Anna Gawlinski

Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP)

Despite scientific evidence that secondary prevention medical therapies reduce mortality in patients with established coronary artery disease, these therapies continue to be underutilized in patients receiving conventional care. To address this issue, a Cardiac Hospital Atherosclerosis Management Program (CHAMP) focused on initiation of aspirin, cholesterol-lowering medication (hydroxymethylglutaryl coenzyme A [HMG CoA] reductase inhibitor titrated to achieve low-density lipoprotein [LDL] cholesterol < or =100 mg/dl), beta blocker, and angiotensin-converting enzyme (ACE) inhibitor therapy in conjunction with diet and exercise counseling before hospital discharge in patients with established coronary artery disease. Treatment rates and clinical outcome were compared in patients discharged after myocardial infarction in the 2-year period before (1992 to 1993) and the 2-year period after (1994 to 1995) CHAMP was implemented. In the pre- and post-CHAMP patient groups, aspirin use at discharge improved from 68% to 92% (p <0.01), beta blocker use improved from 12% to 62% (p <0.01), ACE inhibitor use increased from 6% to 58% (p <0.01), and statin use increased from 6% to 86% (p <0.01). This increased use of treatment persisted during subsequent follow-up. There was also a significant increase in patients achieving a LDL cholesterol < or =100 mg/dl (6% vs 58%, p <0.001) and a reduction in recurrent myocardial infarction and 1-year mortality. Compared with conventional guidelines and care, CHAMP was associated with a significant increase in use of medications that have been previously demonstrated to reduce mortality; more patients achieved an LDL cholesterol < or =100 mg/dl, and there were improved clinical outcomes in patients after hospitalization for acute myocardial infarction.

Rationale and design of the Cardiac Hospitalization Atherosclerosis Management Program at the University of California Los Angeles.

Despite clear and consistent clinical-trial evidence that secondary-prevention medical therapies reduce mortality in patients with established coronary artery disease, these therapies are underutilized in patients receiving conventional care. To address this issue, a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) focused on initiation of aspirin, cholesterol-lowering medication (3-hydroxy-3-methylglutaryl-coenzyme A [HMG-CoA] reductase inhibitor titrated to achieve low-density lipoprotein [LDL] cholesterol < 100 mg/dL), beta-blocker, and angiotensin-converting enzyme (ACE)-inhibitor therapy in conjunction with diet and exercise counseling before hospital discharge in patients with established coronary artery disease was designed and implemented at the University of California Los Angeles (UCLA) Medical Center starting in 1994. This treatment program was based on the hypothesis that initiation of therapy in the hospital setting would result in higher utilization rates both at the time of discharge and during longer-term follow-up. Implementation of this program involved the use of a focused treatment guideline, standardized admission orders, educational lectures by local thought leaders, and tracking/reporting of treatment rates. To assess the impact of the program, treatment rates and clinical outcome were compared in patients discharged in the 2-year periods before and after CHAMP was implemented. Hospital-based treatment protocols such as CHAMP have the potential to significantly increase treatment utilization of therapies previously demonstrated to improve survival and thus substantially improve the outcome of the 2 million patients diagnosed and hospitalized each year with coronary artery disease.

Surveillance: A Strategy for Improving Patient Safety in Acute and Critical Care Units

Surveillance is a nursing intervention that has been identified as an important strategy in preventing and identifying medical errors and adverse events. The definition of surveillance proposed by the Nursing Intervention Classification is the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making. The term surveillance is often used interchangeably with the term monitoring, yet surveillance differs significantly from monitoring both in purpose and scope. Monitoring is a key activity in the surveillance process, but monitoring alone is insufficient for conducting effective surveillance. Much of the attention in the bedside patient safety movement has been focused on efforts to implement processes that ultimately improve the surveillance process. These include checklists, interdisciplinary rounds, clinical information systems, and clinical decision support systems. To identify optimal surveillance patterns and to develop and test technologies that assist critical care nurses in performing effective surveillance, more research is needed, particularly with innovative approaches to describe and evaluate the best surveillance practices of bedside nurses.

Selecting a model for evidence-based practice changes: a practical approach.

Evidence-based practice models have been developed to help nurses move evidence into practice. Use of these models leads to an organized approach to evidence-based practice, prevents incomplete implementation, and can maximize use of nursing time and resources. No one model of evidence-based practice is present that meets the needs of all nursing environments. This article outlines a systematic process that can be used by organizations to select an evidence-based practice model that best meets the needs of their institution.

Infusing research into practice: a staff nurse evidence-based practice fellowship program.

This article describes the framework and dynamics of an evidence-based practice mentorship program for staff nurses. Staff development educators can be instrumental as leaders in an evidence-based practice fellowship program, as they foster a thirst for lifelong learning, assist with developing a questioning attitude, and inspire nurses to ask clinical questions. The program serves as a bridge to bring research into real-world patient care that results in improved patient outcomes.

Development of a tool to assess risk for falls in women in hospital obstetric units

Because women hospitalized in obstetric units are typically young and healthy, they might be overlooked when health care providers assess for risk for falls. Recent literature has identified pregnant and postpartum women as being prone to falls, with hospitalization compounding their risk. A review of current practices among perinatal units for assessing risk for falls revealed that existing fall risk tools, which were created for geriatric and/or medical surgical patients, are used. Without any focused prevention efforts, hospitalized obstetric patients are vulnerable to a preventable event. The Obstetric Fall Risk Assessment System™ is intended to improve safety among hospitalized women on obstetric units, using an assessment tool and scoring system to determine fall risk.

Advancing Nursing Research Through a Mentorship Program for Staff Nurses

This article describes a unique model of implementing unit-based research teams to provide staff nurses with knowledge, skills, and mentoring. The essential elements of designing and conducting a research study are emphasized in an effort to improve nursing practice and the quality of patient care. The research education and practicum are incorporated into team meetings. This unique model provides greater efficiency and effectiveness of resources and allows for more interactive education than occurs in traditional models. Unit-based nursing teams learn together to design research studies, test hypotheses, and answer clinically relevant research questions, using the scientific process.

Cumulative perinatal steroids: child development of preterm infants.

The development of premature infants may be altered due to exposure to high cumulative doses of the perinatal corticosteroid dexamethasone during critical growth periods. To compare child behavioral development of prematurely born infants who were exposed to higher perinatal steroids (PNS; >0.2 mg/kg) with that of infants exposed to lower PNS (<or=0.2 mg/kg), we used the Vineland Adaptive Behavioral Scales to assess school-age behavioral outcomes of a historical cohort of 45 prematurely born infants. Children who had received higher PNS treatment were more likely to have lower overall behavioral developmental scores, especially lower social skills (p < .05). Higher PNS plus higher severity of illness during the first day of life based on the Clinical Risk Index for Babies (p = .016) and lower birth head size (p = .015) were linked with poorer behavioral outcomes among participants. Nursing practice includes promotion of quality care and should include closer evaluation of cumulative steroid therapy, severity of illness, and promotion of long-term follow-up support for premature infants.

Facts and fallacies of patient positioning and hemodynamic measurement.

Research-based guidelines regarding patient positioning and hemodynamic measurement are compared with nonscientific routines. Published research is critiqued and synthesized. Research based practice algorithms are presented based on this synthesis and critique of current research. The challenge is to balance the many patient care activities that critically ill patients require with the need for positioning and hemodynamic measurement. The duration patients are left in the supine position can be minimized, and accurate and reliable measurements can still be obtained.

Effect of positioning on mixed venous oxygen saturation.

Positioning critically ill patients is a frequently used intervention in nursing practice. However, positioning can have a beneficial or adverse effect depending on the effect on oxygen delivery and oxygen consumption. This article examines the physiologic effect of positioning on the balance between oxygen delivery and oxygen consumption. In addition, a critical analysis of the research on the effect of positioning on mixed venous oxygen saturation is presented. Recommendations for patient management are discussed as well as the implications for future research.