Utilising Evidence Based Care- Hand Hygiene

The author chose hand hygiene due to its frequency of use and importance in nursing practice. An intensive care nurse can wash their hands up to 40 times an hour. The aim of hand hygiene is to decrease the transient flora, and ideally the technique should be quick to perform, reduce skin contamination effectively and does not cause skin irritation (Hugonnet and Pittet, 2000). Hand hygiene can be conducted by either the use of hand washing with un-medicated detergent and water or hand disinfecting using an alcohol solution (Rotter, 1999). I have chosen hand hygiene and student compliance as the basis of my search and this essay because I feel this is relevant to my experience as a student as well as to my practice as a qualified nurse. Researching articles on this subject interests the author because it provides up to date and relevant evidence to support current and future practice as well as influence the behaviour of my colleagues. This subsequently affects the quality of care that service users receive, whatever clinical setting the author is working in. Health care professionals acquire pathogens on their hands from patient contact, and may transmit them to other patients if hand hygiene guidelines and recommendations are not followed. Studies have shown that compliance with hand hygiene rarely exceeds fifty percent (Pittet, 2000). Hand hygiene is considered the most important measure for preventing nosocomial infections (Picheansathian, 2004). A nosocomial infection is defined as an infection that is evident but previous to admission was not present or incubating (Mayone-Ziomek, 1998).

The Nursing and Midwifery Council’s code of professional conduct clearly states that care and patient advice must be “based on the best available evidence” (NMC, p. 4). Keeping the skills and knowledge base up to date will require utilising the most current and relevant research. As a registered professional under the code of professional conduct by the NMC a nurse has the responsibility to deliver care based on current evidence. The United Kingdom National Health Service has experienced various policy changes highlighting the need and encouraging the use of relevant evidence into the practice of all registered health care professionals. This move towards evidence-based practice is a move away from care or treatment based on a knowledge base. Evidence based practice is considered the combination of evidence from research, with clinical expertise and patient values to provide effective care (Sackett et al., 1997). The Department of Health argues that it is no longer acceptable for healthcare professionals to base care on tradition. They must be able to justify the decisions they have made using professional expertise which clearly includes using relevant and up to date evidence to inform practice.

A Nursing Times supplement that gives further insight into what is expected and recognises that there may not always be a current and/or relevant piece of literature available and instead alternative sources may need to be utilised (Kirkland, et al., 2008). Not all evidence is judged to be of equal value. A number of hierarchies of evidence have been developed to enable different research methods to be ranked according to the validity of their findings. The hierarchies only provide a guide to the strength of the evidence and other issues such as the quality of research also have an important influence. Evans (2006) proposed a hierarchy that is specific to healthcare, particularly because when the evaluation process of healthcare studies considers the appropriateness or relevance; existing hierarchies are inadequate (Evans, 2006).

During my searches I accessed several electronic sources. I used the search engine google as well as directly searching appropriate web sites such as the National Institute of Clinical Excellence, British Medical Journal and Royal College of Nurses.

The primary research I found was a quantitative study titled ‘Efficacy of hand rubbing with alcohol based solution versus standard hand washing with antiseptic soap: randomised clinical trial’ and it was conducted by Girou et al (2002). The aim of the study was to compare the efficacy of hand rubbing with an alcohol based solution with hand washing with antiseptic soap in reducing contamination of hands during patient contact. The trial was based in three French intensive care units and 23 health care workers volunteered to take part. The randomised participants performed 114 patient care activities. All participants were previously educated in the use of the alcohol based solution. When the need for hand hygiene arose, an imprint of finger tips and the palm of the dominant hand were taken, before and one minute after. Each finger tip and palm was imprinted on a commercial contact agar plate. In both groups the counts of bacteria were significantly reduced after hand hygiene, but the hand rubbing with the alcohol solution was more effective than hand washing.

The motivation of the quantitative study can be question due to the trial being funded by the company that provided the alcohol solution, Bode SA, Hamburg Germany. As to whether this had any implications to the results we can only question. The company who produce the alcohol solution have obvious financial incentives. The sample size is not particularly large, but also the findings are not externally valid. The findings apply particularly to an intensive care setting. Care in intensive care units is very different to that of various other wards as it is one to one whereas nurses on other wards may have contact with a number of other patients. This limits the extent to which the findings can be generalised to other clinical settings; but also the study is culturally bound. How French and British nursing practices vary must be considered if I was to attempt to apply the evidence into practice. In studies such as this when the participants are educated and are aware of the investigators intention the Hawthorne Effect may be present. The Hawthorne effect relates to an increase in worker productivity produced by the psychological stimulus of being singled out and made to feel important (Holden, 2001). In relation to Girou et al’s (2002) research it was not possible to blind nursing staff to the conduction of the study so the Hawthorn effect may contribute to outcomes of the study.

Nurses may have had their own beliefs or perceptions as to how they should be performing the clinical task of hand hygiene. The technique to record the growth of bacteria by only sampled the palm and finger tips will not provide information about contamination of the other parts to the hand. Ayliffe et al (1992) suggests that between the fingers and the finger nail area are the most frequently missed during hand washing and these areas were not monitored using the technique employed in this study. The more accurate technique was recognised in the studies report but claimed that this technique was more time consuming and it could not be implemented without an unethical breach on delivery of care. This study has vast amounts of current and relevant evidence to support the findings it has produced. Evidence produced using randomised controlled trial is considered the second most valuable evidence according to the hierarchy of evidence.

The secondary research piece chosen is titled ‘A systematic review on the effectiveness of alcohol based solutions for hand hygiene’ and was conducted by Picheansathian (2004). Articles and studies published from January 1992 till April 2002, in English and Thai, which related to the use of alcohol solution, were assessed. There were 41 articles selected that all explored various usages of alcohol solutions. The study results were pooled in statistical Meta analysis. This systematic review supported the use of alcohol solutions for a number of reasons; Alcohol solutions removed more micro organisms more effectively required less time and irritated the hands less than hand washing with other various solutions. Also studies showed that increased availability of alcohol solutions improved compliance by health care professionals, it is easier to increase the number of alcohol solutions availably than increase the number of sinks.

The studies were divided into groups as some of the research aims varied. Nearly all studies favoured the use of alcohol solutions. This review recognises that there are a number of factors that may indicate the use of alcohol solutions. Of the 58 studies retrieved from the search process on 41 were considered appropriate for the review. It is suggested that the 17 excluded articles, were so because they were either an expert opinions or they lacked sufficient details surrounding the findings. This would be an opportunity for the investigator to dismiss articles that go against the hypothesis of the review. The quantity of studies is sufficient enough to contribute to the validity of the findings. However, as to what kind of care setting the 41 articles refer to is unknown. This can bring into question whether the findings can be appropriately generalised to all nursing contexts from community nursing to intensive care and ward nursing.

The articles reviewed were from both English and Thai nursing settings; and these two cultures vary greatly and if nursing staff were to apply these findings to practice, consideration must be made as to ways the two cultures differ in a nursing context. So application of the findings can be questions. But I am confident these findings are applicable to my future practice settings. All the articles under review by Picheansathian (2004) are quite recently published, 1992-2002. However some are over ten years old, but all are of a satisfactory quality. This article is a systematic review, this brings with it increased value according to the hierarchy of evidence.

There are a number of factors that influence non compliance with evidence based practice, particularly surrounding hand hygiene. For example, culture, values, beliefs, tradition. Doctors tend to be worst at compliance with hand hygiene policy (Suchitra and Lakshmidevi, 2006). This tends to be due to tradition. Doctor’s practice has previously not been questioned by anyone other than between Doctors themselves. Still it remains that they are rarely instructed by fellow staff of their poor practice. This may be due to their medical expertise deterring staff of a perceived lower hierarchal status confronting them.

Despite the call from the Department of Health and the Nursing and Midwifery Council for nurses to utilise evidence based practice it is not uncommon for the findings of latest research not to be implemented. Barrett and Randle identifies that even though students can receive and be armed with the latest evidence “professional socialisation” (Barrett & Randle, 2008, p. 1855) leads them to adopt the culture of their placement and to emulate their mentors. Hannes et al identified several themes but amongst them was “fear the negative comments of others” (Hannes et al, 2007, p. 166). A further study identified a feeling of time constraints as a barrier to implementing new practices and utilising the latest evidence, additionally this also made the nurses feel they didnt have time to keep up to date with current developments (Retsas & Nolan, 1999). Also when nurses did have the time to investigate the latest ideas and developments the quantity of new research is seen as overwhelming with many nurses feeling inadequately capable of evaluating, critiquing and identifying relevant evidence and research (Retsas & Nolan, 1999).

The feeling of being overwhelmed by the amount of research and evidence available is seen by Glasziou & Haynes (2005) as expected when there is so much information at hand. Identifying what is made even more difficult by advertising and biased research. Davis et al (2003) instead present continuing medical education, continuing professional development and knowledge translation as pathways for utilising evidence based practice. Continuing medical education and continuing or professional development are argued to have limited effects on changing practice (Davis, et al., 2003). Knowledge translation builds on these increasing the knowledge and skill base, once this is done then the practice environment is made conducive to the new skill base and the new changes are reinforced and reviewed (Davis, et al., 2003). The changing of the practive environment to encourage the development of evidence based practice could be useful in reducing the effects of Barrett & Randle’s (2008) professional socialisation and also support those who feel they lack the authority to implement change as seen in the Retsas & Nolan (1999) study. This encouragement to implement would also appear to be supported by Glasziou & Haynes who identify that even when there is recognition, awareness and willingness to change, “habits do not change easily, despite our best intentions” (Glasziou & Haynes, 2005, p. 38)

The NHS work force is diverse and is made up of many nationalities and cultures. The validity of research must be questioned in its application to other cultures to the culture the research was conducted. Ahmed (2002) highlighted this in his article which explained that some, not all, Muslims could not use the alcohol based solutions as the Islamic Doctrine describes alcohol as ‘Haram’ Forbidden in the Koran. Some Muslims fear the potential inhalation of fumes and systemic dermal diffusion of the alcohol solution (Ahmed, 2002). There has been no definitive research in to the likelihood of this, Muslims concerned by this may be exempt from new policy surrounding the implementation of alcohol solution; but suitable alternatives must be considered.

According to the NMC a registered nurse it is your duty to facilitate students and help them develop and your responsibility to deliver care based on up to date evidence and when possible to ‘validate research’. Once a qualified nurse, it will be my duty to wash my hands using the most up to date evidence at the time. This can be done by consulting infection control guidelines, it will also be my duty to ensure that other member of staff and students abide by most recent policy and guidelines, if not, then actions must be taken to educate them. In practice I have recognised the importance of alcohol solutions and most obviously the reduction in time spent decontaminating hands. It is unrealistic to expect busy professional to spend 17% of the valuable time at a sink (Voss & Widmer, 1997).

The importance of hand hygiene cannot be ignored. There is much evidence to support the need to decontaminate hands before and after patient contact; and as a result reducing the rate of nosocomial infections. The evidence obtained from the research articles I discussed would both support the use of an alcohol solution to decontaminate hands. Even traditionally nurses understand the implications of not washing their hands but they need to be aware of the use of more effective means of maintaining hand hygiene in nursing practice. The National Patient Safety Agency’s ‘clean your hands’ campaign has been implemented in the North Bristol Trust. This action seems to be addressing the issue surrounding availability. Alcohol solution dispensers are now available at every bedside, entrance to all wards and clinical areas, on all notes and drugs trolley and in clinical rooms. These interventions are vital in the reduction of nosocomial infections.

It is important for healthcare professionals to be aware that evidence is not ‘proof’ (Van Zelm, 2006). Much thought must take place to implement research. Duffin (2004) explains that solely placing alcohol dispensers at patient bedsides will not improve hand hygiene. Health care professionals need to be educated in their use and the importance of their use. Evidence based practice is a form of decision making. If a healthcare professional was to implement evidence without critically considering the validity of the research, it would be considered dangerous practice and not truly evidence based (Van Zelm, 2006). Evidence generally seems to support the use of alcohol solutions. The use of alcohol rub reduces time spent undertaking performance of hand washing. Previous to the use of waterless alcohol solutions nurses that would comply 100% to hand washing with soap would spend up to 17% of their time doing the task; whereas with the use of alcohol solution, this is reduced to less than 3% (Voss & Widmer, 1997).

In conclusion there is a vast amount of research and new ideas available at the moment. Evidence is being produced regulalry and it can be difficult to stay up to date (Hannes et al, 2007). Additionally we are expected to obtain informed consent and where this is not possible act in the best interests of the patient (Nursing and Midwifery Council). Informed consent means providing the patient with all the information they need to make a decision, as practices and treatments change we need to stay informed so that the information we give to patients is correct and current. Additionally we are called upon to share information with colleagues as well as to work effectively within the team (Nursing and Midwifery Council). A willingness to share current evidence based practice helps to keep colleagues informed and up to date and ensure te increased effectiveness of the nursing teams. Staying informed and up to date with current evidence and research not only ensures patients receive the best possible care but make the role of a nurse easier at a time when the NHS is under going many changes and the lines between different professions become more and more blurred.

Bibliography

Ahmed, Q.C. (2006) Muslim Healthcare workers and Alcohol Based Hand Rubs. The Lancet, Vol. 367, Pgs. 1025-1027

Ayliffe, G. A., Lowbury, E.J., Geddes, A. M. and Williams, J.D. (1992) Control of Hospital Infection- A practical Hand book. 3rd Edition. London: Chapham and Hall Medical

Barrett, R., & Randle, J. (2008). Hand hygiene practices: nursing students’ perceptions. Journal of Clinical Nursing , 17, 1851-1857.

Davis, D., Evans, M., Jadad, A., Perrier, L., Rath, D., Ryan, D., et al. (2003). The case for knowledge translation: shortening the journey from evidence to effect. British Medical Journal , 327, 33-35.

Department of Health. (2000). Towards a strategy for nursing research and development. London: The Stationery Office.

Duffin, C. (2004) Educate nurses to use gel say experts. Nursing Standards, Vol. 18(52), Pg. 4.

Evans, D. (2003) Hierarchy of evidence: A framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, Vol. 12, pgs. 77-84.

Girou, E., Loyeau, S., Legrand, P., Oppein, F. and Brun-Buisson, C. (2002) Efficacy of hand rubbing with alcohol based solution versus standard hand washing with antiseptic soap: randomised clinical trial. BMJ, Vol 325

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In the era of introduction of programs that evaluate the risk involved in managing of disease by analyzing the risks involved through the thorough examination of clinical data collected by the help of general practitioners, pharmacies and major hospital records

As such programs have scaled to a lager extent with still a lot of scope, it has become critically essential to justify their returns. It is no longer sufficient to defend a program based on an illustrated ROI. Insurers are spectacle about which members are being identified and how, what interventions can be applied to them most effectively, and which mechanism leads to genuine behaviour change and savings [1].

This points to the fact that the insurers and program developers are just becoming smarter about the economic pay back and optimization of the disease management programs hence resulting in the sudden demand and increase in data procurement These data requirements will only increase in the future for optimization of disease management efforts. This will require intensive risk profiling, predictive modelling and stratification on the part of all who are involved in program design and execution [2].

WHAT IS RISK STRATIFICATION?

Exact definitions of risk stratification in theoretical terms are given below,

“The constellation of activities (e.g. Lab and clinical testing) used to determine a person’s risk for suffering a particular condition and need for preventive intervention.”(McGraw-Hill Concise Dictionary of Modern Medicine)

OR

“The method of delimiting sub-populations within a cohort which have different risks of a particular outcome, based upon severity of illness and co-morbidity.”(Society for Cardiothoracic Surgery in Great Britain and Ireland)

Let us acquaint ourselves with the basic terms related to Risk Stratification.

RISK:

The term risk in preoperative context include the chances of an adverse medical outcome like persistence, recurrence of the medical condition finally leading to ultimate reduction in the survival rate of the patient.

RISK ASSESMENT:

The evaluation of the clinical data collected at hospitals, GP’S, and pharmacies can be used to derive the probability of a medical risk occurring. The evaluation of this information made available through various procurement techniques. This assessment may help in identifying the level of risk, the treatment to be administered and chances of survival of the particular member.

Risk assessment helps determine the probable patients that may require immediate or future surgeries (i.e. operable patients), who would need multimodality therapy and who may require treatment under the practitioners watchful eye.

The stratification of patients divides the probable risks as low risk score which lies between 21 to 100% ,moderately relative risk that lies between 6 to 20 % and high risk between 0.5 to 5% score anything lying below a probable 0.5% lies under the high risk radar leading to a surety that the patient would require future medical care.

Figure 1 Risk Score Model

NEED OF RISK STRATIFICATION

Risk stratification provides a thorough examination of the risk of future hospital admission varying across a population where the health and social care can be intervened to patients.

Who may require it the most

Who may benefit from it the most

Hence encouraging and providing proactive healthcare to the emergencies and also support delivery of efficient service.

HOW DOES RISK STRATIFYING WORK?

Three approaches are commonly used for risk stratification:

Accurate stratification of the risk involved with the patient is a key component in health care assessment of the procedural outcomes .An increasing no of health care organizations are getting dependent on the health care assessment through such programs as a means for assistance in making patient risk-stratification decisions. The only difficulty persist that the process of outcome model development is both time consuming and difficult due to the preliminary stage.

Many techniques can be used for medical assessment of risk like modelling techniques (logistic regression, artificial neural network (ANN), and Bayesian) to rapidly develop models for risk stratifying patients. The only difference is their method of analysis. The problem pertains that none of the technique give accurate results or are or hundred percent dependable.

Threshold Analysis where a set of criteria are defined describe ‘high risk’ patients alone.

Thresholds are target based research technique based on evidence that provides numerical targets for healthy development. Targets are derived by careful evaluation of the given literature on account of the case studies agree on a particular phenomenon. Various different sub populations like

Children who are vulnerable in health conditions.

Heart patients who suffer the risk of sudden casualty and medical attention.

Diabetic patients.

Cancer patients so on.

Various such evaluations are being conducted by evaluation of patient data for all above sub populations.

Associations are conditions should be fulfilled, through a careful evaluation of the existing research literature. A committee may be formed to agree on the nature and direction of the conditions, the particular phenomena may not lend it well to the numerical thresholds precisely.

Clinical knowledge where practitioners based on their knowledge, experience and training identifies individuals who may in future prove to be ‘high risk’; and their current status. Patients keep visiting hospital and their general practitioners for pre and post operative care have their records maintained with health professional which may in the future be evaluated and help in the finding out the hospitalization risk and mortality risk of patients.

Predictive modelling the historic data made available through varying sources is used to evaluate and create an association between the patient’s current health condition and the likelihood o the patient to become a high risk in the future.

PREDICTIVE RISK STRATIFICATION (PRISM)

Predictive modelling

Is a process used in predictive analytics to create a statistical model of future behaviour? Predictive analytics is the area of data mining concerned with forecasting probabilities and trends.

[Definition from http://searchdatamanagement.techtarget.com/definition/predictive-modeling]

Predictors

A predictive model consist number of predictors that are variable factors which may tend to influence future behaviour or results. For example the age of a heart patient plays a potent role in the outcome of analysis.

In predictive modelling, data is accumulated for a relevant set of predictors, a statistical model is formulated, and on the basis of the available data predications are validated. The model may be based on a simple liner equation or may be formulated using a highly complicated neural network lattice.

Risk Stratification Tools

Risk stratification models can assist clinicians in making decisions on the subject of the need for additional testing once a preliminary clinical estimate has been performed. The American Society of Anaesthesiologists (ASA) categorization of Physical Status was the first clinical manifestation developed to forecast risk. Introduced in 1941, it was remodelled to its current form in 1962 [4]. Patients are categorized into one of 5 major classes based upon the presence and manifestations of affiliated medical disorders and whether emergency surgery is required. The utility of this index is limited by intra viewer inconsistency in rating and variations in the predictive power for postoperative hitches.

Demand of Predictive Modelling in Health Care:

A process when applied to available data identifies a person having high medical need and are “at risk” for the medical attention.

The concept is in demand for several reasons:

Most plans are saturated in data and want to use them to increase the efficiency and effective application of medical care.

In this time of severe medical inflation, it’s understandable that we focus on very high cost persons.

Case management and disease management (DM) programs are everywhere. Predictive Modelling could increase the reliability for returns of these programs.

Vendors and consultants have created a steering demand for Predictive Modelling Which is highly dependent on the marketing and scientific back grounds.

Predictive Modelling for Risk Measurement

Predictive modelling is part of a larger risk assessment and adjustment scale.

Risk factors, outcome measures, and estimation period to be related.

Predictive Modelling requires a more complex statistical engines Prediction/forecasting in medicine and healthcare is not new. Today the new reason for predictive modelling introduction is high risk case identification.

Figure 2 Stages of Prevention

Disease Stage, Prevention, and The Care Management Process are correlated in a way where at an initial stage the patient visits a GP based on early symptoms or distress at this stage the practitioner accesses the patients treatment needs or suggest certain tests t the patient. At the next stage where after evaluation of the disease the future predication is made on the need of hospitalization and hence the population is sorted into the sects required. On encountering a major disease where reoccurrence of disease or mortality is a condition a set of principles for disease management in performed by the practitioners if hospitalization is required an operative need arises case management under hospital administration is the final stage which may lead to either complete treatment of the high risk patient or mortality, complication or reoccurrence.

THUS THE NEED OF PREDICTIVE MODELLING ARISES WHEN

There is a need to identify persons for admission in intensive case-management program.

To more effectively target disease management programs and focus on providing medical attention to the persons who are in need of attention.

To provide properly calculated risk information useful in making financial decisions and budget management.

To provide information to clinicians that may prove useful for quality improvement of patient standards.

To identify the need for educational campaigns and camps for better clinical outreach programs.

STEPS IN IMPLEMENTING OF PREDICATIVE MODEL

Data Requirement

Various types of factual data like administrative records, increase and disease in records or encounter of rare or recurrent cases. The various means of data collection is through GP records, in house and out house patient records, emergency and accident case histories and so on. This phase may also be called initialization or pre processing stage.

Data warehousing or creation of a repository

The data collected over a fixed period of time of a similar format represents a warehouse. This data is collected through reliable sources. This warehouse data is subject to analysis as a processed input this marks the beginning of the stratification process.

Statistical analysis

The most important phase is to create a statistical engine with regressive research, setting conditions and associations there which the outcome is dependent. This marks the start of stratification of risked based on a scaring system that is predetermined by various conditional studies before product release.

Reporting

Reporting the outcome in systematically and targeting the treatments cause and financial management. This out generated report represents the final outcome where the scores given to people mark the risk of re admissions in the future or casualties.

Care management and intervention in treatment

Intervening the ongoing treatments and healthcare routines determined by the resultant outcome .Relying on the systems output report the treatment may be altered to prevent the risk predicted.

Patients treatment feedback:

Filing and assessing patient feedbacks and managing of surveys to measure the pros n cons of the analytical system and where the model stands and the future enhancement required.

4. THE PRISM TOOL

PRISM is a probabilistic model inspection tool. Probabilistic model checking is an automatic formal veri¬cation technique for the analysis of systems which exhibit stochastic behaviour.

THE MODEL OF PREDICTIVE RISK STRATIFICATION TOOL (PRISM)

Figure 3 Working of Stratification Model

PRISM model specification

PRISM has direct support for three types of probabilistic models: discrete-time Markov chains (DTMCs), Markov decision processes (MDPs) and continuoustime Markov chains (CTMCs. They are suitable for analysing systems with simple probabilistic behaviour and no concurrency[5].

e.g. synchronous randomised distributed algorithms.

PRISM caculates by performing a series of permutations and combination of nondeterminism and probability, building them to suite modelling multiple probabilistic processes executing in parallel. In some cases where parameters of the system or environmental the behaviour in which it is operating are unknown e.g. component failures and job arrivals[5].

PRISM can also be improved with costs and rewards, real values that manipulate the states and transitions of the model. Thus the reasoning capability off the model is exceeded to atrributes like “completion time”, “energy consumption” or “number of messages lost”.

Models are specified using the PRISM modelling language for the Reactive Modules formalism based on state change. Systems are described modules arranged parallely for processing. Each module’s state is controlled by the assigned probabilistic guarded commands. The language also supports various process algebraic operations with means of global variables and synchronisation. See the PRISM documentation and example repository at [6] for more information.

RESULTANT REPORT

Figure 4 Example to Illustrate the Report of Risk Stratification

4.1 USING PRISM TO STRENGTHEN AND EVALUATE HEALTH INFORMATION SYSTEMS

The PRISM framework identifies strengths and weaknesses in RHIS performance bridging the gaps hence found, leading to the enhancement of health system performance. Routine health information systems (RHIS) try record and present quality information about the health sector organizations. This information is then used as a guide to day-to-day treatments, track routine, rectifying the past results, and hence increasing the accountability.

But the information available in such cases falls short the ideal requirements to produce high quality systems, data quality may be low, intermediate processes of data other may not exist, or managers and staff may have limited knowledge regarding information utility and use of systems, incentives to give attention to the management of information system processes may be few. Looking narrowly at technical issues such as data collection forms we understand the difficulties associated with improving the RHIS systems through PRISM.

PROSPECTS ON CANCER MANAGEMENT

Refined ways to identify and employ multiple, often aggressive, therapies to achieve maximal cancer control its essential to help high-risk patient. Clinician can also give these patients the option to enrol in clinical trials that offer novel therapies. Categorization of patients into established and consistent risk categories is also of key importance in making comparisons between patients in clinical databases.

Sophisticated analytical instruments incorporate risk grouping of similar preoperative clinic pathologic parameters like pre-treatment serum PSA, biopsy score and capacity parameters, and medical tumour stage. Stirring research in the characterization of prostate cancer may one day provide more accurate and individual-specific risk assessment.

First introduced in 1966, Gleason score was introduced to evaluate prostate cancer. In many multivariate cases, the Gleason score proves to be an independent predictor of both pathologic tumours stage and time to biochemical recurrence. Gleason grade may be the most powerful preoperative prognostic factor.

Gleason score as:

• 6 or less as low-risk

• 7 as intermediate-risk

• 8 or above as high-risk

Also, Gleason 7 tumour can be sub classified into either 3+4 or 4+3, depending on which grade is most prevailing in the scores. This category of Gleason score classification and sub classification predicts postoperative outcomes. But the cancer tumour may increase or decrease based on treatment accepted by the recipient it’s a limitation of biopsy Gleason score as a predictor of outcome, its poor correlation with pathologic Gleason score of the surgical specimen Gleason score but still proves to be a good estimator of post operative outcome.

PROSPECT IN CARDIAC ARREST

Preoperative risk scores are a vital tool for risk evaluation, cost-benefit analysis, and preface of new trends. A series of score systems have been developed to predict mortality after performing an adult heart surgery these score systems are based on patient derived data, such as age, gender, and so forth, but there are considerable differences between scores with regard to their design and validity for heart surgery with regard to their predictive values and clinical applicability for our patient population.

Although most of the particular score systems were first and foremost designed to predict mortality, postoperative morbidity has been acknowledged as the major determinant of hospital cost and quality of life after surgery. Therefore, we analyzed the selected risk scores not only with regard to their predictive value for mortality, but for postoperative morbidity as well.

The entire population was then characterized into groups of vague probability of risk of major complications as follows: estimated probability of major cardiac complication <5%, low risk; 5.1% to 25%, medium risk; >25%, high risk. These three sub groups were chosen to provide large enough groups for adequate statistical comparison.

PROSPECT IN DIABETIC HEALTHCARE

Diabetes may be present for up to 7 years before diagnosis early diagnosis, lifestyle modification, and tight glycemic control are necessary to reduce complications; however, these cannot occur if diabetes remains undiagnosed. There is insufficient evidence for or against routine diabetes screening. Reason being the burden and inconvenience caused by fasting visits to meet the diagnostic centres. Diabetes is usually diagnosed by fasting plasma glucose, values which require confirmation on a second visit [7].

Opportunistic programme for high-risk individuals during unscheduled outpatient, urgent care, or hospital visits may improve rates of diagnosis. From the household interview data, we analyzed information on self-reported age, sex, race/ethnicity, education, and income. While providers may choose to use different tools for risk stratification, the principle of deriving a low (<0.5%), moderate (4% to 5%) and high pre-test probability (>10%) could remain similar.[8] Prior reports of diabetes screening in community and clinical venues have yielded mixed results, often limited by low prevalence rates and poor follow-up. Similar to any disease screening, patient adherence with confirmatory testing and subsequent therapy is vital to the successful implementation. Additionally, the cost-effectiveness of opportunistic diabetes screening is unclear and will require further investigation. The proposed algorithm of risk stratification relied on practical reasoning and interpretation of the data; others may suggest thresholds corresponding to different predictive values, and cost effectiveness analysis would further clarify optimal thresholds for clinical practice. Finally, this analysis provides a proposed algorithm, which, if validated, can serve as a guideline for providers, but should not substitute for sound clinical judgment for individual patients.

THE COST ASSOCIATION

Management of the institutes where stratification of health care has been implemented or tested argue the value of disease management programs from a conceptual angle however, most have a difficult time correlating dollars and cents to that value from its practical view point.

As disease management programs have started maturing in size and capacity there exceeds an importance in the task of justifying their expense by demonstrating financial. It is no longer sufficient to defend a program based on an illustrated ROI. Insurers and investors seek in turn the factual relevance, about which members are being identified, the hence taken interventions that can possibly be applied to them with most effectiveness, and which approach leads to genuine performance change and savings. These requirements for data will only amplify in the future, which will lead to insurers and program architects gaining additional concern about economic optimization of disease management efforts. Intensive risk profiling, predictive modelling and stratification will be hence compulsory requirements on the part of all who are involved in program design and execution. [2]

Intervening early reduces costs

Typical high-cost, high-risk disease management program has been administered by a insurer. Members are at high risk because their care is high cost and because they meet definite clinical triggers. Managing these members at the disease stage which may be a non recoverable during this insurer intervenes is largely palliative. In addition, insurer identification methods typically result in a relatively large number of members being referred for management by costly clinical resources.[2]

A more efficient program would identify high-risk members’ earlier prompting intervention with those whose behavior can be changed using risk profiling, prediction and economic modeling for the same.

Summary

As quality control and cost-benefit analysis have gained new relevance with recent developments in the health care system, selection of appropriate score systems for the evaluation of hospital performance has become an important issue to predict and estimate risk scores to predict future admissions and causalities and to ensure health care quality.

Risk stratification is a statistical process by which quality of care can be assessed independently. Evaluation of risk-adjusted patient outcome has become an imperative component of managed care constricting in some markets, and risk-adjusted result rates for hospitals are being reported more frequently in the popular press and on the internet.

The process of risk stratification does not require or assume an extensive arithmetical background. A description of the assumptions for risk stratification provides the quality of various published risk-stratification studies information on evaluation of health care. Numerous practical examples using authentic clinical data help to illustrate risk stratification in health care.

Risk stratification and predictive modelling applications are used in a variety of disease state classification systems derived using claims data. Algorithms based only on pharmacy claims have the recompense of timeliness, hygiene, and accessibility, while still being robust and efficient in the prediction of prospective healthcare outcomes and the costs relative to their incorporated therapeutic and pharmacy counterparts.

The author will discuss in this essay the standards of evidence based practice. It will also be discussed the different levels of evidence. The author will also discuss the different processes of research including qualitative, quantitative, meta-analysis and randomised controlled trials. The author has looked at a wide range of evidence to back up this essay. The author has also looked at dissemination and barriers that prevent this. The author will also critique two articles to identify the different types of research used and the evidence provided.

First of all the author will primarily briefly discuss the principles of research evidence based practice and will then inform the reader of the types of research available. Sackett et al (1996) as cited by Gerish (2006, pg 492) defined research evidence based practice as ‘the conscientious, explicit and judicious use of current based evidence in making decisions about the care of individual clients. The practice of evidence based medicine means integrating individual clinical experience with the best available external clinical evidence from the systematic research’ (Sackett et all 1996). Parahoo (2006) states that research evidence based practice is important in clinical practice to inform up to date interventions and effective decisions. Dissemination of the best available evidence is useful to improve clinical guidelines and service user autonomy as information technology has increased providing the public with greater access to knowledge which can encourage informed choices for service user’s in health care. Types of research are widely known as quantitative, qualitative or mixed methods of both. According to Burns and Grove (2007) quantitative research is defined as a ‘formal, objective, systematic process used to describe variables, test relationships between them and examine cause and effect interactions among variables’ (Burns and Grove 2007 p 551). This type of research primarily deals with statistics and aims to measure relationships between variables; this approach is researched by data collection using questionnaires and structured interviews. Structured questionnaires are usually used incorporating mainly closed questions such as questions with set responses. Qualitative research according to Burns and Grove (2007) is defined as ‘a systematic, subjective methodological approach used to describe life experiences and give them meaning’ (Burns and Grove 2007 p 551). Qualitative research findings are presented in numbers or statistics to answer the research question. Randomised control trials aim to evaluate the effectiveness of interventions in nursing (Centre for Reviews and Dissemination, 2001). This type of research is considered gold standard for nursing implementation of research that is quantitative in evaluation. Both quantitative and qualitative have pros and cons but would work well together. Qualitative research aims to understand human experience that promotes understanding of social phenomena. The qualitative researcher is interactive within the study in order to get close to personal experience. The researcher uses interviews, observations and scales to gain evidence for the research findings. Mixed methods combine quantitative and qualitative research. There has been many debates about this although within nursing mixed methods provide valid, reliable evidence and reflect service users experiences. This is important to consider for implementation of interventions.

Health care research and the need for evidence based practice have become evident and more advanced for professionals in practice. Different codes of practice have now highlighted the identification and application in health care and why it is important. Opinions of experts including traditions can no longer be legally or clinically justifiable in evidence based practice (Rice 2008 p 181). It is important to all professionals including service users and carers that the efficient and effective up to date treatments be used in their care. It is important that evidence is there to prove this is the case by basing decisions on clinical decision making guided by research, science and evidence. This is a move away from past practice being based on opinions and the way it has always been done. It has now moved towards clinical decision making (Appleby 1996). Sackett et al (1996) states that ‘without clinical expertise, practice risks becoming, tyrannized by evidence but without best available evidence, practice risks becoming rapidly out of date’ (page 312).

In the research process there are different types and levels of evidence used. There are also different ways to correlate the findings from different studies to produce evidence. These are mostly systematic reviews, literature reviews and meta-analysis. A literature review is an objective, thorough summary with critical analysis of the relevant available research and non research literature on the topic being studied (Hart 1998). This reviews the methods and theories around particular studies (Burns and Grove 2007 p 509). A systematic review summarise available literature on a precise topic both systematic and literature reviews summarise available literature on specific topics. Systematic reviews provide a full list which is carried out of published and unpublished studies available on a particular subject (Cronin et al 2008). The aim of this is to summarise the evidence of a particular problem or topic. This is beneficial for professionals as it demonstrates the effects of treatment methods, interventions or a variety of different measures (www.sos.se/socialtj/cus/cuse/Definite/defkunse.htm).

For results to be compared in a methodical manner, meta-analysis has been known to be used. Egger et al (1997) had described this as statistical procedure integrated in the results of several studies completed independently which is considered to be ‘combinable’. To come to the conclusion, gathering the data from numerous studies is essential for the outcome. In order to come to conclusions and identify patterns and relationships between findings methods of research and analysis are used (Polit and Beck, 2006). This has often produced a balanced result. Melnyk (2004) disputes that systematic reviews and meta-analysis of randomised controlled trials and evidence based practice are considered to be very strong levels of evidence in which to guide practice based decisions.

Dissemination of research is very important to inform the public of new evidence which may have an impact on the effectiveness in the care and treatment of clients. A study was conducted at Edinburgh University, Crosswaite and Curtice (1994) said that ‘dissemination is about the communication of innovation, this being either a planned and systematic process or a passive, unplanned diffusion process’ (page 289). Although there is an extensive awareness of how important dissemination of research is, active implementation of research into practice remains limited. Difficulties arising are because of disseminating research findings to different users. A major problem seems to be that practitioners do not have the access or have not been told how to access recent findings of research. Training has been an issue and has been a barrier for most. Researchers received specific training language used is specialised and technical it makes it difficult for untrained individuals to understand the findings of the research (Last, 1989). It has been found that the cost of research findings to be disseminated is almost as costly as the research itself to other professionals and disciplines in health care. This has been known to cause problems. In addition there can be factors that can hinder the research findings to be made available for all professionals and disciplines. These factors may include professional’s attitudes towards change, lack of education and support and fear of the unknown including the risk involved. The research has been known to be a problem in itself. An example of this is research that has been recommended can be difficult to implement into practice or university based research that may not have been implemented into practice and leave a large gap between these two.

Nevertheless these obstacles and barriers can be overcome to allow implementation of practical implication of procedures. Various organisations have a responsibility to set the high quality of standards for research and have the responsibility to disseminate the finalised research materials that has been finalised. In Scotland the guidelines are collated by The Scottish Intercollegiate Guidelines (SIGN). The aim of SIGN is to ‘improve the quality of healthcare for patients in Scotland by reducing variation in practice and outcome, through the development and dissemination of national clinical guidelines containing recommendations for effective practice based on current evidence’. In addition to the SIGN guidelines there is also the National Institute for Health and Clinical Excellence (NICE). NICE is an organisation associated with the NHS. NICE provides professionals and practitioners with guidance on treatment, promotes good health and prevent ill health. It would be helpful if such organisations looked at developing guidelines on evidence based practice. As this relates to clinical practice therefore the organisation may also facilitate the change (Stonestreet & Lamb-Harvard, 1994). Information systems could also be put in place to make information more accessible to other professionals and practitioners. ‘NHS Evidence’ has been available since April 2009. This ‘will help find, access and use high quality clinical and non clinical evidence and best practice’.

The author has informed the reader the importance of evidence based practice in a health care setting. A lot of training is required as it can also be rigorous. It is also a complex process. In order for professionals and practitioners to develop the best quality of care it is essential that they keep themselves up to date with the latest research findings.

‘Why are my friends changing?’ Explaining dementia to people with learning disabilities

This article was carried out on a group of people co-habiting who have learning disabilities. The article shows this is an example of qualitative research and the aim was to educate them about dementia as two of the residents had a diagnosis of this. Burns and Grove (2007, pp 551) describe qualitative research as ‘as systematic, subjective methodological approach used to describe life experiences and give them meaning’. Parahoo (2006) illustrates the key aspect of the qualitative research as being investigative in the approach in order to appreciate the actions and sensitivity of participants within the group.

As the participants had little of no knowledge regarding what dementia was or the effects this had on an individual and instead became frustrated and annoyed with their peers not realising how this affected their friends, the authors used different tools including visual aids, use of equipment, role play and props that the group could interact with. The group the writers were working with demonstrated that it helped educate the targeted group they were working with.

Although the group was small as it only had four group members aged between 37 and 54 (mean 45 years) and included two females and two males, the chosen group was successful in teaching all involved. The writers involved in this study admitted that there was not a independent assessment nor a control group carried out prior to the study that could have showed the evaluation of results and prove success or validity of the study carried out. Although the tools used in this group were effective it may not have been effective in another group as the mean age may be different. The group had also lived together for ten years which is a long time and they may have felt more at ease with each other and felt more comfortable in each others company to engage in the activities asked of them. As the group members all got on very well it may be that the group participants felt more sympathetic towards the people who have dementia. If a group had been set up using the same educating methods the results may not have been the same due to the relationships not being as close.

At the beginning of the sessions it was not explained why the methods used to educate the residents were changed other than them saying it was too complex although this may have been a positive step as this meant the facilitators working with the individuals in the group could work at a level they were comfortable with. The methods used to teach the group involved or the tools used were not advised if they had been effective with another group. The data collection used did work well with a qualitative research study. The interviews and questionnaires used with staff were to gain feedback. The group participants used a semi structured interview to gain feedback. The interviews were carried out one week before then one month after and then six months after. The study was completed after the six months to allow the writers to gain knowledge on the group participants involved regarding their level of education on dementia and then after the study was carried out to gain an insight of how much they learned regarding dementia therefore assessing the success of their teaching. Although they did admit that their methods of evaluation were weak to response effects (i.e. questionnaires and interviews). Although it was found that the use of the proven Psychosocial Interventions framework along with several tools and methods used could educate people with learning disabilities about dementia successfully.

Caring for older people with dementia in residential care: nursing students’ experience

This article aimed to determine student’s attitudes toward working with people with dementia and improve their experiences of working with these people. The students involved in this study were 2nd year Bachelor of Nursing Students. Two projects were completed over a four year period and the students participated in three week placements in eight residential care facilities. The group used consisted of 87 people which is a large number for a group although is a reasonable size for a qualitative study. The study was carried out in Tasmania between 2001 and 2005. There was not a guarantee that the study being carried out at this university would produce the same results if done with another group due to student training with another university. Also students did not have any previous experience working with dementia and also only had three week placement in the facility. As three weeks is not a long time this could have an impact on their feelings and opinions regarding the work in this area. Throughout the students practice placements including their mentors they both engaged in focus groups and this was facilitated by the research team member. According to Welman and Kruger (1999, p189) ‘the phenomenologist are concerned with understanding social and psychological phenomena from the perspectives of people involved’. The focus group involved is illustrating that experiences and opinions on a personal level can be valuable and effective. Morgan (1997p 12) said about focus groups that ‘interactions within the group based on topics that are supplied by the researcher’. Kitzinger (1995) states that working within a group can help build up trust and find solutions to problems being experienced by individuals and can be helped by working with the group to resolve the problems. It has been known within group work for people who are shy or quiet can at times be overpowered by others in the group. Questionnaires are beneficial in this case to allow the more quiet members of the group to get their point across without being interrupted or not being heard. The writers of this article recorded the sessions on audio tapes. This will be used for further analysis and the facilitator also took minutes and these were given to the group members to reflect on and allow them to address issues. The group members were then able to validate the discussion previously. Throughout this study the writer used thematic analysis so that they could identify repeated points raised by the group members. This helped the researchers to set up suggestions for those involved. The recommendations put forward to be considered for further education where caring for people with dementia and more support for students and mentors. To help the reader relate more to the article the author has used direct quotes. This allowed the reader to communicate the fears and some concerns that the students where involved in.

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Cronin P., Coughlan M., Ryan F (2008) ‘Undertaking a literature review: a step by step approach’ British Journal of Nursing. 17(1) 38-43

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