Atrial fibrillation: prevalence after minimally invasive direct and standard coronary artery bypass.

BACKGROUND: This study identified and compared the prevalence of new-onset atrial fibrillation (AFIB) following standard coronary artery bypass grafting (SCABG) with cardiopulmonary bypass (CPB) and minimally invasive direct vision coronary artery bypass grafting (MIDCAB) without CPB. A further comparison was made between AFIB prevalence in SCABG and MIDCAB subjects with two or fewer bypasses. METHODS: This is a retrospective, comparative survey. Patients with new-onset AFIB who underwent SCABG or MIDCAB alone were identified electronically using a triangulated method (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9 CM] code; clinical database word search; and pharmacy database drug search). RESULTS: The total sample (n = 814; 94 MIDCAB, 720 SCABG) exhibited a trend toward lower AFIB prevalence in MIDCAB (23.4%) versus SCABG (33.1%) subjects (p = 0.059). AFIB prevalence in the SCABG subset with two or less vessel bypasses (n = 98; n = 18 single vessel, n = 80 double vessels) and MIDCAB subjects (n = 94; n = 90 single vessels, n = 4 double vessels) was almost identical (SCABG subset 24.5% versus MIDCAB 23.4%, p = 0.860). Slightly more than half (56.9%) of new-onset AFIB subjects were identified by ICD-9 CM codes, with the remainder by word search (37.7%) or procainamide query (5.4%). CONCLUSIONS: In this sample, the number of vessels bypassed seemed to have a greater influence on AFIB prevalence than the application of CPB or the surgical approach. Retrospective identification of AFIB cases by ICD-9 CM code grossly underestimated AFIB prevalence.

Minimally invasive coronary artery bypass grafting: a kinder cut.

Minimally invasive coronary artery bypass graft (CABG) surgery is a promising variation on traditional CABG, avoiding the risks of sternotomy and cardiopulmonary bypass. This article describes the procedure, patient-selection criteria, and postoperative care.

Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison.

BACKGROUND: Little information is available on the practice of acute care nurse practitioners and physician assistants in acute care settings. OBJECTIVES: To compare the care activities performed by acute care nurse practitioners and physician assistants and the outcomes of their patients with the care activities and patients' outcomes of resident physicians. METHODS: Sixteen acute care nurse practitioners and physician assistants and a matched group of resident physicians were studied during a 14-month period. Data on the subjects' daily activities and on patients' outcomes were collected 4 times. RESULTS: Compared with the acute care nurse practitioners and physician assistants, residents cared for patients who were older and sicker, cared for more patients, worked more hours, took a more active role in patient rounds, and spent more time in lectures and conferences. The nurse practitioners and physician assistants were more likely than the residents to discuss patients with bedside nurses and to interact with patients' families. They also spent more time in research and administrative activities. Few of the acute care nurse practitioners and physician assistants performed invasive procedures on a regular basis. Outcomes were assessed for 187 patients treated by the acute care nurse practitioners and physician assistants and for 202 patients treated by the resident physicians. Outcomes did not differ markedly for patients treated by either group. The acute care nurse practitioners and physician assistants were more likely than the residents to include patients' social history in the admission notes. CONCLUSIONS: The tasks and activities performed by acute care nurse practitioners and physician assistants are similar to those performed by resident physicians. However, residents treat patients who are sicker and older than those treated by acute care nurse practitioners and physician assistants. Patients' outcomes are similar for both groups of subjects.

Is there a health promotion and protection foundation to the practice of acute care nurse practitioners?

Currently, debate continues regarding defining the role of nurse practitioners in the acute care setting. Health maintenance, health promotion, disease prevention, and health restoration are central goals of nurse practitioner care. Some question the degree (if any) to which acute care nurse practitioners regard health promotion as a basis for their practice. In this article, the concept of health promotion and protection is explored, with application to patients in the acute care setting; and the extent to which acute care nurse practitioners support such practices is examined.

Hypotension.

Advanced practice nurses are responsible for diagnosing and treating patients with acute onset hypotension. The potential diagnostic hypotheses for hypotension are related to a wide variety of pathophysiologic processes. These processes are represented by the acronym VINDICATE--Vascular (and cardiac), Inflammatory, Neoplastic, Degenerative, Intoxication/Iatrogenic, Congenital, Allergic/Autoimmune, Traumatic, Endocrine/Metabolic However, acute onset hypotension experienced by the adult patient in the hospital is likely to be caused by the vascular (and cardiac) processes of absolute hypovolemia, relative hypovolemia, and pump failure. Developing the differential diagnosis for acute onset hypotension involves making a series of clinical decisions in a stepwise manner. The clinician bases these decisions on information contained in a subjective and objective database and on recognizing patterns in the central findings. However, treatment of hypotension may be necessary before or during the diagnostic process, depending on the severity of the patient's symptoms.

One school's experience with the development of an oncology nurse practitioner curriculum.

PURPOSE/OBJECTIVES: To describe the foundational work and implementation of a nurse practitioner (NP) curriculum geared toward oncology nurses. The study is selective (not comprehensive) and reflective of one school's experience. DATA SOURCE: Journal articles, curriculum guidelines, anecdotal experience, and interviews. DATA SYNTHESIS: The NP is used more frequently in oncology, both as a clinician and for other aspects of advanced practice nursing. NPs must be prepared to fulfill graduate criteria as outlined by definitive sources for curriculum development. CONCLUSIONS: Schools must work with employers, graduates, and patients in conducting outcome evaluations to measure safety issues and role effectiveness of oncology NPs (ONPs), as well as fulfillment of all aspects of the advanced nursing practice role. IMPLICATIONS FOR NURSING PRACTICE: If healthcare employers continue to rely heavily on the use of ONPs, schools of nursing must be prepared to graduate safe clinicians, experts in oncology, and advanced practice nurses, all combined into one graduate. This difficult task requires evaluation of current practices.

Credentialing and privileging: insight into the process for acute-care nurse practitioners.

Acute-care nurse practitioners must be knowledgeable of the mechanisms whereby their scope of practice is defined and regulated, and through which professional competence is ensured. The mechanisms whereby hospitals determine scope and practice parameters is through credentialing and the delineation of clinical privileges. This article supplies background for the influences to the credentialing and privileging process and provides insight into how the process is conducted. The potential future trend of economic credentialing is discussed briefly. Acute-care nurse practitioners are encouraged to negotiate for delineation of clinical privileges that are consistent with their professional and legal scope of practice, educational and individual capabilities, and the safe delivery of quality patient care. It is important that the process not be misused to erect barriers to practice, resulting in underserving of patient and organizational needs.

Nurses' perceptions of the impact of a computerized information system on a critical care unit.

Critical care nurses work in complex environments and encounter a vast amount of information daily. To learn how a computerized information system (CIS) impacted nursing practice on a critical care unit, this foundational research was conducted before and after implementation of a CIS. Qualitative methods using interviews and open ended questions were employed. Results showed that nurses felt positive overall about the implementation of a bedside CIS. Nurses liked the readability of the information and having the CIS near the bedside. They disliked the periodic slowness or downtime. Broad themes of reflection, questioning and action emerged from the content analysis. The themes were in accord with the theoretical framework that guided the study. Recommendations for future research included exploring nursing medication documentation, use of hand held devices, and having resource databases within the CIS.

Current questions with regard to acute care nurse practitioner preparation and role implementation.

The role of the acute care nurse practitioner is being implemented in acute and tertiary care settings. As the role evolves, questions arise. Some of these questions relate to: 1) whether a need for the role has been clearly established; 2) whether the scope of acute care nurse practitioner practice has been identified distinctly; 3) the adequacy of educational preparation; 4) certification versus licensure; and 5) the nature of the relation between this role and other forms of advanced practice nursing. In this article, the authors identify and discuss some of these questions, provide information regarding current status, and postulate further potential resolutions.

Acute care nurse practitioner curriculum: content and development process.

Curriculum development for preparation of acute care nurse practitioners requires a comprehensive process. To develop a program for their preparation at a large university, the faculty examined needs of the target patient population and care delivery system; scope of acute care nurse practitioner practice; current guidelines for the education of primary care nurse practitioners; evolving guidelines for the didactic and clinical education of acute care nurse practitioners; educational requirements of governing or licensing and certifying bodies; and placement of this new role within the existing healthcare team structure. A curriculum was then developed using a collaborative, multidisciplinary approach.

Actualizing theory to practice: preparing for computerized information system research on a critical care unit.

In preparation for conducting research on the work of nurses before and after the installation of a computerized information system on a critical care unit, an actualizing process was applied. This process, derived from Actualizing Theory, provided the researchers with an opportunity to study congruence and appropriateness among the components of the intended research. Actualizing Theory uses twelve main strategies to assist in linking theory to a concrete situation. These strategies were employed as the research proposal was being developed and helped both to clarify the fitness of the main components of the research and in representing them in operational form.

Trial of nurse practitioners in intensive care.

As public concern for quality control of medical care at the beginning of this century forced regulations on medical licensing of physicians, the forces of change in health care are again substantial, this time driven by concerns for cost and access. Our experience at the University of Pittsburgh Medical Center leads us to believe that well-trained physician extenders will play a valuable role in improving efficiency and effectiveness in the care of critically ill patients. We have developed a method for training and supervision. Graded practice supervision, with physician-led professional review, is considered a reasonable goal. We propose that the appropriate degree of supervision in any given area can be determined by: a) careful development of training programs; b) careful assessment of the individual's practice with the target patient population; and c) application of a review process that is sensitive in that population. Issues surrounding the independent practice and reimbursement of acute care nurse practitioners (ACNPs) are not resolved. These issues should be addressed by joint position statements that are based on objective documentation of the safe, effective performance of ACNPs, and on the incorporation of routine performance measurements with continued medical or joint evaluation of the quality review system. Guidelines regarding the evolving roles of ACNPs should be established by professional associations and state or national boards of both nursing and medical practice. Critical care physician and nursing leaders should lead such initiatives.

Management of chronic left ventricular assist device percutaneous lead insertion sites.

Patients with ventricular assist devices must necessarily have percutaneous leads linking the internal device to the external console. In the chronic circumstance, the percutaneous lead insertion site may become the location of irritation or infection. At the University of Pittsburgh, a procedure has been developed for care of this site. Since the institution of the procedure, 30 patients have been mechanically supported, representing a total of 1688 patient days of support. Positive cultures were obtained from the lead insertion sites of four patients in this series, whose length of support ranged from 72 to 144 days. All four patients were hemodynamically unstable requiring support with the intraaortic balloon pump before institution of the ventricular assist device, and two patients had significant risk factors for infection development at the lead insertion site before implementation. Two of the infections were considered minor, and posttransplantation sequelae developed in only one patient. With current therapeutic protocols and the defined procedure for care of the lead insertion site, the occurrence of positive cultures associated with clinical signs and symptoms of site infection appears to be infrequent.

Ongoing development of the Critical Care Information System: the collaborative approach to automating information management in an intensive care unit.

Point-of-care (bedside) clinical information systems can fulfill a variety of functions. Included in these functions are: becoming receptacles for patient data and allowing data to be manipulated into formats that facilitate clinical decision making; functioning as sources for billing and auditing processes; interfacing to other hospital systems and bringing distant data to the bedside; and being a repository for information used in the development of hierarchical and/or relational databases. The initial and ongoing development of these systems in a dynamic clinical environment requires the construction of processes and work pathways to ensure that the needs and requirements of myriad personnel, departments and agencies within the health center milieu are addressed.

Nursing considerations for the patient with a total artificial heart.

At our institution, the TAH has been identified as a valuable support to a select subgroup of individuals with end-stage heart disease as a bridge to transplantation. Length of implantation has varied from 1 to 48 days in the PUH series. Management of the care of the TAH-implanted patient requires a collaborative effort by nurses, physicians, and biomedical engineers. Nurses caring for the patient must have extensive knowledge of postoperative care of the high-risk cardiac surgical patient that is supplemented by the specialized knowledge of TAH function and monitoring. We have identified specialized components to the nursing care of the patient following TAH implantation. Monitoring for hemorrhage is important in the immediate postoperative period; anticoagulation and assessment of possible embolic events are later considerations. Knowledge of the relationship between TAH function and changing preload and afterload enhances the nurses' interpretation of COMDU and hemodynamic monitoring parameters, and is essential when applied to other nursing interventions, such as patient positioning and mobilization. Nursing-care measures to prevent atelectasis or consolidation are essential to prevention of pneumonia. Prevention of infection is crucial to facilitate transplantation. Practice of aseptic technique with particular care to drive-line insertion sites is necessary. Pain management, as well as nutritional and psychologic support, are important to promote patient well-being (a nursing-care plan is outlined in Table 1). The goals of all nursing-care measures are an improved perfusion state as offered by the TAH, prevention of possible complications associated with TAH implantation, and prevention of possible complications of critical illness and immobility. The desired outcome is a patient with a stabilized or improving condition prior to cardiac transplantation. It has been exciting to participate in the development of nursing-care guidelines for a patient population that has little precedent. The TAH creates a symbiotic relationship between man and machine, and nursing-care responsibilities have grown to encompass the mechanical aspects of this relationship. Satisfaction has increased as well, as the nurse is able to provide a specialized service in the provision of a life-saving therapy and be a vital element in the successful implementation of an artificial-heart program. As advances are made in the development of mechanical devices that assist or replace the human heart, ongoing evaluation and refinement of nursing care guidelines are essential.