Innovation in diabetic care : from patient-centered care to public policies to reduce the impact of diabetes

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2022Introdução A diabetes, nomeadamente a diabetes tipo 2, é uma doença crónica, que necessita de cuidados de saúde em continuidade, de longa duração e muitas vezes multidisciplinares. A diabetes consome vastos recursos de saúde, financeiros e de assistência social, exigindo, em todos os níveis de cuidados de saúde, e às famílias um grande esforço. Sendo uma doença que exige capacitação do paciente, literacia, adesão ao tratamento e promoção de comportamentos saudáveis, é também o paradigma de uma doença onde a relação com os profissionais de saúde e o cuidado centrado no paciente são fatores fundamentais para seu controle. A saúde tem sido palco de muitas inovações, tanto tecnológicas, como também de gestão, prática clínica, farmacológicas, dispositivos vários e uso da informação. Os cuidados na diabetes e outras doenças crónicas estão na linha de frente do desenvolvimento, testagem e implementação destas inovações, o que iremos ilustrar ao longo deste trabalho. Objetivo Identificar e analisar como a inovação nos cuidados prestados aos doentes com diabetes tem vindo a alterar a capacidade de prestar cuidados centrados no doente, e demonstrar abertura a novas iniciativas e ao desenvolvimento de políticas públicas de gestão em saúde, financiamento, tecnologia/informação e sociais com vista providenciar melhores cuidados e reduzir os impactos desta doença. Neste contexto, é nosso objetivo descrever, conceptualizar e sistematizar como a inovação tem evoluído e influenciado os cuidados ao paciente diabético e identificar os respetivos impactos. Métodos Procedeu-se à revisão da literatura usando as bases de dados PubMed, Scopus e Word of Science, pesquisando a associação entre diabetes tipo 2 e inovação. Foram encontrados 254 artigos. A partir da seleção desses trabalhos foi efetuada uma busca manual de artigos a descrever, ilustrar e avaliar as inovações identificadas, num total de 69 artigos.Resultados No âmbito dos cuidados aos doentes com diabetes, foram identificados dezasseis processos de inovação com inegável relevância em quatro áreas – três casos de inovação em gestão, quatro financeiras, seis tecnológicas e três de ação social. Conclusão Constata-se que as diversas categorias de inovação estão interligadas e são complementares, possibilitando oferecer melhores cuidados centrados no paciente, ao mesmo tempo que vislumbram a necessidade de proceder ao “redesenho” dos sistemas e serviços de saúde. Admite-se que, no futuro, a sua adequada integração acarretaria melhores cuidados e permitiria reduzir o impacto da diabetes, podendo vir a ser o modelo a utilizar no manejo de outras doenças crónicas.Background Diabetes, namely type-2 diabetes, is a chronic disease that requires continuous, long-term, and often multidisciplinary medical care. Diabetes consumes a vast amount of health, financial and social care resources, demanding great efforts at all levels of health care and families. As a disease that requires patient training, literacy, adherence to treatment, and the promotion of healthy behaviors, it is also the paradigm of a disease where health professionals’ relationship and patient-centered care are key factors for its control. Health has been the scene of many innovations, both technological, as well as management, clinical practice, medication, a wide variety of devices, and information uses. Diabetic, and of other chronic diseases, is at the forefront of the development, testing, and implementation of these innovations, which we will illustrate throughout this work. Aim Identify and analyze how innovation in care provided to patients with diabetes has been changing the ability to provide patient-centered care, and open-up new initiatives and development of public policies in health, financing, technological/information and social management with the view to provide better care and reduce the impacts of this disease. In this context, we will describe, conceptualize and systematize how innovation has evolved and influenced diabetic patient care and identify the respective impacts. Methods A literature review was carried out using PubMed, Scopus, and Word of Science databases, investigating the association between type 2 diabetes and innovation. Two hundred and fifty-four articles were found. From the research, a manual search of articles aiming to describe, exemplify, and evaluate the innovations in diabetes care, was carried out, resulting in a total of 69 articles.Results Four main areas were identified within the scope of diabetes patients’ care, in which innovation processes are present with undeniable relevance – management, financial, technological, and social action, which will be analyzed on the course of this work. Conclusion It was possible to observe that the different categories of innovation are interconnected and complementary, making it possible to offer better patient-centered care, while at the same time envisioning the need to “redesign” of health systems and services. It is accepted that, in the future, their appropriate integration would lead to better care and reduce the impact of diabetes, as well as potentially become the model that could be used in the management of other chronic diseases

The Missing Link: the key to improved wound assessment

Clinicians discuss using Debrisoft to improve wound assessement, quality of life and cost effectiveness

NURSING CARE FOR GRADE II DIABETIC ULCUS

Background –Uncontrolled diabetes mellitus will cause various complications, one of which is diabetic ulcers. The incidence of diabetic ulcers in DM patients is still high, namely in 2020 it has reached 25% throughout their lives. Patients will be susceptible to severe infections if they do not understand how to properly care for wounds, so that patients with diabetic ulcers can experience problems in the form of impaired tissue integrity. The development of wound care with modern dressing methods has become a trend now, because this wound treatment uses the moist concept so that it speeds up the wound drying process.Objectives –The case study aims to provide nursing care to patients with grade III diabetic ulcers with the main problem being impaired tissue integrity.Method –This type of case study uses a qualitative research design with a case study approach. The sample in this study consisted of 2 diabetic ulcer patients with conventional wound care for 6 days.Results –The results of case management for 6x8 hours showed that the wound condition had decreased in the BJWAT assessment score, but the wound healing process had not been resolved, namely patient 1 on the first day the BJWAT score was 38 then the sixth day it became 28 , while patient 2 on the first day was 39 then days sixth to 27. The wound healing process does take quite a long time, which can reach 12-20 weeks.Conclusion– The conclusion of this scientific paper is that after treating the wound using 0.9% NaCl solution compressed with metronidazole and gentamicin ointment for 6x8 hours, the wound healing process has not been resolved, but the BJWAT wound assessment score has decrease

Influencing the Inflammatory Response Through Multi-Scale Geometry, Antibiotic Release, and Fluid Management in a Textile-Based Biomaterial Wound Dressing

The total population of diagnosed and undiagnosed diabetes mellitus in the United states is expected to rise by 54% between the years of 2015 and 2030 contributing to $200 billion in health care expense. The exponential rise in common diabetic wounds, such as diabetic foot ulcers, puts a large population at risk for complications such as infection, amputation, and even death. Peripheral neuropathy leading to late diagnoses, patient non-compliance, and lack of holistic treatment options all contribute to complications with the incidence of new ulcer formation after treatment reaching 50%. This work explores the design, development, and in vitro evaluation of a multicomponent textile-based biomaterial and absorptive dressing that combines the need to manage infection, eliminate excess exudate levels, and provide an ideal environment for healthy tissue to repair and remodel the wound site. Melt-splun poly-l-lactide (PLLA) yarn of fibers with round or 4-deep-grooved (4DG) geometry were knitted into the skin-contact layer, the first layer of the dressing. Different methods of gentamicin sulfate (GS) incorporation, along with the impact of fiber geometry, were studied to explore optimal antibiotic release and efficacy. Results indicated that an increase in surface area as well as heat-enabled diffusion allowed for higher release of GS. Because each factorial treatment, with the exception of exhaustion dyeing method of incorporation, released GS at or above the minimum inhibitory concentration, there showed no difference in geometry and method of incorporation on antibacterial efficacy. The GS incorporated skin contact layer also appeared to be biocompatible in cultures of mouse bone marrow stromal D1 cells. Cell adhesion studies showed that a polyethylene glycol (PEG) surface treatment is needed to prevent non-specific protein and cellular attachment upon dressing changes. A microscopically thin layer of PEG was added to the surface of the contact layer and showed less cell attachment as seen in fluorescently labeled LIVE/DEADTM analysis, while showing no impact on GS release and antibacterial efficacy. In this aim, it can be concluded that the combination of GS release and a PEG surface coat can simultaneously kill and prevent infection while providing a non-adhesive surface upon removal from the wound. Polyurethane (PU) foam was characterized in a two-factor analysis based on foam density and mixing speed used to create the foam layer. PU foam V was chosen as the absorptive layer of the dressing and a comparative analysis was conducted using commercialized absorptive dressings. The PU foam layer was exposed to different time durations of ultra-violet ozone to increase the surface wettability and initiate moisture absorption. To prevent saturation, PLLA yarn of 4DG fibers was braided into an evaporative and moisture wicking layer. The braided fabric was able to vertically wick porcine serum at a rate of 0.88 mm/sec. The combination of absorptive and moisture wicking layers stimulate wound healing by removing moisture from the ulcer, while preventing maceration and premature saturation of the dressing, leading to fewer dressing changes. Additionally, an in vitro chronic wound model was constructed to verify the efficacy of the combined layers of the dressing. After applying the dressing for a duration of 48 hours, the dressing inhibited bacterial infection, while acting as a superabsorbent material without causing saturation. Further work explored healthy cell viability and any oxidative stress levels after exposing cells to both bacterial infection and the dressing. Although the in vitro model maintains some limitations and assumptions at the present time, it can be concluded that with the addition of the wound dressing, cell viability increased over time, and therefore promoted tissue repair. Future work will explore alternative antimicrobials for a more gradual release as well as improving the in vitro model by discovering the interaction between the co-culture in different types of medias and substrates while including proinflammatory biomarkers that could affect oxidative stress

What does it take to make integrated care work? A ‘cookbook’ for large-scale deployment of coordinated care and telehealth

The Advancing Care Coordination & Telehealth Deployment (ACT) Programme is the first to explore the organisational and structural processes needed to successfully implement care coordination and telehealth (CC&TH) services on a large scale. A number of insights and conclusions were identified by the ACT programme. These will prove useful and valuable in supporting the large-scale deployment of CC&TH. Targeted at populations of chronic patients and elderly people, these insights and conclusions are a useful benchmark for implementing and exchanging best practices across the EU. Examples are: Perceptions between managers, frontline staff and patients do not always match; Organisational structure does influence the views and experiences of patients: a dedicated contact person is considered both important and helpful; Successful patient adherence happens when staff are engaged; There is a willingness by patients to participate in healthcare programmes; Patients overestimate their level of knowledge and adherence behaviour; The responsibility for adherence must be shared between patients and health care providers; Awareness of the adherence concept is an important factor for adherence promotion; The ability to track the use of resources is a useful feature of a stratification strategy, however, current regional case finding tools are difficult to benchmark and evaluate; Data availability and homogeneity are the biggest challenges when evaluating the performance of the programmes

Diabetic foot ulcers - predictors of healing time and aspects of telemedicine

Background: A diabetic foot ulcer (DFU) is a feared complication of diabetes. Both duration and severity of ulcer before start of treatment in specialist health care are factors that can effect healing time for patient with DFUs. More research about duration and severity of DFUs before seeking care as predictors of healing time might contribute to knowledge of importance for clinical interventions. Treatment of DFUs puts pressure on the health care system in terms of utilization of available resources. Moreover, the prevalence of diabetes is increasing dramatically and, as a result, longterm diabetes-related complications are also likely to increase. Telemedicine can be one way to address these issues, because telemedicine follow up may enable more integrated care pathways across health care levels. Telemedicine has been used in different settings, but knowledge of telemedicine’s effect on clinical outcomes and patients’ experiences among patients with DFUs is limited. Aims: The overall aim of this study was to provide new knowledge about predictors of healing time in patients with a DFU and to assess the effect of and experience with a telemedicine intervention for patients with a DFU. To achieve the overall aim, three specific aims were established: 1) to investigate whether A) duration of ulcer before start of treatment in specialist health care, and B) severity of ulcer according to the University of Texas (UT) classification system at the start of treatment (baseline), are independent predictors of healing time; 2) to evaluate whether telemedicine follow up of patients with DFUs treated in primary health care, in collaboration with hospital outpatient specialist care, is noninferior to standard outpatient care in terms of ulcer healing time. Further, to assess for superior whether amputations, death, consultations and patient satisfaction are different from telemedicine follow up compared to standard outpatient care; and, 3) to explore the experiences of patients with DFUs receiving telemedicine compared to patients receiving standard outpatient care health care delivered in the context of a cluster randomised controlled trial. Methods: Three different study designs were used. Study I: A retrospective cohort study included data from electronic medical records system of 105 patients with new DFUs from two outpatient clinics in Western Norway during 2009-2011. Competing risk regression with adjustment for potential confounders was used to evaluate the associations of duration and severity of the ulcer with healing time. Study II: In this pragmatic cluster randomised controlled non-inferiority trial, 182 patients (94/88 in telemedicine/standard outpatient care; 42 clusters) with a new DFU were recruited from three hospital outpatient clinics in Western Norway (from September 2012 to June 2016). The primary endpoint was healing time and secondary endpoints included amputation, death, number of consultations per month, and patient satisfaction. Study III: In the qualitative study individual interviews were conducted with 24 adults recruited from the cluster randomised controlled non-inferiority trial (n=13/ n=11 from the telemedicine /standard outpatient care group) in the period March 2014-May 2015. Results: Study 1: Of the 105 adults, 48 (45.7%) achieved ulcer healing, 38 (36.2%) underwent amputations, 10 (9.5%) died before ulcer healing and 9 (8.5%) were lost to follow up. For those who healed, mean healing time was 3.8 months (113 days), measured from start of treatment in the specialist health care to end of follow up. Time from patient-reported ulcer onset to referral by general practitioner (GP) to specialist health care was found to be a strong predictor of healing time. Patients who were referred to specialist health care by a GP ≥ 52 days after ulcer onset had a 58% (Sub hazard ratio (SHR) 0.42, CI 0.18, 0.98) decreased healing rate compared with patients who were referred earlier. Ulcers with the highest severity i.e. ulcer penetrating to tendon or bone (grade 2/3) and peripheral arterial disease with and without infection (stage C/D) according to the UT classification system had an 86% (SHR 0.14, CI 0.05, 0.43) decreased healing rate compared with low severity i.e. superficial ulcer (grade 1) with infection (stage A/B) or ulcer penetration to tendon/capsula (grad 2) and clean ulcer (stage A). Study II: Of 182 patients, 142 (78.9%) achieved complete ulcer healing, and 75 (79.8%) healed in the telemedicine group and 67 (76.1%) in the standards outpatient care group. Mean healing including only those who healed was 3.4 months and 3.8 months in the telemedicine group and standard outpatient group, respectively. Telemedicine was non-inferior to standard outpatient care regarding healing time (mixed-effects regression analysis: (mean difference –0.43 months, 95% CI –1.50, 0.65). This finding persisted also after taking into account competing risk from death and amputation (SHR 1.16, 95% CI 0.85, 1.59). There were no significant differences between the telemedicine follow up and standard outpatient care related to the effect estimate of the secondary outcomes, except for significantly fewer amputations in the telemedicine group. Study III: Three themes emerged from the analysis: 1) competence of health care professionals, 2) continuity of care, and 3) easy access, i.e. to receive treatment and follow up near home or at their home. Group allocation seemed to have limited impact on the patients’ follow-up experiences. Competence of health care professionals and continuity of care were important, because they could either enhance or impair wound care. When telemedicine functioned as intended, it was an advantage in the treatment. Easy access was important for the participants, but the importance of accessibility appeared only when competence among health care professionals and continuity of care were present. Conclusions: Early referral to specialist health care if an ulcer occurs is crucial for optimal ulcer healing and has a clear implication for routine care. Grade and stage severity are also important predictors for healing time, and early screening to assess the severity and initiation of prompt treatment is important. Telemedicine can be an alternative but also a supplement to usual care for patients with DFUs, at least for patients with more superficial ulcers. As the number of outpatient clinic consultations in the telemedicine group did not differ from the standard care group, there is need to focus on organisational aspects to facilitate the use of telemedicine. Health care professionals’ competence, continuity of care and easy access to health care services were essential for patients with DFUs, and telemedicine may compensate for lack of these factors

Proceeding: 3rd Java International Nursing Conference 2015 “Harmony of Caring and Healing Inquiry for Holistic Nursing Practice; Enhancing Quality of Care”, Semarang, 20-21 August 2015

This is the proceeding of the 3rd Java International Nursing Conference 2015 organized by School of Nursing, Faculty of Medicine, Diponegoro University, in collaboration with STIKES Kendal. The conference was held on 20-21 August 2015 in Semarang, Indonesia. The conference aims to enable educators, students, practitioners and researchers from nursing, medicine, midwifery and other health sciences to disseminate and discuss evidence of nursing education, research, and practices to improve the quality of care. This conference also provides participants opportunities to develop their professional networks, learn from other colleagues and meet leading personalities in nursing and health sciences. The 3rd JINC 2015 was comprised of keynote lectures and concurrent submitted oral presentations and poster sessions. The following themes have been chosen to be the focus of the conference: (a) Multicenter Science: Physiology, Biology, Chemistry, etc. in Holistic Nursing Practice, (b) Complementary Therapy in Nursing and Complementary, Alternative Medicine: Alternative Medicine (Herbal Medicine), Complementary Therapy (Cupping, Acupuncture, Yoga, Aromatherapy, Music Therapy, etc.), (c) Application of Inter-professional Collaboration and Education: Education Development in Holistic Nursing, Competencies of Holistic Nursing, Learning Methods and Assessments, and (d) Application of Holistic Nursing: Leadership & Management, Entrepreneurship in Holistic Nursing, Application of Holistic Nursing in Clinical and Community Settings

Wound infection in clinical practice : principles of best practice

The International Wound Infection Institute (IWII) is an organisation of volunteer interdisciplinary health professionals dedicated to advancing and improving practice relating to prevention and control of wound infection. This includes acute wounds (surgical, traumatic and burns) and chronic wounds of all types, although principally chronic wounds of venous, arterial, diabetic and pressure aetiologies. Wound infection is a common complication of wounds. It leads to delays in wound healing and increases the risk of loss of limb and life. Implementation of effective strategies to prevent, diagnose and manage, is important in reducing mortality and morbidity rates associated with wound infection. This second edition of Wound Infection in Clinical Practice is an update of the first edition published in 2008 by the World Union of Wound Healing Societies (WUWHS). The original document was authored by leading experts in wound management and endorsed by the WUWHS. The intent of this edition is to provide a practical, updated resource that is easy-to-use and understand. For this edition, the IWII collaborative team has undertaken a comprehensive review of contemporary literature, including systematic reviews and meta-analyses when available. In addition, the team conducted a formal Delphi process to reach consensus on wound infection issues for which scientific research is minimal or lacking. This rigorous process provides an update on the science and expert opinion regarding prevention, diagnosis and control of wound infection. This edition outlines new definitions relevant to wound infection, presents new paradigms and advancements in the management and diagnosis of a wound infection, and highlights controversial areas of discussion

Factors affect the social engagement among community dwelling older person: community nurses perspective.

INTRODUCTION: Remaining involved in activities that are meaningful and purposeful and maintaining chose relationship. METHOD: Descriptive qualitative research approach. CONCLUSION: Promoting a considerate cultures in all levels of society is fundamental to create friendly and conducive environment for all people