Improving patient outcomes with the Cardiac Advanced Life Support-Surgical (CALS-S) guideline

Nurses' roles and responsibilities in cardiac advanced life support: A single-site eDelphi study

BACKGROUND

Nurses are often the first responders to in-hospital cardiac arrest in postoperative cardiac surgical patients. Poor clarity about role expectations and responsibilities can hinder nurses' performance during cardiac advanced life support (CALS) procedures.

AIM

To seek expert consensus on nurses' roles and responsibilities in CALS for patients in postoperative cardiac surgical patients.

STUDY DESIGN

A two-round modified eDelphi survey. Delphi items were informed by guideline literature, an audit of resuscitation records and expert interviews. Panellists, drawn from a single site of a large tertiary health service in metropolitan Melbourne, included nurses, doctors and surgeons familiar with the management of cardiac arrest in post-operative cardiac surgical patients.

RESULTS

The two rounds of the modified eDelphi generated 55 responses. A consensus of >80% agreement was reached for 24 of the 41 statements in Round 2. All items related to nurses' roles and responsibilities during nurses pre- and post-arrest phases reached consensus. In contrast, only 29% (n = 4/14) of items related to peri-arrest, and 36% of those related to nurse scope of practise in CALS arrest (n = 4/11) reached consensus.

CONCLUSION

The study's aim was only partially achieved. Findings indicate high agreement about nurses' roles and responsibilities before and immediately after a cardiac arrest, but limited clarity about nurses' roles when implementing the CALS protocol, such as resternotomy and internal cardiac massage. There is an urgent need to address uncertainty about nurses' roles and scope of practice in CALS, which is essential to the recognition of nurses' contribution to the cardiac specialty workforce.

RELEVANCE TO CLINICAL PRACTISE

Uncertainty about nurses 'roles and responsibilities when implementing the CALS protocol may hinder their performance to their full scope of practice, leading to poor patient outcomes.

Improving outcomes after low-risk coronary artery bypass grafting: understanding phase of care mortality analysis, failure to rescue and recent perioperative recommendations

PURPOSE OF REVIEW

Avoidable adverse events are responsible for up to 50% of deaths after low-risk coronary artery bypass grafting. This article reviews recent quality improvement efforts to improve outcomes after cardiac surgery.

RECENT FINDINGS

Systematic quality improvement methodology in cardiac surgery has improved significantly over the past decade. Contemporary efforts with phase of care mortality analysis (POCMA) focus on identifying and addressing root causes for mortality. Each patient's perioperative course is an interconnected sequence of clinical events, decisions, interventions, and treatment responses occurring across five perioperative phases. A single seminal event within a specific phase of care has been found to often trigger the eventual death of a patient. Several groups have made significant improvements to perioperative outcomes by addressing these avoidable mortality trigger events. Failing that, failure to rescue (FTR) metrics can be used to identify institutional factors responsible for poor perioperative outcomes. This ongoing focus on quality improvement serves to further improve outcomes after low-risk cardiac surgery.

SUMMARY

Modern quality improvement methodology, including POCMA and FTR analysis, has the potential to significantly improve outcomes after cardiac surgery. Larger future studies with multiinstitutional data sharing will be key to facilitate ongoing quality improvement and knowledge translation in this field.