The evaluation of evidence-informed changes to an internationally educated nurse registration process.

AIM: To evaluate effectiveness of specific policy and practice changes to the process of registration for internationally educated nurses. BACKGROUND: Little research exists to inform registration policy for internationally educated health professionals. INTRODUCTION: Internationally educated nurse employment can help address nursing shortages. Regulators assess competencies for equivalency to Canadian-educated nurses, but differences in health systems, education and practice create challenges. METHODS: The study setting was a Canadian province. We used a mixed methods approach, with a pre-post-quasi-experimental design and a qualitative evaluation. Previous analysis of relationships between applicant variables, registration outcomes and timelines informed changes to our registration process. Implementation of these changes composes the intervention. Comparisons between pre- and post-implementation exemplar subgroups and timeline analyses were conducted using descriptive statistics, univariate analysis and non-parametric tests. Data were collected from complete application files before (n = 426) and after (n = 287) implementation of the intervention. Interviews, focus groups and consultations were completed with various stakeholders. FINDINGS: The time between steps in the process was significantly reduced following implementation. Stakeholders reported an increase in perceived efficiency, transparency and use of evidence. DISCUSSION: Results indicated that initial impacts of the policy changes streamlined the process for applicants and staff. CONCLUSION: Maintaining a consistent and systematic review of an organization's data coupled with implementation of findings to effect policy and practice change may have an important impact on regulatory policy. IMPLICATIONS FOR NURSING POLICY: These findings represent the beginning of an international policy conversation. Policy changes based on organizational data can underlie major process improvement initiatives. Ongoing nursing shortages across the globe and increasing mobility of nurses make it important to have efficient and transparent regulatory policy informed by evidence.

Wisdom within: unlocking the potential of big data for nursing regulators.

AIM: This paper explores the potential for incorporating big data in nursing regulators' decision-making and policy development. Big data, commonly described as the extensive volume of information that individuals and agencies generate daily, is a concept familiar to the business community but is only beginning to be explored by the public sector. BACKGROUND: Using insights gained from a recent research project, the College and Association of Registered Nurses of Alberta, in Canada is creating an organizational culture of data-driven decision-making throughout its regulatory and professional functions. The goal is to enable the organization to respond quickly and profoundly to nursing issues in a rapidly changing healthcare environment. SOURCES OF EVIDENCE: The evidence includes a review of the Learning from Experience: Improving the Process of Internationally Educated Nurses' Applications for Registration (LFE) research project (2011-2016), combined with a literature review on data-driven decision-making within nursing and healthcare settings, and the incorporation of big data in the private and public sectors, primarily in North America. DISCUSSION: This paper discusses experience and, more broadly, how data can enhance the rigour and integrity of nursing and health policy. CONCLUSION: Nursing regulatory bodies have access to extensive data, and the opportunity to use these data to inform decision-making and policy development by investing in how it is captured, analysed and incorporated into decision-making processes. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Understanding and using big data is a critical part of developing relevant, sound and credible policy. Rigorous collection and analysis of big data supports the integrity of the evidence used by nurse regulators in developing nursing and health policy.

Reduction of leg wound infections following coronary artery bypass surgery.

OBJECTIVE: To reduce the rate of infection at the saphenous vein harvest site after coronary artery bypass surgery, to identify predictors of infection and to determine the best method for leg wound closure. DESIGN: A randomized clinical trial was undertaken to determine the best technique for reducing the postoperative leg wound infection rate. Patients were allocated to one of four leg wound closure methods: staples, close immediately; staples, close after protamine administration; subcuticular sutures, close immediately; and subcuticular sutures, close after protamine. Risk factors evaluated were age, sex, diabetes, obesity, peripheral vascular disease, reoperation, time in surgery, wound length, wound depth, time that the wound was open, wound quality and harvest site. SETTING: The Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta. PATIENTS: All consenting patients undergoing elective coronary artery bypass surgery involving saphenous vein harvesting were considered for the study. Exclusion criteria were insertion of a drain, insertion of an intra-aortic balloon pump in the index limb and inability to complete follow-up at the authors' centre. Eighty patients were initially enrolled, with 77 completing the study. INTERVENTIONS: Patients underwent standard saphenous vein harvesting followed by wound closure as indicated by the study group. MAIN RESULTS: The major infection rate was reduced from 13% to 3% (P = 0.02). Each closure method was equally effective, and wound depth was the only factor related to infection. CONCLUSIONS: Leg wound infections continue to be a major source of morbidity after coronary bypass surgery.

Acute aortic dissection and ventricular septal defect repair.

A 37-year-old male with long-standing heart murmur and ventricular septal defect developed acute chest pain and was diagnosed with an aortic dissection and aortic insufficiency. The ventricular septal defect and aortic dissection were repaired successfully as a combined procedure. At late follow-up (three years), he continued to enjoy an excellent result.

Recurrent aortic dissection after orthotopic heart transplantation.

A patient with Marfan's syndrome and previous Bentall repair for aortic dissection required orthotopic cardiac transplantation for end-stage cardiomyopathy. Postoperatively he suffered recurrent aortic dissection involving the transverse and descending aorta leading to tracheal and esophageal compression. He underwent successful surgical replacement of his ascending aorta, transverse arch, and descending aorta.

Perimembranous ventricular septal defect repair: keeping it simple.

OBJECTIVE: A simplified method of repairing perimembranous ventricular septal defects (VSDs) was employed to reduce the incidence of complete heart block and significant residual defects. PATIENTS AND INTERVENTIONS: Twenty-three children (mean age 1.2 +/- 0.3 years, range 0.1 to 5.8; mean weight 8.2 +/- 0.9 kg, range 3.7 to 20), one adolescent (16 years old) and one adult (30 years old) with perimembranous VSDs were operated on using the simplified method to correct the defect. The repairs were done from a right atrial approach by sewing the patch directly to the rim of the defect, by using very small bites in the area of the conduction tissue. In 36% of cases, the tricuspid valve was temporarily detached close to the annulus to improve operative exposure. Concomitant procedures were required in 91% of children. MAIN RESULTS: Early postoperative echocardiography showed a tiny residual ventricular septal defect in 28% (seven of 25) of patients, none requiring reoperation. There were no perioperative deaths. At follow-up there were no significant residual VSDs and no patient required reoperation. Postoperative electrocardiography revealed no evidence of heart block, but 64% showed a right bundle branch block pattern. There were no problems with tricuspid valve function postoperatively. At late follow-up (22 +/- 2 months) there were no significant problems related to the VSD repair. CONCLUSIONS: This simplified method of VSD repair produces excellent results avoiding significant leaks and the need for reoperation. This method has shown freedom from complete heart block and the need for pacemaker implantation. Temporary detachment of the tricuspid valve improves visualization in many children and is a safe practice.

Modified Blalock-Taussig shunts: to heparinize or not to heparinize?

OBJECTIVE: To demonstrate shunt function of modified Blalock-Taussig Shunts (MBTSs) when no heparin is administered postoperatively. PATIENTS AND INTERVENTIONS: Twenty-four MBTSs were performed on 23 children with various congenital heart problems needing palliation before the primary repair could be completed. A single low dose of heparin was given intraoperatively and no heparin was given postoperatively. Patients were evaluated for shunt patency, bleeding problems and the incidence of significant seromas at the graft site. MAIN RESULTS: There was one perioperative death and no incidence of early shunt failure. Two children died from causes unrelated to shunt function. There were no postoperative bleeding difficulties (no reoperations), and no seromas surrounding the grafts. Late follow-up (mean 18 +/- 1 months) revealed no shunt failure. CONCLUSIONS: Avoidance of heparin after an MBTS procedure is a safe practice and may reduce bleeding problems and the incidence of significant seromas surrounding the graft. Postoperative shunt thrombosis is more likely related to intraoperative technical difficulty or extremely small pulmonary artery size.

Splenorenal arterial bypass in a child with Takayasu's disease: a case report.

In adults splenorenal arterial bypass is a highly effective treatment for renovascular hypertension, but in children the procedure has been less successful because of the small size of the splenic artery. However, with the improvement in microvascular techniques the procedure is now possible in children. A 2-year-old child with Takayasu's arteritis, previous right nephrectomy and severe renovascular hypertension required revascularization to salvage his remaining left kidney. A splenorenal arterial bypass was performed through a left retroperitoneal flank incision. Postoperatively his creatinine level returned to normal and his requirements for antihypertensive medication were markedly diminished. The advantages of a splenorenal arterial bypass for left renal revascularization in a developing child are discussed.

Traumatic rupture of the thoracic aorta during the second trimester of pregnancy.

A 36-year-old woman in the second trimester of pregnancy underwent emergent operative repair of a traumatic aortic disruption caused by a motor vehicle accident. Left atrial-to-femoral artery bypass was used to maintain fetal circulation during the cross-clamp period. Her healthy, full-term child was subsequently delivered 3 months later by normal vaginal delivery.

Metastatic testicular tumor requiring inferior vena cava resection.

A patient undergoing radical retroperitoneal lymphadenectomy for metastatic embryonal cell testicular carcinoma is presented. Tumor resection required removal of the inferior vena cava due to transmural invasion. The inferior vena cava was replaced using externally stented polytetrafluoroethylene (PTFE) graft. Patency was documented by postoperative Doppler studies, duplex scanning, and computed tomographic scanning. Stented PTFE is currently the graft of choice for inferior vena caval replacement.