Aaron Conway

Alternative models of cardiac rehabilitation: a systematic review

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council’s designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual’s risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

Not all systematic reviews are systematic: a meta-review of the quality of systematic reviews for non-invasive remote monitoring in heart failure

We carried out a critical appraisal and synthesis of the systematic reviews and meta-analyses of remote monitoring for heart failure. A comprehensive literature search identified 65 relevant publications from 3333 citations. Seventeen studies fulfilled the inclusion and exclusion criteria. Seven (41%) systematic reviews pooled results for meta-analysis. Eight (47%) considered all non-invasive remote monitoring strategies. Five (29%) focused on telemonitoring. Four (24%) included both non-invasive and invasive technologies. The reviews were appraised by two independent reviewers for their quality and risk of bias using the AMSTAR tool. According to the AMSTAR criteria, ten (58%) systematic reviews were of poor methodological quality. In the high quality reviews, the relative risk of mortality in patients who received remote monitoring ranged from 0.53 to 0.88. The high quality reviews also reported that remote monitoring reduced the relative risk of all-cause (0.52 to 0.96) and heart failure-related hospitalizations (0.72 to 0.79) and, as a consequence, healthcare costs. However, further research is required before considering widespread implementation of remote monitoring. The subset of the heart failure population that derives the most benefit from intensive monitoring, the best technology, and the optimum duration of monitoring, all need to be identified.

Effective Technologies for Noninvasive Remote Monitoring in Heart Failure

BACKGROUND Trials of new technologies to remotely monitor for signs and symptoms of worsening heart failure are continually emerging. The extent to which technological differences impact the effectiveness of noninvasive remote monitoring for heart failure management is unknown. This study examined the effect of specific technology used for noninvasive remote monitoring of people with heart failure on all-cause mortality and heart failure-related hospitalizations. MATERIALS AND METHODS A subanalysis of a large systematic review and meta-analysis was conducted. Studies were stratified according to the specific type of technology used, and separate meta-analyses were performed. Four different types of noninvasive remote monitoring technologies were identified, including structured telephone calls, videophone, interactive voice response devices, and telemonitoring. RESULTS Only structured telephone calls and telemonitoring were effective in reducing the risk of all-cause mortality (relative risk [RR]=0.87; 95% confidence interval [CI], 0.75-1.01; p=0.06; and RR=0.62; 95% CI, 0.50-0.77; p<0.0001, respectively) and heart failure-related hospitalizations (RR=0.77; 95% CI, 0.68-0.87; p<0.001; and RR=0.75; 95% CI, 0.63-0.91; p=0.003, respectively). More research data are required for videophone and interactive voice response technologies. CONCLUSIONS This subanalysis identified that only two of the four specific technologies used for noninvasive remote monitoring in heart failure improved outcomes. When results of studies that involved these disparate technologies were combined in previous meta-analyses, significant improvements in outcomes were identified. As such, this study has highlighted implications for future meta-analyses of randomized controlled trials focused on evaluating the effectiveness of remote monitoring in heart failure.

Nurse-administered procedural sedation and analgesia in the cardiac catheter laboratory: An integrative review

OBJECTIVES To identify and appraise the literature concerning nurse-administered procedural sedation and analgesia in the cardiac catheter laboratory. DESIGN AND DATA SOURCES An integrative review method was chosen for this study. MEDLINE and CINAHL databases as well as The Cochrane Database of Systematic Reviews and the Joanna Briggs Institute were searched. Nineteen research articles and three clinical guidelines were identified. RESULTS The authors of each study reported nurse-administered sedation in the CCL is safe due to the low incidence of complications. However, a higher percentage of deeply sedated patients were reported to experience complications than moderately sedated patients. To confound this issue, one clinical guideline permits deep sedation without an anaesthetist present, while others recommend against it. All clinical guidelines recommend nurses are educated about sedation concepts. Other findings focus on pain and discomfort and the cost-savings of nurse-administered sedation, which are associated with forgoing anaesthetic services. CONCLUSIONS Practice is varied due to limitations in the evidence and inconsistent clinical practice guidelines. Therefore, recommendations for research and practice have been made. Research topics include determining how and in which circumstances capnography can be used in the CCL, discerning the economic impact of sedation-related complications and developing a set of objectives for nursing education about sedation. For practice, if deep sedation is administered without an anaesthetist present, it is essential nurses are adequately trained and have access to vital equipment such as capnography to monitor ventilation because deeply sedated patients are more likely to experience complications related to sedation. These initiatives will go some way to ensuring patients receiving nurse-administered procedural sedation and analgesia for a procedure in the cardiac catheter laboratory are cared for using consistent, safe and evidence-based practices.

Trends in nurse-administered procedural sedation and analgesia across cardiac catheterisation laboratories in Australia and New Zealand: Results of an electronic survey

BACKGROUND Knowledge of current trends in nurse-administered procedural sedation and analgesia (PSA) in the cardiac catheterisation laboratory (CCL) may provide important insights into how to improve safety and effectiveness of this practice. OBJECTIVE To characterise current practice as well as education and competency standards regarding nurse-administered PSA in Australian and New Zealand CCLs. DESIGN A quantitative, cross-sectional, descriptive survey design was used. METHODS Data were collected using a web-based questionnaire on practice, educational standards and protocols related to nurse-administered PSA. Descriptive statistics were used to analyse data. RESULTS A sample of 62 nurses, each from a different CCL, completed a questionnaire that focused on PSA practice. Over half of the estimated total number of CCLs in Australia and New Zealand was represented. Nurse-administered PSA was used in 94% (n=58) of respondents CCLs. All respondents indicated that benzodiazepines, opioids or a combination of both is used for PSA (n=58). One respondent indicated that propofol was also used. 20% (n=12) indicated that deep sedation is purposefully induced for defibrillation threshold testing and cardioversion without a second medical practitioner present. Sedation monitoring practices vary considerably between institutions. 31% (n=18) indicated that comprehensive education about PSA is provided. 45% (n=26) indicated that nurses who administer PSA should undergo competency assessment. CONCLUSION By characterising nurse-administered PSA in Australian and New Zealand CCLs, a baseline for future studies has been established. Areas of particular importance to improve include protocols for patient monitoring and comprehensive PSA education for CCL nurses in Australia and New Zealand.

The effectiveness of non-pharmacological interventions in improving psychological outcomes for heart transplant recipients: A systematic review

Background: Post-heart transplant psychological distress may directly hinder physiological health as well as indirectly impact on clinical outcomes by increasing unhealthy behaviors, such as immunosuppression non-adherence. Reducing psychological distress for heart transplant recipients is therefore vitally important in order to improve not only patients’ overall health and well-being but also clinical outcomes, such as morbidity and mortality. Evidence from other populations suggests that non-pharmacological interventions may be an effective strategy. Aim: The purpose of this study was to appraise the efficacy of non-pharmacological interventions on psychological outcomes after heart transplant. Method: A systematic review was conducted using the Joanna Briggs Institute methodology. Experimental and quasi-experimental studies that involved any non-pharmacological intervention for heart transplant recipients were included, provided that data on psychological outcomes were reported. Multiple electronic databases were searched for published and unpublished studies and reference lists of retrieved studies were scrutinized for further primary research. Data were extracted using a standardized data extraction tool. Included studies were assessed by two independent reviewers using standardized critical appraisal instruments. Results: Three studies fulfilled the inclusion and exclusion criteria, which involved only 125 heart transplant recipients. Two studies reported on exercise programs. One study reported a web-based psychosocial intervention. While psychological outcomes significantly improved from baseline to follow-up for the recipients who received the interventions, between-group comparisons were not reported. The methodological quality of the studies was judged to be poor. Conclusions: Further research is required, as we found there is insufficient evidence available to draw conclusions for or against the use of non-pharmacological interventions after heart transplant.

Clinical practice guidelines for nurse‐administered procedural sedation and analgesia in the cardiac catheterization laboratory: a modified Delphi study

Aim To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory. Background Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist present means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances where nurse-administered procedural sedation and analgesia is used in the cardiac catheterization laboratory. Methods A sequential mixed methods design was used. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised according to responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterization laboratory nurses. All but one of the draft recommendations met the predetermined cut-off point for inclusion with 59 responses to the second round. Consensus was reached on all recommendations. Implications for nursing The guidelines that were derived from the Delphi study offer 24 recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Postprocedural patient assessment and monitoring. Conclusion These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterization laboratory setting.AIM To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory. BACKGROUND Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist present means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances where nurse-administered procedural sedation and analgesia is used in the cardiac catheterization laboratory. METHODS A sequential mixed methods design was used. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised according to responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterization laboratory nurses. All but one of the draft recommendations met the predetermined cut-off point for inclusion with 59 responses to the second round. Consensus was reached on all recommendations. IMPLICATIONS FOR NURSING The guidelines that were derived from the Delphi study offer 24 recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Postprocedural patient assessment and monitoring. CONCLUSION These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterization laboratory setting.

A Review of the Effects of Sedation on Thermoregulation: Insights for the Cardiac Catheterization Laboratory

PURPOSE To examine the effects that the sedative and analgesic medications commonly used in the cardiac catheterization laboratory have on thermoregulation. DESIGN A structured review strategy was used. METHODS MEDLINE and CINAHL were searched for published studies, and reference lists of retrieved studies were scrutinized for further studies. Data were extracted using a standardized extraction tool. FINDINGS A total of nine studies examined the effect that sedative and analgesic medications have on thermoregulation. Midazolam has minimal impact on thermoregulation, whereas opioids, dexmedetomidine, and propofol markedly decrease vasoconstriction and shivering thresholds. CONCLUSIONS Patients who receive sedation in the cardiac catheterization laboratory may be at risk of hypothermia because of the use of medications that impair thermoregulation. Further research is required to identify the prevalence of unplanned hypothermia during sedation in the cardiac catheterization laboratory.

Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a matched case-control study

Background: Side effects of the medications used for procedural sedation and analgesia in the cardiac catheterisation laboratory are known to cause impaired respiratory function. Impaired respiratory function poses considerable risk to patient safety as it can lead to inadequate oxygenation. Having knowledge about the conditions that predict impaired respiratory function prior to the procedure would enable nurses to identify at-risk patients and selectively implement intensive respiratory monitoring. This would reduce the possibility of inadequate oxygenation occurring. Aim: To identify pre-procedure risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory. Design: Retrospective matched case–control. Methods: 21 cases of impaired respiratory function were identified and matched to 113 controls from a consecutive cohort of patients over 18 years of age. Conditional logistic regression was used to identify risk factors for impaired respiratory function. Results: With each additional indicator of acute illness, case patients were nearly two times more likely than their controls to experience impaired respiratory function (OR 1.78; 95% CI 1.19–2.67; p = 0.005). Indicators of acute illness included emergency admission, being transferred from a critical care unit for the procedure or requiring respiratory or haemodynamic support in the lead up to the procedure. Conclusion: Several factors that predict the likelihood of impaired respiratory function were identified. The results from this study could be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

The Effectiveness of the Nurse Care Coordinator Role on Patient-Reported and Health Service Outcomes: A Systematic Review

This systematic review examined the effectiveness of nurse care coordinator (CC) roles on patient-reported and health service outcomes. Multiple electronic databases (Medline, CINAHL, and EMBASE) were searched and the Cochrane Risk of Bias Assessment Tool was applied by two independent reviewers. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess the quality of evidence. A total of 45 articles (reporting on 36 studies) were included. The majority of studies (n = 28, 78%) were conducted in the United States and published after 2009 (n = 24, 67%). Thirteen studies (36%) used a randomized controlled trial design. A total of 17 studies evaluated patient-reported outcomes and 29 studies reported health service outcomes. The individual components of nurse CC roles that were evaluated ranged considerably. The impact of nurse care coordination on patient-reported and health service outcomes was inconsistent. There was an indication from higher quality studies that nurse care coordination roles were more likely to result in improved patient and health service outcomes where they involved frequent, in-person interactions, had ongoing follow-up with monitoring of disease status, and involved transition care and the application of behavior change principles.