Performance evaluation of arterial femoral sheath removal by registered nurses after PCI

Background

Sheath removal after PCI by registered nurses can improve patients’ comfort and shorten immobilisation time. As sheath removal is not without risk, it is important to assure the quality of performance.

Aims

The aim was (a) to check if nurses’ performance in 1999 and 2005 was in accordance with the protocol for arterial sheath removal and (b) to compare both measurements to explore differences in performance over time.

Methods

We trained registered nurses in sheath removal and observed them during sheath removal in elective uncomplicated PCI-patients. We developed and used a checklist, including 10 elements and 65 items.

Results

Both in 1999 ( n=43 observations with 13 nurses) and 2005 ( n=42 observations with 16 nurses) the norm of more than 90% for the total score was not achieved: we found 82% and 80%, respectively. Four elements scored more than 90%, and three elements scored less than 80% at both points in time. The results on the other three elements differed significantly over time.

Conclusion

Registered nurses achieved the norm for good performance (80–89%) of removing arterial sheaths according to protocol after a training programme and this is stable in time. Since the norm for excellent performance (≥90%) was not achieved, current performance could be improved, e.g. by yearly repetition of training and observation of skills. More research is needed, and could focus on the validation of the instrument. Also multi-centre studies with this checklist could test the association between the quality of arterial femoral sheath removal and the occurrence of vascular complications.

CABG and PTCA Patients' Expectations of Informational Support in Health-Related Quality of Life Themes and Adequacy of Information in 1-Year Follow-Up

The purpose of this study was to describe coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) patients' need for nursing informational support in health-related (HRQoL) items before and after coronary artery procedures. As well we present the adequacy of informational support from patients' viewpoint. The study sample (N=625) consisted of consecutive male (N=439) and female (N=176) patients with CAD who were treated with elective CABG or PTCA. The data were collected by structured interview before coronary artery procedures and by mailed questionnaires 6 and 12 months afterwards in 1999-2001. Patients in both groups reported needing the most information about recovery and psychosocial functioning before and after the treatments. Single HRQoL items identified that the expectations of women and men differed during the follow-up period. Women in the PTCA group needed more informational support than men before procedures, while men needed more support afterwards. Our results suggest that the content of informational support is different for male and female patients before and after the coronary artery procedures. The effects of nursing interventions and instruments for measuring change in patients' outcome resulting from nursing interventions should be developed further.

Hours During and After Coronary Intervention and Angiography

The purpose of this study was to describe patients’ experience during and after coronary angiography and percutaneous coronary intervention. Data were collected by interviews with 14 patients. A qualitative content analysis approach was used. Four main categories were identified that describe patients’ experience of the hours during and following intervention: emotional thoughts, bodily sensations, nursing intervention of importance, and personal strategies. All patients made a comment on staff conduct and pointed out that even minor nursing actions may be of great importance. Patients were most positive toward the transradial approach. Even though the approach via arteria radialis will increase, many patients will still have their procedure done via arteria femoralis. In spite of all research and technical developments, the patients’ experience from intervention via arteria femoralis is pretty much the same as it was 1997.

Vascular Access Complications after Cardiac Catheterisation: A Nurse-Led Quality Assurance Program

BACKGROUND

Vascular access complications may be a cause of discomfort, prolonged hospital stay, and impaired outcomes in patients undergoing cardiac catheterisation.

AIMS

To assess vascular access complication in our patients with/without the use of closure devices as a first local benchmark for subsequent quality improvement.

METHODS

A nurse-led single-centre prospective survey of all vascular access complications in consecutive patients submitted to cardiac catheterisation during 4 months.

RESULTS

The radial and femoral access were used in 78 (14%) and 470 (83%), respectively, of 564 procedures, and a closure device was used in 136 of the latter. A haematoma (any size) was isolated and uneventful in 9.6% of cases. More severe complications (haemoglobin loss >2 g, need for blood transfusion or vascular repair) occurred in 1.2% of cases, namely: in none of the procedures with radial access, and in 0.4% and 2.4% of femoral diagnostic and interventional coronary procedures, respectively. During complicated (n=40) vs uncomplicated (n=172) transfemoral interventions, the activated coagulation time was 309+/-83 vs 271+/-71 s (p=0.004), but the use of closure devices was similar.

CONCLUSION

Severe vascular access complications in our patients were fewer than in most reports, and virtually absent in radial procedures. Vigorous anticoagulation was associated with increased complications in our patients, but closure devices were not. A new policy including both the use of the radial access whenever possible, and a less aggressive anticoagulation regimen during transfemoral interventions will be tested.

Care of the Patient Undergoing Radial Approach Heart Catheterization: Implications for Medical-Surgical Nurses

Primary treatment for coronary vascular disease focuses on therapeutic lifestyle changes. However, additional medical management or even coronary intervention may be required. Access sites for catheterization include the brachial, radial, and femoral arteries. As an increasing number of providers implement transradial cardiac catheterization, education for nurses is a priority.

Patients' perception of their experience of primary percutaneous intervention for ST segment elevation myocardial infarction

Many patients experiencing ST segment elevation myocardial infarction (STEMI) are currently treated with primary percutaneous intervention (PCI). This relatively new procedure has reduced the time patients with the diagnosis of STEMI spend in hospital. In this literature review we explore patients' perceptions of their experience of receiving primary percutaneous intervention (PCI) as a treatment for STEMI. We critiqued and graded for relevance 10 papers that included original research and other sources. Key findings indicate that there is considerable variability in how patients treated for STEMI perceive the experience of PCI. Further, there is a misalignment between some patients' perceptions and health professionals' perceptions of this experience related to the event as well as the language used to speak of it. Thus, we recommend that nurses assess patients' perception of the experience and patients' health literacy level, then tailor the content and language of patient and family education to ensure an effective educative intervention.

The effectiveness of "Siriraj Leg Lock" brace on back pain after percutaneous coronary intervention: PCI

BACKGROUND

The most common problem experienced by patients after Percutaneous Coronary Intervention (PCI) is back pain. After the procedure, patients are restricted to complete bed rest with no hip flexion for up to 10 hours, causing much discomfort, especially back pain. In some patients, anxiety arises due to limited movement, with the belief that movement might cause re-bleeding from the wound. To alleviate these problems, the "Siriraj Leg Lock" brace or SLL was initiated to confine the hip while allowing patients to freely move other parts of their body without complicating the wound. Hence, anxiety is relieved and mobility can lower the chance of getting back pain with more comfort.

OBJECTIVE

The aims of this experimental study were to investigate the effect and satisfaction of SLL on back pain in post-PCI patients, and to compare bleeding and/or hematoma occurrences at the site of incision between experimental and control groups.

MATERIAL AND METHOD

The randomized controlled trial (RCT) was conducted in 100 patients who underwent coronary angioplasty and/or stent placement interventions and received post procedural care at the intermediate cardiac care ward, Her Majesty Cardiac Center from December 2006 to February 2007. The control group (49 patients) was to get standard care after the intervention, whereas the experimental group (51 patients) was fitted with the SLL device to allow free mobility right after the procedure.

RESULTS

Lower maximum back pain scores and mean back pain scores in the experimental group than in the control group, with statistical significance (p < 0.001). Back pain score reduced from the day of admission in the experimental group after applying SLL, but increased in the control group. The occurrence of hematoma in both groups was not significantly different (p = 0.114). The experimental group with the SLL could freely change positions from upright to decubitus without any effects to the wound, feeling more comfortable and experiencing less back pain. Patients' satisfaction towards the SLL from 1 to 5 scale was 4.3. The satisfaction was evident especially in patients who had previous PCI experience, and desired to ask for SLL application if a future procedure to be needed.

CONCLUSION

Using SLL after sheath removal post PCI allows the patient to freely change position without any effects to the wound and reduces back pain with more patients' satisfaction.

Improving outcomes following elective percutaneous coronary intervention: the key role of exercise and the advanced practice nurse

Percutaneous coronary intervention (PCI) is a safe, effective, non-surgical treatment for coronary artery disease (CAD). The demand for PCI has increased exponentially since the 1980s and it has become the treatment of choice for many individuals with CAD. Since PCI is not a cure, secondary prevention strategies are critical to prevent disease progression. Unfortunately, current strategies ignore the specific needs of the elective PCI population. In this article, the authors highlight the unique characteristics of these patients, which may contribute to their lack of engagement in healthy lifestyles. Elective PCI patients are vulnerable due to limited knowledge and follow-up, and lack of enrolment in secondary prevention programs. Exercise is a central component of any cardiac prevention strategy. Individualized exercise programs that incorporate physical activity and counselling can potentially improve the clinical outcomes of these patients. Advanced practice cardiovascular nurses play a key role in developing, implementing, and evaluating exercise programs in this population.

Blood Pressure and Risks of Vascular Complications After Percutaneous Coronary Intervention

Evidence-based protocols are needed for care of the nearly 1,000,000 patients in the United States who undergo percutaneous coronary interventional procedures. This article describes a case-matched control study of 300 patients undergoing percutaneous coronary intervention in which specific demographic, physician-sensitive, and nurse-sensitive factors were tested to determine their relative contribution to the incidence of vascular complications. Findings included that patients with a mean systolic blood pressure of 160 mm Hg or higher were 8 times more likely to have vascular complications (P < .001). Patients receiving heparin (with and without glycoprotein IIb/IIIa inhibitors) versus bivalirudin were 3 times more likely to have vascular complications (P = .008). Patients with hemostasis by AngioSeal and those with a history of hypertension were 77% (P =.031) and 61% (P = .005), respectively, less likely to have complications.

Overview of the transradial approach in percutaneous coronary intervention

Thirteen years have passed since the first percutaneous coronary intervention was performed at Onze Lieve Vrouwe Gasthuis in Amsterdam using the transradial approach (TRA). Since then TRA has spread through the interventional community and many centres have now adopted TRA as the arterial access of choice. This review is focused on the hot issues and the latest developments in this field. The following subjects will be addressed and discussed: drawbacks and learning curve, procedural technique, indications (with particular attention to acute coronary patients), complications, contraindications, nurse workload, patient management, and economics.

Percutaneous interventions

The catheterization laboratory is no longer limited to coronary arterial interventions. Physicians have been striving to make more interventions less invasive that now can include carotid, renal, and peripheral arterial stenting, as well as less invasive repair of atrial septal abnormalities. Even cardiac assist devices can be implanted percutaneously to bridge a critically ill patient to other modes of treatment. This article will give a brief overview of each intervention and identify important nursing care.

Capacity for Direct Attention in Patients Undergoing Percutaneous Coronary Intervention: The Effects of Psychological Distress

Emphasis is placed on educating coronary heart disease patients about lifestyle choices to reduce the risk of further cardiovascular events, but little attention has been paid to the impact of attentional capacity on patients' learning. The purpose of this study is to identify and compare the capacity for direct attention and the effect of psychological distress during hospitalization and 6 weeks after percutaneous coronary intervention. Forty subjects, mean age of 63 years, 27 men and 13 women, completed components of the Wechsler Memory Test to measure direct attention, and the Profile of Mood States. There were significant differences in the Digit Span Test-backward, a measure of working memory (t=-2.79; p<0.009), and the Profile of Mood States total score, a measure of psychological distress (t=3.183; p<0.003), from hospitalization to 6 weeks post-percutaneous coronary intervention. Data demonstrate psychological distress and reduced capacity for direct attention during hospitalization indicating that hospital environments are suboptimal for learning.

Primary angioplasty for acute ST-elevation myocardial infarction

This article examines primary percutaneous coronary intervention as a reperfusion treatment for acute ST-segment elevation myocardial infarction. It discusses the nursing care of patients undergoing this procedure.

Evaluation of In-patient Interventional Cardiology

The ACNP service in this study decreased the TA, TC, and LOS for patients transferred from outlying hospitals for cardiac catheterization or PCI. Patients on the ACNP service were provided prescription for appropriate discharge medications including beta-blockers, aspirin, ACE inhibitors, and lipid-lowering agents more often than patients on the housestaff service. Other aspects of care, including follow-up appointments and elements of patient education, were documented more often for patients on the ACNP interventional cardiac service and expand the role of ACNPs into other areas of acute-care cardiology practice.

Predictors of Vascular Complications Post Diagnostic Cardiac Catheterization and Percutaneous Coronary Interventions

Care of patients after cardiac catheterization and/or percutaneous coronary intervention is largely the responsibility of nurses. The identification of risk factors for vascular complications from these procedures is important for the development of protocols to prevent complications. This article describes a retrospective, descriptive, and correlational study of 11,119 patients who underwent cardiac catheterization and/or percutaneous intervention, with femoral artery access, in the years 2001 to 2003. Increased risk for vascular complications was found in patients who were older than 70 years, were female, had renal failure, underwent percutaneous intervention, and had a venous sheath.

Effects of Three Groin Compression Methods on Patient Discomfort, Distress, and Vascular Complications Following a Percutaneous Coronary Intervention Procedure

BACKGROUND

Incidence of vascular complications (VCs) after sheath removal following a percutaneous coronary intervention procedure (PCIP) vary widely by the compression method used to achieve femoral artery hemostasis.

OBJECTIVE

To determine if one groin compression method causes the least discomfort and distress for patients and results in fewer VCs.

METHODS

Patients (n = 306, mean age = 62.3 years, 77% male, 96.4% Caucasian) undergoing PCIPs at a tertiary care center in the urban Midwest participated in this three-group experimental design study. They were randomly assigned to Femostop, C-clamp, or manual compression and rated level of groin discomfort and distress on a 0-10 Numeric Rating Scale (NRS) prior to, during, and after arterial compression was released. The groin area was assessed for any VCs (oozing, ecchymosis, hematoma) prior to sheath removal, after compression released, and 12 and 24 hr after sheath removal.

RESULTS

No significant differences were found by compression method for discomfort, distress, or VCs. Regardless of method, not having a VC prior to femoral sheath removal contributes to less oozing (z = -3.1, p = .0019), hematoma (z = -9.4, p < .0001), and ecchymosis(z = -10.1, p < .0001). C-clamp contributes to less oozing when hemostasis time is < 30 min (z = -2.2, p = .03), and Femostop is superior when time to hemostasis is >30 min (z = -2.3, p = .02). Not receiving eptifibatide (Integrilin) contributes to less ecchymosis (z = -2.9, p = .004).

CONCLUSIONS

Nurses need to be vigilant when caring for patients who have a VC prior to femoral sheath removal and have received antiplatelet medications. Further research is needed to identify patient characteristics that may contribute to VCs.

Clinical and procedural predictors of nurse workload during and after invasive coronary procedures: the potential benefit of a systematic radial access

BACKGROUND

Invasive coronary procedures are increasing in number and complexity over time. This trend translates in an increased need for economical and human resources, among which is nurse staffing the most affected.

AIMS

To identify possible predictors of nurse workload, during and after diagnostic and interventional procedures.

METHODS

Two hundred and sixty consecutive patients were included: 52 and 208 patients underwent femoral and radial access, respectively. Nurse workload was calculated with a self-developed model.

RESULTS

Cathlab nurse workload was 103 [63--156] min. Independent predictors of increased Cathlab nurse workload were: femoral access, failed radial access and cross-over, interventional procedures, procedural time, urgent procedures. Cathlab nurse workload was 174 [134--218] and 86 [58--126] min, for femoral and radial access, respectively (p<0.001). Among the overall population, 174/260 patients (44 females, mean age 66+/-11 years) were hospitalised at our Center after the procedure. Fifty-six and 118 patients had femoral and radial access, respectively. Ward nurse workload was 457 [226--954] min. Independent predictors of increased Ward nurse workload were: access-site complication, length of in-hospital stay, admission to CCU, interventional procedures. Ward nurse workload was 386 [226--652] and 720 [314--1375] min, respectively for radial and femoral access (p<0.001).

CONCLUSIONS

A systematic radial access is an effective strategy for reducing nurse workload, both during, by simplifying nurse tasks in the CathLab, and after coronary invasive procedures, by preventing access-site complications, shortening in-hospital stays, and reducing admissions to CCU.

Determining best practice: Comparison of three methods of femoral sheath removal after cardiac interventional procedures

OBJECTIVE

To test the null hypothesis that there is no significant difference between 3 methods of sheath removal: manual compression, mechanical compression with the Compressar, and mechanical compression with the Femostop.

METHODS

The research design was experimental. Ninety patients were randomly assigned using a random-numbers table to undergo one of 3 methods of sheath removal. The principal investigator (L.M.B.) requested the patients' consent to undergo randomization of the sheath removal. Post procedure, each patient was told which method of sheath removal he or she would undergo based on results of the random-numbers table assignment.

RESULTS

There were no significant differences between the groups with regard to age, body mass index, sheath size, heparin utilization, antiplatelet agents, or use of IIb-IIIa inhibitors. The complications between the methodologies for sheath removal were statistically significant. Patients who underwent manual sheath removal had fewer complications compared with those who underwent sheath removal using the Compressar or Femostop (chi2 P = .04). When complications were compared with the other parameters, only the presence of postprocedure heparin infusion (chi2 P = .014) and ACT values (Student t test P = .044) proved to be statistically significant.

CONCLUSIONS

Based on the results of this study, staff in the study setting are currently exploring manual sheath removal as the preferred practice. Randomized controlled studies with larger sample populations at multicenter research sites are needed to ensure generalizability of results to larger populations. When using manual pressure application in conjunction with closure pad devices, hold times can be decreased, thus resulting in cost savings through decreased equipment use, earlier discharge times, and improved bed utilization.

Nursing care of the client requiring percutaneous coronary intervention

The scope of interventions for a wide variety of cardiac conditions and the research basis for practice are continuing to expand at a phenomenal rate. Nurses need to be actively engaged in all phases of the research process,to address ongoing questions of interest to continually improve client care. New research findings, building on an understanding of the foundations for interventional cardiology practice, are key to providing the highest quality of nursing care for this unique client population.

Nursing Outcomes

Percutaneous coronary interventional (PCI) procedures are commonly performed in the United States. The process of caring for this patient population has changed dramatically over the last 10 years, with many of the changes being driven by an evolution in the knowledge base underlying nursing practice. The purpose of this article is to provide a summary and critique of nurse-sensitive outcomes related to patients undergoing PCI procedures and to identify gaps in the literature to provide recommendations for future research. Nursing research on indicators related to costs of care, morbidity, symptom management, functional status, patient/family knowledge, patient responses, behavior, and home/occupational function following PCI are discussed in this review.

Pre-procedures: make a list and check it twice

Review how one facility updated its pre-procedure checklist for transferring patients from the telemetry unit to the cardiovascular laboratory.

Percutaneous coronary intervention

Symptoms associated with coronary heart disease include chest pain, dyspnoea, palpitations and collapse (Delahaye, 1999). Percutaneous transluminal coronary angioplasty (PTCA) has been found effective for relieving some of these symptoms (RITA-2 trial participants, 1997). The National Service Framework for Coronary Heart Disease (Department of Health, 2000) identified a need to double the number of these procedures carried out per year by 2010 to provide a service comparable with the rest of western Europe.

Interventions in pediatric cardiac catheterization

Since its inception in 1929, cardiac catheterization has undergone many changes. In the last two decades we have seen an evolution in cardiac catheterization from a diagnostic (anatomic and physiologic) to a therapeutic modality. This article highlights some of the more common and newer interventional procedures now performed.

Removal of a femoral sheath following PTCA in cardiac patients

Patients with coronary heart disease may require a percutaneous transluminal coronary angioplasty, involving the use of a balloon catheter to dilate the arteries introduced via a sheath. It is now increasingly common for the removal of the sheath to be a nursing procedure. This paper reviews the literature, best practice, potential complications and post-removal nursing care.

Developing best practice in arterial sheath removal for registered nurses

The purpose of this study was to evaluate the consistency of nursing practice in the discontinuation of sheaths on designating nursing units. The sample population was randomly selected based on interventional cardiac procedures where sheaths remained in place after leaving the catheterization lab. The data collected demonstrated inconsistencies in current practice of sheath removal and specific device preference by the nursing staff. Changes to the policies and physician order set were revised to best practice standards. Annual competency training was developed for the staff as was written and visual education. The changes that were implemented throughout the project provided for a positive change in patient outcome, revenue savings, and patient satisfaction.

Preparing for coronary angioplasty: the patients' experiences

Coronary angioplasty and stent placement procedures now represent one of the fastest growing specialties in cardiac care; patients undergo a short stay admission with limited care time with nurses. The purpose of this study was to describe participants' experiences of preparing for angioplasty in such an environment. Eight men and three women were interviewed 1 month after discharge from hospital. Verbatim transcripts were analysed for major themes using the qualitative techniques of grounded theory. Participants described working through a problem solving process in response to the perceived health threat associated with undergoing angioplasty. In step one, the problem was identified. In step two, coping responses were taken to try and solve the problem. In step three, the results of the coping responses were appraised or evaluated. The two problems identified were ongoing chest pain and anxiety related to fear of the unknown. The coping responses initiated included acquiring knowledge of the angioplasty, confidence in the skill of the doctor, support from family and gearing up psychologically. In the final appraisal of the coping responses, the participants decided to either go ahead with, or delay the angioplasty procedure. The results of this study indicate that the preparation for angioplasty represents a period of adjustment that may be anxiety provoking. Participants' experiences provide new knowledge of the concerns and challenges faced when undergoing such an invasive procedure in a short stay environment. The results clearly highlight that psychosocial aspects of nursing care are an essential component of nursing practice for angioplasty patients.

The patients' perception of recovery after coronary angioplasty

Coronary angioplasty and stent placement is associated with short hospital stays. Patients are expected to recover at home, alone, following limited care time with nurses. The purpose of the study was to describe participants' perceptions of recovery after angioplasty. Eight men and three women were interviewed 1 month after discharge from hospital. Verbatim transcripts were analysed for major themes using the qualitative techniques of grounded theory. Data analysis revealed three major categories: awareness of the problem, coping response and appraisal of the situation. These were linked via a problem solving process. In step one, the problem was identified. In step two, coping responses were taken to try and solve the problem. In step three, the results of the coping responses were appraised or evaluated. These categories were further defined by four phases identified as: pre-admission, admission, during the angioplasty and recovery. This paper describes the recovery phase. Awareness of the problem in the recovery phase was associated with 'relief from chest pain' for most participants. In contrast, anxiety continued and was associated with 'uncertainty over future health'. Participants described coping responses of "taking control of their life again" by undertaking both physical and psychological strategies. Finally, the situation was appraised to be either a 'good' or a 'bad' recovery. This appraisal was based on such considerations as the absence of chest pain, improvement in well-being and energy levels. The results of this study highlight patients' concerns and support the need for greater emphasis on their psychosocial needs. This care must be provided within the time constraints of short hospital stays. Nurses must also consider providing support to patients in the pre-admission and recovery phases.

Nursing interventions to decrease bleeding at the femoral access site after percutaneous coronary intervention. SANDBAG Nursing Coordinators. Standards of Angioplasty Nursing Techniques to Diminish Bleeding Around the Groin

BACKGROUND

This trial is the first prospective, multicenter clinical nursing trial conducted to measure the effect of nursing interventions on bleeding at the femoral access site after percutaneous coronary intervention with or without a potent antiplatelet agent given along with heparin and aspirin.

OBJECTIVE

To measure the relationship between nursing interventions and complications at the arterial access site in patients undergoing percutaneous coronary interventions and to recommend a standard of care to minimize bleeding complications.

METHODS

In a descriptive, correlational 4010-patient study, nursing care interventions after coronary procedures were measured. Observed standards of care were assessed, and regression techniques were used to evaluate nursing interventions and the effect of the interventions on bleeding at the access site after percutaneous coronary procedures.

RESULTS

Several significant correlations between nursing interventions and the occurrences of moderate to severe bleeding at the access site were found; however, most interventions had little effect. The most significant factors in decreasing complications at the access site were early removal of the arterial sheath, the type of pressure mechanism used to achieve arterial hemostasis, staffing allocation, and the person and method used to remove the sheath.

CONCLUSION

Many nursing interventions after percutaneous coronary intervention have become routine in the absence of clinical outcome data. Most nursing interventions aimed at decreasing bleeding at the vascular access site increase nursing workload but do not significantly affect bleeding in the groin. These results underscore the importance of continued clinical research studies to validate nursing practice on the basis of patients' outcomes.

Post procedural interventional cardiology patients on the progressive care unit

A community hospital undertakes having stable, elective percutaneous transluminal coronary angioplasties (PTCA) on the progressive care unit (PCU) immediately post procedure. The processes of organizational change, staff development, and quality assurance were practiced with the change in procedure. Patient, staff, and physician satisfaction has remained high.

Evidence-based clinical outcome management in interventional cardiology

In conclusion, through the use of pathways and case management, evidence-based clinical outcome management has occurred. The author's institution now has a process that enables it to accomplish three objectives: (1) the ability to track outcomes, (2) the ability to obtain information about opportunities for improvement and develop action plans for this, and (3) the ability to judge through continued variance analysis whether the actions taken made a difference or whether more changes are necessary. Based on this evidence, supported by the literature, the author's institution has been able to offer quality patient care at a reasonable cost.

Performance indicators and standards of care for coronary angioplasty procedures: a quality initiative

The growth of coronary angioplasty procedures in Australia has provided opportunities for role development in nursing practice. In response to changes in health care demands, the angioplasty nurse specialist role was developed. This paper discusses a quality activity with two goals. First, to facilitate a change in culture within the angioplasty service from the existing fragmented system to a cohesive system based on a quality approach. Second, to develop a process improvement strategy involving a data collection tool that would facilitate the monitoring of performance indicators and patient outcomes.

Recovery patterns and lifestyle changes after coronary angioplasty: the patient's perspective

BACKGROUND

Progression of coronary atherosclerosis remains a significant problem after percutaneous transluminal coronary angioplasty (PTCA), requiring patients to make ongoing modifications in their coronary risk factors and lifestyle.

OBJECTIVE

To examine patients' reactions to suggested lifestyle changes, to identify barriers and facilitators to risk reduction, to identify sources of health information, and to elicit suggestions for nursing interventions to aid in long-term recovery.

DESIGN

Qualitative study using 2-hour, tape-recorded focus group sessions. Participants were enrolled in one of seven groups (4 to 9 members each).

SAMPLE

Forty-five patients (26 men, 19 women) who had undergone PTCA 3 to 18 months earlier were recruited from a university-affiliated midwestern medical center.

RESULTS

Using a constant-comparative method for data analysis, six major themes emerged. Positive themes included seeking control from successful changes made; compromise with medical recommendations to maintain quality of life; and acceptance of the uncertain nature of their disease. Negative themes included powerlessness to stop disease progression; frustration with enacting lifestyle changes; and concerns about the uncertainty of the future. Specific barriers and facilitators for risk reduction were readily identified. Though patients had few suggestions for nursing interventions, the most predominant requests were for newsletters, "hot lines," and a video library.

CONCLUSION

These results provide insight into the experiences of the relatively understudied PTCA population. Patients were making at least some of their necessary lifestyle changes, though often with some difficulty. Nurses have an excellent opportunity to expand their focus and provide guidance and support to patients as they adopt a heart-healthy lifestyle.