Elective orthopedic and cardiopulmonary bypass surgery causes a reduction in serum endostatin levels

Background

Endostatin is an endogenous inhibitor of angiogenesis that inhibits neovascularisation. The aim of the study was to evaluate the effect of elective surgery on endostatin levels.

Methods

Blood samples were collected prior to elective surgery and 4 and 30 days postoperatively in 2 patient groups: orthopedic surgery (n =27) and coronary bypass patients (n =21). Serum endostatin levels were measured by ELISA.

Results

Serum endostatin was significantly reduced 30 days after surgery in comparison with presurgical values in both the orthopedic (P =0.03) and cardiopulmonary surgery (P =0.04) group.

Conclusion

Serum endostatin is reduced 30 days after surgery. This reduction would favor angiogenesis and wound-healing.

Reduced pressure for fewer pressure ulcers: can real-time feedback of interface pressure optimise repositioning in bed?

The aim of this study was to (i) describe registered nurses' and assistant nurses' repositioning skills with regard to their existing attitudes to and theoretical knowledge of pressure ulcer (PU) prevention, and (ii) evaluate if the continuous bedside pressure mapping (CBPM) system provides staff with a pedagogic tool to optimise repositioning. A quantitative study was performed using a descriptive, comparative design. Registered nurses (n = 19) and assistant nurses (n = 33) worked in pairs, and were instructed to place two volunteers (aged over 70 years) in the best pressure-reducing position (lateral and supine), first without viewing the CBPM monitor and then again after feedback. In total, 240 positionings were conducted. The results show that for the same person with the same available pressure-reducing equipment, the peak pressure varied considerably between nursing pairs. Reducing pressure in the lateral position appeared to be the most challenging. Peak pressures were significantly reduced, based on visual feedback from the CBPM monitor. The number of preventive interventions also increased, as well as patients' comfort. For the nurses as a group, the knowledge score was 59·7% and the attitude score was 88·8%. Real-time visual feedback of pressure points appears to provide another dimension to complement decision making with respect to PU prevention.

Attitudes towards pressure ulcer prevention: a psychometric evaluation of the Swedish version of the APuP instrument

The primary aim was to conduct a psychometric evaluation of the Attitude towards Pressure ulcer Prevention (APuP) instrument in a Swedish context. A further aim was to describe and compare attitudes towards pressure ulcer prevention between registered nurses (RNs), assistant nurses (ANs) and student nurses (SNs). In total, 415 RNs, ANs and SNs responded to the questionnaire. In addition to descriptive and comparative statistics, confirmatory factor analyses were performed. Because of a lack of support for the instrument structure, further explorative and consecutive confirmatory tests were conducted. Overall, positive attitudes towards pressure ulcer prevention were identified for all three groups, but SNs reported lower attitude scores on three items and a higher score on one item compared to RNs and ANs. The findings indicated no support in this Swedish sample for the previously reported five-factor model of APuP. Further explorative and confirmative factor analyses indicated that a four-factor model was most interpretable: (i) Priority (five items), (ii) Competence (three items), (iii) Importance (three items) and (iv) Responsibility (two items). The five-factor solution could not be confirmed. Further research is recommended to develop a valid and reliable tool to assess nurses' attitudes towards pressure ulcer prevention working across different settings on an international level.

Medication administration accuracy: using clinical observation and review of patient records to assess safety and guide performance improvement

RATIONALE, AIMS AND OBJECTIVES

Medication-related errors are common and can occur at every step of the medication process. The aim was to explore (1) the extent to which nurses perform fundamental safe practices related to medication administration (MA); (2) the frequency and characteristics of MA errors; and (3) the clinical significance of medication types (classes) subject to error.

METHODS

A descriptive, exploratory cross sectional design with point in time sampling was used combining direct observations, conducted by naïve observers, and medical record review. A convenience sample of three adult surgical units was drawn from a 1000-bed university hospital. Seventy-two patient-nurse MA encounters were observed including 306 MA doses based on a minimum sample of 100 doses per unit. The Medication Administration Accuracy Assessment developed by the Collaborative Alliance for Nursing Outcomes in the United States was used.

RESULTS

Observed adherence to MA safe practices varied between units. Identity control (9%), explaining medication to patient (11%) and medication labelled throughout the process (25%) were found to be safe practices with greatest deviation. 18% of doses involved a MA error (n = 54). Wrong time (9%) was the most common MA error, typically involving analgesics.

CONCLUSIONS

Given recent reports suggesting MA safe practices are strongly associated with MA errors, it is timely to strengthen RN awareness of the critical role of safe practices in MA safety. In nursing education, clinical examination using the six safe practices studied herein may enhance medication administration accuracy.

The prevalence, prevention and multilevel variance of pressure ulcers in Norwegian hospitals: a cross-sectional study

BACKGROUND

Pressure ulcers are preventable adverse events. Organizational differences may influence the quality of prevention across wards and hospitals.

OBJECTIVE

To investigate the prevalence of pressure ulcers, patient-related risk factors, the use of preventive measures and how much of the pressure ulcer variance is at patient, ward and hospital level.

DESIGN

A cross-sectional study.

SETTING

Six of the 11 invited hospitals in South-Eastern Norway agreed to participate.

PARTICIPANTS

Inpatients ≥18 years at 88 somatic hospital wards (N=1209). Patients in paediatric and maternity wards and day surgery patients were excluded.

METHODS

The methodology for pressure ulcer prevalence studies developed by the European Pressure Ulcer Advisory Panel was used, including demographic data, the Braden scale, skin assessment, the location and severity of pressure ulcers and preventive measures. Multilevel analysis was used to investigate variance across hierarchical levels.

RESULTS

The prevalence was 18.2% for pressure ulcer category I-IV, 7.2% when category I was excluded. Among patients at risk of pressure ulcers, 44.3% had pressure redistributing support surfaces in bed and only 22.3% received planned repositioning in bed. Multilevel analysis showed that although the dominant part of the variance in the occurrence of pressure ulcers was at patient level there was also a significant amount of variance at ward level. There was, however, no significant variance at hospital level.

CONCLUSIONS

Pressure ulcer prevalence in this Norwegian sample is similar to comparable European studies. At-risk patients were less likely to receive preventive measures than patients in earlier studies. There was significant variance in the occurrence of pressure ulcers at ward level but not at hospital level, indicating that although interventions for improvement are basically patient related, improvement of procedures and organization at ward level may also be important.

Pressure-reducing interventions among persons with pressure ulcers: results from the first three national pressure ulcer prevalence surveys in Sweden

RATIONALE, AIMS AND OBJECTIVES

The overall aim of this study was to describe preventive interventions among persons with pressure ulcer (PU) in three nationwide PU prevalence surveys in Sweden.

METHODS

A cross-sectional research design was used; more than 70 000 persons from different hospitals and nursing homes participated in the three prevalence surveys conducted in March 2011, October 2011 and March 2012. The methodology used was that recommended by the European Pressure Ulcers Advisory Panel.

RESULTS

The overall prevalence of PU categories I-IV in hospitals was 16.6%, 14.4% and 16.1%, respectively. Corresponding figures for nursing homes were 14.5%, 14.2% and 11.8%, respectively. Heel protection/floating heels and sliding sheets were more frequently planned for persons with PU category I.

CONCLUSIONS

Despite the three prevalence studies that have showed high prevalence of PU the use of preventing interventions is still not on an acceptable level. Heel protection/floating heels and sliding sheets were more frequently planned for persons with PUs, and individual-planned repositioning also increased. However, when persons already have a PU they should all have pressure-reducing preventive interventions to prevent the development of more PUs. Preventing PUs presents a challenge even when facilities have prevention programmes. A PU prevention programme requires an enthusiastic leader who will maintain the team's focus and direction for all staff involved in patient care.

The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden

AIM

To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers.

METHODS

A cross-sectional research design was used in a total sample of 35,058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel.

RESULTS

The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure-reducing mattress (23.3-27.9%) or planned repositioning in bed (50.2-57.5%).

CONCLUSIONS

Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence-based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.

Pressure ulcer knowledge of registered nurses, assistant nurses and student nurses: a descriptive, comparative multicentre study in Sweden

The aim of this study was to describe and compare the knowledge of registered nurses (RNs), assistant nurses (ANs) and student nurses (SNs) about preventing pressure ulcers (PUs). PU prevention behaviours in the clinical practice of RNs and ANs were also explored. A descriptive, comparative multicentre study was performed. Hospital wards and universities from four Swedish county councils participated. In total, 415 participants (RN, AN and SN) completed the Pressure Ulcer Knowledge Assessment Tool. The mean knowledge score for the sample was 58·9%. The highest scores were found in the themes 'nutrition' (83·1%) and 'risk assessment' (75·7%). The lowest scores were found in the themes 'reduction in the amount of pressure and shear' (47·5%) and 'classification and observation' (55·5%). RNs and SNs had higher scores than ANs on 'aetiology and causes'. SNs had higher scores than RNs and ANs on 'nutrition'. It has been concluded that there is a knowledge deficit in PU prevention among nursing staff in Sweden. A major educational campaign needs to be undertaken both in hospital settings and in nursing education.

Increased energy intake in hip fracture patients affects nutritional biochemical markers

BACKGROUND AND AIMS

We have previously shown that nutritional guidelines decreased the incidence of pressure ulcers in hip fracture patients. In the present study, we evaluate whether the nutritional biochemical markers S-IGF-1 (Insulin-like Growth Factor 1), S-Transthyretin and S-Albumin are affected by patients' energy intake, and whether the markers are useful as predictors of postoperative complications.

MATERIAL AND METHODS

Quasi-experimental design, with one intervention and one control group, as well as pre- and post-study measurements. Eighty-eight hip fracture patients were included: 42 in the control group and 46 in the intervention group. The control group received regular nutritional support pre- and postoperatively, while the intervention group received nutritional support that followed new, improved clinical guidelines from admission to five days postoperatively. S-Albumin, S-Transthyretin, C-Reactive Protein (S-CRP) and S-IGF-1 were analysed at admission and five days postoperatively as well as complications like pressure ulcer and infection.

RESULTS

The intervention group had a significantly higher energy intake; for example, 1636 kcal versus 852 kcal postoperative day 1. S-IGF-1 levels decreased significantly in the control group, while no decrease in the intervention group. S-Albumin and S-Transthyretin decreased and S-CRP increased significantly in both groups, indicating that those markers were not affected short-term by a high-energy intake. There was no correlation between short-term post-operative complications and S-IGF-1, S-Transthyretin or S-Albumin at admission.

CONCLUSION

The results of our study showed that S-IGF-1 can be used as a short-term nutritional biochemical marker, as it was affected by a five-day high-energy regimen. However, neither S-IGF-1, S-Transthyretin or S-Albumin were useful in predicting postoperative complications within five days postoperatively.

Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action

AIM

To compare overall unit-level pressure ulcer (PU) prevalence, hospital-acquired pressure ulcer (HAPU) prevalence and prevention strategies, as well as nurse staffing and workload in two hospitals in Sweden with data from the USA.

METHODS

Medical and surgical units in a university hospital and a general hospital in Sweden were compared with 207 hospitals in the USA participating in the Collaborative Alliance for Nursing Outcomes (CALNOC) benchmarking registry. All adult inpatients in university hospital (n = 630), general hospital (n = 253) and CALNOC hospitals (n = 3506) were included in the study. Outcome indicators were pressure ulcer prevalence for all types (PU) and HAPU prevalence, specifically. Process indicators were risk assessment and PU prevention strategies. Structure indicators were nurse staffing (hours of care, and skill mix) and workload (admissions, discharges and transfers).

RESULTS

The prevalence of PU (categories 1-4) was 17.6% (university hospital) and 9.5% (general hospital) compared with 6.3-6.7% in the CALNOC sample. The prevalence of full thickness HAPU (categories 3 and 4) was 2.7% (university hospital) and 2.0% (general hospital) compared with 0-0.5% in the CALNOC sample. Risk and skin assessment varied between 6% and 60% in the Swedish hospitals compared with 100% in the CALNOC sample. Total hours per patient day were 8.4 in both Swedish hospitals and 9.5 to 9.8 in the CALNOC hospitals

CONCLUSIONS

The findings suggest a link between processes of care and outcomes that is exciting to observe internationally and suggest the opportunity to expedite performance improvement through global benchmarking. Using HAPU as a complement to point prevalence of PU in Sweden has revealed this indicator as a more valid measure for patient care quality.

The impact of an intervention to improve patient participation in a surgical care unit: a quasi-experimental study

BACKGROUND

Organizational changes in surgical care are requiring patients to become more responsible for their own care, both before and after surgery, and also during recovery. Involving patients in their care is vital to improving quality of care and patient safety.

OBJECTIVE

The aim of this study was to investigate the impact of the 'Tell-us' card on patients' perceptions of quality of care, with a specific focus on patient participation. Another aim was to evaluate the use of the Tell-us card from the patients' perspective.

DESIGN

A quasi-experimental design with an intervention group and control groups was used. The patient's self-written Tell-us card was introduced as the intervention.

SETTING

The study was conducted in two surgical care units at a Swedish university hospital.

PARTICIPANTS

A consecutive sample of patients admitted from the waiting list and from the emergency department was included (n=310). The inclusion criteria were surgical patients with a hospital stay of at least one day. Patients who were younger than 18 years, not able to speak or write in Swedish, or unable or unwilling to give informed consent to participate were excluded.

METHODS

Quality of care was assessed using the questionnaire 'Quality from the Patient's Perspective'. The patients included in the intervention group were asked to write what was most important for them during the day or just before discharge on patient-written Tell-us cards.

RESULTS

The use of the Tell-us card resulted in significant improvements (5 out of 17 items) in patients' abilities to participate in decisions about their nursing and medical care. The patients found the Tell-us card more useful in their interaction with registered nurses and assistant nurses than with physicians.

CONCLUSIONS

The use of the Tell-us card improved patients' participation in some areas of nursing and medical care in the surgical care units. The Tell-us card is an uncomplicated and inexpensive tool that could be an important step towards improved patient participation in the surgical care unit. More research is needed to evaluate the use of the Tell-us card in different hospital units and over a longer period of time.

Hospital-acquired pressure ulcers in two Swedish County Councils: cross-sectional data as the foundation for future quality improvement

The objectives of the study were to examine the prevalence of pressure ulcers and hospital-acquired pressure ulcers (HAPU) and identify modifiable factors in patients who develop HAPU as the basis for subsequent quality assurance studies and improvement in hospital care. The study was conducted in five hospitals in two Swedish County Councils. A 1-day prevalence study (n = 1192) using the standards of the European Pressure Ulcer Advisory Panel and Collaborative Alliance for Nursing Outcomes was conducted. The prevalence of ulcers was 14·9% and 11·6% were HAPU. Older age, more days of hospitalisation, less activity, problems with shear and friction and reduced sensory perception contributed significantly to HAPU. Pressure ulcer prevention strategies used more often in those with HAPU were risk assessment at admission, provision of a pressure relief mattress, having a turning schedule and using a heel or chair cushion. The prevalence of pressure ulcers continues to be a significant issue in acute care and the prevalence of HAPU is high. There is significant room for quality improvement in pressure ulcer prevention in Swedish hospitals. Future research needs to address both HAPU and community-acquired pressure ulcers and focus on preventive strategies, including when they are initiated and which are effective in mitigating the high HAPU rate.

Why is pain still not being assessed adequately? Results of a pain prevalence study in a university hospital in Sweden

AIM

The aim of this study was to investigate the prevalence of pain and pain assessment among inpatients in a university hospital.

BACKGROUND

Pain management could be considered an indicator of quality of care. Few studies report on prevalence measures including all inpatients.

DESIGN

Quantitative and explorative.

METHOD

Survey.

RESULTS

Of the inpatients at the hospital who answered the survey, 494 (65%) reported having experienced pain during the preceding 24 hours. Of the patients who reported having experienced pain during the preceding 24 hours, 81% rated their pain >3 and 42.1% rated their pain >7. Of the patients who reported having experienced pain during the preceding 24 hours, 38.7% had been asked to self-assess their pain using a Numeric Rating Scale (NRS); 29.6% of the patients were completely satisfied, and 11.5% were not at all satisfied with their participation in pain management.

CONCLUSIONS

The result showed that too many patients are still suffering from pain and that the NRS is not used to the extent it should be. Efforts to overcome under-implementation of pain assessment are required, particularly on wards where pain is not obvious, e.g., wards that do not deal with surgery patients. Work to improve pain management must be carried out through collaboration across professional groups.

RELEVANCE TO CLINICAL PRACTICE

Using a pain assessment tool such as the NRS could help patients express their pain and improve communication between nurses and patients in relation to pain as well as allow patients to participate in their own care. Carrying out prevalence pain measures similar to those used here could be helpful in performing quality improvement work in the area of pain management.

Patient information and participation still in need of improvement: evaluation of patients' perceptions of quality of care

AIMS

To identify areas in need of quality improvement by investigating inpatients' perceptions of quality of care, and to identify differences in perceptions of care related to patient gender, age and type of admission.

BACKGROUND

Nursing managers play an important role in the development of high-quality care.

METHODS

Quality of care was assessed using the Quality from the Patients' Perspective (QPP). In all, 2734 inpatients at a Swedish university hospital completed the QPP.

RESULTS

Inadequate quality was identified for 15 out of 24 items, e.g. information given on treatment and examination results, opportunities to participate in decisions related to care and information on self-care. Patients with emergency admissions reported lower scores for quality of information and doctors' care than did patients with planned admissions.

CONCLUSION

Results from the present survey identified areas in need of quality improvement and differences in perceived care quality between patients. Quality of care must be developed in close collaboration with other healthcare professionals; in this respect, nursing managers could play an important role.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers could play a more active part in measuring quality of care, and in using results from such measurements to develop and improve quality of care.

Barriers to change hindering quality improvement: the reality of emergency care

PURPOSE

The aim of this study was to investigate physicians' and nurses' perspectives and prerequisites for quality improvement in the emergency department based on results from a previous patient survey.

METHOD

The study used an explorative design with a qualitative approach and was conducted at the main emergency department of a Swedish university hospital. Interviews were conducted with 5 focus groups. In total, the groups comprised 22 respondents.

RESULTS

The respondents suggested goals and quality improvements, such as more patient-centered care, reduced waiting times, and better pain management. However, barriers to quality improvement also were identified and represented 3 themes: the patient is looked upon as an object or a problem; the physicians and nurses belong to different organizational cultures; and the hospital's organization hinders the optimal flow of patients and improvements to quality.

DISCUSSION

When assigning priority to the topic areas, most of the focus groups ranked "information, respect, and empathy" as most important to improve. Adequate information, proper care, and treatment within a reasonable time in the emergency department were cited as the goals for patient care, but the health care professionals perceived barriers to change in the hospital culture and organization. To ensure quality care and patient safety, these barriers should be addressed by leaders on all levels in the organization, including the hospital board. Health care professionals' perspectives of quality of care are valuable and should be included in quality improvement work.