Monitoring Patient and Caregiver Adherence to Treatment in Management of Vascular Ulcers

Chronic diseases have increased the incidence of vascular ulcer development. These ulcers require long-term wound management and other interventions from different health care specialists to achieve healing and decrease further complications. Following acute hospital and clinic vascular ulcer care interventions, patients are discharged home or to other facilities in the communities with vascular ulcer care instructions. Often, these patients come back to the vascular clinic or get readmitted into the hospital with deterioration of their wounds. This project used questionnaires to determine what barriers vascular ulcer patients and their caregivers have in the management of these wounds in the community. Dorothy Orem`s self-care theory was used to describe the self-care deficit of patients with vascular ulcers, and the nursing systems designed by the vascular clinic nurses to educate patients and their caregivers on appropriate wound care and vascular ulcer interventions. Adherence to treatment was monitored through return demonstrations at the vascular clinic during appointments, as well as a review of video-recordings of ulcer management at home by patients and their caregivers. The identified barriers to treatment adherence include knowledge deficit, lack of motivation, inability to apply compression socks, and difficulty obtaining wound care supplies due to lack of cost coverage by their health insurance. The results indicate the need to individualize care plan, and for appropriate coordination of care for vascular ulcer patients in the community to improve wound healing and prevent hospital readmissions

Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Diez Canseco, Francisco. Universidad Peruana Cayetano Heredia; PerúFil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Miranda, Jaime. Universidad Peruana Cayetano Heredia; PerúFil: Ramirez Zea, Manuel. Institute of Nutrition of Central America and Panama; GuatemalaFil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Report on the EHCR (Deliverable 26.2)

This deliverable is the second for Workpackage 26. The first, submitted after Month 12, summarised the areas of research that the partners had identified as being relevant to the semantic indexing of the EHR. This second one reports progress on the key threads of work identified by the partners during the project to contribute towards semantically interoperable and processable EHRs. This report provides a set of short summaries on key topics that have emerged as important, and to which the partners are able to make strong contributions. Some of these are also being extended via two new EU Framework 6 proposals that include WP26 partners: this is also a measure of the success of this Network of Excellence

Implementing Hospital-Acquired Pressure Injury (HAPI) Prevention Program

Practice Problem: Hospital-Acquired Pressure Injury (HAPI) is a serious problem in patient care and has deleterious implications for the patient and the healthcare system. A 530-bed acute care hospital in the Rio Grande Valley identified a similar challenge and implemented a HAPI preventive program. PICOT: This evidence-based practice (EBP) project was guided by the following PICOT question: In the Intensive Care Unit/Medical Intensive Care Unit (ICU/MICU) patients aged 18 and older, does a pressure preventive bundle, compared to routine pressure injury care, reduce the incidence of pressure injury, within 21 days? Evidence: The reviewed literature supported evidence of effective use of a pressure injury preventive bundle in reducing the incidence of pressure injuries in an acute care setting. Seven articles met the inclusion criteria and were used for this literature review. Intervention: The evidence-based pressure injury preventive bundle are interventions that included consistent skin risk assessment and the application of a group of clinical practice guidelines composing of moisture management, optimizing nutrition and hydration and minimizing pressure, shear, and friction that were proven to prevent the occurrence of pressure injuries. Outcome: Post-implementation findings showed that there was no reduction in the incidence of HAPI but significant decrease in the severity of the pressure injury from Stage two to Stage one. Conclusion: The staff education, training, and implementation of an evidence-based bundle intervention to prevent the incidence of HAPI proved a positive outcome on reducing the pressure injury severity from Stage Two pressure injuries to Stage One pressure injuries

From PALSA PLUS to PALM PLUS: adapting and developing a South African guideline and training intervention to better integrate HIV/AIDS care with primary care in rural health centers in Malawi

<p>Abstract</p> <p>Background</p> <p>Only about one-third of eligible HIV/AIDS patients receive anti-retroviral treatment (ART). Decentralizing treatment is crucial to wider and more equitable access, but key obstacles are a shortage of trained healthcare workers (HCW) and challenges integrating HIV/AIDS care with other primary care. This report describes the development of a guideline and training program (PALM PLUS) designed to integrate HIV/AIDS care with other primary care in Malawi. PALM PLUS was adapted from PALSA PLUS, developed in South Africa, and targets middle-cadre HCWs (clinical officers, nurses, and medical assistants). We adapted it to align with Malawi's national treatment protocols, more varied healthcare workforce, and weaker health system infrastructure.</p> <p>Methods/Design</p> <p>The international research team included the developers of the PALSA PLUS program, key Malawi-based team members and personnel from national and district level Ministry of Health (MoH), professional associations, and an international non-governmental organization. The PALSA PLUS guideline was extensively revised based on Malawi national disease-specific guidelines. Advice and input was sought from local clinical experts, including middle-cadre personnel, as well as Malawi MoH personnel and representatives of Malawian professional associations.</p> <p>Results</p> <p>An integrated guideline adapted to Malawian protocols for adults with respiratory conditions, HIV/AIDS, tuberculosis, and other primary care conditions was developed. The training program was adapted to Malawi's health system and district-level supervision structure. PALM PLUS is currently being piloted in a cluster-randomized trial in health centers in Malawi (ISRCTN47805230).</p> <p>Discussion</p> <p>The PALM PLUS guideline and training intervention targets primary care middle-cadre HCWs with the objective of improving HCW satisfaction and retention, and the quality of patient care. Successful adaptations are feasible, even across health systems as different as those of South Africa and Malawi.</p

Improving health outcomes by preventing intensive care related infection in Malaysia Intensive Care Unit (INVEST study)

Ventilator-associated pneumonia (VAP), catheter-related blood stream infection (CRBSI) and pressure ulcers (PU) are well recognized complications in intensive care units (ICUs). Many of these are preventable but can also complicate patient recovery, prolong length of stay, increase costs, morbidity and mortality. In Malaysia, the majority of studies investigating VAP and CRBSI in Malaysia have focussed on identifying risk factors, diagnostic criteria and treatment of ICU-related complications. Further, in spite of the burden of PU there are limited studies undertaken in Malaysia and few of these have been nurse-led. Importantly, to date there has been limited investigation of the efficacy and effectiveness of quality improvement initiatives and the contextual issues impacting on clinical practice improvement in Malaysia.In spite of the increasing emphasis on quality assurance in Malaysian ICUs there has been a limited focus on nurse-specific interventions and the majority of projects have been initiated by physicians. This study has evaluated the utility of a nurse-led action research project to drive clinical practice improvement in the ICU and is significant in demonstrating the capacity of nurses to critique and control their practice. The project conducted for this thesis was called the Improving health outcomes by preveNting intensiVe care related infEction in Malaysia intenSive care uniT - INVEST study. The INVEST Study as reported in this thesis has been undertaken using an action research approach to improve the uptake of evidence-based strategies to prevent infection in the ICU in the Malaysian cultural context.The aims of this thesis were to identify best practices, evaluate the current nursing practice in prevention of VAP, CRBSI and PU in ICU patients in a single Malaysian ICU, and evaluate the impact of the evidence-based interventions to improve patient outcomes. The specific and research objectives of this study were to:1. Identify best practice interventions for preventing VAP, CRBSI and PU in the ICU. 2. Document the current rates of VAP, CRBSI and PU in an ICU in Malaysia. 3. Implement an action research intervention to collaboratively develop and implement strategies for improvement 4. Assess the impact of the intervention on clinical outcomes, staff dynamics, work place culture and sustainability of practice change An action research approach was used in this study to involve and empower nurses and drive practice change. A literature review identified that many action research studies conducted in the ICU were mainly most focused on process measures and not outcomes. In this study the data were collected in three phases following the action research cycles which comprised of a period of planning, acting, observation, reflecting and re-planningIn Phase I of the thesis current best practice interventions for the prevention of VAP, CRBSI and PU in ICU are described. A literature search was conducted to identify evidence-based practices (EBP) that were recommended by bodies to improve the prevention of VAP, CRBSI and PU. A core set of nursing activities was identified in preventing the complications of VAP, CRBSI and PU. These were hand washing, hygiene care, positioning of patient, elevation of the head of bed and providing adequate nutrition.Pre- intervention data collection consisted of an environmental scan, including interview with the key stakeholders, patient profiling and a nurse survey. Twenty-one cases of ICU complications were identified in 18 of the 91 patients (19.8%) admitted in December 2009. Of the patients, three developed two complications - PU and VAP (two patients) or CRBSI (one patient). The findings indicated that this ICU had a high case load due to the high ICU bed demand. Patients needing ICU care were being nursed in general wards due to the unavailability of ICU beds.Nurses reported a good knowledge of prevention strategies with a mean score of 124.84 ±SD14.66 and reported a high level of positive regard for their professional practice environment based on the results of Revised Professional Practice Environment (RPPE). Three components had mean scores of ≥3 and five 55%. The nurses reported a positive regard for their practice environment in the pre- and post-intervention groups. The mean scores for each component were comparable for both the pre- and post-intervention groups except for Internal Work Motivation, Control Over Practice and Staff Relationship With Physician. The highest mean scores within the eight components for the post-intervention group were for Internal Work Motivation (M 3.13; SD 0.27), Relationship With Physician (M 3.04; SD 0.33) and Cultural Sensitivity (M 3.01; SD 0.23). The three lowest were for Handling Disagreement and Conflict (2.80; SD 0.20), Control Over Practice (2.71; SD 0.34) and Teamwork (2.48; SD 0.31).There was a reduction in overall complications from 19.8% to 8.7%. Few nurses in the focus group were optimistic that at least some changes had taken place, and positively improving their knowledge on assessment of patients and some of their common practices in the ICU. The challenge, which they were presently facing was the implementation of hospital information system because most of them were not knowledgeable in information technology.The main outcome of this study was that there was a reduction in number of patients with PU from 16 to 6 in pre and post intervention groups. This reduction of PU was statistically significant (χ[superscript]2=8.14, df=1, p=0.04).In conclusion whether there was a real improvement in patient care provided due to the interventions given was not able to be determined due to methodological considerations and inability to control for confounders. These data underscore the importance of considering cultural factors, both organisational and societal in quality improvement initiatives and empowering nurses for practice change. A risk management system which acknowledges competing demands in dynamic, real world environments is important to consider in future quality improvement studies. The series of studies presented in this thesis have contributed to understanding of factors influencing implementation and sustainability of quality improvement initiatives in a Malaysia ICU. Information acquired from the thesis will be useful information for further improvement targeting education, services, research, policy and future quality improvement project plans in Malaysia

From Evidence to Practice: A Systematic Approach to Implementing Electrical Stimulation Therapy for Treating Pressure Injuries in Community Dwelling Individuals with Spinal Cord Injury

Pressure injuries are a common secondary health complication among individuals with a spinal cord injury (SCI) and can have a profound effect on quality of life. Unfortunately, pressure injury care in community dwelling individuals with SCI is often fragmented and inconsistent across Canada. Current best practice guidelines strongly recommend the use of electrical stimulation therapy (EST) to manage pressure injury in this population; however, there is little uptake of EST, and is not considered as a first-line treatment by many clinicians. Therefore, the objective of this dissertation is two-folds 1) to determine the impact of pressure injuries on individuals with SCI (Chapter 2), and 2) to utilize a systematic approach to implementing EST for managing pressure injuries in community dwelling individuals with SCI living in South West Local Health Integrated Network (LHIN) in Ontario (Chapters 3, 4, and 5). The first study highlighted the importance of implementing pressure injury prevention and management programs in this high-risk population by reporting the negative effect that pressure injuries has on the ability of individuals with SCI to participate in activities of daily living and recreational activities, and the significant impact on quality of life and health care utilization. In studies 2 and 3, a pressure injury model of care involving EST was developed based on the barriers and facilitators identified by local stakeholders. The model was later adapted to fit the local environment by a team of local experts and a SCI consumer in a two-day workshop. The final study used iterative plan, do, study, act (PDSA) cycles to implement the adapted model of care into current practices. Multiple issues associated with key implementation activities were identified to limit the sustainability of EST for treating pressure injuries in community dwelling individuals with SCI, despite the numerous strategies put in place to solve the issues. However, these studies not only provide a clear approach to implementing pressure injury best practices, but the findings provide important insight to future researchers or clinicians interested in implementing EST for managing pressure injuries in community dwelling individuals with SCI

Pressure injury management: An exploration of current practice within New South Wales and Victorian Health Services

INTRODUCTION Pressure injuries (PIs) are a multifactorial issue affecting those with complex chronic care needs. PI is also an important quality and safety issue, which presents challenges across all health service settings (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2012a, 2012b). When PI occur they result in poor client and health system outcomes. Research in the area of PI has traditionally focused on acute and long-term aged care settings. The aim of the research project, which will be described in the present thesis, was to explore current practice in PI management, with a particular emphasis on PI management within community service settings. An enhanced understanding of current practice, captured across the main health service settings that comprise the Australian Health Care System (AHCS), informed new mechanisms to support the workforce in this challenging area of practice. METHODS A health services research approach was used to inform the current project. The aim of health services research is to improve health care through enhanced clinical and organisational practices and health care policy (Shi, 2008). All decisions regarding the research process were informed by a desire to influence outcomes of care through the application of the research findings in everyday practice. This applied approach was achieved through mixed qualitative methods, which were selected for there ability to address the research questions (Patton, 2002). Phase One involved two community based case explorations during which data related to the provision of PI services, experience of PI services and perceptions of real need for PI management were gathered. Phase Two involved five interdisciplinary group discussions with clinicians (n=38) from community based, hospital based and long-term aged care settings. These discussions were used to gather a range of perspectives and experiences regarding current practice. Phase Three involved peer validation processes including the provision of overall feedback to health services, two in-depth interviews and a series of presentations to clinicians and researchers at key conferences. All data were analysed using a thematic analysis approach (Braun & Clark, 2006). FINDINGS AND DISCUSSION Data collected over the course of this project were aggregated, synthesised and presented at the key levels of operation within health care: the system, client and clinician levels. This approach enabled consideration of the key issues influencing PI management, the capacity for change and the potential impact of innovations at each level of the AHCS. Participants discussed health systems as well as clinician and client behaviour at length. There were a number of issues occurring at the system, clinician and client levels that influenced PI management. The data suggested that participants were not convinced that the general approaches to PI were meeting the needs of all clients and services. Key issues relating to workforce development included skill-mix and organisation of services, along with education and training. Consideration of the key issues at the system, client and service levels of the AHCS, suggested that longer-term PI needs may be best met by supporting team-based approaches within primary health care. Most participants believed that increasing client and support care involvement in PI management was essential to meet increasing demands for these services. Additionally, the role of clients and their informal support care was found to be necessary in the early recognition of the signs and symptoms of PI, due to its natural history. Clients and their support care would thus benefit from clinicians, learning how to effectively educate clients as partners in their own care. SUGGESTIONS FOR PRACTICE AND RESEACH A new model of care is proposed and its necessary supports are described. This new model of care enhances client access to PI management by ensuring the best use of skills and local resources, toward team based approaches within community based care. By creating a ‘hub’ for PI needs within primary health care, this will better support the transition of PI management between hospital based and community based services, as well as facilitate improved continuity of care and co-ordination of care for those with longer-term PI needs. A necessary support for the model, amongst others, is a new role that works to address ‘gaps’ and the cross organisational boundaries that influence daily practice. This new role will also provide important support for clinicians in partnering with clients in their own care, by acting as an educative resource within community service settings. CONCLUSION As clients and their support care have the greatest opportunity to identify the early signs and symptoms of PI, the up-skilling of clinicians to effectively impartinformation to lay-persons isnecessary. The proposed new model of care and its accompany of supports may assist health services to enhance continuity ofcareandaccess to PI services, through the optimum organisationof skills at the local service level. Facilitating greater client and support care participation in PI management may assist health services to enhance preventative efforts, and assist in the earlier identification and expedited management of PI. KEYWORDS Pressure injury, Pressure ulcer, community, workforce, allied health, health services research

How Do Health Care Providers Identify and Address Lifestyle Factors with Community Dwelling Adults Who Have Chronic Wounds?

Wound prevention and management best practice guidelines and literature contain recommendations that treatment plans need to consider the client’s lifestyle but offer little guidance about the specific lifestyle factors to be considered, nor how to address these. A post positivist constructivist grounded theory study was used to explore this gap Participants were health care providers with at least 5 years of experience working with community dwelling adults with chronic wounds. Data were transcripts of two semi structured individual interviews, a reflective journal, relevant documents identified by participants and transcripts of focus groups. A common understanding of lifestyle factors was not found; however, a substantive theory was co-constructed. This work builds on a concept described by Schon (1987, pg 3)where best practices and research studies are described as occupying a high ground overlooking a swamp, where complex clients are managed with limited resources. In this study, three major themes emerged – the high ground, the swamp and co-occupation. The high ground included how the health care provider entered wound prevention and management, and that their initial task was local wound care. Health care providers expected wounds to heal with specific treatments within specific time frames. Practice, however, happens in the “swamp”. Participants described the context of the swamp to include ideas such as; the practicality of treatment, client characteristics, the client’s vocation, etc. Co-occupation occurs when the clinician and client are both engaged, working together on the common goal of identifying and addressing lifestyle factors within the context of the swamp