Active older adults goal setting outcomes for engaging in a physical activity app and the motivation characteristics of these goals (MOVEAGE-ACT).

Approximately 70% of older adults do not meet physical activity (PA) guidelines. While many interventions, are used in promoting PA, few target older adults or include substantial behavioural change techniques. Setting PA goals is often used but there is less research on goal setting outcomes, like improving health, preventing age effects, improving flexibility, goals that have been associated with increased likelihood of maintenance of PA. To understand the concept more fully in this cohort, the aim of this study was to identify older adults' goal setting outcomes - the purpose of engaging in a PA app and through analysis determine the motivation characteristics of these. A cross-sectional, qualitative online survey was completed by 24, 60+, community dwelling, mostly active, French and Irish older adults. Thematic template analysis was used, and the motivation of these outcomes was assessed using the Self-Determination Theory of Motivation. The themes were: improving/staying healthy or physically active, maintaining functional aspects of physical health, continuing to do the things I want, sustaining mental wellbeing, and preventing disease and aging. Individuals cited goal setting outcomes that were generic, specific or both, and goals related to maintenance of PA and prevention of aging decline, were cited most. The motivation characteristics of these goals in mostly active older adults were autonomous and internally driven. Interventions, including apps, for older adults that encourage them to set specific goal setting outcomes/purposes for PA, are likely to generate stronger internally driven motivation, enhance ownership and participation, and may therefore increase effectiveness.

The Association of Persistent Symptoms of Depression and Anxiety with Recurrent Acute Coronary Syndrome Events: A Prospective Observational Study.

The purpose of this study was to examine the role of persistent symptoms of depression and anxiety in a second acute coronary syndrome (ACS) event. Data presented in this study were from an RCT study. A follow-up for 24 months after baseline to detect a second ACS event among 1162 patients from five hospitals. Hierarchal Cox regression analyses were used. The results showed that persistent depression only (HR 2.27; 95% CI: 1.35-3.81; p = 0.002), and comorbid persistent depression and anxiety (HR 2.03; 95% CI: 1.03-3.98; p = 0.040) were the significant predictors of a second ACS event. Secondary education level compared to primary educational level (HR 0.63; 95% CI: 0.43-0.93; p = 0.020) and college or more education level compared to primary educational level (HR 0.47; 95% CI: 0.27-0.84; p = 0.011) were the only demographic variables that were significant predictors of a second event. The study reveals that attention must be paid by healthcare providers to assess and manage persistent depression; particularly when it is co-morbid with anxiety.

A National Survey Identifying the Factors Associated With Cardiovascular Care Nurses' Perceived Knowledge of International Practice Guidelines: The First Step in the Development of an Implementation Strategy.

BACKGROUND: The implementation of international guidelines within everyday practice remains problematic, which can have a detrimental impact on quality of care delivered. This study aimed to ascertain the factors associated with clinical nurses' perceived knowledge of international guidelines. METHODS: In this cross-sectional survey, nurses from 45 hospitals across Ireland were recruited. A previously validated anonymous questionnaire that assessed guideline knowledge, use, and barriers to implementation was used. Data were analyzed using SPSS 23 and logistic regression. RESULTS: Of the 542 responses, 54% had used international guidelines relevant to their practice and 50% had consulted within the last year. Most nurses perceived that poor patient follow-up, lack of time and resources, poor clinical leadership, workload, long guidelines, and not understanding guideline detail were barriers to guideline use and implementation. Forty-five percent rated their perceived knowledge of guidelines as "low." Logistic regression identified that "high" knowledge levels were significantly associated with having read guidelines in the last year and their use with practice. In contrast, low knowledge of the guidelines was associated with perceptions that they were lengthy and not easy to use, lack of confidence to challenge colleagues when guidelines are not implemented, or not being able to influence current practice. CONCLUSIONS: This study identified the specific knowledge needs in this cohort of mainly basic grade registered nurses, with low perceived guideline knowledge. A whole unit or team approach led by nurse champions is needed to develop and establish practice and educational strategies that would increase the availability, application, and knowledge of guidelines within everyday practice.

Optimising implementation of European guidelines on cardiovascular disease prevention in clinical practice: what is needed?

Cardiovascular disease is a model example of a preventable condition for which practice guidelines are particularly important. In 2016, the joint task force created by the European Society of Cardiology (ESC) together with 10 other societies released the new version of the European guidelines on cardiovascular disease prevention. To facilitate the implementation of the ESC guidelines, a dedicated prevention implementation committee has been established within the European Association of Preventive Cardiology. The paper will first explore potential barriers to the guidelines' implementation. It then develops a discussion that seeks to inform the future development of the committee's work, including a new definition of the guidelines' stakeholders (health policy-makers, healthcare professionals and health educators, patient organisations, entrepreneurs and the general public), future activities within four specific areas: strengthening awareness of the guidelines among stakeholders; supporting organisational changes to facilitate the guidelines' implementation; motivating stakeholders to utilise the guidelines; and present ideas on new implementation strategies. Providing multifaceted cooperation between healthcare professionals, healthcare management executives and health policy-makers, the novel approach proposed in this paper should contribute to a wider use of the 2016 ESC guidelines and produce desired effects of less cardiovascular disease morbidity and mortality. Furthermore, the solutions presented within the paper may constitute a benchmark for the implementation of practice guidelines in other medical disciplines.

Prevalence of tobacco smoking among European migrants residing in EU 15 countries: a quantitative systematic review protocol.

OBJECTIVES: The objective of this systematic review is to summarize the prevalence of tobacco smoking in European migrants residing in EU 15 countries. INTRODUCTION: Most of the migration within the World Health Organization European Region is intracontinental. The prevalence of smoking varies greatly across the European Region. Migrants may choose to adopt the smoking behaviors of their host countries or retain the smoking behaviors of their countries of origin. Several studies have identified the high prevalence of smoking of some migrant groups in comparison to their host countries, but no systematic reviews have been completed on intracontinental migrants within the European Region. INCLUSION CRITERIA: Epidemiological studies, which include data on the prevalence of tobacco smoking in European migrants aged ≥ 15 years of age living in the following EU 15 countries host countries for ≥ 1 year: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, and the United Kingdom. METHODS: MEDLINE, Embase, CINAHL, PsycINFO, ASSIA, and Web of Science will be searched to identify published studies. General gray literature (eg, Open Grey) as well as gray literature for migrants (Migrant Health Research Portal) and tobacco will be searched. The JBI methodology for systematic reviews of prevalence will be used in this review. Data synthesis will use meta-analysis where appropriate and narrative synthesis.

Patients' knowledge and opinions of ICDs during life, illness and at the time of death.

Use of an implantable cardioverter defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death. However, at the end of life, these devices can prolong the dying experience, causing physical and psychological trauma. Patients are often unaware of their options regarding ICD management at the end of their life, which highlights the need for health professionals to have these discussions with patients. This study aimed to identify patients' knowledge and opinions about their ICD and the factors influencing their knowledge and opinions. Of the 30 participants in this study, 59% had sufficient knowledge about ICDs. There was no relationship between knowledge and time since implantation (p=0.11). A relationship existed between knowledge and age; those that were older were better informed (p=0.008). The authors conclude that patient education and communication are essential for patients with ICDs to enhance decision-making about ICD management at the end of life.

Towards prompt electrocardiogram acquisition in triage: Preliminary testing of a symptom-based clinical prediction rule for the Android tablet.

BACKGROUND: For patients with suspected acute coronary syndrome, international guidelines indicate that an Electrocardiogram (ECG) should be performed within 10 min of first medical contact, however success at achieving these guidelines is limited. AIMS: The purpose of this study was to develop and perform initial testing of a clinical prediction rule embedded in a tablet application, and to expedite the identification of patients who require an electrocardiogram within 10 min. METHODS: This derivation of the Acute Coronary Syndrome Application (AcSAP) comprised of three local studies, an unpublished audit and literature critique. The AcSAP was prospectively tested over four months in patients presenting to the Emergency Department (ED) of a Dublin teaching hospital. An audit form retrieved data pertaining to times of: registration to the emergency department, triage, first electrocardiogram and diagnosis. The AcSAP was subsequently evaluated by experienced triage nurses ( n=18) who had utilised it. RESULTS: The AcSAP was activated 379 times. Patients with ST Elevation Myocardial Infarction (STEMI) and non-ST Elevation Myocardial Infarction (NSTEMI) were significantly more likely to return a categorisation of 'immediate ECG' or 'ECG within 10 min' ( p<0.001). There was a significant difference in 'triage to ECG' times across categories, the 'immediate ECG' categorisation resulting in the shortest time ( p=0.002). Evaluations suggest that staff found the tool quick and easy to use and results seemed accurate. CONCLUSION: Testing of the AcSAP suggests that it accurately identifies patients who require an ECG within 10 min. As such, it has the potential to support the meeting of clinical guidelines for ECG acquisition.

A cohort study examining the factors influencing changes in physical activity levels following an acute coronary syndrome event.

BACKGROUND: Low physical activity has long been identified as a risk factor for coronary heart disease. AIMS: The aim of this study was to determine the factors that influence changes in the physical activity of patients following an acute coronary syndrome event. METHODS: The prospective, inferential cohort design recruited patients admitted to hospital following an acute coronary syndrome event across five research sites. Physical activity was assessed using the short form international physical activity questionnaire. RESULTS: Data were collected at baseline and 3 months on 380 patients. The sample profile was: 21% women; body mass index 28 ± 4.6; unstable angina 36%; ST-segment elevation myocardial infarction 25%; non-ST-segment elevation myocardial infarction 39% and a mean age of 63 ± 11.8. There was a significant improvement in physical activity at 3 months ( n=380, t=-3.704, P≤0.001). All regression models, baseline, 3 months and change in physical activity were significant ( p≤0.001). Low physical activity was associated with: at baseline not having health insurance, older age and depression; at 3 months not having health insurance, not in employment and low baseline physical activity; and improvement in physical activity was associated with low physical activity at baseline and not being in employment. CONCLUSIONS: While physical activity improved significantly, 45% did not reach guideline recommendation levels at 3 months post-event. Physical activity change was little influenced by sociodemographic, clinical, psychological and behavioural factors, suggesting the need to look elsewhere such as behavioural change and improved processes across the care divide to improve physical activity in this at-risk population.

A cluster and inferential analysis of myocardial infarction symptom presentation by age.

BACKGROUND: Pre-hospital delay time in myocardial infarction is usually longer in older than in younger patients, with symptom presentation known to be a contributing factor. AIM: The aim of this article is to examine symptom presentation differences, by age, in patients with myocardial infarction. METHODS: This is a cross-sectional study using secondary analysis of a multi-site randomised controlled trial on pre-hospital delay time. Data were analysed using logistic regression and factor analysis. RESULTS: Post-myocardial infarction patients were recruited prior to discharge ( n=1211), 54% were ≥65 years and 80% male. The average number of symptoms was three, with the ≥65 years age group reporting significantly less symptoms. Logistic regression controlling for gender, diabetes and diagnosis with 11 symptoms (χ2=52.09, p<0.001) was significant. Those ≥65 years had less chest symptoms, sweating, stomach upset and left arm pain, in addition to longer pre-hospital delay time. This group also had less symptom clustering and fewer symptoms within atypical clusters. Non-chest clusters occurred in 22% and 18% of the older and younger group respectively. Of note, two clusters 'atypical' (upset stomach/sweating) and 'typical arm' (right and left arm pain symptoms), accounted for 14% and 5% of myocardial infarction presentations in the ≥65 years group, within which 25% and 24% had no chest symptoms. CONCLUSIONS: The results of this study indicate that myocardial infarction symptom presentation in older patients is likely to be less recognisable and more complex. Increased awareness of the presentation profile of older patients could expedite their triage, diagnosis and, consequently, their prognosis.

Nursing sensitive outcomes in patients with rheumatoid arthritis: A systematic literature review.

BACKGROUND: Although rheumatology nursing has been shown to be effective in managing patients with rheumatoid arthritis, patient outcomes sensitive to nursing interventions (nursing sensitive outcomes) have not been systematically studied. OBJECTIVES: The objective of this study was to identify and delineate relevant patient outcomes measured in studies that reported nursing interventions in patients with rheumatoid arthritis. DESIGN: A systematic search was conducted from 1990 to 2016. Inclusion criteria were (i) patients with rheumatoid arthritis, (ii) adult population age ≥16years, (iii) nurse as part of the care team or intervention delivery, (iv) primary research only, (v) English language, and (vi) quantitative studies with nursing sensitive outcomes. DATA SOURCES: Medline, CINAHL, Ovid nursing, Cochrane library and PsycINFO databases were searched for relevant studies. REVIEW METHODS: Using the predetermined inclusion/exclusion criteria, nine reviewers working in pairs assessed the eligibility of the identified studies based on titles and abstracts. Papers meeting the inclusion criteria were retrieved and full texts were further assessed. Critical Appraisal Skills Programme tools were used to assess the quality of the included studies. Data on nursing sensitive outcomes were extracted independently by two reviewers. The Outcome Measures in Rheumatology comprehensive conceptual framework for health was used to contextualise and present findings. RESULTS: Of the 820 articles retrieved, 7 randomised controlled trials and 3 observational studies met the inclusion criteria. Seventeen nursing sensitive outcomes were identified (disease activity, clinical effects, pain, early morning stiffness duration, fatigue, patient safety issues, function, knowledge, patient satisfaction, confidence in care received, mental health status, self-efficacy, patient attitude/perception of ability to control arthritis, quality of life, health utility, health care resources, death). These fitted into 10 health intervention domains in keeping with the pre-specified conceptual framework for health: disease status, effectiveness, safety, function, knowledge, satisfaction, psychological status, quality of life, cost, death. A total of 59 measurement instruments were identified comprising patient reported outcome measures (n=31), and biologic measures and reports (n=28). CONCLUSIONS: This review is notable in that it is the first to have identified, and reported, a set of multidimensional outcome measures that are sensitive to nursing interventions in rheumatology specifically. Further research is required to determine a core set of outcomes to be used in all rheumatology nursing intervention studies.

The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis.

BACKGROUND: Nurses are pivotal in the provision of high quality care in acute hospitals. However, the optimal dosing of the number of nurses caring for patients remains elusive. In light of this, an updated review of the evidence on the effect of nurse staffing levels on patient outcomes is required. AIM: To undertake a systematic review and meta-analysis examining the association between nurse staffing levels and nurse-sensitive patient outcomes in acute specialist units. METHODS: Nine electronic databases were searched for English articles published between 2006 and 2017. The primary outcomes were nurse-sensitive patient outcomes. RESULTS: Of 3429 unique articles identified, 35 met the inclusion criteria. All were cross-sectional and the majority utilised large administrative databases. Higher staffing levels were associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use and a greater number of patients receiving percutaneous coronary intervention within 90 minutes. A meta-analysis involving 175,755 patients, from six studies, admitted to the intensive care unit and/or cardiac/cardiothoracic units showed that a higher nurse staffing level decreased the risk of inhospital mortality by 14% (0.86, 95% confidence interval 0.79-0.94). However, the meta-analysis also showed high heterogeneity (I2=86%). CONCLUSION: Nurse-to-patient ratios influence many patient outcomes, most markedly inhospital mortality. More studies need to be conducted on the association of nurse-to-patient ratios with nurse-sensitive patient outcomes to offset the paucity and weaknesses of research in this area. This would provide further evidence for recommendations of optimal nurse-to-patient ratios in acute specialist units.

Describing the implementation of an innovative intervention and evaluating its effectiveness in increasing research capacity of advanced clinical nurses: using the consolidated framework for implementation research.

BACKGROUND: Despite advanced nursing roles having a research competency, participation in research is low. There are many barriers to participation in research and few interventions have been developed to address these. This paper aims to describe the implementation of an intervention to increase research participation in advanced clinical nursing roles and evaluate its effectiveness. METHODS: The implementation of the intervention was carried out within one hospital site. The evaluation utilised a mixed methods design and a implementation science framework. All staff in advanced nursing roles were invited to take part, all those who were interested and had a project in mind could volunteer to participate in the intervention. The intervention consisted of the development of small research groups working on projects developed by the nurse participant/s and supported by an academic and a research fellow. The main evaluation was through focus groups. Output was analysed using thematic analysis. In addition, a survey questionnaire was circulated to all participants to ascertain their self-reported research skills before and after the intervention. The results of the survey were analysed using descriptive statistics. Finally an inventory of research outputs was collated. RESULTS: In the first year, twelve new clinical nurse-led research projects were conducted and reported in six peer reviewed papers, two non-peer reviewed papers and 20 conference presentations. The main strengths of the intervention were its promptness to complete research, to publish and to showcase clinical innovations. Main barriers identified were time, appropriate support from academics and from peers. The majority of participants had increased experience at scientific writing and data analysis. CONCLUSION: This study shows that an intervention, with minor financial resources; a top down approach; support of a hands on research fellow; peer collaboration with academics; strong clinical ownership by the clinical nurse researcher; experiential learning opportunities; focused and with needs based educational sessions, is an intervention that can both increase research outputs and capacity of clinically based nurses. Interventions to further enhance nursing research and their evaluation are crucial if we are to address the deficit of nurse-led patient-centred research in the literature.

Barriers to ESC guideline implementation: results of a survey from the European Council on Cardiovascular Nursing and Allied Professions (CCNAP).

BACKGROUND: The European Society of Cardiology (ESC) has a comprehensive clinical guideline development programme, relevant for all clinicians. However, implementation of guidelines is not always optimal. AIM: The aim of this study was to determine nurses' and allied professionals' awareness and barriers regarding clinical guideline implementation. METHODS: A cross-sectional survey was administrated online and in print at EuroHeartCare 2015. A questionnaire was developed which examined awareness and barriers to implementation of ESC guidelines on cardiovascular disease prevention in clinical practice (2012) and ESC guidelines in general. RESULTS: Of the 298 respondents, 12% reported that the prevention guidelines were used in their practice area. Respondents identified, in order of magnitude, that lack of leadership, workload, time, resources and a perception that they were unable to influence current practice were barriers to the use of the prevention guidelines. When asked to rank barriers to use of any ESC guidelines, time (22%) and leadership (23%) were ranked highest. CONCLUSIONS: Implementation of ESC guidelines by nurses, the majority responders in this survey, is a serious problem, requiring urgent improvement to ensure patients receive optimal evidence based care. Issues of leadership, workload, time and resources are significant barriers to guideline implementation. It is of concern that these professionals perceive both that they have little influence on implementation decisions and lack of leadership regarding guideline implementation. Educational and organisational strategies to improve leadership skills are imperative. These will build self-efficacy and empower nurses and allied professionals to advocate for evidence-based care in the clinical environment.

The patients' perspective of international normalized ratio self-testing, remote communication of test results and confidence to move to self-management.

AIMS AND OBJECTIVES: To elicit the perceptions of patients, who self-tested their international normalized ratio and communicated their results via a text or phone messaging system, to determine their satisfaction with the education and support that they received and to establish their confidence to move to self-management. BACKGROUND: Self-testing of international normalized ratio has been shown to be reliable and is fast becoming common practice. As innovations are introduced to point of care testing, more research is needed to elicit patients' perceptions of the self-testing process. DESIGN: This three site study used a cross-sectional prospective descriptive survey. METHODS: Three hundred and thirty patients who were prescribed warfarin and using international normalized ratio self-testing were invited to take part in the study. The anonymous survey examined patient profile, patients' usage, issues, perceptions, confidence and satisfaction with using the self-testing system and their preparedness for self-management of warfarin dosage. RESULTS: The response rate was 57% (n = 178). Patients' confidence in self-testing was high (90%). Patients expressed a high level of satisfaction with the support received, but expressed the need for more information on support groups, side effects of warfarin, dietary information and how to dispose of needles. When asked if they felt confident to adjust their own warfarin levels 73% agreed. Chi-squared tests for independence revealed that none of the patient profile factors examined influenced this confidence. The patients cited the greatest advantages of the service were reduced burden, more autonomy, convenience and ease of use. The main disadvantages cited were cost and communication issues. CONCLUSION: Patients were satisfied with self-testing. The majority felt they were ready to move to self-management. RELEVANCE TO CLINICAL PRACTICE: The introduction of innovations to remote point of care testing, such as warfarin self-testing, needs to have support at least equal to that provided in a hospital setting.

Perceptions of the Cause, Impact and Management of Persistent Fatigue in Patients with Rheumatoid Arthritis Following Tumour Necrosing Factor Inhibition Therapy.

INTRODUCTION: Fatigue is a major symptom of rheumatoid arthritis (RA), the most common chronic inflammatory joint disease. The present study explored patients' experiences of RA fatigue to elucidate unique elements and management strategies. METHODS: This single site study recruited tumour necrosis factor-α inhibitor (TNFi)-treated RA patients with a moderate/good response in disease activity and persistent moderate/greater fatigue on a five-point verbal rating scale. This qualitative descriptive design used semi-structured questions, individual interviews and content analysis of narrative data. RESULTS: Ten patients were interviewed (six women), with age and disease duration ranges of 44-75 and 6-36 years, respectively. Perceptions of the RA fatigue experience generated four categories (experiencing a distinct, yet seldom discussed RA symptom; seeking an explanation for fatigue; being in an incapacitating state; and trying to manage) and eight subcategories. Fatigue was newly identified as a distinct part of the entity of RA. While patients proposed many plausible root causes, the only rational explanation for the nature of this fatigue was that it was integral to their RA. Singularly, fatigue contributed considerably to RA-imposed lifestyle restrictions. Patients had learnt to accommodate and self-manage fatigue in the absence of professional input. Novel management strategies proposed included patients talking about the nature of RA fatigue with others and the need for staff to alert patients to this distinct symptom of RA. CONCLUSION: Fatigue, branded as a distinct symptom of RA, exerted an identifiable impact on patients. Fatigue is potentially amenable to modification; talking about fatigue was proposed as a novel management strategy. Copyright © 2016 John Wiley & Sons, Ltd.

Factors associated with ADL/IADL disability in community dwelling older adults in the Irish longitudinal study on ageing (TILDA).

PURPOSE: To identify the factors associated with disability across many domains using a large powered sample in the activities of daily living (ADL) and instrumental activities of daily living (IADL). METHODS: Those aged ≥65 years from the Irish longitudinal study on ageing (TILDA) were included in this cross sectional analysis. Three logistic regression models were used to examine the relationships between 25 health, psychological and sociodemographic variables and difficulties in ADL, IADL and ADL/IADL combined. RESULTS: The proportion of those reporting combined ADL/IADL difficulties was 18%. More individuals reported difficulty with ADLs (13%) than IADLS (11%). The main model showed that after age, the top three factors associated with difficulty in ADL/IADL combined were pain, taking five or more medications and depression. After age, the factors with the highest impact on ADL disability were pain, taking five or more medications and body mass index (BMI); the factors with the highest impact on IADL were being separated or divorced, living with others (non-spouse) and self-rated memory. CONCLUSIONS: Awareness of sociodemographics and early interventions for pain and cognitive deficits could reduce ADL/IADL disability and promote successful ageing. Identification of variables that influence ADL/IADLs can be used to inform policy and practice. Implications for rehabilitation After age, pain and taking five or more medications were the strongest factors associated with difficulty in ADL/IADL combined and ADL alone. Practice therefore needs to be cognizant that it is not the disease label but the symptoms of a disease that affect ADL and IADL activities. Given the strong influence of pain on difficulties with ADL and IADL, there is a need for early interventions from a multidisciplinary perspective for pain reduction, control, and self-management. These interventions should include development of pain-coping strategies and exercises to maintain mobility. After age, being separated/divorced or living with non-spouse others are the strongest factors associated with IADL difficulties. Awareness of these social factors can be used to inform support mechanisms, such as development of community services and suitable housing for those with these changing sociodemographics. Unsurprisingly, cognitive impairments were strongly associated with IADL difficulties. Simple cognitive screening assessments could be used for early detection of cognitive changes. In order to maintain optimal cognitive functioning, rehabilitation professionals should facilitate older adults' engagement in activities that are cognitively demanding and socially interactive.

Discharge of Non-Acute Coronary Syndrome Chest Pain Patients From Emergency Care to an Advanced Nurse Practitioner-Led Chest Pain Clinic: A Cross-Sectional Study of Referral Source and Final Diagnosis.

BACKGROUND: Chest pain is a common presentation to emergency departments (EDs). Pathways for patients with non-acute coronary syndrome (ACS) chest pain are not optimal. An advanced cardiology nurse-led chest pain service was commenced to address this. The aim of the study was to assess the outcomes of non-ACS patients discharged from ED to an advanced cardiology nurse-led chest pain clinic and compare by referral type (nurse or ED physician). METHODS: The service consisted of advanced cardiology nurse or ED physician consultation in the ED and discharge to advanced nurse-led chest pain clinic review less than 72 hours after discharge. Referrals were by the advanced nurses during consult hours and out-of-hours were by the ED physicians. Data were extracted from case notes. This was a 1-site cross-sectional study of patients attending the chest pain clinic over 2 years. RESULTS: Confirmed coronary disease was diagnosed in 24% of patients. Of the 1041 patients, 45% were referred by the advanced nurses, who referred significantly more patients who were older (56.5 years/52.3 years), had positive exercise stress test results (21%/12%), and were diagnosed with stable coronary artery disease (19%/11%) and less patients with musculoskeletal diagnosis (5%/13%) and other noncardiac pain (36%/45%). CONCLUSIONS: The study fills a gap in the literature on the follow up of non-ACS patients who present to ED and used advanced cardiology nursing expertise in the ED and chest pain clinic. The advanced nurse referred more patients who were diagnosed with coronary disease, reflecting the expertise, experience, and efficiency of the advanced cardiology nurse-led service.

Is Knowledge Level of Coronary Heart Disease and Risk Factors Among Post-Percutaneous Coronary Intervention Patients Adequate?

BACKGROUND: Percutaneous coronary intervention (PCI) is now commonly used in the treatment of coronary heart disease. However, shorter hospital stays after intervention may affect patients' knowledge and subsequent required lifestyle changes. OBJECTIVE: The aim of this study is to investigate participants' risk factor profile, knowledge of coronary heart disease, and the influence of demographic and risk factors on this knowledge. METHODS: This prospective, cross-sectional 1-site study recruited both elective and emergency PCI patients postdischarge. The questionnaire collected data on demographics, risk factor profile, and coronary heart disease knowledge as measured on the Bergman Heart Disease Knowledge Questionnaire. Bivariate and multivariate analyses were used to analyze the influence of 11 risk and sociodemographic factors on knowledge. RESULTS: The response rate was 67% (n = 84). The sample was mostly male and aged 65.79 ± 9.9 years, and 59% had an elective PCI. Risk factor burden was high; 2 or more risk factors were seen in 66% of participants. Mean knowledge score overall was 51%, with the highest score achieved in the risk factor domain (61%). Lowest scores were in the medical and symptoms domains (both 46%). Neither the bivariate nor the multivariate analyses were significant. A large proportion of patients believed that coronary heart disease was no longer a concern for them after PCI. CONCLUSIONS: As expected, the risk factor profile of post-PCI patients was high. However, their knowledge levels and awareness were unrelated to risk factor profile and poor in comparison with studies in other cardiac patients. This, in addition to the short stay in hospital and the low attendance of this cohort at cardiac rehabilitation, identifies this group of patients as a priority for further targeted education. Innovations are needed to increase knowledge and begin behavioral change predischarge after PCI. This should include target and goal setting for lifestyle change to avail of this critical education opportunity.

Ambulance use in acute coronary syndrome in Ireland: A cross-sectional study.

BACKGROUND: As myocardial salvage is time dependent, prompt emergency department attendance is imperative in the presence of unresolved acute coronary syndrome symptoms. Although ambulance use is the recommended mode of transport during an acute coronary syndrome event, people regularly have misperceptions about its role. Consequently, many fail to use this service when warranted. AIM: To evaluate factors associated with ambulance usage among patients admitted to emergency departments with acute coronary syndrome symptoms in Ireland. METHODS: Patients (N=1947) diagnosed with acute coronary syndrome were recruited across five hospitals. The ACS Response Index was used to identify mode of transport to access the emergency department, symptom context and experience and the rationale for non-ambulance use. Using logistic regression, predictors of ambulance use were identified. RESULTS: Only 40.1% of the sample used an ambulance. The primary reason for non-ambulance use was the perception that it was unwarranted (31%). A further 23.8% thought another mode of transportation would be faster. Independent predictors of ambulance usage differed among the three sub-diagnoses of acute coronary syndrome. For each group, visiting the general practitioner with symptoms was associated with a greater likelihood of not using an ambulance. CONCLUSION: The use of ambulance services is not positively embraced by the public. Furthermore, it appears that general practitioners may not always promote its use, particularly in the early stages of acute coronary syndrome symptom onset. The findings from our study suggest that a public education drive is necessary to promote ambulance usage during an acute coronary syndrome event.

Factors that influence fatigue status in patients with severe rheumatoid arthritis (RA) and good disease outcome following 6 months of TNF inhibitor therapy: a comparative analysis.

The objective of the present study is to determine the factors associated with persistent fatigue in patients with severe rheumatoid arthritis (RA) and good disease response to 6 months of tumour necrosis factor inhibitor therapy. Eligible patients with either persistent (PF) or no fatigue (NF) were compared. Using validated questionnaires and bivariate analysis, this cross-sectional survey explored if clinical characteristics, pain, self-efficacy, sleep and mood/depression differed between groups. Patients with PF (PF; NF) (n = 28; 28) reported significantly more overall pain (11.3 ± 9.4 (0-33); 6.9 ± 8.9 (0-33)), more recent and current pain intensity (41.4 ± 26.6 (0-80) 24.4 ± 26.6 (0-100) and depression (11.8 ± 7.5 (1-35); 8.2 ± 6.6 (0-26)), than the NF group. There was no significant difference between groups in self-efficacy and both groups experienced poor sleep quality (Pittsburgh Sleep Quality Index >5). Despite having good disease response, the PF group had significantly higher rheumatoid factor incidence, disease activity score-28, early morning stiffness duration and lower incidence of ever-failing disease-modifying anti-rheumatic drugs than the NF group. These findings enhance the fatigue literature in patients with RA prescribed tumour necrosis factor (TNF) inhibition therapy, identifying the potentially modifiable factors of pain and depression, previously demonstrated to be strongly associated with fatigue in non-biologic populations. In addition, this study highlights the association between persistent fatigue and an on-going state of low disease activity. This infers that more judicious disease management could minimise the symptom burden of pain and depression and consequentially fatigue.