Skills taught in acute care NP programs: a national survey.
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Acute Disease↗
Biomedical subjects
Marilyn Hravnak
Publications and source records attributed to Marilyn Hravnak.
Short-term complications and resource utilization in matched subjects after on-pump or off-pump primary isolated coronary artery bypass.
BACKGROUND: Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results. OBJECTIVES: To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors. METHODS: Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons. RESULTS: The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative beta-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs. CONCLUSION: Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.
Adrenergic beta-Antagonists↗
Who should do role outcome research on advanced practice nurses?
Who should perform role outcomes research of APNs? The short answer is "nurses". The published research examining the outcomes of APNs ranges from studies conducted autonomously by master's prepared CNSs and NPs for the purposes of intemal QI/QA to large funded studies conducted by multidisciplinary teams led by nurse researchers. Small studies are beneficial and are not to be discouraged; however, publication of such endeavors, particularly in journals of professions other than nursing, should be undertaken with caution. Frequently such studies are underpowered with a sample not large enough to detect the effect. Studies that seek significant funding are large in scope and frequently longitudinal, with the objective of generalizability across the profession and publication in multidisciplinary refereed research journals, and should be led by doctorally prepared nurse researchers. Other aspects of study design determine the makeup of the remainder of the research team. A multidisciplinary team is recommended for accuracy, breadth, depth, rigor, and scientific robustness.
Data Collection↗
Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting.
OBJECTIVE: Although an extensive number of studies have attempted to identify predictors of new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG), a strong predictive model does not exist. Prior studies have included patients recruited from multiple centers with variant AFIB prevalence rates and those who underwent CABG in combination with other surgical procedures. Also, most studies have focused on pre- and perioperative characteristics, with less attention given to the initial postoperative period. The purpose of this study was to comprehensively examine pre-, peri-, and postoperative characteristics that might predict new-onset AFIB in a large sample of patients undergoing isolated CABG in a single medical center, utilizing data readily available to clinicians in electronic data repositories. In addition, length of stay and selected postoperative complications and disposition were compared in patients with AFIB and no AFIB. DESIGN: Retrospective, comparative survey. SETTING: University-affiliated tertiary care hospital. PATIENTS: Patients with new-onset AFIB who underwent isolated standard CABG or minimally invasive direct vision coronary artery bypass were identified from an electronic clinical data repository. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prevalence of AFIB in the total sample (n = 814) was 31.9%. Predictors of AFIB included age (p =.0004), number of vessels bypassed (p =.013), vessel location (diagonal [p <.003] or posterior descending artery [p <.001]), and net fluid balance on the operative day (p =.015). Forward stepwise regression analysis produced a model that correctly predicted AFIB in only 24% of cases, with age (14%) and body surface area (9%) providing the most prediction. The incidence of embolic stroke was higher in AFIB (n = 8) vs. no AFIB (n = 4) patients, but stroke preceded AFIB onset in seven of eight cases. Subjects with AFIB had a longer stay (p =.0004), more intensive care unit readmissions (p =.0004), and required more assistance at hospital discharge (p =.017). CONCLUSIONS: Despite attempts to examine comprehensively predictors of new-onset AFIB, we were unable to identify a robust predictive model. Our findings, in combination with prior work, imply that it may not be feasible to predict the development of new-onset AFIB after CABG using data readily available to the bedside clinician. In this sample, stroke was uncommon and, when it occurred, preceded AFIB in all but one case. As anticipated, AFIB increased length of stay, and patients with this complication required more assistance at discharge.
Aged↗
Resource utilization related to atrial fibrillation after coronary artery bypass grafting.
BACKGROUND: Studies of resource utilization by patients with new-onset atrialfibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges. OBJECTIVE: To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrialfibrillation after isolated coronary artery bypass grafting. METHODS: Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrialfibrillation. RESULTS: The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrialfibrillation, subjects with atrialfibrillation had a longer stay (5.8 +/- 2.4 vs. 4.4+/-1.2 days, P<.001), more days receiving mechanical ventilation (P =.002) and oxygen therapy (P<.001), and higher rates of readmission to the intensive care unit (4.6% vs. 0.2%, P<.001). Subjects with atrial fibrillation also had more laboratory tests (P<.001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrialfibrillation had higher total postoperative charges ($57261 +/- $17101 vs. $50905 +/- $10062, P = .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582). CONCLUSION: The economic impact of atrialfibrillation after coronary artery bypass grafting has been underestimated.
Aged↗
Racial disparities in outcomes following coronary artery bypass grafting.
More than 12 million people in the United States have coronary heart disease, the second leading cause of hospitalization in the United States. It is known that persons within racial minorities, specifically African Americans, have a higher prevalence of coronary heart disease, yet are much less likely to undergo invasive cardiac treatment interventions. An invasive intervention commonly used to treat coronary heart disease is coronary artery bypass grafting, with over 140,000 operations performed annually in the United States. However, blacks are known to experience higher post-coronary artery bypass graft morbidity and mortality. The causes for racial disparities in post-coronary artery bypass graft outcomes are not well known but may include factors related to the individual, provider, system, and society/environment, either alone or in combination. The purpose of this article is to provide an overview of the literature regarding disparities in the health and healthcare of black patients with coronary heart disease with respect to CABG, and examine potential hypotheses for variant outcomes after surgery.
Black or African American↗
Simulator technology as a tool for education in cardiac care.
Assisting nurses in gaining the cognitive and psychomotor skills necessary to safely and effectively care for patients with cardiovascular disease can be challenging for educators. Ideally, nurses would have the opportunity to synthesize and practice these skills in a protected training environment before application in the dynamic clinical setting. Recently, a technology known as high fidelity human simulation was introduced, which permits learners to interact with a simulated patient. The dynamic physiologic parameters and physical assessment capabilities of the simulated patient provide for a realistic learning environment. This article describes the High Fidelity Human Simulation Laboratory at the University of Pittsburgh School of Nursing and presents strategies for using this technology as a tool in teaching complex cardiac nursing care at the basic and advanced practice nursing levels. The advantages and disadvantages of high fidelity human simulation in learning are discussed.
Cardiovascular Diseases↗
Credentialing for nurse practitioners: an update.
The public has the right to safe, quality healthcare delivered by professionals with the appropriate education, training, and experience. The Joint Commission on Accreditation of Healthcare Organizations, the Accreditation Association for Ambulatory Healthcare, and managed care organizations take this commitment very seriously. One mechanism required by these agencies to ensure patient safety is the process of credentialing and delineation of clinical privileges for medical staff and allied health professionals, such as Acute Care Nurse Practitioners. This commitment extends to patients receiving healthcare through the technology of telemedicine and to those requiring emergency care resulting from trauma, disasters, and varying forms of terrorism. In addition, safeguards must be in place to prevent identity theft of healthcare providers, including Acute Care Nurse Practitioners. It is essential that Acute Care Nurse Practitioners be familiar with the regulations that impact and guide the process of credentialing and obtaining clinical privileges in a variety of venues.
Acute Disease↗
Expanding acute care nurse practitioner and clinical nurse specialist education: invasive procedure training and human simulation in critical care.
Programs educating advanced practice nurses (APNs), including acute care nurse practitioners (ACNPs) and clinical nurse specialists (CNSs) may struggle with the degree to which technical and cognitive skills necessary and unique to the care of critically ill patients should be incorporated within training programs, and the best ways these skills can be synthesized and retained for clinical practice. This article describes the critical care technical skills training mechanisms and use of a High-Fidelity Human Simulation (HFHS) Laboratory in the ACNP and CNS programs at the University of Pittsburgh School of Nursing. The mechanisms for teaching invasive procedures are reviewed including an abbreviated course syllabus and documentation tools. The use of HFHS is discussed as a measure to provide students with technical and cognitive preparation to manage critical incidents. The HFHS Laboratory, scenario development and implementation, and the debriefing process are discussed. Critical care technical skills training and the use of simulation in the curriculum have had a favorable response from students and preceptors at the University of Pittsburgh School of Nursing, and have enhanced faculty's ability to prepare APNs.
Acute Disease↗