Barriers and Enablers to Implementing a High-Dependency Care Model in Pediatric Care: A Preimplementation Study.

BACKGROUND: As the level of acuity of pediatric hospital admissions continues to increase, additional pressure is being placed on hospital resources and the nursing workforce. LOCAL PROBLEM: Currently, there is no formalized approach to care for high-acuity patients on our pediatric inpatient unit. METHODS: We used a qualitative descriptive design, guided by the Theoretical Domains Framework and Capability, Opportunity, Motivation-Behaviour (COM-B) model, to conduct focus groups and interviews with clinicians and administrators to identify potential barriers and enablers to implementing a high-dependency care (HDC) model. An HDC model focuses on the relationship between adequate nursing staff resources and patient acuity to improve patient health outcomes. RESULTS: Participants identified the need for clear guidelines and supportive physical structures to facilitate HDC implementation. Anticipated benefits included enhanced nursing confidence and family-centered care. CONCLUSIONS: Study findings highlight multilevel factors to consider prior to implementing an HDC model on a pediatric inpatient unit.

Ovariectomy enhances SR Ca²âº release and increases Ca²âº spark amplitudes in isolated ventricular myocytes.

This study compared Ca(2+) homeostasis in ventricular myocytes from 8-month-old female C57BL/6J mice that had either a bilateral ovariectomy (OVX) or a sham surgery at 3 weeks of age. Cells were loaded with fura-2 and field-stimulated or voltage-clamped with steps to membrane potentials between -40 and +80 mV (37°C). Peak Ca(2+) transients increased by two-fold in OVX myocytes when compared to sham, and Ca(2+) transient rates of rise and decay were faster in OVX cells. In contrast, Ca(2+) current densities were similar in sham and OVX cells. Sarcoplasmic reticulum (SR) Ca(2+) content, assessed by caffeine, also was higher in OVX compared to sham cells (111.7 ± 11.9 vs. 61.2 ± 10.4 nM; p<0.05). Furthermore, the gain of Ca(2+) release (Ca(2+) release/Ca(2+) current) was significantly greater in OVX than in sham cells (16.3 ± 2.5 vs. 7.7 ± 2.0 nM/pApF(-1) at 0 mV; p<0.05). As changes in unitary Ca(2+) release might account for the increased gain in OVX cells, spontaneous Ca(2+) sparks were compared in fluo-4-loaded myocytes (37°C). Spark frequency was higher in OVX cells than in sham cells. In addition, spark amplitudes were greater in OVX than in sham myocytes (ΔF/F(0)=0.379 ± 0.006 vs. 0.342 ± 0.006; p<0.05). However, spark widths and time courses were similar in the two groups. These data suggest that the size of individual SR Ca(2+) release units is larger and the SR Ca(2+) content is greater in myocytes of OVX mice, producing augmented gain and SR Ca(2+) release. These observations show that OVX disrupts intracellular Ca(2+) homeostasis and suggest that sex steroid hormones modulate unitary Ca(2+) release in individual cardiac myocytes.

The Na+/Ca2+ exchange inhibitor SEA0400 limits intracellular Ca2+ accumulation and improves recovery of ventricular function when added to cardioplegia.

BACKGROUND: The Na+/Ca2+ exchange inhibitor SEA0400 prevents myocardial injury in models of global ischemia and reperfusion. We therefore evaluated its potential as a cardioplegia additive. METHODS: Isolated rat cardiomyocytes were exposed to hypoxia (45 min) followed by reperfusion. During hypoxia, cells were protected using cardioplegia with (n=25) or without (n=24) SEA0400 (1 µM), or were not protected with cardioplegia (hypoxic control, n=8). Intracellular Ca2+ levels were measured using Ca2+ sensitive dye (fura-2 AM). Isolated rat hearts were arrested using cardioplegia with (n=7) or without (n=6) SEA0400 (1 µM) then reperfused after 45 min of ischemia. Left ventricular (LV) function, troponin release, and mitochondrial morphology were evaluated. RESULTS: Cardiomyocytes exposed to hypoxia without cardioplegia had poor survival (13%). Survival was significantly improved when cells were protected with cardioplegia containing SEA0400 (68%, p=0.009); cardioplegia without SEA0400 was associated with intermediate survival (42%). Cardiomyocytes exposed to hypoxia alone had a rapid increase in intracellular Ca2+ (305 ± 123 nM after 20 minutes of ischemia). Increases in intracellular Ca2+ were reduced in cells arrested with cardioplegia without SEA0400; however cardioplegia containing SEA0400 was associated with the lowest intracellular Ca2+ levels (110 ± 17 vs. 156 ± 42 nM after 45 minutes of ischemia, p=0.004). Hearts arrested with cardioplegia containing SEA0400 had better recovery of LV work compared to cardioplegia without SEA0400 (23140 ± 2264 vs. 7750 ± 929 mmHg.µl, p=0.0001). Troponin release during reperfusion was lower (0.6 ± 0.2 vs. 2.4 ± 0.5 ng/mL, p=0.0026), and there were more intact (41 ± 3 vs. 22 ± 5%, p<0.005), and fewer disrupted mitochondria (24 ± 2 vs. 33 ± 3%, p<0.05) in the SEA0400 group. CONCLUSIONS: SEA0400 added to cardioplegia limits accumulation of intracellular Ca2+ during ischemic arrest in isolated cardiomyocytes and prevents myocardial injury and improves recovery of LV function in isolated hearts.