Specialist nurse supported discharge in gynaecology: a randomised comparison and economic evaluation.

AIM: To determine the effect on quality of life and cost effectiveness of specialist nurse early supported discharge for women undergoing major abdominal and/or pelvic surgery for benign gynaecological disease compared with routine care. STUDY DESIGN: Randomised controlled trial comparing specialist nurse supported discharge with routine hospital care in gynaecology. The SF-36, a generic health status questionnaire, was used to measure women's evaluation of their health state before surgery and at 6 weeks after surgery. A further questionnaire scoring patient symptoms, milestones of recovery, information given and satisfaction, was administered prior to discharge from hospital and at 6 weeks thereafter. SETTING: Gynaecology service at the Western Infirmary Glasgow, part of North Glasgow University, NHS Trust. PARTICIPANTS: One hundred and eleven women scheduled for major abdominal or pelvic surgery for benign gynaecological disease. MAIN OUTCOME MEASURES: SF-36 health survey questionnaire baseline scores were reported before surgery and at 6 weeks follow-up. Complications, length of hospital stay, readmission, information on discharge support and satisfaction of women were recorded at discharge from hospital and at 6 weeks follow-up. A cost consequence analysis was conducted based on the perspective of the NHS. RESULTS: The addition of a specialist nurse to routine hospital care in gynaecology significantly reduced the post-operative length of hospital stay p = 0.001, improved information delivery and satisfaction of women. The specialist nurse supported discharge group was associated with significantly lower total costs to the NHS than routine care resulting principally from the difference in the cost of the post-operative length of stay. CONCLUSIONS: Women undergoing major abdominal and pelvic surgery were discharged home earlier with provision of support from a specialist gynaecology nurse. The results of this study suggest that duration of hospital stay can be shortened by the introduction of a specialist nurse without introducing any adverse physical and psychological effects. This process of care is associated with receipt of information on health and lifestyle issues and maintenance of high levels of patient satisfaction and demonstrates the effectiveness of the specialist nurse role in the provision of health information for women. Earlier hospital discharge at 48 h after major abdominal and pelvic surgery is an acceptable, cost effective alternative to current routine practice in the absence of further randomised evidence.

The adjunctive role of mental practice in the rehabilitation of the upper limb after hemiplegic stroke: a pilot study.

OBJECTIVE: To assess the feasibility and practicalities of using the technique of mental practice as an adjunct in the rehabilitation of the upper limb following stroke. DESIGN: A series of single-case studies. SETTING: A stroke rehabilitation unit in Belfast. SUBJECTS: Fourteen patients admitted for rehabilitation of their first stroke: six men and four women, aged 45-81 between 10 and 176 days post stroke. INTERVENTION: Each patient underwent a single-case design, with two weeks baseline, two weeks intervention and one week withdrawal. The intervention consisted of structured daily mental practice sessions of a reach and grasp task, in addition to their usual therapy. MAIN OUTCOME MEASURES: The upper limb component of the Motricity Index was used to grade motor activity sequentially across the timescale of the study. RESULTS: Of the 14 patients recruited, four withdrew and 10 completed the study. Nine showed improvement in upper limb Motricity Index score with mental practice as measured by the two-band standard deviation method. One of these cases demonstrated an unstable baseline such that changes could not be attributed to intervention. CONCLUSIONS: This pilot study suggests that mental practice may be useful as an adjunct to physiotherapy after stroke.

Factors influencing prescription of CNS medications in different elderly populations.

Factors influencing the use of neuroleptic and other CNS-acting medications ('antidepressants' and 'hypnotics/anxiolytics') were examined in different elderly populations (> 65 years): long-stay care hospital subjects (n = 381), nursing home subjects (n = 1247), private residential home subjects (n = 321), statutory residential home subjects (n = 525), old age psychiatry facility subjects (n = 48), community dwellers (n = 97), in different geographical areas (urban n = 1223 and rural n = 1396). Neuroleptics were prescribed in 28% of the individuals, hypnotics/anxiolytics in 33% and antidepressants in 12%. Prescription of neuroleptics was significantly predicted by institutional placement (other than long-stay care hospital facility), lower cognitive function and rural geographical area. Age greater than 75 years and lower functional score (lower dependency) significantly decreased the likelihood of receipt of neuroleptics. Antidepressant use was significantly less likely in male subjects, patients with cognitive impairment and patients greater than 85 years. Institutional placement (other than long-stay care hospital facility and old age psychiatry facility) and rural locality predicted increased likelihood of antidepressant prescription. Institutional placement (other than long-stay care hospital facility) and geographical (rural) location were significant independent predictors of hypnotic/anxiolytic use. Prescription of hypnotic/anxiolytic drug class was significantly less likely in those individuals with lower cognitive status. In this representative elderly cohort, patient characteristics: age, sex, cognitive score, functional score, place of residence and geographical location markedly influenced drug utilisation.

Institutional care for elderly people in North and West Belfast. A decade of change from 1989-1999.

BACKGROUND AND AIMS: We wished to document the pattern of institutional care for dependent elderly people during a period of altered provision of care, namely a shift from National Health Service long-term hospital care provision to residential and nursing home provision in the private sector. METHODS: We systematically studied all Institutionalized people aged 65+ years in a single geographic area in 1989, 1992, 1995 and 1999. Subjects' physical and mental function was assessed using the Barthel Index and the Abbreviated Mental Test. Descriptive and statistical comparisons between years and care facilities were made. RESULTS: There were large changes in facilities providing for care between 1989 and 1999, with an 84% increase in nursing home placements and an 89% decrease in hospital admissions. Smaller reductions in residential and psychogeriatric placements were observed together with a large increase in Elderly Mentally Infirm (EMI) placements. We found significant increases in the physical dependency and mental impairment of those receiving nursing, psychogeriatric and long-term hospital care. Residential homes are now caring for people who are significantly less physically dependent, and there have been no changes in the dependency level of residents in EMI homes. CONCLUSIONS: There has been an overall mean reduction from 4.3 to 3.9% in the percentage of elderly people aged 65 and over receiving institutional care between 1989 and 1999. This trend has included a radical shift in care from hospital-based provision to nursing home care and undoubtedly an increase in support for people wishing to remain in their own homes. The increased dependency found in institutional care is believed to be due to the higher threshold now necessary for provision of care, which may be due to fiscal constraints.