From hospital to community-based cancer care
Oral anti-cancer medications (OAM) are increasingly being used in cancer care. They have the potential to particularly benefit patients in the community who can be treated in their homes, while also freeing up hospital beds. However, because the clinical assessment for each cycle of these medications requires specialist patient review, usually performed in a hospital-based oncology unit, potential gains such as improved patient expediency or increases in hospital capacity are not being fully realised in Ireland, where this study took place.
In a recently published pilot study, Richmond et al (2024) sought to assess the feasibility of a novel community-based integrated oncology care model led by advanced nurse practitioners (ANPs) for adults based in Ireland receiving OAM. The new model of care was assessed in terms of patient safety, acceptability to patients and staff, and cost.
Before determining whether to progress to phase 2, which marks this single-centre pilot study, the authors carried out a scoping review, which examined international guidelines and carried out a qualitative study (Richmond et al, 2022). The aim was to determine the acceptability of ANP-led care and the possible transition to integrated care.
This study took place over a 4-month period between January and May 2022, during which eligible patients received care and continual communication took place with community staff. Close links were also maintained with the hospital-based oncology staff. From a convenience sample of 67 patients being cared for by the ANP in the hospital-based OAM clinic, 37 were deemed eligible if the days of their cyclical assessments lined up with the intervention days set in the study (which were chosen based on the availability of the Health Service Executive's community-based location).
The findings of this pilot study revealed that intervention adherence, as well as acceptability assessments, among both patients and staff were excellent. Patient recruitment and retention of eligible patients was close to 100%, and patient safety was effectively assessed and maintained throughout the pilot study. Methods to assess the cost and outcomes of the intervention were successfully implemented and the authors concluded that progression to a main trial was warranted.
District nurse assessment of mental illness in young adults
Mental illness in young adults is on the rise internationally, and district nurses play a key role in promoting health and wellbeing, as well as detecting mental health issues in the community. In Sweden, where this study is based, the district nurse is the first person to meet young adults in primary care and carry out an initial healthcare assessment.
In this qualitative study, semi-structured interviews were carried out with nine district nurses across rural and urban primary care centres in southeastern and northern Sweden, including five managers. Following qualitative content analysis of the data gathered during the interviews, three categories emerged with associated subcategories.
The first category was ‘the difficult meeting’ encompassing emotionally challenging encounters: to listen, confirm, and dare to ask; trying to encourage the young adults to talk; and looking beyond the obvious. The second category was the district nurse's ability to promote health which consists of assessing, correctly prioritising and passing on these young adults to other health professionals; and nurturing the whole person. The third and final category was ‘a sense of inadequacy’, which incorporated a lack or shortage of time, the importance of having sufficient resources, and the need for appropriate knowledge and skills.
The study revealed that all district nurses experienced challenges, noting a lack of time, resources and knowledge as consistent barriers to creating trusting relationships with young adults, sometimes leading to feelings inadequacy. District nurses' experiences of pain and grief as a result of seeing young adults with mental illness were also highlighted. The courage to ask questions to help people open up for conversation and to identify mental illness was emphasised, as well as the importance of listening. However, when young adults had difficulty expressing their emotions, this led to feelings of powerlessness and was sometimes perceived by the district nurses as a failure to create trust.
A common experience was for mental illness to be masked by physical ailments such as high blood pressure or trouble sleeping. All district nurses emphasised the importance of good collaboration between different professions. It was also noted that appropriate knowledge surrounding mental illness is required to provide safe and secure care, and that continuous training and development of district nurses is needed.
Managing hard-to-heal wounds in the community
Wounds are common and their burden and prevalence are growing. However, despite this, most wounds are not looked after by a qualified wound care provider (QWCP). It is common for people to attempt to care for wounds resulting from injury themselves at home and community nurses, as well as other community-based healthcare providers, who may not have received specialised wound care training, will often see patients requiring wound care. However, various issues can cause delayed healing resulting in stalled, hard-to-heal wounds (HTHWs) that do not follow a normal or desired healing trajectory and which are not always identified early on.
In this study published in the International Wound Journal, an expert advisory panel of QWCPs, comprising eight nurses, one physiotherapist and three physicians from across Europe, North America, Australia and Africa, met to discuss the issue of HTHW management, review relevant literature, share clinical experiences and develop a set of simplified recommendations for community-based healthcare providers.
Acute wounds normally heal within 4–6 weeks, with a wound size reduction of 40–50% at 4 weeks of a good standard of care. However, HTHWs will not follow this trajectory and early identification of this, followed by appropriate referral to a QWCP or multidisciplinary wound care team, is essential. There are wound characteristics, as well as person-related factors (eg obesity, older age) that are known to delay wound healing, and which can be identified early to prevent wound complications that place a burden on both the patient and the healthcare system.
Combining the best available evidence and consensus among the expert panel, 15 actionable, evidence-based recommendations were created, along with key implementation strategies. The 15 recommendations, which are expanded upon within the original article, are as follows:
- Predict hard-to-heal status early by identifying and addressing (when possible) person-related factors known to delay wound healing
- Use clinical signs to identify a HTHW as early as possible
- Refer patients to a QWCP as soon as a HTHW is suspected, that is, before or at 4 weeks if not healed or the surface area is not reduced by 40%–50%
- Perform a thorough holistic patient, wound and periwound assessment, including basic bedside vascular screening examinations and tests if applicable
- Deliver best practice standard of care when treating any wound
- Follow the ‘TIMERS’ (Tissue debridement, Infection or inflammation control/reduction, Moisture balance, Edge effect to advance epithelialisation and wound closure, Regeneration/repair of tissue to close the wound, and Social factors to be considered) framework for optimal preparation of the HTHW and periwound for healing
- Cleanse the HTHW and periwound with a skin-friendly cleanser
- Remove unhealthy tissue from the wound bed
- Manage infection and inflammation or refer as needed
- Manage moisture in the wound and periwound to create a healthy, moist environment for healing
- Apply appropriate advanced wound dressing according to wound characteristics, for example, moisture level and wound depth
- Arrange for compression therapy as appropriate over wounds of patients with poor venous return, including lower leg venous insufficiency ulcers
- Manage wound and periwound skin to promote epithelial advancement of the wound edges
- Refer the repair and regeneration step of the framework to a QWCP for advanced adjunctive therapies
- Be attentive to the patient's over-arching social situation.
In order to translate the above recommendations into practice, the following five implementation strategies are provided:
- Facilitate easy access to these recommendations through digital platforms and training sessions to ensure widespread dissemination among community-based healthcare providers
- Foster a culture of continuous learning and professional development through workshops and case discussions can aid in understanding nuances of the recommendations
- Incorporate recommendations into electronic health record systems to serve as a digital prompt during patient encounters, helping to ensure adherence to guidelines
- Carry out regular audits and feedback mechanisms to help monitor the application of recommendations and identify any barriers or challenges faced by community-based healthcare providers
- Foster collaboration among community-based healthcare providers and qualified wound care providers through multidisciplinary meetings to provide a platform for knowledge exchange, addressing queries and sharing best practices.