Acupuncture Program For Convalescent Hospital Essay
Acupuncture Program For Convalescent Hospital Essay
The paper “Acupuncture Program For Convalescent Hospital” is a wonderful example of an assignment on nursing. In the past few decades, thousands of Americans have resorted to Complementary Alternative Medicine which on its own can be an alternative to orthodox therapies or as a supplement to mainstream medicine whit the purpose of alleviating conditions and/ or promote a healthy lifestyle. A good example of CAM would be Traditional Chinese Medicine (TCM) that has its beginnings in China for more than thousands of years. According to the National Institutes of Health, TCM “ is considered is considered part of complementary and alternative medicine (CAM) in the United States”. Acupuncture is one of the most popular TCM treatment. This treatment can be applied to the elderly for the following reasons: 1. As a treatment for chronic-related stress. In a study made by Greenwood some patients that were not responsive to physical therapy on their neck condition showed a favorable response to acupuncture. Acupuncture can complement the medication that the hospital prescribes to the elderly. 2. According to breastcancer.org, stress can trigger hot flash s in elderly women and acupuncture can help alleviate the condition. Acupuncture Program For Convalescent Hospital Essay. Caring for the elderly requires patience and sensitivity since this group of patients have complex psychological make-up and delicate biological needs. It is imperative that we find alternative ways in alleviating the pain or discomfort that they are suffering from. As medical practitioners, we must aim to view healing in a holistic manner; thus, we explore different ways of caring for our elderly patients. The elderly do not have much time but relieving them from pain has greatly contributed to their quality of life at this stage
Acupuncture is a form of treatment that involves inserting very thin needles through a person’s skin at specific points on the body, to various depths.
Research suggests that it can help relieve pain, and it is used for a wide range of other complaints.
However, according to the National Center for Complementary and Integrative Health (NCCIH), there is limited evidence for its effectiveness in areas other than pain.
How acupuncture works scientifically remains unclear. Some people claim it works by balancing vital energy, while others believe it has a neurological effect.
Acupuncture remains controversial among Western medical doctors and scientists. Acupuncture Program For Convalescent Hospital Essay.
An acupuncurist will insert needles into a person’s body with the aim of balancing their energy.
This, it is claimed, can help boost wellbeing and may cure some illnesses.
Conditions it is used for include different kinds of pain, such as headaches, blood pressure problems, and whooping cough, among others.
Traditional Chinese medicine explains that health is the result of a harmonious balance of the complementary extremes of “yin” and “yang” of the life force known as “qi,” pronounced “chi.” Illness is said to be the consequence of an imbalance of the forces.
Qi is said to flow through meridians, or pathways, in the human body. These meridiens and energy flows are accessible through 350 acupuncture points in the body.
Inserting needles into these points with appropriate combinations is said to bring the energy flow back into proper balance.
There is no scientific proof that the meridians or acupuncture points exist, and it is hard to prove that they either do or do not, but numerous studies suggest that acupuncture works for some conditions. Acupuncture Program For Convalescent Hospital Essay.
Some experts have used neuroscience to explain acupuncture. Acupuncture points are seen as places where nerves, muscles, and connective tissue can be stimulated. The stimulation increases blood flow, while at the same time triggering the activity of the body’s natural painkillers.
It is difficult to set up investigations using proper scientific controls, because of the invasive nature of acupuncture. In a clinical study, a control group would have to undergo sham treatment, or a placebo, for results to be compared with those of genuine acupuncture.
Some studies have concluded that acupuncture offers similar benefits to a patient as a placebo, but others have indicated that there are some real benefits. Acupuncture Program For Convalescent Hospital Essay.
Research carried out in Germany has shown that acupuncture may help relieve tension headaches and migraines.
The NCCIH note that it has been proven to help in cases of:
- low back pain
- neck pain
- osteoarthritis
- knee pain
- headache and migraine
They list additional disorders that may benefit from acupuncture, but which require further scientific confirmation.
In 2003, the World Health Organization (WHO) listed a number of conditions in which they say acupuncture has been proven effective.
These include:
- high and low blood pressure
- chemotherapy-induced nausea and vomiting
- some gastric conditions, including peptic ulcer
- painful periods
- dysentery
- allergic rhinitis
- facial pain
- morning sickness
- rheumatoid arthritis
- sprains
- tennis elbow
- sciatica
- dental pain
- reducing the risk of stroke
- inducing labor
Other conditions for which the WHO say that acupuncture may help but more evidence is needed include: Acupuncture Program For Convalescent Hospital Essay.
- fibromyalgia
- neuralgia
- post-operative convalescence
- substance, tobaccor and alcohol dependence
- spine pain
- stiff neck
- vascular dementia
- whooping cough, or pertussis
- Tourette syndrome
The WHO also suggest that it may help treat a number of infections, including some urinary tract infections and epidemic hemorrhagic fever.
They point out, however, that “only national health authorities can determine the diseases, symptoms, and conditions for which acupuncture treatment can be recommended.”
Acupuncture can be beneficial in that:
- Performed correctly, it is safe.
- There are very few side effects.
- It can be effectively combined with other treatments.
- It can control some types of pain.
- It may help patients for whom pain medications are not suitable.
The NCCIH advise people not to use acupuncture instead of seeing a conventional health care provider.
According to traditional Chinese medical theory, acupuncture points are located on meridians, through which vital energy runs. This energy is known as “qi” or “chi.”
An acupuncturist will examine the patient and assess their condition, insert one or more thin, sterile needles, and offer advice on self-care or other complementary therapies, such as Chinese herbs.
The patient will be asked to lie down on their back, front, or one side, depending on where the needles are to be inserted. The acupuncturist should use single-use, disposable, sterile needles. As each needle is inserted, the patient may feel a very brief stinging or tingling sensation.
After the needle is inserted, there is occasionally a dull ache at the base of the needle that then subsides. Acupuncture is usually relatively painless.
Sometimes the needles are heated or stimulated with electricity after insertion.
The needles will stay in place for between 5 and 30 minutes.
The number of treatments needed depend on the individual. A person with a chronic condition may need one to two treatments a week over several months. Acupuncture Program For Convalescent Hospital Essay. An acute problem normally improves after 8 to 12 sessions.
Effective pain management among hospitalized patients is an important aspect of providing quality care and achieving optimal clinical outcomes and patient satisfaction. Common pharmacologic approaches for pain, though effective, have serious side effects and are not appropriate for all inpatients. Findings from randomized controlled trials (RCTs) support the efficacy of acupuncture for many symptoms relevant to inpatients including postoperative pain, cancer-related pain, nausea and vomiting, and withdrawal from narcotic use. However, the extent to which findings from RCTs translate to real-world implementation of acupuncture in typical hospital settings is unknown.
Methods/Design
In partnership with the launch of a clinical program offering acupuncture services to inpatients at the University of California, San Francisco’s Mount Zion Hospital, we are conducting a pilot study using a hybrid effectiveness-implementation design to: (1) assess the effectiveness of acupuncture to manage pain and other symptoms and improve patient satisfaction; and (2) evaluate the barriers and facilitators to implementing an on-going acupuncture service for inpatients. During a 2-month pre-randomization phase, we evaluated and adapted clinical scheduling and treatment protocols with acupuncturists and hospital providers and pretested study procedures including enrollment, consent, and data collection. During a 6-month randomization phase, we used a two-tiered consent process in which inpatients were first consented into a study of symptom management, randomized to be offered acupuncture, and consented for acupuncture if they accepted. We are also conducting in-depth interviews and focus groups to assess evidence, context, and facilitators of key provider and hospital administration stakeholders.
Discussion
Effectiveness research in ‘real-world’ practice settings is needed to inform clinical decision-making and guide implementation of evidence-based acupuncture practices.Acupuncture Program For Convalescent Hospital Essay. To successfully provide clinical acupuncture services and maintain a rigorous research design, practice-based trials of acupuncture require careful planning and attention to setting-specific, contextual factors.
Trial Registration
This trial has been registered in ClinicalTrials.gov. The identifier is NCT01988194, registered on November 5, 2013.
Background
Pain is highly prevalent and difficult to manage among hospitalized patients: 80% of surgical patients and 53–60% of non-surgical, general medicine patients experience pain during their hospital stay; less than half report adequate pain relief[1–4]. Unrelieved pain can lead to a range of negative consequences including patient discomfort, greater morbidity, poor patient satisfaction, longer recovery times from surgery, and high risk of developing chronic pain[1]. Opioid medications are among the most effective and widely prescribed treatments for pain but associated side effects and complications are well known[5]. Pain management among general medicine patients presents unique clinical challenges because opioids and epidural analgesia used in surgical settings are often inappropriate for chronic pain or for complex patients[3]. Safe, effective pain management is needed to achieve optimal clinical care for hospitalized patients. Acupuncture Program For Convalescent Hospital Essay. Non-pharmacologic approaches, such as acupuncture, may alleviate pain with fewer side effects and adverse reactions than commonly used opioid analgesics.
Findings from randomized controlled trials (RCTs) indicate the efficacy of acupuncture for a range of pain conditions including chronic, surgical, and cancer-related pain[6–9]. A meta-analysis of 17,922 individuals from 29 RCTs found that patients receiving acupuncture had significantly less pain than patients receiving no acupuncture (effect sizes from 0.42 to 0.57) or sham acupuncture (effect sizes from 0.15 to 0.23) for back and neck pain, chronic headache, and osteoarthritis[10]. Acupuncture as an effective treatment for post-operative pain has been well established with multiple RCTs[11–14], including a 2008 systematic review indicating that acupuncture reduces pain intensity, opioid consumption and opioid-associated side effects[7]. Studies of post-operative pain in cancer patients also favor acupuncture[6, 15], although a recent Cochrane review was unable to draw conclusions based on the quality of evidence from prior trials[16]. Many RCTs also show strong evidence that acupuncture effectively treats chemotherapy-induced and postoperative nausea and vomiting[17–21].
Nearly 400 hospitals in the United States offer complementary and integrative health approaches, including 42 programs of acupuncture for inpatient services[22]. Rigorous evaluations of the effectiveness of such programs are sparse and inconclusive[23, 24]. An observational study of 1837 hospitalized patients receiving integrative medicine (e.g., acupuncture, acupressure, massage therapy, or reflexology) found an overall 56% reduction in pain (average decrease of 1.9 points on an 11-point scale)[23], but did not include a comparison group. Similarly, a large scale retrospective study of nearly 11,000 oncology-related hospital admissions found that cancer inpatients receiving integrative medicine had a 47% reduction in pain and a 56% reduction in anxiety, and acupuncture was one of the most effective therapies[25]. In an RCT of inpatients receiving usual care with and without acupuncture, Painovich et al. found high acceptability of acupuncture but no significant difference in length of stay[24]. Despite strong evidence of acupuncture’s efficacy for pain management[7, 10], and high acceptability of acupuncture among inpatients[24], the therapeutic advantage of adding acupuncture to routine care for hospitalized patients is unclear. Acupuncture Program For Convalescent Hospital Essay.
Explanatory RCTs are designed to estimate efficacy of an intervention under highly controlled conditions. While useful for addressing cause and effect under ideal circumstances, findings from these studies are often not broadly applicable because of relatively homogenous study participants, highly standardized interventions, and comparator conditions that may not be meaningful in clinical practice. To inform clinical decision making about acupuncture, rigorously conducted trials that are representative of actual routine clinical care are needed[26]. In addition, to bolster the clinical value of research, hybrid designs that combine effectiveness and implementation research are recommended.
To address this gap in the literature, we are conducting a pilot study to prepare for a large-scale practical clinical trial to test the effectiveness of acupuncture among inpatients. Our primary objective is to assess the effectiveness of adjunctive acupuncture for pain and symptom management compared with usual care. Our secondary objective is to identify potential barriers and facilitators to implementing a sustainable acupuncture service in the context of inpatient care.
Methods/Design
Overall Study Design
In conjunction with the launch of clinical acupuncture services for inpatients at a university hospital, we sought to rigorously evaluate the effectiveness and implementation of acupuncture in a high volume clinical setting. We therefore chose a Hybrid Type 1 design, defined as “testing a clinical intervention while gathering information on its delivery during the effectiveness trial and/or on its potential for implementation in a real-world situation”[27]. A Hybrid Type 1 design is indicated when the clinical intervention is safe, has strong face validity and a strong evidence base that support applications in the populations of focus, and minimal associated risks[27]. Given the growth of hospital-based acupuncture services[22, 28], the inclusion of acupuncture in clinical guidelines for pain management[29–31], and the low risks associated with acupuncture[32–34], the evidence base and safety profile of acupuncture support the use of a Hybrid Type 1 design.
To assess whether providing acupuncture along with routine inpatient care improves pain and symptom management compared with routine care alone, we are conducting an exploratory, randomized controlled trial of acupuncture services among inpatients using a parallel group design with participants randomized to usual care alone or usual care with adjunctive acupuncture. Acupuncture Program For Convalescent Hospital Essay. We conducted (1) a pre-trial phase to refine implementation of clinical acupuncture services and to pilot and finalize study procedures with minimal impact on clinic flow and (2) a pilot effectiveness RCT.
To assess barriers and facilitators of providing a sustainable acupuncture service, we are collecting qualitative data through one-on-one interviews and focus groups of providers and hospital leadership. The University of California San Francisco, Committee on Human Research (institutional review board) reviewed and approved all study procedures and modifications. The study is registered in ClinicalTrials.gov with the identifier NCT01988194.
Objective #1: Assess the effectiveness of adjunctive acupuncture for pain and symptom management compared with usual care
Study setting
We are conducting a pilot effectiveness study for objective 1 at the University of California, San Francisco’s Mount Zion Hospital, an urban academic hospital in the United States with 90-beds and specialty care including internal medicine; gastrointestinal; gyno-, ortho- and uro-oncology; headache; orthopedics; pain; radiation; tracheostomy. Inpatient wards at Mount Zion Hospital are usually at 75–80% capacity, with approximately 70 patients on any given day and an average length of stay of nine days. For logistical feasibility, we launched our study focusing primarily on the surgical oncology ward and expanded to include the medicine and breast cancer wards as capacity allowed.
Study population
Consistent with the design of an effectiveness trial, inclusion criteria were intentionally broad to reflect the heterogeneity of clinical practice. Eligible participants were: admitted to Mount Zion Hospital for an anticipated length of stay of at least 48 hours, 18 years of age or older, English-speaking, and under the care of a surgical or medical team that had given prior approval for their patients to receive acupuncture treatments. Exclusion criteria included: contraindication to acupuncture (e.g., sepsis or endocarditis); inability to consent (e.g., cognitive or communication impairment); knowledge of the study (e.g., hospital readmission with prior study participation); or unstable medical condition (e.g., myocardial infarction, patients in the intensive care unit, severe depression, severe pulmonary disease). Acupuncture Program For Convalescent Hospital Essay.
Study procedures
Phase I of our study included a pre-randomization run-in period over two months to finalize study procedures. The run-in phase allowed us to introduce acupuncture services to the hospital staff; develop our systems for identifying new admissions, screening for eligibility, establishing work flow for acupuncturists; and establish rapport with patient care managers, nurses, and hospitalists. This phase also allowed us to accurately estimate how many inpatients at Mount Zion Hospital would be interested in acupuncture, to identify reasons for lack of interest, and to improve our approach to offering and explaining acupuncture. We also consented a small subsample of patients to pilot study instruments, assess administration time, and identify data collection challenges.
After the two-month run-in phase, Phase II of the study was a pilot effectiveness RCT with the following procedures.
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Identification, Recruitment, and Consent of Participants. To determine initial eligibility, research staff reviewed the electronic medical records of newly admitted patients and conferred with the ward’s charge nurse regarding the inclusion/exclusion criteria described above. All patients who met initial eligibility criteria were asked if they were interested in participating in a study of symptom management with a stated purpose of learning more about the management of pain and other symptoms in the hospital and patient satisfaction with care. Participants were consented and enrolled in the study on postoperative day 1 for surgical patients or on hospital day 2 for non-surgical patients. As an incentive, study participants were entered into a raffle to win one of three Amazon.com gift certificates for $75. A research coordinator trained in human subjects protection obtained informed consent from interested patients to participate in data collection for the study and to grant permission to access their records. A total of 237 participants were recruited from the inpatient wards at Mount Zion Hospital at the UCSF Medical Center in San Francisco from December 2013 to August 2014. Wards of primary focus included surgical oncology, medicine, and breast cancer.
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Randomization and Blinding. We used Zelen’s design, a two-tiered consent process in which only study participants randomized to the experimental condition are asked to consent to treatment[35]. Acupuncture Program For Convalescent Hospital Essay. This allowed us to maintain some level of blinding and to minimize disappointment bias among patients in the treatment as usual group. Participants who consented to the study of symptom management responded to a series of questions about their level of interest in different types of complementary and integrative health therapies, such as massage, guided imagery, acupuncture, and nutritional counseling if available during their hospital stay[36]. Those that indicated at least a minimal interest in receiving acupuncture were randomized either to usual care or to be offered acupuncture treatments in a 1:1 ratio.
A randomization table with random block sizes of two or four were constructed using a Python script. The data manager for the study (JC) programmed the study’s database system to assign condition sequentially through the randomization table records using Microsoft Access 2010 (Microsoft Corporation, Redmond, WA, USA). Research coordinators consenting participants were blind to the randomization sequence. Participants randomized to treatment as usual were blinded to the existence of acupuncture in the study. Those who were offered acupuncture and accepted were then voluntarily consented to receive acupuncture treatments. Participants who were offered acupuncture but declined received usual care (see Figure 1).
Figure 1Participant flow chart
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Data collection. Consented participants completed surveys about their symptoms during their hospital stay at baseline, four daily follow-ups, and an exit interview on the day of hospital discharge or over the telephone within two weeks of discharge. Participants in the acupuncture group completed additional questionnaires specific to their experience with acupuncture (see Table 1). Acupuncture Program For Convalescent Hospital Essay. Trained study staff administered surveys using a tablet computer. Study data were collected and managed using Research Electronic Data Capture (REDCap) [37], hosted at the University of California, San Francisco. REDCap is a secure, web-based application designed to support quality data collection for research studies, providing validated data entry, audit trails for tracking data changes, and automated export procedures to common statistical packages[37]. Since inpatient schedules are unpredictable, we offered participants three options for data collection: (1) via iPad with the research coordinator, (2) via a self-administered paper-based survey, or (3) via a link sent to their smartphone.
Table 1
Schedule of study procedures and data collection
Day in hospital 1 2 3 4 5+ Study procedures Inclusion/exclusion criteria ● Informed consent ● Random allocation ● Acupuncture treatment ○ ○ ○ ○ Data collection measures Demographic characteristics ● Complementary and integrative health survey ● Pain intensity ● ● ● ● Impact of pain ● ● ● ● Nausea and vomiting ● ● ● ● Patient-reported symptoms ● ● ● ● Sleep disturbance ● ● ● ● Profile of moods ● ● ● ● Health-related quality of life ● ● ● ● Global impression of change ● Pain treatment satisfaction ● Exit interview ● Open in a separate window● All participants, ○ Acupuncture group only
Intervention
Acupuncture treatment
As this study is ‘piggybacking’ on a clinical program, we used protocol guidelines consistent with a pragmatic study design [38]. The study team opted not to use standardized acupuncture protocols with prescribed point selection. Rather, acupuncturists had flexibility in determining treatment plans and provided care typical of clinical practice. Two licensed acupuncturists (JA, MT) from the UCSF Osher Center for Integrative Medicine provided acupuncture services to inpatients. Each acupuncturist has more than 20 years of experience as a traditional Chinese medicine (TCM) practitioner and has worked in an integrative medicine setting for over 10 years. Practitioners diagnosed participants according to principles of TCM, including a physical examination with tongue and pulse diagnosis. Acupuncture treatments were individualized to the participants. Treatments were performed with sterile, disposable acupuncture needles (0.16 × 30 mm, 0.18 × 30 mm, and 0.20 × 40 mm, Seirin, Shizuoka, Japan) after the acupuncture points were sterilized with a disposable 70% isopropyl alcohol pad. Acupuncturists inserted needles at a depth of approximately 1–2 mm and manually manipulated needles with a twisting motion to achieve a propagating sensation along the channel (referred to in TCM as de qi sensation). Needles were left in place for approximately 30 minutes. Acupuncture Program For Convalescent Hospital Essay. During the treatments, participants were encouraged to lie on their hospital beds in a comfortable position, and practitioners remained at the participant’s bedside throughout the treatment. Practitioners reviewed the participants’ electronic medical records before each treatment for information about type of surgery, reason for hospitalization, and relevant updates. Details of acupuncture treatments (e.g., frequency and duration, TCM diagnosis, needles and points used) were documented in standard charting used by the Osher Center for Integrative Medicine.
Scheduling of acupuncture treatments
Day-to-day management of the acupuncture schedule was based on priorities of ensuring that participants in the research study received treatments, providing the maximum amount of clinical care available through the acupuncturists, and accommodating clinical referrals from providers. Acupuncture treatments were offered to participants in the following order: (1) participants newly randomized to the acupuncture group, (2) participants who had been randomized to the acupuncture group, declined treatments, and then changed their minds, (3) on-going participants in the acupuncture group receiving a follow-up treatment, and (4) patients receiving acupuncture as a clinical service not part of the study. Acupuncture treatments were provided four afternoons per week. New study participants were allotted one hour per treatment, while on-going study participants and patients receiving acupuncture off-study were allotted 45 minutes per treatment. Study participants received a maximum of four acupuncture treatments, after which point they were only offered additional treatments if there was room on the schedule. Patients receiving acupuncture off-study included those who were ineligible for the study based on the inclusion/exclusion criteria, those who had requested to leave the study but still wanted acupuncture treatments, or those referred by their providers in other wards. Patients could refuse acupuncture treatment at any point.
Treatment as usual
All study participants who did not receive acupuncture received the usual care under the guidance of their surgical or medical teams. The research coordinators did not give educational materials or symptom management advice to the participants. All patients in the usual care group did not receive any additional treatments beyond routine care. No changes were made to the participants’ medication regimens. Acupuncture Program For Convalescent Hospital Essay.
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We chose usual care as our control group to address our primary question of whether adding adjunctive acupuncture to routine pain management would improve pain and symptom management. However, changes in usual care during the course of the study are important to consider [39]. For instance, during our study, certain surgical teams implemented a “fast track” protocol [40] for their patients, a quality improvement initiative which encouraged rapid recovery and early discharge from the hospital using a multimodal care plan that included physical activity and pain control. We considered whether we should exclude ‘fast track’ patients from our study because of potential bias from co-interventions. We decided not exclude these patients based on the rationale that ‘fast track’ was part of usual care at the time and because using randomization procedures would help balance ‘fast track’ patients between groups.
Co-interventions
Participants in all of the groups were allowed to use any modalities or medications for the treatment of pain and other symptoms as prescribed by their surgical or medical teams, such as intravenous opioids and anti-emetics or epidural opioids. We did not impose any co-interventions in the study.
Outcome Measures
To test the hypotheses that compared to usual care, adjunctive acupuncture improves pain managment and other symptoms among hospitalized patients, we assessed core outcome domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT)[41, 42] delineated below.
Participants’ worst, least, and average daily pain intensity scores were measured on a numeric rating scale ranging from 0 to 10 assessed in the late morning for up to five days during the participants’ hospital stay (baseline and four follow up days). As recommended by Shi et al.[43], our primary outcome is worst pain over the past 24 hours. For a comprehensive assessment of patients’ pain, we administered the revised American Pain Society’s Patient Outcome Questionnaire[44], which measures pain severity and relief; impact of pain on activity, sleep, and negative emotions; side effects of treatment; helpfulness of information about pain treatment; and ability to participate in pain treatment decisions. We used the single item Patient Global Impression of Change scale on the last hospital day to assess minimal clinically important difference in changes in participants’ pain[45]. Acupuncture Program For Convalescent Hospital Essay.
