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Health Needs Assessment
This essay explores the prevalence of Myocardial Infarction (MI) within a clinical placement area (Accident and Emergency department), (A&E) with reference to relevant demography in the surrounding community. The health and social care needs of this client group will be described with reference to the National Service Framework (NSF) for Coronary Heart Disease (CHD) preceding discussion on the strengths and limitations of resources available to meet the needs of the client group within the placement area. The essay concludes with the implications of the findings for nursing practice.
An MI is a coronary thrombosis occurring in one of the coronary arteries supplying the heart muscle with oxygen, the lack of blood supply leads to death of the area supplied by the affected artery (Richards and Edwards 2003).
The incidence of MI varies around the United Kingdom (UK), but on average the rate for men is 600 per 100,000 between the ages of 30 and 69, and the rate for women 200 per 100,000 (British Heart Foundation 2004) (BHF). It is highly likely that the incidence of MI rates in the north of England are exceeding those in the south of England (BHF 2004). A major contribution is socio-economic circumstances. Between the years of 1996 and 1998, nearly two thirds of Pakistani and Bangladeshi people lived in low income households, compared to over a quarter of other minority ethnic groups and only 17 per cent of White people (National Office for Statistics 2002). The Joint Health Surveys Unit (1999), have produced national figures for health in minority ethnic groups after questions were asked about the frequency of consumption of a range of foods. This is relevant to the discussion since the surrounding area of A&E is predominantly a western cultured community. The Joint Health Surveys Unit (1999) found that thirty per cent of deaths from CHD are due to unhealthy diets. The survey also suggests that Bangladeshi's are more likely to consume red meat and fried food than adults from other ethnic groups. Proportions of overall fat scores were highest in Bangladeshi men and women (22%) and Bangladeshi adults have the lowest consumption of fruit intake with fifteen per cent of men and sixteen per cent of women consuming fruit six or more times a week. The lowest levels of vegetable consumption were among the Pakistani community, with seven per cent of men and eleven per cent of women consuming vegetables six or more times a week. The above data therefore highlights the vulnerability of Bangladesh people, as they are represented as amongst the most poorest of minority ethnic groups.
Studying the register of A&E, certain districts or streets repeatedly emerge, suggesting a relation between location (therefore social-economic status) and the probability of attending A&E (Walsh and Kent 2001). There is a significant amount of deprivation in this particular area surrounding A&E, with only 39.5% of the population employed, and 14.4% of the population who are not in good health (National Office for Statistics 2004). Our Healthier Nation (DOH 1999) is the government's public health policy document, which demonstrates where individuals stand in a social scale determining their health and duration of life (DOH 1999). There is a diverse ethnic group around the placement area, with 7.6% of the population Pakistani, 11.7 Bangladeshi and 1.9% of people Indian (National Office for Statistics 2004). The figures shown earlier concerning diet are manifesting themselves within this ethnic community being studied. Tackling Health Inequalities: A programme for Action (DOH 2003) addresses the inequalities amongst geographical locations and the inequalities between different ethnic and socio-economic groups, whilst identifying the consequences of ill health and low life expectancy. One of the aims of Tackling Health Inequalities, is that by the year 2010, the prevention and management of CHD risks such as obesity and poor diet will be through primary care and public health interventions (DOH 2003). This target, if successful, will reduce mortality rates amongst disadvantaged groups.
In the White Paper Saving Lives: Our Healthier Nation (1999), the government set out a new and modern approach to public health. The document found that the proportion of young people who start to smoke is similar among all social classes, but is much higher amongst young girls whose parents are less economically affluent but by the time these people are aged in their thirties, half of the more wealthier people will stop smoking, while three quarters of those on a lower income will carry on smoking, demonstrating that the cycle of social disadvantage leads to premature death, illness and disability (DOH 1999). This paper also refers to the amount of physical activity by varying social classes. Keeping physically active reduces the risk of CHD, weight control, diabetes and hypertension; the last three all risk factors for CHD. It has been found that people in more unskilled professions are more active than in their leisure time than people in professional occupations and six out of ten men and seven out of ten women do not exercise enough to prevent CHD (DOH 1999). The health and social care needs of this client group that emerge is the need for a healthy balanced diet, stopping smoking, increase of physical activity, public education and also the recognition of disadvantaged communities who embark on this unhealthy lifestyle because of their vulnerability to this way of living.
Professional and organisational policies determine interventions after identifying the needs of a client group (Hooper and Longworth 2002). The NSF for CHD identifies these group needs and states the interventions required. The Government set a target of reducing the death rate from CHD and stroke related diseases in people under the age of 75 by at least 40% by 2010. The NSF for CHD sets the agenda for the modernisation of CHD services and treatment over a ten year period to achieve this (DOH 2000).
The NSF for CHD states that access to care in the first minutes or hours of the onset of symptoms of MI is crucial and dealing effectively with people experiencing an MI will be discussed in addition to the suggestions on MI prevention. Aspirin is needed to reduce clot formation and reduces the risk of death after MI (DOH 2000). The NSF highlights that Anti thrombotics reduce the risk of death rates in people with unstable angina. Also identifying the needs of the client group, the NSF encourages public education, especially to those at risk of a heart attack, to recognise the symptoms and seek emergency help. Vital minutes can be saved by combining better public information with more pre-hospital diagnosis (DOH 2000).
The NSF CHD set out guidelines to ensure that the use of effective medicines in the duration and after an MI is improved. Standard seven of the NSF CHD dictates that all hospital trusts should agree and implement protocols of care so that MI victims are accurately assessed and offered treatment of proven clinical and cost effectiveness to reduce the risk of disability and death. Standard eight states that individuals with stable angina should receive appropriate investigations and treatment to relieve pain and more importantly, reduce the risk of any coronary events. The guidelines set out by the NSF CHD illustrate the appropriateness and benefits of the implementation of this in practice, to reduce the mortality rate by providing the most effective treatment and services to those who have suffered an MI or those at risk. To seek evidence of effectiveness of care, literature reviews or policies should be brought to discussion, such as the NSF (Hooper and Longworth 2002).
Determining needs and prioritising needs is a complex process (Clegg and Doherty 2001). The Government target introduced in 2004 for all A&E departments has proved very difficult to achieve (DOH 2005). It was stated that by December 2004, all A&E patients should be seen and discharged within four hours (DOH 2005). This contradicts what is set out in the guidelines from the NSF CHD, on improving health education. The pressure of this government target means that MI patients do not receive any health education in the first four hours of admission. However, verbally advising patients not to smoke, lose weight and exercise is not acceptable whilst their condition is so acute in the A&E department (Walsh and Kent 2001). This means that the A&E department are considering health education as a priority, but at a later stage, whereby the patient will have been admitted to a Coronary Care Unit (CCU), and predictably in a less anxious state. As the patient is too ill to receive any form of health education whilst in A&E, BHF leaflets and additional information from A&E may be dispatched to the relative/carer for future reference, an appropriate time being on discharge from CCU. However, a progress report involving a hospital trust in the UK on their implementation of the NSF CHD found that all the organisations in the review have adopted the BHF booklets and locally produced information as a source of information for patients and their families. The locally produced information was of high quality but was found insufficient to meet the needs of all patients, particularly those from minority ethnic groups (Commission for Healthcare Audit and Inspection 2004). As the surrounding area of the A&E department concerned is predominantly ethnic minority then this will require attention. After all, the provision of effective and accessible information, increases patient and relative satisfaction (Clegg and Doherty 2001). There are at present, no forms of health education on CHD for other, non-acute patients in this particular department, which is a target within the NSF CHD.
If the triage assessment is carried out accurately by the nurse, the patient will be assigned the highest priority (category 1 on the Manchester Triage Scale), so that pain relief, in its urgent priority can be effectively relieved by the use of aspirin, Entonox gas and diamorphine (Walsh and Kent 2001). This meets the identified need stated in the NSF CHD that the first minutes of care are crucial after symptoms are made known, reducing the risk of death.
The NSF CHD declare that patients presenting to A&E with the onset of stable angina need to be given the appropriate treatment and investigations. In all chest pain and any radiation through the arms, wrists or jaw, an Electrocardiogram (ECG) is recorded, a Chest Xray performed and the relevant drugs administered such as Glyceryl nitrate or morphine (Harrison and Daly 2001). Another step is obtaining a history from the patient so that other possible causes can be eliminated (Walsh and Kent 2001). Vital signs such as blood pressure, respiratory rate, pulse and temperature should be observed regularly and the patient's psychological status and anxiety should be a constant assessment (Walsh and Kent 2001). The above treatment and investigation is necessary for all cardiac presenting patients and is carried out in the A&E department, adhering to the expectation of standards seven and eight of the NSF CHD.
The author has discussed the positive impact of health needs assessments on a CHD population, in an A&E setting. Current policy initiatives such as the NSF CHD are transferable into practice, but there are obstacles and other guidelines within the NSF CHD which are unachievable in A&E. Health care professionals may disagree with the NSF CHD but still need to continue implementing this into their practice, leading to frustration. It has become apparent that A&E is a department, which treats only the complications with the highest priority, such as reducing the risk of death, disability and chronic pain, and does not incorporate health education into practice as it is lowest in priority, especially since the addition of the four hour breach time by the Government. Health education, however does exist with other client groups such as Asthmatics, who present in a lower category. Locally produced information needs to be tailored to suit the needs of everybody, including those from ethnic minority groups, since a high number live in the surrounding community of this department. To encourage more public education in A&E, the department could produce a poster for the main waiting room, where patients of a lower priority wait, with non cardiac presenting symptoms. This way the public are informed about the signs and symptoms of CHD and educated about the importance of achieving a healthy lifestyle to avoid the possibility of CHD.
Investigations and treatment are also of prime importance, which is encouraged by the NSF CHD, to aid patient diagnosis and discharge before the breach time occurs. A progress report produced in 2004 portrays the improvements in CHD services since the NSF was introduced with the number of children eating fruit in schools now over one million, and zero before the year 2000. The percentage of MI victims receiving thrombolysis in the first thirty minutes of admission to hospital has increased from 38% to 81%. The trends in CHD mortality in men and women have also decreased and adult smoking prevalence has decreased from 28% in 1998 to 26% in 2002. Therefore the implications for nursing practice are being able to recognise disadvantaged people and teaching these people about their lifestyle choices whilst providing the best possible care in A&E by following the standards set out in the NSF CHD.
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