Jenny Tagney

Exploring the patient's experiences of learning to live with an implantable cardioverter defibrillator (ICD) from one UK centre: a qualitative study.

BACKGROUND: International expansion of indications for implantable cardioverter defibrillator (ICD) implant means increasing numbers of patients with devices worldwide. However, smaller numbers of patients with ICDs in the UK has meant that clinical expertise available to care for this specialized group is limited. Whilst North American patients’ experiences of living with an ICD are well documented, European perspectives remain underrepresented. AIM: The aim of this study was to explore and describe patients experiences around the time of their ICD device implant and after they returned home from one UK centre. METHODS AND RESULTS: Eligible patients were recruited from one regional cardiothoracic centre and interviewed in their own homes using semi-structured schedules. Analysis of data elicited three themes; non-individualised nature of information, adjustments to living with the device and future outlook. Unique findings identified were; (a) concealment of concerns and symptoms; (b) funding issues; and (c) unavailability of appropriate support and advice during and after time in hospital. CONCLUSION: Individualized care and support for these ICD patients appeared lacking according to respondents. Opportunities to discuss concerns appeared non-existent, which may indicate that UK patients are disadvantaged in the domain of psychological support compared with their European and North American counterparts. Findings remain tentative until explored with a larger, more representative and international sample.

1353: A Pilot Postal Survey of Patients' Experiences Following Implantable Cardioverter Defibrillator (ICD) Implant

Purpose: Despite improving survival and some aspects of quality-of-life, implantation and activation of an ICD may cause adverse psycho-social impact including anticipation and fear of shocks, changes in relationship, resentment at imposed driving ban and employment concerns. Recent qualitative data from the UK and elsewhere suggests that service providers fail to address individualised needs of ICD patients. Thus a survey was designed with the purpose of identifying the scope of patient concerns and priorities and whether these changed over time. Method: A questionnaire was designed based on previous research findings. Questions related to: assessing the nature of preparation patients received prior to going home; identifying patients’ main concerns and whether, or how, these changed over time; assessing the physical, emotional and social responses to living with an ICD; discovering any gender differences regarding the process of adjustment and identifying any helpful interventions. Between February and July 2003, all patients receiving ICD follow-up care at one UK centre(ns134) were invited to participate in the study by means of a letter. Those who consented returned their questionnaire by post. Quantitative data were analysed using non-parametric tests in SPSS(version 11) software. Qualitative responses were collated and analysed using inductive content analysis. Results: 96 of the 134 questionnaires were returned providing a high response rate of 75%. 78 ( 1%) reported their gender, of which 66(85%) were male and had their ICD fitted over18months ago(65.6%). Most patients indicated that they received technical, safety and physical care information prior to discharge but fewer indicated that they were given the opportunity to explore feelings and concerns. Not being permitted to drive was the most frequently identified concern at the time of implant (67.7% ns65) closely linked with being dependent on others for transport (60.4% ns58). However, qualitative responses indicated that the overall greatest concern for patients revolved around device function and having a shock. Reported concerns altered considerably over time. No specific interventions were identified that helped although technical and medical staff at follow-up clinics were found to be supportive. Conclusion: These preliminary findings indicate that physical and technical aspects of care remain dominant over psycho-social needs. Additionally, this study indicates that patients’ needs change over time. Although only pilot data, results could be used to enlighten preparation information prior to implant and enhance discharge planning to ensure patients are made aware of and prepared for commonly identified concerns.

101 All Patients Immediately Post Primary Percutaneous Coronary Intervention (PPCI) Are Cared for in An Acute Cardiac Care Environment. Is it About Time We Reviewed Our Practice

Introduction Primary percutaneous coronary intervention (PPCI) targets early intervention, achieving better outcomes for patients suffering from ST elevation myocardial infarction (STEMI). European Society of Cardiology (ESC) guidelines (2012) advocate acute cardiac units as the environment of choice in which patients should be cared for by highly trained and skilled nurses who provide close monitoring and rapid response to acute changes. However the advancements in accessing early intervention by PPCI with fewer complications and improved outcomes, anecdotally some patients following uncomplicated PPCI are the most stable patients on the acute cardiac ward. We re-evaluated the nursing care pathway of the PPCI group of patients. Method A review of the literature on the nursing care post PPCI to establish an evidence base. A national benchmarking exercise on the context of the care setting, the timing of nursing interventions and length of stay on the acute cardiac units and within the hospital to identify whether unpublished care standards exist. Results The literature review identified few studies which established the standards of nursing care in this group (Oriolo and Tagney 2011, Viana-Tejedor et al 2009), much of the written nursing care is based upon traditional practices or consensus of medical opinion founded on the anticipation of complications post PPCI. For the bench marking exercise, 17/30 centres provided information by telephone. All patients post PPCI were admitted to an acute cardiac unit with ECG monitoring. There was large variation in the timing of nursing interventions; length of ECG monitoring (12 – 48 hrs), fluid balance monitoring (0 – 24 hrs) or mobilisation of the patients (6 – 24hrs). More than half kept their patients routinely on the acute cardiac unit for at least 24 h before stepping down to the ward. Two centres would step down at 12 h routinely, however five centres stated that step down was reviewed earlier dependant on patients need. Three centres discharge their patients home at 48 h with the largest number between 48–72 h, some considering “sleeps” rather than hours. One unit had no set criteria for movement, moving as part of acuity; however this was part of a larger unit so easier to manage patients. Some units varied the discharge home depending on area of STEMI or LV function or Doctor Preference. Conclusion There is little evidence to support the current timing of care of the patient post PPCI and the subsequent bench marking exercise demonstrated that set criteria was being applied to this patient group based on tradition or experience. There is little evidence that practices have changes with the advances in the outcomes post PPCI. With this variation nationally there is a need for further exploration in this area to provide a more concise, evidence based standards which would improve that patient pathway and make better use of the resources available.

The ‘New Order’ requests our help

It’s an interesting tactic isn’t it? We’ve all been asked to contribute our ideas ‘to make things better for less money’ via the Prime Minister’s specially-established website ‘The Spending Challenge’ (2010), following a letter sent by the Prime Minister David Cameron and Deputy Prime Minister Nick Clegg to all public sector workers (Cameron and Clegg, 2010). Apparently, public sector workers have responded well already—20 000 responses received when I access the site on June 28th. Who will review all the ideas? Who gets to say what will work and what will not? Does it give the government the power to say ‘well, these were your ideas—now you need to make them work’? Challenging it certainly will be, but how will success be judged: job losses or lack thereof? It does seem slightly perplexing that some jobs were created apparently specifi cally to meet the previous government’s targets (for example, NHS Direct appeared largely as part of attempts to prevent attendances to accident and emergency and GP surge...

It’s all about awareness

Did you know that the average wine drinker now consumes around 2000 calories in alcohol per month? In the recent Department of Health ‘Know your Limits’ campaign survey many women admitted that they did not know that a glass of white wine contains the same calories as a bag of crisps or that two large glasses of white wine put a woman over her daily recommended alcohol intake (DH, 2009). The leaflets that have been produced as part of the campaign aim to raise awareness of such simple facts, particularly in young people.

The shape of things to come

As I write this, there is a strange mix of developments within the health service. Obviously, we remain fairly dominated by swine flu and all the potential problems this will bring, including staff shortages. But there are many other significant issues that I fear have been overshadowed by the media frenzy this has attracted.

Semi-skimmed but fully skilled

Well, for the many of us that sought solace from the wild and wet conditions in the UK over the ‘summer’ by over-indulging in cream teas, this issue may bring an unwelcome potential threat to our attention—cholesterol! NICE has also been busy developing related clinical guidelines over the past few months too so it cannot have escaped your notice (NICE, 2008a; NICE, 2008b)! It is easy to see why GPs might find it difficult to keep up-to-date with recommendations as even the quick reference guides for both these new guidelines are quite sizable documents. All the more reason for cardiovascular nurses in every setting to be informed and able to explain such issues to patients.

A guide to coronary care

The first edition of this established reference text Comprehensive Coronary Care was published in 1989.This fourth edition, with foreword by Professor Roger Boyle CBE, National Director for Heart Disease and Stroke, comes nearly 20 years after the idea for the first edition was conceived by Jowett and Thompson while working together on a coronary care unit (CCU) in Leicester, UK.

1367: Caring for and Supporting the Patient with an ICD—The Experiences of Partners in the United Kingdom

taking, review of body systems and physical examination. These latter elements of clinical assessment have traditionally been viewed as exclusively the remit of the medical profession. Indeed the four cornerstones of inspection, palpation, percussion and auscultation are not considered to be fundamental skills within the scope of nursing practice in the UK. The current climate within the health sector and government legislation has provided an opportunity for nurses to develop their roles. The cardiac field of nursing is no exception when considering the introduction and implications of the national service frameworks for heart disease. Implementation of which requires a shift in traditional professional boundaries if improvements in efficiency and quality are to be achieved. Method: It is recognised that education and training needs to be in place to support such initiatives. In particular post registration cardiac nurse education should be inclusive of history taking, clinical assessment, triage and prescribing. To meet this demand in the South Wales area, a degree level, 15 week module, in clinical assessment was devised. The planning team consisted of both lecturers in cardiac and critical care together with senior clinicians in practice. The module offered the opportunity for any practising registered nurse to gain skills in advanced clinical assessment Results: Two cohorts totalling 40 nurses have enrolled to date. Five were cardiac nurses working in the acute hospital environment. Preliminary review indicates that many of the assessment skills acquired during the module are not being utilised by these cardiac nurses in their everyday clinical practice. Conclusion: Despite a growing demand for cardiac nurses to attend such educational and training programmes, the application in practice is not realised. Reflecting a dichotomy between government proposals and the clinical reality of traditional role diversification. There has been no formalised evaluation as to the utilisation of these newly acquired skills within the clinical area following completion of the module. Before adoption of advanced clinical assessment as a fundamental skill for cardiac nurses, there must be evaluation of existing developments.