Elective Surgical Delays Due to COVID-19: The Patient Lived Experience.

BACKGROUND: This qualitative research explored the lived experiences of patients who experienced postponement of elective cardiac and vascular surgery due to coronavirus disease 2019 (COVID-19). We know very little about patients during the novel coronavirus pandemic. Understanding the patient voice may play an important role in prioritization of postponed cases and triage moving forward. METHODS: Utilizing a hermeneutical phenomenological qualitative design, we interviewed 47 individuals who experienced a postponement of cardiac or vascular surgery due to the COVID-19 pandemic. Data were analyzed and informed by phenomenological research methods. RESULTS: Patients in our study described 3 key issues around their postponement of elective surgery. Patients described robust narratives about the meanings of their elective surgeries as the chance to "return to normal" and alleviate symptoms that impacted everyday life. Second, because of the meanings most of our patients ascribed to their surgeries, postponement often took a toll on how patients managed physical health and emotional well-being. Finally, paradoxically, many patients in our study were demonstrative that they would "rather die from a heart attack" than be exposed to the coronavirus. CONCLUSIONS: We identified several components of the patient experience, encompassing quality of life and other desired benefits of surgery, the risks of COVID, and difficulty reconciling the 2. Our study provides significant qualitative evidence to inform providers of important considerations when rescheduling the backlog of patients. The emotional and psychological distress that patients experienced due to postponement may also require additional considerations in postoperative recovery.

Elective cardiovascular care in the era of the COVID-19 pandemic: managing tragic choices.

The COVID-19 pandemic has led to significant morbidity and mortality globally. As health systems grapple with caring for patients affected with COVID-19, cardiovascular procedures that are deemed 'elective' have been postponed. Guidelines concerning which cardiac procedures should be performed during the pandemic vary by specialty and geography in the USA. We propose a clinical heuristic to guide individual physicians and governing bodies in their decision making regarding which cardiac procedures should be performed during the COVID-19 pandemic using the behavioural economics concept of heuristics and ecological rationality.

Thoracic and cardiovascular surgery patients: Intensive care unit experiences.

BACKGROUND: Intensive care units are stressful places where patients experience physical and psychological discomfort. Understanding the experience of these patients regarding nursing care is very important. AIMS AND OBJECTIVES: To determine the intensive care experiences of thoracic and cardiovascular surgery patients and the factors that affect them. DESIGN: The research consists of two phases: quantitative and qualitative. METHODS: This was a descriptive and cross-sectional study. Its research sample comprised 100 patients who spent at least one night in an intensive care unit after thoracic or cardiovascular surgery. The Intensive Care Experiences Scale (ICES) and the Numeric Rating Scale were used. Two open-ended questions were asked to the patients to understand what they felt when they were attached to mechanical ventilation and to describe their intensive care experiences. RESULTS: The ICES mean score was 66.35 ± 6.88. Significant negative relationships were found between length of stay and severity of pain and ICES total scores. A significant difference was found between scale scores and being understood by health care professionals when attached to mechanical ventilation. The patients stated that, when they were attached to mechanical ventilation and during their stay in the intensive care unit, they experienced feelings of helplessness, uncertainty, and fear. They also experienced physical discomfort and reported no longer fearing death. CONCLUSION: It was determined that patients partially positively perceived their experiences. It was found that they focused on coming out of surgery alive. The physical discomfort and negative emotions reported can be reduced or relieved by competent care. RELEVANCE TO CLINICAL PRACTICE: The intensive care experiences and emotions of intensive care patients are important. Physical discomfort and negative emotions can be mitigated or alleviated by competent nursing care.

Understanding patients' experiences of recovery after staged complex aortic repair: A phenomenological study.

AIM: To explore patients' with complex aortic diseases lived experiences of recovery between and after staged endovascular aortic repair (EVAR) procedures, including adjunctive open surgery. DESIGN: Qualitative descriptive phenomenological design, applying person-centred care and lifeworld-led health care. METHODS: Patients operated on in a staged fashion between 2012-2017 were invited to participate. Six participants underwent in-depth interviews 1-5 years postoperatively. The interviews were analysed using descriptive phenomenological method. FINDINGS: The essence of the patients' experiences was described as: a necessary, overwhelming, hard, and prolonged process with life changing consequences. Between the operations: expected tiredness where life goes on as usual and insufficient time for recovery. Short-term after all operations: overwhelming tiredness, pain and complications, mostly from neurological deficits. Losing 'yourself' and struggling to manage daily life one day to another. Long-term after all operations: gradually recovering back to 'yourself' and having to accept life with permanent setbacks and limitations. CONCLUSION: Patients with complex aortic diseases struggle with physical and psychological setbacks, continuing years after their operations. There is a need to prospectively assess different aspects of these patients' recovery, identify those with impaired recovery and establish preventive and supporting strategies. IMPACT: Patients' experience of recovery after staged aortic repair has not previously been investigated. The findings indicate that these patients struggle with various physical and psychological setbacks continuing years after their operations. These results will inform further research on this group of patients and guide healthcare professionals in the care of these patients in their transition back to recovery.

Use of Quality of Life in Cardiovascular Surgery in Coronary Artery Bypass Grafting: Validation, Reproducibility, and Quality of Life in One Year of Follow-Up.

BACKGROUND: The objectives of this study are to validate the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire and to observe the evolution of quality of life in the first year of postoperative follow-up of patients who underwent coronary artery bypass grafting (CABG). METHODS: This was a prospective observational study of patients undergoing CABG from July 2016 to June 2017 who survived and answered the QLCS with 1, 6, and 12 months of follow-up. Validation was evaluated for internal consistency by Cronbach's alpha, test-retest reproducibility by correlation coefficient of concordance, and accuracy for interrater reliability by the kappa statistic. The nonparametric analysis of variance test was used for analysis of repeated measures, during follow-up, of the QLCS was considered significant at p < 0.05. RESULTS: Included were 360 patients, with a mean age of 63 years; 72% were men. Cronbach's alpha was 0.82, demonstrating adequate internal consistency. The correlation coefficient of concordance was 0.93 and accuracy 0.99, showing good precision and accuracy. The kappa statistic for questions ranged from 0.58 to 0.78, which ensures a moderate reproducibility. Scores of the QLCS in patients undergoing CABG of 17.69, 18.82, and 19.52 were found at 1, 6, and 12 months, respectively. Thus there was a progressive improvement in quality of life over the first year of follow-up (p < 0.0001). CONCLUSIONS: The QLCS proved to be a good questionnaire in this population, with adequate internal consistency and moderate reproducibility. Its use revealed a progressive and significant improvement in the quality of life of patients undergoing CABG.

Effectiveness of reflexology on anxiety of patients undergoing cardiovascular interventional procedures: A systematic review and meta-analysis of randomized controlled trials.

AIM: To appraise the evidence concerning the effect of reflexology on the anxiety in patients undergoing cardiovascular interventional procedures. BACKGROUND: Anxiety, fear, and other unpleasant emotional experiences are common among patients before and after cardiovascular interventional procedures. The higher anxiety may affect prognosis and recovery of patients. DESIGN: A systematic review and meta-analysis. DATA SOURCES: The MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Central Register of Controlled Trials (Cochrane Library), EMBASE, PsycINFO, and Web of Science were searched between 2001-2017. REVIEW METHODS: Randomized controlled trials evaluated the effectiveness of reflexology on anxiety among patients undergoing cardiovascular interventional procedures were included. Meta-analysis was done using Revman 5.3. RESULTS: Ten trials, representing 760 patients with the mean age of 59, fulfilled the inclusion criteria. Reflexology significantly decreased the anxiety of patients undergoing cardiovascular interventional procedures in the treatment group compared with the control group. CONCLUSION: Reflexology has some positive effects on anxiety among patients undergoing cardiovascular procedures. It may be a useful complementary therapy and further research is necessary to create reliable evidence.

Quality of Life in Cardiovascular Surgery: Elaboration and Initial Internal Validation of a Quality of Life Questionnaire.

OBJECTIVE: Elaboration and internal validation of the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire adapted to the reality of Brazilian cardiovascular surgery. METHODS: Cross-sectional pilot study of a prospective cohort included in the Documentation and Surgical Registry Center (CEDREC) for internal validation of the QLCS questionnaire. Four hundred forty-five patients submitted to cardiovascular surgery and who answered a QLCS questionnaire 30 days after hospital discharge were included. It was applied via telephone. To verify the questions' internal consistency, Cronbach's alpha was used. The total QLCS score was calculated as the sum of 5 questions, ranging from 5 to 25 points. Mann-U-Whitney test was used to relate the symptoms with the quality of life (QoL). Level of significance was 5%. RESULTS: After 30 days of surgery, about 95% of the patients had already returned to normal routine and 19% of them were already performing physical activity. In the evaluation of the QLCS's internal consistency, a Cronbach's alpha of 0.74 was found, suggesting that this was probably an adequate questionnaire to evaluate QoL in this population. In the comparison between the presence and absence of symptoms and the median of QoL, the presence of pain at the incision (P=0.002), chest pain (P<0.001), shortness of breath (P<0.001), and return to physical activity (P<0.001) were statistically significant. CONCLUSION: The process of elaboration and validation of questionnaires includes a series of steps. The QLCS questionnaire is probably an adequate tool for the evaluation of QoL in the postoperative patient of cardiovascular surgery, in this first stage of internal validation.

Quality of life in cardiovascular surgery: elaboration and initial internal validation of a quality of life questionnaire

Abstract Objective: Elaboration and internal validation of the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire adapted to the reality of Brazilian cardiovascular surgery. Methods: Cross-sectional pilot study of a prospective cohort included in the Documentation and Surgical Registry Center (CEDREC) for internal validation of the QLCS questionnaire. Four hundred forty-five patients submitted to cardiovascular surgery and who answered a QLCS questionnaire 30 days after hospital discharge were included. It was applied via telephone. To verify the questions' internal consistency, Cronbach's alpha was used. The total QLCS score was calculated as the sum of 5 questions, ranging from 5 to 25 points. Mann-U-Whitney test was used to relate the symptoms with the quality of life (QoL). Level of significance was 5%. Results: After 30 days of surgery, about 95% of the patients had already returned to normal routine and 19% of them were already performing physical activity. In the evaluation of the QLCS's internal consistency, a Cronbach's alpha of 0.74 was found, suggesting that this was probably an adequate questionnaire to evaluate QoL in this population. In the comparison between the presence and absence of symptoms and the median of QoL, the presence of pain at the incision (P=0.002), chest pain (P<0.001), shortness of breath (P<0.001), and return to physical activity (P<0.001) were statistically significant. Conclusion: The process of elaboration and validation of questionnaires includes a series of steps. The QLCS questionnaire is probably an adequate tool for the evaluation of QoL in the postoperative patient of cardiovascular surgery, in this first stage of internal validation.

Future-Focused Therapeutic Strategies for Integrative Health.

For many years, the therapy field was dominated by a focus on the past. In this context, many clinicians were trained to use hypnosis as a tool to explore the past, and there is a rich literature documenting the use of hypnosis as a tool to induce age regression and the uncovering of traumatic memories. This article presents a therapeutic paradigm that focuses on the future. Hypnosis is used to induce creativity, flexibility, and openness to the future. In the context of health care, hypnosis is used to explore the best possible treatment outcome, which may be pharmacological, surgical, or a combination of both as well as other nonsurgical interventions. This article elaborates on the effective use of a therapeutic hypnosis strategy and technique focused on the future.

[Shared decision-making: when the doctor becomes the patient]. / 'Shared decision-making': als de dokter patiënt wordt.

It was when a patient with a type A aortic dissection refused surgical treatment that our eyes were opened to the importance of shared decision-making (SDM). As these patients are usually transferred to the operating theatre without any opportunity for discussion about the indication for surgery, our department of cardiothoracic surgery rapidly became keen on applying the principles of SDM to all our patient contacts - as did other departments in our hospital. However, when I became a patient myself and was invited by my physicians to take part in the decision-making process about my treatment, I was surprised to find that I felt very reluctant to do so and preferred to be not involved at all. The various reasons I raised to explain this unexpected behaviour made good sense. Consequently, in my daily practice if a patient evidently does not want to take part in SDM, I now compassionately offer to make decisions myself without requiring their involvement.

Stress and distress in parents of neonates admitted to the neonatal intensive care unit for cardiac surgery.

BACKGROUND: Parents of infants admitted to the Neonatal Intensive Care Unit (NICU) are at risk of psychological distress and NICU-related stress. However, parents of infants admitted to NICU for cardiac surgery are an under-researched population. AIMS: Identify levels of NICU-related stress, and levels of psychological distress, reported by parents of infants admitted to the NICU for cardiac surgery. STUDY DESIGN: Observational study. SUBJECTS: 69 parents of infants admitted to the NICU for cardiac surgery (cardiac group) and 142 parents of healthy infants (control group). OUTCOME MEASURES: Questionnaire packs provided to parents prior to discharge (time-point 1), and at six and 12months corrected age included: Hospital Anxiety and Depression Scale, Coping Inventory for Stressful Situations, and Family Support Scale. The Parental Stressor Scale:NICU was administered to the cardiac group at time-point 1. RESULTS: The cardiac group reported (i) that parental role alteration was the most stressful aspect of the NICU and (ii) higher scores for anxiety and depression than the control group at all three time-points, with the highest levels reported during the NICU stay. Correlation analyses indicated (i) stress associated with the sights and sounds of the NICU, and the appearance and behaviour of the infant in the NICU, had a significant positive association with anxiety and depression, and (ii) a significant negative relationship between anxiety and task-focused coping. CONCLUSIONS: An individualised parent-targeted intervention aimed at reducing stress associated with the NICU and enhancing task-focused coping style may help to reduce levels of anxiety and depression within this group of parents.

Cardio-thoracic surgical patients' experience on bedside nursing handovers: Findings from a qualitative study.

The purpose of this study was to describe the experiences of postoperative cardio-thoracic surgical patients experiencing nursing bedside handover. A descriptive qualitative approach was undertaken. A purposeful sampling technique was adopted, including 14 patients who went through cardio-thoracic surgery and witnessed at least two bedside handovers. The study was performed in a Cardio-thoracic ICU localised in a Joint Commission International accredited Academic Hospital in north-eastern Italy from August to November 2014. The experience of patients participating at the bedside handover is based on four main themes: (1) 'discovering a new nursing identity', (2) 'being apparently engaged in a bedside handover', (3) 'experiencing the paradox of confidentiality' and (4) 'having the situation under control'. With the handover performed at the bedside in a postoperative setting, two interconnected potential effects may be achieved with regard to patients, nurses and the nursing profession. Nurses have a great opportunity to express their closeness to patients and to promote awareness of the important growth that nursing has achieved over the years as a profession and discipline. Therefore, patients may better perceive nursing competence and feel safer during the postoperative care pathway. They can appreciate nurses' humanity in caring and trust their competence and professionalism.

Parental perception of functional status and impact on the family of children with congenital heart surgery.

AIMS: To assess the functional status and the family impact of children with congenital heart defects (CHD), using the parental Functional Status II (FS-II) and the Impact on Family (IOF) questionnaires. METHODS: In this prospective observational study, parents of children who underwent surgery for CHD during the first year of life completed the FS-II and the IOF questionnaires. Genetic syndromes and prematurity <32weeks were exclusion criteria. The FS-II generates a total score and age specific general health (GH), activity (A) and, responsiveness (R) subscales. The IOF generates a total scale and financial and sibling subscales. RESULTS: Our cohort (n=100), comprised 54% males; the median (IQR) age was 32 (10-56) months. Eighteen children had age-specific scores in the 1-2 SD below mean range (n=17) or more than 2 SD below the mean (n=1) for "ill children". There were significant negative correlations between the total FS-II and total IOF (r=-0.35, p<0.001) and financial IOF (r=-0.35, p<0.001). RACHS-1 category of CHD 4-6 was associated with higher likelihood of lower functional status. CONCLUSIONS: More complex CHD was associated with lower functional status, which correlated with a greater impact on the families. Parental questionnaires may be useful instruments for developmental surveillance in this population.

A comparison of the intensive care experiences of emergency and elective cardiac surgery patients.

PURPOSE: The study was planned to review the experiences of patients in the intensive care units (ICUs) and determine their states of awareness following an emergency or elective cardiac surgery. MATERIALS AND METHODS: This was a multicenter and descriptive study. Approval was granted by the Institutional Ethics Committee and informed consent for participation in the study was obtained from all the patients. The study included a total of 300 patients who underwent emergency or elective cardiovascular surgery and were then transferred to the ICU. Data were gathered from the demographic data form and the intensive care experience scale, which was developed by the researchers and applied through face-to-face interviews with the patients. The independent-samples t-test, Mann-Whitney U (Exact) test, one-way ANOVA (Robust Test: Brown-Forsythe), and multivariate analysis of variance were used in the analysis of the data. RESULTS: The study included 300 patients, comprising 108 (36%) females and 192 (64%) males. No difference was found between the groups in respect of total intensive care points of emergency (57.9 ± 4.92) and elective (56.6 ± 4.58) operations (P = 0.32). The environmental awareness level and patient satisfaction of the elective group were seen to be higher, and the emergency group reported more bad experiences. Patients who had undergone emergency cardiac valve surgery were more satisfied (P < 0.001) and remembered more (P = 0.001). CONCLUSION: Patients who had undergone urgent and elective cardiac surgery were seen to have had a relatively negative intensive care experience. When there was more environment awareness in patients with ICU experience, it was determined that as the duration of stay in the ICU lengthens out, the pessimistic experiences increased and ICU satisfaction decreases.

Cardiovascular Surgery Patients: Intensive Care Experiences and Associated Factors.

PURPOSE: The purpose of this study was to determine the intensive care unit (ICU) experiences of cardiovascular surgery (CS) patients and to define the associations between their ICU experiences and related factors. METHODS: The study used a descriptive design. In total, 106 CS patients were interviewed at least 24 hours after discharge from an ICU in an educational research hospital in Ankara, Turkey between January and July 2012. Data were collected using the Intensive Care Experience Scale (ICES), a sociodemographic and clinical characteristics data form and two open-ended questions inquiring about smells and light. Statistical analyses were conducted using SPSS 15.0. RESULTS: The patients were moderately aware of their ICU environments, partly recalled their ICU experiences, highly recollected frightening experiences, and expressed good satisfaction with care. Age, education, marital status, and pain were associated with ICU experiences. Patients who sensed smell had higher scores of frightening experiences than those who did not. Patients who were annoyed with excessive light reported less satisfaction with care than those who were not. CONCLUSIONS: The results suggest that measuring the patients' characteristics and environmental factors may be beneficial for healthcare teams to improve the recovery of CS patients in the ICU.

Cardiovascular Surgery Patients: Intensive Care Experiences and Associated Factors

PURPOSE: The purpose of this study was to determine the intensive care unit (ICU) experiences of cardiovascular surgery (CS) patients and to define the associations between their ICU experiences and related factors. METHODS: The study used a descriptive design. In total, 106 CS patients were interviewed at least 24 hours after discharge from an ICU in an educational research hospital in Ankara, Turkey between January and July 2012. Data were collected using the Intensive Care Experience Scale (ICES), a sociodemographic and clinical characteristics data form and two open-ended questions inquiring about smells and light. Statistical analyses were conducted using SPSS 15.0. RESULTS: The patients were moderately aware of their ICU environments, partly recalled their ICU experiences, highly recollected frightening experiences, and expressed good satisfaction with care. Age, education, marital status, and pain were associated with ICU experiences. Patients who sensed smell had higher scores of frightening experiences than those who did not. Patients who were annoyed with excessive light reported less satisfaction with care than those who were not. CONCLUSIONS: The results suggest that measuring the patients' characteristics and environmental factors may be beneficial for healthcare teams to improve the recovery of CS patients in the ICU.

Effect of standard versus patient-targeted in-patient education on patients' anxiety about self-care after discharge from cardiovascular surgery clinics.

We compared standard and patient-targeted in-patient education in terms of their effect on patients' anxiety. One hundred and ninety-eight patients who were hospitalised for coronary artery bypass surgery were given standard education (group 1) or individualised education (group 2) on the management of their healthcare after discharge. Patients in group 2 were assessed on the patient learning needs scale and were given education according to their individual needs. The level of anxiety was measured by the state-trait anxiety inventory. Anxiety scores were significantly lower in group 2 than group 1 after education (p < 0.001). While state anxiety did not change after education in group 1 (p = 0272), it decreased significantly in group 2 (p < 0.001). For cardiovascular surgery patients, patient-targeted in-patient education was more effective than standard education in decreasing anxiety levels, therefore the content of the education should be individualised according to the patient's particular needs.

A randomized controlled trial of the safety and promise of cognitive-behavioral therapy using imaginal exposure in patients with posttraumatic stress disorder resulting from cardiovascular illness.

OBJECTIVE: We investigated the physical safety of cognitive-behavioral therapy (CBT) utilizing imaginal exposure in patients who suffered from posttraumatic stress disorder (PTSD) following a life-threatening cardiovascular event. METHOD: In this phase I, prospective, single-blind trial conducted from April 2006 through April 2008, we randomly assigned 60 patients to receive either 3 to 5 sessions of imaginal exposure therapy (experimental group) or 1 to 3 educational sessions only (control group). Criteria for PTSD and other mental health disorders were evaluated according to DSM-IV using the full Structured Clinical Interview for DSM-IV (SCID). Safety assessments included patients' blood pressure and pulse before and after each study session and the occurrence of deaths, hospitalizations, repeat myocardial infarctions, or invasive procedures. We also investigated the effects of the treatment on PTSD symptoms (Impact of Event Scale and Posttraumatic Stress Disorder Scale), depression (Beck Depression Inventory-II), and the Clinical Global Impressions-Severity of Illness (CGI-S) scale. RESULTS: There were no significant differences between the experimental and control groups and between exposure and nonexposure sessions in any of the safety measures. In addition, confidence intervals were such that the nonsignificant effects of exposure therapy were not of clinical concern. For example, the mean difference in systolic pressure between control and exposure sessions was 0.5 mm Hg (95% CI, -6.1 to 7.1 mm Hg). Nonsignificant improvements were found on all psychiatric measures in the experimental group, with a significant improvement in CGI-S in the entire cohort (mean score difference, -0.6; 95% CI, -1.1 to -0.1; P = .02) and a significant improvement in PTSD symptoms in a subgroup of patients with acute unscheduled cardiovascular events and high baseline PTSD symptoms (mean score difference, -1.2; 95% CI, -2.0 to -0.3; P = .01). CONCLUSIONS: Cognitive-behavioral therapy that includes imaginal exposure is safe and promising for the treatment of posttraumatic stress in patients with cardiovascular illnesses who are traumatized by their illness. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00364910.