An Interprofessional Approach to Reducing the Risk of Falls Through Enhanced Collaborative Practice.

Falls are the leading cause of accidental deaths in older adults and are a growing public health concern. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) published guidelines for falls screening and risk reduction, yet few primary care providers report following any guidelines for falls prevention. This article describes a project that engaged an interprofessional teaching team to support interprofessional clinical teams to reduce fall risk in older adults by implementing the AGS/BGS guidelines. Twenty-five interprofessional clinical teams with representatives from medicine, nursing, pharmacy, and social work were recruited from ambulatory, long-term care, hospital, and home health settings for a structured intervention: a 4-hour training workshop plus coaching for implementation for 1 year. The workshop focused on evidence-based strategies to decrease the risk of falls, including screening for falls; assessing gait, balance, orthostatic blood pressure, and other medical conditions; exercise including tai chi; vitamin D supplementation; medication review and reduction; and environmental assessment. Quantitative and qualitative data were collected using chart reviews, coaching plans and field notes, and postintervention structured interviews of participants. Site visits and coaching field notes confirmed uptake of the strategies. Chart reviews showed significant improvement in adoption of all falls prevention strategies except vitamin D supplementation. Long-term care facilities were more likely to address environmental concerns and add tai chi classes, and ambulatory settings were more likely to initiate falls screening. The intervention demonstrated that interprofessional practice change to target falls prevention can be incorporated into primary care and long-term care settings.

[PREVFNAIT prevention of foetal/neonatal alloimmune thrombocytopenia (FNAIT) in Polish foetuses and newborns--the PREVFNAIT program]. / Zapobieganie alloimmunologicznej maloplytkowosci plodów i noworodków (AIMPN) w Polsce--program PREVFNAIT.

The scientific goals related to the grant include 1) estimation of FNAIT prevalence in Poland and 2) search for biomarkers to predict the risk of the antibody production and severity of fetal thrombocytopenia. Fetal/Neonatal Alloimmune Thrombocytopenia (FNAIT) is caused by destruction of fetal blood platelets due to maternal antibodies. This condition, which most commonly results from incompatibility between the mother and the fetus for the Human Platelet Antigen-1a (HPA-1a), may lead to intracranial hemorrhage, damage of the central nervous system (CNS) and even death of the fetus or the newborn. It can be the cause of strokes in term newborns. FNAIT is usually attributed to the presence of anti-HPA-1a antibodies. Its incidence rate is estimated at approximately 1/1000-2000 live births. In the absence of a screening program, it is usually diagnosed after birth of a child with symptoms of thrombocytopenia or CNS hemorrhage. Monitoring of antibody production and thrombocytopenia treatment to effectively minimize the risk of stroke are therefore launched only at the next pregnancy. Testing indications are broader to include fetal ultrasound for symptoms of stroke to the CNS, ventricular enlargement or hydrocephalus, and obstetric failure. Diagnostic process is also recommended prior to the planned cordocentesis, in vitro fertilization and in sisters of mothers with children with FNAIT history. HPA-1a testing remains the best method for diagnosing pregnancies at risk. The detection frequency for FNAIT in Poland remains low. Therefore, the Institute of Hematology and Transfusion Medicine (IHTM) will have performed such HPA-1a antigen testing in 30 000 Polish women within the framework of the PREVFNAIT program by March 2016. HPA-1a negative women (2% of the population) are a risk group for production of anti- HPA-1a antibodies responsible for FNAIT therefore all of them will be monitored for the presence and activity of anti-HPA-1a antibodies. Such testing will be performed free of charge for the women.

Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care.

The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.

Using simulation to identify and resolve threats to patient safety.

BACKGROUND: The simulation-based team training used in commercial aviation can provide healthcare professionals with guidance on improving patient safety. OBJECTIVE: To show how in situ simulation can identify latent environmental threats to patient safety. STUDY DESIGN: Case study. METHODS: This in situ simulation took place at a large Midwestern hospital in January 2007. It involved a patient with chest pain and hypotension that required cardiac catheterization. The simulation had 2 phases: emergency department and catheterization laboratory. Materials included a patient manikin, a high-definition camcorder, and software for annotating the video in real time. Props (eg, simulated electrocardiogram results, chest x-rays) were used. A Master Scenario Event List was used to orchestrate the entire simulation event. RESULTS: Three latent environmental threats to patient safety were identified: procedures for transporting patients between the 2 units, for managing the handoff process, and for organizing the cardiac catheterization process. These were not training issues, but were due to poorly developed or nonexistent procedures that affected the performance of all healthcare teams on those units every working day. The threats were identified by the simulation participants (along with their supervisors) during the post-simulation debriefing as being sufficiently common and dangerous to warrant further review and remedy. CONCLUSION: By conducting our simulations in the actual environment of care, using intact teams of healthcare professionals who practiced their actual technologies and work processes during the simulation, we could identify latent environmental threats to patient safety that could never be explored in an artificial laboratory environment.

[Integrated care for patients with advanced chronic obstructive pulmonary disease]. / Zintegrowana opieka medyczna u chorych na zaawansowana przewlekla obturacyjna chorobe pluc.

Chronic obstructive pulmonary disease (COPD) is the third cause of mortality and disability (assessed by DALY) among patients above 60 year old. Severe and very severe COPD (FEV(1) = equal or less than 50% and 30% of expected value, respectively) is estimated at 20% of all COPD patients. Advanced COPD usually leads to physical and mental deterioration, the patients often manage with the problems caused by the disease and other comorbidities poorly. This leads to increased risk of COPD exacerbations and further deterioration of the patient's status, increased costs of medical care and eventually increased risk of death. Current organization of medical care for those patients does not provide adequate health and social support for them. However, it seems that introducing an integrated approach proposed by World Health Organization, could improve the situation of advanced COPD patients. In Poland, this kind of care has been provided in advanced cancer patients throughout stationary palliative care units and hospices during the last several years. This experience should be helpful in integrating actions of general practitioners and specialized nurses, as well as providing access for the specialists' consultations according to the individual needs of the patients. It should also allow for broad cooperation with auxiliary staff, such as social workers, medical assistants and volunteers, as well as psychologists and clergymen (especially in the terminal phase of the disease).

Risk evaluation and mitigation strategies for drugs with abuse liability: public interest, special interest, conflicts of interest, and the industry perspective.

Risk evaluation and mitigation strategies (REMS) formerly known as Risk Minimization Action Plans (RiskMAPs) are a regulatory technique for dealing with anticipated risks of new medications and are especially important for new drugs with abuse potential. This paper describes the origin and history of risk-management plans for drugs that might be abused, the proper use of these plans in minimizing the risk to the public, and the special difficulties inherent in managing risks for drugs with abuse potential. Drugs with abuse liability are distinctive since the risks inherent in manufacture and distribution include not only risks to patients prescribed the medications, but also risks to the general public including subgroups in the population not intended to get the drug and who receive no medical benefit from the medication. The crafting of risk-management plans intended to protect nonpatient populations is unique for these products. The content, extent, and level of intensity of these plans affect areas of medical ethics, civil liability, and criminal prosecution. The need for risk-management plans for drugs with abuse liability can potentially act as a deterrent to investment and is a factor in decisions concerning the development of new medications for the treatments of pain, ADHD, anxiety disorders, and addictions. This paper provides a framework for moving the process of REMS development forward and criteria for evaluating the probity and adequacy of such programs.

Scoping the family history: assessment of Lynch syndrome (hereditary nonpolyposis colorectal cancer) in primary care settings--a primer for nurse practitioners.

PURPOSE: To describe and discuss the characteristic features and red flags of Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer, that warrants referral for genetic cancer risk assessment (GCRA). A focus on the nurse practitioner's (NP) role in familial risk assessment, physical examination, initiation of genetic referrals, and issues related to the genetic counseling process are also discussed. DATA SOURCES: A review and synopsis of professional guidelines, clinical articles, and research studies on Lynch syndrome and the genetics of inherited cancer syndromes associated with colorectal cancer. Online resources from the American Gastroenterological Association, American Medical Association, the American Nurses Association, the National Comprehensive Cancer Network, the National Cancer Institute, the National Cancer Institute-Physician Data Query, the National Coalition of Health Professional Education in Genetics, the National Human Genome Research Institute, the National Society of Genetic Counselors, International Society of Nurses in Genetics, and the Oncology Nursing Society. CONCLUSIONS: Approximately 5% of all colon cancers are because of a germ line mutation predisposing individuals and their family members to colorectal and other cancers. Although the efficacy of screening modalities is established, healthcare providers often fail to identify those at greatest risk for disease. The extended family history is the first step in recognition of individuals "suspect" for hereditary colon cancers such as Lynch syndrome. Early-age onset of Lynch syndrome-associated cancers, an autosomal-dominant pattern, multiple primary tumors in an individual or multiple family members with Lynch syndrome-associated cancers, characteristic pathological features of colon cancer, or a known germ line Lynch syndrome mutation in a family member are "red flags" that will aid NPs in identifying individuals who may benefit from GCRA. IMPLICATIONS FOR NURSE PRACTITIONER PRACTICE: The importance of enhanced surveillance for early diagnosis and prevention of disease is a critical part of primary care. Thus, it is imperative that NPs obtain a minimum of a three-generation pedigree, recognize hereditary cancer patterns, and provide referral counseling for consideration of genetic testing of individuals suspect for Lynch syndrome.

Integrated approach for managing health risks at work--the role of occupational health nurses.

Currently, many organizations are using a department-centered approach to manage health risks at work. In such a model, segregated departments are providing employee benefits such as health insurance, workers' compensation, and short- and long-term disability or benefits addressing work-life issues. In recent years, a new model has emerged: health and productivity management (HPM). This is an employee-centered, integrated approach, designed to increase efficiency, reduce competition for scarce resources, and increase employee participation in prevention activities. Evidence suggests that corporations using integrated HPM programs achieve better health outcomes for their employees, with consequent increased productivity and decreased absenteeism. Occupational health nurses are well positioned to assume leadership roles in their organizations by coordinating efforts and programs across departments that offer health, wellness, and safety benefits. To assume their role as change agents to improve employees' health, nurses should start using the language of business more often by improving their communication skills, computer skills, and ability to quantify and articulate results of programs and services to senior management.

Assessment of feminization of male fish in English rivers by the Environment Agency of England and Wales.

In recent years there has been considerable concern over the ability of substances discharged into the environment to disrupt the normal endocrine function of wildlife. In particular, the apparent widespread feminization of male fish in rivers has received significant attention from regulators in the United Kingdom, the United States, Europe, and Japan. The U.K. and European epidemiological data sets have demonstrated that the occurrence of feminized fish is associated with effluent discharges and that the incidence and severity is positively correlated with the proportion of treated sewage effluent in receiving waters. Although weakly estrogenic substances may contribute to the overall effect, studies have concluded that steroid estrogens are the principal and most potent estrogenic components of domestic sewage. Extensive laboratory data sets confirm that steroid estrogens are capable of eliciting the effects observed in wild fish at concentrations that have been measured in effluents and in the environment. Based on evaluation of the available information, the Environment Agency (England and Wales) has concluded that the weight of evidence for endocrine disruption in fish is sufficient to develop a risk management strategy for estrogenically active effluents that discharge to the aquatic environment.

Protecting people against radiation exposure in the event of a radiological attack. A report of The International Commission on Radiological Protection.

This report responds to a widely perceived need for professional advice on radiological protection measures to be undertaken in the event of a radiological attack. The report, which is mainly concerned with possible attacks involving 'radioactive dispersion devices', re-affirms the applicability of existing ICRP recommendations to such situations, should they ever occur. Many aspects of the emergency scenarios expected to arise in the event of a radiological attack may be similar to those that experience has shown can arise from radiological accidents, but there may also be important differences. For instance, a radiological attack would probably be targeted at a public area, possibly in an urban environment, where the presence of radiation is not anticipated and the dispersion conditions commonly assumed for a nuclear or radiological emergency, such as at a nuclear installation, may not be applicable. First responders to a radiological attack and other rescuers need to be adequately trained and to have the proper equipment for identifying radiation and radioactive contamination, and specialists in radiological protection must be available to provide advice. It may be prudent to assume that radiological, chemical, and/or biological agents are involved in an attack until it is proven otherwise. This calls for an 'all-hazard' approach to the response. In the aftermath of an attack, the main aim of radiological protection must be to prevent the occurrence of acute health effects attributable to radiation exposure (termed 'deterministic' effects) and to restrict the likelihood of late health effects (termed 'stochastic' effects) such as cancers and some hereditable diseases. A supplementary aim is to minimise environmental contamination from radioactive residues and the subsequent general disruption of daily life. The report notes that action taken to avert exposures is a much more effective protective measure than protective measure the provision of medical treatment after exposure has occurred. Responders involved in recovery, remediation and eventual restoration should be subject to the usual international standards for occupational radiological protection, which are based on ICRP recommendations, including the relevant requirements for occupational dose limitation established in such standards. These restrictions may be relaxed for informed volunteers undertaking urgent rescue operations, and they are not applicable for voluntary life-saving actions. However, specific protection measures are recommended for female workers who may be pregnant or nursing an infant. The immediate countermeasures to protect the public in the rescue phase are primarily caring for people with traumatic injuries and controlling access. Subsequent actions include respiratory protection, personal decontamination, sheltering, iodine prophylaxis (if radio-iodines are involved), and temporary evacuation. In the recovery phase, the relocation and resettlement of people may be needed in extreme cases. This phase may require remedial action, including cleanup, management of the resulting radioactive waste, management of any human remains containing significant amounts of radioactive substances, and dealing with remaining radioactive residues. The guidance given in relation to public protection is based solely on radiological protection considerations and should be seen as a decision-aiding tool to prepare for the aftermath of a radiological attack. It is expected to serve as input to a final decision-making process that may include other societal concerns, consideration of lessons learned in the past (especially these involving the public perception of the risks posed by radioactive contamination) and the participation of interested parties. A radiological attack could also be the cause of radioactive contamination of water, food, and other widely consumed commodities. This possible outcome is considered unlikely to lead to significant internal contamination of a large number of people owing to the large amounts of radioactive material that would be required to cause high levels of contamination of water, food, and other commodities. Nonetheless, the report recommends radiological criteria for restricting the use of commodities under such circumstances. The report concludes by re-iterating that the response to radiological attacks should be planned beforehand following the customary processes for optimisation of radiological protection recommended by ICRP, and that optimised measures should be prepared in advance. Such plans should result in a systematic approach that can be modified if necessary to take into account the prevailing conditions and to invoke actions as warranted by the circumstances. Many potential scenarios clearly cannot induce immediate severe radiation injuries. Therefore, in order to prevent over-reaction, response measures prepared in advance should reflect the real expected gravity of the various possible scenarios.

International radiobiology archives of long-term animal studies: structure, possible uses and potential extension.

Animal experiments have contributed a great deal to our information on effects and risks arising from exposure to radionuclides. This applies, in particular, to alpha-emitting radionuclides where information from man is limited to thorotrast, 224Ra and 226Ra. The late C.W. Mays was the first to suggest that animal data in conjunction with epidemiological data could allow estimates of human risks for radionuclides - predominantly from actinides - where information in man is scarce. The 'International Radiobiology Archives of Long-term Animal Studies' were created through the combined efforts of European, American and Japanese scientists and aim to safeguard the large amount of existing data on long-term animal experiments and make them available for, among others, an improved assessment of risks from alpha-emitting radionuclides. This paper summarizes the structure of the archives and reviews their present status and future plans. It also demonstrates the extensive information available in these archives on alpha-emitting radionuclides which is suitable for further analysis. Also, the structure of the animal archives could - in a slightly modified form - accommodate the epidemiological data available on 224Ra and thorotrast and, thus, facilitate a direct comparison of data from man, dogs and rodents.