The three-term Hawke’s Bay DHB member and Hastings Health Centre primary care liaison and long-term conditions nurse specialist received her PhD from Massey University’s School of Nursing. Her studies included following 16 people with significant long-term conditions over about 18 months, alongside their primary care clinicians.

She was driven to embark on the study after identifying gaps in the self-management approach to healthcare, which was geared to meet the needs of people with only one serious illness, the money or the connections to fully take advantage of that care.

“The families I talked to had all sorts of awful things going on in their lives – poverty and other disadvantages – and their health never really gets to the top of their pile of priorities, and the care we offer does not meet their needs as well as it could.

“One woman in my study was really, really sick, but she was also a caregiver for her brother, who was far more ill than she was. She couldn’t look after her health because her priority was looking after her brother.”

She said another woman had had heart attacks, asthma, diabetes, arthritis, and more. Her daughter had serious mental health issues, so she also took on six grandchildren aged from 4 to 16.

“As health professionals we say to you go for a walk or stop smoking – you may or may not do that, there’s not much stopping you.

“But for other people who may be looking after their grandchildren, have no money, are unemployed, or who are really sick and caring for other people it’s really hard for these people to pay attention to their own health.”

She said the doctors and nurses she spoke to found this frustrating because often they would be caring for other members of the patient’s families.

They had a good idea of what would work, but working within a system where forms had to be filled in and boxes ticked they felt they were not meeting their needs as well as they could be.

“We need to look at other ways of doing things,” Dr Francis said.

Having now completed her studies, she was also preparing to step down after 10 years at Hastings Health Centre, where she was working as a contractor until Christmas.

She said the plan was to create some space to see if she could do something with the findings of her study.

“It’s a bit difficult in Hawke’s Bay being quite far away from the main centres but I will look at what opportunities there are and how I can use my studies to help people regionally and nationally.

“I really hope my research might go some way to making people think differently about how we approach this sector of the community.”

The Healthier Lives National Science Challenge, the Ministry of Health and the Health Research Council of New Zealand (HRC) joined forces to establish the $7.9 million research funding pool to tackle long-term chronic health conditions.

Yesterday’s $2.3 million announcement follows the $5.7 million announced for diabetes research in February.

Massey University research fellow Dr Riz Firestone, who is of Samoan descent, received almost $1 million in health research funding to develop and put into practice a Pacifika community-based intervention programme to reduce prediabetes, the precursor to full-blown diabetes.

Dr Michael Epton, Director of the Canterbury Respiratory Research Group at Christchurch Hospital, has received just over $1 million for a 24-month study that will address New Zealand’s low referral and attendance rates for rehabilitation programmes for people with multiple long-term conditions (LTCs), such as diabetes, heart failure, arthritis, and chronic obstructive pulmonary disease.

Dr Firestone’s study will establish a Pasifika prediabetes youth empowerment programme involving Pacific youth (15–24 years old) from community groups in South Waikato and Auckland. It will build on Firestone’s recent HRC-funded pilot study in which a group of Pacific youth was taught how to plan and champion community-based interventions to counteract the key public health issues of obesity.

Epson says current approaches to rehabilitation for people with multiple LTCs focus too much on the biological aspects of their diseases and don’t include all the aspects of wellbeing that are important for improving health.

“Rather than developing new disease-specific interventions, we’ll work together with communities to develop and try initiatives that help people with multiple LTCs access community support, increase their sense of connectedness within their community, improve physical activity, and thus live lives they feel are fulfilling and worthwhile,” he said.

The announcement of an extra $6.5m for the adult cochlear implant programme came just over a week after an online petition by 22-year-old Danielle Mackay, signed by 26,643 people, was presented to Parliament by the country’s first deaf MP Mojo Mathers. The petition called for the Government to increase funding so Mackay could receive cochlear implant surgery before she lost her hearing.

Health Minister Jonathan Coleman said that in 2013 the number of funded cochlear implants for adults increased from 20 to 40 a year and the latest announcement meant that 100 implants could be funded this financial year. The money is to come from “reprioritisation” within Vote Health.

The findings indicated that certain occupations may put workers at elevated risk, with male workers in the manufacturing sector found to be at a higher risk than workers in the professional, administrative or technical sectors, and bricklayers and concrete workers at a threefold increased risk. Women in the manufacturing sector did not have an increased risk, but only a relatively small number of women in the study worked in this sector.

The women’s occupational grouping in which there was a slight increase was assistant nurses and attendants, but there was no increase for female nurses, doctors or physiotherapists.

The researchers said the male findings indicated that work-related factors such as airborne harmful exposures may contribute to the development of rheumatoid arthritis. “But a common trait in all four occupational groups associated with an increased risk of rheumatoid arthritis in our study is that they are physically demanding. Physical workload is a proposed risk factor for osteoarthritis, but for rheumatoid arthritis less research has been conducted,” said the study.

The full study can be read here.

The experienced aged care nurse is the general manager of the Selwyn Institute for Ageing and Spirituality, which initiated a pilot into using tablet-based telehealth technology to help older people living at home to manage their long-term conditions.

The case study Johnson-Bogaerts shared was of George, a man with heart failure (leading to multiple hospital admissions, COPD (chronic obstructive pulmonary disease) and hypertension.

As part of the pilot, George had access to a blood pressure monitor, pulse oximeter, thermometer and scales, which were connected by Bluetooth to a touchscreen tablet. He used the devices to take his ‘vitals’ daily, with the information digitally delivered to his telehealth nurse Sandi Milner.

During follow-up teleconferences on the tablet – to discuss missed out or out-of-range readings – Sandi found out that George had a problem with constipation, had little energy and had stopped gardening. She also found out that George – who had been advised to go on a low-salt diet – wasn’t sharing meals with his family and was trying to resolve his constipation by eating cornflakes.

Johnson-Bogaerts said the telehealth nurse guided George on how to check the salt content on the packaging of food, like his cornflakes, and shared advice on how to better manage his fluid and salt intakes.  Sandi also suggested he try kiwifruit and he slowly started to introduce fruit and vegetables back into his diet and to eat with his family again.

Over six weeks he improved and over the four months he learnt to better control his symptoms. At the post-discharge check, George reported he was out in the garden planting vegetables, feeling better than he had felt in years and had had no hospital admissions.

Following the pilot, the telehealth-based chronic disease management programme is now being delivered by a joint venture between the Selwyn Foundation and Australian provider Feros Care, called Inviga. A second telehealth care pilot also got underway late last year, which involved retirement village residents having home-based video consultations with the on-site doctor.

This New Zealand-developed app allows the user to search and compare nutritional information, ingredients and claims on 8,000 New Zealand food products.

Using their smartphone or tablet the user can scan the barcode of a food label and get easy to interpret nutritional information on the product using a traffic light-style colour rating for levels of total fat, saturated fat, sugar, and salt. This allows them to compare products at a glance. They also receive immediate suggestions for ‘healthier’ alternative foods or products.

PROS include: Produced by trustworthy organisations: The University of Auckland’s National Institute for Health Innovation, The George Institute for Global Health, and Bupa New Zealand.

CONS include: Does not include information and messages on portion size.

More information on this and other reviewed apps at:
www.healthnavigator.org.nz/app-library.

Full FoodSwitch review at: https://www.healthnavigator.org.nz/app-library/f/foodswitch-new-zealand-app/

More information at https://cpd.whitireia.ac.nz.

The Southern District Health Board clinic has a diabetes nurse specialist, herself, a vascular surgeon, orthopaedic surgeon, a podiatrist and the orthotics team offering a holistic approach to patient-centred care, including optimising diabetes control, effective wound care and infection control, pressure-relieving techniques and ensuring adequate blood flow to the limb.

Aburn believes that if people, when first diagnosed with diabetes, could see the potential impacts on their feet of diabetes complications like neuropathy and peripheral vascular disease, then health professionals may see a lot fewer diabetic foot or lower leg ulcers.

She is a strong supporter of nurses providing quality foot care education right from the outset of diabetes diagnosis and regular foot screening thereafter – annual screening for the low risk and more frequently for those with poorly controlled diabetes, loss of sensation and other risk factors.

She also believes a key message for nurses wanting to help prevent diabetes foot disease is to try and help address the underlying causes of why the person has difficulty controlling their diabetes or is at risk of foot disease. And if the nurse is not a specialist in treating diabetic wounds – or people at risk of them – to promptly refer them to a service or clinic where they can get the specialist care required.

“You can’t muck around with diabetic feet by waiting around to see whether a wound is infected or giving oral antibiotics in the hope it goes away.”

Aburn shares some case studies illustrating how quickly a simple rubbing injury or blister may lead to an ulcer requiring months to heal or the loss of toes or even a foot.

The case studies also show that every wound, like every Kiwi, has a story and Aburn believes it helps to know the ‘story’ or underlying causes if you are going to help somebody successfully heal or avoid another wound in the future.

CASE STUDY: The fashion shoe-lover

A 40-year-old woman newly diagnosed with type 1 diabetes wanted to keep wearing fashion shoes as she had a corporate-type job. Her first blister saw her heel go black; a pharmacist gave her an antimicrobial cream but the infection escalated until she needed a skin graft and was hospitalised for a long time.

The woman had been fit, healthy and had her diabetes well under control until the ulcers developed.

Following her first bad experience she inserted some gel pads into a pair of old fashioned boots in the belief she was doing the right thing. But the pad altered the position of her foot so she ended up with six blisters on her other foot – three of which turned into ulcers.

Because of her job she was very reluctant to wear a moon boot, an off-loading shoe, or go into a total contact cast, so the diabetes foot clinic team had to find a more attractive footwear solution that worked for her.

 It took three months to heal the ulcers. After a tough learning curve the woman has not re-presented at the clinic with any more ulcers.

CASE STUDY: The recently widowed

A  woman turned up at the diabetes foot clinic with multiple small wounds on her feet. The team discovered she hadn’t been managing herself or her diabetes well since losing her husband. She had lost her appetite, smoked, had peripheral vascular disease and hadn’t been looking after her skin so had callouses and cracks on her feet. The cracks had broken open and bacterial infection had set in.

 Recognising the multiple factors behind the wounds, the clinic worked with her to boost her nutrition with supplements and help her sign up to a quit smoking programme with the support of her GP and practice nurse.

A recent clinic appointment showed her wound had taken a turn for the worse and the team discovered she’d had a bad week where she stopped taking her supplements and begun to smoke heavily again.

 They sat down and talked with her again about the benefits of eating better and smoking less. They also showed her on the electronically graphed treatment record how her bad week had impacted on the healing of her wound. Seeing the reality on the graph meant the woman agreed to try to cutting back on the cigarettes and eating better to get healing back on track.

CASE STUDY: The whitebaiter

A trim man in his 60s with well-controlled type 2 diabetes had gone whitebaiting at the weekend in his gumboots and got a very small blister on the right side of his foot.

He went to his GP on the Monday and Rebecca Aburn, a district nurse at the time, was assigned to change his dressing on the Wednesday.

 “I took the dressing down and there was a very small wound area – probably less than 5mm but the surrounding area was grey and boggy.”

She knew his history included vascular surgery about seven years previously so sent him straight into the diabetic foot clinic. On arrival he was quickly admitted to hospital as his underlying vascular disease had deteriorated, which meant the tiny innocuous gumboot blister had an impact far beyond its actual size. They had to debride his foot back to the bone and he eventually lost two toes. The healing time was more than six months.

But for people with diabetes these experiences may mean they are just a few numb and unfeeling steps away from a diabetic foot ulcer. And for some those steps could be taking them down the path to losing toes, a foot or even a lower leg.

The International Diabetes Federation reports that every 20 seconds somebody with diabetes has a limb amputated.

Statistics from New Zealand’s Artificial Limb Service show that people with diabetes have gone from making up 24 per cent of new amputees each year to 38 per cent of new amputees (174 people) in less than a decade. And that doesn’t include toes.

Sadly, it is estimated that 85 per cent of all amputations caused by diabetes are preventable if foot complications like diabetic foot ulcers are detected and treated early.

It is also estimated that 15 per cent of the more than 257,000 people in New Zealand with diabetes will have a foot ulcer in their lifetime – that percentage is stable but the number of people getting diabetes is not, so the number needing specialist foot and wound care keeps growing.

Foot screening: “notoriously poorly done”

Michele Garrett is a diabetes specialist podiatrist at Waitemata District Health Board providing such specialist foot care.

She says an unfortunate reality of today’s “flat out and full on” general practice is that annual diabetes foot checks are “notoriously poorly done”.

“Some anecdotal data tells that only about 40 per cent are done and some other audits show that between 30–60 per cent of people with diabetes get an annual foot screen when it is meant to be everybody.”

Garrett says there are multiple factors influencing the poor statistics including patients not liking showing their feet, the doctor or nurse doing the screening not liking feet and sometimes feeling pushed for time to get the person to take their shoes and socks off. “It is amazing how many foot screens get done with footwear still on.”

She says health professionals can’t just ask people with diabetes about their feet – they have actually got to see the feet.

“You must remember that neuropathy or numbness is a major contributing factor to foot problems,” says Garrett. “People will say that their feet are okay but very few foot ulcers are identified by the patient – quite often they are only identified at opportunistic screenings because numbness meant the person was unaware.”

Garrett was part of the New Zealand Society for the Study of Diabetes podiatry team that developed the 2014 diabetes foot screening and risk stratification tool. The tool is built on the Scottish guideline, but with the addition of Māori ethnicity as a risk factor to reflect the much higher risk of amputation experienced by Māori with diabetes (see link in resources next page).

The latest international guidelines recommend on top of the annual diabetes foot screen that all people with high risk feet or neuropathy should have their feet checked each time they see a health professional. This is because people with numb feet may not have pain “as their friend or indicator” that something is wrong. Also obesity, age, vision impairment and other factors sees some people struggle to adequately care for or check their feet.

Bare feet and jandals – the Kiwi attitude to feet

Kiwis also typically think their feet are ‘tough’.

Garrett recently undertook some qualitative research looking at how growing up ‘Kiwi’ influenced the attitudes of people with diabetes towards their feet.

“All of them went barefoot as children and didn’t wear special footwear for sport and grew up with a real ‘she’ll be right’ attitude to their feet,” says Garrett.

The most people did was “dab a bit of Dettol” on a cut or a blister, but once people have diabetes such cursory first aid is not enough as a simple cut can quickly become a major issue for people with a moderate to high risk of diabetes foot ulcers.

Garrett says people with diabetes need to be told not only how to take good care of their feet but also why and the what if consequences of activities like walking barefoot on a black sand beach on a hot summer day with numb feet through neuropathy. :

Regular foot screening is key

The annual diabetes foot screen provides an opportunity for just such patient education as well as detecting any new risk factors or spotting active or potential ulcers.

Garrett says a good foot screen can be a simple process needing only your eyes and fingers and taking just a few minutes.

With their fingers nurses can check the pulses in the feet for signs of vascular problem. Also, if a nurse doesn’t have a 10g monofilament on hand for the neurological test, they can just use their fingers instead to carry out the Ipswich touch test to assess for loss of sensitivity to the toes (see link in resources sidebar).

After asking the set questions on the NZSSD foot screening checklist, the screening process is finished with a visual inspection of the feet for callouses, redness, blisters, cuts or ulcers.

Depending on the screening results, the response can range from patient education and self-management for the low risk foot through to referral to a podiatrist for the moderate to high-risk foot.

For people with active foot disease most regions have some form of specialist diabetes foot clinic that people can be urgently referred to, with clinics often working in conjunction with a district nursing service, says Garrett.

She says it is imperative with foot ulcers to offload the pressure on the foot by putting people in special surgical shoes, moon boots or casts. “It is the constant pressure (on the foot) combined with the diabetes that inhibits ulcers healing.”

Rapid referral to a specialist service with the right offloading strategies in place can see ulcers heal relatively quickly and stop them progressing to complex chronic wounds that are much more time-consuming to heal. It also reduces the risk of amputations.

Foot screening is not only important in primary health settings but also if a person with diabetes or neuropathy is admitted to hospital, because of the increased risk of pressure injuries on their heels and the bottom of their feet, says Garrett.

Also people with neuropathy may be allowed to wander around the ward in bare feet and socks when they should be wearing special footwear.

Urgent hospital admission is needed for people found to have severe or spreading infection or critical ischaemia.

Garrett hopes that regular screening, education and rapid referral can help more Kiwis with diabetes work through their ‘she’ll be right’ attitude to their numb feet and see fewer face chronic ulcers or risk amputations.

In adults with symptomatic heart failure, nurse-led titration of heart failure medications significantly increased the number of participants reaching optimal dose, reduced the time taken to reach optimal dose and improved patient morbidity and survival when compared with physician-led titration. Despite mixed quality evidence, these results suggest that nurse-led titration is an effective and safe strategy for ensuring high-risk patients get the optimal medication dose.

CLINICAL SCENARIO:

You have a leadership role spanning primary and secondary care and are concerned about the number of people with chronic conditions not receiving optimal doses of beneficial medication. You wonder if nurse-led titration (NLT) may be a good strategy for addressing the complex barriers to patients getting the right dose of the right medications. You decide to review the evidence.

QUESTION:

In people with chronic illness and in comparison with usual care, does nurse-led titration safely increase the number of patients receiving optimal doses of medications known to be an effective treatment for their condition?

SEARCH STRATEGY:

PubMed – Clinical queries (Therapy/Narrow): nurse-led titration

CITATION:

Driscoll A, Currey J, Tonkin A, Krum H. Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD009889. DOI: 10.1002/14651858.CD009889.pub2.

STUDY SUMMARY:

A Cochrane systematic review assessing the safety and effectiveness of NLT of beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) for people with heart failure (HF). Inclusion criteria were:

Type of study: Randomised controlled trials comparing NLT with medication optimisation by another health professional involving adults with symptomatic HF and reduced ejection fraction. Uncontrolled and non-randomised studies were excluded.

Intervention: Nurse-led titration of beta-adrenergic blocking agents, ACEIs, and ARBs. Nurses were to have delegated responsibility for making protocol led changes in medication dose or were nurse practitioners titrating medications as part of their scope of practice.

Comparison: Usual care: patients under the management of a physician responsible for titration of ACEIs, ARBs, and/or beta-adrenergic blocking agents or a heart failure nurse who did not alter medication.

OUTCOMES

Primary: all-cause hospital admissions; heart failure-related hospital admissions; all-cause mortality; all-cause, event-free survival.

Secondary: time to maximum dose; adverse events associated with titration; proportion reaching target dose of medications; change in quality-of-life scores; cost-effectiveness.

STUDY VALIDITY:

Search Strategy: Reviewers searched CENTRAL, MEDLINE, EMBASE, clinical trial registries, reference lists of eligible studies and heart failure guidelines and unpublished theses. No date or language restrictions applied.

Review process: Two reviewers independently examined titles/abstracts and then full text to identify relevant studies, extracted data using a data extraction form, and assessed risk of bias in all studies. Discussion resolved any disagreement.

Quality assessment: The Cochrane Collaboration tool was used to assess risk of bias in included studies. Assessment criteria were random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessment, incomplete outcome data and selective reporting.

Overall validity: A high-quality review involving studies of mixed quality and generally small sample size.

STUDY RESULTS:

The search identified 1,016 studies. Following title review, 100 abstracts and then 18 full text articles were closely examined for eligibility, after which a further 11 studies were excluded. Seven RCTs involving 1,684 participants were included in this review. NLT occurred via nurse visits to a residential care facility (one study), telephone follow-up (one study), nurse-led clinic in primary care (one study) and outpatient clinics of tertiary hospital (four studies).

Studies involved titration of beta-adrenergic blockers (three studies), beta-adrenergic blockers and ACEIs (two studies); just two studies involved titration of beta-adrenergic blockers, ACEIs, and ARBs. Median follow-up was 12 months.

Usual care consisted of primary care physician-led titration. Participants receiving NLT experienced a 20 per cent reduction in all-cause hospital admissions, 49 per cent reduction in heart-failure related hospital admissions, and a 34 per cent reduction in all-cause mortality (see table) compared with usual care.

Participants in the NLT group were also twice as likely to reach target dose of medications (see table) and did so in a significantly shorter time (two studies, no meta-analysis). All results were statistically and clinically significant but quality of evidence was mixed.

COMMENTS:

• NLT involved heart failure nurse specialists, was protocol-led and occurred alongside varying levels of patient education and support.
• Low-quality evidence grading (substantial heterogeneity, small studies, risk of bias in included studies) for the outcome of proportion reaching target doses, therefore this result may change with future studies.
• Adverse events related to the study medications were poorly reported so comparing safety of nurse-led and physician-led titration is difficult. Available data suggests that optimising therapeutic medications through NLT is safe, provided specialist nurses monitor risks associated with each medication in keeping with evidence-based prescribing guidelines.
• People with symptomatic heart failure have high mortality and morbidity, therefore strategies for promoting optimal dosing of effective medications are crucial.

Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, the University of Auckland and PhD Candidate, Deakin University, Melbourne [email protected].