- Email: [email protected]
N025 Post-cardiac arrest syndrome and therapeutic hypothermia
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CCCN Abstracts
Worldwide short and long term data exist which describes mortality and morbidity rates for all global participating sites. However, there is a paucity of literature describing the patient experience after this intervention. A telephone survey using scripted interview questions was conducted with twenty patients who had the PAVI between 2007 and 2010. Data gleaned from this descriptive study revealed that these octogenarians experienced significant improvement in all levels of physical, functional and mental well-being measures. More research is needed to evaluate patient experiences within this population in order to adequately understand the value and scope of this intervention.
N023 PULMONARY VEIN ISOLATION: A QUALITATIVE ANALYSIS OF PATIENT LEARNING NEEDS K Kiela, C Seabrook, M Beardsall Southlake Regional Health Centre, Newmarket, ON
Pulmonary vein isolation (PVI) is a highly specialized, minimally-invasive and increasingly accessible treatment for symptomatic Atrial Fibrillation (AF), providing significant benefits in decreasing arrhythmic burden and improving patients’ functional quality of life and wellbeing. According to the recently released Canadian Cardiovascular Society Atrial Fibrillation Guidelines (2010), there is moderate level of evidence to support recommendations for the use of catheter ablation in drug refractory AF. Research has shown increased satisfaction with treatment, minimized anxiety and optimized self-managing behaviours, when patients’ health related learning needs and concerns were acknowledged and adequately addressed by health professionals. However, studies on patient-identified learning and anticipatory needs related to the PVI procedure are lacking. This research is necessary to ensure appropriate strategies in patient preparation and support, both pre and post procedure, to ensure optimal patient outcomes within a patient-centered framework. A prospective qualitative analysis will be conducted to determine the subjective needs of patients undergoing PVI procedures at a regional tertiary care centre. A semi-structured open-ended questionnaire will be utilized by a single nurse during telephone follow up interviews one week post procedure on all PVI patients over a six month period, from March to August, 2011. The data will be analyzed for thematic commonalities. Results will guide development and integration of patient-centered pre-operative and post-operative teaching tools to best meet patient learning needs and incorporate process improvement suggestions to facilitate best practice for future PVI patients.
N024 A REGIONAL HEART FAILURE STRATEGY: ORDER SET DEVELOPMENT M Walker, C Clark, A Kaan Providence Health Care, Vancouver, BC
Cardiac Services BC has dedicated funding in an effort to im-
prove heart failure (HF) care in BC. Within Vancouver Coastal Health Authority/Providence Health Care, one goal is to implement guideline-driven care for hospitalized patients. Two HF Nurse Coordinators were hired to work with hospital teams to develop best practice tools that are guideline driven yet uniquely adapted to the culture and context of the hospital. The purpose of this paper is to describe the process of developing an order set at the pilot hospital. We anticipated that by involving care providers and customizing order sets, uptake would be increased. We began the process by engaging with leadership, evaluating current practice and identifying practice gaps. We then obtained feedback from teams which was used to develop an order set unique to this institution. Pilot testing was done using a ‘plan, do, study, act’ model. This process was not without its challenges. Several contextual factors presented themselves such as: physician groups with different needs and opinions, difficulty engaging staff owing to competing projects, and an elderly patient population. Developing an appreciation of the culture within the hospital proved to be an asset in facilitating and leading change. Guideline driven order sets close gaps between current and best practice. Acceptance may be increased by meeting the needs of the end users. Increasingly, nurses are being asked to participate in the development process, hence an awareness of process protocols, potential barriers, and having an ability to adapt to unique environments will prove an asset.
N025 POST-CARDIAC ARREST SYNDROME AND THERAPEUTIC HYPOTHERMIA S Morris New Brunswick Heart Centre, Saint John, NB
Post-cardiac arrest syndrome (formerly known as post-resuscitation disease) is a unique and complex combination of processes, which include: (1) post cardiac arrest brain injury, (2) post cardiac arrest myocardial dysfunction, and (3) systemic ischemia. This state is often complicated by a fourth component: the unresolved pathological process that caused the cardiac arrest. The 2010 ILCOR (International Liaison Committee on Resuscitation) guidelines suggest that the individual components of post– cardiac arrest syndrome are potentially treatable. The simultaneous need to perfuse the post ischemic brain adequately without putting unnecessary strain on the post ischemic heart is unique to post cardiac arrest syndrome. This presentation will provide a comprehensive overview of post-cardiac arrest syndrome and explore the scientific evidence driving the use of therapeutic hypothermia, in combination with early goal directed therapy, to improve neurological function. The implications for practice are significant, especially when registered nurses discover they play a pivotal role in patient recruitment and treatment success. When the NNT (number needed to treat) to improve neurological outcomes is 6,
S346
registered nurses have an ethical responsibility to be advocates for the use of therapeutic hypothermia.
N026 EVALUATION OF A NURSE PRACTITIONER LED CARDIOVASCULAR RISK REDUCTION CLINIC J Thomas Mazankowski Alberta Heart Institute, Edmonton, AB
Cardiovascular health promotion and risk reduction have been mainly seen as an activity that occurs in primary care by family physicians. Often resources and time limitations prevent health promotion and risk reduction practices to be implemented in acute care and hospital based outpatient clinics. However, control of modifiable cardiovascular risk factors for prevention and treatment of coronary artery disease is necessary to reduce the burden on the health care system. The Mazankowski Alberta Heart Institute in November 2009 introduced a Nurse Practitioner (NP) in the Cardiovascular Risk Reduction Clinic (CRRC) to perform a variety of clinical activities related to cardiovascular risk assessment and reduction services, including follow-up on patients for primary and secondary prevention. The role of the NP and structure of the CRRC will be described. Evaluation of the NP role since its implementation will be presented. Preliminary data suggests reduction of cardiovascular risk factors, particularly in relation to achievement of targets in blood pressure, HgA1c, and LDL as per national guidelines. Further issues experienced and recommendations will be highlighted. Nurse Practitioner led clinics can be an efficient and effective way to provide cardiovascular risk factor reduction.
N027 DEVELOPING BEST PRACTICE FOR TRANSAPICAL TAVI: IMPLEMENTATION AND EVALUATION OF STANDARDIZED GUIDELINES J Forman, S Lauck St. Paul’s Hospital, Vancouver, BC
Since the early pioneering days of performing the first successful transapical transcatheter aortic valve implantation (TA TAVI), our centre has performed over 130 procedures. Although conventional open heart aortic valve replacement remains the gold standard to date, TA TAVI has emerged as a safe and promising therapeutic option for high risk surgical patients with severe aortic stenosis. TA TAVI is a minimally invasive procedure performed through a thoracotomy incision, with catheter-based implant deployment techniques, and without the use of a cardiopulmonary bypass pump. The purpose of this presentation is to outline our experience in developing and evaluating unique practice guidelines to support the optimal recovery of patients undergoing TA TAVI. We will describe how the absence of evidence and our limited experience initially led our program to adopt the standard open
Canadian Journal of Cardiology Volume 27 2011
heart cardiac surgery orders for use in this patient population. This practice proved to be unsuitable. In better understanding the unique needs of TA TAVI patients, we led the interdisciplinary team in the development and implementation of clinical practice guidelines formatted as standardized pre-operative and post-operative prescribers’ orders. We will discuss the process and methods used to implement and evaluate these innovative clinical tools. We will report the changes and deviations to the orders sets upon implementation, and the ensuing modifications required. The procedural complexity and the multiple risk factors of TA TAVI patients necessitate a uniquely tailored process of care. Cardiovascular nurses are at the forefront of implementing best practices to provide optimal care and improve patients’ long term recovery.
N028 EVALUATION OF THE PSYCHOSOCIAL EFFECTS OF A TELEHEALTH PROGRAM FOR CAREGIVERS OF CORONARY ARTERY BYPASS GRAFT (CABG) SURGERY PATIENTS L Keeping-Burke1, M Purden2, N Frasure-Smith2, S Cossette3, F McCarthy4, R Amsel2 1
University of New Brunswick, 2 McGill University, 3 Université de Montréal, 4 Dalhousie University, Saint John, NB
Little previous work has evaluated the benefits of telehealth for family caregivers. A randomized clinical trial was conducted to determine whether a nurse-led telehealth program following CABG surgery resulted in greater decreases in anxiety (SSTAI), depression (CESD-10), uncertainty (MUIS), and conflict (IPRI), and greater perceptions of control (IPQ-r) and support (IPRI) for caregivers who received the program compared to the usual care group. The majority of the caregivers were female spouses (85.6%). CABG surgery patients and their caregivers (n⫽182) were randomly assigned to one week of daily home audio-video nursing visits post-discharge or routine discharge preparation in hospital. Caregivers completed telephone interviews pre-surgery and 3 weeks post-discharge. Results of the analyses of covariance revealed a greater change in anxiety for caregivers of male patients in telehealth compared to caregivers of male patients in usual care (p⫽.0003). Caregivers of male patients in telehealth also experienced greater decreases in uncertainty (p⫽.002). Greater reductions in depression symptoms (p⫽.03) and perceived conflict (p⫽.04) were apparent for all caregivers in telehealth versus usual care, regardless of sex of the caregiver. This randomized control study is one of few to assess the benefits of telehealth programs for family caregivers. The results can help guide recruitment of caregivers into telehealth with knowledge that both male and female CABG surgery caregivers benefit from the program, though in different ways. Future research that examines caregiver outcomes should include sufficient numbers of participants of both sexes to achieve adequate power to detect clinically meaningful results for men and women.
CCCN Abstracts
Worldwide short and long term data exist which describes mortality and morbidity rates for all global participating sites. However, there is a paucity of literature describing the patient experience after this intervention. A telephone survey using scripted interview questions was conducted with twenty patients who had the PAVI between 2007 and 2010. Data gleaned from this descriptive study revealed that these octogenarians experienced significant improvement in all levels of physical, functional and mental well-being measures. More research is needed to evaluate patient experiences within this population in order to adequately understand the value and scope of this intervention.
N023 PULMONARY VEIN ISOLATION: A QUALITATIVE ANALYSIS OF PATIENT LEARNING NEEDS K Kiela, C Seabrook, M Beardsall Southlake Regional Health Centre, Newmarket, ON
Pulmonary vein isolation (PVI) is a highly specialized, minimally-invasive and increasingly accessible treatment for symptomatic Atrial Fibrillation (AF), providing significant benefits in decreasing arrhythmic burden and improving patients’ functional quality of life and wellbeing. According to the recently released Canadian Cardiovascular Society Atrial Fibrillation Guidelines (2010), there is moderate level of evidence to support recommendations for the use of catheter ablation in drug refractory AF. Research has shown increased satisfaction with treatment, minimized anxiety and optimized self-managing behaviours, when patients’ health related learning needs and concerns were acknowledged and adequately addressed by health professionals. However, studies on patient-identified learning and anticipatory needs related to the PVI procedure are lacking. This research is necessary to ensure appropriate strategies in patient preparation and support, both pre and post procedure, to ensure optimal patient outcomes within a patient-centered framework. A prospective qualitative analysis will be conducted to determine the subjective needs of patients undergoing PVI procedures at a regional tertiary care centre. A semi-structured open-ended questionnaire will be utilized by a single nurse during telephone follow up interviews one week post procedure on all PVI patients over a six month period, from March to August, 2011. The data will be analyzed for thematic commonalities. Results will guide development and integration of patient-centered pre-operative and post-operative teaching tools to best meet patient learning needs and incorporate process improvement suggestions to facilitate best practice for future PVI patients.
N024 A REGIONAL HEART FAILURE STRATEGY: ORDER SET DEVELOPMENT M Walker, C Clark, A Kaan Providence Health Care, Vancouver, BC
Cardiac Services BC has dedicated funding in an effort to im-
prove heart failure (HF) care in BC. Within Vancouver Coastal Health Authority/Providence Health Care, one goal is to implement guideline-driven care for hospitalized patients. Two HF Nurse Coordinators were hired to work with hospital teams to develop best practice tools that are guideline driven yet uniquely adapted to the culture and context of the hospital. The purpose of this paper is to describe the process of developing an order set at the pilot hospital. We anticipated that by involving care providers and customizing order sets, uptake would be increased. We began the process by engaging with leadership, evaluating current practice and identifying practice gaps. We then obtained feedback from teams which was used to develop an order set unique to this institution. Pilot testing was done using a ‘plan, do, study, act’ model. This process was not without its challenges. Several contextual factors presented themselves such as: physician groups with different needs and opinions, difficulty engaging staff owing to competing projects, and an elderly patient population. Developing an appreciation of the culture within the hospital proved to be an asset in facilitating and leading change. Guideline driven order sets close gaps between current and best practice. Acceptance may be increased by meeting the needs of the end users. Increasingly, nurses are being asked to participate in the development process, hence an awareness of process protocols, potential barriers, and having an ability to adapt to unique environments will prove an asset.
N025 POST-CARDIAC ARREST SYNDROME AND THERAPEUTIC HYPOTHERMIA S Morris New Brunswick Heart Centre, Saint John, NB
Post-cardiac arrest syndrome (formerly known as post-resuscitation disease) is a unique and complex combination of processes, which include: (1) post cardiac arrest brain injury, (2) post cardiac arrest myocardial dysfunction, and (3) systemic ischemia. This state is often complicated by a fourth component: the unresolved pathological process that caused the cardiac arrest. The 2010 ILCOR (International Liaison Committee on Resuscitation) guidelines suggest that the individual components of post– cardiac arrest syndrome are potentially treatable. The simultaneous need to perfuse the post ischemic brain adequately without putting unnecessary strain on the post ischemic heart is unique to post cardiac arrest syndrome. This presentation will provide a comprehensive overview of post-cardiac arrest syndrome and explore the scientific evidence driving the use of therapeutic hypothermia, in combination with early goal directed therapy, to improve neurological function. The implications for practice are significant, especially when registered nurses discover they play a pivotal role in patient recruitment and treatment success. When the NNT (number needed to treat) to improve neurological outcomes is 6,
S346
registered nurses have an ethical responsibility to be advocates for the use of therapeutic hypothermia.
N026 EVALUATION OF A NURSE PRACTITIONER LED CARDIOVASCULAR RISK REDUCTION CLINIC J Thomas Mazankowski Alberta Heart Institute, Edmonton, AB
Cardiovascular health promotion and risk reduction have been mainly seen as an activity that occurs in primary care by family physicians. Often resources and time limitations prevent health promotion and risk reduction practices to be implemented in acute care and hospital based outpatient clinics. However, control of modifiable cardiovascular risk factors for prevention and treatment of coronary artery disease is necessary to reduce the burden on the health care system. The Mazankowski Alberta Heart Institute in November 2009 introduced a Nurse Practitioner (NP) in the Cardiovascular Risk Reduction Clinic (CRRC) to perform a variety of clinical activities related to cardiovascular risk assessment and reduction services, including follow-up on patients for primary and secondary prevention. The role of the NP and structure of the CRRC will be described. Evaluation of the NP role since its implementation will be presented. Preliminary data suggests reduction of cardiovascular risk factors, particularly in relation to achievement of targets in blood pressure, HgA1c, and LDL as per national guidelines. Further issues experienced and recommendations will be highlighted. Nurse Practitioner led clinics can be an efficient and effective way to provide cardiovascular risk factor reduction.
N027 DEVELOPING BEST PRACTICE FOR TRANSAPICAL TAVI: IMPLEMENTATION AND EVALUATION OF STANDARDIZED GUIDELINES J Forman, S Lauck St. Paul’s Hospital, Vancouver, BC
Since the early pioneering days of performing the first successful transapical transcatheter aortic valve implantation (TA TAVI), our centre has performed over 130 procedures. Although conventional open heart aortic valve replacement remains the gold standard to date, TA TAVI has emerged as a safe and promising therapeutic option for high risk surgical patients with severe aortic stenosis. TA TAVI is a minimally invasive procedure performed through a thoracotomy incision, with catheter-based implant deployment techniques, and without the use of a cardiopulmonary bypass pump. The purpose of this presentation is to outline our experience in developing and evaluating unique practice guidelines to support the optimal recovery of patients undergoing TA TAVI. We will describe how the absence of evidence and our limited experience initially led our program to adopt the standard open
Canadian Journal of Cardiology Volume 27 2011
heart cardiac surgery orders for use in this patient population. This practice proved to be unsuitable. In better understanding the unique needs of TA TAVI patients, we led the interdisciplinary team in the development and implementation of clinical practice guidelines formatted as standardized pre-operative and post-operative prescribers’ orders. We will discuss the process and methods used to implement and evaluate these innovative clinical tools. We will report the changes and deviations to the orders sets upon implementation, and the ensuing modifications required. The procedural complexity and the multiple risk factors of TA TAVI patients necessitate a uniquely tailored process of care. Cardiovascular nurses are at the forefront of implementing best practices to provide optimal care and improve patients’ long term recovery.
N028 EVALUATION OF THE PSYCHOSOCIAL EFFECTS OF A TELEHEALTH PROGRAM FOR CAREGIVERS OF CORONARY ARTERY BYPASS GRAFT (CABG) SURGERY PATIENTS L Keeping-Burke1, M Purden2, N Frasure-Smith2, S Cossette3, F McCarthy4, R Amsel2 1
University of New Brunswick, 2 McGill University, 3 Université de Montréal, 4 Dalhousie University, Saint John, NB
Little previous work has evaluated the benefits of telehealth for family caregivers. A randomized clinical trial was conducted to determine whether a nurse-led telehealth program following CABG surgery resulted in greater decreases in anxiety (SSTAI), depression (CESD-10), uncertainty (MUIS), and conflict (IPRI), and greater perceptions of control (IPQ-r) and support (IPRI) for caregivers who received the program compared to the usual care group. The majority of the caregivers were female spouses (85.6%). CABG surgery patients and their caregivers (n⫽182) were randomly assigned to one week of daily home audio-video nursing visits post-discharge or routine discharge preparation in hospital. Caregivers completed telephone interviews pre-surgery and 3 weeks post-discharge. Results of the analyses of covariance revealed a greater change in anxiety for caregivers of male patients in telehealth compared to caregivers of male patients in usual care (p⫽.0003). Caregivers of male patients in telehealth also experienced greater decreases in uncertainty (p⫽.002). Greater reductions in depression symptoms (p⫽.03) and perceived conflict (p⫽.04) were apparent for all caregivers in telehealth versus usual care, regardless of sex of the caregiver. This randomized control study is one of few to assess the benefits of telehealth programs for family caregivers. The results can help guide recruitment of caregivers into telehealth with knowledge that both male and female CABG surgery caregivers benefit from the program, though in different ways. Future research that examines caregiver outcomes should include sufficient numbers of participants of both sexes to achieve adequate power to detect clinically meaningful results for men and women.