Martha Mackay

Evaluation of a nurse-delivered smoking cessation intervention for hospitalized patients with cardiac disease

OBJECTIVE To determine the effect of a nurse-delivered smoking cessation intervention for hospitalized smokers on smoking cessation rates and smoking cessation self-efficacy at 6 months after enrollment. DESIGN A quasi-experimental design was used; specifically, a nonequivalent control group design was implemented. SETTING A 450-bed major teaching and research tertiary care hospital, serving patients from across the province of British Columbia, Canada. SUBJECTS Smokers with a cardiac diagnosis (n = 102) who were admitted to 1 of 2 inpatient cardiac units for medical or surgical treatment. OUTCOME MEASURES Self-reported smoking status and self-reported smoking cessation self-efficacy. INTERVENTION Two structured, in-hospital contacts, followed by 3 months of telephone support. The interventions focused on problem-solving and reinforcing the patients self-efficacy. RESULTS Of the patients enrolled, 86 completed 6-month follow-up questionnaires. When subjects who were lost to follow-up were assumed to be smokers, 46% of the intervention group, compared with 31% of the control group, were nonsmokers. When key variables were controlled, we found that those subjects in the control group were 3 times more likely to relapse and begin smoking than those who received the intervention. There were no significant differences in follow-up smoking cessation self-efficacy scores in the treatment and control groups. When background variables were controlled, self-efficacy related to positive/social situations and habit/addictive situations were noted to be significantly higher in the intervention group. CONCLUSION The findings of this research are encouraging; they suggest that a nurse-delivered smoking cessation intervention improved the smoking cessation rate in patients with cardiac disease.

Gender differences in symptoms of myocardial ischaemia

AIMS Better understanding of symptoms of myocardial ischaemia is needed to improve timeliness of treatment for acute coronary syndromes (ACS). Although researchers have suggested sex differences exist in ischaemic symptoms, methodological issues prevent conclusions. Using percutaneous coronary intervention (PCI) balloon inflation as a model of myocardial ischaemia, we explored sex differences in reported symptoms of ischaemia. METHODS AND RESULTS Patients having non-emergent PCI, but not haemodynamic instability or left bundle branch block or non-acute coronary occlusion, were prospectively recruited. Pre-procedure, descriptions of pre-existing symptoms were obtained using open-ended questioning. Inflation was maintained for 2 min or until moderate discomfort or clinical instability occurred. During inflation, subjects were exhaustively questioned about their symptoms. Concurrent ECG data were collected. The final sample was 305 [39.7% women; mean age 63.9 (± 10.6)]. No sex differences were found in rates of chest or typical ischaemic discomfort, regardless of ischaemic status. Women were significantly more likely to report throat/jaw discomfort [odds ratio: 2.91; 95% confidence interval: 1.58-5.37] even after statistical adjustment for clinical and demographic variables. CONCLUSION This prospective study with ECG-affirmed ischaemia found no statistically significant differences in womens and mens rates of chest and other typical symptoms during ischaemia, although women were more likely to experience throat and jaw discomfort. Currently both popular press and some patient education materials suggest women experience myocardial ischaemia differently from men. Steps to ensure women and health professionals are alert for the classic symptoms of myocardial ischaemia in women, as well as men, may be warranted.

Myocardial infarction symptom recognition by the lay public: the role of gender and ethnicity

Study objective: To find out if gender and ethnicity are associated with acute myocardial infarction (AMI) symptom recognition and the recommendation of enlisting emergency medical services. Design: In an experiment, a random sample of the public was provided a scenario of a person experiencing symptoms of AMI; the gender of the character (male, female, or indeterminate) was manipulated. Setting: Vancouver, Canada Participants: 976 people from a population based random sample of 3419 people, 40 years of age and older, participated in a telephone survey given in English, Cantonese, Mandarin, and Punjabi. Main results: 78% of the respondents identified the symptoms as heart related. Unadjusted analyses showed that ethnicity, education, income, and AMI knowledge were significantly associated with symptom recognition (Chinese respondents were least likely to identify the symptoms as heart related). Thirty seven per cent recommended calling emergency services, which was associated with symptom recognition, ethnicity (Chinese respondents were least likely to make the recommendation), AMI knowledge, having an immediate family member with AMI, and having talked with a health professional about the signs and symptoms of AMI. Neither the gender of the respondent nor of the affected person in the scenario was associated with symptom recognition. Conclusions: Heart health education must be targeted to and tailored for ethnic communities. Health professionals must discuss the signs and symptoms of AMI, and the correct course of action, with their patients.

RESEARCH UTILIZATION AND THE CNS : CONFRONTING THE ISSUES

Utilization of research in nursing is still inconsistent despite nearly two decades of published models and studies on the subject, and of leaders urging that the profession must increase its use of research. In fact, several questions regarding research utilization in nursing remain unanswered. A review of selected models of research utilization is presented, as well as a review of the published studies of utilization barriers and facilitators. Three key questions for the profession as a whole and for the clinical nurse specialist (CNS) in particular are advanced, and concrete answers for the practicing CNS are offered.

Outcomes following percutaneous coronary intervention and coronary artery bypass grafting surgery in Chinese, South Asian and white patients with acute myocardial infarction: administrative data analysis

BackgroundLittle is known on whether there are ethnic differences in outcomes following percutaneous coronary intervention (PCI) and coronary artery bypass grafting surgery (CABG) after acute myocardial infarction (AMI). We compared 30-day and long-term mortality, recurrent AMI, and congestive heart failure in South Asian, Chinese and White patients with AMI who underwent PCI and CABG.MethodsHospital administrative data in British Columbia (BC), Canada were linked to the BC Cardiac Registry to identify all patients with AMI who underwent PCI (n = 4729) or CABG (n = 1687) (1999–2003). Ethnicity was determined from validated surname algorithms. Logistic regression for 30-day mortality and Cox proportional-hazards models were adjusted for age, sex, socio-economic status, severity of coronary disease, comorbid conditions, time from AMI to a revascularization procedure and distance to the nearest hospital.ResultsFollowing PCI, Chinese had higher short-term mortality (Odds Ratio (OR): 2.36, 95% CI: 1.12-5.00; p = 0.02), and South Asians had a higher risk for recurrent AMI (OR: 1.34, 95% CI: 1.08-1.67, p = 0.007) and heart failure (OR 1.81, 95% CI: 1.00-3.29, p = 0.05) compared to White patients. Risk of heart failure was higher in South Asian patients who underwent CABG compared to White patients (OR (95% CI) = 2.06 (0.92-4.61), p = 0.08). There were no significant differences in mortality following CABG between groups.ConclusionsChinese and South Asian patients with AMI and PCI or CABG had worse outcomes compared to their White counterparts. Further studies are needed to confirm these findings and investigate potential underlying causes.

Percutaneous aortic valve implantation: A case report

The present case demonstrates the percutaneous implantation of a bioprosthetic valve in a patient with severe aortic stenosis. An 85-year-old man with significant comorbidities was determined to be at unacceptable risk with traditional surgical valve replacement. Percutaneous aortic valve implantation was performed, was successful and uncomplicated, with significant clinical and hemodynamic improvement. Currently, this procedure is an option only for symptomatic patients who are not appropriate candidates for surgical valve replacement.

There Are Sex Differences in the Demographics and Risk Profiles of Emergency Department (ED) Patients With Atrial Fibrillation and Flutter, but no Apparent Differences in ED Management or Outcomes

OBJECTIVES In non-emergency department (ED) settings, women with atrial fibrillation and flutter (AFF) have different presentations, treatments, and outcomes than men: they are older, less likely to be treated with rhythm control strategies or appropriate anticoagulation, and more likely to have strokes. This has not been investigated in ED patients. METHODS Records from consecutive ED patients from January 1 to December 31, 2009, with electrocardiogram-proven AFF at two urban hospitals were collected. Review of administrative and clinical data identified patient demographics, clinical characteristics, comorbidities, and ED treatments. The regional ED database was queried to determine 30-day and 1-year follow-up visits, and the provincial vital statistics database was referenced to obtain 30-day and 1-year mortality; all outcomes were stratified by sex. The primary outcome, which reflected overall appropriateness of ED care, was the proportion of patients who were discharged home at their index ED visits, who then had unscheduled 30-day ED revisits. Secondary outcomes included the proportion of eligible patients who underwent acute rhythm control strategies and the proportion of high-risk patients who had previously inadequately anticoagulation strategies corrected by the emergency physician. Additional outcomes included the ED length of stay (LOS) and 30-day and 1-year rates of stroke and death. RESULTS A total of 1,112 records were reviewed: 470 women (42.3%) and 642 men. Women were a median 8 years (interquartile range = 3 to 13 years) older than men, had higher rates of cardiovascular comorbidities, and were more likely to present with atypical symptoms such as weakness or dyspnea. On their index ED visits, 50.2% of women and 41.3% of men were admitted. At 30 days, 39 of 234 (16.7%) women and 55 of 377 (14.6%) men who were discharged at their index ED visits had made revisits, for a risk difference of 2.1% (95% confidence interval = -3.9% to 8.5%). There were no apparent sex differences in the use of acute rhythm control or in the appropriateness of anticoagulation decisions. ED LOS was similar between women and men, as were 30-day and 1-year stroke or death rates. CONCLUSIONS Female ED AFF patients were older, had more comorbidities, and were more likely to be admitted. However, the overall management and outcomes, including 30-day revisits, appeared to be similar to that of males, indicating that there appeared to be little sex-based discrepancy in ED care and outcomes.

Inconsistent measurement of acute coronary syndrome patients' pre-hospital delay in research: a review of the literature.

Background: Patients’ treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research. Methods and results: We reviewed the English-language literature from 1998–2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing. Conclusion: We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.

Why nursing has not embraced the clinician–scientist role

Reasons for the limited uptake of the clinician-scientist role within nursing are examined, specifically: the lack of consensus about the nature of nursing science; the varying approaches to epistemology; and the influence of post-modern thought on knowledge development in nursing. It is suggested that under-development of this role may be remedied by achieving agreement that science is a necessary, worthy pursuit for nursing, and that rigorous science conducted from a clinical perspective serves nursing well. Straddling practice and research is a powerful strategy for ensuring relevant research while forging strong links with practice. The clinician-scientist role, typically requiring a 75:25 ratio between research and clinical activities, is well established in medicine. Nursing, however, has been slow to institute the role; it is rare within North America, Australia, and western European countries, and almost non-existent outside those areas. Beyond structural obstacles, philosophical issues may explain nursings reluctance to implement the role. Following a survey of clinician-scientist roles throughout the world, the nature of nursing science and epistemology, and the influence of post-modern thought on nursing attitudes to research are examined with respect to their influence on this role. The nurse clinician-scientist role holds promise for making strides in clinically relevant research, and for accelerating the knowledge cycle from clinical problem to research question to change in clinical practice.

Sex and Ethnic Differences in Outcomes of Acute Coronary Syndrome and Stable Angina Patients With Obstructive Coronary Artery Disease

Background—The joint contribution of sex, ethnicity, and initial clinical presentation to the long-term outcomes of patients undergoing coronary angiography for acute coronary syndrome (ACS) or stable angina, in whom there is angiographic evidence for obstructive coronary artery disease, remains unknown. Methods and Results—We conducted a population-based cohort study on 49 556 adult ACS or stable angina patients with angiographic evidence of obstructive coronary artery disease (≥50% stenosis) in British Columbia. The 2-year composite outcome was all-cause death and hospital readmissions for myocardial infarction, heart failure, cerebrovascular accident, or angina after the index angiography. Sex and ethnic differences in the composite outcome were examined by clinical presentation using the Cox proportional-hazards and logistic regression models. Overall, 25.6% were women, 9.5% were South Asians, 3.0% were Chinese, and 65.9% presented with ACS. Regardless of ethnicity, women were more likely than men to have adverse outcomes, but the magnitude of the sex difference was greater in the ACS patients (Pinteraction for sex and clinical presentation=0.03). Angina readmission accounted for 45% of the composite outcome and was the main component for all groups with the exception of Chinese women with ACS. Furthermore, women were more likely than men to be readmitted for angina (odds ratio [95% confidence interval], 1.13 [1.04–1.22]). Conclusions—Higher rates of adverse events among women with obstructive coronary artery disease, regardless of ethnicity, as well as high rates of angina readmission, highlight the need for more targeted interventions to reduce the burden of angina because this presentation is clearly not benign.