Patients9 Home Research Articles

Integrated respiratory care: what forms may it take and what are the benefits to patients?

Educational aims To outline the rationale behind and key components of integrated respiratory care. To give an overview of different models of delivery of integrated respiratory care. To explore the benefits to patients with chronic respiratory disease. Summary Providing for the long-term needs of patients with chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD), sets new challenges for healthcare organisations in terms of structure and funding. Integrated respiratory care is a holistic patient-centred approach to long-term conditions encompassing: disease prevention and promotion of lung health; early diagnosis; monitoring and education; coordination of hospital and community care; and implementation of evidence-based guidelines. Models of integrated respiratory care may vary depending on local resources and needs. Key aspects include nurse-led care nearer to or in the patients9 home, self-management support, flexible healthcare design that suits patient needs, effective information sharing, and access to specialist care. These interventions have the potential to improve self-care and understanding of disease, reduce the need for scheduled and unscheduled consultations and length of stay, and enhance patients9 health-related quality of life.

Ivor Gwyndaf Pryce

<h3>Background</h3> DcSSc is associated with high morbidity and mortality, and reduced quality of life. Patient priorities are rarely discussed, with physicians focusing on organ involvement. Using discursive approaches and ethnography,...

Effects of self medication programme on knowledge of drugs and compliance with treatment in elderly patients

To determine whether a programme of self medication for inpatients improves compliance with treatment and knowledge of their drugs after discharge from hospital. Patients were prospectively recruited from four wards: two with a self medication programme and two acting as controls. Ten days after discharge the patients were visited at home. They were questioned about their drugs, and a tablet count was undertaken. The pharmacy department and four medical wards with an interest in elderly patients at a district general hospital, and the patients' homes. 88 patients discharged to their own homes who were regularly taking one or more drugs. A hospital self medication programme in which patients are educated about their medicines and given increasing responsibility for taking them in hospital. Compliance with and knowledge of the purpose of their medicines 10 days after discharge from hospital. The mean compliance score in patients taking part in the self medication programme was 95% compared with 83% in the control group (difference 12%, 95% confidence interval 4% to 21%; P < 0.02). Of the patients in the self medication group, 90% (38/42) knew the purpose of their drugs compared with 46% (17/37) in the control group (difference 44%, 26% to 63%; P < 0.001). A self medication programme is an effective aid for improving compliance with and knowledge of patients' drugs after discharge.

Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II

Abstract Objectives: To define relation between mood and concentrations of progesterone and cortisol during perinatal period to test hypothesis that rapid physiological withdrawal of steroid hormones after delivery is associated with depression. Design: Prospective study of primiparous women from two weeks before expected date of delivery to 35 days postpartum. Setting: Antenatal clinic in university hospital, obstetric inpatient unit, patients9 homes. Subjects: 120 of 156 primiparous women interviewed. Remainder excluded because of major marital, socioeconomic, or medical problems or because caesarean section required. Main outcome measures: Concentrations of progesterone and cortisol in saliva samples; women9s moods assessed by various scores for depression. Results - Changes in salivary progesterone and cortisol concentrations were similar to those already characterised for plasma. Peak mean score for maternity blues (5.3 on Stein scale) was on day five postpartum (P =0.01), and with low progesterone concentrations on day of peak blues score (P =8 on Stein scale) while 39 had no blues. Women with blues had significantly higher antenatal progesterone concentrations and lower postnatal concentrations than women without blues (geometric mean progesterone concentrations: one day before delivery 3860 pmol/l v 3210 pmol/l respectively, P=0.03; ten days postpartum 88 pmol/l v 114 pmol/l, P=0.048). Cortisol concentrations were not significantly associated with mood. Conclusion: Maternal mood in the days immediately after delivery is related to withdrawal of naturally occurring progesterone.

Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II.

To define relation between mood and concentrations of progesterone and cortisol during perinatal period to test hypothesis that rapid physiological withdrawal of steroid hormones after delivery is associated with depression. Prospective study of primiparous women from two weeks before expected date of delivery to 35 days postpartum. Antenatal clinic in university hospital, obstetric inpatient unit, patients' homes. 120 of 156 primiparous women interviewed. Remainder excluded because of major marital, socioeconomic, or medical problems or because caesarean section required. Concentrations of progesterone and cortisol in saliva samples; women's moods assessed by various scores for depression. Changes in salivary progesterone and cortisol concentrations were similar to those already characterised for plasma. Peak mean score for maternity blues (5.3 on Stein scale) was on day five postpartum (P < 0.02 compared with mean scores on other postpartum days). High postpartum scores for maternity blues were associated with high antenatal progesterone concentrations on day before delivery (P < 0.05), with high rate of rise of antenatal progesterone concentrations (P < 0.05), with decreasing progesterone concentrations from day of delivery to day of peak blues score (P > or = 0.01), and with low progesterone concentrations on day of peak blues score (P < 0.01). Seventy eight women were designated as having maternity blues (peak score > or = 8 on Stein scale) while 39 had no blues. Women with blues had significantly higher antenatal progesterone concentrations and lower postnatal concentrations than women without blues (geometric mean progesterone concentrations: one day before delivery 3860 pmol/l v 3210 pmol/l respectively, P = 0.03; ten days postpartum 88 pmol/l v 114 pmol/l, P = 0.048). Cortisol concentrations were not significantly associated with mood. Maternal mood in the days immediately after delivery is related to withdrawal of naturally occurring progesterone.

Diagnosis and management after life threatening events in infants and young children who received cardiopulmonary resuscitation.

To determine the mechanisms and thereby appropriate management for apparent life threatening events treated with cardiopulmonary resuscitation in infants and young children. Prospective clinical and physiological study. Royal Brompton Hospital or in patients' homes, or both. 157 Patients referred at median age 2.8 months (range 1 week to 96 months), 111 (71%) had recurrent events, 44 were born preterm, 19 were siblings of infants who had died suddenly and unexpectedly, and 18 were over 12 months old. Multichannel physiological recordings, including oxygenation, in hospital (n = 150) and at home (n = 61). Additional recordings with electroencephalogram, video, or other respiratory measures were used to confirm diagnoses. Management involved monitoring of oxygen at home, additional inspired oxygen, anticonvulsant treatment, or child protection procedures. Abnormalities on recordings compared to published normal data and their correlation with clinical events; sudden death. 53 of 150 patients had abnormalities of oxygenation on hospital recordings, 28 of whom had an accompanying clinical event. Home recordings produced physiological data from 34 of 61 patients during subsequent clinical events. Final diagnoses were reached in 77 patients: deliberate suffocation by a parent (18), hypoxaemia induced by epileptic seizure (10), fabricated history and data (Munchausen syndrome by proxy; seven), acute hypoxaemia of probable respiratory origin (40), and changes in peripheral perfusion and skin colour without hypoxaemia (two). Four patients died: three suddenly and unexpectedly (none on home oxygen monitors) and one from pneumonia. Identification of mechanisms is essential to the appropriate management of infants with apparent life threatening events.

Cognitive and functional competence after anaesthesia in patients aged over 60: controlled trial of general and regional anaesthesia for elective hip or knee replacement.

To determine the influence of general or regional anaesthesia on long term mental function in elderly patients. Prospective study of patients randomly allocated to receive general or regional anaesthesia. The patients' homes and a large teaching hospital in Cardiff. 146 Patients aged 60 and over scheduled for elective hip or knee replacement. Scores achieved in tests of cognitive function and functional competence. 72 Patients were allocated to receive general anaesthesia and 74 regional anaesthesia. Anaesthetic technique did not influence the duration of the operation, time to mobilisation postoperatively, requirements for analgesia after the operation, or duration of stay in hospital. Three months after the operation there was an improvement in the score for the recognition component (76 ms, 95% confidence interval 9 to 144) and the response component (82 ms, 5 to 158) of the choice reaction time in the group receiving general anaesthesia compared with the group receiving regional anaesthesia. This was the only significant difference between the two groups in the assessments of cognitive and functional competence. Eleven patients receiving regional anaesthesia and 12 receiving general anaesthesia reported that their memory and concentration were worse than before the operation, but this was not confirmed by testing. Cognitive and functional competence in elderly patients was not detectably impaired after either general or regional anaesthesia when attention was paid to the known perioperative influences on mental function.

Facilitating care of patients with HIV infection by hospital and primary care teams.

To complement the role of primary care teams working with patients with HIV disease and AIDS within greater London and to ease the load on the special hospital units a home support team was developed. It comprises six specialist nurses, a general practitioner trained medical officer, and a receptionist and is funded from regional and district sources and charities. A nurse is available for out of hours and emergency weekend calls, with support from the patient's general practitioner or the attached medical officer. During the first 18 months 249 patients were seen; the mean duration of care was five months. Nearly a third (18/50, 30%) of patients who were terminally ill died at home. The team's activities included practical nursing care, emotional support for carers and patients, and advice and guidance to primary care teams. Problems in providing care in patients' homes included issues relating to confidentiality and 24 hour cover. With the increasing incidence of HIV infection the home support team may be a useful model for care of large numbers of patients with symptomatic HIV disease, especially in large urban areas.

Narrowing the health gap between a deprived and an endowed community

A 15 month campaign by a primary health care team in Stockton on Tees raised the uptake of preventive care of its patients in a severely deprived area to a level generally exceeding that of a more endowed neighbouring community. This was achieved by opportunistic attention after unrelated consultations, writing twice to each household with a list of its outstanding items necessary for preventive care, using health visitors to encourage attendance, and occasionally undertaking preventive care in patients' homes. Extra clerical staff were needed to implement the new recording and monitoring procedures introduced. With rigorous monitoring and organisation general practitioners may improve the uptake of preventive health care by their more deprived patients.

Prospective study of drug reporting by general practitioners for an elderly population referred to a geriatric service.

A prospective study was carried out in which the drug history of patients which was provided by general practitioners was compared with the drugs found by geriatricians in patients' homes in 700 referrals to geriatricians. Drug compliance was not assessed. The drug history appeared to be accurate in one third of referrals. Underreporting of medication was common and increased as the number of prescribed drugs increased. Roughly one fifth of patients had at least one potential drug interaction. Keeping careful prescription records, regular review, and accurate reporting of medication should reduce drug associated morbidity in elderly patients.

The Newmarket pump: a new suction pump for external negative pressure ventilation.

A new electronically controlled pump has been developed for use with a cuirass in providing external negative pressure ventilation. It is smaller, lighter, and more versatile than currently available pumps and operates on a servo principle. A rotary valve between the pump and the cuirass varies the rate of extraction of air from the cuirass. The pressure within the cuirass is sensed by a pressure transducer, and the output of this is used to control the position of the rotary valve by means of a motor so that the pressure within the cuirass follows a predetermined half sine wave pattern. The respiratory rate varies from 10 to 30 per minute and the inspiratory to expiratory time (I/E) ratio from 3:2 to 2:3. Inspiratory pressure varies from 0 to -50 cm H2O and an expiratory pressure of 0 to +50 cm H2O can be imposed. The performance of the new pump was assessed in 21 patients with nocturnal hypoxaemia who were accustomed to external negative pressure ventilation. The mean tidal volume achieved increased with increase in cuirass suction pressure, and changing the I/E ratio from 1:1 to 3:2 produced a small increase at a cuirass negative pressure at 20 cm water. Comparison of the Newmarket pump with the Cape pump in 14 patients showed that similar tidal volumes were achieved. Overnight monitoring of cuirass pressure in one patient showed more even control of peak negative pressure with the Newmarket pump than with the Cape pump. Ten pumps are in use in patients' homes; five have been in service for more than six months and no important problems have been encountered. The new pump seems to offer advantages that make external negative pressure ventilation more acceptable.

Peripheral outpatient clinics: use, costs, and benefits.

A census was taken of outpatient bookings at all hospitals and health centres in Oxfordshire for the main medical and surgical specialities. Nine per cent of all bookings were to peripheral clinics (that is, those outsie the two main medical centres at Oxford and Banbury). About half of all bookings in the area were made to clinics within three of four miles of the patients' homes. The work load at peripheral clinics was mainly local: 75% of all patients at these clinics lived in the town or parishes adjacent to the town where the clinic was held. Peripheral clinics were associated with a lower work load at central clinics, but a higher overall work load from the town in which they were sited.