Gayle R. Whitman

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

Alice K. Jacobs, MD, FACC, FAHA, Chair Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect Nancy Albert, PhD, CCNS, CCRN, FAHA Mark A. Creager, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Robert A. Guyton, MD, FACC Jonathan L. Halperin, MD, FACC, FAHA Judith S. Hochman, MD, FACC, FAHA

2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary

2011;58;2584-2614; originally published online Nov 7, 2011; J. Am. Coll. Cardiol. Winniford Joseph F. Sabik, Ola Selnes, David M. Shahian, Jeffrey C. Trost, and Michael D. A. Lange, Martin J. London, Michael J. Mack, Manesh R. Patel, John D. Puskas, Adolph M. Hutter, Jr, Michael E. Jessen, Ellen C. Keeley, Stephen J. Lahey, Richard Bridges, John G. Byrne, Joaquin E. Cigarroa, Verdi J. DiSesa, Loren F. Hiratzka, L. David Hillis, Peter K. Smith, Jeffrey L. Anderson, John A. Bittl, Charles R. Surgeons Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Developed in Collaboration With the American Association for Thoracic Foundation/American Heart Association Task Force on Practice Guidelines Executive Summary: A Report of the American College of Cardiology 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: This information is current as of January 22, 2012 http://content.onlinejacc.org/cgi/content/full/58/24/2584 located on the World Wide Web at: The online version of this article, along with updated information and services, is

The Impact of Staffing on Patient Outcomes Across Specialty Units

Objective Determine the relationships between nursing staffing and specific nurse-sensitive outcomes (central line blood-associated infection, pressure ulcer, fall, medication error, and restraint application duration rates) across specialty units (cardiac and noncardiac intensive care, cardiac and noncardiac intermediate care, and medical–surgical). Background A number of hospital-level studies have demonstrated that lower staffing levels are associated with higher adverse patient outcomes. However, insufficient insight into unit-level staffing relationships is available. Further unit-level inquiry is necessary to fully explicate the relationships between staffing and outcomes and to provide assistance to nurse administrators as they seek to develop blueprints for staffing plans that are linked to quality outcomes. Methods Secondary analysis of prospective, observational data from 95 patient care units (cardiac intensive care, n = 15; noncardiac intensive care, n = 7; cardiac intermediate care, n = 18; noncardiac intermediate care, n = 12, and medical–surgical, n = 43) across 10 acute care hospitals. Results No statistically significant relationships were found between central line infection and pressure ulcer rates and staffing across specialty units. Significant inverse relationships were present between staffing and falls in cardiac intensive care, medication errors in both cardiac and noncardiac intensive care units, and restraint rates in the medical–surgical units. Conclusions Results from this study suggest that the impact of staffing on outcomes is highly variable across specialty units; however, when present, the relationships are inversely related with lower staffing levels, resulting in higher rates of all outcomes.

Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting

Objective Although an extensive number of studies have attempted to identify predictors of new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG), a strong predictive model does not exist. Prior studies have included patients recruited from multiple centers with variant AFIB prevalence rates and those who underwent CABG in combination with other surgical procedures. Also, most studies have focused on pre- and perioperative characteristics, with less attention given to the initial postoperative period. The purpose of this study was to comprehensively examine pre-, peri-, and postoperative characteristics that might predict new-onset AFIB in a large sample of patients undergoing isolated CABG in a single medical center, utilizing data readily available to clinicians in electronic data repositories. In addition, length of stay and selected postoperative complications and disposition were compared in patients with AFIB and no AFIB. Design Retrospective, comparative survey. Setting University-affiliated tertiary care hospital. Patients Patients with new-onset AFIB who underwent isolated standard CABG or minimally invasive direct vision coronary artery bypass were identified from an electronic clinical data repository. Interventions None. Measurements and Main Results The prevalence of AFIB in the total sample (n = 814) was 31.9%. Predictors of AFIB included age (p = .0004), number of vessels bypassed (p = .013), vessel location (diagonal [p < .003] or posterior descending artery [p < .001]), and net fluid balance on the operative day (p = .015). Forward stepwise regression analysis produced a model that correctly predicted AFIB in only 24% of cases, with age (14%) and body surface area (9%) providing the most prediction. The incidence of embolic stroke was higher in AFIB (n = 8) vs. no AFIB (n = 4) patients, but stroke preceded AFIB onset in seven of eight cases. Subjects with AFIB had a longer stay (p = .0004), more intensive care unit readmissions (p = .0004), and required more assistance at hospital discharge (p = .017). Conclusions Despite attempts to examine comprehensively predictors of new-onset AFIB, we were unable to identify a robust predictive model. Our findings, in combination with prior work, imply that it may not be feasible to predict the development of new-onset AFIB after CABG using data readily available to the bedside clinician. In this sample, stroke was uncommon and, when it occurred, preceded AFIB in all but one case. As anticipated, AFIB increased length of stay, and patients with this complication required more assistance at discharge.

Atrial fibrillation : Prevalence after minimally invasive direct and standard coronary artery bypass

BACKGROUND This study identified and compared the prevalence of new-onset atrial fibrillation (AFIB) following standard coronary artery bypass grafting (SCABG) with cardiopulmonary bypass (CPB) and minimally invasive direct vision coronary artery bypass grafting (MIDCAB) without CPB. A further comparison was made between AFIB prevalence in SCABG and MIDCAB subjects with two or fewer bypasses. METHODS This is a retrospective, comparative survey. Patients with new-onset AFIB who underwent SCABG or MIDCAB alone were identified electronically using a triangulated method (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9 CM] code; clinical database word search; and pharmacy database drug search). RESULTS The total sample (n = 814; 94 MIDCAB, 720 SCABG) exhibited a trend toward lower AFIB prevalence in MIDCAB (23.4%) versus SCABG (33.1%) subjects (p = 0.059). AFIB prevalence in the SCABG subset with two or less vessel bypasses (n = 98; n = 18 single vessel, n = 80 double vessels) and MIDCAB subjects (n = 94; n = 90 single vessels, n = 4 double vessels) was almost identical (SCABG subset 24.5% versus MIDCAB 23.4%, p = 0.860). Slightly more than half (56.9%) of new-onset AFIB subjects were identified by ICD-9 CM codes, with the remainder by word search (37.7%) or procainamide query (5.4%). CONCLUSIONS In this sample, the number of vessels bypassed seemed to have a greater influence on AFIB prevalence than the application of CPB or the surgical approach. Retrospective identification of AFIB cases by ICD-9 CM code grossly underestimated AFIB prevalence.

Staffing and pattern of mechanical restraint use across a multiple hospital system.

BackgroundIn an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals. ObjectivesTo determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing. MethodsThis was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1–12 months for a total of 566 cumulative months during 1999. ResultsThe system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3–4.4%). More restraints were applied on night shifts (48.8%;n = 5,296) than on day (33.5%;n = 3,634) or evening shifts (17.7%;n = 1,926) (p < .0001) and most applied at midnight (31.7%;n = 3,441) followed by 0600–0900 (33.3%;n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001). ConclusionsRestraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.

Developing a Multi-institutional Nursing Report Card

As regulatory and public interest groups demand information on the quality of patient care outcomes produced by their hospitals and care providers, nurse administrators are establishing processes for the effective and efficient definition, retrieval, and reporting of patient outcomes thought to be nursing-sensitive. The authors describe the administrative infrastructure and the data management processes used by one large integrated healthcare system to establish a nursing report card and maintain it for several years.

Outcomes research: Getting started, defining outcomes, a framework, and data sources

As key providers of care and as participants in systems delivering care, APNs are in ideal positions to explore, identify, measure, and evaluate patient outcomes. This article has provided an overview of some of the basic knowledge and skills required to undertake outcome studies. Through the application of these basic principles, the beginning APN can start to explore patient outcomes via quality improvement activities. With mastery and expansion of these principles, the expert APN can easily progress into outcomes research studies, which provide substantive contributions to the outcomes research agenda.

Outcomes research in advanced practice nursing selecting an outcome.

APNs should investigate outcomes that will enhance patient care and contribute to building nursing knowledge and science; however, APNs should also consider addressing and including into their daily activities outcomes that are of interest to governmental, accreditation, and not-for-profit groups. APNs can accomplish this in a number of ways within the numerous roles from which they practice. APNs practicing as clinical nurse specialists can incorporate these outcomes into hospital based quality improvement or management activities in which they already routinely initiate or participate. Additionally, in their roles as role model or educator they can provide their professional nursing colleagues with a clear understanding of these outcomes and their importance to patient care and the institutions success. And finally, in their role as acute care nurse practitioners, APNs can seek to measure and benchmark their own performance on many of these measures. Active participation in measuring, reporting, and improving the outcomes addressed within this article will help ensure that all patients achieve a minimum consistent level of quality outcomes. Of equal importance, however, is that by being active partners in achieving these outcomes, APNs will further enhance recognition of the vital role nursing plays in improving the quality of care provided to all Americans by our healthcare system.