Randomized controlled trial on the efficacy of audio-visual health educational materials on CPAP adherence: the AHEAD trial.

STUDY OBJECTIVES: Educational interventions have been proposed to improve continuous positive airway pressure (CPAP) adherence; however, studies to date have not demonstrated robust effectiveness, due to methodological issues. Furthermore, these educational interventions have not specifically targeted low health literacy communication techniques, which have been demonstrated to improve outcomes in numerous other chronic diseases. We hypothesized that the addition of low-cost audio-visual educational videos (EVs) to usual standard-of-care (SC) education would improve CPAP adherence in adults with obstructive sleep apnea (OSA) syndrome. METHODS: At CPAP initiation, treatment-naïve adults with OSA syndrome were randomized to (1) usual SC or (2) SC + 5 EVs showing a patient's journey, designed with low health literacy communication techniques to teach patients about OSA and CPAP therapy. The primary endpoint was CPAP usage at 2 months (hours/night) and secondary endpoints were CPAP usage at 12 months and percentage of patients with ≥ 4 hours/night use at 2 months and 12 months. RESULTS: One hundred and ninety-five patients were randomized (SC 99, EV 96), with a mean age of 57 years (interquartile range [IQR] 44.1-64.8 years). There were no statistically significant differences in patient characteristics at baseline between the SC vs EV groups, with the diagnostic apnea-hypopnea index of 34 events/h (IQR 21-59 events/h) vs 30 events/h (IQR 20-50 events/h) and Epworth Sleepiness Scale score of 12.8 ± 6 vs 11.7 ± 5. At 2 months, there was no significant difference in hours of CPAP usage (SC: 3.45 hours/night [95% confidence interval (CI): 2.76 to 4.13] vs EV: 3.75 hours/night [95% CI: 3.14 to 4.37]) nor in proportion with adequate usage or overall commencement rate. However, at 12 months, there was a significant difference in hours of CPAP usage (SC: 2.50 hours/night [95% CI: 1.94 to 3.06] vs EV: 3.66 hours/night [95% CI: 2.92 to 4.40]). The probability of adequate CPAP usage at 12 months was higher in the intervention arm (odds ratio: 1.33; 95% CI: 1.04 to 1.7; P = .013). Patients with low education backgrounds benefitted substantially from the EV intervention compared with SC (mean difference at 12 months = 2.47 hours/night usage; 95% CI: 1.01 to 2.93; P < .01). CONCLUSIONS: Low health literacy-designed EVs improve CPAP adherence at 12 months compared with SC, with the greatest impact in patients with a low educational background. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; Name: Randomised controlled trial on the efficacy of audio-visual health educational materials on sleep health literacy and continuous positive airway pressure (CPAP) adherence in Sleep Clinic patients; URL: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000523101; Identifier: ACTRN12619000523101. CITATION: Ellender CM, Samaranayake C, Reid N, et al. Randomized controlled trial on the efficacy of audio-visual health educational materials on CPAP adherence: the AHEAD trial. J Clin Sleep Med. 2022;18(11):2617-2625.

Health literacy assessment in the clinic: benefits, pitfalls and practicalities.

Approximately 60% of Australians have low or marginal health literacy, which is associated with poorer outcomes in patients with chronic disease. Patient-centred strategies (such as reduced medical jargon, use of pictograms, multimedia narratives) are effective in improving outcomes for many chronic diseases, with the impact being greatest in individuals with low health literacy. However, clinicians need a reliable and practical tool for assessing health literacy, the results of which help inform the choice of communication techniques best tailored to deliver information to patients. This article reviews the evidence of health literacy as an independent predictor of poor disease outcomes, describes feasible methods for assessing health literacy and presents communication strategies aimed at facilitating shared decision-making among those with low health literacy.

Teacher-as-actor: Investigating the barriers and facilitators of patient education among hospitalized patients in a cardiology clinical unit.

Patient education enables people with cardiovascular disease to develop self-management behaviors. This study aimed to explore facilitators and barriers to teaching patients in a clinical cardiology unit with a single site qualitative investigation involving 21 registered nurses attending four focus groups. This study identified barriers related to patient factors including individual characteristics and responses to education, comorbidities, acuity, and evolving diagnosis, while for nurses the barriers were lack of knowledge and expertise. Barriers associated with the physical environment included nursing workload issues and lack of resources. Facilitators included patients being engaged in the process of education, prepared, and ready to be educated, while a conducive physical environment was also seen as a facilitator. This study exposed inhibiting and enabling variables associated with the exchange between patients and nurses by viewing the nurse and the patient as actors and audience in a theatrical model where communicating to teach patients is seen as a collaborative art. The nurse who understands the barriers and facilitators to teaching will more likely engage the patient in successful learning and development of self-care behaviors.

Adequate health literacy is associated with adherence to continuous positive airway pressure in adults with obstructive sleep apnea.

Study Objectives: Obstructive sleep apnea (OSA) is a chronic disease with significant health implications and adequate adherence to continuous positive airway pressure (CPAP) is essential for effective treatment. In many chronic diseases, health literacy has been found to predict treatment adherence and outcomes. In this study, the aim was to determine the health literacy of a sleep clinic population and evaluate the association between health literacy and CPAP adherence. Methods: A prospective cohort study was undertaken, recruiting 104 consecutive patients with a variety of sleep diagnoses. The Short Form Rapid Estimate of Adult Literacy in Medicine (REALM-SF), a validated questionnaire, was administered to measure health literacy. In a sub-group of 91 patients prescribed CPAP for OSA, CPAP usage was measured, with adequate usage defined as greater than 4 h/night CPAP therapy. Results: Seventy-one percent of the sleep clinic cohort was found to have adequate health literacy, as measured by the REALM-SF. In those prescribed CPAP for OSA, inadequate health literacy was associated with a twofold increased risk for inadequate CPAP usage (adjusted odds ratio [OR] 2.9, 95% CI: 1.1 to 8.22, p = 0.045). There was a 1.7 h/night difference in median CPAP usage comparing those with adequate to inadequate health literacy (4.6 h vs. 6.3 h/night). Conclusions: The majority of this sleep disorders cohort had adequate health literacy as measured by the REALM-SF questionnaire. However, inadequate health literacy appears to be an independent predictor of treatment adherence and may represent a modifiable risk factor of poor treatment outcomes in OSA.

Beyond Access Block: Understanding the Role of Health Literacy and Self-Efficacy in Low-Acuity Emergency Department Patients.

Background: Health literacy, self-efficacy, and patient satisfaction are factors associated with healthcare utilization. The relationships among these factors and their combined impact on patients' self-rated health have historically been studied in chronic disease populations. This study assessed low-acuity emergency department (ED) patients' ratings of these factors, the relationships among these factors, and their effect on re-presentation rates to the ED. Methods: In this single-arm cohort survey, patients provided demographic data, completed health literacy and self-efficacy assessments prior to being seen by a physician, and completed a discharge perceptions questionnaire that included a global satisfaction question at the time of departure. Three months later, patients answered a telephone survey to measure post-ED visit health outcomes. Results: Health literacy (r=0.114, P=0.023) and self-efficacy (r=0.469, P<0.001) were both independently and positively associated with self-rated health. Neither factor was associated with patient satisfaction. Self-rated health was negatively associated with return ED visits (r=-0.137, P=0.011). Conclusion: Existing research shows that health literacy has a linear association with self-efficacy and self-rated health. The results of this study suggest that in the context of low-acuity ED patients, health literacy and self-efficacy affect patients' understanding of their health status (self-rated health) but do not lead to better utilization of healthcare resources. Improvement of health literacy and self-efficacy, specifically to increase self-rated health, may provide a future avenue of intervention to reduce low-acuity ED patient re-presentation.

The effectiveness of pharmacist- led discharge medication counselling in the emergency department (ExPLAIN): A pilot quasi-experimental study.

OBJECTIVE: To evaluate the effectiveness of pharmacist-led discharge medication counselling using a structured, multimodal educational strategy with teach-back (intervention) against standard care. METHODS: This was a quasi-experimental study in a public, metropolitan ED. Participants discharged home with new medications were allocated to receive the intervention or standard care using convenience sampling. Participant characteristics (i.e. age, sex, socio-economic status, medications) and health literacy were collected. The outcomes measured were satisfaction with information, ED re-presentation and length of stay. RESULTS: There were 51 participants: 14 received intervention, 37 had standard care. Overall, 12% had inadequate health literacy. Group characteristics and health literacy were similar. Participants who received the intervention were significantly reported higher satisfaction with information about their new medications compared to standard care (p = 0.009). Specifically, the intervention was associated with a 98% increase in satisfaction with information relating to side-effects. There were no differences in re-presentation and length of stay. CONCLUSION: Pharmacist-led discharge medication counselling incorporating a structured, multimodal educational strategy and teach-back was effective in improving patient satisfaction with medication information in the ED. PRACTICE IMPLICATIONS: A similar intervention could be trialled in other EDs, but outcomes other beyond satisfaction should be considered.

Patient preferences for the delivery of cardiac rehabilitation.

OBJECTIVE: To elicit patients' preferences for cardiac rehabilitation(CR). METHODS: A Discrete Choice Experiment was used to quantify patients' preferences for the delivery of CR. This survey-based method elicited the relative importance of different characteristics of a program. RESULTS: 200 in-patients eligible to attend CR completed the survey. Over half of the patients strongly preferred a centre-based compared to a home-based program. Many but not all preferred a program starting within two rather than six weeks of discharge and exercise delivered in a group rather than individual setting, with exercise via the internet using telehealth strongly disliked. Some respondents preferred lifestyle information delivered one-to-one by a health professional, and there was an overall preference against delivery by smart phone Apps. Some preferred a program out of rather than within working hours and a shorter program (four weeks compared to eight weeks). CONCLUSIONS: This study provides further insight into patient preferences for a CR program. Although the strongest preferences were for centre-based programs with healthcare professionals facilitating exercise classes and one-on-one education, it is important to offer flexible delivery as one approach will not suit everyone. PRACTICE IMPLICATIONS: There is the potential to improve CR programs by focusing on patient preferences.

Simulation for emergency nurses (SIREN): A quasi-experimental study.

BACKGROUND: Within nursing education, simulation has been recognised as an effective learning strategy. Embedding simulation within clinical units has the potential to enhance patient safety and improve clinical outcomes. However it is important to evaluate the effectiveness of this educational technique to support the actual value and effectiveness. OBJECTIVE: This study aimed to implement and evaluate an innovative simulation experience for registered nurses. METHODS: A high-fidelity simulation focusing on nursing assessment was conducted with 50 Registered Nurses in an Emergency Department (ED) at a large tertiary referral hospital. Two questionnaires were completed pre and post simulation to assess anxiety related to participating in the simulation, and self-efficacy in patient assessment. Participant satisfaction and self-confidence in learning was assessed post simulation. Additionally a documentation audit from the patient's electronic chart was completed to review documentation entries before and after participation in the simulation. RESULTS: Anxiety scores decreased significantly from pre (M = 38.56, SD = 9.87) to post (M = 33.54, SD = 8.99), t(49) = 4.273, p < 0.001. There was a statistically significant increase in self-efficacy scores from pre (M = 195.16, SD = 28.09) to post (M = 214.12, SD =25.77), t(49) = 5.072, p < 0.001. ED nurses were highly satisfied with their simulation training and they were in agreement with the statements about self-confidence in learning. There was a statistically significant increase in two components of the documentation scores; initial clinical handover increased from pre (M = 7.88, SD = 1.76) to post (M = 8.79, SD =1.22), t(41) = 3.41, p < 0.001 and indicators of urgent illness increased from pre (M = 7.33, SD = 1.95) to post (M = 8.10, SD = 1.45), t(41) =2.27, p = 0.028. CONCLUSIONS: This study has demonstrated that a high fidelity simulation decreased participants' anxiety, increased self-efficiency in patient assessment, and improved documentation in patient records. Additionally ED nurses were highly satisfied with the simulation training.

A systematic review of the impact of nurse-initiated medications in the emergency department.

BACKGROUND: Nurse-initiated medications are one of the most important strategies used to facilitate timely care for people who present to Emergency Departments (EDs). The purpose of this paper was to systematically review the evidence of nurse-initiated medications to guide future practice and research. METHODS: A systematic review of the literature was conducted to locate published studies and Grey literature. All studies were assessed independently by two independent reviewers for relevance using titles and abstracts, eligibility dictated by the inclusion criteria, and methodological quality. RESULTS: Five experimental studies were included in this review: one randomised controlled trial and four quasi-experimental studies conducted in paediatric and adult EDs. The nurse-initiated medications were salbutamol for respiratory conditions and analgesia for painful conditions, which enabled patients to receive the medications quicker by half-an-hour compared to those who did not have nurse-initiated medications. The intervention had no effect on adverse events, doctor wait time and length of stay. Nurse-initiated analgesia was associated with increased likelihood of receiving analgesia, achieving clinically-relevant pain reduction, and better patient satisfaction. CONCLUSION: Nurse-initiated medications are safe and beneficial for ED patients. However, randomised controlled studies are required to strengthen the validity of results.

The Self-care Educational Intervention for Patients With Heart Failure: A Study Protocol.

BACKGROUND: A variety of educational interventions have been implemented to assist patients with heart failure (HF) to maintain their own health, develop self-care behaviors, and decrease readmissions. The most effective approach to education has yet to be established. OBJECTIVE: The aim of this study is to determine the effectiveness of a multimedia educational intervention for patients with HF in reducing hospital readmissions. Secondary outcomes include changes in knowledge and self-care behaviors. METHODS: A randomized controlled trial in a large tertiary referral hospital in Australia has recruited 200 patients and will follow them for 12 months. Patients diagnosed with HF have been randomly allocated 1:1 to either usual education or a multimedia educational intervention. Framed by the principles of adult learning, this individualized intervention was delivered face to face by a specialized HF nurse, with a targeted educational assessment and subsequent development of an educational plan. The multimedia approach combined viewing a DVD and verbal discussion supported by a written manual. The teach-back strategy at the conclusion of the intervention evaluated the patient's learning through 5 key questions about self-management of HF. Readmissions are assessed at 28 days, 3 months, and 12 months. Knowledge and self-care behavior are assessed at baseline, 3 months, and 12 months. CONCLUSIONS: This study evaluates the effectiveness of a targeted multimedia educational intervention. Study results may inform the design of in-hospital education for HF patients.

What have our patients learnt after being hospitalised for an acute myocardial infarction?

BACKGROUND: Education for hospitalised patients is an important aspect of care for people who have an acute cardiovascular event. OBJECTIVE: To investigate the cardiovascular risk factor behaviours of patients together with their acute coronary syndrome (ACS) knowledge, attitudes and beliefs following admission to hospital for an acute myocardial infarction. METHODS: Patients diagnosed with an acute myocardial infarction participated in an observational study. Patients completed a questionnaire consisting of cardiovascular risk factor behaviour questions and the ACS Response Index prior to discharge and at follow-up 10 weeks later. RESULTS: Of the 135 participants enrolled, 114 (84%) completed follow-up, 70% were males; mean age was 63 (± 11.6) years. The median length of hospital stay was 3 days (IQR 1) and the time to follow-up after discharge was 10 weeks. Self-reported risk factor behaviours improved significantly for diet (p < 0.001) and smoking cessation (p = 0.023) following discharge. At discharge 39% of patients had inadequate knowledge of ACS symptoms. The ACS Response Index improved significantly after discharge for attitudes (p = 0.004) and beliefs (p = 0.008). Despite 85% of patients indicating they would attend cardiac rehabilitation only 30% had commenced a programme at follow-up. CONCLUSION: Patients reported implementing a number of healthy lifestyle changes following discharge including smoking cessation and healthy eating. Attitudes and beliefs regarding ACS showed a significant improvement following discharge. More than one third of patients had inadequate knowledge at discharge, suggesting current education practices may not be meeting the needs of patients with a myocardial infarction.

Education material for heart failure patients: what works and what does not?

Patient education is an important element of care, but evidence with regard to education material is not always apparent, as it is intertwined with educational strategies as components of heart failure management programs. Difficulties have arisen in determining the effectiveness of particular education strategies, as multiple strategies are commonly bundled together and packaged within research protocols. To further complicate this issue, the bundles are diverse, lack precision in describing their components, and report different outcomes. Despite these difficulties, clinicians can utilise a number of proven commonalities to deliver effective education: assessment of learning needs and style, verbal interaction with a healthcare professional, and a selection of multimedia patient education materials.

The need to address poor numeracy skills in the emergency department environment.

Substantial evidence exists for lack of numerical skills among many health professionals. Although poor numeracy has long been recognised as a contributor to medication error, other activities for which numerical literacy are required, such as interpretation of diagnostic results, have been largely ignored. Poor self-awareness of lack of numerical literacy increases the risk, especially in the busy and hurried emergency environment. System changes, such as standardising units and improving number presentation, reduce the potential for misinterpretation; however system changes do not address the underlying deficiencies in mathematical skills. The training of doctors in numeracy has been largely ignored. In contrast, education for nurses frequently occurs during both pre- and post-registration programmes. Interventions have had mixed success, although additional emphasis in increasing conceptual understanding of numbers is encouraging. The consequences of poor numerical literacy should be addressed in all clinical staff, not only by practice change to remove the potential for errors to be made, but also complemented by self-awareness and education.

Decimal numbers and safe interpretation of clinical pathology results.

OBJECTIVE: To determine the understanding of decimal numbers by medical laboratory scientists, doctors and nurses. METHODS: A Decimal Comparison Test determined the comprehension of decimals numbers. Additional questions sought the participants' understanding of concentrations and reference ranges, and their preferences for the presentation of clinical pathology results. RESULTS: Of the 108 participants, 40% exhibited poor comprehension of decimal numbers. One-third of the medical laboratory scientists, a quarter of doctors, and half the nurses were characterised as lacking numeracy skills. The majority of participants (60%) thought it would be safer for results to be presented as whole numbers rather than as decimals with leading zeros. CONCLUSIONS: The number of laboratory and clinical staff who show numeracy issues that could lead to misinterpretation of clinical pathology results and contribute to medical error strongly supports recommendations that pathology results should be presented as whole numbers.

In-hospital cardiac arrests: effect of amended Australian Resuscitation Council 2006 guidelines.

OBJECTIVE: To evaluate cardiac arrest outcomes following the introduction of the Australian Resuscitation Council (ARC) 2006 amended guidelines for basic and advanced life support. METHODS: A retrospective study of all consecutive cardiac arrests during a 3-year phase pre-implementation (2004-06) and a 3-year phase post-implementation (2007-09) of the ARC 2006 guidelines was conducted at a tertiary referral hospital in Brisbane, Australia. RESULTS: Over the 6-year study phase 690 cardiac arrests were reported. Resuscitation was attempted in 248 patients pre-implementation and 271 patients post-implementation of the ARC 2006 guidelines. After adjusting for significant prognostic factors we found no significant change in return of spontaneous circulation (ROSC) (odds ratio 1.21, 95% confidence interval 0.80-1.85, P=0.37) or survival to discharge (odds ratio 1.49, 95% confidence interval 0.94-2.37, P=0.09) after the implementation of the ARC 2006 guidelines. Factors that remained significant in the final model for both outcomes included having an initial shockable rhythm, a shorter length of time from collapse to arrival of cardiac arrest team, location of the patient in a critical-care area, shorter length of resuscitation and a day-time arrest (0700-2259 hours). In addition the arrest being witnessed was significant for ROSC and younger age was significant for survival to discharge. CONCLUSIONS: There are multiple factors that influence clinical outcomes following an in-hospital cardiac arrest and further research to refine these significant variables will assist in the future management of cardiac arrests. WHAT IS KNOWN ABOUT THIS TOPIC? The evaluation of outcomes from in-hospital cardiac arrests focuses on immediate survival expressed as ROSC and survival to hospital discharge. These clinical outcomes have not improved substantially over the last two decades. WHAT DOES THIS PAPER ADD? This paper identifies the factors that are related to ROSC and survival to discharge following the implementation of the ARC 2006 guidelines, which included a refocus on providing quality cardiopulmonary resuscitation with minimal interruptions. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Given that multiple factors can influence clinical outcomes following an in-hospital cardiac arrest, focusing on maximising a range of factors surrounding cardiopulmonary resuscitation is essential to improve outcomes.

Pilot testing of a self-care education intervention for patients with heart failure.

BACKGROUND: A key component of the structured approach to the management of chronic heart failure (CHF) is effective patient education. Patient education is a precursor to performing appropriate health-related behaviours that can decrease rehospitalizations. AIM: To pilot test an educational intervention and to determine the efficacy of a self-care manual combined with a DVD for patients with CHF. Outcomes of interest included heart failure-related knowledge and self-care behaviours. METHODS: This pilot study enrolled a sample of 38 patients with CHF. A pre-test/post-test design was conducted to assess changes in knowledge and self-care abilities. Knowledge was assessed with the Dutch Heart Failure Knowledge Scale and self-care behaviours were assessed using the Self-Care of Heart Failure Index. RESULTS: Of the 38 participants 71% were male, 50% were aged between 65 and 74 years, and 31.6% had not completed Year 10 education. There was a statistically significantly difference in the pre- and post-test scores for knowledge (p < 0.0001). Self-care showed positive improvement between pre- and post-test scores; maintenance (p = 0.027), management (p < 0.0001) and confidence (p = 0.051). CONCLUSION: This pilot study has indicated that a patient-centred self-care manual combined with a DVD is beneficial and is associated with an improvement in patients' knowledge and self-care abilities. PRACTICE IMPLICATIONS: Healthcare professionals should utilize multimedia educational resources specifically designed to meet the learning needs of patients with CHF.

Cardiac clinical skill assessments for registered nurses.

This article outlines a framework of clinical skill assessments that identify the knowledge and skills required for safe and competent care of cardiac patients. This framework categorizes identified cardiac skills into a logical sequence for assessment, aims to standardize the assessment process, and allows transportability of clinical skills.

Educational interventions for patients with heart failure: a systematic review of randomized controlled trials.

BACKGROUND: Patient education is an important intervention for the management of heart failure; however, in practice patient education varies considerably. AIM: : To systematically review educational interventions that have been implemented for heart failure patients and assess their effectiveness. METHODS: Randomized controlled trials from 1998 to 2008 in CINAHL, MEDLINE, PsychInfo, EMBASE, and Cochrane were reviewed using the following search terms: patient education, education, educational intervention, self-care in combination with heart failure. There were 1515 abstracts reviewed independently by 2 reviewers. RESULTS: A total of 2686 patients were included in the 19 studies that met the inclusion criteria. Commonly, the initial educational intervention was a one-on-one didactic session conducted by nurses supplemented by written materials and multimedia approaches. Seven studies referred to a theoretical model as a framework for their educational intervention. Studies used a variety of outcome measures to evaluate their effectiveness. Of the studies reviewed, 15 demonstrated a significant effect from their intervention in at least one of their outcome measures. CONCLUSION: All we hope from patient education has not yet been realized. Despite improvements in knowledge, we have variable results in outcomes, and this is very likely related to the heterogeneity of the studies included in this review. It was difficult to establish the most effective educational strategy as the educational interventions varied considerably in delivery methods and duration as well as the outcome measures that were used for the evaluation. A patient-centered approach to education based on educational theory and evaluated appropriately may assist to develop an evidence base for patient education.