The impact of a nurse-led elective direct current cardioversion in atrial fibrillation on patient outcomes: A systematic review.

AIMS AND OBJECTIVES: To examine and present the success rate in relation to nurse-led elective DCCV service in AF patients. BACKGROUND: As the incidence of AF increases healthcare settings will continue to face challenges in providing appropriate timely intervention. The provision of DCCV has primarily been medical-led. Due to the increasing requirement of hospital beds, cost restriction and medical team stress the roles of nurse specialists have been driven to include elective DCCV. DESIGN: A systematic review with a narrative synthesis was undertaken. METHODS: The databases searched include the following: The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, Clinical Key, Web of Science, Cochrane Library and HSE library website. A total of 187 articles were identified, and seven studies were included for synthesis. The EBL checklist was used to assess validity. The PRISMA checklist was used for transparency. RESULTS: The results of this review show an acceptable complication rate, no negative patient outcomes and a high rhythm conversion success rate. A disparity was identified due to the lack of distinction between registered nurse (RGN), advanced nurse practitioner (ANP), advanced practice provider (APP) and nurse practitioner (NP) roles. These results support the belief that a highly skilled nurse in this specific background working in a supportive organisational framework can make a valuable contribution to such practices. CONCLUSION: A structured nurse-led elective DCCV service appears safe, effective and has a high success rate in restoration to sinus rhythm in AF. However, the need for further research in order to advance knowledge and support changes in nurse-led DCCV practice is evident. RELEVANCE TO CLINICAL PRACTICE: This review demonstrates that a nurse-led elective DCCV service appears safe and successful in restoring sinus rhythm. It has promising potential effects in terms of waiting time, cost saving and achieving patient satisfaction.

Modified social learning theory re-examined: correlates of self-management behaviors of persons with Type 2 diabetes.

Modified social learning theory (MSLT) applied to health predicts that health behavior is a multiplicative function of health value and perceptions of control over health. The self-management behaviors of persons with Type 2 diabetes mellitus, internal diabetes locus of control (IDLC), diabetes self-efficacy (DSE), and health value (HV) were assessed with an index of diabetes self-care activities in 107 patients receiving insulin. Multiple regression analysis showed DSE as the only MSLT construct that correlated with the index of diabetes self-care behaviors (ß = .21, p < .05). While the predicted three-way interaction of IDLC × DSE × HV was significant (∆R2 = 4.5 %, p < .05) in the final step of the hierarchical model, the pattern of the findings only partially supported MSLT. Instead of finding that patients who were simultaneously high on all three predictors scored highest on the behavioral index, we found that patients who were low on all three constructs reported the least amount of diabetes self-care behavior. Implications for further modification of MSLT and its applications to clinical practice are discussed.

Utilisation of a Suite of Screening Tools to Determine Adverse Healthcare Outcomes in an Older Frail Population Admitted to a Community Virtual Ward.

Risk stratification to assess healthcare outcomes among older people is challenging due to the interplay of multiple syndromes and conditions. Different short risk-screening tools can assist but the most useful instruments to predict responses and outcomes following interventions are unknown. We examined the relationship between a suite of screening tools and risk of adverse outcomes (pre-determined clinical 'decline' i.e., becoming 'unstable' or 'deteriorating' at 60-90 days, and institutionalisation, hospitalisation and death at 120 days), among community dwellers (n = 88) after admission to a single-centre, Irish, Community Virtual Ward (CVW). The mean age of patients was 82.8 (±6.4) years. Most were severely frail, with mean Clinical Frailty Scale (CFS) scores of 6.8 ± 1.33. Several instruments were useful in predicting 'decline' and other healthcare outcomes. After adjustment for age and gender, higher frailty levels, odds ratio (OR) 3.29, (p = 0.002), impaired cognition (Mini Mental State Examination; OR 4.23, p < 0.001), lower mobility (modified FIM) (OR 3.08, p < 0.001) and reduced functional level (Barthel Index; OR 6.39, p < 0.001) were significantly associated with clinical 'decline' at 90 days. Prolonged (>30 s) TUG times (OR 1.27, p = 0.023) and higher CFS scores (OR 2.29, p = 0.045) were associated with institutionalisation. Only TUG scores were associated with hospitalisation and only CFS, MMSE and Barthel scores at baseline were associated with mortality. Utilisation of a multidimensional suite of risk-screening tools across a range of domains measuring frailty, mobility and cognition can help predict clinical 'decline' for an already frail older population. Their association with other outcomes was less useful. A better understanding of the utility of these instruments in vulnerable populations will provide a framework to inform the impact of interventions and assist in decision-making and anticipatory care planning for older patients in CVW models.

Risk Prediction for Adverse Outcomes for Frail Older Persons with Complex Healthcare and Social Care Needs Admitted to a Community Virtual Ward Model.

PURPOSE: Population ageing is challenging healthcare systems with limited resources, necessitating the development of new care models to address the needs of older, frail community-dwellers. Community Virtual Wards (CVW) reduce adverse events in these patients. We examined the effect of an established CVW on pre-defined health trajectories (between "stable", "deteriorating", and "unstable" states) and characteristics that increased the likelihood of adverse healthcare outcomes (hospitalization, institutionalization and death). PATIENTS AND METHODS: We collected prospective data on frail patients admitted to a CVW in a single centre in Ireland. Relationships between risk scores, health states and adverse outcomes at 30, 60 and 90 days after admission were examined using multinomial regression analysis. RESULTS: In total, 88 community-dwellers, mean (±SD) age of 82.8 ±6.4 years, were included. Most were severely frail on the Rockwood Clinical Frailty Scale (mean 6.8/9 ±1.33). Reaching stability ("stable" state) within 30 days was a predictor for stability at 60 and 90 days and remaining at home. Stability was also associated with fewer care episodes (<2) (p=<0.001), a requirement for fewer healthcare professionals (HCP) (<7) (p<0.001) and lower risk of delirium (p<0.001). By contrast, being "unstable" at 60 days increased the numbers of HCP referrals (>7) and was predictive of more acute episodes (>2) and institutionalization or death (p<0.001). Predictors of adverse outcomes of either institutionalization or death included frailty status, function, mobility, nutrition, pressure ulcer risk and cognition. CONCLUSION: A CVW model can provide a framework for monitoring and case management to support older people to remain at home or identify those at risk of institutional care. The use of defined health states helped to stratify those at lower or higher risk in an already high-risk frail population. Level of frailty, function, mobility, nutrition, pressure ulcer risks and cognition were predictive of remaining at home and reaching a level of stability or instability/deterioration and institutional care.

Research excellence across clinical healthcare: a novel research capacity building programme for nurses and midwives in a large Irish region.

Background: A lack of support and research skills development has contributed to low research output by clinically based nurses and midwives in Ireland, including those in specialised and advanced roles. A novel research capacity building (RCB) programme was developed to address existing barriers. The programme was developed and implemented using Cooke's principles of RCB. Nurses and midwives participated from acute hospital, community, public health, mental health, older adult, intellectual disability, addiction and palliative care settings. Aims: This paper provides an evaluation of the Research Excellence Across Clinical Healthcare (REACH) programme from 2013-2016. Methods: Document analysis was used to evaluate RCB activities and outputs. Data were extracted from programme reports, conference proceedings, paper references, and workshop and conference sign-in/evaluation forms. Results: Individuals (n = 17) and small research groups (n = 4) were supported. Increased research capacity was demonstrated through dissemination of research in peer-reviewed journals, posters and oral presentations at national and international conferences. Sustainability was demonstrated by progression of participants to PhD (n = 3) and research projects that remain ongoing (n = 5). Skills development was facilitated by the organisation of workshops and conferences. Conclusions: A programme that provides academic support and mentorship in the clinical environment along with skills development can build research capacity. Future research should involve follow-up to determine any long-term effects.