MRI for Breast Cancer Screening

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Chapter 1

Introduction

In the United States, one in eight women will be diagnosed with breast cancer, accounting for 26% of all cancer cases in women (Jiao, 2014). The standard of care for women over the age of 40 is mammography. It has been shown to increase life expectancy by detecting breast cancer through a quick and easy x-ray. Magnetic resonance imaging, which is more sensitive to breast cancer is costlier and produces more false-positive results, therefore it is not used as often. When mammography is the only test being done, breast cancer is more likely to go undetected in patients with dense breasts and those with small lesions. In high-risk women, MRI has been shown to detect breast cancer in earlier stages than mammography. MRI screening is successfully reported between 77% and 91% (Jiao, 2014). Most detections from MRI are located within axillary lymph nodes during stage 1 breast cancer. A patient may simply refuse yearly mammograms, when she goes five years later breast cancer may be in the final stage whereas MRI could’ve detected it years earlier. Women are recalled

more often

for additional diagnostic testing when screened less frequently and recalled less often when screened more frequently (Orel, 2005). The American Cancer Society recommends MRI testing for women with the BCRA1 & BCRA 2 genes or a lifetime risk of 20% or greater for breast cancer (Saslow, 2007). Women who inherit the BRCA1 or BRCA2 gene have a 45% to 65% chance of developing breast cancer (Plevritis, 2006). BRCA 1 gene carriers are at a greater risk for developing breast cancer at an aggressive pace. Tumors in women

screened with mammography alone

are larger and more likely to have metastasized to axillary nodes (Taneja, 2009).

MRI is approximately ten times more expensive than mammography making its cost effectiveness a critical consideration (Jiao, 2014). Due to its lower specificity than mammography increased costs are related to biopsies and additional exams. Estimated lifetime costs for 10,000 women would be higher by $10.6 million with MRI in combination with mammography than with mammography alone. In 2009, the costs billed to Medicare for a bilateral mammography was $49.76 while a bilateral MRI was $965.57 (Jiao, 2014). The price per quality adjusted life year would be $310,616 when MRI was performed with mammography (Fieg, 2009). MRI screening is most cost effective if the cost of MRI decreased or the cost of mammography decreased, when the risk of breast cancer increases, when mammography performance worsens, and if greater quality of life is accomplished (Orel, 2005). MRI becomes cost effective when patients with high-risk profiles are treated. If cancer was detected early enough, chemotherapy can be reduced. MRI is also needed for surveillance when breast conserving therapy results in recurrences. MRI would yield an additional 106 years of life per 10,000 women (Fieg, 2009). Women with BRCA1 and BRCA2 start mammograms at the age of 25 which makes MRI more cost effective and would decrease their radiation dose. Given the aggressive nature of breast cancer, screening with MRI whether alone or with mammography is cost effective and will prolong life expectancy (Berg, 2012). Contrast enhanced MRI is proven to detect breast cancer in the earliest stages compared to ultrasound and mammography.

Statement of the Problem and Professional Significance

Is MRI effective as screening tool for breast cancer? Which modality is the most effective study for diagnosing breast cancer? Are imaging modalities other than MRI a waste of time and money for patients? Mammography is seen as the first step in preventing breast cancer when a patient turns 40. For some patients, it might already be too late. Mammography is quick and low cost but does not detect breast cancer in patients with dense breasts or small lesions. MRI is considered the gold standard in imaging but is used with fewer women. As the population grows and rates of cancer increase, patients are demanding precise diagnosis and early detection for cancer. What factors should stand out to differentiate who receives MRI vs. mammography? By gathering medical history and diagnosis from several women receiving breast MRI’s, data will be examined to determine whether or not breast MRI’s were needed for proper diagnosis and if testing detected further malignancies.

Research Hypothesis

1. It is hypothesized that MRI will be more effective in detecting breast abnormalities than Ultrasound or Mammography. This can be tested by comparing the results of their MRI with results of previous tests.

2. It is hypothesized that at least 50% of patients will feel more confident regarding their diagnosis following a MRI scan. This can be tested by having patients rank how they felt before and after having the test and talking with a radiologist on staff (using a scale of 1-10).

3. It is hypothesized that patients will not have had a mastectomy or received radiation until an MRI is performed. By surveying patients to determine who was and wasn’t diagnosed prior to MRI and what measures they took to prevent the malignancy from spreading I can determine these results.

4. It is hypothesized that patients positive for breast cancer will have at least one lesion undetected on mammography or ultrasound because of its small size or position in the axillary region.  This can be tested by comparing MRI test results with other imaging modalities.

5. It is hypothesized that 10% of participants will have had inconclusive results. This can be determined by whether the radiologist recommends a breast biopsy. MRI can produce false-positives, which cause the radiologist to compare results with past imaging.

6. It is hypothesized that at least 50% of the participants were recommended to have an MRI after inconclusive testing in other modalities. This information will be obtained through obtaining previous medical history in the survey.

Definitions

Breast cancer – Uncontrolled growth of breast cells resulting in a malignant tumor (Medical Dictionary Online, 2018).

Malignant – Cancerous tumor that can spread to other parts of the body.

Benign – Tumor that is not dangerous to health.

Quality adjusted life year – Used to assess the value for money of medical intervention. One QALY = one year of perfect health (Science Direct Online, 2018).

Probabilistic sensitivity analysis – Technique used in economic modeling that allows the modellar to quantify the level of confidence in the output of the analysis (Science Direct Online, 2018).

National comprehensive cancer network – Not-for-profit alliance of leading cancer centers devoted to patient care, research, and education.

BRCA 1 – breast cancer type 1 susceptibility protein- Identified in 1990 and is on chromosome 17, increases likelihood of cervical, uterine, and colon cancer (National Cancer Institute, 2018).

BRCA 2 – breast cancer type 2 susceptibility protein- Identified in 1994 and is on chromosome 13-, increases likelihood of stomach cancer, gallbladder cancer, and melanoma (National Cancer Institute, 2018).

Ultrasound – Imaging test using high frequency sound waves.

MRI – Imaging test that used magnets to generate a detailed picture.

Mammography – Images produced from low dose radiation.

Gadolinium – Chemical element of atomic number 64, injected into patients as contrast during MRI.

Ductal carcinoma in situ (DCIS) – Presence of abnormal cells inside a milk duct in the breast (Medical Dictionary Online, 2018).

Mastectomy – Surgical operation to remove a breast.

Stereotactic biopsy – Procedure that uses mammography to precisely identify and sample an abnormality within the breast.

Limitations and Delimitations

This study will survey twenty women (all ages) who are scheduled for breast MRI’s at Geisinger Community Medical Center during September-November 2018. I will conduct surveys with the patient prior to their MRI. Breast MRI’s will be conducted on a 1.5T, Siemens machine. All patients will be scanned using the same protocol for imaging regardless of medical history. External limitations are obtaining a medical history, incompletion of the patient’s MRI, lack of intravenous access for contrast, claustrophobia, and no show appointments. I will rely on patients to give me a detailed, accurate medical history.

Assumptions

During a typical work day in MRI at Geisinger Hospital a breast MRI is completed once. Within a typical month at least 20 scans are completed. This should allow me to survey enough patients over a six-week period. Permission for this study will come from patients who allow me to ask questions regarding their medical history and diagnosis. In accordance with HIPAA, I will keep all patient names and identifying information anonymous.

Chapter 2

Introduction

The purpose of this research project is to determine if MRI is effective as an imaging tool for diagnosing breast cancer. By surveying women, who have been diagnosed or are currently being diagnosed, collecting medical history, and analyzing data, imaging modalities will be examined to determine the most reliable, accurate, and timely way to diagnose breast cancer. If MRI is more efficient than mammography and ultrasound, time and money spent on those modalities could be eliminated. Women can be treated faster, and cancer could be diagnosed earlier when proper testing is ordered. Breast cancer during stage one is treatable, thousands of lives could be changed when it is diagnosed in a timely manner.

Cancer is the overall most common cause of death in America with breast cancer being the most common type (Jiao, 2014). One in eight women will be diagnosed with breast cancer during their lifetime making it a very costly disease. Standard protocols for screening are determined by the American Cancer Society. Screening mammography is recommended for women with a 25-30% lifetime risk of breast cancer (National Cancer Institute, 2018). This includes women treated for Hodgkin disease and those with a family history of breast or ovarian cancer. Screening mammography typically starts at age 40 unless preexisting conditions are present, screening begins at age 25. The Gail, Claus, and Tyrer-Cusick models are used to estimate breast cancer based on family history. Breast cancer genes 1 and 2 (BRCA) are found in 1/500-1/1,000 women. Women of Jewish ethnicity have a 1/50 risk (National Cancer Institute, 2018). Those who test positive have a 65% chance of breast cancer by 70 years old (Saslow, 2007).

What are American Cancer Society Guidelines?

Recommendations for women at average risk of breast cancer are women between 40 and 44 have the option to start screening with a mammogram every year. Women ages 45 to 54 should get mammograms every year. Women 55 and older can continue with mammograms every year or switch to having mammograms every other year (American Cancer Society, 2018). Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. Not all types of breast cancer cause a lump in the breast. Many breast cancers are found on screening mammograms which can detect cancers at an earlier stage, before the mass can be felt, and before symptoms develop. Women who are at high risk for breast cancer based on certain factors should get and MRI and a mammogram every year, starting at age 30 (American Cancer Society, 2018). This includes women who have a lifetime risk of breast cancer of about 20% to 25% or greater, have a known BRCA1 or BRCA2 gene mutation, have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, had radiation therapy to the chest when they were between the ages of 10 and 30 years, or have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes. (American Cancer Society, 2018). The American Cancer Society recommends against MRI screening for women whose lifetime risk of breast cancer is less than 15%. MRI in this case would be less cost-effective and timelier for patients to get done.

How does MRI detect breast cancer?

There are three imaging modalities that can effectively detect breast cancer. MRI, mammography, and ultrasound are commonly used in different combinations. MRI uses magnetic fields to produce cross-sectional images of breast tissue. Hydrogen atoms in fat and water contribute to the signal that is produced (Pilewskie, 2014). Gadolinium, IV based contrast, is administered to detect lesions and cancer. Subtraction images are obtained to differentiate fat from enhancing lesions. MRI produces high quality imaging from signal to noise ratio and high spatial resolution (Pilewskie, 2014). MRI is safe for all women (unless contraindicated by pregnancy) and doesn’t use radiation. A drawback to MRI is false positives that are produced and additional testing that this creates. On the other hand, additional testing leads to a higher number of cancer detected. The more women who are being closely watched and recommended for further tests, the greater their likelihood of being diagnosed early. In a study in the UK involving high risk populations, 4% found MRI “extremely distressing” and 47% reported having disturbing thoughts about it six weeks after (Saslow, 2007). Due to the psychological distress of MRI, other testing needs to be considered.

Imaging Limitations

Unlike other imaging tests, MRI candidates need to be screened for metal before considering the test. Pacemakers, aneurysm clips, specific stents and filters, and neuro-stimulators are not allowed in the machine. Body habitus and claustrophobia are also factors to consider. A small, loud environment can cause emotional distress and anxiety for a patient, some patients will refuse MRI testing. Breast MRI testing should be completed with and without contrast. Gadolinium, MRI contrast, can only be injected in patients with a glomerular filtration rate of >60. Patients on dialysis, with impaired kidney function, diabetes, high blood pressure, or certain allergies may not be able to receive contrast, making the test inconclusive.

MRI results can also be misleading. False-negatives and false-positives occur from technical limitations, patient characteristics, quality assurance failures, human error, and heightened medical concern. A false negative exam looks normal even though the patient has breast cancer. They are more likely to occur in younger patients with dense breasts. MRI is commonly used for dense tissue to differentiate benign and malignant lumps. A false positive test looks abnormal even though the patient doesn’t have cancer. False positives occur in half of women getting mammograms over a ten-year period (Gillman, 2014). MRI’s and MRI guided biopsies are usually recommended for more accurate diagnosis. A patient’s need for definitive findings may increase testing ordered. According to the American Medical Association, 7% of women are biopsied only because of MRI findings. The call back and biopsy rates of MRI are higher than mammography in high risk populations due to the increased sensitivity of MRI (Gillman, 2014). MRI is also able to obtain images for women with breast implants. 3D and 2D images are acquired in all planes, whereas mammography could miss an area of interest and compromise the breast implant.

Economic Impact



Cancer treatment can be impacted by lack of insurance, proximity to health care facilities, and availability of services. According to

Cancer Facts & Figures 2018

, “Uninsured patients and those from many ethnic minority groups are substantially more likely to be diagnosed with cancer at a later stage, when treatment can be more extensive, costlier, and less successful.” (American Cancer Society 2018). Without routine mammograms, breast cancer can go undiagnosed and impose much higher costs when it’s found in a later stage. Early detection can potentially eliminate radiation, chemotherapy, mastectomy, and breast reconstruction.

In 2009, the average Medicare reimbursement for a bilateral mammogram was $49.76, a bilateral MRI $965.57, and mastectomy $13,590.03 (Moore, 2009). These procedures drastically differ in costs therefore insurance companies use cost effectiveness and quantity adjusted life years as means in determining which patient will benefit from costlier studies. MRI screening becomes more cost effective as the cost of MRI decreases or the cost of mammography increases. It is also more cost effective for patients with higher risk profiles such as BRCA1 & BRCA2 genes. MRI combined with mammography would produce 106 years of life per 10,000 women compared with mammography alone (Taneja, 2009). The drawback is that MRI in addition to mammography would increase lifetime health care costs for those 10,000 women by $10,600,000 (Taneja, 2009).

What does insurance cover?

Breast cancer is the costliest cancer to treat. In 2010, it cost $16.5 billion in the United States to treat breast cancer. A major concern when ordering breast MRI’s is that insurance will deny it or charge a high co-pay. MRI’s cost more due to radiologist, facility, contrast, and technology fees. According to a survey by the American Cancer Society, many patients are cutting prescriptions, not going to their doctor, and not getting preventive services due to the high costs. Yearly mammograms are covered by insurance companies. The average cost of a breast MRI in the United States is $1,325 with prices ranging from $375 to $2,850. Patients with health insurance are responsible for paying their deductible, copay, and coinsurance amounts. The amount of each of these costs depends on their health plan. Patients without health insurance are responsible for 100% of mammogram and MRI costs.

Case Study

In a study published by the New England Journal of Medicine, titled

MRI evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer,

969 women with a diagnosis of unilateral breast cancer and no abnormalities on mammography went for a breast MRI. MRI detected clinically occult breast cancer in the contralateral breast tissue in 30 women (Lehman, 2007). Biopsies were performed on 121 of the 969 women whose MRI showed breast cancer (Lehman, 2007). Of those 121, 30 were tested positive. MRI was able to detect cancer that was missed by mammography and clinical exam. Within the 969 women, 33 tumors were diagnosed with 30 being from MRI. The three others were diagnosed from a mastectomy specimen before a biopsy could be performed. Those three samples contained ductal carcinomas in situ and measured 1, 3, and 4 mm in diameter. The most common types of invasive cancer found on MRI was ducal carcinoma (67%), invasive lobular carcinoma (22%), and tubular carcinoma (Lehman, 2007). 96.7% of cancer found was stage 0 or 1. The overall high accuracy of MRI is due to technology and interpretation of results. Contrast enhanced MRI aids in distinguishing benign from malignant patterns. This study also showed that screening MRI can improve on mammography by detecting cancer in women at high risk especially those with aggressive cancers.

When ordering MRI, cost effectiveness continues to be a major concern. In the article,

American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography

, benefits of MRI’s sensitivity in detecting lesions is noted but without data on the recurrence and survival rates, MRI is not recommended as a screening exam. The article compares study results from six published studies, sensitivity for MRI is consistently higher than mammogram and ultrasound while specificity was lower than mammogram and ultrasound. High sensitivity means MRI correctly identifies a patient with cancer. Low specificity means MRI is not able to correctly reject a patient without cancer as accurately as other modalities. MRI has higher error but in calling back more patients and performing more biopsies, it diagnoses cancer more accurately. With this being said, the article does not recommend MRI as a screening tool unless women are at an increased risk of breast cancer, have a family history, or carry the BRCA gene (Stephens, 2011).

Conclusion

Women who present with signs and symptoms of breast cancer or have a family history should be screened with MRI in addition to mammography. It is not acceptable to deny patients imaging studies that can prolong their life. Breast cancer is 100% treatable when caught early. Due to advances in technology and a growing healthcare system, facilities are more readily available to treat women. Patients no longer need to wait months for tests or results. Steps should be taken to reduce anxiety associated with MRI cancer screening and wait time. Patients should be informed about the likelihood of false-negative and false-positive findings. Whether or not patients need to go through additional imaging, the chance of early detection outweighs the stress of additional testing. MRI is a very useful imaging test that can save lives if performed. Patients who want to be proactive in their treatment should be encouraged to get routine imaging tests done and educate themselves on different stages of breast cancer, so they understand the process they are going through. By creating high resolution imaging, MRI proves to be the most effective study for diagnosing breast cancer. MRI is able to detect smaller masses and abnormalities than other imaging tests miss. Utilization of MRI is crucial for early detection, with its results breast cancer can be highly treatable and late stages along with metastases can be stopped. MRI used in screening for women with high risk factors proves more cost effective than mammography and ultrasound because it detects cancer in earlier stages which reduces the need for more invasive, long term care. MRI is also able to cover a larger area including axillary lymph nodes where cancer is commonly missed on mammograms.

References:

Jiao, X., & Hay, J. (2014). Cost-Effectiveness Of Breast Mri And Mammography For Screening High Risk Population. Value in Health,17(3). doi:10.1016/j.jval.2014.03.780

Orel, S. (2005). 1–10 Efficacy of MRI and Mammography for Breast-Cancer Screening in           Women With a Familial or Genetic Predisposition. Breast Diseases: A Year Book Quarterly,16(1), 37-38. doi:10.1016/s1043-321x(05)80023-2

Saslow, D., Boetes, C., Burke, W., Harms, S., Leach, M. O., Lehman, C. D., . . . Russell, C. A.    (2007). American Cancer Society Guidelines for Breast Screening with MRI as an             Adjunct to Mammography. CA: A Cancer Journal for Clinicians,57(2), 75-89.             doi:10.3322/canjclin.57.2.75

Feig, S. (2009). Cost Effectiveness of Breast Cancer Screening With Contrast-Enhanced MRI in High-Risk Women. Breast Diseases: A Year Book Quarterly,20(4), 383-385. doi:10.1016/s1043-321x(09)79390-7

Berg WA, Zhang Z, Lehrer D, et al. Detection of Breast Cancer With Addition of Annual             Screening Ultrasound or a Single Screening MRI to Mammography in Women With Elevated Breast Cancer Risk.

JAMA.

2012;307(13):1394–1404. doi:10.1001/jama.2012.388

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https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet#q1

Medical Dictionary Online. (2018). Retrieved August 31,2018, from Medical Dictionary Online:

https://medical-dictionary.thefreedictionary.com/breast+cancer

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https://medical-dictionary.thefreedictionary.com/carcinoma

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https://www.sciencedirect.com/search?qs=QALY&show=25&sortBy=relevance

Elsevier Online. (2018). Retrieved August 31,2018, from Science Direct Online:

https://www.sciencedirect.com/science/article/pii/0010480986900200

National Comprehensive Cancer Network: Practice Guidelines in Oncology – Genetic/Familial    High-Risk Assessment: Breast and Ovarian. 2005, National Comprehensive Cancer    Network, Inc, 1.

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https://www.cancer.org/

Ali, K., & Vinnicombe, S. (2018). Accuracy of contrast enhanced breast tomosynthesis in patients suspected of having breast cancer: Comparison with digital mammography and breast MRI. Http://isrctn.com/. doi:10.1186/isrctn12691785

Gillman, J., Toth, H. K., & Moy, L. (2014). The Role of Dynamic Contrast-Enhanced Screening Breast MRI in Populations at Increased Risk for Breast Cancer. Womens Health,10(6), 609-622. doi:10.2217/whe.14.61

Pilewskie, M., & King, T. A. (2014). Magnetic resonance imaging in patients with newly diagnosed breast cancer: A review of the literature. Cancer,120(14), 2080-2089. doi:10.1002/cncr.28700

Heil, J., Czink, E., Schipp, A., Sohn, C., Junkermann, H., & Golatta, M. (2012). Detected, yet not Diagnosed Breast Cancer Screening with MRI Mammography in High-Risk Women. Breast Care,7(3), 236-239. doi:10.1159/000339688

Lehman, C. D. (2007, March 29). MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer. Retrieved September 19, 2018, from

http://www.nejm.org/

Stephens, T. (2011). Breast Cancer Screening With Imaging: Recommendations From the Society of Breast Imaging and the ACR on the Use of Mammography, Breast MRI, Breast Ultrasound, and Other Technologies for the Detection of Clinically Occult Breast Cancer. Yearbook of Diagnostic Radiology, 2011, 46-47. doi:10.1016/s0098-1672(10)79236-5

Plevritis, S. K., Kurian, A. W., Sigal, B. M., Daniel, B. L., Ikeda, D. M., Stockdale, F. E., & Garber, A. M. (2006). Cost-effectiveness of Screening BRCA1/2 Mutation Carriers With Breast Magnetic Resonance Imaging. Jama,295(20), 2374.            doi:10.1001/jama.295.20.2374

Taneja, C., Edelsberg, J., Weycker, D., Guo, A., Oster, G., & Weinreb, J. (2009). Cost Effectiveness of Breast Cancer Screening With Contrast-Enhanced MRI in High-Risk Women. Journal of the American College of Radiology,6(3), 171-179. doi:10.1016/j.jacr.2008.10.003

Moore, S. G., Shenoy, P. J., Fanucchi, L., Tumeh, J. W., & Flowers, C. R. (2009). Cost-   effectiveness of MRI compared to mammography for breast cancer screening in a high risk population. BMC Health Services Research,9(1). doi:10.1186/1472-6963-9-9

A theory is a set of concepts, definitions, relationships and assumptions that: Formulates legislation Explains a phenomenon Measures nursing functions Reflects the domain of nursing practice.

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A theory is a set of concepts, definitions, relationships and assumptions that: Formulates legislation Explains a phenomenon Measures nursing functions Reflects the domain of nursing practice.
Question1

The following statements about prescriptive theories is accurate

The describe phenomena
They have the ability to explain nursing phenomena
They reflect practice and address specific phenomena
They provide a structural framework for broad abstract ideas.

Question 2

A theory is a set of concepts, definitions, relationships and assumptions that:

Formulates legislation
Explains a phenomenon
Measures nursing functions
Reflects the domain of nursing practice.

Question 3

Which theories describe an orderly process beginning with conception and continuing through death?

Systems theories
Developmental theories
Interdisciplinary theories
Stress and adaptation theories

Question 4

Leininger’s theory of cultural care diversity and universality, specifically addresses

Caring for clients from unique culture
Understanding the humanistic aspects of life
Identifying variables affecting a client’s response to a stressor
Caring for clients who cannot adapt to internal and external environmental demands.

Psoriasis: Immunopathology- Presentation- Complications and Treatments

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Abstract

Psoriasis has been defined as a chronic immune-mediated inflammatory skin disease characterized by uncontrolled proliferation of keratinocytes, activated dendritic cells, release of proinflammatory cytokines, and recruitment of T cells to the skin. This paper discusses the immunopathophysiology, clinical presentation, associated complications, clinical assessment, and interventions related to this condition.


Introduction

Psoriasis has been defined as a chronic immune-mediated inflammatory skin disease characterized by uncontrolled proliferation of keratinocytes, activated dendritic cells, release of proinflammatory cytokines, and recruitment of T cells to the skin. In other words, the life cycle of skin cells is hastened which causes cells to build up rapidly on the surface of the skin. The extra skin cells form scales and red patches that can be itchy and/or painful.

I chose psoriasis as the topic of focus for this paper because my boyfriend, George, was diagnosed with this condition when he was 15 years old. He has the mild-moderate severity of plaque psoriasis. He describes his first experience of noticing this skin condition as itchy red spots that appeared on the back of his knees, chest, and arms after he adopted a cat. He also reports that his path toward diagnosis and treatment took several years because initially he kept getting misdiagnosed with just having dead skin. But after seeking a third opinion, he was correctly diagnosed with plaque psoriasis and found out that he was allergic to cats. He was advised to get rid of the cat and was prescribed coal tar but discontinued using it shortly afterwards because it dried out his skin too much and would leave behind a strong chemical smell. He was then advised to bathe with Selsun blue shampoo due to its acidic properties. This has been his treatment regimen since he was 19 years old and reports that it is effective in managing his outbreaks.

The incidence and prevalence of psoriasis is difficult to pinpoint due to very little studies on this and also because there is no mandated reporting of diagnosed individuals. Despite this, some national foundations provide some statistics. For example, according to the National Psoriasis Foundation, more than 8 million Americans have psoriasis (2019). Many sources state that prevalence is highest in Caucasians and is second highest for African Americans. A cross-sectional study conducted by Rachakonda et al. (2014) using National Health and Nutrition Examination Survey 2009 through 2010 data determined psoriasis prevalence rates. Their results concluded that 3.2% of US adults ages 20 years and older have psoriasis, an estimated 7.4 million US adults were affected in 2013. The prevalence was highest in Caucasians at 3.6%, followed by African Americans 1.9%, and Hispanics 1.6%.


Pathophysiology

The immunopathophysiology of psoriasis is a topic that has been extensively researched. Recent studies have reported that genetic (ex: family history, HLA antigens) and lifestyle factors (trauma, antigens) are both involved in the development of psoriasis. It is understood that several types of cells and biological components are involved in causing this condition, such as: T cells, antigen-presenting cells (APCs), macrophages, neutrophils, and tumor necrosis factor alpha (TNF-α).

Psoriasis is the result of a chronic immune system activation caused by a trigger(s) that leads to abnormal levels of keratinocytes production and psoriatic plaque. When the dermis layer is inflamed, nearby blood vessels dilate which helps neutrophils penetrate to the epidermis. The neutrophils migrate to the stratum corneum layer which leads it to become thickened.  The inflammation also causes the keratinocytes to proliferate abnormally and rapidly at a rate that outpaces the rate of the dead skin cells sloughing off which leads to skin cell pile ups. Due to the rapid maturity of keratinocytes, many contain defects in shapes and retain their nuclei. The defect in shape causes an issues in these cells adhering to each other which is why psoriatic plaques often look scaly and uneven in shape.

The development cycle begins when the APC (dendritic cells) becomes activated after it comes in contact with an antigen in the skin. The APC then travels to the lymph node where it stimulates the naïve T cells to become an activated memory T cell. After activation, adhesion molecules such as ICAM-1 help the memory T cells migrate through the blood so that reach the site of inflammation in the skin. After extravasation in the dermis layers, memory T cells release cytokines such as TNF-α and interferon gamma and lead to an increased production of keratinocytes which caused psoriatic plaques. IL-12 AND IL-23 are cytokines that are released by dendritic cells which activate other T-cells thus leading to the continuation of the inflammation process.

There are seven types of psoriasis: plaque, guttate, pustular, inverse, and erythrodermic. In addition to these identifications, the type of psoriasis can be further classified by the following categories: mild, medium, and severe based on how much body surface area the plaques cover. Plaque psoriasis is the most common type and presents with the following symptoms: skin that is raised, inflamed, red, and covered by silvery, white scales that may itch and burn. These patches can appear anywhere on the body but especially in these areas: elbows, knees, scalp, and lower back. Guttate psoriasis is one of the rare forms of this disease and presents with small, pink-red spots on the skin that often appear on the trunk, upper arms, thighs, and scalp. Pustular psoriasi is uncommon but can be dangerous if it spreads all over the body and it presents with pustules surrounded by red skin. Inverse psoriasis presents with patches of skin that are red, smooth, and shiny found commonly in these areas of the body: armpits, groin, and skin folds near the genitals and buttocks. Lastly, erythrodermic psoriasis is another rare condition and presents with very dark red skin that appears as it is burned and can cover a large area of the body. This condition can be dangerous as it may lead to cardiac abnormalities.

Individuals that have psoriasis are at increased risk of suffering complications. Some studies have proven that individuals that are categorized as moderate-severe have a higher risk of developing certain complications such as obesity, hypertension, type 2 diabetes, and kidney disease. The development of hypertension and type 2 diabetes are discussed in further detail.

One complication that has been linked to psoriasis is hypertension. A prospective cohort study conducted by Salihbegovic et al. (2015) demonstrated a correlation between patients with psoriasis and hypertension. Overall, research has not yet found the exact pathophysiological mechanism for this correlation but Salihbegovic et al. (2015) proposed the following theory that affected individuals may have an increased level of angiotensin-converting enzyme (ACE), endothelin-1 (ET-1), and rennin. Another theory was that medications, such as cyclosporine, are inducing hypertension. It is also important to keep in mind that affected individuals may feel stressed due to their poor health conditions which in turn can lead to the development of high blood pressure.

Another complication is the development of type 2 diabetes mellitus. A study conducted by Lønnberg et al. (2016) examined the association between psoriasis, type 2 diabetes mellitus, and body mass index (BMI) in order to better understand the genetic association. The study population was composed of Danish twins. Their results concluded that a significant association was found between psoriasis and type 2 diabetes mellitus as well as between psoriasis and increasing BMI. The authors discuss that the following components, tumor necrosis factor, tumor necrosis factor receptors, and interleukin 6, are involved the development of psoriasis and are also linked with obesity. The association between type 2 diabetes mellitus and psoriasis could exist because an increased tumor necrosis factor production from psoriatic inflammation and low-grade obesity inflammation contributes to insulin resistance.


Assessment and Intervention:

Diagnosing psoriasis typically includes conducting a physical exam and taking a patient’s medical history. In rare cases, a biopsy can be performed in order to rule out other skin conditions. Healthcare providers can also order laboratory studies in order to diagnose patients if it suspected they have pustular or erythrodermic psoriasis. With respect to pustular psoriasis, the erythrocyte sedimentation rate (ESR) and uric acid level will be abnormal. The ESR will be abnormal as well for erythrodermic psoriasis. Depending on the type of psoriasis and severity, baseline laboratory studies (CBC, BUN, LFTs, etc) should be conducted if the patient’s treatment plan consists of systemic therapies such as immunological inhibitors.

With respect to interventions, treatments are selected based on the type and severity of psoriasis as well as location on the patient’s body. Treatments are categorized as topical, systemic, or phototherapeutic. For mild psoriasis, topical medications are prescribed. For mild-severe psoriasis, a combination treatment plan of topical and systemic is recommended. Some forms of topical, systemic, and phototherapeutic treatments are discussed in further detail.

With respect to topical treatments, many options exist. Choices include corticosteroids and medicated shampoos that contain salicylic acid. Topical corticosteroids reduce inflammation and relieve itching. The type of dosage prescribed depends on what areas need to be treated. For example, low dose corticosteroid ointments are used in sensitive areas and high dose corticosteroid ointments can be used for smaller, less sensitive areas. Although this medication is quite effective, it is best to be used as short term because of its side effects. Salicylic acid removes dead skin cells with its acidic properties and is available in shampoos such as Selsun Blue. It can be used to treat scalp psoriasis as well as mild psoriatic plaques located within any body area.

With respect to systemic treatment, numerous options are also available. One such medication is methotrexate which is an inhibitor of folate biosynthesis that reduces psoriatic inflammation. This is a medication that is best used short term due to its side effects such as severe liver damage (Mayo Clinic, 2019). Cyclosporine another medication that is recommended for temporary use because it is an immunosuppressant. It increases the risk of infection and the development of other conditions, such as cancer and hypertension.

The last treatment category is phototherapy and it is prescribed to patients that have moderate-severe psoriasis that has been unsuccessfully treated with topical medications. This treatment uses natural or artificial ultraviolet light. One such method of phototherapy used is exposure to sunlight. The xxposure to ultraviolet rays in sunlight or artificial light slows down skin cell replication thus reducing scaling and inflammation. This can be a tricky method because it involves momentary, daily exposures to small amounts of sunlight and if the sun exposure is lengthened then it can worsen symptoms and cause skin damage. Another method is ultraviolet B (UVB) phototherapy which involves measured doses of UVB light from an artificial light source.


References:

Improving nurse-nurse handoff communication at report.

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Improving nurse-nurse handoff communication at report.

The project is to be presented in summary format and not more than 3 pages of content. APA formatting is required, and a minimum of (3 to 5) evidenced based references should be included. References are not counted in the page limit for the paper.
Directions:

Begin with the Problem Statement & Literature Support.

A sample problem statement is:

“ Quality patient care and successful clinical and financial outcomes are directly correlated with professional nursing staff competence and turnover (references). In organization X, the current staff turnover rate is 25% after one year on the unit. In settings where nurse turnover exceeds 12%, the following clinical, organizational and financial challenges have been noted: (1) lower patient care scores on national benchmark data; (2) etc. According to Aiken (2003), national studies ……
Continue with a brief but relevant and evidence-based literature that supports the problem statement.

The rationale for selection of this problem relates to findings that directly correlate to the actual performance outcomes with the problem.

Support the need for addressing this from a quality improvement approach and its relationship with patient safety and/or outcomes.

Is there data that suggests performance improvement may impact on the problem?

An appropriate Plan Design is the application of a performance improvement process.

This is the meat of the project where you will discuss the performance improvement process steps that you will employ to address the problem, taking care to include: Who, What, How, and Time Frame. Include in the discussion the process proposed to address the problem.

An example would be:

“The initial approach is to (1) collect accurate data on the extent of the problem, (2) brainstorm with staff, administrators and patients to determine to potential causes of the problem, and (3) conduct focus groups with current and separated staff to elicit additional contributing factors.”

The conclusion of the discussion should project the desired outcomes and future plans.

For example:

“ It is expected though the application of this improvement process that nurse turnover in this organization will be significantly reduced or reduced to not more than 5% yearly. The process plan has been adopted by the organization and is to be reviewed and reassessed quarterly for outcomes and needed changes.”

Grading is as follows:

Problem statement and literature support 30%
Rationale 30%
Plan design 30%
Paper Structure & APA format 10 %

Total 100%

Examples of past QI papers include:

decreasing risk of nosocomial infections; reducing falls;
reducing central line infection; improving competency in use of cardiac monitors;
decreasing catheter associated BSI; reducing medication errors;
interdisciplinary rounds; medication reconciliation and
improving nurse-nurse handoff communication at report.

Is this question part of your Assignment?

What is the ED visit percentage rate of increase of individuals age 45-64 from 2006 to 2011?

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What is the ED visit percentage rate of increase of individuals age 45-64 from 2006 to 2011?

Go to US Department of Health and Human Services website: www.ahrq.gov/data/hcup (Links to an external site.)

Describe what HCUP is and its purpose in your own words; do not copy and paste from the web site.
To complete the questions below, go to the HCUP website: http://hcup-us.ahrq.gov/reports/statbriefs/sbtopic.jsp (Links to an external site.)

Go to Reports, HCUP Statistical Briefs, and topical list. Find the following:

Readmissions to US Hospitals by Diagnosis in 2010; Of the 30 most frequently treated conditions in US hospitals with 30 day readmission rates, what are the top 5 most frequent conditions?

Trends and Projections in Inpatient Hospital Costs and Utilization, 2003–2013; What was the average hospital costs in 2013 projected to be?

Trends in ED Visits; what factors have affected the number of ED visits both positively and negatively in 2006-2011?

What is the ED visit percentage rate of increase of individuals age 45-64 from 2006 to 2011?

In what age group was ED visit rates consistently the highest in 2011?

Most expensive conditions by payer in 2011; What was the aggregate cost of nearly 39 million hospital stays in 2011?

Who was the primary payer and at what % of the stays in 2011?

What the percentage of uninsured in 2011 and how many dollars were spent on those visits?

All answers must be cited and references written out. You may cite/reference after each answer if you wish. Or, you can write up a reference page. APA must be followed.

Legal aspects that affects the Nursing profession

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Legal aspects that affects the Nursing profession

law of nurses

Legal aspects that affects the Nursing profession
LAWS AFFECTING NURSING PRACTICE IN THE PHILIPPINES
Presidential Decree
• PD 223 – Professional Regulation Commission (PRC)
. PD223-Creation of Board of Nursing
Professional Regulation Commission has the power to recommend nominee members of the board to the President of the Republic, June 22, 1973 • PD 541 – Practice of profession in the Philippines by former professionals • PD 651 – Birth Registration Law

• PD 856 – Sanitation Code
• PD 996 – Compulsory immunization of children under 8 years • PD 491 – Nutrition Program Law
• PD 825 – Penalty for improper garbage disposal
• PD 143 – Woman and Child Labor Law (no child below 14 shall be employed) • PD 69 – Four children for tax exemption
• PD 48 – Four children for maternity privilege
• PD 965 – Family Planning and Responsible Parenthood
• PD 442 – New Labor Code of the Philippines
• PD 603 – Child and Youth Welfare Code

Discuss relationship-based and patient-centered care attributes related to your nursing practice experience. How do these attributes impact your nursing practice? What drives the process? What outcomes are anticipated?

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Discuss relationship-based and patient-centered care attributes related to your nursing practice experience. How do these attributes impact your nursing practice? What drives the process? What outcomes are anticipated?

 

Discuss relationship-based and patient-centered care attributes related to your nursing practice experience. How do these attributes impact your nursing practice? What drives the process? What outcomes are anticipated?

*Include this within the FIRST PART post: In parallel practice, one can see very little collaboration between healthcare providers. Each provider functions independent of the others even when working in a collaborative setting.

Methodology Is The Set Of Principles Of Research Nursing Essay

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It is advised to select the appropriate philosophical perspective during the process of research for choosing the appropriate methodology (Sim and Wright, 2000).

The selection of the approach will depend on the three elements of philosophical assumption about the knowledge around the topic, plan of the inquiry and the well crafted process of data collection, analysis and writing (Creswell, 2009). The basic necessity of conducting a comprehensive, thorough and dependable research study is the researcher’s intellectual knowledge and critical thinking (Guba, 1990). In order to adopt an approach which will divulge the knowledge around the topic in many different ways the researcher should not select or favour any approach without first comparing the existing approaches (Hart, 2008). This will build critical thinking which will assist in understanding the theoretical perspective behind the studies and critically review them within the paradigms they are constructed (Hart, 2008).

Paradigm –

Paradigms are defined as the framework or the representation of the philosophical beliefs which will guide the researcher to undertake the disciplined enquiry and analyze the findings on the basis of their assumptions (Guba, 1990).

A paradigm presents a general perspective of the diversified view point of the real world through three philosophical questions based on the ontological, epistemological and methodological outlook. Hence it can be seen as the opening point to determine the inquiry, the opinion behind the process, and finally the measures taken (Guba, 1990).

In relation to the topic of this dissertation, it is assumed that a reality exists that can be uncovered (i.e., the benefits vs. risks of prescribing HRT in menopausal women). Therefore, this study is conducted within the post-positivist paradigm. This paradigm was chosen as its philosophy brings out the various aspects surrounding the question bringing more clarity to the subject and will make the research process more generaliseable and reliable.

The post-positivist paradigm is an extension of the positivist paradigm. It attempts to rectify the limitations of positivism; hence prediction and control become the aim (Guba, 1990). The critical realist ontology of post-positivist approach is built on the belief that a real world or reality does exist but there are limitations to reach there. These limitations might confound the real picture making the findings less reliable, still the fact that the reality does exist remains (Guba, 1990).

Its modified objective epistemological approach presents the opinion that there could be sizable limitations for a human researcher or inquirer to have an objective observation devoid of any human subjectivity. However by being unbiased which Guba (1990; p21) describes “as neutral as possible” and depending on critical reasoning it can be achieved closely (Guba, 1990). Methodologically, the post-positivist approach attempts to address the imbalances by the modified experimental or manipulative approaches which give emphasis to innovation in the research process (Guba, 1990).

The three philosophical questions posed by Guba (1990; p18) are addressed in this dissertation as follows:

1) Ontological: what is the nature of the “knowable” or the nature of the “reality”?

The nature of the knowable in this study are the benefits of prescribing HRT despite the risk of breast cancer.

2) Epistemological: What is the nature of the relationship between the knower (the researcher) and the known (or knowable)?

The relationship between the researcher and the knowable is objective as the researcher will be reviewing data from the existing studies selected by a comprehensive search of various databases.

3) Methodological: Which process shall the inquirer implement for finding the knowledge?

Using the post-positivism paradigm, this dissertation aims to highlight the benefits and risks of HRT. Data will be gathered by conducting a comprehensive search of published primary research studies (Aveyard, 2010). After reviewing, selecting and collecting the data, the researcher will analyze and summarise the findings to answer the research question (Aveyard, 2010; Punch, 2006). The findings of this dissertation might assist menopausal women to know what benefits they could expect from HRT treatment, and uncover the reasons why millions of menopausal women undergo HRT treatment in the presence of the foresaid risk (Banks et al, 2003).

Literature Review as a research methodology –

Conducting primary research could not have answered the research question posed by this dissertation. Therefore, a literature review was undertaken to address the research question. This methodology is appropriate as there is no direct involvement between the researcher and the participant, and there was a time limitation of completing this research study (Aveyard, 2010). There are many relevant research studies which are readily available from different parts of the world. Since these studies already exist the researcher decided to use literature review as the appropriate methodology to undertake this dissertation to answer the research question in the most comprehensive way.

According to Aveyard (2010) a literature review with a well defined question and which is carried out with a systematic approach is a research methodology in its own right. Using this methodology allows the results of such a review to be reliable and generalisable. The preliminary research review (chapter 2) uncovered many studies that evaluated the link between HRT and Breast cancer. Hence it became clear that by using the methodology of literature review many relevant studies from an extensive time span, and from different parts of the world would uncover the opinion of the medical fraternity and would help develop an overview of the topic.

Advantages of Literature Review which made literature review the appropriate methodology for this dissertation –

Hart (2008; p13) defines literature review as “integral to the success of academic research”. One of the advantages of using literature review is that through the preliminary search the research ability of the topic can be ensured even before the dissertation or the study commences (Hart, 2008). At the initial stage a researcher is mostly enthusiastic of a topic of interest which might make them select a topic too broad perhaps out of feasible limitations, but conducting a literature review helps overcome this by narrowing the topic down and giving a practical aspect to it (Hart, 2008). It will help to refine the research process by a systematic approach from the beginning of finalising the research question up to answering if (Hart, 2008; Kumar, 2005). The researcher’s critical thinking and analysis skills also are vital for conducting a literature review (Guba, 1990).

There are various studies conducted in various settings hence critical reading and critical thinking aspects of the literature review methodology will help gather knowledge of a topic and make a decision as to which information would be relevant (Hart, 2008). The literature review methodology brings clarity to the research procedure and broadens the existing knowledge base (Kumar, 2005). This will build the theoretical background of the study (Kumar, 2005) and help identify the relationship between the ideas and practice of use of HRT and rationalise the significance of the dilemma associated with the use of HRT (Hart, 2008). This is done by an extensive reading and developing an in depth understanding of the subject (Aveyard and Sharp, 2009).

And there is less purpose of applying literature review as a methodology if it doesn’t develop this subject further and aid the medical fraternity and women know more than what is already known (Burns and Groove 2005; Hart,2008).

Information in health and social care sector is increasing everyday and literature review would help explore published and un-published primary research studies to give a comprehensive view pertaining to the benefits associated with the use of HRT and the risk of breast cancer (Aveyard, 2010).

The cause and effect relationship of HRT its benefits and prevalent risk of breast cancer would be explored using prospective studies like Randomized Controlled Trails (RCT) and cohort, as they are the most accurate method for measuring disease risk (Aschengrau and Seage, 2008). Case control studies too would be used as they are the cost-effective and time-efficient method for research studies (Smith and Ryan 2008).

Literature review will further assist the identification of the relevant literature from the vast literature available around the topic of the research question. The researcher will then analyze the studies and extract the relevant information (Averyard, 2010). It will help to build the knowledge beyond what is known and advance the understanding of the use of HRT which will help uncover important determinants associated with its use (Hart, 2008). Combining these determinants of the use of HRT and synthesising them would help bring out a new outlook to the study and draw new interpretations about the benefits associated with the use of HRT with the foresaid risk of breast cancer (Hart, 2008).

These aspects of the literature review methodology will help construct a comprehensive study and the analysis of the relevant literature will enable to view the findings of a particular research study within the perspective of the other (Averyard, 2010). It will help to contextualise the findings and interpret them to highlight the benefits of using HRT with the foresaid risk of breast cancer derived which will help to build the existing knowledge of the doctors and the women using them (Kumar, 2005).

The researcher will then answer the research question which will facilitate further interpretations for future research studies (Sim and Wright 2000).

To sum it up the literature review methodology has been used for it striking features of narrowing the topic, refining the research process, broadening the existing knowledge base, identification of the literature, analysing the studies, synthesising and contextualise the findings and interpreting them so as to answer the research question in the most appropriate method.

Limitations of Literature Review

There are limitations to the literature review methodology, for example researcher bias in interpreting the findings of studies, or selecting studies for inclusion into the review. Some research may be missed due to the vast literature available. These limitations may be overcome by maintaining transparency of the method of data selection and analysis and a comprehensive search strategy.

According to Hart (2008) there are important ethical implications which the researcher needs to be aware of before using someone else’s work. The following steps are important to ensure that the quality and value of this dissertation is maintained.

1) Avoid sloppiness and nepotism (Hart, 2008) – Aveyard (2010) suggests that the references of the literature used are cited properly and that the researcher should not abruptly cite the any reference which makes a point but track the sources which have some originality so as to continue the discussion of the relevant topic.

2) Avoid plagiarism (Hart, 2008) – It is important to acknowledge the author even if a direct quotation is not being made. In case of a direct quotation from a source, quotation marks should be used and the source has to be referenced (Averyard, 2010).

3) Avoid falsification and fabrication (Hart, 2008) – It is important to understand the complete synopsis of the review rather than the superficial link (Aveyard, 2010).

Hart (2008) further suggests that it is the responsibility of the researcher to utilize the work of other people in a balanced, legal and fair way. This comprises all the above mentioned steps and also involves abiding by the copyright and Data Protection Act (Hart, 2008). These steps will ascertain ethical standard of the dissertation and avoid any speculation about its efficacy.

Critical Appraisal of literature

Critically appraising studies involves considering the validity, results and relevance of studies which is important to minimize bias in a literature review (Bandolier site, 2009). Aveyard (2010) defines critical appraisal as a structured process of evaluating studies for their strengths and weakness. Critical appraisal is essential skill in evidence based medicine which can be used by researchers to ensure that the studies are reliable and resourceful, and to assess whether bias inherent in different research designs have distorted the results (Bandolier site, 2009). This is the distinguishing feature between a review and an essay (Aveyard, 2010). It is the process of minute and organized examination of appropriate studies identified to evaluate their validity, importance and quality in context to the research question. It is vital for the researcher to develop this skill and use it appropriately (Bandolier site, 2009).

Critical Appraisal tools

This dissertation intends to adapt a structured method of appraisal for quantitative literature which has varied tools to critically evaluate the different types of studies which are going to be selected (Aveyard and Sharp, 2009). The studies selected will be RCT, cohort and case-control studies using quantitative methodology (Aveyard, 2010; Pearson et al. 2007). Quantitative research is often attributed with a strong emphasis on scientific rigor. This is linked to excellence with discipline and consistent approach to detail with accuracy (Burns and Grove, 2005). It is also an appropriate method where pre-existing knowledge is present and hence standardized collection methods could be expected (Bowling, 2002). Quantitative research is predominantly used in medical research based on the philosophy of post-positivist, providing sounder base for applying results into practice by its involvement of rigor, validity, objectivity and control (Burns and Grove, 2005). The selection of the right tool plays an important role in extracting the data relevant for the review (Burns and Grove, 2005). Critical appraisal is a reductionist approach as it involves breaking the whole into parts to have a better examination (Burns and Grove, 2005). This process will enable to review the rigor of the studies; their relevance to the dissertation which will help to decide the credence each study has in answering the research question (Averyard, 2010).

It is suggested that selected studies are critically appraised with specific tools according to their design in order to help evaluate their usefulness and relevance to the topic (Aveyard and Sharp, 2009). There are a number of critical appraisal tools that could be used here, for example the Center for Evidence Based Medicine (CEBM, 2010) RCT tool or the critical review appraisal form developed by McMaster University Occupational Therapy Evidence-Based Practice Research Group (McMaster University, 2008), however these have limitations for assessing a range of studies. The Critical appraisal skills program (CASP) by the Solutions for Public Health (SPH, 2010) developed specific appraisal tools for specific studies and these tools presented a viable alternative for critical appraisal in this dissertation. These tools take into consideration the three broad issues validity, reliability and applicability that are important for reviewing quantitative research (SPH, 2010). Validity is termed as measuring data which it is meant to measure. Reliability means consistency and is concerned with the repetition of same result in future (Aveyard and Sharp, 2009). Replication is of prime concern for quantitative research since if a study couldn’t be replicated its validity would be questioned (Bryman, 2008). This will depict that the derived results were not confined only to this study but can be generalised to a heterogeneous target population (Bryman, 2008). This step will increase the creditability and reliability of the study, further strengthen the knowledge and a better literature review can be expected (Burns and Grove, 2005).

DATA TO BE EXTRACTED

In order to compare and contrast the studies so as to integrate them and interpret the findings, Aveyard (2010) suggest assigning codes and developing themes.

The aim of this study is to highlight the benefits associated with the prescription of HRT despite the risk of breast cancer. Hence given the aim of this dissertation the broad themes which arise are benefits associated with the use of HRT and risk of breast cancer associated with the use of HRT.

The results are presented in two broad “themes” of benefits associated with the use of HRT and risks of breast cancer risk associated with the use of HRT chosen for their relevance to the research question and its objectives.

These themes will be addressed as issues in this dissertation and the following information will be extracted from selected studies:

ISSUE -1 – Benefits associated with the use of HRT

ISSUE -2 – Breast cancer risk associated with the use of HRT.

The codes will be the grading of the reliability of the studies and of the levels of benefits and risk of breast cancer derived from the studies to help ascertain the strength of the findings.

PRESENTATION OF STUDIES

A table will be used to present the studies with detailed methodological characteristics. This will assist in summarising the information extracted form each study, comparing the studies, deducing the results and also aid evaluation of the strength of the studies (Aveyard, 2010; Hart, 2008).

This dissertation is conducted within the post-positivist paradigm using literature review methodology and quantitative research by critically appraising the studies and synthesising the results into relevant and reliable data. The researcher is hopeful to deliver a good review which will link the past research to the present and assimilate the knowledge derived so as to learn from the past and install new ideas for the future.

Analysis of the Institute of Medicine Report: The Future of Nursing

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Analysis of the Institute of Medicine Report: The Future of Nursing

Abstract

The current paper concisely introduces the initiative launched on the part of the Robert Wood Johnson Foundation (RWJF) in collaboration with the Institute of Medicine (IOM) in 2008. The goal is to develop a feasible report assessing the condition of a healthcare field in the US, as well as outline recommendations in the following four key areas: nursing practice, nursing education, the status of nursing, and improved nursing infrastructure. The current paper highlights the major recommendations, as well as introduces a personal reflection upon the IOM recommendations and their practical implementation.

IOM Future of the Nursing Report and its Significance


The nursing profession is one of the oldest professions in the United States. Nursing holds an incredible degree of respect, it alone is of importance to the US and its culture. According to the Institute of Medicine, with more than 3 million members, the nursing profession is the largest part of the nation’s health care workforce. According to the Bureau of Labor Statistics, in 2016 there were 2,955,200 nurses employed in the United States and it is expected that by 2026 it will have increased by 15 percent. This information shows that nursing is huge and it is only going to expand. Nurses practice in different settings, whether it be home health, hospitals, schools, clinics, and many more. They also have many different levels of education such as associate degrees to bachelors to masters, and have different levels of skills, licensed practical nurses, registered nurses, nurse practitioners to name a few. With the increase demand for nurses and its peaking interest, it is vital to progress and improve our education to increase patient outcomes and improve the quality of care.

In the US, there was an issue with healthcare and professionals, the healthcare field was shattering, there were major differences between the patients and healthcare professionals, and patients weren’t having the best quality of care. There was a need for a comprehensive study to find various ways to improve the field of healthcare provision in order to offer affordable and patient-centered service in the future. In 2008, The Robert Wood Johnson Foundation (RWJF) and Institute of medicine collaborated to launch a 2-year initiative to respond to the need to assess and transform the nursing profession (Institute of Medicine, 2010). The basis of the program was to conduct a study that the main goal was to have a transformational report on the future of nursing.

A committee was formed to take action and to make recommendations and changes for the future of nursing. The committee took into consideration nurses’ roles, settings, and education levels in its effort to envision the future of the profession (IOM, 2010). The project focused on amending policies at the national, local and state levels. The Institute of Medicine began the essential and long-awaited transformation in the field of nursing (RWJF, 2014). The committee established four key messages. The first was that nurses should practice to the full extent of their education and training. The second was that nurses should attain higher levels of education and training. The third is nurses should participate with physicians and other health care professionals, in restructuring health care in the United States. The last was effective workforce planning and policy making require better data collection and an improved information infrastructure (IOM, 2010).

“We believe our nation cannot adequately address the challenges facing our health care system without also addressing the challenges facing the nursing profession,” said Risa Lavizzo-Mourey, M.D., M.B.A., President and CEO of RWJF. “For health reform to succeed, and for patients to receive better care at a cost we can afford, we must change the way health care is delivered. And nursing is at the heart of patient care.”

There have been reported many incidents, when the opinion and advice of nurses are overlooked. Furthermore, the hospitals have unhealthy work environments because of the conflicts between nurses and physicians. Hence one of the directions the report is working towards, is to establish effective strategies to manage conflicts and nurture a healthy environment for nurses’ empowerment (Eide et. al, 2007).

As one of the goals, the IOM report emphasizes on transforming the existing nursing

education. To confirm the delivery of safe, patient-centered care across settings, the nursing

education system must be improved. Patient needs are becoming more demanding and nurses

need to learn to skills and competencies to keep up with the changing goals and priorities to be

able to deliver better quality care to patients. Continuing our education prepares us for improved and better effectiveness, improves our actions and thinking and provides us with professional information. Nurses need to continue education courses in order to grow their skills. Studies show that knowledge gained through basic professional education has a half-life of 2.5 years, and needs to be updated (


Zohreh Shahhosseini

, 2014). Lack of continuing education can lead to poor services to our patients. It is necessary to highlight a certain point within the recommendations of the IOM report, as it actively encourages to “increase the proportions of nurses with a baccalaureate degree to 80% by 2020” (IOM report, 2010, p. 2). Not only does the program specify potential nurses obtain a bachelor’s degree but also urges healthcare organizations to reimburse the tuition fee. Institute of Medicine in general is aiming to enhance and change the nursing field for the better by setting forth practical recommendations.

I believe that as the IOM report is a stapled document, every nurse should attempt to include as many recommendations and goals in his/her practice as possible. If we do contribute on an individual level, that will eventually lead to a global change. In order to follow the IOM recommendations, I personally foster inter-professional association and attempt to encourage nursing leadership in the work setting. Pursuing a Bachelor’s degree is just another step toward recognizing the importance of nursing education, as it promotes seamless academic progression. In my view, a nurse should practice to the full extent of her academic training and capabilities, as well as do his/her best to take part in various training,

residency, and research programs to always stay connected with the new findings and information in the field. Naturally, this should not be purely a nurse’s concern, as the healthcare institution

should also prioritize training its personnel, however, in many cases, a personal effort for self-development may encourage the institution to meet the needs of its staff.

I believe that the power to transform the healthcare system and improve patient outcomes lie in the combination of both individual and institutional efforts. It is essential for every healthcare practitioner to consciously be aware that nurses are an essential part of the healthcare system, and without evolving and empowering nursing it would be impossible to better the healthcare services in general.

References

  1. Bureau of Labor Statistics. (2016). Occupational Outlook Handbook: Registered Nurses. Retrieved from:

    https://www.bls.gov/ooh/healthcare/registered-nurses.htm
  2. Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Retrieved from

    http://www.thefutureofnursing.org/IOMReport
  3. Eide, Y., Hansen, J., Keller, P. et al. Implementation of the IOM Future of Nursing Report: A Wisconsin Profile. (2010). Retrieved from: http://www.wisconsincenterfornursing.org/documents/index_docs/2014_WI%20Inventory%20IOM%20Profile%20Report%20FINAL%20Nov%202014.pdf
  4. Robert Wood Johnson Foundation, (2014). Our mission: to improve the health and health care of all Americans. Retrieved from http://www.rwjf.org/en/about-rwjf.html
  5. The Future of Nursing Leading Change, Advancing Health, Report Recommendation. Retrieved from https://floridasnursing.gov/forms/iom-future-nursing-info.pdf Institute of Medicine of the National Academies
  6. Shahhossein. (2014). The Facilitators and Barriers to Nurses’ Participation in Continuing Education Programs: A Mixed Method Explanatory Sequential Study. Retrieved from https://pdfs.semanticscholar.org/bbe1/7293fe34586fceb4106dd03d061a2c513809.pdf  Global Journal of Health Science

Effect of Chlorhexidine Bathing on SSIs and HAIs

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A Limited Integrated Literature Review

Abstract

Patient safety and infection control are two aspects in healthcare that are compromised when a surgical site infection or a hospital acquired infection occurs in healthcare. This literature review compares the impact of chlorhexidine gluconate bathing versus soap and water bathing on surgical site infections or hospital acquired infections in surgical patients. SSIs and HAIs are preventable occurrences. These adverse events are a prevalent problem in healthcare. The results from this review revealed that chlorhexidine offers a significant benefit in decreasing the occurrence of SSIs or HAIs in surgical patients. However, due to the limitations of the evidence more research is needed to make this a standard of care in healthcare.


Keywords:

chlorhexidine gluconate, surgical site infections, healthcare associated infections, surgical patients,

Effect of Chlorhexidine Bathing on SSIs and HAIs

Surgical site infections (SSIs) and hospital acquired infections (HAIs) are a significant adverse event in healthcare. SSIs and HAIs are a patient safety concern for all healthcare professionals. Surgical site infections account for a third of all hospital acquired infections and can be very costly to healthcare organizations (Centers for Disease Control and Prevention, 2018). SSIs and HAIs are never events which can be prevented. In 2007 the Centers for Medicare and Medicaid Services put into place a policy that Medicare will no longer pay hospitals for costs of care associated with never events (Agency for Healthcare Research and Quality, 2018). The cost of a surgical site infection or a hospital acquired infection can be from 28 to 45 billion to the hospital (Stone, 2009). Statistics have shown that surgical site infections occur in 2.6% – 5% of surgeries that take place (Stokowski, 2011). In addition to SSIs and HAIs being costly to hospitals, these incidents are negative patient outcomes that may cause death, increased length of stay, increase risk of rehospitalization, and more (Whitehouse, Friedman, Kirkland, Richardson, & Sexton, 2002). It is estimated that four percent of hospitalized patients has a healthcare acquired infection (Magill, 2014). A Healthy People 2020 goal is aimed at preventing, decreasing, or eliminating these events from occurring (Office of Disease Prevention and Health Promotion, 2018).

A few current practices to prevent these events include having the patient take a chlorhexidine bath or soap and water bath prior to surgery. What is the benefit of using chlorhexidine bathing versus soap and water bathing in preventing a SSI or HAI? It is important to further explore these two interventions to promote patient safety as well as save the hospital money that may be reallocated into another project. SSIs and HAIs are a negative patient outcome; healthcare delivery is aimed at promoting positive patient outcomes. Infection control is also a priority when providing care to patients. The purpose of this review is to determine in surgical patients how a chlorhexidine bath, as compared to a soap and water bath, influences whether the patient acquires a surgical site infection or a hospital acquired infection?


Methods

A systematic literature review search was executed using highly developed search strategies to obtain pertinent results. Multiple electronic databases were cross-examined and specifically selected to provide comprehensive data related to the PICO question. The electronic databases that were searched included MEDLINE, CINAHL, and Cochrane. The following primary key search terms helped in identifying the impact of chlorhexidine bathing in decreasing SSIs or HAIs, which include

surgical patients, chlorhexidine bath, surgical site infections, and hospital acquired infections

. The primary key terms were searched independently and then searched again with the use of MeSH terms and synonyms. Expanding the literature search by means of Medical Subject Headings (MeSH terms), synonyms, and the Boolean operator “or” was intended to maximize the retrieval of applicable results (Melnyk & Fineout-Overholt, 2015). MeSH terms and synonyms that were examined included:

  • surgical patients or operative patients
  • chlorhexidine bath or chlorhexidine bathing or chlorhexidine gluconate or                     chlorhexidine gluconate bathing or chlorhexidine wipes or soap and water bath
  • surgical site infection or surgical wound infection or SSI or hospital acquired infection or healthcare associated infections or nosocomial infections

To limit the search results to articles related to the PICO question the Boolean operator “and” was utilized to connect each of the subject headings. For each separate database search the same key words and Boolean operators were used.A search tactic was used to include articles only if published between 2010 and 2018, limiting the results to the most recently published literature. Articles were included if the publication type was a clinical trial, comparative study, controlled clinical trial, evaluation study, meta-analysis, multicenter trial, randomized controlled trial, or a validation study. Only articles in the English language were included. Articles were excluded if they did not address the population, the intervention and at least one of the outcomes. Article quality and level of evidence was determined by utilizing criteria published in


Evidence-Based Practice in


Nursing & Healthcare: A Guide to Best Practice

(Melnyk & Fineout-Overholt, 2015).


Results


Search Results

The initial search resulted in 22,751 from the key search terms. Upon using Boolean operators, exclusion criteria and inclusion criteria the search results were decreased to 49. Articles were only used or reviewed if published between 2010 and 2018. The titles were then read to scan for the essential elements of the PICO question. A total of 43 articles were excluded. One reason articles were excluded is for the reason that the articles did not address the surgical patient population. Another reason articles were excluded is that they focused on interventions other than CHG bathing and soap/water bathing such as iodine. Articles that were excluded that included iodine in the title amounted to 10 articles. Finally, articles were excluded if the article did not address surgical infections or hospital acquired infections.

Five quantitative research articles were kept to evaluate this PICO question. The final five articles that were pertinent to the PICO question were reviewed for validity, reliability, and applicability. The articles were critically appraised for their level of evidence. Of the five articles that were retrieved three were randomized trials or studies. Randomized controlled trials are considered level 2 evidence in the hierarchy of evidence published in

Evidence-Based Practice in


Nursing & Healthcare: A Guide to Best Practice

(Melnyk & Fineout-Overholt, 2015). The other two articles were cohort studies. Cohort studies are considered level 3 evidence (Melnyk & Fineout-Overholt, 2015).

The articles included sample sizes ranging from 100 participants to 1134 participants. Four of the articles reported surgical site infection or hospital acquired infection incidences when comparing presurgical bathing techniques such as chlorhexidine bathing vs standard bathing methods (Graling et al., 2013; Johnson et al., 2010; Kapadia et al., 2016; Swan et al., 2016). One of the articles although it did not report SSI or HAI incidences, it did report a decrease in bacterial flora when CHG bathing was implemented vs standard of care (Murray et al., 2011). Of the articles three out of five were focused on the outcome of some type of orthopedic surgical site infection (Johnson et al., 2010; Kapadia et al., 2016; Murray et al., 2011).


Chlorhexidine Bathing Products

Chlorhexidine is an antimicrobial agent that reduces bacterial flora on the patients’ skin when applied. Most CHG products have alcohol in them, which make them very effective in killing viruses and bacteria (Stokowski, 2011). Chlorhexidine comes in many different forms and is used for many different antimicrobial purposes. Chlorhexidine comes as impregnated wipes, liquid CHG soap, oral solution, CHG impregnated dressings, CHG impregnated catheters, and more (Chlorhexidine, 2018). This literature review brings up the question, which is more effective in preventing SSIs and HAIs the impregnated CHG cloths or the CHG soap? Minor skin irritation or contact dermatitis is a risk in utilizing CHG topical wipes or soap (Cheng & Kroshinsky, 2011). However, this adverse event does not occur in all patients and the patient must consider the risk versus the benefit of preventing an infection.


Surgical Site Infections

Surgical site infections are events that can be prevented with best evidence-based practices. Every patient has their own skin flora and surgical site infections can occur because of this (Milstone, Passaretti, & Perl, 2008). Surgical site infections are a quality outcome measure for acute care hospitals (Biscione, 2009). Hospitals are not paid by Medicare for SSIs since the policy change made by the Centers for Medicare and Medicaid Services in 2007 (Agency for Healthcare Research and Quality, 2018). It is recommended and accepted into practice that patients wash with an antimicrobial agent 24 hours prior to surgery to prevent surgical site infections; this recommendation is a classified as a category IB recommendation which is supported by low-quality evidence suggesting net clinical benefits (Berrios et al., 2017).


Resistance Concerns

CHG is a commonly accepted antimicrobial used for surgical infection prophylaxis, but this raises the concern of bacteria developing resistance to this product. Already in healthcare there are three common antibiotic resistant bacteria which include MRSA, VRE, and C-Diff; each year 23,00 patients die from some type of antibiotic resistant infection (CDC, 2018). What is the risk of CHG products in becoming resistant to different types of bacteria? There is evidence that CHG is resistant in the presence of gram-negative

Bacilli

and MRSA isolates with prolonged use of CHG products for regular bathing (Kassakian, Mermel, Jefferson, Parenteau, & Machan, 2011; Wang et al., 2008).


Limitations of Evidence

Some limitations of the evidence include small sample sizes, unevenly divided intervention groups, compliance issues and following up with patients. Different types of biases compromise the validity of a study (Melnyk & Fineout-Overholt, 2015). Multiple types of bias exist within this review, which comprise of a loss to follow up bias, information bias, an external bias and more (Graling & Vasaly, 2013; Johnson et al., 2010; Kapadia, Elmallah, & Mont, 2016; Murray et al., 2011; Swan et al., 2016). The results reported significant p values in the effect of CHG preoperative bathing in reducing SSIs or HAIs. This review will help me when caring for my patients in preventing SSIs and HAIs. More evidence is needed to provide a stronger evidence base recommendation in preventing SSIs and HAIs.


Discussion

To answer the question “In surgical patients how a chlorhexidine bath, as compared to a soap and water bath, influences whether the patient acquires a surgical site infection, or a hospital acquired infection?”, significant evidence has been provided in literature as to how well CHG bathing is at preventing SSIs or HAIs versus a standard bath. This review comprises of multiple cohort studies and a few randomized trials; however, the evidence base is limited due to multiple biases in all the studies. Stronger evidence types are needed to provide a higher certainty of benefit. CHG bathing is an accepted standard of practice to prevent SSIs and HAIs (CDC, 2018).  To fully interpret the significance of CHG bathing on SSIs and HAIs more RCTs are needed. Randomized controlled trials (RCTs) are a high level of evidence if planned correctly with specific guidelines for interventions, correct implementation, good measurement techniques, and more (Melnyk & Fineout-Overholt, 2015).


Recommendations

Based on the evidence in this review I would recommend the use of CHG bathing prior to surgery to prevent surgical site infections and hospital acquired infections. The evidence although limited does present significant p values in most of the studies (Graling & Vasaly, 2013; Kapadia, Elmallah, & Mont, 2016; Murray et al., 2011; Swan et al., 2016). Disseminating this information or research is crucial for more healthcare organizations in adopting this standard of infection control and patient safety. Nurse leaders can have a strong influence on healthcare policies. Nurses are important stakeholders in healthcare because we have a vested interest to promote positive patient outcomes as well as being at the bedside implementing these policies.

Another recommendation is that research studies need to evaluate the impact of CHG routine bathing on developing resistances to multidrug-resistant organisms. The limitations in the research evidence base solidifies the need for further research studies in this area to present stronger evidence in making CHG bathing a standard of care.


References

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Appendix

Table 1


Citation


Evidence Level


Sample


Variables


Interventions


Measurement


Results


Appraisal

Graling, et al., (2013)

Cohort

Level 4

619 adult surgical patients

CHG (n=335)

No CHG (n=284)

Independent Variables:

  • 2% CHG pre-operative cloth bath.
  • No bath

Dependent Variables:

  • Incidences of overall surgical site infections within 30 days after surgery
  • Incidences of postoperative organ space infections

Historical controls were utilized for the no bath cohort. Patients in the CHG cohort received a 2% CHG preoperative cloth bath prior to surgery when admitted for a four-month period.

t-tests or Wilcoxon signed rank tests to analyze continuous data and chi-square or Fisher exact tests for categorical data.

SSI

CHG = 2.1%

No CHG = 6.3%

p= 0.01


Implications for Practice

Surgical site infections are preventable events. Healthcare professionals should follow evidence-based practices to prevent these events from occurring.


Key Limitations

  • Following up with patients
  • Historical controls

Johnson, et al., (2010)

Prospective Cohort

Level 4

1134 hip replacement patients

Home CHG (n=157)

Usual Care (n=897)

Independent Variables:

  • At home CHG cloth skin preparation
  • No at home presurgical skin preparation

Dependent Variables:

  • Surgical site infection rates
  • Incidences of periprosthetic infections

Patients were

randomized to

either home CHG group or a usual care group.

A statistical analysis was conducted using a χ

2

test to provide P values and to evaluate differences between the study groups.

SSI

Home CHG = 0%

Usual Care =1.6% p=0.231


Implications for Practice

Surgical site infections or peri-prosthesis infections are preventable events. Healthcare professionals should follow evidence-based practices to prevent these events from occurring.


Key Limitations

  • The two cohorts were unevenly divided
  • External validity/bias; as the study was performed at the authors institution.

Kapadia, et al., (2016)

Randomized controlled trial; Level 2

554 lower extremity total joint arthroplasty patients

CHG (n=275)

Soap & Water (n=279)

Independent Variables:

  • 2% CHG preoperative cloth bath
  • standard soap & water bath

Dependent Variables:

  • Incidences of periprosthetic infection/SSI post-surgery

Patients were enrolled between March 1, 2012 and November 30, 2012 who were preparing to undergo a joint arthroplasty. Patients were randomly put into two cohorts; the patients received an advance preadmission CHG bath or standard-of-care bath (soap bathing). Specific instructions were given to each cohort. The aim of this study was to evaluate periprosthetic infection risk at 1-year follow-up between the 2 cohorts.

Fisher’s exact tests and independent samples’ t- tests were used to compare baseline and outcome variables between patients in the cohorts.

SSI

CHG = 0.4%

Soap & Water= 2.9%

p=0.049


Implications for Practice

Surgical site infections or peri-prosthesis infections are preventable events. Healthcare professionals should follow evidence-based practices to prevent these events from occurring.


Key Limitations

  • Small sample size
  • Compliance issues with the chlorhexidine protocol
  • Following up/surveillance


Murray,

et al., (2011)

Randomized controlled trial; Level 2

100 shoulder surgical patients

CHG (n=50)

Soap & Water (n=50).

Independent variables:

  • 2% chlorhexidine gluconate impregnated cloth bath.
  • Soap/water shower

Dependent Variables:

  • Incidence of SSIs
  • Bacterial load

Patients divided into 2 cohorts. The study compared the incidences of SSIs and bacterial load at the surgical site after standard soap and water bath vs CHG bath preoperatively

Participants were monitored for possible development of infection for a 2-month period after their operation.

Quantitative bacterial cultures positive for bacterial growth were analyzed for the bacterial load. Clinical characteristics were compared between groups using the Wilcoxon rank sum test for age; the Fisher exact test for other dichotomous variables. Posterior and axilla qualitative measures were each compared between the CHG cohort and the standard soap-and-water cohort using the Fisher exact test.

Positive Cultures

CHG = 66%

Soap/Water= 94%

p = 0.0008


Implications for Practice

Surgical site infections are preventable events. Healthcare professionals should follow evidence-based practices to prevent these events from occurring.


Key Limitations

  • Limited sample size
  • Follow up with patients’ post-operation.
  • Limited evidence on surgical site infection rates.
  • Possible bias; the manufacturer of the 2% CHG impregnated cloths provided the funding for this study.

Swan, et al., (2016)

Randomized controlled trial; Level 2

325 surgical ICU patients

CHG (n=161)

Soap & water (n=164)

Independent Variables:

  • 2% CHG bath
  • standard soap & water bath

Dependent Variables:

  • Incidences of hospital acquired infections (HAI) post-surgery.
  • 2% CHG bath
  • Standard soap & water bath

Cox regression analysis, chi-square tests, t-tests, Poisson regression

The results indicated a statistically significant overall reduction of risk for a HAI.

CI 0.309-0.997

P=.049


Implications for Practice

Healthcare acquired infections (HAIs) are preventable events. Healthcare professionals should follow evidence-based practices to prevent these events from occurring.


Key Limitations

  • 2 of the clinicians involved in the study provided direct care.
  • Nonstandardized surveillance could lead to bias.
  • Potential bias due to compliance issues regarding disposing wash basins.

*CHG; chlorhexidine*

*NSQIP; National Surgical Quality Improvement Program*