study. Three themes emerged with interventions predominantly around Interacting with the target sample; Culture and Connection and Service Delivery interventions were also identified. Few studies integrated more than one dimension of PFCC.ConclusionsResearch into PFCC interventions is diverse; however, few researchers present a multi-dimensional approach incorporating a culture shift to enact PFCC throughout the ICU trajectory. There is an opportunity for future research to describe, develop, and test instruments that measure PFCC based on its multiple dimensions and not on one component in isolation. Importantly, for PFCC to successfully individualise quality patient care, a commitment and enactment of partnerships between health care professionals, patients, and family members is imperative.     

Breast and Prostate Cancer Survivors in a Diabetic Cohort: Results from the Living With Diabetes Study

Objective

Diabetes is more common in cancer survivors than in the general population. The objective of the present study was to determine cancer frequency in a cohort of patients with diabetes and to examine demographic, clinical, and quality of life differences between cancer survivors and their cancer-free peers to inform better individualized care.

Methods

Self-reported survey data from 3,466 registrants with type 2 diabetes from Australia’s National Diabetes Services Scheme (NDSS) were analyzed to compare relevant variables between cancer survivors and cancer-free patients. Analyses were focused on breast and prostate cancer to reflect the most common cancers in women and men, respectively.

Results

Five percent of diabetic women reported a history of breast cancer and 4.2% of men reported a history of prostate cancer. Diabetic patients with a history of breast or prostate cancer were older at time of survey and diabetes diagnosis, less likely to report metformin use (women), and more likely to have two or more comorbidities than their cancer-free peers. More diabetic prostate cancer survivors also reported problems with mobility and performing usual tasks. However, cancer-free diabetic subjects reported a lower diabetes-dependent quality of life than diabetic cancer survivors. There was no association between cancer survivorship and duration of diabetes, indices of glycemic control, obesity, or diabetic complications.

Conclusions

Cancer survivors comprise a significant minority of diabetic patients that are particularly vulnerable and may benefit from interventions to increase screening and treatment of other comorbidities and promote a healthy lifestyle.     

Staff experiences,perceptions of care,and communication in the intensive care unit during the COVID-19 pandemic in Australia

BackgroundIn 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission.AimThe aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale.MethodsThis was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis.FindingsFour major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods.ConclusionThe results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.     

Exploring falls prevention capabilities,barriers and training needs among patient sitters in a hospital setting: A pilot survey

Older patients in hospitals are at high risk of falls. Patient sitters are sometimes employed to directly observe patients to reduce their risk of falling although there is scant evidence that this reduces falls. The primary aim of this pilot survey (n = 31) was to explore the patient sitters' falls prevention capability, self-efficacy and the barriers and enablers they perceived influenced their ability to care for patients during their shifts. Feedback was also sought regarding training needs. Most (90%) participants felt confident in their role. The most frequent reasons for falls identified were patient-related (n = 91, 64%), but the most frequent responses identifying preventive strategies were environment-related (n = 54, 64%), suggesting that the sitters' capability was limited. The main barriers identified to keeping patients safe from falling were patient-related (n = 36, 62%) such as cognitive impairment. However, opportunities that would enable sitters to do their work properly were most frequently categorized as being staff-related (n = 20, 83%), suggesting that the sitters have limited ability to address these barriers encountered. While 74% of sitters reported they had received previous training, 84% of participants would like further training. Patient sitters need more training, and work practice needs to be standardized prior to future research into sitter use for falls prevention.