Pretreatment malnutrition and quality of life - association with prolonged length of hospital stay among patients with gynecological cancer: A cohort study

Background Length of hospital stay (LOS) is a surrogate marker for patients' well-being during hospital treatment and is associated with health care costs. Identifying pretreatment factors associated with LOS in surgical patients may enable early intervention in order to reduce postoperative LOS. Methods This cohort study enrolled 157 patients with suspected or proven gynecological cancer at a tertiary cancer centre (2004-2006). Before commencing treatment, the scored Patient Generated - Subjective Global Assessment (PG-SGA) measuring nutritional status and the Functional Assessment of Cancer Therapy-General (FACT-G) scale measuring quality of life (QOL) were completed. Clinical and demographic patient characteristics were prospectively obtained. Patients were grouped into those with prolonged LOS if their hospital stay was greater than the median LOS and those with average or below average LOS. Results Patients' mean age was 58 years (SD 14 years). Preoperatively, 81 (52%) patients presented with suspected benign disease/pelvic mass, 23 (15%) with suspected advanced ovarian cancer, 36 (23%) patients with suspected endometrial and 17 (11%) with cervical cancer, respectively. In univariate models prolonged LOS was associated with low serum albumin or hemoglobin, malnutrition (PG-SGA score and PG-SGA group B or C), low pretreatment FACT-G score, and suspected diagnosis of cancer. In multivariable models, PG-SGA group B or C, FACT-G score and suspected diagnosis of advanced ovarian cancer independently predicted LOS. Conclusions Malnutrition, low quality of life scores and being diagnosed with advanced ovarian cancer are the major determinants of prolonged LOS amongst gynecological cancer patients. Interventions addressing malnutrition and poor QOL may decrease LOS in gynecological cancer patients.

Adherence to nutrition supplements among patients with a fall-related lower limb fracture

Background The purpose of this study was to provide a detailed evaluation of adherence to nutrition supplements by patients with a lower limb fracture. Methods These descriptive data are from 49 nutritionally“ at-risk” patients aged 70+ years admitted to the hospital after a fall-related lower limb fracture and allocated to receive supplementation as part of a randomized, controlled trial. Supplementation commenced on day 7 and continued for 42 days. Prescribed volumes aimed to meet 45% of individually estimated theoretical energy requirements to meet the shortfall between literature estimates of energy intake and requirements. The supplement was administered by nursing staff on medication rounds in the acute or residential care settings and supervised through thrice-weekly home visits postdischarge. Results Median daily percent of the prescribed volume of nutrition supplement consumed averaged over the 42 days was 67% (interquartile range [IQR], 31–89, n = 49). There was no difference in adherence for gender, accommodation, cognition, or whether the supplement was self-administered or supervised. Twenty-three participants took some supplement every day, and a further 12 missed <5 days. For these 35 “nonrefusers,” adherence was 82% (IQR, 65–93), and they lost on average 0.7% (SD, 4.0%) of baseline weight over the 6 weeks of supplementation compared with a loss of 5.5% (SD, 5.4%) in the “refusers” (n = 14, 29%), p = .003. Conclusions We achieved better volume and energy consumption than previous studies of hip fracture patients but still failed to meet target supplement volumes prescribed to meet 45% of theoretical energy requirements. Clinicians should consider alternative methods of feeding such as a nasogastric tube, particularly in those patients where adherence to oral nutrition supplements is poor and dietary intake alone is insufficient to meet estimated energy requirements.

An epidemiological study of the relationship between time to surgery and health status for elderly patients with a hip fracture

A hip fracture causes permanent changes to life style for older people. Further, two important mortality indicators found post operatively for this group include, the time until surgery after fracture, and pre-operative health status prior to surgery, yet no research is available investigating relationships between time to surgery and health status. The researchers aimed to establish the health status risks for patients aged over 65 years with a non-pathological hip fracture to guide nursing care interventions. A prospective cohort design was used to investigate relationships between time to surgery and measures on pre-operative health status indicators including, skin integrity risk, vigor, mental state, bowel function and continence. Twenty-nine patients with a mean age in years of 81.93 (SD,9.49), were recruited. The mean number of hours from time 1 assessment to surgery was 52.72 (SD,58.35) and the range was 1 hour to 219 hours. At Time 2, the mean scores of vigor and skin integrity risk were significantly higher, indicating poorer health status. A change in health status occurred but possibly due to the small sample size it was difficult to relate this result to time. However the results informed preoperative care prior to surgery, for this group.

Evaluating the effect of a patient education brochure on patients’ expectations and satisfaction with emergency department service

Introduction: The purpose of this study was to assess the capacity of a written intervention, in this case a patient information brochure, to improve patient satisfaction during an Emergency Department (ED) visit. For the purpose of measuring the effect of the intervention the ED journey was conceptualised as a series of distinct areas of service comprising waiting time, service by the triage nurse, care from doctors and nurses and information giving Background of study: Research into patient satisfaction has become a widespread activity endorsed by both governments and hospital administrations. The literature on ED patient satisfaction has consistently indicated three primary areas of patient dissatisfaction: waiting time, nursing care and communication. Recent developments in the literature on patient satisfaction studies however have highlighted the relationship between patients. expectations of a service encounter and their consequent assessment of the experience as dissatisfying or satisfying. Disconfirmation theory posits that the degree to which expectations are confirmed will affect subsequent levels of satisfaction. The conceptual framework utilised in this study is Coye.s (2004) model of disconfirmation. Coye while reiterating satisfaction is a consequence of the degree expectations are either confirmed or disconfirmed also posits that expectations can be modified by interventions. Coye.s work conceptualises these interventions as intra encounter experiences (cues) which function to adjust expectations. Coye suggests some cues are unintended and may have a negative impact which also reinforces the value of planned cues intended to meet or exceed consumer expectations. Consequently the brochure can be characterized as a potentially positive cue, encouraging the patient to understand processes and to orient them in what can be a confronting environment. Only a limited number of studies have examined the effect of written interventions within an ED. No studies could be located which have tested the effect of ED interventions using a conceptual framework which relates the effect of the degree to which expectations are confirmed or disconfirmed in terms of satisfaction with services. Method: Two studies were conducted. Study One used qualitative methods to explore patients. expectations of the ED from the perspective of both patients and health care professionals. Study One was used in part to direct the development of the intervention (brochure) in Study Two. The brochure was an intervention designed to modify patients. expectations thus increasing their satisfaction with the provision of ED service. As there was no existing tools to measure ED patients. expectations and satisfaction a new tool was also developed based on the findings and the literature of Study One. Study Two used a non-randomised, quasi-experimental approach using a non-equivalent post-test only comparison group design used to investigate the effect of the patient education brochure (Stommel and Wills, 2004). The brochure was disseminated to one of two study groups (the intervention group). The effect of the brochure was assessed by comparing the data obtained from both the intervention and control group. These two groups consisted of 150 participants each. It was expected that any differences in the relevant domains selected for examination would indicate the effect of the brochure both on expectation and potentially satisfaction. Results: Study One revealed several areas of common ground between patients and nurses in terms of relevant content for the written intervention, including the need for information on the triage system and waiting times. Areas of difference were also found with patients emphasizing communication issues, whereas focus group members expressed concern that patients were often unable to assimilate verbal information. The findings suggested the potential utility of written material to reinforce verbal communication particularly in terms of the triage process and other ED protocols. This material was synthesized within the final version of the written intervention. Overall the results of Study Two indicated no significant differences between the two groups. The intervention group did indicate a significant number of participants who viewed the brochure of having changed their expectations. The effect of the brochure may have been obscured by a lack of parity between the two groups as the control group presented with statistically significantly higher levels of acuity and experienced significantly shorter waiting times. In terms of disconfirmation theory this would suggest expectations that had been met or exceeded. The results confirmed the correlation of expectations with satisfaction. Several domains also indicated age as a significant predictor with older patients tending to score higher satisfaction results. Other significant predictors of satisfaction established were waiting time and care from nurses, reinforcing the combination of efficient service and positive interpersonal experiences as being valued by patients. Conclusions: Information presented in written form appears to benefit a significant number of ED users in terms of orientation and explaining systems and procedures. The degree to which these effects may interact with other dimensions of satisfaction however is likely to be limited. Waiting time and interpersonal behaviours from staff also provide influential cues in determining satisfaction. Written material is likely to be one element in a series of coordinated strategies to improve patient satisfaction during periods of peak demand.

Implications for the design of a digital stethoscope for anaesthetic preadmission consultations

Background This research addresses the development of a digital stethoscope for use with a telehealth communications network to allow doctors to examine patients remotely (a digital telehealth stethoscope). A telehealth stethoscope would allow remote auscultation of patients who do not live near a major hospital. Travelling from remote areas to major hospitals is expensive for patients and a telehealth stethoscope could result in significant cost savings. Using a stethoscope requires great skill. To design a telehealth stethoscope that meets doctors’ expectations, the use of existing stethoscopes in clinical contexts must be examined. Method Observations were conducted of 30 anaesthetic preadmission consultations. The observations were video- taped. Interaction between doctor, patient and non-human elements in the consultation were “coded” to transform the video into data. The data were analysed to reveal essential aspects of the interactions. Results The analysis has shown that the doctor controls the interaction during auscultation. The conduct of auscultation draws heavily on the doctor’s tacit knowledge, allowing the doctor to treat the acoustic stethoscope as infrastructure – that is, the stethoscope sinks into the background and becomes completely transparent in use. Conclusion Two important, and related, implications for the design of a telehealth stethoscope have arisen from this research. First, as a telehealth stethoscope will be a shared device, doctors will not be able to make use of their existing expertise in using their own stethoscopes. Very simply, a telehealth stethoscope will sound different to a doctor’s own stethoscope. Second, the collaborative interaction required to use a telehealth stethoscope will have to be invented and refined. A telehealth stethoscope will need to be carefully designed to address these issues and result in successful use. This research challenges the concept of a telehealth stethoscope by raising questions about the ease and confidence with which doctors could use such a device.

Unraveling the complexity of driving while intoxicated: a study into the prevalence of psychiatric and substance abuse comorbidity

Objective Research is beginning to provide an indication of the co-occurring substance abuse and mental health needs for the driving under the influence (DUI) population. This study aimed to examine the extent of such psychiatric problems among a large sample size of DUI offenders entering treatment in Texas. Methods This is a study of 36,373 past year DUI clients and 308,714 non-past year DUI clients admitted to Texas treatment programs between 2005 and 2008. Data were obtained from the State's administrative dataset. Results Analysis indicated that non-past year DUI clients were more likely to present with more severe illicit substance use problems, while past year DUI clients were more likely to have a primary problem with alcohol. Nevertheless, a cannabis use problem was also found to be significantly associated with DUI recidivism in the last year. In regards to mental health status, a major finding was that depression was the most common psychiatric condition reported by DUI clients, including those with more than one DUI offence in the past year. This cohort also reported elevated levels of Bipolar Disorder compared to the general population, and such a diagnosis was also associated with an increased likelihood of not completing treatment. Additionally, female clients were more likely to be diagnosed with mental health problems than males, as well as more likely to be placed on medications at admission and more likely to have problems with methamphetamine, cocaine, and opiates. Conclusions DUI offenders are at an increased risk of experiencing comorbid psychiatric disorders, and thus, corresponding treatment programs need to cater for a range of mental health concerns that are likely to affect recidivism rates.

Adherence to fish oil intervention in patients with chronic kidney disease

Objective: With growing recognition of the role of inflammation in the development of chronic and acute disease, fish oil is increasingly used as a therapeutic agent, but the nature of the intervention may pose barriers to adherence in clinical populations. Our objective was to investigate the feasibility of using a fish oil supplement in hemodialysis patients. ---------- Design: This was a nonrandomized intervention study.---------- Setting: Eligible patients were recruited at the Hemodialysis Unit of Wesley Hospital, Brisbane, Queensland, Australia. Patients The sample included 28 maintenance hemodialysis patients out of 43 eligible patients in the unit. Exclusion criteria included patients regularly taking a fish oil supplement at baseline, receiving hemodialysis for less than 3 months, or being unable to give informed consent.---------- Intervention: Eicosapentaenoic acid (EPA) was administered at 2000 mg/day (4 capsules) for 12 weeks. Adherence was measured at baseline and weekly throughout the study according to changes in plasma EPA, and was further measured subjectively by self-report.---------- Results: Twenty patients (74%) adhered to the prescription based on changes in plasma EPA, whereas an additional two patients self-reported good adherence. There was a positive relationship between fish oil intake and change in plasma EPA. Most patients did not report problems with taking the fish oil. Using the baseline data, it was not possible to characterize adherent patients.---------- Conclusions: Despite potential barriers, including the need to take a large number of prescribed medications already, 74% of hemodialysis patients adhered to the intervention. This study demonstrated the feasibility of using fish oil in a clinical population.

The relationship between deformity correction and clinical outcomes after thoracoscopic scoliosis surgery : a prospective series of one hundred patients

Prospective clinical case series of 100 patients receiving thoracoscopic anterior scoliosis correction surgery. The objective was to evaluate the relationship between clinical outcomes of thoracoscopic anterior scoliosis surgery and deformity correction using the Scoliosis Research Society (SRS) outcomes instrument questionnaire. The surgical treatment of scoliosis is quantitatively assessed in the clinic using radiographic measures of deformity correction, as well as the rib hump, but it is important to understand the extent to which these quantitative measures correlate with self-reported improvements in patients’ quality of life following surgery. A series of 100 consecutive adolescent idiopathic scoliosis patients received a single anterior rod via a thoracoscopic approach at the Mater Children’s Hospital, Brisbane, Australia. Patients completed SRS outcomes questionnaires pre-operatively and at 24 months post-operatively. There were 94 females and 6 males with a mean age of 16.1 years. The mean Cobb angle improved from 52º pre-operatively to 25º post-operatively (52%) and the mean rib hump improved from 16º to 8º (51%). The mean total SRS score for the cohort was 99.4/120. None of the deformity related parameters in the multiple regression were significant. However, patients with the lowest post-operative major Cobb angles reported significantly higher SRS scores than those with the highest post-operative Cobb angles, but there was no difference on the basis of rib hump correction. There were no significant differences between patients with either rod fractures or screw-related complications compared to those without complications.

Diagnostic and treatment pathways for men with prostate cancer in Queensland : investigating spatial and demographic inequalities

Background: Patterns of diagnosis and management for men diagnosed with prostate cancer in Queensland, Australia, have not yet been systematically documented and so assumptions of equity are untested. This longitudinal study investigates the association between prostate cancer diagnostic and treatment outcomes and key area-level characteristics and individual-level demographic, clinical and psychosocial factors.---------- Methods/Design: A total of 1064 men diagnosed with prostate cancer between February 2005 and July 2007 were recruited through hospital-based urology outpatient clinics and private practices in the centres of Brisbane, Townsville and Mackay (82% of those referred). Additional clinical and diagnostic information for all 6609 men diagnosed with prostate cancer in Queensland during the study period was obtained via the population-based Queensland Cancer Registry. Respondent data are collected using telephone and self-administered questionnaires at pre-treatment and at 2 months, 6 months, 12 months, 24 months, 36 months, 48 months and 60 months post-treatment. Assessments include demographics, medical history, patterns of care, disease and treatment characteristics together with outcomes associated with prostate cancer, as well as information about quality of life and psychological adjustment. Complementary detailed treatment information is abstracted from participants’ medical records held in hospitals and private treatment facilities and collated with health service utilisation data obtained from Medicare Australia. Information about the characteristics of geographical areas is being obtained from data custodians such as the Australian Bureau of Statistics. Geo-coding and spatial technology will be used to calculate road travel distances from patients’ residences to treatment centres. Analyses will be conducted using standard statistical methods along with multilevel regression models including individual and area-level components.---------- Conclusions: Information about the diagnostic and treatment patterns of men diagnosed with prostate cancer is crucial for rational planning and development of health delivery and supportive care services to ensure equitable access to health services, regardless of geographical location and individual characteristics. This study is a secondary outcome of the randomised controlled trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12607000233426)

A snapshot of Australian nurse practitioners’ extended practice activities

Introduction The Australian Nurse Practitioner Project (AUSPRAC) was initiated to examine the introduction of nurse practitioners into the Australian health service environment. The nurse practitioner concept was introduced to Australia over two decades ago and has been evolving since. Today, however, the scope of practice, role and educational preparation of nurse practitioners is well defined (Gardner et al, 2006). Amendments to specific pre-existing legislation at a State level have permitted nurse practitioners to perform additional activities including some once in the domain of the medical profession. In the Australian Capital Territory, for example 13 diverse Acts and Regulations required amendments and three new Acts were established (ACT Health, 2006). Nurse practitioners are now legally authorized to diagnose, treat, refer and prescribe medications in all Australian states and territories. These extended practices differentiate nurse practitioners from other advanced practice roles in nursing (Gardner, Chang & Duffield, 2007). There are, however, obstacles for nurse practitioners wishing to use these extended practices. Restrictive access to Medicare funding via the Medicare Benefit Scheme (MBS) and the Pharmaceutical Benefit Scheme (PBS) limit the scope of nurse practitioner service in the private health sector and community settings. A recent survey of Australian nurse practitioners (n=202) found that two-thirds of respondents (66%) stated that lack of legislative support limited their practice. Specifically, 78% stated that lack of a Medicare provider number was ‘extremely limiting’ to their practice and 71% stated that no access to the PBS was ‘extremely limiting’ to their practice (Gardner et al, in press). Changes to Commonwealth legislation is needed to enable nurse practitioners to prescribe medication so that patients have access to PBS subsidies where they exist; currently patients with scripts which originated from nurse practitioners must pay in full for these prescriptions filled outside public hospitals. This report presents findings from a sub-study of Phase Two of AUSPRAC. Phase Two was designed to enable investigation of the process and activities of nurse practitioner service. Process measurements of nurse practitioner services are valuable to healthcare organisations and service providers (Middleton, 2007). Processes of practice can be evaluated through clinical audit, however as Middleton cautions, no direct relationship between these processes and patient outcomes can be assumed.

Excess length of stay due to central line–associated bloodstream infection in intensive care units in Argentina, Brazil, and Mexico

Objective.To estimate the excess length of stay in an intensive care unit (ICU) due to a central line–associated bloodstream infection (CLABSI), using a multistate model that accounts for the timing of infection. Design.A cohort of 3,560 patients followed up for 36,806 days in ICUs. Setting.Eleven ICUs in 3 Latin American countries: Argentina, Brazil, and Mexico. Patients.All patients admitted to the ICU during a defined time period with a central line in place for more than 24 hours. Results.The average excess length of stay due to a CLABSI increased in 10 of 11 ICUs and varied from −1.23 days to 4.69 days. A reduction in length of stay in Mexico was probably caused by an increased risk of death due to CLABSI, leading to shorter times to death. Adjusting for patient age and Average Severity of Illness Score tended to increase the estimated excess length of stays due to CLABSI. Conclusions.CLABSIs are associated with an excess length of ICU stay. The average excess length of stay varies between ICUs, most likely because of the case‐mix of admissions and differences in the ways that hospitals deal with infections.

Diarrhoea risk factors in enterally tube fed critically ill patients : a retrospective audit

Objective: Diarrhoea in the enterally tube fed (ETF) intensive care unit (ICU) patient is a multifactorial problem. Diarrhoeal aetiologies in this patient cohort remain debatable; however, the consequences of diarrhoea have been well established and include electrolyte imbalance, dehydration, bacterial translocation, peri anal wound contamination and sleep deprivation. This study examined the incidence of diarrhoea and explored factors contributing to the development of diarrhoea in the ETF, critically ill, adult patient. ---------- Method: After institutional ethical review and approval, a single centre medical chart audit was undertaken to examine the incidence of diarrhoea in ETF, critically ill patients. Retrospective, non-probability sequential sampling was used of all emergency admission adult ICU patients who met the inclusion/exclusion criteria. ---------- Results: Fifty patients were audited. Faecal frequency, consistency and quantity were considered important criteria in defining ETF diarrhoea. The incidence of diarrhoea was 78%. Total patient diarrhoea days (r = 0.422; p = 0.02) and total diarrhoea frequency (r = 0.313; p = 0.027) increased when the patient was ETF for longer periods of time. Increased severity of illness, peripheral oxygen saturation (Sp02), glucose control, albumin and white cell count were found to be statistically significant factors for the development of diarrhoea. ---------- Conclusion: Diarrhoea in ETF critically ill patients is multi-factorial. The early identification of diarrhoea risk factors and the development of a diarrhoea risk management algorithm is recommended.

Probiotics and diarrhoea management in enterally tube fed critically ill patients : what is the evidence?

Objective: The aim of this literature review is to identify the role of probiotics in the management of enteral tube feeding (ETF) diarrhoea in critically ill patients.---------- Background: Diarrhoea is a common gastrointestinal problem seen in ETF patients. The incidence of diarrhoea in tube fed patients varies from 2% to 68% across all patients. Despite extensive investigation, the pathogenesis surrounding ETF diarrhoea remains unclear. Evidence to support probiotics to manage ETF diarrhoea in critically ill patients remains sparse.---------- Method: Literature on ETF diarrhoea and probiotics in critically ill, adult patients was reviewed from 1980 to 2010. The Cochrane Library, Pubmed, Science Direct, Medline and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) electronic databases were searched using specific inclusion/exclusion criteria. Key search terms used were: enteral nutrition, diarrhoea, critical illness, probiotics, probiotic species and randomised clinical control trial (RCT).---------- Results: Four RCT papers were identified with two reporting full studies, one reporting a pilot RCT and one conference abstract reporting an RCT pilot study. A trend towards a reduction in diarrhoea incidence was observed in the probiotic groups. However, mortality associated with probiotic use in some severely and critically ill patients must caution the clinician against its use.---------- Conclusion: Evidence to support probiotic use in the management of ETF diarrhoea in critically ill patients remains unclear. This paper argues that probiotics should not be administered to critically ill patients until further research has been conducted to examine the causal relationship between probiotics and mortality, irrespective of the patient's disease state or projected prophylactic benefit of probiotic administration.