Non-acute Settings Research Articles

Prevention and control of infection in non-acute healthcare settings

This article discusses the main principles of infection prevention and control in non-acute healthcare settings. It explores the use of a set of ten tools developed by the Infection Control Nurses Association (ICNA) to audit infection prevention and control, using the standard statements and criteria within the tools as a checklist. The results of the audit of facilities, commodities and practice using the ICNA audit tools will help staff to identify areas of best practice and areas where improvements are needed to enhance patient care.

Prevention and control of infection in non-acute healthcare settings

Prevention and control of infection in non-acute healthcare settings

Pragmatism and idealism in community child health

Pragmatism and idealism in community child health

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From spring 2006, qualified nurse prescribers will be able to prescribe any licensed medicine with the exception of controlled drugs. Most registered nurse prescribers work in primary care but secondary care nurses, especially those working in non-acute settings, are 'in an excellent position to improve patient care through prescribing'. Some decisions, such as whether to give capsules or syrup, can be made more easily by nurses because of their knowledge of the patient. Nurse prescribing in primary care has meant that patients receive treatment more quickly and this could be mirrored in hospitals.

Issue Highlights

HomeCirculationVol. 111, No. 22Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published7 Jun 2005https://doi.org/10.1161/circ.111.22.2865Circulation. 2005;111:2865FREEDOM FROM ATRIAL TACHYARRHYTHMIAS AFTER CATHETER ABLATION OF ATRIAL FIBRILLATION: A RANDOMIZED COMPARISON BETWEEN 2 CURRENT ABLATION STRATEGIES, by Karch et al.Catheter ablation for maintaining sinus rhythm increasingly is considered when atrial fibrillation is highly symptomatic despite antiarrhythmic drug therapy. Rapidly activating regions in and around the pulmonary veins are causative in many patients. Ablation techniques targeting these regions, reported results, and complications vary among centers. Comparative data for different approaches are limited. The randomized trial by Karch et al in this issue of Circulation compared 2 more commonly used approaches: ablation encircling a wide area around the pulmonary vein ostia guided by anatomy, versus an electrogram-guided approach ablating only segments of the pulmonary vein ostia. In contrast to a previous trial, the segmental ablation approach was associated with better arrhythmia control. Many recurrences were asymptomatic in both groups. Serious complications included tamponade, pulmonary vein stenosis, and thromboemboli. These findings add fuel to the continuing controversy as to the optimal method and support the practice of confining this procedure to highly symptomatic patients. See p 2875.PERCUTANEOUS CORONARY INTERVENTION VERSUS CONSERVATIVE THERAPY IN NONACUTE CORONARY ARTERY DISEASE: A META-ANALYSIS, by Katritsis and Ioannidis.Clinicians have often debated the incremental benefit of percutaneous coronary interventions for patients with stable angina. This study sought to synthesize the existing data by conducting a meta-analysis of the 11 randomized clinical trials of medical therapy versus percutaneous coronary intervention (PCI) in patients with angiographically documented coronary stenoses in nonacute coronary artery disease settings. The study specifically sought to determine whether PCI was associated with a subsequent reduction in risk of mortality, cardiac death or myocardial infarction, nonfatal myocardial infarction, and coronary artery bypass grafting or PCI. The follow-up was more than 2 years for 5 of the studies. This meta-analysis provides the best current evidence about whether PCI for patients with stable angina does more than improve symptoms. See p 2906.REDUCED NUMBER OF CIRCULATING ENDOTHELIAL PROGENITOR CELLS PREDICTS FUTURE CARDIOVASCULAR EVENTS: PROOF OF CONCEPT FOR THE CLINICAL IMPORTANCE OF ENDOGENOUS VASCULAR REPAIR, by Schmidt-Lucke et al.Endothelial function has been linked to the future risk of cardiovascular events in patients at risk. An emerging concept in vascular disease is the notion that circulating endothelial progenitor cells repopulate the vasculature to preserve normal endothelial function. Cardiovascular risk factors have been associated with a reduced number of circulating endothelial progenitor cells, suggesting that availability of these cells is key to maintaining normal vascular function. In this issue, Schmidt-Lucke and colleagues add important new information to this paradigm by demonstrating that the availability of endothelial progenitor cells is directly linked to the future incidence of cardiovascular events. See p 2981.Visit www.circ.ahajournals.org:Images in Cardiovascular MedicineSpontaneous Left Atrial Dissection Presenting as Pulmonary Edema. See p e372.ST Elevation During Open Heart Surgery: Floating Air Bubble in Saphenous Vein Graft. See p e374.Fluorine-18–Labeled Deoxyglucose Positron Emission Tomography in the Diagnosis and Management of Aortitis With Pulmonary Artery Involvement. See p e375.Download figureDownload PowerPointCorrespondenceSee p e377. Previous Back to top Next FiguresReferencesRelatedDetails June 7, 2005Vol 111, Issue 22 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.111.22.2865 Originally publishedJune 7, 2005 PDF download Advertisement

Predictors of Quality-of-Life Benefit After Percutaneous Coronary Intervention

Improving patients' quality of life is a primary indication for percutaneous coronary intervention (PCI), yet little is known about patient characteristics associated with greater quality-of-life improvement from the procedure. This study was conducted to identify patient characteristics associated with quality-of-life benefit after PCI. A consecutive series of 1518 patients undergoing PCI in nonacute myocardial infarction settings were prospectively enrolled into an observational study documenting their postprocedural health status. We examined univariate and multivariable associations between baseline patient characteristics and quality of life 1 year after the procedure using the disease-specific Seattle Angina Questionnaire (SAQ) to quantify the impact of patients' coronary disease on their quality of life. Baseline angina frequency and physical function were the strongest predictors of quality-of-life improvement 1 year after PCI. In comparing patients without angina to those experiencing monthly, weekly, and daily angina, the quality-of-life improvements (mean+/-SEM) were 21.4+/-2.1, 30.7+/-2.2, and 34.6+/-2.6 points greater (P<0.001). Patients with mild, moderate, and severe physical limitation improved 13.8+/-1.9, 20.0+/-2.1, and 13.5+/-3.5 points more than those with minimal baseline physical limitation (P<0.001). These findings were maintained in multivariable models correcting for baseline differences in demographic, clinical, disease-severity, and health-status variables. Preprocedural angina frequency is the most important prognostic indicator of quality-of-life improvement after PCI. Although substantial quality-of-life benefits are attained in most patients with preprocedural angina, more careful consideration of the potential benefits and risks of the procedure are needed in asymptomatic patients.

Measuring nursing care quality and using large data sets in nonacute care settings: state of the science

The general state of the science of nursing quality measurement in nonacute care settings has accelerated in the last several years. Examples of current research using large data sets to measure quality of nursing care in nursing homes, home health, and other community-based care delivery are presented. Federally available data sets are reviewed as potential measures of care quality, and accessing these data sets is explained. Large data sets are becoming commonly used in long-term care research. Multiple databases are available for researcher use that can provide measures of nursing care quality. Large data sets in nonacute care hold much potential for measuring quality of care in long-term care settings. Public policy makers must facilitate timely data access so that research can move beyond descriptive studies to interventions that can be tested and proven to improve quality of care and outcomes of those we serve.

Infection control: Its evolution to the current standard precautions

The use of appropriate infection control precautions to protect against transmission of bloodborne and other occupational microbial pathogens has become a routine component of health care provision. Evolution and revision of recommendations continues to be based on updated scientific information, as well as documented and inferred clinical applications of new knowledge. In addition, surveillance of occupational risks in medical treatment settings often has served as a basis for subsequent disease prevention recommendations for dental care. Guidelines designed to protect dental professionals and their patients have focused on bloodborne pathogens since the first published American Dental Association recommendations in the 1970s. Subsequent statements developed by the Centers for Disease Control and Prevention, the ADA and other organizations during the past 30 years also have addressed prevention of other infections, transmitted by either direct or indirect contact with a variety of potentially infectious body fluids. Review of the major features of these recommendations provides an appropriate framework to consider current guideline revisions. The success of long-standing universal precautions, or UP, against bloodborne infection has been augmented with the incorporation of body substance isolation, or BSI, practices into the infection control protocol designated "standard precautions." Combination of the major tenets of UP with the BSI systems routinely employed in acute care facilities affords all health care professionals the means of preventing a spectrum of bloodborne, respiratory, contact and other potential exposures during provision of patient care. As infection control recommendations for dentistry are updated this year, they undoubtedly will include guidelines expanding previous UP to provide expanded protection for dental professionals in the multiple types of nonacute treatment settings in which routine treatment is provided.

Capnography for nonintubated patients: The wave of the future for routine monitoring of procedural sedation patients

THE USE OF procedural sedation is growing dramatically because of the increase in performance of minimally invasive procedures in nonacute and acute care settings. As anesthesia agents have been refined to provide short-acting sedation with minimal side effects, procedural sedation is becoming increasingly desirable. Procedural sedation is not only commonly used in the operating room, but has many other applications such as endoscopy, radiology, cardiology, dentistry, physicians’ offices, and pediatrics. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defined 4 levels of sedation and anesthesia in January 2001. These defined levels made clear that because sedation-to-anesthesia is a continuum, sedation patients should be monitored and treated the same as general anesthesia patients. Capnography is the continuous measurement and display of carbon dioxide (CO2) concentration in exhaled breath. A capnogram is the graphical waveform depicting CO2 concentration throughout respiration (Table 1). A normal capnogram has a near zero baseline with a sharp rapid rise, a plateau, then a sharp rapid down shift (Fig 1). Abnormal capnograms occur for a multitude of reasons and present with varying changes from the normal (Fig 2). Table 1. Capnography Waveforms: Interpreting the Capnogram

Assessing Provider-Patient-Parent Communication in the Pediatric Emergency Department

Patient-provider communication is related to the satisfaction with and process and outcome of emergency department care. Barriers to communication include noise, anxiety, confusion about process, and differences in language and expectations. In the emergency care setting, as in nonacute ambulatory settings, children tend to be left out of discussions of their own care. Both retrospective and real-time methods are available for studying communication during emergency department visits. Well-standardized generic communication assessment tools are applicable to emergency department communication, but assessment tools specific for emergency settings have yet to be developed and standardized. Although the emergency department poses some methodologic difficulties not present in other settings, studies of communications are feasible and likely to yield useful data.

Control of infections in nonacute care pediatric settings

During the past decade, pediatric health care has been delivered increasingly in nonacute care facilities, outpatient settings, and patients' homes. Despite this redistribution, little is known about infection control risks related to these settings. Much of the existing medical literature centers on outbreak reporting. Few standardized definitions or methodologies exist to benchmark infection rates. For the most part, existing guidelines for infection control are developed for adult facilities and may not be applicable to pediatric settings, especially since the two populations have different underlying comorbidities. Systematic investigation is needed to provide data on which development of infection control guidelines specific to various pediatric nonacute care settings can be based. Copyright © 2001 by W.B. Saunders Company

The Role of Critical Access Hospital Status in Mitigating the Effects of New Prospective Payment Systems Under Medicare

This article examines rural hospitals that potentially qualify as critical access hospitals (CAH) and identifies facilities at substantial financial risk as a result of Medicare's expansion of prospective payment systems (PPS) to nonacute settings. Using Health Care Financing Administration (HCFA) cost reports from the federal year ending Sept. 30, 1996, combined with county-level sociodemographic data from the Area Resource File (ARF), characteristics of potential CAHs were identified and their finances analyzed to determine whether they could benefit from the cost-based reimbursement rules applicable to CAH status. Rural hospitals were identified as potential CAHs if they met a combination of federal and state criteria for necessary providers. Rural facilities were classified as "at risk" if they had poor financial ratios in conjunction with high levels of dependence on outpatient, home-care or skilled nursing services. Almost 30 percent of all rural hospitals were identified as potential CAHs. Ninety percent of potential CAH facilities were identified as "at risk" by at least one of five possible risk criteria, and one-third were identified by at least three. Of those classified "at risk," 48 percent might not benefit from conversion to CAH because their inpatient Medicare reimbursement would likely be less under CAH payment rules than under their current PPS payment rules. Many potential CAHs were doing well under inpatient PPS because they were sole community hospitals (SCH) and were therefore eligible for special adjustments to the PPS rates. The Rural Hospital Flexibility Act would be more beneficial to the population of isolated rural hospitals if those eligible for both CAH and SCH status were given the option of retaining their SCH inpatient payment arrangements while still qualifying for outpatient cost-based reimbursement.

Nutrition, ageing and ill health.

There are physical, mental, social and environmental changes which take place with ageing; for example, decreased physical activity, increase in body fat, decrease in lean body mass and consequently decreased energy intake may be associated with physiological functions that affect metabolism, nutrient intake, physical activity and risk of disease. There are now many studies which have found that undernutrition is prevalent and often unrecognized in patients admitted to hospitals and institutions. There is also evidence which links protein-energy undernutrition or its markers with clinical outcomes in acute and non-acute hospital settings and that nutritional supplements can improve outcomes in some of these settings. However, most clinically-available nutrition screening instruments lack sensitivity and specificity, and abnormal nutritional indicators may simply reflect effects of age, functional disability, or severe underlying disease. Thus, causal relationship cannot be assumed without a sufficiently powerful intervention study which adequately adjusts for the effects of non-nutritional factors, such as the number and severity of co-morbid conditions on clinical outcome.

Achievement of appropriate self-care. Does care delivery system make a difference?

The purpose of this article is to review the evidence linking variations in care delivery system with achievement of appropriate self-care. This synthetic review of the research literature used the Outcomes Model for Health Care Research. The concept of self-care was reviewed from several theoretical perspectives, as was the quality of instruments used to measure aspects of self-care. Finally, studies examining the linkage between care delivery system and self-care were critically analyzed. Reliable and valid instruments exist to measure self-care agency and self-care performance, and these data elements are collected routinely in many care settings. Only a few studies, however, have examined the relation between achievement of self-care and variations in delivery systems. Achievement of appropriate self-care may be an outcome measure better suited to nonacute care settings or across the continuum of care. Additionally, work is needed in applying risk-adjustment strategies to the measurement of achievement of appropriate self-care.

Preparing to change from acute to community-based care. Learning needs of hospital-based nurses.

Increasingly, professional nurses will be required to function in practice settings other than acute care, yet little is known about how nurses perceive the skill sets required to practice in these nonacute care settings. This study explores nurses' perceptions and needs concerning the transition from acute to home care and community-based healthcare facilities. Because the healthcare reform environment of the 1990s mandates changes in the ways hospitals and hospital nurses care for patients, many nurses in acute care settings anticipate that their roles will include or perhaps shift completely to practice in the home and other community-based settings. How professional nurses perceive the skills required to practice in these nonacute care settings may well influence their willingness to accept work redesign initiatives and voluntary employment transitions that involve working outside the hospital setting. Based on focus groups and the literature a three-part 56-item questionnaire was developed as the study instrument to assess skill needs and concerns related to functioning in the acute, home, and community-based setting. A total of 879 nurses representing various specialties in healthcare institutions in the Philadelphia and five-county surrounding areas participated. Test retest for the study instrument was 0.87 for a 2-week period, and alpha coefficients ranged from 0.90 to 0.94. Multivariate analyses revealed that proficiency on certain skill items in the acute care setting predicted feelings of proficiency in home and community-based settings. Based on regression and discriminant function analyses, top predictors and differentiators of proficiency in the nonacute care settings were wound care and dressing, knowledge of community resources, diabetic education, patient and family advocacy, communication with third-party payers, and neonatal care. Some nurses, such as those working in critical care, perceive themselves as being able to function proficiently in a wide variety of care settings-acute home, and community based. Furthermore, certain acute care skills were identified as top differentiators of proficiency in nonhospital settings, thus providing direction for nursing administrators and academic institutions. In addition, the tool developed for the study can serve as a self-assessment for individual nurses.

Surveillance in acute care and nonacute care settings: Current issues and concepts

Infection surveillance programs should be designed to meet the needs of a given health care organization. Opportunities to learn how to design epidemiologically sound surveillance programs are not readily available. This report describes the results of small-group discussions held with infection control professionals from various health care settings. Facilitators coached participants through a series of discussions to generate ideas about scientific surveillance for specific patient populations. Key strategies were identified, and suggestions for surveillance studies were given. Before these strategies can be widely recommended, reports of actual application are needed.

Is Metabolic Rate Measurement Useful in Nonacute Settings?

LEARNING OUTCOME: To identify the problems associated with predicting energy requirements and a method for measuring metabolic rate.Weight management clients often ask: Is my metabolic rate normal? In most cases there is not equipment available to provide an objective measurement of metabolic rate such as can be accomplished using indirect calorimetry. Over the past three years, 39 males who entered a nationally recognized weight management program have had their metabolic rates measured (MRM) as an optional part of the program. MRM's were measured using a portable metabolic cart which allows clients to be measured at rest, prior to beginning their daily activities on site. Clients MRM's were compared to those estimated from the Harris-Benedict equations(HBE) using actual body weight (ABW) and ideal body weight (IBW). The HBE are used as the starting point in predicting maintenance calories and therefore weight loss calorie requirements. Overall, participants were 33% above IBW ranging from 7-94% above IBW and when all participants data was grouped together there were no correlations between MRM and HBE-IBW or HBE-ABW. Clients were stratified according to their percentages above IBW: Gp 1 ≤20%, n = 13; Gp 2 >21%≤30%n=10; Gp 3 >31 ≤ 50%n=10; Gp4 >51%n=6 and MRM was compared to HBE calculated using ABW and IBW for each group. In conclusion: MRM was accurately predicted by HBE whether ABW or IBW for Gp 1; however HBE-IBW did not correlate with MRM for any of the other groups. HBE-ABW correlated with MRM for GPs 2 and 4, but not for Gp 3. For clients MRM was more accurately predicted using ABW rather than IBW in the HBE. For Gp 3 who were betwenn 31 and 50% above IBW, neither HBE-IBW or ABW was accurate in predicting MRM. An objective measurement of metabolic rate provides both the dietitian and the client with the information to develop a program which will provide for the client's individualized metabolic needs and thereby a greater potential for long-term success.

Alcohol-impregnated wipes as an alternative in hand hygiene

The antimicrobial effectiveness of four hand-wash products for health care personnel included three liquid soaps that contained 4% chlorhexidine gluconate, 1% triclosan, or no antiseptic ingredient, respectively, and a 30% w/w ethyl alcohol-impregnated hand wipe. These products were evaluated for reduction in bacterial counts on hands after extended use of 15 handwashes per day for 5 consecutive days. The order of greatest to least log reduction among products at the end of the 5-day test period was chlorhexidine gluconate (2.01), triclosan (1.52), alcohol wipe (0.04), and control soap (0.03). Skin condition before and after handwash was assessed for each treatment group. Subjects reported less skin irritation with alcohol wipes than with the two antiseptic products. Repeated washing with alcohol wipes results in reductions in bacterial colony counts comparable with nonmedicated soap, sufficient to prevent transmission of pathogens by the hands in most situations that arise in nonacute health care settings. This evidence, in addition to increased user acceptability reported by the subjects who used alcohol wipes, suggests that alcohol wipes are an acceptable alternative to soap-and-water handwashing in nonacute health care settings.

Comprehensive Assessment of the Healthy Gravida

A prenatal assessment guide which will assist in the synthesis of data collected from the physiological, psychosocial, and experience realms of the healthy gravida is presented. The guide can be used by antepartum nurses working in a variety of nonacute settings.

Postcards Illustrate Pharmacy History

To measure the relationships among stressors (personal factors, job/role factors, hospital factors), job stress, and outcomes experienced by nurse leaders and examine moderation of autonomy and leadership style on outcomes of job stress.A cross‐sectional, quantitative design.Acute and nonacute care settings throughout North America.A nonprobability convenience sample of 392 was drawn from a population of nurse leaders across the United States and Canada who were members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN).A mailing list was obtained from AWHONN, and a total of 3,986 recruitment and follow‐up postcards were sent to nurse leaders. Participants were asked to complete the survey online or request a hard copy to return by mail. Study variables were measured using previously published scales with demonstrated psychometric properties.Nurse leaders reported stress averages above the midpoint of the scales. Personal factors did not significantly predict stress, but role overload, organizational constraints, and role ambiguity were found to be the best predictors of stress. Job satisfaction, intent to quit, and mental health symptoms were the most significant outcomes of stress. Autonomy moderated relationships between perceptions of stress and outcomes with low autonomy showing greater negative outcomes when levels of stress are higher.Nurse leaders experience significant job stress that may suggest a need to design and implement evidence‐based interventions to reduce stress among this group.