Oliva Marognolli

Factors affecting in-hospital informal caregiving as decided by families: findings from a longitudinal study conducted in acute medical units.

BACKGROUND Informal caregiving offered by family members has been widely studied in the community setting, but little attention to date has been dedicated to that offered at the hospital level. AIMS To describe the proportion of patients admitted to acute medical units receiving care from informal caregivers as decided by the family and to identify the factors affecting the numbers of care shifts performed by informal caregivers. DESIGN AND METHODS A longitudinal study was performed involving 12 acute medical units located in 12 northern Italian hospitals. RESULTS All patients (N = 1464) admitted to medical units were included, and 77.1% of them received at least one shift of informal care during their in-hospital stay, especially during the mornings and afternoons. At the patient level, those at higher risk of prolonged hospitalisation and difficult discharge at admission, and those reporting higher occurrence of adverse events, such as pressure sores, confusion events and use of physical restraints during hospitalisation, were more likely receiving informal care. At the nursing care level, a higher amount of missed nursing care was associated with an increased number of care shifts offered by informal caregivers during patient hospitalisation, whereas the amount of care offered by staff was a protective factor. CONCLUSIONS Families play a care role in the care of older patients admitted to acute medical units. They contribute substantially to the care of patients, especially during morning and afternoon shifts.

[Validation of the Italian Clinical Learning Environment Instrument (SVIAT): study protocol].

UNLABELLED . Validation of the Italian Clinical Learning Environment Instrument (SVIAT): study protocol. INTRODUCTION Nursing students obtain most of their university credits in internship environments whose quality can affect their clinical learning. Several tools are available to measure the quality of the clinical learning environment (CLE) as perceived by students: these instruments developed in other countries, were validated in Italian but do not discriminate those CLEs capable (or not) to promote significant clinical learning. AIM To validate an instrument to measure the capability of the CLE to generate clinical learning; the secondary aim is to describe the learning environments as perceived by nursing students according to individual course site and tutorial models adopted. METHODS The study will be developed in three phases: a) instrument development and pilot phase, b) validation of the psychometric properties of the instrument and c) description of the CLEs as perceived by the students including factors/item confirmed in the validation process. Expected outcomes. A large validation, with more than 8,000 participating students is expected; the construct under lying will be confirmed through exploratory and confirmatory factor analysis and will report high internal consistency; the instrument will report also a high test-retest and inter-rater reliability; in addition, the instrument will demonstrate predictive ability by discriminating those units able (or not) to activate effective learning processes.

Prevalence and incidence density of unavoidable pressure ulcers in elderly patients admitted to medical units

To describe the prevalence and incidence density of hospital-acquired unavoidable pressure sores among patients aged ≥65 years admitted to acute medical units. A secondary analysis of longitudinal study data collected in 2012 and 2013 from 12 acute medical units located in 12 Italian hospitals was performed. Unavoidable pressure ulcers were defined as those that occurred in haemodynamically unstable patients, suffering from cachexia and/or terminally ill and were acquired after hospital admission. Data at patient and at pressure ulcer levels were collected on a daily basis at the bedside by trained researchers. A total of 1464 patients out of 2080 eligible (70.4%) were included. Among these, 96 patients (6.5%) hospital-acquired a pressure ulcer and, among 19 (19.7%) were judged as unavoidable. The incidence of unavoidable pressure ulcer was 8.5/100 in hospital-patient days. No statistically significant differences at patient and pressure ulcers levels have emerged between those patients that acquired unavoidable and avoidable pressure sores. Although limited, evidence on unavoidable pressure ulcer is increasing. More research in the field is recommended to support clinicians, managers and policymakers in the several implications of unavoidable pressure ulcers both at the patient and at the system levels.

Nursing care as a predictor of phlebitis related to insertion of a peripheral venous cannula in emergency departments: findings from a prospective study.

BACKGROUND To date, few studies have investigated the occurrence of phlebitis related to insertion of a peripheral venous cannula (PVC) in an emergency department (ED). AIM To describe the natural history of ED-inserted PVC site use; the occurrence and severity of PVC-related phlebitis; and associations with patient, PVC and nursing care factors. METHODS A prospective study was undertaken of 1262 patients treated as urgent cases in EDs who remained in a medical unit for at least 24h. The first PVC inserted was observed daily until its removal; phlebitis was measured using the Visual Infusion Phlebitis Scale. Data on patient, PVC, nursing care and organizational variables were collected, and a time-to-event analysis was performed. FINDINGS The prevalence of PVC-related phlebitis was 31%. The cumulative incidence (78/391) was almost 20% three days after insertion, and reached >50% (231/391) five days after insertion. Being in a specialized hospital [hazard ratio (HR) 0.583, 95% confidence interval (CI) 0.366-0.928] and receiving more nursing care (HR 0.988, 95% CI 0.983-0.993) were protective against PVC-related phlebitis at all time points. Missed nursing care increased the incidence of PVC-related phlebitis by approximately 4% (HR 1.038, 95% CI 1.001-1.077). CONCLUSIONS Missed nursing care and expertise of the nurses caring for the patient after PVC insertion affected the incidence of phlebitis; receiving more nursing care and being in a specialized hospital were associated with lower risk of PVC-related phlebitis. These are modifiable risk factors of phlebitis, suggesting areas for intervention at both hospital and unit level.

Overcoming redundancies in bedside nursing assessments by validating a parsimonious meta-tool: findings from a methodological exercise study.

Rationale There is growing interest in validating tools aimed at supporting the clinical decision-making process and research. However, an increased bureaucratization of clinical practice and redundancies in the measures collected have been reported by clinicians. Redundancies in clinical assessments affect negatively both patients and nurses. Methods To validate a meta-tool measuring the risks/problems currently estimated by multiple tools used in daily practice. A secondary analysis of a database was performed, using a cross-validation and a longitudinal study designs. In total, 1464 patients admitted to 12 medical units in 2012 were assessed at admission with the Brass, Barthel, Conley and Braden tools. Pertinent outcomes such as the occurrence of post-discharge need for resources and functional decline at discharge, as well as falls and pressure sores, were measured. Explorative factor analysis of each tool, inter-tool correlations and a conceptual evaluation of the redundant/similar items across tools were performed. Therefore, the validation of the meta-tool was performed through explorative factor analysis, confirmatory factor analysis and the structural equation model to establish the ability of the meta-tool to predict the outcomes estimated by the original tools. Results High correlations between the tools have emerged (from r 0.428 to 0.867) with a common variance from 18.3% to 75.1%. Through a conceptual evaluation and explorative factor analysis, the items were reduced from 42 to 20, and the three factors that emerged were confirmed by confirmatory factor analysis. According to the structural equation model results, two out of three emerged factors predicted the outcomes. Conclusions From the initial 42 items, the meta-tool is composed of 20 items capable of predicting the outcomes as with the original tools.RATIONALE There is growing interest in validating tools aimed at supporting the clinical decision-making process and research. However, an increased bureaucratization of clinical practice and redundancies in the measures collected have been reported by clinicians. Redundancies in clinical assessments affect negatively both patients and nurses. METHODS To validate a meta-tool measuring the risks/problems currently estimated by multiple tools used in daily practice. A secondary analysis of a database was performed, using a cross-validation and a longitudinal study designs. In total, 1464 patients admitted to 12 medical units in 2012 were assessed at admission with the Brass, Barthel, Conley and Braden tools. Pertinent outcomes such as the occurrence of post-discharge need for resources and functional decline at discharge, as well as falls and pressure sores, were measured. Explorative factor analysis of each tool, inter-tool correlations and a conceptual evaluation of the redundant/similar items across tools were performed. Therefore, the validation of the meta-tool was performed through explorative factor analysis, confirmatory factor analysis and the structural equation model to establish the ability of the meta-tool to predict the outcomes estimated by the original tools. RESULTS High correlations between the tools have emerged (from r 0.428 to 0.867) with a common variance from 18.3% to 75.1%. Through a conceptual evaluation and explorative factor analysis, the items were reduced from 42 to 20, and the three factors that emerged were confirmed by confirmatory factor analysis. According to the structural equation model results, two out of three emerged factors predicted the outcomes. CONCLUSIONS From the initial 42 items, the meta-tool is composed of 20 items capable of predicting the outcomes as with the original tools.

Fluid Therapy Management in Hospitalized Patients: Results From a Cross-sectional Study

PURPOSE Intravenous (IV) fluid therapy is widely used in hospitalized patients. It has been internationally studied in surgical patients, but little attention to date has been dedicated to medical patients within the Italian context. The aims of the present study were to describe the prevalence of fluid therapy and associated factors among Italian patients admitted to medical and surgical units, describe the methods used to manage fluid therapy, and analyze the monitoring of patients by clinical staff. METHODS In this cross-sectional study of 7 hospitals in northern Italy, data on individual and monitoring variables were collected, and their associations with in-hospital fluid therapy were analyzed by using logistic regression analysis. Patients aged ≥18 years who were admitted to medical and surgical units were included. Patients who received at least 500 mL of continuous fluids were included in the fluid therapy group. FINDINGS In total, 785 (median age, 72 years; women, 52%) patients were included in the study, and 293 (37.3%) received fluid therapy. Maintenance was the most frequent reason for prescribing IV fluid therapy (59%). The mean (SD) volume delivered was 1177 (624) mL/d, and the highest volume was infused for replacement therapy (1660 [931] mL/d). The mean volume infused was 19.55 (13) mL/kg/d. The most commonly used fluid solutions were 0.9% sodium chloride (65.7%) and balanced crystalloid without glucose (32.9%). The proportion of patients assessed for urine output (52.6% vs 36.8%; P < 0.001), serum electrolyte concentrations (74.4% vs 65.0%; P = 0.005), and renal function (70.0% vs 58.7%; P = 0.002) was significantly higher in patients who did receive fluid therapy versus those who did not. In contrast, the use of weight and fluid assessments was not significantly different between the 2 groups (P = 0.216 and 0.256, respectively). Patients admitted for gastrointestinal disorders (odds ratio [OR], 3.5 [95% CI, 1.8-7.05) and for fluid/electrolyte imbalances (OR, 3.35 [95% CI, 1.06-10.52) were more likely to receive fluids. However, the likelihood of receiving fluids was lower for patients admitted to a surgical unit (OR, 0.36 [95% CI, 0.22-0.59]) and with cardiovascular diseases (OR, 0.37 [95% CI, 0.17-0.79). IMPLICATIONS Only one third of the study patients received fluid therapy. Crystalloid fluids, are the fluids of choice for maintaining plasma volume. During fluid therapy, measurement of the serum electrolyte concentrations, renal function, and urine output was largely used while weight and fluid balance were rarely assessed.