Improve Standards Of Care Research Articles

Orthogeriatric units. They are really necessary

The fragility hip fracture orthogeriatric co-management model of care, integrated in specific functional ortogeriatric units, undoubtedly benefit elderly patients with this type of fracture, improving care standards of quality. The authors of this editorial recommend this multi and interdisciplinary approach to improve both intra and extra hospitalary care of patients with fragility hip fracture. The authors invite all the actors involved in this process to adopt a positive disposition to create, endow and develop ortogeriatric units.

A Systematic Review and Meta-Analysis of Molecular Biomarkers Associated with Early Neurological Deterioration Following Acute Stroke

Background: Early neurological deterioration (END) following acute stroke is associated with poorer long-term outcomes. Identification of patients at risk could assist early monitoring and treatment decisions. This review summarised the evidence describing non-radiological biomarkers for END. Summary: Electronic searches from January 1990 to March 2017 identified studies reporting a blood/cerebrospinal fluid (CSF)/urine biomarker measurement within 24 h of acute stroke and at least 2 serial assessments of clinical neurological status (< 24 h and < 7 days). Out of 12,895 citations, 82 studies were included, mostly focusing on ischaemic stroke. Using higher neurological thresholds, the n-weighted END incidence for ischaemic stroke was 11.9% (95% CI 11.4–12.4%) and 18.6% (17.9–19.2%) for lower thresholds. Incidence decreased with advancing study publication year (Pearson r-squared 0.23 and 0.15 for higher and lower threshold studies). After classification into 3 broad categories, meta-analysis showed that biomarkers associated with increased END risk (n; fixed-effects mean difference; 95% CI) were “metabolic” (glucose [n = 9,481; 0.90 mmol/L; 0.74–1.06], glycosylated haemoglobin [n = 3,146; 0.33%; 0.19–0.46], low-density lipoprotein [n = 4,839; 0.13 mmol/L; 0.06–0.21], total cholesterol [n = 4,762; 0.21 mmol/L; 0.11–0.31], triglycerides [n = 4,820; 0.11 mmol/L; 0.06–0.17], urea [n = 1,351; 0.55 mmol/L; 0.14–0.96], decreasing albumin [n = 513; 0.33 g/dL; 0.05–0.61]); “inflammatory and excitotoxic” (plasma glutamate [n = 688; 60.13 µmol/L; 50.04–70.22], CSF glutamate [n = 369; 7.50 µmol/L; 6.76–8.23], homocysteine [n = 824; 2.15 µmol/L; 0.68–3.61], leucocytes [n = 3,766; 0.54 × 10⁹/L; 0.34–0.74], high-sensitivity C-reactive protein [n = 1,707; 3.79 mg/L; 1.23–6.35]); and “coagulation/haematological” (fibrinogen [n = 3,132; 0.32 g/L; 0.25–0.40]; decreasing haemoglobin [n = 3,586; 2.38 g/L; 0.15–4.60]). Key Messages: Declining incidence of END may represent improving care standards; however, it remains a frequent occurrence. Although statistical associations exist between biomarkers and an increased risk of END, the most promising still need prospective evaluation to determine their additional value relative to baseline radiological and clinical characteristics.

Maternal Mortality in Malaysia

Maternal health and well-being have extended to international consideration since the global launching of WHO’s Safe Motherhood Initiative in 1987. In 1990, Malaysia set itself an ambitious vision to achieve high income and developed status by 2020. A relatively low maternal mortality rate (23.2 in 2012), noteworthy increase in the proportion of safe deliveries and antenatal coverage have been achieved. Introduction of Confidential Enquiries into Maternal Deaths (CEMD) in 1991 was an important step towards a full-fledged audit taking into consideration the identification of shortfalls in the care of pregnant mothers and taking cognizance of the remedial measures set forth, thus improving standards of care. The High-Risk Approach system, the introduction of a colour coding system for identification of pregnancies that were at greater risk than average risk, the strengthening of referral systems, and home based maternity assessment cards kept by the patient present at any level of antenatal care were used as additional tools. Swift development of rural infrastructure, increase in skilled personnel to attend deliveries, and recruitment of traditional birth attendants (TBAs) as a short-gap measure was undertaken. In addition, midwives in rural areas were allowed to administer heparin as thromboprophylaxis, antenatal steroids to mothers with preterm labour and intramuscular magnesium sulphate to mothers with hypertension. These drugs are given under guidance by the Ministry of Health protocols and given before transfer to tertiary centres. In addition, partograph use, protocol development and creation of a “red alert system” in hospitals to mobilize specialists and other healthcare personnel were deployed to reinforce existing measures. In 1985, MOH initiated a national quality assurance programme (QAP). This programme was used as a managerial tool to justify the needs for further resources in terms of money, manpower, machinery and materials. Malaysia’s significant decline in maternal mortality has been as a result of development of rural health services (introduction of maternal and child health programmes and TBAs) , adopting specific approaches (strengthening of referral system and colour coding system), assuring quality of care by tracking progress (outcome), providing standardize care, and identifying outliers that needed further improvement.

Real-World Impact of a Decision Support Tool on Colony-Stimulating Factor Use and Chemotherapy-Induced Febrile Neutropenia Among Patients With Breast Cancer.

Background: White blood cell colony-stimulating factors (CSFs) decrease the incidence of chemotherapy-induced febrile neutropenia (FN). Widespread use of CSFs that is not guideline-concordant has been reported. Among patients with breast cancer receiving chemotherapy, the ability of evidence-based decision support tools to promote risk-appropriate reductions in CSF use without increased incidence of FN has not been examined. Methods: A retrospective cohort design and US commercial claims data were used. The impact of CSF decision support was analyzed among women with breast cancer receiving first-cycle chemotherapy from April 1, 2013, to March 30, 2015. The tool was implemented as part of a prior authorization process in 9 states starting July 1, 2014. Patients were assigned to intervention (ie, states where the decision support tool had been implemented) or nonintervention states (ie, 39 states where the tool had not been implemented). CSF use and subsequent incidence of FN were compared using difference-in-difference (DID) regressions adjusting for baseline differences in FN risk factors such as comorbidities and various infections. Results: The study sample of 7,224 patients (intervention states: pre-implementation, 1,991 and post-implementation, 2,010; nonintervention states: pre-implementation, 1,569 and post-implementation, 1,654) showed no significant difference in risk factors. Before and after implementation, a significant decrease in the proportion of patients with CSF use was observed in the intervention states (75% to 69%) compared with no significant change in the nonintervention (72% to 71%) states (DID, -5.4%; 95% CI, -6.0% to -4.7%; P=.006). No significance increase in FN incidence occurred in intervention (5.0% to 5.5%) and nonintervention (5.4% to 4.8%) states (DID, 0.2%; 95% CI, -0.20 to 0.30; P=.78). Similar results were obtained in subgroups by comorbidities and in sensitivity analyses by claims-based FN definitions. Conclusions: CSF use decreased modestly after implementation of the decision support tool, with no observed changes in FN rates. Such tools can reduce practice variation to improve care standards.

Management and outcome of children and adolescents with non-medulloblastoma CNS embryonal tumors in Spain: room for improvement in standards of care.

Non-medulloblastoma CNS embryonal tumors (former PNET/Pineoblastomas) are aggressive malignancies with poor outcome that have been historically treated with medulloblastoma protocols. The purpose of this study is to present a tumor-specific, real-world data cohort of patients with CNS-PNET/PB to analyze quality indicators that can be implemented to improve the outcome of these patients. Patients 0-21years with CNS-PNET treated in eight large institutions were included. Baseline characteristics, treatment and outcome [progression-free and overall survival (PFS and OS respectively)] were analyzed. From 2005 to 2014, 43 patients fulfilled entry criteria. Median age at diagnosis was 3.6years (range 0.0-14.7). Histology was pineoblastoma (9%), ependymoblastoma (5%), ETANTR (7%) and PNET (77%). Median duration of the main symptom was 2weeks (range 0-12). At diagnosis, 28% presented with metastatic disease. Seventeen different protocols were used on frontline treatment; 44% had gross total resection, 42% craniospinal radiotherapy, 86% chemotherapy, and 33% autologous hematopoietic stem cell transplantation (aHSCT). Median follow-up for survivors was 3.5years (range 1.7-9.3). 3-year PFS was 31.9% (95% CI 17-47%) and OS 35.1% (95% CI 20-50%). Age, extent of resection and radiotherapy were prognostic of PFS and OS in univariate analysis (p < 0.05). Our series shows a dismal outcome for CNS-PNET, especially when compared to patients included in clinical trials. Establishing a common national strategy, implementing referral circuits and collaboration networks, and incorporating new molecular knowledge into routine clinical practice are accessible measures that can improve the outcome of these patients.

P.60 - Co-morbidities in a cohort of adult Duchenne muscular dystrophy patients attending a Neuromuscular Complex Care Centre - an observational study

Current guidelines for DMD care include early treatment with glucocorticoids, as well as cardiorespiratory, orthopaedic and rehabilitative intervention. Improvement in standards of care has altered the natural history of the condition, leading to increased survival of a population of patients with special needs, from the late teens to the third or even fourth decades. We present the observational data from a cohort of 87 adult patients with DMD who are registered with our neuromuscular services from January 2010 to March 2017. Young adults with varying degrees of cognitive impairment ranging from reduced verbal IQ to severe autistic spectrum disorder (18/87) pose specific difficulties in management within adult services that are not well supported to manage these complex needs. Other co-morbidities which have developed in our cohort include epilepsy (4/87), urological symptoms including urinary hesitancy, urgency, urge incontinence and nephrolithiasis (8/87), diabetes mellitus occurring in steroid naïve patients requiring treatment with oral hypoglycaemic agents alone or in combination with insulin (3/87) and cerebrovascular events (2/87). With increasing life expectancy in this population of patients, recognising these co-morbidities associated with DMD is highly important as they contribute to morbidity and mortality in the patient group, affect health related quality of life and add to carer burden.

Person-centered care and engagement via technology of residents with dementia in aged care facilities.

Touchscreen technology (TT) is a resource that can improve the quality of life of residents with dementia, and care staff, in residential aged care facilities (RACF) through a person-centered care approach. To enable the use of TTs to engage and benefit people with dementia in RACFs, education is needed to explore how these devices may be used, what facilitates use, and how to address barriers. We sought to provide education and explore RACF staff views and barriers on using TT to engage their residents with dementia. An educational session on using TT with residents with dementia was given to staff from three long-term RACFs in Melbourne, Australia. A cross-sectional convenience sample of 17 staff members (personal care attendants, registered nurses, enrolled nurses, allied health clinicians, and domestic staff) who attended were administered questionnaires pre- and post-sessions. As a result of the education seminar, they were significantly more confident in their ability to use TT devices with residents. TT, and education to staff about its use with residents with dementia, is a useful strategy to enhance RACF staff knowledge and confidence, thereby enhancing the use of technology in RACFs in order to improve care standards in people with dementia.

Impact of three decades of improvements in standards of care on clinical outcomes in Duchenne muscular dystrophy

Objective: The last three decades have seen significant improvements in clinical care for patients with Duchenne muscular dystrophy (DMD). Consequently, international guidelines on Standards of Care in DMD were introduced in 2010, providing recommendations for diagnosis and management. We explore the impact of progressive implementation of these Standards of Care on key clinical outcomes in patients with DMD from the North of England and managed within our tertiary centre for neuromuscular diseases. Methods: This is a retrospective cohort study, 108 patients born between 1980 and 2009 were identified from clinical records. They were divided in three groups based on the decade of birth, 1980s, 1990s and 2000s. Data was collected on corticosteroid treatment, ambulation, respiratory function and cardiac function. Data was analysed according to decade of birth and corticosteroid treatment. Results: A significant increase in number of patients receiving corticosteroids and decrease in age at start of treatment was observed between 1980s and 2000s. This resulted in a significant increase in age at loss of ambulation over that period (11 vs 13 years of age, P < 0.05). Compared to non-treated patients, corticosteroids significantly delay the age at onset of respiratory failure (forced vital capacity<1 litres/min), 18.6 vs 25.7 years of age (P < 0.05). Our data also showed a significant correlation between timing of cardiac medication and onset of cardiomyopathy. Conclusion: The field of DMD has seen a significant change in patient management and treatment options over the last decade. Translational research is rapidly developing with several investigational drugs currently being tested in clinical trials. Natural history data on a stable clinic population is increasingly important to ensure an objective evaluation of new treatments. This study provides on update on natural history and evaluates the impact of the Standards of Care on clinical outcomes in DMD.

Improving care standards for patients with spinal trauma combining a modified e-Delphi process and stakeholder interviews: a study protocol

IntroductionAround 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent...

Current Delivery of Hyperthermic Intraperitoneal Chemotherapy with Cytoreductive Surgery (CS/HIPEC) and Perioperative Practices: An International Survey of High-Volume Surgeons.

Cytoreductive surgery and heated intraperitoneal chemotherapy (CS/HIPEC) is performed for selected indications at a limited number of specialized centers worldwide. Currently there is no standardized approach to the perioperative care process. We sought to capture current practices in the perioperative management of patients who undergo CS/HIPEC at high-volume centers. Surgeon members of the American Society of Peritoneal Surface Malignancies working at high-volume CS/HIPEC centers (>10 cases/year) were invited to complete an online survey. The survey included questions relating to preoperative preparation of patients, intraoperative practices, and postoperative care. Ninety-seven surgeons from five continents completed the survey (response rate 55%). The majority (80%) practiced in academic environments. Most respondents (68%) indicated that a formal preoperative preparatory pathway for CS/HIPEC surgery existed at their centers, but few (26%) had used enhanced recovery protocols in this group of patients. Whereas the intraoperative technical practices of the CS/HIPEC procedure were relatively consistent across respondents, there was little agreement on pre- and postoperative care practices, including use of mechanical bowel preparation, nutritional supplementation, methods of perioperative analgesia, timing of physical therapy and ambulation, nasogastric tube and Foley removal, intravenous fluids, blood transfusion parameters, and postoperative use of deep-vein thrombosis prophylaxis and antibiotics. Perioperative care practices for CS/HIPEC are widely variable nationally and internationally. Standardization of such practices offers an opportunity to incorporate evidence-based interventions and may enhance patient outcomes and improve care standards across all centers that offer this procedure.

The Decrease in Traumatic Brain Injury Epidemics Deriving from Road Traffic Collision Following Strengthened Legislative Measures in France.

BackgroundSince 2002, France has been strengthening legislation on road traffic. This study is intended to evaluate the changes in Traumatic Brain Injury (TBI) incidence and mortality resulting from Road Traffic Collision (RTC) in the two 6-year periods before and after 2002.MethodsWe used a Registry of all RTC casualties in the Rhône Department of France. Each casualty was coded according to the Abbreviated Injury Scale (AIS). The study describes changes in demographic variables, TBI (AIS ≥ 2) incidence and mortality, other body lesions (AIS ≥ 3) associated with TBI, road user types, seatbelt and helmet wearing.FindingsRTC casualty occurrences decreased by 21% (from 64,312 to 50,746) during the period after 2002. TBI occurrence accounted for 8.6% and 6.7% of all RTC in both periods. This corresponds to a reduction of TBI casualty incidence (-42%), which was much more pronounced than RTC casualty incidence (-25%) (p < 0.0001). Severe and critical TBI (AIS-4 and -5) incidences were reduced by half as much (-21%), compared to TBI incidence. TBI mortality rate (among population) and lethality (among TBI related to RTC casualties) decreased 56% and 23%, respectively. This reduction particularly affected car occupants and victims who deceased. TBI incidence decreased 43% in all 10-year age classes until 60 on average, this decrease declining with age in the period after 2002. After adjustment for age, sex, road user types, and severity of lesions at the head and other body regions, logistic regression analysis displayed a protective effect of the period following 2002, on the risk of death after RTC-related TBI.InterpretationThe greater reductions in the incidence, severity and mortality of TBI when compared with the reduction of casualty incidence have mainly affected car users. These results should be attributable to the improvements in standards of care, primary safety of the car fleet and general road architecture safety. However, the increased reduction in the TBI epidemics in France, when compared to those observed in other developed countries for the same periods, suggests that the effects should be strongly attributable to changes in road user behaviour induced by law enforcement. The at-risk groups for TBI after RTC are now two-wheel users (motorized or not) and individuals over 60 years of age.

Management of type 2 diabetes: the current situation and key opportunities to improve care in the UK.

In common with global trends, the number of individuals with type 2 diabetes in the UK is rising, driven largely by obesity. The increasing prevalence of younger individuals with type 2 diabetes is of particular concern because of the accelerated course of diabetes-related complications that is observed in this population. The importance of good glycaemic control in the prevention of microvascular complications of diabetes is widely accepted, and there is a growing body of evidence to support a benefit in the reduction of cardiovascular events in the long term. Despite the importance of maintaining a healthy weight for the prevention of type 2 diabetes, the results from trials of lifestyle intervention strategies to reduce body weight have been disappointing. New glucose-lowering agents offer some promise in this regard, offering an opportunity to combat the dual burden of hyperglycaemia and obesity simultaneously. The timing and appropriate choice of glucose-lowering therapy has never been more complex as a result of rising prevalence of obesity in the young, concomitant obesity in some 90% of adults with type 2 diabetes and an ever-increasing range of therapeutic options. The present review evaluates performance measures specific to weight and glycaemic control in type 2 diabetes in the UK using data from the Quality and Outcomes Framework in England and Wales, and the Scottish Diabetes Survey. Potential barriers to improvement in standards of care for people with type 2 diabetes are considered, including patient factors, clinical inertia and the difficulties in translating therapeutic guidelines into everyday clinical practice.

G.P.51 - Impact of three decades of improvement in standards of care for Duchenne muscular dystrophy

G.P.51 - Impact of three decades of improvement in standards of care for Duchenne muscular dystrophy

PTH-199 Home parenteral nutrition: safe and effective documentation

Introduction The aim of The Care profile was to develop a robust system of nursing documentation. This was to ensure the provision of safe, evidence based nursing care in the delivery of home parenteral nutrition with improved patient clinical outcomes. Method Standards in Nutritional Care have been widely documented as unsafe and calls for improved care highlighted in many recent reports. BAPEN specifically supports the implementation of Care Pathways and includes this as one of the key areas of guidance in the, Malnutrition Matters Toolkit. Improved clinical outcomes and prevention of patient deterioration at home requires robust systems to be in place and used effectively. In response to the High impact intervention Catheter Care Bundle and Epic guidelines we commissioned the development of a new consistent, transparent, equitable document. We developed a working party. We carried out a review of current documentation. Questionnaires about current documentation were circulated across the national nursing team. These were reviewed; the results guided our change process. A literature search was undertaken; this included reviewing current local and national guidelines in Central Venous Access Devices and Parenteral Nutrition. We reviewed care pathways across a variety of health care settings. Version 1 of the Intravenous Care Profile was created. In consultation with our engaged Stakeholders we selected a pilot group and trialled the document. Clinical and documentation audits were developed and used following a three month trial. Audit helped to provide a way of improving and measuring the implementation of key elements of care. Audit 1 results guided adaptation of version 1, Audit 2 results reflected the improvements made; the clinical audit achieved 100% the documentation audit score close at 98%. A national rollout followed. Audit has allowed a cycle of continuous development and improvements to the document. An awareness of local and national influences has helped us understand how to use clinical governance systems including audit to make improvement happen in our area. Using the care profile in our routine daily clinical practice, the risk to patients was minimised. A programme of training was implemented across the company to ensure effective use of the care profile was achieved. Results The document is intended to provide a structured approach to improve clinical outcomes. It aims to support local and national guidelines that support improvement in standards of care. In collaboration with our stakeholders we have seen a marked change when reviewing anecdotal evidence of reduction of patient hospital readmission for Parenteral Nutrition related issues. In 2015 we will develop our audit systems and review patient data to investigate the perceived improvement in clinical outcomes and reduction in hospital bed days. Conclusion See results. Disclosure of interest None Declared.

PTH-211 Improving standards of care for patients receiving total parental nutrition (tpn) at a district general hospital. a completed audit cycle: Abstract PTH-211 Table 1

<h3>Introduction</h3> Total parenteral nutrition (TPN) is an invasive feeding method, with stringent indications due to higher associated cost and morbidity. The National Confidentiality Enquiry into Patient Outcome and Death (NCEPOD) review – A Mixed Bag,¹identified good clinical practice in only 19% of patients receiving TPN as recently as 2010. We present improvements in standards of care for patients receiving TPN, which were found on completion of an audit cycle at our institution. <h3>Method</h3> Retrospective data collection was undertaken on all patients receiving TPN from December 2013–January 2014 at The Countess of Chester Hospital (Audit 2). This was compared to the same dataset extracted from November 2010–February 2011 (Audit 1). NCEPOD¹and NICE²guidance recommendations were used as gold standards. <h3>Results</h3> Over the 13 month period, 64 patients received TPN. The median age was 68 (range 23–89); male:female ratio 1.5:1. Median duration of TPN was 8 days (range 1–144 days). TPN was commenced in level 1 care in 59.4% of cases; level 2/3 40.6%. 36 patients (56%) received TPN via a dedicated PICC line and 28 (44%) through a central line. Data comparison between audit 1 and 2 is tabulated below. <h3>Conclusion</h3> Early involvement and supervision by the nutrition support team remained at a high standard. Following earlier recommendation, major improvements were seen in the monitoring of daily bloods, obtaining central venous access, and documentation of weekly weight measurements. A multi-disciplinary electronic referral and assessment proforma is now being developed to enable NCEPOD targets to continue to be met. <h3>Disclosure of interest</h3> None Declared.

London Alliance says multidisciplinary teams improve care standards

London Alliance says multidisciplinary teams improve care standards

Leadership and innovation in nursing seen through a historical lens

To explore nurses' archived accounts of Matron Muriel Powell's management and leadership style and the impact of this on the implementation and sustainability of innovation in the workplace. In popular discourse, the matron has become an emblem of leadership. Although the title disappeared in the UK in the late 1960s as part of the re-organization recommended by the Salmon Report, it re-appeared in 2002 in an attempt to improve care standards by reasserting a strong nursing presence and clinical leadership role. Secondary data analysis using qualitative thematic analysis. This paper draws on interview data held in the 'Nurses Voices' archive. The interview transcripts of 132 nurses who trained or worked at St George's hospital in 1920-1980 were analysed in depth between March 2011-January 2012 and themes were generated inductively by grouping together emergent codes in the data with similar meaning. Looking back, the nurses recalled strong memories of the leadership of Matron Powell. Her presence emerged as a significant influence throughout the interviews. Two resonant themes were identified: innovation and open communication. Through her visibility and direct access with patients and staff, Dame Muriel Powell showed what we would now call transformative leadership qualities. Her leadership created a culture of open communication and innovation that initiated change in the organization and the nursing workforce. Looking back and learning from historical figures can deepen understanding and provide pointers for the nurse leaders of today.

Effectiveness and Preclinical Safety Profile of Doxycycline to Be Used “Off-Label” to Induce Therapeutic Transgene Expression in a Phase I Clinical Trial for Glioma

Glioblastoma multiforme (GBM) is the most common malignant primary brain cancer in adults; it carries a dismal prognosis despite improvements in standard of care. We developed a combined gene therapy strategy using (1) herpes simplex type 1-thymidine kinase in conjunction with the cytotoxic prodrug ganciclovir to kill actively proliferating tumor cells and (2) doxycycline (DOX)-inducible Fms-like tyrosine kinase 3 ligand (Flt3L), an immune stimulatory molecule that induces anti-GBM immunity. As a prelude to a phase I clinical trial, we examined the efficacy and safety of this approach (Muhammad et al., 2010, 2012). In the present article, we investigated the efficacy and safety of the "off-label" use of the antibiotic DOX to turn on the high-capacity adenoviral vector (HC-Ad) encoding therapeutic Flt3L expression. DOX-inducible Flt3L expression in male Lewis rats was assessed using DOX doses of 30.8 mg/kg/day (low-DOX) or 46.2 mg/kg/day (high-DOX), which are allometrically equivalent (Voisin et al., 1990) to the human doses that are recommended for the treatment of infections: 200 or 300 mg/day. Naïve rats were intracranially injected with 1×10(9) viral particles of HC-Ad-TetOn-Flt3L, and expression of the therapeutic transgene, that is, Flt3L, was assessed using immunohistochemistry in brain sections after 2 weeks of DOX administration via oral gavage. The results show robust expression of Flt3L in the rat brain parenchyma in areas near the injection site in both the low-DOX and the high-DOX groups, suggesting that Flt3L will be expressed in human glioma patients at a DOX dose of 200 or 300 mg/day. These doses have been approved by the U.S. Food and Drug Administration to treat infections in humans and would thus be considered safe for an off-label use to treat GBM patients undergoing HC-Ad-mediated gene therapy in a phase I clinical trial.

Practical diagnosis and management of dementia due to Alzheimer's disease in the primary care setting: an evidence-based approach.

To review evidence-based guidance on the primary care of Alzheimer's disease and clinical research on models of primary care for Alzheimer's disease to present a practical summary for the primary care physician regarding the assessment and management of the disease. References were obtained via search using keywords Alzheimer's disease AND primary care OR collaborative care OR case finding OR caregivers OR guidelines. Articles were limited to English language from January 1, 1990, to January 1, 2013. Articles were reviewed and selected on the basis of study quality and pertinence to this topic, covering a broad range of data and opinion across geographical regions and systems of care. The most recent published guidelines from major organizations were included. Practice guidelines contained numerous points of consensus, with most advocating a central role for the primary care physician in the detection, diagnosis, and treatment of Alzheimer's disease. Review of the literature indicated that optimal medical and psychosocial care for people with Alzheimer's disease and their caregivers may be best facilitated through collaborative models of care involving the primary care physician working within a wider interdisciplinary team. Evidence-based guidelines assign the primary care physician a critical role in the care of people with Alzheimer's disease. Research on models of care suggests the need for an appropriate medical/nonmedical support network to fulfill this role. Given the diversity and breadth of services required and the necessity for close coordination, nationwide implementation of team-based, collaborative care programs may represent the best option for improving care standards for patients with Alzheimer's disease.

PM’s improvement plan ignores loss of 197 nurses every month

The prime minister has come under fire for issuing a package of measures to improve care standards while refusing to acknowledge that thousands of nursing posts have been axed since he took office.