Factors influencing non-conveyance care encounters in the ambulance service, registered nurses experiences - a qualitative study.

BACKGROUND: There is a notable variation in the percentage of non-conveyed patients within the ambulance service. Discharging patients at the scene includes a risk of adverse events, and both patients and ambulance clinicians experience the complexity of non-conveyance. Therefore, this study aimed to describe factors influencing the care encounter when care in the ambulance service concludes with non-conveyance. METHOD: A qualitative study design employing the critical incident technique for data collection through individual interviews, and a qualitative analysis based on Fridlund et al. descriptions was utilized. The study conforms to the COREQ checklist for reporting qualitative research. RESULTS: Fourteen Registered Nurses (RN) described 30 incidents and various factors were identified as influencing the care encounter. The factors included communication, sharing information, maintaining a secure and confident approach, organizational aspects, applying person-centered care in collaboration with the patient, relatives, and other caregivers, and an overall understanding of the patient's entire situation. These factors were integrated into the RNs' decision-making process for non-conveyance. CONCLUSION: The decision-making process for non-conveyance by RNs is a multifaceted approach that incorporates several factors. Communication, sharing of information, maintaining a secure and confident approach, organizational aspects, applying person-centered care in collaboration with the patient, relatives, and other caregivers, and a comprehensive understanding of the patient's entire situation. These findings have the potential to contribute to the development of guidelines supporting the RNs working in the ambulance service in their decisions regarding non-conveyance. Further research is needed on the patient's and relatives' perspective on non-conveyance otherwise, patient participation and partnership in person-centered care are not possible to achieve.

Reduction of brain stem pathology and transient amelioration of early cognitive symptoms in transgenic mice treated with a monoclonal antibody against α-synuclein oligomers/protofibrils.

Immunotherapy against alpha-synuclein (α-syn) is a promising novel treatment strategy for Parkinson's disease (PD) and related α-synucleinopathies. We have previously shown that systemic treatment with the monoclonal oligomer/protofibril-selective antibody mAb47 targeting cytotoxic α-syn leads to reduced central nervous system levels of such species as well as an indication of reduced late-stage symptoms in aged (Thy-1)-h[A30P] α-syn transgenic mice. Here, we performed an early-onset long-term treatment study with this antibody to evaluate effects on brain pathology and behavioral outcomes in the same mouse model. Compared to the placebo group, the treatment strongly reduced phosphorylated α-syn (pS129 α-syn) pathology in the upper brain stem. Moreover, a preserved recognition memory and risk assessment behavior could be seen in antibody-treated mice at six months of age, even although these effects were no longer significant at eleven months of age. Importantly, no evidence of inflammatory responses or other potential toxic effects was seen with the treatment. Taken together, this study supports the strategy to target α-syn oligomers/protofibrils with monoclonal antibodies to counteract early symptoms and slow down the progression of PD and other α-synucleinopathies.

Emergency care nurses' self-reported clinical competence before and after postgraduate education - a cross-sectional study.

Changing prerequisites in healthcare leads to the increased complexity of nursing. Since there are no regulations on re-validation of competencies for emergency nurses in Sweden there is sparse knowledge on how nurses develop competencies after registration as nurses (RN). AIM: To describe self-reported professional competence after postgraduate education among RNs in emergency care settings. METHOD: A cross-sectional design and STROBE guidelines were used. The short version of the Nurse Professional Competence Scale was used for data collection and the data were collected before and after postgraduate education, descriptive and comparative statistic was used for analysis. RESULTS: 62 (71%) students participated in the first data collection and an independent group of 31 (48%) students participated in the second data collection. The results showed generally good competencies before entering education and significantly improved competencies after education were found in areas of working independently and reviewing literature for evidence-based nursing Conclusion: The competencies were assessed as very good after education. Evaluating nurses' competencies supports educators in developing education to ensure the need for knowledge in emergency care. To ensure required competencies among emergency care nurses there is a need to regulate additional training and re-validation of emergency nurses' competencies.

Digital feedback during clinical education in the emergency medical services: a qualitative study.

BACKGROUND: Clinical education is essential for students' progress towards becoming registered nurses (RN) in Sweden. Assessment of caring skills in the Emergency Medical Services (EMS) is complex due to the ever-changing scenarios and the fact that multiple supervisors are involved in the student's education. Currently, assessments of student's skills are summative and occur twice during the six weeks of clinical education. A digitalized assessment tool (DAT) with an adaptation for formative assessment is a new approach to assessment of nursing skills in the EMS. Since new technologies and changes in procedures are likely to affect both students and supervisors, our aim in this study is to describe students' and clinical supervisors' experience of formative assessments using DAT in the EMS. METHOD: This study is qualitative, using semi-structured group interviews (N = 2) with students and semi-structured individual telephone interviews (N = 13) with supervisors. The data was analysed according to Graneheim and Landman's method for content analysis. This analysis generated 221 codes organized into 10 categories within which three themes were identified. The students in this study were nursing students in their last semester and all supervisors were experienced RNs. RESULTS: The results showed that students and supervisors had mainly positive views of the DAT and the formative assessment stating that the information they provided while using the DAT offered opportunities for reflection. The DAT supported the students' learning by visualizing strengths and areas of improvement, as well as displaying progress using a Likert scale. The application improved communication, but additional features linking the assessment tool with the university were requested. The application contributed to transparency in the assessments and was seen as preferable to the traditional 'pen and paper' method. CONCLUSION: A digital system was described in a positive manner, and the assessment using the DAT facilitated reflection and formative assessment. The use of a Likert scale was considered positive in order to demonstrate progression which with advantage could be demonstrated visually.

Do we need a pandemic to improve hygiene routines in the ambulance service? A cross-sectional study.

BACKGROUND: We know that ambulance staff may have sparse knowledge on how to comply with care approaches that ensure appropriate hygiene in the ambulance, but we do not know if and how the COVID-19 pandemic has affected ambulance staff's perceived compliance with hygiene routines. AIM: To investigate ambulance staff's self-reported hand hygiene (HH) perceptions and compliance; and to explore if and how the COVID-19 pandemic has affected ambulance staff's perceived compliance with hygiene routines. METHODS: A cross-sectional study design using the WHO-validated Perception Survey for Healthcare Workers regarding hygiene. Thematic analysis and descriptive statistics were used for analysis. RESULTS: 204 surveys were analysed, 92% of participants stated that their hygiene routine compliance had improved during the COVID-19 pandemic, and some participants also described that their colleagues' practice had improved. These improvements were reportedly driven by the need to acquire new knowledge to deal with the pandemic and sometimes with fear. CONCLUSIONS: Experience acquired during the pandemic needs to be sustainable if we are to increase HH and hygiene routine compliance in ambulance services. Interventions aimed at changing ambulance staff's perceived behaviour are warranted, and stakeholders should try and identify the personal motivations that lead these staff to seek self-betterment regarding HH and hygiene routine compliance. Otherwise, the risk of patients suffering from healthcare-associated infection may not decrease as wished.

Finnish and Swedish prehospital emergency care providers' knowledge and attitudes towards pressure ulcer prevention.

BACKGROUND: Despite the knowledge that transportation by emergency medical services may increase the risk of pressure ulcers (PU), there is still lack of knowledge about the possibility of prehospital emergency care providers to be a part of preventing and reducing the risk of PUs. METHODS: A survey was carried out during 2017 in Finland and Sweden. Validated questionnaires were used. RESULTS: A total of 179 (72.7%) Finnish and 188 (28.8%) Swedish prehospital emergency care providers participated in the study. The overall rate of correct answers and the mean total knowledge score was 58.8% (SD 21.8), 20/34, in the Finnish group and 70.5% (SD 15.7), 24/34, in the Swedish group (p < 0.000). The percent of the total and the mean attitude score was in the Finnish group 71.3% (SD 0.48), 37.1/52, and in the Swedish group 69.4% (SD 0.77), 36.1/52 (p < 0.813). Half of the Finnish and most of the Swedish participants felt they needed more education about PUs (Fin 50.2% & Swe: 76.0%). CONCLUSIONS: Prehospital emergency care providers don't see themselves as responsible for PU prevention. Therefore, there is a need for increasing the level of knowledge on PU prevention and classification among prehospital emergency care providers. They could play a key role in developing methods to improve PU prevention and identifying patients in risk of developing PUs.

The learning environment and supportive supervision promote learning and are based on the relationship between students and supervisors - A qualitative study.

During clinical education, teaching and supervision are essential. Teaching is a process intended to facilitate students' learning, and to lead and support the students in discovering knowledge by themselves. But, the understanding of learning is not only to understand the students' learning process but also to understand conditions that influence that process. Therefore the aim of this study was to identify what factors support students learning in the ambulance service from both the students' and supervisors' perspectives. An inductive qualitative study design with four group interviews and content analysis was used. One main theme was identified including the sub-themes; reflection in practice, preparations for clinical education, motivation to learn, mutual trust in students' abilities and contextual factors supporting learning Conclusion: Reflection, preparations, motivation, trust, sense of belonging in a community and the context are essential factors supporting undergraduate nursing students' learning. However, supervisors sometimes had a hard time reflecting, teaching and supporting learning about care and caring science. The lack of knowledge and/or interest about caring science among supervisors needs to be addressed in the ambulance service otherwise it will be difficult to support undergraduate nursing students' learning about caring skills.

The effects of interprofessional education - Self-reported professional competence among prehospital emergency care nursing students on the point of graduation - A cross-sectional study.

The aim of the study was to investigate whether interprofessional education (IPE) and interprofessional collaboration (IPC) during the educational program had an impact on prehospital emergency care nurses' (PECN) self-reported competence towards the end of the study program. A cross-sectional study using the Nurse Professional Competence (NPC) Scale was conducted. A comparison was made between PECN students from Finland who experienced IPE and IPC in the clinical setting, and PECN students from Sweden with no IPE and a low level of IPC. Forty-one students participated (Finnish n=19, Swedish n=22). The self-reported competence was higher among the Swedish students. A statistically significant difference was found in one competence area; legislation in nursing and safety planning (p<0.01). The Finnish students scored significantly higher on items related to interprofessional teamwork. Both the Swedish and Finnish students' self-reported professional competence was relatively low according to the NPC Scale. Increasing IPC and IPE in combination with offering a higher academic degree may be an option when developing the ambulance service and the study program for PECNs.

Actions to improve documented pain assessment in adult patients with injury to the upper extremities at the Emergency Department - A cross-sectional study.

BACKGROUND: Pain is one of the most common symptoms in the Emergency Department (ED) and is the cause of more than half of the visits to the ED. Several attempts to improve pain management have been done by using, for example, standards/guidelines and education. To our knowledge no one has investigated if and how different actions over a longitudinal period affect the frequency of pain documentation in the ED. Therefore the aim of this study was to describe the frequency of documented pain assessments in the ED. METHOD: A cross-sectional study during 2006-2012 was conducted. The care of patients with wrist/arm fractures or soft tissue injuries on upper extremities was evaluated. RESULT: Despite various actions our result shows that mandatory pain assessment in the patient's computerized medical record was the only successful intervention to improve the frequencies of documentation of pain assessment during care in the ED. During the study period, no documentation of reassessment of pain was found despite the fact that all patients received pain medication. CONCLUSION: To succeed in increasing the frequency of documented pain assessment, mandatory pain rating is a successful action. However, the re-evaluation of documented pain assessment was nonexisting.

Ambulance personnel's experience of pain management for patients with a suspected hip fracture: A qualitative study.

Pain management is described to be insufficient for patients suffering from a hip fracture, and the management for this vulnerable group of patients may be challenging due to their medical history (multiple comorbidities) and polypharmacy. Previous research has mainly focused on fast tracks aiming to reduce time to surgery. But the research on how pain management is handled for these patients in the prehospital context has been sparse. Therefore, the purpose of this study was to describe the ambulance personnel's experience of managing the pain of patients with a suspected hip fracture. A descriptive and qualitative design with Critical Incident Technique was used for collecting data. Moreover, a qualitative content analysis was used for analysing the collected data. Twenty-two participants communicated their experiences and 51 incidents were analysed. The main finding in the study was that the ambulance personnel, by using their clinical knowledge and by empowering the patients to participate in their own care, managed to individualize the pain relief for patients with a suspected hip fracture through a variety of interventions.

Prevalence of sleep problems and pain among the elderly in Sweden.

BACKGROUND/OBJECTIVES: Sleep problems and pain are common among the elderly and have been shown to affect quality of life. The objectives were to determine the prevalence of sleep problems and pain among the elderly and to compare the two factors in relation to age and gender. DESIGN: A cross-sectional study based on baseline material collected by the Swedish National Study on Aging and Care in Blekinge (SNAC-Blekinge). SETTING: The data were gathered from questionnaires distributed between the years 2001 and 2003 in the municipality of Karlskrona, Sweden. PARTICIPANTS: The participants comprised 1402 Swedish men and women aged 60-96. RESULTS: Of all the participants 70 percent met the criteria for sleep problems and 62 percent indicated some experience of pain during the preceding 4 weeks. Both sleep problems and pain were more frequent among women than men and sleep problems tended to be more common with increasing age. Among the participants who experienced pain during the preciding 4 weeks 77 percent suffered from sleep problems. CONCLUSIONS: Sleep problems and pain are common among older people. Furthermore it is common to suffer from sleep problems when pain has been experienced during the preciding 4 weeks.

Serum amyloid a protein and C-reactive protein in normal pregnancy and preeclampsia.

AIMS: To study plasma levels of serum amyloid A protein and C-reactive protein in pregnant women with and without preeclampsia and non-pregnant women. Plasma levels of haptoglobin, orosomucoid and ceruloplasmin were also analyzed. METHODS: The study included 295 women with uncomplicated pregnancies, 57 women diagnosed with preeclampsia, and 58 healthy non-pregnant women. Plasma concentrations of acute phase proteins were analyzed by particle-enhanced immunoassays. Non-parametric Kruskal-Wallis and Mann-Whitney U tests were used to test differences between the groups. RESULTS: Plasma levels of C-reactive protein and ceruloplasmin were increased in pregnant women with and without preeclampsia compared to non-pregnant women. Plasma levels of serum amyloid A protein and C-reactive protein were not elevated in women with preeclampsia compared to women with normal pregnancy. CONCLUSION: The description of preeclampsia as a systemic inflammatory state was not reflected in the plasma levels of serum amyloid A protein and C-reactive protein.

Interindividual differences in o,p'-DDD enantiomer kinetics examined in Göttingen minipigs.

Five minipigs were given a single oral dose of a racemic mixture of o,p'-DDD (30 mg kg(-1)b.w., EF=0.49). Blood plasma and subcutaneous adipose tissue were collected for analysis, at different time-points over 180 d. At the end of the experiment also liver, kidney and brain tissue were collected. Low concentrations of o,p'-DDD still remained after 180 d in plasma (mean 0.5+/-0.3 ng g(-1)f.w.) and in adipose tissue (mean 40+/-40 ng g(-1)f.w.). The mean concentrations in liver and kidney were 500+/-300 pg g(-1)f.w. and 90+/-50 pg g(-1)f.w., respectively. The enantiomers of o,p'-DDD were isolated by HPLC and the absolute configuration of the enantiomers were determined by X-ray crystallography and polarimetry as R-(+)-o,p'-DDD and S-(-)-o,p'-DDD. The enantiomer fractions (EFs) of o,p'-DDD were determined in plasma, adipose tissue and kidney using GC/ECD equipped with a chiral column. The EFs of o,p'-DDD in the individual minipigs showed large variability, ranging from 0.2 to 0.6 after 24h in plasma and from 0.2 to 0.7 after 90 d in adipose tissue. Hence in two of the minipigs, the S-(-)-o,p'-DDD enantiomer was dominating while the other enantiomer, R-(+)-o,p'-DDD was dominating in three minipigs. We propose that a yet not identified factor related to polymorphism, regulating the metabolism and/or elimination of the enantiomeric o,p'-DDD, is responsible for the differences in enantiomeric retention of the compound in the minipigs.

Standardization of Cystatin C: development of primary and secondary reference preparations.

A Primary Reference Preparation has been produced using pure, recombinant, Cystatin C in a solvent of 0.1 mol/L KCl. Dry mass determination of the Primary Reference Preparation resulted in a Cystatin C concentration of 5.20 g/L. Agarose-electrophoresis and SDS-electrophoresis, as well as N-terminal sequencing, verified the purity, homogeneity and identity of Cystatin C in the Primary Reference Preparation. For the Secondary Reference Preparation, a serum pool was collected and stabilized. A pilot batch was made to verify the selected procedure and spiking with the pure, recombinant Cystatin C. The final Secondary Reference Preparation is now produced (4468 vials) and ready for value assignment and further characterization.

Therapeutical aspects and outcome of HIV/HCV coinfected patients treated with pegylated interferon plus ribavirin in an Italian cohort.

BACKGROUND: One-third of HIV-infected individuals suffer from chronic hepatitis C virus infection (HCV) in Europe. Recommendations from HCV-HIV International Panel advise current treatment with pegylated interferon plus ribavirin. We assessed the impact of interferon and ribavirin combination in 43 patients between 2002 and 2006. PATIENTS AND METHODS: All coinfected patients treated for HCV during the 5-year period were included in retrospective data collection. CD4+ T-lymphocyte count, HAART discontinuation, reasons for treatment interruption and factors correlated to sustained virological response (SVR) were monitored. RESULTS: The mean age was 41 +/- 6.7 years; the risk factor for coinfection was intravenous drug abuse in 32/43 (74%). The baseline CD4+ T-lymphocytes cell count was > 500 in 51% (22/43). Genotype 3a represented 51% (22/43); 37% were on HAART at baseline (16/43) and half of patients showed high HCV RNA levels (> 800,000 IU/ml). High rates of treatment discontinuation were observed (27/43, 63%), caused by voluntary interruptions in 52% (14/27) and virological failure in 26% (7/27). The overall population had an SVR of 30%; genotypes 3a and 1 had SVR of 38% and 24%, respectively. The SVR was significantly lower in three groups: high HCV RNA viral load (chi2 = 6, p < 0.0025), CD4+ T-lymphocyte historical nadir <350 cells/mm3 (chi2 = 3.26, p < 0.01) and genotype 1 with high viral load (chi2 = 4.8, p < 0.005). CONCLUSIONS: Although factors such as HCV viral load rates and genotype 1 have been confirmed to threaten the response to therapy, we observed a significant response rate when patients had a history of CD4+ T-lymphocyte nadir >350 per mm3. The high dropout rates due to voluntary discontinuations complicated the patients' case management.

A case of Cunninghamella bertholettiae rhino-cerebral infection in a leukaemic patient and review of recent published studies.

Cunninghamella bertholletiae infection occurs most frequently in neutropenic patients affected by haematological malignancies, is associated with an unfavourable outcome. We report a case of rhino-mastoidal fungal infection in a leukaemic patient. Bioptical tissue cultures yield the isolation of a mould with typical properties of Cunninghamella species. Liposomal amphotericin B (L-Amb) therapy combined with surgical intervention brought the lesion to recovery. Nevertheless, the patient died 14 days after bone marrow transplantation (BMT) from bacterial sepsis. Mastoiditis was documented at CT-scan. The conditioning regimen probably caused the reactivation of the Cunninghamella infection that led to the patient's fatal outcome; fungal hyphae were detected after autopsy of brain and lung tissue.

Increased plasma levels of beta2-microglobulin, cystatin C and beta-trace protein in term pregnancy are not due to utero-placental production.

OBJECTIVE: To study concentration gradients of the low molecular mass proteins, beta2-microglobulin, cystatin C and beta-trace protein, between the uterine and ante-cubital veins, the umbilical artery and vein and in the amniotic fluid compartment. MATERIALS AND METHODS: The study comprised 27 healthy women with uncomplicated pregnancies undergoing caesarean section at term. Samples were collected simultaneously and paired t-tests were used to compare mean plasma concentrations. RESULTS: There was no significant concentration gradient in the plasma levels of beta2-microglobulin, cystatin C or beta-trace protein between the uterine and antecubital veins. There were no correlations between the protein levels in the compartments. CONCLUSION: The utero-placental unit does not contribute significantly to the maternal levels of beta2-microglobulin, cystatin C and beta-trace protein in normal pregnancy, and the proteins are not likely to be transferred across the placental barrier.

Prediction of relative glomerular filtration rate in adults: new improved equations based on Swedish Caucasians and standardized plasma-creatinine assays.

OBJECTIVE: To evaluate newly developed equations predicting relative glomerular filtration rate(GFR) in adult Swedish Caucasians and to compare with the Modification of Diet in Renal Disease(MDRD) and Mayo Clinic equations using enzymatic and zero-calibrated plasma creatinine assays. MATERIAL AND METHODS: GFR was measured with iohexol clearance adjusted to 1.73 m(2). One population sample (n=436/Lund) was used to derive an equation based on plasma-creatinine/age/gender, and a second with the addition of lean body mass (LBM). Both equations were validated in a separate sample (n=414/Malmö). The coefficients of the equations were eventually fine-tuned using all 850 patients and yielding Lund-Malmö equations without (LM) and with LBM-term (LM(LBM)). Their performance was compared with the MDRD(CC) (conventional creatinine calibration), MDRD(IDMS) (isotope dilution mass spectroscopy traceable calibration) and Mayo Clinic equations. RESULTS: The Lund equations performed similarly in both samples. In the combined set, the Mayo Clinic/MDRD(CC) resulted in +19.0/+10.2 % median bias, while bias for the other equations was < 10 %. LM(LBM) had the highest accuracy (86 % of estimates within 30 % of measured GFR), significantly (p < 0.001) better than for MDRD(IDMS) (80 %). In men with BMI < 20 kg/m(2), MDRD(IDMS)/LM had +46 %/+19 % median bias. MDRD(IDMS) also overestimated GFR by 22 %/14 % in men/women above 80 years of age. The LM(LBM) equation had < 10 % bias irrespective of BMI, age or GFR except for a 15 % negative bias at GFR > 90 mL/min/1.73 m(2). CONCLUSION: The newly developed Lund-Malmö equations for GFR estimation performed better than the MDRD(IDMS) and Mayo Clinic equations in a Swedish Caucasian sample. Inclusion of an LBM term improved performance markedly in certain subgroups.

Temporal changes of the plasma levels of cystatin C, beta-trace protein, beta2-microglobulin, urate and creatinine during pregnancy indicate continuous alterations in the renal filtration process.

OBJECTIVE: To determine the plasma levels of the renal functional markers creatinine, urate, cystatin C, beta2-microglobulin and beta-trace protein in samples from the first, second, early third and late third trimesters of 398 healthy women with uncomplicated singleton pregnancies. MATERIAL AND METHODS: Plasma samples from 58 healthy non-pregnant women served as controls. The creatinine levels were significantly lower at all time-points in pregnancy, whereas the urate levels were lower during the first and second trimesters but increased in the late third trimester. The cystatin C, beta2-microglobulin and beta-trace protein levels displayed similar changes with increased levels in the third trimester but unaltered levels during the first and second trimesters. RESULTS: The results indicate an increased filtration of low-molecular weight molecules during pregnancy, particularly during the first and second trimesters, whereas filtration of 10-30 kDa molecules is decreased in the third but unaltered in the first and second trimesters. The levels of albumin and alph2-macroglobulin were measured in the same samples. CONCLUSIONS: The albumin levels decreased in the second and third trimesters, whereas the levels of chi2-macroglobulin were unchanged, which is compatible with a virtually unaltered transfer of chi2-macroglobulin between the intra- and extravascular space during pregnancy and a significantly increased extravascular fraction of albumin.