The SPHERE Study: Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Communication at the bedside to enhance patient care : a survey of nurses’ experience and perspective of handover

Strategies to support continuity of care and improve patient safety during clinical handover have been developed. The aims of this study were to identify the strengths and limitations in current practice of nursing clinical handover and implement a new bedside handover process. A total of 259 nurses completed a cross-sectional survey at change of shift on 1 day, which was followed by an audit of the pilot implementation of bedside handover. The survey results showed great variation in the duration, location and method of handover with significant differences in the experience of nurses employed part-time compared with full-time. Following implementation of standardized bedside handover on two wards, the audit revealed significant improvement in the involvement of patients, use of Situation-Background-Assessment-Recommendation, active patient checks and checking of documentation. These findings suggest the use of standardized protocols and communication tools for bedside handover improve continuity of patient care

The impact structured patient assessment frameworks have on patient care: an integrative review

Aims and objectives:
To evaluate structured patient assessment frameworks' impact on patient care.

Background:
Accurate patient assessment is imperative to determine the status and needs of the patient and the delivery of appropriate patient care. Nurses must be highly skilled in conducting timely and accurate patient assessments to overcome environmental obstacles and deliver quality and safe patient care. A structured approach to patient assessment is widely accepted in everyday clinical practice, yet little is known about the impact structured patient assessment frameworks have on patient care.

Design:
Integrative review.

Methods:
An electronic database search was conducted using Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System, PubMed and ProQuest Dissertations and Theses. The reference sections of textbooks and journal articles on patient assessment were manually searched for further studies. A comprehensive peer review screening process was undertaken. Research studies were selected that evaluated the impact structured patient assessment frameworks have on patient care. Studies were included if frameworks were designed for use by paramedics, nurses or medical practitioners working in prehospital or acute in-hospital settings.

Results:
Twelve studies met the inclusion criteria. There were no studies that evaluate the impact of a generic nursing assessment framework on patient care. The use of a structured patient assessment framework improved clinician performance of patient assessment. Limited evidence was found to support other aspects of patient care including documentation, communication, care implementation, patient and clinician satisfaction, and patient outcomes.

Conclusion:
Structured patient assessment frameworks enhance clinician performance of patient assessment and hold the potential to improve patient care and outcomes; however, further research is required to address these evidence gaps, particularly in nursing.

Relevance to clinical practice:
Acute care clinicians should consider using structured patient assessment frameworks in clinical practice to enhance their performance of patient assessment.

Mindfulness-based cognitive therapie for depression (MBCT) in clinical practice - baseline patient characteristics, process and outcome

Introduction: Mindfulness based cognitive therapy for depression (MBCT) has shown to be effective for the reduction of depressive relapse. However, additional information regarding baseline patient characteristics and process features related to positive response could be helpful both for the provision of MBCT in clinical practice, as well as for its further development. Method: Baseline characteristics, process data, and immediate outcome (symptom change, change in attitudes and trait mindfulness) of 108 patients receiving MBCT in routine care were recorded. A newly developed self-report measure (Daily Mindfulness Scale, DMS) was applied daily during the MBCT program. Additionally, patients filed daily reports on their mindfulness practice. There was no control group available. Results: Patients with more severe initial symptoms indicated greater amounts of symptom improvement, but did not show great rates of dropout from the MBCT intervention. Younger age was related to higher rates of dropout. Contradictory to some previous data, patients with lower levels of initial trait mindfulness showed greater improvement in symptoms, even after controlling for initial levels of symptoms. Adherence to daily mindfulness practice was high. Consistent with this result, the duration of daily mindfulness practice was not related to immediate outcome. Process studies using multivariate time series analysis revealed a specific role of daily mindfulness in reducing subsequent negative mood. Conclusions: Within the range of patient present in this study and the given study design, results support the use of MBCT in more heterogeneous groups. This demanding intervention was well tolerated by patients with higher levels of symptoms, and resulted in significant improvements regarding residual symptoms. Process-outcome analyses of initial trait mindfulness and daily mindfulness both support the crucial role of changes in mindfulness for the effects of MBCT.

Role of ubiquitous sensor network in patient care

Efficient caring for the patient's information is an important aspect of caring for the patient. If these processes are possible to monitor anytime anywhere as per the patients' and doctors desecrations the cost of patient care could be minimised. In this connection, Ubiquitous Sensor Network is playing a key role on communication between physicians and patients as well as information sharing among health care providers with rapid access to medical information through reliable and trusted computer network systems. This paper argues possibilities of such scenarios by introducing a ubiquitous sensor network in patient care for 21st century's requirements and standards.

Is there a place for pixels in our practice? Dietitians' attitudes towards the use of photographic dietary records within the nutrition care process

Photographic records of dietary intake (PhDRs) are an innovative method for the dietary assessment and may alleviate the burden of recording intake compared to traditional methods of recording intake. While the performance of PhDRs has been evaluated, no investigation into the application of this method had occurre within dietetic practice. This study examined the attitudes of dietitians towards the use of PhDRs in the provision of nutrition care. A web-based survey on the practices and beliefs with regards to technology use among Dietitians Association of Australia members was conducted in August 2011. Of the 87 dietitians who responded, 86% assessed the intakes of clients as part of individualised medical nutrition therapy, with the diet history the most common method used. The majority (91%) of dietitians surveyed believed that a PhDR would be of use in their current practice to estimate intake. Information contained in the PhDR would primarily be used to obtain a qualitative evaluation of diet (84%) or to supplement an existing assessment method (69%), as opposed to deriving an absolute measure of nutrient intake (31%). Most (87%) indicated that a PhDR would also be beneficial in both the delivery of the intervention and to evaluate and monitor goals and outcomes, while only 46% felt that a PhDR would assist in determining the nutrition diagnosis. This survey highlights the potential for the use of PhDRs within practice. Future endeavours lie in establishing resources which support the inclusion of PhDRs within the nutrition care process.

Implementation of a chest pain management service improves patient care and reduces length of stay

Objective Chest pain is one of the most common complaints in patients presenting to an emergency department. Delays in management due to a lack of readily available objective tests to risk stratify patients with possible acute coronary syndromes can lead to an unnecessarily lengthy admission placing pressure on hospital beds or inappropriate discharge. The need for a co-ordinated system of clinical management based on enhanced communication between departments, timely and appropriate triage, clinical investigation, diagnosis, and treatment was identified. Methods An evidence-based Chest Pain Management Service and clinical pathway were developed and implemented, including the introduction of after-hours exercise stress testing. Results Between November 2005 and March 2013, 5662 patients were managed according to a Chest Pain Management pathway resulting in a reduction of 5181 admission nights by more timely identification of patients at low risk who could then be discharged. In addition, 1360 days were avoided in high-risk patients who received earlier diagnosis and treatment. Conclusions The creation of a Chest Pain Management pathway and the extended exercise stress testing service resulted in earlier discharge for low-risk patients; and timely treatment for patients with positive and equivocal exercise stress test results. This service demonstrated a significant saving in overnight admissions.

Developing a toolkit for assessing the impact of health library services on patient care

Urquhart,C., Spink, S., Thomas, R. & Weightman, A. (2007). Developing a toolkit for assessing the impact of health library services on patient care. Report to LKDN (Libraries and Knowledge Development Network). Aberystwyth: Department of Information Studies, Aberystwyth University. Sponsorship: Libraries and Knowledge Development Network/ NHS

Experiences of the foster care process in the Republic of Ireland: retrospective accounts from biological children of foster carers

This thesis examines the experiences of the biological children of foster carers. In particular it explores their experiences in relation to inclusion, consultation and decision-making. The study also examines the support and training needs of birth children in foster families. Using a qualitative methodology in-depth, semi-structured interviews were conducted with fifteen birth children of foster carers aged between 18 and 30 years. The research findings show that for the majority of birth children, fostering was overall a positive experience which helped them develop into individuals who were caring and nonjudgemental. However, from the data collected in this study, it is clear that fostering also brings a range of challenges for birth children in foster families, such as managing feelings of loss, grief, jealousy and guilt when foster children leave. Birth children are reluctant to discuss these issues with their parents and often did not approach fostering social workers as they did not have a meaningful relationship in order to discuss their concerns. The findings also demonstrate that birth children undertake a lot of emotional work in supporting their parents, birth siblings and foster siblings. Despite the important role played by birth children in the fostering process, this contribution often goes unrecognised and unacknowledged by fostering professionals and agencies with birth children not included or consulted about foster care decisions that affect them. It is argued here that birth children are viewed by foster care professionals and agencies from a deficit based perspective. However, this study contends that it is not just foster parents who are involved in the foster care process, but the entire foster family. The findings of this study show that birth children are competent social actors capable of making valuable contributions to foster care decisions that affect their lives and that of their family.