Manifesto for a healthy and health-creating society.

Brexit and the troubled state of the NHS call for re-thinking the UK's approach to health. The EU referendum vote reveals deep social divisions as well as presenting the country with important decisions and negotiations about the future. At the same time, health problems are growing; the NHS faces severe financial constraints and appears to lurch from crisis to crisis, with leaving the European Union likely to exacerbate many problems including staffing issues across the whole sector. However, new scientific developments and digital technology offer societies everywhere massive and unprecedented opportunities for improving health. It is vital for the country that the NHS is able to adopt these discoveries and see them translated into improved patient care and population health, but also that the UK benefits from its capabilities and strengths in these areas.

The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units--an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland.

OBJECTIVE: To establish whether a nationally guided programme can lead to more widespread implementation of enhanced recovery after surgery (ERAS), a well-established optimised care pathway for lower limb arthroplasty. DESIGN: In 2010, National Services Scotland's Musculoskeletal Audit was asked to perform a 'snapshot' audit of the current peri-operative management of patients undergoing total hip and knee arthroplasty in all 22 Scottish orthopaedic units with an identical follow-up audit in 2011 after input and support from the national steering group. POPULATION: Audit 1 and audit 2 involved 1,345 and 1,278 patients, respectively. RESULTS: The number of Scottish units that developed an ERAS programme increased from 8 (36 %) to 15 (68 %). Units that included more ERAS patients had earlier mobilisation rates (146/474, 36 % ERAS patients mobilised same day vs. 34/873, 4 % non-ERAS; n = 22 units, r = 0.55, p = 0.008) and shorter post-operative length of stay (median 4 days vs. ERAS, 5 days non-ERAS, n = 22 units, r = -0.64, p = 0.001). ERAS knee arthroplasty patients had lower blood transfusion rates (5/205, 2 % vs. 51/399, 13 %, n = 22 units, r = -0.62, p = 0.002). Units that restricted the use of IV fluids post-operatively had higher early mobilisation rates (n = 22 units, r = 0.48, p = 0.03) and shorter post-operative length of stay (n = 22 units, r = -0.56, p = 0.007). Reduced use of patient-controlled analgesia was also associated with earlier mobilisation (n = 22 units, r = 0.49, p = 0.02) and shorter length of stay (n = 22 units, r = -0.39, p = 0.07). Urinary catheterisation rates also dropped from 468/1,345 (35 %) in 2010 to 337/1,278 (26 %) in 2011 (n = 22 units, z = 2.19, p = 0.03). CONCLUSION: A clinically guided and nationally supported process has proven highly successful in achieving a further uptake of enhanced recovery principles after lower limb arthroplasty in Scotland, which has resulted in clinical benefits to patients and reduced length of hospital stay.

The effect of nurse champions on compliance with Keystone Intensive Care Unit Sepsis-screening protocol.

Sepsis poses a major threat to patient safety in intensive care units (ICU) across the country. An accumulating body of evidence supports using established protocols to screen ICU patients regularly for sepsis indicators; however, there often is a gap between what is known and what is practiced. Compliance with sepsis screening was noted to be less than acceptable at one Regional Michigan Medical Center. The 2-fold purpose of this study was to evaluate the effect of introducing nurse champions into an ICU environment on (1) ICU nurses' compliance with Michigan Health and Hospital Association Keystone ICU sepsis screening protocols and (2) patient safety outcomes. A 1-group pretest-posttest quasi-experimental design was used for the study. A nonprobability, convenience sample of patient charts from a 16-bed ICU in a 352-bed regional referral center was used for the study. Findings from this study demonstrated that the introduction of nurse champions significantly improved compliance with ICU sepsis screening, from 23% preintroduction to 74% postintroduction, but had virtually no effect on patient outcomes related to percentage of patients treated for sepsis.

Using clinical simulations in geriatric nursing continuing education.

Accompanying an increased number of older adults in the population is the need for knowledgeable and clinically competent nurses to provide care for this group, especially those experiencing sudden changes in health status. A continuing education program was designed to improve geriatric nursing competencies through the use of clinical simulations. Three-day nurse educator institutes and one-day workshops for registered and licensed practical nurses were offered to 312 nurses. The clinical simulations that were developed specifically focused on acute health events or conditions. Specific geriatric clinical competencies were also emphasized. Different types of clinical simulations included unfolding cases, use of a human patient simulator, and online case studies. Geriatric nursing knowledge significantly increased and clinical simulations were well-received. Clinical simulations involving the human patient simulator were highly rated. Clinical simulations are an excellent teaching strategy to help nurses increase knowledge and skill in caring for older adults.

Policy and political advocacy: Comparison study of nursing faculty to determine current practices, perceptions, and barriers to teaching health policy.

PURPOSE: To better understand policy/advocacy concepts and methodology utilized in all levels of nursing educational programs and develop clarity concerning structure of policy content and integration across all levels of education. DESIGN AND METHODS: Cross-sectional analysis of data obtained from a survey sent to 19,043 nursing faculty in the United States; 598 total responses; 514 complete responses. Quantitative data points were analyzed using SPSS and qualitative data was grouped and analyzed by theme. FINDINGS: Barriers and perceptions of student engagement and student learning outcomes along with institutional and faculty development barriers were explored in baccalaureate, masters, and doctoral level nursing programs. Thirty-six percent of respondents reported having experience in development and implementation of policy, ranging from local to international spheres and 21% reported active involvement in current state and federal policy development. Seventy percent of respondents have advocated for the nursing profession through professional organizations while 44% report current activity in legislative advocacy. CONCLUSIONS: The value of nursing policy education, advocacy, and analysis must be valued in higher education.

Elder care supportive interventions protocol: reducing discomfort in confused, hospitalized older adults.

This study tested the Elder Care Supportive Interventions Protocol (ECSIP), which are nursing and family support interventions designed to reduce discomfort and the associated consequences of delirium, impaired physical function, and need for post-hospital care in hospitalized older adults experiencing confusion from delirium or dementia. All adults older than age 74 or older than age 64 if from a nursing home who were admitted to the medical and surgical units of a tertiary care hospital were screened for a diagnosis of dementia, dependence on functional activities, or delirium. The ECSIP includes interventions to prevent and control discomfort, and to promote environmental organization and familiarity. Outcome measures administered within 48 to 72 hours of admission and again within 24 hours prior to discharge included the modified Discomfort Screen--Dementia Alzheimer's Type, NEECHAM Confusion Scale, and Katz Index of Activities of Daily Living. Patients problems with delirium and impaired physical function improved over hospitalization but were still pronounced at discharge. With the exception of reduced discomfort, there were no significant treatment effects for patients, which is attributed, in part, to inadequate implementation of the ECSIP protocol by nursing staff.

Discharge teaching about warfarin: patient retention of knowledge.

For patients who are post-hospitalization and on warfarin therapy, one key component is the proper management of warfarin therapy. This descriptive study was conducted using a telephone survey to determine what level of knowledge exists regarding management of warfarin among patients back at home. Analysis of data collection results provides recommendations for evidenced-based practices for the home health clinician, which may improve patient outcomes. Basic knowledge of food and medication interactions can make a significant impact on reduction of adverse events of bleeding or clot formation. An understanding of the therapeutic level of warfarin obtained from lab tests could be of greater value.

Aspects of diurnal rhythmicity in pain, stiffness, and fatigue in patients with fibromyalgia.

OBJECTIVE: To determine diurnal rhythm characteristics of pain, stiffness, and fatigue in self-ratings performed by patients with fibromyalgia (FM). METHODS: Twenty-one women with FM made self-measurements of pain, stiffness, and fatigue on 100 mm horizontal visual analog scales at 6 prespecified timepoints at home for 10 consecutive days. Linear and multiple regressions were performed on the original data and the 24-hour means vs FM classifiers (age, disease duration, tender points, dolorimetry score, Fibromyalgia Impact Questionnaire score), respectively. Data were analyzed for 24-hour and 7-day time-effects by ANOVA and for diurnal and weekly rhythms by the cosinor technique. RESULTS: Individual ratings for pain, stiffness, and fatigue correlated highly with each other throughout the day and over the days of the week. Of the FM classifiers, dolorimetry score was found to be inversely related to the pain, stiffness, and fatigue scores. For the group of subjects with a low dolorimetry score (< 2.25 kg), a significant diurnal rhythm was found in each self-rated variable, with greater pain, stiffness, and fatigue observed in the morning and least in the late afternoon. No rhythm in pain or stiffness was observed in those subjects with a higher threshold for pain (dolorimetry score > 2.25 kg), while fatigue showed the same significant diurnal pattern as in the first group. For the group as a whole, the possible presence of a weekly variation was found with ratings for pain, stiffness, and fatigue higher on Sunday and Monday and lower on Friday. CONCLUSION: Ratings of pain, stiffness, and fatigue in FM are significantly correlated, and show diurnal and possibly weekly rhythmicity, especially when pain threshold is low (dolorimetry score < 2.25 kg), and are thus predictive of each other over these time spans. This has important implications for scheduling activities of daily living, for measurement in clinical trials, and possibly for timing the administration of medications.

Hindgut fermentation in three species of marine herbivorous fish.

Symbioses with gut microorganisms provides a means by which terrestrial herbivores are able to obtain energy. These microorganisms ferment cell wall materials of plants to short-chain fatty acids (SCFA), which are then absorbed and used by the host animal. Many marine herbivorous fishes contain SCFA (predominantly acetate) in their hindgut, indicative of gut microbial activity, but rates of SCFA production have not been measured. Such information is an important prerequisite to understanding the contribution that gut microorganisms make in satisfying the energy needs of the fish. We have estimated the rates of acetate production in the gut of three species of temperate marine herbivorous fish from northeastern New Zealand: Kyphosus sydneyanus (family Kyphosidae), Odax pullus (family Odacidae), and Aplodactylus arctidens (family Aplodactylidae). Ex vivo preparations of freshly caught fish were maintained with their respiratory and circulatory systems intact, radiolabeled acetate was injected into ligated hindgut sections, and gut fluid was sampled at 20-min intervals for 2 h. Ranges for acetate turnover in the hindguts of the studied species were determined from the slope of plots as the log of the specific radioactivity of acetate versus time and pool size, expressed on a nanomole per milliliter per minute basis. Values were 450 to 570 (K. sydneyanus), 373 to 551 (O. pullus), and 130 to 312 (A. arctidens). These rates are comparable to those found in the guts of herbivorous reptiles and mammals. To determine the contribution of metabolic pathways to the fate of acetate, rates of sulfate reduction and methanogenesis were measured in the fore-, mid-, and hindgut sections of the three fish species. Both rates increased from the distal to proximal end of the hindgut, where sulfate reduction accounted for only a small proportion (<5%) of acetate methyl group transformed to CO(2), and exceeded methanogenesis from acetate by >50-fold. When gut size was taken into account, acetate uptake from the hindgut of the fish species, determined on a millimole per day per kilogram of body weight basis, was 70 (K. sydneyanus), 18 (O. pullus), and 10 (A. arctidens).

A comparative study of telephone versus onsite completion of the WOMAC 3.0 osteoarthritis index.

OBJECTIVE: Outcome assessment in clinical trials using the Western Ontario and McMaster University (WOMAC 3.0) Osteoarthritis Index is traditionally achieved through self-administration of the Index. However, in other areas of clinical measurement, telephone administration has been shown to be a reliable method of acquiring data that are both accurate and complete. To address this issue in knee osteoarthritis (OA), we conducted a comparative study of telephone administration by interviewer of WOMAC LK3.0 versus onsite self-completion at the hospital. METHODS: Fifty consenting patients with knee OA were randomized to complete the WOMAC LK3.0 Index by telephone interview one day, followed by onsite completion the following day, or vice versa. Neither patients nor interviewers had access to any prior scores. RESULTS: The mean age of the 50 patients was 66.3 years (range 44-82); 34 (68%) were female and 16 (32%) male. There was excellent agreement between the mean office and telephone scores, with mean differences for the WOMAC LK3.0 pain, stiffness, and function subscale scores and total score of 0.09, 0.12, 0.78, and 0.98, respectively. These differences were well within the respective protocol defined equivalence criteria of +/- 1.7, +/- 0.9, +/- 6.4, and +/- 9.1, and represented differences from office scores of 0.9, 2.6, 2.4, and 2.2%, respectively. CONCLUSION: The use of telephone interviews for the WOMAC LK3.0 Index is a valid method of obtaining OA outcome measurements. These observations have important implications for designing data acquisition strategies for future OA clinical trials and for longterm observational studies.