'Value-based methodology for person-centred, integrated care supported by Information and Communication Technologies' (ValueCare) for older people in Europe: study protocol for a pre-post controlled trial

Background

Older people receive care from multiple providers which often results in a lack of coordination. The Information and Communication Technology (ICT) enabled value-based methodology for integrated care (ValueCare) project aims to develop and implement efficient outcome-based, integrated health and social care for older people with multimorbidity, and/or frailty, and/or mild to moderate cognitive impairment in seven sites (Athens, Greece; Coimbra, Portugal; Cork/Kerry, Ireland; Rijeka, Croatia; Rotterdam, the Netherlands; Treviso, Italy; and Valencia, Spain). We will evaluate the implementation and the outcomes of the ValueCare approach. This paper presents the study protocol of the ValueCare project; a protocol for a pre-post controlled study in seven large-scale sites in Europe over the period between 2021 and 2023.

Methods

A pre-post controlled study design including three time points (baseline, post-intervention after 12 months, and follow-up after 18 months) and two groups (intervention and control group) will be utilised. In each site, (net) 240 older people (120 in the intervention group and 120 in the control group), 50–70 informal caregivers (e.g. relatives, friends), and 30–40 health and social care practitioners will be invited to participate and provide informed consent. Self-reported outcomes will be measured in multiple domains; for older people: health, wellbeing, quality of life, lifestyle behaviour, and health and social care use; for informal caregivers and health and social care practitioners: wellbeing, perceived burden and (job) satisfaction. In addition, implementation outcomes will be measured in terms of acceptability, appropriateness, feasibility, fidelity, and costs. To evaluate differences in outcomes between the intervention and control group (multilevel) logistic and linear regression analyses will be used. Qualitative analysis will be performed on the focus group data.

Discussion

This study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people, their informal caregivers, and health and social care practitioners in seven different European settings.

Trial registration

ISRCTN registry number is 25089186. Date of trial registration is 16/11/2021.

COVID-19: A systematic evaluation of personal protective equipment (PPE) performance during restraint

BACKGROUND

Restraint is widely practised within inpatient mental health services and is considered a higher-risk procedure for patients and staff. There is a sparsity of evidence in respect of the efficacy of personal protective equipment (PPE) used during restraint for reducing risk of infection.

METHODS

A series of choreographed restraint episodes were used to simulate contact contamination in research participants playing the roles of staff members and a patient. For comparison, one episode of simulated recording of physical observations was taken. Ultraviolet (UV) fluorescent material was used to track the simulated contact contamination, with analysis undertaken using established image registration techniques of UV photographs. This was repeated for three separate sets of PPE.

RESULTS

All three PPE sets showed similar performance in protecting against contamination transfer. For teams not utilising coveralls, this was dependent upon effective cleansing as part of doffing. There were similar patterns of contamination for restraint team members assigned to specific roles, with hands and upper torso appearing to be higher-risk areas. The restraint-related contamination was 23 times higher than that observed for physical observations.

DISCUSSION

A second layer of clothing that can be removed showed efficacy in reducing contact contamination. PPE fit to individual is important. Post-restraint cleansing procedures are currently inadequate, with new procedures for face and neck cleansing required. These findings leave scope for staff to potentially improve their appearance when donning PPE and engaging with distressed patients.

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

A growing evidence base for management guidelines

We review key recent research and guidance for staff working with acutely disturbed psychiatric patients. Assessment of aggressive patients and their situation should enable full risk assessment, which may ideally involve the use of advance directives. We discuss appropriate use of the Mental Health Act 1983 and consider benefits and adverse effects of rapid tranquillisation. We present a simple protocol for oral or intramuscular rapid tranquillisation. Staff using physical restraint should be properly trained and consider sensitively issues of the patient's diginity, gender and the most appropriate location for restraint to occur. Simple precautions can improve safety when working with potentially disturbed patients. Staff need support during and after the management of an aggressive incident.

Psychiatric intensive care units, a design for living

The psychiatric intensive care unit (PICU) is now at the cutting edge of acute psychiatric care. Very little guidance has been produced to ensure that the PICU structure and design is able to meet the complex demands put upon it. The creation, development and relocation of a PICU has taken place within the Severn NHS Trust. We describe the experience gained from a recently commissioned unit together with a review of the relevant literature. Recommendations are offered for core features and design.

A nurse-led psychiatric intensive care unit

Severn NHS Trust has recently commissioned a psychiatric intensive care unit (PICU) which became operational on 18 July 1994. Although the number of PICUs is increasing and their services are greatly valued, they are often fraught with problems. A model for the development of PICU services is described. It includes admission criteria, overall clinical organisation of the PICU, discharge criteria and a discussion. The model described is based on the hypothesis that the primary role of the PICU is to deal with clinical nursing problems rather than medical problems. The discussion points out some of the instrumental components necessary for the successful development of PICU services.

Guidelines for the management of acutely disturbed patients

The treatment of acutely disturbed patients is a stressful area of psychiatric practice. Castleet al(1994) found that MRCPsych Part II trainees expressed a general dissatisfaction with training in the management of violence, and in our experience junior trainees are even less confident in the treatment of the disturbed patient. A survey by Cunnane (1994) found that no consensus exists among consultant psychiatrists on which drug treatment is most appropriate for the management of the aggressive, acutely disturbed psychotic patient. There was uncertainty as to optimal management, low expectation of quick results, unwillingness to express an opinion and the use of drug cocktails of dubious rationale.

Searching for prohibited items in mental-health hospitals: A randomised controlled trial of two metal-detecting technologies

Weapons and other items with potential to cause harm are usually prohibited in mental-health hospitals and other psychiatric facilities. Detecting such prohibited items (PIs) can be problematic, particularly if concealed, and metal detectors are commonly used to search for such items. Our study compared two types of metal detection: continuous wave detection (CWD) by hand-held metal detector (HHMD) and magnetic anomaly detection (MAD) by a static pole device. In the study, real and dummy PIs were hidden on test subjects and in a simulated body cavity. The results showed MAD to be significantly superior to CWD in detecting small concealed PIs containing ferrous metal. The MAD pole found 100% of the real PIs on the test subjects and in the simulated body cavity. The CWD HHMD found only 5.2% of the real PIs, and these were limited to those on the test subjects, as it detected none in the simulated body cavity. In addition, the time taken to search by MAD pole was shorter than time taken to search by CWD HHMD.

Development of a Pedal Powered Wheelchair

A first student project to put pedals on a wheelchair for exercise and propulsion was unsuccessful. The need remained and in June of 2005 the “Eureka” event occurred. Seeing a five-year-old on her training-wheel-equipped bicycle suggested that a fifth wheel could be added in the center between the wheelchair's two large rear wheels, and a mast supported by the fifth wheel's axle could extend forward to support a front axle and pedal set. A chain drive completed the propulsion system. There are no pedal-powered wheelchairs currently on the market. Around 2001 a product (EZChair) without retractable pedals was on the market but withdrawn. A team at the University of Buffalo invented and patented a pedal-powered wheelchair in 1993 (US Patent 5,242,179), but it was not commercialized. Also, a Japanese company designed and built a series of fifth-wheel wheelchair designs. Between 2006 and late 2008 we built many prototypes incorporating geometries that permitted retracting the pedal. For compactness a “Pedalong” with three telescoping tubes was built but it proved impossible to secure tightly. In the next design twin telescoping tubes passing above and to the rear of the rear axle provided the desired extension. A clamp at the front of the outer tube provided tightness of the assembly. In the Northwestern research program (see below), there was some success, but awkwardness in operation prevented commercialization. In October 2008 a major design change from a fifth wheel in the center to a powering of the two standard rear wheels was begun. This required a new chain path geometry and addition of a differential to the drive train. With the new design user control, arm-powering and braking through the rear wheels is retained, and chair stability is improved. Twelve individuals with chronic post-stroke hemiplegia (>6 months post-stroke event) participated in a study to examine the metabolic energy expended when participants performed a 6-minute walk test, a 6 minute leg-propelled wheelchair trial (using the Pedalong), and a 6 minute arm-propelled wheelchair trial. VO2, VCO2, and distance traveled were measured using a portable metablic cart system and wheel-based distance measurement system. The Pedalong and walking trials showed equivalent oxygen consumption levels, but manual pushing was, on average, significantly less. All three modes (walking, leg-propelled and arm-propelled) resulting in similar distances traveled within the 6 minute period. The leg-propelled trials generated the greatest amount of VCO2 during expiration compared with the other modes. This means that more of the available oxygen is being utilized (metabolized) during the leg-propelled mode and so, a greater number of calories were being burned during this 6-minute test.

Comparison of three approaches to doxorubicin therapy: free doxorubicin, liposomal doxorubicin, and beta-glucuronidase-activated prodrug (HMR 1826)

BACKGROUND

Three approaches to doxorubicin therapy are directly compared: free doxorubicin, liposomal doxorubicin and beta-glucuronidase-activated prodrug (HMR 1826).

MATERIALS AND METHODS

The optimal dose of HMR 1826 was determined to be 200 mg/kg once a week and subsequent studies were carried out comparing HMR 1826 at 200 mg/kg 1x/wk, liposomal doxorubicin (Doxil) at 9 mg/kg 1x/wk and free doxorubicin at 7 mg/kg 1x/wk in seven different human tumor xenograft models.

RESULTS

All three forms of doxorubicin inhibited tumor growth with similar efficacy in each of the tumor models with the exception of MDA-MB-231 tumor xenografts, which were resistant to free doxorubicin but sensitive to Doxil and HMR 1826. Overall less weight loss was observed with HMR 1826 treatment.

CONCLUSIONS

The efficacy of HMR 1826 is equal to or better than that of doxorubicin and Doxil at a safe dose and schedule, indicating that the beta-glucuronidase activated prodrug approach is safe and effective.

Effects of food and sucralfate on a single oral dose of 500 milligrams of levofloxacin in healthy subjects

The effects of food and sucralfate on the pharmacokinetics of levofloxacin following the administration of a single 500-mg oral dose were investigated in a randomized, three-way crossover study with young healthy subjects (12 males and 12 females). Levofloxacin was administered under three conditions: fasting, fed (immediately after a standardized high-fat breakfast), and fasting with sucralfate given 2 h following the administration of levofloxacin. The concentrations of levofloxacin in plasma and urine were determined by high-pressure liquid chromatography. By noncompartmental methods, the maximum concentration of drug in serum (Cmax), the time to Cmax (Tmax), the area under the concentration-time curve (AUC), half-life (t1/2), clearance (CL/F), renal clearance (CLR), and cumulative amount of levofloxacin in urine (Ae) were estimated. The individual profiles of the drug concentration in plasma showed little difference among the three treatments. The only consistent effect of the coadministration of levofloxacin with a high-fat meal for most subjects was that levofloxacin absorption was delayed and Cmax was slightly reduced (Tmax, 1.0 and 2.0 h for fasting and fed conditions, respectively [P = 0.002]; Cmax, 5.9 +/- 1.3 and 5.1 +/- 0.9 microg/ml [90% confidence interval = 0.79 to 0.94] for fasting and fed conditions, respectively). Sucralfate, which was administered 2 h after the administration of levofloxacin, appeared to have no effect on levofloxacin's disposition compared with that under the fasting condition. Mean values of Cmax and AUC from time zero to infinity were 6.7 +/- 3.2 microg/ml and 47.9 +/- 8.4 microg x h/ml, respectively, following the administration of sucralfate compared to values of 5.9 +/- 1.3 microg/ml and 50.5 +/- 8.1 microg x h/ml, respectively, under fasting conditions. The mean t1/2, CL/F, CLR, and Ae values were similar among all three treatment groups. In conclusion, the absorption of levofloxacin was slightly delayed by food, although the overall bioavailability of levofloxacin following a high-fat meal was not altered. Finally, sucralfate did not alter the disposition of levofloxacin when sucralfate was given 2 h after the administration of the antibacterial agent, thus preventing a potential drug-drug interaction.

Cesarean section--indications and risks in rural Zaire

In a retrospective study in rural Zaire, 10.2% of all deliveries were conducted by cesarean section. Common indications were contracted pelvis and uterine dysfunction (37%) and previous cesarean delivery (32%). Compared with normal delivery, mortality was higher after cesarean section. Cesarean section should only be performed by well-trained personnel and when vaginal delivery is deemed inappropriate.

Treatment of the acute retinal necrosis syndrome with intravenous acyclovir

We treated 13 eyes of 12 patients with the acute retinal necrosis syndrome (ARN) with intravenous acyclovir (1500 mg/M2/day) for an average of 10.9 days. All patients were also treated with oral aspirin or Coumadin. in an attempt to prevent thrombotic complications and nine of twelve patients were treated with oral prednisone after intravenous acyclovir had been initiated. Regression of retinal lesions was first seen on average 3.9 days after initiation of therapy and required 32.5 days on average for completion. No eye developed new retinal lesions or progressive optic nerve involvement 48 hours or more after initiation of therapy, although progression within the first 48 hours was occasionally seen. Treatment did not ameliorate vitritis or prevent retinal detachment, which occurred in 11 of 13 eyes, an average of 59 days after the initiation of therapy. There were no evident ocular or systemic complications of therapy. Our data suggest the need for a prospective randomized clinical trial to evaluate the efficacy of intravenous or oral acyclovir in the treatment of the acute retinal necrosis syndrome.

Stimulation of the vestibular receptor by means of step temperature changes during continuous aural irrigation

A technique for rapid, balanced hot/cold stimulation of the vestibular receptor is presented. During continuous aural irrigation the temperature of the irrigation fluid is switched between hot and cold values at times computed according to a mathematical model of heat conduction in the labyrinth area. As a result, the induced temperature difference across the lateral semicircular canal describes an approximately sinusoidal time course, reaching peak values of equal magnitude but opposite sign. Application of the test to 32 clinical subjects demonstrated that the heat conduction model and the analysis used in timing the sequence of thermal pulses was accurate. We expect that, with further refinements, the new technique will prove superior to conventional caloric test methods in the detection and measurement of subtle as well as gross abnormalities of the vestibular system.