Views from the NHS frontline: Health Visitors

Amid drastic cuts to health visiting services, I’m struggling to help the vulnerable families I see every day | The Guardian Healthcare Network

112-2Health visitors don’t always get good press at the school gates or toddler groups. Among my fellow nursing friends, the standing joke is that I spend my day simply weighing babies. I guess as a result it’s not hard to see why in some areas the value placed on health visiting has fallen so far that the service will be cut completely.

At the moment most councils are reviewing the funding for health visiting amid drastic cuts to public health budgets. Cumbria and Staffordshire are planning on cutting health visiting posts and a number of other NHS trusts have job freezes and have discussed redundancies. NHS Digital reported this year that the number of health visitors dropped in UK by 433 posts.

While perhaps there may be some truth in the comments I so often hear, the reality of health visiting feels very different.

Read the full article here

Identifying and reporting modern slavery for all NHS staff

Modern slavery is the recruitment, movement, harbouring or receiving of children, women or men through the use of force, coercion, abuse of vulnerability, deception or other means for the purpose of exploitation. Individuals may be trafficked into, out of or within the UK, and they may be trafficked for a number of reasons including sexual exploitation, forced labour, domestic servitude and organ harvesting.

The Home Office estimates there are 13,000 victims and survivors of modern slavery in the UK; 55% of these are female and 35% of all victims are trafficked for sexual exploitation.

The NHS England safeguarding team are working with:

  • The Crown Prosecution Service (CPS) in Wales who are piloting basic training for staff in social care, education, police and health
  • The pan-London Safeguarding Adults Board who are developing multi-agency training at safeguarding level 1 (basic awareness level)
  • The Helen Bamber Organisation (with Kings College Hospital) to produce a level 2 and 3 training programme for specialist professionals and in line with the intercollegiate guidance on level 2-3 safeguarding training
  • The RCN to deliver a Modern Slavery “Kick Start” Workshop and campaign for professionals in November.
  • We are also working with the RCGP to refresh their safeguarding toolkits which will include reference to Modern Slavery

Read the full overview here

Read the related NHS England blog post here

Assessment and management of pain for people with dementia in hospital

Closs, S.J. et al. NIHR. Published online: October 2016

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It is difficult for people with dementia to communicate their pain to health-care professionals. Pain often has damaging effects on mental and physical health, and research has shown that pain is often poorly managed in people with dementia in hospital.

We aimed to develop a new system that would help staff to manage pain. To this end, we first identified any accurate and reliable pain assessment tools available for use with hospital patients who have dementia. We then explored how pain is currently recognised, assessed and managed in people with dementia in four hospitals in England and Scotland.

We found 28 pain assessment tools which had been reviewed, but none had been tested rigorously. Seven had potentially useful features, but no single tool could be recommended for wider use. The 11 hospital wards studied were all different, with their own complex pain assessment and management practices. Information from different staff and carers was produced at different times and in different formats, and was recorded in separate documents. This information was mentally pulled together into an ‘overall picture’ of pain by each staff member for each individual patient.

We suggest developing a combined education package and electronic health record, the Pain And Dementia Decision Support (PADDS) intervention, to help staff recognise, assess and manage pain. This should incorporate carer input, staff narratives, pain histories, intensity assessments, medication and other interventions provided, and present an overall picture of pain in an integrated and easily accessible visual format. This will require thorough development and testing.

Read the full report here

Long-Term Oxygen for COPD

Rothaus, L. Now@NEJM Blog. Published online: 27 October 2016

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Image source: Now@NEJM

Two trials that were conducted in the 1970s showed that long-term treatment with supplemental oxygen reduced mortality among patients with chronic obstructive pulmonary disease (COPD) and severe resting hypoxemia. In the 1990s, two trials evaluated long-term treatment with supplemental oxygen in patients with COPD who had mild-to-moderate daytime hypoxemia; neither trial showed a mortality benefit, but both were underpowered to assess mortality. The effects of oxygen treatment on hospitalization, exercise performance, and quality of life are unclear. The Long-Term Oxygen Treatment Trial assessed the potential benefits of supplemental oxygen among patients with COPD and moderate resting desaturation or exercise-induced desaturation. In this trial, long-term supplemental oxygen treatment did not result in longer survival than no use of supplemental oxygen among patients with stable COPD and moderate resting desaturation (Spo2, 89 to 93%) or moderate exercise-induced desaturation. A new Original Article explains.

Clinical Pearl

What are the estimated oxygen-related costs for patients with COPD in the United States?

Medicare reimbursements for oxygen-related costs for patients with COPD exceeded $2 billion in 2011. If long-term treatment with supplemental oxygen reduces the incidence of COPD-related hospitalizations, increased use could be cost-effective. Reliable estimates of the number of prescriptions for supplemental oxygen that are written for the indication of exercise-induced desaturation are unavailable. Data suggest that many patients with advanced emphysema who are prescribed oxygen may not have severe resting hypoxemia.

Clinical Pearl

What Spo2 values (oxyhemoglobin saturation), as measured by pulse oximetry, are consistent with moderate resting desaturation and moderate exercise-induced desaturation?

In the Long-Term Oxygen Treatment Trial, a total of 14 regional clinical centers and their associated sites (a total of 47 centers) screened patients who had stable COPD and moderate resting desaturation (Spo2, 89 to 93%) or moderate exercise-induced desaturation (during the 6-minute walk test, Spo2 ≥80% for ≥5 minutes and <90% for ≥10 seconds).

Read the full overview here

Read the original research article here

Public unaware of the factors that increase the risk of dementia

Just 2% of people in Britain can identify all the health and lifestyle factors that can increase risk of developing dementia. | Public Health England

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Image source: http://www.natcen.ac.uk/

More than a quarter (28%) of the British public is unable to correctly identify any potentially modifiable risk factor for developing dementia, according to new findings from the British Social Attitudes survey, which was commissioned by Public Health England (PHE).

The survey, carried out by the National Centre for Social Research (NatCen), asked the public if they could identify any of the following risk factors: heavy drinking, smoking, high blood pressure, depression and diabetes as well as the protective factor of taking regular exercise and found just 2% of the public is able to identify all of them.

Also, more than 1 in 4 people (27%) in Britain incorrectly believe that there is nothing anyone can do to reduce their risks of getting dementia. There is growing evidence that a third of dementia cases could be a result of factors potentially in our control, and actions like taking regular exercise and not smoking can reduce your risk of developing it. This means there is huge potential for prevention.

Full report: Attitudes to dementia: Findings from the 2015 British Social Attitudes survey

Doctors’ low morale ‘puts patients at risk’

Poor morale among doctors could put patients at risk, the General Medical Council has warned. | Story via BBC

stethoscope-1584223_960_720The GMC’s latest annual report into the state of medical education and practice in the UK has  said there was “a state of unease within the medical profession across the UK that risks affecting patients as well as doctors”.

The GMC noted that following the anger and frustration of the dispute between junior doctors in England and the Department of Health, levels of alienation “should cause everyone to pause and reflect”.

The GMC criticised healthcare funding, saying that years of constraint coupled with social care pressures were leaving services struggling to cope with rising demand.

NHS Employers, which represents management in the health service, said the report highlighted the need for skilled foreign workers in the NHS, adding: “We welcome the insight the report gives into the huge financial and service pressures the NHS is under.”

The Department of Health said listening to the concerns of staff was central to plans to improve services.

The state of medical education and practice in the UK report: 2016:

Full report

Executive summary

Factors important for women who breastfeed in public: a content analysis of review data from FeedFinder

Simpson, E. et al. BMJ Open.6:e011762

baby-21167_960_720Objective: To examine how the breastfeeding experience is represented by users of FeedFinder (a mobile phone application for finding, reviewing and sharing places to breastfeed in public).

Design: Content analysis using FeedFinder database.

Setting: FeedFinder, UK, September 2013–June 2015.

Methods: Reviews obtained through FeedFinder over a period of 21 months were systematically coded using a conventional content analysis approach, average review scores were calculated for the rating criteria in FeedFinder (comfort, hygiene, privacy, baby facilities) and review texts were analysed for sentiment. We used data from Foursquare to describe the type of venues visited and cross-referenced the location of venues with the Indices of Multiple Deprivation.

Results: A total of 1757 reviews were analysed. Of all the reviews obtained, 80% of those were classified as positive, 15.4% were classified as neutral and 4.3% were classified as negative. Important factors that were discussed by women include facilities, service, level of privacy available and qualities of a venue. The majority of venues were classified as cafes (26.4%), shops (24.4%) and pubs (13.4%). Data on IMD were available for 1229 venues mapped within FeedFinder, 23% were located within the most deprived quintile and 16% were located in the least deprived quintile.

Conclusions: Women create content that is positive and informative when describing their breastfeeding experience in public. Public health bodies and business owners have the potential to use the data from FeedFinder to impact on service provision. Further work is needed to explore the demographic differences that may help to tailor public health interventions aimed at increasing breastfeeding rates in the UK.

Read the full article here

Using digital notifications to improve attendance in clinic: systematic review and meta-analysis

Robotham, D. et al. BMJ Open.6:e012116

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Objectives: Assess the impact of text-based electronic notifications on improving clinic attendance, in relation to study quality (according to risk of bias), and to assess simple ways in which notifications can be optimised (ie, impact of multiple notifications).

Design: Systematic review, study quality appraisal assessing risk of bias, data synthesised in meta-analyses.

Data sources: MEDLINE, EMBASE, PsycINFO, Web of Science and Cochrane Database of Systematic Reviews (01.01.05 until 25.4.15). A systematic search to discover all studies containing quantitative data for synthesis into meta-analyses.

Eligibility criteria: Studies examining the effect of text-based electronic notifications on prescheduled appointment attendance in healthcare settings. Primary analysis included experimental studies where randomisation was used to define allocation to intervention and where a control group consisting of ‘no reminders’ was used. Secondary meta-analysis included studies comparing text reminders with voice reminders. Studies lacking sufficient information for inclusion (after attempting to contact study authors) were excluded.

Outcome measures: Primary outcomes were rate of attendance/non-attendance at healthcare appointments. Secondary outcome was rate of rescheduled and cancelled appointments.

Results: 26 articles were included. 21 included in the primary meta-analysis (8345 patients receiving electronic text notifications, 7731 patients receiving no notifications). Studies were included from Europe (9), Asia (7), Africa (2), Australia (2) and America (1). Patients who received notifications were 23% more likely to attend clinic than those who received no notification (risk ratio=1.23, 67% vs 54%). Those receiving notifications were 25% less likely to ‘no show’ for appointments (risk ratio=.75, 15% vs 21%). Results were similar when accounting for risk of bias, region and publication year. Multiple notifications were significantly more effective at improving attendance than single notifications. Voice notifications appeared more effective than text notifications at improving attendance.

Conclusions: Electronic text notifications improve attendance and reduce no shows across healthcare settings. Sending multiple notifications could improve attendance further.

Read the full article here

Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial

Aveyard, P. et al. The Lancet. Published online: 24 October 2016

Background: Obesity is a common cause of non-communicable disease. Guidelines recommend that physicians screen and offer brief advice to motivate weight loss through referral to behavioural weight loss programmes. However, physicians rarely intervene and no trials have been done on the subject. We did this trial to establish whether physician brief intervention is acceptable and effective for reducing bodyweight in patients with obesity.

Methods: In this parallel, two-arm, randomised trial, patients who consulted 137 primary care physicians in England were screened for obesity. Individuals could be enrolled if they were aged at least 18 years, had a body-mass index of at least 30 kg/m2 (or at least 25 kg/m2 if of Asian ethnicity), and had a raised body fat percentage. At the end of the consultation, the physician randomly assigned participants (1:1) to one of two 30 s interventions. Randomisation was done via preprepared randomisation cards labelled with a code representing the allocation, which were placed in opaque sealed envelopes and given to physicians to open at the time of treatment assignment. In the active intervention, the physician offered referral to a weight management group (12 sessions of 1 h each, once per week) and, if the referral was accepted, the physician ensured the patient made an appointment and offered follow-up. In the control intervention, the physician advised the patient that their health would benefit from weight loss. The primary outcome was weight change at 12 months in the intention-to-treat population, which was assessed blinded to treatment allocation. We also assessed asked patients’ about their feelings on discussing their weight when they have visited their general practitioner for other reasons. Given the nature of the intervention, we did not anticipate any adverse events in the usual sense, so safety outcomes were not assessed. This trial is registered with the ISRCTN Registry, number ISRCTN26563137.

Findings: Between June 4, 2013, and Dec 23, 2014, we screened 8403 patients, of whom 2728 (32%) were obese. Of these obese patients, 2256 (83%) agreed to participate and 1882 were eligible, enrolled, and included in the intention-to-treat analysis, with 940 individuals in the support group and 942 individuals in the advice group. 722 (77%) individuals assigned to the support intervention agreed to attend the weight management group and 379 (40%) of these individuals attended, compared with 82 (9%) participants who were allocated the advice intervention. In the entire study population, mean weight change at 12 months was 2·43 kg with the support intervention and 1·04 kg with the advice intervention, giving an adjusted difference of 1·43 kg (95% CI 0·89–1·97). The reactions of the patients to the general practitioners’ brief interventions did not differ significantly between the study groups in terms of appropriateness (adjusted odds ratio 0·89, 95% CI 0·75–1·07, p=0·21) or helpfulness (1·05, 0·89–1·26, p=0·54); overall, four (<1%) patients thought their intervention was inappropriate and unhelpful and 1530 (81%) patients thought it was appropriate and helpful.

Interpretation: A behaviourally-informed, very brief, physician-delivered opportunistic intervention is acceptable to patients and an effective way to reduce population mean weight.

Read the full article here

Effects of an Intervention on Hand Hygiene Compliance in a Radiography Unit

O’Donoghue, M. et al. Antimicrobial Resistance & Infection Control. Published online: 19 October 2016

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Background: Whilst numerous studies have investigated nurses’ compliance with hand hygiene and use of alcohol-based hand rub (ABHR), limited attention has been paid to these issues in allied health staff. Reports have linked infections to breaches in infection control in the radiography unit (RU). With advances in medical imaging, a higher proportion of patients come into contact with RU staff increasing the need for good hand hygiene compliance. This study aimed to evaluate effectiveness on compliance of an intervention to improve awareness of hand hygiene in the RU of a district hospital.

Methods: A quasi-experimental study design including questionnaires assessing knowledge and attitudes of hand hygiene and direct observation of participants was used to evaluate an educational programme on hand hygiene of the RU of a large district hospital. All healthcare workers (HCW), comprising 76 radiographers, 17 nurses, and nine healthcare assistants (HCA), agreed to participate in the study. Of these, 85 completed the initial and 76 the post-test anonymous questionnaire. The hand hygiene compliance of all 102 HCW was observed over a 3-week period prior to and after the intervention. The 2-month intervention consisted of talks on hand hygiene and benefits of ABHR, provision of visual aids, wall-mounted ABHR dispensers, and personal bottles of ABHR.

Results: Before the intervention, overall hand hygiene compliance was low (28.9 %). Post-intervention, compliance with hand hygiene increased to 51.4 %. This improvement was significant for radiographers and HCA. Additionally, knowledge and attitudes improved in particular, understanding that ABHR can largely replace handwashing and there is a need to perform hand hygiene after environmental contact. The increased use of ABHR allowed HCW to feel they had enough time to perform hand hygiene.

Conclusions: The educational intervention led to increased awareness of hand hygiene opportunities and better acceptance of ABHR use. The reduced time needed to perform hand rubbing and improved access to dispensers resulted in fewer missed opportunities. Although radiographers and other allied HCW make frequent contact with patients, these may be mistakenly construed as irrelevant with respect to healthcare associated infections. Stronger emphasis on hand hygiene compliance of these staff may help reduce infection risk.

Read the full article here