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EVALUATING THE INTEGRATION OF REMOTE MONITORING FOR CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICE FOLLOW-UP
CCCN Abstracts
N029 SAME-DAY DISCHARGE VERSUS USUAL CARE AFTER UNCOMPLICATED PERCUTANEOUS CORONARY INTERVENTION IN ELECTIVE AND LOW-RISK ACUTE CORONARY SYNDROME PATIENTS: A PROSPECTIVE AND RANDOMIZED TRIAL S Brons1, E Matthews1, M Ferber1, S Mehta1, K Etherington1, M Mercuri2, J Gorman1, C Beck1, G Wong1, T Lai3 1 Hamilton Health Sciences, Hamilton, ON, 2 Columbia University, New York, USA, 3 Gold Coast Centre, Queensland, Australia
It is unclear if patients are more or less satisfied with same day discharge home after uncomplicated percutaneous coronary intervention (PCI). Thus, we undertook a randomized controlled, parallel group, prospective study designed trial to determine if same-day discharge results in improved overall patient satisfaction when compared to those who receive usual care (consisting of at least one overnight stay in hospital). Secondary objectives included; death, MI, stroke or recurrent ischemia (MACE), unplanned revascularization, vascular complications, and bleeding. A sample of 164 elective and low-risk ACS patients that underwent uncomplicated PCI were randomly assigned by a web-based randomization system to usual care or same-day discharge. Patients in both groups were followed by telephone interview on day 1, 7 and 30 post discharge. Secondary outcome events were recorded during the telephone interview. In addition, a patient satisfaction questionnaire was completed on Day 7. The questionnaire included satisfaction with provided health education, (smoking, diet, care of site, medication) as well as overall satisfaction with timing of discharge. Respondents in the same day discharge group reported higher satisfaction compared to those in the usual care group (mean scale score 94.8 vs. 86.4; difference of 12.4; 95%CI: 2.8 to 14, p¼0.004) 54 of the 79 respondents in the same day discharge group reported 100% satisfaction, compared to 42 of the76 respondents in the usual care group. There were no reported secondary outcomes in either group. Same day discharge should be considered an option after uncomplicated PCI in stable low-risk patients.
N030 MITRAL CLIPS: MORE THAN JUST A PROCEDURE C Cross, E MacPhee University of Ottawa Heart Institute, Ottawa, ON
Mitral Regurgitation (MR) is one of the most frequent valve conditions, both in North America and in Europe, and its prevalence is increasing owing to the aging population. MR is common in patients with heart failure and depressed left ventricular ejection fraction and is associated with an adverse prognosis. Until recently, when medical therapy has failed, surgery has been the only option for these patients. However, nonsurgical mitral valve repair is a rapidly evolving area, with new
S357
technologies being developed. Transcatheter implantations of the Mitral Clip device have recently evolved into a therapeutic alternative for patients with significant MR of both degenerative and functional origin whose surgical risk is considered high. The management and treatment of these patients has presented a unique opportunity for nursing to develop preprocedure assessment tools, patient teaching information and data collection tools. The referral, assessment, work-up and pre-procedure monitoring represents a collaborative effort ensuring that patients are cared for from referral to procedure to post procedural care. The implementation of assessment standards for the management of MR patients will have an impact on their wait time, access to services and ultimately quality of life. The data reported locally, provincially and nationally will affect program sustainability. This presentation will provide an overview of the Mitral Clip procedure, the use of the Minnesota Living with Heart Failure Questionnaire, and the development of the Mitral Clip Registry.
N031 EVALUATING THE INTEGRATION OF REMOTE MONITORING FOR CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICE FOLLOW-UP J Forman, S Flavelle, O Van Breemen, E Hahn, C McIlroy, J Carleton St. Paul’s Hospital, Vancouver, BC
Cardiovascular implantable electronic devices (CIED’s) are commonly used in the treatment of cardiac arrhythmias and management of heart failure. Indications for the use of CIED’s have expanded in the past decade leading to an increase in the number of implants. Common clinical practice for all CIED’s includes routine follow-up assessments at set time intervals. Conventional follow-up includes in-person assessment at a designated device clinic but newer CIED’s are manufactured with remote monitoring (RM) capabilities. RM is a type of telemedicine that provides a method of transmitting rhythm strips to the clinic from their own home without an in-person visit. In a 2013 position statement, the Canadian Cardiovascular Society recommended integration of RM follow-up into standard practice at all device clinics. In 2011, our centre developed and implemented care processes to incorporate RM into clinic practice. Since then, approximately 350 patients have been enrolled in our RM program. The purpose of this presentation is to share our experience in adopting RM into standard practice at our clinic. We found that using RM decreases anxiety levels with improved communication of device information and is patient-centered with access to specialized care for those living in rural communities. Integrating RM has also presented challenges such as changes to clinic work-flow, compliance and usability by patients and education required to initiate monitoring with new patients. Implications for nursing practice will be highlighted
S358
such as ongoing management of RM transmissions and clinic workload, clarifying roles and responsibilities of team members and developing effective patient education strategies.
N032 HARVEST LIMB INFECTIONS; THE SECRET SURGICAL NIGHTMARE AND HOW TO PREVENT THEM W Bowles Vancouver Coastal Health, Vancouver, BC
Cardiac Surgery is a growing reality within an aging population. One of the major contributors to postoperative morbidly is Surgical Site Infections (SSI). The costs are significant, both monetary and in loss of quality of life; it is estimated that one SSI event can cost approximately $30,000. At Vancouver General Hospital (VGH) Cardiac Surgery, our goal was to reduce our SSI rates from 8% to 2% by January 30, 2014. The multidisciplinary team designed a strategy to reduce the SSI rate using best practices. VGH has a number of established practices to reduce infection. The new processes introduced included tightened antibiotic timing and redosing, new dressing products and protocols for the surgical and harvest site. Based on the American College of Surgeons National Surgical Quality Improvement Program database (ASC NSQIP) our SSI rate for the last 7 months is 1.0%. The new dressing for harvest limb incisions has an estimated added cost of $25,000 per year. Over 6 months, a possible cost avoidance of $ 180,000 was achieved based on previous surveillance data. The front line staff is an essential part of realizing these results. This presentation focuses on the addition of new dressing protocols for the post operative harvest limb site. Patient surveillance was followed for 90 days of the post operative period. This has shown a decrease in post operative swelling and drainage in the harvest limb, decrease in home care referrals, readmissions, and antibiotic use in the post hospital environment along with improved patient satisfaction. N033 EARLY ACCESS TO CARE FOR PATIENTS WITH CARDIAC SYMPTOMS R Pike1, P Grainger1, D Best2 1
Eastern Regional Health Authority, St. John’s, NL, 2 Memorial University of Newfoundlland, St. John’s, NL
Activation of the Emergency Measures System (EMS) and thus transportation to hospital by ambulance is the recommended first step in the chain of survival for patients with chest pain. In Newfoundland and Labrador, the number of patients who activate EMS for chest pain is not known. The objectives of this study are to: a) determine the mode of transportation patients with chest pain use to go to the Emergency Department (ED), b) identify factors associated with activating EMS or other transportation, and c) determine
Canadian Journal of Cardiology Volume 30 2014
the time lapse between symptom onset and ED arrival. Patients transferred by ambulance have earlier delivery of reperfusion therapy and subsequently better clinical outcomes than patients who self transport. One reason for not activating EMS may be lack of knowledge of the importance of rapid treatment. The strongest predictor in several studies reviewed for activation of EMS was the clinical signs and symptoms of hemodynamic instability such as heart failure or low blood pressure. Conversely, patients who lived closer to hospital were more likely to use self transport than those living longer distances. Data has been collected from a hospital database and through electronic chart review. Descriptive and inferential statistics will be used to examine the data and determine the extent to which cardiac patients in this province activate EMS or provide own transportation to hospital. Findings can be used to provide education to patients and families about the importance of early access to emergency services as well as direct future research in this area. N034 CAREGIVER SUPPORT FOR SELF-CARE ACTIVITIESBUILDING AN INSTRUMENT K Harkness1, H Buck2, R Wion2 1 Hamilton Health Sciences, McMaster University, Toronto, ON, 2 Penn State University, USA
Self-care for heart failure (HF) patients is essential for optimizing patient outcomes. While informal caregiver (CG) contributions to HF patients’ self-care are vital, there is currently no standardized, valid and reliable tool to measure this construct. In order to test self-care behavioral interventions, a psychometrically sound instrument measuring CG contribution to patient self-care is critical. The purpose of this study was to develop items for a disease-specific instrument that measures CG contribution to HF patient self-care. The theory of self-care of chronic illness provided the theoretical framework. Using an instrument development process guided by well-established principles, we conducted a systematic review of the HF caregiving literature followed by semi-structured interviews of CGs (n¼14) to identify the measureable activities contributing to self-care in HF patients. Data collection and analysis was iterative and recruitment continued until data saturation was achieved. Constant comparative analysis techniques were used to explore and understand CG activities. Instrument items were then derived from a thematic analysis of the narratives. The first draft of the instrument underwent a content validity assessment with 10 CGs and 4 HF clinicians. From the initial list of 36 items, 33 items were retained and represent CG contributions to selfcare maintenance, monitoring and management. Strategies to improve HF self-care need to include the vital support of CGs. Accurate measurement of CG contribution to self-care is critical for clinicians and researchers to assess the degree to which CGs are co-providers of care and improve patientcentred outcomes.
N029 SAME-DAY DISCHARGE VERSUS USUAL CARE AFTER UNCOMPLICATED PERCUTANEOUS CORONARY INTERVENTION IN ELECTIVE AND LOW-RISK ACUTE CORONARY SYNDROME PATIENTS: A PROSPECTIVE AND RANDOMIZED TRIAL S Brons1, E Matthews1, M Ferber1, S Mehta1, K Etherington1, M Mercuri2, J Gorman1, C Beck1, G Wong1, T Lai3 1 Hamilton Health Sciences, Hamilton, ON, 2 Columbia University, New York, USA, 3 Gold Coast Centre, Queensland, Australia
It is unclear if patients are more or less satisfied with same day discharge home after uncomplicated percutaneous coronary intervention (PCI). Thus, we undertook a randomized controlled, parallel group, prospective study designed trial to determine if same-day discharge results in improved overall patient satisfaction when compared to those who receive usual care (consisting of at least one overnight stay in hospital). Secondary objectives included; death, MI, stroke or recurrent ischemia (MACE), unplanned revascularization, vascular complications, and bleeding. A sample of 164 elective and low-risk ACS patients that underwent uncomplicated PCI were randomly assigned by a web-based randomization system to usual care or same-day discharge. Patients in both groups were followed by telephone interview on day 1, 7 and 30 post discharge. Secondary outcome events were recorded during the telephone interview. In addition, a patient satisfaction questionnaire was completed on Day 7. The questionnaire included satisfaction with provided health education, (smoking, diet, care of site, medication) as well as overall satisfaction with timing of discharge. Respondents in the same day discharge group reported higher satisfaction compared to those in the usual care group (mean scale score 94.8 vs. 86.4; difference of 12.4; 95%CI: 2.8 to 14, p¼0.004) 54 of the 79 respondents in the same day discharge group reported 100% satisfaction, compared to 42 of the76 respondents in the usual care group. There were no reported secondary outcomes in either group. Same day discharge should be considered an option after uncomplicated PCI in stable low-risk patients.
N030 MITRAL CLIPS: MORE THAN JUST A PROCEDURE C Cross, E MacPhee University of Ottawa Heart Institute, Ottawa, ON
Mitral Regurgitation (MR) is one of the most frequent valve conditions, both in North America and in Europe, and its prevalence is increasing owing to the aging population. MR is common in patients with heart failure and depressed left ventricular ejection fraction and is associated with an adverse prognosis. Until recently, when medical therapy has failed, surgery has been the only option for these patients. However, nonsurgical mitral valve repair is a rapidly evolving area, with new
S357
technologies being developed. Transcatheter implantations of the Mitral Clip device have recently evolved into a therapeutic alternative for patients with significant MR of both degenerative and functional origin whose surgical risk is considered high. The management and treatment of these patients has presented a unique opportunity for nursing to develop preprocedure assessment tools, patient teaching information and data collection tools. The referral, assessment, work-up and pre-procedure monitoring represents a collaborative effort ensuring that patients are cared for from referral to procedure to post procedural care. The implementation of assessment standards for the management of MR patients will have an impact on their wait time, access to services and ultimately quality of life. The data reported locally, provincially and nationally will affect program sustainability. This presentation will provide an overview of the Mitral Clip procedure, the use of the Minnesota Living with Heart Failure Questionnaire, and the development of the Mitral Clip Registry.
N031 EVALUATING THE INTEGRATION OF REMOTE MONITORING FOR CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICE FOLLOW-UP J Forman, S Flavelle, O Van Breemen, E Hahn, C McIlroy, J Carleton St. Paul’s Hospital, Vancouver, BC
Cardiovascular implantable electronic devices (CIED’s) are commonly used in the treatment of cardiac arrhythmias and management of heart failure. Indications for the use of CIED’s have expanded in the past decade leading to an increase in the number of implants. Common clinical practice for all CIED’s includes routine follow-up assessments at set time intervals. Conventional follow-up includes in-person assessment at a designated device clinic but newer CIED’s are manufactured with remote monitoring (RM) capabilities. RM is a type of telemedicine that provides a method of transmitting rhythm strips to the clinic from their own home without an in-person visit. In a 2013 position statement, the Canadian Cardiovascular Society recommended integration of RM follow-up into standard practice at all device clinics. In 2011, our centre developed and implemented care processes to incorporate RM into clinic practice. Since then, approximately 350 patients have been enrolled in our RM program. The purpose of this presentation is to share our experience in adopting RM into standard practice at our clinic. We found that using RM decreases anxiety levels with improved communication of device information and is patient-centered with access to specialized care for those living in rural communities. Integrating RM has also presented challenges such as changes to clinic work-flow, compliance and usability by patients and education required to initiate monitoring with new patients. Implications for nursing practice will be highlighted
S358
such as ongoing management of RM transmissions and clinic workload, clarifying roles and responsibilities of team members and developing effective patient education strategies.
N032 HARVEST LIMB INFECTIONS; THE SECRET SURGICAL NIGHTMARE AND HOW TO PREVENT THEM W Bowles Vancouver Coastal Health, Vancouver, BC
Cardiac Surgery is a growing reality within an aging population. One of the major contributors to postoperative morbidly is Surgical Site Infections (SSI). The costs are significant, both monetary and in loss of quality of life; it is estimated that one SSI event can cost approximately $30,000. At Vancouver General Hospital (VGH) Cardiac Surgery, our goal was to reduce our SSI rates from 8% to 2% by January 30, 2014. The multidisciplinary team designed a strategy to reduce the SSI rate using best practices. VGH has a number of established practices to reduce infection. The new processes introduced included tightened antibiotic timing and redosing, new dressing products and protocols for the surgical and harvest site. Based on the American College of Surgeons National Surgical Quality Improvement Program database (ASC NSQIP) our SSI rate for the last 7 months is 1.0%. The new dressing for harvest limb incisions has an estimated added cost of $25,000 per year. Over 6 months, a possible cost avoidance of $ 180,000 was achieved based on previous surveillance data. The front line staff is an essential part of realizing these results. This presentation focuses on the addition of new dressing protocols for the post operative harvest limb site. Patient surveillance was followed for 90 days of the post operative period. This has shown a decrease in post operative swelling and drainage in the harvest limb, decrease in home care referrals, readmissions, and antibiotic use in the post hospital environment along with improved patient satisfaction. N033 EARLY ACCESS TO CARE FOR PATIENTS WITH CARDIAC SYMPTOMS R Pike1, P Grainger1, D Best2 1
Eastern Regional Health Authority, St. John’s, NL, 2 Memorial University of Newfoundlland, St. John’s, NL
Activation of the Emergency Measures System (EMS) and thus transportation to hospital by ambulance is the recommended first step in the chain of survival for patients with chest pain. In Newfoundland and Labrador, the number of patients who activate EMS for chest pain is not known. The objectives of this study are to: a) determine the mode of transportation patients with chest pain use to go to the Emergency Department (ED), b) identify factors associated with activating EMS or other transportation, and c) determine
Canadian Journal of Cardiology Volume 30 2014
the time lapse between symptom onset and ED arrival. Patients transferred by ambulance have earlier delivery of reperfusion therapy and subsequently better clinical outcomes than patients who self transport. One reason for not activating EMS may be lack of knowledge of the importance of rapid treatment. The strongest predictor in several studies reviewed for activation of EMS was the clinical signs and symptoms of hemodynamic instability such as heart failure or low blood pressure. Conversely, patients who lived closer to hospital were more likely to use self transport than those living longer distances. Data has been collected from a hospital database and through electronic chart review. Descriptive and inferential statistics will be used to examine the data and determine the extent to which cardiac patients in this province activate EMS or provide own transportation to hospital. Findings can be used to provide education to patients and families about the importance of early access to emergency services as well as direct future research in this area. N034 CAREGIVER SUPPORT FOR SELF-CARE ACTIVITIESBUILDING AN INSTRUMENT K Harkness1, H Buck2, R Wion2 1 Hamilton Health Sciences, McMaster University, Toronto, ON, 2 Penn State University, USA
Self-care for heart failure (HF) patients is essential for optimizing patient outcomes. While informal caregiver (CG) contributions to HF patients’ self-care are vital, there is currently no standardized, valid and reliable tool to measure this construct. In order to test self-care behavioral interventions, a psychometrically sound instrument measuring CG contribution to patient self-care is critical. The purpose of this study was to develop items for a disease-specific instrument that measures CG contribution to HF patient self-care. The theory of self-care of chronic illness provided the theoretical framework. Using an instrument development process guided by well-established principles, we conducted a systematic review of the HF caregiving literature followed by semi-structured interviews of CGs (n¼14) to identify the measureable activities contributing to self-care in HF patients. Data collection and analysis was iterative and recruitment continued until data saturation was achieved. Constant comparative analysis techniques were used to explore and understand CG activities. Instrument items were then derived from a thematic analysis of the narratives. The first draft of the instrument underwent a content validity assessment with 10 CGs and 4 HF clinicians. From the initial list of 36 items, 33 items were retained and represent CG contributions to selfcare maintenance, monitoring and management. Strategies to improve HF self-care need to include the vital support of CGs. Accurate measurement of CG contribution to self-care is critical for clinicians and researchers to assess the degree to which CGs are co-providers of care and improve patientcentred outcomes.