Engaging the Wisdom of Older Veterans to Enhance VA Healthcare, Research, and Services.

BACKGROUND: Stakeholder engagement helps ensure that research is relevant, clinical innovations are responsive, and healthcare services are patient-centered. OBJECTIVE: Establish and sustain a Veteran engagement board involving older Veterans and caregivers to provide input on aging-related research and clinical demonstration projects. DESIGN AND PARTICIPANTS: The Older Veteran Engagement Team (OVET)-a group of eight Veterans and one caregiver who range in age from 62 to 92-was formed in November 2017 and has met monthly since January 2018. The OVET provides feedback on topics that reflect the foci of the VA Eastern Colorado Geriatric Research Education and Clinical Center (GRECC) (e.g., physical functioning, hearing health, and emotional wellness/mental health). Ongoing evaluation documents the return on investment of Veteran engagement. MAIN MEASURES: The OVET member and provider/investigator meeting evaluations with longitudinal follow-up at 6 and 12 months. RESULTS: Return on investment of Veteran engagement is multi-faceted. For OVET, ROI ranges from grant support to improved healthcare quality/efficiency to social-emotional benefits. To date, funding awards total over $2.3 M for NIH and VA-funded projects to which OVET provided substantive feedback. Documented impacts on healthcare services include reductions in patient wait times, more appropriate utilization of services and increased patient satisfaction. Social-emotional benefits include generativity, as OVET members contribute to improving clinical and community-based supports for other Veterans. The OVET provides an opportunity for older Veterans to share their lived experience with trainees and early career investigators who are preparing for careers serving Veterans. CONCLUSION: The OVET is similar to other established stakeholder engagement groups; team members offer their individual viewpoints at any stage of research, clinical demonstration, or quality improvement projects. The OVET provides a mechanism for the voice of older Veterans and caregivers to shape aspects of individual projects. Importantly, these projects support patient-centered care and promote the characteristics of an age-friendly healthcare system.

Care delays in patients with signs and symptoms of acute myocardial infarction.

AIM: More than six million patients with signs and symptoms suggestive of a heart attack present to emergency departments (EDs) in the US each year. Of those diagnosed with acute myocardial infarction (AMI), one third die in the acute phase. Rapid ED triage can reduce the mortality rate, yet there are still delays in patient care. The aim of this study is to explore the relationship between patient and nurse characteristics, patient presentations, delays in triage, and delays in obtaining electrocardiograms (ECGs) of patients with signs and symptoms of AMI. METHODS: A retrospective correlational study drawing on data from the records of 286 patients with signs and symptoms of AMI. RESULTS: Delays in triage are related significantly to patients' gender and race. Most patients were triaged by nurses with associate degrees in nursing, a mean age of 45 and a mean of 18 years' experience. An increase in nurse years of experience predicted greater delay in triage. Delays in obtaining ECGs were also significantly greater with more experienced nurses and when patients reported no chest pain. CONCLUSION: The study adds to the literature on delays in triage and ECGs in care of patients with possible AMI, and further research of the effects of ED crowding and availability of resources in emergency cardiac care is warranted. Studies should identify the processes that cause delays in the emergency care of patients with signs and symptoms of AMI to ensure timely treatment and care.

Accuracy in ED Triage for Symptoms of Acute Myocardial Infarction.

UNLABELLED: More than 6 million people present to emergency departments across the United States annually with symptoms of acute myocardial infarction (AMI). Of the 1 million patients with AMI, 350,000 die during the acute phase. Accurate ED triage can reduce mortality and morbidity, yet accuracy rates are low. In this study we explored the relationship between patient and nurse characteristics and accuracy of triage in patients with symptoms of AMI. METHODS: This retrospective, descriptive study used patient data from electronic medical records. The sample of 286 patients was primarily white, with a mean age of 61.44 years (standard deviation [SD], ±13.02), and no history of heart disease. The sample of triage nurses was primarily white and female, with a mean age of 45.46 years (SD, ±11.72) and 18 years of nursing experience. Nineteen percent of the nurses reported having earned a bachelor's degree. RESULTS: Emergency nurse triage accuracy was 54%. Patient race and presence of chest pain were significant predictors of accuracy. Emergency nurse age was a significant predictor of accuracy in triage, but years of experience in nursing was not a significant predictor. DISCUSSION: Of the 9 variables investigated, only patient race, symptom presentation, and emergency nurse age were significant predictors of triage accuracy. Inconsistency in triage decisions may be due to other conditions not yet explored, such as critical thinking skills and executive functions. This study adds to the body of evidence regarding ED triage of patients with symptoms of AMI. However, further exploration into decisions at triage is warranted to improve accuracy, expedite care, and improve outcomes.

Hospital pharmacy staffing levels in England: has anything changed in the last 5†years?

OBJECTIVE: To undertake an analysis of hospital pharmacy staffing levels in England comparing national and regional averages for 2007/2008 and 2012/2013. METHODS: Individual hospital pharmacy staffing establishment data were extracted from the National Health Service (NHS) Pharmacy Education and Development Committee's National NHS Pharmacy Staffing Establishment and Vacancy Survey for 2007/2008 and 2012/2013. Hospital activity data for the 2 years were extracted from the NHS Health and Social Care Information Centre website. For each hospital, the number of whole time equivalent (WTE) pharmacy staff was divided by the number of admissions and a percentage WTE/admission calculated. Acute hospitals were analysed separately from mental health hospitals. RESULTS: The mean % WTE pharmacy staff/admission in acute hospitals in England 2012/2013 was 0.114 compared with 0.112 in 2007/2008 (p>0.05). The means for individual staff groups have either remained unchanged or have reduced slightly. There were also changes by region with some increasing and others decreasing. The changes in mental health and social care trusts were more marked with the median % WTE pharmacy staff/admission almost doubling in 2012/2013 compared with 2007/2008. This increase in establishment was seen in all pharmacy staff groups. CONCLUSIONS: The number of pharmacy staff per admission in acute hospitals in England between 2007/2008 and 2012/2013 has not changed significantly. This indicates that pharmacy services have kept pace with increasing activity. In contrast, pharmacy staffing levels in mental health trusts have almost doubled in the intervening 5 years as a result of a national initiative to develop the workforce in mental health services.

Making better decisions during triage.

Interactions between nurses and patients during triage are crucial if the urgency of patient need is to be assessed accurately. This article reports on the results of a study of emergency nurses' perspectives and experience of triage in the United States. Findings indicate that triage encounters are multifaceted and that emergency nurses require experience as well as knowledge to make good decisions. Two themes emerged from the study's findings: the need for nurses to connect with patients and the ability of nurses to 'read between the lines'. Nurses who connect with patients can take more detailed histories, while those who can read between the lines can identify the salient points and subtle signs from patients. Nurses with these skills can make better triage decisions.

Safety and efficacy of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation of atrial fibrillation: a systematic review and meta-analysis.

AIMS: To examine the safety (defined as bleeding risk) and efficacy (defined as prevention of thromboembolic events) of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation (CA) of atrial fibrillation (AF) in comparison with warfarin. METHODS AND RESULTS: Reviewers independently searched literature databases from January 2010 through April 2013 for studies comparing the safety and efficacy of dabigatran and warfarin in CA of AF and extracted pre-defined data. The Mantel-Haenszel method was used to pool data of bleeding and thromboembolism outcomes into random and fixed effect model meta-analyses, respectively. Odds ratios (ORs), and risk difference (RD) analysis when studies reported no events in either arm, were used to generate an overall effect estimate of both outcomes. Publication bias and heterogeneity were assessed by contour funnel plot and the I(2) test, respectively. Nine citations, including 3036 patients (1073 dabigatran), met the inclusion criteria. There was no significant difference between interrupted dabigatran and warfarin therapy in CA of AF in occurrence of bleeding [dabigatran 58 (5.4%), warfarin 103 (5.2%); OR 0.92 (95% confidence interval (CI) 0.55-1.45); χ(2) = 13.03-P = 0.11; I(2) = 39%] or thromboembolism [dabigatran 5 (0.4%), warfarin 2 (0.1%); OR 2.15 (95% CI-0.58-7.98); χ(2) = 2.14, P = 0.54; I(2) = 0%; RD 0.00 (95% CI-0.00 to 0.01); χ(2) = 3.37, P = 0.81; I(2) = 0%]. Analysis of pre-defined subgroups (published articles vs. abstracts), sensitivity analyses (interrupted warfarin, USA studies, and Japanese studies) and fixed effect model analyses showed similar results. Heterogeneity was mild in the bleeding outcome analysis and zero in thromboembolism. There was no evidence of publication bias in either meta-analysis. CONCLUSION: Meta-analysis of currently available studies showed no significant difference in bleeding and thromboembolism between interrupted dabigatran and warfarin therapy in CA of AF. Dabigatran appears to be safe and effective for peri-procedural anticoagulation in CA of AF.

Invertebrate models for biomedical research, testing, and education.

Invertebrate animals have been used as medicinals for 4,000 years and have served as models for research and teaching since the late 1800s. Interest in invertebrate models has increased over the past several decades as the research community has responded to public concerns about the use of vertebrate animals in research. As a result, invertebrates are being evaluated and recognized as models for many diseases and conditions. Their use has led to discoveries in almost every area of biology and medicine--from embryonic development to aging processes. Species range from terrestrial invertebrates such as nematodes and insects to freshwater and marine life including planarians, crustaceans, molluscs, and many others. The most often used models are the fruit fly Drosophila melanogaster and the minuscule nematode Caenorhabditis elegans. Topics in this article are categorized by biologic system, process, or disease with discussion of associated invertebrate models. Sections on bioactive products discovered from invertebrates follow the models section, and the article concludes with uses of invertebrates in teaching. The models reviewed can serve as references for scientists, researchers, veterinarians, institutional animal care and use committees (IACUCs), and others interested in alternatives to vertebrate animals.

Outcomes of national community organization cardiovascular prevention programs for high-risk women.

The purpose of this study was to reduce cardiovascular disease (CVD) risk in women by implementing a cardiovascular prevention health promotion program in faith- and community-based sites. The primary outcomes were reducing obesity and increasing physical activity. A longitudinal cohort of high-risk (age > 40, ethnic minority) women (n = 1,052) was enrolled at 32 sites across the USA. The pre- or post-educational intervention consisted of eight biweekly counseling sessions conducted over 4 months each addressing one of six of the major CVD risk factors (smoking, diabetes, hypertension, cholesterol, obesity, and physical inactivity) as well as signs and symptoms of a heart attack and stroke; plus 4-6 maintenance sessions over three additional months. A multifaceted approach delivered by lay and medically trained personnel involving medical screenings, health behavior counseling, risk behavior modification, and stage of change were determined at baseline and end of counseling or maintenance. Following list-wise deletion, data were analyzed on 423 women who completed all follow-up time-points. Overall, significant improvement was attained in most of 28 secondary outcomes but not in the primary outcomes. Knowledge and awareness of heart disease as the leading killer or women, all of the signs and symptoms of a heart attack, calling 911, and CVD risk factors increased significantly (p < 0.05) by 8.8%, 13.6%, 5.8%, and 10%, respectively. There was a 10% (p < 0.05) increase in participants attaining control for hypertension (blood pressure < 140/90) coupled with a significant reduction in mean blood pressure in the entire cohort. Knowledge of effective CVD risk modification strategies for all CVD risk factors increased significantly (p < 0.05), except for obesity. In addition, there were significant (p < 0.05) increases in forward movement in stage of change for each CVD risk factor (range +10% to +39%). Thus, a heart disease prevention intervention built around a model of community engagement, advocacy, self-efficacy, resource knowledge, and health promotion in faith- and community-based organizations is successful at improving cardiovascular knowledge and awareness outcomes in high-risk women. Limitations of our study include the high dropout rate, significant time demands on site coordinators, limited resources for program implementation, lack of morbidity and mortality endpoints, and failure to attain the primary outcomes of weight loss and physical activity. Future studies should not only assess the effect of community education interventions on lifestyle change and knowledge and awareness of participants but should also address program duration, cost, and resources required to attain improved outcomes.

Attitudes, practices, and concerns about child feeding and child weight status among socioeconomically diverse white, Hispanic, and African-American mothers.

Parents play an important role in the development of their children's eating behaviors. We conducted 12 focus groups (three white, three African-American, and three Hispanic-American low-income groups; three white middle-income groups) of mothers (N=101) of 2- to less than 5-year-old children to explore maternal attitudes, concerns, and practices related to child feeding and perceptions about child weight. We identified the following major themes from responses to our standardized focus group guide: 12 groups wanted to provide good nutrition, and most wanted children to avoid eating too many sweets and processed foods; 12 groups prepared foods their children liked, accommodated specific requests, and used bribes and rewards to accomplish their feeding goals (sweets were commonly used as bribes, rewards, or pacifiers); and 11 of 12 groups believed their children were prevaricating when they said they were full and mothers encouraged them to eat more. The common use of strategies that may not promote healthful weight suggests work is needed to develop culturally and socioeconomically effective overweight prevention programs. Further study is needed to verify racial/ethnic or income differences in attitudes, practices, and concerns about child feeding and perceptions of child weight.

A community-based intervention for siblings and parents of children with chronic illness or disability: the ISEE study.

OBJECTIVE: Siblings of children with chronic illness or disability have been reported to have a 1.6 to 2.0 risk for behavioral and mental health problems. Our objective was to examine the effects of an intervention for siblings (age 7-15 years) of children with chronic illness or disability. METHOD: A randomized, three-group repeated-measures design was used: full intervention (n=79), partial intervention (n=71), and a waiting list control group (n=102). Outcomes were sibling knowledge about illness, behavior problems, social support, self-esteem, attitude, and mood measured over four postintervention periods. Covariates were family cohesion, maternal mood, socioeconomic status, and well sibling age. The full intervention included structured teaching and psychosocial sessions at a 5-day residential summer camp. The partial intervention included camp only. Treatment effects were estimated by using generalized estimating equation panel analyses. RESULTS: The full treatment group showed significant improvements on all six outcomes over most periods, the partial treatment group on three outcomes, and the control group on two outcomes. Improvements in outcomes ranged from 5% to 25% increases over baseline measures. CONCLUSIONS: A dose-response relationship to intervention was found. Treatment gains were sustained over a period of 12 months.

Interrelationships among variables affecting well siblings and mothers in families of children with a chronic illness or disability.

A structural equation model (SEM) examined interrelationships among psychosocial variables known to affect the health and development of well siblings and parents when a child with a chronic illness or disability is a member of the family. Using dyads of 252 well children and parents, socioeconomic status (SES) and family cohesion were associated with the parent-reported behavior of the well sibling. SES also influenced the mood of the mother that in turn influenced family cohesion. The well sibling's knowledge about the illness of the brother or sister, attitude toward the illness, mood, self-esteem, and feelings of social support were interrelated and related to the behavior of the well sibling. The SEM suggests that interventions may be directed at several points in these interactions including boosting knowledge levels of the well sibling, improving family cohesion, and assuring adequate "income" support to the family through income transfers or in-kind services.