bluuebunny/crossref_metadata_2025_split huggingface dataset:
Assessing healthcare professionals knowledge and improving mouth care within a palliative care unit
Authors: Smith Louise , Gale Sue , Newberry Leanne 
Published: March 2012

IntroductionMouth care is essential to provide comfort for the dying patient. Good oral care (assessment, planning and delivery) is underpinned by healthcare professionals' (HCPs) knowledge and utilisation of appropriate tools and care plans. A multi-phase study was commenced within a 16 bed inpatient unit to ascertain factors impeding nursing practice, which staff had felt to be suboptimal.MethodIn phase 1, qualitative data were collected from 42 HCPs in a survey comprising 14 open questions and thematic analysis applied. The survey asked HCPs' knowledge, current practice and ideas on improving oral care. Following this an assessment tool, care plan and a purposefully designed product guide were introduced. In phase 2, a second survey reanalysed HCPs' knowledge acquired after implementation of the tools. The Royal Marsden Manual (2008) was used as a point of reference during both phases.FindingsPhase 1 found that 95% of respondents understood the aims of good mouth care, factors leading to poor oral health (reduced oral intake (75%), poor oral hygiene (65%) and medication (45%)) and actions to be taken if problems were suspected (70%). However procedural knowledge of oral assessment was poor and use of assessment tool/s deficient. 90% of respondents failed to identify half the recommended equipment for assembling an oral care tray. Following introduction of the tools, phase 2 survey showed HCPs' knowledge had increased, and patients had benefitted.ConclusionAlthough collectively some responses in phase 1 appeared good, on an individual basis findings showed HCPs' knowledge was suboptimal. Phase 2 showed that the introduction of the assessment tool, care plan and product guide, had increased HCPs' knowledge and confidence. Consequently patients routinely experienced higher quality care, now evidenced in the revised documentation.
An audit of opioid prescribing at a teaching hospital
Authors: Chhana Sital , Dickman Andrew 
Published: March 2012

BackgroundAfter receiving reports of 5 deaths and over 4200 dose-related patient safety incidents concerning opioid medicines up to June 2008, the UK National Patient Safety Agency issued a rapid response report.1The NPSA issued guidance that should be applied when prescribing, dispensing or administering opioids.Aims and objectivesThe aim of this project was to assess the current prescribing of schedule 2 and 3 opioids in teaching hospital and identify preventable errors over a 2-week period.MethodOver a 2-week period, pharmacists on medical wards identified patients receiving schedule 2 or 3 opioids for chronic pain, whether the patient was admitted on treatment or it was newly prescribed. This generated a list of inpatient charts that were audited prospectively against local and national guidelines.ResultsSeventy patients who had been prescribed opioids for chronic pain were identified. The majority of prescriptions (56%) were written by FY1 doctors. Most of the patients (83%) were already prescribed regular opioids on admission; 81% were prescribed the correct opioid dose as per admission drug history, while the 19% were purposefully changed to new treatment. Dose changes were performed correctly in 80% of the cases, with increases being within 30–50% of the previous dose. Two thirds of ‘as required’ doses were prescribed inadequately, either not being prescribed at all, or the dose had not been calculated as 1/6 of the background dose. Almost three-quarters (73%) of patients were not co-prescribed a laxative.Discussion/conclusionDuring this audit two main areas of error with opioid prescribing were highlighted: prescription of ‘as required’ medication and appropriate co-prescription of a laxative. The results suggest that prescribers are not familiar with certain aspects of opioid treatment. Since the majority of prescribing was performed by junior doctors, this study has highlighted the need for additional education and training.
Comparison of management of noisy breathing at the end of life in two Hospices in the UK
Authors: Subramaniam Sivakumar , Thiru Thirukumaran , Cawley Declan , McGee Helen , Parker Georgina , Fisher Simon 
Published: March 2012

BackgroundExcessive respiratory secretions are common at the end of life. A Cochrane review concluded that there was no current evidence of effectiveness of current interventions but it is a symptom that relatives find distressing in end of life care. Therefore clinicians need to balance the available evidence with the distress remarked on by relatives.AimTo compare audits on the management of ‘death rattle’ in two hospices against national guidelines.MethodologyRetrospective, case note review of inpatients who died over a 5 month period in 2010 (Unit 1) and in 2011 (Unit 2). Results Unit 1: 73 patients: 66 had antisecretory medication prescribed. Twenty-four patients needed the medication. 27/66 had incorrect doses prescribed. 21/24 had response assessed/documented. 18/24 patients documented benefit from the antisecretory drug. Non-Pharmacological measures, 2/24 patients had evidence of re-positioning only with no documentation of communication with the family (0/24). 20/24 patients died within 48 h of the first dose of antisecretory medication. Results Unit 2: 72 patients: 65 had antisecretory medication prescribed. 36 patients needed the medication. 16/65 had incorrect doses prescribed.29/36 response assessed/documented. 24/29 patients had documented benefit from the antisecretory drug. Non-Pharmacological measures, 3/36 patients had evidence of re-positioning with 4/36 documentation of communication with the family. 22/36 patients died within 48 h of the first dose of antisecretory medication.ConclusionPatterns of antisecretory medication appears very similar pattern in both hospices. In the majority of cases, documentation supported adherence to the national guidelines. Of note is the considerable dose variation in the drugs prescribed. This has been highlighted as an education and training issue. The supporting documentation to evidence the use of non-pharmacological measures but also in communicating with the relatives about the ‘death rattle’ needs further work.
Cross purposes? Challenges of providing palliative care to frail older people in a community service
Authors: Skilbeck Julie , Arthur Antony , Seymour Jane 
Published: March 2012

BackgroundProviding palliative care to frail older people in the last years of life is challenging. Increasingly this is becoming a focus of Community Matrons (CM) work. Effective communication between CMs and frail older people is vital, ensuring that palliative care needs are identified, responded to and met; a key requisite of the End of Life Care Strategy (DOH 2008).AimTo explore interactions between CMs and frail older people towards the last year of life.Study designA prospective, longitudinal case study design, using ethnographic data collection methods. Ten participants aged 75 years and over, receiving care from a CM, were recruited. Participants followed up approximately monthly for 6 months or until death. In total, 49 interviews were conducted with older people; 49 CM visits were observed. Medical documents were reviewed for 10 participants. Data were audio-recorded and transcribed verbatim. Analysis involved theme identification, with cross case comparison.FindingsA feature of the interaction between the older person and CM was ‘being at cross purposes’. This occurred when: the older person's concerns were discussed; changes were proposed to their routine; end of life conversations were initiated; role expectations differed. The outcome of these interactions led to the older person's concerns not being identified, and at times a lack of trust. These interactions typically occurred during transitions in health status.DiscussionHow care is organised contributes to CMs and older people unintentionally being at cross purposes. CMs work is framed by a policy of Risk and Clinical Assessment, which can be at odds with a palliative approach. Assumptions underpinning the label of frailty, and the impact of transition on the older person, compound this further. Commissioners of community services for frail older people need to consider these competing demands so that CMs can engage more effectively in palliative care provision.
Identifying and managing the emotional support needs of nurses delivering paediatric palliative care in the community
Authors: Reid Fiona 
Published: March 2012

BackgroundThe death of a child is a rare phenomenon in the western world, being a highly emotive and subjectively distressing event. There is a misconception surrounding the level of nursing expertise, and an underestimation of the degree of emotional work required to undertake the delivery of end-of-life care to children and young people (CYP).1 Exposure to repetitive episodes of stress and psychological dysfunction influences nurses grief, relationships, personal health, professionalism, decision-making and ultimately, future care delivery.AimTo identify the stressors, obstacles, emotional demands, and support needs of nurses delivering paediatric palliative care in the community setting.MethodologyA qualitative design was used, involving indirect purposive sampling of relevant nurses. Seventeen 1:1 semistructured interviews were conducted, and the data analysed using a thematic approach, with defined topics extrapolated.ResultsInterrelated factors emerged that influenced the stressors for nurses, and coping mechanisms that they utilised: organisational structure, relationships and team working, community context, self-efficacy, coping strategies and support systems. shared and/or discrete issues could be distinguished between the various nurses dependent on qualification, care context, rurality, education and numbers of paediatric palliative care episodes delivered.ConclusionThe delivery of palliative care to CYP is complex and multifaceted. This qualitative exploration serves to provide insight into nurses previously undocumented feelings. It highlights the private, professional and work-related variables that impact on the stressors, challenges, rewards and support systems for those nurses working in this field. New findings and areas for further research are identified, and recommendations made regarding comprehension of rural healthcare, team-working, support platforms and education for this group of nurses.
Comparing the use of Edmonton symptom assessment system (ESAS-r) in hospice & oncology outpatients
Authors: Subramaniam Sivakumar , Burcombe Russell , Cawley Declan 
Published: March 2012

Current guidance, nationally and internationally, would suggest within oncology and hospice outpatient settings holistic assessment be completed. However how this should occur and what assessment tool be used, there is no agreed consensus.AimTo explore the use of a validated patient reported symptom assessment tool within a lung oncology and hospice outpatient setting.MethodologyAn exploratory study looking at patient reported ESAS-r assessment form completion prior to attending their clinic review with an oncology and hospice setting and the data collected, analysed for comparison.ResultsTotal number of Hospice patents: 22 (male13: female 9), age: 42–80 versus total number of Oncology out patients: 26 (male14: female 12), age: 54–91. The median total symptom score for hospice outpatients was 34.5/100 versus median total score for Oncology outpatients was 23.5/100. Tiredness (6.5/10) and drowsiness (5/10) were the high scoring symptoms within hospice outpatients while tiredness (5/10) and wellbeing (5/10) were in the lung cancer outpatient setting. The median score for pain and shortness of breath was 3/10 & 0/10 in Hospice patients versus 1/10 & 1.75/10 in Oncology clinic patients.ConclusionThe symptom scores were comparable and not surprisingly the median scores were higher in the hospice outpatient setting. The physical and psychological symptoms scored significantly higher in the hospice outpatient population. The authors acknowledge the small sample size and this was an exploratory piece of work. However, clinicians found the ESAS-r tool to be clinically useful and helped focus discussions about what was important from a patient's agenda but helped in the disclosure of commonly ignored symptoms such as fatigue. This then prompted further assessment for eligibility for clinical trials specifically directed at fatigue management. Therefore the use of a patient, self-reported holistic assessment tool is a useful addition to oncology and hospice outpatient clinics.
The management of breakthrough cancer pain (BTCP) and the use of immediate release fentanyl products
Authors: Nwosu Amara , Marley Kate , Sulaivany Esraa , Dickman Andrew , Curie Marie , Littlewood Clare 
Published: March 2012

BackgroundBreakthrough pain is a common problem for people with cancer, and is associated with significant morbidity in these individuals. The association of palliative medicine (APM) has produced guidelines for the management of breakthrough cancer pain (BTcP). Immediate release fentanyl products are licensed for the management of BTcP; however, some practical concerns exist about their safety and routine use in clinical practice.Aims(1) To identify the multi-disciplinary team (MDT) experience in managing BTcP in relation to APM guidance. (2) To identify the MDT experience of using immediate-release Fentanyl products in the management of breakthrough cancer pain. (3) To develop new regional guidelines to help health professionals manage breakthrough cancer pain.MethodsA literature review informed the development of two audit surveys which examined the health professional's experience of: (1) Managing a patient with BTcP. (2) Using short acting Fentanyl products. Electronic surveys were distributed to multidisciplinary members of four integrated cancer networks during the month of August 2011.ResultsTwenty-eight BTcP surveys and 29 fentanyl products surveys proformas were completed. BTcP was identified correctly in most instances (80.8% of individuals had their background cancer pain controlled). Oxynorm was the most popular short-acting opioid (32% of occasions); Abstral was the most popular immediate-release Fentanyl preparation across hospice, hospital and community settings. Most episodes of BTcP were relieved in 30 min (56%). Concerns about storage and disposal (45%), delay in accessing medicines (45%), prescribing issues (62%) and education of generalists (62%) were highlighted by respondents.ConclusionMost episodes of BTcP were correctly identified and pain tended to resolve within 30 min of receiving analgesia. Concerns around prescribing and the education of generalists were highlighted by respondents. The findings were presented and discussed at the Regional Specialist Palliative Care Audit Group Meeting. Local guidelines and standards were agreed for publication.
The potential role of wicking fabric for the management of sweating in advanced malignant disease
Authors: Brooks Simon , Harris Dylan 
Published: March 2012

BackgroundSweating is an underreported and frequently distressing symptom that can occur in cancer patients. Treatment options are varied and often unsuccessful and patients may not want to try new medication that has adverse effects or increases their tablet load. Non-pharmacological interventions such as cotton T-shirts can be tried but patients may find that they quickly become wet and cold and require frequent changing. There may be a role for garments made from wicking fabric which draw sweat away from the body.AimTo explore the potential role of wicking fabric for the management of sweats in advanced malignant disease through a case study.* A 54-year-old lady with multiple myeloma experienced frequent drenching sweats, mainly at night. There was no associated fever. Paracetamol, non-steroidal anti-inflammatory drugs and corticosteroids were not helpful. She found that cotton T-shirts became uncomfortably wet, making her feel cold, and they often needed changing overnight leading to lack of sleep. By using wicking fabric T-shirts instead, she was able to enjoy undisturbed nights for several weeks and awoke feeling refreshed and relatively dry. She also found the wicking T-shirts helpful in the management of her daytime sweating. Overall she felt that the wicking garments significantly improved her quality of life at that time.ConclusionThis case study, in the context of the available evidence, suggests a potential useful role of wicking fabric. A randomised crossover study comparing cotton T-shirts with those made from wicking fabric in the management of malignant sweating is now being developed to explore this theme further. *Verbal consent was obtained from the patient who sadly passed away before written consent could be obtained. Written assent provided by patient's husband.
An audit of the multidisciplinary management of malignant bowel obstruction on an oncology ward in an acute tertiary hospital
Authors: Ryan Richella , Bruce Emma , Leithead Jane 
Published: March 2012

BackgroundMalignant bowel obstruction is common in advanced cancer. It is frequently associated with a poor prognosis. Management is complex and requires multidisciplinary input. Though management decisions need to be individualised, the assessment process leading to such decisions should be systematic.AimsThe primary aim was to provide baseline information on key areas of malignant bowel obstruction management for future auditing purposes. A secondary aim was to assess compliance with the current hospital guidelines for the medical management of this condition.MethodsThe medical notes for 32 admissions to the oncology ward of an acute tertiary hospital between 31 July 2009 and 1 August 2010 were reviewed. Data was entered onto a proforma. Descriptive statistical analysis was performed using SPSS.ResultsThe majority of patients had advanced cancer with peritoneal metastases (28.88%). Ovarian was the most common primary site (17.57%). 15 (47%) patients were committed to a course of chemotherapy at presentation. The majority of patients had symptoms of nausea (26.81%), vomiting (26.81%), abdominal pain (26.81%) and altered bowel habit (27.78%). Medications were administered via a continuous subcutaneous infusion in 19 (60%) cases. A nasogastric tube was inserted in 10 (31%) cases. Cyclizine was the most commonly used first-line antiemetic (57%). Octreotide was rarely used (3.9%). Treatment of persisting bowel obstruction included: chemotherapy (13.41%), surgery (3.9.4%), radiotherapy (1.3%), stenting (5.15%) and venting gastrostomy (1.3%). 7 (22%) patients were commenced on parenteral nutrition. Twenty-seven patients (84%) survived to discharge and, of these, 20 (74%) were discharged home.ConclusionThe results indicate that the presentation and nature of malignant bowel obstruction is heterogeneous and that treatment decisions vary widely. The current local guidelines are under review to promote more consistent management and to guide referral to important disciplines.
Pictorial prescribing reduces error in administration of fentanyl for breakthrough pain
Authors: Booth Stephen , Gloag Maria , Kinna Sara , Wheble Andrew Bell Jo , Wheeler Daniel 
Published: March 2012

ObjectivesFentanyl is commonly used in patients with transient exacerbations of cancer pain due to its rapid transmucosal absorption. Intranasal sprays, sublingual tablets, and buccal tablets or lozenges are available. The preparations are not interchangeable, with varying bioavailability, creating potential for opioid prescribing errors. This study aimed to demonstrate a reduction in opioid medication errors via a novel and low cost strategy: the use of printed stickers for prescription charts with a pictorial cue illustrating the preparation.MethodsFifty-four nurses from our institution were shown 10 handwritten or printed pictorial sticker prescriptions for fentanyl for breakthrough pain. They were asked to indicate which preparation and dose they would administer from boxes of Instanyl (Nycomed), Abstral (ProStrakan), Effentora and Actiq (Cephalon), and to indicate the ease with which they understood the prescription on four-point Likert items. The authors measured the frequency with which nurses selected the wrong preparation or dose. Likert items were analysed categorically as positive or negative responses. Results are reported as OR with 95% CI, and were compared using the χ2test.ResultsNurses were more likely to choose the correct fentanyl preparation when using pictorial printed stickers compared to handwritten prescriptions: errors were significantly reduced from 20 to 6 (OR 3.52, 95% CI 1.39 to 8.90, p<0.005). Also, dose errors were non-significantly reduced from 27 to 19 (OR 1.47, 95% CI 0.80 to 2.70, p=0.057). Analysis of Likert items showed a significant improvement in understanding of which preparation to administer: positive responses increased from 227 of 267 responses with handwritten prescriptions to 247 of 266 responses with pictorial printed stickers (p<0.0005). Conclusion: Using pictorial printed stickers is an effective strategy for reducing errors in choice of rapid-onset fentanyl preparations. There may be a wider use for pictorial prescribing where many non-interchangeable preparations of the same drug exist.
Malignant bowel obstruction: current practice in an inpatient specialist palliative care unit
Authors: MacKay Helen , Isherwood Ruth 
Published: March 2012

BackgroundMalignant bowel obstruction (MBO) is a distressing complication of many advanced cancers, notably those of ovarian or colorectal origin. Most patients with advanced disease are managed medically to improve their symptoms, however variation exists in how this is achieved.AimsThe audit aimed to establish current practice in the management of MBO within a hospice inpatient unit, prior to writing evidence-based guidelines for use locally.MethodsCases were identified by reviewing letters written for the last 100 patients who had died in the inpatient unit. Records were retrieved for patients with: MBO as certified cause of death; symptoms suggesting obstruction (nausea, vomiting, colic, abdominal distension, constipation); or cancers with a propensity to cause obstruction at any level. Case notes were reviewed and a database created to collate information including; primary diagnosis, presence of metastatic disease, likely cause of MBO, symptom response, pharmacological agents used and outcome of obstructive episode.ResultsFifty-one case records were consulted after screening. Twenty-three patients had clinical presentations suggestive of MBO. The majority (n=17) were female. Ages ranged from 50–89 years. Colorectal and gastric cancers were the commonest primaries. Eighteen patients received an antisecretory agent; nine were prescribed octreotide alone, two hyoscine butylbromide alone and seven a combination of both agents. Octreotide doses ranged from 200 mcg–1200 mcg/24 h. Indications for adding hyoscine butylbromide (20 mg 180 mg/24 h) were persisting large volume vomiting and the development of colic. Symptom improvement was recorded for all patients. The episode of obstruction resolved clinically in only two cases.ConclusionThis audit suggests that octreotide is the first line antisecretory agent in use within the Hospice. Hyoscine butylbromide was added for patients with on-going symptoms. Inclusion of hyoscine butylbromide as an additional antisecretory appeared of value in achieving symptom control, which the forthcoming guidelines will reflect.