Journal articles on the topic 'Clinical Nursing: Secondary (Acute Care)'
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Kalánková, Dominika, Daniela Bartoníčková, Ewelina Kolarczyk, Katarína Žiaková, and Agnieszka Młynarska. "Factors Contributing to Rationed Nursing Care in the Slovak Republic—A Secondary Analysis of Quantitative Data." International Journal of Environmental Research and Public Health 19, no. 2 (January 8, 2022): 702. http://dx.doi.org/10.3390/ijerph19020702.
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Rationed nursing care is a significant problem in healthcare facilities worldwide. Awareness of contributing factors to rationed care might support the development and implementation of strategies for reducing this phenomenon from clinical practice. The study examined the association between selected hospital, unit, and staff variables and the prevalence of rationed nursing care. Secondary analysis of cross-sectional data collected between December 2017 and July 2018 from 895 registered nurses in seven acute care hospitals in the Slovak Republic was performed. Data were collected using the questionnaire Perceived Implicit Rationing of Nursing and analyzed by descriptive and inferential statistics in the statistical program SPSS 25.0. Statistically significant associations were found between rationed nursing care and unit type, education, shift type, nurses’ experience in the current unit, overtime hours, missed shifts, intention to leave the position, perceived staff adequacy, quality of patient care, and job satisfaction. Differences in rating rationed nursing care, quality of patient care, and job satisfaction were identified based on hospital type. Together with top hospital management, nurse managers should develop targeted interventions focusing on mitigating rationed nursing care from the clinical practice with a focus placed on university hospitals. Quality and safe care might be ensured through constant monitoring of the quality of patient care and job satisfaction of nurses as these factors significantly predicted the estimates of rationed nursing care.
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Mc Lernon, Siobhan, Philip S. Nash, and David Werring. "Acute spontaneous intracerebral haemorrhage: treatment and management." British Journal of Neuroscience Nursing 18, no. 3 (June 2, 2022): 116–24. http://dx.doi.org/10.12968/bjnn.2022.18.3.116.
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Acute spontaneous intracerebral haemorrhage is a devastating form of stroke, with high rates of mortality and disability in survivors. Despite the burden of intracerebral haemorrhage, there remain few effective treatments that improve the patient outcome when compared to ischaemic stroke. Nonetheless, patients still benefit from specialist stroke unit care, including early interventions to prevent complications. Therapeutic nihilism should be avoided during the acute phase, as well as early care limitations. A proactive multi-targeted approach based on therapeutic strategies to prevent early haematoma expansion and attenuation of secondary brain injury are likely to be important in improving patient outcomes.
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Gott, Merryn, Christine Ingleton, Michael I. Bennett, and Clare Gardiner. "Transitions to palliative care in acute hospitals in England: qualitative study." BMJ 342 (2011): d1773. http://dx.doi.org/10.1136/bmj.d1773.
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Objective To explore how transitions to a palliative care approach are perceived to be managed in acute hospital settings in England.Design Qualitative study.Setting Secondary or primary care settings in two contrasting areas of England.Participants 58 health professionals involved in the provision of palliative care in secondary or primary care.Results Participants identified that a structured transition to a palliative care approach of the type advocated in UK policy guidance is seldom evident in acute hospital settings. In particular they reported that prognosis is not routinely discussed with inpatients. Achieving consensus among the clinical team about transition to palliative care was seen as fundamental to the transition being effected; however, this was thought to be insufficiently achieved in practice. Secondary care professionals reported that discussions about adopting a palliative care approach to patient management were not often held with patients; primary care professionals confirmed that patients were often discharged from hospital with “false hope” of cure because this information had not been conveyed. Key barriers to ensuring a smooth transition to palliative care included the difficulty of “standing back” in an acute hospital situation, professional hierarchies that limited the ability of junior medical and nursing staff to input into decisions on care, and poor communication.Conclusion Significant barriers to implementing a policy of structured transitions to palliative care in acute hospitals were identified by health professionals in both primary and secondary care. These need to be addressed if current UK policy on management of palliative care in acute hospitals is to be established.
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Rountree, W. Donald. "The Hemopump Temporary Cardiac Assist System." AACN Advanced Critical Care 2, no. 3 (August 1, 1991): 562–74. http://dx.doi.org/10.4037/15597768-1991-3020.
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The Hemopump temporary cardiac assist system is currently in clinical trials at several centers across the United States and abroad. Patients with postcardiotomy low cardiac output or patients with cardiogenic shock secondary to acute myocardial infarction may greatly benefit from this device. Theory of pump operation, patient selection, and nursing management is discussed. Presentation of a case study demonstrating the effect of Hemopump support will be provided. A detailed nursing care plan as well as application of research findings to clinical practice will be outlined. As cardiovascular technology progresses, the critical care nurse must continue to be involved in all aspects of patient care. The Hemopump may prove to be a highly beneficial mode of ventricular assistance for patients with inadequate cardiac function
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Yang, Meijuan, Lijiao Chen, Min Zhang, Xiaoling Huang, Wenjun Zhao, and Hui Wang. "Evidence-Based Nursing Model in Interventional Thrombolysis for Acute Lower Extremity Arterial Embolism." Contrast Media & Molecular Imaging 2022 (May 25, 2022): 1–9. http://dx.doi.org/10.1155/2022/4488797.
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Acute lower extremity arterial embolism (AE) is a serious clinical emergency, and, if not treated in time, it can easily lead to limb ischemia and necrosis and eventually facing amputation, which seriously damages patients' physical and mental health. In the past, the conventional drug thrombolytic therapy had slow and limited efficacy, and the best time for treatment is easily delayed, while arterial dissection and thrombectomy treatment, although fast, is traumatic and has many complications, which is not easily accepted by patients. The aim of this study was to investigate the value of evidence-based care model in the application of interventional thrombolysis for acute lower limb arterial embolism. Seventy-two patients with acute lower limb arterial embolism who underwent interventional thrombolysis treatment received by the Department of Vascular Surgery of our hospital from July 2016 to December 2021 were randomly divided into a control group (given conventional nursing services) and a quality group (given full quality nursing services) to compare the effect of nursing services in the two groups. The results showed that the postoperative psychological status of patients in the quality group was significantly better than that of patients in the control group ( P < 0.05 ). The total incidence of postoperative adverse events and the total treatment efficiency of the quality group were better than those of the control group ( P < 0.05 ). The efficacy of quality nursing care in patients with acute lower extremity arterial embolism is more desirable than conventional nursing care and is recommended. The site of vascular occlusion after bypass surgery can be clarified when angiography is performed after thrombolytic therapy, which can help secondary surgical intervention to prolong the time to patency. The efficacy of quality nursing care in patients with acute lower extremity arterial embolism is more desirable than that of conventional nursing care and is recommended.
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Tan, Maria, Andrea Adjetey, Catalina Wee, Ian Perry, Chris Corbett, Azeez Olajide, Aaron Yamamoto, James Owen, and Saqib Mumtaz. "Decompensated cirrhosis: targeted training of acute medical teams to improve quality of care in first 24 hours." British Journal of Nursing 31, no. 21 (November 24, 2022): 1112–19. http://dx.doi.org/10.12968/bjon.2022.31.21.1112.
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Background: A quality improvement project in a secondary care centre was initiated to investigate and evaluate the impact of staff education and the use of the British Society of Gastroenterology/British Association for the Study of the Liver cirrhosis care bundle in improving care of patients admitted to hospital with decompensated liver cirrhosis. Method: A staff training programme was implemented, involving around 30 health professionals consisting of consultants, junior doctors, physician associates and nurses from the acute medical unit. A review of electronic documentation and analysis of key clinical parameters, pre- and post-intervention, was carried out. Results: The data show that the intervention has led to an improvement in patient management and clinical outcomes. Conclusion: This project illustrates that collaboration between hepatology and medical teams, with emphasis on education and training, benefits patients who present to hospital with decompensated liver cirrhosis.
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Bourassa, Stephane, Emmanuelle Paquette-Raynard, Daniel Noebert, Marc Dauphin, Pelumi Samuel Akinola, Jason Marseilles, Philippe Jouvet, and Jacinthe Leclerc. "Gaps in Prehospital Care for Patients Exposed to a Chemical Attack – A Systematic Review." Prehospital and Disaster Medicine 37, no. 2 (March 11, 2022): 230–39. http://dx.doi.org/10.1017/s1049023x22000401.
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AbstractIntroduction:The survivability of mass casualties exposed to a chemical attack is dependent on clinical knowledge, evidence-based practice, as well as protection and decontamination capabilities. The aim of this systematic review was to identify the knowledge gaps that relate to an efficient extraction and care of mass casualties caused by exposure to chemicals.Methods:This systematic review was conducted from November 2018 through September 2020 in compliance with Cochrane guidelines. Five databases were used (MEDLINE, Web of Science Core Collection, Embase, Cochrane, and CINAHL) to retrieve studies describing interventions performed to treat victims of chemical attacks (protection, decontamination, and treatment). The outcomes were patient’s health condition leading to his/her stabilization (primary) and death (secondary) due to interventions applied (medical, protection, and decontamination).Results:Of the 2,301 papers found through the search strategy, only four publications met the eligibility criteria. According to these studies, the confirmed chemical poisoning cases in acute settings resulting from the attacks in Matsumoto (1994), Tokyo (1995), and Damascus (2014) accounted for 1,333 casualties including 11 deaths. No study reported comprehensive prehospital clinical data in acute settings. No mention was made of the integration of specialized capabilities in medical interventions such as personal protective equipment (PPE) and decontamination to prevent a secondary exposure. Unfortunately, it was not possible to perform the planned meta-analysis.Conclusions:This study demonstrated gaps in clinical knowledge application regarding the medical extraction of casualties exposed during a chemical attack. Further research is required to optimize clinical practice integrating mixed capabilities (protection and decontamination) for the patient and medical staff.
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Duncan, Pamela W., Cheryl Bushnell, Mysha Sissine, Sylvia Coleman, Barbara J. Lutz, Anna M. Johnson, Meghan Radman, Janet Pvru Bettger, Richard D. Zorowitz, and Joel Stein. "Comprehensive Stroke Care and Outcomes." Stroke 52, no. 1 (January 2021): 385–93. http://dx.doi.org/10.1161/strokeaha.120.029678.
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Worldwide, stroke is prevalent, costly, and disabling in >80 million survivors. The burden of stroke is increasing despite incredible progress and advancements in evidence-based acute care therapies and despite the substantial changes being made in acute care stroke systems, processes, and quality metrics. Although there has been increased global emphasis on the importance of postacute stroke care, stroke system changes have not expanded to include postacute care and outcome follow-up. Our objectives are to describe the gaps and challenges in postacute stroke care and suboptimal stroke outcomes; to report on stroke survivors’ and caregivers’ perceptions of current postacute stroke care and their call for improvements in follow-up services for recovery and secondary prevention; and, ultimately, to make the case that a paradigm shift is needed in the definition of comprehensive stroke care and the designation of Comprehensive Stroke Center. Three recommendations are made for a paradigm shift in comprehensive stroke care: (1) criteria should be established for designation of rehabilitation readiness for Comprehensive Stroke Centers, (2) The American Heart Association/American Stroke Association implement an expanded Get With The Guidelines–Stroke program and criteria for comprehensive stroke centers to be inclusive of rehabilitation readiness and measure outcomes at 90 days, and (3) a public health campaign should be launched to offer hopeful and actionable messaging for secondary prevention and recovery of function and health. Now is the time to honor the patients’ and caregivers’ strongest ask: better access and improved secondary prevention, stroke rehabilitation, and personalized care.
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Quinn, Charlene C., Anthony Roggio, Barr Erik, and Ann Gruber-Baldini. "NURSING HOME TELEED INTERVENTION: ADVANCING NEW CARE MODELS." Innovation in Aging 3, Supplement_1 (November 2019): S337—S338. http://dx.doi.org/10.1093/geroni/igz038.1225.
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Abstract New reimbursement and managed care models demonstrate the need to reduce avoidable Emergency Department (ED) use and limit preventable inpatient admissions for older adults in Skilled Nursing Facilities (SNF). The objective was to develop an ED telemedicine consultation intervention for SNF residents with acute medical problems. Secondary objectives including evaluation of health care utilization, provider satisfaction. Demonstration evaluation in three urban SNFs, telemedicine linked to university medical center ED. Mobile telemedicine cart equipment assessed SNF residents for any change in condition. ED physicians used tablets with secure access to conduct the resident assessment. Provider satisfaction measures imbedded in EMRs were completed at consultation visit end. 460 patients had changes in condition, 327 resulted in 911 calls, 85 deemed eligible for telemedicine consult. Conducted 57 telehealth consults. Forty (70%) telemedicine consult residents remained in the SNF. Fourteen residents were transferred to the ED. Average satisfaction scores were 5.8/7 for SNF nurses (n=49) and 5.6 for ED physicians (n=45). Lower-rated items related to technical equipment problems. ED physicians reported residents transferred to ED after telehealth visit had better continuity of care. The intervention was effective in preventing or delaying transfer of acutely ill, medically complex SNF residents. Implementation of the intervention identified need for SNF admission policy and procedure changes; weekly telemedicine training; SNF clinical advocates; on-site tracking and linkage of EMRs across providers; HIPAA shared medical record concerns. Future research plans include analyses of detailed SNF resident characteristics and business case assessment for reduction of transfers, ED and hospital utilization.
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Wong, Chui King, Glen Chiang Hong Tan, and Mohd Johar Jaafar. "An acute ST-elevation myocardial infarction which went viral." Journal of Emergency Practice and Trauma 8, no. 1 (November 30, 2021): 74–76. http://dx.doi.org/10.34172/jept.2021.27.
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Objective: ST-elevations in electrocardiogram (ECG) secondary to an acute myocarditis may mimic ST-elevation myocardial infarction (STEMI). It is vital to distinguish between the two entities to avoid inappropriate clinical management and complications. Case Presentation: A previously well 19-year-old male presented with two episodes of central chest pain which were resolved spontaneously. His presentation was preceded by multiple episodes of vomiting, diarrhoea and abdominal pain. Physical examination was unremarkable except for a low-grade temperature of 37.7°C. The first ECG revealed ST-segment elevations in anterior leads without reciprocal changes. Serial ECGs showed increasing ST elevations and his cardiac markers were significantly raised. As the initial clinical presentation was potentially an acute coronary syndrome, he was instinctively treated with anti-platelets. Fortunately, this patient was not given thrombolysis as there were clinical suspicions of an acute myocarditis due to his young age, presence of viral symptoms, and absence of cardiac risk factors. Subsequent cardiac MRI confirmed the diagnosis of an acute myocarditis. Conclusion: An acute myocarditis is well known but less common presentation of viral infections. ST-segment elevations in ECG of any young patients with chest pain but without risk factors for acute coronary syndrome should always raise the suspicion of acute myocarditis especially in the presence of viral symptoms. Investigations such as cardiac magnetic resonance imaging (MRI) should be carried out emergently to distinguish both conditions.
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Duncan, Pamela W., Ronnie D. Horner, Dean M. Reker, VA Medical Ctr, Kansas City, KS, Gregory P. Samsa, et al. "Adherence to Post-Acute Rehabilitation Guidelines Improves Functional Recovery in Stroke." Stroke 32, suppl_1 (January 2001): 333. http://dx.doi.org/10.1161/str.32.suppl_1.333-c.
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97 Purpose & Methods: To assess if compliance with post-stroke rehabilitation guidelines improves functional recovery. The design of the study was an inception cohort of stroke patients followed prospectively for 6 months. The setting was eleven Department of Veteran Affairs Medical Centers providing care to stroke patients. The subjects included 288 selected patients with stroke admitted between January 1998 - March 1999. Data were abstracted from medical records and telephone interviews. Primary outcome was the Functional Independence Motor Score (FIM). Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, and the Stroke Impact Scale (SIS). Acute and post-acute rehabilitation composite compliance scores (range 0–100) were derived from an algorithm. All outcomes were adjusted for case mix. Results: Average compliance scores in acute and post acute care settings were 68.2% (+ 14) and 69.5% (+ 14.4), respectively. After case-mix adjustment, level of compliance with post-acute rehabilitation guidelines was significantly associated with FIM motor, IADL, and the SIS physical domain scores. SF-36 physical function scores and mortality were not affected by compliance with post-acute rehabilitation guidelines. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures. Conclusion: Process of care in post-acute stroke rehabilitation affects 6-month functional recovery. Our findings support the use of guidelines as means of assessing quality of care and improving outcomes. These quality indicators are needed to ensure that quality of care is not comprised with new organizational and funding changes involving post-acute stroke care.
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Fuentes, Blanca, María Alonso de Leciñana, Sebastián García-Madrona, Fernando Díaz-Otero, Clara Aguirre, Patricia Calleja, José A. Egido, et al. "Stroke Acute Management and Outcomes During the COVID-19 Outbreak." Stroke 52, no. 2 (February 2021): 552–62. http://dx.doi.org/10.1161/strokeaha.120.031769.
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Background and Purpose: The coronavirus disease 2019 (COVID-19) outbreak has added challenges to providing quality acute stroke care due to the reallocation of stroke resources to COVID-19. Case series suggest that patients with COVID-19 have more severe strokes; however, no large series have compared stroke outcomes with contemporary non–COVID-19 patients. Purpose was to analyze the impact of COVID-19 pandemic in stroke care and to evaluate stroke outcomes according to the diagnosis of COVID-19. Methods: Retrospective multicenter cohort study including consecutive acute stroke patients admitted to 7 stroke centers from February 25 to April 25, 2020 (first 2 months of the COVID-19 outbreak in Madrid). The quality of stroke care was measured by the number of admissions, recanalization treatments, and time metrics. The primary outcome was death or dependence at discharge. Results: A total of 550 acute stroke patients were admitted. A significant reduction in the number of admissions and secondary interhospital transfers was found. COVID-19 was confirmed in 105 (19.1%) patients, and a further 19 patients were managed as suspected COVID-19 (3.5%). No differences were found in the rates of reperfusion therapies in ischemic strokes (45.5% non–COVID-19, 35.7% confirmed COVID-19, and 40% suspected COVID-19; P =0.265). However, the COVID-19 group had longer median door-to-puncture time (110 versus 80 minutes), which was associated with the performance of chest computed tomography. Multivariate analysis confirmed poorer outcomes for confirmed or suspected COVID-19 (adjusted odds ratios, 2.05 [95% CI, 1.12–3.76] and 3.56 [95% CI, 1.15–11.05], respectively). Conclusions: This study confirms that patients with COVID-19 have more severe strokes and poorer outcomes despite similar acute management. A well-established stroke care network helps to diminish the impact of such an outbreak in stroke care, reducing secondary transfers and allowing maintenance of reperfusion therapies, with a minor impact on door-to-puncture times, which were longer in patients who underwent chest computed tomography.
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Becker, Elke Ingeborg, A. Jung, H. Völler, K. Wegscheider, H. P. Vogel, and H. Landgraf. "Pathogenese des zerebralen ischämischen Insults: eine interdisziplinäre Studie." Vasa 30, no. 1 (February 1, 2001): 43–52. http://dx.doi.org/10.1024/0301-1526.30.1.43.
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Background: It is essential to understand the pathogenesis of ischemic stroke to ensure rational acute therapy and secondary prevention. We wanted to know the distribution of pathogenesis in patients of a city hospital and the differences in risk factors, neurologic deficits, disability, and delay in clinical admittance. Patients and methods: During a period of one year, 222 patients (mean age 76,6 years; 59% women) with complete acute ischemic stroke were admitted and underwent complete clinical and diagnostic procedures: CCT/MRI; Doppler- and color-coded duplex and transcranial sonography; echocardiography; use of the NINCDS stroke scale and the Oxford disability scale; study of risk factors, and exploration of delay in admittance. Results: The following percentages of etiologies were evident: 31% cardiogenic embolism (60% with atrial fibrillation), 13% microangiopathy, 9% macroangiopathy, 11% cerebellar or brain stem infarction, 18% more than one cause and 18% no cause found. The patients with cardiogenic embolism showed significantly the highest scores on the stroke scale and the disability scale and had the shortest delay in admittance (57% were admitted within 3 hours). Conclusions: In a city hospital, cardiogenic embolism is the main cause of ischemic stroke. These patients suffer significantly the most severe neurologic deficits, dependence, and requirement of daily nursing care. These patients have the shortest delay in clinical admittance and the best chance of benefiting from acute therapy and early secondary prevention.
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Subramaniam, Hari, and Alex J. Mitchell. "The prognosis of depression in late life versus mid-life: implications for the treatment of older adults." International Psychogeriatrics 17, no. 4 (October 25, 2005): 533–38. http://dx.doi.org/10.1017/s1041610205002437.
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Depression in late life is extremely common. Of those aged 65 years or older, 2–5% have syndromal depression, but up to 20% of elderly people have depressive symptoms (Horwath et al., 2002). Both syndromal and subsyndromal depression carry a high risk of long-term complications and both are associated with elevated risks of morbidity and mortality (Penninx et al., 1999). Despite repeated alerts, depression is consistently under-recognized in acute medical settings, in nursing homes and in primary care (Volkers et al., 2004). For reasons that are inadequately understood, late-life depression seems to be under-treated to an even greater extent than depression in mid-life (Mackenzie et al., 1999). This issue is particularly important, given that effective and safe treatments for depression are available (Bartels et al., 2003), even though the evidence regarding maintenance therapies in older people is inconsistent (Geddes et al., 2003; Wilson et al., 2003). Recent evidence suggests that a package of care can improve the care of older depressed patients in primary care settings (Bruce et al., 2004) and in nursing homes (Ciechanowski et al., 2004). This has led to the development of several clinical guidelines specifically for late-life depression (Baldwin et al., 2003; Charney et al., 2003; Lebowitzet al., 1997). Yet, in the recent National Institute of Clinical Excellence (NICE) guidelines for the management of depression in primary and secondary care, no distinction was made between early, middle and late-life depression (Malone and Mitchell, 2005).
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Zuler, Mor, Joseph Offenbacher, Yotam Deri, and Baruch Berzon. "Concomitant intravascular and extravascular obstructive shock: a case report of cardiac angiosarcoma presenting with pericardial tamponade." Clinical and Experimental Emergency Medicine 9, no. 2 (June 30, 2022): 150–54. http://dx.doi.org/10.15441/ceem.20.052.
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Atraumatic pericardial tamponade and intracardiac masses are both recognized etiologies of acute obstructive shock. Pericardial tamponade, is a cardiovascular emergency commonly considered by emergency physicians and, as a result, evaluation for this process has been incorporated into standardized point of care ultrasound algorithms for assessing hypotension. Obstructive shock secondary to intracardiac tumors is an atypical clinical presentation, and although it is evaluated by the same ultrasound imaging modality, it is generally not considered or evaluated for in the emergency department setting. The concomitant presentation of these two pathologic processes is an extremely rare oncologic emergency. Existing literature on the subject is found in a small number of case reports with nearly no prior descriptions in emergency medicine references. In the right clinical context this unique presentation should be considered and evaluated for in the emergency department via point of care ultrasound modality to help guide in the management of the resulting obstructive shock.
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Luengo-Fernandez, Ramon, Alastair M. Gray, and Peter M. Rothwell. "Population-Based Study of Determinants of Initial Secondary Care Costs of Acute Stroke in the United Kingdom." Stroke 37, no. 10 (October 2006): 2579–87. http://dx.doi.org/10.1161/01.str.0000240508.28625.2c.
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Napolitano, D., A. Cocchieri, N. Orgiana, C. Fanali, A. Poscia, E. Schiavoni, T. Bernabei, et al. "N14 The satisfaction of IBD patients’ nursing care in biological therapy. Observational study." Journal of Crohn's and Colitis 17, Supplement_1 (January 30, 2023): i1047—i1048. http://dx.doi.org/10.1093/ecco-jcc/jjac190.1073.
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Abstract Background Inflammatory Bowel Disease (IBD) management requires a multidisciplinary team, in which nurses have a pivotal role. Although patient care is the main focus of all clinical actions, satisfaction with healthcare professionals is an aspect of growing importance that has been related to positive clinical outcomes. In this setting, evaluating the satisfaction of the nursing provided could be a pivotal component for the satisfaction of the patient, particularly in the IBD unit, where patients in intravenous (iv) biological therapy spend a major amount of time compared to non-complicated acute hospitalization. The aim of the study is to measure the overall quality of nursing care perceived by IBD patients receiving biological therapy. Furthermore, the opinion of loyal and non-loyal patients was measured at the IBD center as a secondary objective Methods Cross-sectional observational study to assess nursing satisfaction through the Newcastel Satisfaction Nursing Scale (NSNS). The instrument consists of two separate scales: the Scale of Nursing Care Experiences ("A") and the Scale of Nursing Satisfaction ("B"). The patient who is followed by the center, at the time of administering the questionnaire, for a period of more than 12 months, will be considered in the arm long follow-up while all patients treated at the center for a period ranging from 0 to 12 months, in those short follow-up. The study protocol was approved by the Ethics Committee. Results Two hundred and thirty-four in biological therapy, questionnaires were administered, of these, with an excellent response rate, 200 (86.2%). The result was an overall level of satisfaction compared to the first scale "A", equal to 88.4%, while for the second scale "B" the total result was 90.7%. By analyzing the satisfaction of nursing care received, differentiating the patient between short and long follow-up, the results seem to confirm how the patient in the long follow-up positively affects satisfaction, significantly in the first scale "A" 90.5% vs 82.9% p = 0.0002 and in the second scale "B" 92.5% vs 86% p = 0.0001. The lowest average satisfaction scores were recorded in the doctor-nurse ratio and in the communicative aspects, while the highest scores are related to the empathic components and professional competence of nursing. Conclusion In conclusion, the level of satisfaction of patients in biological therapy is high and this seems to increase significantly with time and with patient loyalty to the center (Fig. 1). Further research projects could aim to fill gaps in knowledge and validate scales of assessment of nursing skills in the field of IBD, including by structuring studies with a control cohort.
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DiBlasio, Christina, Mackenzie E. Fowler, Roy Martin, Yue Zhang, and Richard E. Kennedy. "GENERALIZABILITY OF CLINICAL TRIALS OF DELIRIUM INTERVENTIONS." Innovation in Aging 3, Supplement_1 (November 2019): S448—S449. http://dx.doi.org/10.1093/geroni/igz038.1682.
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Abstract Delirium, or acute confusional state, affects up to 7 million hospitalized older adults annually, and is associated with increased risk of mortality, institutionalization, and cognitive and functional impairment. There has been a proliferation of both pharmacological and nonpharmacological clinical trials to reduce the incidence and sequelae of delirium. In other neuropsychiatric disorders, exclusion criteria prevent up to 75% of individuals with the condition under study from participating. It is unclear how well these trial samples represent the population of older adults with delirium. We selected all intervention trials registered at ClinicalTrials.gov containing the keyword “delirium” (N=131), regardless of type of intervention. We manually examined study descriptions to restrict analysis to studies with delirium as a primary or secondary outcome (N=92). Of these 92 studies, 76% enrolled only adults, with 45% enrolling only older adults. 38% of studies were restricted to surgical units, 27% to intensive care units, and 7.6% to medical units. Only 1 study examined nursing homes and 4 studies examined palliative care. 50% of studies excluded individuals with pre-existing dementia, 28% excluded individuals with psychiatric disorders, and 30% excluded individuals with neurological disorders. 34% of studies excluded individuals with alcohol or drug abuse. Overall, many intervention studies for delirium are limited to the surgical and ICU populations, and they exclude individuals with common comorbidities associated with an increased risk of delirium. Similar to other neuropsychiatric disorders, these findings raise significant concerns about the generalizability of clinical trials in delirium to the hospitalized older adult population.
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Altersberger, Valerian L., Lotte J. Stolze, Mirjam R. Heldner, Hilde Henon, Nicolas Martinez-Majander, Christian Hametner, Annika Nordanstig, et al. "Maintenance of Acute Stroke Care Service During the COVID-19 Pandemic Lockdown." Stroke 52, no. 5 (May 2021): 1693–701. http://dx.doi.org/10.1161/strokeaha.120.032176.
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Background and Purpose: Timely reperfusion is an important goal in treatment of eligible patients with acute ischemic stroke. However, during the coronavirus disease 2019 (COVID-19) pandemic, prehospital and in-hospital emergency procedures faced unprecedented challenges, which might have caused a decline in the number of acute reperfusion therapy applied and led to a worsening of key quality measures for this treatment during lockdown. Methods: This prospective multicenter cohort study used data from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry of patients with acute ischemic stroke treated with reperfusion therapies, that is, intravenous thrombolysis or endovascular therapy. We compared prehospital and in-hospital time-based performance measures (stroke-onset-to-admission, admission-to-treatment, admission-to-image, and image-to-treatment time) during the first 6 weeks after announcement of lockdown (lockdown period) with the same period in 2019 (reference period). Secondary outcomes included stroke severity (National Institutes of Health Stroke Scale) after 24 hours and occurrence of symptomatic intracranial hemorrhage (following the ECASS [European-Australasian Acute Stroke Study]-II criteria). Results: Across 20 stroke centers, 540 patients were treated with intravenous thrombolysis/endovascular therapy during lockdown period compared with 578 patients during reference period (−7% [95% CI, 5%–9%]). Performance measures did not change significantly during the lockdown period (2020/2019 minutes median: onset-to-admission 133/145; admission-to-treatment 51/48). Same was true for admission-to-image (20/19) and image-to-treatment (31/30) time in patients with available time of first image (n=871, 77.9%). Median National Institutes of Health Stroke Scale on admission (2020/2019: 11/11) and after 24 hours (2020/2019: 6/5) and percentage of symptomatic intracranial hemorrhage (2020/2019: 6.2/5.7) did not differ significantly between both periods. Conclusions: The COVID-19 pandemic lockdown resulted in a mild decline in the number of patients with stroke treated with acute reperfusion therapies. More importantly, the solid stability of key quality performance measures between the 2020 and 2019 period may indicate resilience of acute stroke care service during the lockdown, at least in well-established European stroke centers.
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Vickrey, Barbara G., Thomas Rector, Elizabeth Sloss, Steven Wickstrom, Steven Garber, Daniel McCaffrey, Peter Guzy, Philip B. Gorelick, and Regina Levin. "Incidence of Secondary Stroke and Myocardial Infarction Based on Managed Care Administrative Data." Stroke 32, suppl_1 (January 2001): 321–22. http://dx.doi.org/10.1161/str.32.suppl_1.321-e.
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32 Background: Little data exist on the incidence of subsequent acute ischemic events in persons with established atherosclerotic vascular disease in managed care plans. Objective: To estimate the incidence of secondary stroke and myocardial infarction (MI) over 3 years. Methods: Patients were identified as having atherosclerotic vascular disease (either stroke, MI, or peripheral arterial disease {PAD}) using administrative data from 11 UnitedHealthcare plans (3 with Medicare) from 1995–98. The stroke cohort includes patients ≥ 40 years old hospitalized with a primary or secondary ICD-9-CM code of either 434 or 436, and length of stay ≥ 1 day. Patients with a carotid endarterectomy or claims consistent with cardioembolic strokes were excluded. Persons age ≥ 40 with a primary ICD-9-CM code of 410 and a length of stay ≥ 2 days were included in the MI cohort. The PAD cohort included patients ≥ 40 with a hospital admission or an office visit with an ICD-9-CM code of 440.2x or 440.3. Cumulative incidences of subsequent stroke or MI were estimated for each cohort using Kaplan-Meier survival analysis. Results: For stroke, MI, and PAD cohorts, 3527 (49% Medicare), 9039 (26% Medicare), and 10,925 (46% Medicare) members were identified, respectively. Nearly 96% of MI and 89% of stroke patients were discharged alive. During an average follow-up period of 12 months in the stroke cohort, the cumulative incidences of stroke or MI were 4%, 7%, 12% and 14% at 0.5, 1, 2, and 3 years, respectively. Incidences in the MI cohort were 4%, 6%, 8% and 11% at 0.5, 1, 2, and 3 years (mean follow-up=15 months). In the PAD cohort with a mean follow-up of 15 months, the cumulative percentages with subsequent AMI or stroke were 2%, 3%, 5% and 8% after 0.5, 1, 2, and 3 years. Stroke accounted for 79%, 16%, and 39% of the secondary events in the stroke, MI, and PAD cohorts, respectively. Conclusions: Among persons with atherosclerotic vascular disease enrolled in managed care plans around the US, the incidence of subsequent ischemic events is consistent with a significant burden of symptomatic disease. Among stroke patients who have a subsequent ischemic event, stroke is the secondary event in the vast majority of cases.
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Cadilhac, Dominique A., Joosup Kim, Geoffrey Cloud, Craig S. Anderson, Emma K. Tod, Sibilah J. Breen, Steven Faux, et al. "Effect of the Coronavirus Disease 2019 Pandemic on the Quality of Stroke Care in Stroke Units and Alternative Wards: A National Comparative Analysis." Journal of Stroke 24, no. 1 (January 31, 2022): 79–87. http://dx.doi.org/10.5853/jos.2021.02530.
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Background and Purpose Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients’ treatment setting (stroke unit or alternate ward).Methods We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients’ treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses.Results In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks).Conclusions During the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.
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Saeed, D., G. Carter, and C. Parsons. "A systematic review of interventions to improve medicines optimisation in frail older patients in secondary and acute care settings." International Journal of Pharmacy Practice 29, Supplement_1 (March 26, 2021): i22—i23. http://dx.doi.org/10.1093/ijpp/riab015.026.
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Abstract Introduction Frailty is a geriatric syndrome in which physiological systems have decreased reserve and resistance against stressors. Frailty is associated with polypharmacy, inappropriate prescribing and unfavourable clinical outcomes [1,2]. Aim To identify and evaluate studies of interventions designed to optimise the medications of frail older patients, aged 65 years or over, in secondary or acute care settings. Methods The protocol was registered and published on PROSPERO (CRD42019156623). A literature review was conducted across the following databases and trial registries: Medline, Scopus, Embase, Web of Science, Cochrane Library, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature Plus (CINAHL Plus), ClinicalTrials.gov, International Clinical Trials Registry Platform and Research Registry. All types of randomised controlled trials (RCTs) and non-randomised studies (NRSs) of interventions relating to any aspect of ‘medicines optimisation’, ‘medicines management’ or ‘pharmaceutical care’ to frail older inpatients (aged ≥ 65 years) were included. Eligible studies published in English were identified from the date of inception to October 2020. Screening and selection of titles, abstracts and full texts were followed by data extraction. Risk of bias was assessed using the Cochrane Collaboration ROB 2.0 tool for RCTs and risk of bias in non-randomized studies-of Interventions (ROBINS-I) tool for NRSs. Results 36 articles were identified and of these, three were eligible for inclusion (Figure 1). All included studies were RCTs. Although all included studies examined the effect of different types of interventions on different outcomes, they all concluded that medication optimisation interventions reduced suboptimal prescribing (measured as polypharmacy, inappropriate prescribing, and underuse) among frail older inpatients. The included studies used different tools to assess prescribing appropriateness; one used the STOPP criteria, one used STOPPFrail criteria and one employed inpatient/ outpatient geriatric evaluation and management according to published guidelines and Veterans Affairs (VA) hospital standards. Two of the included studies was assessed as having ‘some concerns’ of bias, and one was judged to be at ‘high risk’ of bias. Due to the heterogeneity of the included studies, a meta-analysis was not possible. Conclusion This systematic review demonstrates that medication optimisation interventions may improve medication appropriateness in frail older inpatients. Limitations include the small number of included studies and the exclusion of non-English language articles. However, this review highlights the paucity of evidence that examines impact of medication optimisation on quality of prescribing and clinical outcomes for frail older inpatients including hospitalisation, falls, quality of life and mortality. High-quality studies are needed to address this gap and to outline the framework of medication optimisation for this vulnerable cohort group. References 1. Clegg A, Young J, Life S, Rikket MO, Rockwood K. Frailty in Older People. Lancet. 2013;381(9868):752–62. 2. Fried, L. P. Tangen, C. M.Walston, J.Newman, A. B.Hirsch, C.Gottdiener et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2011; 56(3), 146–M15
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Ziai, Wendy C., Sung-Min Cho, Michelle C. Johansen, Bahattin Ergin, and Mona N. Bahouth. "Transcranial Doppler in Acute COVID-19 Infection." Stroke 52, no. 7 (July 2021): 2422–26. http://dx.doi.org/10.1161/strokeaha.120.032150.
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Background and Purpose: Stroke may complicate coronavirus disease 2019 (COVID-19) infection based on clinical hypercoagulability. We investigated whether transcranial Doppler ultrasound has utility for identifying microemboli and clinically relevant cerebral blood flow velocities (CBFVs) in COVID-19. Methods: We performed transcranial Doppler for a consecutive series of patients with confirmed or suspected COVID-19 infection admitted to 2 intensive care units at a large academic center including evaluation for microembolic signals. Variables specific to hypercoagulability and blood flow including transthoracic echocardiography were analyzed as a part of routine care. Results: Twenty-six patients were included in this analysis, 16 with confirmed COVID-19 infection. Of those, 2 had acute ischemic stroke secondary to large vessel occlusion. Ten non-COVID stroke patients were included for comparison. Two COVID-negative patients had severe acute respiratory distress syndrome and stroke due to large vessel occlusion. In patients with COVID-19, relatively low CBFVs were observed diffusely at median hospital day 4 (interquartile range, 3–9) despite low hematocrit (29.5% [25.7%–31.6%]); CBFVs in comparable COVID-negative stroke patients were significantly higher compared with COVID-positive stroke patients. Microembolic signals were not detected in any patient. Median left ventricular ejection fraction was 60% (interquartile range, 60%–65%). CBFVs were correlated with arterial oxygen content, and C-reactive protein (Spearman ρ=0.28 [ P =0.04]; 0.58 [ P <0.001], respectively) but not with left ventricular ejection fraction (ρ=−0.18; P =0.42). Conclusions: In this cohort of critically ill patients with COVID-19 infection, we observed lower than expected CBFVs in setting of low arterial oxygen content and low hematocrit but not associated with suppression of cardiac output.
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Gdovinova, Zuzana, Michal Kovačik, and Diana Urbani. "How stroke care has changed in Slovakia in the last 5 years." European Stroke Journal 8, no. 1_suppl (January 2023): 52–58. http://dx.doi.org/10.1177/23969873221115457.
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Introduction: Although stroke patients in Slovakia had been treated according to European recommendations, no network of primary and comprehensive stroke centers had been officially established; the ESO recommended quality parameters had not been fulfilled. Therefore, the Slovak Stroke Society decided to change the stroke management concept and introduced mandatory evaluation of quality parameters. This article focuses on key success factors of the change in stroke management in Slovakia and presents the 5-year results and perspectives for the future. Material and methods: We processed data from the stroke register at the National Health Information Center, which is mandatory in Slovakia for all hospitals designated as primary and secondary stroke care centers. Results: Since 2016, we have started to change stroke management. New National Guideline for Stroke Care was prepared in 2017 and published in 2018 as a Recommendation of the Ministry of Health of the Slovak Republic. The recommendation included pre-hospital as well as in-hospital stroke care, a network of primary stroke centers (hospitals administering intravenous thrombolysis – 37), and secondary stroke centers (hospitals treating with intravenous thrombolysis + endovascular treatment (ET) – 6). A stroke priority was instituted, having equally high priority as myocardial infarction. More efficient in-hospital workflow and pre-hospital patient triage shortened the time to treatment. Prenotification became mandatory in all hospitals. Non-contrast CT, and CT angiography is mandatory in all hospitals. In patients with suspected proximal large-vessel occlusion the EMS stays at the CT facility in primary stroke centers until the CT angiography is finished. If LVO is confirmed, the patient is transported to an EVT secondary stroke center by the same EMS. From 2019 all secondary stroke centers offer endovascular thrombectomy in a 24/7/365 system. We consider the introduction of quality control one of the most critical steps in stroke management. The result of these activities is 25.2% of patients treated with IVT and 10.2% by endovascular treatment, and median DNT 30 min. Number of patients screened for dysphagia increased from 26.4% in 2019 to 85.9% in 2020. In the most of the hospitals the proportion of ischemic stroke patients discharged with antiplatelets and in case of AF with anticoagulants was >85%. Discussion: Our results indicate that it is possible to change stroke management at a single hospital and national level. For continuous and further improvement, regular quality monitoring is necessary; therefore, the results of stroke hospital management are presented regularly once a year at national and international level. Collaboration with the “Second for Life” patient organization is very important for the “time is brain” campaign in Slovakia. Conclusion: Due to the change in stroke management over the last 5 years, we have reduced the time for acute stroke treatment and improved the proportion of patients with acute treatment, and in this area, we have achieved and exceeded the goals of the Stroke Action Plan for Europe for 2018–2030. Nevertheless, we still have many insufficiencies in stroke rehabilitation and post-stroke nursing that need to be addressed.
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Verma, Aradhana, Amytis Towfighi, Arleen Brown, Anshu Abhat, and Alejandra Casillas. "Moving Towards Equity With Digital Health Innovations for Stroke Care." Stroke 53, no. 3 (March 2022): 689–97. http://dx.doi.org/10.1161/strokeaha.121.035307.
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Abstract: Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems’ integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention—stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.
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Ryan, Grace V., Shauna Callaghan, Anthony Rafferty, Mary F. Higgins, Eleni Mangina, and Fionnuala McAuliffe. "Learning Outcomes of Immersive Technologies in Health Care Student Education: Systematic Review of the Literature." Journal of Medical Internet Research 24, no. 2 (February 1, 2022): e30082. http://dx.doi.org/10.2196/30082.
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Background There is a lack of evidence in the literature regarding the learning outcomes of immersive technologies as educational tools for teaching university-level health care students. Objective The aim of this review is to assess the learning outcomes of immersive technologies compared with traditional learning modalities with regard to knowledge and the participants’ learning experience in medical, midwifery, and nursing preclinical university education. Methods A systematic review was conducted according to the Cochrane Collaboration guidelines. Randomized controlled trials comparing traditional learning methods with virtual, augmented, or mixed reality for the education of medicine, nursing, or midwifery students were evaluated. The identified studies were screened by 2 authors independently. Disagreements were discussed with a third reviewer. The quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). The review protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews) in April 2020. Results Of 15,627 studies, 29 (0.19%) randomized controlled trials (N=2722 students) were included and evaluated using the MERSQI tool. Knowledge gain was found to be equal when immersive technologies were compared with traditional learning modalities; however, the learning experience increased with immersive technologies. The mean MERSQI score was 12.64 (SD 1.6), the median was 12.50, and the mode was 13.50. Immersive technology was predominantly used to teach clinical skills (15/29, 52%), and virtual reality (22/29, 76%) was the most commonly used form of immersive technology. Knowledge was the primary outcome in 97% (28/29) of studies. Approximately 66% (19/29) of studies used validated instruments and scales to assess secondary learning outcomes, including satisfaction, self-efficacy, engagement, and perceptions of the learning experience. Of the 29 studies, 19 (66%) included medical students (1706/2722, 62.67%), 8 (28%) included nursing students (727/2722, 26.71%), and 2 (7%) included both medical and nursing students (289/2722, 10.62%). There were no studies involving midwifery students. The studies were based on the following disciplines: anatomy, basic clinical skills and history-taking skills, neurology, respiratory medicine, acute medicine, dermatology, communication skills, internal medicine, and emergency medicine. Conclusions Virtual, augmented, and mixed reality play an important role in the education of preclinical medical and nursing university students. When compared with traditional educational modalities, the learning gain is equal with immersive technologies. Learning outcomes such as student satisfaction, self-efficacy, and engagement all increase with the use of immersive technology, suggesting that it is an optimal tool for education.
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Burt, Wendy, and Lucy Spowart. "Assessing the impact of a new central venous access device training progam for nurses: A quasi-experimental evaluation study." Journal of Infection Prevention 22, no. 4 (January 12, 2021): 166–72. http://dx.doi.org/10.1177/1757177420982041.
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Background: Central venous access devices (CVAD) are widely used for both long- and short-term purposes within healthcare and are suitable for both hospital and community management. Training is essential in the prevention of complications such as infection. Objectives: To assess the impact of a new standardised education programme on clinical practice and patient care. The new education programme was introduced to all registered nurses working in one care group within an acute healthcare Trust with the aim of improving knowledge and skills and reduce CVAD-related complications. Methods: This retrospective quasi-experimental evaluation study analyses the impact of the programme on direct patient care. Secondary data sources such as infection incidence rates and CVAD clinical audits were used to identify and measure the relationship between staff confidence, infection incidence and care audit results. Data spanning a two-year period were used to capture an accurate representation of the patient group. Results: Improvements in audited care elements and a reduction of infection incidences were evident during and after implementation of the education programme. This was reflective of the self-reported increased confidence and knowledge and skill acquisition from staff who attended the programme. Discussion: Recommendations have been made including a review of the education content to target all key elements and promotion of an end goal with regular feedback to staff reinforcing the importance. The challenge of using secondary data sources also highlighted the need for quality improvements in the current care audit process.
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Burns, Jonathan, Dave Williams, Danielle Mlinaritsch, Maryna Koechlin, Trena Canning, and Andrew Neitzel. "Early detection and treatment of acute illness in medical patients with novel software: a prospective quality improvement initiative." BMJ Open Quality 11, no. 3 (July 2022): e001845. http://dx.doi.org/10.1136/bmjoq-2022-001845.
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ObjectiveAn ageing population and rising healthcare costs place healthcare systems at risk of failure. Our goal was to develop a technology that would identify illness early, initiate action and therein improve patient care, outcomes and save healthcare resources.DesignThis was a prospective interventional quality improvement study.SettingA 40 bed medical floor in a 300 bed Canadian tertiary care regional referral hospital.ParticipantsGeneral ward patients randomly assigned to control or treatment groups. There was no cross-over or loss to follow-up.InterventionWe designed an algorithm and software programme capable of detecting the sentinel change in a deteriorating patient’s clinical condition and once detected direct early investigation and care. Study duration was 1 year.Main outcome measuresPrimary outcome was patient transfer from the general medical ward to the intensive care unit (ICU). The secondary outcome was the time needed to (1) order investigations (2) contact senior medical staff and (3) senior medical staff intervention.ResultsWe identified a decrease in the transfer of patients from the medical ward to the ICU. Over the course of the study including 273 patients (110 in the control group and 163 in the treatment group), transfers dropped from 14 to 3 with a relative risk reduction of 85.54% (95% CI 84.96 to 86.1), a number needed to treat of 9.19 (95% CI 9.01 to 9.36) and a absolute risk reduction of 10.89% (95% CI 10.7 to 11.1). We also found a statistically significant reduction in the time required to order investigations (p=0.049), contact senior medical staff (p=0.040) and senior medical staff intervention (p=0.045).ConclusionA novel algorithm and software in the hands of nursing staff identified acute illness with adequate sensitivity and specificity to dramatically reduce ICU transfers and time to clinical intervention on a medical ward.
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Henry, Sharen, Doramarie Arocha, Dawn Brown, Hope Sutterfield, Lisa Kielpinkski, Ruth Fisher, Mary-Grace Reed, Emily Flahaven, Michelle L. Olson, and Julie B. Trivedi. "1155. CAUTI Path to Zero: A Triple-Pronged Approach to Minding Our Pees and Cues." Open Forum Infectious Diseases 6, Supplement_2 (October 2019): S412—S413. http://dx.doi.org/10.1093/ofid/ofz360.1018.
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Abstract Background Catheter-associated urinary tract infections (CAUTIs) account for nearly 30% of all hospital-acquired infections. From 2009 to 2013, the frequency of CAUTIs increased by 6% with associated increases in length of stay, antibiotic usage and mortality (2.3%); they are also a risk factor for secondary bloodstream infections. In 2017, the CAUTI SIR for the UTSW University hospitals was 0.990 for Clements University Hospital (CUH) and 1.224 for Zale-Lipshy (ZL), placing UTSW above the 50th percentile compared with similar academic medical centers. By the end of 2018, the aim of the quality improvement project was to reduce CAUTIs by 25% or improve the SIR to 0.78, which is at or below the 50th percentile. Methods Baseline data included identifying indications and duration of catheter placement as well as performing debriefings on all CAUTIs along with analysis of adherence to the CAUTI bundle. Using evidence-based guidelines, the three primary interventions were (1) streamlining indications for insertion, (2) ensuring prompt removal and (3) providing alternative care pathways after removal. We observed insertion technique and catheter care; nursing services were engaged to understand barriers to catheter removal and subsequently informed of other options such as in-and-out protocols, bladder scanners and female external catheters. Nursing leadership also performed daily necessity audits of all patients with indwelling catheters. Results Urine output monitoring in acute/critical illness and urinary obstruction/retention were the top two indications for use. Catheter utilization rates have decreased since 2016. The average dwell time at CUH was 51 hours (excl. urology) and 40 hours at ZL. There was actually a 34% decrease in the total number of CAUTIs from 38 in 2017 to 25 in 2018, exceeding the goal of 25% reduction; the 2018 SIR for CUH was 0.818 and 0.496 for ZL. The prevention of 13 CAUTI events from 2017 to 2018 resulted in ~$180,000 savings. Conclusion Successful reduction of CAUTI is an interdisciplinary effort requiring consistent attention and support from infection prevention, nursing, education, quality improvement, IT and hospital administration. Empowering nursing staff, providing clear protocols post-removal and options for alternative external urinary devices is key. Disclosures All authors: No reported disclosures.
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O’Shaughnessy, Íde, Katie Robinson, Margaret O'Connor, Mairéad Conneely, Damien Ryan, Fiona Steed, Leonora Carey, Aoife Leahy, and Rose Galvin. "Effectiveness of acute geriatric unit care on functional decline and process outcomes among older adults admitted to hospital with acute medical complaints: a protocol for a systematic review." BMJ Open 11, no. 10 (October 2021): e050524. http://dx.doi.org/10.1136/bmjopen-2021-050524.
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IntroductionOlder adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints.DesignUpdated systematic review and meta-analysisMethods and analysisMEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow‐up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data.Ethics and disseminationFormal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper.PROSPERO registration numberCRD42021237633.
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Stoian, Marilena, Gabriel Scarlat, Bassil Dona, Bianca Procopiescu, and Claudia Ciofu. "Clinico-Pathological Correlations of Poststreptococcal Glomerulonephritis." Internal Medicine 19, no. 2 (February 1, 2022): 63–70. http://dx.doi.org/10.2478/inmed-2022-0208.
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Abstract Postinfectious glomerulonephritis is associated with bacterial, viral, fungal, and parasitic infectious agents and histologically appears most often as acute diffuse endocapillary or proliferative glomerulonephritis secondary infection with: group A streptococcus, streptococcus viridans, staphilococus aureus, diploccocus pneumoniae, Brucella melitensis, Salmonella typhi, Yershinia enterocolitica, Plasmodium falciparum, meningococcus, Mycoplasma, Klebsiella, varicella, variola, mumps. Less commonly, it appears as diffuse crescentic glomerulonephritis and a lot of infectious causes are incriminated like: streptococcus, legionella, varicella, Treponema pallidum or as focal crescentic glomerulonephritis: streptococcus A. It rarely appears as mesangiocapillary glomerulonephritis secondary infection with: streptococcus viridans, hepatitis C virus; diffuse or focal mesangial proliferative glomerulonephritis: hepatitis B virus, salmonella, adenovirus, influenza virus, salmonella; focal segmental, necrotizing and sclerosing glomerulonephritis: bacterial endocarditis; membranous glomerulonephritis: hepatitis B virus, syphilis, filarial, Mycobacterium, plasmodium falciparum; focal proliferative: Mycoplasma; mesangiolytic glomerulonephritis :Echo virus. Poststreptococcal glomerulonephritis (PSGN) is caused by prior infection with specific nephritogenic strains of group A beta-hemolytic streptococcus. The clinical presentation of PSGN varies from asymptomatic, microscopic hematuria to the full-blown acute nephritic syndrome, characterized by red to brown urine, proteinuria (which can reach the nephrotic range), edema, hypertension, and acute kidney injury. The prognosis is generally favorable, especially in children, but in some cases, the long-term prognosis is not benign. Managing a case of PSGN requires cooperation between internists, nephrologists, infectious disease consultants, pharmacists, and nursing staff, functioning as an interprofessional team, to provide excellent care for their patients.
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Agarwal, Nikunj, and M. P. Sebastian. "Utility of clinical technology-processes for developing countries." Clinical Governance: An International Journal 19, no. 3 (July 1, 2014): 253–68. http://dx.doi.org/10.1108/cgij-04-2014-0019.
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Purpose – The purpose of this paper is to evaluate the utility of clinical processes in healthcare institutions of different sizes. The implications of adoption rate of computerized physicians order entry (CPOE) and electronic medical/health records (EMRs/EHRs) in different sized healthcare institutions in the USA were studied in terms of understanding its impact on enhancement of quality of patient care. Design/methodology/approach – This study has used secondary data to obtain insights on the processes and technologies used in hospitals of different sizes in the USA and enlighten those in the developing countries to adopt a strategy that would be most appropriate for them. The Dorenfest Institute for H.I.T. Research and Education Analytics database (The Dorenfest Institute, 2011) provided the data for 5,038 US hospitals. Logistic regression was performed to study the impact of the different types of processes and technologies on institutions of different sizes, classified based on the number of beds, physicians, and nurses. Findings – The findings show that small sized hospitals had a positive relationship with drug dosing interactions process and nursing and clinician content process. On the contrary, medium sized hospitals had a negative relationship with the usage of CPOE for entering medical records, i.e. <25 percent (p<0.05). In order to be effective, these institutions should increase the usage of EMRs by more than 25 percent to get positive outcomes. Large hospitals showed a positive relationship with the usage of >75 percent of CPOE to enter medical records and usage of medical records >75 percent. Practical implications – The authors demonstrate the need for an evaluation of utility of acute care hospitals based on hospital size in terms of number of physicians, and nurses, which have not been dealt earlier by the past studies. Moreover, there is also a need for an evaluation of utility of acute care hospitals for implementation of CPOEs and EMRs that are integrated with clinical decision support systems. Originality/value – Although the data are US-centric, the insights provided by the results are very much relevant to the Indian scenario to support the improvement of the quality of care. The findings may help those implementing processes in healthcare institutions in India. No study has addressed the measurement of the positive and negative outcomes arising due to the implementation of different percentages of CPOEs and EMRs in different sized institutions. Further the number of physicians and nurses have not been considered earlier. Therefore, the authors have classified the hospitals based on physicians and nurses and studied their impact on the adoption of CPOEs, clinical decision support systems, and EMRs.
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Clark, John Alexander, Iain Robert Louis Kean, Martin D. Curran, Fahad Khokhar, Deborah White, Esther Daubney, Andrew Conway Morris, et al. "Rapid Assay for Sick Children with Acute Lung infection Study (RASCALS): diagnostic cohort study protocol." BMJ Open 11, no. 11 (November 2021): e056197. http://dx.doi.org/10.1136/bmjopen-2021-056197.
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IntroductionLower respiratory tract infection (LRTI) is the most commonly treated infection in critically ill children. Pathogens are infrequently identified on routine respiratory culture, and this is a time-consuming process. A syndromic approach to rapid molecular testing that includes a wide range of bacterial and fungal targets has the potential to aid clinical decision making and reduce unnecessary broad spectrum antimicrobial prescribing. Here, we describe a single-centre prospective cohort study investigating the use of a 52-pathogen TaqMan array card (TAC) for LRTI in the paediatric intensive care unit (PICU).Methods and analysisCritically ill children with suspected LRTI will be enrolled to this 100 patient single-centre prospective observational study in a PICU in the East of England. Samples will be obtained via routine non-bronchoscopic bronchoalveolar lavage which will be sent for standard microbiology culture in addition to TAC. A blood draw will be obtained via any existing vascular access device. The primary outcomes of the study will be (1) concordance of TAC result with routine culture and 16S rRNA gene sequencing and (2) time of diagnostic result from TAC versus routine culture. Secondary outcomes will include impact of the test on total antimicrobial prescriptions, a description of the inflammatory profile of the lung and blood in response to pneumonia and a description of the clinical experience of medical and nursing staff using TAC.Ethics and disseminationThis study has been approved by the Yorkshire and the Humber-Bradford Leeds Research Ethics Committee (REC reference 20/YH/0089). Informed consent will be obtained from all participants. Results will be published in peer-reviewed publications and international conferences.Trial registration numberNCT04233268.
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Kerleroux, Basile, Thibaut Fabacher, Nicolas Bricout, Martin Moïse, Benoit Testud, Sivadji Vingadassalom, Héloïse Ifergan, et al. "Mechanical Thrombectomy for Acute Ischemic Stroke Amid the COVID-19 Outbreak." Stroke 51, no. 7 (July 2020): 2012–17. http://dx.doi.org/10.1161/strokeaha.120.030373.
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Background and Purpose: The efficiency of prehospital care chain response and the adequacy of hospital resources are challenged amid the coronavirus disease 2019 (COVID-19) outbreak, with suspected consequences for patients with ischemic stroke eligible for mechanical thrombectomy (MT). Methods: We conducted a prospective national-level data collection of patients treated with MT, ranging 45 days across epidemic containment measures instatement, and of patients treated during the same calendar period in 2019. The primary end point was the variation of patients receiving MT during the epidemic period. Secondary end points included care delays between onset, imaging, and groin puncture. To analyze the primary end point, we used a Poisson regression model. We then analyzed the correlation between the number of MTs and the number of COVID-19 cases hospitalizations, using the Pearson correlation coefficient (compared with the null value). Results: A total of 1513 patients were included at 32 centers, in all French administrative regions. There was a 21% significant decrease (0.79; [95%CI, 0.76–0.82]; P <0.001) in MT case volumes during the epidemic period, and a significant increase in delays between imaging and groin puncture, overall (mean 144.9±SD 86.8 minutes versus 126.2±70.9; P <0.001 in 2019) and in transferred patients (mean 182.6±SD 82.0 minutes versus 153.25±67; P <0.001). After the instatement of strict epidemic mitigation measures, there was a significant negative correlation between the number of hospitalizations for COVID and the number of MT cases ( R 2 −0.51; P =0.04). Patients treated during the COVID outbreak were less likely to receive intravenous thrombolysis and to have unwitnessed strokes (both P <0.05). Conclusions: Our study showed a significant decrease in patients treated with MTs during the first stages of the COVID epidemic in France and alarming indicators of lengthened care delays. These findings prompt immediate consideration of local and regional stroke networks preparedness in the varying contexts of COVID-19 pandemic evolution.
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Huttner, Hagen B., Stefan T. Gerner, Joji B. Kuramatsu, Stuart J. Connolly, Jan Beyer-Westendorf, Andrew M. Demchuk, Saskia Middeldorp, et al. "Hematoma Expansion and Clinical Outcomes in Patients With Factor-Xa Inhibitor–Related Atraumatic Intracerebral Hemorrhage Treated Within the ANNEXA-4 Trial Versus Real-World Usual Care." Stroke 53, no. 2 (February 2022): 532–43. http://dx.doi.org/10.1161/strokeaha.121.034572.
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Background and Purpose: It is unestablished whether andexanet alfa, compared with guideline-based usual care including prothrombin complex concentrates, is associated with reduced hematoma expansion (HE) and mortality in patients with factor-Xa inhibitor–related intracerebral hemorrhage (ICH). We compared the occurrence of HE and clinical outcomes in patients treated either with andexanet alfa or with usual care during the acute phase of factor-Xa inhibitor–related ICH. Methods: Data were extracted from the multicenter, prospective, single-arm ANNEXA-4 trial (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) and a multicenter observational cohort study, RETRACE-II (German-Wide Multicenter Analysis of Oral Anticoagulant-Associated Intracerebral Hemorrhage - Part Two). HE was based on computed tomography scans performed within 36 hours from baseline imaging. Inverse probability of treatment weighting was performed to adjust for baseline comorbidities and ICH severity. Patients presenting with atraumatic ICH while receiving apixaban or rivaroxaban within 18 hours of admission were included. Patients with secondary ICH or not fulfilling the inclusion criteria for the ANNEXA-4 trial were excluded. We compared ANNEXA-4 patients, who received andexanet alfa for hemostatic treatment, with RETRACE-II patients who were treated with usual care, primarily administration of prothrombin complex concentrates. Primary outcome was rate of HE defined as relative increase of ≥35%. Secondary outcomes comprised mean absolute change in hematoma volume, as well as in-hospital mortality and functional outcome. Results: Overall, 182 patients with factor-Xa inhibitor–related ICH (85 receiving andexanet alfa versus 97 receiving usual care) were selected for analysis. There were no relevant differences regarding demographic or clinical characteristics between both groups. HE occurred in 11 of 80 (14%) andexanet alfa patients compared with 21 of 67 (36%) usual care patients (adjusted relative risk, 0.40 [95% CI, 0.20–0.78]; P =0.005), with a reduction in mean overall hematoma volume change of 7 mL. There were no statistically significant differences among in-hospital mortality or functional outcomes. Sensitivity analysis including only usual care patients receiving prothrombin complex concentrates demonstrated consistent results. Conclusions: As compared with usual care, andexanet alfa was associated with a lower rate of HE in atraumatic factor-Xa inhibitor–related ICH, however, without translating into significantly improved clinical outcomes. A comparative trial is needed to confirm the benefit on limiting HE and to explore clinical outcomes across patient subgroups and by time to treatment. Registration: URL: https://clinicaltrials.gov ; Unique identifier: NCT02329327 and NCT03093233.
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Kim, Moinay, Joonho Byun, Yeongu Chung, Si Un Lee, Ji Eun Park, Wonhyoung Park, Jung Cheol Park, Jae Sung Ahn, and Seungjoo Lee. "Reactive Oxygen Species Scavenger in Acute Intracerebral Hemorrhage Patients." Stroke 52, no. 4 (April 2021): 1172–81. http://dx.doi.org/10.1161/strokeaha.120.032266.
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Background and Purpose: Patients with intracerebral hemorrhage (ICH) have oxidative stress. Oxidative stress contributes to the development and progression of perihematomal edema (PHE) in brain hemorrhage patients. We hypothesized that reactive oxygen species (ROS) scavengers might have a neuroprotective role in the acute period of patients with ICH. Methods: This prospective, multicenter, single-blind, randomized study was conducted between June 2017 and October 2019. Intracranial bleeding, including spontaneous ICH, secondary ICH due to vascular anomalies, venous thrombosis, neoplasms, or hemorrhagic infarction, were included in our study. These ROS scavengers were given for 14 days with a dose of N-acetylcysteine 2000 mg/d and selenium 1600 µg/d intravenously. Other patients received a placebo. The primary outcome was hemorrhage and PHE volume changes in 2-week follow-up computed tomography between ROS scavenger versus placebo groups. Results: In total, 448 patients were enrolled with 123 patients remaining after applying the inclusion and exclusion criteria. There were no significant differences in baseline characteristics between the ROS scavenger (n=57) and placebo (n=66) groups. No significant differences in baseline hematoma and PHE volumes were observed but 2 weeks follow-up computed tomography showed significant differences in PHE volume (21.90±17.63 versus 30.66±32.35, P <0.01) and PHE ratio (1.19±0.73 versus 2.05±1.27, P <0.01). Among clinical factors, time to reach target Richmond Agitation Sedation Scale (5.98 hours [95% CI, 4.82–7.241 versus 8.42 hours], [95% CI, 6.57–10.77], P <0.01) and the length of intensive care unit stays (6.46 days [95% CI, 2.38–10.55 versus 12.66 days], [95% CI, 8.47–16.85], P <0.01) were significantly shortened among patients who received ROS scavengers than among patients who did not receive ROS scavenger. Conclusions: ROS scavenger showed a significantly reduced PHE volume, time to reach target Richmond Agitation Sedation Scale, and shortened length of intensive care unit stay in patients with acute ICH. Early and high doses of ROS scavengers in a combination regimen may have played a key role in obtaining a favorable outcome in our study. Registration: URL: https://cris.nih.go.kr/cris/en ; Unique identifier: KCT0004628.
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Singh, Sunny R. K., Sindhu Janarthanam Malapati, Rohit Kumar, Kannan Thanikachalam, and Yaser Alkhatib. "Predictors of transfer to different facility at discharge in patients admitted with metastatic solid malignancy: Five-year National Inpatient Sample (NIS) database analysis." Journal of Clinical Oncology 37, no. 31_suppl (November 1, 2019): 38. http://dx.doi.org/10.1200/jco.2019.37.31_suppl.38.
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38 Background: Improvement in cancer treatment has led to an increase in prevalence of metastatic malignancy (met-Ca) with a rise in healthcare utilization secondary to this. We aim to identify predictive factors for transfer at discharge to another non-acute facility, such as nursing home and sub-acute rehab. Methods: This is a retrospective cohort analysis of NIS database (from years 2010 to 2014.) Inclusion criteria was any admission of adults (≥18 years) with met-Ca (identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes.) Patients transferred in from a different acute care hospital or another type of health facility were excluded. Primary outcome was transfer upon discharge to a different facility (transfer out) excluding acute care hospital. Statistical analysis was done using STATA. Results: There were 3,204,631 admissions with met-Ca, 15.3% (n= 490,735) had transfer out. Of these, 50.6% were females, 69.6% Caucasians and mean age was 70.9 years. On multivariate regression analysis, African Americans had higher odds for transfer out versus Caucasians (OR 1.06 p <0.005). Admission type- weekend vs weekday and elective vs non elective were also associated with this outcome (OR 1.08 p<0.005 and OR 0.56 p<0.005). Odds ratio for other predictors are shown below (p value <0.005 for all). Conclusions: Age, race, increased length of stay, cancer type, hospital size and teaching status, admission type and insurance type had a significant predictive value for transfer out after discharge in patients with met-Ca. A future area of exploration is the development of a scoring system to predict risk of transfer to a different facility at discharge- this will allow early mobilization of resources for these patients with complex healthcare needs. [Table: see text]
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Jim Tan, Win, and Mohan Tiruchittampalam. "Hepatorenal Syndrome in the Emergency Department: A Case Report." International Journal of Medical Students 3, no. 1 (December 31, 2014): 51–54. http://dx.doi.org/10.5195/ijms.2015.116.
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Background: Hepatorenal syndrome is a condition where there is functional renal failure in a background of liver disease. It is relatively common in patients with liver cirrhosis and is associated with a high mortality rate if untreated. Case: This is a case report of an 88-year-old Chinese man presenting from a community hospital with a new onset of abdominal distension on a background of cryptogenic liver cirrhosis diagnosed on computed tomography scan. Clinical history and physical findings were consistent with that of fluid overload. Investigations performed indicated acute kidney injury together with liver failure secondary to liver cirrhosis. The patient was diagnosed with hepatorenal syndrome in accordance with the criteria established by the International Ascites Club and managed with an infusion of vasopressin and albumin in the emergency department. He was subsequently admitted to the general ward (gastrology), where he was managed for hepatorenal syndrome, improved clinically and was discharged to the nursing home. Conclusion: Hepatorenal syndrome can be managed effectively with albumin and vasopressin, and such treatment can be started as early as in the emergency department. Acute care physicians should not be hesitant in diagnosing and treating hepatorenal syndrome as early as in the emergency department for appropriate patients.
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Amatangelo, Mary P. "Abstract P868: Clinical Challenges of the ICU Complex Stroke Patient." Stroke 52, Suppl_1 (March 2021). http://dx.doi.org/10.1161/str.52.suppl_1.p868.
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Ischemic stroke accounts for approximately 85% of all strokes. Reperfusion therapy with intravenous Alteplase and/or endovascular thrombectomy is mainstay of acute stroke management. Approximately 30% of ischemic stroke patients will deteriorate in the first 24 hours regardless of pharmacologic and/or mechanical intervention. 15%-20% will require care in an intensive care unit (ICU). Severe strokes constitute a minority of cases though are associated with a majority of subsequent disability and death. The complex stroke patient presents many clinical challenges for the ICU nurse. This presentation will review nursing clinical challenges of the complex stroke patient in the ICU. The ICU Nurse is challenged with a variety of complex interventions caring for the ICU stroke patient. There is a significant subset of ischemic stroke patients at risk for secondary brain injury who may benefit from critical care monitoring and intervention. Nursing assessment, treatments, goals of care, and collaboration with the interdisciplinary ICU team will be addressed. There is evidence that care in a neuroscience-specific ICU leads to improved outcomes in traumatic brain injury, intraparenchymal hemorrhage, and subarachnoid hemorrhage and reduced cost of care for neurosurgical patients. There is less direct evidence to support benefit of ICU care in ischemic stroke, but the association between care at a specialized stroke center and outcome is well established. Recognizing nursing’s role in the care of the ICU stroke patient is key. The assessment and identification of subtle changes are imperative. Intervening with a variety of timely treatment options to eliminate complications must occur. Implementing current evidence-based practice allows for the best patient outcomes. The ICU nurse is challenged with the early recognition and appropriate management of neurological and non-neurological complications of the stroke patient in the ICU. This can be a significant factor in reducing mortality during the acute hospitalization. Standardized care implemented by the collaboration of nursing, neurointensivist and a critical care team, can not only decrease the length of stay, though also offer a greater chance of being discharged to home.
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Daggett, Virginia, Linda Williams, Nicholas Burrus, Jennifer Myers, Laura Plue, Joshua Robinson, Edward Miech, Heather Woodward-Hagg, and Teresa Damush. "Abstract 90: Nursing Education: A Critical Need in the Delivery of High Quality Stroke Care." Stroke 45, suppl_1 (February 2014). http://dx.doi.org/10.1161/str.45.suppl_1.90.
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Objectives: High quality stroke care is complex, and requires strong multidisciplinary teams, including nurses, to ensure care processes are timely and appropriate. The purpose of this study was to identify training needs of nurses who deliver care to patients who present with acute stroke and are admitted to inpatient units. Methodology: Using semi-structured interviews, we conducted a qualitative study for a formative evaluation in 12 Department of Veterans Affairs Medical Centers (VAMCs) that had ≥ 50 acute ischemic stroke admissions a year and were diverse in the structure of stroke care. The interviews focused on current context and structure of stroke care, including educational practices and training needs. Secondary analyses were conducted, targeting frontline nurse and physician respondents (N = 113) in emergency, acute care and rehabilitation units. Results: Respondents across the sites reported insufficient nurse education and training for acute stroke care as an overarching theme. Moreover, themes related to the acute stroke care quality indicators emerged as areas of competencies that nurses needed training on a continuum: a) timely recognition of acute stroke and transient ischemic attacks, b) NIH Stroke Scale and neurological exams, c) dysphagia screening, d) administration of tissue plasminogen activator and management post treatment, and e) deep vein thrombosis prophylaxis. Themes that were related to structure of stroke care and/or context also emerged and attributed to training challenges across the sites, listed in order of prevalence: a) centralized care versus decentralized care, b) low volume of acute strokes, c) nurse engagement, d) structured acute stroke care education, and e) release time. Conclusions: VA stroke care providers identify educational needs around specific stroke quality indicators, but also describe key barriers including lower volume, time for training and engagement of nursing staff in acute stroke care. Future programs to improve VA stroke care need to address these barriers to optimally support high quality multidisciplinary stroke care.
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Gonçalves, Alexia Louisie Pontes, Daiane Lopes Grisante, Renan Alves Silva, Vinicius Batista Santos, and Camila Takao Lopes. "Relationship Between Frailty, Sociodemographic and Clinical Characteristics, and Disease Severity of Older Adults With Acute Coronary Syndrome." Clinical Nursing Research, August 4, 2022, 105477382211152. http://dx.doi.org/10.1177/10547738221115231.
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This study aimed to evaluate the relationship between frailty, sociodemographic and clinical characteristics, and disease severity of older adults with acute coronary syndrome (ACS). A total of 57 hospitalized patients ≥60 years with ACS were assessed for frailty through the Tilburg Frailty Indicator. Disease severity was assessed by the Global Registry of Acute Coronary Events, by the maximum troponin level, and by the number of severely obstructed coronary arteries. The relationship between variables was assessed by Mann Whitney’s test, Pearson’s chi-square test, likelihood-ratio test, Fisher’s exact test, or Student’s t test. Analyses were bootstrapped to 1,000 to reduce potential sample bias. About 54.4% were frail. Frailty was associated with ethnicity ( p = .02), marital status ( p = .05), ischemic equivalents ( p = .01), self-perceived health ( p = .002), arthritis/rheumatism/arthrosis ( p = .002), and number of severely obstructed coronary arteries ( p = .05). These relationships can support intensified surveillance planning for the elderly at greatest risk, structuring of transitional care, appropriate nurse-coordinated secondary prevention delivery in primary care, and cardiac rehabilitation following ACS.
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Koppitz, Andrea L., Susanne Suter-Riederer, Gabriela Bieri-Brünig, Heike Geschwinder, Anita Keller Senn, Frank Spichiger, and Thomas Volken. "Prevention Admission into Nursing homes (PAN): study protocol for an explorative, prospective longitudinal pilot study." BMC Geriatrics 22, no. 1 (March 19, 2022). http://dx.doi.org/10.1186/s12877-022-02885-z.
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Abstract Background In Switzerland, there is a lack of adequate rehabilitation services, and effective coordination, that take into account the multifactorial health risks of older people. The literature shows that the hospitalisation rate in rehabilitation facilities has increased in recent years and that a gender bias exists. Additionally, there is little or no evidence available on the effect that a post-acute care programme might have over an extended period on functioning, quality of life and the informal network of older people. Therefore, the aim of this trial is to evaluate the sustainability of post-acute care within three nursing homes in Zurich, Canton of Zurich, Switzerland. Methods The Prevention Admission into Nursing homes (PAN) study is a explorative, prospective, longitudinal pilot trial based on a convenience sample of three long-term care facilities in the Swiss Canton of Zurich. The proposed pilot study will examine the effects of a post-acute care programme on people aged ≥65 years with a post-acute care potential ≥ three admitted to any of the three post-acute care units (n = 260). Older people of all sexes admitted to one of the post-acute care units and likely to be discharged to home within 8 weeks will be eligible for participation in the study. The primary endpoint is functionality based on the Barthel Index. The secondary endpoints are independency based on delirium, cognition, mobility, falling concerns, frailty, weight/height/body mass index, post-acute care capability, quality of life, and lastly, the informal network. As part of process evaluation, a qualitative evaluation will be conducted based on constructive grounded theory to specifically analyse how the experience of informal caregivers (n = 30) can contribute to a successful daily life 6 months after discharge. Discussion We expect to observe improved functional status and independence after the post-acute care programme. The qualitative evaluation conducted with caregivers will complement our description of the transition of older people towards living at home. Trial registration This study is registered in the German Clinical Trials Register under DRKS00016647 (registered on 23.05.2019).
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Li, Zixiao, Yilong Wang, Xudong Ma, Xingquan Zhao, Liping Liu, Hongqiu Gu, Caiyun Wang, et al. "Abstract WP298: Achievement of Guideline-concordant Process of Care and 1-year Outcomes in Patients with Acute Ischemic Stroke in Secondary and Tertiary Hospitals: Results From China National Stroke Registry Ii." Stroke 48, suppl_1 (February 2017). http://dx.doi.org/10.1161/str.48.suppl_1.wp298.
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Background: Guideline-concordant processes of care improve longitudinal outcomes in patients with acute stroke. Little is known whether there are different processes of acute ischemic stroke (AIS) care or outcomes between secondary and tertiary hospitals. Methods: We analyzed 19 604 AIS patients across 219 hospitals in China National Stroke Registry II from June 2012 to January 2013. The primary outcome was guideline-concordant care, defined as compliance with 13 guideline-recommended performance metrics and composite score. Propensity score matching was used to balance the baseline characteristics. We used cox model and logistic regression with generalized estimating equation to compare the relationship between secondary and tertiary hospitals on quality measures and all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Results: Among 19 604 AIS patients, 6 038 (30.8%) and 13 566 (69.2%) were admitted to 66 (30.1%) secondary and 153 (69.9%) tertiary hospitals separately. After matching, 5959 pairs of patients in secondary and tertiary were analyzed. The composite score was higher at tertiary hospitals than secondary hospitals (77% versus 74%, P<0.001). Tertiary hospitals were more likely to perform early antithrombotic, carotid imaging, anticoagulation for atrial fibrillation, antihypertensive therapy, hypoglycemic medications, and rehabilitation (Figure 1). Furthermore, comparing to AIS patients among tertiary hospitals, those admitted to secondary hospitals had higher hazard of disability at 3 months (19.3% versus 21.5%) and 1-year stroke recurrence (4.4% versus 5.4%) after matching. Conclusions: In China, tertiary hospitals have better processes of AIS care and more favorable clinical outcomes than secondary hospitals. The quality of process of AIS care should be further increased to improve the patients’ clinical outcomes especially among secondary hospitals.
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Smith, Ann, Kathleen Bledsoe, Thomas Madden, Jamie Artale, and Ted Sindlinger. "Abstract P301: Evaluating the Impact of a Pharmacist-Managed Hypertension Collaborative Care Model in Vascular Neurology Patients in an Inpatient Acute Care Setting." Stroke 52, Suppl_1 (March 2021). http://dx.doi.org/10.1161/str.52.suppl_1.p301.
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Introduction: The utility of pharmacist-managed collaborative practice agreements (CPA) in the management of hypertension is well established in the outpatient setting. There has been little evaluation of the use of CPAs in the inpatient acute care setting, and none described specifically in the vascular neurology population. Treatment of hypertension is a critical intervention for the secondary prevention of acute ischemic stroke. This quality improvement project evaluated the implementation of a CPA for the inpatient acute care management of hypertension in vascular neurology patients at University of Virginia Health. Methods: A CPA was developed between the neurosciences clinical pharmacist group and the inpatient vascular neurology service, legally vetted, and implemented in June 2019. All vascular neurology patient charts in which an electronic CPA referral was placed from June 2019 through June 2020 were reviewed. Patients were excluded if they were discharged within 24 hours of the referral being placed. The primary objective was to describe and evaluate the implementation of a pharmacist-driven hypertension management practice in the inpatient acute care setting. All patient demographic and clinical data were analyzed using descriptive statistics. Secondary safety outcomes included documented hypotensive events (SBP <90) and acute kidney injury (AKI, increase in SCr by 0.3 mg/dl within 48 hours). Results: During the study period, 26 referrals were placed, and 19 patients were included for review. On average, patients were on 2 anti-hypertensive medications prior to admission. From the time of referral to discharge (mean 6 days), systolic blood pressure (SBP) was reduced on average by 36 mmHg (mean percentage reduction 20%) and diastolic blood pressure (DBP) by 12 mmHg (mean percentage reduction 7%). Ten patients (53%) met the goal of SBP < 140 at discharge. There were 5 hypotensive events and 4 instances of AKI, all of which were mild and recovered prior to discharge. Conclusion: A pharmacist-managed hypertension CPA was successfully implemented in vascular neurology patients in the inpatient acute care setting. The practice demonstrated improved blood pressure control and minimal adverse outcomes.
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Kang, Jihoon, Seong Eun Kim, Hyunjoo Song, and Hee-joon Bae. "Abstract P184: Effect of Acute Stroke Care Hospital Networks in Korea." Stroke 52, Suppl_1 (March 2021). http://dx.doi.org/10.1161/str.52.suppl_1.p184.
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Purpose: Stroke patients generally transport stroke patients either to nearest stroke hospital with secondary transfers or to hub hospitals in selective cases. This study aimed to determine the stroke community of close networks and to evaluate their role for the access the endovascular treatment (EVT). Methods: Using the nationwide acute stroke hospital (ASH) surveillance data assessed the major quality indicators of all stroke patients of South Korea, triage information both initial visit and secondary interhospital transfers were extracted according to the hospitals. Based on them, stroke community with dense linkages were partitioned using the network-based Louvain algorithm. The hierarchical model estimated the function of stroke community for the EVT. Results: For 6-month surveying period, 19113 subjects admitted to the 246 ASHs. Of them, 1831 (9.6%) were transferred from 763 adjacent facilities not ASH, while 1283 (6.7%) from the other ASHs. The algorithm determined the 113 stroke communities where composed median 7 hospitals (2 ASHs and 5 adjacent facilities) and treated about 30 subjects per month. Most of communities formed the spindle shape with higher centralization index and located within 150 Km (Figure). Stroke communities significantly affected 11% of EVT after adjustments. Conclusions: Network analysis method effectively contoured the high centralizing stroke communities and helped the functions on the EVT accessibility.
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Streib, Christopher D., Oladi Bentho, Kathryn Bard, Eric Jaton, Sarah Engkjer, Matthew Ronck, Monica Ngo, et al. "Abstract TMP86: Telestroke Improves Guideline-Based Comprehensive Stroke Care: The TELECAST Trial." Stroke 51, Suppl_1 (February 2020). http://dx.doi.org/10.1161/str.51.suppl_1.tmp86.
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Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge. Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0. Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p<0.01) as did adherence to DSE guidelines (subgroup score: 90 vs 95%, p<0.01). SSP, HSE, and SE subgroup scores were not significantly different. See Table 1. Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.
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Butzko, Ryan, and Mangala Narasimhan. "Acute Budd Chiari syndrome in an ECMO patient." Perfusion, March 26, 2021, 026765912110038. http://dx.doi.org/10.1177/02676591211003874.
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Introduction: Point-of-care ultrasound (POCUS) is widely utilized to make timely decisions regarding patient care. This approach allowed us to diagnose the cause of acutely rising transaminases in a patient in severe ARDS secondary to influenza pneumonia requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO). Case report: A 36-year-old female presented with acute hypoxemic respiratory failure secondary to influenza A infection. Within 24 hours, she required intubation and met severe ARDS criteria with a PaO2/FiO2 ratio of 62. She was managed with high PEEP and low tidal volume ventilation strategy, however her clinical status continued to deteriorate and the decision was made to pursue VV-ECMO. Within hours of cannulation her aspartate aminotransferase (AST) dramatically increased from 736 to 4512 µ/L, with concurrent mild increases in alanine aminotransferase (ALT) and creatine phosphokinase (CPK). Point-of-care ultrasound was performed which revealed a complete absence of flow in the hepatic vein, secondary to acute obstruction by an 25-French drainage catheter for the ECMO circuit. The catheter was exchanged with a smaller French catheter and the patient’s transaminases and CPK levels quickly decreased and returned to normal within several days. Discussion: Budd-Chiari syndrome (BCS) is a rare but potentially life-threatening condition caused by acute obstruction of hepatic vein blood flow that can lead to fulminant liver failure if left untreated. BCS is usually caused by a hepatic vein thrombus, however any mechanical obstruction can lead to the same pathology. Point-of-care ultrasound lead to a prompt diagnosis and allowed for quick action to correct the obstruction. Although BCS is not a common problem with VV-ECMO, the syndrome should always be on the differential of any patient on VV-ECMO with acutely rising transaminases. Conclusion: Ultrasound played an integral role in providing a crucial diagnosis of BCS secondary to obstruction by an ECMO drainage catheter.
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Olimpia, Cimmino, Falconio Lucio Marcello, Ruocco Vincenzo, Sanselmo Salvatore, Cacace Simona, Sanselmo Mirko, Pontillo Ermelinda, and Addeo Domenico. "Nursing Assistance To The Patient With Acute Myocardial Infarction; Nursing Implications." Journal of Advanced Health Care, June 23, 2022. http://dx.doi.org/10.36017/jahc2206-01.
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In this treatise we intend to deepen the theme of Acute Myocardial Infarction (AMI), one of its main risk factors at the cardiovascular level, namely smoking, and in particular, deepen the role of the nurse in patient education. after the ischemic event and implement strategies aimed at smoking cessation. If we look at the data from the World Health Organization (WHO), it is striking that the main cause of mortality in the modern world is heart ischemia which alone causes 7 million and 400 thousand deaths; while in second place we find stroke and cerebral vasculopathies with 6 million and 700 thousand deaths (Cesta 2014). Having established that tobacco plays a primary role in our society and that its active or passive use has a negative impact on the health of the individual (WHO 2014), we will first briefly mention the anatomy and physiology of the cardiovascular system, then we will discuss the implications between heart and smoking and, in particular, between heart attack and smoking, trying to understand - through authoritative sources such as the WHO and databases - where the roots of such a widespread habit lie and its impact on the system cardiovascular. Later we will address the educational issue of secondary prevention, we will examine the strategies implemented for smoking cessation. By dealing directly with patients, acquaintances and friends we realized how, despite the widespread information on the dangers of smoking, several people, even knowing the possible consequences, not only do not try to quit smoking, but almost underestimate the damage that can be caused by this “dangerous” habit of theirs is paradoxical. We believe that the role of the nurse in the post-heart attack moment is of extreme importance not only to provide specific direct assistance, also because that relationship of trust is created and to make him understand the risks to the patient in case he decides to continue smoking, but also because a correct education and the use of some strategies, personalized to each patient, to quit smoking, are essential in reducing the risk of a relapse. The choice of the topic dealt with in this work was dictated by a strong SOCIAL motivation. Although I am a smoker, noting the importance and the close relationship between health and a habit such as smoking, I have always been interested in being able to deepen my knowledge on the effects of the cardiovascular system and the problems that orbit around it. We still believe that an in-depth study on an issue so debated today and which will still be discussed for a long time can give the opportunity to approach smoking patients in a more conscious, personalized and adequate way and thus making treatment a better means. comprehensive within the health sector. We believe that this work can enhance our personal and professional background, allowing us in the near future to prevent, identify and deal more effectively with clinical problems involving both doctors and nurses. Finally, the hope is to acquire greater critical capacity in problematic cardiological situations and to have a greater capacity for acceptance and respect for the patient's will. This work aims to highlight and deepen the cardiovascular problems secondary to the phenomenon of smoking, implementing a therapy for smoking cessation. The methodology is based on articles researched from databases, on journals specialized in cardiology and on textbooks. From the observed articles it emerged that the nurse must use a multisystemic , multifaceted and multidisciplinary approach that includes different roles, namely: member of a working group, role of health promoter, role of teacher and communicator, of educator and expert in nursing care , and taking a look at post-ischemic nursing care. In this treatise we intend to deepen the issue of Acute Myocardial Infarction (AMI), one of its main cardiovascular risk factors, namely smoking, and in particular, deepen the role of the nurse in patient education after the ischemic event and in implementing strategies aimed at smoking cessation. If we look at the data from the World Health Organization (WHO), it is striking that the main cause of mortality in the modern world is heart ischemia which alone causes 7 million and 400 thousand deaths; while in second place we find stroke and cerebral vasculopathies with 6 million and 700 thousand deaths (Cesta 2014). Having established that tobacco plays a primary role in our society and that its active or passive use has a negative impact on the health of the individual (WHO 2014), we will first briefly mention the anatomy and physiology of the cardiovascular system, then we will discuss the implications between heart and smoking and, in particular, between heart attack and smoking, trying to understand - through authoritative sources such as the WHO and databases - where the roots of a widespread habit and its impact on the cardiovascular system lie. Later I will address the educational issue of secondary prevention, I will examine the strategies implemented for smoking cessation. By dealing directly with patients, acquaintances and friends we realized how, despite the information seems to be more than abundant on the dangers of smoking, several people, even knowing the possible consequences, not only do not try to quit smoking, but underestimate in the damage that can be caused by this “dangerous” habit of theirs is almost paradoxical. We believe that the role of the nurse in the post-heart attack moment is of extreme importance not only to make the patient aware of the risks in case he decides to continue smoking, but also because proper education and the use of some strategies, customized to each patient, to quit smoking, are essential in reducing the risk of a relapse.
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Dashefsky, Larry, Carol Hren, Tiffanie Munici, and Melissa Richardson. "Abstract WP472: Improving Neurologic Follow-Up After Stroke Utilizing a Nurse Practitioner." Stroke 51, Suppl_1 (February 2020). http://dx.doi.org/10.1161/str.51.suppl_1.wp472.
Full textAbstract:
Background: Patients who experience acute ischemic stroke are at increased risk for a secondary vascular event. Risk factor management as well as review of the medication regimen are important components to secondary prevention. Neurologic follow-up is an essential step during transitions of care to ensure these components are addressed. For a variety of reasons, stroke patients do not always complete follow up appointments. The literature suggests that such patients are at increased risk for readmission. Purpose: The purpose of this project was to improve access to neurologic follow-up for patients diagnosed with acute ischemic stroke after discharge from an acute care or rehabilitation setting. The secondary goal was to decrease readmission rates. Methods: A nurse practitioner (NP) was added to the inpatient stroke neurology service. The model of care was redesigned with the NP performing subsequent assessments after the initial evaluation was completed by the neurologist. The NP also organized the plan of care, including appropriate post discharge follow-up. Over time, due to challenges with access to appointments, the NP started an outpatient stroke clinic. Data were entered into Get With The Guidelines®-Stroke to identify the patients who had a neurology provider appointment scheduled prior to hospital discharge, regardless of discharge disposition. Results: Between the first quarter of 2018 and the second quarter of 2019, the percentage of patients with a neurologic follow-up appointment scheduled prior to hospital discharge improved from 23% to 61%. During this same time period, the readmission rates decreased from 14% to 9%. Conclusions: Adding the NP position to an inpatient stroke neurology service and using this role to lead an outpatient stroke clinic improves the percentage of patients who have appointments scheduled prior to hospital discharge. Improving access to follow-up care influences readmission rates.
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Stein, Joel, Alyson Downs, Barbara J. Lutz, Deborah Hoffnung, Janna Pietrzak, Kathleen G. Volkman, Kristy Weissling, et al. "Abstract WP55: Development Of Comprehensive Post-Acute Stroke Program Standards." Stroke 54, Suppl_1 (February 2023). http://dx.doi.org/10.1161/str.54.suppl_1.wp55.
Full textAbstract:
Introduction: Evidence-based rehabilitation and secondary prevention interventions improve post-stroke functional recovery and reduce secondary complications. However, stroke rehabilitation expertise, processes of care, and educational resources vary among sites where post-acute care (PAC) is delivered. Purpose: The American Heart Association (AHA) developed quality standards based on the AHA 2016 Guidelines for Adult Stroke Rehabilitation and Recovery to address these gaps. Methods: An interdisciplinary PAC standards writing committee identified key areas for PAC: quality improvement, medical management, care coordination, patient/caregiver and personnel education, and program management. Subgroups developed draft standards, combining results from a national landscape survey of PAC sites with clinical practice guidelines. The committee then refined the draft standards using a consensus-based process. AHA staff and PAC sites in Montana (MT) convened a learning collaborative to gather feedback and provide gap analyses of the standards relative to current practices. Qualitative input from beta testing in MT, and quantitative results from the nationwide survey and MT sites were analyzed and used to refine the standards further. Results: The national landscape survey demonstrated that most sites do not meet the proposed standards: stroke program oversight structure (78% fall short), stroke rehabilitation leadership (70%), stroke-specific order sets/protocols (61%), and policies requiring staff stroke education (66%). Regarding MT findings, 41% of the PAC sites have no mechanisms to identify areas of quality improvement specific to their stroke rehabilitation programs, and 59% do not use standardized tools to ensure performance improvement initiatives are followed. However, with adequate support and resources, most MT sites stated they would be able to meet the proposed standards. Conclusions: The Stroke PAC Program Standards are applicable in diverse PAC settings and provide a pathway to improving access to high-quality care for stroke survivors. Outcome studies are needed to confirm anticipated improvements in medical and functional outcomes.