Patient self-management in chronic heart failure – establishing concordance between guidelines and practice

 Chronic heart failure (CHF) is a progressive and debilitating disease with a broad symptom profile, intermittently marked by periods of acute decompensation. CHF patients are encouraged to self-manage their illness, such as adhering to medical regimens and monitoring symptoms, to optimise health outcomes and quality of life. In so doing, patients are asked to collaborate with their health service providers with regard to their care. However, patients generally do not self-manage well, even with specialist support. Moreover, self- management interventions are yet to demonstrate morbidity or mortality benefits. Social network approaches to self-management consider the availability and mobilisation of all resources, beyond those of only the patient and healthcare providers. Used in conjunction with e-health platforms, social network approaches may offer a means by which to optimise self-management programmes of the future.

Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study

BACKGROUND: Patients can have an important role in reducing harm in primary-care settings. Learning from patient experience and feedback could improve patient safety. Evidence that captures patients' views of the various contributory factors to creating safe primary care is largely absent. The aim of this study was to address this evidence gap. METHODS: Four focus groups and eight semistructured interviews were conducted with 34 patients and carers from south-east Australia. Participants were asked to describe their experiences of primary care. Audio recordings were transcribed verbatim and specific factors that contribute to safety incidents were identified in the analysis using the Yorkshire Contributory Factors Framework (YCFF). Other factors emerging from the data were also ascertained and added to the analytical framework. RESULTS: Thirteen factors that contribute to safety incidents in primary care were ascertained. Five unique factors for the primary-care setting were discovered in conjunction with eight factors present in the YCFF from hospital settings. The five unique primary care contributing factors to safety incidents represented a range of levels within the primary-care system from local working conditions to the upstream organisational level and the external policy context. The 13 factors included communication, access, patient factors, external policy context, dignity and respect, primary-secondary interface, continuity of care, task performance, task characteristics, time in the consultation, safety culture, team factors and the physical environment. DISCUSSION: Patient and carer feedback of this type could help primary-care professionals better understand and identify potential safety concerns and make appropriate service improvements. The comprehensive range of factors identified provides the groundwork for developing tools that systematically capture the multiple contributory factors to patient safety.

Nurses' views of patient participation in nursing care

AIMS: To explore nurses' views of patient participation in nursing care on medical wards. BACKGROUND: Nurses have frequent contact with patients, highlighting their potential role in enabling patient participation. However, some nurses' actions and attitudes act as barriers, failing to achieve core requirements of patient participation. Discovering nurses' views may assist in developing strategies to encourage patient participation in hospitals. DESIGN: Interpretive study. METHODS: Twenty nurses were recruited from four medical wards, located in two Australian hospitals. In-depth semi-structured interviews were conducted between November 2013-March 2014 and analysed using content analysis. FINDINGS: Five categories emerged from the nurses' views. The first category, acknowledging patients as partners, showed nurses respected patients as legitimate participants. In the second category, managing risk, nurses emphasized the need to monitor participation to ensure rules and patient safety were maintained. Enabling participation was the third category, which demonstrated nurses' strategies that enhanced patients' participation. The fourth category was hindering participation; encapsulating nurses' difficulty in engaging patients with certain characteristics. In the final category, realizing participation, nurses believed patients could be involved in physical activities or clinical communication. CONCLUSION: Nurses have a crucial role in promoting patient participation. Through acknowledging and enabling participation, nurses may facilitate patient participation in a range of nursing activities. The nurse's role in enacting participation is complex, having to accommodate each patient's risks and characteristics, highlighting the need for good assessment skills. Education, policy and research strategies are essential to foster nurses' pivotal role in patient participation.

A framework for cloud-based healthcare services to monitor noncommunicable diseases patient

Monitoring patients who have noncommunicable diseases is a big challenge. These illnesses require a continuous monitoring that leads to high cost for patients' healthcare. Several solutions proposed reducing the impact of these diseases in terms of economic with respect to quality of services. One of the best solutions is mobile healthcare, where patients do not need to be hospitalized under supervision of caregivers. This paper presents a new hybrid framework based on mobile multimedia cloud that is scalable and efficient and provides cost-effective monitoring solution for noncommunicable disease patient. In order to validate the effectiveness of the framework, we also propose a novel evaluation model based on Analytical Hierarchy Process (AHP), which incorporates some criteria from multiple decision makers in the context of healthcare monitoring applications. Using the proposed evaluation model, we analyzed three possible frameworks (proposed hybrid framework, mobile, and multimedia frameworks) in terms of their applicability in the real healthcare environment.

Patient and nurse preferences for nurse handover-using preferences to inform policy: a discrete choice experiment protocol

INTRODUCTION: Nursing bedside handover in hospital has been identified as an opportunity to involve patients and promote patient-centred care. It is important to consider the preferences of both patients and nurses when implementing bedside handover to maximise the successful uptake of this policy. We outline a study which aims to (1) identify, compare and contrast the preferences for various aspects of handover common to nurses and patients while accounting for other factors, such as the time constraints of nurses that may influence these preferences.; (2) identify opportunities for nurses to better involve patients in bedside handover and (3) identify patient and nurse preferences that may challenge the full implementation of bedside handover in the acute medical setting. METHODS AND ANALYSIS: We outline the protocol for a discrete choice experiment (DCE) which uses a survey design common to both patients and nurses. We describe the qualitative and pilot work undertaken to design the DCE. We use a D-efficient design which is informed by prior coefficients collected during the pilot phase. We also discuss the face-to-face administration of this survey in a population of acutely unwell, hospitalised patients and describe how data collection challenges have been informed by our pilot phase. Mixed multinomial logit regression analysis will be used to estimate the final results. ETHICS AND DISSEMINATION: This study has been approved by a university ethics committee as well as two participating hospital ethics committees. Results will be used within a knowledge translation framework to inform any strategies that can be used by nursing staff to improve the uptake of bedside handover. Results will also be disseminated via peer-reviewed journal articles and will be presented at national and international conferences.

Patient engagement in clinical communication: an exploratory study

AIM: Existing practice strategies for actively involving patients in care during hospitalisation are poorly understood. The aim of this study was to explore how healthcare professionals engaged patients in communication associated with care transitions.

METHOD: An instrumental, collective case study approach was used to generate empirical data about patient transitions in care. A purposive sample of key stakeholders representing (i) patients and their families; (ii) hospital discharge planning team members; and (iii) healthcare professionals was recruited in five Australian health services. Individual and group semi-structured interviews were conducted to elicit detailed explanations of patient engagement in transition planning. Interviews lasted between 30 and 60 minutes and were digitally recorded and transcribed verbatim. Data collection and analysis were conducted simultaneously and continued until saturation was achieved. Thematic analysis was undertaken.

RESULTS: Five themes emerged as follows: (i) organisational commitment to patient engagement; (ii) the influence of hierarchical culture and professional norms on patient engagement; (iii) condoning individual healthcare professionals' orientations and actions; (iv) understanding and negotiating patient preferences; and (v) enacting information sharing and communication strategies. Most themes illustrated how patient engagement was enabled; however, barriers also existed.

CONCLUSION: Our findings show that strong organisational and professional commitment to patient-centred care throughout the organisation was a consistent feature of health services that actively engaged patients in clinical communication. Understanding patients' needs and preferences and having both formal and informal strategies to engage patients in clinical communication were important in how this involvement occurred.

Clinical reasoning sessions: back to the patient

BACKGROUND: Problem-based learning (PBL) was developed as a facilitated small group learning process based around a clinical problem. Originally designed for pre-clinical years of medical education, its application across all years poses a number of difficulties, including the risk of reducing patient contact, providing a learning process that is skewed towards an understanding of pathophysiological processes, which may not be well understood in all areas of medicine, and failing to provide exposure to clinically relevant reasoning skills. CONTEXT: Curriculum review identified dissatisfaction with PBLs in the clinical years of the Sydney Medical School's Graduate Medical Program, from both staff and students. A new model was designed and implemented in the Psychiatry and Addiction Medicine rotation, and is currently being evaluated. INNOVATION: We describe an innovative model of small-group, student-generated, case-based learning in psychiatry - clinical reasoning sessions (CRS) - led by expert facilitators. IMPLICATIONS: The CRS format returns the student to the patient, emphasises clinical assessment skills and considers treatment in the real-world context of the patient. Students practise a more sophisticated reasoning process with real patients modelled upon that of their expert tutor. This has increased student engagement compared with the previous PBL programme.

Adding a new anticoagulant or antiplatelet agent for patient receiving aspirin after an acute coronary syndrome? - Results from a pairwise and network meta-analysis of randomized-controlled trials

 Objectives: To synthesize the efficacy and safety outcomes from randomized-controlled trials (RCTs) regarding new oral anticoagulant, protease-activated receptor-1 (PAR-1) antagonist, and warfarin adjunctive to aspirin for patients after acute coronary syndrome (ACS) via pair-wise and network meta-analyses.
Methods: A comprehensive literature search was performed in Embase, Medline, Cochrane Library Web of Knowledge, and Scopus. The pair-wise meta-analysis was undertaken respectively to each agent/treatment category via Revmen 5.1. In order to estimate the relative efficacy of each agent/treatment category whilst preserving the randomized comparisons within each trial, a Bayesian network meta-analysis was conducted in WinBUGS using both fixed- and random-effects model. Covariate analysis was performed to explore the effects of length of follow-up and age of subject on the final results.
Results: In total, 23 RCTs were included in the meta-analysis. As shown by the results (OR,95%CI) for the pair-wise meta-analysis, new oral anticoagulants (0.85, [0.78, 0.93] and 3.04, [2.21, 4.19]), PAR-1 antagonists (0.80, [0.52, 1.22] and 1.55, [1.25, 1.93]) and warfarin (0.87, [0.74, 1.02] and 1.77, [1.46, 2.14]) might be able to provide better outcome in the incidences of major adverse events (MAE) but with higher bleeding risk comparing to aspirin treatment alone. Based on the model fit assessment, the random-effects model was adopted. The network meta-analysis (treatment effect comparing to aspirin lone) identified ximelagatran (-0.3044, [-0.8601, 0.2502]), dabigatran (-0.2144, [-0.8666, 0.4525]), rivoroxaban (-0.2179, [-0.5986, 0.1628]) and vorapaxar (-0.2272, [-0.81, 0.1664]) produced better improvements in MAE incidences whereas vorapaxar (0.3764, [-0.4444, 1.124]), warfarin (0.663, [0.3375, 1.037]), ximelagatran (0.7509, [-0.4164, 2.002]) and apixaban (0.8594, [-0.0049, 1.7]) produced less major bleeding events. The indirect comparisons among drug category (difference in incidence comparing to aspirin lone) showed new oral anticoagulants (-0.1974, [-0.284, -0.111]) and PAR-1 antagonists (-0.1239, [-0.215, -0.033]) to besuperior to warfarin (-0.1004, [-0.166, -0.035]) in the occurrences of MAE whereas PAR-1 antagonists (0.4292, [0.2123, 0.6476]) afforded better outcomes in major bleeding events against warfarin (0.5742, [0.3889, 0.7619]) and new oral anticoagulants (1.169, [0.8667, 1.485]).
Conclusion: Based on the study results, we cannot recommend the routine administration of new oral anticoagulant as add-on treatment for patients after ACS. However, for ACS patients comorbid with atrial fibrillation, new oral anticoagulant might be superior to warfarin in both efficacy and safety outcomes.

Inter-hospital 'patient expect' calls of clinical handovers for expected patients transferred from rural to metropolitan hospitals: a retrospective clinical audit

Patients requiring inter-hospital air transport across large geographical spaces are at significant risk of adverse outcomes. The aims of this study were to examine the characteristics of clinical handover conducted by telephone and subsequently transcribed in medical records during the inter-hospital transfer of rural patients, and to identify any deficits of this telephone clinical handover. A retrospective audit was conducted of transcribed telephone handovers ('patient expect' calls) occurring with inter-hospital transfers from two rural hospitals to a metropolitan tertiary hospital of all rural patients (n = 127) between January and June 2012. Patient transport between various sites occurred through the Royal Flying Doctor Service. For these hospitals, patient expect calls constituted the only handover record for clinicians during the time of patient transport. Information on patient identification stickers relating to patients' age or gender did not always correspond with details collected during patient expect calls. The name of a clinician at the receiving hospital authorising the transfer was provided in 14 calls (11.1%). It was difficult to determine who made and received calls, and who accepted responsibility for patients at the receiving site. Deterioration in a patient's condition was made in three calls. Actions to be taken after patients' arrival were included in 24 (19%) calls. Planning was restricted to identifying who to contact to review instructions. Inconsistent and overuse of abbreviations was likely to have affected the ability to accurately read back patient information. Crucial information was missing from calls, which may have contributed to delayed and inappropriate delivery of care.

The 45 year old health check - feasibility and impact on practices and patient behaviour

Background: The 45 year old health check (MBS item 717) for patients aged 45-49 years was introduced in 2006. This study evaluated its impact on preventive care and patient reported risk factors. Methods: A quantitative and qualitative study was conducted in eight general practices in Sydney, New South Wales. It involved follow up surveys of 118 patients taken both before the check and 3 months after. Practice staff were trained and supported to conduct the health checks and appropriate interventions. Results: There was ambivalence among some of the general practitioners toward the health check, but most found it feasible. The reported frequency of GP advice relating to each of the SNAP (smoking, nutrition, alcohol, and physical activity) risk factors increased; patient referrals, however, were infrequent. Patients' readiness to change their diet and exercise habits improved as a result of the check, with respondents showing an increase in both the consumption of vegetables and the frequency of physical activity. There was no change in body mass index, smoking or alcohol consumption. Discussion: The health check was associated with a short term improvement in diet and physical activity behaviours. Mechanisms to enhance referral need to be developed.

Patient perceptions about anesthesia and anesthesiologists before and after surgical procedures

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Retrograde Endovascular Treatment of Internal Iliac Aneurysm in a Patient with Marfan Syndrome

To report a technique to maintain pelvic flow to an internal iliac artery (IIA) with aneurysm in a patient with Marfan syndrome, and previously treated by infrarenal abdominal aortic aneurysm open procedure. Retrograde endovascular hypogastric artery preservation (REHAP) through flexible endograft implantation from external iliac artery (EIA) to internal iliac artery (IIA) was used. REHAP was a reasonable, minimally invasive and elegant alternative (new) to maintain pelvic arterial flow in Marfan syndrome. However, the long-term durability is unknown, and so, it should be used in selected patients.

Modified 'Stent-Graft Sandwich' Technique for Treatment of Isolated Common Iliac Artery Aneurysm in Patient With Marfan Syndrome

Isolated iliac artery aneurysms are rare in the general population (0.03%) and represent 2% of all abdominal aneurysms, and the association with Marfan syndrome is even rarer. We report a Marfan syndrome case with an isolated common iliac artery aneurysm treated by using a modified 'stent-graft sandwich' technique, with preservation of the internal iliac artery perfusion. The modified 'stent-graft sandwich' technique involves building an appropriate proximal neck just in the common iliac artery for fittingly housing two new stent-grafts inside, both deployed simultaneously and each one going to both distal iliac arteries (internal and external).