- Email: [email protected]
Psychiatrists on the coronary care unit
Steven L. Dubovsky, M.D. Carl J. Getto, M.D. Susan Adams Gross, R.N. Judy A. Paley, M.D.
!.!!lPact on nursing care and mortality:
Psychiatrists on the coronary care unit Since 1962, coronary care units have been increasingly utilized in the general hospital! -3 As these units have come under increasing scrutiny, data have accumulated that suggest death from cardiac disease is influenced by psychological factors, and that control of these factors may influence survival. The purpose of this article is to review this evidence, add to it some of our own observations on a coronary care unit, and suggest directions for future research.
Psychophysiologic aspects Intense emotion has been commonly held to be associated with cardiac arrest even in healthy individuals"'~ and a number of case reports docu-
menting the association of ventricular tachycardia or fibrillation with psychosocial stress have appeared in the course of the last 20 years. Harvey and Levine6 showed that psychological stress in a patient without apparent heart disease precipitated brief paroxysms of ventricular tachycardia. Rahe and Christ7 suggested that paroxysmal ventricular tachycardia in an 11year-old boy was associated with emotional stress and was improved by psychotherapy. A recent intensive investigation of a 39-year-old man with recurrent ventricular fibrillation demonstrated convincingly that psychosocial stress was causally related to the arrhythmia. While
From the psychosomatic research group. department of psychiatry. University of Colorado Medical Center.
III
psychiatric interviews preCIpItated bouts of ventricular tachycardia, transcendental meditation helped to improve the arrhythmia, and the importance of non-drug measures in the treatment of cardiac disease received new emphasis. 8 . 9 Beginning with Richter lO and Cannon's· work. animal and experimental studies have sought to further elucidate the mechanism by which emotions may produce potentially lethal cardiac electrical activity. Lown, Verrier. and Corbaban " demonstrated that a psychologically stressful environment produced electrical instability and a rapid heart rate in the hearts of healthy dogs. A year later the same authors demonstrated that a psychologically aversive situation precipitated a variety of ventricular arrhythmias in dogs two to three days after myocar-
AUGUST 1977
Psychiatrists on the coronary care unit
dial infarction. 12 Hypothalamic overactivity, excess sympathetic and parasympathetic activity;l 13 instability of neuroregulatory systems,l4·U and excess catecholamine secretion \6 have all been said to underlie the development of potentially lethal arrhythmias in patients under emotional stress.
Coronary care patient The relationship between emotional experience, arrhythmia, and sudden death in patients with vulnerable cardiovascular systems is available for careful study in the coronary care unit (CCU). Among the spectrum of emotional reactions to myocardial infarction observed on the CCU, particular attention has been given to the value of denial of dysphoric affects as an emergency psychological measure. 17 - 19 The CCU environment itself has been found to be stressful, 16.20-23 and differences in the physical plant of the CCU may affect patients' emotional status. 24.25 Emotional reactions have, moreover, been shown to affect the patient's physiologic status. 26 Bruhn and associates U demonstrated that witnessing the death of another patient was correlated with increased systolic blood pressure in the postinfarction period. Transfer from the CCU to the medical ward without adequate emotional preparation has been correlated
PSYCHOSOMATICS
with increased catecholamine secretion and with rhythm disturbances. 27 CCU nurse The CCU is unique in its emphasis on the importance of the staff nurse. Use of her initiative and clinical expertise is encouraged 28 and her relationship with patients is more intense than on general medical floors. 27 When a nurse followed CCU patients after discharge to the medical floor. the incidence of elevated catecholamine excretion accompanying transfer was reduced. 27 Recent interest has therefore been focused on the stresses on the CCU nurse. 29 The psychological impact of the patient's illness and its treatment, overwhelming work load, excess responsibility, and poor communication between nurses and physicians30 often result in depression and anxiety for the nurse,31 which may make it difficult for her to function at maximal efficiency.
Psychiatrist The psychiatrist. too. has had the opportunity to play an increasingly important role on the CCU in several capacities. Work with individual patients can reduce the psychiatric complications of hospitalization 20 and possibly the cardiovascular complications of psychological distress. 26 The psychiatric consultant can also correlate psy-
chological, physiologic, and statistical data on psychological status and outcome. Regular consultation with CCU physicians can increase their effectiveness in managing patients' reactions to their hospital experience. 32 -35 The psychiatrist also has an opportunity to consult with the nursing staff and to observe the results of his interventions on ward milieu. In addition to increasing the nurses' expertise in the recognition and treatment of psychological distress. pressures on nursing staff might be reduced by increasing the opportunities for support and learning from the psychiatrist and from other nurses. 32 .34 Cassem and Hackett have proposed that regular meetings of nurses with a psychiatrist for these purposes might result in "reduction of tension in the primary caretaking personnel" which would be "indispensable to the smooth function of the coronary care unit. "36 Research to date therefore suggests that the CCU milieu, especially as influenced by the nursing staff, may affect patient outcome directly by recognition of dangerous situations by the nurse and indirectly by decreasing adverse physiologic changes associated with the emotional experience of the ward. While the time is therefore ripe for further studies of the outcome of changes in ward milieu on staff and nurses. few such studies have been reported. We recently had the opportunity to investigate some of the effects of the regular psychiatric consultation with a group of CCU nurses who had never before met with a psychiatrist. After attending a sym-
21
Psychiatrists on the coronary care unit
posium on the psychological aspects of intensive care nursing, the nursing staff of a CCU ("experimental unit") asked one of us (e.G.) to meet regularly with them to discuss the psychiatric aspects of patient care. At the time the psychiatric consultant began meeting regularly with experimental unit nurses, he was at the end of his first year of residency. He discussed each nursing group meeting with a faculty member (S.D.) who had led nursing groups on other acute care wards for some time. A senior resident who rotated yearly was available to the medical house staff for psychiatric consultation. In order to begin to determine the effect of the consultation, we also looked at a similar unit in a comparable hospital that had a staff psychiatrist available for psychiatric consultation to the medical staff only. This was designated the "control unit." During the time the psychiatrist served as a consultant to the experimental unit, the following data were collected. Questionnaire data Beginning four months after the group meetings started, questionnaires were distributed every three months on both the experimental and control units by a nurse (S.A.G.) who was not otherwise associated with either unit. In addition to demographic data, nurses were asked
22
to keep a log of the amount of time spent each day in routine ward activities such as "direct patient care" (e.g., giving medications); "medical skills" (e.g., starting IVs, reading monitors); working with physicians; charting: and time spent with patients while not engaged in other nursing activities. Nurses were also asked to rate their enjoyment or dislike and comfort or discomfort with these activities and with the various types of patients encountered. Nurses were interviewed at random in an attempt to determine whether the same information could be obtained by interview. Questions about time spent at varying tasks were especially scrutinized. Because of the length of the questionnaire, nurses were paid for its return. Monthly review One of us (J.P.) carried out a monthly review of both the chart and nursing care plan log ("Kardex") for each patient on the experimental and control units. The nursing care plan log was scored for the presence of a nursing care plan for newly admitted patients, a revised nursing care plan for patients on the ward more than 24 hours, and mention of progress toward meeting nursing care objectives. Charts were scored for the presence of nursing notes for each shift, and for a correlation between the objectives in the nurs-
ing care plan and interventions actually noted in the chart. A net efficiency score for each unit was then constructed, a score of 1.0 being assigned if all items were present for all patients. After 18 months, data reflecting patient mortality and length of stay were also collected from each unit being studied. Results-nurses' group The psychiatrist made it clear that group discussion would be limited to issues related to improving delivery of patient care, medical and psychological. Discussion of personal problems and interpersonal difficulties that did not specifically relate to patient care was discouraged. Individual patients were discussed whenever possible. The importance of confidentiality was strongly underscored. The character of the nursing group seemed to reflect the character of the ward: acute problems were solved in a crisisoriented way as they arose, the nurses cancelling a meeting or two and taking a "breather" when the ward was quiet. Group discussion usually centered around specific patient problems. Other topics discussed included administrative problems, staffing problems, complaints about the inexperience of new house staff, and topics such as depression, death and dying, organic brain syndrome, and alcohol abuse. At times, the psychiatrist began with a didactic presentation, which was then discussed and applied to specific patients. A great deal of discussion centered around a patient who needed to stay on the ward for several months. Initially, management of the patient's regression was a
AUGUST 1977
Table 1
Amount of time spent In, end Importenc end enjoyment of, two nur Ing ectlvltl (questlonnelr dete) Change In mean Change In mean Change in mean Importance enjoyment Initial mean dally time spent dally time (hrs) In activity- (hrs) scoret seoret
Activity
Unit
Direct patient care
Experimental Control
6.0 5.8
+1.32 -0.48
+0.88 -0.21
1.25 -0.59
Medical skills
Experimental Control
1.8 1.9
+0.47 -1.38
+0.67 -1.05
+1.08 -1.26
- A + seore indicates an increase; - a decrease. t Importance and enjoyment were rated from 1 to 10.
central issue. Later. nurses' reactions to this patient. who could not be discharged within several days. began to interfere with their ability to effectively care for the patient. Open discussion of these reactions led to greater comfort with the patient. The patient's anxiety. which had increased prior to the group discussion. decreased as the nursing staff looked after her more assiduously. When there was an occasional expression of interest in discussing personal problems. the psychiatrist stated that while he would not deal with these matters in the group. he would arrange for this to be done elsewhere. His offer was never accepted.
Questionnaire results As the group meetings progressed. an increasing amount of time appeared to be spent in two of the nursing activities studied by questionnaire. After 18 months. experimental unit nurses stated that they
PSYCHOSOMATICS
spent about 80 minutes more each day in direct patient care. and about 30 minutes more practicing medical skills (more than one activity was carried out at the same time-for ex-
ample. medical skills and talking to patients). Less time was spent away from the unit. This was accompanied by slight increases in the nurses' estimates of how important and enjoyable
Table 2
Chertlng efficiency during 15 months on experlmentel vs. control units: noted In chert for eech hilt Month Net efficiency seoret number- (experimental-control)
J
1 2 4 7 8
-0.10 -0.17 -0.08 +0.40J -0.05]
9
+0.25 +0.40] +0.10
10 12 13 14 15
+0.47 +0.40 +0.30
Number of "runs"
p
4
<0.05
r. rz r. rt
• During months 3, 5, 6, and 11, efficiency on the experimental ward was equal to that on the control ward. net efficiency score was 0, and the scores were excluded. tA score Indicates a greater efficiency on the control unit.
23
these activities were. While experimental unit nurses were spending more time with their patients. control unit nurses spent less time with their patients and considered the same two activities slightly less enjoyable and less important (Table I). There was a non-significant increase in comfort (rated I to 10) working with patients in all diagnostic categories on the experimental unit, in contrast with a non-significant decrease in comfort on the control unit.
Chart review Efficiency of charting was expressed as a fraction, with 1.0 representing maximum efficiency for the category measured at the time of review (e.g., 1.0 = all patients on unit have notes in chart for all shifts). As the nurses' group discussions progressed. the experimental unit was increasingly more likely than the control unit to have a nursing note in each patient's chart for each shift (Table 2), and these notes were increasingly more likely to correspond to actual nursing care objectives stated in the nursing care plan (Table 3). Application of the Wald-Wolfowitz runs test· to this data indicates that the trend toward increased charting efficiency is significant at the 0.05 level. and application of the Wald-Wolfowitz test to the experimental unit data alone shows the same significant trend. Because of record keeping ·This h:st examines series of events or measures. Similar measures (e.g .. all "+") that occur in a sequence are called "runs." A small numher of 'runs compared with the IOtal number of measures indicate that they do not occur in random fashion"
24
problems. mortality statistics were available for only six months prior to the beginning of the nurses' group. During
this time, the mean mortality was 9.8% on the experimental unit and 6.2% on the control unit. The difference between
Table 3
Charting efficiency during 15 months: nursing care plan objectives noted In chart Month number1
3 4 5 6 7 8 9
10 12 13 14 15
Net efficiency score
=g:~~]
-0.27 -0.33 +0.20 0.30 +0.17 +0.11 +0.15 +0.16 +0.43. +0.10 +0.37
Number of "runs"
p
2
<0.05
rl
r2
- Net efficiency score was 0 during months 2 and 11, and the scores were excluded.
Table 4
Monthly mortality rate on experimental unit, compared with the median Month number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Mortality rate value
+ + + + +
Number of "runs"
P
4
<0.05
rl
+
=]
r2
~]
r.
+J
r,
AUGUST 1977
these rates (3.6%) is statistically significant (X 2 = 4.11; p < 0.05 ). For the 15 months after the group began. the mean mortality on the experimental unit was 6.62%. compared with 6.3% on the control unit (X2 = 0.2539; P = ns). The experimental unit mortality rate decreased by 3.18% (X 2 = 2.084; P < 0.05), while the control unit mortality rate did not change appreciably over the same 15 months (X 2 = 0.137; P = ns). When the mortality rate for each month is assigned a + or value, according to whether it is above or below the median mortality rate (7%), and the number of "runs" of + or - examined by the Wald-Wolfowitz test, the gradual decrease in mortality on the experimental unit is seen to have occurred in a non-random fashion (Table 4). To examine the possibility that the decline in mortality rate on the experimental unit was caused by changes in populations with particular disease entities or their treatment, monthly mortality rates for each of these entities were examined. There was no obvious drop in mortality rate in any category other than acute cardiac disease and this was confirmed by chisquare test. In addition, there was no significant change in total number of patients in any diagnostic category (including cardiac) or in admission policy on either unit. No obvious new major treatment modalities were introduced, and total number of nursing and ancillary personnel (LPNs, aides). as well as average number of months of experience of R Ns on each ward, did not change appreciably when compared on a month-for-month basis. Mor-
PSYCHOSOMATICS
tality did not change appreciably on other wards in the same hospital as the experimental unit. There were no significant decreases in numbers of patients with high-risk lengths of stay (one day or less. five or more days). While mean length of stay decreased non-significantly on the experimental unit from 3.52 to 2.28 days per patient, there was no trend toward changes in number of patients with shorter or longer lengths of stay. There was no discernible change in patient population. and a chart review of selected experimental unit patients indicated that patients were not discharged earlier from the experimental unit only to die elsewhere or to be re-admitted. Discussion One obvious explanation for the initial higher mortality rate on the experimental unit is that it had a population of sicker patients who were at higher risk of death and who stayed longer on the CCU. For example. patients admitted for cardiac catheterization are routinely hospitalized on general medical floors of the experimental hospital, and on the CCU of the control hospital. Rather than considering the initial mortality rate on the experimental unit unusually high, one might consider the control unit mortality rate a difficult-to-attain ideal. Within a year after institution of regular psychiatric consultation to the nursing stafT, t he mortality rate on the experimental unit decreased in a non-random way until it was indistinguishable from the already low mortality rate obtained on the control unit. There are several possible
explanations for this observation. One is that the mortality rate increased in the months prior to the onset of the group and then returned to baseline for reasons unrelated to the intervention. Mortality and length of stay should of course have been measured for a longer period of time before the group began. but these data are available only for the six months before it started. Also, in evaluating any study in which mortality is a possible outcome variable. it is important to remember that mortality rates on CCUs may fluctuate markedly in the absence of any known change in patient population.! However. the mortality rate on the experimental unit was high for at least six months. the decrease in mortality was non-random. and once it dropped. it never again reached the initial mortality rate. The increasing efficiency of charting suggests that nurses were at least charting and writing patient care plans more efficiently. Bearing in mind the obvious limitations of a self-report, the questionnaire data at least suggest that increased time was spent with patients in activities related to their survival. Open discussion and resolution of interpersonal difficulties as they related to patient care. and the direct solution of problems with medical staff. were encouraged as a group norm. 38 Tensions that might have interfered with rapid recognition of cardiac emergencies were therefore reduced. A more complete intellectual knowledge of the range of emotional reactions of patients to their illness may have allowed nurses to support
25
appropriate reactions to the CCU experience and to expend less effort devising effective psychological care plans, allowing them to attend more carefully to the medical aspects of patient care. Thus, a knowledge of the proper management of organic brain syndrome could allow nurses to have short frequent talks with delirious patients and spend more time with other patients requiring medical attention. The intellectual mastery of such issues would also be expected to add to the confidence with which nurses approached their patients. Nurses appeared to become more sensitive to emotional situations that have the potential to trigger fatal arrhythmias in their patients. Confident that their approach to these situations would be useful to the patients, the nurses could deal with the emotions before arrhythmias developed. Less hampered by their own concerns about ward life. the nurses could attend more carefully to their patients. Finally, a calmer, smoother-running CCU in which open communication is fostered may have a dampening effect on potentially dangerous emotions in all its patients. Of course. numerous alternative explanations can be found for the apparent increased efficiency of charting, increased comfort with a variety of patients. increased time spent with patients, and lowered patient mortality associated with the institution of regular consultation to staff nurses. However, insofar as these findings are in keeping with the suggestions raised in the literature that nonmedical changes affecting nurses may affect patient outcome, the
26
findings underscore the need to carefully study the impact of any change in ward milieu. More studies need to be done to document that changes in milieu that can predictably be influenced by the psychiatrist produce favorable changes in patient outcome. Such studies should document the ways in which a psychiatrist influences the ward. and the ways in which these changes affect patients. Indepth studies of small groups of patients, with appropriate physiologic studies, as well as outcome studies of large groups of patients correlated with the institution of new interventions, # should be designed. Supported in part by a grant from the research assistance fund. University of Colorado Medical Center, and NIH general research support RR 05357. Reprint requests to Container C 260, University of Colorado Medical Center, 4200 East Ninth Avenue, Denver. CO 80262 (Dr. Dubovsky).
REFERENCES
I. Lown B. Selyer A: The coronary care unit. Am J CardioI22:597-602, 1968. 2. Oliver MF. Julian DG, Donald K W: Problems in evaluating coronary care units. Alii J Cardiol 20:465-474. 1967. 3. Schaffer W A, Cobb LA: Recurrent ventricular fibrillation and modes of death in survivors of out of hospital fibrillation. N Engl J Med 293:259-262, 1975. 4. Cannon WB: Voodoo death. PsyChO.WlIII Med 19:182.1957. 5. Engel GL: Sudden and rapid death during psychological stress: Folklore or folk wisdom? Ann Intern Med 74:771-782. 1973. 6. Harvey WP, Levine SA: Paroxysmal ventricular tachycardia due to emotion. JA M A 150:479-480. 1952.
7. Rahe RH. Christ AE: An unusual cardiac (ventricular) arrhythmia in a child: Psychiatric and psychophysiologic aspects. Psychosom Med 28: 181-188. 1966. 8. Lown B. Reich P: Ventricular fibrillation and psychologic stress. IV EnglJ Med 294: 1347-1348. 1976. 9. Lown B, Temte JV. Reich P. et al: Basis for recurring ventricular fibrillation in the absence of coronary heart disease and its management. N Engl J Med 294:623-629. 1976. 10. Richter CP: On the phenomenon of sudden death in animals. Psycho-'0111 Med 19:191. 1957. II. Lown B. Verrier R. Corbaban R: Psychological stress and threshold for repetitive ventricular response. Scil'llce 182:834-836, 1973. 12. Corbaban R. Verrier R, Lown B: Psychological stress and ventricular arrhythmias during myocardial infarction in the conscious dog. Alii J Cardiol34:692-696. 1974. 13. Lown B. Verrier R: Neural activity and ventricular fibrillation. N Engl J Med294:1165-1170. 1976. 14. Engel GL: Psychologic factors in instantaneous cardiac death (I). N Engl J Med 294:664-665. 1976. 15. Engel GL: Psychologic factors in instantaneous cardiac death (2). N t:llgl J Med 294:1165-1170. 1976. 16. Taggart P. Parkman P. Carruthers M: Cardiac responses to thermal. physical. and emotional stress. 8r Med J 3:71-76. 1972. 17. Brown IW. Hackett TP: Emotional reactions to the threat of impending death: A study of patients on monitor cardiac pacemakers. Irish J Med Sci 6:177-187. 1967. 18. Druss RG, Kornfeld DS: The survivors of cardiac arrest. JAM A 210:295-296, 1967. 19. Hackett TP, Cassem N H: The psychology of intensive care problems and their management. Presented at a symposium on intensive care units at St. Vincent's Hospital and Medical Center. New York. May 10-14, 1971. 20. Abram HS: Psychological aspects of the intensive care unit. Ho-,pital Medicine S( 12):94-95. 1969. 21. Cleveland Sl, Johnson DL: Personality patterns in young males with coronary disease. PSl'chO-'OIll Med 24:600-610. 1962.
22. Hackett TP. Cassem N H. Wishnie
AUGUST 1977
HA: The coronary care unit. S
t:1I~1
.I Med279:1J65-1J70. 196K.
23. Kornfeld DS: Psychiatric problems of an intensive care unit. Med ('!ill .\ ..I Iller SS:IJ5J-1J6J. 1971. 2-1. Bruhn JG. Thurman A E. Chandler Be. et al: Patients' reactions to death in a coronary care unit. J 1'.'.1'd/tl.wlII Res 14:65-70. 1970. 25. Leigh H. Hofer MA. Cooper J. et al: !\ psychological comparison of patients in "open" and "dosed" coronary care units. J P.ITCho.WIII ReI 16:-149-457. 1972. 26. Kornfeld DS: The hospital environment: Its impact on the patient. in .-ldl'all<"<'.I· ill I'srcho.wlIIlIIic '''It'di<'ille Vol K. Lipowski ZJ (ed): Psydww<'ial "'-'I','CI.I l'''.ni<'
or
PSYC 1I0S0MA TICS
Looking Ahead • In Psychosomatics E cerpt from upcoming article The e , .. phantom urinar phen mena related to of urinary function ... occur not in re p n e to a traumatic phy ical 10 of an organ, but rather in re pon e t the dramatic 10 of a vital. but ph iologicall replaceable, functi n.
10
-Phantom urinary phenomena in hemodialy i paTient , by Franci J. Kane, Jr., M.D. and Lee ime, M.D.
Our tud did not find patient with thi di ea e to be homogeneou .... However, there doe eern to be a chronic di ea e per onalit . The ubje t we e amined were imilar to other group of di abled patient. -The rheumaToid arlhriTic per onality: a PS) chodiagno tic mYTh, by Philip pergel, Ed. D., Geor e E. Ehrlich, M.D., and DoroThea D. Glas , M.D.
Once a pecific e ual dy function ha been identified. the mo t u eful wa to con eptualize the problem i to identif what a pect of e ualit i being u edthe reproductive, the interper onal, or the auti ticand what tage of the life Ie the patient i now at. Thi method provide a u eful h rthand to begin to under tand a ver difficult and omple problem. - exualilJ' ThroughouT The life c ·cle. by Thoma Wise, M.D.
The "cia ic even" p ycho omati di order have been e panded to include all illne e mpha i ha hifted from exploration of cau e to re pon e and prevention by reducing life tre . Better under tanding fh the brain integrate bi I gic and p ch logical proce e will certain) dimini h the gap between p ycho ornatic and other di order. -P ycho omaTics and p ycholog)', bl' Frank Engel mann, Ph.D.
The e and man other intere ting arti Ie are c ming up in future i ue. f P v ho omali .
27
!.!!lPact on nursing care and mortality:
Psychiatrists on the coronary care unit Since 1962, coronary care units have been increasingly utilized in the general hospital! -3 As these units have come under increasing scrutiny, data have accumulated that suggest death from cardiac disease is influenced by psychological factors, and that control of these factors may influence survival. The purpose of this article is to review this evidence, add to it some of our own observations on a coronary care unit, and suggest directions for future research.
Psychophysiologic aspects Intense emotion has been commonly held to be associated with cardiac arrest even in healthy individuals"'~ and a number of case reports docu-
menting the association of ventricular tachycardia or fibrillation with psychosocial stress have appeared in the course of the last 20 years. Harvey and Levine6 showed that psychological stress in a patient without apparent heart disease precipitated brief paroxysms of ventricular tachycardia. Rahe and Christ7 suggested that paroxysmal ventricular tachycardia in an 11year-old boy was associated with emotional stress and was improved by psychotherapy. A recent intensive investigation of a 39-year-old man with recurrent ventricular fibrillation demonstrated convincingly that psychosocial stress was causally related to the arrhythmia. While
From the psychosomatic research group. department of psychiatry. University of Colorado Medical Center.
III
psychiatric interviews preCIpItated bouts of ventricular tachycardia, transcendental meditation helped to improve the arrhythmia, and the importance of non-drug measures in the treatment of cardiac disease received new emphasis. 8 . 9 Beginning with Richter lO and Cannon's· work. animal and experimental studies have sought to further elucidate the mechanism by which emotions may produce potentially lethal cardiac electrical activity. Lown, Verrier. and Corbaban " demonstrated that a psychologically stressful environment produced electrical instability and a rapid heart rate in the hearts of healthy dogs. A year later the same authors demonstrated that a psychologically aversive situation precipitated a variety of ventricular arrhythmias in dogs two to three days after myocar-
AUGUST 1977
Psychiatrists on the coronary care unit
dial infarction. 12 Hypothalamic overactivity, excess sympathetic and parasympathetic activity;l 13 instability of neuroregulatory systems,l4·U and excess catecholamine secretion \6 have all been said to underlie the development of potentially lethal arrhythmias in patients under emotional stress.
Coronary care patient The relationship between emotional experience, arrhythmia, and sudden death in patients with vulnerable cardiovascular systems is available for careful study in the coronary care unit (CCU). Among the spectrum of emotional reactions to myocardial infarction observed on the CCU, particular attention has been given to the value of denial of dysphoric affects as an emergency psychological measure. 17 - 19 The CCU environment itself has been found to be stressful, 16.20-23 and differences in the physical plant of the CCU may affect patients' emotional status. 24.25 Emotional reactions have, moreover, been shown to affect the patient's physiologic status. 26 Bruhn and associates U demonstrated that witnessing the death of another patient was correlated with increased systolic blood pressure in the postinfarction period. Transfer from the CCU to the medical ward without adequate emotional preparation has been correlated
PSYCHOSOMATICS
with increased catecholamine secretion and with rhythm disturbances. 27 CCU nurse The CCU is unique in its emphasis on the importance of the staff nurse. Use of her initiative and clinical expertise is encouraged 28 and her relationship with patients is more intense than on general medical floors. 27 When a nurse followed CCU patients after discharge to the medical floor. the incidence of elevated catecholamine excretion accompanying transfer was reduced. 27 Recent interest has therefore been focused on the stresses on the CCU nurse. 29 The psychological impact of the patient's illness and its treatment, overwhelming work load, excess responsibility, and poor communication between nurses and physicians30 often result in depression and anxiety for the nurse,31 which may make it difficult for her to function at maximal efficiency.
Psychiatrist The psychiatrist. too. has had the opportunity to play an increasingly important role on the CCU in several capacities. Work with individual patients can reduce the psychiatric complications of hospitalization 20 and possibly the cardiovascular complications of psychological distress. 26 The psychiatric consultant can also correlate psy-
chological, physiologic, and statistical data on psychological status and outcome. Regular consultation with CCU physicians can increase their effectiveness in managing patients' reactions to their hospital experience. 32 -35 The psychiatrist also has an opportunity to consult with the nursing staff and to observe the results of his interventions on ward milieu. In addition to increasing the nurses' expertise in the recognition and treatment of psychological distress. pressures on nursing staff might be reduced by increasing the opportunities for support and learning from the psychiatrist and from other nurses. 32 .34 Cassem and Hackett have proposed that regular meetings of nurses with a psychiatrist for these purposes might result in "reduction of tension in the primary caretaking personnel" which would be "indispensable to the smooth function of the coronary care unit. "36 Research to date therefore suggests that the CCU milieu, especially as influenced by the nursing staff, may affect patient outcome directly by recognition of dangerous situations by the nurse and indirectly by decreasing adverse physiologic changes associated with the emotional experience of the ward. While the time is therefore ripe for further studies of the outcome of changes in ward milieu on staff and nurses. few such studies have been reported. We recently had the opportunity to investigate some of the effects of the regular psychiatric consultation with a group of CCU nurses who had never before met with a psychiatrist. After attending a sym-
21
Psychiatrists on the coronary care unit
posium on the psychological aspects of intensive care nursing, the nursing staff of a CCU ("experimental unit") asked one of us (e.G.) to meet regularly with them to discuss the psychiatric aspects of patient care. At the time the psychiatric consultant began meeting regularly with experimental unit nurses, he was at the end of his first year of residency. He discussed each nursing group meeting with a faculty member (S.D.) who had led nursing groups on other acute care wards for some time. A senior resident who rotated yearly was available to the medical house staff for psychiatric consultation. In order to begin to determine the effect of the consultation, we also looked at a similar unit in a comparable hospital that had a staff psychiatrist available for psychiatric consultation to the medical staff only. This was designated the "control unit." During the time the psychiatrist served as a consultant to the experimental unit, the following data were collected. Questionnaire data Beginning four months after the group meetings started, questionnaires were distributed every three months on both the experimental and control units by a nurse (S.A.G.) who was not otherwise associated with either unit. In addition to demographic data, nurses were asked
22
to keep a log of the amount of time spent each day in routine ward activities such as "direct patient care" (e.g., giving medications); "medical skills" (e.g., starting IVs, reading monitors); working with physicians; charting: and time spent with patients while not engaged in other nursing activities. Nurses were also asked to rate their enjoyment or dislike and comfort or discomfort with these activities and with the various types of patients encountered. Nurses were interviewed at random in an attempt to determine whether the same information could be obtained by interview. Questions about time spent at varying tasks were especially scrutinized. Because of the length of the questionnaire, nurses were paid for its return. Monthly review One of us (J.P.) carried out a monthly review of both the chart and nursing care plan log ("Kardex") for each patient on the experimental and control units. The nursing care plan log was scored for the presence of a nursing care plan for newly admitted patients, a revised nursing care plan for patients on the ward more than 24 hours, and mention of progress toward meeting nursing care objectives. Charts were scored for the presence of nursing notes for each shift, and for a correlation between the objectives in the nurs-
ing care plan and interventions actually noted in the chart. A net efficiency score for each unit was then constructed, a score of 1.0 being assigned if all items were present for all patients. After 18 months, data reflecting patient mortality and length of stay were also collected from each unit being studied. Results-nurses' group The psychiatrist made it clear that group discussion would be limited to issues related to improving delivery of patient care, medical and psychological. Discussion of personal problems and interpersonal difficulties that did not specifically relate to patient care was discouraged. Individual patients were discussed whenever possible. The importance of confidentiality was strongly underscored. The character of the nursing group seemed to reflect the character of the ward: acute problems were solved in a crisisoriented way as they arose, the nurses cancelling a meeting or two and taking a "breather" when the ward was quiet. Group discussion usually centered around specific patient problems. Other topics discussed included administrative problems, staffing problems, complaints about the inexperience of new house staff, and topics such as depression, death and dying, organic brain syndrome, and alcohol abuse. At times, the psychiatrist began with a didactic presentation, which was then discussed and applied to specific patients. A great deal of discussion centered around a patient who needed to stay on the ward for several months. Initially, management of the patient's regression was a
AUGUST 1977
Table 1
Amount of time spent In, end Importenc end enjoyment of, two nur Ing ectlvltl (questlonnelr dete) Change In mean Change In mean Change in mean Importance enjoyment Initial mean dally time spent dally time (hrs) In activity- (hrs) scoret seoret
Activity
Unit
Direct patient care
Experimental Control
6.0 5.8
+1.32 -0.48
+0.88 -0.21
1.25 -0.59
Medical skills
Experimental Control
1.8 1.9
+0.47 -1.38
+0.67 -1.05
+1.08 -1.26
- A + seore indicates an increase; - a decrease. t Importance and enjoyment were rated from 1 to 10.
central issue. Later. nurses' reactions to this patient. who could not be discharged within several days. began to interfere with their ability to effectively care for the patient. Open discussion of these reactions led to greater comfort with the patient. The patient's anxiety. which had increased prior to the group discussion. decreased as the nursing staff looked after her more assiduously. When there was an occasional expression of interest in discussing personal problems. the psychiatrist stated that while he would not deal with these matters in the group. he would arrange for this to be done elsewhere. His offer was never accepted.
Questionnaire results As the group meetings progressed. an increasing amount of time appeared to be spent in two of the nursing activities studied by questionnaire. After 18 months. experimental unit nurses stated that they
PSYCHOSOMATICS
spent about 80 minutes more each day in direct patient care. and about 30 minutes more practicing medical skills (more than one activity was carried out at the same time-for ex-
ample. medical skills and talking to patients). Less time was spent away from the unit. This was accompanied by slight increases in the nurses' estimates of how important and enjoyable
Table 2
Chertlng efficiency during 15 months on experlmentel vs. control units: noted In chert for eech hilt Month Net efficiency seoret number- (experimental-control)
J
1 2 4 7 8
-0.10 -0.17 -0.08 +0.40J -0.05]
9
+0.25 +0.40] +0.10
10 12 13 14 15
+0.47 +0.40 +0.30
Number of "runs"
p
4
<0.05
r. rz r. rt
• During months 3, 5, 6, and 11, efficiency on the experimental ward was equal to that on the control ward. net efficiency score was 0, and the scores were excluded. tA score Indicates a greater efficiency on the control unit.
23
these activities were. While experimental unit nurses were spending more time with their patients. control unit nurses spent less time with their patients and considered the same two activities slightly less enjoyable and less important (Table I). There was a non-significant increase in comfort (rated I to 10) working with patients in all diagnostic categories on the experimental unit, in contrast with a non-significant decrease in comfort on the control unit.
Chart review Efficiency of charting was expressed as a fraction, with 1.0 representing maximum efficiency for the category measured at the time of review (e.g., 1.0 = all patients on unit have notes in chart for all shifts). As the nurses' group discussions progressed. the experimental unit was increasingly more likely than the control unit to have a nursing note in each patient's chart for each shift (Table 2), and these notes were increasingly more likely to correspond to actual nursing care objectives stated in the nursing care plan (Table 3). Application of the Wald-Wolfowitz runs test· to this data indicates that the trend toward increased charting efficiency is significant at the 0.05 level. and application of the Wald-Wolfowitz test to the experimental unit data alone shows the same significant trend. Because of record keeping ·This h:st examines series of events or measures. Similar measures (e.g .. all "+") that occur in a sequence are called "runs." A small numher of 'runs compared with the IOtal number of measures indicate that they do not occur in random fashion"
24
problems. mortality statistics were available for only six months prior to the beginning of the nurses' group. During
this time, the mean mortality was 9.8% on the experimental unit and 6.2% on the control unit. The difference between
Table 3
Charting efficiency during 15 months: nursing care plan objectives noted In chart Month number1
3 4 5 6 7 8 9
10 12 13 14 15
Net efficiency score
=g:~~]
-0.27 -0.33 +0.20 0.30 +0.17 +0.11 +0.15 +0.16 +0.43. +0.10 +0.37
Number of "runs"
p
2
<0.05
rl
r2
- Net efficiency score was 0 during months 2 and 11, and the scores were excluded.
Table 4
Monthly mortality rate on experimental unit, compared with the median Month number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Mortality rate value
+ + + + +
Number of "runs"
P
4
<0.05
rl
+
=]
r2
~]
r.
+J
r,
AUGUST 1977
these rates (3.6%) is statistically significant (X 2 = 4.11; p < 0.05 ). For the 15 months after the group began. the mean mortality on the experimental unit was 6.62%. compared with 6.3% on the control unit (X2 = 0.2539; P = ns). The experimental unit mortality rate decreased by 3.18% (X 2 = 2.084; P < 0.05), while the control unit mortality rate did not change appreciably over the same 15 months (X 2 = 0.137; P = ns). When the mortality rate for each month is assigned a + or value, according to whether it is above or below the median mortality rate (7%), and the number of "runs" of + or - examined by the Wald-Wolfowitz test, the gradual decrease in mortality on the experimental unit is seen to have occurred in a non-random fashion (Table 4). To examine the possibility that the decline in mortality rate on the experimental unit was caused by changes in populations with particular disease entities or their treatment, monthly mortality rates for each of these entities were examined. There was no obvious drop in mortality rate in any category other than acute cardiac disease and this was confirmed by chisquare test. In addition, there was no significant change in total number of patients in any diagnostic category (including cardiac) or in admission policy on either unit. No obvious new major treatment modalities were introduced, and total number of nursing and ancillary personnel (LPNs, aides). as well as average number of months of experience of R Ns on each ward, did not change appreciably when compared on a month-for-month basis. Mor-
PSYCHOSOMATICS
tality did not change appreciably on other wards in the same hospital as the experimental unit. There were no significant decreases in numbers of patients with high-risk lengths of stay (one day or less. five or more days). While mean length of stay decreased non-significantly on the experimental unit from 3.52 to 2.28 days per patient, there was no trend toward changes in number of patients with shorter or longer lengths of stay. There was no discernible change in patient population. and a chart review of selected experimental unit patients indicated that patients were not discharged earlier from the experimental unit only to die elsewhere or to be re-admitted. Discussion One obvious explanation for the initial higher mortality rate on the experimental unit is that it had a population of sicker patients who were at higher risk of death and who stayed longer on the CCU. For example. patients admitted for cardiac catheterization are routinely hospitalized on general medical floors of the experimental hospital, and on the CCU of the control hospital. Rather than considering the initial mortality rate on the experimental unit unusually high, one might consider the control unit mortality rate a difficult-to-attain ideal. Within a year after institution of regular psychiatric consultation to the nursing stafT, t he mortality rate on the experimental unit decreased in a non-random way until it was indistinguishable from the already low mortality rate obtained on the control unit. There are several possible
explanations for this observation. One is that the mortality rate increased in the months prior to the onset of the group and then returned to baseline for reasons unrelated to the intervention. Mortality and length of stay should of course have been measured for a longer period of time before the group began. but these data are available only for the six months before it started. Also, in evaluating any study in which mortality is a possible outcome variable. it is important to remember that mortality rates on CCUs may fluctuate markedly in the absence of any known change in patient population.! However. the mortality rate on the experimental unit was high for at least six months. the decrease in mortality was non-random. and once it dropped. it never again reached the initial mortality rate. The increasing efficiency of charting suggests that nurses were at least charting and writing patient care plans more efficiently. Bearing in mind the obvious limitations of a self-report, the questionnaire data at least suggest that increased time was spent with patients in activities related to their survival. Open discussion and resolution of interpersonal difficulties as they related to patient care. and the direct solution of problems with medical staff. were encouraged as a group norm. 38 Tensions that might have interfered with rapid recognition of cardiac emergencies were therefore reduced. A more complete intellectual knowledge of the range of emotional reactions of patients to their illness may have allowed nurses to support
25
appropriate reactions to the CCU experience and to expend less effort devising effective psychological care plans, allowing them to attend more carefully to the medical aspects of patient care. Thus, a knowledge of the proper management of organic brain syndrome could allow nurses to have short frequent talks with delirious patients and spend more time with other patients requiring medical attention. The intellectual mastery of such issues would also be expected to add to the confidence with which nurses approached their patients. Nurses appeared to become more sensitive to emotional situations that have the potential to trigger fatal arrhythmias in their patients. Confident that their approach to these situations would be useful to the patients, the nurses could deal with the emotions before arrhythmias developed. Less hampered by their own concerns about ward life. the nurses could attend more carefully to their patients. Finally, a calmer, smoother-running CCU in which open communication is fostered may have a dampening effect on potentially dangerous emotions in all its patients. Of course. numerous alternative explanations can be found for the apparent increased efficiency of charting, increased comfort with a variety of patients. increased time spent with patients, and lowered patient mortality associated with the institution of regular consultation to staff nurses. However, insofar as these findings are in keeping with the suggestions raised in the literature that nonmedical changes affecting nurses may affect patient outcome, the
26
findings underscore the need to carefully study the impact of any change in ward milieu. More studies need to be done to document that changes in milieu that can predictably be influenced by the psychiatrist produce favorable changes in patient outcome. Such studies should document the ways in which a psychiatrist influences the ward. and the ways in which these changes affect patients. Indepth studies of small groups of patients, with appropriate physiologic studies, as well as outcome studies of large groups of patients correlated with the institution of new interventions, # should be designed. Supported in part by a grant from the research assistance fund. University of Colorado Medical Center, and NIH general research support RR 05357. Reprint requests to Container C 260, University of Colorado Medical Center, 4200 East Ninth Avenue, Denver. CO 80262 (Dr. Dubovsky).
REFERENCES
I. Lown B. Selyer A: The coronary care unit. Am J CardioI22:597-602, 1968. 2. Oliver MF. Julian DG, Donald K W: Problems in evaluating coronary care units. Alii J Cardiol 20:465-474. 1967. 3. Schaffer W A, Cobb LA: Recurrent ventricular fibrillation and modes of death in survivors of out of hospital fibrillation. N Engl J Med 293:259-262, 1975. 4. Cannon WB: Voodoo death. PsyChO.WlIII Med 19:182.1957. 5. Engel GL: Sudden and rapid death during psychological stress: Folklore or folk wisdom? Ann Intern Med 74:771-782. 1973. 6. Harvey WP, Levine SA: Paroxysmal ventricular tachycardia due to emotion. JA M A 150:479-480. 1952.
7. Rahe RH. Christ AE: An unusual cardiac (ventricular) arrhythmia in a child: Psychiatric and psychophysiologic aspects. Psychosom Med 28: 181-188. 1966. 8. Lown B. Reich P: Ventricular fibrillation and psychologic stress. IV EnglJ Med 294: 1347-1348. 1976. 9. Lown B, Temte JV. Reich P. et al: Basis for recurring ventricular fibrillation in the absence of coronary heart disease and its management. N Engl J Med 294:623-629. 1976. 10. Richter CP: On the phenomenon of sudden death in animals. Psycho-'0111 Med 19:191. 1957. II. Lown B. Verrier R. Corbaban R: Psychological stress and threshold for repetitive ventricular response. Scil'llce 182:834-836, 1973. 12. Corbaban R. Verrier R, Lown B: Psychological stress and ventricular arrhythmias during myocardial infarction in the conscious dog. Alii J Cardiol34:692-696. 1974. 13. Lown B. Verrier R: Neural activity and ventricular fibrillation. N Engl J Med294:1165-1170. 1976. 14. Engel GL: Psychologic factors in instantaneous cardiac death (I). N Engl J Med 294:664-665. 1976. 15. Engel GL: Psychologic factors in instantaneous cardiac death (2). N t:llgl J Med 294:1165-1170. 1976. 16. Taggart P. Parkman P. Carruthers M: Cardiac responses to thermal. physical. and emotional stress. 8r Med J 3:71-76. 1972. 17. Brown IW. Hackett TP: Emotional reactions to the threat of impending death: A study of patients on monitor cardiac pacemakers. Irish J Med Sci 6:177-187. 1967. 18. Druss RG, Kornfeld DS: The survivors of cardiac arrest. JAM A 210:295-296, 1967. 19. Hackett TP, Cassem N H: The psychology of intensive care problems and their management. Presented at a symposium on intensive care units at St. Vincent's Hospital and Medical Center. New York. May 10-14, 1971. 20. Abram HS: Psychological aspects of the intensive care unit. Ho-,pital Medicine S( 12):94-95. 1969. 21. Cleveland Sl, Johnson DL: Personality patterns in young males with coronary disease. PSl'chO-'OIll Med 24:600-610. 1962.
22. Hackett TP. Cassem N H. Wishnie
AUGUST 1977
HA: The coronary care unit. S
t:1I~1
.I Med279:1J65-1J70. 196K.
23. Kornfeld DS: Psychiatric problems of an intensive care unit. Med ('!ill .\ ..I Iller SS:IJ5J-1J6J. 1971. 2-1. Bruhn JG. Thurman A E. Chandler Be. et al: Patients' reactions to death in a coronary care unit. J 1'.'.1'd/tl.wlII Res 14:65-70. 1970. 25. Leigh H. Hofer MA. Cooper J. et al: !\ psychological comparison of patients in "open" and "dosed" coronary care units. J P.ITCho.WIII ReI 16:-149-457. 1972. 26. Kornfeld DS: The hospital environment: Its impact on the patient. in .-ldl'all<"<'.I· ill I'srcho.wlIIlIIic '''It'di<'ille Vol K. Lipowski ZJ (ed): Psydww<'ial "'-'I','CI.I l'''.ni<'
or
PSYC 1I0S0MA TICS
Looking Ahead • In Psychosomatics E cerpt from upcoming article The e , .. phantom urinar phen mena related to of urinary function ... occur not in re p n e to a traumatic phy ical 10 of an organ, but rather in re pon e t the dramatic 10 of a vital. but ph iologicall replaceable, functi n.
10
-Phantom urinary phenomena in hemodialy i paTient , by Franci J. Kane, Jr., M.D. and Lee ime, M.D.
Our tud did not find patient with thi di ea e to be homogeneou .... However, there doe eern to be a chronic di ea e per onalit . The ubje t we e amined were imilar to other group of di abled patient. -The rheumaToid arlhriTic per onality: a PS) chodiagno tic mYTh, by Philip pergel, Ed. D., Geor e E. Ehrlich, M.D., and DoroThea D. Glas , M.D.
Once a pecific e ual dy function ha been identified. the mo t u eful wa to con eptualize the problem i to identif what a pect of e ualit i being u edthe reproductive, the interper onal, or the auti ticand what tage of the life Ie the patient i now at. Thi method provide a u eful h rthand to begin to under tand a ver difficult and omple problem. - exualilJ' ThroughouT The life c ·cle. by Thoma Wise, M.D.
The "cia ic even" p ycho omati di order have been e panded to include all illne e mpha i ha hifted from exploration of cau e to re pon e and prevention by reducing life tre . Better under tanding fh the brain integrate bi I gic and p ch logical proce e will certain) dimini h the gap between p ycho ornatic and other di order. -P ycho omaTics and p ycholog)', bl' Frank Engel mann, Ph.D.
The e and man other intere ting arti Ie are c ming up in future i ue. f P v ho omali .
27