[How to assess the nutritional status of my patient]

Protein-energy-malnutrition is a growing problem in industrialised countries. Many studies have found malnourishment in 20-60% of hospitalized medical or surgical patients, as well as out-patients. Malnutrition negatively influences patients' prognosis, immune system, muscle strength, and quality of life. As it is a largely treatable co-morbidity, systematic screening for malnutrition and effective management will improve patient outcomes and reduce healthcare costs. Early diagnosis and assessment depends on a simple and standardised screening tool that identifies at-risk patients, allowing the medical team in charge to solve patients' nutritional problems with an interdisciplinary approach.

Vancomycin resistance has no influence on outcomes of enterococcal bacteriuria

Background Infections with vancomycin-resistant enterococci (VRE) are a growing concern in hospitals. The impact of vancomycin resistance in enterococcal urinary tract infection is not well-defined. Aim To describe the epidemiology of enterococcal bacteriuria in a hospital and compare the clinical picture and patient outcomes depending on vancomycin resistance. Methods This was a 6-month prospective cohort study of hospital patients who were admitted with or who developed enterococcal bacteriuria in a 1250-bed tertiary care hospital. We examined clinical presentation, diagnostic work-up, management, and outcomes. Findings We included 254 patients with enterococcal bacteriuria; 160 (63%) were female and median age was 65 years (range: 17–96). A total of 116 (46%) bacteriurias were hospital-acquired and 145 (57%) catheter-associated. Most patients presented with asymptomatic bacteriuria (ASB) (119; 47%) or pyelonephritis (64; 25%); 51 (20%) had unclassifiable bacteriuria and 20 (8%) had cystitis. Secondary bloodstream infection was detected in 8 (3%) patients. Seventy of 119 (59%) with ASB received antibiotics (mostly vancomycin). There were 74 (29%) VRE bacteriurias. VRE and vancomycin-susceptible enterococci (VSE) produced similar rates of pyelonephritis [19 (25%) vs 45 (25%); P = 0.2], cystitis, and ASB. Outcomes such as ICU transfer [10 (14%) VRE vs 17 (9%) VSE; P = 0.3], hospital length of stay (6.8 vs 5.0 days; P = 0.08), and mortality [10 (14%) vs 13 (7%); P = 0.1] did not vary with vancomycin susceptibility. Conclusions Vancomycin resistance did not affect the clinical presentation nor did it impact patient outcomes in this cohort of inpatients with enterococcal bacteriuria. Almost half of our cohort had enterococcal ASB; more than 50% of these asymptomatic patients received unnecessary antibiotics. Antimicrobial stewardship efforts should address overtreatment of enterococcal bacteriurias.

Short-term functional versus patient-reported outcome of the bicruciate stabilized total knee arthroplasty: prospective consecutive case series

BACKGROUND The main goals of the standard treatment for advanced symptomatic knee osteoarthritis, total knee arthroplasty (TKA), are pain reduction and restoration of knee motion.The aim of this study was to analyse the outcome of the patient-based Knee Injury and Osteoarthritis Outcome Score (KOOS), and the surgeon-based Knee Society Score (KSS) and its Knee Score (KS) and Knee Functional Score (KFS) components after (TKA) using the Journey knee prosthesis, and to assess the correlation of these scores with range of motion (ROM). METHODS In a prospective case series study between August 1st 2008 and May 31st 2011, 99 patients, all operated by a single surgeon, received Journey bicruciate stabilized total knee prostheses. The female/male ratio was 53/34, the mean patient age at surgery was 68 years (range 41-83 years), and the left/right knee ratio was 55/44. The KOOS, range of motion, and KS and KFS were obtained preoperatively and at 1-year follow-up. The pre- and postoperative levels of the outcome measures were compared using the Wilcoxon signed-rank test. Correlation between ROM and patient outcomes was analysed with the Spearman coefficient. RESULTS All KOOS subscores improved significantly. Ninety percent of patients improved by at least the minimum clinically relevant difference of 10 points in stiffness and other symptoms, 94.5% in pain, 94.5% in activities of daily living, 84.9% in sports and recreation, and 90% in knee-related quality of life. The mean passive and active ROM improved from 122.4° (range 90-145°) and 120.4° (range 80-145°) preoperatively to 129.4° (range 90-145°) and 127.1° (range 100-145°) postoperatively. The highest correlation coefficients for ROM and KOOS were observed for the activity and pain subscores. Very low or no correlation was seen for the sport subscore.There was a significant and clinically relevant improvement of KSS (preop/postop 112.2/174.5 points), and its KS (preop/postop 45.6/86.8 points) and KFS (preop/postop 66.6/87.8 points) components. CONCLUSIONS The Journey bicruciate stabilized knee prosthesis showed good 1-year postoperative results in terms of both functional and patient-based outcome. However, higher knee ROM correlates only moderately with patient-based outcome, implying that functionality afforded by the Journey bicruciate TKA is not equivalent to patient satisfaction.

SEVERE HEAD TRAUMA, EMERGENCY TRANSPORT, AND PATIENT OUTCOME

Trauma and severe head injuries are important issues because they are prevalent, because they occur predominantly in the young, and because variations in clinical management may matter. Trauma is the leading cause of death for those under age 40. The focus of this head injury study is to determine if variations in time from the scene of accident to a trauma center hospital makes a difference in patient outcomes.^ A trauma registry is maintained in the Houston-Galveston area and includes all patients admitted to any one of three trauma center hospitals with mild or severe head injuries. A study cohort, derived from the Registry, includes 254 severe head injury cases, for 1980, with a Glasgow Coma Score of 8 or less.^ Multiple influences relate to patient outcomes from severe head injury. Two primary variables and four confounding variables are identified, including time to emergency room, time to intubation, patient age, severity of injury, type of injury and mode of transport to the emergency room. Regression analysis, analysis of variance, and chi-square analysis were the principal statistical methods utilized.^ Analysis indicates that within an urban setting, with a four-hour time span, variations in time to emergency room do not provide any strong influence or predictive value to patient outcome. However, data are suggestive that at longer time periods there is a negative influence on outcomes. Age is influential only when the older group (55-64) is included. Mode of transport (helicopter or ambulance) did not indicate any significant difference in outcome.^ In a multivariate regression model, outcomes are influenced primarily by severity of injury and age which explain 36% (R('2)) of variance. Inclusion of time to emergency room, time to intubation, transport mode and type injury add only 4% (R('2)) additional contribution to explaining variation in patient outcome.^ The research concludes that since the group most at risk to head trauma is the young adult male involved in automobile/motorcycle accidents, more may be gained by modifying driving habits and other preventive measures. Continuous clinical and evaluative research are required to provide updated clinical wisdom in patient management and trauma treatment protocols. A National Institute of Trauma may be required to develop a national public policy and evaluate the many medical, behavioral and social changes required to cope with the country's number 3 killer and the primary killer of young adults.^

Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes

Objectives: To compare hospital at home care with inpatient hospital care in terms of patient outcomes.

Toward better outcomes with tacrolimus therapy: Population pharmacokinetics and individualized dosage prediction in adult liver transplantation

Patient outcomes in transplantation would improve if dosing of immunosuppressive agents was individualized. The aim of this study is to develop a population pharmacokinetic model of tacrolimus in adult liver transplant recipients and test this model in individualizing therapy. Population analysis was performed on data from 68 patients. Estimates were sought for apparent clearance (CL/F) and apparent volume of distribution (V/F) using the nonlinear mixed effects model program (NONMEM). Factors screened for influence on these parameters were weight, age, sex, transplant type, biliary reconstructive procedure, postoperative day, days of therapy, liver function test results, creatinine clearance, hematocrit, corticosteroid dose, and interacting drugs. The predictive performance of the developed model was evaluated through Bayesian forecasting in an independent cohort of 36 patients. No linear correlation existed between tacrolimus dosage and trough concentration (r(2) = 0.005). Mean individual Bayesian estimates for CL/F and V/F were 26.5 8.2 (SD) L/hr and 399 +/- 185 L, respectively. CL/F was greater in patients with normal liver function. V/F increased with patient weight. CL/F decreased with increasing hematocrit. Based on the derived model, a 70-kg patient with an aspartate aminotransferase (AST) level less than 70 U/L would require a tacrolimus dose of 4.7 mg twice daily to achieve a steady-state trough concentration of 10 ng/mL. A 50-kg patient with an AST level greater than 70 U/L would require a dose of 2.6 mg. Marked interindividual variability (43% to 93%) and residual random error (3.3 ng/mL) were observed. Predictions made using the final model were reasonably nonbiased (0.56 ng/mL), but imprecise (4.8 ng/mL). Pharmacokinetic information obtained will assist in tacrolimus dosing; however, further investigation into reasons for the pharmacokinetic variability of tacrolimus is required.

Advanced patient monitoring displays: Tools or continuous informing

We reviewed the use of advanced display technologies for monitoring in anesthesia. Researchers are investigating displays that integrate information and that, in some cases, also deliver the results continuously to the anesthesiologist. Integrated visual displays reveal higher-order properties of patient state and speed in responding to events, but their benefits under an intensely timeshared load is unknown. Head-mounted displays seem to shorten the time to respond to changes, but their impact on peripheral awareness and attention is unknown. Continuous auditory displays extending pulse oximetry seem to shorten response times and improve the ability to time-share other tasks, but their integration into the already noisy operative environment still needs to be tested. We reviewed the advantages and disadvantages of the three approaches, drawing on findings from other fields, such as aviation, to suggest outcomes where there are still no results for the anesthesia context. Proving that advanced patient monitoring displays improve patient outcomes is difficult, and a more realistic goal is probably to prove that such displays lead to better situational awareness, earlier responding, and less workload, all of which keep anesthesia practice away from the outer boundaries of safe operation.

The Responsiveness, Content Validity, and Convergent Validity of the Measure Yourself Concerns and Wellbeing (MYCaW) Patient-Reported Outcome Measure

Objective Measure Yourself Concerns and Wellbeing (MYCaW) is a patient-centred questionnaire that allows cancer patients to identify and quantify the severity of their ‘Concerns’ and Wellbeing, as opposed to using a pre-determined list. MYCaW administration is brief and aids in prioritising treatment approaches. Our goal was to assess the convergent validity and responsiveness of MYCaW scores over time, the generalisability of the existing qualitative coding framework in different complementary and integrative healthcare settings and content validity. Methods Baseline and 6-week follow-up data (n=82) from MYCaW and FACIT-SpEx questionnaires were collected for a service evaluation of the ‘Living Well With The Impact of Cancer’ course at Penny Brohn Cancer Care. MYCaW construct validity was determined using Spearman's Rank Correlation test, and responsiveness indices assessed score changes over time. The existing qualitative coding framework was reviewed using a new dataset (n=158) and coverage of concern categories compared to items of existing outcome measures. Results Good correlation between MYCaW and FACIT-SpEx score changes were achieved (r= -0.57, p≥0.01). MYCaW Profile and Concern scores were highly responsive to change: SRM=1.02 and 1.08; effect size=1.26 and 1.22. MYCaW change scores showed the anticipated gradient of change according to clinically relevant degrees of change. Categories including ‘Spirituality’, ‘weight change’ and ‘practical concerns’ were added to the coding framework to improve generalisability. Conclusions MYCaW scores were highly responsive to change, allowing personalized patient outcomes to be quantified; the qualitative coding framework is generalisable across different oncology settings and has broader coverage of patient-identified concerns compared with existing cancer-related patient-reported outcome measures.

Can early dietetic intervention improve outcomes in patients with hip fracture?

Aim: To assess whether the introduction of a new approach to nutritional care for hip fracture patients, in both acute and subacute admissions, can improve nutritional status, length of stay and pressure injuries. Methods: Medical records of patients admitted to Austin Health, Melbourne, Australia with a fractured hip between January and June 2014 after implementation of a new nutritional care guideline were compared to a historical control group admitted between January and June 2013 prior to introduction of the guideline. Data were collected for both acute and subacute admissions and included length of stay, date of first contact with a dietitian, subjective global assessment category and occurrence of pressure injuries. Results: There was a significantly shorter length of stay overall for patients who received care under the new guideline (21.6 ± 15.1 vs 26.4 ± 20.4 days; P = 0.043) and during the subacute admission (20.1 ± 10.6 vs 28.8 ± 15.8 days; P < 0.001); however, there was no significant difference in the acute hospital length of stay period. The post-guideline group had a significantly shorter time between admission and first contact with a dietitian (4.8 ± 3.3 vs 7.5 ± 6.2 days; P < 0.001). Post-guideline patients also had a significantly lower incidence of pressure injuries with 29, compared to 41 in pre-guideline patients (P = 0.045). There were significantly less malnourished patients in the post-guideline group compared to the pre-guideline group across both acute and subacute admissions (29% vs 35%; P = 0.015). Conclusions: A nutritional care guideline for patients with hip fractures is associated with improved patient outcomes with a significant reduction in overall and subacute length of stay and pressure injury incidence and earlier dietetic assessment and intervention.

Patient participation in postoperative care activities in patients undergoing total knee replacement surgery: multimedia intervention for managing patient experience (MIME). Study protocol for a cluster randomised crossover trial

BACKGROUND: Patient participation is an important indicator of quality care. Currently, there is little evidence to support the belief that participation in care is possible for patients during the acute postoperative period. Previous work indicates that there is very little opportunity for patients to participate in care in the acute context. Patients require both capability, in terms of having the required knowledge and understanding of how they can be involved in their care, and the opportunity, facilitated by clinicians, to engage in their acute postoperative care. This cluster randomised crossover trial aims to test whether a multimedia intervention improves patient participation in the acute postoperative context, as determined by pain intensity and recovery outcomes.

METHODS/DESIGN: A total of 240 patients admitted for primary total knee replacement surgery will be invited to participate in a cluster randomised, crossover trial and concurrent process evaluation in at least two wards at a major non-profit private hospital in Melbourne, Australia. Patients admitted to the intervention ward will receive the multimedia intervention daily from Day 1 to Day 5 (or day of discharge, if prior). The intervention will be delivered by nurses via an iPad™, comprising information on the goals of care for each day following surgery. Patients admitted to the control ward will receive usual care as determined by care pathways currently in use across the organization. The primary endpoint is the "worst pain experienced in the past 24 h" on Day 3 following TKR surgery. Pain intensity will be measured using the numerical rating scale. Secondary outcomes are interference of pain on activities of daily living, length of stay in hospital, function and pain following TKR surgery, overall satisfaction with hospitalisation, postoperative complications and hospital readmission.

DISCUSSION: The results of this study will contribute to our understanding of the effectiveness of interventions that provide knowledge and opportunity for patient participation during postoperative in-hospital care in actually increasing participation, and the impact of participation on patient outcomes. The results of this study will also provide data about the barriers and enablers to participation in the acute care context.

Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

AIMS AND OBJECTIVES: This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. BACKGROUND: Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. DESIGN: A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. METHODS: A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. FINDINGS: Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. CONCLUSIONS: The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication management in an acute hospital setting. Language discourses shaped and were shaped by complex power relations between patients and clinicians and among clinicians themselves. RELEVANCE TO CLINICAL PRACTICE: Clinicians need to be encouraged to have regular conversations to talk about and challenge each other's practices. More emphasis should be placed on ensuring that patients are given opportunities to voice their concerns about how their medications are managed.

A medical data reliability assessment model

There is currently a strong focus worldwide on the potential of large-scale Electronic Health Record (EHR) systems to cut costs and improve patient outcomes through increased efficiency. This is accomplished by aggregating medical data from isolated Electronic Medical Record databases maintained by different healthcare providers. Concerns about the privacy and reliability of Electronic Health Records are crucial to healthcare service consumers. Traditional security mechanisms are designed to satisfy confidentiality, integrity, and availability requirements, but they fail to provide a measurement tool for data reliability from a data entry perspective. In this paper, we introduce a Medical Data Reliability Assessment (MDRA) service model to assess the reliability of medical data by evaluating the trustworthiness of its sources, usually the healthcare provider which created the data and the medical practitioner who diagnosed the patient and authorised entry of this data into the patient’s medical record. The result is then expressed by manipulating health record metadata to alert medical practitioners relying on the information to possible reliability problems.

Compliance in peritoneal dialysis : a qualitative study of renal nurses

End-stage renal failure is a life-threatening condition, often treated with home-based peritoneal dialysis (PD). PD is a demanding regimen, and the patients who practise it must make numerous lifestyle changes and learn complicated biomedical techniques. In our experience, the renal nurses who provide mostPDeducation frequently express concerns that patient compliance with their teaching is poor. These concerns are mirrored in the renal literature. It has been argued that the perceived failure of health professionals to improve compliance rates with PD regimens is because ‘compliance’ itself has never been adequately conceptualized or defined; thus, it is difficult to operationalize and quantify. This paper examines how a group of Australian renal nurses construct patient compliance with PD therapy. These empirical data illuminate how PD compliance operates in one practice setting; how it is characterized by multiple and often competing energies; and how ultimately it might be pointless to try to tame ‘compliance’ through rigid definitions and measurement, or to rigidly enforce it in PD patients. The energies involved are too fractious and might be better spent, as many of the more experienced nurses in this study argue, in augmenting the energies that do work well together to improve patient outcomes.

The impact of health information technology on the quality of medical and health care : a systematic review

Objective: To systematically review the published evidence of the impact of health information technology (HIT) on the quality of medical and health care specifically clinicians’ adherence to evidence-based guidelines and the corresponding impact this had on patient clinical outcomes. In order to be as inclusive as possible the research examined literature discussing the use of health information technologies and systems in both medical care such as clinical and surgical, and other health care such as allied health and preventive services.----- Design: Systematic review----- Data Sources: Relevant literature was systematically searched on English language studies indexed in MEDLINE and CINAHL(1998 to 2008), Cochrane Library, PubMed, Database of Abstracts of Review of Effectiveness (DARE), Google scholar and other relevant electronic databases. A search for eligible studies (matching the inclusion criteria) was also performed by searching relevant conference proceedings available through internet and electronic databases, as well as using reference lists identified from cited papers.----- Selection criteria: Studies were included in the review if they examined the impact of Electronic Health Record (EHR), Computerised Provider Order-Entry (CPOE), or Decision Support System (DS); and if the primary outcomes of the studies were focused on the level of compliance with evidence-based guidelines among clinicians. Measures could be either changes in clinical processes resulting from a change of the providers’ behaviour or specific patient outcomes that demonstrated the effectiveness of a particular treatment given by providers. ----- Methods: Studies were reviewed and summarised in tabular and text form. Due to heterogeneity between studies, meta-analysis was not performed.----- Results: Out of 17 studies that assessed the impact of health information technology on health care practitioners’ performance, 14 studies revealed a positive improvement in relation to their compliance with evidence-based guidelines. The primary domain of improvement was evident from preventive care and drug ordering studies. Results from the studies that included an assessment for patient outcomes however, were insufficient to detect either clinically or statistically important improvements as only a small proportion of these studies found benefits. For instance, only 3 studies had shown positive improvement, while 5 studies revealed either no change or adverse outcomes.----- Conclusion: Although the number of included studies was relatively small for reaching a conclusive statement about the effectiveness of health information technologies and systems on clinical care, the results demonstrated consistency with other systematic reviews previously undertaken. Widescale use of HIT has been shown to increase clinician’s adherence to guidelines in this review. Therefore, it presents ongoing opportunities to maximise the uptake of research evidence into practice for health care organisations, policy makers and stakeholders.

Who's talking? Communication and the casual/part-time nurse : a literature review

The rapidly evolving nursing working environment has seen the increased use of flexible non standard employment, including part-time, casual and itinerate workers. Evidence suggests that the nursing workforce has been at the forefront of the flexibility push which has seen the appearance of a dual workforce and marginalization of part- time and casual workers by their full-time peers and managers. The resulting fragmentation has meant that effective communication management has become difficult. Additionally, it is likely that poor organisational communication exacerbated by the increased use of non standard staff, is a factor underlying current discontent in the nursing industry and may impact on both recruitment and retention problems as well as patient outcomes. This literature review explores the relationship between the increasing casualisation of the nursing workforce and, among other things, the communication practices of nurses within healthcare organisations.