Experience of cardiac tele-rehabilitation: analysis of patient narratives.

INTRODUCTION: Research suggests the need for further studies of patients' experiences of cardiac tele-rehabilitation to understand how they adapt to life with heart disease in a program with long-distance contact, remote supervision and monitoring of health behavior. Therefore, the aim of this study was to explore patients' experiences of tele-rehabilitation and the perceived gains of taking part in the program. MATERIALS AND METHODS: Seven patients were interviewed using a phenomenological-hermeneutic approach. Interview transcripts were analyzed as narratives using the interpretation theory of the French philosopher Paul Ricoeur. This involves three levels of textual analysis: a naïve reading as the first interpretation followed by a structural analysis, where the text is explored in detail, before identifying the most significant interpretation through critical interpretation. RESULTS: Patients valued cardiac tele-rehabilitation because it was not restricted to the hospital setting. They felt that the program's flexibility was an advantage because the program could be adjusted to their daily lives. The patients showed greater acknowledgement of and commitment towards the rehabilitation interventions if they were consistent with the patients' self-image, and if the activities were already part of their daily lives. If they were not, they were experienced as an extra challenge. CONCLUSIONS: Understanding patients' self-image and prior lifestyle may better inform clinicians about why it can be difficult for patients to follow rehabilitation recommendations. Therefore, clinicians may need to focus more on these two factors to help patients adapt to life with heart disease. IMPLICATIONS FOR REHABILITATION Patients' self-image and prior lifestyle may be important factors for how patients adapt to their new life situation with heart disease within a cardiac tele-rehabilitation program. Patients' commitment to selected rehabilitation interventions may be either too high or too low if it fails to take into consideration their self-image and prior lifestyle. Understanding patients' self-image and prior lifestyle may better inform clinicians and their understanding of why it can be difficult for patients to follow the rehabilitation recommendations.

Telemonitored exercise-based cardiac rehabilitation improves physical capacity and health-related quality of life.

INTRODUCTION: Cardiac rehabilitation improves physical capacity, health-related quality of life, and reduces morbidity and mortality among cardiac patients. Telemonitored exercise-based cardiac rehabilitation may innovate existing programmes and increase participation rates. OBJECTIVE: The purpose of this study was to investigate if telemonitored exercise-based cardiac rehabilitation improves physical capacity, muscle endurance, muscle power, muscle strength and health-related quality of life in cardiac patients. METHODS: A follow-up study on moderate risk patients with ischaemic heart and heart valve disease referred to a 12-week telemonitored exercise-based cardiac rehabilitation intervention at Aarhus University Hospital (Denmark). Participants were encouraged to exercise 60 min three times weekly with moderate/high intensity for 20 min per session. Intensity and duration of training sessions were visualised on a smartphone and uploaded to a website. Participants received individual feedback from physiotherapists on their training efforts by telephone/email. Outcome measures were changes in physical capacity (peak oxygen uptake), muscle endurance, power, and strength, and health-related quality of life between baseline end of telemonitored exercise-based cardiac rehabilitation intervention, and at six and 12 months after end of telemonitored exercise-based cardiac rehabilitation. RESULTS: Thirty-four participants completed telemonitored exercise-based cardiac rehabilitation. We identified a significant increase in peak oxygen uptake of 10%, in muscle endurance of 17%, in muscle power of 7%, and in muscle strength of 10% after the telemonitored exercise-based cardiac rehabilitation programme. Health-related quality of life was significantly improved by 19% in the physical and 17% in the mental component scores. We found no significant improvement in peak oxygen uptake between baseline and 12 months follow-up, but a significant improvement in muscle endurance (0.3 watts/kg, 95% confidence interval; 0.2-0.4), muscle power (0.4 watts/kg; 0.2-0.5), muscle strength (0.5 N/m/kg; 0.1-0.9), physical health-related quality of life (five points; 2-8) and mental health-related quality of life (six points; 3-9). DISCUSSION: This study demonstrated that the self-elected type of physical exercise in cardiac rehabilitation with telemonitoring improved all outcome measures both on the short and long-term, except for peak oxygen uptake at 12 months follow-up.

A comparison of high versus low dose of exercise training in exercise-based cardiac rehabilitation: a randomized controlled trial with 12-months follow-up.

OBJECTIVE: To assess if a higher dose of exercise training in exercise-based cardiac rehabilitation could affect improvements in aerobic capacity and muscle strength. DESIGN: Assessor-blinded randomized controlled trial with 12-months follow-up. SETTING: Aarhus University Hospital, Aarhus, Denmark. SUBJECTS: A total of 164 cardiac patients referred to exercise-based cardiac rehabilitation were recruited. INTERVENTIONS: Patients were randomized to 1-hour exercise sessions either three times weekly for 12 weeks (36 sessions, high-dose group) or twice weekly for 8 weeks (16 sessions, low-dose group). The same standardized exercise and intensity protocol including aerobic and muscle strength training was used in all participants. MAIN MEASURES: Primary outcome was changes in VO2peak. Secondary outcomes were changes in maximal workload, muscle strength and power. Measures were obtained at baseline, after termination of the rehabilitation programme and at follow-up after 6 and 12 months. RESULTS: After the end of intervention, statistically significant between-group differences were seen in favour of the high-dose group in all outcomes: VO2peak 2.6 (mL kg-1 min-1) (95% confidence interval (CI): 0.4-4.8), maximal workload 0.3 W kg-1 (95%CI: 0.02-0.5), isometric muscle strength 0.7 N m kg-1 (95%CI: 0.1-1.2) and muscle power 0.3 W kg-1 (95%CI: 0.04-0.6). After 12 months, a significant between-group difference only persisted in VO2peak and maximal workload. CONCLUSION: A higher dose of exercise training had a small effect on all outcomes at termination of intervention. A long-term effect persisted in VO2peak and maximal workload. Although the effect was small, it is an important finding because VO2peak is the most important predictor of all-cause mortality in cardiac patients.

Tele-rehabilitation and hospital-based cardiac rehabilitation are comparable in increasing patient activation and health literacy: A pilot study.

BACKGROUND: Cardiac tele-rehabilitation is defined as using information and communication technology to support rehabilitation services. However, it requires a high level of patient activation and health literacy; this has not yet been explored. AIMS: The purpose of this study was to evaluate patient activation and health literacy in tele-rehabilitation compared to hospital-based cardiac rehabilitation. METHODS: We conducted a pilot study in patients with ischaemic or heart valve disease. In a non-randomised design, 24 patients attended a 12-week tele-rehabilitation programme, and 53 matched controls a 12-week hospital-based cardiac rehabilitation programme. The primary outcome was patient activation, which was assessed using the Patient Activation Measure before the intervention, at the end of the intervention and at follow-up six months after the intervention. The secondary outcome was health literacy, assessed using three dimensions from the Health Literacy Questionnaire before rehabilitation and at six-month follow-up: actively manage my health (HLQ3), ability to engage with healthcare providers (HLQ6) and understanding health information (HLQ9). RESULTS: Patient activation improved similarly in tele-rehabilitation and hospital-based cardiac rehabilitation at all time points. Six months after the intervention, patients in tele-rehabilitation significantly improved on the dimension HLQ6 compared to patients in hospital-based cardiac rehabilitation. No significant between-group differences were found in HLQ3 or HLQ9. CONCLUSION: Tele-rehabilitation and hospital-based cardiac rehabilitation seemed to be equally successful in improving patient activation and health literacy. Tele-rehabilitation should be further tested in a randomised controlled trial, with a focus on whether patient levels of education and self-management at the initiation of rehabilitation are decisive factors for tele-rehabilitation participation.

Coping with interruptions in clinical nursing-A qualitative study.

AIMS AND OBJECTIVES: To gain knowledge on how nurses' cope with interruptions in clinical practice. BACKGROUND: Interruptions may delay work routines and result in wasted time, disorganised planning and ineffective working procedures, affecting nurses' focus and overview in different ways. Research has identified a growing problem linking errors or adverse events with interruptions. It may affect patient safety if nurses are not paying attention to interruptions. Little is known about how nurses cope with interruptions DESIGN: The study was inspired by ethnographic fieldwork with a hermeneutical phenomenological approach. METHODS: Observations were performed combined with semi-structured qualitative interviews. RESULTS: Managing interruptions depend on level of competence, working environment, dialogue and matching of expectations, collegial roles and implicit rules. Working procedures impact on how nurses are exposed to unnecessary interruptions. The latter affects overview and the ability to put the foot down and decline being interrupted. Professional competencies for example prioritising, keeping focus and collaborating across disciplines are needed to cope with interruptions. CONCLUSION: Culture work and matching of expectations are important to reflect on and discuss personal- and group behaviour caused by interruptions. We need to focus on the role of each nurse in the professional team, types of personality and unspoken rules. Professional competencies for example prioritising, keeping focus and cooperating across disciplines are needed to cope with interruptions. RELEVANCE TO CLINICAL PRACTICE: Coping with interruptions is important for the nursing profession, quality of care and patient safety. Changing practice requires multidisciplinary cooperation accepting different agendas at personal, group and organisational levels. Nurses must understand the meaning and nature of different types of interruptions to develop coping strategies and maintain quality in care and patient safety in multidisciplinary teamwork.

Correlation Between Exercise Capacity and Quality of Life in Patients With Cardiac Disease.

PURPOSE: Patients are referred to exercise-based cardiac rehabilitation (ECR) to increase exercise capacity and health-related quality of life (HRQOL) and thereby reduce risk of morbidity and mortality. The purpose of this study was to examine the correlation between exercise capacity and HRQOL. Furthermore, this study examined whether improvements in HRQOL were directly related to improvements in exercise capacity. METHODS: The study included 277 patients participating in ECR. HRQOL was assessed using the Medical Outcomes Study 36-item Short Form Health Survey (SF-36), and exercise capacity was measured as peak oxygen uptake ((Equation is included in full-text article.)O2peak) and oxygen uptake ((Equation is included in full-text article.)O2) at the ventilatory threshold (VTh). Patients were examined before and after completion of an 8-wk ECR program. RESULTS: Analyses at baseline showed a significant correlation between (Equation is included in full-text article.)O2peak and VTh and physical functioning (PF), role limitations because of physical problems (RP), general health perceptions (GH), vitality (VT), and physical component summary (PCS) on the SF-36; PF was the only dimension showing a moderate correlation (>0.40 Spearman ρ) with (Equation is included in full-text article.)O2peak. The follow-up analyses demonstrated a significant correlation between changes in (Equation is included in full-text article.)O2peak and changes in PF, RP, VT, and MH. Changes in (Equation is included in full-text article.)O2 peak explained 4% of the changes in the PF and VT scores. CONCLUSION: The correlations between exercise capacity and HRQOL were weak and varied considerably among patients. The ECR program improved both exercise capacity and HRQOL, but it was not necessarily the same patients who improved both parameters. Therefore, it is recommended to use separate objective measures and patient-reported outcomes when evaluating the effect of ECR.

Effectiveness of Patient Safety Leadership WalkRounds™ on patient safety culture: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The review objective is to synthesize the effect of Patient Safety Leadership WalkRounds (PSLWs) on patient safety culture (PSC).Specifically, the review question is: What is the effect of PSLWs on the PSC in hospitals, measured with validated surveys?

Exercise-based cardiac rehabilitation in surgically treated type-A aortic dissection patients.

OBJECTIVES: Surgically treated type-A aortic dissection patients are often restricted from physical exercise due to a lack of knowledge about the blood pressure increase. Our aims were to evaluate the hemodynamic responses during exercise, and to assess changes in peak oxygen uptake, maximal workload, and quality-of-life after completion of an exercise-based cardiac rehabilitation program. DESIGN: Three subgroups were retrospectively identified based on their different eligibility criteria. Group I (n = 10) had performed an exercise-based cardiac rehabilitation program including exercise tests. Group II (n = 9) had followed the program without the tests. Group III (n = 10) had neither been rehabilitated nor tested. For evaluation of hemodynamic parameters, we included a group of surgically treated patients with aortic valve stenosis, group IV (n = 32). Questionnaires were obtained to measure quality-of-life. RESULTS: At baseline the group I and IV mean systolic blood pressure changed from 143 ± 16 mmHg and 150 ± 16 mmHg to 200 ± 32 mmHg and 213 ± 27 mmHg, respectively. The group I mean peak oxygen uptake changed from 23.5 ± 7.9 ml/min/kg before rehabilitation to 28.6 ± 8.4 ml/min/kg, p = .001, after rehabilitation. The mean maximal workload changed from 143 ± 80 W before rehabilitation to 178 ± 97 W, p = .003, after rehabilitation. At follow-up, the groups I-III physical quality-of-life score was 45.1 ± 15.0, 40.0 ± 9.0, and 30.0 ± 11.3, p < .025, respectively, and the mental quality-of-life score was 51.1 ± 6, 41.7 ± 6.7, and 32.5 ± 13.3, p < .001, respectively. CONCLUSIONS: Our results suggest that type-A aortic dissection patients have hemodynamic responses to exercise that are comparable to other cardiovascular patients. Moreover, we found significant increases in peak oxygen uptake, maximal workload, and quality-of-life after ended ECR.

Exercise-based pre-habilitation is feasible and effective in radical cystectomy pathways-secondary results from a randomized controlled trial.

BACKGROUND: Physical exercises offer a variety of health benefits to cancer survivors during and post-treatment. However, exercise-based pre-habilitation is not well reported in major uro-oncology surgery. The aim of this study was to investigate the feasibility, the adherence, and the efficacy of a short-term physical pre-habilitation program to patients with invasive bladder cancer awaiting radical cystectomy (RC). METHODS: A parent prospective randomized controlled clinical trial investigated efficacy of a multidisciplinary rehabilitation program on length of stay following RC. A total of 107 patients were included in the intension-to-treat population revealing 50 patients in the intervention group and 57 patients in the standard group. Pre-operatively, the intervention group was instructed to a standardized exercise program consisting of both muscle strength exercises and endurance training. The number of training sessions and exercise repetitions was patient-reported. Feasibility was expressed as adherence to the program and efficacy as the differences in muscle power within and between treatment groups at time for surgery. RESULTS: A total of 66 % (95 % confidence interval (CI) 51; 78) adhered more than 75 % of the recommended progressive standardized exercise program. In the intervention group, a significant improvement in muscle power of 18 % (p < 0.002) was found at time for surgery. Moreover, muscle power was significantly improved compared to that in the standard group with 0.3 W/kg (95 % CI 0.08; 0.5 %) (p < 0.006). Adherence was not associated with pre-operative BMI, nutritional risk, comorbidity, pain, gender, or age. CONCLUSION: In patients awaiting RC, a short-term exercise-based pre-habilitation intervention is feasible and effective and should be considered in future survivorship strategies.

Abnormal ventilatory response to exercise in young adults operated for ventricular septal defect in early childhood: A long-term follow-up.

BACKGROUND: Ventricular septal defects (VSDs) are normally closed in early childhood, and postsurgical physical capacity is generally considered normal. Despite an increasing understanding of late cardiac morbidity among these patients, long-term pulmonary function remains to be investigated. Therefore, the aim of this prospective follow-up study was to describe ventilatory function during exercise in VSD-repaired adults operated in early life. METHODS: We tested cardiopulmonary exercise capacity in 27 patients and 30 healthy control subjects on an ergometer cycle. Each test was preceded by a standard spirometry, and the exercise test was performed as a maximal incremental test. Pulmonary ventilation and gas exchange were simultaneously measured breath-by-breath with minute ventilation at peak exercise as our main endpoint. RESULTS: In the VSD-group the median surgical age was 1.9 (95% CI 1.1-2.8 years) and the mean age at time of examination was 21.1 ± 3.1 years in the VSD-group vs. 21.2 ± 2.5 years in the control group. Mean minute ventilation at peak exercise was significantly lower in the VSD-group compared with the controls: 1.4 ± 0.4 L/kg/min vs. 1.8 ± 0.4 L/kg/min, p<0.01. Likewise, mean oxygen uptake was reduced: 38.0 ± 8.2 ml/kg/min in the VSD-cohort vs. 47.9 ± 6.5 ml/kg/min among controls, p<0.01. In terms of breath rate and ventilatory equivalents (O2 and CO2) there were no differences between the groups. CONCLUSIONS: Patients with a surgically closed VSD have a markedly abnormal ventilatory response to exercise with significantly reduced minute ventilation despite a similar breath rate. With a follow-up of almost two decades our finding most certainly reflects an unknown but persisting abnormality.

Surgical correction of pectus carinatum improves perceived body image, mental health and self-esteem.

PURPOSE: The purpose of this study was to assess the effects of surgical correction of pectus carinatum on health-related quality of life and self-esteem. METHODS: Between May 2012 and May 2013, a prospective observational single-center cohort study was conducted on consecutive patients undergoing surgical correction of pectus carinatum at our institution. Patients filled in questionnaires on health-related quality of life and self-esteem before and six months after surgery. RESULTS: Disease-specific health-related quality of life was improved by 33% (95% CI: 23; 44%) according to responses to the Nuss Questionnaire modified for Adults. The improvement for generic mental health-related quality of life was 7% (95% CI: 3; 12%) in responses to the Short Form-36 Questionnaire. The improvement in self-esteem was 9% (95% CI: 2; 17%) as assessed with the Rosenberg Self-Esteem Scale. A Single Step Questionnaire supported the improvements in health-related quality of life and self-esteem six months postsurgery. CONCLUSION: This study confirms positive effects of surgical correction of pectus carinatum on health-related quality of life and self-esteem. Patients were to a greater extent self-satisfied about chest appearance following surgery, indicating this to be a step in the right direction toward improved body image, mental health and self-esteem.

Efficacy of a multiprofessional rehabilitation programme in radical cystectomy pathways: a prospective randomized controlled trial.

INTRODUCTION: Radical cystectomy with lymph-node dissection is a complex procedure and often followed by high postoperative morbidity and physical impairments leading to prolonged length of stay (LOS). Fast-track principles are standard procedure in radical cystectomy. Additional preoperative and postoperative physical exercises and enhanced mobilization may reduce LOS and early complications. MATERIALS AND METHODS: In total, 107 patients were included in a prospective randomized controlled design, 50 in the intervention group (nI = 50) and 57 in the standard group (ns = 57). The standard regimen comprised regular fast-track principles. The intervention included standardized preoperative and postoperative strength and endurance exercises and progressive postoperative mobilization. The programme was initiated 2 weeks before surgery. Efficacy was expressed as a reduction in postoperative LOS. Early complications were defined as events occurring at most 90 days postoperatively and graded using the Clavien-Dindo classification system. RESULTS: Adherence to prehabilitation, i.e. patients who accomplished at least 75% of the programme, was 59%. Postoperative mobilization was significantly improved by walking distance (p ≤ 0.001). The ability to perform personal activities of daily living was improved by 1 day (p ≤ 0.05). The median LOS was 8 days in both treatment groups (p = 0.68). There was no significant difference between treatment groups in severity of complications (p = 0.64). CONCLUSIONS: There was no reduction in LOS due to the preoperative and postoperative rehabilitation programme, although enhanced mobilization was achieved. The optimized minimal surgical procedure may have affected the ability to reduce LOS further with available techniques and procedures. Alternative parameters for recovery may offer more precise and relevant information.

Preoperative planning of renal transplantation: a comparison of non-contrast-enhanced ultrasonography, computed tomography, and magnetic resonance angiography with observations from surgery.

BACKGROUND: Many candidates for kidney transplantation need to undergo vessel examination before the transplantation procedure. PURPOSE: To identify the optimal preoperative modality for the examination of vessel status without the use of contrast agents in kidney transplant candidates. MATERIAL AND METHODS: Fifty-three consecutive patients were examined and 31 patients were transplanted. Ultrasonography (US), non-contrast-enhanced computed tomography (NCCT), and non-contrast-enhanced magnetic resonance angiography (NCMRA) were compared using inspection during kidney transplantation (TX) as a reference standard. The sensitivity and specificity to severe arteriosclerotic changes and the accuracy were calculated. Kappa statistics were used to assess the agreement between TX and the different examination modalities, and McNemar's test was used to test for significant differences. RESULTS: US had higher sensitivity (1.0) and better agreement with observations from surgery (k = 0.89) than both NCCT (sensitivity = 0.60; k = 0.72) and NCMRA (sensitivity = 0.20; k = 0.30). No significant difference was found between TX and US (P = 0.3173) or TX and NCCT (P = 0.1573), but there was a significant difference between TX and NCMRA (P = 0.0455). US was inconclusive in 20% of cases, and the internal iliac artery could not be visualized in 69% of cases. CONCLUSION: Either US or NCCT can be used as the preferred preoperative imaging modality to examine vessel status before kidney transplantation, but a combination of the two is preferable. NCMRA should not be used as the sole imaging modality for preoperative imaging before kidney transplantation because of its low sensitivity in detecting severe arteriosclerotic disease without the presence of stenosis.

Reduced long-term exercise capacity in young adults operated for ventricular septal defect.

BACKGROUND: Ventricular septal defects are normally closed in early childhood, and post-surgically the patients are considered as healthy and fit as their peers. However, data are inconsistent. We exercise-tested a cohort of ventricular septal defect-operated patients and a group of matched controls to evaluate long-term physical fitness. METHODS: Cardiopulmonary exercise capacity was tested on an ergometer cycle in 30 patients and 30 healthy age and gender-matched controls. Pulmonary ventilation and gas exchange were simultaneously measured breath-by-breath with Jaeger MasterScreen CPX® (CareFusion, San Diego, United States of America). During the test session, respiratory gas exchange was measured along with heart rate, blood pressure, and electrocardiogram. The endpoints were peak oxygen uptake, maximal workload, and ventilatory anaerobic threshold. The International Physical Activity Questionnaire and the SF-36 were applied for Health-Related Quality-of-Life assessment. RESULTS: Ventricular septal defect-operated adults had a markedly lower peak oxygen uptake: mean 38.0(±8.2 ml O2/kg/minute) versus 47.9(±6.5 ml O2/kg/minute) in controls, p<0.01. Furthermore, ventilatory anaerobic threshold was impaired in ventricular septal defect patients: mean 25.3(±7.8 ml O2/kg/minute) versus 35.2(±7.7 ml O2/kg/minute) in controls, p<0.01. Maximal workload was reduced: mean 3.3(±0.7 W/kg) versus 4.0(±0.5 W/kg) in the control group, p<0.01. Lastly, ventricular septal defect patients had a significantly lower peak heart rate: mean 182(±8.8 beats/minute) versus 188(±9.0 beats/minute) in controls, p=0.03. Regarding Health-Related Quality of Life, the ventricular septal defect group had significantly lower scores in physical functioning, role physical, and social functioning. CONCLUSION: Young adults with a surgically closed ventricular septal defect had a markedly reduced cardiopulmonary exercise capacity and a lower peak heart rate compared with controls.

Multidisciplinary rehabilitation can impact on health-related quality of life outcome in radical cystectomy: secondary reported outcome of a randomized controlled trial.

PURPOSE: Health related quality of life (HRQoL) is an important outcome in cancer care, although it is not well reported in surgical uro-oncology. Radical cystectomy (RC) with lymph-node dissection is the standard treatment of muscle-invasive bladder cancer and high-risk noninvasive bladder cancer. A wide range of impairments are reported postsurgery. The aims were to evaluate whether a standardized pre- and postoperative physical exercise program and enhanced mobilization can impact on HRQoL and inpatient satisfaction in RC, as defined by the European Organisation for Research and Treatment of Cancer (EORTC). MATERIALS AND METHODS: Patients were randomized to fast-track RC and intervention (nI=50) or fast-track standard treatment (nS=57). HRQoL and inpatient satisfaction was measured using valid questionnaires: EORTC Quality of Life Questionnaire Core 30 (QLQ-C30) combined with the disease-specific EORTC BLS24 (baseline), and EORTC BLM30 (follow-up), and IN-PATSAT32 inpatient-satisfaction survey at discharge. Efficacy was defined as the differences in HRQoL-scores between treatment groups at the 4-month follow-up. RESULTS: The intervention group significantly improved HRQoL scores in dyspnea (P≤0.05), constipation (P<0.02), and abdominal flatulence (P≤0.05) compared to the standard group. In contrast, the standard group reported significantly reduced symptoms in sleeping pattern (P≤0.04) and clinically relevant differences in role function, body function, and fatigue. The intervention did not compromise inpatient satisfaction. CONCLUSION: We found no overall impact on global HRQoL due to a physical rehabilitation program. However, pre- and postoperative physical rehabilitation can significantly and positively impact on HRQoL aspects related to bowel management and respiratory function (dyspnea) without compromising inpatient satisfaction. These results highlight the role of multimodal rehabilitation, including physical exercises in fast-track RC.

Predictors for not completing exercise-based rehabilitation following cardiac surgery.

OBJECTIVES: The beneficial effects of exercise-based cardiac rehabilitation (ECR) are well documented. A substantial proportion of patients fail to complete ECR. The purpose of this study was to identify factors associated with patients not completing ECR. DESIGN: Registry based and data from medical records. The study population was surgically treated heart patients with ischaemic and/or heart valve diseases referred to ECR between August 2008 and January 2011 at Aarhus University Hospital, Denmark. The ECR was an 8-week course with 1-h biweekly sessions. Patients were non-completers when attending ≤ 75% of sessions. Data were analysed in a multivariate logistic regression model. RESULTS: Of 364 patients, 73% were referred to ECR, 42% did not complete the ECR and 28% never showed up. Readmission within 8 weeks post-discharged odds ratio (OR) of 2.50 (95% confidence interval [CI], 1.40-4.46), prescribed antidepressant medication OR of 2.40 (95% CI, 1.21-4.74), overweight OR of 1.81 (95% CI, 1.03-3.18), or being single OR of 1.12 (95% CI, 1.07-1.70) was significantly associated with not completing ECR. CONCLUSION: We identified a high rate of patients not completing ECR. Readmissions, antidepressant medication, marital status and obesity should warrant clinical attention when designing future interventions to improve adherence to ECR.

The Urostomy Education Scale: a reliable and valid tool to evaluate urostomy self-care skills among cystectomy patients.

AIM: : The purpose of this study was to validate a quantitative scale for nurses to evaluate self-care skills among patients undergoing cystectomy with creation of a urostomy. SUBJECTS AND SETTINGS: Twelve patients undergoing cystectomy with formation of a urostomy participated in the research. The study took place at Aarhus University Hospital, Denmark-a bladder cancer center performing approximately 100 cystectomies annually. INSTRUMENT: The Urostomy Education Scale was developed in 2010 based on review of stoma care literature. Areas recognized as standard procedure in urostomy care were identified and categorized into 7 self-care skills necessary for changing the pouching system. The 7 skills were reaction to the stoma, removing the pouching system, measuring the stoma diameter, adjusting the size of the urostomy diameter in a new stoma appliance, skin care, fitting a new stoma appliance, and emptying procedure. Each skill is rated on a 4-point scale according to the patient's need of assistance from the nurse. Higher scores indicate a higher level of patient self-care skills related to changing a urostomy pouching system. METHODS: Content, criterion, and construct validity were evaluated by a panel of experts using the Delphi method in 2010. To test interrater reliability and criterion validity, 4 nurses attended 12 patient training sessions at different postoperative days. Each patient was taught how to change a urostomy appliance using a standardized approach. One experienced enterostomal therapy nurse acted as the instructor and 3 other nurses observed and scored the patient's self-care skills. The 3 nurses' scores were analyzed using Bland Altman Plots with Limits of Agreements.To test construct validity, patients were categorized into 3 groups. The mean score in each group was used to analyze differences between groups using one way analysis of variance. RESULTS: Analysis revealed that the Urostomy Education Scale distinguished urostomy self-care skills practice by beginners versus experienced patients (P= .01). Comparison of scores among the 3 nurses revealed no statistically significant differences. In addition, the Urostomy Education Scale demonstrated satisfactory reliability with Limits of Agreements ranging from -3 to 3; 86% of scores differed by 2 points or less. CONCLUSIONS: To our knowledge, the Urostomy Education Scale is the first validated tool for nurses to document the patient's level of urostomy self-care skills.

Amount of alcohol-based hand rub used and incidence of hospital-acquired bloodstream infection in a danish hospital.

We investigated the association between the amount of alcohol-based hand rub (hereafter, "hand rub") used and the incidence of healthcare-acquired bloodstream infection (HCR-BSI) from 2004 through early 2008. The amount of hand rub used increased significantly, and the incidence of HCR-BSI remained stable. There was no significant association between the amount of hand rub used and the incidence of HCR-BSI.

E-learning may improve adherence to alcohol-based hand rubbing: a cohort study.

BACKGROUND: Since 2004, we have promoted alcohol-based hand rubbing (HR) with an e-learning program (ELP) among hospital staff. This study sought to determine whether an ELP improves adherence to correct HR. METHODS: This was a cohort study of staff members at Aarhus University Hospital, Skejby, Denmark who completed the ELP and were repeatedly observed for correct HR before and after clinical procedures in 2006 and/or 2007. RESULTS: Of the 496 participants, 13% completed the ELP in both 2006 and 2007, 29% completed the ELP only in 2006, 15% completed the ELP only in 2007, and 43% never completed the ELP. Compared with noncompleters, completers of the 2006 and 2007 ELP had a significantly higher adherence to correct HR both before clinical procedures (odds ratio [OR] = 1.54; 95% confidence interval [CI] = 1.11 to 2.13) and after clinical procedures (OR = 1.40; 95% CI = 1.03 to 1.89). Time since completing the ELP seemed to be inversely associated with adherence to correct HR. CONCLUSION: Completion of an ELP may have a positive impact on the performance of correct HR. The demands of lifelong education and training of hospital staff may call for the use of an ELP as a supplement to existing efforts aimed at improving HR to help prevent health care-related infections.

Cohort study of adherence to correct hand antisepsis before and after performance of clinical procedures.

OBJECTIVE: To investigate the rate of adherence by hospital staff members to the correct use of alcohol-based hand rub before and after performance of clinical procedures. DESIGN: A cohort study conducted during the period from 2006 through 2007 and 2 cross-sectional studies conducted in 2006 and 2007. SETTING: Arhus University Hospital, Skejby, in Arhus, Denmark. PARTICIPANTS: Various hospital staff members. METHODS: Following an ongoing campaign promoting the correct use of alcohol-based hand rub, we observed rates of adherence by hospital staff to the correct use of alcohol-based hand rub. Observations were made before and after each contact with patients or patient surroundings during 5 weekdays during the period from 2006 through 2007 in 10 different hospital units. A logistic regression model was used to estimate the rate of adherence to the correct use of alcohol-based hand rub before and after performance of a clinical procedure. RESULTS: A total of 496 participants were observed during 22,906 opportunities for hand hygiene (ie, 11,177 before and 11,729 after clinical procedures) that required the use of alcohol-based hand rub. The overall rates of adherence to the correct use of alcohol-based hand rub were 62.3% (6,968 of the 11,177 opportunities) before performance and 68.6% (8,041 of the 11,729 opportunities) after performance of clinical procedures. Compared with male participants, female participants were significantly better at adhering to the correct use of alcohol-based hand rub before performance (odds ratio [OR] 1.51 [95% confidence interval {CI}, 1.09-2.10]) and after performance (OR, 1.73 [95% CI, 1.27-2.36]) of clinical procedures. In general, the rate of adherence was significantly higher after the performance of clinical procedures, compared with before (OR, 1.43 [95% CI, 1.35-1.52]). For our cohort of 214 participants who were observed during 14,319 opportunities, the rates of adherence to the correct use of alcohol-based hand rub were 63.2% (4,469 of the 7,071 opportunities) before performance and 69.3% (5,021 of the 7,248 opportunities) after performance of clinical procedures, and these rates increased significantly from 2006 to 2007, except for physicians. CONCLUSION: We found a high and increasing rate of adherence to the correct use of alcohol-based hand rub before and after performance of clinical procedures following a campaign that promoted the correct use of alcohol-based hand rub. More hospital staff performed hand hygiene with alcohol-based hand rub after performance of clinical procedures, compared with before performance. Future campaigns to improve the rate of adherence to the correct use of alcohol-based hand rub ought be aware that certain groups of hospital staff (eg, male staff members) are known to exhibit a low level of adherence to the correct use of alcohol-based hand rub.