The nursing management of elderly patients with pain in the community: study and recommendations

This study is designed to identify factors which influence quality of life for elderly people suffering from painful conditions. It is based upon a theoretical model of control in which mood state is used as the indicator of coping. One hundred and ninety elderly patients took part in semi-structured interviews about their pain and coping experiences, and data were also collected from their nurses in the community. Multivariate statistical analysis revealed that the key determinants of mood were having regrets about the past, being occupied, perceived level of pain control, additional personal problems (notably bereavement) and feeling informed about the painful condition. Active personal coping strategies were identified as more therapeutic than passive strategies. Nurses' data revealed that pain complaints were associated with perceived exaggeration. Few nurses used formal pain assessment. Recommendations for the management of persistent pain in the community are given.     

Tricortical Calcaneal Bone Graft and Management of the Donor Site

The clinical outcomes of 19 patients requiring autogenous grafts for foot surgery were followed up until healing at the donor site occurred. In all cases, tricortical bone was extracted from the calcaneus for use at another pedal site. The first cohort of 9 patients had the calcaneal deficit replaced with allogenic cubes. The second cohort received no tissue replacement. Patients were reviewed postoperatively with a questionnaire and clinical examination to evaluate the outcome of the operations. Radiographic outcomes were observed at the donor and recipient sites in both groups until healing was confirmed as bridging trabeculation. Incorporation of the graft at the donor site was also reviewed. Clinical outcomes, namely pain, local sensory function, and return to footwear, were satisfactory in all patients and were not significantly different between groups. One patient from each group sustained a heel fracture. The donated autogenous grafts at the recipient sites were all incorporated uneventfully at 6 months. In the first cohort, allogenic graft incorporation in the calcaneus was complete in only 2 patients at the 12-month stage. The remaining 7 cases showed reduction of the deficit by new bone formation arising from the calcaneus. Donor sites with allogenic bone replacement healed at a median of 18 months (interquartile range, 18-18 months). In the group without replacement, healing occurred at a median of 6 months (interquartile range, 6-12 months), a highly statistically significant difference (P < .001). In the second cohort without allogenic graft replacement, radiographic filling at the donor site was complete within a 12-month period. Tricortical bone can be successfully harvested from the calcaneus, but there may an associated risk of heel fracture. The role of replacement allogenic bone in assisting healing at the donor site is unclear.     

The nursing management of pain in the community: a theoretical framework

This paper is based upon a research project designed to investigate the nursing management of pain in the community. A theoretical framework is described which has been designed to encompass the complexities of different types of pain, individual differences in reaction to pain, and to identify key differences between patients who cope with pain and those who do not. The framework is based on a model of stress, the concept of controllability, and contemporary learning theory. It identifies a unique role for the nurse in pain management and will be used to direct a study into strategies which nurses can use to enhance the coping abilities and resources of elderly patients in the community with pain.     

Combined Nonablative Skin Rejuvenation with the 595- and 1450-nm Lasers

BACKGROUND: Histologic findings are not echoed in the visible effect in the epidermis after skin rejuvenation. SUBJECTS AND METHODS: Ten women (Group A) received five treatment sessions with a 595-nm pulsed dye laser immediately followed by a 1450-nm diode laser. Two other demographically similar groups of 10 patients each, Groups B and C, were treated with the 595-nm pulsed dye laser or the 1450-nm diode laser alone, respectively. RESULTS: Good dermal collagen remodeling was observed in Group A. Overall better and faster results were seen in Group A. The 6-month clinical outcome was best in Group A followed by Group C and Group B. CONCLUSIONS: Wavelengths of 595 plus 1450 nm for skin rejuvenation produced good results with much higher patient satisfaction than those obtained with the 595- or 1450-nm wavelengths alone.     

Validation of the Revised 10-Item HIV Treatment Satisfaction Questionnaire Status Version and New Change Version

OBJECTIVES: Previous validation of the HIV Treatment Satisfaction Questionnaire status version (HIVTSQs) found that nine of the 10 items performed well, but the demands item needed revision. This study investigated the psychometric properties of the revised HIVTSQs and new change version (HIVTSQc). METHODS: English-speaking Americans completed the HIVTSQs at baseline and Week 48 of a clinical trial of HIV treatments, and the HIVTSQc at Week 48. Demographic and viral load information was collected. Psychometric validation used item frequency distributions, Confirmatory Factor Analysis (CFA), item-total correlations, Cronbach's alpha, Spearman's rank correlation, Kruskal-Wallis and Mann-Whitney tests. RESULTS: At baseline, 126 of the 152 patients completed the HIVTSQs fully (100 of 106 at Week 48). The negatively skewed distribution of the revised demands item resembled that of the other nine, with comparable missing data. CFA (baseline and Week 48) supported the general satisfaction/clinical subscale (alpha 0.83; 0.85), lifestyle/ease subscale including demands (alpha 0.82; 0.85), and 10-item treatment satisfaction scale (alpha 0.89; 0.91). Subscale and scale scores differed significantly between ethnic groups. Viral load was not significantly related to subscale or scale scores. At Week 48, 97 of 106 patients completed the HIVTSQc fully. All items had negatively skewed distributions. CFA supported two subscales (general satisfaction/clinical change alpha 0.85; lifestyle/ease change alpha 0.88) and 10-item treatment satisfaction change scale (alpha 0.92). Viral load change between baseline and Week 48 correlated significantly with patients' perceptions of change in HIV control (control(c) item), but not with scale or subscale scores. CONCLUSION: The excellent psychometric properties of the HIVTSQs and HIVTSQc support their use in clinical trials.     

New bed configurations and discharge timing policies: A hospital-wide simulation

Objective

Optimising patient flow is becoming an increasingly critical issue as patient demand fluctuates in healthcare systems with finite capacity. Simulation provides a powerful tool to fine-tune policies and investigate their impact before any costly intervention.

Methods

A hospital-wide discrete event simulation is developed to model incoming flow from ED and elective units in a busy metropolitan hospital. The impacts of two different policies are investigated using this simulation model: (i) varying inpatient bed configurations and a load sharing strategy among a cluster of wards within a medical department and (ii) early discharge strategies on inpatient bed access. Several clinically relevant bed configurations and early discharge scenarios are defined and their impact on key performance metrics are quantified.

Results

Sharing beds between wards reduced the average and total ED length of stay (LOS) by 21% compared to having patients queue for individual wards. The current baseline performance level could be maintained by using fewer beds when the load sharing approach was imposed. Earlier discharge of inpatients resulted in reducing average patient ED LOS by approximately 16% and average patient waiting time by 75%. Specific time-based discharge targets led to greater improvements in flow compared to blanket approaches of discharging all patients 1 or 2 hours earlier.

Conclusions

ED access performance for admitted patients can be improved by modifying downstream capacity or inpatient discharge times. The simulation model was able to quantify the potential impacts of such policies on patient flow and to provide insights for future strategic planning.