Feeding tubes in patients with dementia

This is an example of an approach to improve quality on the wards, for a problem where the evidence was clear but being ignored.

A growing body of research over the past decade has questioned the utility of placing feeding tubes (percutaneous endoscopic gastrostomy (PEG) or jejunostomy) in patients with advanced dementia. Studies have found no evidence that feeding tubes in this population prevent aspiration, prolong life,  improve overall function, or reduce pressure sores.

Additionally, the quality of life of a patient with advanced dementia can be adversely affected when a feeding tube is inserted. The patient may require wrist restraints to prevent pulling on the tube or may develop cellulitis at the gastrostomy site, develop decubitus ulcers, be deprived of the social interaction and pleasure surrounding meals, and require placement in a nursing home.

Unfortunately, many doctors are unfamiliar with this literature or face barriers—attitudinal, institutional, or imposed by the healthcare industry—to applying its findings to their practice. Thus feeding tubes are placed in patients who will not benefit from this intervention and whose quality of life in the terminal stage of their illness will be adversely affected.

Despite lack of evidence that enteral feeding tubes benefit patients with dementia, and often contrary to the wishes of patient and family, patients with dementia who have difficulty swallowing or reduced food intake often receive feeding tubes when hospitalised for an acute illness.

The authors conducted a retrospective chart review of all patients receiving percutaneous endoscopic gastrostomy or jejunostomy tubes between March and September 2002. Interventions including a palliative care consulting service and educational programmes were instituted. They conducted a second chart review for all patients receiving feeding tubes between March and September 2003.

They measured the number of feeding tubes placed in patients with dementia, the number of feeding tubes placed in patients with dementia capable of taking food by mouth, and the number of feeding tubes placed in patients with dementia with an advance directive stating the wish to forgo artificial nutrition and hydration.

Medical and allied health staff received educational programmes on end of life care and on feeding management of patients with dementia. A palliative care consulting team was established.

After the interventions, the number of feeding tubes placed in all patients and in patients with dementia was greatly reduced. they felt that multidisciplinary involvement, including participation by the administration, was essential to effect change in practice.

The intensive focus on a particular issue and rapid change led to a culture shift within the hospital community. The need to establish unified goals of care for each patient was highlighted.

Source: Web

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Reducing MRSA

Most transmission of MRSA from patient to patient is thought to be mediated by transiently colonised healthcare workers, although airborne dispersal and transmission through contacts with contaminated surfaces may also be important. Isolation measures for patients are intended to interrupt such transmission.

The most intensive forms of isolating patients are isolation wards and nurse cohorting (the physical segregation of MRSA patients in one part of a ward, with nursing by designated staff who care exclusively for these patients).

This BMJ paper evaluated the evidence for the effectiveness of isolation measures in reducing the incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital inpatients.

Articles reporting MRSA related outcomes and describing an isolation policy were selected. Forty-six studies were accepted; 18 used isolation wards, nine used nurse cohorting, and 19 used other isolation policies. Most were interrupted time series, with few planned formal prospective studies.

All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies.

Most others provided evidence consistent with a reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures including patient isolation were effective in controlling MRSA. In two others, isolation wards failed to prevent endemic MRSA.

The authors’ overall conclusion was that major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded.

No well designed studies exist that allow the role of isolation measures alone to be assessed. None the less, there is evidence that concerted efforts that include isolation can reduce MRSA even in endemic settings. Current isolation measures recommended in national guidelines should continue to be applied until further research establishes otherwise.

Source: Web

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Pelvic floor exercises during pregnancy

This study was et up to examine a possible effect on labour of training the muscles of the pelvic floor during pregnancy, using a randomised controlled trial. It was carried out at Trondheim University Hospital and three outpatient physiotherapy clinics in a primary care setting. The participants were 301 healthy nulliparous women randomly allocated to a training group (148) or a control group (153).

A structured training programme with exercises for the pelvic floor muscles between the 20th and 36th week of pregnancy was carried out.

The study examined the duration of the second stage of labour and number of deliveries lasting longer than 60 minutes of active pushing among women with spontaneous start of labour after 37 weeks of pregnancy with a singleton foetus in cephalic position.

Women randomised to pelvic floor muscle training had a lower rate of prolonged second stage labour (24%) 22 out of 105 women were at risk (undelivered) at 60 minutes in the survival analysis, than women allocated to no training (38%) . The duration of the second stage was not significantly shorter (40 minutes v 45 minutes).

The authors conclude that a structured training programme for the pelvic floor muscles is associated with fewer cases of active pushing in the second stage of labour lasting longer than 60 minutes.

Source: Web

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