Developing from within: ensuring the ambulatory emergency care workforce is fit for purpose.

Emergency healthcare provision is changing, and services need to respond to evolving health economies while providing safe, effective, patient-centred care. Ambulatory care is developing to meet these needs, but workforce planners need to ensure that staff are fit for purpose. To address this, one trust, in partnership with a local university, designed a bespoke in-house, work-based learning package on ambulatory care, which was delivered to registered nurses by practice experts. This article describes the project and discusses the evaluation, which highlighted the benefits of this way of learning for the nurses, the trust and the university, and identified some areas that require development.

Relieving the pain of sentinel lymph node biopsy tracer injection.

Sentinel lymph node biopsy (SLNB) has been reliably accurate as a minimally invasive surgical alternative for identifying lymphatic breast metastasis. During mapping, the injection of a radioactive tracer or isosulfan blue dye to differentiate the SLN is acutely painful. The use of the eutectic mixture of lidocaine and prilocaine (EMLA) cream to reduce tracer injection pain has been reported anecdotally. A retrospective study compared injection discomfort of 20 women who had undergone SLNB without EMLA and 20 women who had undergone SLNB with the EMLA protocol. Results indicated a significant difference in mean pain rating. Standards of care should include the use of EMLA prior to intradermal SLN tracer injection unless contraindicated.

Perceived readiness for hospital discharge in adult medical-surgical patients.

PURPOSE: The purpose of the study was to identify predictors and outcomes of adult medical-surgical patients' perceptions of their readiness for hospital discharge. DESIGN: A correlational, prospective, longitudinal design with path analyses was used to explore relationships among transition theory-related variables. SETTING: Midwestern tertiary medical center. SAMPLE: 147 adult medical-surgical patients. METHODS: Predictor variables included patient characteristics, hospitalization factors, and nursing practices that were measured prior to hospital discharge using a study enrollment form, the Quality of Discharge Teaching Scale, and the Care Coordination Scale. Discharge readiness was measured using the Readiness for Hospital Discharge Scale administered within 4 hours prior to discharge. Outcomes were measured 3 weeks postdischarge with the Post-Discharge Coping Difficulty Scale and self-reported utilization of health services. FINDINGS: Living alone, discharge teaching (amount of content received and nurses' skill in teaching delivery), and care coordination explained 51% of readiness for discharge score variance. Patient age and discharge readiness explained 16% of variance in postdischarge coping difficulty. Greater readiness for discharge was predictive of fewer readmissions. CONCLUSIONS: Quality of the delivery of discharge teaching was the strongest predictor of discharge readiness. Study results provided support for Meleis' transitions theory as a useful model for conceptualizing and investigating the discharge transition. IMPLICATIONS FOR PRACTICE: The study results have implications for the CNS role in patient and staff education, system building for the postdischarge transition, and measurement of clinical care outcomes.

Preparing Family Caregivers to Recognize Delirium Symptoms in Older Adults After Elective Hip or Knee Arthroplasty.

OBJECTIVES: To test the feasibility of a telephone-based intervention that prepares family caregivers to recognize delirium symptoms and how to communicate their observations to healthcare providers. DESIGN: Mixed-method, pre-post quasi-experimental design. SETTING: A Midwest Veterans Affairs Medical Center and a nonprofit health system. PARTICIPANTS: Forty-one family caregiver-older adult dyads provided consent; 34 completed the intervention. INTERVENTION: Four telephone-based education modules using vignettes were completed during the 3 weeks before the older adult's hospital admission for elective hip or knee replacement. Each module required 20 to 30 minutes. MEASUREMENTS: Interviews were conducted before the intervention and 2 weeks and 2 months after the older adult's hospitalization. A researcher completed the Confusion Assessment Method (CAM) and a family caregiver completed the Family Version of the Confusion Assessment Method (FAM-CAM) 2 days after surgery to assess the older adults for delirium symptoms. RESULTS: Family caregivers' knowledge of delirium symptoms improved significantly from before the intervention to 2 weeks after the intervention and was maintained after the older adult's hospitalization. They also were able to recognize the presence and absence of delirium symptoms in the vignettes included in the intervention and in the older adult after surgery. In 94% of the cases, the family caregiver rating on the FAM-CAM approximately 2 days after the older adult's surgery agreed with the researcher rating on the CAM. Family caregivers expressed satisfaction with the intervention and stated that the information was helpful. CONCLUSION: Delivery of a telephone-based intervention appears feasible. All family caregivers who began the program completed the four education modules. Future studies evaluating the effectiveness of the educational program should include a control group.

Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing.

A systematic analysis of the research literature on skeletal pin site care was conducted, and the opinions of an expert panel were obtained. Four specific recommendations for skeletal pin site care are offered, with explicit discussions of the level of research support and/or expert panel support for each. Discussion of other pin site care issues is provided, and characteristics of the research base regarding skeletal pin site care are described.

Developing a symptom distress scale for terminal malignant disease.

Symptom control is an important component of palliative care. The degree of distress caused by symptoms is individual. Instruments to measure symptom distress in patients with cancer have been developed, but have been poorly validated in the terminally ill. This study was an exploratory, descriptive, cross-sectional survey of 49 dying cancer patients, 60 professional carers (doctors and nurses) and 30 bereaved relatives. Semi-structured interviews were used to identify distressing symptoms for the dying cancer patient. The results indicated a diversity in the symptom experience and were used in the development of a physical symptom distress scale. Items were selected from a pool of symptoms generated from the three data sources, and compared with the literature of symptom distress in general cancer patients and symptom prevalence studies in terminal care. These were then compared with existing symptom distress scales. An adaptation of the physical sub-scale of the Rotterdam Symptom Checklist is proposed.

Rare presentation of Rosai-Dorfman disease mimicking a cervical intramedullary spinal cord tumor.

BACKGROUND: Rosai-Dorfman disease, or sinus histiocytosis with massive lymphadenopathy, is a rare, benign, lymphoproliferative disorder that commonly manifests as a massive painless cervical lymphadenopathy with associated fever and weight loss. Central nervous system involvement is extremely rare, and cervical spinal cord manifestation has not been reported. METHODS: A 76-year-old man presented with a 10-week history of right hemiparesis. Magnetic resonance imaging identified an enhancing cervical intramedullary lesion consistent with a primary spinal cord tumor. RESULTS: Histopathology revealed intramedullary histiocytosis. CONCLUSIONS: This cervical presentation of Rosai-Dorfman disease with central nervous system involvement suggests variation in the clinical manifestations of the disease, necessitating greater surgical awareness.

Road to excellence in pain management: research, outcomes and direction (ROAD).

Effective pain management is a critical patient care goal mandated by numerous health care organizations. There remains great opportunity to improve pain management across all sites of care. This article describes an interdisciplinary model for process improvement within an integrated health care system. An outcome-based approach to pain management resulted in the development of four key clinical indicators that are measured across sites, including acute care, long-term, ambulatory, and home care. Early outcome data are presented. Strategies for improving pain management focus on visibility, staff accountability, patient rights, and education.