Telephone monitoring after early discharge for cardiac surgery patients

Very Early Discharge After Coronary Artery Bypass Grafting Does Not Affect Readmission or Survival

BACKGROUND

This study evaluated the impact of very early hospital discharge after coronary artery bypass grafting (CABG) on subsequent readmission and survival.

METHODS

Adults undergoing isolated CABG from 2011 to 2018 at a single institution were included. Patients were stratified on the basis of their postoperative length of hospital stay: short stay (≤4 days) and nonshort stay (>4 days). The primary outcomes were longitudinal survival and freedom from hospital readmission. Secondary outcomes included rates of postoperative complications. Propensity score matching with a 1:1 ratio was performed to generate cohorts with comparable baseline characteristics.

RESULTS

A total of 6327 patients underwent CABG during the study period, and a matched cohort of 2286 patients was identified. In matched analysis, the average Society of Thoracic Surgeons predicted risk of operative mortality was low in both groups (average, 0.7%). Rates of postoperative complications were low and several complication rates were even lower in the short-stay cohort: stroke (1.14% vs 0.26%; P = .01), renal failure (0.87% vs 0.09%; P = .007), reoperations (1.84% vs 0.26%; P < .001), and new-onset atrial fibrillation (34.21% vs 13.04%; P < .001). Survival was similar between the matched groups at 30 days (99.56% vs 99.21%), 1 year (97.73% vs 97.46%), and 5 years (91.15% vs 92.48%) (all P > .05). Readmission rates were also comparable at all time intervals, and there were no differences in cardiac-related or heart failure-specific readmissions (all P > .05). Risk-adjusted analyses confirmed these findings.

CONCLUSIONS

This study demonstrates that very early discharge within 4 days of isolated CABG is safe and has no substantial impact on subsequent mortality or readmission risk.

The challenge of non-adherence to early rehabilitation after coronary artery bypass surgery: Secondary results from the SheppHeartCABG trial

BACKGROUND

Attending and maintaining a cardiac rehabilitation programme is a challenge.

AIMS

The purpose of this study was to explore associations between non-adherence to early coronary artery bypass graft rehabilitation and sociodemographic and clinical baseline data.

METHODS

Coronary artery bypass graft patients were randomised 1:1 to either four weeks of comprehensive early rehabilitation or usual care. Outcomes were assessed at three time-points points: baseline, discharge and four weeks post-coronary artery bypass graft. Differences in sociodemographic and clinical baseline data in adherent versus non-adherent patients were tested using the Pearson χ² test for categorical variables. To test associations between non-adherence to exercise training and sociodemographic and clinical baseline data, multivariate logistic regression was used to estimate the odds ratio for in-hospital training and post-discharge training adjusted for age, sex and left ventricular ejection fraction.

RESULTS

Non-adherence to in-hospital versus post-discharge exercise training was 31% (n=48) versus 53% (n=81). Female non-adherence was 20% versus 70%. Non-adherence to in-hospital versus post-discharge mindfulness was 87% versus 70%. Male non-adherence to mindfulness was 85% versus 70%. Non-adherence to psycho-educational consultations was 3%, most of whom were men. Patients with university level education were more adherent to in-hospital exercise training than patients with lower educational level (odds ratio=3.14 (95% confidence interval; 1.16-8.51), p=0.02). Diabetic patients were more non-adherent to exercise training after discharge (3.74 (1.54-9.08), p=0.004) as were overweight patients (0.37 (0.17-0.80), p=0.01).

CONCLUSIONS

This study demonstrated wide acceptance of psycho-educational consultations in post-coronary artery bypass graft patients. Adherence to physical rehabilitation was low especially after discharge from hospital and the opportunity to attend a mindfulness programme was not used.

Factors Associated With Patient-Initiated Telephone Calls After Orthopaedic Trauma Surgery

OBJECTIVES

The primary aim of this study is to investigate the incidence of early patient-initiated postoperative telephone calls and reasons for those calls. Secondary goals are to determine perioperative predictive factors for calls including the procedures most frequently associated with them.

DESIGN

Retrospective chart review.

SETTING

Academic Level-1 Trauma Center.

PATIENTS/PARTICIPANTS

Six hundred eighty-four patients who underwent surgical treatment by our orthopaedic trauma division between 01/01/2014 and 31/12/2014.

MAIN OUTCOME MEASUREMENTS

Patient-initiated telephone call documented within 14 days after discharge.

RESULTS

Twenty-nine percent (n = 199) of patients initiated a telephone call within 14 days after discharge. The most common reasons for telephone calls were pain control (22%), bathing/dressing/wound questions (16%), and questions regarding discharge medications (8%). The procedures associated with the highest percentage of telephone calls were tibial shaft intramedullary nailing (36.0%), calcaneus open reduction internal fixation (31.3%), and cephalomedullary nailing for proximal femur fractures (29.3%). Perioperative factors predictive of an increase in phone calls included discharge directly to home, higher baseline level of health of the patient (based on comorbidities and the American Society for Anesthesiologists score), and a more robust support network (based on marital and employment status).

CONCLUSIONS

This study identifies the incidence and common reasons for patient-initiated calls after orthopaedic trauma surgery and an analysis of perioperative factors predictive of increased phone calls. These data give direction for communication at the time of discharge to improve efficiency, patient care, and patient satisfaction.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modifying a generic postoperative recovery profile instrument to an instrument specifically targeting coronary artery bypass grafting

Patients may suffer from a wide range of postoperative symptoms after coronary artery bypass grafting. In-depth knowledge of the recovery process is a prerequisite for nursing interventions. However, we found no specific instrument covering the entire range and duration of postoperative symptoms related to this procedure. We therefore modified and extended the 19 items, generic Postoperative Recovery Profile questionnaire for the specific evaluation of the recovery after coronary artery bypass grafting. We here report on the development process of the new questionnaire. Procedure-specific symptoms were identified by a literature review and by experts. The content validity was assessed by healthcare professionals (n = 15), inpatients (n = 12) and outpatients (n = 4). A test run was done with inpatients (n = 10), which was followed by a test-retest reliability evaluation with inpatients (n = 24). We identified 15 new symptoms in the literature review and six in the content validity assessment. Only three of the 35 items had an acceptable content validity index, but all 35 items in the test run were reported by at least two patients. The questionnaire took 4-9 minutes to complete and was considered easy to use. The final instrument used in the reliability test included 22 new items, and 25 of the 35 items were satisfactory stable. To conclude, we developed a 35 items, procedure-specific questionnaire that was easy to use and may aid systematic assessment of the recovery after coronary artery bypass grafting.

Comparison of Symptoms of Younger and Older Patients Undergoing Coronary Artery Bypass Surgery

Little is known about the symptom experience throughout the trajectory of recovery for patients after coronary artery bypass surgery (CABS). This study investigates the preoperative and postoperative symptoms experienced by younger (< 65 years) and older (= 65 years) patients (N= 102) who had undergone CABS. Reported preoperative symptoms were angina, shortness of breath, dizziness, and sweating. At 1 week post-CABS, symptoms were incisional pain, wound drainage, chest congestion, shortness of breath, dizziness, sweating, swollen feet, and loss of appetite; incisional pain and swollen feet were reported by a few patients at 6 weeks after CABS. The incidence and frequency of postoperative symptoms declined over time. There were several age-related differences in symptom reports prior to and at 1 and 6 weeks after the procedure. Such information can be used to plan the care of patients undergoing CABS, to prepare them for normal recovery, and to determine the need for symptom management by health care providers.

Changes in Body Mass Index and Late Postoperative Outcomes in Elderly Coronary Artery Bypass Grafting Patients: A Follow-up Study

The purpose of this study was to describe the extent to which late postoperative health outcomes vary as a function of change in body mass index (BMI) in persons 65 years of age undergoing elective coronary artery bypass grafting (CABG). The mean age of the 90 persons in the original sample was 72.27 (±4.85) years. At follow-up (x = 18.73,s = 2.56 months postsurgery), 90% (n = 79 alive,n = 2 deceased, proxy completed interview) were contacted; 73% (n = 59) completed the telephone interview; and 9% (n = 8) were alive but lost to follow-up. BMI (kg/m2) was calculated from self-reported weight at follow-up. Outcomes included the Physical Component Summary (PCS) scale of the SF-36 Health Survey and readmission data. Thex (s ) for BMI at preoperative, postoperative, postdischarge, and follow-up were 28.1 (4.9) kg/ m2 , 28.76 (4.9) kg/m2, 27.11 (4.8) kg/m2, and 27.95 (4.7) kg/m2, respectively. BMI changed over time,P < 0.05. Those who were readmitted lost more weight between preoperative and postdischarge than those who were not readmitted (x BMI = –2.26 vs.x BMI = –1.35),t = 2.17,df = 27.05,P = 0.04. Those who lost less weight between preoperative and postdischarge were less likely to be readmitted,.2 = 5.755 (1),P = 0.02, with 25% sensitivity and 92% specificity. Thex (sx) for PCS at preoperative, postdischarge, and follow-up were 36.93 (1.62), 35.72 (1.27), and 42.26 (1.45), respectively, reflecting change over time,F = 11.43 (2),P < 0.001. At follow-up, older elective CABG patients do not appear to regain weight lost between preoperative and postdischarge; however, self-reported physical health is improved. Also, initial weight loss is related to readmissions.

Enhancing Postoperative Recovery of Cardiac Surgery Patients

The purpose of this trial was to determine the effectiveness of advanced practice nursing support on cardiac surgery patients’ during the first 5 weeks following hospital discharge. Patients ( N = 200) were randomly allocated to two groups: (a) an intervention group who received telephone calls from an advanced practice nurse (APN) familiar with their clinical condition and care needs, twice during the first week following discharge then weekly thereafter for 4 weeks, and (b) a usual care group. Measures of health-related quality of life (HRQL), symptom distress, satisfaction with recovery care, and unexpected health care contacts were obtained at 5 weeks following discharge. There were no significant group differences in HRQL, unexpected contacts with the health care system, or symptom distress. The provision of APN support via telephone followup after cardiac surgery is feasible. However, further randomized trials of single and multicomponent APN interventions are needed to prove effectiveness.

Cardiac rehabilitation patients' perspectives on the recovery following heart valve surgery: a narrative analysis

AIMS

To explore the structure and content of narratives about the recovery process among patients undergoing heart valve surgery participating in cardiac rehabilitation.

BACKGROUND

Several studies with short-term follow-up have shown that recovering from cardiac surgery can be challenging, but evidence on the long-term recovery process is very limited, especially following heart valve surgery. Furthermore, few studies have explored the recovery process among cardiac rehabilitation participants.

DESIGN

A qualitative study with serial interviews analysed using narrative methods.

METHODS

We collected data over 18 months (April 2013-October 2014). We recruited nine patients undergoing heart valve surgery from a randomized trial, CopenHeartVR and conducted 27 individual narrative interviews at 2-3 weeks, 3-4 months and 8-9 months after surgery.

FINDINGS

Following heart valve surgery, the participants expected to return to normality. The analysis identified four courses of recovery, with three non-linear complex pathways deviating from the classic restitution narrative: the frustrated struggle to resume normality, the challenged expectation of normality - being in a limbo and becoming a heart patient. These deviating pathways were characterized by physical, existential and mental challenges even up to 9 months after surgery.

CONCLUSION

The recovery processes of participants' in cardiac rehabilitation were often more complicated than anticipated. Patients undergoing heart valve surgery may benefit from more extensive medical follow-up immediately after discharge, individual psychological assessment and individualized, realistic information about the recovery trajectory.

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.

Post-discharge symptoms following fast-track colonic cancer surgery: a phenomenological hermeneutic study

OBJECTIVE

To obtain knowledge of patients' experiences of postoperative symptoms during the initial two weeks following fast-track colonic cancer surgery.

METHOD

Semi-structured in-depth interviews with seven colonic cancer patients two weeks post hospital discharge. Analysis was performed using a phenomenological hermeneutical approach.

RESULTS

During the first two weeks after discharge the patients experienced unfamiliar symptoms that affected their everyday lives. Despite distressing symptoms, they applied a "wait-and-see" strategy, and only reacted when symptoms became intolerable. The patients failed to report their unfamiliar symptoms during hospital nurse follow-up telephone call. While waiting for the final histology patients suffered loss of sleep and chaotic thinking, and experienced ambiguity of hoping for the best and expecting the worst.

CONCLUSION

Although fast-track surgery programmes lead to shorter hospitalisation and improved physical performance, post-colonic surgery patients experience various symptoms after discharge. Healthcare professionals need to address symptoms that might have immediate and long-term consequences on patients' everyday life. Follow-up studies are encouraged to explore the patient perspective to identify the needs of individual patients after hospital discharge.

Integrated literature review of postdischarge telephone calls

This systematic review of the literature assessed the impact of a postdischarge telephone call on patient outcomes. Nineteen articles met inclusion criteria. Data were extracted and an evidence table was developed. The content, timing, and professional placing the call varied across studies. Study strength was low and findings were inconsistent. Measures varied across studies, many sample sizes were small, and studies differed by patient population. Evidence is inconclusive for use of phone calls to decrease readmission, emergency department use, patient satisfaction, scheduled and unscheduled follow-up, and physical and emotional well-being. Among these studies, there was limited support for medication-focused calls by pharmacists but no support for decreasing readmission. Health care providers benefited from feedback but did not need to place the call to realize this benefit. Inpatient nurses were unable to manage the volume of calls. There was no standardized approach to the call, training, or documentation requirements.

Patient recovery and transitions after hospitalization for acute cardiac events: an integrative review

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients' trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients' perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Patients' experiences with symptoms and needs in the early rehabilitation phase after coronary artery bypass grafting

BACKGROUND

The first month after discharge for Coronary artery bypass graft (CABG) is particularly challenging for the patients. A larger interview study is warranted to elicit CABG patients' detailed experiences, and give direction for future clinical practice.

AIM

To explore the CABG patients' symptoms and needs in the early rehabilitation phase.

METHODS

A qualitative, mixed method design integrating qualitative and quantitative approaches was used. Ninety-three CABG patients aged 39-77, participated in interviews at home after 2 and 4 weeks. The semi-structured interview guide covered: experiences of relief of angina pectoris after surgery, experiences with prescribed discharge medications, psychological experiences: anxiety, depression, sexuality, health professional contact persons, and patient defined experiences.

RESULTS

Two weeks after CABG the patients symptoms and needs were characterised by a substantial amount of uncertainty and worries related to what to expect and what was normal for postoperative pain, assessment and sensation of surgical site, different experiences with physical activity/exercise, uncertainty about medications, difficulties with sleep pattern, irritability, postoperative complications,uncertainty about return to work, and insufficient information at discharge. Four weeks after surgery the patients' symptom level was decreased, and they experienced life beginning to return back to normal. Patency with grafts after CABG, decision to drive a car, impotence (erectile dysfunction), and a missing link to the hospital remained challenges.

CONCLUSION

CABG patients' experiences indicate a need to extend the hospital's discharge care to the first month after surgery for specific themes to promote rehabilitation outcomes.

Perspectives on specialist nursing in Saudi Arabia: a national model for success

In many parts of the world, vulnerable patient populations may be cared for by a clinical nurse specialist (CNS). Nurses desiring to develop themselves professionally in the clinical arena, within the specialty of their choice, have the opportunity to obtain the knowledge, skills, experience and qualifications necessary to attain advanced practice positions such as CNS or nurse consultant (NC). Although studies have demonstrated the benefits of such roles and while the World Health Organization (WHO) recommends it, advanced nursing practice is not yet integrated into the health care culture in Saudi Arabia. The reasons for this are multiple, but the most important is the poor image of clinical nursing throughout the country. This article aims to share a perspective on CNS practice, while casting light on some of the obstacles encountered within Saudi Arabia. A model is proposed representing specialist nurse-physician collaborative practice for implementation nationally. The model has been implemented in the care of the colorectal and stoma patient populations while taking into consideration patient population needs and local health care culture. This model is based on the concepts of holistic "patient-centered care", specialist nurse-physician collaborative practice, and the four practice domains for NCs (expert practice, leadership, research and education) as indicated by the Department of Health in the United Kingdom. We suggest this model will enable the introduction of advanced specialist nursing and collaborative partnerships in Saudi Arabia with benefits for patients, physicians, health care organizations and the nursing profession as a whole.

Information level of patients in discharge training given by nurses following open heart surgery

Providing discharge information following a surgery is one of the most common nursing approaches. Patients should be given discharge training after open heart surgery in order to eliminate or reduce physical and emotional problems. The study aims to assess the information level of patients in discharge training provided by nurses following open heart surgery. The study is a prospective study including 50 patients who underwent open heart surgery. The information level of patients who received discharge training was assessed before training and 1 month after the training. Data were collected using the personal information form, and pretest and post-test questionnaires. Data were assessed by using percentage, McNemar chi-squared, Wilcoxon signed ranks and stepwise linear regression analysis tests. Results indicated that patients were well informed following discharge training (Z = -6.166, P < 0.05), and that age and marriage variables affected the information level (P = 0.032, P = 0.045, respectively). Discharge training following open heart surgery increases the knowledge of patients and should be given to patients in a planned manner.

Medications and associated symptoms/problems after coronary artery bypass surgery

OBJECTIVE

The purpose of this secondary analysis was to describe medication use and examine the relationship between medications and postoperative symptoms/problems in the first 3 months after coronary artery bypass surgery (CABS).

METHODS

The sample consisted of older (≥65 years) men and women (n = 232) who had undergone CABS. Medication data were collected through self-report 3 and 6 weeks and 3 months after surgery.

RESULTS

Most patients reported taking aspirin (88.2%-85.7%), statins or cholesterol-lowering drugs (88.6%-87%), and beta-blockers (68%-55.6%). No significant differences were found between the proportion of patients taking and not taking beta-blockers, antiarrhythmics, cholesterol-lowering drugs, or angiotensin-converting enzyme inhibitor medications for common medication-specific symptoms/problems.

CONCLUSION

Patients experience symptoms after surgery, but these symptoms did not seem to be side effects from medications. Nursing assessments and interventions targeting postoperative symptoms, symptom management, and medication side effects can enhance recovery and reinforce medication adherence.

Nurse-led telephone interventions for people with cardiac disease: a review of the research literature

BACKGROUND

Nurse-led telephone follow-up offers a relatively inexpensive method of delivering education and support for assisting recovery in the early discharge period; however, its efficacy is yet to be determined.

AIM

To perform a critical integrative review of the research literature addressing the effectiveness of nurse-led telephone interventions for people with coronary heart disease (CHD).

METHODS

A literature search of five health care databases; Sciencedirect, Cumulative Index to Nursing and Allied Health Literature, Pubmed, Proquest and Medline to identify journal articles between 1980 and 2009. People with cardiac disease were considered for inclusion in this review. The search yielded 128 papers, of which 24 met the inclusion criteria.

RESULTS

A total of 8330 participants from 24 studies were included in the final review. Seven studies demonstrated statistically significant differences in all outcomes measured, used two group experimental research design and valid and reliable instruments. Some positive effects were detected in eight studies in regards to nurse-led telephone interventions for people with cardiac disease and no differences were detected in nine studies.

DISCUSSION

Studies with some positive effects generally had stronger research designs, large samples, used valid and reliable instruments and extensive nurse-led educative interventions.

CONCLUSION

The results suggest that people with cardiac disease showed some benefits from nurse-led/delivered telephone interventions. More rigorous research into this area is needed.

Perceptions of recovery, physical health, personal meaning, role function, and social support after first-time coronary artery bypass graft surgery

Coronary artery bypass graft surgery is one of the most frequently performed major surgeries in the United States. Because of fast-track protocols and decreased lengths of stay, critical care nurses have even more demanding challenges in the care of these patients. Critical care nurses are well aware that these patients still have health needs that extend beyond discharge from the hospital, but these needs are now addressed by the patient's caregiver. This descriptive, comparative study was conducted to examine perceptions of recovery by these patients and the relationships among physical health, personal meaning, role function, and social support. The results of the study are presented, as well as the implications for critical care nurses.

Development and content validity testing of the Cardiac Symptom Survey in patients after coronary artery bypass grafting

BACKGROUND

Patients who have undergone coronary artery bypass grafting often experience numerous symptoms after surgery. There is a need for a symptom tool for this population that is disease-specific, comprehensive, and responsive to change.

AIMS

The aims of this study were to describe the development and preliminary content validity testing of the Cardiac Symptom Survey (CSS), assess further content validity of the CSS through an expert panel, and assess responsiveness of the CSS to change.

METHODS

The original development of the CSS is described. An expert panel of four judges was used to rate the clarity of the items (content validity) and the relevance of the symptoms and items to the domain. Responsiveness to change of the CSS was assessed in a sample of 90 subjects who underwent coronary artery bypass grafting.

RESULTS

Percent agreement and content validity index coefficients ranged from .90 to 1.00. Repeated measures analyses of variance showed significant changes over time as hypothesized in some of the symptom evaluation and symptom response scores.

CONCLUSION

Support is documented for both content validity and responsiveness of the CSS.

Randomized-Controlled Trial of a Telephone and Mail Intervention for Alcohol Use Disorders: Three-Month Drinking Outcomes

BACKGROUND

Alcohol screening, brief intervention, and referral to specialized treatment (ASBIR) reduce drinking and related harms. Unanswered questions are how to manage nondependent patients with poor response to brief interventions, how to manage dependent patients who do not obtain treatment, and how to ensure population-wide delivery of ASBIR. Telephone-administered counseling may provide answers.

METHODS

We conducted a 12-month randomized controlled trial of a telephone and mail intervention for non-treatment-seeking primary care patients with alcohol use disorders. We enrolled 897 subjects after systematic screening in 18 primary care clinic waiting rooms in and around Madison and Milwaukee, Wisconsin, and subsequent telephone-administered diagnostic interviews. Experimental subjects received up to six sessions of protocol-driven telephone counseling based on principles of motivational interviewing and stages of readiness to change. Control subjects received a pamphlet on healthy lifestyles. The paper reports on 3-month drinking outcomes for men and women with alcohol abuse and dependence.

RESULTS

Male experimental subjects (N=199) manifested a 30.6% decline in risky drinking days, compared with a 8.3% decline in controls (N=201, p<0.001). The total consumption declined by 17.3% compared with 12.9% by controls (p=0.001). Female experimental subjects (N=246) manifested a 17.2% decrease in risky drinking days compared with an 11.5% decrease by controls (N=251; p=NS) and a 13.9% decline in total consumption compared with 11.0% by controls (p=NS). Greater numbers of telephone counseling sessions were associated with greater declines in drinking.

CONCLUSION

Following systematic screening, a six-session telephone and mail intervention is more effective than a pamphlet in reducing drinking at 3 months for non-treatment-seeking men with alcohol abuse and dependence. An intervention effect of the enrollment procedures may have obscured further intervention effectiveness. Telephone counseling shows promise for non-treatment-seeking primary care patients with alcohol use disorders.

Use of a Telehealth Device to Deliver a Symptom Management Intervention to Cardiac Surgical Patients

A variety of approaches can provide cardiac patients with needed follow-up care. However, with the explosion of telehealth capabilities, clinicians are more ready to explore other methods to integrate the use of telehealth devices into the delivery of effective nursing interventions. This article summarizes the development of a symptom management intervention for coronary artery bypass graft patients using the Health Buddy to deliver a nursing intervention in the early recovery period after hospital discharge. Considerations used to design the symptom management intervention and selection of this telehealth modality are discussed. This overview can help clinicians and researchers gain perspective on how to evaluate telehealth modalities to aid in the delivery of interventions for cardiac and other clinical populations.

Telephone interventions by nursing students: improving outcomes for heart failure patients in the community

Community care for heart failure patients is difficult due to multiple comorbidities, polypharmacy, and advanced age of patients. Studies show that hospital admissions and emergency room visits decrease with increased nursing interventions in home and community settings. The purpose of this study(1) was to assess the effectiveness of regular telephone interventions by nursing students on outcomes of heart failure patients in the home. Senior students were paired with community nursing staff and assigned 2 heart failure patients to follow up by telephone calls for 12 to 14 weeks. Patients who received telephone interventions had fewer hospital readmissions (13%) than the comparison group (35%). Patients in the telephone intervention group also had fewer overt heart failure symptoms as measured by the Minnesota Living With Heart Failure Questionnaire.

Clinical depression in women after cardiac surgery

BACKGROUND AND RESEARCH OBJECTIVE

After coronary artery bypass graft (CABG), women are particularly vulnerable to depression because they are more socially isolated and are more likely to have preoperative mood disorders than men. The purpose of this study was to (1) describe the incidence and course of clinical depression in women during the first 6 months after CABG; (2) describe the frequency of depressive symptoms after CABG in women; and (3) identify factors associated with post-CABG depression in women.

SUBJECTS AND METHODS

Before hospital discharge, 75 women undergoing CABG for the first time participated in a semistructured interview to determine the presence of major or minor depression using the Diagnostic and Statistical Manual, Fourth Edition, criteria. In 55 women, additional interviews were conducted within the first month and at 6 months after discharge. Data were evaluated using frequencies, analysis of variance, Mann-Whitney U test, and logistic regression.

RESULTS AND CONCLUSIONS

Clinical depression occurred before hospital discharge, in the first month after discharge, and 6 months after discharge in 30.9%, 16.4%, and 12.8%, respectively, of the women who completed a 6-month follow-up. Younger women, those with more perioperative complications, and those with a history of depression were at greater risk for clinical depression. After hospital discharge, the occurrence of any clinical depression within the first month was associated with an increased occurrence of clinical depression 6 months later. Younger women, those with more perioperative complications and early depressive symptoms, and those with persistent occurrence of the most commonly reported symptoms (anhedonia, dysphoria, and fatigue) should be carefully evaluated.

Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery

BACKGROUND

Enrollment in cardiac rehabilitation (CR) after coronary artery bypass graft (CABG) surgery is suboptimal (25%-30%).

OBJECTIVES

The purpose of this study was to examine the effect of a nurse-initiated telephone call (NIC) on attendance at a CR intake appointment.

METHODS

By using a retrospective cohort design, data were collected on 3536 patients who underwent CABG between April 1996 and March 2000 and were referred to CR. Of these, 2285 patients received standard care (no NIC) and 1251 received the NIC.

RESULTS

Patients who received the NIC were significantly more likely to attend their CR intake appointment compared with standard care (78.1% vs. 50.1%; P < .0001). Hierarchic logistic regression analysis revealed the NIC as the strongest predictor of attendance at a CR intake explaining 56.9% of the total variance (odds ratio =3.429; 95% confidence interval = 2.919-4.028; P < .0001).

CONCLUSION

These findings suggest that pre-appointment telephone contact by a cardiovascular nurse is a valuable tool to enhance attendance at a CR intake appointment after CABG.

Coronary artery bypass graft surgery: discharge planning for successful recovery

BACKGROUND

Coronary artery bypass graft (CABG) surgery is a lifesaving intervention, but the early recovery period presents a number of challenges for patients, carers and nurses. Early and adequate discharge planning based on in-depth knowledge of the postdischarge experience can help to ensure optimal recovery.

AIM

This paper reports a study to examine the range of postdischarge issues, concerns and needs of patients and their family carers after discharge after CABG surgery, and explore their perceptions of unmet needs 1 year later.

METHODS

A two-phase naturalistic inquiry was undertaken. Interviews were conducted with 30 patients and their carers 4-5 weeks after coronary artery bypass grafting (phase 1) and 1 year after the initial interview (phase 2). Thematic analysis was used to identify the major concerns of participants.

FINDINGS

Almost half the patients experienced heart surgery as a huge personal shock. Adjusting to life afterwards was difficult, and they experienced a variety of changes, including pain. An unexpected finding was a heightened sense of body awareness and the need for postoperative physical adjustments. The financial implications of surgery were a major burden. Lifestyle adjustments were important and led to suggestions for support services, using telephone support and/or community patient networks. All participants recommended strengthening discharge planning with more accurate information about what to expect during recovery, to help them anticipate fluctuations in health and wellbeing. Carers experienced a wide range of unanticipated feelings during early recovery and had to deal with a number of personal changes.

CONCLUSIONS

The findings suggest a need to improve discharge preparation and provide enhanced home support services. Further research should evaluate models of periodic follow-up and mechanisms for mutual support, and compare the experiences of cardiac patients and their carers with those of other surgical cohorts.

Nursing-Sensitive Outcomes in Cardiac Surgery Patients

Achieving optimum patient outcomes has always been the primary focus of healthcare providers. The degree to which any healthcare discipline can impact outcomes varies since patient outcomes are multiple and diverse. As the measurement and reporting of outcomes has moved into the arena of public reporting, it has become essential for disciplines to be able to identify which outcomes they can either partially or completely influence. The focus of this article is to (1) identify what specific nursing-sensitive outcomes have been measured or monitored on cardiac surgery patients in the past and then (2) suggest potential next generation outcomes.

Comparison of recovery patterns for patients undergoing coronary artery bypass grafting and minimally invasive direct coronary artery bypass in the early discharge period

The purpose of this pilot study was to compare the postoperative problems, evaluation and response of symptoms, and functional status (physiologic and psychosocial functioning) during the early recovery period (2, 4, and 6 weeks after surgery) in 35 individuals who underwent coronary artery bypass grafting (n=24) or minimally invasive direct coronary artery bypass (n=11). The most frequent postoperative problem reported by the coronary artery bypass grafting group was an incisional infection (either sternal or leg); 26% reported infection at 2 and 4 weeks, and 21% at 6 weeks after surgery. Respiratory problems (pleural effusion, pneumonia) were the second most frequently reported problem, reported by 10% of the subjects at 2 and 4 weeks and by 16% at 6 weeks. Other, less frequent problems were severe nervousness, rhythm problems, and pericarditis. Minimally invasive direct coronary artery bypass patients reported fewer postoperative or cardiac-related problems, as only 5% indicated a problem with heart failure at both 2 and 4 weeks, and 36% reported being very nervous or having emotional problems at 4 weeks. Unlike postoperative problems, there were numerous similarities in postprocedural symptoms between these two groups. Fatigue, shortness of breath, and pain were the major symptoms reported postdischarge by both groups in this study. In addition, sleeping problems were also fairly prevalent in the coronary artery bypass grafting group, which is understandable, considering the fatigue ratings. Physiologic and psychosocial functioning varied minimally between the two procedures. While there were many similarities in the recovery patterns of both groups, the occurrence of postprocedural problems and symptoms of these two patient groups should be considered by clinicians to further tailor patient education.

Changes in nutritional status and postoperative outcomes in elderly CABG patients

OBJECTIVES

To systematically examine the pattern of nutritional status over time in older people undergoing elective coronary artery bypass grafting (CABG) and the extent to which nutritional status affects health outcomes postdischarge.

DESIGN

The sample consisted of 91 community-dwelling English-speaking persons > or = 65 (72.27 +/- 4.85) years of age with normal cognitive function and no active cancer. Data collected prospectively at 3 time points (preoperatively, postoperatively on day 5, and 4 to 6 weeks postdischarge) included serum albumin, transferrin, and calculated Body Mass Index (BMI). The Short-Form 36 Health Status Survey Questionnaire was administered 4 to 6 weeks postdischarge as a primary health outcome measure.

RESULTS

Nutritional status changed over time. For albumin and transferrin, the pattern of change corresponded to the phases of surgical stress (P = 0.001). The BMI decreased from preoperative to 4 to 6 weeks postdischarge (P = 0.001), and this decrease explained 13.8% of the variance in physical health 4 to 6 weeks postdischarge (P = 0.008). The change in the BMI corresponds to an average weight loss of 5% from preoperative to postdischarge.

CONCLUSIONS

Older people undergoing CABG who lose significant weight from preoperative to postdischarge are more likely to have lower self-reported physical health.

Use of telephone follow-up for post-cardiac surgery patients

Telephone follow-up has been used in a variety of settings as a means of supporting patients post-discharge. This paper describes the implementation of a telephone follow-up service for cardiac surgical patients, both to monitor their progress and to bridge the gap between home and hospital. Surgical unit nurses called 1594 patients between May 1995 and October 1997. These calls were made a month after each patient had been discharged and a specially designed form was used as a guideline for the calls. This covered three main aspects of their recovery: discharge monitoring; medical problems; and convalescence problems. As well as providing a framework for the calls, the forms were then used for data collection. The forms were audited on a monthly basis with the results being communicated to the ward staff. Data gathered from the calls have highlighted areas where patient education needs to be improved, e.g. pain control, and this has been addressed. In October 1996, an evaluation of the service was performed. One hundred patients were sent a postal questionnaire asking for their views on the telephone service. Eighty-two of these were returned and the results of this survey are also contained in this report. Over time, the number of patients called each month has increased; information regarding support post-discharge has improved and the form used for calls has been revised to make the questions more appropriate.

Patient problems and nurse interventions during acute care and discharge planning

Standardization and computerization of medical documentation has provided a method to describe patient care by naming and linking patients' needs with nursing interventions. This study used a standardized nursing classification system to describe the types and frequency of problems experienced by elders hospitalized and discharged to home and the interventions used by staff nurses and advanced practice nurses (APNs) as they provided acute care and discharge planning for these cardiac patients. The patients' hospital records and the APN logs were content analyzed and then coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. Patients experienced an average of 8.6 problems that required a total of 7,000 interventions in all four Omaha System intervention categories. The results provided a description of the most frequent problems experienced by the patients linked with the most common nursing interventions. The nature, complexity, and prevalence of patient problems and the importance of communication across settings are evident. In addition, the study findings increase understanding of the contribution of nurses to the care of hospitalized elders as they make the transition from hospital to home.