Outcomes of variation in hospital nurse staffing in English hospitals.
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England↗
Biomedical subjects
Peter Griffiths
Publications and source records attributed to Peter Griffiths.
Evaluation of a MS specialist nurse programme.
BACKGROUND: Specialist nurses are being promoted as a means of improving the health care provided to people with multiple sclerosis (MS). OBJECTIVES: To identify the impact of a programme of MS specialist nurses on MS health care provision and on the health and well-being of people with MS. DESIGN: A quasi-experimental design comparing an intervention group in which new MS nurse posts were installed with a control group that had no MS nurse posts. SETTING: Six neurological services in four English regions. PARTICIPANTS: Seven hundred and fifty-three of the 1510 people invited to participate returned completed questionnaires at baseline. Follow-up of participants was 82% with 616 patients participating in the main outcome analysis. METHOD: Data were collected prospectively before the appointment of the MS nurses and then at 12 and 24 months. Data were collected via a postal questionnaire comprising questions related to care processes (information provision and care quality) and health outcome measures, hospital admissions, MS complications, health-related quality of life (SF36) and disease impact (MS Impact Scale-29). Analysis repeated measures in CAT MOD for process variables and ANCOVA to longest follow-up for outcome measures. RESULTS: Information provision was higher in the intervention group (68% (n=153) compared to 53% (n=98) at 24 months) but no significant improvement was observed in information provision through time compared to the control group. There was an increase in the availability of a contact person in the intervention group, at 24 months 83% (n=42) had a contact person compared to 44% in the control (p=0.01). The only significant finding in relation to MS complications was a reduction of 17% in the incidence of pressure ulcers in the intervention sites compared to a 3% reduction in the control (p<0.001). In relation to the disease and health-related quality of life measures, the intervention group showed a small but significant (p<0.05) worsening in the physical and symptom scales of the SF36 compared to the control (mean differences: physical function -2.81, CI -5.45 to -0.1; bodily pain -4.09, CI -7.2 to -0.9; general health -5.35, CI -8.1 to -2.5; and energy and vitality -2.82, CI -5.5 to -0.1). No differences were observed in relation to disease impact or psychosocial well-being, although a relative benefit in mental health (with a 7.8 point advantage on the SF36 mental health scale, p=0.04) was observed in some of the intervention sites for people with relapsing/remitting MS. CONCLUSION: The specialist nurse programme was found to impact positively on the provision of MS-related health care. However, there was very limited evidence that the programme led to any improvements in disease-related problems, impact or health-related quality of life, These findings were in part explained by the inherent difficulties of measuring effects in evaluations of complex phenomena such as a nursing role. The deterioration observed in the intervention group on the physical outcome measures was explained by a selection bias in which people with worsening health were more likely to seek contact with a specialist nurse. It is contended that future research in this area may be better directed toward identifying specific interventions that nurses and other health professionals might employ in addressing the many problems confronting people with MS.
Analysis of Variance↗
Screening for autism in pre-school children in primary care: systematic review of English Language tools.
OBJECTIVES: To review the accuracy of brief screening tools for autism in pre-school children. DESIGN: Systematic review of diagnostic accuracy studies. DATA SOURCES: Medline, Embase, Cinahl and Psychlit plus references of identified papers and contact with authors. SUBJECTS: Children and infants aged 5 years or less without a prior diagnosis of autism or pervasive development delay. INTERVENTIONS: Tools/checklists appropriate for use in screening for autism in primary care settings. OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive value of screening tools and likelihood ratios relative to a diagnostic assessment made using either DSM-III/IV or ICD 10 diagnosis. RESULTS: Three studies considering two tools were identified. The CHecklist for Autism in Toddlers (CHAT) was tested on an appropriate population sample with moderate long-term follow-up but demonstrated poor sensitivity and positive predictive value. Weaker evidence suggested that the Modified CHecklist for Autism in Toddlers (M-CHAT) had high sensitivity but follow-up was of shorter term and less comprehensive. CONCLUSIONS: The CHAT demonstrated a level of sensitivity unlikely to be useful for population screening purposes, however, its high specificity suggests it has utility in secondary screening. The M-CHAT is a parent only report and might be more sensitive, and therefore appropriate for population screening. However, full conclusions regarding its accuracy cannot be drawn until follow-up data has been collected.
Age Factors↗
Moving elderly inpatients to a transitional care facility reduced hospital stay but increased time to transfer to long term care.
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Comment↗
Health problems and health-related quality of life in people with multiple sclerosis.
OBJECTIVE: To explore the interrelationship between a number of common multiple sclerosis-related problems and health-related quality of life independent of the effect of physical disease impact. DESIGN: A cross-sectional postal survey. SETTING: The study was conducted in seven treatment centres within England. SUBJECTS: Nine hundred and twenty-nine people with multiple sclerosis. MEASURES: The severity of the multiple sclerosis problems (fatigue, pain, urinary incontinence, bowel, depression, pressure ulcers, sexual and employment problems) was assessed using 5-point self-report ordinal scales. Disease impact was measured using the Multiple Sclerosis Impact Scale-29. Health-related quality of life was measured using the 36-Item Short Form Health Survey, version 2 (SF-36). The relationship between the problems, disease impact and health-related quality of life was determined using multivariate analysis of covariance. RESULTS: Seventy four per cent of the sample experienced four or more of the selected problems. The extent and severity of problems increased with the level of disease impact (P< 0.001). Fatigue, pain, employment, depression and relationship problems were all found to have negative effect on the SF-36 scales independent to the effect of disease impact. SF-36 scores were most compromised in patients experiencing multiple problems. The data suggest an interdependent relationship between depression, fatigue and pain. CONCLUSION: The data suggest that many multiple sclerosis complications negatively affect health-related quality of life, independent of the effect of overall disease impact.
Adolescent↗
Interprofessional education to improve pain management.
Pain is a prevalent problem in community care and there is evidence that knowledge and understanding of pain management can be lacking among health professionals, leading to under-treatment. This mini-review aimed to assess the effectiveness of interprofessional education on health professionals' pain documentation and on the pain intensity reported by patients. A search of key databases identified two randomized controlled trials and two quasi-experimental studies. Two studies assessed change in pain documentation following interprofessional education; one revealed a statistically significant improvement and another indicated 29% increase in documentation of pain assessments. Two studies demonstrated no significant changes in patient outcomes, while the other revealed significant improvements. However, integration of the results was not possible because of the various methods of measurement used by the different researchers. Although broadly supportive of interprofessional education, the evidence is not helpful in determining the best way of improving pain management in the community.
Attitude to Health↗
Do people with cancer comply with oral chemotherapy treatments?
Many people with cancer have oral medication as part or all of their regime. This medication is primarily self administered in the community. This mini-review aimed to determine the level of compliance of adult cancer patients with oral chemotherapy and to assess the quality of the available evidence. Searches were undertaken using three electronic databases (Medline, Embase, CINAHL) for studies which evaluated the compliance of adult cancer patients with oral anti-neoplastic agents through self-report, pill counts, drug/metabolite levels or microelectronic monitoring system (MEMS). Articles were selected if the follow-up was higher than 80% of patients. Six papers were identified for the review. The methodological quality of the studies was poor. The sample size of the majority of them was small and the method used to measure adherence was not entirely reliable. The results of these papers were varied and contradictory. A firm conclusion cannot be drawn because the studies present significant methodological flaws. The comparison of results between studies is difficult due to the lack of a gold-standard measure of adherence and a standardised definition of non-compliance. Further research in this area is needed. However it does appear that compliance is a problem in this patient group.
Administration, Oral↗
Catheter valves for indwelling urinary catheters: a systematic review.
This mini-review aimed to systematically review the evidence on the effect of catheter valves compared to free drainage into a bag for patients with indwelling urinary catheters. Data sources used were Medline, British Nursing Index, CINAHL, Ahmed, EMBASE, EBM Reviews, the Cochrane Library and reference lists of relevant papers. Papers considered were controlled trials comparing the use of a catheter valve with the catheter bag that were published as a full report, or detailed abstract (containing sufficient information to critique) in Dutch, German or English. Two studies with a total of 122 subjects were identified. The main outcome measures considered were reduction of incidence of bladder spasm and urinary tract infection (UTI) and patient preference. No statistically difference in the incidence of bladder spasm or UTI was demonstrated but patients showed a clear preference for the valve. Further research into catheter valves is needed, with larger study groups, which include housebound male and female patients, and longer follow-up period.
Catheters, Indwelling↗
Effectiveness of intermediate care delivered in nurse-led units.
This mini-review provides an overview of evidence regarding the effectiveness, costs and patient experience relating the intermediate care in nursing-led units. The core of the evidence is derived from a high quality systematic review of 10 controlled trials involving 1669 patients. Other studies on patient experience and costs not included in the review are also considered. There is some evidence of patient benefit in the short term in terms of independence. However this does not seem to be sustained. Total inpatient stay is increased and hence overall costs of the initial episode are increased with no evidence of longer-term savings. The approach seems to be broadly acceptable to patients. Provided it is not simply used to house patients who cannot benefit, nursing-led units may be a viable alternative to acute care for some patients. However, the core features of the units that provided the evidence must be considered in order to maximize the potential for delivering quality care.
Cost-Benefit Analysis↗
Care needs and point prevalence of post-acute patients in the acute medical wards of an Italian hospital.
BACKGROUND: Despite considerable literature identifying large numbers of post-acute patients in acute medical wards, their needs have not been clearly described. Such information is required to plan alternative services. OBJECTIVE: Identify the size of and care needs of the post-acute population within the group of patients receiving acute medical care in an Italian General Hospital. SETTING: Five medical wards of a District General Hospital in Northern Italy. DESIGN: Point prevalence survey. Data were collected on all 211 patients using the most recent Italian version of the Appropriateness Evaluation protocol, Barthel Index, and the Northwick Park Dependency Score. Length of stay up to the data collection (index) day and total length of stay were identified and pre- and post-discharge dependence was assessed. RESULTS: The mean of the length of stay of the patients up to the index day was 12 days. Fourty four percent of patients were assessed as inappropriate. The mean age was 70 years. They were moderately physically dependent and stayed in hospital for a further 8 days after the day of the survey. The family met most of the care needs both before and after admission to hospital. Inappropriate patients differed little from the appropriate patients in terms of their care needs, which were relatively high. CONCLUSION: There is scope for the development of alternatives to acute care in the Italian health service but the intensity on non-medical care needs is not discernibly lower than for acute care. Prospective identification of patients who might require such services using tools that focus on needs other than medical needs remains problematic.
Activities of Daily Living↗
Post-acute intermediate care in nursing-led units: a systematic review of effectiveness.
OBJECTIVE: In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence. REVIEW METHODS: The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions. OUTCOMES: Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost. RESULTS: Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality. CONCLUSIONS: The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.
Aged↗
Evidence-based practice: a deconstruction and postmodern critique: book review article.
This paper discusses the significance of postmodernism for healthcare practice, specifically the discourse known as 'evidence-based practice'. It considers two texts, both of which present postmodern analyses of contemporary issues. One text presents a deconstruction of evidence-based practice in an attempt to reveal its 'true' nature, which is portrayed as one that does not respect research paradigms other than the randomised controlled trial, merely pays lip service to expertise and fails to connect with the real nature of clinical practice. The second text considers the accusation that absolute relativism implied by postmodern approaches may permit an 'anything goes' mentality and provide succour to those advocating unacceptable practices. A 'defence' of postmodernism in relation to the accusation that it encourages holocaust denial is used to consider further the nature and limitations of postmodern critiques of evidence-based practice. This review concludes that postmodernism fundamentally challenges the apparent 'objectivity' of evidence-based practice but it does not challenge the fundamental rules for acquiring and testing evidence. Rather it is the selection of questions to be asked and answered by evidence-based practice/practitioners that is the true limitation. This is the ground upon which fruitful argument can be had about the significance of evidence without undermining the requirement that there be evidence and standards to judge such evidence.
Denial, Psychological↗
Science and art in reviewing literature.
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Publishing↗
Economic evaluation of a nursing-led inpatient unit: the impact of findings on management decisions of service utility and sustainability.
AIMS: The nursing-led inpatient unit is designed to substitute for a period of care in acute hospital wards and to improve patient outcome prior to discharge to the community. This paper aims to evaluate the cost, from the UK National Health Service perspective, of transfer to a nursing-led inpatient unit for intermediate care and to discuss the impact of these findings to the future development and sustainability of the nursing-led inpatient unit. BACKGROUND: Recent economic analyses have showed that nursing-led inpatient units are associated with increased costs of care with length of stay as the main driver of inpatient costs. METHOD: The cost-effectiveness analysis was part of a randomized-controlled trial with a sample size of 175, of which 89 were in the nursing-led inpatient unit arm and 86 in the control arm. Resource use data included length of stay, investigations performed, multiprofessional input and nursing input. Clinical outcome was measured using Barthel Index, a functional status measure. RESULTS: Cost per day was lower on the nursing-led inpatient unit although cost per hospital stay was higher due to significantly increased length of stay. Postdischarge community care costs were lower. The incremental cost-effectiveness ratio of the treatment was 1044 pounds sterling per point improvement of the Barthel Index. CONCLUSIONS: The nursing-led inpatient unit was associated with higher costs however, the question of whether the nursing-led inpatient unit is cost-effective has not been clearly answered because of the limited follow-up period of the study. The increased cost of care on the nursing-led inpatient unit was not a major factor in local management decisions about the future of the unit. The changes in the context of service provision within which the nursing-led inpatient unit operated as a result of substantial investment in intermediate care did have a major impact.
Activities of Daily Living↗
Review: evidence from individually randomised trials shows that hip protectors do not reduce hip fractures in elderly people.
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Comment↗
Self-assessment of health and social care needs by older people: a review.
This article explores the meaning and significance of 'self-assessment', a term that is increasingly being used in relation to developments affecting community practice. Self-assessment for health and social care needs has been used over a considerable period of time and for purposes as diverse as case finding for depression to assessment of housing options. Self-assessment has usually involved the use of short scales and questionnaires, but it can involve the use of physiological tests (such as testing urine for glucose) or complex, computerized decision-support systems. Although often explored as a simple means for extending the 'reach' of professional assessments (e.g. mass screening) and ensuring 'appropriate' use of health services (e.g. self-care algorithms), self-assessment is increasingly being advocated as a means of actively involving and empowering service users. However, a recent review of the topic (Griffiths et al, 2005) revealed the complexity of the topic and the pitfalls of a simplistic approach to self-assessment, which those engaged in developing the process should bear in mind.
Aged↗
Is tea tree oil effective at eradicating MRSA colonization? A review.
In vitro studies show that tea tree oil is capable of killing methicillin-resistant Staphylococcus aureus (MRSA) in a laboratory setting. This review of randomized controlled trials (RCTs) was undertaken to find out whether it is effective at eradicating MRSA colonization compared to standard mupirocin-based regimens in colonized patients. A wide range of databases and internet sources were searched to identify published and unpublished studies. Two RCTs were found that researched the effectiveness of tea tree oil preparations against MRSA. One small RCT (n = 30) showed a large but non-significant improvement at eradicating MRSA compared to traditional treatment, whereas a larger study (n = 224) demonstrated little difference in rates of eradication overall (41% for tea tree and 49% for mupirocin, p = 0.286). However, the larger study found that those with nasal colonization receiving a tea tree regimen were more likely to remain colonized with MRSA in the nose (absolute risk increase 31%, p<0.001). Currently there is insufficient evidence to support the routine use of tea tree oil in clinical practice for eradication of MRSA colonization.
Anti-Infective Agents, Local↗
A Japanese version of the perceived stress scale: translation and preliminary test.
This paper describes the development of a Japanese version of the Perceived Stress Scale (PSS). Four independent Japanese translations were made and used to develop a single Japanese version. This was back-translated into English. Discrepancies between the original and the back-translation were identified. The Japanese version was altered accordingly, and again back-translated. This forward-backward process was repeated until satisfactory agreement was attained. The PSS was administered to 38 native English speakers and the Japanese version (PSSJ) to 23 native Japanese. High Cronbach's alpha coefficient was shown for both versions. Factor analysis revealed that the PSS and PSSJ showed an almost identical factor structure. Therefore, the equivalence between the PSS and PSSJ and the validity for each scale was underpinned.
Adult↗