Implementation of the cardiovascular assessment screening program (CASP) by nurse practitioners-it's time to focus on early identification of cardiovascular risk

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Newfoundland and Labrador Support for Patient-Oriented Research (NL SUPPORT)

Background

There is inconsistent utilization of clinical practice guidelines (CPGs) for cardiovascular disease (CVD) screening and management by advanced practice nurses/nurses practitioners (NPs) to identify CVD risk factors early and to intervene using current recommendations. To address this clinical practice issue and increase utilization of Canadian CPGs, an exploratory multiphase sequential mixed methods study was conducted and the Cardiovascular Assessment Screening Program (CASP) was developed, implemented, and evaluated.

Objective

Phase 2 of the mixed methods study, a cluster randomized controlled trial (cRCT), evaluated the implementation of CASP by NPs with individuals aged 40-74 years, without established CVD or vascular disease (VD), in order to identify CVD risk factors early, to determine the level of risk for a CV event, to calculate the Heart Age, and to set heart health priorities and management, according to current CPGs in Canada.

Methods

In a cRCT, block randomization randomly divided ten NPs into the intervention group clusters (IGCs) and the control group clusters (CGCs). In turn, eight NPs recruited 166 patients in their own communities; the four NP IGCs recruited patients (n=67) and the four NP CGCs recruited patients (n=99). The web-based CASP intervention was implemented with patients in the IGCs, and the CGCs received standard care. The CASP intervention consisted of four components: an electronic CVD Database, an NP toolkit, an educational resource for NPs and patients, and a website containing CPGs. The data on CVD risk factors, Framingham Risk Score (FRS), Heart Age, and priorities for heart health were recorded in the CVD Database utilized by the NP IGCs.

Results

Utilizing the CVD database, CVD risk factors were consistently identified in patients by NPs in the IGCs compared to the NP CGCs. The patients in the IGCs had a high number of risk factors for CVD documented by NPs, including family history of CVD, hypertension, diabetes, obesity, renal dysfunction, and dyslipidemia, and found that 62 patients (91%) were at moderate to high risk for having a CV event in the next 10 years using the FRS. In comparison, NPs in the CGCs did minimal documentation of risk factors; the level of CVD risk was largely unknown (96%) for control group patients as the FRS was only documented on 7 patients (4%). The Heart Age was calculated in the IGCs (92%); in the CGCs, the Heart Age was not calculated. The recommendations made by IGC NPs matched their patients’ priorities 94% of the time; 75% of the intervention group patients developed personalised goals that matched their top priorities for improving heart health.

Conclusion

The key benefit of the CASP implementation by NPs was the identification of CVD risk factors earlier in individuals without established CVD or VD. Engaging individuals to participate in screening to learn about their CVD risk encourages priority setting for heart health using a patient-focused approach.

Measuring handwashing performance in health service audits and research studies

Handwashing is regarded as the most effective way of controlling healthcare-associated infection. A search of the literature identified 42 intervention studies seeking to increase compliance in which the data were collected by directly observing practice. The methods used to undertake observation were so poorly described in most studies that it is difficult to accept the findings as reliable or as valid indicators of health worker behaviour. Most studies were limited in scope, assessing the frequency of handwashing in critical care units. The ethical implications of watching health workers during close patient contact were not considered, especially when observation was covert or health workers were misinformed about the purpose of the study. Future studies should take place in a range of clinical settings to increase the generalizability of findings. Observation should be timed to capture a complete picture of 24h activity and should include all health workers in contact with patients because all have the potential to contribute to cross-infection. Reported details of observation should include: vantage of data collectors; inter-rater reliability when more than one individual is involved; and attempts to overcome the impact of observation on usual health worker behaviour. Ideally an additional data collection method should be used to corroborate or refute the findings of observation, but no well-validated method is presently available.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure.

OBJECTIVES

To assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH STRATEGY

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. All databases were searched to July 2006; MEDLINE was searched from 1980, CINAHL from its inception, and the remainder from 1990 until July 2006.

SELECTION CRITERIA

Randomised controlled trials; controlled clinical trials; controlled before and after studies; and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group. Studies reporting proxy indicators of hand hygiene compliance were considered. Studies to promote compliance with universal precautions were included providing data relating specifically to hand hygiene were presented separately.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed data quality.

MAIN RESULTS

Two studies met the criteria for review. One was a randomised controlled trial. The other was a controlled before and after study. Both were poorly controlled. Statistically significant post-intervention increase in hand washing was reported in one study up to four months after the intervention. In the other there was no post-intervention increase in hand hygiene compliance.

AUTHORS' CONCLUSIONS

There is little robust evidence to inform the choice of interventions to improve hand hygiene. It appears that single interventions based on short, 'one off' teaching sessions are unlikely to be successful, even short-term. There is a need to undertake methodologically robust research to explore the effectiveness of soundly designed interventions to increase hand hygiene compliance.

Biochemical polymorphisms in wild rats (Rattus norvegicus) captured in Oita city, Japan

The investigation of biochemical markers in wild rats (Rattus norvegicus) is thought to be useful in the efficient establishment of inbred strains with a wide range of genetic variability of wild rats. In this study, 21 marker proteins were analyzed by electrophoresis in nine wild rats captured in Oita city. It was found that eleven marker samples in six animals were heterogeneous. We further found that the investigated wild rat population possessed the interesting polymorphisms of esterase-4 (ES-4) with high frequency, which are very rare in laboratory rats.

The Mock Isolation Room: A Fun Way to Review Infection Control

The Infection Control Unit of the Montreal General Hospital implemented a Mock Isolation Room that tested nurses' knowledge with a review of common medical device and isolation infractions and recommendations. Consultants reinforced correct practices and clarified misconceptions. The Mock Isolation Room is recommended as an effective review strategy that encompasses the principles of adult learning. The material was identified by the nurses as clinically relevant and the learning method was considered to be fun and effective. The exercise can also be used as a needs assessment tool.

Biochemical polymorphisms in Long-Evans Cinnamon (LEC) inbred strain of rat

Long-Evans Cinnamon (LEC) rat is an inbred strain of mutant rat which has been proposed to be an animal model for human Wilson's disease. In the present study, 28 genetic marker proteins were analyzed by electrophoresis in sublines of LEC inbred strain held separately by four facilities. As expected, the 27 markers were homozygous and identical in all of examined animals. We further found a novel variant of esterase-2 (ES-2) showing an intermediate mobility between profiles of ES-2A and ES-2C types.