A framework for challenging deficits in compression bandaging techniques

Northern Irish (and all UK-based) health care is facing major challenges. This article uses a specific theory to recommend and construct a framework to address challenges faced by the author, such as deficits in compression bandaging techniques in healing venous leg ulcers and resistance found when using evidence-based research within this practice. The article investigates the challenges faced by a newly formed community nursing team. It explores how specialist knowledge and skills are employed in tissue viability and how they enhance the management of venous leg ulceration by the community nursing team. To address these challenges and following a process of reflection, Lewin's forcefield analysis model of change management can be used as a framework for some recommendations made.

A community nurse referral system for HMRs: Can it work?

The HMR model contains a mechanism whereby anyone who is concerned about the risk of medication misadventure can request a HMR from the patient's GP. Since nurses are widely involved in a range of triage and gatekeeping roles, utilising their primary care skills to identify patients for a HMR is a logical extension of this role. Furthermore, community nurses visit their clients in the home situation and see many difficulties the client may be experiencing at first hand. They are therefore well placed to request specialist assistance for the client. Blue Care in Brisbane, a community nursing service, approached its local Division of General practice to determine how best to request HMRs for its clients. The Division contacted The University of Queensland which initiated this study to engage the health care team to tailor the established HMR request process to the needs of community nurses and test the system developed. (non-author abstract)

Compression for preventing recurrence of venous ulcers

Background: Up to 1% of adults will suffer from leg ulceration at some time. The majority of leg ulcers are venous in origin and are caused by high pressure in the veins due to blockage or weakness of the valves in the veins of the leg. Prevention and treatment of venous ulcers is aimed at reducing the pressure either by removing / repairing the veins, or by applying compression bandages / stockings to reduce the pressure in the veins. The vast majority of venous ulcers are healed using compression bandages. Once healed they often recur and so it is customary to continue applying compression in the form of bandages, tights, stockings or socks in order to prevent recurrence. Compression bandages or hosiery (tights, stockings, socks) are often applied for ulcer prevention. Objectives To assess the effects of compression hosiery (socks, stockings, tights) or bandages in preventing the recurrence of venous ulcers. To determine whether there is an optimum pressure/type of compression to prevent recurrence of venous ulcers. Search methods The searches for the review were first undertaken in 2000. For this update we searched the Cochrane Wounds Group Specialised Register (October 2007), The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library 2007 Issue 3, Ovid MEDLINE - 1950 to September Week 4 2007, Ovid EMBASE - 1980 to 2007 Week 40 and Ovid CINAHL - 1982 to October Week 1 2007. Selection criteria Randomised controlled trials evaluating compression bandages or hosiery for preventing venous leg ulcers. Data collection and analysis Data extraction and assessment of study quality were undertaken by two authors independently. Results No trials compared recurrence rates with and without compression. One trial (300 patients) compared high (UK Class 3) compression hosiery with moderate (UK Class 2) compression hosiery. A intention to treat analysis found no significant reduction in recurrence at five years follow up associated with high compression hosiery compared with moderate compression hosiery (relative risk of recurrence 0.82, 95% confidence interval 0.61 to 1.12). This analysis would tend to underestimate the effectiveness of the high compression hosiery because a significant proportion of people changed from high compression to medium compression hosiery. Compliance rates were significantly higher with medium compression than with high compression hosiery. One trial (166 patients) found no statistically significant difference in recurrence between two types of medium (UK Class 2) compression hosiery (relative risk of recurrence with Medi was 0.74, 95% confidence interval 0.45 to 1.2). Both trials reported that not wearing compression hosiery was strongly associated with ulcer recurrence and this is circumstantial evidence that compression reduces ulcer recurrence. No trials were found which evaluated compression bandages for preventing ulcer recurrence. Authors' conclusions No trials compared compression with vs no compression for prevention of ulcer recurrence. Not wearing compression was associated with recurrence in both studies identified in this review. This is circumstantial evidence of the benefit of compression in reducing recurrence. Recurrence rates may be lower in high compression hosiery than in medium compression hosiery and therefore patients should be offered the strongest compression with which they can comply. Further trials are needed to determine the effectiveness of hosiery prescribed in other settings, i.e. in the UK community, in countries other than the UK.

Cost effectiveness of community leg ulcer clinics: randomised controlled trial

Objectives: To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses.

Negotiating : experiences of community nurses when contracting with clients

A community nurse is required to have excellent interpersonal, teaching, collaborative and clinical skills in order to develop effective individualised client care contracts. Using a descriptive qualitative design data was collected from two focus groups of fourteen community nurses to explore the issues surrounding negotiating and contracting client care contracts from the perspective of community nurses. Thematic analysis revealed three themes: ‘assessment of needs’, ‘education towards enablement’, and ‘negotiation’. ‘Assessment of needs’ identified that community nurses assess both the client’s requirements for health care as well as the ability of the nurse to provide that care. ‘Education towards enablement’ described that education of the client is a common strategy used by community nurses to establish realistic goals of health care as part of developing an ongoing care plan. The final theme, ‘negotiation’, involved an informed agreement between the client and the community nurse which forms the origin of the care contract that will direct the partnership between the client and the nurse. Of importance for community nurses is that development of successful person-centred care contracts requires skillful negotiation of care that strikes the balance between the needs of the client and the ability of the nurse to meet those needs.

The long and winding road : health services for clients with chronic leg ulcers in the community

The prevalence of leg ulcers of is 0.12%–1.1% and >3,000 lower limb amputations are performed yearly in Australia due to non-healing leg or foot ulcers. Although evidence on leg ulcer management is available, a significant evidence-practice gap exists. To identify current leg ulcer management, a cross-sectional retrospective study was undertaken in Brisbane, Australia. A sample of 104 clients was recruited from a community specialist wound clinic and a tertiary hospital outpatient’s specialist wound clinic. All clients had an ulcer below their knee or on their foot for ≥4 weeks. Data were collected on ulcer care, health service usage and clinical history for the year prior to admission. On admission, participants reported having their ulcer for a median of 25 weeks (range 2-728 weeks); with 51% (53/104) reporting an ulcer duration of ≥24 weeks. Including the wound clinic, participants sought ulcer care from a median of 3 health care providers (range 2-7). General Practitioners provided ulcer care to 82% of participants. Nearly half (42%) had self-cared for their ulcer; 29% (30/104) received treatment by a community nurse. A gap was found between the community-based ulcer care experienced by this population and evidence-based guidelines in regards to assessment, management, advice, and referrals.

Provisional matrix deposition in hemostasis and venous insufficiency: Tissue preconditioning for nonhealing venous ulcers

Significance: Chronic wounds represent a major burden on global healthcare systems and reduce the quality of life of those affected. Significant advances have been made in our understanding of the biochemistry of wound healing progression. However, knowledge regarding the specific molecular processes influencing chronic wound formation and persistence remains limited. Recent Advances: Generally, healing of acute wounds begins with hemostasis and the deposition of a plasma-derived provisional matrix into the wound. The deposition of plasma matrix proteins is known to occur around the microvasculature of the lower limb as a result of venous insufficiency. This appears to alter limb cutaneous tissue physiology and consequently drives the tissue into a ‘preconditioned’ state that negatively influences the response to wounding. Critical Issues: Processes, such as oxygen and nutrient suppression, edema, inflammatory cell trapping/extravasation, diffuse inflammation, and tissue necrosis are thought to contribute to the advent of a chronic wound. Healing of the wound then becomes difficult in the context of an internally injured limb. Thus, interventions and therapies for promoting healing of the limb is a growing area of interest. For venous ulcers, treatment using compression bandaging encourages venous return and improves healing processes within the limb, critically however, once treatment concludes ulcers often reoccur. Future Directions: Improved understanding of the composition and role of pericapillary matrix deposits in facilitating internal limb injury and subsequent development of chronic wounds will be critical for informing and enhancing current best practice therapies and preventative action in the wound care field.

Remote sensing utility expansion through Earth Portal internet browser

A modular, graphic-oriented Internet browser has been developed to enable non-technical client access to a literal spinning world of information and remotely sensed. The Earth Portal (www.earthportal.net) uses the ManyOne browser (www.manyone.net) to provide engaging point and click views of the Earth fully tessellated with remotely sensed imagery and geospatial data. The ManyOne browser technology use Mozilla with embedded plugins to apply multiple 3-D graphics engines, e.g. ArcGlobe or GeoFusion, that directly link with the open-systems architecture of the geo-spatial infrastructure. This innovation allows for rendering of satellite imagery directly over the Earth's surface and requires no technical training by the web user. Effective use of this global distribution system for the remote sensing community requires a minimal compliance with protocols and standards that have been promoted by NSDI and other open-systems standards organizations.

Self-neglect: a case study and implications for clinical practice

Self-neglect is a worldwide and serious public health issue that can have serious adverse outcomes and is more common in older people. Cases can vary in presentation but typically present as poor self-care, poor care of the environment and service refusal. Community nurses frequently encounter self-neglect cases and health and social care professionals play a key role in the identification, management and prevention of self-neglect. Self-neglect cases can give rise to ethical, personal and professional challenges. The aim of this article is to create a greater understanding of the concept of self-neglect among community nurses.

Efetividade da terapia fisica descongestiva na cicatrização de úlceras venosas

A venous ulcer is the most serious clinical manifestation of chronic venous failure, and the most frequent in lower limbs, accounting for 70% of all ulcers. Patients may suffer from this infirmity for several years without healing of the lesion if treatment is inadequate. The aim of this investigation was to verify the effectiveness of decongestive physical therapy in the healing of venous ulcers. This is a quasi-experimental, interventionist study, with paired, non-probabilistic sampling, composed of 50 patients divided into two groups: control and intervention, each composed of 25 patients. Both groups were identically treated for six months with daily dressings and the latter also underwent complex physical therapy consisting of a combination of the following techniques: manual lymphatic drainage, compression bandaging, lower limb elevation, myolymphokinetic exercises and skin care. The study was approved (Protocol no. 59/2007) by the Ethics Committee of the State University of Southeast Bahia. The Mann-Whitney and Chi-square tests were applied for data analysis. After statistical analysis the patients who underwent therapy showed a statistically significant difference with respect to wound contraction starting in the second month of treatment. Compared to the control, the intervention group showed a greater reduction in both pain and edema starting in the third and fourth month of therapy, respectively. To reinforce these findings, the mean percentage of tissue present at the base of the ulcer (granulation/fibrin ratio) was calculated. The intervention group showed greater granulation at the base of the ulcer compared to the control, significant from the second month of treatment on. It was observed in this study that lymphotherapy, when compared between the intervention and control groups, accelerated the healing process, and reduced pain and edema in the affected limbs. It is expected, therefore, that these results widen scientific knowledge and we suggest that this therapy be used 78 not only to reduce lymphedema, but also as a treatment option for venous ulcers, given its easy application and low cost. The data, therefore, demonstrated the importance of basic care on the part of a multiprofessional and transdisciplinary health team involved in the healing process of these infirmities, thereby contributing to better quality of life in these individuals

Effectiveness of screening for risk of medical emergencies in the elderly

Study objective: UK government policy mandates the introduction of 'intermediate care services' to reduce emergency admissions to hospital from the population aged 75 years or more. We evaluated one of these initiatives-the Keep Well At Home (KWAH) Project-in a West London Primary Care Trust. Design: KWAH involves a two-phase screening process, including a home visit by a community nurse. We employed cohort methods to determine whether KWAH resulted in fewer emergency attendances and admissions to hospital in the target population, from October 1999 to December 2002. Results: estimated levels of coverage in the two phases of screening were 61 and 32%, respectively. The project had not maintained records of which additional health and social care services had been delivered following screening. The rates of emergency admissions to hospital in the 9 months before screening were similar in practices that did and did not join the project (rate ratio (RR) = 1.05; 95% CI 0.95-1.17), suggesting absence of volunteer bias. Over the first 37 months of the project, there was no significant impact on either attendances at Accident & Emergency departments (RR = 1.02; 95% CI 0.97-1.06) or emergency admissions of elderly patients (RR = 0.98; 95% CI 0.93-1.05). Conclusion: the KWAH Project has been ineffective in reducing emergency admissions among the elderly. Significant questions arise in relation to selection of the screening instruments, practicality of achieving higher coverage of the eligible population, and creation of a new postcode lottery.

Medication review of children on long term medications:a review of the literature

INTRODUCTION: Children on long term medication may be under the care of more than one medical team including the patients GP. Children on chronic medication should be supported and their medications reviewed, especially in cases of polypharmacy. Medicines Use Reviews (MURs) were introduced into the pharmacy contract in 2005. The service was designed for community pharmacists to review patients on long term medication. The service specified that MURs were done on patients who can give consent and cannot be conducted with a parent or carer. Hence the service may be inaccessible to paediatric patients. This review aims to find studies that identify medication review services in primary care that cater for children on long term medication. METHODS: A literature search was conducted on 6th June 2015 using the keywords, ("Medication" or "review" or "Medication Review" or "Medicines use review" or "Medication use review" or "New Medicine Service") AND ("community pharmacy" OR "community pharmacist" OR "primary care" OR "General practice" OR "GP" OR "community paediatrician" OR "community pediatrician" OR "community nurse"). Bibliographic databases used were AMED, British Nursing Index, CINAHL, EMBASE, HMIC, MEDLINE, PsycINFO and Health Business Elite. Inclusion criteria were: paediatric specific medication review in primary care, for example by either a GP, community paediatrician, community nurse or community pharmacist. Exclusion criteria were studies of medication review in adults/unclear patient age and secondary care medication reviews. RESULTS: From the 417 articles, 6 relevant articles were found after abstract and full text review. 235 articles were excluded after title and abstract review (11 did not have full text in English); 96 were adult or non-age specified medication review/MUR/New Medicine Service studies; 63 referred to observational, evaluative studies of interventions in adults; 6 were non-paediatric specific systematic reviews and 17 were protocols, commentaries, news, and letters.The 6 relevant articles consisted of 1 literature review (published 2004), 3 research articles and 1 published protocol. The literature review[1] recommended that children's long term medication should be reviewed. The published protocol stated that the NMS minimum age for inclusion in the trial was for children aged over 13 years of age. The four studies were related to psychiatrists reviewing paediatric mental health patients in the USA, a pharmacist using Drug Related Problem to review patients in GP practices in Australia, a UK study based on an information prescription concept by providing children dispensed medications in community pharmacy with signposting them to health information and one GP practice based study observing pharmaceutical care issues in children and adults. CONCLUSION: The results show that there are currently no known studies on medication use reviews specific to children, whereas in adults, published evaluations are available. The terms of the MUR policy restrict children's access to the service and so more studies are necessary to determine whether children could benefit from such access.

Myths and Realities of Inter-professional Working

Introduction: Childhood cancers are rare and community based health care professionals have limited experience in caring for these children and often even less experience in providing their palliative care. It is well recognised that the provision of palliative care falls beyond the remit of any one profession, thus inter professional working is the standard model. This qualitative study aims to examine the experiences of the range of health care professionals involved in providing palliative care at home for children with cancer, focusing on how knowledge is exchanged; the level of communication and support both interprofessionally and at the community/specialist interface. It also aims to examine interprofessional collaboration in palliative care; identifying healthcare professional's perceptions of problems involved, interprofessional boundaries, specific areas of the organisation or provision of care that could be enhanced through changes in practice, support issues and the educational needs of health professionals. Methods The study involves three types of data collection; in-depth interviews, facilitated case discussion (FCD) and field notes from up to 20 cases (a "case" refers to the provision of palliative care to one child). Cases are selected from children who were treated at one regional childhood caner centre. For each case the community based health care professionals (for example the GP, community nurse or health visitor) involved in the care of the child at home are invited to participate in a one-to-one tape recorded in-depth interview followed by a group discussion in the form of a FCD. Field notes are completed following each interview. Data analysis follows a grounded theory approach. The term "social worlds theory" (SWT) his used to define a type of social organisation with no fixed or formal boundaries (such as membership boundaries), for example the range of health professionals that work together to provide palliative care. The boundaries of SW's are determined by the interaction and communication between recognised organisations, such as community nursing teams and general practitioners. SWT examines encounters between different professional groups and can be used to extend knowledge in both the organisation (for example general practice) and the content of what is being provisioned (for example, palliative care). The use of SWT in the analysis of the data is through examining the ethos of the different professions and the associated individual approaches to palliative care, exploring how this determines their roles in the provision of palliative care. Results 10 cases have so far been completed: 47 1:1 interviews (with a range of between 2-7 health care professionals being involved in each case): ( 9 x GP, 19 x CCN, 4 x DN, 3 x HV, 1 x HV assistant 7 x paediatric palliative care nurses, 1 x home support worker, 1 x OT, 1 x physiotherapist, 1 x community paediatrician) and 5 x FCD. The range of participants in the FCDs reflected that of the individual interview sampler. Data obtained to date gives clear insight into the personal experience of the individual health care professional in providing palliative care. Two themes emerging from the data will be focused upon: the continuity of care provision throughout treatment and palliation and the emotional burden experiences by the health care professional. Conclusions SWT can provide a useful framework in examining the social worlds of a disparate group of health care professionals working together for the first and maybe, the only time. A wide variation in the continuity of care provision has been found not only between professions, but also within professions. The emotional burden is evident across the professions.