Renal access coordinators' impact on hemodialysis patient outcomes and associated service delivery: a systematic review

Background
Renal access coordinators contribute specifically to dialysis access care for people with chronic and end stage renal disease. Since the introduction of renal access coordinators into Australia in the early 2000s, there have been anecdotal examples of associated improvements in patient outcomes and service delivery; however scant published quantitative evidence exists. Thus, the impact of the implementation of renal access coordinators has not undergone a rigorous review to date.

Objective
The objective of this systematic review was to critically appraise and synthesize the best available evidence related to the impact of renal access coordinators on dialysis patient outcomes and associated service delivery.

INCLUSION CRITERIA

Types of participants
This review considered studies that included renal access coordinators (noting variations of the titles) and adult hemodialysis patients (aged 18 years and over).

Types of intervention(s)
This review considered studies that evaluated the effectiveness of the renal access coordinator. This role typically consists of clinical and administration duties such as providing pre dialysis access coordination, access surveillance patient education and nurse education.

Types of studies
The types of studies considered within this review included experimental and epidemiological study designs. Thus randomized controlled trials (RCT), non-randomized controlled trials, and quasi-experimental, before and after studies, prospective and retrospective cohort studies were considered as were case control studies, analytical cross sectional studies and descriptive cross sectional studies.

Types of outcomes
Patient outcomes considered included: days to first vascular access complication (such as stenosis or thrombosis) and/or primary intervention (such as angioplasty or surgical intervention); percentage of central line insertions (negative); rate of arteriovenous fistula (AVF)/arteriovenous graft (AVG)/central venous catheter (CVC) at start of dialysis (incidence); prevalent rate of AVF/AVG/CVC; time to occlusion of AVF and time from referral to surgery. Service outcomes included: knowledge/up skilling of renal nurses; cannulation skills, ultrasound skills, knowledge of anatomy and physiology and other access related knowledge.

Search strategy
The search strategy aimed to locate published and unpublished studies, utilizing a three-step searching approach. Studies published in English from 1990 to October 2013 were considered for inclusion in this review.

Methodological quality
The studies were assessed by two independent reviewers using the appropriate standardized critical appraisal instruments from the Joanna Briggs Institute.

Data collection
Data were extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute, namely JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

Data synthesis
This review aimed to conduct meta-analyses of the findings: however, because of the limitations of the data found, this was not possible and so the findings are presented in a narrative format.

Results
Five studies were identified for inclusion in the review. No RCTs were found, therefore four of the five studies were pre-post intervention cohort studies and one was a prospective quality assurance report. Data were heterogeneous and thus did not allow for meta-analysis. All studies included multidisciplinary teams with variable emphasis on the renal access coordinator role. The pre post intervention cohort studies measured incident and/or prevalent AVF, AVG and CVC rates in the hemodialysis population and the quality assurance report measured the difference in patency rates between AVF and AVG. All discussed the role of central coordination as a contributor to the success of vascular access care.

Conclusions
This review found insufficient data to make firm conclusions about the impact that renal access coordinators have on patient outcomes. The results of this review suggest an association between renal access coordinators and improved patient outcomes. These improved patient outcomes were apparent in an increase in incident and prevalent AVFs, and a decrease in the incidence and prevalence of CVCs. Both associations are correlated with a reduction in infection rates, length of hospital stay and healthcare costs.

Indicators for evaluating cancer organizations' support services: performance and associations with empowerment

Community-based cancer organizations provide services to support patients. An anticipated benefit of these services is patient empowerment. However, this outcome has not been evaluated because of the lack of validated health-related empowerment questionnaires in the cancer context. In this validation study, the authors assessed the extent to which 16 indicators used by the Canadian Cancer Society (CCS) and the Cancer Council Victoria, Australia (CCV) to evaluate their services were associated with health-related empowerment.

Dementia in older people admitted to hospital: a regional multi-hospital observational study of prevalence, associations and case recognition

BACKGROUND: previous studies have indicated a prevalence of dementia in older admissions of ∼42% in a single London teaching hospital, and 21% in four Queensland hospitals. However, there is a lack of published data from any European country on the prevalence of dementia across hospitals and between patient groups. OBJECTIVE: to determine the prevalence and associations of dementia in older patients admitted to acute hospitals in Ireland. METHODS: six hundred and six patients aged ≥70 years were recruited on admission to six hospitals in Cork County. Screening consisted of Standardised Mini-Mental State Examination (SMMSE); patients with scores <27/30 had further assessment with the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Final expert diagnosis was based on SMMSE, IQCODE and relevant medical and demographic history. Patients were screened for delirium and depression, and assessed for co-morbidity, functional ability and nutritional status. RESULTS: of 598 older patients admitted to acute hospitals, 25% overall had dementia; with 29% in public hospitals. Prevalence varied between hospitals (P < 0.001); most common in rural hospitals and acute medical admissions. Only 35.6% of patients with dementia had a previous diagnosis. Patients with dementia were older and frailer, with higher co-morbidity, malnutrition and lower functional status (P < 0.001). Delirium was commonly superimposed on dementia (57%) on admission. CONCLUSION: dementia is common in older people admitted to acute hospitals, particularly in acute medical admissions, and rural hospitals, where services may be less available. Most dementia is not previously diagnosed, emphasising the necessity for cognitive assessment in older people on presentation to hospital.

Comparison of patient-reported need of psycho-oncologic support and the doctor's perspective: how do they relate to disease severity in melanoma patients?

Objective: Psycho-neuro-immune research suggests an association between cancer outcomes and psychosocial distress. Objective criteria to determine patients’ levels of distress are important to establish potential links to disease outcomes. Methods: We compared three patient-reported with one doctor-reported measures of psychooncologic distress frequently used in routine cancer care and investigated associations with standard disease severity parameters in melanoma patients. We enrolled n = 361 patients, successively seen at two outpatient university clinics in Germany. In the naturalistic study, n = 222 patients had been diagnosed <180 days and were seen for the first time (Group I); n = 139 had been diagnosed >180 days and were in after-care (Group II). Results: Across groups, only moderate associations were seen between patient- reported and doctorreported measures. Regarding clinical variables, disease severity and perceived need of psychooncologic support reported by patients or doctors showed hardly any association. After subgroup stratification, in patients of Group II, patient-reported and doctor-reported instruments showed some small associations with disease parameters commonly linked to more rapid cancer progression in patients who are in cancer after-care. Conclusions: Overall, the few and low associations suggest that need of psycho-oncologic support and clinical variables were largely independent of each other and doctors’ perception may not reflect the patient’s view. Therefore, the assessment of the patient perspective is indispensable to ensure that melanoma patients receive appropriate support, as such need cannot be derived from other disease parameters or proxy report. More research is needed applying psychometrically robust instruments that are ideally combined with sensitive biomarkers to disentangle psycho-neuro-immune implications in melanoma patients.

Compliance to exercise-oncology guidelines in prostate cancer survivors and associations with psychological distress, unmet supportive care needs, and quality of life

Objective The purpose of this study was to determine prevalence of Australian prostate cancer survivors meeting contemporary exercise-oncology guidelines and identify associations with distress, unmet supportive care needs, and quality of life. Methods A population-based cohort of 463 prostate cancer survivors who were on 10.8 months post-curative therapy was assessed for compliance with current exercise guidelines for cancer survivors, motivational readiness for physical activity, psychological distress, unmet supportive care needs, and quality of life. Results Only 57 men (12.3%) reported sufficient exercise levels (150 min of moderate intensity or 75 min of strenuous exercise per week and twice weekly resistance exercise), 186 (40.2%) were insufficiently active, and 220 (47.5%) were inactive. Among inactive men, 99 (45.0%) were in the contemplation or preparation stage of motivation readiness. Inactive men had higher global distress (p=0.01) and Brief Symptom Inventory-Anxiety (p<0.05) than those who were insufficiently active. Total Supportive Care Needs and International Prostate Cancer Symptom scores were higher in inactive than insufficiently and sufficiently active men (p<0.05). Lack of physical activity contributed to poorer quality of life. Conclusions Only a small proportion of Australian prostate cancer survivors met contemporary exercise-oncology recommendations despite increasing recognition of exercise to improve patient outcomes. Strategies are urgently required to increase prostate cancer survivors' participation in aerobic and resistance exercise training.

A trial of e-simulation of sudden patient deterioration (FIRST2ACT WEB) on student learning

BACKGROUND: High-fidelity simulation pedagogy is of increasing importance in health professional education; however, face-to-face simulation programs are resource intensive and impractical to implement across large numbers of students. OBJECTIVES: To investigate undergraduate nursing students' theoretical and applied learning in response to the e-simulation program-FIRST2ACT WEBTM, and explore predictors of virtual clinical performance. DESIGN AND SETTING: Multi-center trial of FIRST2ACT WEBTM accessible to students in five Australian universities and colleges, across 8 campuses. PARTICIPANTS: A population of 489 final-year nursing students in programs of study leading to license to practice. METHODS: Participants proceeded through three phases: (i) pre-simulation-briefing and assessment of clinical knowledge and experience; (ii) e-simulation-three interactive e-simulation clinical scenarios which included video recordings of patients with deteriorating conditions, interactive clinical tasks, pop up responses to tasks, and timed performance; and (iii) post-simulation feedback and evaluation. Descriptive statistics were followed by bivariate analysis to detect any associations, which were further tested using standard regression analysis. RESULTS: Of 409 students who commenced the program (83% response rate), 367 undergraduate nursing students completed the web-based program in its entirety, yielding a completion rate of 89.7%; 38.1% of students achieved passing clinical performance across three scenarios, and the proportion achieving passing clinical knowledge increased from 78.15% pre-simulation to 91.6% post-simulation. Knowledge was the main independent predictor of clinical performance in responding to a virtual deteriorating patient R(2)=0.090, F(7, 352)=4.962, p<0.001. DISCUSSION: The use of web-based technology allows simulation activities to be accessible to a large number of participants and completion rates indicate that 'Net Generation' nursing students were highly engaged with this mode of learning. CONCLUSION: The web-based e-simulation program FIRST2ACTTM effectively enhanced knowledge, virtual clinical performance, and self-assessed knowledge, skills, confidence, and competence in final-year nursing students.