Continence Management in MS Special Feature Pressure ulceration

Transcription

ISSN 1361 -4177
Vol. 10 - Issue 11 June/July 2007
Parkinsons Disease
Nurse Specialists in Scotland
Infection Control
Urinary catheterisation
Continence
Management in MS
Fat Happens
Anne Diamond part 4
DVT
Treatment & prevention
Diabetes part 4
Complications
Turn to page 39
Anemia
Classification
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Go to page 45
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JOJOUFSOBUJPOBMOVSTFSFDSVJUNFOU
Special Feature
Pressure ulceration
Various opportunities on page 54
Recruitment section
General
& Overseas
www.scottishirishhealthcare.com
1
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particularly in the out of hours period. We in return will give you the opportunity to enhance your current skills and acquire new ones, which will
benefit your nursing career, wherever it takes you.
NHS 24 is committed to your ongoing continued Professional Development. We will actively support your career through a range of resources such
as Bursary Award & Study Leave Schemes, E-learning, Clinical Supervision and our Coaching Programme. All new recruits are also supported by
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Join us on a part-time or full-time basis working mainly in the evenings, nights, weekends and public holidays. Various hours of employment
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Contents
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S
N
SCOTTISH
NURSE
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International and local news
What’s On
Find out what’s on in and around your area
Parkinsons Disease
Nurse specialists in Scotland
Infection Control part4
Continence
Management in MS
Nutrition & Obesity
Fat Happens part 3 by Anne Diamond
DVT
Treatment & diagnosis
Diabetes part3
Diabetic complications
Anaemia
Classification
Special Feature
The cost of pressure ulceration
Nursing in Australia
Opportunities and information
General Recruitment
Various job opportunities
Nursing in America
Nursing in New Zealand
Nursing in Canada
Nursing in Ireland
Product focus
Products & services
Education & Training
Skills for Nurses 2007
Scotlands Biggest & Best Nursing Exhibition
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News
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press releases etc., to the Editor at the address opposite.
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Deadline date for redundancy
retirement protection for NHS
Hard-up NHS trusts cut back on
unproven homoeopathy treatment
New retirement protection for NHS staff means those
who are over the age of 50 and made redundant before
30 June 2007 will be in no worse a position than if they
had been made redundant on 30 September 2006.
The NHS is turning its back on homoeopathy and other
unproven alternative medicines in the face of a financial
crisis and pressure from doctors.
The retirement protection, which is effective from 1 October 006,
ensures that the over-50s continue to have their NHS service
enhanced for retirement purposes and those made redundant after
June will have their entitlement to enhanced service reduced; with
the reduction in enhancement increasing the later redundancy occurs
after the June deadline. Staff who are made redundant who are not
seeking retirement but a redundancy payment under the new
arrangements will not be affected by the deadline.
RCN requests an extended protection period
The NHS staff side unions wrote to Lord Philip Hunt, Minister of
State at the Department of Health, asking that the 0 June date be
extended to 1 September 007, but in his letter of 5 April 007 he
refused the application on the grounds that it would not comply with
the EU Directive on Age Discrimination.
More than half of the primary care trusts (PCTs) in England are now
refusing to pay for homoeopathy or severely restricting access a year
after The Times revealed that 1 senior doctors had urged them to
fund only therapies that were backed up by scientific evidence.
Figures obtained by Les Rose, one of the doctors, and The Times
under the Freedom of Information Act show that at least 86 of
the 147 trusts have either stopped sending patients to the four
homoeopathic hospitals, or are introducing strict measures to limit
referrals. Another 40 trusts have yet to provide data. More than 0
have taken action since receiving a letter organised a year ago today
by Professor Michael Baum, a cancer specialist at University College
London, which argued that “unproven or disproved treatments” such
as homoeopathy and reflexology ought not to be available free to
patients.
The RCN is against compulsory redundancies and is continuing to
fight to keep members in work. However, some organisations have yet
to resolve their service re-organisations, which means there is still no
final decision about redundancies and the date of these.
The NHS should not be funding such therapies while it had to refuse
or ration access to effective cancer drugs such as Herceptin and
Velcade, the authors said. Financial issues have also contributed to
the trend. The NHS overspent by £547 million in 005-06 and many
trusts have made savings on homoeopathy to avoid cuts.
Although the RCN does not want undue delays in redundancy
decisions, where there is clearly no suitable alternative employment
available, it wants to ensure that staff being made redundant get the
best possible benefits. And for those aged over 50 that is likely to
mean ensuring their employment is terminated by 0 June this year.
The move away from homoeopathy has been so significant that two
homoeopathic hospitals are threatened with closure. West Kent
PCT is consulting over plans to shut Tunbridge Wells Homoeopathic
Hospital and the Royal London Homoeopathic Hospital (RLHH) has
asked supporters to lobby trusts and MPs.
The RCN and other unions will continue to work at a local level
with employers to ensure that reorganisation is concluded in a timely
manner before 0 June 007 and that any necessary termination of
employment is dealt with before June 0.
London trusts have been particularly tough, partly as they have had to
reduce some of the largest deficits in the country. Six trusts, including
some of the RLHH’s most important financial backers such as Barnet
and Islington, have introduced referral management systems that will
restrict spending.
Who will pay for long-term care?
At least ten more from London and southeast England have cancelled
their contracts.
The RCN has joined forces with 14 other organisations
to launch a national initiative looking at the future
funding of long-term care in the UK.
Caring Choices: who will pay for long-term care? is a nationwide
initiative to help shape future policy on long-term care for older
people. It focusses on asking the key question: “Who will pay for
long-term care?”.
Along with a website, a series of events will be held across England
and Scotland over the next seven months. The events will give older
people, carers and individuals working in long-term care to consider
strategies for better care and give their views on how it could be
funded in a way that is fair and equitable.
To join the debate, take part in the online survey, and find out more
about the campaign go to the website: www.caringchoices.org.uk.
4
Homoeopathy involves treating patients with substances that have
been diluted so many times that there is often no active ingredient
left. It is popular with members of the Royal Family but derided by
most scientists. Research suggests that it has no benefits beyond
being a placebo.
Doctors behind the original letter sent a second document to PCTs
yesterday, providing a sample commissioning paper that many trusts
have used to reduce homoeopathy funding.
Gustav Born, Emeritus Professor of Pharmacology at King’s College
London, its lead author, said: “Progress has been slower than we’d
like and there are still trusts that continue to use these unproven
remedies through clinics and prescriptions. That is why we have
written again to all the PCTs urging them to follow the
commissioning example set by others.”
News
Hilary Pickles, director of public health at Hillington PCT, said: “It
isn’t just that there is no evidence base for homoeopathy; it is also a
question of spending priorities. Every time you decide to spend NHS
money on one thing, something else is losing out. It is completely
inappropriate to spend money on homoeopathy that is unproven,
as it means less money for other treatments that are known to
be effective.”
One person who could benefit from a switch is Anne Fleming, 58,
who had multiple myeloma diagnosed 2½ years ago. She has been
told that she will need treatment with Velcade, an anticancer drug
that costs up to £25,000 for eight cycles. Her primary care trust in
South Cambridgeshire has diverted funds from homoeopathy to
conventional medicine.
She said that the NHS should also abandon non-essential treatments.
“I feel very strongly about using public money on tattoo removal.
Things on the national health should be about life or death,” she said.
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Breakthrough in fight against
healthcare associated infections
NHS Lothian staff have developed a successful new
approach to tackling dangers faced by intensive care
units across the world.
A new education and care package for the insertion of central venous
catheters has achieved a dramatic fall in the number of infections
related to the use of these important devices.
The education package has been developed by staff at the Royal
Infirmary of Edinburgh (RIE), in consultation with NHS Education for
Scotland. It was initially trialed in the Intensive Care Unit at the RIE
and is now being rolled out to intensive care units at the Western
General Hospital and St John’s Hospital in Livingston.
Carol Fraser, Interim Associate Director for Health Protection, NHS
Lothian, said: “Intensive care units face big challenges in preventing
infections. They are obviously dealing with the sickest patients and
devices such as central lines are vital to the patients’ management.
“The Intensive Care Unit of the RIE has participated in HELICS
(Hospital in Europe Link for Infection Control through Surveillance)
surveillance for the past two years. The second annual report from
HELICS has been published and it highlights the achievement of NHS
Lothian staff in reducing the incidence of central venous catheter line
infection to seven cases in 2006/7 compared to 22 the previous year.”
Details of this achievement are contained in a report to the board of
NHS Lothian, which meets on Wednesday, the 23rd of May.
The report states that the level of healthcare associated infectionssuch as MRSA has remained stable in NHS Lothian, as has been the
case for the last five years.
The report also details progress made on NHS Lothian’s Cleanliness
Champions initiative, the national healthcare associated infection education programme that provides key staff with enhanced education in
infection control which they can share with colleagues.
Two study days are being held by the Cleanliness Champions
organisers, with the first, being held on the same day as the board
meeting, having over 170 delegates registered to attend.
www.fallsavers.co.uk
[email protected]
The HeART Health Wallchart
A new wallchart highlighting the importance of heart health
is to be offered free of charge to healthcare professionals
(HCPs). The HeART Health Wallchart is an interactive tool for
use in practices and with patients. Developed with experts in
heart health, the A1-sized chart offers clearly outlined tips to
help deliver the message of heart health to patients.
Designed in a visual, question and answer format, the chart
provides answers
to common queries
concerning dietary
choices, helping HCPs
advise their patients
on healthier nutritional
alternatives.
The Wallchart will be
included free of charge
within the next
edition of the heart
health publication
Spread It.
It will also be available
to download at www.
proactivscience.com
News
Fizz taken out of sugary drinks sale
in hospitals
HOSPITALS are to be banned from selling sugar-laden
fizzy drinks to staff and visitors in the Lothians as part
of a new health drive.
The soft drinks will be removed from canteens and cafeterias, while
vending machines will be ditched or re-stocked with healthier
alternatives.
Local celebrities the McDonald Brothers, contestants
on the TV show the X Factor, have opened the newly
refurbished day room in the Buchanan Ward, Biggart
Hospital.
Craig and Brian took time out of their busy schedules to cut the
tartan ribbon and spent time chatting with patients and staff.
There was a real buzz of excitement around the ward as both staff
and patients had been keen supporters of the boys during their time
on the X Factor.
The move has been ordered by NHS Lothian in an effort to help
improve the health of staff and patients. The ban covers full sugar soft
drinks such as Coca-Cola and Irn-Bru, but not diet versions of the
same brands.
The only hospital to escape the crackdown is the ERI. Staff and
visitors will continue to get a choice there, because its shops, cafés
and vending machines are operated by private firms.
However, NHS Lothian may approach the private operators at a
future date.
Dr Allan Gunning, Chief Operating Executive commented: “We would
like to thank the McDonald Brothers for taking the time to come and
visit Biggart Hospital. They signed autographs, posed for photos and
went for a walk around the hospital, it certainly brightened up the day
for both patients and staff.”
Health chiefs hope the initiative, to be in place by the start of July, will
win the hospitals an award for encouraging healthy living. But it has
angered many staff, who have described it as “a dictatorial measure”
and say it is treating them “like babies”.
Gene offers hope of progress
on cancer
A patients’ watchdog, however, has supported the move. The ban
will affect all shops and canteens run by the NHS, as well as those
operated by volunteers from the WRVS, at the Western General,
Liberton, St John’s, Astley Ainslie and Royal Edinburgh hospitals.
SCIENTISTS are a step closer to finding out why some
people get cancer, thanks to research unveiled today.
The move has been announced in an e-mail to staff, which states:
“NHS Lothian catering services are pursuing the Healthy Living
Award, promoting healthy choices to staff and visitors.
A team from Dundee University discovered that people who carry a
variant of a specific gene are less likely to develop cancer of the lung.
The experts found that the changed gene results in the potentially
cancer-producing protein it makes being broken down and rendered
harmless at a much faster rate.
So far the discovery applies to lung cancer only, but researchers now
want to find out if the gene’s mechanism has implications for other
forms of the disease. All humans have the unaltered gene, CYP1B1,
while fewer than 10 per cent of people carry its variant.
Dr Thomas Friedberg, who has led the work at Ninewells Hospital,
Dundee, said the dangerous protein is broken down three times as
fast in people with the altered gene.
“As part of that process it is the wish of the board to remove
carbonated, sugary drinks from sale within NHS Lothian’s catering
outlets and to promote the sale of perceived healthier options.”
Reacting to the move, one nurse said: “Don’t we have a right to
choose anymore? Sometimes you want to have a fizzy drink even
though you know it’s not good for you. I know some of the doctors
like to have an Irn-Bru when they are hung over.”
Another said: “Where is it going to end? Are they going to ban crisps
and chips too? It’s treating us like babies not offering us a choice.”
But Margaret Watt, chairwoman of the Scotland Patients Association,
said that the move was a “step in the right direction”.
Having lower levels of the protein corresponds to a lower risk of
developing cancer, he said, although the precise relationship is not yet
known.
“These fizzy drinks can cause a lot of health problems, which the
older generation didn’t know about when they were children,” she
said.
Dr Friedberg, 56, added: “We found that the levels of this protein in
cells differed depending on the type of the CYP1B1 gene.
“Nowadays it is appropriate to educate youngsters that these drinks
are not good for them.”
“This was because some varieties of the CYP1B1 protein were broken down much faster by cellular enzymes.
“This in turn results in individuals in the metabolism of cancer-causing
substances, leading to differences in cancer susceptibility.”
He added: “We believe our findings will lead to novel approaches in
treatment.”
James McCaffery, NHS Lothian’s director of human resources, said:
“The removal of sugary drinks is just one way we can encourage
our staff, patients and visitors to enjoy a healthier diet while in our
premises.
In the past, women who carry the one changed form of the gene have
been found to have lower incidence of the disease compared with
individuals with the other forms of the CYP1B1, but the reason was
not known.
6
“Low-calorie carbonated drinks will still be available in shops, snack
bars and vending machines. People who still want to have sugary fizzy
drinks will not be prevented from bringing them into our facilities.
“Research has shown us that reducing intake of sugary drinks can
help in maintaining a healthy weight.”
News
Roger Daltrey unveils Scotland’s
first Teenage Cancer Trust unit
Roger Daltrey CBE launched Scotland’s first Teenage
Cancer Trust unit at the Beatson West of Scotland
Cancer Centre in Glasgow.
The 6-bed ward, funded by Teenage Cancer Trust, will treat patients
from West of Scotland. This is Teenage Cancer Trust’s eighth ward in
the UK and, like other TCT units, it is expected to improve survival
rates by as much as 15%. The unit will give teenagers going through
cancer treatment the opportunity to be treated with people their
own age and help them to come to terms with the disease and its
effects. State-of-the-art equipment such as flat-screen TVs, computers,
game consoles and internet access will keep patients occupied during
long hospital stays and allow them to stay in touch with friends and
family.
The unit, which cost TCT £500,000 to build, has 6 beds, 4 of which
are on one level with the remaining on a lower level, connected
via a lift which goes directly onto a day room. The day room has
panoramic views across the city and contains a cafe-style space for
patients to take part in various activities. There are also two giant
TVs - one for playing computer games and the second to watch
films, with comfy seats around it. When well enough, patients will be
encouraged to get out of bed and socialise. Each bedroom has a flat
screen TV, internet access and a game console with wireless controls.
Special attention has been paid to the furnishings, making each room
feel more like a teenager’s bedroom or hotel room, than a hospital.
For example, clinical functions such as piped gases have been hidden
behind smart wooden panels and each bathroom has unique vinyl
wraps on the walls.
Each day in the UK, 6 teenagers will find out they have cancer – that
is over ,000 diagnoses a year. Around 160 of those live in Scotland.
Seventy per cent of teenagers with cancer in the UK still do not
have access to a specialist TCT facility and will receive treatment on
wards with young children or the elderly. To date, TCT has built units
in London, Leeds, Liverpool, Birmingham, Manchester, Newcastle and
Sheffield and desperately needs more so that every teenager in the
UK can have access to one. Plans for further TCT units in Glasgow
and in Edinburgh are at an early stage.
Roger Daltrey CBE, Who frontman and TCT patron said, “Teenage
Cancer Trust units give our teenagers the moral support to help
fight this terrible disease. It’s great we’ve been able to open a ward in
Glasgow but we need more of them so that every teenager in the UK
can have access to one”.
Simon Davies, CEO, Teenage Cancer Trust said, “We are delighted to
have opened Scotland’s first Teenage Cancer Trust unit at the New
Beatson in Glasgow. The facility will ensure that Scottish teenagers
with cancer are getting the best possible treatment.
“We are grateful to all at the New Beatson for their continued support and assistance in creating this state-of-the-art facility”.
Professor Alan Rodger, Medical Director of the new Beatson West
of Scotland Cancer Centre, said: “The Teenage Cancer Trust unit is a
magnificent new facility for young people. We very much hope that
this unit will provide a home away from home for young people, so
they will feel more relaxed while receiving treatment and hopefully
recuperate more quickly.
“The new Beatson has benefited from many additional facilities,
features and other enhancements made possible by our charitable
partners. We are very grateful to Teenage Cancer Trust for
funding this state-of-the-art centre of excellence for young people
with cancer.”
Healthcare Professionals Invited to
Nominate Their Specialist Colitis
and Crohn’s Nurses for
NACC Nursing Award
As part of NACC’s ongoing campaign to raise
awareness of the important role played by Specialist
Nurses in the quality and continuity of care for Colitis
and Crohn’s patients, NACC is inviting
Gastroenterologists, General Physicians, Surgeons
and Nursing Staff to nominate their Specialist Colitis
and Crohn’s Nurse for the 2007 NACC Nursing Award.
Previously, this Award was nominated by the NACC membership
who responded enthusiastically by explaining how and why their
Specialist Nurse had gone beyond the normal call of duty to provide
and in many cases set-up new nursing-led patient initiatives.
With over 140 excellent nominations, the judges had an extremely
difficult task in deciding upon a winner but after careful deliberation
they all agreed that Belle Gregg, IBD Nurse Specialist and Nurse
Endoscopist of the Royal Liverpool University Hospital was the
005 Award winner.
This year NACC is inviting all healthcare professionals involved in
the care of patients with Colitis and Crohn’s Disease to download
a nomination form from the NACC website and tell us why the
Colitis and Crohn’s Nurse in your hospital deserves this Award.
The specialist nurse(s) in your hospital may be Colitis and Crohn’s
Nurses, IBD Nurses, Gastroenterology, Colorectal or Stoma Care
Nurses – their titles are unimportant. As long as they play a specialist
nursing role in the care of people with Colitis and Crohn’s Disease,
they are eligible for nomination.
The entries will be judged by NACC and a small expert panel with an
award of £1,000 for further education being presented to the winning
Nurse in the Autumn of 007. Richard Driscoll, Director of NACC
explains, “We are delighted to be offering this award in recognition of
the essential role played by specialist nurses within the IBD team.
We look forward to receiving a high level of nominations from
healthcare professionals in hospitals throughout the country, and
raising awareness of the importance of the Specialist Nurse in the
care and management of Colitis and Crohn’s disease.”
To nominate your Specialist Nurse simply log on to www.nacc.org.uk
and download the nomination form.
7
News
Concerns over decontamination
of reusable medical devices
Decontamination of reusable medical devices is a key service
supporting primary care in Scotland. But it is a service that has
caused considerable concerns in recent years.
These concerns have grown since identification in the mid-nineties
of the potential risk of transmission of vCJD by inadequately
decontaminated medical devices.
Suspicions that something might be wrong in decontamination
practices nationally were emphatically confirmed in the Old
Report of 2002, which described widespread failings in facilities,
equipment and decontamination training of staff in primary and
secondary care services in Scotland. This followed the 2001 report
The Decontamination of Surgical Instruments and other Medical
Devices, which included a review of procedures in general practices.
In addition, a large-scale observational survey of 179 dental
practices in Scotland, published in 2004, highlighted many
shortcomings in the cleaning and sterilization of dental instruments
and low levels of support and training for the dental team.
These reports and the concerns that preceded them emphasise
just how vital it is for staff who are involved in decontamination
processes to practice in a safe and effective manner. The health
and well-being of their patients, their colleagues and themselves
depends upon it.
Although primary care staff works hard at providing a good
service, there are strong indications that they are unaware of what
constitutes good decontamination practice and what guidance,
standards and formal quality management systems are available to
support them.
This lack of awareness needs to be addressed through appropriate
education and training. And a new online programme is being
developed precisely to meet that need by supporting practitioners
in primary care to gain the knowledge and skills necessary to carry
out decontamination processes safely and effectively.
The programme - Education and Training Programme on
Decontamination for Primary Care Staff in NHS Scotland - is the
product of a partnership involving NHS Education for Scotland
(NES), Health Protection Scotland (HPS) and a specialist e-learning
organisation. It is based on a combination of current policy, practice,
standards and guidelines, both national and international, and
reflects existing education models in Scotland and elsewhere.
A wide range of topics focusing on key issues vital to ensuring
patient safety is presented in the programme (see text box).
Coverage is given to all aspects of the decontamination lifecycle
through the provision of essential information and advice on best
practice.
Programme topics include…
•Decontamination – An Overview
•Acquiring Medical Devices
•Protecting Yourself & Others
•Microbiology
•Cleaning & Disinfection
•Inspection
•Packaging
•Sterilization
•Disposal
•Transport
•Storage
•Ensuring Quality
Programme developers recognised that while practitioners working
in dental, podiatry and GP clinics or practices face very different
clinical issues and challenges on a day-to-day basis, the fundamental
principles underpinning their decontamination practices are the
same. This provided an opportunity to create a learning resource
that has equal value and validity across a range of professions and
practitioners working in primary care settings, including dental
nurses, practice nurses, practice managers and podiatrists.
Each study unit should take approximately one hour of computer
time to complete. Support from managers will be an essential
prerequisite for taking the programme, and potential participants
will have to ensure this is in place prior to registering. Participants
won’t be asked to sit any exams, but their learning will be assessed
through a series of online questions to help them identify how well
they have understood the theory component of each learning unit.
The online delivery mode is considered ideal in that it allows
participants to learn at their own pace and in their own time and
gives programme developers the opportunity to quickly update
the resource to reflect new guidelines and evidence. But while
the online programme will provide the theoretical knowledge
practitioners need to recognise good decontamination practice, the
most important priority is to ensure new knowledge is translated
into their everyday work.
For this reason, suggestions will be offered on issues participants
might like to consider as work-based activities to be included in a
special ‘folder of evidence of learning’ which will be available to
those registering for the programme. Work-based activities may
include initiatives related to, for instance, performing workplace
audits, creating development plans or maintaining a reflective log or
learning diary.
Central to both theoretical and practical components of the
programme will be mentors appointed to support practitioners in
their learning. The mentors are likely to be experienced colleagues
who have either completed the programme previously or who have
a strong background in decontamination. They will help participants
with the theoretical elements of the programme and in choosing
appropriate work-based activities, and will assess their folders of
evidence of learning to make sure they are achieving programme
and personal objectives.
The expectation is that the programme will enable practitioners
who have responsibility for decontamination in primary care areas
to practice from a better-informed base, leading to an improved
and safer standard of care for patients. The programme will go to
pilot with a view to the first of the learning units being available
in the spring, with any lessons learned from the pilot feeding into
revisions. In the meantime, interested individuals can find out more
and register their interest at [email protected]
Evidence based new roles
for Older Peoples Care
Skills for Health competences bring new
roles in NHS Forth Valley
With a growing population of older people, planning to ensure
community infrastructure and supports are able to meet their healthcare needs is vital. NHS Forth Valley recognised this need in their
Healthcare Strategy for Older People, with particular focus on shifting
the balance of care in rehabilitation and intermediate care from acute
to community hospitals.
As part of the Workforce Plan, they decided to carry out a workforce
planning project, using Skills for Health’s competence tools to ensure
that the planned move from existing models of care to smaller community units could be achieved safely and smoothly, thereby
supporting the “Delivering for Health” policy.
News
Identifying skills gaps
The project began with the Skills Mapping Project Manager, Katie
Callaghan mapping the future care needs, using a variety of methods
including Skills for Health’s Older People’s Framework, which covers
the competences needed to care for older people with age related
needs. Using similar methods Katie then mapped the skills of the staff
currently delivering care within existing Older Peoples wards.
Awareness sessions provided by Maggie Havergal, Skills for Health
Scotland Director, were held for staff who would be involved to
encourage participation. Cooperation from staff throughout the
project was excellent.
The advantages of using a competence based approach to workforce
planning soon became clear. The Team Assessment tool on the Skills
for Health website was used to highlight development needs.
This ensured that patient needs and pathways were matched with
appropriate care related competences from the Skills for Health
database. The outcome was the creation of some new roles with
competence profiles to ensure that the patient and service needs
were met e.g. Rehabilitation Support Worker and Senior Clinical
Nurse.
New roles emerge from the evidence
Another advantage of using the competence based approach to
workforce planning was that it helped to identify where future
development needs should be concentrated. The project identified
areas where existing staff roles could be enhanced to meet the needs
of patients in the future Community Hospitals. The competence
profiling provided evidence to support the development of trained
nurses to minimise the impact of Modernising Medical Careers.
Some ‘tasks’ carried out by medical staff, which are at KSF levels
3 and 4, could be done by qualified nurses with additional
development, for example; advanced clinical examination and
extended nurse prescribing.
With approximately 400 Nursing, Allied Health Professionals and
Medical staff currently supporting services for older people, the
new competence based approach is a powerful tool for healthcare
managers responsible for workforce planning and development at
NHS Forth Valley. The success of this project has resulted in the
organisation’s continued use of the Skills for Health Competences to
create profiles to support KSF Post Outlines, advise staff recruitment
and induction needs and is now informing many other areas of staff
development.
Skills for Health have a range of electronic tools that support the
database of competences available on their website. The tools are
there for designing roles, services, education, training, and forecasting
future needs, and designed specially for the health sector.
“This has been a tremendously useful project not just for the patients,
service users and health care managers of Forth Valley, but it has
demonstrated how useful Skills for Health’s products are for
organisations that have to implement Delivery for Health.”
Argyll helps LSMS get tough on
violence
locally and provide a single point of contact for staff and the police.
A network of 179 accredited specialists is currently in place across
the country, with many more being trained. They work with all staff
in the Trust and the NHS CFSMS as well as external organisations
including the local police services, professional representative bodies
and trade unions.
“My role is to investigate, advise and bring those who are violent to
NHS staff to court”, says Henry Grant, LSMS at North Middlesex
University Hospital NHS Trust, a busy acute general hospital serving
the communities of the London Borough of Enfield and Haringey and
surrounding areas. “The objective is to deliver an environment that
is safe and secure so that the highest standards of clinical care can be
made available to patients”.
Whilst the Panorama investigation focused on the violence to NHS
staff in hospitals, NHS lone workers are even more vulnerable to
verbal and physical abuse having no direct support from colleagues.
Midwives, health visitors, GPs, district nurses and paramedics are in
the front line everyday often facing potential violence from patients
and their families.
“There are times when lone workers may be faced by an extremely
disturbed person”, continued Henry Grant. “Simply being out and
about on some of the estates our staff have to visit, where alcohol
and other substances are consumed, can in itself feel threatening”.
Faced with the need to support NHS lone workers, LSMS like Henry
Grant are turning to companies such as Argyll Telecom that can offer
a range of lone worker products to safeguard lone workers and help
combat increasing poor staff moral.
After investigating a range of safety systems, Henry Grant, selected a
mix of solutions from Argyll Telecom from which the Trust’s managers
could choose.
These included Argyll’s IdentiCare‘ lone worker device which looks
like a normal ID card-holder but is equipped with mobile telephone
technology and its CommuniCare‘ service which enables lone
workers to summon assistance from a mobile phone or specialist
device should they find themselves in a potentially abusive situation.
Both solutions are monitored by Argyll’s integrated control room
through which the Trust manages and monitors lone worker locations,
time at risk and provides them with an effective duress facility 4/7.
Should a member of staff experience a potentially hazardous situation,
they are a single button-press away from quickly and discreetly
summoning assistance. When an alert is received, Argyll’s trained
operators put into effect an agreed incident management procedure,
and if required, use existing links with the police to ensure a swift
response. Sophisticated voice recording ensures that every incident
is captured and can be produced as evidence if required.
“Lone worker devices supplied by companies like Argyll Telecom are
helping us in the fight to stop violence against NHS staff”, concluded
Henry Grant. They are giving us the technology to record violent
behaviour, bring successful prosecutions and improve moral amongst
staff”.
Violent and abusive patients attacked an estimated
75,000 NHS staff last year costing the NHS more than
£100 million, according to a recently televised
Panorama investigation. To help combat the growing
rise of attacks on NHS staff, a new role has been
created within the NHS - that of Local Security
Management Specialist (LSMS). They are turning to
companies such as Argyll Telecom to provide state-ofthe-art technology to help in the fight against violence.
LSMS are trained and accredited professionals who have been
appointed in health bodies across England to tackle security issues
To help combat the growing rise of attacks on NHS staff, a new role has been created within the
NHS - that of Local Security Management Specialist (LSMS). They are turning to companies such as
Argyll Telecom to provide state-of-the-art technology to help in the fight against violence.
9
Healthcare Events
.........
in and around your area
• 24th August 2007
Energising Modern Midwifery Conference
Venue:
The Robert Gordon University, Faculty of Health
and Social Care, Garthdee Road, Aberdeen
The 4th annual RGU Midwifery Conference is to be
held at the University on Friday the 4th August.
• 22nd June 2007
Understanding Rape & Sexual Abuse
Cost: £100 per person (includes coffee & lunch)
Venue:
School of Health, Nursing & Midwifery
University of Paisley
Paisley PA1 BE
Understanding Rape & Sexual Abuse offers
delegates the opportunity to participate in a
thought provoking one-day conference.
The Conference aims to bring together key
professionals working in this specialised field to
share their expertise.
For further information / enquiries, please contact:
Irene McKeown, School Administrator
School of Health, Nursing & Midwifery, University of
Paisley Paisley PA1 BE
Tel: 0141 848 968
E-mail: [email protected]
• 23rd August 2007
Nurse Practitioners: Back to the Future
One-Day Conference
Venue:
The Robert Gordon University, Faculty of Health
and Social Care, Garthdee Road, Aberdeen
The role of Nurse Practitioners in advancing nursing
practice has evolved over the last 0 years in the UK
and, more recently, in Scotland, particularly the North
and North East of Scotland. Many opportunities exist
for nurses and other health professionals to further
develop their knowledge and clinical skills by integrating
these with skills from the medical domain.
Jean Cowie
School of Nursing and Midwifery
School of Health and Social Care
Garthdee Road
Aberdeen
Tel.: 014-6616
10
Lynn Grove - Midwifery Lecturer
School of Health and Social Care
Garthdee Road
Aberdeen
Tel: 014 66
Barbara Jones - Events/PR Co-ordinator
Communications Dept
The Robert Gordon University
Schoolhill
Aberdeen
Tel: 014 604
• 5th September 2007
Annual Immunisation Update Day
Annual conference
Venue:
Glasgow Royal Concert Hall
This annual conference will address a wide range of
issues that have arisen in the past year and appraise
recent developments in immunisation and the epidemiology of vaccine preventable disease.It will also examine
issues related to the effectiveness of immunisation
services and facilitate debate about these in Scotland
and work towards their improvement.
We hope to target all those involved in the delivery
of immunisation throughout Scotland, and particularly
those involved in advisory/educational roles, for example Public Health Practitioners, Paediatricians and those
working in NHS Boards such as CPHMs and Public
Health Nurses.
The format will comprise presentations from national
and international speakers, with opportunity for questions and discussion.
For further information, contact:
Courses & Conferences Team
Health Protection Scotland, nd Floor Clifton House,
Clifton Place, Glasgow, G 7LN
0141 00 1100
[email protected]
Healthcare Events
.........
• 20th September 2007
Group-working Skills
One-Day Course
A 1 day course Free to Stewards, Learning & Safety
Reps, £25 to RCN Members
Venue:
RCN Scotland
42 South Oswald Road
Edinburgh
EH9 2HH
How should you summarise discussions? How do you
select key points? How do you hold the interest of
other groups while you feedback? If you’ve ever
wondered, or you’d like a chance to practice – come
along and develop skills that will ensure your feedback
is heard.
For further information, contact:
Ali Shire, Administrative Assistant
42 South Oswald Road, Edinburgh, EH9 2HH
Tel: 0131 662 6165
Fax: 0131 662 1032
• 24th October 2007 DUBLIN
• 6th November 2007 GLASGOW
Skills for Nurses 2007
2 x One-Day Events
Skills for Nurses are pleased to announce the latest
One day Nursing Exhibitions which will be held in
Dublin and Glasgow.
(See pages 62 - 63)
fit and well
But what if something
goes wrong
We are presently helping a
number of Nurses both
young and elderly. If you
know someone who you
think needs our help
contact:
Margaret Sturgeon
15 Camp Road
Motherwell ML1 2RQ
Telephone: 01698 252034
Venues:
RDS, Shelbourne Hall, Dublin
SECC, Glasgow
Previous events have helped many NHS, international
recruiters and employers in the private sector to fill
posts and the latest events promise to do even better.
As with all our events we have a full range of seminars
and workshops featuring prominent speakers and
celebrities including Anne Diamond.
This year we are having skills challenges with large cash
prizes. Entry is free,
log on to www.scottishirishhealthcare.com to find out
more.
Enquiries from Nurses and other Healthcare
professionals please contact:
Tracy Hamilton on 01324 411013
or email [email protected]
Exhibitors please contact:
Scottish & Irish Nurse magazines on
tel. +44 (0)1292 525 970
email. [email protected]
Donations required
to continue the
work of the Fund
Visit our website for more details
www.bfns.org.uk
Registered charity no. SC006384
11
Clinical Articles Wanted
At Scottish & Irish Nurse we are always interested in
good quality clinical editorial. We’d love to hear from
you regardless of whether you’ve had work published
before.
Your submission needn’t be a very detailed clinical paper.
For example you can forward:
• A review of a local initiative that has delivered best practice leading
to an improvement in patient care.
• Results of an audit or survey that has led to an improved service to
patients and their relatives
• An article relating to an area of particular interest to you or involving
your specialist area. We are particularly keen to receive articles
related to Cardiology, Respiratory, Diabetes, Nutrition, Midwifery,
Mental Health, Intensive Care and Dementia
• A service redesign initiative that has achieved demonstrable results
• Or just anything that’s going on locally or that you and your team has
achieved that you’d like to share with over 0,000 Nurses fortnightly.
Our articles are typically 1500 words, although there is a fair degree of flexibility, and fully
referenced where appropriate.
Don’t worry about pictures and graphics as we can insert these for you.
For authoring guidelines or to submit editorial e-mail: [email protected]
Postal address: Charles Bloe Training Ltd, Editorial Dept, 15 Highland Dykes Drive, Bonnybridge. FK4 1PE.
Or if you have any queries give me a call on 01324 814946.
Clinical Editorial Board
Charles Bloe BSc RN NDN ITU cert
Clinical Editor CEO Charles Bloe Training Ltd
Charlie graduated with a BSc in Social Sciences and Nursing Studies from the
University of Edinburgh in 1984 and spent much of his clinical career as a senior
nurse in Cardiac Care and Medical High Dependency. He is now CEO of
Charles Bloe Training Ltd. who deliver onsite and online clinical updates to
healthcare staff across the UK and beyond.
Scott Kane RMN MSc
Assistant Clinical Editor Clinical Nurse Specialist in Liaison
Psychiatry, Tayside Health Board
Scott undertook his RMN training in Dundee, qualifying in 1991. Since that time
has worked in acute, long-term, rehab and supported accommodation.
He was appointed Clinical Nurse Specialist in Liaison Psychiatry in 1996.
Michael Canavan Dip N RN ALS
Lead Resuscitation Training Officer
Ayrshire & Arran NHS Trust
After a period of 7 years as senior Staff Nurse in Coronary Care Michael was
appointed Resuscitation Training Officer in Forth Valley Acute Hospitals NHS
Trust. He has since moved to Ayrshire where he is lead Resuscitation Training
Officer at Ayrshire & Arran NHS Trust. Michael is a Resuscitation Council (UK)
approved Advanced Life Support Instructor and ALS course Director.
Sheenagh Orchard RN RNT Cert Ed (FE) DN (Lond)
Moving & Handling Consultant
Sheenagh qualified in 1975 and is currently a Moving & Handling of People
Specialist undertaking assessment, training and a number of speaking
appointments at National Conferences. She is one of the co-authors
of ‘The Guide to the handling of People’ 5th edition.
Deborah Ward MA, BSc (Hons), RN
Infection Control Nurse Specialist
Deborah has worked as an infection control nurse since 1998, working both
inside and outside the NHS in both acute and non-acute settings.
She now works outside the NHS for a national organisation across England,
Scotland and Wales.
1
Greig Ferguson BSc RN DSc MD ATLS ALS EPLS
Registered Nurse Accident & Emergency Critical Care
Greig initially trained as a Royal Marines Commando, undertaking the military
Paramedic course in 1992. On attachment he attended Chicago Medical School
1993 at the Rosalind Franklin University of Medicine and Science.
Completed initial internship at the Department of Emergency Medicine.
Maureen Benbow MSc BA RN HERC
Senior Lecturer, University of Chester
Maureen worked as a Tissue Viability Nurse at Mid Cheshire Hospital Trust,
Crewe for 14 years and in 2004 transferred to the University of Chester.
Her clinical background is in orthopaedics and accident and emergency.
Steven Morrison Dip N Bachelor Nursing RN ALS
Hospital at Night Practiitoner,
Forth Valley Acute Hospitals
Steven has spent much of his clinical career in Coronary Care and has been
particularly proactive in the development & implementation of Acute Coronary
Syndrome management programmes.
Kirsten Ramsay RN DipN ALS
Hospital at Night Practitioner, Fife Acute Hospitals NHS Trust
Kirsten spent much of her early clinical career as Staff Nurse in Coronary Care
and Medical High Dependency. She was among the first Nurses in the UK to
undertake the role of nurse initiated coronary thrombolysis.
Jamie Jones RN (Adult) BSc DipHE PGDip ALS(I) APLS(I)
Emergency Nurse Practitioner,
Pontypridd & Rhondda NHS Trust.
Jamie has spent his career working in the Accident & Emergency environment.
He has held Staff Nurse, Deputy Charge Nurse and Charge Nurse Positions
before moving onto his current position as an Emergency Nurse Practitioner.
Heather Liddell BSc RN ALS SPQ
Senior Charge Nurse, CCU, Wishaw General Hospital
Heather has spent much of her senior clinical career working in Cardiac Care
and Medical High Dependency. She is currently a chest pain assessment
practitioner at Stirling Royal Infirmary.
Write letter to friend in
large, shaky print
Dictate letter to husband
for the umpteenth time
Simply drop friend a line
Lose touch
ropinirole
PUT THEIR LIVES BACK IN THEIR HANDS
REQUIP® (ropinirole hydrochloride) Prescribing Information
(Please refer to the full Summary of Product Characteristics before prescribing.
Presentation ‘ReQuip’ Tablets, PL 10592/0085-0089, each containing ropinirole
hydrochloride equivalent to either 0.25, 0.5, 1, 2 or 5 mg ropinirole. Starter Pack (105
tablets), £40.10. Follow On Pack (147 tablets), £74.40; 1 mg tablets – 84 tablets,
£47.26; 2 mg tablets – 84 tablets, £94.53; 5 mg tablets – 84 tablets, £163.27.
Indications Treatment of idiopathic Parkinson’s disease. May be used alone (without Ldopa) or in addition to L-dopa to control “on-off” fluctuations and permit a reduction in
the L-dopa dose. Dosage Adults: Three times a day, with meals. Titrate dose against
efficacy and tolerability. Initial dose for 1st week should be 0.25 mg t.i.d., 2nd week
0.5 mg t.i.d., 3rd week 0.75 mg t.i.d., 4th week 1 mg t.i.d. After initial titration, dose
may be increased in weekly increments of up to 3mg/day until acceptable therapeutic
response established. If using Follow On Pack, the dose for 5th week is 1.5mg t.i.d., 6th
week 2.0mg t.i.d., 7th week 2.5mg t.i.d., 8th week 3.0mg t.i.d. Do not exceed 24
mg/day. Concurrent L-dopa dose may be reduced gradually by around 20%. When
switching from another dopamine agonist follow manufacturer’s guidance on
discontinuation. Discontinue ropinirole gradually by reducing doses over one week.
Renal or hepatic impairment: No change needed in mild to moderate renal impairment.
Not studied in severe renal or hepatic impairment – administration not recommended.
Elderly: Titrate dose in normal manner. Children: Parkinson’s disease does not occur in
children – do not give to children. Contra-indications Hypersensitivity to ropinirole or to
any excipients, pregnancy, lactation and women of child-bearing potential unless using
adequate contraception. Special warnings and precautions Caution advised in patients
with severe cardiovascular disease and when co-administering with anti-hypertensive
and anti-arrhythmic agents. Patients with a history or presence of major psychotic
disorders should be treated with dopamine agonists only if potential benefits outweigh
the risks. Pathological gambling, increased libido and hypersexuality reported in
patients treated with dopamine agonists for Parkinson’s disease, including ropinirole.
Ropinirole has been associated with somnolence and episodes of sudden sleep onset.
01506_igreqp_ad_adapt_fa.indd 1
Patients must be informed of this and advised to exercise caution while driving or
operating machines during treatment with ropinirole. Patients who have experienced
somnolence and/or an episode of sudden sleep onset must refrain from driving or
operating machines. Caution advised when taking other sedating medication or alcohol
in combination with ropinirole. If sudden onset of sleep occurs in patients, consider dose
reduction or drug withdrawal. Drug interactions Neuroleptics and other centrally active
dopamine antagonists may diminish effectiveness of ropinirole – avoid concomitant use.
No dosage adjustment needed when co-administering with L-dopa or domperidone.
No interaction seen with other Parkinson’s disease drugs but take care when adding
ropinirole to treatment regimen. Other dopamine agonists may be used with caution. In
a study with concurrent digoxin, no interaction seen which would require dosage
adjustment. Metabolised by cytochrome P450 enzyme CYP1A2 therefore potential for
interaction with substrates or inhibitors of this enzyme – ropinirole dose may need
adjustment when these drugs are introduced or withdrawn. Increased plasma levels of
ropinirole have been observed with high oestrogen doses. In patients on hormone
replacement therapy (HRT) ropinirole treatment may be initiated in normal manner,
however, if HRT is stopped or introduced during ropinirole treatment, dosage adjustment
may be required. No information on interaction with alcohol – as with other centrally
active medications, caution patients against taking ropinirole with alcohol. Pregnancy
and lactation Do not use during pregnancy – based on results of animal studies. There
have been no studies of ropinirole in human pregnancy. Do not use in nursing mothers
as lactation may be inhibited. Effects on ability to drive and use machines Patients
should be warned about the possibility of dizziness (including vertigo). Patients being
treated with ropinirole and presenting with somnolence and/or sudden sleep episodes
must be informed to refrain from driving or engaging in activities where impaired
alertness may put themselves or others at risk of serious injury or death (e.g. operating
machines) until such recurrent episodes and somnolence have resolved. Adverse
reactions Psychiatric disorders; common: confusion, hallucinations, uncommon: Psychotic
reactions including delusion, paranoia, delirium. Patients treated with dopamine agonists
for treatment of Parkinson’s disease, including ropinirole, especially at high doses, have
been reported as exhibiting signs of pathological gambling, increased libido and
hypersexuality, generally reversible upon reduction of the dose or treatment
discontinuation. Nervous System Disorders; very common: somnolence, dyskinesia,
common: dizziness (including vertigo), syncope, uncommon: extreme somnolence,
sudden onset of sleep, Vascular disorders; common: hypotension, postural hypotension.
Gastrointestinal disorders; very common: nausea, common: abdominal pain, vomiting
dyspepsia. General disorders and administrative site conditions; common: leg oedema.
Hepatobiliary disorders; very rare: hepatic enzymes increased. Overdosage Symptoms
of overdose likely to be related to dopaminergic activity.
POM Legal category
Marketing Authorisation Holder SmithKline Beecham plc t/a GlaxoSmithKline, Stockley
Park West, Uxbridge, Middlesex UB11 1BT. Further information is available from:
Customer Contact Centre, GlaxoSmithKline, Stockley Park West, Uxbridge,
Middlesex UB11 1BT; [email protected]; Freephone 0800 221 441.
Prescribing information last revised: April 2007.
In order to continually monitor and evaluate the safety of ReQuip®, we
encourage healthcare professionals to report adverse events, pregnancy,
overdose and unexpected benefits to GlaxoSmithKline on 0800 221 441.
Please consult the Summary of Product Characteristics for full details on the
safety profile of ReQuip®. Information about adverse event reporting can
also be found at www.yellowcard.gov.uk.
ReQuip® is a Registered Trademark of the GlaxoSmithKline Group of Companies.
Date of preparation: June 2007
REQ/FPA/07/31357/1
1
6/13/07 12:24:11 PM
The role of Parkinson’s
• Help support self care and preserve patients’ sense of wellbeing
• Assist unpaid carers to care effectively
• Deliver education to all health and social care professionals
involved along the patient care pathway
How a PDNS can make cost savings
Parkinson’s Disease Nurse Specialists (PDNS) offer great potential for
NHS providers and commissioners to improve quality of care while at
the same time contributing to the achievement of healthcare targets
and reducing costs.
Introduction
Parkinson’s disease is a progressive, neurological condition that
affects approximately 120,000 people in the UK , with 10,000
new diagnoses each year. It is estimated that over 10,000 people
are living with Parkinson’s in Scotland alone.
The principle signs of Parkinson’s disease are rest tremor, rigidity and
slowness of movement. However, although the condition is
predominantly a movement disorder, non-motor symptoms, such
as cognitive damage and dementia, bladder and bowel problems,
and sleep disturbance, are also widely associated with Parkinson’s.
These symptoms often increase and become more severe as the
condition progresses, as do the needs and costs of the care of
people with Parkinson’s.
In the absence of a cure, provision of information throughout the
course of the condition, from diagnosis onwards, regular reviews of
patients’ symptoms and medication, and access to appropriate health
and social care services are all important in keeping the patient’s
condition under control.
Specialist health professionals therefore play a key role in managing
Parkinson’s, especially in helping the patient come to terms with their
diagnosis and being a source of support. Indeed evidence suggests that
people with Parkinson’s have improved health outcomes and a better
quality of life when they are able to access prompt and ongoing advice
and support from practitioners with dedicated neurological expertise,
such as a specialist nurse.
Parkinson’s Disease Nurse Specialists
People with Parkinson’s can live a full and active life with the proper
support and access to appropriate services, and a Parkinson’s Disease
Nurse Specialist (PDNS) is crucial in maintaining an independent
lifestyle.
A PDNS has a wide role, contributing to the management of care,
providing support for carers, educating health care professionals,
patients and their families.
By providing expert advice and support to patients, they promote selfcare and ensure patients are able to manage their symptoms effectively.
This leads to a more appropriate use of health and social care services.
One man in his forties, who has had Parkinson’s for five years, is
keen to highlight the importance of a Parkinson’s Disease Nurse
Specialist. He said: “I was having a nightmare with my Parkinson’s
medication after the doses had been changed. My PDNS came and
sorted me out quickly, adjusting the doses so that I could get back to
normal. At other times, she has used her in-depth knowledge of the
condition and measured judgement to determine which therapies and
services are right for me. My PDNS has given me both the emotional
and medical support I have needed since being diagnosed with
Parkinson’s, has helped me to take control of my own condition
and encouraged me to live my life to the full.”
Using their in-depth knowledge of the condition, Parkinson’s Disease
Nurse Specialists work hard to understand the needs of individual
patients and advise and link them to appropriate therapies and services
at all stages of the disease. They provide the continuity of care for a
person with Parkinson’s, as they join together the many healthcare professionals involved in the management of the condition, and often work
as part of a multi-disciplinary team alongside neurologists, geriatricians,
general practitioners, therapists and social care professionals.
In addition, a PDNS will also:
• Contribute significantly to improved symptom control and the
general health of people with Parkinson’s
• Maintain people in the community and contribute to a reduction
in hospital admissions
• Divert appointments away from consultants, helping them to
meet outpatient waiting times for diagnosis and complex cases
14
In a healthcare organisation with a population of 500,000 people, there
may be approximately 1,000 patients with Parkinson’s, and between 0
and 100 people will be diagnosed each year . Not surprisingly, this has
significant cost implications to health and social services.
However, it has been estimated that by developing and funding
community-based services for people with Parkinson’s, the savings in
health costs would be around £56 million . Although this figure applies
to England and Wales, it is evident that Parkinson’s Disease Nurse
Specialists are fundamental in achieving healthcare targets and reducing
costs, regardless of their location.
An example of how these cost savings are possible is in Harlow. For
two years before the PDNS came into post, Harlow Primary Care Trust
(PCT) had established robust data on hospital admissions for primary
and secondary diagnosis of Parkinson’s. When the nurse came into post,
she was able to identify trigger factors for hospital admissions.
She worked with the multidisciplinary team to ensure early therapy
interventions and established herself with patients as the first port of
call in a crisis. She was also able to use daily admissions reports and
PARR reports (patients at risk of readmissions) to allocate her
resources to where they were most needed. Ten months after the
post was created, recorded data clearly indicated the upward trend
in admissions and length of stay was reversed, with a saving to the
PCT of £80,000.
The Role of a Parkinson’s Disease Nurse Specialist in Scotland
Systematic support for people with long-term conditions is a key pillar
of Delivering for Health , the Scottish Executive’s vision for the NHS.
The overall direction of the policy is moving towards early
interventional, community-based health services with multidisciplinary teams delivering patient-centred care. This contrasts
with the traditional model of doctor-led, hospital-focused services,
with high levels of unplanned admissions.
Parkinson’s Disease Nurse Specialists can help make this vision a reality
for people with Parkinson’s in Scotland by managing patients
throughout the course of the condition and by acting as a regular
point of contact, enabling them to pick up potential problems before
they occur.
The work of a Parkinson’s Disease Nurse Specialist
There are a number of ways a Parkinson’s Disease Nurse Specialist can
help to achieve the Scottish Executive’s vision for the NHS, which are
explained below.
Empowering patients
Parkinson’s Disease Nurse Specialists play an important role in
empowering patients and families to become experts in the condition.
Evidence suggests that people with long-term neurological conditions
such as Parkinson’s have improved health outcomes and a better quality
of life when they are able to access prompt and ongoing advice and
support from practitioners with dedicated neurological expertise, such
as specialist nurses .
The PDNS in Fife believes this to be the case, saying: “We are there
as an ongoing source of support for the patient in whatever setting
that may be. Patients say they value having someone to support them
through their diagnosis, and also during the changes in their condition
as it progresses, who understands their condition.”
Reducing the need for outpatient care
Expert opinion suggests that access to specialist Parkinson’s nursing
care and therapy services may potentially reduce outpatient attendance
by a staggering 40%. A large part of outpatient attendance for people
with Parkinson’s is for clinical monitoring and medical adjustment.
The NICE Guideline, although only relevant for England and Wales,
recommends that these services may be provided by specialist nurses,
which has been the case in Tayside.
The PDNS for Perth and Kinross has established a nurse-led clinic at
Perth Royal Infirmary for regular medication reviews, and continues
home visits for new referrals and for those who cannot make the clinic.
She works alongside GPs, Neurologists and Geriatricians to get patients
with Parkinson’s as independent as possible.
Disease Nurse Specialists in Scotland
Author: Andrea Sim, PDS Manager of Scotland
Management of Parkinson’s medication can be complex, and regular
clinical reviews and medical adjustments are therefore key to
keeping patients in control of their symptoms. Parkinson’s Disease
Nurse Specialists are ideally placed to be available to patients when
they are needed. If patients do not have access to a specialist
Parkinson’s nurse, hospital based specialists will need to conduct
these reviews, which takes up clinic time that could be used to shorten
waiting times for referrals and to deal with complex cases.
Another PDNS in Fife also plays a role in reducing the need for
outpatient care. She says: “We work with many consultants, both
Geriatricians and Neurologists, to run nurse-led clinics and visit
patients in hospital. Waiting times for the clinics are very short because
we are reviewing patients that were previously being reviewed more
frequently by the consultants. Our service is available to anyone with a
confirmed diagnosis of Parkinson’s and their relatives, carers or anyone
involved in the care and management of someone with Parkinson’s.”
Reducing unplanned admissions
Expert opinion estimates that PDNS care, as part of a multidisciplinary
team, can reduce admission for Parkinson’s disease by 50%. Although
there are no official figures for Scotland as yet, this estimation is
reinforced by a local Audit conducted in Fife regarding the role of their
PDNS over three years. The results clearly indicated that patients who
had access to a PDNS were four times less likely to be admitted to
hospital.
Preventing unnecessarily extended stays in hospital
Keeping people with Parkinson’s out of hospital is not always possible,
and in those cases, Parkinson’s Disease Nurse Specialists can be
instrumental in preventing unnecessarily extended hospital stays by
educating other hospital staff about the condition and the need for
medication to be administered on time.
People with Parkinson’s will often be on a number of drugs, each of
which must be taken throughout the day at specific times. If a person
is unable to take their prescribed medication at the right time, the
balance of chemicals in their bodies can be severely disrupted – and
this will lead to their Parkinson’s symptoms being uncontrolled with a
possible lengthy recovery time. Inflexible drug rounds, low levels of
support for self-administration processes and lack of understanding
among ward staff can all lead to problems for patients.
Disruption of an individual’s medication regimen can have serious
consequences for ward management and the treatment for which
the person was originally admitted. Therefore, a PDNS is crucial in
improving the management of medication in hospital for people with
Parkinson’s.
When the PDNS for Perth and Kinross was appointed in 006, she
immediately recognised the importance of timely medication
management, and has been instrumental in disseminating information
and educating hospital and care home staff. Upon admission of a patient
with Parkinson’s, she will contact the ward staff to explain the need
for medication to be administered on time, and will provide them with
information sheets with further details. She identified link nurses in
Medicines for the Elderly, acute wards, community hospitals and
psychiatry to raise awareness of the issue in the hope that they
can then pass on their knowledge in these areas.
Investing in a Parkinson’s Disease Nurse Specialist
With NHS reforms pointing the way to more healthcare activity in the
community, now is an excellent time for commissioners in Scotland to
create specialist Parkinson’s nursing posts.
Local cost pressures need not prevent the creation of these posts, as
there is no investment needed upfront. The Parkinson’s Disease Society
will fund a new PDNS post for two years, providing the local health
board confirms it will pick up the funding after this point. This gives the
local health organisations time to evaluate for themselves the clinical
and financial value of having a specialist nurse.
The PDS, Parkinson’s Disease Nurse Specialist Association (PDNSA)
and the Royal College of Nursing (RCN) have collaborated as one body
to produce an integrated career and competency framework for nurses
working in Parkinson’s disease management . These competencies have
been produced to maintain the highest level of standard, competence
and professional integrity within Parkinson’s disease nurse management.
The gap in specialist nurse care in Scotland
Although there have been some clear examples of the benefits of
Parkinson’s Disease Nurse Specialists, and what help is available to fund
their posts, there are only 16 specialist nurses dealing with a caseload
of approximately 10,000 people living with Parkinson’s in Scotland.
The recommended caseload of a PDNS is around 00 people, but this
clearly isn’t the case in Scotland, with some areas not having access to
a specialist nurse at all. This is further compounded by the fact that the
land mass of Scotland is two-thirds that of England, with a population
one-tenth its size. This means that each PDNS would need to cover a
much larger area than his or her equivalent in England and Wales.
For example, the PDNS for the Highland Health Board encompasses
an area from Wick, right down to Campbelltown, including all the
islands, with over 00 miles between the two furthest points.
Conclusion
The benefits of a PDNS are countless, from cost savings to health
services, to empowering and educating patients with Parkinson’s to
become experts in their condition. However, in Scotland there is
clearly a shortage of Parkinson’s Disease Nurse Specialists, despite
overwhelming evidence of the need and importance of their role, the
support of Hospital Consultants and years of hard campaigning.
This continues with the Parkinson’s Disease Society’s willingness
to fund new posts for the first two years.
Although a key pillar of Delivering for Health, the Scottish Executive’s
vision for the NHS, is focused on early interventions and
community-based health services, a comprehensive clinical guideline
is still needed for clinicians and health commissioners in Scotland to
use as a basis to design high-quality health services for people with
Parkinson’s.
The Scottish Intercollegiate Guideline Network (SIGN) is due to
start developing a Guideline in June, but it appears it will be narrowly
focussed on medication. To fully meet the needs of people with
Parkinson’s in Scotland, we believe the Guideline should be expanded
to cover diagnosis and management of this complex condition, including
therapies and specialist nurses. Indeed, using available evidence, the
National Institute for Health and Clinical Excellence acknowledged
the central role of specialist nurses in its Guideline for Parkinson’s
published last year for England and Wales.
References
i Parkinson’s Disease Society estimate
ii Dodel RC et al (1998) ‘Costs of drug treatment in Parkinson’s Disease’ Movement Disorders; 13(2):249-254
iii Thomas S et al on behalf of the PDS UK Primary Care Task Force (2006)
Moving and Shaping, A Guide to commissioning integrated services for people
with Parkinson’s disease, Parkinson’s Disease Society, London
iv Scottish Executive (2005) Delivering for Health
v Hutwitz B et al (2005) ‘Scientific evaluation of community-based Parkinson’s
disease nurse specialists on patient outcomes and healthcare costs’ Journal of
evaluation in Clinical Practice; 11:97-110
vi NICE (2006) Parkinson’s disease diagnosis and management in primary and
secondary care National Cost-impact report, NICE, London
vii NICE (2006) Parkinson’s disease diagnosis and management in primary and
secondary care National Cost-impact report, NICE, London
viii Royal College of Nursing, Parkinson’s Disease Society, Parkinson’s Disease
Nurse Specialist Association (2005) Competencies: an integrated career and
competency framework for nurses working in Parkinson’s disease management,
PDS, London
The Society has helped many local health organisations scope their
nurse services, and will help local teams find a model of specialist
Parkinson’s nursing that works for them and works for the needs of
people with Parkinson’s in their area.
Employers of specialist nurses can also be confident that support is
available throughout their career. Both formal and informal PDNS
networks exist across the UK, which promote best practice and
provide mentorship.
Healthy Alliance is a unique collaboration between the PDS and
GlaxoSmithKline to provide a dedicated package of support and
training for PDNSs across the UK, carrying out nurse inductions,
running conferences and providing training materials.
15
Experts from two European paediatric groups
have issued a framework for vaccination of
babies against rotavirus, the most common
cause of gastroenteritis in infants and
children.1 At its annual conference this week,
the European Society for Paediatric Infectious
Diseases (ESPID) joined with the European
Society for Paediatric Gastroenterology,
Hepatology and Nutrition (ESPGHAN) to
issue the first European evidence-based
recommendations on rotavirus vaccination.
Professor Adam Finn, Professor of Paediatrics
at the University of Bristol and ESPID
Secretary welcomed the recommendations:
“ESPID and ESPGHAN have concluded that
the logical way to deploy the new safe and
efficacious rotavirus vaccines now available
is through universal immunisations of infants
in Europe. As a practising paediatrician, I look
forward to seeing these vaccines being used
in the UK in the not too distant future.”
New data shows rotarixTM vaccine
could reduce nhs costs of treating
rotavirus gastroenteritis
New data presented at the ESPID conference
predicted that universal vaccination against
rotavirus could reduce NHS costs by over
85 per cent from £27.4M to £4M over five
years.2 The modelling study, sponsored by
GlaxoSmithKline, suggested that immunisation
with the oral rotavirus vaccination, Rotarix™,
could reduce hospitalisations, hospitalacquired infections, A&E visits and cases seen
by GPs, at a cost per Quality Adjusted Life
Year (QALY) of £27,522. 2 This cost compared
favourably with the recently adopted
pneumococcal conjugate vaccine, suggested
the study. 2
New information on the burden of rotavirus
infections across Europe was also presented
which found high levels of hospitalisations for
rotavirus gastroenteritis (RVGE) in children
under 5 years of age over a 19-month period.
16
The study of 12 centres from the UK, France,
Germany, Italy, and Spain concluded that
rotavirus accounted for 56.2% of
hospitalisations due to acute gastroenteritis.3
The study found that RVGE was more common in younger children, with a majority of
cases occurring in children under 2 years and
18% of cases occurring in babies less than 6
months old. 3 Previous studies have reported
that the duration of hospitalisation is longest
in young infants, particularly those who are
under 4 months of age. 4
A further study showed that Rotarix™
provided sustained protection against RVGE
in vaccinated infants who were monitored
after the first dose at between 6-24 weeks
of age and up to two years of age. 5 In the
pan-European study, Rotarix™ prevented
96% of hospitalisations due to rotavirus
gastroenteritis and reduced the need for
medical attention by 84%.5 Given in a
convenient two-dose schedule from the age
of six weeks, the oral vaccine offers early
protection, before the peak incidence of the
disease at 6-24 months. 6
Principle investigator, Prof. Dr. Timo Vesikari,
commented, “The new data substantiate the
evidence for Rotarix™ showing that the
vaccine’s efficacy is proven over two years,
which covers the peak age for RVGE
episodes.”
References
1.Van Damme P. Evidence based recommendations for the use of rotavirus
vaccines in Europe. ESPID ESPGHAN Rotavirus Expert Working Group,
ESPID Abstract
2. Martin A, et al. Cost-effectiveness of infant vaccination with RotarixTM in
the UK. Abstract, ESPID annual meeting, May 2007.
3. Forster J, et al. Hospital-based surveillance to estimate the burden of
rotavirus gastroenteritis among European children aged <5 years. Abstract,
ESPID annual meeting, May 2007.
4. Berner R , Schumacher RF, Hameister S et al. Occurrence and impact of
community acquired and nosocomical rotavirus infections-a hospital-based
study over 10 years. Acta Paediatr Suppl 1999;88 (426):48-52.
5.Vesikari T, et al. Human rotavirus vaccine RotarixTM is highly efficacious
in Europe during the first two years of life. Abstract, ESPID annual meeting,
May 2007.
6. Linhares AC, et al. Rotavirus vaccines and vaccination in Latin America.
Pan Am J Public Health 2000;8(5):305-331.
7. RotarixTM Summary of product characteristics. December 2006.
“Rotarix provides early protection
from rotavirus gastroenteritis, pass it on.”
Winner of
the UK Prix
Galien 2006
Medal engraved by
Albert de Jaeger
Only two ORAL doses1
Provides highly effective protection from
rotavirus gastroenteritis2
Has a good tolerability and safety profile1
®
rotavirus vaccine
Rotarix is not currently part of the routine UK childhood immunisation programme
Rotarix is only available direct from GlaxoSmithKline - Call the dedicated Customer Contact Centre on 0808 100 9997
Prescribing information (Please refer to the full SPC before
prescribing) ROTARIX® Live attenuated human rotavirus oral
vaccine. Composition: Each 1 ml dose contains not less than 106.0
CCID50 human rotavirus RIX4414 strain (live attenuated). Uses:
Active immunisation of infants from 6 weeks of age against
gastroenteritis due to rotavirus infection. Dosage and
administration: Two oral doses. First dose can be administered
from 6 weeks of age. Minimum interval of 4 weeks between
doses. Vaccination course must be completed by 24 weeks of age.
Rotarix should under no circumstances be injected.
Contraindications: Hypersensitivity to the active substance or any
of the excipients, or after previous administration of rotavirus
vaccines. Previous history of intussusception or uncorrected
congenital malformation of the gastrointestinal tract that would
predispose for intussusception. Known or suspected
immunodeficiency. Asymptomatic HIV infection is not expected to
affect the safety or efficacy of Rotarix. However, in the absence of
sufficient data, administration to asymptomatic HIV subjects is not
recommended. Administration should be postponed in subjects
with acute severe febrile illness, diarrhoea or vomiting. Presence
of a minor infection is not a contra-indication for immunisation.
Precautions: Administer with caution to individuals with
gastrointestinal illness, growth retardation, and individuals with
immunodeficient close contacts. FOR ORAL USE ONLY.
Interactions: No interactions with co-administered paediatric
vaccines. Pregnancy and Lactation: Not intended for use in
adults. Breastfeeding may be continued during the vaccination
schedule. Adverse reactions: Irritability, loss of appetite,
diarrhoea, vomiting, flatulence, abdominal pain, regurgitation of
food, fever, fatigue. Legal category: POM. MA number:
EU/1/05/330/001-004. Presentation and basic NHS cost: 1 dose
powder in a vial; 1ml of solvent in glass container; oral applicator;
transfer adapter for reconstitution. NHS Cost £41.38 MA holder:
GlaxoSmithKline Biologicals s.a., Rue de l’Institut 89 1330
Rixensart, Belgium. Further information is available from:
Customer Contact Centre, GlaxoSmithKline, Stockley Park West,
Uxbridge, Middlesex UB11 1BT; [email protected];
Freephone 0808 100 9997. Date of preparation of PI:
December 2006 Rotarix® is a registered trademark of the
GlaxoSmithKline Group of companies ROT/PRI/06/27986/2
GlaxoSmithKline encourages healthcare professionals
to report adverse events, pregnancy, overdose and
unexpected benefits to the company on 0808 100
9997. Information about adverse event reporting can
also be found at www.yellowcard.gov.uk
References 1. Rotarix Summary of Product Characteristics
2. Vesikari T, Karvonen A, Prymula R et al. Human rotavirus
vaccine RotarixTM (RIX4414) is highly efficacious in Europe.
24th European Society for Paediatric Infectious Diseases
(ESPID), Basel, May 2006
© GlaxoSmithKline group of companies
ROT/FPA/07/27148/3 - Feb 2007
17
Infection Control
Infection Control Part 4
Author: Deborah Ward MA, BSc (Hons), RN, Infection Control Specialist Nurse.
Deborah has worked as an infection control nurse since 1998, working
both inside and outside the NHS in both acute and non-acute settings.
She now works outside the NHS for a national organisation across
England, Scotland and Wales
Learning objectives for this section:
By the end of this section the student will be able to:
• Describe the role of urinary catheterisation in urinary
tract infection
• Describe the indications for urinary catheterisation
• Describe and demonstrate the correct technique for insertion and after care of a urinary catheter
• Describe the signs and symptoms of a urinary
tract infection
INFECTION CONTROL IN URINARY CATHETERISATION
Urinary tract infections are the most common type of hospital acquired
infection.
Catheterisation
When inserting a urinary catheter for short or long term use the following
should be considered:
• TOnly use a urinary catheter after considering other less hazardous alternatives
• TReview the need for catheterisation regularly and remove catheters at the earliest possible opportunity
• TCatheterisation should be performed by suitably trained and skilled personnel adhering to a strict aseptic technique.
• TAccurately document insertion and care of the catheter in patient notes
• TSelect the smallest gauge catheter that will allow
free urinary flow
• TThe catheter balloon should be inflated with 5 – 10 mls o sterile water in adults and 3 – 5 mls in children
• TCatheterisation is an aseptic procedure
• TClean the urethral meatus prior to insertion as
per local guidelines
• T Use an appropriate lubricant from a single use container to minimise trauma and infection
e.g. sterile Lignocaine gel
Intermittent self catheterisation
The NICE guidelines mention intermittent self catheterisation in the
community context as an option which should be used in preference to an
indwelling catheter, as long as this is appropriate for the individual patient.
While insertion of an indwelling catheter is an aseptic procedure, insertion
of an intermittent catheter is actually a clean procedure. Reusable
catheters used intermittently should be cleaned with water and dried
according to the manufacturer’s instructions.
Post Catheterisation
Once an indwelling catheter has been inserted, it should be connected to a
sterile closed drainage system. The connection between the catheter and
drainage system should not be broken except for good clinical reasons.
UTI – urinary tract infection
LRTI – Lower respiratory tract infection
There are numerous factors which predispose a patient to UTI, including:
•
•
•
•
•
•
•
•
•
•
Urinary Catheterisation
Surgical instrumentation
Prostatic disease
Abnormalities of the urinary tract
Ageing process
Diabetes
Pregnancy
Altered bladder control
Urinary calculi
Functional disability
Indications for Catheterisation
There are several reasons why a patient may require catheterisation,
Such as urinary retention, pre-operative drainage, post-operative drainage,
paralysis and spinal cord injury, bladder irrigation, measurement of urinary
output, urodynamic investigations, diagnostic purposes, administration
of medication, care of debilitated patients with incontinence (only after
considering other options first)
Why do catheters predispose to UTI?
• The catheter is a foreign body
• It interferes with the normal flow of urine
• The catheter and drainage system become a
culture reservoir
• Biofilms form on the catheter which interfere with normal flora and antibiotic therapy
Points of entry for infective agents.
There are numerous points of entry for infection in a catheterised patient.
A: Catheter tip on catheterization
B: Urethral meatus around catheter
C: Catheter/drainage bag junction
D: Sampling sleeve or port
E: Reflux from bag to tubing
F: Drainage bag tap
18
After several days the urinary catheter may become encrusted and
blocked. The use of bladder washouts in preventing this is not clear.
After insertion observe the patient for any signs of urinary tract infection
such as:
• TPyrexia and raised white cell count in blood
• TLower abdominal pain
• TOffensive smelling urine, cloudy urine, particles of blood in urine
• TConfusion in elderly
• TDischarge around catheter site
• TBypassing of urine
Prior to manipulating a urinary catheter, hands should be appropriately
decontaminated and clean gloves should be worn. The drainage bag
should be positioned below the level of the bladder but not be in contact
with the floor. The bag must be emptied sufficiently frequently to maintain
urine flow.
Catheters should not be changed unnecessarily and routine personal
hygiene is all that is needed. Where an overnight bag is used, it should be
attached to the bottom of the day bag as a linkage system to avoid breaks
in the system. In general, catheter drainage bags are single use only.
Patients with a long term catheter in place, and their carers, should
be educated in hand decontamination and any procedures such as
intermittent catheterisation prior to discharge. Follow up support should
be provided.
Catheters are changed when clinically indicated or according to
manufacturers recommendations.
Work based activities
• Identify a patient with a urinary catheter in place and discuss with them the reasons for this and any other options that were considered.
• TObserve a skilled practitioner as they insert a urinary catheter and ask them to supervise you if your role involves insertion of a urinary catheter
• TIdentify the brands of urinary catheter and drainage bags that are used
in your clinical areas and discuss the qualities of these devices with the
manufacturers representative
• TKeep a log of any infections that occur in patients that you have cared for
over a period of time e.g. 2 weeks and identify which type are most common
• T Identify the ongoing tests and observations that are undertaken to identify
infection of the urinary tract e.g. observations, obtaining urine samples etc.
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19
Introduction
Multiple Sclerosis (M.S.) is one of the most common
neurological disabling conditions. It is one of the primarily
frequent causes of disability in young adults with a mean onset
age of 0 (Sadonick and Ebers, 199). It has been recognised by
the Department of Health as a chronic long-term condition in
the Long – term Conditions National Service Framework (2005).
Prevalence is higher in northern Europe 10 per 100,000
population compared to southern Europe and the
Mediterranean 0 per 100,000 population (Roberts et al,
1991). The British Society of Rehabilitation Medicine (199)
suggests that this could equate to 5-8 new cases per 100,000
per annum. The National Institute for Clinical Excellence
(NICE) 2003 have calculated that about 52,000 – 62,000
suffer with M.S. NICE also estimated that 1800 – 3400 people
are newly diagnosed with M.S. per annum.
Within Cardiff and Vale there is an estimated population of
over 500,000 this could liken to between 500 – 700 patients
who suffer with M.S. with between 15 – 35 new patients
per annum. With these statistics in mind the Continence
Service and the Helen Durham Multiple Sclerosis service
both of Cardiff and Vale NHS set about creating a unique
post of a Multiple Sclerosis Continence Nurse Specialist.
Background to the disease
M.S is a disease of the central nervous system. It is when the
white matter within the brain or spinal cord becomes inflamed
and destroys the person’s own immune system (Nice 00).
The cause is unknown although both genetic and environmental
factors are said to contribute (Barnes, Gilhus and Wender, 001).
Diagnosis can be made accurately with modern techniques
such as MRI scanning. However, there are no precise
prognostic indicators for disease progression.
M.S. usually starts in adult life; the diagnosis is for life with
no known cure. There are recognised ways of describing
the patterns of M.S. (table 1).
Table 1.
Secondary progressive M.S. – follows on from relapsing/remitting M.S. There are gradually more or worsening symptoms with
fewer remissions (about 50% of those with relapsing/remitting M.S.
develop secondary progressive M.S. during the first 10 years of the
illness).
Primary progressive M.S. – from the beginning, symptoms
gradually develop and worsen over time (10 – 15% of people at
onset).
NICE 00
Table . Common symptoms of Multiple Sclerosis
Visual – loss /double vision
Cerebella – in coordination
Mood – depression/anxiety
Cognition – concentration
Motor – weakness/ spasticity
Sensory – loss of sensation
Sexual dysfunction – loss of libido
Fatigue – lassitude, reduced endurance
Bladder – urgency, frequency, hesitancy, retention and/or
incontinence
Bowel – constipation, urgency and/or faecal incontinence
Bladder / bowel problems have been highlighted as having
major implications on the quality of life of M.S sufferers.
Goldman et al suggest that up to 90% of M.S. patients will
have bladder dysfunction, which can exacerbate the underlying
disease via secondary infection (Bradley, 1978), which can
be associated with lower limb deficit (Betts et al, 1993).
Bowel dysfunction although not as common will have an even
greater impact on quality of life. Chia et al (1995) identify
incidents of 68% of M.S. sufferers who report bowel
dysfunction with 36 – 53% having constipation and 50%
faecal incontinence.
The problems with continence in M.S. have been identified in
national documentation including National Institute of Clinical Excellence (00) and the National Service Framework
Long Term Conditions – Good Practice Guide for People with
Neurological Conditions (006). These documents highlighted to both services the need to improve continence
care to patients with M.S. within the Cardiff and Vale area.
The Project
Both services had realised that care of the M.S. patient with
continence problems was uncoordinated and referrals were
inconsistent (table ). Both services wanted the patients journey to be more direct and less duplication of referrals.
Table .
Patterns of Multiple Sclerosis.
Relapsing/remitting M.S. – symptoms come and go. Periods
of good health or remission are followed by sudden symptoms or
relapse (80% of people at onset)
0
Goldman et al (2006) have identified common symptoms
associated with M.S., which can be addressed with simple
interventions or may need a more complex approach via
a multidisciplinary team (table ).
Referral patterns of M.S. patients for continence services prior to 2004.
M.S. Patient
Continence service (0%)
Urology
Urodynamics
Gynaecology
urodynamics
M.S. Team neurology (50%)
Continence Physio
Continence
Service (5%)
conservative therapies
Thus the problems were identified with the referral system and
streamlining the service was implemented (table 4).
find the consultation and did the service offered improve
the problem. The results are shown in the following graphs.
Table 4.
Graph 1. Do your Bladder/Bowel problems impact on your
quality of life? N = 1
Referral patterns of M.S. patients for continence services after 2004.
M.S. Patient
M.S. team (100%)
M.S. continence nurse specialist (90%)
Continence Team
Urology
Gynaecology
Physio
The post was designed in response to a Welsh health circular
(00) and funded by the Neurology department. The post
was established in 004 and was initially an 18.5 hour
permanent post.
To prepare for the post the nurse specialist had to under go
set training which included the M.S. trust clinical development
module,Trust continence module, digital rectal course and catheterisation course. Mentorship was provided by the Director
of continence service and M.S service manager.
The Current Service
We now provide an exclusive continence service for M.S. patients
offering nurse led clinics within both community settings and
hospitals, home visits for patients who cannot attend clinics, ward
based assessments and a direct access for patients via telephone.
Full continence assessments are offered for both bladder
and bowel continence dysfunction. Interventions include
conservative therapies such as intermittent self-catheterisation,
pharmacology and pelvic floor rehabilitation. Specialist
interventions include electrical stimulation and direct access
into specialist secondary care services for Botox or anal
physiology investigations.
To monitor the success of the service an audit over 1 year was
undertaken in 005 showing that the M.S continence nurse
specialist saw 109 patients in the nurse led clinics, 00 patients
seen in their own homes and 50 patients reviewed in the
multi disciplinary team neuro – inflammatory clinic (chart 1).
Chart 1
Activity over one year
NURSE LED
CLINIC 109
HOME
VISITS 00
NEURO
INFLAMITORY
CLINIC 50
WARD
VISITS 50+
A survey was undertaken of 1 patients looking at the impact
bladder/bowel problems on quality of life, how useful did they
5
4.5
4
.5
.5
1.5
1
0.5
0
Not at all
Sometimes
Often/most days
All the time
Graph 2. How helpful did you find the consultation? N =12
9
8
7
6
5
4
1
0
Not at all
Minimal help
Quite helpful
Extremely helpful
Graph . How did the service/treatment received improve
your problem and therefore quality of life? N = 1
6
5
4
No sign of improvement
Minimal improvement
Moderate improvement
greatly improved
1
0
Benefits to patients have been significant and include direct access to the M.S. team and better communication between the
M.S. service and the continence team including the M.S. nurse
specialist attending a multi disciplinary meeting every week.This
has provided more continuity of care and a streamline service. The Trust is fully in line with the national guidance from
both the NICE guidelines and NSF for long-term conditions.
Both services are keen to take this development forward.
We have already due to demand increased the nurse’s hour
to 5 hours per week. We are already benchmarking the
service to see where we can make improvements. We are
undertaking routine audits and patients evaluating patient
satisfaction and are interfacing with the local M.S. society
to provide details about the service and what it can offer.
References
Barnes MP, Gilhus NE,Wender M (2001) European Federation of Neurological Societies.Task
force on minimum standards for health care of people with multiple sclerosis: June 1999. European Journal of Neurology.Vol 8: 215 –221.
Betts CD, D’Mellow MT, Fowler CJ, (1993). Urinary symptoms and the neurological features of
bladder dysfunction in multiple sclerosis. J.Neurol Neurosurg Psychiatry. 56: 245 – 250.
Bradley WE (1978) Urinary bladder dysfunction in multiple sclerosis. Neurology 29: 52-58.
British Society of Rehabilitation Medicine (1993). Multiple Sclerosis:- a working party report of
the British society of Rehabilitation Medicine. British Society of Rehabilitation Medicine, London.
Chia YW, Fowler CJ, Kamm MA et al (1995) Prevalence of bowel dysfunction in patients with
multiple sclerosis and bladder dysfunction. J Neurol 242: 105 –108.
DOH National Service Framework long term conditions (2005) Dept of Health. London.
Goldman MD, Cohen JA, Fox RJ, Bethoux FA (2006) Multiple Sclerosis: - Treating symptoms and
other general medical issues.Cleveland clinical journal of medicine, 73,2:177-186.
NHS National Institute for clinical excellence (2003) Multiple Sclerosis: - management of M.S. in
primary and secondary care. London.
Roberts MHW et al (1991) Prevalence of multiple sclerosis in the Southampton and South West
Hampshire health district. J. Neurol Neurosurg Pyschiatry. 54:55 – 59.
Sadovnick AD, Ebers GC (1993) Epidemiology of multiple sclerosis: a critical overview. Can J
Neurol Sci 20:17 – 29.
1
Nutrition & Obesity
Part 4
Last week I claimed a breakthrough in my fight
to get fit and lose weight. I ran 3km every day,
something I thought I’d never do. Now I’m
wondering (though please don’t hold me to it
yet) if I’ll ever be able to run a fun-run or even
a mini marathon, perhaps even this year?
Before I get too excited, though, let me quickly
remind myself that it wasn’t quite a
continuous run, it was three minutes
running followed by two minutes walking, so
completing the km in thirty minutes or so.
But it’s a major milestone for me, because
I remember adding a ten second run to my
daily walk just six months ago, and feeling that
I’d die from exhaustion. I really did sit on the
edge of the treadmill, purple faced and panting,
thinking of reporting myself to the RSPCA for
cruelty to beached whales and almost giving
up. But I stuck at it, added five seconds every
fortnight and, it worked!
Perhaps I wouldn’t have stuck at it so grimly
if I hadn’t had a buddy, in this case my trainer,
Steve.
It helps if you have someone else egging you on (not nagging
you, just encouraging your own ideas!). Anyone who might
have watched me in that awful programme on ITV (Celebrity
Ugh Club), will remember that I really hate being told what
to do. And I loathe even more being ordered to do it. But I
wanted to prove to myself that I could jog. Besides, I would go
to the gym, and walk for thirty minutes, whilst watching slim,
lithe, young ladies do a quick ten minute run, work off more
calories than I did in my half hour of walking, and then buzz
off. That’s for me, I thought. If I can get my daily exercise into
a ten minute jog, then I might be able to fit it into my daily
routine, as the experts recommend.
A buddy is also great for stopping you from fooling yourself.
You can’t boast you exercise every day, or you eat a totally
healthy diet, if you have a buddy who knows that she last
saw you at the gym six weeks ago and then you were helping
yourself to a chocolate muffin at the coffee bar!
According to a recent study in America, we weight losers are
brilliant at deluding ourselves.
They asked 11,000 seriously overweight adults about their
eating and exercising habits. Three quarters of them said they
had healthy diets and 40 per cent of them reckoned they did
vigorous exercise at least three times a week. When their
families were asked about them, it appeared that these men
and women were kidding themselves.
Former President Bill Clinton admitted the same when he
recently launched a ten year initiative to reverse America’s
trend in childhood obesity. He was a fat kid, and hated it. He
grew up in America’s deep south, with an abiding love of all
things fried and super-sized. It is said that whenever he flew in
Air Force One, he ordered the galley filled with McDonald’s
and Kentucky Fried, and he was particularly partial to jalapeño
cheeseburgers and pork rinds. When Hillary flew too, it was
Caesar salads and grilled fish!
He did pride himself on being fairly fit, though, and would run
regularly. But, he admits, he was kidding himself that he was
healthy, because of his eating habits. It certainly took its toll.
Last year, he had a quadruple heart bypass, lost over a stone in
weight, and says it’s given him a new insight into America’s
obesity crisis.
Everything he says on the subject shows he really understands
BY ANNE DIAMOND
and knows how hard it is to lose weight.
“When I was a little boy, if you grew up in
a place that was as poor as Arkansas was,
it was generally believed that the best
evidence of a baby’s health was how fat it
was,” he said recently when he pledged to
get soft drinks and junk foods out of US
schools and campuses. “My grandmother,
who was a nurse, would have thought I was
terribly anaemic or something was wrong
with me if I was normal. Now we know if
you are normal size you are healthy.”
His “Alliance for a Healthier Generation”,
formed by his own foundation and the
American Heart Association, say they’re
in this for the long haul, and Clinton admits
it’s not a
glamorous cause:
“I got into it knowing I have a higher risk of
not being
effective and a higher risk of not being able
to prove it than anything else I have done,”
he says, “because it requires millions upon
millions upon millions of people and a long time frame.”
Interesting what he said about babies, because American studies show that their babies are getting bigger and bigger, and
paediatricians are wondering whether intervention, at baby
clinic level would be intrusive or helpful.
True, many chunky babies grow into slim, healthy adults. But
if a baby comes from a family which is predisposed to obesity,
should questions then be asked about the family’s lifestyle and
eating habits?
No-one’s suggesting putting babies on diets, but does a family’s
eating habits become ingrained in that infant from day one?
And should we be thinking of ways to stop bad habits taking
root? Or is that Nanny State gone too far?
I keep quoting studies from America (because, let’s face it,
that’s where the obesity volcano started and is still
erupting) but this week, there was more research from Bristol
and Glasgow universities showing a distinct link between childhood obesity and watching TV. Perhaps Nanny State has to
find a way to lure us from our TV sets and play (and exercise)
outdoors, though with the tragic disappearance of little
Madeline McCann, I suspect more parents will prefer to keep
their children inside, passively ogling The Tweenies.
It’s clear that we can no longer afford to talk about the child
obesity epidemic without factoring in screen time, and the
Americans have even come up with an initiative for that, a
family based programme called “Switch”, working with schools
and communities to give kids advice about food, something to
do, and a reason NOT to watch TV all the time!
I must say, I rather like the slogan - “Switch what they Do,
View, and Chew!”
We’re going to need that sort of thing here very soon. I hope
Bill Clinton comes with it!
Recently, hospital infection outbreaks caused by
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DVT
Author: Dr Greig Ferguson, MD, DSc, BN (Hons), RN, BSc (Hons), ATLS, ALS, EPLS
INTRODUCTION
Deep Venous Thrombosis or DVT’s are not acutely life threatening per
se however they are associated with complications, which can be
acutely fatal (1). Venous thrombosis is a condition in which a blood clot
(thrombus) forms in a vein. This clot can limit blood flow through the vein,
causing swelling and pain. Most commonly, venous thrombosis occurs
in the “deep veins” in the legs, thighs, or pelvis. When this occurs, it is
called a deep vein thrombosis, or DVT.
Vein within
calf muscle
Vein wall
Part of the
clot may
break off
and travel
up the vein
DIAGNOSIS
If the patient’s history, symptoms, and physical exam suggest a venous
thrombosis, tests are needed to establish a diagnosis (5,6). Diagnosing
DVT — Tests used to establish a diagnosis of DVT may include
compression ultrasonography, contrast venography, magnetic resonance
imaging (MRI), computerised tomography (CT scan) and a blood test
called D-dimer.
D-dimer — D-dimer is a substance that is often found to be elevated in
the blood of people with venous thromboembolism or PE. It can be used
to eliminate the possibility of deep venous thrombosis. If the D-dimer test
is negative and the patient is thought to be at low probability of DVT or PE
on the Wells score, DVT or PE are unlikely and further testing may not be
needed (9).
Clot
Blood clot
stuck to
inside lining
of the vein
Deep Vein Thrombosis
If a part or all of the blood clot breaks off from the site where it was
created, it can travel through the venous system this. If the clot lodges in
the lung, it is called pulmonary embolism (PE), a serious condition that
led to over 100,000 deaths in an 8-year period in the United Kingdom
and it is estimated that at least 60,000 a year can be attributed to DVT
(7)
. In most cases, PE is caused by a DVT between one in three and
one in four cases of DVT (6). Venous thrombosis can form anywhere
in the venous system. However, DVT and PE are the most common
manifestations of venous thrombosis.
RISK FACTORS
There are a number of factors that increase a person’s risk of developing
a venous thrombosis. At least one risk factor can be identified in over 80
percent of patients who develop a venous thrombosis. An increased risk
of developing a blood clot is sometimes referred to as a “thrombophilia”
or a hypercoagulable disorder (1,2).
• Previous surgery (especially orthopaedic surgery and
neurosurgery)
• Trauma
• Pregnancy (Hypercoagulable state)
• Obesity
• Use of certain medications (e.g., Oral Contraceptive Pill, HRT)
• Immobilisation or prolonged bed rest
• Cancer
• Heart failure
• Elevated blood levels of homocysteine (genetic)
• Certain disorders of the blood, such as polycythaemia vera
• Kidney problems, such as nephrotic syndrome
• Antiphospholipid antibodies (antibodies that affect the clotting
process).
• A previous episode of a clot in the leg (deep vein thrombosis)
or PE.
Smoking and increased age may also increase the risk of venous
thromboembolism, but it is not clear what role these factors play.
SIGNS AND SYMPTOMS
There are signs and symptoms of DVT and PE; these may be caused
by the thrombus, or maybe related to another condition. In most cases,
testing is needed to determine if a clot is present (7,8).
Deep vein thrombosis — Classic symptoms of DVT include swelling,
pain, warmth and discoloration in the involved leg however this pain
occurs in 50% of patients and is entirely non-specific. Pain can occur
on dorsiflexion of the foot (Homans sign) (6). Homan’s sign is described,
as discomfort in the calf muscles on forced dorsiflexion of the foot with
the knee straight has been a time-honoured sign of DVT. However, this
sign is present in less than one third of patients with confirmed DVT. The
Homan’s sign is found in more than 50% of patients without DVT and
therefore is very non-specific (5).
Pulmonary embolism - The most common symptoms of pulmonary
embolism are difficulty breathing, chest pain while taking a deep
breath, cough and coughing up blood.
The most common physical findings are an increased rate of breathing,
abnormal lung sounds heard with respiration and a rapid heart rate (3,4).
4
TREATMENT
The treatment of deep vein thrombosis and pulmonary embolism is
similar. In DVT, the main goal of treatment is to prevent a PE (10). Other
goals of treatment include prevention of further clot extension, prevention
of a recurrence of thrombosis, and the prevention of complications, such
as the postphlebitic syndrome and chronic high blood pressure in the
vessels between the heart and lungs (pulmonary hypertension).
The mainstay of treatment for venous thrombosis is anticoagulation
. Other treatments may include thrombolytic therapy or inferior vena
caval interruption. If a reversible risk factor, such as immobility, exists in
a particular patient, the clinician may opt to treat the patient until the risk
factor is resolved.
(11,12)
• Patients with a first episode of venous thrombosis without an
apparent cause should be treated for a minimum of six months.
• Patients who have recurrent venous thrombosis should be treated
for a minimum of 12 months.
Treatment may be continued indefinitely in patients with three or more
episodes of venous thrombosis and in patients with a risk factor that
cannot be reversed (6).
PREVENTION
Surgical patients — Certain high-risk patients undergoing surgery
(especially orthopaedic surgery and cancer surgery) may be given
anticoagulants to decrease the risk of blood clots. Anticoagulants may
also be given to women at high risk for venous thrombosis during and
after pregnancy (8).
In surgical patients with a moderate to low risk of blood clots, other
preventive measures may be used. For example, some surgical patients
are fitted with inflatable compression devices that are worn around the
legs and periodically fill with air; these exert gentle pressure to improve
circulation and help prevent clots (10). Low risk and some moderate risk
patients may be asked to wear graduated compression stockings. For all
patients, walking as soon as possible after surgery can decrease the risk
of a blood clot.
REFERENCES & FURTHER READING
1. Bertina, RM. Genetic approach to thrombophilia. Thromb Haemostat 2001; 86:92.
2. Martinelli, I. Risk factors in venous thromboembolism. Thromb Haemost 2001; 86:395.
3. Prandoni, P, Lensing, AW, Cogo, A, et al. The long-term clinical course of acute venous
thrombosis. Ann Intern Med 1996; 125:1.
4. Hyers, TM. Venous thromboembolism. Am J Respir Crit Care Med 1999;159:1.
5. Donnelly, R, Hinwood, D, London, NJ. ABC of arterial and venous disease. Non-invasive methods
of arterial and venous assessment. BMJ 2000; 320:698.
6. Mannucci, PM, Poller, L. Venous thrombosis and anticoagulant therapy. Br J Haematol 2001;
114:258.
7. Turpie, AG, Chin, BS, Lip, GY. ABC of antithrombotic therapy: Venous thromboembolism:
treatment strategies. BMJ 2002; 325:948.
8. Turpie, AG, Chin, BS, Lip, GY. Venous thromboembolism: pathophysiology, clinical features, and
prevention. BMJ 2002; 325:887.
9. Stein, PD, Fowler, SE, Goodman, LR, et al. Multidector Computerised Tomography for Acute
Pulmonary Embolism. N Engl J Med 2006; 354:2317.
10. Bates, SM, Ginsberg, JS. Clinical practice. Treatment of deep-vein thrombosis. N Engl J Med
2004; 351:268.
11. Geerts, WH, Pineo, GF, Heit, JA, et al. Prevention of Venous Thromboembolic Disease: The
Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. CHEST 2004; 126:338S.
12. Blann, AD, Lip, GY. Venous thromboembolism. BMJ 2006; 332:215.
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25
Preventing
a Crisis!
Best
selling
confere
n
in the U ce
.S.!
Subclinical Signs of Impending Doom
Conference Speaker
Carol Whiteside, MSN, PhD, has been a nurse in the U.S. for over 35 years.
She is a
clinical nurse specialist and a cardiovascular nurse specialist. Carol has been a staff nurse, cath lab
manager, nursing supervisor and director of education. She previously worked in a trauma unit,
medical surgical unit, cardiac ICU, medical ICU, adult and pediatric open heart surgery, neonatal ICU
and a burn unit.
She has also educated nurses internationally and is an extremely talented and entertaining presenter.
Carol has also been a preceptor and a clinical nursing instructor. Additionally, she is a nurse entrepreneur presenting courses in critical care topics, EKG interpretation, ACLS, critical thinking and a
variety of other nursing topics. Carol has been a sought-after speaker for many years. She has the
unique ability to combine her vast clinical background and information with critical thinking strategies. You will leave with the skills and techniques to anticipate the subclinical signs of impending
doom and therefore improve the care you provide your patients.
N See the signs of compensation in the body — before
the patient crashes
N Know when to call the rapid
response team
N Goal setting and priorities
for decisive action
To register, or for more
information:
web: www.cb-training.com
Phone: 01324-411013
Conference Objectives
1. Recognize the signs of compensation in the human body before illness appears.
2. Interpret what is happening in the body physiologically when the heart rate and respiratory rate
go up.
3. Identify the components of cardiac output.
4. List three signs of left heart failure and describe the physiology behind them.
5. Describe two symptoms that differentiate ARDS from other forms of respiratory failure.
6. Identify the level of oxygen to be given a CO2 retaining COPDer in crisis.
7. Recognize three ways that CHF differs from the other forms of shock.
8. Explain two ways in which benign and malignant headaches differ in their presentation.
9. Relate four signs found through the look test indicating a change in the patient’s condition.
10. Describe the physiological mechanism driving the changes seen in patients after surgery.
11. Identify the first sign of compartment syndrome.
12. List three components of “painting the picture”.
Conference Fee:
£125 + VAT (£146.87) single registration postmarked by 8/31/07 • OR • £145 + VAT (£170.37) standard seminar tuition
Glasgow, Stobhill Hospital October 23, 2007
Dublin, Royal Dublin Showground (RDS) October 24, 2007
London, Hammersmith Hospitals NHS Trust October 25, 2007
made possible by a joint venture between:
26
27
Diabetes
Author: June Currie, Lead Specialist Nurse in Diabetes, Forth Valley Acute Hospitals Diabetes Service Part of 4
Abstract:
Diabetes Mellitus (DM) is known to have a significant
impact on the morbidity and mortality of those people
who suffer from this condition, resulting in a higher
incidence of premature death, often from cardiovascular
disease. Early detection of problems and stricter control
of risk factors and glycaemia are essential in reducing
complications.
The chronic complications associated with DM can be broadly
divided into macrovascular and microvascular disease.
Macrovascular disease (macroangiopathy)
The formation of atherosclerotic plaques occurs more frequently and
at an earlier age in those people with DM. The arterial endothelium,
known to be more fragile, is more likely to rupture allowing the
accumulation of lipoproteins high in cholesterol.
Accelerated atheroma formation in medium and large sized arteries
is responsible for the presence of premature and excessive
cardiovascular, cerebrovascular and peripheral vascular disease (1).
Microvascular disease (microangiopathy)
Microangiopathy is fundamentally the narrowing of the vascular
lumen, due to a thickening of the basement membrane within the
blood vessels.
The major pathogenic factors associated with the development of
microangiopathy are blood flow and clotting abnormalities, and
hormonal and biochemical disorders.
This condition is responsible for retinopathy, nephropathy and
neuropathy (1).
What causes micro/macrovascular disease?
One of the major underlying causes of diabetic complications would
appear to be prolonged exposure to hyperglycaemia.
This is particularly significant in the case of Type 1 DM.
Continued exposure to hyperglycaemia causes both acute and
cumulative changes to cellular metabolism, which will eventually
result in chronic and irreversible tissue damage.
The acceleration of atherosclerotic changes within larger blood
vessels, which occurs in macroangiopathy, is affected by a combination
of metabolic and hormonal imbalances, dyslipidaemia and decreased
antioxidant defence mechanisms.
Environmental and genetic factors also play a significant role in the
development of macrovascular disease. Contributing factors are no
different as for the general population, and include diet (ie. increased
fat intake) and known hyperlipidaemia; excessive weight; hypertension,
smoking and lack of exercise (1).
Cardio- & Cerebrovascular complications
Evidence from a large trial carried out in the UK and published in the
1990s – the UKPDS () – highlighted that 50% of people with Type 2
DM had complications at the time of diagnosis, with symptoms of the
condition evident for up to 10 years prior to formal diagnosis. It is
also widely accepted that there is an increased risk of cardiovascular
(CV) complications developing during the ‘pre-diabetic’ stages known
as impaired glucose tolerance or impaired fasting blood glucose ().
Approximately 80% of those people with Type DM will die
prematurely from CV complications (4), with a -4 times increase in
the likelihood of a cerebrovascular event, such as a stroke or TIA ().
It is clearly recognised that aggressive management of
hypertension in the person with DM is essential to reduce both
cardio- and cerebrovascular damage. A reduction of 5-6 mmHg in
the diastolic BP can lead to a 8% reduction in stroke, a 16%
reduction in MI and a 1% reduction in all cause mortality ().
Increasing exercise, dietary changes, reducing excessive alcohol and
stopping smoking are also essential.
8
The use of multiple drug therapy in the treatment of
hypertension has been identified by NICE and the Joint British
Societies as required to reach ever tighter targets (5)
[see table below].
Guideline
Optimal BP target
Audit standard BP target
(mmHg)
(mmHg)
1. NICE (00)
(National Institute for Health
and Clinical Excellence)
≤ 135/75
(People with T and
microalbuminuria)
≤ 140/80
. BHS (004)
(British Heart Society)
< 10/80
< 140/80
. JBS- (005)
(Joint British Societies)
< 10/80
< 140/80
There have been a number of clinical trials carried out over the
last 5-10 years identifying which combinations of anti-hypertensive
medications are beneficial for those people with DM. ACE inhibitors
(such as Ramipril and Perindopril) and Angiotensin-II receptor
blockers (such as Irbesartan and Losartan) have been proven to be
successful in the Prevention and treatment of hypertension, whilst
also providing a renoprotection benefit (5).
It is often necessary to include diuretics (such as Bendrofluazide),
calcium channel-blockers (such as Amlodipine and Felodipine) and
also alpha-blockers (such as Doxazosin) in order to achieve ideal
BP targets. Traditional beta-blockers (such as Atenolol) are less
frequently used as evidence now suggests that this group of drugs is
more likely to cause hyperglycaemia.
Lipid management is seen by many as the single most effective
intervention in reducing CV risk in those people with DM (). Many
studies have again provided the evidence to back this up, including
the 4S trial, 1994 (Scandinavian Simvastatin Survival Study Group),
the Heart Protection Study, 00 and CARDS, 004 (Collaborative
Atorvastatin Diabetes Study).
Cardio- & Cerebrovascular complications
The most recent guidelines produced by the JBS in 005 suggested a
total cholesterol (TC) level of less than 4 (or a 5% reduction in TC),
with a low-density lipoprotein (LDL) level of less than . It is widely
accepted that these levels will be extremely difficult to achieve unless
aided by lipid-lowering medication, with statins still considered the
first-line choice in DM.
All people with DM (regardless of type of DM and ‘starting’
cholesterol level) aged 40 years and over should be commenced
on lipid-lowering medication as a matter of course. Those people
younger should be assessed on an individual basis, with emphasis still
on initiating medication if the TC level is sub-optimal.
Maintaining good glycaemic control was confirmed by the UKPDS
as beneficial in reducing CV risk in patients with Type 2 DM. A 1%
reduction in the HbA1c level was shown to reduce the incidence of
myocardial infarction by 14%, with a 1% reduction in stroke ().
The Diabetes Control and Complications Trial (DCCT) for Type 1
DM was carried out in the USA and published it’s findings in 1993.
During the initial period of 10 years, this particular trial concentrated
on the link between improved glycaemic control and significant
reduction in microvascular complications. However, on follow-up of
the participants, a 57% reduction in non-fatal MIs, stroke or CV death
was identified ().
Peripheral vascular disease
Peripheral vascular disease (PVD) can be a major complication for
those people with DM and is recognised as the greatest single cause
of lower limb amputation, second only to traumatic injury (6).
Prevalence of PVD in the diabetic population in the UK has been
Diabetes
estimated to be up to %. Diabetic foot ulceration is often
associated with a combination of PVD and peripheral neuropathy,
with contributing factors including a known history of CV disease
and smoking (7).
It is recommended that all people with DM should have an annual
foot screening by an appropriately trained health care professional,
with appropriate education regarding maintaining good glycaemic
control, reducing risk factors, appropriate footwear and general care
of the foot (7).
Nephropathy
It is estimated that 40% of all Type 1s will develop nephropathy within
5 years of diagnosis. Although a lower number of Type s go on to
develop the same condition, this is due to the fact that many of this
group will die prematurely as a result of CV disease. 5-10% of Type
s will already have evidence of nephropathy at diagnosis, thought to
be as a result of prolonged and undetected hyperglycaemia (8).
Early detection and treatment of this condition is crucial in avoiding
progression to eventual dialysis, with DM identified as being the
leading cause of end-stage renal failure.
Renal function should be assessed at least annually, with
microalbuminuria and glomerular filtration rates checked as
standard. Strict management of CV risks and control of
hypertension is essential, with tighter BP targets for those people
diagnosed with early stage nephropathy. The use of multiple drug
therapies is commonplace, with strong evidence that the use of ACE
inhibitors and Angiotensin-II receptor blockers delays the progression
of this condition (8).
Retinopathy
The prevalence of diabetic retinal disease increases with the duration
of DM, with approximately a 0% risk to this population of
developing moderate to severe retinopathy. Retinopathy remains
the commonest cause of blindness worldwide, with an incidence
of between 50-65% per 100,000 diabetic population per year in
Europe (7), (9).
Retinal capillary damage occurs as a result of microangiopathy and
prolonged hyperglycaemia and can lead to retinal oedema and
exudates, the formation of new vessels and the potential for
haemorrhage (1). Diabetics also have a two-fold risk of developing
cataracts at an accelerated rate and this risk is further exacerbated
by poor glycaemic control (7).
of the causes of ED has led to an increase in effective treatments for
this condition, although often a reluctance to discuss ED by both the
diabetic male and the health care professional does remain an issue.
Conclusion
Complications of DM can have a major impact on the quality of life
of the diabetic individual and can result in a significant reduction in
overall life expectancy. Evidence has shown, however, that with early
detection of both the condition and complications, followed by the
appropriate and, in some cases, intensive therapeutic input, outcomes
can be improved dramatically.
References
1. Pickup J. C.,Williams G.Textbook of Diabetes, 3rd Edition Oxford: Blackwell Science 2003
2. UKPDS Group Complications in newly diagnosed type 2 patients… Diabetes Res
1990: 13: 1-13
3. Morrissey J. et al JBS 2 guidelines: A strategy to prevent CVD in diabetes Diabetes
& Primary Care 2006: 8 (2): 82-92
4. Barnett A.H., O’Gara G. In Clinical Practice Series: Diabetes and the Heart London:
Churchill Livingstone 2003
5. Gadsby R. Managing CV risk in type 2 diabetes:Towards best practice Diabetes &
Primary Care 2006: 8 (4): 182-192
6. Scottish Intercollegiate Guidelines Network (SIGN) Cardiac Rehabilitation, Clinical
Guideline 57 Edinburgh 2002
7. Scottish Intercollegiate Guidelines Network (SIGN) Management of Diabetes, A
National Clinical Guideline 55 Edinburgh 2001
8. Harris H. et al Diabetic nephropathy: Implications for the renal NSF for primary
care Diabetes & Primary Care 2007: 9 (1): 50-57
9. Swindlehurst H., Prasad S. Importance of screening and early treatment of diabetic
retinopathy Cardiabetes 2002: 3: 26-33
10. Jude E. Management of diabetic neuropathy Modern Diabetes Management
2003:4 (2): 6-9
11. Heald A.H.,Young R.J. Diabetic autonomic neuropathy presenting early in the
course of DM Diabetes Today 2001: 4 (1): 6-8
12. Mills L. Erectile dysfunction: assessment and treatment in diabetes Journal of
Hypofit
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9/3/07 2:58 pm Page 1
Diabetes Nursing
2003:1.03.07
7 (4): 146-149
Flavours available:
Mint
Orange
Tropical
Annual retinal screening is accepted as ‘gold-standard’ practice, with
the use of highly specialised digital cameras now commonplace. Early
detection and treatment of contributing risk factors, such as poor
glycaemic control and hypertension, are again essential in reducing
both the incidence of background retinopathy and the advancement
of this condition to a sight-threatening stage.
Neuropathy
Peripheral neuropathy (PN) is known to affect 0-50% of the diabetic
population, occurring in both Type 1s and Type s and more
commonly in those diagnosed for more than 10 years. PN causes
sensory deficits in the extremities (mainly the feet), often resulting
in pain and discomfort which can be difficult to manage and can lead
to an increased risk of foot ulceration, infection and ultimately
amputation. Charcot foot, associated with PN, is a severely
debilitating condition resulting in destructive arthropathy and
significant deformity (10). Both metabolic and vascular factors are
present in PN, with restricted blood flow to the nerve fibres and
prolonged hyperglycaemia recognised as causes.
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Each batch tested
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Abnormal autonomic function is present in a significant number of
people with DM, with severe cases of this type of neuropathy leading
to postural hypotension, gastroparesis and impotence (11). Whilst
regarded by many as a late complication of DM, it is not unknown
for symptoms to present early in diagnosis, suggesting again that
any delay in this diagnosis can result in significant life-affecting
complications.
Erectile dysfunction
At least 50% of men aged 40-70 years with DM develop erectile
dysfunction (ED) at some stage (1). Metabolic effects of
persistent hyperglycaemia, vasculopathy and smooth muscle myopathy
are all considered to be factors in this condition, with the increased
incidence of hypertension and subsequent treatment of same
recognised as a contributing cause (1). An improved understanding
t: +44 (0)1303 298 286
f: +44 (0)20 7900 2255
e: [email protected]
www.arcticmedical.co.uk
Arctic Medical Limited
Folkestone Enterprise Centre
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Folkestone, Kent. CT19 4RH
9
P14898_Scott Nurse_267x92_5aw.qxd
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Page 1
Diabetes
Prescribing Information For Avandamet Use In Dual and Triple Therapy
Refer to full Summary of Product Characteristics before prescribing
AVANDAMET
Rosiglitazone/metformin HCl
Presentations AVANDAMET 2mg/500mg film-coated tablets containing 2mg rosiglitazone
with 500mg metformin HCl. AVANDAMET 2mg/1000mg & 4mg/1000mg film-coated tablets
containing 2mg or 4mg rosiglitazone respectively with 1000mg metformin HCl. Indications
Treatment of Type 2 diabetes mellitus patients, particularly overweight patients:
• who are unable to achieve sufficient glycaemic control at their maximally tolerated dose
of metformin alone.
• in triple oral therapy with sulphonylurea in patients with insufficient glycaemic control
despite dual oral therapy with their maximally tolerated dose of metformin and a
sulphonylurea.
Posology & administration 4mg rosiglitazone/2000mg metformin with food. Can be
increased to 8mg rosiglitazone/2000mg metformin if greater glycaemic control is required.
For patients on metformin and sulphonylurea: when appropriate Avandamet may be
initiated at 4 mg/day rosiglitazone with the dose of metformin substituting that already being
taken. For patients on triple oral therapy Avandamet may substitute rosiglitazone and
metformin doses already being taken. Caution is advised when using the 8mg rosiglitazone/
2000mg dose in triple therapy as there is an increased risk of heart failure. Elderly Renal
function should be monitored regularly. Children & adolescents Not recommended.
Contraindications Hypersensitivity; history of cardiac failure (NYHA stages I to IV);
diseases which may cause tissue hypoxia; hepatic impairment, acute alcohol intoxication/
alcoholism, diabetic ketoacidosis/pre-coma; renal impairment; acute conditions that may
alter renal function; lactation. Special warnings & precautions Lactic acidosis can occur
as a result of metformin accumulation, primarily in patients with significant renal failure.
Renal function serum creatinine concentrations should be determined regularly (see SPC).
Hypoglycaemia Triple oral therapy with a sulphonylurea increases risk of dose-related
hypoglycaemia. A reduction in the dose of the sulphonylurea may be necessary. Increased
risk when used in combination with insulin; dose adjustment of insulin may be necessary.
Fluid retention & cardiac failure Rosiglitazone can cause dose-related fluid retention that,
may very rarely be associated with rapid & excessive weight gain, & may exacerbate or
precipitate heart failure. Monitor signs & symptoms of fluid retention. Discontinue if
deterioration in cardiac status. Heart failure reported more frequently when history of heart
failure, elderly, or mild or moderate renal failure, or when used in combination with a
sulphonylurea or insulin. Concomitant administration with NSAIDs may increase risk of
oedema. The use of rosiglitazone in triple therapy with a sulphonylurea is associated
with increased risk of fluid retention. Increased monitoring is recommended and doseadjustment of the sulphonylurea as is necessary. Increased monitoring of the patient is also
particularly recommended if AVANDAMET is used in combination with insulin. Monitoring
of liver function Rare reports of hepatocellular dysfunction. Therapy should not be initiated
when increased baseline ALT levels (>2.5xULN), or other evidence of liver disease. Liver
enzymes should be checked prior to therapy initiation and periodically thereafter based on
clinical judgement. Discontinue if jaundice is observed. Eye disorders Reports of new or
worsening diabetic macular oedema with rosiglitazone. Commonly occurs with concurrent
peripheral oedema. Ophthalmologic referral should be considered where reported.
Surgery AVANDAMET should be discontinued 48 hrs before elective surgery with general
anaesthesia & not be resumed earlier than 48 hrs after. Iodinated contrast agents
Discontinue prior to/at time of tests & do not reinstitute until 48 hrs after & only after renal
function has been found to be normal. Interactions Caution when administering CYP2C8
inhibitors (e.g. gemfibrozil) or inducers (e.g. rifampicin), concomitantly. Caution when
administering cationic drugs eliminated by renal tubular secretion (e.g. cimetidine).
Increased risk of lactic acidosis in acute alcohol intoxication. Avoid consumption of alcohol
and medicinal products containing alcohol. If needed adjust dosage when used with agents
that effect blood glucose levels e.g. glucocorticoids, beta-2 agonists, diuretics & ACEinhibitors. Pregnancy & lactation Do not use. Rosiglitazone has been reported to cross
the placenta. Risk unknown. Ability to drive & use machines No effects observed.
Undesirable effects Adverse reactions identified from clinical trial data (frequencies: very
common, ≥1/10; common, ≥1/100 to <1/10; uncommon, ≥1/1000 to <1/100; rare, ≥1/10,000 to
<1/1000; very rare, <1/10,000): Rosiglitazone+metformin (AVANDAMET or as separate
components): Common: anaemia, hypercholesterolaemia, hyperlipaemia, weight
increase, hypoglycaemia, dizziness, cardiac ischemia, constipation, oedema.
Rosiglitazone+metformin+sulphonylurea (as separate components or as AVANDAMET +
sulphonylurea): Very common: hypoglycaemia, oedema. Common: anaemia,
granulocytopenia, hypercholesterolaemia, hyperlipaemia weight increase, headache,
cardiac ischemia, constipation, myalgia. Uncommon: cardiac failure. Additional
information on individual active substances Rosiglitazone Hypercholesterolemia reported
in up to 5.3% of all patients treated with rosiglitazone. Increases were generally mild to
moderate and usually did not require discontinuation. Elevations of ALT >3xULN were equal
to placebo in double-blind clinical trials. Adverse events reported post-marketing with
rosiglitazone treatment: Rare: macular oedema, congestive heart failure & pulmonary
oedema, elevated liver enzymes & hepatocellular dysfunction (in very rare cases fatal
outcome reported). Very rare: anaphylactic reaction, rapid & excessive weight gain,
angioedema & skin reactions. Adverse events reported in clinical trials and postmarketing with metformin treatment: Very common: GI symptoms (most frequent at
initiation of therapy, resolving spontaneously in most cases). Common: Metallic taste. Very
rare: Lactic acidosis, vitamin B12 deficiency (very rarely resulting in clinically significant
vitamin B12 deficiency, e.g. megaloblastic anaemia), liver function disorders, hepatitis,
urticaria, erythema, pruritis. Overdose No data for AVANDAMET. Basic NHS cost:
AVANDAMET: 2mg/500mg – 112 film-coated tablets £52.45 (EU/1/03/258/006); 2mg/1000mg –
56 film-coated tablets £27.71 (EU/1/03/258/009); 4mg/1000mg – 56 film-coated tablets
£52.45 (EU/1/03/258/012). Marketing Authorisation holder: SmithKline Beecham plc, 980
Great West Road, Brentford, Middlesex TW8 9GS. Legal category: POM Date of
preparation: February 2007. Further information is available from: Customer Contact
Centre, GlaxoSmithKline, Stockley Park West, Uxbridge, Middlesex UB11 1BT;
[email protected]; Freephone 0800 221 441. AVANDAMET is a registered
trademark of the GlaxoSmithKline Group of Companies. © (March 2007) GlaxoSmithKline.
References: 1. Avandamet Summary of Product Characteristics, November 2006. 2. Avandia
Summary of Product Characteristics, November 2006. 3. Jones TA et al. Diab Obes Metab
2003; 5: 163-170. 4. Fonseca V et al. JAMA 2000; 283(13): 1695-1702. 5. Bailey CJ et al. Clin
Ther 2005; 27(10): 1548-1561. 6. Rosak C et al. Int J Clin Pract 2005; 59(10): 1131-1136.
AVM/ADO/07/29443/1
GlaxoSmithKline encourages healthcare professionals to report adverse
events, pregnancy, overdose and unexpected benefits to the company on
0800 221 441. Information about adverse event reporting can also be
found at www.yellowcard.gov.uk
30
When metformin is no longer
enough*, help him use his
body’s own insulin again.
• Avandamet makes use of the body’s
own insulin:1-5
– Improve β-cell function1,3-5
– Achieve and maintain glycaemic control1,6
rosiglitazone maleate/metformin HCI
*When at maximal tolerated dose.
Freephone: 0800 221 441
Fax: 020 8990 4328
[email protected]
Prescribing information appears on the next page.
AVM/ADO/07/29443/1
31
The cells that make up human blood are suspended in a fluid medium
in which they circulate through veins and arteries.
Blood cells are produced in the bone marrow.
The main blood cells are:
• Red Blood Cells (erythrocytes) Responsible
for transport of oxygen
• White Blood Cells (leukocytes) Provide
an immune defence
• Platelets (thrombocytes) Provide
blood clotting mechanism
Erythrocytes are the most abundant blood cell numbering
about 5 million per microlitre blood. They are small,
biconcave disc shaped cells that contain haemoglobin.
The average lifespan for an erythrocyte is 10 days.
The main function of the Red Blood Cells is to transport
oxygen around the body to fuel metabolising tissues.
Oxygen is carried around the body in two ways:
• Dissolved in the plasma (1–2%)
• Chemically bound to the haemoglobin
molecule in red blood cells (98–99%)
Haemoglobin is a complex protein molecule that carries
oxygen. It consists of four iron containing haem groups
and the protein, globin. Oxygen molecules are carried
attached to the haem groups.
Haemoglobin with no oxygen attached is said to be
unsaturated whereas haemoglobin that is carrying oxygen
(oxyhaemoglobin) is saturated
Haemoglobin Levels:
A normal haemoglobin level varies between the sexes as testosterone stimulates red blood cell production. Lower levels are
also to be expected in menstruating women.
Normal haemoglobin (Hb) values:
Male:
13.0–18.0g/dL
Female:
12.0–16.5g/dL
The Haematocrit is the proportion of whole blood that is
taken up by all of the blood cells and is normally expressed as
a percentage. As red blood cells are the most abundant cells in
the blood they account for most of the haematocrit.
Normal Haematocrit (Hct) values:
Male:
40 – 50%
Female:
37 – 47%
The relationships between the haemoglobin level and haematocrit are converted through mathematical formulas to give the
Red Blood Cell Indices.
Anaemia meaning “without blood”, refers to a condition
where there is a deficiency of red blood cells and / or haemoglobin.Values have to be adjusted for a number of factors such
as age and sex but Hb values below 1.0g/dL in males and
below 1.0g/dL in females are suggestive of anaemia.
Fig 1. Blood cells
Anaemia is the most common disorder of the blood. The main
causes are:
• Excessive blood loss e.g. acute or chronic bleeding
• Diet deficiency: e.g iron, vitamin B12 and folate
• Deficient red blood cell production by the bone
marrow: e.g infiltrating cancer such as leukaemia,
drug side effects
• Excessive blood cell destruction e.g. haemolysis
Symptoms of Anaemia:
• Fatigue
• Breathlessness
• Palpitations
• Headaches
• Faints / collapse
• Worsening angina
Signs of Anaemia:
• Pale skin, lips and conjunctiva
• Tachycardia
• Dyspnoea
• Peripheral oedema
• Extended peripheral capillary return
There are numerous causes of anaemia. The morphology / size
of the red blood cells often gives us a clue as to the cause of
the anaemia.
Red blood cells can be:
• Normal sized (80–99fL) i.e. Normocytic red
blood cells
• Larger than normal (greater than 99fL) i.e.
Macrocytic red blood cells
• Smaller than normal (less than 80fL) i.e.
Microcytic red blood cells
Normocytic red blood cells
are normal sized i.e. 80–99fL
Red blood cells are normal
but the patient may still be
anaemic due to a lower
overall Haemoglobin level
Fig . Normocytic red blood cells.
Table 1: Causes
•
•
•
•
•
•
of normocytic anaemia:
Acute blood loss e.g. gastrointestinal bleeds
Anaemia of chronic disease
Rheumatoid arthritis
Chronic infection
Renal failure
Malignancy
Iron deficiency anaemia (IDA) is often an inadequately managed
condition which can seriously affect patients’ quality of life.
Its effect may be compounded by underlying pathology e.g.
heart failure, cancer or inflammatory disease or from insidious
blood loss from the gastro intestinal tract. The physiological
demand for iron can sometimes be met by supplementation with
oral iron but often parenteral iron therapy is more appropriate.
Microcytic red blood cells
are smaller than normal i.e.
smaller than 80 fL
Fig . Microcytic red blood cells
Table : Causes of microcytic anaemia:
Iron deficiency due to:
• Insufficient dietary intake
• Malabsorption
• Chronic blood loss e.g. menstruation
Macrocytic red blood cells
are larger than normal i.e.
greater than 99 fL
Fig 4. Macrocytic red blood cells
Table : Causes of macrocytic anaemia:
Vitamin B12 deficiency due to:
• Insufficient dietary intake
• Malabsorption in the stomach
and terminal ileum
• Gastrointestinal surgery
• Pernicious anaemia ~ autoimmune
condition
Folate deficiency due to:
• Insufficient dietary intake e.g. green
leafy vegetables
• Malabsorption e.g. coeliac disease
• Alcoholism
Charles Bloe Training Limited has developed a
suite of online training programmes, including
Interpretation of Blood Results. These courses
are currently available for half-price.
For further details visit:
www.cb-training.com
The bone marrow produces - million red blood cells per
second, requiring 0-40mg of iron per day which is virtually all
derived from red cell breakdown. In the anaemic patient the supply
of iron from the old red cells is often dramatically reduced and rates
of absorption of oral iron, even if not impaired, often cannot be
upregulated enough to meet the iron demands of erythropoiesis.
The rate of absorption is often insufficient in the time frame
available. This commonly occurs in the patient who presents for
elective surgery at the pre-assessment clinic. Equally, in the latter
stages of pregnancy an iron deficit occurs when demand
exceeds supply.
In inflammatory conditions such as chronic kidney disease (CKD)
and inflammatory bowel disease oral iron is particularly poorly
absorbed resulting in a minimal haemoglobin improvement.
The recent NICE guidelines (006) for Anaemia Management
in CKD1, recognises that normal serum ferritin levels >0µg/l
are inadequate in renal patients, and 100µg/l is considered
as the lower limit of normal. The Renal Association and Royal
College of General Practitioners guidelines (006) on the
management of CKD specify that where a patient’s Hb<11g/dl
they should be referred for intravenous iron with or without
an ESA.
Historically, there have been concerns over anaphylaxis with
intravenous iron. However, the use of iv iron sucrose (Venofer®)
has been associated with far fewer serious adverse events than
iron dextran (Cosmofer®), and iron sucrose has come to be the
most widely prescribed iv iron preparation in both the UK
and Ireland.
References
1. Anaemia Management in Chronic Kidney Disease www.nice.org.uk/cg39
2. RCP/RA CKD Guidelines www.renal.org/eGFR/anaemia.html
3. Chertow GM et al (2006) Nephrol Dialysis Transplant 21: 378-382
Treating iron deficiency anaemia in 1o & 2o care:
• intolerance to oral iron
• pregnancy (2nd & 3rd trimester only)
• chronic blood loss
“Life threatening
ADE’s are 5.5x less
likely with Venofer ®
than Cosmofer ®”
Parenterally administered iron preparations can cause severe
allergic or anaphylactoid reactions, which may be fatal. A test
dose, and facilities for cardio-pulmonary resuscitation (including
administration of intramuscular adrenaline) is required with
Venofer ®
Chertow, 2006. based on 30 million doses of iv iron
[Nephrology, Dialysis, Transplantation (2006) 21:378-382]
Information about adverse event reporting can be found at
www.yellowcard.gov.uk
Adverse events should also be reported to Syner-Med (PP) Ltd.
Tel: 0845 634 2100
Abbreviated Prescribing Information. Active ingredient iron sucrose. Presentation. Solution for injection or concentrate for infusion. Product name Venofer®. Active ingredient (qualitative, quantitative). 5 ml ampoules
containing 100 mg iron as iron sucrose corresponding to 2% iron w/v. Indications. Demonstrated intolerance to oral iron preparations, where there is a clinical need to deliver iron rapidly to iron stores, in active inflammatory bowel
disease where there is intolerance to oral iron preparations, demonstrated patient non-compliance with oral iron therapy. Contraindications. Venofer® must not be used in cases of: anaemias not attributable to iron deficiency, iron
overload or disturbances in iron utilisation, a history of hypersensitivity to parenteral iron preparations, a history of asthma, eczema, or other atopic allergies, history of cirrhosis or hepatitis or the presence of serum transaminases at three
times the upper limit, acute or chronic infection and in the first trimester of pregnancy. Adverse drug reactions in clinical trials were transient taste perversion, hypotension, fever and shivering, injection site reactions and nausea,
occurring in 0.5 to 1.5% of the patients. Non serious anaphylactoid reactions occurred rarely. Interactions. Venofer® should not be administered concomitantly with oral iron preparations. Oral iron therapy should be started at least 5
days after the last injection of Venofer®. Pregnancy and lactation. Data on a limited number of exposed pregnancies indicated no adverse effects of iron sucrose on pregnancy or on the health of the foetus/new born child. Pregnancy
first trimester is contraindicated. Non-metabolised iron(III)-hydroxide sucrose complex is unlikely to pass into the mother’s milk. Therefore, Venofer® should not present a risk to the suckling child. Warnings and special precautions
for use. Use Venofer® only in the approved indications. Parenterally administered iron preparations can cause severe allergic or anaphylactoid reactions. Facilities for cardio-pulmonary resuscitation must be available. In the event of a
serious anaphylactic or allergic reaction, administration of Venofer® must be stopped, intramuscular adrenaline should be administered immediately and other supportive cardio-pulmonary resuscitation procedures initiated. Mild allergic
reactions should be managed by stopping the administration of Venofer® and administering antihistamines. Hypotensive episodes may occur if the injection is administered too rapidly. Patients with low iron binding capacity and/or folic
acid deficiency are particularly at risk of an allergic or anaphylactoid reaction. Paravenous leakage must be avoided because leakage of Venofer® at the injection site may lead to pain, inflammation, tissue necrosis, sterile abscess and
brown discolouration of the skin. Dosage and duration of treatment. Adults and the elderly only: The total cumulative dose of Venofer® is determined by the haemoglobin level and body weight. The dose and dosage schedule of
Venofer® must be individually estimated for each patient based on a calculation of the total iron deficit. Refer to the summary of product characteristics for the calculations. The normal recommended dosage schedule is 100 mg of iron
(1 ampoule of Venofer®) administered not more than 3 times per week. However if clinical circumstances require rapid delivery of iron to the body iron stores, the dosage schedule may be increased to 200 mg of iron not more than 3
times per week. Children: Venofer® is not recommended for use in children. Method of administration. Venofer® must only be administered by the intravenous route. Before administering the first dose to a new patient a test dose
should be given. Facilities for cardio-pulmonary resuscitation must be available. Intravenous drip infusion. This is the preferred route of administration as this may help to reduce the risk of hypotensive episodes and paravenous leakage.
Venofer® must be diluted only in 0.9% sodium chloride solution (normal saline). One 5ml ampoule (100mg iron) may be diluted in 100 ml of 0.9% saline. The first 25 mg of solution should be infused as a test dose over 15 minutes. If
no adverse reactions occur during this time then the remaining portion of the infusion should be given at an infusion rate of not more than 50 ml in 15 minutes. Intravenous injection. Slow intravenous injection at a rate of 1 ml undiluted
solution per minute (i.e. 5 minutes per ampoule), not exceeding 2 ampoules Venofer® (200 mg iron) per injection. The test dose is 1 ml (20 mg of iron) injected slowly over a period of 1-2 minutes. If no adverse events occur within 15
minutes of completing the test dose, then the remaining portion of the injection may be given. After an IV injection extend and elevate the patient’s arm and apply pressure to the injection site for at least 5 minutes to reduce the risk of
paravenous leakage. Injection into dialyser. Administer Venofer® during the middle of a haemodialysis session directly into the venous limb of the dialyser under the same procedures as for IV administration. Venofer® must never be
administered by the subcutaneous or intramuscular routes. Legal category: POM. Packaging and NHS Price Pack 5 x 5 ml type 1 glass ampoules, £42.50. MA number. PL 15240/0001. Marketing authorisation holder. Vifor
France S.A., 123 rue Jules Guesde, F-92300 Levallois-Perret, France. Distributed in the UK by Syner-Med (Pharmaceutical Products) Ltd., Beech House, 840 Brighton Road, Purley, Surrey, CR8 2BH, UK. The word Venofer® is a
registered trademark. Date of first authorisation: 8th June, 1998. Lasted revised: 27th October, 2003. Code /date of preparation: V10/21-05-07.
Syner-Med
(PP) Ltd, Beech House, 840 Brighton Road, Purley, Surrey CR8 2BH United Kingdom, Tel: +44 (0)845 634 2100 Web: www.syner-med.com
34 www.scottishirishhealthcare.com
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35
Special Feature
Peter J Franks
Professor of Health Sciences & EWMA President
Centre for Research & Implementation of Clinical Practice
Faculty of Health & Human Sciences, Thames Valley University,
32-38, Uxbridge Road, London W5 2BS
Tel: 0208 280 5020
Fax: 0208 280 5285
e-mail: [email protected]
Introduction
Pressure ulcers are a major cause of morbidity in the
population, yet it is largely an unseen problem. It is
known that the treatment and prevention of pressure
ulcers is costly to health services, but as yet there is still
little information on precise costs. Moreover, there is a
cost to patients of pressure ulceration, both in financial
terms, but also in terms of their quality of life. This paper
will review some of the key evidence in respect to both
the costs to society and the costs to individual patients.
Measuring the burden of pressure ulceration
on relatives and carers
It is important examine both the costs of providing the
health services to patients suffering from the disease in
question, but also to determine the costs to patients and
relatives since care falls increasingly outside the formal
health services, and on to patients and their families.
Indirect costs should be derived from estimates of lost
production by the patient or family members caused
by the disease, losses to society caused by the patient
being unable to function to their potential, and quality of
life issues, particularly problems associated with pain, poor
mobility, discomfort and distress. Relatives and carers
provide substantial support to health services, without
which it is argued that health and social services
would collapse under the burden if such informal care was
not available. In is estimated that some 6.8 million people
in the UK could be defined as carers1. These carers
provide support and care to relatives and friends who are
unable to care for themselves independently. In England
the value of informal carers providing care in the
community is estimated to be £57 billion per year2.
The Financial Costs of Pressure Ulceration
The costs of pressure ulcer care and prevention are largely
unknown, perhaps due to the fact that it is a condition
largely secondary to other diseases. However, there has
been a long-standing interest in estimating the costs of
pressure ulcers, sometimes using these costs to calculate
which other services (surgery and bed stays) could
instead be provided3.
In 1993, the UK government commissioned accountants
Touche Ross to provide them with an estimate of health
service costs of pressure ulcers4. They used existing
research where available and expert opinion where
necessary to provide a theoretical cost of prevention
and treatment of pressure ulceration in an average 600
bedded hospital. Different models were proposed,
36
depending on whether the hospital was high or low cost,
and depending on whether there was an active prevention
strategy with treatment, or treatment alone.
The final estimates indicated that with a treatment
strategy alone a low cost hospital would spend €901,000
(£644,000) per year on pressure ulcers whilst a high cost
hospital would spend in the region of €1,614,000 per year
in 1993. When including a prevention strategy into the
care of patients the low cost hospitals used a similar budget
(€901,000), but the high cost hospitals used €3,794,000.
Most the excess cost associated with prevention was
consumed by additional nursing time spent assessing and
turning the patients. This report concluded that the cost
of pressure prevention and treatment would cost the UK
health service approximately 0.4-0.8% of the total annual
budget. This analysis was limited in that it only estimated
costs in the acute (hospital) services and was unable to
estimate costs in the community. Moreover, there was
no attempt to estimate indirect costs, costs to patients,
nor any value placed on the patients’ quality of life.
A more global investigation of cost of pressure ulceration
was undertaken in the Netherlands, examining the costs in
different care settings including home care; nursing homes;
general hospitals and university hospitals5. Prevalence
figures for different pressure ulcer stages were determined
from estimates given by the Health Council for the
Netherlands on Pressure Ulcers6.These data were combined
with expert opinion (Dutch Society of Pressure Ulcer
Experts) to determine personnel time, extra days of care,
use of special beds and medical materials. Both low and
high estimates were given to indicate the potential range of
costs. Costs were dependent not only on ulcer stage, but
were also highly dependent on where care took place. As
an example of this mean low and high daily costs of stage II
pressure ulcers were highest when treated in a university
hospital (low €71.6, high €110.2) and lowest in the general
hospital (low €23.7, high €25.1) with conversion factor
€1= $1.3. Home care was similar to University Hospital
costs whereas nursing home care was similar to that of the
general hospital costs. The authors estimated annual costs
of pressure ulcer care to be in the range €371 million to
€1,695 million per annum for a country with a population
of just 16.5 million, or 1% of the Dutch health care budget.
More recently, a model of costs of pressure ulcers has been
developed in the UK,which adopted a more epidemiological
approach7. It also looked at different health states for
pressure ulcers, namely normal healing; critical colonisation,
cellulitis and osteomyelitis. Each health state and pressure
ulcer grade was ascribed a cost based on the research
evidence and/or expert opinion. The average cost of healing
the different pressure ulcer grades was estimated at €1489
for a grade I, €6,162 for grade II, €10,238 for grade III and
€14,771 for grade IV. In the UK (population 60 million)
annual incidence (new cases) was estimated at 140,000
for grade I, 170,000 for grade II, 50,000 for grade III and
Special Feature
50,000 for grade IV based on available incidence data8. By
combining average costs and number of cases the total
cost of pressure ulcers was estimated at €214 million
(grade I), €1047 million (grade II), €544 million (grade III)
and €670 million (grade IV), giving a total cost of all
pressure ulcers at €2,473 million. This is equivalent of
approximately 2.6% of the total current NHS budget.
As expected most cost (90%) was associated with nursing
time, though in-patient stays accounted for 8% of overall
costs and 30% for grades III and IV. Cost for antibiotics,
dressings and pressure relieving equipment was all
relatively low.
Other studies have concentrated on specific costs of
pressure ulceration. In Australia a study was undertaken
to examine the bed days lost to pressure ulceration in
2001-2. It was estimated that a pressure ulcer led to
an extra 4.31 days per patient leading to 398,432 bed
days lost and an opportunity cost of AU$ 285 million
(€170.7 million) in a population of 20.3 million9,10.
Costs to the patient: Quality of life
Health related quality of life (HRQoL) is an important
measure of the impact of a condition on the patient’s
physical and mental well being and their ability to function
socially. While most clinicians would accept that HRQoL
is an important measure to determine the impact of
disease on the patient relatively few studies have been
undertaken to assess this. One influential qualitative
study used a phenomenology approach to determine
the impact of the condition on 8 subjects who mostly
were suffering (or had suffered from) a stage IV pressure ulcer in the USA11,12. Key themes identified were:
• Perceived aetiology of the ulcer
• Life impact and changes
• Psycho spiritual impact
• Extreme painfulness associated with the PU
• Need for knowledge and understanding
• Grieving process
grade II to IV experienced pain, even at rest, with 18%
reporting this as excruciating14. In addition 88% reported
pain at dressing change. Only 6% reported pain relief
being prescribed, with nursing staff frequently denying
the pain their patients’ experienced.
A further study was undertaken using a generic quality of life
tool (SF-36) in 60 patients in the community15. Compared
with the general population, patients with pressure ulcers
experienced greater problems with physical and social
functioning. At present no studies have examined utility
scores of patients with pressure ulceration to determine
the potential deficit associated with the condition and the
potential cost in terms of QALYs (Quality adjusted life years).
Discussion.
In the area of pressure ulceration there has been some
interest in the evaluation of outcomes of treatment, but
very little attention to the overall cost of care, nor impact
on the patients’ quality of life. Surprisingly, health services
do not appear to be aware of the financial burden that
pressure ulceration causes. As an example, the €2.5 billion
spent on pressure ulceration is equivalent to the cost of
treating mental health in the UK or all community health
services7. The cost estimates are highly dependent on the
incidence of pressure ulcers, although few studies have
been undertaken on a population basis to determine this
important aspect of pressure ulcer evidence. The results
from studies so far undertaken have shown that pressure
ulcers lead to a clear deficit in quality of life, though
again, these are based on small local studies of patients.
There is a clear need for governments to understand
that pressure ulceration causes a major financial burden
on them and on patients’ lives. Until the magnitude is
appreciated it is hard to push for cost effective treatments
and prevention strategies on a national basis to rationalise
the care of patients who suffer from this distressing
condition.
References.
The pressure ulcer had effects on the patients in terms
of their physical, ability, their ability to function socially,
their financial situation, changes in their perceived body
image, and loss of independence and control of their
own lives. Patients who had an ulcer for longer than six
months experienced pessimism and a poorer adherence
to treatment, which left them feeling depressed and frustrated. Coping with the pressure ulcer was difficult, and
patients felt isolated, particularly when they were often
left in a side room on their own. Patients felt humiliated
that health care professionals were seeing parts of their
body which were normally kept private. The odour from
the pressure ulcer made them feel dirty and they often
resorted to deodoriser to mask the smell. Financial
costs were associated with having to miss work, for
medical care, prescriptions and travel. The theme of living
a restricted lifestyle was examined more recently, with
more detail given for the impact on families13.
1.
Maher, J., Green, H. (2000) Carers 2000. London, Office of National Statistics
2.
Carers UK (2002a) Without us carers. London, Carers UK.
3.
Hibbs, P. (1990) The Economics of Pressure Sore Prevention. In: Pressure Sores: Clinical Practice and Scientific Approach. Ed Bader, D. London, Macmillan Press Ltd.
4.
Touche Ross ‘Pressure sores: a key quality indicator’ Department of Health, Heywood 1993
5.
Severens JL Habraken JM, Duivenvoorden S, Frederiks CMA.The cost of illness of pressure ulcers in the
Netherlands. Adv Skin & Wound Care 2002; 15: 72-77.
6.
Health Council of the Netherlands. Pressure Ulcers. The Hague: Health Council of the Netherlands 1999
(In Dutch).
7.
Bennett G, Dealey C & Posnett J The cost of pressure ulcers in the UK. Age & Ageing 2004; 33(3):230-5
8.
Clark M Watts S. The incidence of pressure sores within a national health service trust hospital during 1991.
9.
Graves N, Birrell F,Whitby M Effect of pressure ulcers on length of hospital stay. Infect Control Hosp
J Adv Nurs 1994: 20; 33-6
Epidemiol 2005; 26(3): 293-7
10. Graves N, Birrell FA Whitby M Modelling the economic losses from pressure ulcers among hopsitalized
patients in Australia. Wound Repair Regen 2005; 13 (5):462-7
11 Langemo DK, Melland H, Hanson D, Olson B, Hunter S The lived experience of having a pressure ulcer: a
qualitative analysis Adv. Skin Wound Care 2000; 13: 225-35
12. Langemo DK Psychosocial aspects in wound care. Quality of life and pressure ulcers: what is the impact?
Wounds 2005 17(1): 3-7.
13. Hopkins A, Dealey C, Bale S, Defloor T,Worboys F. Patient stories of living with a pressure ulcer J Adv Nurs.
2006 56(4):345-53.
14. Szor JK, Bourguignon C. Description of pressure ulcer pain at rest and at dressing change. J Wound Ostomy
Pain associated with the the pressure ulcer appears
to have a substantial impact on patients and their
lives13,14. In the study by Szorall 84% of patients with a
Continence Nurs. 1999; 26(3):115-20.
15. Franks PJ,Winterberg H, Moffatt CJ Health related quality of life and pressure ulceration: assessment in
patients treated in the community. Wound Repair & Regeneration 2002; 10 (3): 133-140.
37
Overseas educated nurses must be able to speak English for working in
Australia. Nurses from countries where English is not the first language are
required to complete and pass either the Occupational English Test (OET)
for Nurses or the International English Language Testing System (IELTS).
Australia’s strong economic performance over the last
decade is clearly seen through its economic growth,
low inflation, low unemployment and low interest rates.
The Australian economy is open and competitive, aided
by a dynamic private sector and a skilled, flexible
workforce.
economic stability, and a general quality of life envied
by many around the world.
The appeal of Australia is evident in the large number
of people who migrate under the Department of
Immigration and Citizenship (DIAC) Migration Program
every year. Over 100,000 people will migrate to
Australia every year for the next four years, further
enhancing the existing multicultural population.
The Australian Government seeks skilled workers &
professionals to fill shortages created by the growing
Australian economy. 97,500 work rights visas will be
made available between July 006-June 007, allowing
skilled workers to work and live in Australia.
Despite being the sixth largest country in the world,
Australia has a lot of space but not many people. It has
the lowest population density in the world - only .5
people per square kilometre - a far cry from the packed
cities of other countries ! Aussie lifestyle is arguably the
finest in the world and is the number one reason that
most people flock to its sandy shores to live and work.
Over 150,000 jobs are advertised each week, and the
current unemployment rate at its lowest level in
10 years. Australian Government statistics confirm 89%
of Skilled Visa holders gain employment within 6 months.
Australia is often referred to as “The Lucky Country”,
with its spacious surroundings, high standard of living,
excellent health and education systems, temperate
climate, wide and varied landscape, political and
Australia’s not a place where you stand on the sidelines
and simply watch - there is so much on offer for
you to see, do, and experience.
There are two levels of nurse in Australia: registered and enrolled nurses.
Registered nurses are educated in degree level courses at universities.
Enrolled nurses are primarily educated through advanced certificate or
diploma level courses in colleges of technical and further education.
There are six states and two territories in Australia. Each have
a nurse regulatory authority which maintains its own register
of qualified nurses. Each nurse must be registered or enrolled
in the state or territory in which they intend to practice.
8
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9
Put yourself
in this picture
Make your next career move to the
Royal Children’s Hospital
in sunny Brisbane, Australia.
Positions are now available for experienced paediatric
nurses in Perioperative, Intensive Care, Neurosurgery,
Oncology, Orthopaedic, Medical, Emergency,
Community Child and Youth Mental Health. Health
visitors may apply.
to stimulating continuing education, career development
and active nursing research mentorship programs.
Up to $5,000 (AU) relocation and accommodation
assistance is available on successful appointment
(conditions apply). Sponsorship to Australia is also
available. The Royal Children’s Hospital Brisbane offers
the opportunity to work across acute and community
settings in supportive team environments, with access
This is destination nursing at its best. It’s one hour to
the world renowned beaches of the Gold and Sunshine
Coasts and only ten minutes to the city centre. A green
sub-tropical environment and active cafe society makes
this one of the most liveable cities in the world where
sunny winter days average 11-21° C.
In five years, following a major redevelopment, the
hospital will merge with other facilities, expanding
to a 400-bed world class paediatric hospital.
The time is right to make your career move to
the Royal Children’s Hospital, Brisbane, Australia.
Photos courtesy
of Tourism Queensland
Enquiries and applications to:
[email protected]
or visit our website www.health.qld.gov.au/rch
health • care • people
40
Nursing in Australia
Life’s a beach!
Good weather…Great food…Beach barbecue …
Good salaries…low cost of living…and lots m o re .
CCU,ICU, CTICU, CathLab, Midwives, OT/PACU, Surgical, M e d i c a l ,
Oncolog y, Rehab, Or thopaedics, MentalHealth, AgedCare… … A L L A re a s
Locations all over Australia & New Zealand avai l a b l e
A l l ove r s e a s ap p l i c a n t s w i l l b e o f fe re d :
• M i n i mu m 2 y r s p o n s o r s h i p + r e s i d e n c y v i s a
•Full time positions
• 4 - 6 we e k s l e ave + 1 0 d ay s s i c k l e ave
•Assistance with Registration,Visas & airpor t pick up
•Assist with accommodation on arrival
C o n t a c t u s n ow f o r m o re i n f o r m a t i o n
D F Re c ru i t i n g & N u rs i n g S e r v i c e - A u s t ra l i a
Apply online
w w w. d f rc . c o m . a u
E m a i l Re s u m e - m a rc i a w @ d f rc . c o m . a u
- t h e re s e w @ d f rc . c o m . a u
Te l e p h o n e
+ 612 66286438
It pays to travel Down Under.
7
7
7
7
General and Mental Health Specialists
Top rates paid weekly
Sponsorships available
Enjoy shift flexibility
Experience Nursing Australian-Style with one of Australia’s
Largest Private Healthcare Groups.
One of the most respected private healthcare groups in Australia is seeking
interest from qualified and experienced RGN’s from the UK. It is an ideal
opportunity for those RGN’s with a valid UK PIN Number to widen their
horizons on a working holiday or to start a brand new life with adventure
doing important work in beautiful Australia.
Questions?
Call us on 007 9944 or 0115 877 199 or 0780819151 to learn more
Call us on +61 3 9481 7222 or visit us at
www.australiannursingagency.com
and have your questions answered. Alternatively, for a free consultation
forward your CV to [email protected].
We look forward to hearing from you soon!
Madeleine, from Rothley, Leicestershire, disappeared
from an apartment in the resort of Praia da Luz.
Madeleine has a very distinct birth mark on her right
eye
Rewards totalling £.5m have been offered to anyone who can help
with information leading to the safe return of Madeleine McCann.
The News of the World and businessmen including Sir Richard
Branson have jointly pledged £1.5m. Scottish tycoon Stephen Winyard
has offered £1m.
British and Portuguese police are also asking anyone to contact them
on the numbers below if they have seen anything suspicious related
to the disappearance of Madeleine or if you believe you know where
Madeleine is being concealed or hidden.
Portuguese police have searched extensively
around Praia da Luz and she has not been
found. It is possible that she is being hidden or
concealed in some way and if you know where
then by now you may have realised that it is in
everyone’s interest that she is returned to her
family.
The family of Madeleine McCann have launched
the Madeleine’s Fund: Leaving No Stone
Unturned appeal.
The funds will be used to help find Madeleine
McCann, support her family and bring her
abductors to justice.
Any surplus funds will be used to help families
and missing children in United Kingdom, Portugal
and elsewhere in similar circumstances.
Members of the public will be able to make
donations to ‘Madeleine’s Fund : Leaving No
Stone Unturned Limited’ over-the-counter in
any branch of NatWest and The Royal Bank of
Scotland.
Postal Donations can be made with cheques
payable to ‘Madeleine’s Fund : Leaving No Stone
Unturned’.
Cheques should be posted to the following
address:
‘Madeleine’s Fund’
c/o The International Family Law Group
6 Southampton Street
Covent Garden
London
WCE 7RS
41
42
General Recruitment
Vacancies to Fill
Advertise your jobs here
and have in excess of
0,000 healthcare
professionals reading
your ad.
Contact our recruitment
section on 019 55970
or email
[email protected]
-- ÊÊ£ÎÈ£Ê{£ÇÇ
ÊÊÊÊÊÊÊÊÊ6°Ê£äÊÊÃÃÕiÊn
ISSN 1361 -4177
Vol. 10 - Issue 10
Scottish Nurse magazine is the most widely read
Nursing journal in Scotland - and it is FREE!
Prostate Cancer
Sitting on the Fence?
Subscribe today, receive every
issue direct to your home for
only £25.00 for one whole year.
See page 57
Share in our Success story
Scotland: Occupational
Health Opportunities
Inventive Solutions/Refer2Us are part of the Healthcare At Home Group
a nationwide supplier of healthcare services. We are developing our bank
and permanent nursing resources in the area of Occupational Health
throughout Scotland; as such are looking for experienced OHN or nurses
that have OH experience to register their interest with us for forthcoming
contracts. Experience in the Rail/ Public sector/ Police and local government
would be of an advantage.
These are exciting positions for Nurses to gain experience of working in
a travelling capacity across a range of contracts Nationwide. Salary negotiable but an excellent package is available for the right candidate.
Exciting career path, prospects and development.
Elements of the role will include the following provision for our clients:
Assessing Fitness for work
Prevention and Promotion
Rehabilitation
�
Pre Employment screening
�
Health surveillance
�
Management referrals
� Workplace
visits / assessments and advice
�
Health Promotion
�
Management referrals
�
Occupational Therapy
Alcohol
Infection Control
part 1
Consumption & Consequences
Trauma Management
part 1
Infection Control
Hand Hygiene
Group Psychotherapy
parts1 & 2
ECG Rhythms
part 5 (final assesment)
ECG Rhythms
part 3
Trauma
Part2
Care Planning
in long-stay care
Nutrition & Obesity
‘Fat Happens’ part 3
Diabetes
part 2
Clinical feature:
Warts & Verrucas
Recruitment section
General
& Overseas
Specialised
Services
Division
Brain Injury
Rehab. Centres
1
Recruitment section
General
& Overseas
1
Central Scotland Brain Injury
Rehabilitation Centre, Murdostoun
Castle, Newmains,Wishaw ML2 9BY.
Situated between Glasgow and
Edinburgh, we are now recruiting the
following staff:
CLINICAL NURSE
MANAGER
We are seeking a nurse manager with experience at
ward manager level, preferably in a related field.
You will be a dynamic individual, taking a lead role in managing our nursing
services and being a member of the multi-disciplinary team.You will focus
on the management and development of the nurses and in the continuous
improvement of standards in line with best practice.You will also have the
opportunity to participate in clinical care of the patients.
An attractive package of remuneration will be offered to
the successful candidate.
For informal enquiries and application form please contact:
Ann Hunter, Centre Manager: 01698 384055 (Mon-Thurs).
Visit our website: www.huntercombe.com
Closing date: Monday 23rd July 2007.
Full time and part time will be considered
All discussions we have with you are in total confidence
For further information on these positions and to find out how we can
work towards successfully placing you in a new position contact
Inventive Solutions 0845 1298582 9am-5.30pm or email a CV to
[email protected] quoting Ref. ScotOH06/07.
www.huntercombe.com
a division of Healthcare at Home
Inventive Solutions committed to equal opportunities
4
The United States is attracting over a million immigrants a year - a
greater number than at any time in its history. Nearly eleven million
newcomers have made their home here during the past decade.
Those serious about working in America need to know how to go
about acquiring a green card or visa that will grant them both
residency and employment rights in the USA.
If you’re a nursing professional looking for a change in lifestyle,
new opportunities or simply a career that stands out from the
others, you could find everything you’re looking for in America.
Currently experiencing a major shortage of trained Nurses,
employers in the USA now place a high value on overseas
nursing professionals, offering them a variety of opportunities
that just can’t be found in other countries. And because
working abroad demonstrates real self-motivation and
adaptability to change, it’s a move that will only help to
boost your career prospects back home - should you
ever decide to return.
Add to all this the chance of choosing a new home that
perfectly suits your lifestyle needs, and you’ll understand
why so many Nurses are crossing the pond to start a new
life in the States.
Generally speaking when we think about America we think
about a first world country where the standard of living is
incredibly high, employment opportunities abound and where
one can live a good life in a free thinking society.
Many of US industries are the leaders in their particular field
and so are its academic institutions. It remains one of the world’s
leading economies, politically it is the most powerful country
on earth and it is a trendsetter in many ways.
Working in a U.S. hospital introduces nurses to cutting edge technology;
the ability to work with top-notch professionals; terrific benefits; respect
by patients, peers and administrators and the chance for increased
responsibility. Enhance your career by doing something many others only
dream of. Come to America and work among the world’s finest health care
professionals. The U.S. hospital — it’s waiting for you!
44
Naturally enough these features of the American way of life
are highly attractive to immigrants from across the world.
In a country as geographically and demographically diverse as
the United States, you will find great variety in the landscape,
climate, culture and lifestyles. Some of the most breathtaking
sites of natural beauty in the world are located in the States.
There are large metropolitan cities, sprawling suburban towns
and countless rural communities.
8BOUUPOVSTFJOUIF64"
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Under the guidance of its membership, the National Council
of State Boards of Nursing, Inc. (NCSBN) develops and
administers the national nurse licensure examination NCLEX-RN (®) (the National Council Licensure
Examination for Registered Nurses).
This examination is used by the Boards of Nursing to test
entry-level nursing competence for licensure as a Registered
Nurse. The NCLEX-RN examination is provided exclusively
as a computerized adaptive test and may be taken in many
countries outside of the U.S. – go to www.pearsonvue.com
and click on Locate a Test Center for details on a test center
close to you.
America has always been known as the land of the free, a place where
theoretically anyone from any back ground can achieve anything! A
country seemingly without personal restrictions and one that promotes
liberty and freedom of speech so vociferously, America naturally draws
thousands of applications for residency and working visas annually.
45
i
n
g
n
i
N
s
r
ew Zealand
u
N
New Zealand offers a great climate with a diverse and sophisticated
society. There are just over four million New Zealanders, and every single
one is either an immigrant or descended from one. English is the main
written and spoken language in New Zealand – with a number of
different accents!
New Zealand needs skilled people to drive its development. Its relatively
small population and low unemployment means specialist talent and skills
are always welcome and encouraged. The presence of comminities with
experience and skills from around the world strengthens new Zealand .
New Zealand offers unique opportunities for registered
nurses to practice in a diverse range of nursing practice
areas, in a variety of settings. New Zealand’s health
system is comprehensive and modern and is renowned
for the quality of its health professionals. Since 000,
registered nurses in New Zealand are educated in a
three year Bachelor of Nursing degree. The role of the
nurse practitioner has recently been introduced in
New Zealand’s health and disability system,
offering for the first time a clear clinical career pathway
for nurses in clinical practice.
Registered nurses who have gained their registration
in countries other than New Zealand need to apply
to the Nursing Council of New Zealand before being
able to practice as a registered nurse in New Zealand.
The Nursing Council of New Zealand is the statutory
authority governing the practice of nurses and midwives
in New Zealand and sets and monitors standards
in the interests of public safety.
The Nursing Council assesses each applicant on an
individual basis and does not operate a system
Being in the Southern Hemisphere, our seasons are
completely opposite to countries north of the equator.
Winter is June through August and our Summer is
between December and March. With majestic mountain
ranges, sweeping plains, fjords, imposing native
forests, crystal clear inland lakes, miles of golden
sand beaches and numerous bays dotted around one of
the longest coastlines in the world.
46
of reciprocal registration or enrolment except for
Australian applicants who meet the requirements
of the Trans-Tasman Mutual Recognition Act (1988).
Principle considerations for registrations are:
• The applicant has undertaken a nursing programme
that is similar in all specified content and length to
the equivalent programme in New Zealand, and is
able to meet the competencies for registration
• The applicant has practised as a nurse within the past
five years
• The applicant has supplied the Nursing Council with
evidence obtained within the past two years of ability
to speak and write in the English language when
English is not the applicants first language. Tests
recognised by the Nursing Council are CGNFS, IELTS,
OET, or as part of a competency programme
• Applicants who do not meet the requirements for
nursing registration may be required to undergo
further experience with instruction through a
Department of Nursing within a New Zealand
educational institution. The applicant is responsible
for negotiating the arrangements for the experience
and instruction and for informing the Nursing Council
about those arrangements
New Zealands economy has grown by more than 25% since
1999. During this time , real income per capita rose by
just under 19%. New Zealand offers sophisticated urban
living, with fine restaurants and a vibrant arts scene. Most
New Zealanders live within half an hour of the coast .
Neurosciences
Intensive Care Unit
Capital & Coast District Health Board is an Equal Opportunities Employer and supports the professional development of all its employees.
VACANCIES FOR
Mental Health Nurses
www.otagodhb.govt.nz
Dunedin, New Zealand
New Zealand’s South Island is a geographical playground of
remarkable ski fields, water sports, fishing, tramping and adventure
tourism.
Benefits include:
• High registered nurse/patient ratios
• A family friendly city/Affordable lifestyles
• Relocation assistance offered *
• History of successful recruitment from the UK
To discuss what opportunities there maybe for you please contact
the Adult Mental Health Services Manager, Chris Munro by phone
0064 3 474 0999 or email [email protected]
*Conditions Apply
www.otagodhb.govt.nz
Otago DHB is an EEO employer and is committed to its
obligations under the Treaty of Waitangi
ISSN 1361 -4177
Vol. 10 - Issue 10
See page 57
Prostate Cancer
Alcohol
Infection Control
part 1
Trauma Management
part 1
Infection Control
Hand Hygiene
Group Psychotherapy
parts1 & 2
ECG Rhythms
ECG Rhythms
part 3
Trauma
Part2
Care Planning
in long-stay care
Nutrition & Obesity
Clinical feature:
Warts & Verrucas
Diabetes
part 2
Recruitment section
General
& Overseas
1
Recruitment section
General
& Overseas
1
47
g
n
i
s
i
n
r
u
Canada
N
Canada has had a publicly funded system of hospital and
medical care since 1968. The majority of nurses work within
the publicly funded sector of health care, a minority work
in the private sector and a small number of nurses are
self-employed.
Canadian nurses are accountable for providing competent nursing care
to their clients. The Canadian Nurses Association (CNA) believes that to
provide competent nursing care, a registered nurse must maintain and
continuously enhance the knowledge, skills, attitude and judgement
required to meet client needs in an evolving health care system.
Because health is a provincial jurisdictional area, the health
care delivery system is not centralized and there is no one
place where nurses can apply for work. They must apply
directly to individual employers.
The Canadian Hospital Association publishes a large
directory that lists and gives addresses for hospitals, health
centres, nursing homes, health associations and health
education programs. This directory may be available through
a public library or Canadian Consulate.
The nursing employment situation in Canada is improving
after several years of health care restructuring and hospital
downsizing. Nurses with skills and experience in specialty
areas (e.g., emergency, critical care and operating room) and
those willing to work in smaller communities or isolated
communities are in the most demand. The Canadian Nurses
Association is predicting a continued shortage of nurses for
the future.
Unlike many other countries the registration of nurses does
not occur at the national level. In order to practise nursing
you must be licensed or registered in the province or
territory in which you will work. Licensing or registering
bodies can also provide information about employment
opportunities. They may have a referral service or be able to
direct you to appropriate journals to find advertised positions
or employer contacts.
Canadian provinces and territories, with the exception of
Québec, require that you write the Canadian Registered
Nurses Examination as part of the registration or licensure
process. At present, this examination can only be written in
Canada on the recommendation of a provincial or territorial nurses association. The Canadian Nurses Association
publishes The Canadian RN Exam Prep Guide, which you will
find useful in preparing for the exam. Québec nurses have
their own exam.
You require language proficiency to become registered or
licensed in Canada. Bilingualism (French and English) is an
asset. Candidates must have knowledge of French to
practise in Québec. In New Brunswick, Manitoba and Ontario,
candidates must be proficient in either French or English.
Employment and nursing education programs for unilingual
French speaking nurses are available in Québec and in certain
areas in New Brunswick, Manitoba and Ontario. In these
provinces the Canadian RN exam may be written in either
French or English. In the other provinces and territories of
Canada proficiency in English is the requirement.
48
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This is an excellent time to enter nursing as there is a shortage. At
some point in their life, every Canadian will require the services of
a nurse. Since many nurses will soon retire, Canada needs bright
young men and women to choose nursing as a career. Changes in the
health care system continue to broaden the opportunities for nurses.
Nursing in Canada
Photo credits: Tourism British Columbia
This is your year to have a fresh start on Canada’s west coast!
Incredible Nursing Careers and Lifestyle
Vancouver, British Columbia, Canada - Discover the unlimited possibilities that come with renewing your career in a city rated “most livable in
the world” by international media. A place where you can ski the local mountains in the morning and rollerblade along the waterfront in the
afternoon. Vancouver offers you a once-in-a-lifetime chance for excitement as the city prepares to host the 2010 Winter Olympics!
What are you waiting for?
If you are a UK-trained nurse with at least one year of experience or a non-UK-trained nurse with at least two
years of experience, we have an opportunity for you in one of the following nursing specialties
• Neonatal Intensive Care
• Obstetrics
• Perinatal
• Pediatrics
• Oncology/Bone Marrow Transplant
• OR/Post Anaesthetic Care Unit
• Cardiac
• Cardiac Surgery Intensive Care
• Emergency
• ICU/Critical Care
• Neurosciences/Acute Spine
• Operating Room
• Renal
• Medical/Surgical
• Community & Home Health
• Infection Control
• Gerontology
• Mental Health – Adult,
Acute & Community
• Occupational Health & Safety
Our Nurse Vancouver International Recruitment Specialists and Clinical Leaders will work with you to uniquely
identify a skills match and your individual relocation requirements.
Experience the benefits of relocating to British Columbia: refresh your professional life and live your dream career within one of Greater Vancouver’s four diverse
Health Authority organizations. Committed to investing in your ongoing career pathing and professional development, we offer attractive relocation funding and
incredible employer-paid benefits including extended medical and dental coverage, life insurance, paid sick time, and four weeks of vacation.
Send us your CV/resume today! Our International Nurse Recruitment Specialists will be in touch with you to discuss the many exciting opportunities
available and to answer your questions regarding nurse registration and immigration.
E-mail: [email protected] or call us at 0800-051-7316 today!
Apply now
www.nursevancouver.com
Discover Vancouver
49
Nursing in Canada
Vancouver, British Columbia, Canada
Offers The Recreational Experiences Nurses Dream About
working in their own language, in a culture that is familiar. BC has a
universally funded and accessible health care system. The provincial
government sets province-wide goals, standards and performance
agreements for health service delivery by the health authorities, who
manage and deliver health services to acute and specialty hospitals,
long-term care facilities and community-based programs of public health
and home-care within their jurisdiction. And Vancouver is the home of
one of the largest medical education programs in the country.
Best Practice in Nursing
BC’s Health Authorities recognize that nurses are integral members of
health care teams. Here, you will work closely with interprofessional
teams to provide personal and caring support to each patient. Nurses
practicing in BC are also surrounded by an extensive support team of
care aides, ECG technicians and house keeping staff, just to name a few.
This extensive support team allows for a greater amount of time for
nursing patients.
Ranked “One Of The World’s Most Livable Cities” and voted “Canada’s
Healthiest City” by international media,Vancouver is incredibly
picturesque and vibrant. It’s a place where nurses like you can fill days
and nights with as much or as little adventure as you like.
Some of the best skiing on earth, challenging mountainside hiking trails
and exciting shopping experiences are within a drive away. Here, nurses
can head to the local mountains in the morning, walk along the waterfront in the afternoon, picnic in the Fraser Valley and enjoy nightlife in the
evening.
Vancouver’s climate is wonderful. In the summer, temperatures reach a
comfortable 30∞C, perfect for windsurfing on one of five sparkling lakes,
golfing or just relaxing at an outdoor café that makes great coffee and
pastries.
Home to the 010 Winter Olympics,Vancouver enjoys a mild winter
with temperatures rarely below 0∞C. Here, we only see snowfall about
a half dozen times a year and it doesn’t last long, but when we see it, it’s
fluffy and white. If you are a winter sports fan, you can indulge yourself at
Whistler, the number one ski resort in North America, which is about an
hour away. So when you’re not saving lives, you will have plenty to do in
Vancouver.
Four World-Class Organizations—One Incredible Nursing Career
Nurse Vancouver is a collaborative recruitment campaign representing
the four Greater Vancouver Health Authorities who employ over 60,000
health care professionals. We attract and provide qualified nurses like you
a wealth of career and lifestyle opportunities in Vancouver.
To ensure that your nursing needs are addressed, our Nursing Programs
have nurses at every level of decision-making including the most senior
executive tables. We offer paid support for ongoing education in
specialized settings. Due to the emphasis on education and training,
nurses with Nurse Vancouver are able to work in multiple fields; such as
OR\Theatres, Accident & Emergency, Acute and Community—all in the
same career path. Support for new, qualified nurses through orientation
programs and preceptorships are also the norm. Access to continuing
graduate education and opportunities for advanced practice are
increasingly supported as well as self-scheduling options.
Supported by a strong union, British Columbia’s nurses are among the
highest paid in Canada. Our nurses receive premiums for working weekends and nights and generous pension plan packages including one month
paid vacation after one year, eleven paid statutory holidays, full-extended
medical/dental coverage and generous retirement and insurance packages. Our Health Care Authorities offer both 7.5 and 11.5-hours shifts
depending on the program, including bedside nursing, front-line leadership
and educator positions.
The Benefits You’d Expect From The Best:
Our Health Authorities offer a comprehensive and competitive employerpaid benefits package:
• Medical, Dental, Extended health for you and your family
• Life Insurance & Long Term Disability
• Municipal Pension Plan
• Paid Leave, including Paid Sick Days, eleven statutory
holidays per year and Maternity, Adoption and Parental Leave
• Relocation funding and assistance is also a benefit provided
on employment to our international nurses.
Vancouver Coastal Health (VCH) is BC’s largest Health Authority and
is at the forefront of research and teaching. With specialties in Trauma,
Neurosciences, Bone Marrow Transplant, Burns & Plastics, Solid Organ
Transplant, Thoracic and Maternal/Child,VCH is a great place to build a
career.
A Choice Location & the Employer of Choice
Whether it’s access to some of the world’s best recreational activities,
waking up every morning surrounded by breathtaking scenery or the
most rewarding career you can imagine in a state-of-the-art environment
that fosters a work/life balance while maintaining a commitment to your
professional development, you’ll find it all in Vancouver—with one of our
world-renowned Health Authority hospitals.
Providence Health Care (PHC) is a faith-based care provider, known
for our mission, vision and values and guided by the principle, “how you
want to be treated”. Our populations of emphasis include Cardiac, Renal,
Mental Health, Urban Health, Elder Care and HIV/AIDS, creating a great
environment for nurses.
Nurse Vancouver is your ticket to adventure, and to explore a new
career and exceptional lifestyle in Vancouver, British Columbia, Canada.
www.nursevancouver.com
Fraser Health (FHA) is a recognized leader in integrated health care,
research into Population Health and the exploration of more effective
ways of delivering health services. With 1 acute care sites and multiple
community-based residential, home health, mental health and public health
services, the possibilities for a rewarding nursing career are endless.
Provincial Health Services (PHSA) maintains province-wide specialty care
through its various agencies including BC Children’s Hospital, BCWomen’s
Hospital & Health Centre, BC Cancer Agency, BC Mental Health &
Addiction Services, BC Centre for Disease Control and BC Transplant
Society, each offering nurses various career choices.
Nursing in British Columbia
Nurses come to British Columbia from around the world - countries
like the UK, Australia, New Zealand and the United States because
they’re offered a wide range of opportunities with the added benefit of
50
Nursing in Canada
Canada
Baby BC
Birthing, Babies and New Beginnings
In support of British Columbia, Canada’s Perinatal/Neonatal network, BC’s Health Authorities
have come together in collaboration on this unique, focused province-wide recruitment
initiative: Baby BC. Led by the Provincial Specialized Perinatal Services Clinical Leadership
team, Baby BC, has been established to recruit specialized Neonatal and Perinatal (Labour
& Delivery, Post-Partum, High Risk Antepartum) nursing staff to meet both current and
future staffing requirements across British Columbia, Canada.
The lifestyle change and nursing career you have been dreaming of in the heart of
Canada's land of opportunity, British Columbia, the most liveable place on earth.
Focusing on care for women, newborns and their families from pregnancy to postpartum,
including neonatal intensive care, and working in your specialty area, you will benefit from
our commitment to your clinical development. From ongoing learning opportunities,
including an introduction to Canadian healthcare that encompasses best practices, our
clinical orientations are customized to support international nurses. Our Canadian
nurses will personally welcome you and provide an in-depth clinical transition into
our specialty programs.
crave
If you
adventure, British Columbia's four seasons provide a playground right at
your fingertips. World-class ski resorts, exquisite shopping and dining experiences,
agricultural heartlands, rich vineyards and beautiful gardens...British Columbia’s
residents enjoy an unsurpassed quality of life. Explore the stunning contrast of
the rugged North’s coastline to that of the peaceful rolling hills, lush valleys,
and tranquil waters of the interior that define our northern
experience. This picturesque landscape provides the perfect
backdrop to host the 2010 Winter Olympic games. If you have
ever dreamed of living and working in another country while
refocusing your professional life, we currently have exciting
opportunities in both urban and rural health facilities.xciting
opportunities in both urban and rural health facilities.
Baby BC Can take you there
Discover
The Career
You Crave
If you are an experienced NICU or Perinatal/Obstetrics nurse looking for a relocation
, we are committed to investing in your ongoing nursing career path and
professional development. We offer generous relocation funding and assistance
• incredible employer-paid benefits • extended medical and dental coverage for you and
your family • life insurance • paid sick time • four weeks of vacation
adventure
Relocate your career today. Our Baby BC Recruitment Specialists will work with you
individually to identify your unique relocation requirements and provide you with all the
information you need regarding BC nurse registration and immigration details (including
temporary and permanent residency).
Please visit our website at
www.perinatalcareersbc.ca for further information.
Call toll free 1-866-577-7262 or
e-mail [email protected]
to speak to a Baby BC
Recruitment Specialist today!
Photo credits: Tourism British Columbia
www.perinatalcareersbc.ca
Perinatal • Neonatal •
Obstetrics • Newborns • Nurse Midwife
Interior Health
51
Fulfillment
at work
As a health care professional, we understand
that you want to make a difference. We also
know that you want to be valued for your
unique interests and gifts, and challenged to
learn and grow in your skills and qualifications.
Building on a strong team approach to care,
Caritas Health Group strives to support
employees in their quest for excellence—
standing beside them in a shared quest to
provide hope and healing to the people we serve.
Each year, over 400,000 people come to
Caritas Health Group seeking help for lifechanging events and life’s daily challenges.
Ready to serve them are more than 8,000 staff,
physicians and volunteers who are based at
the Misericordia and Grey Nuns Community
H e a l i n g
t h e
B o d y
E n r i c h i n g
t h e
Hospitals and the Edmonton General
Continuing Care Centre. Together these
facilities have served Edmonton and area
for more than 111 years.
As a Catholic organization extending care
to people of all faiths and traditions, Caritas
is guided by its mission of healing the body,
enriching the mind and nurturing the soul.
It is a mission rooted in a commitment to
care for the whole person—body, mind and
spirit. This mission us at work each day in the
leading edge approaches, innovative programs,
moments of excellence, and the dedicated and
compassionate people of our Caritas team.
For a full list of Caritas programs, current
job postings, and information on joining the
Caritas team, visit our website at
www.caritas.ab.ca or call Human Resources
toll-free at 1-877-450-7555
M i n d
N u r t u r i n g
t h e
S o u l
Join our team–
make a difference
In a moment, a person can have a lasting impact on the life of another human
being. Seven days a week, 24 hours a day, members of the Caritas Health Group
Team enter people’s lives and make a difference at the most profound and
vulnerable moments of life. Join a team of caring professionals who strive to
make each of these moments count.
Based in Edmonton, Alberta and rooted in a tradition that is 112 years strong–Caritas
Health Group strives to create an environment of hope and healing for both caregivers
and the people we serve.Caritas strives to create an environment of hope and healing
for both caregivers and the people we serve. Our interdisciplinary team provides an
opportunity for our staff to explore and create a progressive approach to excellent patient
care. We partner with local and national universities, colleges and technical schools to
provide clinical placements for students to gain expertise within their chosen career.
Join the Caritas team
www.caritas.ab.ca
1-877-450-7555
CANADA
5
Caritas is poised to grow in patient capacity by approximately 25% over the next
several years, resulting in new opportunities for team members who want to make
a difference – people of creativity, vision, hope and energy.
We currently have a number of opportunities in the following areas:
Registered Nurse • Licensed Practical Nurse • Allied Health Professionals
Caritas Health Group is Alberta’s largest faith-based provider of healthcare.
email to: [email protected]
One of the reasons why so many companies choose Ireland is because
of the unique workforce - Ireland has one of the youngest population
in Europe with over 36% under the age of 25 years. Ireland’s
unique population and age structure that has fuelled much of
Ireland’s recent prosperity will continue for the next 15 years
with a key focus on education and research in Ireland.
Modernisation is gradually taking over some of the old ways but the easy
going Irish lifestyle centered around music, sport and The Pub - continues.
Ireland - is now a country on the rise. Poverty and
unemployment used to be widespread, but the EU has
brought new life. For the first period in decades Ireland
has seen population increases.
New Zealanders & South Africans
New Zealanders and South Africans must apply to
prior to leaving their own country to the Irish Trade
Commission in Auckland and the Irish Embassy in
Pretoria respectively.
EU nationals do not require a work permit to live and
work in Ireland, you are entitled to be treated like any
other applicant when you apply for work in Ireland.
You are free to apply for any job vacancy, including jobs
in the public sector. If you are qualified to practice a
certain profession in your home country, then you will
generally find that you are qualified to practice the
same profession in Ireland.You will, however, need to
apply for recognition of your training.
Non European Union & European Economic Area
Nationals
Normally only available to people with specific skills
and where there is a shortage in the existing labour
market e.g. nurses or IT professionals.
Visas are arranged in advance of arrival in Ireland by the
employer.They take - weeks to process and area valid
for up to 1 year. Visas can be obtained from the
Department of Enterprise, Trade & Employment.Visas
can be renewed at the Visa Office, Hainult House.
Non-EU nationals who do not require employment
permits to work in Ireland
You are entitled to apply for work in Ireland without an
employment permit if you:
•are married to an Irish citizen, or are a
parent of an Irish citizen and have been
granted permission to reside in the state
•have been granted refugee status by the
Minister of Justice
•are studying at postgraduate level and
are required to work as an integral part
of your course.
Ireland is a country steeped in tradition and history
with a long established reputation for its education
excellence. It has a unique and interesting culture which
retains many features of its ancient Celtic origins while
also reflecting the influence of other traditions and
trends.
Although we do have our own distinctive Celtic
language and culture, English is the predominant
language spoken in Ireland today. The Irish use it so
effectively that it has been said that better English is
spoken in Ireland than anywhere else in the world!
Australians Working Holiday Permit
Australian nationals can apply in Australia, London
and in Dublin via the Department of Foreign Affairs
- Working Holiday Permit Section.
Irish people have a great love of conversation and have a genuine
interest in other people. This friendliness and hospitality for which
the Irish people are renowned contributes to the ease with which
overseas workers adapt to the way of life and in particular, nursing
life in Ireland.
Ireland’s educational system has reflected, benefited from and
reinforced some important cultural characteristics: creativity,
flexibility,
agility,
nimbleness,
pragmatism
and
informality.
The education system in Ireland is one of the best in the world
according to the 2006 independent IMD World Competitiveness
Report. Almost 1 million people are in full time education.
5
Founded in 1745, The Rotunda Hospital is the oldest maternity hospital in Ireland. With a complement of 189
beds and approximately 850 staff, the Hospital is a provider of a comprehensive range of specialist services in the
treatment, education and care of mothers and babies - a public voluntary Hospital whose mission is to achieve the
optimal health and well-being of the women and infants for whom it is responsible.
OPPORTUNITIES FOR STAFF MIDWIVES
In 2006, just short of 7,325 babies were born in the Hospital. The Hospital is situated in the heart of Dublin within
30 minutes of Dublin Airport and convenient to bus and rail services. The Hospital is committed to the recruitment,
development and retention of the highest calibre of staff, in order to provide the best quality health care to all of its
patients. A midwife working in the Hospital has the opportunity to practice normal midwifery as well as experience a
wide complexity of pregnancy related conditions.
Recent additions to our services is an integrated model of Community and Hospital care facilitating the DOMINO and
Early Transfer Home models of care. A number of community based antenatal booking and review clinics are managed
from the Hospital.
The Hospital also has a wide range of specialty pregnancy clinics including:
•
•
•
•
•
teenage pregnancy
diabetic
cardiac
metabolic and
a range of paediatric and gynaecology clinics.
A range of day care facilities, which include maternal and fetal assessment, are available.
The ultrasound department facilitates a full range of pregnancy and gynaecology assessment. An early pregnancy unit is
designed to minimise the distress of women and their partners, who experience pregnancy loss. A full range of maternity
inpatient services are available including a Delivery Unit of 9 individual rooms with a 5 bed ward for induction of labour.
The 36 cot Neonatal Unit is a tertiary referral centre and is part of a national neonatal transport system. This unit was
opened in 2002 and offers the highest standard of facilities and care in the country.
Opportunities for midwives to engage in both in-house and external education programmes exist - The School of
Midwifery is linked to the University of Dublin, Trinity College. A Clinical Skills Facilitator is employed with the
specific remit of working with newly qualified or newly appointed midwives to support their development within
the Hospital.
Currently there are vacancies for MIDWIVES who wish to work either full or part-time
in all areas of The Rotunda Hospital.
• Advice on employment terms and conditions is available on request.
• Application forms and job descriptions may be downloaded from www.loadzajobs.ie
or www.hospital jobs.ie and are also available upon request from the Human
Resources Department on 0035318171714 or at [email protected]
If you would like to know more about the Hospital please visit our websites on
www.rotunda.ie www.loadzajobs.ie www.hospitaljobs.ie
Please Quote Reference Number: Vac. Ref. 2007/55
54
Nursing in Ireland
COPE Foundation provides a wide
range of services for children and
adults with intellectual disabilities
throughout the city and county of
Cork.
COPE Foundation’s objective is to
provide and develop the best model
of service and care for persons with
intellectual disability through our
team of caring professionals.
Fulfilling the Potential of Persons with Intellectual Disability
We want YOU to join our team of Caring professionals
We are currently recruiting for:
Staff Nurses
Applicants must be interested in working as part of a trans-disciplinary team, in the field
of intellectual disability and on the current register or eligible to register with An Bord
Altranais. Previous relevant experience of working with people with an intellectual
disability is desirable.
How to apply:
Application forms may be obtained from the Human Resource Department,
COPE Foundation, Bonnington, Montenotte, Cork (Tel. 00353 21 4507131)
or by e-mailing [email protected].
Completed application forms must be returned no later than Friday 6th July 007.
APPLICANTS MAY BE SHORTLISTED ON THE BASIS OF THEIR APPLICATION
Visit our website at www.cope-foundation.ie
Careers in
Healthcare
Careers in
Healthcare
NURSING
NURSING
Registered General Nurses
Dublin South West, Kildare/West Wicklow
Ref: IN/HRSS/143/07
Staff Nurses
Midwives
Cork University Maternity Hospital, Ireland
Ref: N1607
For further information and job descriptions or to apply online:
1. ICU/HDU/Special Care,
Galway University Hospitals
Ref: IN/2007978W
2. Theatres,
Galway University Hospitals
Ref: IN/2007979W
For further information and job descriptions or to apply online:
Freephone 0800 056 9710
www.careersinhealthcare.ie
We are an equal opportunities employer. Shortlisting may apply and
panels may be formed from which future vacancies may be filled.
Freephone 1800 400 350
www.careersinhealthcare.ie
We are an equal opportunities employer. Shortlisting may apply and
panels may be formed from which future vacancies may be filled.
ISSN 1361 -4177
Vol. 10 - Issue 10
Prostate Cancer
Alcohol
Infection Control
part 1
Trauma Management
part 1
Infection Control
Hand Hygiene
ECG Rhythms
Group Psychotherapy
parts1 & 2
See page 57
ECG Rhythms
part 3
Trauma
Part2
Care Planning
in long-stay care
Nutrition & Obesity
Diabetes
part 2
Clinical feature:
Warts & Verrucas
Recruitment section
General
& Overseas
1
Recruitment section
General
& Overseas
1
55
Nursing in Ireland
Cappagh National Orthopaedic Hospital has 160 beds and is the major
centre for orthopaedic surgery in the country. The Hospital is a tertiary
referral centre for the treatment of complex orthopaedic problems
including major joint replacement surgery, revision joint surgery,
foot and upper limb surgery, primary bone tumours, spinal surgery,
sports injuries and paediatric orthopaedic surgery.
Applications are invited from suitable candidates who are registered or eligible to register in
the division of the live register of Nurses kept by An Bord Altranais for the positions of:
STAFF NURSES
Theatre
Applications are invited for staff nurse
positions from suitably qualified
candidates.
CLINICAL FACILITATOR
Theatre
(Mon-Fri)
Interested applicants should:
• Have a minimum of five years postregistration experience in an acute
hospital setting.
• A recognised post -registration
qualification relevant to the specialist
area is desirable.
• Experience in mentorship, preceptorship,
teaching and assessing is desirable.
Informal enquiries for the above posts to:
Ms Kathy O’Sullivan, Acting Director of Nursing, Tel: (01)8341211
Cappagh National Orthopaedic Hospital offers:
•
•
•
•
•
Group Health Insurance Schemes • Subsidised staff restaurant • Ample free car parking
Excellent opportunities for professional development in a friendly and supportive environment
Continuing support for on-going education and regular in-service education
Easy access from Dublin City Centre, the Greater Dublin and South Meath areas
Accommodation on site may be provided on a short term basis
Interested candidates should forward a letter of application together with four copies of their
Curriculum Vitae and the names of three referees to:
Ms Kathy O’Sullivan, Acting Director of Nursing, Cappagh National Orthopaedic Hospital, Finglas,
Dublin 11, Ireland.
Shortlisting will take place.
Pay and conditions as per Department of Health & Children guidelines.
Cappagh National Orthopaedic Hospital is an equal opportunities employer.
Visit our website at www.cappagh.ie or www.hospitaljobs.ie
56
Nursing in Ireland
The Irish Blood Transfusion Service, has the sole responsibility for the collection and
distribution of blood and blood products, providing an essential service to the Irish hospital
sector. 3,000 donations are needed every week in Ireland and the team at IBTS work
tirelessly to process the contributions of our kind donors, and to actively recruit new
donors to keep up with the needs of hospitals.
An important part of the IBTS is the participation in, and encouragement of new research
and training in matters relating to blood transfusions and the preparation of blood products.
We pride ourselves on being at the forefront of new practices and techniques in the
process of managing our blood clinics. We are seeking talented individuals to whom we
can offer a truly rewarding career.
We currently have the following career opportunities:
Staff Nurses
Platelet Apheresis Clinic, National Blood Centre, Dublin
D’Olier Street Clinic, Dublin
A panel is being created for both permanent, temporary and full-time and part-time Staff
Nurses for the Platelet Apheresis Clinic & D’Olier Street Clinic in Dublin. These panels will
be in operation for 12 months.
The salary scale attached to the post is €28,877 to €42,164 (incl. LSI) per annum. Entry
point onto the salary scale is dependent upon relevant public sector experience. Location
Allowance applies.
Interested applicants should visit the IBTS website www.ibts.ie for the application form, job
description and further information. Additional queries can be directed to
[email protected]
The closing date for receipt of applications (5 copies) 5pm on 27th July 2007 and
these should be sent to the Human Resources Department, National Blood Centre,
James’s Street, Dublin 8.
The IBTS is an equal opportunities employer.
ibts.ie
ISSN 1361 -4177
Vol. 10 - Issue 10
Prostate Cancer
Infection Control
Hand Hygiene
Group Psychotherapy
parts1 & 2
ECG Rhythms
ECG Rhythms
part 3
Trauma
Part2
Care Planning
in long-stay care
Nutrition & Obesity
Clinical feature:
Warts & Verrucas
Diabetes
part 2
Recruitment section
General
& Overseas
Scottish Nurse magazine is the most widely
read Nursing journal in Scotland - and it is
FREE!
Published since 1994 we keep you up to date on issues
that impact on the way you practice, we offer the latest
recruitment opportunities and now an opportunity to
exchange ideas with other professionals.
From the latest research to updates on
current events and conferences stay up
to date now.
STRATHAYR PUBLISHING LTD
Gibbs Yard
Auchincruive Estate
Ayr
KA6 5HN
Tel: 019 55970
Fax: 019 55979
Alcohol
Infection Control
part 1
Trauma Management
part 1
1
Recruitment section
General
& Overseas
1
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57
Product Focus
Somatuline® Autogel® 120mg, an extended release
preparation of lanreotide, can now be administered
every six to eight weeks in patients with acromegaly
who are well controlled on four weekly Somatuline®
Autogel®, in terms of clinical symptoms and
biochemical parameters, where Growth Hormone
(GH) concentrations are below 2.5ng/mL and
Insulin-like Growth Factor-1 (IGF-1) levels
are in the normal range.
Somatuline® Autogel® is available in three dose
strengths; 60mg, 90mg and 120mg for use every 28
days. For patients with acromegaly receiving a
somatostatin analogue for the first time, the
recommended starting dose is 60mg every 28 days
which can subsequently be titrated to 90mg or
120mg according to the clinical or biochemical
response. In patients who are well controlled on
Somatuline® Autogel® every 28 days, Somatuline®
Autogel® 120mg can be administered every six to
eight weeks.
Somatuline® Autogel® is the only somatostatin
analogue that comes in a ready-to-use, pre-filled
syringe, designed to maximise convenience and
facilitate the community management of patients.
The extended dosing of Somatuline® Autogel®
120mg in well controlled acromegaly patients also
extends cost benefits and convenience.
In an open, prospective, multicentre, Phase III study in
Spain and Portugal, involving 98 patients with
acromegaly (defined as GH level >2ng/mL following
an oral glucose tolerance test and an elevated IGF-1),
Lucas et al1 evaluated whether Somatuline®
Autogel® 120mg every four to eight weeks was as
effective in controlling acromegaly as Somatuline®
LA 30mg every one to two weeks.
The study found that treatment with Somatuline®
Autogel® administered every four to eight weeks
was at least as effective and well tolerated as
Somatuline® LA administered every 7-14 days1.
There was a good level of acceptance of Somatuline®
Autogel®1. The authors concluded that the longer
dosing interval of Somatuline® Autogel® 120mg
maintained the same overall monthly dose as
Somatuline® LA 30mg, but with four times fewer
injections, and thus had a benefit in terms of cost and
patient compliance1.
References
1. Lucas T, Astorga R and the Spanish-Portuguese Multicentre Autogel Study
Group on Acromegaly. Clin Endocrinol 2006;65:320-326
Oxford, the manufacturer of patient hoists, has
unveiled an exciting new structure to help it
bring even more world-class products into the
UK and Europe.
Nathan McWattie, Managing Director Commercial Operations, said that the re-organisation
will create a more flexible and adaptable business better equipped to focus on the needs of
the market and, ultimately, the end client.
“This is good news for our customers because they will benefit from working with a company
that will be even more responsive and display increased market agility.
“Central to this will be our ability to grow into new product categories and markets as the
business expands.
“We are very excited to be entering this next phase of development and the new
organisational structure places Oxford, together with the other core brands, in a better
position for continued and sustainable growth in both new and existing markets.
“Our UK headquarters will still be based at Stourbridge in the West Midlands and all
commercial agreements remain in place”.
Joerns Healthcare also has offices located in the United States, Canada and The Netherlands
with key partners in Germany, Norway, Australia, New Zealand, Spain and Portugal.
Joerns Healthcare is a long-respected brand with a rich history dating back to 1889. This is the
platform and the foundation for the new business. The combined organisation will sell more
products and services into a greater number of long-term care and acute care facilities.
The following established brands form part of the new company.
• Oxford – The UK leader in patient-handling equipment
to the homecare and extended care markets
• Joerns – A leading manufacturer of beds and furnishings
in the acute and long-term care markets
• Hoyer – The North American market leader in patient handling
equipment to the homecare and senior housing markets
• Bio Clinic – A leading manufacturer of specialty mattresses and
therapeutic support surface equipment to the healthcare market
Tom Bulpitt, Marketing Manager, said that Oxford already had a proud 30 year-history of
service and innovation within the homecare and extended care sector.
“This is the next chapter and with the global strength of Joerns behind us we are looking
forward to an exciting and successful future”, he said.
The association between breakfast cereal consumption and
a lower body weight, as measured by Body Mass Index, was
strengthened today by a new systematic review published in the
journal, Nutrition Bulletin.1
HbA1c is used for monitoring of diabetes and is the
parameter of choice for long-term glycaemic
(blood sugar) control. Afinion will provide results
automatically in just three minutes, offering a real
time saving to the busy healthcare professional.
CRP is used as a diagnostic tool for differentiation
between viral and bacterial infections. A rapid CRP
test is valuable in avoiding the prescription of
antibiotics if an infection is likely to have a viral cause.
For further information, visit www.axis-shielduk.com
For patients who have been prescribed NutropinAq® and their carers, there
is also a section of the website available via a username and password.
The patient and carer area has four zones: Adult Zone, Teen Zone, Kids Zone
and the Carer and Sharer Zone. Each of these zones contains information,
tailored to each age level, about growth hormone disorders. The Teen Zone
and Kids Zone also have fun areas with games and other play items.
NutropinAq® is a liquid formulation of somatropin (recombinant DNA
origin, Escherichia coli) for injection and is supplied as a 10mg/ml sterile
liquid somatropin cartridge for
exclusive use with the
NutropinAq® Pen.
NutropinAq® Pen is an
easy-to-use, convenient,
simple, state-of-the-art device
for subcutaneous injection.
Health professionals can request
their username and password
for access to the website from:
Medical Information
Department, Ipsen Ltd,
190 Bath Road, Slough,
Berkshire, SL1 XE
T: 0175 67777
E: [email protected]
New guidelines published today by the National Institute for Health and
Clinical Excellence recommends that post-myocardial infarction (MI) patients
should be considered for treatment with omega- fatty acids (Omacor)
initiated within 3 months of an MI, when dietary intervention is insufficient .
The review concludes that children and adults who eat breakfast
cereals regularly tend to have a lower body mass index (BMI) and
are less likely to be overweight. They also tend to put on less
weight over time than those who don’t eat breakfast regularly.
These findings are important as recent data shows that over a
third of UK adults (.5 million) and almost 4 million UK children
miss breakfast regularly. This is in spite of 9 out of 10 people of
all ages claiming to understand the significant nutritional benefits
of breakfast.
Tests already available on Afinion include glycated haemoglobin (HbA1c) and C-reactive protein (CRP),
with albumin creatinine ratio (ACR) and prothrombin time international normalised ratio (PT-INR) in
the final stages of development. Other tests such as homocysteine will be introduced later.
The website is accessible to health professionals via a username and password. The health professional area provides background information on the
growth hormone disorders that NutropinAq® is licensed to treat, resources
that may be downloaded, conference diary dates and links to other useful
related websites and organisations.
The move sees Oxford line up with three other
core brands working in closely-related markets
bringing global expertise to bear on a
rapidly-growing UK and European market.
58
Axis-Shield UK has launched the Afinion™ multi-parameter desktop analyser for use at point of care.
This novel instrument – a winner at the Medical Design Excellence Awards 2006 – enables immediate
rapid testing, regardless of sample type. Unlike many other systems currently on the market, Afinion is
a genuine multi-assay analyser, offering a wide range of laboratory-quality tests on a single point of care
system. Afinion is well suited to multi-user environments, such as community clinics, where test results
are required quickly and a laboratory service may not be available. The instrument is extremely easy to
operate – users simply insert a cartridge and follow the prompts on the colour touch screen display.
Minimal maintenance is required.
Ipsen Limited, the UK subsidiary of the Ipsen Group, has launched a website
www.gh-d.co.uk providing comprehensive information on growth hormone
disorders and the use of NutropinAq® Pen.
The company - already an established leader in
the UK homecare and extended care markets for
patient handling - is divisionalising from Sunrise
Medical and aligning with Joerns Healthcare,
one of the best-known healthcare names in the
United States.
The causal relationship between breakfast cereals and BMI was
considered. No clear evidence exists to link breakfast cereal
consumption and weight with lower energy intakes or higher
energy expenditures. Lifestyle factors have been thought to play
a role since regular breakfast cereal eaters tend to take more
exercise and drink less alcohol than those who don’t. Although
these and other lifestyle factors were taken into account in a
number of the studies, it is still possible that they can partly
explain the overall result.
Axis-Shield UK launches
Afinion™
a new concept in point of care testing
As manufacturers of Omacor the only omega- product licensed for use
post-MI and the only product containing the highly purified omega-3-acid
ethyl esters in a 1g capsule, Solvay Pharmaceuticals welcomed this
announcement as a major step forward in the treatment of this
vulnerable patient group.
References
1 A de la Hunty & M Ashwell (2007) Are
people who regularly eat breakfast cereals slimmer
than those who don’t? A systematic review of the
evidence. Nutrition Bulletin 32: 118-128.
2 Breakfast cereal Information Service ‘ Putting
Breakfast First’ survey, Jan 2007.
Ian Young, Professor of Medicine, from
Queen’s University Belfast said “Omega-
fatty acids have been shown to reduce
sudden death by 45% in post-MI patients,
it is important to consider how patients
can increase intake of fatty acids.
Omacor is the only fatty acid preparation
licensed for use in secondary prevention post-MI.”
Product Focus
Kerraboot®, now available in two new sizes,
wins Frost & Sullivan’s prestigious 2006
European Product Innovation Award
Study Herbal Medicine
A Napier education’s about taking the right route to the future. We’ll help you maximise your potential in clinical practice with relevant
teaching in the latest subjects. Herbal medicine is experiencing significant growth in terms of research and development, and in its popularity
with patients. We offer two courses in this budding area for orthodox medical practitioners, including GPs and nursing graduates.
Graduate Certificate in Herbal Studies –
one year part-time starting September 2007
MSc in Herbal Medicine – one year full-time
or flexible part-time starting September 2007
This course introduces Western herbal medicine to those
with no prior experience or knowledge of medicinal plants,
and is an essential starting point for those wishing
to go on to the MSc in Herbal Medicine.
For those who have successfully completed the Grad Cert course
in Herbal Studies, this course offers a route to membership
of the National Institute of Medical Herbalists, and to clinical
practice as a herbalist.
To find out more about these courses, and life at Napier, contact us at 08452 60 60 40, [email protected]
or www.napier.ac.uk
Enhance your career.
Modern Western herbal medicine has developed
over many centuries and draws on influences
as diverse as the early Greek physicians
and nineteenth century North American Indians.
Today, it takes advantage of the findings
of the latest scientific research into the actions
and clinical uses of medicinal plants. In recent
years, there has been renewed interest
in herbal medicine as a more sympathetic
and holistic approach to healthcare, making
it increasingly popular.
During a consultation, a herbalist seeks to address
the underlying causes of health problems rather
than just their symptoms, and that means patients
are treated holistically as individuals, each having
a unique set of requirements for optimum health
and wellbeing. Plant preparations are prescribed
to rebalance disturbances in body function and to
restore the body’s own natural healing processes.
At Napier, we recognise the growing importance of
this area of medicine, and the need for a broader
understanding of the subject. We’ve designed courses
for registered healthcare practitioners, such as GPs,
osteopaths, graduate nurses, midwives and dentists,
who would like to know more about the management
of health problems using herbal remedies.
First and foremost we offer a Graduate Certificate
in Herbal Medicine which introduces Western
herbal medicine to those with no prior experience
or knowledge of medicinal plants. This is a one
year part-time course, starting in September this
year, which is ideal for recent nursing graduates.
On completion of this course, you can then
progress to our MSc in Herbal Medicine.
The MSc is a one year full-time course – also
available on a flexible, part-time basis – which also
starts in September 2007. This course offers those
who complete it successfully a route to membership
of the National Institute of Medical Herbalists,
and eventually to clinical practice as a herbalist.
Located in the cosmopolitan and student-friendly
city of Edinburgh, Napier is a welcoming and
vibrant institution. The University offers a wide
range of professional, PG Dip and Masters courses
in many diverse subjects. The University’s
Graduate School provides a central hub for
research study and occasionally offers funded
research studentships. Truly international – over
a sixth of the student body comes from one of
80 different countries –the campuses are modern
learning environments with excellent facilities,
including a purpose-built 500 PC computer lab
with 24/7 access.
To find out more about these courses, and
life at Napier, contact 08452 60 60 40,
[email protected] or www.napier.ac.uk
59
HEALTHCARE LAW & ETHICS
Postgraduate Programme
Bachelor of Nursing/Bachelor of Midwifery
For registered nurses and midwives to complete
studies to degree level. All modules are available
on a ‘stand alone’ basis.
By Distance Learning
This new programme is specifically designed
for healthcare professionals, including doctors,
nurses, and those in the allied professions.
It aims to give you an understanding and
appreciation of law and ethics as they apply
to your professional practice. The modules
are provided on a part-time, distance-learning
basis, giving you the flexibility to tailor your
studies to your individual requirements and
interests, and offering you the chance to
study at the level of your choosing. The
course offers three exit levels of qualification:
Certificate, Diploma or Masters Degree. For
further information and a prospectus please
contact Fiona Clark ([email protected])
Tel 01382 384764
Master of Science Advanced Practice
Flexible pathways for students to pursue
specialist professional studies. A variety
of named awards are also available.
All our programmes offer:
Flexible study options, full-time or
part-time study, e-learning, distance
learning, self-directed study.
For further information
Tel: 01382 388534
www.dundee.ac.uk/nursingmidwifery
NT PRF 4
Keele University
DEGREE AND DIPLOMA
Pre-registration
programmes
• Midwifery
• Nursing
- Adult
- Child
- Mental Health
- Learning
Disability
• Operating
Department
Practice
www.keele.ac.uk/depts/ns
60
tel: 01782 556600 – 01782 556557/8
Open Events
-2007
20th May
20th June
19th August
13th and 14th October
5th December
CALL OR VISIT OUR
WEBSITE FOR DETAILS
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61
Scottish Nurse Magazine,
Scotlands leading independent nursing
magazine, Are proud to announce
Scotlands BIGGEST and BEST nursing
exhibition at the SECC Glasgow.
Everything you need to know about
nursing is conveniently located under
one roof. Nurses from all levels
and nursing students, this exhibition
is especially for you - and it’s
all FREE To enter.
Seminars Are you keeping up with your required continuing professional development? To ensure our seminars are of the
highest quality we have an extensive seminar programme covering key clinical and policy-based topics. Seminars are being
booked online NOW! We recommend that you book in advance as the exhibition and seminars will be over subscribed.
Zone A
‘SKILLS FOR NURSES’
This zone will have the following course
running with breaks to be agreed:
Drug Calculations
‘MENTAL HEALTH COURSE’
This zone will have the following course
running with breaks to be agreed:
How to read a Chest x-ray
Dealing with Child
Sex Offenders
Alcohol Misuse
How to read an ECG
Suicide Risk Awareness
Central Venous Pressure
Cognitive Behavioral Therapy
Pulse Oximetry
(CBT)
Free, but to ensure your place book
early for £5.
Each seminar approximately 1hour
Zone C ‘INTERACTIVE SKILLS ZONE’
We would have skill zones running at the
same time. They would include sessions
for each of the following: 45 mins repeated 4
times during the day i.e. 8 in total
Basic Adult CPR
How to record a 1 Lead ECG
How to perform peripheral
venous cannulation
How to perform venepuncture
These 45 minute Skill Zones would be
FREE drop in sessions repeated 4 times
during the day
6
Zone B
£5 for all 5 seminars.
Each seminar approximately 1hour
Zone D
‘PESI SUBCLINICAL SIGNS OF
IMPENDING DOOM COURSE’
See the signs of compensation
in the body — before the
patient crashes
Know when to call the rapid
response team
Goal setting and priorities
for decisive action
£15 +VAT
6th November 2007, SECC Glasgow
Interactive Zone
Charles Bloe Training Limited, the professionals in healthcare training, will be bringing their fun, interactive
demonstrations and expertise to the Interactive Zone. Join in on the action and practice your skills on the most
up to date manequins and equipment available. It makes learning seem so much more real!
Meet Potential Employees
This is the only exhibition to be if you are looking for nursing jobs. Our Nursing Recruiters are looking for nurses
from all areas of expertise. And if you are thinking of working abroad, our overseas exhibitors can help you realise
your dream and provide you with all the information you need to make that transition as smooth as possible.
In addition we will have:
Clinical Skills Challenge first prize is £500 Zones A and B
Anne Diamond - as a guest speaker (GMTV fame)
Product profiles
Also
CPD certificates issued
Half price online training for all attendees
£100 off onsite Training for all attendees
Booking and enquiries please contact Tracy Hamilton
on 01324 411013 or email [email protected]
Designed specifically to meet the educational needs of all
nurses and other primary care specialists, the programme
features an impressive collection of speakers delivering
highly topical and relevant presentations.
The educational conferences are complemented by an
exhibition featuring key product suppliers, educational
institutes, services to primary care and recruitment
specialists.
Registration & coffee - 09.00
Exhibitors, Product Suppliers and
Recruiters who wish to be included
in this event please contact Jim Brown on
Tel: +44 (0)1292 525 970
Fax: +44 (0) 1292 525 979
63
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Continence Management in MS Special Feature Pressure ulceration

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