Orthopaedic patients' experiences of their sleep during hospitalisation and suggestions for improvements.

PURPOSE: To describe orthopaedic patients' perspectives on their sleep quality and their suggestions for improvement initiatives to achieve better sleep quality during hospitalisation. METHODS: In a qualitative design, 265 (50%) of 533 patients from a questionnaire survey responded to two free-text questions. Data were analysed based on a phenomenological-hermeneutic approach inspired by Paul Ricoeur's theory of narrative and interpretation. RESULTS: Three themes emerged: 1) Sleeping environment and preferences tailored to the individual patient, 2) The link between orthopaedic surgery care and sleeping, and 3) Noise challenged a good night's sleep. Good sleep was related to nurses' professional behaviour and the physical environment, such as quality beds and sleeping aids. Single and shared rooms, room lighting, and fresh air all influenced sleep quality. Unfamiliar and uncomfortable sleeping positions posed a challenge for orthopaedic patients but aids such as pillows, and duvets could provide more comfort at night. Offset circadian rhythms could affect sleep quality, as could nausea and vomiting. Pain and lack of pain relief were associated with poor sleep quality. Noise from both nurses and other patients affected sleep quality. Therefore, unnecessary care activities should be kept to a minimum, and a "night noise level" was suggested. CONCLUSION: Patients' sleep disturbance following orthopaedic surgery needs to be addressed by both nurses and hospital management. Patients' involvement is essential to create a sleep environment tailored to individual needs and to provide strategies patients use at home for addressing sleeping problems.

'Why doesn't anyone ask me'? Patients' experiences of receiving, performing and practices of oral care in an acute Orthopaedic Department.

AIMS AND OBJECTIVES: Oral care is an integrated part of everyday life. Within nursing, barriers related to providing oral care often lead to unmet caring needs. Poor oral care is associated with a risk of respiratory and cardiovascular complications during hospitalisation. Knowledge on patients' perspectives of maintaining or receiving oral care during admissions are limited. Following the Fundamentals of Care (FOC) framework, this study uses a person-centred approach to explore patients' perceptions and experiences of receiving or performing oral care, including the nursing staff's clinical practices. METHODOLOGICAL DESIGN AND JUSTIFICATION: A focussed ethnographic approach was used to explore patients' perspectives and clinical practices during acute admissions in an Orthopaedic Department. ETHICS ISSUES AND APPROVAL: The local Data Protection Agency and the Ethics Committee approved the study. RESEARCH METHODS, RESULTS AND CONCLUSIONS: Data were collected in an Orthopaedic ward at a Copenhagen University hospital, Hvidovre, and consisted of 14 days of field observations of clinical practices and 15 patient interviews. Data were analysed inductively using qualitative content analysis. Two themes were identified. The first, 'The purpose of oral care is defined by the eye of the beholder', describes the social implications for the patients and how patients reject the assumption of oral care being a transgressive act. The second, 'The unspoken need', focus on the lack of dialogue, including the limited provision of oral care and how the nursing staff assesses patients' ability to perform oral care (in)dependently without including the patients. CONCLUSION: Oral care is related to the patient's psychological and physical well-being and affects social appearance. When oral care is provided respectfully, patients do not experience oral care as a transgressive act. Nursing staff's self-assessments of the patients' (in)dependency to perform oral care risk leading to incorrect care. Developing and implementing interventions applicable to the clinical practice is needed.

Estimated glomerular filtration rate based on creatinine, cystatin C, ß-trace protein and ß2 microglobulin in patients undergoing nontraumatic lower extremity amputation.

AIMS: The study's aim is to compare current and new equations for estimating glomerular filtration rate (GFR) based on creatinine, cystatin C, ß-trace protein (BTP) and ß2 microglobulin (B2M) among patients undergoing major amputation. METHODS: This is a secondary analysis of data from a prospective cohort study investigating patients undergoing nontraumatic lower extremity amputation. Estimated GFR (eGFR) was calculated using equations based on creatinine (eGFRcre[2009] and eGFRcre[2021]), cystatin C (eGFRcys), the combination of creatinine and cystatin C (eGFRcomb[2012] and eGFRcomb[2021]) or a panel of all 4 filtration markers (eGFRpanel). Primary outcome was changed in eGFR across amputation according to each equation. Two case studies of prior amputation with GFR measured by 99mTc-DTPA clearance are described to illustrate the relative accuracies of each eGFR equation. RESULTS: Analysis of the primary outcome included 29 patients (median age 75 years, 31% female). Amputation was associated with a significant decrease in creatinine concentration (-0.09 mg/dL, P = 0.004), corresponding to a significant increase in eGFRcre[2009] (+6.1 mL/min, P = 0.006) and eGFRcre[2021] (+6.3 mL/min, P = 0.006). Change across amputation was not significant for cystatin C, BTP, B2M or equations incorporating these markers (all P > 0.05). In both case studies, eGFRcre[2021] yielded the largest positive bias, eGFRcys yielded the largest negative bias and eGFRcomb[2012] and eGFRcomb[2021] yielded the smallest absolute bias. CONCLUSION: Creatinine-based estimates were substantially higher than cystatin C-based estimates before amputation and significantly increased across amputation. Estimates combining creatinine and cystatin were stable across amputation, while the addition of BTP and B2M is unlikely to be clinically relevant.

We are not heroes-The flipside of the hero narrative amidst the COVID19-pandemic: A Danish hospital ethnography.

AIM: To explore how the media and socially established hero narrative, affected the nursing staff who worked in the frontline during the first round of the COVID19-pandemic. BACKGROUND: During the COVID19-pandemic, both media, politicians and the public have supported and cheered on the frontline healthcare workers around the world. We have found the hero narrative to be potentially problematic for both nurses and other healthcare workers. This paper presents an analysis and discussion of the consequences of being proclaimed a hero. DESIGN: Hospital ethnography including fieldwork and focus groups. METHOD: Empirical data was collected in a newly opened COVID19-ward in a university hospital in the urban site of Copenhagen, Denmark. Fieldwork was performed from April until the ward closed in the end of May 2020. Succeeding focus group interviews with nursing staff who worked in the COVID19-ward were conducted in June 2020. The data were abductively analysed. RESULTS: The nursing staff rejected the hero narrative in ways that show how the hero narrative leads to predefined characteristics, ideas of being invincible and self-sacrificing, knowingly and willingly working in risk, transcending duties and imbodying a boundless identity. Being proclaimed as a hero inhibits important discussions of rights and boundaries. CONCLUSION: The hero narrative strips the responsibility of the politicians and imposes it onto the hospitals and the individual heroic health care worker. IMPACT: It is our agenda to show how the hero narrative detaches the connection between the politicians, society and healthcare system despite being a political apparatus. When reassessing contingency plans, it is important to incorporate the experiences from the health care workers and include their rights and boundaries. Finally, we urge the media to cover a long-lasting pandemic without having the hero narrative as the reigning filter.

Sleep quality among orthopaedic patients in Denmark - A nationwide cross-sectional study.

BACKGROUND: Hospitalised patients sleep less and have a lower quality of sleep compared to patients who recover in their own home. Low sleep quality is associated with complications such as increased pain sensation, delirium and reduced rehabilitation capacity. PURPOSE: To investigate patients' self-reported sleep quality and factors related to sleep quality during admission to a department of Orthopaedic Surgery. METHODS: The Richard-Campbell Sleep Questionnaire was used to assess patients' sleep quality, measured using a VAS 0-100 scale, (a higher score indicating good sleep quality). The moderated Pittsburgh Sleep Quality Index assessed the most severe and frequent barriers to high sleep quality. RESULTS: A total of 533 patients undergoing orthopaedic surgery participated. There was an overall mean sleep quality score of 54. The most common and severe factors impacting sleep quality were; waking during the night, difficulties falling asleep, waking early, waking for toileting or pain. The intensity of the pain was found to be proportional to the quality of sleep. CONCLUSION: Patients reported their overall quality of sleep to be moderately good due to difficulties falling asleep, waking up during the night or early morning and having pain. The results call for better pain management and non-pharmacological nursing interventions to optimise sleep quality.

"Wow I had no idea"-How job rotation is experienced by nurses caring for elective orthopaedic patients: A qualitative study.

AIMS AND OBJECTIVES: To explore gains and impacts of job rotation through the experiences of involved nursing personnel responsible for different parts of care during the elective orthopaedic patient's pathway. BACKGROUND: When patients undergo elective orthopaedic surgery, they encounter nurses from different wards. So far, job rotation has only been described through the experiences of the job rotating nurses. This study includes all involved nursing personnel and bases the job rotation on the pathway of the elective orthopaedic patient. DESIGN: This study has an exploratory-descriptive and qualitative approach and follows the Consolidated Criteria for Reporting Qualitative Research guidelines. METHOD: A total of nine focus groups including 16 informants were conducted before, during and after a 5-month trial period. The data were analysed using thematic analysis. RESULTS: The findings show that existing work structures and work content combined with a lack of a common understanding of the job rotation impacted the expectations of the nursing personnel regarding (in)dependence, individual and collegial involvement and investment, as well as the collegial belongingness expressed through terminologies of "home" and "culture." The personal gains among the job rotating nurses showed increased knowledge, skills and influence. When knowledge was shared and exchanged, the job rotating nurses became "cultural translators" of the care to the elective orthopaedic patient. CONCLUSIONS: This study shows personal gains among the job rotating nurses through increased knowledge, skills and influence as well as collegial gains by sharing and exchanging knowledge. When this exchange was utilised, the job rotation was evaluated positively, and contrary, when not utilised the job rotation had a negative impact on the work environment. RELEVANCE TO CLINICAL PRACTICE: Job rotation among nurses following the care of the patient's pathway can be a way of promoting patient safety and quality through increased knowledge across wards by including every aspect and element of the patient's pathway.

A randomized controlled trial of the effect of supervised progressive cross-continuum strength training and protein supplementation in older medical patients: the STAND-Cph trial.

BACKGROUND: During hospitalization, older adults (+ 65 years) are inactive, which puts them at risk of functional decline and loss of independence. Systematic strength training can prevent loss of functional performance and combining strength training with protein supplementation may enhance the response in muscle mass and strength. However, we lack knowledge about the effect of strength training commenced during hospitalization and continued after discharge in older medical patients. This assessor-blinded, randomized study investigated the effect of a simple, supervised strength training program for the lower extremities, combined with post-training protein supplementation during hospitalization and in the home setting for 4 weeks after discharge, on the effect on change in mobility in older medical patients. METHODS: Older medical patients (≥ 65 years) admitted acutely from their home to the Emergency Department were randomized to either standard care or supervised progressive strength training and an oral protein supplement during hospitalization and at home 3 days/week for 4 weeks after discharge. The primary outcome was between-group difference in change in mobility from baseline to 4 weeks after discharge assessed by the De Morton Mobility Index, which assesses bed mobility, chair mobility, static and dynamic balance, and walking. Secondary outcomes were 24-h mobility, lower extremity strength, gait speed, grip strength and activities of daily living. RESULTS: Eighty-five patients were randomized to an intervention group (N = 43) or a control group (N = 42). In the intervention group, 43% were highly compliant with the intervention. Our intention-to-treat analysis revealed no between-group difference in mobility (mean difference in change from baseline to 4 weeks, - 4.17 (95% CI - 11.09; 2.74; p = 0.24) nor in any of the secondary outcomes. The per-protocol analysis showed that the daily number of steps taken increased significantly more in the intervention group compared to the control group (mean difference in change from baseline to 4 weeks, 1033.4 steps (95% CI 4.1; 2062.7), p = 0.049, adjusted for mobility at baseline and length of stay; 1032.8 steps (95% CI 3.6; 2061.9), p = 0.049, adjusted for mobility at baseline, length of stay, and steps at baseline). CONCLUSIONS: Simple supervised strength training for the lower extremities, combined with protein supplementation initiated during hospitalization and continued at home for 4 weeks after discharge was not superior to usual care in the effect on change in mobility at 4 weeks in older medical patients. For the secondary outcome, daily number of steps, high compliance with the intervention resulted in a greater daily number of steps. Less than half of the patients were compliant with the intervention indicating that a simpler intervention might be needed. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01964482. Registered on 14 October 2013. Trial protocol PubMed ID (PMID), 27039381.

Stuck in tradition-A qualitative study on barriers for implementation of evidence-based nutritional care perceived by nursing staff.

AIMS AND OBJECTIVES: To explore the barriers for nutritional care as perceived by nursing staff at an acute orthopaedic ward, aiming to implement evidence-based nutritional care. BACKGROUND: Previous studies indicate that nurses recognise nutritional care as important, but interventions are often lacking. These studies show that a range of barriers influence the attempt to optimise nutritional care. Before the implementation of evidence-based nutritional care, we examined barriers for nutritional care among the nursing staff. DESIGN: Qualitative study. METHODS: Four focus groups with thirteen members of the nursing staff were interviewed between October 2013-June 2014. The interview guide was designed according to the Theoretical Domains Framework. The interviews were analysed using qualitative content analysis. RESULTS: Three main categories emerged: lacking common practice, failing to initiate treatment and struggling with existing resources. The nursing staff was lacking both knowledge and common practice regarding nutritional care. They felt they protected patient autonomy by accepting patient's reluctance to eat or getting a feeding tube. The lack of nutritional focus from doctors decreased the nursing staffs focus leading to nonoptimal nutritional treatment. Competing priorities, physical setting and limited nutritional supplements were believed to hinder nutritional care. CONCLUSION: The results suggest that nutritional care is in a transitional state from experience- to evidence-based practice. Barriers for nutritional care are grounded in lack of knowledge among nursing staff and insufficient collaboration between nursing staff and the doctors. There is a need for nutritional education for the nursing staff and better support from the organisation to help nursing staff provide evidence-based nutritional care. RELEVANCE TO CLINICAL PRACTICE: This study contributes with valuable knowledge before the implementation of evidence-based nutritional care. The study provides an understanding of barriers for nutritional care and presents explanations to why nutritional care has failed to become an integrated part of the daily treatment and care.

Perceptions and experiences of nutritional care following the overwhelming experience of lower extremity amputation: A qualitative study.

INTRODUCTION: Good nutritional care of people following major lower extremity amputation is essential as poor nutritional status can lead to delayed wound healing. Working with patients to identify their perspectives on food, views on nutritional care and the need for dietary counselling enables the development of optimised nutritional care. AIMS AND OBJECTIVES: To explore hospital patients' perspectives on food, dietary counselling and their experiences of nutritional care following lower extremity amputation. DESIGN: A qualitative, explorative study design was employed. METHOD: An inductive content analysis of semi-structured interviews with a purposive sample of 17 people over 50 years of age, who had recently undergone major lower extremity amputation, was undertaken. The study was reported according to the consolidated criteria for reporting qualitative research guideline. FINDINGS: Three themes emerged: responsible for own dietary intake, diet based on preferences and experiences with dietary counselling and feeling overwhelmed. The participants expressed motivation to ensure their nutritional needs were met but described feeling emotionally overwhelmed by the experience of amputation. They appeared not to expect nursing staff to focus on nutritional issues as they expressed belief that they themselves were solely responsible for their dietary intake. They described being motivated to receive nutritional counselling but indicated advice should be compatible with their lifestyle and eating habits. CONCLUSION: Lower extremity amputation can be an overwhelming experience which affects nutritional intake. People appear to consider themselves responsible for their nutritional care and describe not experiencing or expecting nursing staff to engage in this aspect of care. Dietary counselling by nurses who respect and incorporate patient preferences and experiences following amputation has the potential to enhance nutritional care. RELEVANCE TO CLINICAL PRACTICE: This study illustrates that nurses caring for people who undergo lower extremity amputation need to recognise that nutritional care is an essential component of nursing and should focus on working in partnership with the patient.

Progression of disease preceding lower extremity amputation in Denmark: a longitudinal registry study of diagnoses, use of medication and healthcare services 14 years prior to amputation.

OBJECTIVES: Patients with non-traumatic lower extremity amputation are characterised by high age, multi-morbidity and polypharmacy and long-term complications of atherosclerosis and diabetes. To ensure early identification of patients at risk of amputation, we need to gain knowledge about the progression of diseases related to lower extremity amputations during the years preceding the amputation. DESIGN: A retrospective population-based national registry study. SETTING: The study includes data on demographics, diagnoses, surgery, medications and healthcare services from five national registries. Data were retrieved from 14 years before until 1 year after the amputation. Descriptive statistics were used to describe the progression of diseases and use of medication and healthcare services. PARTICIPANTS: An unselected cohort of patients (≥50 years; n=2883) subjected to a primary non-traumatic lower extremity amputation in 2010 or 2011 in Denmark. RESULTS: The prevalence of atherosclerosis, hypertension and diabetes was 70%, 53% and 49%, respectively. Among patients with atherosclerosis, 42% had not received cholesterol-lowering treatment even though 87% had visited their general practitioner within the last year prior to amputation. Further, 16% were diagnosed with diabetes at the time of the amputation. The prevalence of cardiovascular diseases increased from 22% to 70%, atherosclerosis from 5% to 53% and diabetes from 17% to 35% over the 14 years preceding major amputation. Of all patients, 64% had been in contact with the hospital or outpatient clinics within the last 3 years, and 29% received a prescription of opioids 3 years prior to the amputation. CONCLUSION: Among patients with non-traumatic lower extremity amputation, one-third live with undiagnosed and untreated atherosclerosis and one-sixth suffer from undiagnosed diabetes despite continuous contacts to general practitioner and the hospital. This study emphasises a need for enhanced focus, among both hospital clinicians and general practitioners, on the early identification of atherosclerosis and diabetes.

Room for improvement in the treatment of hip fractures in Denmark.

INTRODUCTION: Treatment of hip fractures has evolved since the introduction of fast-track surgical programs in the late 1990s. The aim of our study was to describe the quality of treatment and care related to fast-track hip fracture surgery in Denmark by external audit of patient records. MATERIAL AND METHODS: This was a national multicenter audit of hospital charts from each hospital treating ≥ 50 hip fracture patients per year (n = 594). RESULTS: The study demonstrated significant variability in treatment and care of patients with hip fractures among the regions of Denmark. Pain management, nutritional screening, ambulation characteristics, training in activities of daily living, and rehabilitation planning were consistently inadequate. Length of stay was 7-11 days. CONCLUSION: Although the principles for fast-track surgery have been adapted to some extent at all departments in Denmark with an annual treatment of at least 50 patients with hip fractures, no single department has implemented the whole package. Hospital stay has been reduced since the introduction of fast-track regimes, and improvements were seen in many of the quality indicators. Implications for future practice include better adherence to clinical guidelines, a more homogeneous documentation system in nursing, promotion of evidence-based standards, and improved treatment and care of the physical and psychological consequences of hospitalization.

The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery.

BACKGROUND: Perioperative anemia leads to increased morbidity and mortality and potentially inhibits rehabilitation after hip fracture surgery. As such, the optimum transfusion threshold after hip fracture surgery is unknown. PATIENTS AND METHODS: A total of 120 elderly, cognitively intact hip fracture patients admitted from their own home were randomly assigned to receive transfusion at a hemoglobin threshold of 10.0 g per dL (liberal) versus 8.0 g per dL (restrictive) in the entire perioperative period. Patients were treated according to a well-defined multimodal rehabilitation program. Primary outcome was postoperative functional mobility measured with the cumulated ambulation score (CAS). RESULTS: Patients in the liberal group received transfusions more frequently than those in the restrictive group (44 patients vs. 22 patients; p < 0.01) and received more transfusions during hospitalization (median, 2 units [interquartile range, 1-2] vs. 1 [1-2]; p < 0.0001). There were no significant differences in postoperative rehabilitation scores (CAS: median, 9 [9-15] vs. 9 [9-13.5]; p = 0.46) or in length of stay (median, 18 days vs. 16 days, respectively; p = 0.46). There were fewer patients in the liberal transfusion group with cardiovascular complications (2% vs. 10%; p = 0.05) and a lower mortality (0% vs. 8%; p = 0.02). CONCLUSION: Although a liberal transfusion trigger did not result in increased ambulation scores, restrictive transfusion thresholds should be treated with caution in elderly high-risk hip fracture patients, until their safety has been proved in larger randomized studies.

[Fast-tracking admission from emergency room to orthopaedic ward in hip fracture patients]. / Optimeret modtagelsesprocedure for hoftefrakturpatienter.

INTRODUCTION: The traditional admission protocol for hip fracture patients often results in long waiting hours in the A&E. The aim of this study was to investigate the effect of an optimised admission protocol on the time spent in the A&E in an already established multimodal rehabilitation program. MATERIALS: Descriptive, prospective intervention study in two groups of 150 hip fracture patients admitted before and after the implementation of an optimised admission protocol, which included nurse requested x-ray and opioid-free analgesic. RESULTS: The median waiting time in the control group was 251 min (83-632 min.) compared to 185 min (58-522 min, p < 0,001)) in the intervention group. The median waiting time for operation was 18-19 hours in both groups. CONCLUSION: An optimised admission protocol, including nurse requested X-ray for hip fracture patients, led to a reduction in the time spent in the A&E.

Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery. METHODS: Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 mug/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy. RESULTS: Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups. CONCLUSION: Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction. However, superior analgesia did not translate into enhanced rehabilitation. Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients.