Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation.

Background: Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. Aim: To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England. Design: Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Setting: Three Trusts, one orthopaedic and one older person ward in each. Results: Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. Limitations: Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. Conclusions: (1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. Future work: (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English. Study registration: This study is registered as PROSPERO CRD42020184458. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Many accidental falls by older people in hospitals could be avoided. There are guidelines to prevent falls, but some hospitals are better at following them than others. This study aimed to find out why. First, we looked at research and hospitals' falls policies for ideas about what stops falls. With advice from service users, we tested these ideas in four hospitals in England, watching how falls were prevented on wards for older people and people who need bone care, and talking to 50 staff, 28 patients and 3 carers. We found the following: Falls leadership: wards had staff called falls link practitioners who supported falls prevention, but senior nurses, not link practitioners, made the most important decisions. Sharing responsibility: patients with falls risks were monitored to try to stop falls. Because only nursing teams were always present to monitor patients, they had most responsibility for preventing falls. This limited sharing responsibility with other staff. Computer tools: nurses used computers to record prevention work, but high workloads could make this a 'tick-box' exercise. Computer tools reminded them to do this, although tools varied. Patients had individual falls plans, but they were also ranked more generally as high or low risk of falling, with 'high-risk' patients being monitored. Patient involvement: nursing staff did not have time to explain to patients how to prevent falls, but other staff could have such conversations. Many patients had problems like dementia and found it difficult to follow safety advice, although some could take steps to keep safe, with sensitive staff support. We need to involve patients, carers and different staff in falls prevention. Hospitals could develop computer systems to support this, think how to involve more ward staff, and provide guidance on helpful ways to talk with patients about falls.

Exploring variation in implementation of multifactorial falls risk assessment and tailored interventions: a realist review.

BACKGROUND: Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals. METHODS: A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers. RESULTS: Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging. CONCLUSIONS: Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients' individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate. TRIAL REGISTRATION: PROSPERO: CRD42020184458.

Predictive model-based interventions to reduce outpatient no-shows: a rapid systematic review.

OBJECTIVE: Outpatient no-shows have important implications for costs and the quality of care. Predictive models of no-shows could be used to target intervention delivery to reduce no-shows. We reviewed the effectiveness of predictive model-based interventions on outpatient no-shows, intervention costs, acceptability, and equity. MATERIALS AND METHODS: Rapid systematic review of randomized controlled trials (RCTs) and non-RCTs. We searched Medline, Cochrane CENTRAL, Embase, IEEE Xplore, and Clinical Trial Registries on March 30, 2022 (updated on July 8, 2022). Two reviewers extracted outcome data and assessed the risk of bias using ROB 2, ROBINS-I, and confidence in the evidence using GRADE. We calculated risk ratios (RRs) for the relationship between the intervention and no-show rates (primary outcome), compared with usual appointment scheduling. Meta-analysis was not possible due to heterogeneity. RESULTS: We included 7 RCTs and 1 non-RCT, in dermatology (n = 2), outpatient primary care (n = 2), endoscopy, oncology, mental health, pneumology, and an magnetic resonance imaging clinic. There was high certainty evidence that predictive model-based text message reminders reduced no-shows (1 RCT, median RR 0.91, interquartile range [IQR] 0.90, 0.92). There was moderate certainty evidence that predictive model-based phone call reminders (3 RCTs, median RR 0.61, IQR 0.49, 0.68) and patient navigators reduced no-shows (1 RCT, RR 0.55, 95% confidence interval 0.46, 0.67). The effect of predictive model-based overbooking was uncertain. Limited information was reported on cost-effectiveness, acceptability, and equity. DISCUSSION AND CONCLUSIONS: Predictive modeling plus text message reminders, phone call reminders, and patient navigator calls are probably effective at reducing no-shows. Further research is needed on the comparative effectiveness of predictive model-based interventions addressed to patients at high risk of no-shows versus nontargeted interventions addressed to all patients.

What supports and constrains the implementation of multifactorial falls risk assessment and tailored multifactorial falls prevention interventions in acute hospitals? Protocol for a realist review.

INTRODUCTION: Falls are the most common type of safety incident reported by acute hospitals and can cause both physical (eg, hip fractures) and non-physical harm (eg, reduced confidence) to patients. It is recommended that, in order to prevent falls in hospital, patients should receive a multifactorial falls risk assessment and be provided with a multifactorial intervention, tailored to address the patient's identified individual risk factors. It is estimated that such an approach could reduce the incidence of inpatient falls by 25%-30% and reduce the annual cost of falls by up to 25%. However, there is substantial unexplained variation between hospitals in the number and type of assessments undertaken and interventions implemented. METHODS AND ANALYSIS: A realist review will be undertaken to construct and test programme theories regarding (1) what supports and constrains the implementation of multifactorial falls risk assessment and tailored multifactorial falls prevention interventions in acute hospitals; and (2) how, why, in what contexts and for whom tailored multifactorial falls prevention interventions lead to a reduction in patients' falls risk. We will first identify stakeholders' theories concerning these two topics, searching Medline (1946-present) and Medline In-Process & Other Non-Indexed Citations, Health Management Information Consortium (1983-present) and CINAHL (1981-present). We will then test these theories systematically, using primary studies to determine whether empirical evidence supports, refutes or suggests a revision or addition to the identified theories. ETHICS AND DISSEMINATION: The study does not require ethical approval. The review will provide evidence for how to implement multifactorial falls risk assessment and prevention strategies in acute hospital settings. This will be disseminated to academic and clinical audiences and will provide the basis for a future multi-site study through which the theories will be further refined. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020184458.

Decision-making Factors Associated With Telehealth Adoption by Patients With Heart Failure at Home: A Qualitative Study.

Telehealth has been reported to be effective in helping patients with heart failure manage their symptoms at home. Despite this, the adoption rate for telehealth among home care patients with heart failure is low, and there is limited research on reasons for this. This study was undertaken to explore factors associated with patients' decisions to adopt telehealth at home. A qualitative descriptive study underpinned by the Unified Theory of Acceptance Use of Technology model was conducted using semi-structured telephone interviews with patients with heart failure (N = 20) referred for telehealth. Interviews were analyzed using a mixture of deductive and inductive coding. Among the theoretical model elements, the perceived usefulness of the technology (performance expectancy), the availability of clinical/technical support (facilitating conditions), and the opinion of other individuals important to the patient (social influence) were associated with telehealth initiation. However, the ease of use (effort expectancy) was not an associated factor. Other factors such as experience, knowledge, confidence, satisfaction, and attitudes were also associated with the decision. Identification of factors related to higher telehealth initiation rates can be used to inform individualized care planning by nurses. Knowledge of such associations can inform referral process to improve the efficiency and utilization of telehealth.

Clinical decision-making at the end of life: a mixed-methods study.

OBJECTIVES: To improve the ability of clinical staff to recognise end of life in hospital inpatients dying as a result of cancer and heart failure, and to generate new hypotheses for further research. METHODS: This mixed-methods study used decision theory as a theoretical basis. It involved a parallel databases-convergent design, incorporating findings from previously published research, with equal priority to study groups and synthesis by triangulation. The individual arms were (1) a retrospective cohort study of 102 patients with cancer and 81 patients with heart failure in an acute trust in the North of England, and(2) a semistructured interview study of 19 healthcare professionals caring for the same patient groups. RESULTS: The synthesis of findings demonstrated areas of agreement, partial agreement, silence and dissonance when comparing the cohort findings with the interview findings. Trajectories of change are identified as associated with poor prognosis in both approaches, but based on different parameters. Management of patients has a significant impact on decision-making. The decision process requires repeated, iterative assessments and may benefit from a multidisciplinary approach. Uncertainty is a defining characteristic of the overall process, and objective parameters only have a limited role in predicting end of life. CONCLUSIONS: The role of uncertainty is important as a trigger for discussions and a defined stage in a patient's illness journey. This is consistent with current approaches to recognising irreversible deterioration in those with serious illness. This study contributes ongoing evidence that these concepts are vital for decision-making.

Assessing Sexual Orientation and Gender Identity in Home Health Care: Perceptions and Attitudes of Nurses.

Purpose: The purpose of this study was to explore home health care nurses' attitudes, perceptions, and experiences related to routine collection and documentation of sexual orientation and gender identity data. Methods: This was a qualitative descriptive study. Twenty-four nurses from a large home health care agency in the New York metropolitan area were interviewed between November 2014 and December 2015. Results: Three broad categories of themes emerged from the content analysis: (1) current practices that relate to or influence the assessment of sexual orientation or gender identity by home health care nurses, (2) attitudes and perceptions regarding perceived barriers and facilitators to discussing and documenting sexual orientation and gender identity, and (3) training and resources identified as helpful in preparing nurses to discuss sexual orientation and gender identity with their patients. Nurses emphasized wanting to provide everyone with the same quality of care and wanted documentation to inform the care. They felt unprepared to discuss sexual orientation or gender identity with their patients and indicated a need for training and education related to LGBT health disparities. Conclusions: Results from this study can help inform the development of training materials and resources to enable nurses to collect patients' sexual orientation and gender identity data routinely and in a sensitive and culturally competent manner.

Hospitalization risk factors of older cohorts of home health care patients: A systematic review.

Nearly one million Medicare home health care beneficiaries are hospitalized annually of which one-quarter are considered preventable. Older hospitalized patients are at risk for nosocomial complications and poorer outcomes and incur higher health care costs. This paper reports the results of a systematic review of 28 studies on hospitalization risk factors of older home health care patients. It found that males, Blacks, and non-Asian minorities are at greater hospitalization risk. Factors associated with higher risk included skin ulcers, psychiatric conditions, dyspnea/COPD, cardiovascular conditions, diabetes, functional deficits, more comorbidities, and higher medication usage. These findings can inform practice, research, and policy.

Nurse Documentation of Sexual Orientation and Gender Identity in Home Healthcare: A Text Mining Study.

Health disparities have been documented in the lesbian, gay, bisexual, and transgender population, but more research is needed to better understand how to address them. To that end, this observational study examined what is documented about sexual orientation and gender identity in narrative home care nurses' notes in an electronic health record. Lexical text mining approaches were used to examine a total of 862 715 clinical notes from 20 447 unique patients who received services from a large home care agency in Manhattan, New York, and extracted notes were qualitatively reviewed to build a lexicon of terms for use in future research. Forty-two notes, representing 35 unique patients, were identified as containing documentation of the patient's sexual orientation or gender identity. Documentation of sexual orientation or gender identity was relatively infrequent, compared to the estimated frequency of lesbian, gay, bisexual, and transgender people in the US population. Issues related to fragmentary language emerged, and variety in phrasing and word frequency was identified between different types of notes and between providers. This study provides insight into what nurses in home healthcare document about sexual orientation and gender identity and their clinical priorities related to such documentation, and provides a lexicon for use in further research in the home care setting.

The impact of home care nurses' numeracy and graph literacy on comprehension of visual display information: implications for dashboard design.

Objective: To explore home care nurses' numeracy and graph literacy and their relationship to comprehension of visualized data. Materials and Methods: A multifactorial experimental design using online survey software. Nurses were recruited from 2 Medicare-certified home health agencies. Numeracy and graph literacy were measured using validated scales. Nurses were randomized to 1 of 4 experimental conditions. Each condition displayed data for 1 of 4 quality indicators, in 1 of 4 different visualized formats (bar graph, line graph, spider graph, table). A mixed linear model measured the impact of numeracy, graph literacy, and display format on data understanding. Results: In all, 195 nurses took part in the study. They were slightly more numerate and graph literate than the general population. Overall, nurses understood information presented in bar graphs most easily (88% correct), followed by tables (81% correct), line graphs (77% correct), and spider graphs (41% correct). Individuals with low numeracy and low graph literacy had poorer comprehension of information displayed across all formats. High graph literacy appeared to enhance comprehension of data regardless of numeracy capabilities. Discussion and Conclusion: Clinical dashboards are increasingly used to provide information to clinicians in visualized format, under the assumption that visual display reduces cognitive workload. Results of this study suggest that nurses' comprehension of visualized information is influenced by their numeracy, graph literacy, and the display format of the data. Individual differences in numeracy and graph literacy skills need to be taken into account when designing dashboard technology.

Factors Affecting the Acceptance of Telehealth Services by Heart Failure Patients: An Integrative Review.

BACKGROUND: While telehealth has been shown to improve heart failure patients' health outcomes, patients' acceptance of telehealth at the point of referral is reported to be low. Little is known about the factors related to patients' initial acceptance or refusal of telehealth services. The aim of this review was to synthesize evidence on the factors affecting heart failure patients' decision making to accept telehealth services in a home setting. METHODS: An integrative literature review was conducted. Six electronic databases and three grey literature sites were searched. Two reviewers independently reviewed articles for inclusion. Articles were included if they reported original data related to the acceptance of telehealth services among heart failure patients at home. RESULTS: Five studies met the inclusion criteria and were included in the review. Key findings indicated that patients generally hold positive views about telehealth. Factors that may affect the adoption of telehealth include concerns over equipment or technology, concerns over service change, ease-of-use, knowledge of the benefits of telehealth, access to care, cost, and privacy. CONCLUSIONS: Despite evidence of effectiveness for telehealth, there is a high rate of telehealth refusal among patients. Understanding factors associated with heart failure patients' decisions regarding telehealth can help healthcare organizations structure education programs and other interventions to improve acceptance rates.

Patient perspectives on answering questions about sexual orientation and gender identity: an integrative review.

AIMS AND OBJECTIVES: To examine patients' perceptions of being asked about their sexual orientation and gender identity in the healthcare setting. BACKGROUND: Health disparities exist in the lesbian, gay, bisexual and transgender population, but further research is needed to better understand these disparities. To address this issue, experts recommend the routine collection of sexual orientation and gender identity data in health care. Nurses on the front line of patient care play a key role in the collection of these data. However, to enable nurses to conduct such assessments it is important to understand the perspective of the patients on being asked about their sexual orientation and gender identity in a healthcare setting. DESIGN: An integrative review was conducted using the methodology proposed by Whittemore and Knafl (Journal of Advanced Nursing, 2005, 52, 546). METHODS: Six electronic databases were searched, and two reviewers independently reviewed papers for inclusion. Papers were included if they were empirical studies, peer-reviewed papers or reports, assessing patient perspectives on discussing sexual orientation and gender identity in the healthcare setting. RESULTS: Twenty-one relevant studies that met the inclusion criteria were identified. A majority of the studies indicated patients' willingness to respond to, and a perceived importance of, questions about sexual orientation and gender identity. However, fears of homophobia and negative consequences hindered willingness to disclose this information. CONCLUSIONS: This review indicates that in most cases patients are willing to answer routine questions about their sexual orientation in the healthcare setting and perceive them as important questions to ask. RELEVANCE TO CLINICAL PRACTICE: The findings of this review have implications for nurses looking to incorporate questions about sexual orientation into their routine patient assessment. The findings indicate that care providers need to be mindful of heteronormative assumptions and take steps to ensure they are knowledgeable about lesbian, gay, bisexual and transgender health.

The Future of Home Health Care: A Strategic Framework for Optimizing Value.

The Future of Home Health project sought to support transformation of home health and home-based care to meet the needs of patients in the evolving U.S. health care system. Interviews with key thought leaders and stakeholders resulted in key themes about the future of home health care. By synthesizing this qualitative research, a literature review, case studies, and the themes from a 2014 Institute of Medicine and National Research Council workshop on "The Future of Home Health Care," the authors articulate a vision for home-based care and recommend a bold framework for the Medicare-certified home health agency of the future. The authors also identify challenges and recommendations for achievement of this framework.

The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective.

BACKGROUND: Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group. METHODS: A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory. RESULTS: Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time. CONCLUSIONS: There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.

Using Mixed Methods in Health Information Technology Evaluation.

With the increasing adoption of interactive systems in healthcare, there is a need to ensure that the benefits of such systems are formally evaluated. Traditionally quantitative research approaches have been used to gather evidence on measurable outcomes of health technology. Qualitative approaches have also been used to analyze how or why particular interventions did or did not work in specific healthcare contexts. Mixed methods research provides a framework for carrying out both quantitative and qualitative approaches within a single research study. In this paper an international group of four informatics scholars illustrate some of the benefits and challenges of using mixed methods in evaluation. The diversity of the research experience provides a broad overview of approaches in combining robust analysis of outcome data with qualitative methods that provide an understanding of the processes through which, and the contexts in which, those outcomes are achieved. This paper discussed the benefits that mixed methods brought to each study.

Using sense-making theory to aid understanding of the recognition, assessment and management of pain in patients with dementia in acute hospital settings.

BACKGROUND: The recognition, assessment and management of pain in hospital settings is suboptimal, and is a particular challenge in patients with dementia. The existing process guiding pain assessment and management in clinical settings is based on the assumption that nurses follow a sequential linear approach to decision making. In this paper we re-evaluate this theoretical assumption drawing on findings from a study of pain recognition, assessment and management in patients with dementia. AIM: To provide a revised conceptual model of pain recognition, assessment and management based on sense-making theories of decision making. METHODS: The research we refer to is an exploratory ethnographic study using nested case sites. Patients with dementia (n=31) were the unit of data collection, nested in 11 wards (vascular, continuing care, stroke rehabilitation, orthopaedic, acute medicine, care of the elderly, elective and emergency surgery), located in four NHS hospital organizations in the UK. Data consisted of observations of patients at bedside (170h in total); observations of the context of care; audits of patient hospital records; documentary analysis of artefacts; semi-structured interviews (n=56) and informal open conversations with staff and carers (family members). FINDINGS: Existing conceptualizations of pain recognition, assessment and management do not fully explain how the decision process occurs in clinical practice. Our research indicates that pain recognition, assessment and management is not an individual cognitive activity; rather it is carried out by groups of individuals over time and within a specific organizational culture or climate, which influences both health care professional and patient behaviour. CONCLUSIONS: We propose a revised theoretical model of decision making related to pain assessment and management for patients with dementia based on theories of sense-making, which is reflective of the reality of clinical decision making in acute hospital wards. The revised model recognizes the salience of individual cognition as well as acknowledging that decisions are constructed through social interaction and organizational context. The model will be used in further research to develop decision support interventions to assist with the assessment and management of patients with dementia in acute hospital settings.

Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools.

BACKGROUND: There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment. METHODS: We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach. RESULTS: We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations. CONCLUSIONS: There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.

Developing a pressure ulcer risk factor minimum data set and risk assessment framework.

AIM: To agree a draft pressure ulcer risk factor Minimum Data Set to underpin the development of a new evidenced-based Risk Assessment Framework. BACKGROUND: A recent systematic review identified the need for a pressure ulcer risk factor Minimum Data Set and development and validation of an evidenced-based pressure ulcer Risk Assessment Framework. This was undertaken through the Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research and incorporates five phases. This article reports phase two, a consensus study. DESIGN: Consensus study. METHOD: A modified nominal group technique based on the Research and Development/University of California at Los Angeles appropriateness method. This incorporated an expert group, review of the evidence and the views of a Patient and Public Involvement service user group. Data were collected December 2010-December 2011. FINDINGS: The risk factors and assessment items of the Minimum Data Set (including immobility, pressure ulcer and skin status, perfusion, diabetes, skin moisture, sensory perception and nutrition) were agreed. In addition, a draft Risk Assessment Framework incorporating all Minimum Data Set items was developed, comprising a two stage assessment process (screening and detailed full assessment) and decision pathways. CONCLUSION: The draft Risk Assessment Framework will undergo further design and pre-testing with clinical nurses to assess and improve its usability. It will then be evaluated in clinical practice to assess its validity and reliability. The Minimum Data Set could be used in future for large scale risk factor studies informing refinement of the Risk Assessment Framework.

Barriers to the diagnosis and treatment of venous thromboembolism in advanced cancer patients: a qualitative study.

BACKGROUND: Venous thromboembolism is common in patients with cancer and the risk increases with advanced disease. Evidence-based treatment is administration of low-molecular-weight heparin daily by subcutaneous injection. Clinical uncertainty exists as to whether treating venous thromboembolism in advanced disease is in the patient's best interests. AIM: To explore the barriers faced by doctors when diagnosing and treating patients with cancer-associated thrombosis. DESIGN: Qualitative, in-depth interview study using framework analysis. PARTICIPANTS: Forty-five UK doctors across urban and rural settings, from three specialties, oncology, palliative medicine and general practice, with a mixture of senior and junior staff. RESULTS: Organisational constraints served to act as barriers to the diagnosis and treatment of this patient group. Issues were identified around access to diagnostic testing. A cancer-associated thrombosis patient having to wait for a scan as an inpatient was sometimes deemed unnecessary. Patient ambulance transport (especially transportation of hospice patients) was often viewed as inflexible and bureaucratic. Low-molecular-weight heparin prescribing had sometimes led to tension between the acute, community and hospice sectors about whose prescribing responsibility this was, with different areas having divergent 'rules' and practices. Finally, the doctors interviewed discussed the role of nurses. CONCLUSIONS: Multiple logistical barriers are hindering best patient care for people with cancer-associated thrombosis. There is scope for some of these barriers to be reduced to improve service delivery and ultimately patient care. The research team proposes practical recommendations, which could yield direct benefit for patients and the health services.