Ruud Halfens

Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial

BACKGROUND There is a lack of research on the possible contribution of a structured risk assessment to the reduction of aggression in psychiatric in-patient care. AIMS To assess whether such risk assessments decrease the incidence of violence and coercion. METHOD A cluster randomised controlled trial was conducted with 14 acute psychiatric admission wards as the units of randomisation, including a preference arm. The intervention comprised a standardised risk assessment following admission with mandatory evaluation of prevention in high-risk patients. RESULTS Incidence rates decreased substantially in the intervention wards, whereas little change occurred in the control wards. The adjusted risk ratios suggest a 41% reduction in severe aggressive incidents and a 27% decline in the use of coercive measures. The severity of aggressive incidents did not decrease. CONCLUSIONS Structured risk assessment during the first days of treatment may contribute to reduced violence and coercion in acute psychiatric wards.

Prevalence of Urinary Incontinence and Associated Risk Factors in Nursing Home Residents: A Systematic Review

To determine not only prevalence rates of urinary incontinence (UI) in nursing home residents but also factors influencing these prevalence rates, and to provide an overview of risk factors associated with UI in this group.

Fall risk factors in older people with dementia or cognitive impairment: a systematic review

AIM This paper is a report of a review conducted to identify and summarize specific risk factors for falls in older people with dementia or cognitive impairments as documented by prospective or case-control studies. BACKGROUND People with dementia have a doubled to threefold risk for falls, but the reasons for this have not yet been fully explained. Several integrative literature reviews discuss possible specific fall risk factors. However, there is lack of a systematic evaluation of studies. DATA SOURCES The CINAHL, PubMed, EMBASE and PsychInfo databases were searched for the period between 1980 and May 2007. REVIEW METHODS A systematic review was conducted. Cohort or case-control studies published in English or German were included if they investigated risk factors for falls or fall-related injuries in a sample consisting of participants with dementia or cognitive impairment. Two reviewers independently assessed study quality. RESULTS Six prospective studies were included in the review. These differed concerning samples, settings, follow-up periods and examined variables. Therefore, meta-analysis was not possible. Eight categories of risk factors emerged: disease-specific motor impairments, impaired vision, type and severity of dementia, behavioural disturbances, functional impairments, fall history, neuroleptics and low bone mineral density. CONCLUSION There is lack of sound studies examining fall risk factors in cognitively impaired elders. Well-known risk factors such as motor impairment show particular characteristics in people with dementia. In addition, behavioural disturbances contribute to their high risk for falls. Further prospective studies are needed.

Malnutrition prevalence in The Netherlands: results of the Annual Dutch National Prevalence Measurement of Care Problems

The objective of this study was to provide data on malnutrition prevalence in hospitals, nursing homes and home-care organisations in The Netherlands in a nationally representative sample, and to assess the factors such as age, sex, time since admission, ward type and disease for identifying patients at high risk of malnutrition. A cross-sectional, multi-centre design with a standardised questionnaire was used to measure the prevalence of malnutrition. Nutritional status was assessed by BMI, undesired weight loss and nutritional intake. In this study, 12 883 patients were included. The prevalence of malnutrition was the highest in hospitals (23.8 %), followed by home-care organisations (21.7 %) and nursing homes (19.2 %). Logistic regression analysis revealed no association with age, time since admission and ward type. Being female was associated with malnutrition only in nursing homes. Blood diseases, gastrointestinal tract diseases, infection, chronic obstructive pulmonary disease, dementia and cancer were the factors associated with malnutrition in hospitals. Dementia was associated with malnutrition in nursing homes, while gastrointestinal tract diseases, diabetes mellitus and cancer were the associated factors in home care. This study shows that malnutrition is still a substantial problem in hospitals, nursing homes and home care in The Netherlands. Malnutrition is a problem for more than one in five patients. Despite growing attention to the problem, more continued alertness is required.

Pressure ulcer prevalence and incidence in intensive care patients: a literature review.

BACKGROUND Pressure ulcers remain a common health problem worldwide within the different health-care settings, especially in intensive care settings. AIMS The aims of this were to systematically assess the recent prevalence and incidence of pressure ulcers in intensive care patients (2000-2005), the factors related to pressure ulcer prevalence and incidence and the methodological rigour of studies about pressure ulcer prevalence and incidence in intensive care patients. METHODS The research design involved a review of literature for the period of 2000 to 2005, focused on the prevalence and incidence of pressure ulcers in intensive care patients. RESULTS The analysis of published papers revealed variations in pressure ulcer prevalence in intensive care settings ranging from 4% in Denmark to 49% in Germany, while incidence ranged from 38% to 124%. There was a wide variation in the prevalence and incidence of pressure ulcers in intensive care patients as evidenced in the studies examined. There is also a gap between theory and practice in the prevention and treatment of pressure ulcers which needs to be addressed. CONCLUSION Further research is needed regarding the effectiveness of nursing care on pressure ulcer development and into treatments that may successfully prevent their occurrence in intensive care patients.

Validity and reliability of the Braden scale and the influence of other risk factors: a multi-centre prospective study

The Braden scale is one of the most intensively studied risk assessment scales used in identifying the risk of developing pressure sores. However, not all studies show that the sensitivity and specificity of this scale is sufficient. This study, therefore, investigated whether adding new risk factors can enhance the sensitivity and specificity of the Braden scale. The Braden scale was tested in a prospective multi-centre design. The nurses of 11 wards filled in the Braden scale every 5 days for each patient who was admitted without pressure sores and who had a probable stay of at least 10 days. Based on a literature study and in-depth interviews with experts, the Braden scale was extended by the risk factor blood circulation. In addition, other risk factors, which are more or less stable patient characteristics, were measured during the admission of the patient. Independent research assistants measured the presence of pressure sores twice a week. As the external criterion for the risk of developing pressure sores, the presence of pressure sores and/or the use of preventive activities was used. Results showed that the original Braden scale was a reliable instrument and that the sensitivity and specificity was sufficient. However, reformulating the factors moisture and nutrition, and adding the risk factor age could enhance the sensitivity and specificity. Furthermore, results showed that the factors sensory perception, and friction and shear were especially important risk factors for the Braden scale. In fact, using only the factors sensory perception, friction and shear, moisture (a reformulated factor) and age give the highest explained variance of the risk of developing pressure sores. The added risk factor blood circulation, did not enhance the sensitivity and specificity of the original Braden scale. Suggestions are given on how to use risk assessment scales in practice.

Quality of life in older patients with systolic and diastolic heart failure

To get insight into the quality of life of a clinical practice sample of patients with heart failure that are admitted to the hospital. Secondly to determine differences between patients with systolic and diastolic dysfunction and finally to describe factors relating to quality of life.

Malnutrition in Dutch health care: prevalence, prevention, treatment, and quality indicators.

OBJECTIVE In most health care organizations there is still insufficient awareness for recognizing and treating malnourished patients. To gain more insight into nutritional care policies in Dutch health care organizations, this study investigated screening, treatment, and other quality indicators of nutritional care. METHODS In 2007 a cross-sectional multicenter study was performed that included 20 255 patients (hospitals, n = 6021; nursing homes, n = 11 902; home care, n = 2332). A standardized questionnaire was used to study nutritional screening and treatment at the patient level and quality indicators at institutional and ward levels (e.g., malnutrition guidelines/protocols, nutritional education, and weighing policy). RESULTS Nutritional screening was performed more often in nursing homes (60.2%) than in hospitals (40.3%) and home care (13.9%, P < 0.001). In general, one in every five patients was malnourished, and nutritional treatment was applied in fewer than 50% of all malnourished patients in nursing homes, hospitals, and home care. At ward level nursing homes focused more on the quality of nutritional care than did hospitals and home care, especially with respect to controlling the use of nutritional guidelines (54.6%, P < 0.03), weighing at admission (82.9%, P < 0.01), and mealtime ambiance (91.8%, P < 0.01). CONCLUSION This large-scale study shows that malnutrition is still a considerable problem in one of every five patients in all participating health care settings. It furthermore demonstrates that recognizing and treating malnutrition continues to be problematic. To target the problem of malnutrition adequately, more awareness is needed of the importance of nutritional screening, appropriate treatment, and other nutritional quality indicators.

Relevance of the diagnosis ‘stage 1 pressure ulcer’: an empirical study of the clinical course of stage 1 ulcers in acute care and long‐term care hospital populations

Stage 1 pressure ulcers are difficult to diagnose. Several prevalence studies have shown that almost half of the pressure ulcers identified are stage 1. The present study investigated the importance of stage 1. The following research questions were formulated: Is there a difference between the prevalence of stage 1 pressure ulcers identified in the institutions participating in the present study and that found in the other institutions participating in the Dutch National Prevalence Survey? What percentage of stage 1 pressure ulcers are reversible within a few hours? What is the clinical course of stage 1 pressure ulcers? Which patient characteristics and preventive interventions are related to the clinical course of stage 1? The study used a prospective, descriptive and comparative design. All patients of six long-term care hospitals and six acute care hospitals in whom stage 1 pressure ulcers were identified during the 1999 National Prevalence Survey in the Netherlands were followed for 1 week (acute care hospitals; n = 68 patients) or 2 weeks (long-term care hospitals; n = 115 patients). The patients were reassessed using the questionnaire developed for the National Prevalence Survey (patient characteristics, assessment of risk of pressure ulcers, characteristics of the pressure ulcers and use of preventive methods) on the same day as the national survey itself, and again after 3 days, after 7 days and after 14 days (only long-term care hospitals). The results showed fewer stage 1 pressure ulcers in the institutions participating in the present study than in the National Prevalence Survey, the difference being almost 50%. The first reassessment found the prevalence of stage 1 to be further reduced by an average of almost 50%, a reduction which was greater for the long-term care hospitals than for the acute care hospitals. However, some of the ulcers that had disappeared reappeared in subsequent reassessments. In the long-term care hospitals, 8.7% of the stage 1 pressure ulcers deteriorated to a higher stage, vs. 22.1% in acute care hospitals. No significant patient characteristics were found to affect the course of stage 1, except that women in acute care hospitals more often had a stage 1 pressure ulcer at the first reassessment than men. In general, patients whose stage 1 ulcer deteriorated were undergoing more preventive interventions; not all differences were significant. We conclude that, although stage 1 is reversible in most cases, it can be interpreted as an important warning sign for nurses and patients to act. If no adequate interventions are applied, the pressure ulcer may deteriorate.

On the development of a multidimensional Dutch pain assessment tool for children

&NA; The Abu‐Saad Pediatric Pain Assessment Tool consists of 30 word descriptors in the sensory, affective and evaluative domains as well as a 10 cm scale that measures present and worst pain experienced by the child. In the first phase of the study an inventory was carried out of pain word descriptors used by hospitalized Dutch children. In the second phase, these word descriptors were given an intensity value on the 10 cm scale by 355 children. Alpha reliability coefficient of 0.83 supported instrument homogeneity. Factor analysis (N = 355) was used to investigate construct validity. A 3‐factor solution was carried out to evaluate the validity of the 3 dimensions of pain. Factor I consisted of items in the affective and evaluative domains and factors II and III items from the sensory domain. Ultimately a 2‐factor solution provided the most intelligible conceptual pattern with the least loss of information. Conceptual composition and discussion of these factors are discussed and elaborated.