Helen Walthall

Recording of vital signs in a district general hospital emergency department

Aim: To examine and explore factors that may influence the recording of vital signs in adult patients within the initial 15 min and again within 60 min of arrival in the “resuscitation” and “major” areas of the emergency department (ED). Methods: A retrospective analysis of recording of vital signs was performed on 400 consecutive sets of notes from adult patients presenting to the “major” or “resuscitation” areas of a district general hospital ED. The effect of staffing levels, triage category and attendances on the recording of vital signs was examined using logistic regression. The main outcome measures were the proportion of patients with all vital signs recorded within 15 min of arrival, the proportion of patients with all vital signs repeated within 60 min of arrival and the outcomes of logistic regression analysis. Results: Only 223/387 patients (58%) had all vital signs recorded within 15 min of arrival and only 29/387 (7%) had all vital signs repeated at 60 min. There was a significant relationship between the failure to record vital signs and lower triage categories. There was no evidence that staffing levels or number of attendances predicted the recording of vital signs within 15 min of arrival. Conclusion: Recording of vital signs was poor and unrelated to staffing levels or numbers of patients attending the ED. Failure to record patients’ vital signs undermines strategies to detect and manage ill patients.

Health service provision and the use of pressure-redistributing devices: mixed methods study of community dwelling individuals with pressure injuries

Background: Health care within the home setting is a vital and growing component of pressure injury (PI) prevention and management. Objectives: To describe the use of health services and pressure-redistributing devices in community dwelling patients with PI’s. Design: Mixed-methods collective case study of a defined, diverse geographic postcode area in the United Kingdom. Methods: Quantitative retrospective analysis of electronic and paper medical records of adult PI patients from 2015 district nursing reports. Qualitative semi-structured interviews of community dwelling adult patients receiving, or received, treatment for PI in 2016. Results: Mandatory reports (n = 103) revealed that 90 patients were supplied with a variety of pressure-redistributing devices but only one-third of patients used the equipment as recommended. Qualitative interviews (n = 12), reported to COREQ guidelines, revealed that patients felt reliant on community health services, and were concerned about the consistency of their care. Conclusions: Authentic patient involvement is required to provide care and interventions that are acceptable to PI patients and can be incorporated into self-care strategies and effectively monitored.

Living with breathlessness in chronic heart failure - a qualitative study

AIMS AND OBJECTIVES To explore how patients with Chronic Heart Failure describe their experiences of breathlessness, the pattern of their breathlessness, how daily life is affected and how they adjust to and manage these symptoms. BACKGROUND Chronic Heart Failure is a highly prevalent syndrome often with poor outcomes and in a patient group who are predominately elderly. Breathlessness is the main symptom experienced by patients and often relates to decompensation and hospitalisation, yet subtle changes described by patients are often not discussed with health care professionals. DESIGN A descriptive qualitative design. METHODS Twenty-five participants with heart failure with reduced ejection fraction (HF-rEF) from a tertiary referral centre in England were recruited. Each participant took part in a semi-structured interview exploring the effect of breathlessness had on their lives. Data was analysed through Braun and Clarkes framework for thematic analysis. RESULTS All participants reported experiencing breathlessness daily. Four sub-themes were identified in their accounts: nature of breathlessness, emotional impact of breathlessness, impact of breathlessness on daily life and managing breathlessness. CONCLUSION Participants were able to give vivid descriptions of breathlessness and the way it affected their lives. RELEVANCE TO CLINICAL PRACTICE Health care professionals need to take account of each patients personal assessment of their own breathlessness and how this is having an effect on their life and ability to undertake activities of daily living. Self-care management strategies need to be developed so that subtle changes can be assessed by the patient and reviewed by the healthcare professional to avoid hospitalisation and increased mortality risks.

What is the experience of being readmitted to hospital for people 65 years and over? A review of the literature

Aim: To explore the experience of readmissions to hospital from the perspective of older adults. Methods: A systematic review with an interpretative approach was conducted. CINAHL, Embase, and Medline were consulted in October 2016. Results: Six studies with data collection between 2004 and 2013 fit the relevant criteria and included a total of 68 older adults. Two overarching themes were developed with relevant subthemes: Experience during initial hospital stay distinguished by exclusion (Feeling powerless; Feeling disregarded; Perception of readiness for discharge); Patients experience uncertainty following discharge (Perception that community-based services are not available or adequate; Perception that hospital is the only safe place; Difficulty in adapting to a “new normal”). Conclusions: A cycle of exclusion exists during the initial hospital stay and beyond. The experience of being readmitted to hospital is challenging, mostly perceived as negative, and, existential, emotional and psychological well-being is not satisfactorily addressed by healthcare professionals.

Exploring the quality of the dying and death experience in the Emergency Department: An integrative literature review

AIM The aim of this integrative literature review was to explore the quality of the dying and death experience in the Emergency Department from the perspective of staff and carers. BACKGROUND Death in the Emergency Department is common. Understanding the quality of the death and dying experience of patients and their family members is crucial to building knowledge and improving care. DESIGN Systematic integrative literature review reported following the PRISMA guidelines. DATA SOURCES Pubmed, Cumulative Index to Nursing and Allied Health Literature, Magonline (internurse), and the Cochrane library. Articles used were published in English during 1990- 2017. REVIEW METHOD Appraisal and thematic analysis. RESULTS Sixteen articles are included. Eight themes emerged from the literature: care in the Emergency Department is about living not dying, staff perceive that death is a failure, staff feel underprepared to care for the dying patient and family in this environment, there is limited time for safe standards of care, staff stress and distress, staff use of distancing behaviours, the care of the dying role is devolved from medics to nurses at the end of life, and patients and staff perceive that the Emergency Department is not the preferred place of death CONCLUSION: There are areas of concern about end of life care in the Emergency Department. To improve practice and to ensure that a good death occurs, further research is needed. There is a need to understand more about the experience of caregivers when a relative or friend dies in the Emergency Department.

Assessment and management of refractory breathlessness in interstitial lung disease

Interstitial lung disease (ILD) refers to a cluster of fibroinflammatory conditions. There are limited treatment options and most patients have severe dyspnoea. The prognosis is poor. This study aims to evaluate current literature on the assessment and management of refractory breathlessness in ILD. Few tools are available to assess dyspnoea in advanced respiratory disease. Holistic assessment requires a combination of tools but there are few disease specific tools. The role of opioids is well established in the reduction of breathlessness, but there is insufficient evidence that benzodiazepines are beneficial. Non-pharmcolological breathlessness intervention services can give patients mastery of their disease, reduced distress due to breathlessness and were more cost effective. More research on holistic interventions for use in advanced disease needs to be done. Patient-reported outcome measures could elicit valuable evidence to describe the benefit of breathlessness management services in advanced respiratory disease.

Antiplatelet therapy in the treatment and prevention of thrombus formation

It is established practice to administer antiplatelet drugs to patients with known coronary heart disease (Department of Health, 2000). This pharmacological prevention is based on the findings of a number of randomized controlled trials that have set out to establish a drug of choice and the dose required to reduce the risk of thrombosis formation. The following paper will review the role of platelets in maintaining haemostasis and in cardiovascular diseaseand will discuss how antiplatelet drugs can inhibit the function of platelets and so reduce the risk of thrombosis formation. The pharmacology of aspirin and clopidogrel will be reviewed and the evidence base for their use presented.