Nursing
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Item A review of the enhanced CJD surveillance feasibility study in the elderly in Scotland, UK(BioMed Central, 2024-01-03) Kanguru, Lovney; Cudmore, Sarah; Logan, Gemma; Waddell, Briony; Smith, Colin; Molesworth, Anna; Knight, RichardBackground: Variant Creutzfeldt - Jakob disease (vCJD) arose from dietary contamination with bovine-spongiform-encephalopathy (BSE). Because of concerns that vCJD-cases might be missed in the elderly, a feasibility study of enhanced CJD surveillance on the elderly was begun in 2016. Recruitment was lower than predicted. We describe a review of the challenges encountered in that study: identification, referral, and recruitment, and the effects of actions based on the results of that review. Methods: Review was conducted in 2017. Study data for all eligible cases identified and referred from one participating service (Anne Rowling clinic (ARC)) was curated and anonymised in a bespoke database. A questionnaire was sent out to all the clinicians in medicine of the elderly, psychiatry of old age and neurology (including ARC) specialties in NHS Lothian, exploring possible reasons for low recruitment. Results: Sixty-eight cases were referred from the ARC (March 2016-September 2017): 25% were recruited. Most cases had been referred because of diagnostic uncertainty. No difference was seen between those recruited and the non-recruited, apart from age and referrer. Twelve of 60 participating clinicians completed the questionnaire: only 4 had identified eligible cases. High workload, time constraints, forgetting to refer, unfamiliarity with the eligibility criteria, and the rarity of eligible cases, were some of the reasons given. Suggestions as to how to improve referral of eligible cases included: regular email reminders, feedback to referrers, improving awareness of the study, visible presence of the study team, and integration of the study with other research oriented services. These results were used to increase recruitment but without success. Conclusion: Recruitment was lower than predicted. Actions taken following a review at 21 months did not lead to significant improvement; recruitment remained low, with many families/patients declining to take part (75%). In assessing the failure to improve recruitment, two factors need to be considered. Firstly, the initial referral rate was expected to be higher because of existing patients already known to the clinical services, with later referrals being only newly presenting patients. Secondly, the unplanned absence of a dedicated study nurse. Searching digital records/anonymised derivatives to identify eligible patients could be explored.Item A clinicopathological study of selected cognitive impairment cases in Lothian, Scotland: enhanced CJD surveillance in the 65 + population group(BioMed Central, 2022-07-20) Kanguru, Lovney; Logan, Gemma; Waddel, Briony; Smith, Colin; Molesworth, Anna; Knight, RichardAbstract: Background: Variant Creutzfeldt-Jakob Disease (vCJD) is primarily associated with dietary exposure to bovine-spongiform-encephalopathy. Cases may be missed in the elderly population where dementia is common with less frequent referral to specialist neurological services. This study’s twin aims were to determine the feasibility of a method to detect possible missed cases in the elderly population and to identify any such cases. Methods: A multi-site study was set-up in Lothian in 2016, to determine the feasibility of enhanced CJD-surveillance in the 65 + population-group, and undertake a clinicopathological investigation of patients with features of ‘atypical’ dementia. Results: Thirty patients are included; 63% male, 37% female. They were referred because of at least one neurological feature regarded as ‘atypical’ (for the common dementing illnesses): cerebellar ataxia, rapid progression, or somato-sensory features. Mean-age at symptom-onset (66 years, range 53–82 years), the time between onset-of-symptoms and referral to the study (7 years, range 1–13 years), and duration-of-illness from onset-of-symptoms until death or the censor-date (9.5 years, range 1.1–17.4 years) were determined. By the censor-date, 9 cases were alive and 21 had died. Neuropathological investigations were performed on 10 cases, confirming: Alzheimer’s disease only (2 cases), mixed Alzheimer’s disease with Lewy bodies (2 cases), mixed Alzheimer’s disease with amyloid angiopathy (1 case), moderate non-amyloid small vessel angiopathy (1 case), a non-specific neurodegenerative disorder (1 case), Parkinson's disease with Lewy body dementia (1 case), and Lewy body dementia (2 cases). No prion disease cases of any type were detected. Conclusion: The surveillance approach used was well received by the local clinicians and patients, though there were challenges in recruiting sufficient cases; far fewer than expected were identified, referred, and recruited. Further research is required to determine how such difficulties might be overcome. No missed cases of vCJD were found. However, there remains uncertainty whether this is because missed cases are very uncommon or because the study had insufficient power to detect them.Item Overviews of Person-Centred Practice Research(2021-04-27) Sanders, Kate; Marriott-Statham, Kelly; Logan, GemmaItem New care home admission following hospitalisation: How do older people, families and professionals make decisions about discharge destination? A case study narrative analysis(Wiley, 2018-03-24) Rhynas, Sarah J.; Garcia Garrido, Azucena; Burton, Jennifer K.; Logan, Gemma; MacArthur, JulietAims and objectives: To gain an in-depth understanding of the decision- making pro-cesses involved in the discharge of older people admitted to hospital from home and discharged to a care home, as described in the case records.Background: The decision for an older person to move into a care home is significant and life-changing. The discharge planning literature for older people highlights the integral role of nurses in supporting and facilitating effective discharge. However, little research has been undertaken to explore the experiences of those discharged from hospital to a care home or the processes involved in decision- making.Method: A purposive sample of 10 cases was selected from a cohort of 100 individu-als admitted to hospital from home and discharged to a care home. Cases were se-lected to highlight important personal, relational and structural factors thought to affect the decision- making process. Narrative case studies were created and were thematically analysed to explore the perspectives of each stakeholder group and the conceptualisations of risk which influenced decision-making.Results: Care home discharge decision- making is a complex process involving stake-holders with a range of expertise, experience and perspectives. Decisions take time and considerable involvement of families and the multidisciplinary team. There were significant deficits in documentation which limit the understanding of the process and the patient’s voice is often absent from case records. The experiences of older people, families and multidisciplinary team members making care home decisions in the hospital setting require further exploration to identify and define best practice.Implications for practice: Nurses have a critical role in the involvement of older peo-ple making discharge decisions in hospital, improved documentation of the patient’s voice is essential. Health and social care systems must allow older people time to make significant decisions about their living arrangements, adapting to changing medical and social needs.Item Decisions affecting discharge from hospitals directly to care homes(EMAP, 2017-05-31) Harrison, Jennifer Kirsty; MacArthur, Juliet; Garcia Garrido, Azucena; Logan, Gemma; Rhynas, Sarah J.; MacLullich, Alasdair M. J.; Shenkin, SusanAdmission to care homes following acute hospital admission is common, despite being contrary to UK health policy. Care home admission from hospital is also a care trajectory that is under-researched and poorly understood. A retrospective cohort study reviewed the case notes of 100 people who had experienced this transition, what happened during their hospital stay, and what led to the life changing decision to discharge them to a care home. Only 37% of individuals were documented as having been involved in the decision-making process. This article describes the study methods, highlights some salient results, and makes recommendations for practice.Item New institutionalisation following acute hospital admission: A retrospective cohort study(Oxford University Press, 2016-10-15) Harrison, Jennifer Kirsty; Garcia Garrido, Azucena; Rhynas, Sarah J.; Logan, Gemma; MacLullich, Alasdair M. J.; MacArthur, Juliet; Shenkin, SusanBackground: institutionalisation following acute hospital admission is common and yet poorly described, with policy documents advising against this transition. Objective: to characterise the individuals admitted to a care home on discharge from an acute hospital admission and to describe their assessment. Design and setting: a retrospective cohort study of people admitted to a single large Scottish teaching hospital. Subjects: 100 individuals admitted to the acute hospital from home and discharged to a care home. Methods: a single researcher extracted data from ward-based case notes. Results: people discharged to care homes were predominantly female (62%), widowed (52%) older adults (mean 83.6 years) who lived alone (67%). About 95% had a diagnosed cognitive disorder or evidence of cognitive impairment. One-third of cases of delirium were unrecognised. Hospital stays were long (median 78.5 days; range 14–231 days) and transfers between settings were common. Family request, dementia, mobility, falls risk and behavioural concerns were the commonest reasons for the decision to admit to a care home. About 55% were in the acute hospital when the decision for a care home was made and 44% of that group were discharged directly from the acute hospital. Conclusions: care home admission from hospital is common and yet there are no established standards to support best practice. Decisions should involve the whole multidisciplinary team in partnership with patients and families. Documentation of assessment in the case notes is variable. We advocate the development of interdisciplinary standards to support the assessment of this vulnerable and complex group of patients.Item Clinical judgment and decision-making in wound assessment and management: Is experience enough?(Mark Allen, 2015-04-17) Logan, GemmaThe assessment and management of wounds forms a large proportion of community nurses' workload, often requiring judgment and decision-making in complex, challenging and uncertain circumstances. The processes through which nurses form judgments and make decisions within this context are reviewed in this article against existing theories on these subjects. There is variability in wound assessment and management practice which may be attributed to uncertainties within the context, a lack of knowledge in appropriate treatment choices and the inability to correctly value the importance of the clinical information presented. Nurses may be required to draw on intuition to guide their judgments and decision-making by association with experience and expertise. In addition, a step-by-step analytical approach underpinned by an evidence base may be required to ensure accuracy in practice. Developing an understanding of the different theories of judgment and decision-making may facilitate nurses' abilities to reflect on their own decision tasks, thereby enhancing the care provided.