Spanish transcultural adaptation of the 4AT score for the evaluation of delirium in the emergency department: a prospective diagnostic test accuracy study.

BACKGROUND: Delirium is one of the most common adverse events in older people during hospitalization, especially in the emergency department. Reliable, easy-to-use instruments are necessary to properly manage delirium in this setting. This study aims to evaluate the diagnostic validity of the Spanish version of the 4 'A's Test (4AT) in the ED. METHODS: A diagnostic accuracy study was conducted in patients over 65 years old admitted to the Emergency Department who did not have a formal diagnosis of dementia or a severe mental health disorder. Face and content validity were evaluated by an expert panel. Emergency nurses performed the evaluation with 4AT, whilst blinded and trained researchers assessed patients with the Revised Delirium Rating Scale as the gold standard. The content validity index, sensitivity, specificity, positive and negative predictive values, likelihood ratios, Youden's Index and ROC curves were calculated to evaluate the diagnostic accuracy of the instrument. RESULTS: Of 393 eligible patients, 380 were finally analyzed. Content validity yielded a median content validity index of 4 (interquartile range: 0). The Spanish 4AT sensitivity (95.83%; 95% ECI: 78.9-99.9%), specificity (92.98%; 95% CI: 89.8-95.4%), positive predictive value (47.92%) and negative predictive value (99.7%) were satisfactory. Youden's index was 0.89. Positive likelihood ratio was 13.65, and negative likelihood ratio 0.045. The area under the curve was 0.97. CONCLUSIONS: The Spanish version of the 4AT for use in the Emergency Departments is easy-to-use and applicable. The validation results indicate that it is a valid instrument with sufficient predictive validity to identify patients at risk of delirium in the Emergency Departments. Moreover, it is a tool that facilitates the management of an adverse event that is associated with increased mortality and morbidity.

Quality of Life, Physical and Mental Health, and Economic Evaluation of Family Caregivers of Chronic Dependent Children: INFAPRINT Cohort Study Protocol.

BACKGROUND: Caregivers for children with complex chronic illnesses may experience emotional and physical strain, especially as concerns attention overload and the perceptions of their own psychosocial situation. These concerns, together with the additional financial cost and the socioeconomic inequalities that arise from caregiving responsibilities, create major challenges to the health status of this population group. METHODS: A prospective analytical longitudinal study will be conducted, based on an exposed cohort of adult caregivers (parents or guardians) for children with complex chronic processes, to evaluate the impact of caregiving responsibilities on the health status of this population group. CONCLUSIONS AND IMPLICATIONS: The practical implications of this study are of great significance for clinical practice. The results of this study have the potential to inform the decision-making process in the healthcare sector and guide future research initiatives. The findings of this study will provide crucial insights into the health-related quality of life of caregivers of children with complex chronic illnesses, which will be valuable in addressing the challenges faced by this population group. This information can be used to improve the availability and accessibility of appropriate health services and to facilitate the development of more equitable health outcomes for caregivers of children with complex chronic illnesses. By highlighting the extent to which this population is affected both physically and mentally, the study can contribute to the development of clinical practices that prioritize the health and well-being of caregivers in the care of children with complex chronic illnesses.

Competency Gradients in Advanced Practice Nurses, Specialist Nurses, and Registered Nurses: A Multicentre Cross-Sectional Study.

(1) Background: Identifying differences in the competencies of different areas of nursing is a crucial aspect for determining the scope of practice. This would facilitate the creation of a formal structure for clinical practice in advanced and specialised services. The aims of this study are to analyse the distribution of advanced competencies in registered, specialist and advanced practice nurses in Spain, and to determine the level of complexity of the patients attended by these nurses. (2) Methods: A cross-sectional study was developed on registered, specialist and advanced practice nurses, all of whom completed an online survey on their perceived level of advanced competencies and their professional characteristics. (3) Results: In total, 1270 nurses completed the survey. Advanced practice nurses recorded the highest self-perceived level of competency, especially for the dimensions of evidence-based practice, autonomy, leadership and care management. (4) Conclusions: Among registered, specialist and advanced practice nurses, there are significant differences in the level of self-perceived competencies. Patients attended by advanced practice nurses presented the highest levels of complexity. Understanding these differences could facilitate the creation of a regulatory framework for clinical practice in advanced and specialized services.

Development of a Clinical Prediction Rule for Adverse Events in Multimorbid Patients in Emergency and Hospitalisation.

(1) Background: There is currently a global consensus that the quality of comprehensive care for acutely hospitalised elderly people should include addressing functionality and mobility, cognitive status, prevention of pressure ulcers, urinary incontinence, falls and delirium, as well as pain control and medication-related problems. The aim of this study is to develop and validate a clinical prediction rule for multimorbid patients admitted to an acute care hospital unit for any of the five adverse events included in our vulnerability pentad: falls, pressure ulcers, urinary incontinence, pain and delirium. (2) Methods: Longitudinal analytical clinimetric study, with two cohorts. The study population will consist of multimorbid patients hospitalised for acute care, referred from the Emergency Room. A clinical prediction rule will be proposed, incorporating predictive factors of these five adverse outcomes described. This study has received funding, awarded in November 2020 (PI-0107-2020), and was approved in October 2019 by the Research Ethics Committee ″Costa del Sol″. (3) Conclusions: Preventing adverse events in hospitalised patients is particularly important for those with multimorbidity. By applying a clinical prediction rule to detect specific risks, an estimate can be obtained of their probability of occurrence.

A protocol for a randomized trial measuring flowmetry in risk areas for pressure ulcer: Hyperoxygenated fatty acids vs olive oil.

BACKGROUND: Pressure ulcers are a common adverse event in healthcare. To date, no flowmetry studies have been conducted to compare hyperoxygenated fatty acids (HFA) vs. extra-virgin olive oil (EVOO) in alleviating this condition. AIMS: To determine and evaluate the effect of the application of HFA vs. EVOO on tissue oxygenation and perfusion in heels under pressure, in healthy persons and in hospitalised patients. DESIGN: Two-phase experimental study. METHODS: Phase 1 will be conducted with healthy subjects, using a randomised, open study design, evaluating an intrasubject control group. Phase 2 will focus on hospitalised subjects, with a randomised, open study group vs. a control group. DISCUSSION: This Project is undertaken to identify the mechanisms that intervene in the genesis of pressure ulcers and to determine whether there are differences in outcomes between the application of HFA vs. EVOO as a preventive measure The results of this study are of economic importance (due to the price difference between the products used) and will also impact on usual clinical practice for patients with impaired mobility and liable to suffer from pressure ulcers, by considering an alternative to established preventive measures.

Socioeconomic Factors and Quality of Life Perceived by Parents and Children with Complex Chronic Conditions in Spain.

Health-related quality of life of children with complex chronic conditions could be affected by sociodemographic factors. Most studies focus exclusively on the parents' perceptions of quality of life. This study aimed to determine the health-related quality of life of these children, according to their parents and the children themselves. A cross-sectional study was developed on children aged over five years with complex chronic conditions. Health-related quality of life, educational attainment, and social status were evaluated. A total of 101 children were included with a mean age of 10.48 years, and 35.6% were female. The most frequent disease was oncological (28.7%). Children perceived a better health-related quality of life, compared to their parents' assessment: median difference -8.4 (95%CI: -9.2 to -3.8). Moreover, differences were observed by socioeconomic factors. Parents and children with complex chronic conditions perceive differently the health-related quality of life. Social determinants associate with an uneven perceived quality of life.

Predictors of health service use by family caregivers of persons with multimorbidity.

BACKGROUND: Informal caregivers of patients with multiple chronic conditions are socially good, promoting the sustainability of a large part of home care provision. However, this very demanding activity causes health problems that increase their own need for health services. This study analyses the use of health services by informal carers, comparing it with the use made by the general population with similar characteristics. METHODOLOGY: Cross-sectional analytical study carried out in the Malaga-Valle Guadalhorce Primary Health Care District (Spain). Healthcare demand and perceived health were measured in the family caregivers, compared to the general population. Strobe Statement for observational studies has been used to strength the report of the results. RESULTS: Final sample consisted of 314 family caregivers together with a subsample of 2.290 non-caregivers taken from data of the National Health Survey. This subsample was paired by gender with our sample. Formal caregivers make fewer annual visits to the health services, with respect to the general population, regardless of the perceived level of health. The difference of the means between those who perceive their health as very poor was 0.11 (95% CI: 0.01 to 0.20) consultations with the family doctor, 0.21 (95% CI: 0.15 to 0.26) consultations with medical specialists and 1.70 (95% CI: 1.52 to 1.87) emergency room attention. Three independent factors were identified that predispose to the increased use of health services: background of greater education achievement (OR 8.13, 95% CI: 1.30 to 50.68), non-cohabitation with the care recipient (OR 3.57, 95% CI: 1.16 to 11.11) and a more positive physical quality of life component (OR 1.06; 95% CI: 1.03 to 1.09). DISCUSSION AND IMPLICATIONS: Intrinsic components of the caregiver reveal their independent relationship with the provision of informal care and the use of health services. A broader vision is needed for the factors that influence the health of these caregivers to develop multipurpose interventions and improve the consistency and effectiveness of the health services offered to the caregiver.

Nursing students' perceptions on the use of clinical simulation in psychiatric and mental health nursing by means of objective structured clinical examination (OSCE).

BACKGROUND: In view of the rising incidence and prevalence of mental disorders, and the stigma often attached to persons with these pathologies, the question of specific, appropriate training for nursing students is one of great importance. Objective structured clinical examination (OSCE) and clinical simulation may provide a useful means of introducing the student to this environment. OBJECTIVES: To examine the perceptions and satisfaction of nursing students after their participation in a targeted mental health course in which the main specialist skills were acquired via clinical simulation. DESIGN: A quantitative, descriptive, transversal study was conducted, in which the participants in a mental health course completed a questionnaire on their satisfaction with the experience. PARTICIPANTS: The study population consisted of 141 nursing students enrolled in a mental health course and currently in the third year of their Nursing Degree studies at the University of Málaga (Spain). RESULTS: The overall satisfaction expressed was more than 8 out of 10 (mean score = 8.43, SD = 1.25) and the students' satisfaction with specific aspects of the procedure exceeded 4 out of 5. The study results show that these nursing students considered the methodology in question to be useful preparation for clinical practice (mean score = 4.78, SD = 0.45), that they appreciated the participation of an expert (mean score = 4.72, SD = 0.60) and that receiving the opinions of their peers about their performance was an enriching part of the experience (mean score = 4.54, SD = 0.64). CONCLUSIONS: The participants reported a high degree of satisfaction with the OSCE procedure and observed that this method should be implemented more frequently. Debriefing is viewed as a vital contribution to the learning process and to the participants' satisfaction. However, further research is needed to study the impact of stress and anxiety on the acquisition of skills via OSCEs.

Tissue temperature, flux and oxygen of sacral and trochanteric area under pressure of healthy subjects: A quasi-experimental study.

AIM: To evaluate the changes that take place in the perfusion, oxygenation and local temperature of the skin of the sacrum and trochanter when subjected to direct pressure for 2 h. METHODS: Quasi-experimental study in the preclinical phase with healthy subjects acting as their own controls (intrasubject control). The outcome variables were measured with a laser Doppler system (local temperature and oxygenation) and by near-infrared spectroscopy (perfusion). The pressure exerted was measured with a capacitive pressure sensor. No more than one week elapsed between the sacrum and trochanter measurements. RESULTS: The study sample consisted of 18 persons. The comparative analysis of the fluctuations in the parameters measured on the skin of the trochanters and sacrum, according to the time elapsed, revealed a statistically significant increase in temperature and in the pressure exerted. On the other hand, the changes in capillary blood flow and in SaO2 were not statistically significant. CONCLUSION: Our study results show that changes found in terms of temperature and pressure should be taking into account when planning personalised repositioning to patients according to biomechanical and biological situations that vary between anatomical areas. In future research, the changes reported could be evaluated in patients with risk factors for the development of pressure ulcers, thus facilitating the introduction of more personalised planning in the care and prevention of these injuries.

Quality of Life, Physical and Mental Health of Family Caregivers of Dependent People with Complex Chronic Disease: Protocol of a Cohort Study.

BACKGROUND: informal caregivers have a high risk of suffering from diseases derived from the chronic stress to which they are subjected for their dedication to the care of their relatives. Such stress has a direct influence on the person cared for, mainly affecting the quality of their care. Therefore, the aim of the present study is to assess the association of caregiving on physical and mental perceived health in family caregivers of dependent adults with complex chronic diseases. METHODS: a prospective longitudinal cohort study, with a follow-up period of 36 months (HUELLA cohort). The exposed cohort will be formed by family caregivers of dependent patients with complex chronic pathologies. The unexposed cohort will be taken from the general population adjusted for age, sex and health. Outcome variables will include attendance to health services, consumption of psychoactive drugs, dedication to care (only in exposed cohort), concession of the Act on Promotion of Personal Autonomy and Care for dependent persons (exposed only), perceived physical and mental health, depression level, burden level and new diagnosis of chronic pathology of the caregiver during the study. RESULTS: the expected results will be applicable and will incorporate improvements to the usual health system clinical practice, providing feedback to professionals dedicated to the provision, planning and design of services to family caregivers, as well as to groups and organizations of caregivers. CONCLUSIONS: investments in preventing low-quality informal care are key, mainly through early identification and interventions to support caregivers who suffer from stress, anxiety or depression.

Adverse events encountered during clinical placements by undergraduate nursing students in Spain.

BACKGROUND: During clinical placements, nursing students are exposed to adverse events generated by the clinical tasks they must perform. OBJECTIVES: To describe the profile of adverse events encountered and the risks facing nursing students in clinical practice, as well as the severity and incidence of these events. DESIGN: Observational retrospective longitudinal study. SETTING: Clinical placements of undergraduate nursing students from the University of Málaga, in hospitals and primary health care. PARTICIPANTS: A total of 4284 undergraduate nursing students, enrolled during seven consecutive years (2011-2018). METHODS: Study data were obtained from students' notifications of adverse events during their clinical placements. The form for making this notification is available online, in the virtual campus for the practicum and notification is mandatory. RESULTS: A total of 1638 reports of adverse events were made during the study period. The adverse events most commonly reported were clinical accidents, followed by sharp and needle-stick injuries, and medication errors. By clinical settings, adverse events occurring in critical care were most frequently reported (35.9%). By the severity of the event, the largest proportion (32.4%) were classified as serious. By the risk of recurrence, 49.8% of the events reported were classified as accidents that "could happen again at some time". In this respect, there were significant differences among the respondents, with fourth-year students reporting up to four times more events of this type than second and third-year students (p < 0.001). CONCLUSIONS: Nursing students are subject to clinical safety-related events during their practices, mostly concerning medication errors and sharps and needlestick injuries. The pattern of these events changes over time, as students evolve in their competences. To improve clinical safety competencies among student nurses, priority attention should be paid to medication management, dose calculations and reactions to situations of aggression and violence in healthcare settings.

Quality of Life and Health Services Utilization for Spanish Children With Cerebral Palsy.

PURPOSE: To examine the health-related quality of life of children with cerebral palsy and its relationship with their use of health resources, taking into account sociodemographic factors concerning the family context. DESIGN AND METHODS: Cross-sectional study of children with cerebral palsy in Granada (Spain). Quality of life was evaluated with PedsQL questionnaire. RESULTS: A total of 75 children were analysed (mean age 7.41 years; SD 4.37; 50.7% male). They made an average of 22.80 visits (SD 12.43) per year; greater use was made of resources by children who had been diagnosed with cerebral palsy for <45 months (36.00 vs. 26.93 visits per year, p < 0.0001). Older children suffered more fatigue and pain. Children aged 2-4 years who presented with fatigue had more hospitalizations (r = -0.35; p = 0.20), whereas those >4 years who had a higher quality of life for daily activities had made more visits to hospital A&E (r = 0.35, p = 0.043). Among the children studied, there was no significant association between HRQOL and the parents' education or occupation. CONCLUSION: These findings highlight variables that may influence children's quality of life and their use of health resources, identifying certain profiles of children who might need individualized interventions. PRACTICE IMPLICATIONS: These findings could inform services provided by paediatric nurses to children with cerebral palsy, to individualize interventions and improve patient centred care.

Impact of self-care programmes in type 2 diabetes mellitus population in primary health care: Systematic review and meta-analysis.

AIMS AND OBJECTIVES: To evaluate the effectiveness of self-care programmes in type 2 diabetes mellitus (T2DM) population in primary health care. BACKGROUND: The impact of educational interventions on T2DM has been evaluated in various contexts, but there is uncertainty about their impact in that of primary care. DESIGN: Systematic review and meta-analysis. METHODS: A search was conducted in PubMed, CINAHL, WOS and Cochrane databases for randomised controlled trials carried out in the period January 2005-December 2017, including studies with at least one face-to-face educational interventions. The quality of the evidence for the primary outcome was evaluated using the GRADE System. A meta-analysis was used to determine the effect achieved although only the results classified as critical or important were taken into consideration. Checklist of Preferred Reporting Items for Systematic Reviews and Meta-analyses has been followed. PROSPERO registration Number: CRD42016038833. RESULTS: In total, 21 papers (20 studies) were analysed, representing a population of 12,018 persons with T2DM. For the primary outcome, HbA1 c, the overall reduction obtained was -0.29%, decreasing the effect in long-term follow-up. The quality of the evidence was low/very low due to very serious risk of bias, inconsistency and indirectness of results. Better results were obtained for individual randomised trials versus cluster designs and in those programmes in which nurses leaded the interventions. The findings for other cardiovascular risk factors were inconsistent. CONCLUSIONS: Educational interventions in primary care addressing T2DM could be effective for metabolic control, but the low quality of the evidence and the lack of measurement of critical results generates uncertainty and highlights the need for high-quality trials. RELEVANCE TO CLINICAL PRACTICE: Most of self-care programmes for T2DM in primary care are focused on metabolic control, while other cardiovascular profile variables with greater impact on mortality or patient-reported outcomes are less intensely addressed.

Perfusion, tissue oxygenation and peripheral temperature in the skin of heels of healthy participants exposed to pressure: a quasi-experimental study.

AIM: To evaluate the relationship between the pressure exerted on the heel of one foot resting directly on a mattress, versus that exerted on the other heel, protected by a pillow beneath the Achilles tendon area and the changes thus produced in perfusion, oxygenation and temperature in the skin of heels of healthy volunteers lying in a supine position. DESIGN: Experimental study in a pre-clinical phase, with healthy volunteer participants and intrapeople control. METHODS: The study was carried out from November 2017 - May 2018. A pressure measurement surface was placed between the participant and the constant low-pressure support surface. Doppler laser devices were used to measure local temperature and perfusion. The degree of oxygenation was determined using an infrared beam close to the pressure zone in each heel. Both feet rested immobile on the bed, in a natural position, for 2 hr. To ensure intrapeople control, in every case the left heel was raised slightly, compared with the right. RESULTS: Eighteen participants took part in this study. Analysis of the results obtained showed that capillary blood flow was significantly reduced in the heel subjected to pressure, compared with the other heel, while no significant effects on oxygen saturation or temperature were observed. The variables associated with greater oxygen saturation were capillary blood flow, local temperature and pressure exerted. Fat-free mass, fat mass and duration of exposure to pressure were all significantly associated with reduced oxygen saturation. CONCLUSIONS: In healthy participants, when the heel is subjected to constant pressure against a constant low-pressure support surface, there is a significant reduction in blood flow, compared with the heel where pressure is relieved. However, there are no significant differences in temperature or tissue oxygenation. IMPACT: Significant reductions in vascular flow were observed; however, the oxygenation and temperature of the heel tissues remained unchanged. These findings, corroborated in real patients, would advance our understanding and facilitate decision-making on measures to prevent pressure ulcers, such as repositioning or tissue protection. TRIAL REGISTRATION: The protocol is registered in ClinicalTrials.gov (NCT02736838).

A scoping review of safety management during clinical placements of undergraduate nursing students.

BACKGROUND: The abundant knowledge on nursing students' competencies in clinical safety, and the multiple approaches adopted make it difficult to obtain an overview of the current status of this question. PURPOSE: To review the literature on undergraduate nursing students' safety competencies during their clinical placements. METHOD: A scoping review was carried out. Searches were executed in PubMed, CINAHL, WOS, MEDES, and websites of relevant organizations. The framework proposed by the Joanna Briggs Institute was adopted. FINDINGS: A total of 43 studies were selected for the final sample. The review identified four major topics: the presence of adverse events in clinical placements, the acquisition of competencies in clinical safety, student experiences regarding clinical safety, and pedagogical approaches for clinical safety. DISCUSSION: Nursing students encounter adverse events and clinical safety incidents throughout their clinical training. Faculties should assign the highest priority to this question, due to its importance in the creation of a culture of safety.

Validation of the Spanish version of the Edinburgh Feeding Evaluation in Dementia Scale for older people with dementia.

AIMS: To adapt the Edinburgh Feeding Evaluation in Dementia Scale (EdFED) for use in a Spanish-speaking population and to assess its validity and reliability in patients with dementia. METHOD: A cross-sectional study was carried out in two stages: 1. Cross-cultural adaptation (translation, back-translation, review by committee of experts, pilot test and weighting of results); 2. Clinimetric validation comprising interobserver reliability assessment, test-retest reliability and internal consistency. To determine construct validity, confirmatory factorial analysis and principal components analysis were performed by oblique rotations. Criteria validity was analysed using the Pearson correlation (p<0.05) with the BMI, MNA and analytical values of albumin, transferrin, cholesterol, absolute lymphocytes and total proteins. Data collection was carried out for six months in 2016 in nursing homes and Alzheimer's day centers in the province of Málaga (Spain), at nine centers, with 262 patients (aged over 60 years and presenting feeding difficulties), 20 nurses, 20 professional caregivers and 103 family caregivers. RESULTS: A version of EdFED culturally adapted to Spanish was obtained. The sample presented the following characteristics: 76.3% women, mean age 82.3 years (SD: 7.9); MNA 18.73 (SD: 4.44); BMI 23.99 (SD: 4.72); serum albumin 3.79 mg/dl (SD: 0.36). A Cronbach's alpha of 0.88 was obtained, with an inter-item global correlation of 0.43 and a homogeneity index ranging from 0.42 to 0.73. The exploratory factor analysis reproduced the three-factor model identified by the original authors, explaining 62.32% of the total variance. The criterion validity showed a good inverse correlation with MNA and a moderate one with albumin, total proteins, transferrin and BMI. DISCUSSION: The Spanish version of EdFED is reliable and valid for use in elderly people with dementia. The most appropriate for our environment is the three-factor model, which maintains the original factors, with a slight redistribution of the items.

Cultural adaptation and validation of the Lasater Clinical Judgment Rubric in nursing students in Spain.

BACKGROUND: The clinical judgment and decision-making abilities of nurses can influence many health outcomes, hence the importance of addressing these qualities in university studies. In this respect, clinical simulation is a commonly employed teaching method. The evaluation of simulation activities requires standardised instruments, such as the Lasater Clinical Judgment Rubric, which is widely used for this purpose, although a culturally adapted and validated version in Spain is not available. AIMS: To obtain a Spanish culturally adapted and validated version of the rubric for undergraduate students of nursing. DESIGN, PARTICIPANTS AND SETTING: Cultural adaptation and psychometric validation study carried out with undergraduate nursing students in the simulation laboratories at the University of Málaga (Spain). METHODS: A process of translation/back-translation and cultural adaptation was carried out in accordance with international standards. The rubric was empirically evaluated in standardised scenarios with high and medium-fidelity simulators. Each student took part in two different simulation sessions, led by two instructors. In each simulation, the data were collected by two independent observers. RESULTS: 152 observations were obtained from 76 students. The interobserver reliability was high, with an intraclass correlation coefficient of 0.93 (95% CI 0.92-0.95) (p = 0.0001) and Cronbach's alpha of 0.93. According to the confirmatory factor analysis, the fit of the model was satisfactory in all indices, with a χ2/df value of 1.08, GFI 0.96, TLI 0.99, NFI 0.97 and RMSEA 0.24 (90% CI 0.000-0.066). CONCLUSIONS: The rubric obtained is culturally adapted to the Spanish educational context, and is valid and reliable for nursing students. Further prospective studies should be undertaken to evaluate the responsiveness, potential for transfer to clinical practice and cost-benefit ratios of different simulation designs.

Peripheral perfusion and oxygenation in areas of risk of skin integrity impairment exposed to pressure patterns. A phase I trial (POTER Study).

AIM: The aim of this study was to analyse the change in peripheral oxygenation and microvascular flow in tissues subjected to different pressure regimes in healthy subjects and in hospitalized patients. BACKGROUND: The presence of pressure ulcers in hospitalized patients is a common complication that has a negative impact on health and often prolongs hospital stay and increases healthcare costs. DESIGN: Experimental non-controlled, non-randomized study in two phases: pre-clinical and clinical. METHODS: The pre-clinical phase will be conducted in healthy volunteers and the clinical phase, in patients at risk of impaired skin integrity. Vascular flow, tissue oxygenation and local temperature in areas at risk of pressure ulcers will be evaluated by Doppler laser in subjects lying on a capacitive surface to measure pressure at 10,249 points. Different levels of pressure will be generated by changes in body position and changes in tissue perfusion and oxygenation will be monitored for up to 4 hours, to determine the implications for repositioning interventions in patients at risk. This study was funded in July 2015. The protocol is registered in ClinicalTrials.gov (NCT02736838). DISCUSSION: Pressure ulcer is a significant and complex health problem in long-term bedridden patients and there is currently no effective treatment or efficient prevention method. The information provided by our study will provide an accurate assessment of different thresholds for the onset of damage to the skin, associated with different body positions and pressure levels. TRIAL REGISTRATION: The protocol is registered in ClinicalTrials.gov (NCT02736838).

Living with chronicity and complexity: Lessons for redesigning case management from patients' life stories - A qualitative study.

RATIONALE, AIMS AND OBJECTIVES: Case management is commonly used to provide health care for patients with multiple chronic conditions. However, the most effective form of team organization and the necessary support structures need to be identified. In this respect, patients' views could provide a valuable contribution to improving the design of these services. To analyse the experiences of patients with chronic diseases and of caregivers, in relation to health care services and mechanisms, and to identify means of modelling case management services. METHODS: The method used was a qualitative study based on life stories, and semi-structured interviews with 18 patients with complex chronic diseases and with their family caregivers, selected by purposeful sampling in primary health care centres in Andalusia (southern Spain) from 2009 to 2011. RESULTS: Three transition points were clearly identified: the onset and initial adaptation, the beginning of quality-of-life changes, and the final stage, in which the patients' lives are governed by the complexity of their condition. Health care providers have a low level of proactivity with respect to undertaking early measures for health promotion and self-care education. Care is fragmented into a multitude of providers and services, with treatments aimed at specific problems. CONCLUSIONS: Many potentially valuable interventions in case management, such as information provision, self-care education and coordination between services and providers, are still not provided.

A systematic review of the effectiveness and roles of advanced practice nursing in older people.

OBJECTIVES: To identify, assess and summarize available scientific evidence about the effect of interventions deployed by advanced practice nurses when providing care to older people in different care settings, and to describe the roles and components of the interventions developed by these professionals. BACKGROUND: In older people, evidence of advanced practice roles remains dispersed along different contexts, approaches and settings; there is little synthesis of evidence, and it is not easy to visualize the different practice models, their components, and their impact. DESIGN: Systematic review. DATA SOURCES: Sixteen electronic databases were consulted (1990-2014). The research also included screening of original studies in reviews and reports from Centers of Health Services Research and Health Technology Agencies. REVIEW METHODS: Studies were assessed by two reviewers with the Cochrane risk of bias tool. They were classified depending on the type of follow-up (long and short-term care) and the scope of the service (advanced practice nurses interventions focused on multimorbid patients, or focused on a specific disease). RESULTS: Fifteen studies were included. In long-term settings, integrative, multi-component and continuous advanced practice nursing care, reduced readmissions, and increased patients' and caregivers' satisfaction. Advanced practice nurses were integrated within multidisciplinary teams and the main interventions deployed were patient education, multidimensional assessments and coordination of multiple providers. CONCLUSION: Positive results have been found in older people in long-term care settings, although it is difficult to discern the specific effect attributable to them because they are inserted in multidisciplinary teams. Further investigations are needed to evaluate the cost-effectiveness of the two modalities detected and to compare internationally the interventions developed by advanced practice nurses.