Development of an Algorithm to Screen for Frailty Using the Clinical Frailty Scale with Postoperative Patients Entering Cardiac Rehabilitation

Purpose

Frailty is not commonly assessed on intake to cardiac rehabilitation (CR), but screening could enable targeted interventions and potentially reduce secondary complications. This study aimed to develop and retrospectively examine the feasibility of utilizing a CR-specific algorithm based on the Clinical Frailty Scale (CFS). Our CFS-CR algorithm endeavoured to screen for frailty in older adults (> 65 y) entering CR following cardiac surgery/procedure.

Method

The charts of 30 former patients (mean age: 74.0 ± 6.9 y) were examined by a clinician working in CR.

Results

The clinician was unable to score any of the patients based on their medical charts using the CFS-CR due to insufficient data. Documentation was typically limited in the areas of instrumental and basic activities of daily living whereas exercise data were readily available.

Conclusions

Current intake documentation in CR limited the ability to retrospectively screen for frailty. This finding suggests a need for a frailty-specific tool to support routine clinical screening. Prospective evaluation of the CFS-CR is warranted to further examine the clinical utility of the algorithm during CR intake assessments.

Two-month point prevalence of exposure to critical incidents in firefighters in a single fire service

BACKGROUND

Firefighters have high rates of exposures to critical events that contribute to physical and mental stress, resulting in high rates of injury and work-injury compensation claims.

OBJECTIVE

To determine the prevalence of critical incidents in firefighters from a single fire service, and whether the number of critical events varied based on age, gender, years of service and/or rank.

METHODS

We recruited 300 full-time firefighters. Firefighters were asked to complete a self-report Critical Incident Inventory survey that included questions on exposure to critical events during firefighting duties, with a time reference point of the past two months.

RESULTS

Among the 293 firefighters, 252 (85%) indicated exposure to some type of critical incident. More specifically, 187 (64%) reported a respond to incident involving one or two deaths, 155 (53%) indicated a direct exposure to blood and body fluids, and 98 (33%) reported a response to an incident involving multiple serious injuries. Age, gender, years of service and rank accounted for only 1% of the variance in the number of critical incidents among firefighters.

CONCLUSIONS

In this study, 85% of firefighters had been exposed to some type of critical incident in the previous 2-months and this did not vary by age, gender, years of service and/or rank.

In vitro and in vivo modulation of the equine immune response by parapoxvirus ovis

REASON FOR PERFORMING STUDY

While immune modulators are used routinely in equine medicine, their mechanism of action is not always known.

OBJECTIVES

To determine the effect of a commercial preparation of inactivated parapoxvirus ovis (Orf virus; PPVO) on cytokine gene expression by equine peripheral blood mononuclear cells (PBMC) both in vitro and in vivo.

METHODS

PBMC were prepared from 6 mixed-breed yearlings and cultured in vitro with PPVO with or without Concanavalin A (Con A) for 24 h. Effects on the expression of IFNalpha, IFNbeta IFNgamma, TNFalpha and IL-18 were analysed by real time quantitative PCR (RT-PCR). In addition, 12 yearling horses were treated with PPVO and whole blood RNA samples were prepared at regular intervals to assess effects on in vivo cytokine gene expression. Six of those yearlings were later treated with saline and served as treatment controls. Nine additional yearlings were injected intradermally with a single dose and their injection sites biopsied at 24 and 48 h for cytokine expression.

RESULTS

In vitro culture of PBMC with PPVO led to a significant increase in IFNalpha and IFNbeta gene expression compared to mock-stimulated cultures. In addition, expression of IFNgamma and TNFalpha was significantly higher in PBMC stimulated with PPVO and Con A, than those stimulated with Con A alone. No changes were observed in IL-18 gene expression in vitro. Treatment of horses with a 3-dose regimen of PPVO resulted in elevation of IFNgamma gene expression, which was detected 24 h after the first dose and declined thereafter. Intradermal inoculation led to increased expression of IFNgamma along with IFNbeta, IL-15 and IL-18.

CONCLUSIONS

Together these results indicate that PPVO stimulated IFNgamma production both in vitro and in vivo. Increased cytokine expression could account for its immunomodulatory activity.

POTENTIAL RELEVANCE

The absence of adverse reactions and clear indications of increased expression of cytokine gene expression supports previous clinical uses for this immune modulator in those situations when increased expression of IFNgamma is warranted.

The patient's view: the benefits and limitations of nurse prescribing

This study was undertaken in a primary care group to explore nurse prescribing from the patient/client's viewpoint. All prescribing health visitors, district nurses and practice nurses were asked to recruit five patients for whom they had prescribed; 50 patients/clients participated in the study. Identified benefits of nurse prescribing included a more effective use of the nurse's and doctor's time; a quality relationship between the nurse and patient; nurses' awareness of their own professional limitations; their expertise in certain types of care; and their providing timely, convenient, practical and successful treatment. Limitations and the proposed options for change included the training and competency of nurse prescribers and the limitations of the Nurse Prescribers' Formulary. On a local level the study informs nurse prescribers that they are currently meeting the needs of the majority of recipients, and provides evidence of some of the benefits and limitations of nurse prescribing.

Nurse prescribing: what do patients think?

AIM

To explore nurse prescribing from the patient's viewpoint.

METHOD

This study was undertaken in one primary care group in Leicestershire. All prescribing health visitors (n = 17), district nurses (n = 9) and practice nurses (n = 1) were asked to recruit five patients for whom they had prescribed. Fifty patients took part in a telephone or face-to-face interview. Participants were predominantly low or new users of nurse prescribing, while the nurse prescribers were experienced.

RESULTS

Participants identified that nurse prescribers had key skills in assessment, observation, diagnosing and providing information. Nurse prescribing was accepted by all participants as a practical and responsive method of service delivery. Gains identified were better use of the nurse's and doctor's time, convenience, a quality relationship with the nurse and expertise of the nurse. Disadvantages identified included the limitations of the Nurse Prescribers' Formulary and the training and competence of nurse prescribers.

CONCLUSION

This study helps affirm that nurse prescribers meet the needs of patients, with positive experiences in terms of the process and outcomes. Future developments suggested by participants appear to reflect government concerns. Such changes include the need to develop and maintain competence to uphold public safety and for the formulary to be expanded. To ensure that the NHS workforce is used more effectively, participants agreed with providing patient-centred services and the renegotiation of traditional roles.

Philosophical implications of the use of advance statements (living wills)

The growing prevalence of advance statements represents an important shift away from paternalistic care. Patients' willingness to begin to take more personal responsibility for their own health, and demand for a collaborative partnership with healthcare professionals, is evidence of a new paradigm. In this article, the concepts of rights, values and personhood are used to analyse the ethical issues raised by advance statements.

Who cares for students with epilepsy in mainstream education?

RATIONALE

For children with specific healthcare needs, educational staff must be able to act in 'loco parentis', so that families can safely place their child in the school of choice. If a student has unstable epilepsy, staff must know its potential effects on the individual, and understand enough to manage this. Needs will vary from career advice to management issues such as administration of rectal medication.

METHOD

A pilot study involved two primary school children with unstable epilepsy, whose medical treatment included intermittent rectal Diazepam. The study started in September 1994 and was undertaken by two senior nurses who worked with the school nurses to set up a protocol for each child, family and school respectively, that was clear, workable and safe.

RESULTS

By September 1995 all school nurses in Leicester/Leicestershire had been trained in epilepsy awareness, the safe administration of rectal Diazepam and the legal implications of volunteers administering medicines in schools. In 1996 school nurses were caretaking the scheme and initiating the uninitiated. The conclusion was that it is possible to train staff in the mainstream educational environment in the special health needs of children with unstable epilepsy thereby supporting continued attendance at the school of choice.