A qualitative study of barriers and facilitators to using tenecteplase to treat acute ischemic stroke.

BACKGROUND: Tenecteplase (TNK) is emerging as an alternative to alteplase (ALT) for thrombolytic treatment of acute ischemic stroke (AIS). Compared to ALT, TNK has a longer half-life, shorter administration time, lower cost, and similarly high efficacy in treating large vessel occlusion. Nevertheless, there are barriers to adopting TNK as a treatment for AIS. This study aimed to identify thematic barriers and facilitators to adopting TNK as an alternative to ALT as a thrombolytic for eligible AIS patients. METHODS: Qualitative research methodology using hermeneutic cycling and purposive sampling was used to interview four stroke clinicians in Texas. Interviews were recorded and transcribed verbatim. Enrollment was complete when saturation was reached. All members of the research team participated in content analysis during each cycle and in thematic analysis after saturation. RESULTS: Interviews were conducted between November 2022 and February 2023 with stroke center representatives from centers that either had successfully adopted TNK, or had not yet adopted TNK. Three themes and eight sub-themes were identified. The theme "Evidence" had three sub-themes: Pro-Con Balance, Fundamental Knowledge, and Pharmacotherapeutics. The theme "Process Flow" had four subthemes: Proactive, Reflective self-doubt, Change Process Barriers, and Parameter Barriers. The theme "Consensus" had one sub-theme: Getting Buy-In. CONCLUSION: Clinicians experience remarkably similar barriers and facilitators to adopting TNK. The results lead to a hypothesis that providing evidence to support a practice change, and identifying key change processes, will help clinicians achieve consensus across teams that need to 'buy in' to adopting TNK for AIS treatment.

Multicenter exploration of tenecteplase transition factors: A quantitative analysis.

BACKGROUND: Tenecteplase (TNK) is gaining recognition as a novel therapy for acute ischemic stroke (AIS). Despite TNK offering a longer half-life, time and cost saving benefits and comparable treatment and safety profiles to Alteplase (ALT), the adoption of TNK as a treatment for AIS presents challenges for hospital systems. OBJECTIVE: Identify barriers and facilitators of TNK implementation at acute care hospitals in Texas. METHODS: This prospective survey used open-ended questions and Likert statements generated from content experts and informed by qualitative research. Stroke clinicians and nurses working at 40 different hospitals in Texas were surveyed using a virtual platform. RESULTS: The 40 hospitals had a median of 34 (IQR 24.5-49) emergency department beds and 42.5 (IQR 23.5-64.5) inpatient stroke beds with 506.5 (IQR 350-797.5) annual stroke admissions. Fifty percent of the hospitals were Comprehensive Stroke Centers, and 18 (45 %) were solely using ALT for treatment of eligible AIS patients. Primary facilitators to TNK transition were team buy-in and a willingness of stroke physicians, nurses, and pharmacists to adopt TNK. Leading barriers were lack of clinical evidence supporting TNK safety profile inadequate evidence supporting TNK use and a lack of American Heart Association guidelines support for TNK administration in all AIS cases. CONCLUSION: Understanding common barriers and facilitators to TNK adoption can assist acute care hospitals deciding to implement TNK as a treatment for AIS. These findings will be used to design a TNK adoption Toolkit, utilizing implementation science techniques, to address identified obstacles and to leverage facilitators.

Door to needle time trends after transition to tenecteplase: A Multicenter Texas stroke registry.

BACKGROUND: Tenecteplase (TNK) is considered a promising option for the treatment of acute ischemic stroke (AIS) with the potential to decrease door-to-needle times (DTN). This study investigates DTN metrics and trends after transition to tenecteplase. METHODS: The Lone Star Stroke (LSS) Research Consortium TNK registry incorporated data from three Texas hospitals that transitioned to TNK. Subject data mapped to Get-With-the-Guidelines stroke variables from October 1, 2019 to March 31, 2023 were limited to patients who received either alteplase (ALT) or TNK within the 90 min DTN times. The dataset was stratified into ALT and TNK cohorts with univariate tables for each measured variable and further analyzed using descriptive statistics. Logistic regression models were constructed for both ALT and TNK to investigate trends in DTN times. RESULTS: In the overall cohort, the TNK cohort (n = 151) and ALT cohort (n = 161) exhibited comparable population demographics, differing only in a higher prevalence of White individuals in the TNK cohort. Both cohorts demonstrated similar clinical parameters, including mean NIHSS, blood glucose levels, and systolic blood pressure at admission. In the univariate analysis, no difference was observed in median DTN time within the 90 min time window compared to the ALT cohort [40 min (30-53) vs 45 min (35-55); P = .057]. In multivariable models, DTN times by thrombolytic did not significantly differ when adjusting for NIHSS, age (P = .133), or race and ethnicity (P = .092). Regression models for the overall cohort indicate no significant DTN temporal trends for TNK (P = .84) after transition; nonetheless, when stratified by hospital, a single subgroup demonstrated a significant DTN upward trend (P = 0.002). CONCLUSION: In the overall cohort, TNK and ALT exhibited comparable temporal trends and at least stable DTN times. This indicates that the shift to TNK did not have an adverse impact on the DTN stroke metrics. This seamless transition is likely attributed to the similarity of inclusion and exclusion criteria, as well as the administration processes for both medications. When stratified by hospital, the three subgroups demonstrated variable DTN time trends which highlight the potential for either fatigue or unpreparedness when switching to TNK. Because our study included a multi-ethnic cohort from multiple large Texas cities, the stable DTN times after transition to TNK is likely applicable to other healthcare systems.

The Relationship Between Lesion Localization and Dysphagia in Acute Stroke.

Factors that can facilitate early identification of individuals at risk of dysphagia such as stroke location are potentially of great benefit. The aim of this study was to examine the role of hemisphere and lesion location in assessing dysphagia pattern and airway invasion as identified through the use of validated, standardized interpretation measures for the videofluoroscopic swallowing study. Consecutive patients (N = 80) presenting with stroke symptoms who had a first-time acute ischemic stroke confirmed on diffusion-weighted magnetic resonance imaging (DW-MRI) scan participated. Three swallowing outcome variables were assessed using regression models: modified barium swallow impairment profile (MBSImP) oral impairment (OI) and pharyngeal impairment (PI) scores and penetration aspiration scale (PAS) score. Subjects were primarily male and demonstrated mild stroke and mild to moderate dysphagia. There was a significantly higher likelihood of abnormal PAS scores for infratentorial lesions compared to right hemisphere location (Odds ratio: 3.1, SE: 1.8, p = 0.046) and for Whites compared to African Americans (Odds ratio: 5.5, SE: 2.6, p = <0.001). However, OI scores were higher (worse) in African Americans compared to Whites (Beta = -1.2; SE: 0.56; p = 0.037). PI scores had no significant association with race or lesion location. Using DW-MRI to identify infratentorial stroke can help identify individuals at risk of airway invasion; however, imaging information concerning supratentorial infarct hemisphere and location may not be useful to predict which individuals with mild stroke are at risk for dysphagia and aspiration when admitted with acute stroke symptoms. Future studies should explore the role of race in the development of stroke-related dysphagia.

A Multiple Behavior Self-Monitoring Intervention for African- American Veterans with Type 2 Diabetes: A Feasibility Implementation Study.

The purpose of this study was to determine the feasibility of implementing a multiple-behavior self-monitoring intervention within a diabetes education program. This study was a 3-month pre- post-design, conducted with African-Americans (N = 20), who attended diabetes education classes at a large Veteran's Affairs (VA) hospital in Southwest Texas. Participants selfmonitored their blood glucose, diet, exercise, and weight on either a smart phone application or paper diaries. Paired t tests showed strong evidence that patient self-monitoring of healthy lifestyle behaviors improved blood glucose (t = -3.858, p = .001) and HbAlc (t = -4.428, p <.001), respectively. Moreover Spearman's correlation coefficient showed significant correlations between blood glucose and exercise (rs = -.68, p = .008) and HbAlc and exercise (rs = -.56, p = .036). This feasibility study showed that multiple-behavior self-monitoring was effective in lowering blood glucose and HbA1c levels among African-American Veterans; however, a randomized controlled trial with a larger sample is needed to validate these preliminary findings.

Rapid Aspiration Screening for Suspected Stroke: Part 2: Initial and Sustained Nurse Accuracy and Reliability.

OBJECTIVE: To determine registered nurses' (RNs') ability to obtain and maintain accurate procedural skills and reliable interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. DESIGN: Prospective, observation study. SETTING: A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS: RNs (N=15) were recruited and trained in the administration and interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. INTERVENTIONS: RNs completed a total of 239 screenings of patients admitted with suspected stroke over a 2-year period. RNs administered the swallowing screening items and interpreted the patient's response to each item. Independent of the RN, a speech-language pathologist simultaneously interpreted the response of the participant with stroke to each swallowing screening item. MAIN OUTCOME MEASURES: Reliability of the interpretation and accuracy of the administration of the swallowing screening items. RESULTS: The average accuracy rate for the administration of the Rapid Aspiration Screening for Suspected Stroke was 98.33%, with the overall accuracy rate for each procedural task ranging from 95.42% to 100%. For the specific swallowing screening items that formed the Rapid Aspiration Screening for Suspected Stroke, dysarthria and a positive sign after water swallow, reliability was high (k=.817). The accuracy rate for the administration and reliability of the interpretation of the swallowing screening items improved as RNs gained experience, and both were maximized at 20 screening opportunities. CONCLUSIONS: RNs demonstrate both excellent accuracy of procedural administration and reliability of interpretation of the items of the Rapid Aspiration Screening for Suspected Stroke. With feedback and repeated opportunities to practice, maintenance of skills is achievable.

Rapid Aspiration Screening for Suspected Stroke: Part 1: Development and Validation.

OBJECTIVE: To develop and validate a nurse-administered screening tool to identify aspiration risk in patients with suspected stroke. DESIGN: Validity study comparing evidence-based swallowing screening items with the videofluoroscopic swallowing study (VFSS) results. SETTING: A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS: Consecutive patients (N=250) admitted with suspected stroke. INTERVENTIONS: Patients were administered evidence-based swallowing screening items by nurses. A VFSS was completed within 2 hours of swallowing screening. MAIN OUTCOME MEASURES: Validity relative to identifying VFSS-determined aspiration for each screening item and for various combinations of items. RESULTS: Aspiration was identified in 29 of 250 participants (12%). Logistic regression revealed that age (P=.012), dysarthria (P=.001), abnormal volitional cough (P=.030), and signs related to the water swallow trial (P=.021) were significantly associated with aspiration. Validity was then determined on the basis of the best combination of significant items for predicting aspiration. The results revealed that age >70 years, dysarthria, or signs related to the water swallow trial (ie, cough, throat clear, wet vocal quality, and inability to continuously drink 90mL water) yielded 93% sensitivity and 98% negative predictive value. CONCLUSIONS: The final validated tool, Rapid Aspiration Screening for Suspected Stroke, is a valid nurse-administered tool to detect risk of aspiration in patients presenting with suspected stroke.

Using Medical Mannequins to Train Nurses in Stroke Swallowing Screening.

Screening patients admitted with stroke symptoms for risk of aspiration is often the responsibility of registered nurses (RNs). Simulation technology has become a widely used evidence-based form of training for healthcare professionals. The purpose of this study was to determine if the use of medical simulation mannequins as a training component is feasible when training and evaluating nurses administering swallowing screenings to stroke patients. A total of 32 RNs were divided into one of two training groups: didactic training only or didactic training plus simulation. Acquisition of skills was assessed immediately post-training and compared between the groups revealing significant differences between simulation group and didactic-only group for interpretation (p = 0.01) and administration (p = 0.05) accuracies. Following training to 100 % accuracy for post-training baseline competency, maintenance of skills across participants was assessed three more times over 6 weeks with the third follow-up screening completed with a standardized patient (live patient actor). While interpretation performance at each subsequent trial never equaled the baseline 100 % post-training accuracy (p = 0.001), steady improvement in performance was observed with each follow-up assessment. For screening administration, no significant differences in skills were evident between post-training baseline competency and the 6-week follow-up (p = 0.269) further confirming improvement in skills over time. Extension of screening administration and interpretation skills to the standardized patient was evident. Findings indicate that simulation training using medical mannequins can be used to train and evaluate nurses for obtainment and maintenance of swallowing screening competency.

Speech Pathology Reliability for Stroke Swallowing Screening Items.

Swallowing screening is critical in rapid identification of risk of aspiration in patients presenting with acute stroke symptoms. Accuracy in judgments is vital for the success of the screening. This study examined speech-language pathologists' (SLPs) reliability in interpreting screening items. Swallowing screening was completed in 75 individuals admitted with stroke symptoms. Screening items evaluated were lethargy, dysarthria, wet voice unrelated to swallowing, abnormal volitional cough, and cough, throat clear, wet voice after swallowing, and inability to continuously drink with ingestion of 5 and 90 ml water. Two SLPs, each with more than 10 years of experience, made simultaneous independent judgments of the same observations obtained from the screening. Overall, generally high agreement was identified between the SLPs (k[SE] = 0.83[0.03]). Individual kappas ranged from 0.38 (fair) for non-swallowing wet voice to 0.95 (almost perfect) for cough after swallow, with one item omitted due to minimal variation. SLPs demonstrate high reliability in swallowing screening. Results, however, indicate some potential variability. Items associated with trial swallows had the highest reliability, whereas items related to judgments of speech and voice quality had the lowest. Although SLPs have dedicated training and ample opportunity to practice, differences in agreement are evident. Routine practice in hospital departments is recommended to establish and maintain sensitive perceptual discrimination. If other professionals are to provide swallowing screening, knowledge of SLPs' reliability levels must be considered when identifying screening items, creating education modules, and determining acceptable levels of agreement.

Percutaneous cryoablation of renal tumours: outcomes from 171 tumours in 147 patients.

OBJECTIVE: To evaluate the technical and oncological efficacy of an image-guided cryoablation programme for renal tumours. PATIENTS AND METHODS: A prospective analysis of technical and radiological outcomes was undertaken after treatment of 171 consecutive tumours in 147 patients. Oncological efficacy in a subset of 125 tumours in 104 patients with >6 months' radiological follow-up and a further subset of 62 patients with solitary, biopsy-proven renal carcinoma was also analysed. Factors influencing technical success, as determined by imaging follow-up, and complication rates were statistically analysed using a statistics software package and logistic regression analyses. RESULTS: No variables were found to predict subtotal treatment, although gender (P = 0.08), tumour size of >4 cm (P = 0.09) and central location of tumour (P = 0.07) approached significance. Upper pole location was the single variable that was found to predict complications (P = 0.006). Among the 104 patients (125 tumours), radiologically assessed at ≥6 months and with a mean radiological follow-up of 20.1 months, we found a single case of unexpected late local recurrence. CONCLUSION: Percutaneous image-guided cryoablation, at a mean of 20.1 months' follow-up, appears to provide a safe and effective treatment option with a low complication rate. Anteriorly sited tumours should not be considered a contraindication for percutaneous image-guided cryoablation.

Valid items for screening dysphagia risk in patients with stroke: a systematic review.

BACKGROUND AND PURPOSE: Screening for dysphagia is essential to the implementation of preventive therapies for patients with stroke. A systematic review was undertaken to determine the evidence-based validity of dysphagia screening items using instrumental evaluation as the reference standard. METHODS: Four databases from 1985 through March 2011 were searched using the terms cerebrovascular disease, stroke deglutition disorders, and dysphagia. Eligibility criteria were: homogeneous stroke population, comparison to instrumental examination, clinical examination without equipment, outcome measures of dysphagia or aspiration, and validity of screening items reported or able to be calculated. Articles meeting inclusion criteria were evaluated for methodological rigor. Sensitivity, specificity, and predictive capabilities were calculated for each item. RESULTS: Total source documents numbered 832; 86 were reviewed in full and 16 met inclusion criteria. Study quality was variable. Testing swallowing, generally with water, was the most commonly administered item across studies. Both swallowing and nonswallowing items were identified as predictive of aspiration. Neither swallowing protocols nor validity were consistent across studies. CONCLUSIONS: Numerous behaviors were found to be associated with aspiration. The best combination of nonswallowing and swallowing items as well as the best swallowing protocol remains unclear. Findings of this review will assist in development of valid clinical screening instruments.

Veteran stroke survivors' lived experiences after being discharged home: a phenomenological study.

BACKGROUND: Stroke is a leading cause of disability in adults and third cause of death in the United States. Survivors face challenges postdischarge, including risks in self-management (SM) following prescribed regimens. Although SM education can help develop skills to control risk factors for stroke recurrence, little is known about lived experiences of patients adopting SM. AIMS: To examine Veterans' lived poststroke experiences after discharge and their experiences in SM goal setting/attainment. METHODS: Patients within one year of discharge from a Veterans Administration Medical Center in the United States with two risk factors for stroke recurrence were enrolled and received an SM workbook. Eight patients were interviewed (six males, two females; mean age 62: range 45-80). Part I concerned lived experience. Part II described experiences with goal setting and attainment. Data were analyzed inductively, identifying common experiences. Deductive analysis described goal setting and attainment. Transcript reviews identified SM themes and strategies. RESULTS: Lived experiences included 1) uncertainty about life, 2) anger and frustration, and 3) healthcare system challenges. Coping skills and setting goals to manage risks were critical for physical and emotional functioning. CONCLUSIONS: SM coping and goal setting aided recovery and improved life quality among Veterans after stroke. SM interventions assisted in regaining physical and emotional function. Findings may help in design of interventions for survivors, using SM and goal setting and attainment.IMPLICATIONS FOR REHABILITATIONSeveral implications for clinical practice were identified:Providers should acknowledge Veterans' challenges and struggles after their stroke and help Veterans to re-establish social identity, enhance self-esteem and improve mood.More emphasis should be given to the Veterans' caregivers' availability and willingness to help with their loved one's recovery, work reinstatement status and financial struggles.Recognition of the importance of the social context of recovery after a stroke is important, as nonmedical social interaction is often overlooked.Improvements are needed in the area of providers working with social workers and physical, occupational and mental health therapists to arrange more inpatient and outpatient treatments, including more frequent home visits.Veterans should be strongly encouraged to attend self-management diabetes education classes and smoking cessation and weight-loss programs offered for free within the Veterans Health Administration system.Self-management strategies using goal-setting and attainment concepts may assist individuals with stroke to regain physical and emotional functions, subsequently preventing another stroke.

Using Mobile Video-Teleconferencing to Deliver Secondary Stroke Prevention Interventions: A Pilot Study.

Objectives: Patient self-management support (SMS) interventions help stroke survivors control stroke risk factors and assist with secondary prevention. We examined utility and preliminary effectiveness of mobile video-teleconferencing (VT) to deliver SMS to stroke survivors in rural and low-income urban Texas communities. Methods: We applied a within-subjects design to assess improvement in self-management behaviors and stroke risk factors among stroke survivors receiving SMS intervention through mobile VT. Adults with stroke and two or more uncontrolled stroke risk factors were eligible. The SMS program, Video-teleconference-Self-management TO Prevent stroke (V-STOP) was delivered over 6 weeks by trained health coaches through VT. We applied Generalized Estimating Equations with site and time in intervention as covariates to evaluate psychological, social, physiological outcomes, self-management behaviors, and quality of life. Results: Mean age of 106 participants was 59.3 (±10.9); most were White, Hispanic men, living with someone, with low income. Approximately 69% completed all measures at 6 weeks. Median number of sessions attended was 5 (interquartile range 3) potentially avoiding 210 km of travel per person. Satisfaction with V-STOP and VT delivery was high, at (4.8 [±0.5]) and (4.7 [±0.5]), respectively. Stroke knowledge was improved from 8.8 (±1.0) at baseline to 9.6 (±0.7) at 12 weeks, (p < 0.0001). Improvements were observed in self-efficacy, exercise behaviors, depression and anxiety, disability, and quality of life. Conclusion: Implementation of SMS is feasible and shows good utility and preliminary effectiveness of using mobile VT to provide stroke follow-up care to stroke survivors. Participants improved self-management behaviors and stroke risk factors.

Prototype to practice: Developing and testing a clinical decision support system for secondary stroke prevention in a veterans healthcare facility.

A clinical decision support system that guides nurse practitioners and other healthcare providers in secondary stroke prevention was developed by a multidisciplinary team with funding received from the Veterans Health Administration Office of Nursing Services. This article presents alpha-testing results obtained while using an integrated model for clinical decision support system development that emphasizes end-user perspectives throughout the development process. Before-after and descriptive methods were utilized to evaluate functionality and usability of the prototype among a sample of multidisciplinary clinicians. The predominant functionality feature of the tool is automated prompting and documentation of secondary stroke prevention guidelines in the electronic medical record. Documentation of guidelines was compared among multidisciplinary providers (N = 15) using test case scenarios and two documentation systems, standard versus the prototype. Usability was evaluated with an investigator-developed questionnaire and one open-ended question. The prototype prompted a significant increase (P < .05) in provider documentation for six of 11 guidelines as compared with baseline documentation while using the standard system. Of a possible 56 points, usability was scored high (mean, 48.9 [SD, 6.8]). These results support that guideline prompting has been successfully engineered to produce a usable and useful clinical decision support system for secondary stroke prevention.

A highly enriched niche of precursor cells with neuronal and glial potential within the hair follicle dermal papilla of adult skin.

Skin-derived precursor cells (SKPs) are multipotent neural crest-related stem cells that grow as self-renewing spheres and are capable of generating neurons and myelinating glial cells. SKPs are of clinical interest because they are accessible and potentially autologous. However, although spheres can be readily isolated from embryonic and neonatal skin, SKP frequency falls away sharply in adulthood, and primary sphere generation from adult human skin is more problematic. In addition, the culture-initiating cell population is undefined and heterogeneous, limiting experimental studies addressing important aspects of these cells such as the behavior of endogenous precursors in vivo and the molecular mechanisms of neural generation. Using a combined fate-mapping and microdissection approach, we identified and characterized a highly enriched niche of neural crest-derived sphere-forming cells within the dermal papilla of the hair follicle of adult skin. We demonstrated that the dermal papilla of the rodent vibrissal follicle is 1,000-fold enriched for sphere-forming neural crest-derived cells compared with whole facial skin. These "papillaspheres" share a phenotypic and developmental profile similar to that of SKPs, can be readily expanded in vitro, and are able to generate both neuronal and glial cells in response to appropriate cues. We demonstrate that papillaspheres can be efficiently generated and expanded from adult human facial skin by microdissection of a single hair follicle. This strategy of targeting a highly enriched niche of sphere-forming cells provides a novel and efficient method for generating neuronal and glial cells from an accessible adult somatic source that is both defined and minimally invasive.

Knowledge management: organizing nursing care knowledge.

Almost everything we do in nursing is based on our knowledge. In 1984, Benner (From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984) described nursing knowledge as the culmination of practical experience and evidence from research, which over time becomes the "know-how" of clinical experience. This "know-how" knowledge asset is dynamic and initially develops in the novice critical care nurse, expands within competent and proficient nurses, and is actualized in the expert intensive care nurse. Collectively, practical "know-how" and investigational (evidence-based) knowledge culminate into the "knowledge of caring" that defines the profession of nursing. The purpose of this article is to examine the concept of knowledge management as a framework for identifying, organizing, analyzing, and translating nursing knowledge into daily practice. Knowledge management is described in a model case and implemented in a nursing research project.

Clinical decision support systems in nursing: synthesis of the science for evidence-based practice.

The aim of this article is to present a synthesis of the research literature on the state of nursing science regarding the development, use, and application of clinical decision support systems for the implementation of evidence-based practice in nursing. The authors sought to answer three specific questions in this metasynthesis: (1) What progress has nursing science made regarding the development and use of clinical decision support systems?; (2) What research methods and theoretical models are being applied by nurse researchers in this area?; and (3)Are there evidence-adaptive clinical decision support systems designed specifically to aid nurses' decisions related to evidence-based practice? Of 183 articles, 17 were included in the final analysis, and six were specific for clinical decision support systems to aid nurses in evidence-based practice. Implications for practice are considered, and recommendations for future research are made.

Management of Lipids in Patients with Diabetes.

Abnormal lipids, sometimes referred to as diabetes dyslipidemia, is a common condition in patients with diabetes. With the increasing number of patients with abnormal lipids, especially those with type 2 diabetes, health care practitioners, including nurses, have to properly manage patients with diabetes as well as abnormal lipids. This article examines the pathophysiology of abnormal lipids, the management of abnormal lipids, and the lipid goals for patients with diabetes. Lastly, this article discusses pharmacologic and nonpharmacologic therapies and the role of primary care providers and nurses in the management of abnormal lipids.

Determining predictors of delayed recovery and the need for transitional cardiac rehabilitation after cardiac surgery.

PURPOSE: To examine the relationship between demographic and clinical characteristics of cardiac surgery patients with postoperative length of stay (PLOS) greater than 7 days and determine the demographic, social, and clinical predictors of the need for transitional cardiac rehabilitation (TCR) after cardiac surgery. DATA SOURCES: A retrospective review of characteristics, clinical indices, caregiver availability, and patient status (whether living alone) was completed for 304 patients undergoing cardiac surgery over 24 consecutive months. Univariate analyses and multivariable logistic regression models were used to evaluate risk factor characteristics for PLOS greater than 7 days and to predict discharge disposition to TCR or home. CONCLUSIONS: Older patients, those with preoperative comorbidities, and those without a caregiver at home experience delays in functional recovery and discharge and are more likely to need TCR services. IMPLICATIONS FOR PRACTICE: Our findings support the addition of functional recovery and social support risk items to the preoperative cardiac surgery risk assessment.