Barbara Leeper

Nursing outcomes: percutaneous coronary interventions.

Percutaneous coronary interventional (PCI) procedures are commonly performed in the United States. The process of caring for this patient population has changed dramatically over the last 10 years, with many of the changes being driven by an evolution in the knowledge base underlying nursing practice. The purpose of this article is to provide a summary and critique of nurse-sensitive outcomes related to patients undergoing PCI procedures and to identify gaps in the literature to provide recommendations for future research. Nursing research on indicators related to costs of care, morbidity, symptom management, functional status, patient/family knowledge, patient responses, behavior, and home/occupational function following PCI are discussed in this review.

Development of the Sternal Wound Infection Prediction Scale

OBJECTIVE To develop an instrument to reliably predict the occurrence of sternal wound infection (SWI). DESIGN Instrument development with retrospective chart review. SETTING Southwestern university-affiliated medical center. PATIENTS One hundred eighty-five adults who underwent cardiac surgery. SWI developed in 94 patients, and 91 remained infection free. In phase 1, there were 82 subjects: SWI developed in 41, and 41 remained infection free. In phase 2, there were 103 subjects: SWI developed in 53, and 50 remained infection free. OUTCOME MEASURE Development of a postoperative SWI. INTERVENTION The Sternal Wound Infection Prediction Scale (SWIPS) was developed in 2 phases. Phase 1 consisted of designing the SWIPS with use of 19 risk factors most often identified with SWI and revising this scale (SWIPS-R) with use of 21 risk factors. Eighty-two patient records were reviewed. After determining the mean cutscores in phase 1, phase 2 provided cross-validation results with use of 103 additional patient records. RESULTS The SWIPS produced 62.1% correct predictions of infection and noninfection; whereas the SWIPS-R produced 72.8% correct predictions. Phase 2 cross-validation results for the 21 risk factors demonstrated that 62.1% and 72.8% of the patients were correctly diagnosed using the SWIPS and SWIPS-R, respectively. A multivariate logistic regression was also performed on the risk factors to predict infection/noninfection groups for all 185 patients. A reduced logistic regression model included 9 of the risk factors and correctly classified 76.2% of the subjects. CONCLUSIONS The SWIPS-R, with 21 risk factors, and the logistic regression model, with 12 risk factors, provided excellent classification rates of infection/noninfection. However, more data need to be collected to further strengthen reliability.

Continuous ST-Segment Monitoring.

Continuous ST-segment monitoring has been shown to be beneficial for patients with acute coronary syndromes as well as for other patients in the intensive care unit (ICU). This article reviews the significance and value of continuous ST-segment monitoring with emphasis on the value of 12-lead ST-segment monitoring across the continuum of care from the emergency department, to the cardiac catheterization laboratory, the ICU, and the telemetry unit.

Disparities in cardiac care for patients with complex cardiovascular care needs.

The United States continues to have a prevailing public health problem related to disparities in healthcare. Factors contributing to disparities include ethnicity, gender, socioeconomic status, educational level, geographic location, and hospital characteristics. In cardiovascular care, gaps in care have been associated with lack of conformity to evidence-based therapies known to improve clinical outcomes, including survival, quality of life, and freedom from rehospitalization. Specifically, there are disparities in use of a number of cardiovascular life-saving procedures including cardiac catheterization, percutaneous coronary intervention, coronary artery bypass surgery, and implantation of defibrillators and cardiac resynchronization devices. The purpose of this article was to illustrate the range of disparities that exist in relation to management of patients with acute coronary syndromes, interventional cardiology procedures, cardiac surgery, heart failure, and device implantation. Because the impact on patient outcomes is high, potential interventions to address disparities will be provided.

Impact of Obesity on Care of Postoperative Coronary Bypass Patients

Obesity has become a major health problem in the United States and is well known to be a risk factor for the development of cardiovascular disease. Many clinicians perceive obesity, particularly severe or morbid obesity, to be associated with increased risk for mortality and morbidity following coronary artery bypass graft (CABG) surgery. This article provides a review of the literature related to mortality and morbidity, including the impact of diabetes, risk for acute respiratory failure, and sternal wound infection associated with obese patients undergoing CABG surgery. Implications for nursing practice are addressed with recommendations for practice in this patient population.

In-hospital survival rates following cardiac arrest.

Survival rates associated with in-hospital cardiac arrest remain stagnant in spite of recent advances in technology. The purpose of this article is to provide a review of the recent literature addressing in-hospital cardiac arrest outcomes and factors that may play a role affecting the outcomes. Recent recommendations demonstrating potential for improved outcomes are discussed.

Management of heart failure: use of biventricular pacing.

Congestive heart failure (CHF) is a clinical syndrome that affects more than 4 million people in the United States. The grim prognosis for this population has led to a search for new therapies to treat CHF. Resynchronization of the ventricles is one such therapy. The pathophysiology associated with conduction defects and the evolution of the use of pacing technologies for this patient population will be discussed. Early data have been encouraging, suggesting that patients may gain important hemodynamic, functional, and quality-of-life improvements with biventricular pacing.

Resynchronization therapy for the management of heart failure

Biventricular pacing offers real benefit to some patients with HF, but several questions remain unanswered. One is which patients will benefit the most from this technology. Although there are some indications, the ideal patient group has yet to be identified. The best electrical configuration for pacing and the best pacing site have not been identified for all patients. Another question is whether resynchronization will improve mortality rates. A final question is the cost-effectiveness of this therapy. Studies in progress may answer some of these questions. Meanwhile, this intervention offers hope for improved quality of life and perhaps survival in this high-risk patient population.

Overview of extracorporeal membrane oxygenation in cardiogenic shock.

In recent years, the use of extracorporeal membrane oxygenators (ECMO) has proliferated in cardiovascular intensive care units (ICUs) partially due to advances in technology with the development of smaller, more portable machines, and the increasing numbers of patients with end-stage heart failure and cardiogenic shock. The use of ECMO has been found to improve survival rates in this deadly situation. Due to higher volumes of patients requiring ECMO, additional qualified resources for providing ECMO services may be necessary. The purpose of this article was to review cardiogenic shock etiologies, the role of ECMO, and to discuss the transition process of implementing a nurse-run ECMO program.

DIABETES AND CARDIOVASCULAR DISEASE

Inpatient glucose control today is complex and challenging for the clinician. The importance of avoiding wide swings in the BG levels and hypoglycemic events cannot be underestimated. Nurses must be at the table as insulin protocols or physician order sets are being developed to address issues with readability and understanding. Education of all staff is extremely important with follow-up education at intervals for both nurses and physician providers. While there are no official guidelines for quality of inpatient glycemic control, a multidisciplinary team consisting of key physicians (endocrinology and others), clinical nurse specialists, and diabetes educator and clinical pharmacist can develop quality improvement projects for monitoring and process improvement. Continuous monitoring of practices will reduce the risk for errors and support safe practices.