Increased energy intake in hip fracture patients affects nutritional biochemical markers.

BACKGROUND AND AIMS: We have previously shown that nutritional guidelines decreased the incidence of pressure ulcers in hip fracture patients. In the present study, we evaluate whether the nutritional biochemical markers S-IGF-1 (Insulin-like Growth Factor 1), S-Transthyretin and S-Albumin are affected by patients' energy intake, and whether the markers are useful as predictors of postoperative complications. MATERIAL AND METHODS: Quasi-experimental design, with one intervention and one control group, as well as pre- and post-study measurements. Eighty-eight hip fracture patients were included: 42 in the control group and 46 in the intervention group. The control group received regular nutritional support pre- and postoperatively, while the intervention group received nutritional support that followed new, improved clinical guidelines from admission to five days postoperatively. S-Albumin, S-Transthyretin, C-Reactive Protein (S-CRP) and S-IGF-1 were analysed at admission and five days postoperatively as well as complications like pressure ulcer and infection. RESULTS: The intervention group had a significantly higher energy intake; for example, 1636 kcal versus 852 kcal postoperative day 1. S-IGF-1 levels decreased significantly in the control group, while no decrease in the intervention group. S-Albumin and S-Transthyretin decreased and S-CRP increased significantly in both groups, indicating that those markers were not affected short-term by a high-energy intake. There was no correlation between short-term post-operative complications and S-IGF-1, S-Transthyretin or S-Albumin at admission. CONCLUSION: The results of our study showed that S-IGF-1 can be used as a short-term nutritional biochemical marker, as it was affected by a five-day high-energy regimen. However, neither S-IGF-1, S-Transthyretin or S-Albumin were useful in predicting postoperative complications within five days postoperatively.

Factors influencing early postoperative recovery after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) can prolong survival in selected patients with peritoneal carcinomatosis (PC). However, there is little data on patients' recovery process after this complex treatment. This study aimed to describe the in-hospital postoperative recovery and factors related to the recovery of patients who undergo CRS and HIPEC. METHOD: A retrospective audit of the electronic health record (EHR) was undertaken for 76 PC patients (42 women, 34 men) treated primarily with CRS and HIPEC between 2005 and 2006 in Sweden. RESULTS: Oral intake, regaining bowel functions and mobilisation usually occurred between 7 and 11 days postoperatively. Patients experienced nausea for up to 13 days postoperatively. Forty-two patients were satisfied with their pain management, which usually took the form of epidural anaesthesia and which continued for about one week post-surgery. Sleep disturbance was observed in 51 patients and psychological problems in 49 patients during the first three postoperative weeks. Tumour burden, stoma formation, use of CPAP, primary diagnosis, and the length of stay in the ICU were factors related to an early recovery process. CONCLUSION: Drinking, eating, regaining bowel functions and mobilisation were re-established within 11 days of CRS and HIPEC. Tumour burden, stoma formation, use of CPAP, primary diagnosis and the length of stay in the ICU all had an impact on postoperative recovery, and should be discussed with the patients preoperatively and taken into consideration in designing an individualised patient care plan, in order to attain a more efficient recovery.

Quality of life and social life situation in islet transplanted patients: time for a change in outcome measures?

BACKGROUND: One of the overall goals in health care is to prolong life, increase patients' wellbeing and quality of life. Many of patients with severe insulin-dependent diabetes mellitus experience fear of hypoglycemia (FoH), which forces them to change their lives both physically and socially to avoid episodes of hypoglycemia. OBJECTIVE: To investigate the quality of life and the social life situation, with special focus on the consequences of FoH in islet transplanted patients. METHODS: 11 patients (4 women and 7 men) were included; they have undergone islet transplantation at Uppsala University Hospital during the period 2001-2009. Short Form 36 (SF-36) and the Swedish version Hypoglycemia Fear Survey (Swe-HFS) were used to investigate quality of life, in relation to FoH. In addition, telephone interviews were conducted to investigate the patients social life situation in relation to FoH, after islet transplantation and were analyzed using a content analysis method. RESULTS: The mean value for quality of life was lower than that in the normal population. 3 out of 10 patients experienced FoH; one patient declined to answer the questionnaire. 3 predominant themes were revealed; one theme associated with pre-transplant, was "struggle for control of social life situation" and two themes associated with post-transplant, were "regain power and control of social life situation" and "at peace with the balance between the present and the future." CONCLUSION: The patients experienced improved control over social life situation while quality of life in relation to FoH may have improved following islet transplantation.

Job satisfaction or production? How staff and leadership understand operating room efficiency: a qualitative study.

BACKGROUND: How to increase efficiency in operating departments has been widely studied. However, there is no overall definition of efficiency. Supervisors urging staff to work efficiently may meet strong reactions due to staff believing that demands for efficiency means just stress at work. Differences in how efficiency is understood may constitute an obstacle to supervisors' efforts to promote it. This study aimed to explore how staff and leadership understand operating room efficiency. METHODS: Twenty-one members of staff and supervisors in an operating department in a Swedish county hospital were interviewed. The analysis was performed with a phenomenographic approach that aims to discover the variations in how a phenomenon is understood by a group of people. RESULTS: Six categories were found in the understanding of operation room efficiency: (A) having the right qualifications; (B) enjoying work; (C) planning and having good control and overview; (D) each professional performing the correct tasks; (E) completing a work assignment; and (F) producing as much as possible per time unit. The most significant finding was that most of the nurses and assistant nurses understood efficiency as individual knowledge and experience emphasizing the importance of the work process, whereas the supervisors and physicians understood efficiency in terms of production per time unit or completing an assignment. CONCLUSIONS: The concept 'operating room efficiency' is understood in different ways by leadership and staff members. Supervisors who are aware of this variation will have better prerequisites for defining the concept and for creating a common platform towards becoming efficient.

Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care.

OBJECTIVE: To compare the accuracy in recording of pressure-ulcer prevalence and prevention before and after implementing an electronic health record (EHR) with templates for pressure-ulcer assessment. METHODS: All inpatients at the departments of surgery, medicine and geriatrics were inspected for the presence of pressure ulcers, according to the European Pressure Ulcer Advisory Panel-methodology, during 1 day in 2002 (n = 357) and repeated in 2006 (n = 343). The corresponding patient records were audited retrospectively for the presence of documentation on pressure ulcers. RESULTS: In 2002, the prevalence of pressure ulcers obtained by auditing paper-based patient records (n = 413) was 14.3%, compared with 33.3% in physical inspection (n = 357). The largest difference was seen in the geriatric department, where records revealed 22.9% pressure ulcers and skin inspection 59.3%. Four years later, after the implementation of the EHR, there were 20.7% recorded pressure ulcers and 30.0% found by physical examination of patients. The accuracy of the prevalence data had improved most in the geriatric department, where the EHR showed 48.1% and physical examination 43.2% pressure ulcers. Corresponding figures in the surgical department were 22.2% and 14.1%, and in the medical department 29.9% and 10.2%, respectively. The patients received pressure-reducing equipment to a higher degree (51.6%) than documented in the patient record (7.9%) in 2006. CONCLUSIONS: The accuracy in pressure-ulcer recording improved in the EHR compared with the paper-based health record. However, there were still deficiencies, which mean that patient records did not serve as a valid source of information on pressure-ulcer prevalence and prevention.

Improving assessment of postoperative pain in surgical wards by education and training.

PROBLEM: There is a need to improve postoperative pain organisation and management in hospitals. One of the most important factors in achieving this is to improve active assessment of pain in the postoperative phase. DESIGN: Repeated audits on an annual basis over a 3 year period. Ward nurses, appointed as "pain control representatives", performed the data collection. SETTING: Departments of general surgery and orthopaedics in a university hospital with 1200 beds. KEY MEASURE FOR IMPROVEMENT: Assessment of postoperative pain intensity using a numerical rating scale. STRATEGIES FOR CHANGE: On the basis of the first audit in 1999 the team decided to introduce a mandatory training programme in postoperative pain management for all involved staff, including surgeons and ward nurses. Guidelines for postoperative care were upgraded and made accessible through the intranet. Regular staff meetings in the surgical wards with representatives from the acute pain service team were introduced. EFFECTS OF CHANGE: The assessment of pain according to protocols increased from 71% to 91% in the surgical wards and from 60% to 88% in the orthopaedic wards between 1999 and 2001/2. LESSONS LEARNT: To increase the awareness of pain and improve pain assessment, the importance of mandatory training, regular staff meetings and regular audits must be emphasised. It is also imperative to give feedback on the regular audits to the ward and staff members involved.

Pressure ulcer prevention: evaluation of an education programme for Swedish nurses.

OBJECTIVE: To investigate the effect of an education programme for 20 registered nurses on the following three areas: nurses' knowledge of pressure ulcer risk and prevention; nursing documentation of ulcer prevention; routine use of prevention strategies. METHOD: The study had a quasi-experimental design. Data were collected immediately before and after the education programme and at eight-month follow-up. To measure knowledge of pressure ulcer management, a questionnaire was distributed to course participants (n = 19) pre- and post-education. Nursing documentation (n = 138) was audited pre- and post-education. To gain information on the routine use of prevention strategies, head nurses (n = 20) were interviewed and the patients' care environment (n = 21) was observed pre-education, while a nurse questionnaire was completed (n = 15) at the eight-month follow-up. RESULTS: In relation to pressure ulcer prevention, nurses' knowledge, documentation and ward routines were unsatisfactory before the education programme. However, the eight-month follow-up showed that 11 nurses (55%) had implemented new ward routines. Documentation was still lacking after the programme, although it was more detailed. CONCLUSION: The education programme succeeded in encouraging and empowering the nurses to change clinical practice.

Risk, prevalence and prevention of pressure ulcers in three Swedish healthcare settings.

OBJECTIVE: This cross-sectional survey set out to delineate risk, prevalence and prevention of pressure ulcers in a university hospital, a general hospital and a nursing home in Sweden. It also looked at the differences in risk factors and preventive strategies between patients with and without pressure ulcers. METHOD: The one-day survey followed the methodology developed by the European Pressure Ulcer Advisory Panel (EPUAP). It was conducted on Tuesday 5 February 2002. Each patient was visited by two registered nurses, their skin was inspected and any pressure ulcer classified according to the EPUAP grading system. A total of 695 patients were included: 612 from the university hospital, 38 from the general hospital and 45 from the nursing home. RESULTS: The prevalence of pressure ulcers was 23.9% (university hospital), 13.2% (general hospital) and 20.0% (nursing home). Most (60-66%) of the pressure ulcers in the hospitals were assessed as grade I. Only half of the patients at risk or with pressure ulcers were placed on a pressure-reducing mattress and a third of these patients had a plan for repositioning. Significant variables associated with pressure ulcers were old age, geriatric care, low Braden score and incontinence. CONCLUSION: Prevalence of pressure ulcers was higher than expected. Results relating to both prevalence of pressure ulcers (grade I excluded) and the preventive care given to patients at risk or with pressure ulcers accord with those of a larger Dutch study. Attention must focus on the appropriate risk-assessment skills, highlighting grade I as pressure damage, and the use of appropriate preventive strategies, based on the level of risk.

Reduced incidence of pressure ulcers in patients with hip fractures: a 2-year follow-up of quality indicators.

OBJECTIVE: The aims of the present study were to (i) investigate the incidence of pressure ulcers in 1997 and 1999 among patients with hip fracture, (ii) study changes of nursing and treatment routines during the same period and (iii) to identify predictors of pressure ulcer development. DESIGN: The present comparative study was based partly on data collected in two prospective, randomized, controlled studies conducted in 1997 and 1999. SETTING: The study was carried out in the Accident & Emergency (A&E) Department and the Department of Orthopaedics at the University Hospital in Uppsala, Sweden. INCLUSION CRITERIA: patient with hip fracture, > or = 65 years, admitted without pressure ulcers. Forty-five patents were included in 1997 and 101 in 1999. INTERVENTIONS: Risk assessment, pressure ulcer grading, pressure-reducing mattress and educational programme. MAIN OUTCOME MEASURES: Incidence of pressure ulcers. RESULTS: There was a significant reduction of the overall incidence of pressure ulcers from 55% in 1997 to 29% in 1999. The nursing notes had become significantly more informative. Nursing and treatment routines for patients with hip fractures had changed both in the A&E Department and the orthopaedic ward through initiatives developed and implemented by pressure ulcer nurses. CONCLUSION: In the framework of a quality improvement project, where research activities were integrated with practice-based developmental work, the incidence of pressure ulcers was reduced significantly in patients with hip fractures. The best predictor of pressure ulcer development was increased age.

Risk, prevention and treatment of pressure ulcers--nursing staff knowledge and documentation.

The aims were to investigate (i) registered nurses' and nursing assistants' knowledge of risk, prevention and treatment of pressure ulcer before implementing a system for risk assessment and pressure ulcer classification for patients with hip fracture (ii) interventions documented in the patient's records by registered nurses, and (iii) to what extent reported and documented interventions accord with the Swedish quality guidelines. Nursing staff (n=85) completed a questionnaire, and patient's records (n=55) were audited retrospectively. The majority of the nursing staff reported that they performed risk assessment when caring for a patient with hip fracture. These risk assessments were, however, not comprehensive. The most frequently reported preventive interventions were repositioning, use of lotion, mattresses/overlays and cushions for the heels. These interventions were to some extent documented in the patient's records. Nutritional support, reduction of shear and friction, hygiene and skin moisture, and patient's education were reported to a small extent and not documented at all. The Swedish quality guidelines regarding prevention and treatment of pressure ulcers were not fully implemented in clinical practice. It was concluded that nursing staff's knowledge and documentation of risk, prevention and treatment of pressure ulcers for patients with hip fractures could be improved.

The development of pressure ulcers in patients with hip fractures: inadequate nursing documentation is still a problem.

The aims of the study were to investigate, on a daily basis: (i) the development and progress of pressure ulcers, (ii) the documented nursing interventions for prevention and treatment of pressure ulcers, and (iii) when nursing interventions regarding prevention and treatment of pressure ulcers were documented, in relation to patient risk status and the development of pressure ulcers. The study design was prospective, comparative and descriptive. A total of 55 patients with hip fracture were included. To facilitate the nurse's assessment, a 'pressure ulcer card' was developed, consisting of the Modified Norton Scale (MNS) and descriptions of the four stages of pressure ulcers. The incidence of pressure ulcers was 55%. The mean rank of the lowest MNS score was significantly lower for patients who developed pressure ulcers than for patients without pressure ulcers. The majority of the pressure ulcers occurred between admission to the ward and the fourth day after surgery. Documented interventions regarding prevention and treatment were: repositioning, overlays, cushions, use of lotion and observation. The mean number of interventions per patient was 2.2 for patients who developed pressure ulcers during their hospital stay. The comprehensiveness and quality of the nursing record was unsatisfactory, and only three nursing records reached the level required by Swedish law. Preventive interventions such as repositioning were documented when the pressure ulcer had already occurred. The lack of nursing documentation regarding prevention and treatment of pressure ulcers may indicate that nurses did not identify pressure ulcers as a prioritized nursing problem for this patient group. The Modified Norton Scale could be a valuable tool for nurses, both identifying the patient at risk and acting as a guide for nursing interventions. The study was approved by the ethics committee of the Faculty of Medicine at Uppsala University.

Effect of visco-elastic foam mattresses on the development of pressure ulcers in patients with hip fractures.

This study had three aims: to investigate if visco-elastic foam mattresses are more effective than standard hospital mattresses in reducing the incidence of pressure ulcers in patients with hip fractures; to compare pressure ulcer grade and location and documented nursing prevention and treatment interventions in patients using the two types of mattresses; to identify possible predictors of pressure ulcer development. Using a prospective randomised controlled trial design 101 patients (mean age: 84 years) were randomly allocated either a visco-elastic foam mattress or a standard mattress. There was no significant difference in the incidence of pressure ulcers between the two groups, but patients on standard mattresses tended to develop more severe pressure ulcers. Furthermore, according to the documentation, patients with grade I pressure ulcers who were allocated a standard mattress received more preventive interventions, which may have reduced the differences in outcomes between the two groups. The researchers concluded that the results support the use of the test mattress. Significant predictors of pressure ulcer development were long waiting times for surgery and low haemoglobin levels at hospital admission.

Implementation of risk assessment and classification of pressure ulcers as quality indicators for patients with hip fractures.

The aims of the study were (i) to investigate the prevalence of pressure ulcers in patients with hip fracture, on arrival at a Swedish hospital, at discharge, and two weeks post-surgery; (ii) to test whether clinical use of the Modified Norton Scale (MNS) could identify patients at risk for development of pressure ulcers; and (iii) to compare the reported prevalence of pressure ulcer in the experimental group, where risk assessment and classification of pressure ulcers was performed on a daily basis, with that of the control group, where it was not. The study design was prospective, with an experimental and a control group. The intervention in the experimental group consisted of risk assessment, risk alarm and skin observation performed by the nurse on duty, in the A & E Department, and daily throughout the hospital stay. To facilitate the nurse's assessment, a 'Pressure Ulcer Card' was developed, consisting of the MNS and descriptions of the four stages of pressure ulcers. On arrival at the hospital, approximately 20% of patients in both groups had pressure ulcers. At discharge, the rate had increased to 40% (experimental) and 36% (control). Clinical use of the MNS made it possible to identify the majority of patients at risk for development of pressure ulcers. Patients who were confused on arrival developed significantly more pressure ulcers than patients who were orientated to time and place. No significant difference was found in the reported prevalence of pressure ulcers between the experimental and control groups.