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Richards DA, Bollen J, Jones B, Melendez-Torres GJ, Hulme C, Cockcroft E, Cook H, Cooper J, Creanor S, Cruickshank S, Dawe P, Doris F, Iles-Smith H, Kent M, Logan P, O'Connell A, Onysk J, Owens R, Quinn L, Rafferty AM, Romanczuk L, Russell AM, Shepherd M, Singh SJ, Sugg HVR, Coon JT, Tooze S, Warren FC, Whale B, Wootton S. Evaluation of a COVID-19 fundamental nursing care guideline versus usual care: The COVID-NURSE cluster randomized controlled trial. J Adv Nurs 2024; 80:2137-2152. [PMID: 37986547 DOI: 10.1111/jan.15959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
AIM To evaluate the impact of usual care plus a fundamental nursing care guideline compared to usual care only for patients in hospital with COVID-19 on patient experience, care quality, functional ability, treatment outcomes, nurses' moral distress, patient health-related quality of life and cost-effectiveness. DESIGN Parallel two-arm, cluster-level randomized controlled trial. METHODS Between 18th January and 20th December 2021, we recruited (i) adults aged 18 years and over with COVID-19, excluding those invasively ventilated, admitted for at least three days or nights in UK Hospital Trusts; (ii) nurses caring for them. We randomly assigned hospitals to use a fundamental nursing care guideline and usual care or usual care only. Our patient-reported co-primary outcomes were the Relational Aspects of Care Questionnaire and four scales from the Quality from the Patient Perspective Questionnaire. We undertook intention-to-treat analyses. RESULTS We randomized 15 clusters and recruited 581 patient and 418 nurse participants. Primary outcome data were available for 570-572 (98.1%-98.5%) patient participants in 14 clusters. We found no evidence of between-group differences on any patient, nurse or economic outcomes. We found between-group differences over time, in favour of the intervention, for three of our five co-primary outcomes, and a significant interaction on one primary patient outcome for ethnicity (white British vs. other) and allocated group in favour of the intervention for the 'other' ethnicity subgroup. CONCLUSION We did not detect an overall difference in patient experience for a fundamental nursing care guideline compared to usual care. We have indications the guideline may have aided sustaining good practice over time and had a more positive impact on non-white British patients' experience of care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE We cannot recommend the wholescale implementation of our guideline into routine nursing practice. Further intervention development, feasibility, pilot and evaluation studies are required. IMPACT Fundamental nursing care drives patient experience but is severely impacted in pandemics. Our guideline was not superior to usual care, albeit it may sustain good practice and have a positive impact on non-white British patients' experience of care. REPORTING METHOD CONSORT and CONSERVE. PATIENT OR PUBLIC CONTRIBUTION Patients with experience of hospitalization with COVID-19 were involved in guideline development and writing, trial management and interpretation of findings.
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Affiliation(s)
- David A Richards
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Jess Bollen
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Ben Jones
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Claire Hulme
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Emma Cockcroft
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Heather Cook
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Joanne Cooper
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Siobhan Creanor
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Phoebe Dawe
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Faye Doris
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Merryn Kent
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Pip Logan
- Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Abby O'Connell
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Jakub Onysk
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Rosie Owens
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Lynne Quinn
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Anne Marie Rafferty
- Florence Nightingale School of Nursing and Midwifery, Kings College University London, London, UK
| | | | | | - Maggie Shepherd
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Sally J Singh
- Department of Respiratory Science, University of Leicester, Leicester, UK
- University Hospitals of Leicester NHS Trust, Biomedical Research Centre - Respiratory, Glenfield Hospital, Leicester, UK
| | - Holly V R Sugg
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- The National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
| | - Susannah Tooze
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Fiona C Warren
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Bethany Whale
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Stephen Wootton
- Institute of Human Nutrition, University of Southampton, Southampton, UK
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Fletcher J, Porter R, Boulton Z, Brown L, Knight B, Romanczuk L, Aiken S, Delury C, Michell S. In vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure) against polymicrobial communities and individual bacterial strains derived from diabetic foot infections. J Med Microbiol 2022; 71. [PMID: 35604937 DOI: 10.1099/jmm.0.001517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Diabetic foot infection (DFI) is the main reason for diabetes-related hospitalisation and is a major cause of diabetes-related amputation. DFIs are often complicated by ischaemia in the affected limb, the presence of polymicrobial biofilms and increasingly the occurrence of antibiotic resistant bacteria.Hypothesis/Gap statement. Antibiotic loaded beads could inhibit the growth of polymicrobial DFI communities with differing compositions in vitro.Aim. This study investigates the in vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure, Biocomposites Ltd., UK) against polymicrobial DFI communities and individual bacterial strains derived from DFIs.Methodology. Debrided tissue obtained from the base of infected diabetic foot ulcers was homogenised and spread over the surface of Columbia blood agar (CBA) and fastidious anaerobe agar (FAA) plates. Calcium sulfate beads containing a combination of vancomycin and gentamicin were then placed on the surface of the agar and following incubation, zones of inhibition (ZOI) were measured. For individual bacterial strains isolated from the infected tissue, calcium sulfate beads containing vancomycin, gentamicin, flucloxacillin or rifampicin and beads containing a combination of vancomycin and gentamicin or flucloxacillin and rifampicin were tested for their ability to inhibit growth.Results. Calcium sulfate beads loaded with a combination of vancomycin and gentamicin were able to inhibit bacterial growth from all polymicrobial tissue homogenates tested, with ZOI diameters ranging from 15 to 40 mm. In the case of individual bacterial strains, beads containing combinations of vancomycin and gentamicin or flucloxacillin and rifampicin were able to produce ZOI with Gram-positive facultatitive anaerobic strains such as Staphylococcus aureus and Enterococcus faecalis, Gram-negative facultative anaerobic strains such as Pseudomonas aeruginosa and obligate anaerobic strains such as Finegoldia magna even where acquired resistance to one of the antibiotics in the combination was evidenced.Conclusion. The local use of calcium sulfate beads containing a combination of two antibiotics demonstrated high efficacy against polymicrobial DFI communities and individual DFI bacterial strains in in vitro zone of inhibition tests. These results show promise for clinical application, but further research and clinical studies are required.
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Affiliation(s)
- Julie Fletcher
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
| | - Rob Porter
- Microbiology Department, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Zoe Boulton
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Laura Brown
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Bridget Knight
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Lidia Romanczuk
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Sean Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Stephen Michell
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
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Richards DA, Sugg HV, Cockcroft E, Cooper J, Cruickshank S, Doris F, Hulme C, Logan P, Iles-Smith H, Melendez-Torres GJ, Rafferty AM, Reed N, Russell AM, Shepherd M, Singh SJ, Thompson Coon J, Tooze S, Wootton S, Abbott R, Bethel A, Creanor S, Quinn L, Tripp H, Warren FC, Whear R, Bollen J, Hunt HA, Kent M, Morgan L, Morley N, Romanczuk L. COVID-NURSE: evaluation of a fundamental nursing care protocol compared with care as usual on experience of care for noninvasively ventilated patients in hospital with the SARS-CoV-2 virus-protocol for a cluster randomised controlled trial. BMJ Open 2021; 11:e046436. [PMID: 34039574 PMCID: PMC8159671 DOI: 10.1136/bmjopen-2020-046436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/21/2021] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Patient experience of nursing care is correlated with safety, clinical effectiveness, care quality, treatment outcomes and service use. Effective nursing care includes actions to develop nurse-patient relationships and deliver physical and psychosocial care to patients. The high risk of transmission of the SARS-CoV-2 virus compromises nursing care. No evidence-based nursing guidelines exist for patients infected with SARS-CoV-2, leading to potential variations in patient experience, outcomes, quality and costs. METHODS AND ANALYSIS: we aim to recruit 840 in-patient participants treated for infection with the SARS-CoV-2 virus from 14 UK hospitals, to a cluster randomised controlled trial, with embedded process and economic evaluations, of care as usual and a fundamental nursing care protocol addressing specific areas of physical, relational and psychosocial nursing care where potential variation may occur, compared with care as usual. Our coprimary outcomes are patient-reported experience (Quality from the Patients' Perspective; Relational Aspects of Care Questionnaire); secondary outcomes include care quality (pressure injuries, falls, medication errors); functional ability (Barthell Index); treatment outcomes (WHO Clinical Progression Scale); depression Patient Health Questionnaire-2 (PHQ-2), anxiety General Anxiety Disorder-2 (GAD-2), health utility (EQ5D) and nurse-reported outcomes (Measure of Moral Distress for Health Care Professionals). For our primary analysis, we will use a standard generalised linear mixed-effect model adjusting for ethnicity of the patient sample and research intensity at cluster level. We will also undertake a planned subgroup analysis to compare the impact of patient-level ethnicity on our primary and secondary outcomes and will undertake process and economic evaluations. ETHICS AND DISSEMINATION Research governance and ethical approvals are from the UK National Health Service Health Research Authority Research Ethics Service. Dissemination will be open access through peer-reviewed scientific journals, study website, press and online media, including free online training materials on the Open University's FutureLearn web platform. TRIAL REGISTRATION NUMBER ISRCTN13177364; Pre-results.
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Affiliation(s)
- David A Richards
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Holly Vr Sugg
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Emma Cockcroft
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Joanne Cooper
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Faye Doris
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Claire Hulme
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Phillipa Logan
- Community Health Sciences, University of Nottingham, Nottingham, UK
| | | | - G J Melendez-Torres
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Anne Marie Rafferty
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
| | - Nigel Reed
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Anne-Marie Russell
- Academy of Nursing, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Maggie Shepherd
- NIHR Clinical Research Facility, University of Exeter, Exeter, UK
| | - Sally J Singh
- Cardiac/Pulmonary Rehabilitation, Leicester Royal Infirmary, Leicester, UK
| | - Jo Thompson Coon
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Susannah Tooze
- Academy of Nursing, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Stephen Wootton
- Insitute of Human Nutrition, University of Southampton, Southampton, UK
| | - Rebecca Abbott
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Alison Bethel
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Lynne Quinn
- Clinical Trials Unit, University of Exeter, Exeter, UK
| | - Harry Tripp
- Clinical Trials Unit, University of Exeter, Exeter, UK
| | - Fiona C Warren
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Rebecca Whear
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Harriet A Hunt
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Merryn Kent
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Leila Morgan
- Academy of Nursing, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Naomi Morley
- Institute for Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Lidia Romanczuk
- NIHR Clinical Research Facility, University of Exeter, Exeter, UK
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Riddell A, Kirkwood J, Smallwood M, Winyard P, Knight B, Romanczuk L, Shore A, Gilchrist M. Urinary nitrate concentration as a marker for kidney transplant rejection. BMC Nephrol 2020; 21:441. [PMID: 33081704 PMCID: PMC7576839 DOI: 10.1186/s12882-020-02096-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/09/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Early identification and treatment of kidney transplant rejection episodes is vital to limit loss of function and prolong the life of the transplanted kidney and recipient. Current practice depends on detecting a creatinine rise. A biomarker to diagnose transplant rejection at an earlier time point than current practice, or to inform earlier decision making to biopsy, could be transformative. It has previously been shown that urinary nitrate concentration is elevated in renal transplant rejection. Nitrate is a nitric oxide (NO) oxidation product. Transplant rejection upregulates NO synthesis via inducible nitric oxide synthase leading to elevations in urinary nitrate concentration. We have recently validated a urinary nitrate concentration assay which could provide results in a clinically relevant timeframe. Our aim was to determine whether urinary nitrate concentration is a useful tool to predict renal transplant rejection in the context of contemporary clinical practice. METHODS We conducted a prospective observational study, recruiting renal transplant participants over an 18-month period. We made no alterations to the patients' clinical care including medications, immunosuppression, diet and frequency of visits. We collected urine samples from every clinical attendance. We assessed the urinary nitrate to creatinine ratio (uNCR) between patient groups: routine attendances, biopsy proven rejection, biopsy proven no rejection and other call backs. uNCR was examined over time for those with biopsy proven transplant rejection. These four groups were compared using an ANOVA test. RESULTS A total of 2656 samples were collected. uNCR during biopsy proven rejection, n = 15 (median 49 μmol/mmol, IQR 23-61) was not significantly different from that of routine samples, n = 164 (median 55 μmol/mmol, IQR 37-82) (p = 0.55), or biopsy proven no rejection, n = 12 (median 39 μmol/mmol, IQR 21-89) (P = 0.77). Overall uNCR was highly variable with no diagnostic threshold for kidney transplant rejection. Furthermore, within-patient uNCR was highly variable over time, and thus it was not possible to produce individualised patient thresholds to identify rejection. The total taking Tacrolimus was 204 patients, with no statistical difference between the uNCR of all those on Tacrolimus, against those not, p = 0.18. CONCLUSION The urinary nitrate to creatinine ratio is not a useful biomarker for renal transplant rejection.
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Affiliation(s)
- Amy Riddell
- Institute of Biomedical and Clinical Sciences, University of Exeter, and NIHR Exeter Clinical Research Facility, Exeter, Devon, UK.
| | | | - Miranda Smallwood
- Institute of Biomedical and Clinical Sciences, University of Exeter, and NIHR Exeter Clinical Research Facility, Exeter, Devon, UK
| | - Paul Winyard
- Institute of Biomedical and Clinical Sciences, University of Exeter, and NIHR Exeter Clinical Research Facility, Exeter, Devon, UK
| | | | | | - Angela Shore
- Institute of Biomedical and Clinical Sciences, University of Exeter, and NIHR Exeter Clinical Research Facility, Exeter, Devon, UK
| | - Mark Gilchrist
- Institute of Biomedical and Clinical Sciences, University of Exeter, and NIHR Exeter Clinical Research Facility, Exeter, Devon, UK
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Riddell A, Kirkwood J, Smallwood M, Winyard P, Knight B, Steer K, Puddicombe L, Romanczuk L, Shore A, Gilchrist M. P1612CAN THE URINARY NITRATE TO CREATININE RATIO BE USED AS A MARKER FOR KIDNEY TRANSPLANT REJECTION? Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Early identification and treatment of kidney transplant rejection episodes is vital to limit loss of function and prolong the life of the transplanted kidney and recipient. Current practice depends on detecting a creatinine rise. A biomarker to diagnose transplant rejection, either at an earlier time point, or to inform earlier decision making to biopsy, could be transformative. Urinary nitrate concentration is elevated in renal transplant rejection. Nitrate is a nitric oxide (NO) oxidation product. Transplant rejection upregulates NO synthesis via inducible nitric oxide synthase leading to elevations in urinary nitrate concentration. Historically, assays for measurement of inorganic nitrate in biological fluids have been too time consuming to be useful in a clinical setting. We have recently validated a urinary nitrate concentration assay which could provide results in a clinically relevant timeframe. Our aim was to determine whether urinary nitrate concentration is a useful tool to predict renal transplant rejection in the context of contemporary clinical practice.
Method
We conducted a prospective observational study, recruiting renal transplant participants over an 18 month period. We made no alterations to the patients’ clinical care including medications, immunosuppression, diet and frequency of visits. We collected urine samples from every clinical attendance including routine attendances, unscheduled attendances for acute clinical indications, and on the day of attendance for biopsy, for those who underwent biopsy. We measured the urinary nitrate to creatinine ratio (uNCR) between patient groups including routine attendances, biopsy proven rejection and biopsy proven “no rejection”. uNCR was examined over time for those with transplant rejection. Groups were compared using a 2 tail t-test of unequal variance, for statistical significance.
Results
A total of 2656 samples were collected. uNCR during biopsy proven rejection, median 49 µmol/mmol, IQR 23-61, was not significantly different from that of routine samples, median 55 µmol/mmol, IQR 37-82 (p=0.56), or biopsy proven “no rejection”, median 39 µmol/mmol, IQR 21-89, (P=0.77). Overall uNCR was highly variable; median 52 µmol/mmol, IQR 31-81, with no diagnostic threshold for kidney transplant rejection. Furthermore, within-patient uNCR was highly variable over time, and thus it was not possible to produce individualised patient thresholds to identify rejection.
Conclusion
The urinary nitrate to creatinine ratio is not a useful biomarker for renal transplant rejection.
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