Self-management intervention for patients following hospitalization for acute exacerbation of chronic obstructive pulmonary disease (AECOPD): A pilot randomized controlled trial

The purpose of this study was to evaluate the handoff guidance (HG) self-management intervention for multimorbid chronic obstructive pulmonary disease (COPD) patients following hospitalization for acute exacerbation of COPD (AECOPD) using HG self-management intervention compared to a control group on COPD self-management outcomes (self-care, self-efficacy, health engagement) and assess feasibility, acceptability, and healthcare utilization. A randomized pilot study used a 2-group with repeated measures design. Adults with COPD who had been hospitalized for AECOPD were recruited. After discharge, the HG self-management intervention employed health coaching delivered at: 1-3, 10-12, and 20-22 days after hospital discharge. Follow-up data collected was collected at 1-3, 10-12, 20-22, 30, 60, and 90 days after hospital discharge. A total of 29 subjects participated, with a mean age of 66 (+8.7) years old, the majority were females (n = 18). Intervention participants reported the acceptability of the HG self-management intervention. Participants in both groups continued to report COPD symptoms after discharge, which decreased over time, although not significantly different by group. The use of COPD maintenance, monitoring, and management behaviors was higher in the treatment group, although not significantly different.

"It Kills Your Soul": A Mixed Methods Study of Ethical Sensitivity of Critical Care Nurses

BACKGROUND

Critically ill patients often experience distressful and impactful symptoms and conditions that include pain, agitation/sedation, delirium, immobility, and sleep disturbances (PADIS). The presence of PADIS can affect recovery and long-term patient outcomes. An integral part of critical care nursing is PADIS prevention, assessment, and management. Ethical sensitivity of everyday nursing practice related to PADIS is an imperative part of implementing evidence-based care for patients.

OBJECTIVE

The first 2 aims of this study were to determine the measured level of ethical awareness as an attribute of ethical sensitivity among the critical care nurse participants and to explore the ethical sensitivity of critical care nurses related to the implementation of PADIS care. The third aim was to examine how the measured level of ethical awareness and ethical sensitivity exploration results converge, diverge, and/or relate to each other to produce a more complete understanding of PADIS ethical sensitivity by critical care nurses.

METHODS

This was a convergent parallel mixed methods study (QUAL + quant). Ethical sensitivity was explored by conducting an ethnography of critical care nurses. The participants were 19 critical care nurses who were observed during patient care, interviewed individually, participated in a focus group (QUAL), and were administered the Ethical Awareness Scale (quant).

FINDINGS

Despite high levels of individual ethical awareness among nurses, themes of ambiguous beneficence, heedless autonomy, and moral distress were found to be related to PADIS care.

CONCLUSIONS

More effort is needed to establish moral community, ethical leadership, and individual ethical guidance for nurses to establish patient-centered decision-making and PADIS care.

Behavioral Weight Loss Interventions for Overweight and Obese Cardiac Rehabilitation Patients: A Systematic Review

The purpose of this systematic review was to identify evidence pertaining to the effectiveness of behavioral weight loss interventions for overweight and obese cardiac rehabilitation participants. A database search of PUBMED, CINAHL, PsycINFO, and PROSPERO yielded 10 eligible studies. Quantitative studies implementing behavioral weight loss interventions for overweight and obese adult cardiac rehabilitation participants were reviewed. Evidence supported the usefulness and effectiveness of behavioral weight loss interventions for overweight cardiac rehabilitation participants. With the limited number of studies and inclusion of quasi-experimental studies with comparative groups, it was not possible to determine the relative power of behavioral weight loss interventions across studies. In conclusion, behavioral weight loss interventions can be incorporated into cardiac rehabilitation or offered following cardiac rehabilitation to improve weight loss of overweight and obese cardiac rehabilitation participants. Findings reinforce national guidelines emphasizing the role of cardiac rehabilitation to address secondary cardiovascular disease risk factor modification, including integrating behavioral weight loss programs in cardiac rehabilitation, or referring overweight patients to weight management programs following completion of cardiac rehabilitation.

The integration of care ethics and nursing workload: A qualitative systematic review

AIM

The aim of this review was to explore literature from January 2017 to December 2021 for specific aspects of care ethics related to nursing workload in the acute care setting.

BACKGROUND

High nursing workload is associated with adverse outcomes for nurses as well as patients. Nursing workload goes beyond patient-to-nurse ratios and encompasses patient, nurse and organizational factors.

EVALUATION

This qualitative systematic review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis. The four features of care ethics related to nursing workload guided the review of qualitative studies in MEDLINE, CINAHL and PsycINFO, and synthesized findings were presented in the four phases of caring.

KEY ISSUES

Key issues include ethical dilemmas, time pressure, shared moral burden and managerial support.

CONCLUSION

To reduce nursing workload, a care ethics perspective can provide solutions through fortifying interprofessional relationships and enhancing empathetic actions.

IMPLICATIONS FOR NURSING MANAGEMENT

Situational, individual and team approaches to management allows for incorporation of personal values and ethics of care to support patient-centred care. Leadership initiating conversations and being proactive about workload can lead to an improved work environment for both the nurse and the nurse manager.

Implanted Port Access in the Emergency Department: A Unit-Level Feasibility Study of a Nurse-Led Port Access Algorithm

INTRODUCTION

The objective of this study was to determine the impact of an emergency nurse-led implanted port access algorithm for ED patients with implanted ports admitted to the hospital.

METHODS

A feasibility study evaluated the implementation of a central line-associated bloodstream infection algorithm in the emergency department over a 1-month study period. Emergency nurses received central line-associated bloodstream infection education and training for port access algorithm implementation. Pre- and postimplementation surveys measured the nurses' knowledge, attitudes, and behaviors regarding central line-associated bloodstream infections. The nurses' perceptions of the algorithm were assessed pre- and postimplementation. ED patient port access and central line-associated bloodstream infection rates were compared with preimplementation rates.

RESULTS

Emergency nurses (N = 32) received central line-associated bloodstream infection education and algorithm training. Pre- and postimplementation as well as knowledge, attitude, and behavior surveys were completed by 59% (n = 19) of the nursing staff. Knowledge regarding central line-associated bloodstream infections significantly improved, t₍₁₉₎ = -4.8, P < .001. The nurses' pre- and postimplementation attitude and behavior scores did not differ significantly. They expressed no concerns regarding implementation of the algorithm; 89% (n = 17) reported that the algorithm "fit well" with the ED workflow, and 21% (n = 4) integrated the patient's decision regarding venous access into their shift report. The ED port access incidence during the study period was 17.6% (n = 3), compared with 83.3% (n = 15) in the month before the study.

DISCUSSION

The emergency nurse-led port access algorithm decreased ED port access rates. The nurses' pre- and postimplementation knowledge of central line-associated bloodstream infections increased. The emergency nurse-led port access algorithm empowered emergency nurses to educate their patients on implanted port access and decreased central line use.

An Exploration of Factors Associated With Nurses' Perceptions of Decisional Involvement

OBJECTIVE

The purpose of this study was to evaluate nurses' perceptions of decisional involvement (DI).

BACKGROUND

Decisional involvement is a measure or gauge of nurses' perceived shared leadership. There has been limited research examining factors associated with actual and preferred DI.

METHODS

A descriptive, observational study design was used. A total of 189 RNs completed the Decisional Involvement Scale and Evidence-Based Practice Implementation Scale. Nurses' preferred DI (DI-P) and actual DI (DI-A) were analyzed, and DI total and subscale scores were compared based on nurses' demographic and clinical practice characteristics.

RESULTS

The DI-A and DI-P total scores were significantly different, including subscales for DI-A compared with DI-P score. Dissonance scores by subscale were highest for recruitment, governance, and support. Unit-based council (UBC) participants had significantly higher actual DI, compared with non-UBC participants. Nurses' perceptions of implementing evidence-based practice (EBP) was not significantly different by low versus high EBP implementation; nor were the scores significantly correlated with their DI-A or DI-P scores.

CONCLUSIONS

Findings indicate nurses' perceptions of DI-A and DI-P. This study provided further examination of the differences and interrelationships between DI and nurses' demographic and clinical practice characteristics. Dissonance DI scores provide opportunities for targeting interventions to engage nurses in shared leadership.

Use of PADIS Assessment Tools by Critical Care Nurses: An Integrative Review

The purpose of this integrative review was to evaluate the literature from January 2013 to April 2020 and to explore critical care nurses' perspectives of and intent to use recommended Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) patient assessment tools in adult critical care units. A literature search was performed with a total of 47 studies included in the final analysis for this review. The studies' data were organized and further reduced based on The Reasoned Action Approach behavioral theory to reflect the extent to which a nurse plans to use a PADIS assessment tool. Extracted themes were related to behavioral beliefs in patient-centered care and critical thinking; normative beliefs about communication and prioritization; and control beliefs concerning autonomy and confidence. Contextualizing the international phenomenon of variation in PADIS assessment tool use by critical care nurses provides a deeper understanding of its complexity for use in the clinical setting.

Weight management telehealth intervention for overweight and obese rural cardiac rehabilitation participants: A randomised trial

AIMS AND OBJECTIVES

To determine whether a weight management intervention (WMI) plus cardiac rehabilitation (CR) compared to CR alone improves outcomes for overweight and obese cardiac revascularisation patients.

BACKGROUND

Despite participating in cardiac rehabilitation (CR), few cardiac patients lose enough weight to achieve clinically significant cardiovascular disease risk reduction.

DESIGN

A randomised controlled design was used with measurements at baseline, 4 and 6 months, guided by the CONSORT checklist, see Supporting Information File S1. Adults who had undergone either coronary artery bypass surgery (CABS) or percutaneous coronary intervention (PCI) and participated in a rural CR programmes were recruited. Subjects were randomised to a 12-week telehealth WMI or control group. The primary outcome was weight loss. Secondary outcomes included physical activity, patient activation, perceived self-efficacy and use of weight management behaviours.

RESULTS

A total of 43 subjects participated, with a mean age of 63 (±9.3) years. The WMI group had significantly more weight loss averaged across the 4 and 6 months of 13.8 (±2.8) pounds compared to the control group [mean = 7.8 (±2.2) pounds]. There were no significant differences in physical activity (activity counts or daily minutes in moderate or more intense activity). The WMI group had significantly higher levels of patient activation. They also had significantly higher total scores on the Diet and Exercise Self-Management survey, and subscales that included self-efficacy for specific eating habits and managing diet behaviour.

CONCLUSIONS

Findings demonstrated the usefulness and feasibility of using telehealth delivery of the WMI for cardiac rehabilitation participants in rural communities to improve weight management outcomes.

RELEVANCE TO PRACTICE

Study findings underscore the opportunity to further improve weight loss of overweight and obese cardiac participants using a weight management intervention to augment CR participation.

Acute Coronary Syndrome Symptom Clusters: Illustration of Results Using Multiple Statistical Methods

Researchers have employed various methods to identify symptom clusters in cardiovascular conditions, without identifying rationale. Here, we test clustering techniques and outcomes using a data set from patients with acute coronary syndrome. A total of 474 patients who presented to emergency departments in five United States regions were enrolled. Symptoms were assessed within 15 min of presentation using the validated 13-item ACS Symptom Checklist. Three variable-centered approaches resulted in four-factor solutions. Two of three person-centered approaches resulted in three-cluster solutions. K-means cluster analysis revealed a six-cluster solution but was reduced to three clusters following cluster plot analysis. The number of symptoms and patient characteristics varied within clusters. Based on our findings, we recommend using (a) a variable-centered approach if the research is exploratory, (b) a confirmatory factor analysis if there is a hypothesis about symptom clusters, and (c) a person-centered approach if the aim is to cluster symptoms by individual groups.

The Impact of Self-management Knowledge and Support on the Relationships Among Self-efficacy, Patient Activation, and Self-management in Rural Patients With Heart Failure

BACKGROUND

Self-management (SM) is an essential component of heart failure (HF) management. The mechanisms to improve SM behaviors are unclear.

OBJECTIVE

The objective of this study is to examine whether patient activation mediates the effect of self-efficacy on SM behaviors in rural HF patients.

METHODS

A secondary analysis was conducted using data collected from a randomized controlled trial aimed to improve SM behaviors. The main variables included were SM knowledge, self-efficacy, patient activation, and SM behaviors.

RESULTS

Mediation analysis showed patient activation mediated the effect of self-efficacy on SM. Both self-efficacy and patient activation were significantly related to SM behaviors, respectively (r = 0.46, P < .001; β = .48, P = .001). However, self-efficacy was no longer directly related to SM behaviors when patient activation was entered into the final model (β = .17, P = .248). Self-management knowledge and support were significant moderators. In patients with high levels of SM knowledge, patient activation did not mediate the effect of self-efficacy on SM behaviors (β = .15, P = .47). When SM support was entered in the path model, patient activation was not a significant mediator between self-efficacy and SM behavior at high (β = .27, P = .27) or low (β = .27, P = .25) levels of SM support.

CONCLUSIONS

Study findings suggest that targeted SM support for high-risk HF patients with low SM knowledge and support may be useful. In addition, strategies to increase patient activation may improve HF patients' SM confidence.

Feasibility of Using Accelerometer Measurements to Assess Habitual Physical Activity in Rural Heart Failure Patients

(1) Background: Physical inactivity is prevalent in rural heart failure (HF) patients. To evaluate the effectiveness of interventions aimed at improving physical activity (PA), we need an accurate, reliable PA assessment tool that is feasible and acceptable to HF patients. The purpose of this study was to examine the feasibility and reliability of using an accelerometer to assess HF patients' PA. (2) Method: A total of 100 HF patients discharged from a rural hospital participated in the study and wore an accelerometer at baseline, 3, and 6 months following discharge. (3) Result: The daily average wear time across all three time points was 15.7 (±3.3) h for weekdays, and 15.8 (±3.7) h for weekends. Approximately 50% of the participants adhered to the device wear protocol at baseline, 3, and 6 months. Factors related to wear time were also examined. Acceptable reliability assessed by intra-class correlation (ICC > 0.879) was found for daily activity calories, activity counts per minutes, and time spent on moderate or greater PA. (4) Conclusion: The present findings suggest that an accelerometer is a feasible and reliable measure of habitual PA in rural HF patients over time.

Selecting symptom instruments for cardiovascular populations

The purpose of this review is to provide a guide for researchers and clinicians in selecting an instrument to measure four commonly occurring symptoms (dyspnea, chest pain, palpitations, and fatigue) in cardiac populations (acute coronary syndrome, heart failure, arrhythmia/atrial fibrillation, and angina, or patients undergoing cardiac interventions). An integrative review of the literature was conducted. A total of 102 studies summarizing information on 36 different instruments are reported in this integrative review. The majority of the instruments measured multiple symptoms and were used for one population. A majority of the symptom measures were disease-specific and were multi-dimensional. This review summarizes the psychometrics and defining characteristics of instruments to measure the four commonly occurring symptoms in cardiac populations. Simple, psychometrically strong instruments do exist and should be considered for use; however, there is less evidence of responsiveness to change over time for the majority of instruments.

Effects of a home-based activation intervention on self-management adherence and readmission in rural heart failure patients: the PATCH randomized controlled trial

BACKGROUND

Heart failure (HF) patients discharged from rural hospitals have higher 30-day readmission rates. Self-management (SM) reduces readmissions, but adherence to SM guidelines is low in the rural HF population. We tested a home-based intervention to enhance patient activation and lead to improved SM adherence.

METHODS

In this two-group, repeated measures randomized control trial, the main outcomes were patient reported and clinical outcomes associated with SM adherence, and all-cause readmission at 30, 90 and 180 days.

RESULTS

The study included 100 HF patients discharged from a rural critical access hospital. The intervention group received a 12-week SM training and coaching program delivered by telephone and tailored on subjects' activation levels. At α = .10, the PATCH intervention showed significantly greater improvement compared to usual care in patient-reported SM adherence: weighing themselves, following a low-sodium diet, taking prescribed medication, and exercising daily (all p < .0005) at 3 and 6 months after discharge. In contrast, groups did not differ in physical activity assessed by actigraphy or in clinical biomarkers. Contrary to expectation, the 30-day readmission rate was significantly higher (p = .088) in the intervention group (19.6 %) than in the control group (6.1 %), with no differences at 90 or 180 days.

CONCLUSION

It is feasible to conduct a randomized controlled trial in HF patients discharged from rural critical access hospitals. Significantly higher patient-reported SM adherence was not accompanied by lower clinical biomarkers or readmission rates. Further research is needed to understand mechanisms that influence outcomes and healthcare utilization in this population.

TRIAL REGISTRATION

CLINICAL TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov; NCT01964053 .

Baccalaureate nursing students' application of social-cognitive sexual counseling for cardiovascular patients: A web-based educational intervention

BACKGROUND

A gap in knowledge and practice exists for sexual counseling of cardiovascular patients, and innovative approaches are needed to address patients' sexual quality of life.

AIM

To evaluate a web-based social-cognitive intervention for evidence-based sexual counseling by baccalaureate nursing students with cardiovascular patients.

METHODS

A pre- post-test survey design was used: pre-test (T1), immediate post-test after intervention (T2), and at 4 to 6weeks post-intervention (T3). Data were collected using the Survey of Sexuality Related Nursing Practices -Cardiac version (SSRNP-CV). Data were analyzed using descriptive statistics and t-tests.

RESULTS

From T1 to T2, students (N=95) significantly increased their responsibility and confidence in sexual counseling; from T1 to T3 (N=57), students significantly improved sexual counseling for confidence and practice subscales, total SSRNP score, and cardiac-specific subscales of sexual counseling, sexual activity, and gender.

CONCLUSION

This study clearly demonstrated that a web-based social-cognitive sexual counseling intervention was effective in improving students' ability to provide evidence-based sexual counseling of cardiovascular patients.

Awakening: a qualitative study on maintaining weight loss after bariatric surgery

AIMS AND OBJECTIVES

To describe the experiences of adults who were successful in maintaining weight loss after bariatric surgery.

BACKGROUND

The majority of studies examine a homogenous demographic group of postbariatric surgical patients who have gone through initial weight loss, which occurs within the first 12-24 months post surgery. Maintenance of weight loss begins 24 months after bariatric surgery; however, there is a paucity of research examining experiences during this period. The lack of conclusive research related to interactions between intrapersonal, behavioural and environmental influences suggests a need to develop a better understanding of patients' experiences related to weight loss maintenance post bariatric surgery.

DESIGN

Bandura's Social Cognitive Theory provided the framework for the semi-structured interviews for this qualitative descriptive study.

METHODS

In-person interviews with n = 14 participants who were able to maintain weight loss at least 24 months after a bariatric surgery.

RESULTS

Participants experienced an awakening and gained a new perspective on their life. They identified negative attitudes, influences and behaviours and modified their environment to support their desired healthy behaviour.

CONCLUSIONS

To maintain weight loss, an individual must seek out and be surrounded by positive family and peer support influences. Positive support may provide the opportunity for an individual to place personal health needs as a priority.

RELEVANCE TO CLINICAL PRACTICE

Therapeutic education and counselling for individuals, couples and families should occur during all phases of bariatric surgery. Communication techniques may empower clients to deflect negative comments and influences in a constructive manner. Support groups should accommodate the various phases of bariatric surgery. Clients should be prepared for how to work through emotions associated with weight fluctuations.

Review Strategies to Recruit and Retain Rural Patient Participating Self-management Behavioral Trials

Self-management plays a vital role in improving health outcomes and reducing costs in patients with cardiovascular disease (CVD) and associated risk factors. Based on existing studies, rural residents with CVD and/or risk factors show low engagement in self-management behaviors. Due to low participation in behavioral intervention trials, the most promising mechanism to promote self-management among rural populations is unknown. In turn, the purpose of this article is to review the evidence that supports strategies to recruit and retain rural patients to participate in behavioral intervention trials aimed to promote self-management of CVD and its risk factors. This review is expected to assist researchers in identifying effective solutions to overcome barriers in the recruitment and retention processes when conducting intervention research studies on the self-management of CVD in rural communities.

Uptake of Dietary Sodium Restriction by Overweight and Obese Patients After Cardiac Revascularization

PURPOSE

High sodium intake increases the risk of cardiovascular diseases. Cardiac patients are recommended a daily sodium restriction of ≤1,500 mg. The purpose of this article is to describe daily sodium intake and sodium restriction adherence and its correlates in cardiac rehabilitation (CR) program participants following cardiac revascularizations.

DESIGN

This is a descriptive correlational study.

METHODS

A subanalysis was performed using the data collected from a randomized controlled trial to determine the effect of a 12-week weight management intervention.

FINDINGS

The average daily sodium intake was 3,020 mg ± 1,134 at baseline, 4,047 mg ±1,517 at 4 months, and 4,399 mg ± 1,722 at 6 months. The adherence rates were 4.8% at baseline and zero at 4 and 6 months. The factors influencing daily sodium intake were identified.

CONCLUSION

The CR program participants failed to adhere to the sodium restriction guidelines.

CLINICAL RELEVANCE

Rehabilitation nurses need to identify effective strategies to educate CR participants and their family members regarding dietary sodium adherence in CR participants.

Transitions of care in heart failure: a scientific statement from the American Heart Association

In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

Using “Think Aloud” to Capture Clinical Reasoning during Patient Simulation

Think Aloud (TA), a strategy in which subjects are instructed to verbalize thoughts as they occur while completing an assigned task, was integrated into a study of clinical reasoning during high fidelity patient simulation by baccalaureate nursing students. TA methods in nursing education research with patient simulation have not previously been reported. Concurrent TA (verbalization of thoughts in short-term memory) and retrospective TA (reflective thoughts verbalized during an immediate post-simulation interview) methods facilitated the collection of rich and meaningful data. Students demonstrated distinct patterns in verbalization during concurrent TA, including public and private thoughts, narration of care, and the use of the pause to facilitate clinical reasoning. Retrospective TA data provided rich descriptions of reflection-on-action. TA provides a rich source of data regarding clinical reasoning as experienced by the baccalaureate nursing student during high fidelity patient simulation.

Preferred Thinking Style, Symptom Recognition, and Response by Nursing Students During Simulation

A better understanding of the relationships between symptom recognition, nursing response, and preferred thinking style is needed to improve nursing education practices. Final semester nursing students ( N = 29) completed a high fidelity patient simulation (HFPS) scenario; recognized symptoms (i.e., dyspnea) and responses (i.e., apply oxygen) were recorded, and compared with students’ preferred thinking style using the Rational-Experiential Inventory–40. Relationships between concepts were explored. Significant relationships were noted between preference for Rational thinking styles and symptom recognition ( p < .05). Preferred thinking style was not related to numbers of therapeutic responses. Thirty percent of students delayed application of oxygen until directed to do so by members of the health care team. Students having a stronger preference for rational thinking demonstrate greater accuracy in cue recognition. More nursing research is needed to explore the cognitive processing during simulation .

Choosing the Best Evidence to Guide Clinical Practice: Application of AACN Levels of Evidence

Evidence-based nursing care is informed by research findings, clinical expertise, and patients’ values, and its use can improve patients’ outcomes. Use of research evidence in clinical practice is an expected standard of practice for nurses and health care organizations, but numerous barriers exist that create a gap between new knowledge and implementation of that knowledge to improve patient care. To help close that gap, the American Association of Critical-Care Nurses has developed many resources for clinicians, including practice alerts and a hierarchal rating system for levels of evidence. Using the levels of evidence, nurses can determine the strength of research studies, assess the findings, and evaluate the evidence for potential implementation into best practice. Evidence-based nursing care is a lifelong approach to clinical decision making and excellence in practice.

Cost-effectiveness of a symptom management intervention: improving physical activity in older women following coronary artery bypass surgery

Older women have lower levels of physical functioning and higher associated health care costs than men after coronary artery bypass surgery (CABS). Clinical trials have demonstrated that interventions to increase physical activity levels can reduce the risk of recurrent cardiac events, reduce health care expenditures, prolong life, improve functional capacity, and increase quality of life in the elderly cardiac population. It is important for the patients, providers, health care payers, and policymakers to identify a cost-effective recovery intervention that has the potential to increase women's physical activity and functioning during their early recovery from CABS, especially in this time of limited health care resources. This home-based symptom management intervention has the potential to reduce the risk of recurrent cardiac events and health care cost by improving women's physical activity level after surgery. This information is vital to nursing leaders in making resource decisions regarding followup care of women who have had heart surgery.

Rural Versus Urban Comparison: Physical Activity and Functioning Following Coronary Artery Bypass Surgery

PURPOSE

The purpose of this sub-analysis was to compare the early recovery of elderly patients following coronary artery bypass surgery (CABS) by geographic location (urban/rural) on physical functioning and physical activity.

METHODS

The sample was 124 subjects who had been in the usual care group (or control group) of a randomized controlled trial. Subjects were categorized into geographic locales using Rural Urban Commuting Area (RUCA) codes: urban n=35, large rural n=17, small rural n=23 and isolated rural n=33. Measures included the Medical Outcomes Study Short-Form 36 and the RT3® accelerometer. Mixed linear models were used to analyze the data.

RESULTS

No significant differences were found for physical functioning by RUCA group. However, there was a statistically significant difference for physical activity, for average kcals/kg/ per day (F = 3.01, p < .05) and average daily activity counts (F = 3.95, p <.01), with the subjects in large rural communities having significantly (p < 0.05) more average kcals/kg per day than urban subjects (M = 29.04 and M = 27.25 respectively). Subjects in the large rural also had significantly (p < .005) more average daily activity counts than urban (M = 216635 and M = 161221 respectively).

CONCLUSIONS

This is the first study to compare early recovery functioning and activity outcomes of CABS subjects by rural/urban locations. Additional study is warranted to evaluate why these differences exist and the potential need to tailor interventions for CABS based on geographic location.

Gender differences in recovery outcomes after an early recovery symptom management intervention

BACKGROUND

Despite known gender differences in recovery, few studies have examined symptom management (SM) interventions or responses by gender after coronary artery bypass surgery (CABS).

OBJECTIVE

The purpose of this subanalysis was to describe and evaluate differences in response by gender to an SM intervention on the presence and burden of symptoms, physical activity, and physical functioning in elderly CABS patients during the early discharge period (3 and 6 weeks after CABS, and 3 and 6 months after CABS).

METHODS

The parent study whose data were analyzed to examine gender differences involved a two-group, randomized clinical trial design. The 6-week early recovery SM telehealth intervention was delivered by the Health Buddy. Measures included the Cardiac Symptom Survey, a Modified 7-Day Activity Interview, an RT3 accelerometer, an Activity Diary, and the Medical Outcomes Study Short Form 36. This study was not powered for a gender × group analysis, and we used descriptive statistics, χ(2) tests, t tests, and analysis of variance for statistical analyses.

RESULTS

Subjects (n = 232) included 192 men and 40 women, with a mean age of 71.2 SD, 7 years. The intervention group consisted of 86 men and 23 women, and the usual care (UC) group consisted of 106 men and 17 women. Data trends suggest that the SM intervention exerted greater impact on women than on men for symptoms such as fatigue, depression, sleep problems, and pain. Again, men exhibited higher levels of physical activity than did women. However, women in the SM group generally had higher scores than did women in the UC group.

CONCLUSION

Although the parent study found no effect of an early recovery SM intervention, this exploratory secondary analysis indicated that women in the intervention group demonstrated more improvement in measures of physical activity than did those in the UC group. Further study, using a larger sample, is necessary to test these preliminary results.

Influence of a symptom management telehealth intervention on older adults' early recovery outcomes after coronary artery bypass surgery

OBJECTIVE

The study objective was to examine the effect of a symptom management (SM) telehealth intervention on physical activity and functioning and to describe the health care use of older adult patients (aged > 65 years) after coronary artery bypass surgery (CABS) by group (SM intervention group and usual care group).

METHODS

A randomized clinical trial design was used. The study was conducted in 4 Midwestern tertiary hospitals. The 6-week SM telehealth intervention was delivered by the Health Buddy (Health Hero Network, Palo Alto, CA). Measures included Modified 7-Day Activity Interview, RT3 accelerometer (Stayhealthy, Inc, Monrovia, CA), physical activity and exercise diary, Medical Outcomes Study Short-Form 36, and subjects' self-report and provider records of health care use. Follow-up times were 3 and 6 weeks and 3 and 6 months after CABS.

RESULTS

Subjects (N = 232) had a mean age of 71.2 (+4.7) years. There were no significant interactions using repeated-measures analyses of covariance. There was a significant group effect for average kilocalories/kilogram/day of estimated energy expenditure as measured by the RT3 accelerometer, with the usual care group having a higher estimated energy expenditure. Both groups had significant improvements over time for role-physical, vitality, and mental functioning. Both groups had similar health care use.

CONCLUSION

Subjects were able to return to preoperative levels of functioning between 3 and 6 months after CABS and to increase their physical activity over reported preoperative levels of activity. Further study of those patients undergoing CABS who could derive the most benefit from the SM intervention is warranted.

Pilot testing of a medication self-management transition intervention for heart failure patients

This pilot study examined the impact of a hospital transition intervention for older adults (≥ 65 years of age) with heart failure (HF) to promote medication use self-management. Forty subjects, hospitalized with either primary or secondary HF, had a mean age of 76.9 ± 6.5 years; 65% were males. The majority of subjects (55%) had NYHA Class III HF. A prospective, repeated measures experimental design was used. Baseline and follow-up data (1- and 3-months after hospitalization) were obtained using the Medication Regimen Complexity Index, Brief Medication Questionnaire, Drug Regiment Unassisted Grading Scale, and Kansas City Cardiomyopathy Questionnaire. Using repeated measures analysis of covariance (ANCOVA), with baseline measures as covariates, the transition intervention group had higher levels of medication adherence (F(1,35) = 13.4, p < .001), self-efficacy for HF self-care (F(1,35) = 17.9, p < .001) and had significantly fewer HF related symptoms that impaired health related quality of life (F(1,35) = 9.1, p = .006).

Symptom burden clusters and their impact on psychosocial functioning following coronary artery bypass surgery

Although there is extensive literature on symptoms experienced by patients after coronary artery bypass surgery (CABS), there is a paucity of data on symptom clusters and their impact on functional outcomes. The purpose of these descriptive, secondary analyses was to identify and describe cluster subgroups of 226 elderly CABS patients at discharge and to examine the cluster's impact on psychosocial functioning over time (baseline, 6 weeks, and 3 months) using the 36-item Medical Outcome Study Short Form subscales. Cluster analysis revealed a 3-cluster solution with low, low-moderate, and moderate symptom burden clusters. Significant differences were detected for Duke Activity Status Index (F(2,223) = 5.12, P = .007), Barnason Efficacy Expectation Scale (F(2,223) = 9.60, P < .0001), Hospital Anxiety and Depression Scale (F(2,219) = 15.14, P < .0001), and New York Heart Association classification (chi = 17.44, P = .008). Significant differences were noted on all variables between the low and moderate symptom burden clusters with differences between the low-moderate and moderate clusters for only the Barnason Efficacy Expectation Scale and the Hospital Anxiety and Depression Scale. Those in the moderate symptom burden cluster had more symptoms, anxiety, and depression along with lower self-efficacy and physiological functioning than those in the other 2 clusters. There was no interaction or simple main effects for the role-emotional or social subscales as measured by the 36-item Medical Outcome Study Short Form. There was no significant interaction for mental functioning by time and cluster (F(4,641) = .30, P = .88); however, there was a simple main effect for cluster (F(2,641) = 4.11, P = .02). Follow-up analysis indicated significant differences between the low and low-moderate clusters, indicating that those with low symptom burden had significantly better mental health functioning than those with moderate symptom burden. Findings provide a foundation of knowledge on symptom clusters in CABS populations and may be useful to clinicians to identify patients at risk for slowed or delayed recovery and for early intervention.

Influence of an early recovery telehealth intervention on physical activity and functioning after coronary artery bypass surgery among older adults with high disease burden

OBJECTIVE

Older adults with poor functioning preoperatively are at risk for delayed recovery and more impaired outcomes after coronary artery bypass surgery (CABS). The study objective was to determine whether a 6-week early recovery telehealth intervention, designed to improve self-efficacy and management related to symptoms after CABS, was effective in improving outcomes (physical activity, physiologic, and psychologic functioning) for older adults (aged > 65 years) with higher disease burden.

METHODS

A descriptive, repeated-measures experimental design was used. Follow-up data were collected at 3 and 6 weeks and 3 months after CABS. Subjects were drawn from a larger randomized clinical trial. Parent study subjects who had high disease burden preoperatively (physical component score of < 50 on the Medical Outcome Study Short Form-36 and RISKO score of > 6) were included (N = 55), with 23 subjects in the early recovery intervention group and 31 subjects in the usual care group (n = 31). Subjects ranged in age from 65 to 85 years (M = 71.6 + 5.1 years).

RESULTS

There was a significant main effect by group (F[1,209] = 4.66, P < .05). The intervention group had a least square means of 27.9 kcal/kg/d of energy expenditure compared with the usual care group of 26.6 kcal/kg/d per the RT3 accelerometer (Stayhealthy, Inc, Monrovia, CA). Both groups had significantly improved physical (F[2,171] = 3.26, P < .05) and role-physical (F[2,171] = 6.64, P < .005) functioning over time.

CONCLUSION

The subgroup of subjects undergoing CABS with high disease burden were responsive to an early recovery telehealth intervention. Improving patients' physical activity and functioning can reduce morbidity and mortality associated with poor functioning after cardiac events.

Relationships between fatigue and early postoperative recovery outcomes over time in elderly patients undergoing coronary artery bypass graft surgery

BACKGROUND

Despite successful coronary artery bypass graft (CABG) surgery, some patients continue to experience fatigue after their surgery.

OBJECTIVE

The purpose of this secondary analysis study was to examine the relationships of fatigue and early recovery outcomes (psychosocial and physiologic functioning, and physical activity) over time (6 weeks and 3 months) among older adult subjects, age 65 years and older, after CABG surgery. Comparison groups were those subjects who had fatigue at 3 weeks after surgery and nonfatigued subjects.

DESIGN

A prospective, comparative design was used for this secondary analysis study.

SAMPLE

Subjects in this study were drawn from the control group of subjects enrolled in the larger parent study. Subjects (N = 119) were dichotomized into fatigue (n = 66) and nonfatigued (n = 53) groups on the basis of their 3-week self-reports of postoperative fatigue.

RESULTS

At 6 weeks after surgery, fatigued subjects had significantly (P < .05) more impaired psychosocial functioning (role-emotional [t = 1.9], social [t = 2.6], and mental [t = 1.9] functioning) on the basis of the Medical Outcome Study Short Form 36. They had significantly (P < .005) higher mean hospital anxiety (t = -3.6) and depression (t = -2.9) subscale scores, respectively. Anxiety (t = -2.3, P < .05) remained significantly (P < .05) impaired at 3 months. At 6 weeks, role physical functioning, measured by the Medical Outcome Study Short Form 36, was significantly impaired (t = 2.4, P < .01). There were no significant differences in physical activity variables as measured by an RT3 accelerometer (Stayhealthy, Inc., Monrovia, CA) and self-report diary.

CONCLUSIONS

Persistent fatigue can hamper early recovery after CABG surgery. Tailored interventions are needed to address fatigue management and improve patient outcomes.

Impact of an early recovery management intervention on functioning in postoperative coronary artery bypass patients with diabetes

BACKGROUND

Approximately 30% of patients undergoing coronary artery bypass graft (CABG) procedures have diabetes and, as such, are at increased risk for postoperative complications and a lengthy recovery.

OBJECTIVE

To test the feasibility of an in-home early recovery management intervention to improve physical and psychosocial functioning in the diabetic CABG population.

METHODS

This pilot study was a 2-group, randomized, experimental study. The 6-week in-home early recovery intervention was delivered by way of a device called the Health Buddy (Health Hero Network, Redwood City, CA). Subjects were 49 diabetic patients who had undergone a first-time CABG procedure.

RESULTS

Although no statistical differences between groups were found, descriptively, the intervention group's baseline means on Medical Outcomes Study Short Form-36 subscales measuring physical functioning were lower but improved to levels comparable with that of the control group. Improvements in psychosocial functioning were comparable between the 2 groups.

CONCLUSION

This in-home telehealth intervention may have promise for improving functioning outcomes in high-risk CABG patients with diabetes. However, weaknesses of the intervention and the need for a more focused, directive intervention were identified.

Usefulness of RISKO Heart Hazard Appraisal to Quantify CAD risk factor burden on the preoperative functioning of coronary artery bypass graft surgery patients

The preoperative status of coronary artery bypass graft (CABG) surgical patients is often evaluated as a means to assess operative risk for mortality and morbidity and to inform how preoperative status influences or predicts outcomes following CABG surgery. The purpose of this study was to examine the influence of coronary artery disease (CAD) risk factor burden on CABG patients' preoperative functioning (functional status and functional capacity). A convenience sample of 152 subjects, 65 years and older, who had been consecutively enrolled in a larger randomized clinical trial, was evaluated. The RISKO Heart Hazard Appraisal was used to quantify CAD risk factor burden of the subjects. There were significant differences by CAD risk factor burden group, with subjects in the highest CAD risk factor burden group having poorer general health functioning (F2,147=3.45; P<.05) and functional capacity (F2,147=5.43; P<.01). These findings elucidate the potential usefulness of evaluating CABG patients' preoperative CAD risk factor burden status.