Managing fire risk in housebound people who smoke and require air-alternating pressure-relieving equipment.

Air-alternating pressure mattresses are advised for housebound patients with poor mobility and at risk of developing pressure ulcers. However, those patients who smoke are under significant dangers of fire risks, especially as the pump to provide alternating pressure requires oxygen. This article describes the development and introduction of a comprehensive risk assessment to help guide community nurses' discussions with any patient on their caseload who smokes and also requires air alternative mattresses. A questionnaire was developed by the Task and Finish Group comprising of nurses from the community and tissue viability teams, members from South Yorkshire Fire and Rescue and a trust fire officer. This questionnaire was developed to guide clinicians when discussing the problem of smoking and the risk of fire with patients, their families and general practitioners. The questionnaire was shared with all teams who visited patients at home, who met the criteria to promote its use. Further work is planned to audit the use of this questionnaire and to ascertain how it can help the decision-making process when discussing risks with this vulnerable and at-risk group of patients.

Are we getting it right? A review of end-of-life care in community nursing.

End-of-life (EoL) care is an important role in community nursing. In order to assess a community nursing team's performance in the delivery of EoL care, an evaluation of the EoL care template was undertaken from electronic patient records. Records were assessed against a set of four care priorities across 23 nursing teams in a large acute/community trust. Some 103 electronic patient records were evaluated out of a convenience sample of 110 (94% response rate). The results demonstrated that patients' wishes are being discussed and documented and the priorities of care are being considered with patients needing EoL care. Thus, patients and their families are being supported by the community nursing service, which is communicating with them sensitively and involving patients in the decision-making process. In some cases, the EoL Care Template was not fully completed, which would result in poorer communication across teams and organisations of practice within the wider community. Future action will be focused on continuing to encourage and improve the use of the EoL care template as well as the local online e-learning package for EoL care.

Role of the podiatrist and common foot problems.

In this article, the author discusses the role of the podiatrist in sustaining and maintaining foot health. A number of core podiatry problems that are most commonly seen in the population are described, along with possible treatment options and when to refer to a podiatrist. The author also explains what is required to carry out a diabetic foot assessment, providing helpful links to resources and literature to aid practitioners' understanding of the processes involved, as well as providing a list of foot care tips to aid self-care.

The Sheffield Caseload Classification Tool: testing its inter-rater reliability.

Community nursing caseloads are vast, with differing complexities. The Sheffield Caseload Classification Tool (SCCT) was co-produced with community nurses and nurse managers to help assign patients on a community caseload according to nursing need and complexity of care. The tool comprises 12 packages of care and three complexities. The present study aimed to test the inter-rater reliability of the tool. This was a table top validation exercise conducted in one city in South Yorkshire. A purposive sample of six community nurses assessed 69 case studies using the tool and assigned a package of care and complexity of need to each. These were compared with pre-determined answers. Cronbach's alpha for the care package was 0.979, indicating very good reliability, with individual nurse reliability values also being high. Fleiss's kappa coefficient for the care packages was 0.771, indicating substantial agreement among nurses; it was 0.423 for complexity ratings, indicating moderate agreement. The SCCT can reliably assign patients to the appropriate skilled nurse and care package. It helps prioritise and plan a community nursing caseload, ensuring efficient use of staff time to deliver appropriate care to patients with differing needs.

Hearing the voices of older adult patients: processes and findings to inform health services research.

PLAIN ENGLISH SUMMARY: Whilst Patient and Public Involvement and Engagement (PPIE) are widely regarded as critical to developing clinical research, there is a perception that older adults may not be able to contribute and there is less emphasis on gaining a wide range of opinions before developing research questions or projects; for example an organisational change. This PPIE initiative used three PPIE processes including existing panels and wider networking to access older adults in the community who had used the hospital services and been discharged. Older adults expressed a range of views about their experience of discharge planning and this provided an important perspective on patients' research priorities associated with their personal independence. Efforts were taken to ensure representative views across a cross section of the population. As a result of this initial PPIE, a permanent, co-ordinated 'elders' panel has been established to ensure a representation of older adult views for research, service development and evaluation. This panel has permanent, fully supported members who provide reflection and feedback on any projects and programmes relating to older people's services in the City. ABSTRACT: Background Clinical academic research and service improvement is planned using Patient and Public Involvement and Engagement (PPIE) but older PPIE participants are consulted less often due to the perception that they are vulnerable or hard to engage. Objectives To consult frail older adults about a recently adopted service, discharge to assess (D2A), and to prioritise services improvements and research topics associated with the design and delivery of discharge from hospital. To use successive PPIE processes to enable a permanent PPIE panel to be established. Participants Following guidance from an established hospital PPI panel 27 older adult participants were recruited. Participants from Black, Asian and Minority Ethnic (BAME) communities, affluent and non-affluent areas and varied social circumstances were included. Methods Focus groups and individual interviews were conducted in participants own homes or nearby social venues. Results Priorities for discharge included remaining independent despite often feeling lonely at home; to remain in hospital if needed; and for services to ensure effective communication with families. The main research priority identified was facilitating independence, whilst establishing a permanent PPIE panel involving older adults was viewed favourably. Conclusions Taking a structured approach to PPIE enabled varied older peoples' voices to express their priorities and concerns into early discharge from hospital, as well as enabling the development of health services research into hospital discharge planning and management. Older people as participants identified research priorities after reflecting on their experiences. Listening and reflection enabled researchers to develop a new "Community PPIE Elders Panel" to create an enduring PPIE infrastructure for frail older housebound people to engage in research design, development and dissemination.

Okay to Stay? A new plan to help people with long-term conditions remain in their own homes.

AimsTo assess the 'Okay to Stay' plan to investigate if this reduces visits to emergency departments, unplanned admissions and elective admission to hospital in elderly patients with long-term health conditions. BACKGROUND: The incidence of long-term conditions is rising as the elderly population increases, resulting in more people from this group attending emergency departments and being admitted to hospital. Okay to Stay is a simple plan for people with long-term conditions to help them remain in their own home if they suffer an acute exacerbation in their health. It was co-designed with professional and patient representatives with the aim of empowering patients and their carers to more effectively manage their long-term conditions. METHODS: Data from 50 patients (20 males, 30 females, mean baseline age 77.5 years) were compared 12 months before implementation of the plan and in the subsequent 12 months, with the significance of effects assessed at the 5 per cent significance level using t-tests.FindingsVisits to emergency departments were reduced by 1.86; unplanned emergency admissions were reduced by 1.28 and planned elective admissions were raised by 0.22 admissions per annum. The reduction in visits to the emergency department was significant (p = 0.009) and the reduction in emergency admissions was significant (p = 0.015). The change in elective admissions was not significant (p = 0.855). The Okay to Stay plan is effective in reducing visits to the emergency department and unplanned hospital admissions in people with long-term conditions. This is a positive step to supporting vulnerable and complex patients who are cared for at home, and facilitates the recognition by the individual of the possibility to stay at home with the support of health professionals. There are potential cost benefits to the investment of initiating an Okay to Stay plan through the avoidance of visits to the emergency department and non-elective admissions to hospital.

The PodPAD project: a podiatry-led integrated pathway for people with peripheral arterial disease in the UK - a pilot study.

BACKGROUND: Peripheral arterial disease affects the lower limb and is associated with diabetes, high cholesterol, smoking and obesity. It increases the risk of cardiovascular morbidity and mortality. It can be symptomatic causing intermittent claudication, but often there are few clinical signs. Podiatrists are able to detect the presence of peripheral arterial disease as part of their lower limb assessment and are well placed to give advice on lifestyle changes to help reduce disease progression. This is important to improve health outcomes and is offered as a prevention/public health intervention. METHOD: We describe the clinical and patient-centred outcomes of patients attending a podiatry-led integrated care pathway in a multi-use clinic situated in a venue supported by the National Centre for Sports and Exercise Medicine in the UK. At the baseline appointment, patients were given a full assessment where symptoms of intermittent claudication using the Edinburgh Intermittent Claudication Questionnaire, foot pulses, Doppler sounds, Ankle Brachial Pressure Indices, glycated haemoglobin (HbA1c) and cholesterol levels, and smoking status were recorded. A tailored treatment plan was devised, including referral to an exercise referral service, smoking cessation programmes (if applicable) and each participant was also seen by a dietician for nutritional advice. Participants were followed up at 3 and 6 months to assess any improvement in vascular status and with each completing the EQ-5D quality of life questionnaire and a simple satisfaction questionnaire at the end of the study. As this was a complex intervention a pilot study design was adopted to evaluate if the method and outcomes were suitable and acceptable to participants the results of which will then inform the design of a larger study. RESULTS: Data was collected on 21 individuals; 15 men (71.4%) and 6 women (28.6%) across the 6-month study period. Eleven participants were referred onto the exercise referral service; 16 participants saw the dietician for nutritional advice at baseline and had one-to-one or telephone follow-up at 3 months. Five out of 14 participants had reduced scores from baseline of intermittent claudication during the study period. No evidence for substantive changes in Doppler sounds or ABPI measurements was revealed. Quality of life scores with the EQ-5D improved in 15 participants; this was statistically significant (p = 0.007) with 14 participants who completed the simple satisfaction questionnaire expressing a positive view of the programme. Of the four people who were smokers, two stopped smoking cigarettes and moved to e-cigarettes as part of smoking cessation advice. CONCLUSION: As this was a pilot study the sample size was low, but some statistically significant improvements with some measures were observed over the 6-month study. Podiatrists are able to provide a comprehensive vascular assessment of the lower limb and accompanying tailored advice on lifestyle changes including smoking cessation and exercise. Locating clinics in National Centres for Sports and Exercise Medicine enables easy access to exercise facilities to encourage the adoption of increased activity levels, though the long term sustainability of exercise programmes still requires evaluation.This study was reviewed and approved by London Brent Ethics Committee IRAS ID 204611 and received research governance approval from the sponsor, Sheffield Teaching Hospitals NHS Foundation Trust Research and Innovation Office STH19410.

The impact of community pharmacy-led medicines management support for people with COPD.

Chronic obstructive pulmonary disease (COPD) is a common long-term condition involving restricted airflow, which reduces quality of life. Treatments include lifestyle changes (smoking cessation), pulmonary rehabilitation and medication with inhaled therapies. However, medication adherence is often suboptimal, resulting in poor health outcomes. A pilot project assessed the impact of medicines management support from a community pharmacy team for people with COPD, delivered in their own homes. Individuals were given a medication review and an assessment of their inhaler technique and were followed up at 3 and 6 months. The COPD Assessment Test (CAT) score was administered before and after the intervention. A change in score of 2 or more suggests a significant difference; the average score was 19.2 at the first assessment and 16.7 at the six month follow-up. Seventeen patients had improved CAT scores, 10 patients had a reduced score and three remained unchanged. Most patients evaluated the project positively as it helped them to improve their inhaler technique. Medicines optimisation was also achieved as a person-centred approach was taken; suboptimal practice had not been picked up by health professionals previously. Community pharmacists working in integrated care teams provide invaluable support to patients with COPD. This project will be rolled out across the community team, and training on medicines management and inhaler technique provided to other health professionals involved in the care of these patients.

The impact of community pharmacy-led medicines management support for people with COPD.

Chronic obstructive pulmonary disease (COPD) is a common long-term condition involving restricted airflow, which reduces quality of life. Treatments include lifestyle changes (smoking cessation), pulmonary rehabilitation and medication with inhaled therapies. However, medication adherence is often suboptimal, resulting in poor health outcomes. A pilot project assessed the impact of medicines management support from a community pharmacy team for people with COPD, delivered in their own homes. Individuals were given a medication review and an assessment of their inhaler technique and were followed up at 3 and 6 months. The COPD Assessment Test (CAT) score was administered before and after the intervention. A change in score of 2 or more suggests a significant difference; the average score was 19.2 at the first assessment and 16.7 at the six month follow-up. Seventeen patients had improved CAT scores, 10 patients had a reduced score and three remained unchanged. Most patients evaluated the project positively as it helped them to improve their inhaler technique. Medicines optimisation was also achieved as a person-centred approach was taken; suboptimal practice had not been picked up by health professionals previously. Community pharmacists working in integrated care teams provide invaluable support to patients with COPD. This project will be rolled out across the community team, and training on medicines management and inhaler technique provided to other health professionals involved in the care of these patients.

'A good fit?' Bringing the sociology of footwear to the clinical encounter in podiatry services: a narrative review.

BACKGROUND: This narrative review explores the ways in which drawing on theories and methods used in sociological work on footwear and identity can contribute to healthcare research with podiatrists and their patients, highlighting recent research in this field, implications for practice and potential areas for future development.Traditionally, research within Podiatry Services has tended to adopt a quantitative, positivist focus, developing separately from a growing body of sociological work exploring the importance of shoes in constructing identity and self-image. Bringing qualitative research drawing on sociological theory and methods to the clinical encounter has real potential to increase our understanding of patient values, motivations and - crucially - any barriers to adopting 'healthier' footwear that they may encounter. Such work can help practitioners to understand why patients may resist making changes to their footwear practices, and help us to devise new ways for practitioners to explore and ultimately break down individual barriers to change (including their own preconceptions as practitioners). This, in turn, may lead to long-term, sustainable changes to footwear practices and improvements in foot health for those with complex health conditions and the wider population. CONCLUSION: A recognition of the complex links between shoes and identity is opening up space for discussion of patient resistance to footwear changes, and paving the way for future research in this field beyond the temporary 'moment' of the clinical encounter.

Changing roles in community health care: Delegation of insulin injections to health care support workers.

Diabetes is a common long-term condition affecting many people many of whom require support with their insulin injections at home. These injections are often carried out by community nurses if individuals are unable to self-manage their condition. This paper describes a pilot project where health care support workers were trained to administer insulin at home for suitable patients. Four patients took part in the pilot study and two support workers were trained to give the insulin injections. The project was evaluated well by all those who took part. It freed up 80 hours of nursing time while also providing the support workers with an extended scope of practice and associated increased in job satisfaction. No untoward medication errors were reported as a result of this initiative. This project will now be rolled out to the wider nursing teams with a staggered approach to the delivery of the training to ensure there is not a detrimental effect on patient care.

Developing a caseload classification tool for community nursing.

Acuity and dependency in the community nursing caseload in combination with safe staffing levels are a national issue of concern. Current evidence suggests that there are no clear approaches to determining staff capacity and skill mix in these community settings. As community nursing caseloads are large with differing complexities, there is a need to allocate community nursing with the best skill mix to achieve the best patient outcomes. A city-wide service improvement initiative developed a tool to classify and categorise patient demand and this was linked to an electronic patient record system. The aim was to formulate an effective management response to different levels of acuity and dependency within community nursing teams and a consensus approach was used to allow the definition of complexity for twelve packages of care. The tool was piloted by a group of community nurses to assess the validity as a method to achieve a caseload classification. Seventy nurses were trained and applied the tool to 3000 patient referrals. Based on this, standards of care were agreed including expectations of assessment, intervention, visit length and frequency. Community nursing caseloads can now be organised according to acuity and complexity of patient need, which determines allocation of staff and skill mix.

If the shoe fits: development of an on-line tool to aid practitioner/patient discussions about 'healthy footwear'.

BACKGROUND: A previous study highlighted the importance of footwear to individuals' sense of their identity, demonstrating that shoes must 'fit' someone socially, as well as functionally. However, unhealthy shoes can have a detrimental effect on both foot health and mobility. This project utilises qualitative social science methods to enable podiatrists to understand the broader contribution of footwear to patients' sense of themselves and from this an online toolkit was developed to aid footwear education. METHOD: Semi-structured interviews were conducted with six podiatrists/shoe-fitters and 13 people with foot pathologies, some of whom also completed shoe diaries. These were supplemented with some follow-up interviews and photographs of participants' own shoes were taken to allow in-depth discussions. RESULTS: Four areas related to 'fit' were identified; practicalities, personal, purpose and pressures, all of which need to be considered when discussing changes in footwear. These were incorporated into an online toolkit which was further validated by service users and practitioners in a focus group. CONCLUSION: This toolkit can support podiatrists in partnership with patients to identify and address possible barriers to changing footwear towards a more suitable shoe. Enabling patients to make healthier shoe choices will help contribute to improvements in their foot health and mobility.

Analysis of a trial assessing the long-term effectiveness of salicylic acid plasters compared with scalpel debridement in facilitating corn resolution in patients with multiple corns.

This study assesses the effect of salicylic acid plasters on the time to resolution of 324 corns experienced by 201 participants taking part in a randomized controlled trial. While the rate of corn resolution was substantively higher in the treatment group than in the control group, treatment was found to be not significantly related to time to corn recurrence when analyzed over the full 12-month follow-up period. Parametric survival analysis modeling of interval-censored data and incorporating patient-specific frailty terms was utilized, to model correlation of corns within patients (hazard ratio [HR], 1.189; 95% confidence interval [CI], 0.780-1.813; P = 0.422). Median resolution times were 10.0 months for corns in the treatment group and 13.4 months for corns in the control group. Controlling for treatment, corn type was found to be related to resolution time, with dorsal/interdigital (ID) corns showing better resolution than plantar corns (HR, 1.670; 95% CI, 1.061-2.630; P = 0.027). Median resolution times were 5.9 months for dorsal/ID corns and 14.9 months for plantar corns. Secondary measures relating to quality of life (QoL) and foot-related disability, using the EQ-5D questionnaire and the Manchester Foot Pain and Disability Index (MFPDI), were also assessed at the patient level in multivariate models. Treatment was not significantly related to any of these measures over the whole period of analysis. However, a trend analysis revealed a quadratic trend in QoL and MFPDI scores, arising from a substantive initial improvement between baseline and 3 months, followed by a gradual decrease between 3 and 12 months.

A survey to investigate the association of pain, foot disability and quality of life with corns.

BACKGROUND: Corns are a common foot problem affecting a large proportion of the population. This study describes the characteristics of corns experienced by 201 participants taking part in a randomised controlled trial to investigate associations between demographic and corn parameters on pain, foot related disability and quality of life (QoL). METHODS: Pain from the main (index) corn was measured using a visual analogue scale (VAS); foot related disability was assessed with the Foot Disability Questionnaire (now known as the Manchester Foot Pain and Disability Index) and quality of life was recorded with the EQ-5D questionnaire. The effect of demographic and corn parameters on the pain and quality of life outcomes was assessed with analysis of variance (ANOVA) methods. The effect of the same factors on a linear combination of the foot-related disability outcome measures was assessed using multivariate ANOVA methods. Pain was also tested for its mediating properties on the causal pathway between the independent variables and quality of life. RESULTS: The mean pain score was 5.29 points on a 10 cm VAS, with females reporting substantively higher pain levels than males. Age affected foot-related disability, with lower levels on all domains of the MFPDI reported in older participants; each year of advancing age was associated with falls of: 0.009 points on the Concern about Appearance (CA) domain; 0.047 points on the Functional Limitation (FL) domain and 0.048 points on the Pain Intensity (PI) domain. Sex and corn type also affected disability, with higher scores reported by females and participants with plantar corns. CONCLUSIONS: The effect of pain was shown to mediate the relationship between sex and foot-related disability. The presence of plantar corns has a more detrimental effect on QoL than dorsal/inter-digital corns. TRIAL REGISTRATION: ISRCTN 13166839.

The effectiveness of salicylic acid plasters compared with 'usual' scalpel debridement of corns: a randomised controlled trial.

BACKGROUND: Corns are a common foot problem and surveys have indicated that between 14-48% of people suffer from them. Many of these will seek podiatry treatment, however there is little evidence to indicate which current treatments provide long term resolution. This study compared 'usual' treatment (enucleation with a scalpel) with the application of 40% salicylic acid plasters to corns to investigate which is the most effective in terms of clinical, economic and patient-centred outcomes. METHODS: A parallel-group randomised controlled trial was carried out in two centres where adults who presented with one or more corns and who met the inclusion criteria were allocated to either 'usual' scalpel debridement or corn plaster treatment. All participants had measurements of corn size, pain using a 100 mm visual analogue scale (VAS) and health-related quality of life (EQ-5D) measures by an independent podiatrist, blind to treatment allocation at baseline, 3, 6, 9 and 12 months. RESULTS: 202 participants were randomised to receive scalpel debridement or corn plaster treatment (101 in each group). At 3 months 34% (32/95) of corns had completely resolved in the corn plaster group compared with 21% (20/94) in the scalpel group (p = 0.044), and 83% (79/95) had reduced in size in the corn plaster group compared with 56% (53/94) in the scalpel group (p < 0.001). At 12 months, time to corn recurrence was longer in the corn plaster group (p < 0.001). Pain from the corns was significantly lower in the corn plaster group at 3 months (p < 0.001) and EQ-5D scores changed (improved), from baseline, by 0.09 (SD ±0.31) and 0.01 (SD ±0.25) points in the corn plaster and scalpel groups respectively (p = 0.056). By month 12, EQ-5D scores had changed by 0.12 and -0.05 in the corn plaster and scalpel groups respectively (p = 0.005). The EQ-5D, VAS scores and the four domains of the Foot Disability Scale were similar in both groups at 3 and 12 months. The economic analysis indicated that corn plasters were a cost effective intervention. CONCLUSIONS: The use of corn plasters was associated with a higher proportion of resolved corns, a prolonged time to corn recurrence, less pain and reduced corn size over the first 6 months in comparison with 'usual' scalpel treatment and this intervention was cost effective. Used under supervision of a podiatrist on appropriate patients, corn plasters offer an effective alternative to scalpel debridement.

Comparison of shoe-length fit between people with and without diabetic peripheral neuropathy: a case-control study.

BACKGROUND: Amongst the many identified mechanisms leading to diabetic foot ulceration, ill-fitting footwear is one. There is anecdotal evidence that people with diabetic peripheral neuropathy wear shoes that are too small in order to increase the sensation of fit. The aim of this study was to determine whether people with diabetic sensory neuropathy wear appropriate length footwear. METHODS: A case-control design was used to compare internal shoe length and foot length differences between a group of people with diabetes and peripheral sensory neuropathy and a group of people without diabetes and no peripheral sensory neuropathy. Shoe and foot length measurements were taken using a calibrated Internal Shoe Size Gauge® and a Brannock Device®, respectively. RESULTS: Data was collected from 85 participants with diabetes and 118 participants without diabetes. The mean difference between shoe and foot length was not significantly different between the two groups. However, a significant number of participants within both groups had a shoe to foot length difference that lay outside a previously suggested 10 to 15 mm range. From the diabetic and non-diabetic groups 82% (70/85) and 66% (78/118), respectively had a foot to shoe length difference outside this same range. CONCLUSIONS: This study shows that although there is no significant difference in shoe-length fit between participants with and without neuropathy, a significant proportion of these populations wear shoes that are either too long or too short for their foot length according to the 10 to 15 mm value used for comparison. The study has highlighted the need for standardised approaches when considering the allowance required between foot and internal shoe length and for the measurement and comparison of foot and shoe dimensions.

Clinical audit of core podiatry treatment in the NHS.

BACKGROUND: Core podiatry involves treatment of the nails, corns and callus and also giving footwear and foot health advice. Though it is an integral part of current podiatric practice little evidence is available to support its efficacy in terms of research and audit data. This information is important in order to support the current NHS commissioning process where services are expected to provide data on standards including outcomes. This study aimed to increase the evidence base for this area of practice by conducting a multi-centre audit in 8 NHS podiatry departments over a 1-year period. METHODS: The outcome measure used in this audit was the Podiatry Health Questionnaire which is a self completed short measure of foot health including a pain visual analogue scale and a section for the podiatrist to rate an individual's foot health based on their podiatric problems. The patient questionnaire was completed by individuals prior to receiving podiatry care and then 2 weeks after treatment to assess the effect of core podiatry in terms of pain and foot health. RESULTS: 1047 patients completed both questionnaires, with an age range from 26-95 years and a mean age of 72.9 years. The podiatrists clinical rating at baseline showed 75% of patients had either slight or moderate podiatric problems. The differences in questionnaire and visual analogue scores before and after treatment were determined according to three categories - better, same, worse and 75% of patients' scores either remained the same or improved after core podiatry treatment. A student t-test showed a statistical significant difference in pre and post treatment scores where P < 0.001, though the confidence interval indicated that the improvement was relatively small. CONCLUSION: Core podiatry has been shown to sustain or improve foot health and pain in 75% of the patients taking part in the audit. Simple outcome measures including pain scales should be used routinely in podiatric practice to assess the affect of different aspects of treatments and improve the evidence base for podiatry.