Implementing Practice Standards for Inpatient Electrocardiographic Monitoring.

BACKGROUND: Although electrocardiographic monitoring is common in hospitalized patients, many patients receive unnecessary monitoring, contributing to patients' inconvenience, clinicians' alarm fatigue, and delayed admissions. OBJECTIVE: To evaluate the impact of implementation of an electronic order set based on the American Heart Association practice standards for electrocardiographic monitoring on the occurrence of appropriate monitoring. METHODS: The sample for this preintervention-to-postintervention quasi-experimental study consisted of 297 adult patients on medical, surgical, neurological, oncological, and orthopedic patient care units that used remote electrocardiographic monitoring in a 627-bed hospital in Minneapolis, Minnesota. The intervention was the introduction into the electronic health record of order sets prompting physicians to order electrocardiographic monitoring per the American Heart Association practice standards. Indications for monitoring according to the practice standards and adverse outcomes (unexpected transfer to intensive care unit, death, code blue events, and call for the rapid response team) were compared before and after implementation of the order set. RESULTS: Implementation of the order set was associated with an increase in appropriate monitoring (48.0% to 61.2%; P = .03); the largest increase was in ordering by medical residents (30.8% to 76.5%; P = .001). No significant increase in adverse patient outcomes was noted. CONCLUSIONS: Implementation of the practice standards via an electronic order set was associated with a statistically significant increase in appropriate monitoring, with no increase in adverse events. Use of electronic order sets is an effective and safe way to enhance appropriate electrocardiographic monitoring.

Place Atrium to Water Seal (PAWS): Assessing Wall Suction Versus No Suction for Chest Tubes After Open Heart Surgery.

BACKGROUND: Traditionally chest tubes are set to -20 cm H2O wall suctioning until removal to facilitate drainage of blood, fluid, and air from the pleural or mediastinal space in patients after open heart surgery. However, no clear evidence supports using wall suction in these patients. Some studies in patients after pulmonary surgery indicate that using chest tubes with a water seal is safer, because this practice decreases duration of chest tube placement and eliminates air leaks. OBJECTIVE: To show that changing chest tubes to a water seal after 12 hours of wall suction (intervention) is a safe alternative to using chest tubes with wall suction until removal of the tubes (usual care) in patients after open heart surgery. METHODS: A before-and-after quality improvement design was used to evaluate the differences between the 2 chest tube management approaches in chest tube complications, output, and duration of placement. RESULTS: A total of 48 patients received the intervention; 52 received usual care. The 2 groups (intervention vs usual care) did not differ significantly in complications (0 vs 2 events; P = .23), chest tube output (H1 = 0.001, P = .97), or duration of placement (median, 47 hours for both groups). CONCLUSION: Changing chest tubes from wall suction to water seal after 12 hours of wall suction is a safe alternative to using wall suctioning until removal of the tubes.

Assessing the Impact of Acupuncture on Pain, Nausea, Anxiety, and Coping in Women Undergoing a Mastectomy.

PURPOSE/OBJECTIVES: To compare the effect of acupuncture to a standard-of-care (control) group on pain, nausea, anxiety, and ability to cope. 
. DESIGN: Pilot randomized, controlled trial. 
. SETTING: Abbott Northwestern Hospital, a large, urban, tertiary care hospital in Minneapolis, Minnesota.
. SAMPLE: 30 adult women undergoing surgery for breast cancer.
. METHODS: Women were randomly assigned to two hospital-based acupuncture treatments versus usual care after breast cancer surgery. Pain, nausea, anxiety, and the patient's ability to cope pre- and post-treatment were compared within and between groups at two different time points postoperatively.ʉ۩. MAIN RESEARCH VARIABLES: Mean change in pain, nausea, anxiety, and ability to cope by treatment group.
. FINDINGS: Compared to women assigned to the control group, women who received acupuncture reported a statistically significant greater reduction in pain, nausea, anxiety, and increase in ability to cope on the first postoperative day and in pain on the second postoperative day following mastectomy surgery.
. CONCLUSIONS: Acupuncture delivered postoperatively in the hospital after mastectomy can reduce the severity of symptoms experienced, as well as increase the patient's ability to cope with her symptoms. However, before implementation as a standard of care, further research needs to be conducted.
. IMPLICATIONS FOR NURSING: Acupuncture adds a nonpharmacologic intervention for symptom management in women undergoing mastectomies for breast cancer.

Alarm fatigue.

The number of false high alarms in the hospital setting remains a serious problem. False alarms have desensitized care providers and, at times, have led to dire consequences for patients. Efforts by both industry and clinicians are beginning to address this situation in collaborative approaches. Research is needed to establish an evidence base around issues such as which patients need to be monitored, and what the threshold settings and delay settings should be on devices. Initial and ongoing education needs to be considered for any new medical device, and be included in the hospital's annual budget.

Temperature measurement in patients undergoing colorectal surgery and gynecology surgery: a comparison of esophageal core, temporal artery, and oral methods.

Maintaining perioperative normothermia reduces postoperative complications. An accurate, noninvasive method to take temperatures representative of core temperature is needed. Oral thermometry is accepted as the most accurate means of non-core temperature assessment, but poses challenges in patients who are intubated or wearing oxygen masks. The purpose of this study was to determine the difference, if any, between core temperature as measured by an esophageal thermometer and temperatures measured by oral and temporal artery methods in patients undergoing colorectal or gynecology surgery. A repeated-measures design was used with a convenience sample of 23 patients undergoing colorectal or gynecology surgery. Two series of intraoperative temperatures were taken (oral and temporal artery thermometry) and compared with core temperature measured by esophageal probe. Repeated-measures analysis of variance tested for biases of oral or temporal temperatures versus core temperatures. Bland-Altman plots were drawn to test dependence of bias on actual core temperature. A priori, a temperature difference >0.4 degrees C was defined as clinically significant. Oral temperature was biased high relative to esophageal temperature by 0.12 degrees C on average (P = .0008; 95% confidence interval [0.061, 0.187]). Temporal artery temperature was biased high relative to esophageal, by 0.074 degrees C on average (P = .03; 95% confidence interval [0.010, 0.133]). Differences between core (esophageal) thermometry and oral or temporal artery thermometry were statistically significant but much smaller than the 0.4 degrees C identified as clinically acceptable. Oral and temporal artery temperatures are within the 0.4 degrees C of core (esophageal) temperatures, a difference that is considered clinically acceptable. Temperatures taken orally or by temporal artery thermometry are acceptable as noninvasive core measures for adult patients undergoing colorectal or gynecology surgery.

Challenges of implementing a feasibility study of acupuncture in acute and critical care settings.

A majority of people in the United States use complementary and alternative therapies, and this use is increasing. With the increasing interest, providers must evaluate potential risks and benefits of these therapies. This article describes challenges of a feasibility study of acupuncture as a potential therapeutic adjunct to prevent atrial fibrillation following coronary artery bypass graft surgery. Institutional review board approval, consent logistics, implementation issues, and rapid changes in clinical practice were the primary challenges faced. Unique technological features of the institution helped address these challenges. The study protocol was acceptable to staff, patients, and family and was considered safe for these patients. However, the protocol was not feasible as designed; therefore, the efficacy of acupuncture could not be determined. Continued research is needed to evaluate the effectiveness of acupuncture to prevent atrial fibrillation following coronary artery bypass graft surgery. Recommendations for future studies of complementary and alternative therapies in acute and critical care settings are offered.

Delirium in the orthopaedic patient.

Published incidence of delirium in orthopaedic patients ranges from 5.1% to 61%. Delirium may present before or after the patient undergoes the surgical procedure and has demonstrated increased risk, including mortality. Yet, delirium goes unrecognized by both physicians and nurses. This article focuses on the literature on delirium in the orthopaedic patient, including incidence, how to identify those patients at risk, patient outcomes, nonpharmacological and pharmacological interventions, and provides an example of how one tertiary care hospital implemented a prevention and management program of delirium in orthopaedic patients.

Postoperative complications of coronary artery bypass grafting surgery.

Coronary artery bypass grafting (CABG) surgery continues to be an effective and well-used intervention for coronary artery disease. Older patients and those with sicker hearts will become the norm. In spite of increased risk for patients undergoing CABG, overall mortality rates have decreased. Nursing contributions to these improved outcomes cannot be overestimated. Continued understanding and appreciation of these complications will be necessary to effectively care for patients and create optimal outcomes.

Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery.

BACKGROUND: Cardiac surgery is a common interventional procedure for ischemic and valvular heart disease. Cardiac surgery is accompanied by postoperative pain and anxiety. The use of music therapy has been shown to reduce pain, anxiety, and physiological parameters in patients having surgical procedures. OBJECTIVES: To compare the effects of music therapy versus a quiet, uninterrupted rest period on pain intensity, anxiety, physiological parameters, and opioid consumption after cardiac surgery. SUBJECTS AND METHODS: An experimental design was used. A total sample of 86 patients (69.8% males) were randomized to 1 of 2 groups; 50 patients received 20 minutes of music (intervention), whereas 36 patients had 20 minutes of rest in bed (control). Anxiety, pain, physiologic parameters, and opioid consumption were measured before and after the 20-minute period. RESULTS: A significant reduction in anxiety (P < or = .001) and pain (P = .009) was demonstrated in the group that received music compared with the control group, but no difference was observed in systolic blood pressure (P = .17), diastolic blood pressure (P = .11), or heart rate (P = .76). There was no reduction in opioid usage in the 2 groups. CONCLUSIONS: Patients recovering from cardiac surgery may benefit from music therapy.

Correlates of neurocognitive function of patients after off-pump coronary artery bypass surgery.

BACKGROUND: Decreases in neurocognitive function have been reported in patients who have undergone off-pump coronary artery bypass surgery; however, few investigators have examined the correlates of the decreases. OBJECTIVES: To explore and determine the correlates of neurocognitive function at the time of discharge from the hospital in patients undergoing off-pump coronary artery bypass surgery. METHODS: Patients undergoing off-pump coronary artery bypass surgery at Abbott Northwestern Hospital, Minneapolis, Minn, were administered tests of neuro-cognition (cognition and motor function), anxiety, depression, and quality of life preoperatively (within 72 hours of surgery) and postoperatively (at least 72 hours after surgery but before discharge from the hospital). RESULTS: A total of 54 patients (79.6% men), mean age 64.5 years, completed tests both preoperatively and postoperatively. When baseline function was controlled for, increased age and new-onset atrial fibrillation (F(3,40)=42.97; P<.001) were associated with decreases in postoperative cognitive function; increased age and anxiety (F(3,35)=15.83; P<.001) were associated with decreases in postoperative motor function. CONCLUSION: Older patients, anxious patients, and patients with new-onset atrial fibrillation are at risk for neurocognitive changes after off-pump coronary artery bypass surgery. Further studies with larger sample sizes should be done to examine interventions to reduce preoperative anxiety in these patients. Interventions to prevent postoperative atrial fibrillation should be explored to determine whether the interventions prevent a decline in neurocognitive function.

Complementary alternative medical therapies for heart surgery patients: feasibility, safety, and impact.

BACKGROUND: Complementary therapies (touch, music) are used as successful adjuncts in treatment of pain in chronic conditions. Little is known about their effectiveness in care of heart surgery patients. Our objective is to evaluate feasibility, safety, and impact of a complementary alternative medical therapies package for heart surgery patients. METHODS: One hundred four patients undergoing open heart surgery were prospectively randomized to receive either complementary therapy (preoperative guided imagery training with gentle touch or light massage and postoperative music with gentle touch or light massage and guided imagery) or standard care. Heart rate, systolic and diastolic blood pressure, and pain and tension were measured preoperatively and as pre-tests and post-tests during the postoperative period. Complications were abstracted from the hospital record. RESULTS: Virtually all patients in the complementary therapy group (95%) and 86% in standard care completed the study. Heart rate and blood pressure patterns were similar. Decreases in heart rate and systolic blood pressure in the complementary therapies group were judged within the range of normal values. Complication rates were very low and occurred with similar frequency in both groups. Pretreatment and posttreatment pain and tension scores decreased significantly in the complementary alternative medical therapies group on postoperative days 1 (p < 0.01) and 2 (p < 0.038). CONCLUSIONS: The complementary medical therapies protocol was implemented with ease in a busy critical care setting and was acceptable to the vast majority of patients studied. Complementary medical therapy was not associated with safety concerns and appeared to reduce pain and tension during early recovery from open heart surgery.

Early neurocognitive function of patients after off-pump coronary artery bypass surgery.

DESIGN: This was a prospective, descriptive study. SETTING: The study took place in cardiovascular units at a large urban metropolitan, midwestern tertiary care hospital. SAMPLE: Fifty-four patients undergoing off-pump coronary artery bypass surgery were included. OUTCOME MEASURES: Outcome measures were neurocognition preoperatively at baseline (within 72 hours of surgery) and postoperatively (at least 72 hours after surgery but before discharge). RESULTS: In neurocognitive tests of cognition (memory, language, and attention) there was an improvement in the cognitive composite from the preoperative baseline to the postoperative follow-up (P < .001). However, in tests of motor function (motor speed and information processing speed) there was a decline in the motor composite (P = .006). CONCLUSIONS: After off-pump coronary artery bypass surgery, patients had an overall improvement in tests of memory, language, and attention (cognitive composite), but a decline in tests of motor speed and information processing speed (motor composite).