Early warning systems and rapid response to the deteriorating patient in hospital: a realist evaluation.

AIM: To identify those contexts and mechanisms that enable or constrain the implementation of Rapid Response Systems on acute general hospital wards to recognise and respond to patient deterioration. BACKGROUND: Rapid Response Systems allow deteriorating patients to be recognised using Early Warning Systems, referred early via escalation protocols and managed at the bedside by competent staff. DESIGN: Realist Evaluation. METHODS: The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland which followed the principles of Realist Evaluation. We used various mixed methods including individual and focus group interviews, observation of nursing practice between June - November 2010 and document analysis of Early Warning Systems audit data between May - October 2010 and hospital acute care training records over 4.5 years from 2003-2008. Data were analysed using NiVivo8 and SPPS. RESULTS: A cross case analysis highlighted similar patterns of factors which enabled or constrained successful recognition, referral and response to deteriorating patients in practice. Key enabling factors were the use of clinical judgement by experienced nurses and the empowerment of nurses as a result of organisational change associated with implementation of Early Warning System protocols. Key constraining factors were low staffing and inappropriate skill mix levels, rigid implementation of protocols and culturally-embedded suboptimal communication processes. CONCLUSION: Successful implementation of Rapid Response Systems was dependent on adopting organisational and cultural changes that facilitated staff empowerment, flexible implementation of protocols and ongoing experiential learning. This article is protected by copyright. All rights reserved

Mental health nurses' contributions to community mental health care: An Australian study

Australian mental health policy is focused on providing mental health care in the community setting and community mental health teams provide services to clients in a shared model with primary care. The historical literature reports that community mental health nurses’ experience high levels of stress and are often allocated the most complex and challenging clients managed by the team. Yet information on their specific roles remains limited. This paper reports on research conducted at one Australian public mental health service to identify the components of the community mental health nursing role and to quantify the time nurses spent in each component during the study period. Six focus groups were conducted with community mental health nurses to identify their perceived role within the team. Data analysis identified 18 components of which 10 were related to direct clinical contact with clients and eight covered administrative and care coordination activities. A data collection tool based on the findings of the focus groups was designed and nurses recorded workload data on the tool in 15-min intervals over a 4-week period. Seventeen nurses collected 1528 hours of data. Internal coordination of care was identified as the top workload item followed by clinical documentation and national data collection responsibilities supporting the complexity of the community mental health nursing role. The high rating attached to the internal coordination of care role demonstrates an important contribution that community mental health nurses make to the functioning of the team and the delivery of quality mental health care

Rating neighborhoods for older adult health: results from the African American Health study

<p>Abstract</p> <p>Background</p> <p>Social theories suggest that neighborhood quality affects health. Observer ratings of neighborhoods should be subjected to psychometric tests.</p> <p>Methods</p> <p>African American Health (AAH) study subjects were selected from two diverse St. Louis metropolitan catchment areas. Interviewers rated streets and block faces for 816 households. Items and a summary scale were compared across catchment areas and to the resident respondents' global neighborhood assessments.</p> <p>Results</p> <p>Individual items and the scale were strongly associated with both the catchment area and respondent assessments. Ratings based on both block faces did not improve those based on a single block face. Substantial interviewer effects were observed despite strong discriminant and concurrent validity.</p> <p>Conclusion</p> <p>Observer ratings show promise in understanding the effect of neighborhood on health outcomes. The AAH Neighborhood Assessment Scale and other rating systems should be tested further in diverse settings.</p

Recommended level of physical activity and health-related quality of life among Japanese adults

<p>Abstract</p> <p>Background</p> <p>The benefits of a recommended level of physical activity on physiological health indicators such as morbidity and mortality are well-accepted, but less research has addressed whether or not the association between the recommended level of physical activity and a health-related quality of life (HRQOL) exists in the Japanese population. Thus, the present study examined whether the recommended physical activity would be associated with HRQOL in the general Japanese middle-aged population.</p> <p>Methods</p> <p>Data were obtained from 1211 male and female respondents (39.4 ± 10.9 year, mean ± SD) from an Internet-based survey of registrants of an Internet research service. Physical activity level was estimated from the short form of the International Physical Activity Questionnaire. HRQOL was assessed with the Medical Outcomes Survey Short Form-8 questionnaire (SF-8). Based on the current national guidelines for exercise in Japan, respondents were divided into a recommended group, an insufficient group, and an inactive group according to their estimated weekly physical activity level. Multivariate analyses of covariance were utilized.</p> <p>Results</p> <p>Across both genders, the recommended group had significantly higher physical functioning (PF) scores than the inactive group (p < .05). Additionally, across both genders, the recommended group had significantly higher general health perception scores than the insufficient and inactive groups (p < .05). The recommended group had significantly higher vitality scores than the insufficient and inactive groups in males, and higher than only the inactive group in females (p < .05). The insufficient group had significantly higher PF scores than the inactive group across both genders (p < .05). The recommended group had significantly higher physical component scores than the inactive group (p = .001).</p> <p>Conclusion</p> <p>Individuals who attained the recommended level of physical activity had better scores on some dimensions of HRQOL than those who did not, suggesting that the recommended level of physical activity may be applicable not only to the physiological objective outcomes but also to some dimensions in both the physical and mental aspects of HRQOL.</p

Measuring Patient and Clinician Perspectives to Evaluate Change in Health-Related Quality of Life Among Patients with Chronic Obstructive Pulmonary Disease

CONTEXT: Many treatments aim to improve patients’ health-related quality of life (HRQoL), and many care guidelines suggest assessing symptoms and their impact on HRQoL. However, there is a lack of consensus regarding which HRQoL outcome measures are appropriate to assess, and how much change on those measures depict significant HRQoL improvement. OBJECTIVE: We used triangulation methods to identify and understand clinically important differences (CIDs) for the amount of change in HRQoL that reflects both health professionals and patients’ values, among patients with chronic obstructive pulmonary disease (COPD). DESIGN, SETTING, AND PARTICIPANTS: We incorporated three perspectives: (1) an expert panel of physicians familiar with the measurement of HRQoL in COPD patients; (2) 610 primary care COPD outpatients who completed baseline and bimonthly follow-up HRQoL interviews over the 12-month study; and (3) the primary care physicians (PCPs; n = 43) of these outpatients who assessed their patients’ disease at baseline and at subsequent PCP visits during the year long study. MEASUREMENTS: The Chronic Respiratory Disease Questionnaire (CRQ), the Medical Outcomes Study Short Form 36-item survey (SF-36, version 2.0), and global assessments of change from each of the three perspectives for all HRQoL domains. RESULTS: With few exceptions, the CRQ was able to detect small changes at levels reported by the patients (1–2 points) and their PCPs (1–5 points). These results confirm minimal important difference standards developed in 1989 by Jaeschke et al. anchored on patient-perceived changes in HRQoL. In general, the expert panel and PCP CIDs were larger than the patient CIDs. CONCLUSION: This triangulation methodology yielded improved interpretation, understanding, and insights on stakeholder perspectives of CIDs for patient-reported outcomes

A survey on worries of pregnant women - testing the German version of the Cambridge Worry Scale

Background: Pregnancy is a transition period in a woman's life characterized by increased worries and anxiety. The Cambridge Worry Scale (CWS) was developed to assess the content and extent of maternal worries in pregnancy. It has been increasingly used in studies over recent years. However, a German version has not yet been developed and validated. The aim of this study was (1) to assess the extent and content of worries in pregnancy on a sample of women in Germany using a translated and adapted version of the Cambridge Worry Scale, and (2) to evaluate the psychometric properties of the German version. Methods: We conducted a cross-sectional study and enrolled 344 pregnant women in the federal state of Baden-Wurttemberg, Germany. Women filled out structured questionnaires that contained the CWS, the Spielberger-State-Trait-Anxiety Inventory (STAI), as well as questions on their obstetric history. Antenatal records were also analyzed. Results: The CWS was well understood and easy to fill in. The major worries referred to the process of giving birth (CWS mean value 2.26) and the possibility that something might be wrong with the baby (1.99), followed by coping with the new baby (1.57), going to hospital (1.29) and the possibility of going into labour too early (1.28). The internal consistency of the scale (0.80) was satisfactory, and we found a four-factor structure, similar to previous studies. Tests of convergent validity showed that the German CWS represents a different construct compared with state and trait anxiety but has the desired overlap. Conclusions: The German CWS has satisfactory psychometric properties. It represents a valuable tool for use in scientific studies and is likely to be useful also to clinicians

Constructing and identifying predictors of frailty among homeless adults—A latent variable structural equations model approach

Homeless urbanites are a heterogeneous population with unique health and social service needs. The study examined situational, behavioral, health-related and resource indicators in terms of their direct impact on frailty, hypothesized as a latent variable. Using structural equation modeling (SEM), a model was tested with 150 homeless men and women, ages 40–73, from three homeless day center drop-in sites on Skid Row and one residential drug treatment (RDT) facility that works with homeless parolees and probationers. In bivariate analyses with the latent construct frailty, months homeless (p &lt; 0.01), female gender (p &lt; 0.05), education (p &lt; 0.05), comorbid conditions (p &lt; 0.001), nutrition (p &lt; 0.001), resilience (p &lt; 0.001), health care utilization (p &lt; 0.01), and falls (p &lt; 0.001) were significantly associated with frailty. In the final path model, significant predictors of frailty included educational attainment (p &lt; 0.01), comorbid conditions (p &lt; 0.001), nutrition (p &lt; 0.001), resilience (p &lt; 0.001), and falls (p &lt; 0.01). These findings will serve as a foundation for future nurse-led, community-based initiatives that focus on key predictors of frailty among the homeless and the development of interventions

Clustering of cancer among families of cases with Hodgkin Lymphoma (HL), Multiple Myeloma (MM), Non-Hodgkin's Lymphoma (NHL), Soft Tissue Sarcoma (STS) and control subjects

<p>Abstract</p> <p>Background</p> <p>A positive family history of chronic diseases including cancer can be used as an index of genetic and shared environmental influences. The tumours studied have several putative risk factors in common including occupational exposure to certain pesticides and a positive family history of cancer.</p> <p>Methods</p> <p>We conducted population-based studies of Hodgkin lymphoma (HL), Multiple Myeloma (MM), non-Hodgkin's Lymphoma (NHL), and Soft Tissue Sarcoma (STS) among male incident case and control subjects in six Canadian provinces. The postal questionnaire was used to collect personal demographic data, a medical history, a lifetime occupational history, smoking pattern, and the information on family history of cancer. The family history of cancer was restricted to first degree relatives and included relationship to the index subjects and the types of tumours diagnosed among relatives. The information was collected on 1528 cases (HL (n = 316), MM (n = 342), NHL (n = 513), STS (n = 357)) and 1506 age ± 2 years and province of residence matched control subjects. Conditional logistic regression analyses adjusted for the matching variables were conducted.</p> <p>Results</p> <p>We found that most families were cancer free, and a minority included two or more affected relatives. HL [(OR_adj(95% CI) <b>1.79 (1.33, 2.42)]</b>, MM <b>(1.38(1.07, 1.78))</b>, NHL <b>(1.43 (1.15, 1.77)</b>), and STS cases <b>(1.30(1.00, 1.68)) </b>had higher incidence of cancer if any first degree relative was affected with cancer compared to control families. Constructing mutually exclusive categories combining "family history of cancer" (yes, no) and "pesticide exposure ≥10 hours per year" (yes, no) indicated that a positive family history was important for HL <b>(2.25(1.61, 3.15))</b>, and for the combination of the two exposures increased risk for MM <b>(1.69(1.14,2.51))</b>. Also, a positive family history of cancer both with <b>(1.72 (1.21, 2.45)) </b>and without pesticide exposure <b>(1.43(1.12, 1.83)) </b>increased risk of NHL.</p> <p>Conclusion</p> <p>HL, MM, NHL, and STS cases had higher incidence of cancer if any first degree relative affected with cancer compared to control families. A positive family history of cancer and/or shared environmental exposure to agricultural chemicals play an important role in the development of cancer.</p