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REVIEW OF THE LITERATURE |
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 Top REVIEW OF THE LITERATURE CLINICAL PATHWAYS AND VALVULAR...CASE STUDY 1CASE STUDY 2EVALUATIONSUMMARYReferences |
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Cotton10 described a clinical pathway for a rapid recovery program for patients undergoing coronary artery bypass surgery that included an accelerated activity program and efforts to prevent bowel dysfunction by giving patients medications to improve gastric motility and soften stool. The patients in the rapid recovery program had a decrease in mean length of stay of almost 2 days and had fewer complications than did patients not in the program.
Engelman et al11 reported the use of a clinical pathway for fast-track recovery of coronary artery bypass patients that incorporated a progression of accelerated physical activity and early extubation. Patients on the fast track had significantly greater decreases in postoperative length of stay and extubation time and lower mortality than did patients not on the fast track.
Velasco et al12 developed a pathway for patients undergoing coronary artery bypass surgery at New York Hospital-Cornell Medical Center. When the pathway was used, patients’ length of stay decreased, from 11.1 days to 7.7 days. In addition, costs decreased $1181 per patient.
Strong and Sneed13 noted a significant correlation between postoperative length of stay and the critical path variables of activity progression, use of incentive spirometry and telemetry, and adherence to the pathway. They observed that the more closely a patient adhered to the path in relation to activity progression and telemetry use, the shorter was the length of stay.
Rudisell et al14 monitored 168 patients who were following a clinical path. The patients had undergone coronary artery bypass surgery, a valve replacement surgery, or both. The researchers found that patients following the clinical path were discharged a mean of 1 day earlier than were patients who were not following the path.
Meisler and Midyette15 used a fast-track pathway for all patients undergoing coronary artery bypass and valve surgery. They also developed protocols for early extubation, activity progression, prophylaxis for atrial dysrhythmias, and gastrointestinal signs and symptoms. They noted decreases in length of stay and subsequent cost.
St. Francis Medical Center (Honolulu, Hawaii) implemented a fast-track program that included early extubation and accelerated rehabilitation. Use of the program facilitated decreases in intubation time, mean length of stay in the intensive care unit, and mean postoperative length of stay in the hospital while improving patients’ outcomes.16
Jacavone et al17 reported the use of a critical pathway with cardiac surgery patients undergoing coronary artery bypass grafting, mitral valve replacement, and aortic valve replacement. Changes in practice with use of the pathway included earlier extubations, earlier ambulation, changes in sedative medications, and the administration of prophylactic gastrointestinal medications. The results were a decrease in complications and length of stay and cost savings of $201 000 annually.
Clark et al18 reevaluated the care provided at their institution to cardiac surgery patients undergoing coronary bypass surgery or valve replacement. Changes in care included the use of care maps and preprinted physicians’ orders that paralleled the care maps. Implementation of the changes led to a decrease in patients’ length of stay and a cost savings for the institution while the quality of patients’ care was maintained.
St. Francis Hospital and Health Center in Indiana implemented the use of a combined clinical pathway for patients undergoing coronary artery bypass surgery and patients undergoing valve surgery. Use of the pathway facilitated a decrease in the length of stay in the recovery area, from 2.5 to 3 days down to 1 day.19
Riegel et al20 used a clinical pathway for cardiac surgery, which included patients undergoing coronary artery bypass surgery and valve surgery. After the pathway was implemented, the mean length of stay decreased, from 10.2 days to 9.3 days.
Rook21 noted a decrease in length of stay from 10 days to 7 days after a cardiac surgery pathway was followed. The pathway included all patients undergoing cardiac surgery and was not specific to a single procedure. A decrease also occurred in intubation time, from 16 hours to 7 hours.
Cohn et al22 described the use of a 5-day pathway at Brigham and Women’s Hospital in Boston for all uncomplicated cardiac surgery patients, including patients undergoing coronary artery bypass surgery, cardiac valve operations, and other procedures including repair of thoracic aortic aneurysms and correction of congenital defects in adults. In 1996, 50% of patients without complications completed the pathway, with a mean length of stay for all patients of 7.8 days. Cohn et al reported an overall decrease of 15% in length of stay, a decrease in cost, and an increase in patients’ satisfaction.
Newer surgical techniques developed to manage cardiac surgery patients have also included pathways to help facilitate the care of patients and to decrease length of stay. Scarlett23 reported the use of a clinical pathway for patients undergoing minimally invasive cardiac surgery that outlined a 3-day–long postoperative stay. Rogers et al24 developed a clinical pathway for use with patients undergoing port-access cardiac surgery. They also incorporated the use of a fast-track extubation protocol, a nursing care protocol, and a diltiazem protocol. Rogers et al noted a decreased length of stay and intubation time and increased satisfaction among patients when the pathway and protocols were used.
Use of clinical pathways and protocols can lead to improvements in patients’ care and utilization of resources and can help achieve desired lengths of stay. When using clinical pathways, clinicians must monitor all variances from the pathway. Variances occur when patients’ care or outcomes differ from what was predicted.6 These variances alert the healthcare team of the need for a plan to address the problem as quickly as possible. Addressing problems quickly will ensure patients’ timely progression along the pathway.
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CLINICAL PATHWAYS AND VALVULAR SURGERY |
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TopREVIEW OF THE LITERATURECLINICAL PATHWAYS AND VALVULAR...CASE STUDY 1CASE STUDY 2EVALUATIONSUMMARYReferences |
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). Any patients who had valve repair, valve replacement, or a combination of coronary artery bypass and valve surgery would be eligible for this pathway. The goal was to organize patients’ care, make the care provided more consistent, and improve efficiency with this population of patients.
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In order to facilitate use of the pathway, sets of standing orders for cardiothoracic surgery were developed. These orders direct the care of patients in the intensive care unit, the step-down unit, and the medical surgical unit. The orders outline all therapies, laboratory blood work, and medications that may be required for patient care. They also include the pathways and protocols used for these patients. The physician indicates which orders are appropriate for the patient upon completion of the order set. The standing order sets organize care and provide consistency of orders for all cardiothoracic patients.
In conjunction with the pathway and the standing order sets, protocols are used to organize and manage patients’ care. Four protocols were developed: an activity/ ambulation protocol, a bowel protocol, an early extubation protocol, and a protocol for preventing pressure ulcers. The first 3 protocols all require a physician’s order before they can be used. The protocol for preventing pressure ulcers is considered a nursing protocol and does not require a physician’s order. Once a protocol is ordered, it is expected that all items in the protocol will be completed.
The activity/ambulation protocol (Table 2) describes the desired activities that the patient should complete for each day of the pathway. The nurse and physical therapist will automatically advance the patient’s activities. Once the patient is able to complete the activities for day zero, they will then be advanced to the activities expected for day one. If the patient cannot complete activities outlined in the protocol, the physician is notified. Depending on the patient’s preference and insurance coverage, a referral to a rehabilitation center or a home consultation with a physical therapist is considered.
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) was developed to ensure that the patient has a bowel movement before discharge from the hospital. The nurse assesses the patient for abdominal complications each day and administers a stool softener 3 times a day as outlined in the protocol. If the patient has no abdominal complications and does not have a bowel movement by the third postoperative day, the nurse administers medications or implements interventions outlined in the protocol for that day. If the patient does not respond to the protocol, the nurse then informs the physician and further orders are obtained.
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) was developed to provide a consistent plan for extubation. The registered nurses in the intensive care unit wean patients off the mechanical ventilator and extubate them 2 to 4 hours after the patients awaken from anesthesia, provided the criteria outlined in the protocol are met. If the patient does not meet the criteria outlined in the protocol, the nurse continues to monitor the patient and consults the physician for further orders.
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) is used for all patients. It provides guidelines for the nurses and outlines assessments and interventions to be used to prevent pressure ulcers.
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CASE STUDY 1 |
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TopREVIEW OF THE LITERATURECLINICAL PATHWAYS AND VALVULAR...CASE STUDY 1CASE STUDY 2EVALUATIONSUMMARYReferences |
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Immediately after surgery, S.B. was transferred to the cardiothoracic intensive care unit (CTICU) accompanied by the cardiothoracic surgeon and anesthesiologist. The surgeon requested initiation of the clinical pathway for valve surgery and completed the CTICU standing order sets. The nurse initiated the protocol for preventing pressure ulcers when S.B. arrived in the CTICU. Postoperative intravenous medications included nitroglycerin to prevent coronary artery spasm and norepinephrine for hypotension. S.B. received 1000 mL of intravenous fluids to maintain a systolic blood pressure of 90 mm Hg. S.B.’s monitor indicated sinus rhythm. S.B. met the criteria for early extubation; he was extubated without difficulty and was given oxygen via nasal cannula at 5 L/min.
On postoperative day 1, S.B. was weaned off the nitroglycerine and norepinephrine. He was retaining fluids, as indicated by an increase in weight and crackles auscultated bilaterally during the respiratory assessment. Furosemide was ordered to promote diuresis. The pulmonary artery and arterial catheters were discontinued according to the pathway and standing orders. S.B. was started on the bowel protocol, which included abdominal assessments and the administration of stool softener 3 times per day. Because S.B. had excess fluid accumulation, additional fluids were contraindicated. The pericardial, mediastinal, and pleural chest tubes were removed. S.B. dangled his legs at the bedside without difficulty and was assisted out of bed to a chair. Anticoagulation was initiated with warfarin. S.B. was transferred to the step-down unit, and standing order sets for the step-down unit were completed.
On postoperative day 2, the central intravenous catheter, epicardial pacing wires, and Foley catheter were removed. S.B. voided without difficulty and was out of bed for all 3 meals, as outlined in the activity/ambulation protocol. S.B. was seen by the physical therapist, who facilitated increased activity. Administration of oxygen was decreased to 2 L/min via nasal cannula. Peripheral edema persisted, and additional furosemide was administered intravenously. S.B. was treated with intravenous heparin at 600 U/h, and daily warfarin administration was continued. On the evening of postoperative day 2, S.B. had atrial fibrillation, and sotalol was administered.
On postoperative day 3, S.B. was weaned off oxygen. He had not had a bowel movement, so a suppository was administered. A bowel movement was noted after administration of the suppository; therefore, milk of magnesia and an enema, as outlined in the bowel protocol, were not required. S.B.’s monitor indicated conversion to sinus rhythm. S.B. did not have physical therapy because no physical therapy services are available on Sundays. However, the nurses continued the plan of care as outlined by the physical therapist and in the activity/ambulation protocol.
On postoperative day 4, an echocardiogram was obtained according to pathway guidelines, and no pericardial effusion was noted. S.B. remained in normal sinus rhythm, and the cardiac monitor was discontinued. S.B. was ambulating well and showered without difficulty. He was able to climb a flight of stairs with the assistance of the physical therapist. The heparin lock was not discontinued, because S.B. continued to receive intravenous heparin for anticoagulation. Daily administration of warfarin continued.
On postoperative day 5, S.B. continued to ambulate. He no longer had physical therapy, because he had completed all activities outlined in the activity/ ambulation protocol and was independent in activities of daily living. Daily checks of prothrombin and partial thromboplastin levels revealed subtherapeutic levels, which required continued administration of heparin and warfarin. S.B. was transferred to a medical-surgical unit, and orders were completed by using the order sets for that unit.
On postoperative day 6, S.B.’s prothrombin level remained sub-therapeutic, requiring additional warfarin and continued administration of heparin. S.B. continued with independent ambulation in preparation for discharge on day 7. He and his family were taught about drug administration and diet restrictions for patients receiving warfarin.
On postoperative day 7, S.B. had sufficient levels of anticoagulants and had met all the criteria on the pathway. S.B. and his family demonstrated understanding of his discharge instructions and medications. S.B. was discharged home with his family. He was instructed to follow up with his cardiologist for blood work monitoring.
Atrial fibrillation and atrial flutter, the most common supraventricular dysrhythmias noted after cardiac surgery, occur in 10% to 30% of patients. Risk of atrial fibrillation increases with age, with 3.7% occurrence in patients younger than 40 years and at least a 28% occurrence rate in patients older than 70 years. Atrial fibrillation is most likely to occur on the second postoperative day. Eighty percent of the patients return to normal sinus rhythm within 1 to 3 days with only digoxin or ß-blocker therapy.26 S.B. experienced a short episode of atrial fibrillation that responded to the administration of sotalol.
Patients undergoing valve procedures commonly have heart failure preoperatively that persists into the postoperative phase. Common causes of heart failure include coronary artery disease and mitral and aortic valve disease. Signs and symptoms of heart failure include tachypnea, orthopnea, and crackles in the lung fields. Peripheral edema and distended neck veins may also be noted. Lethargy and restlessness may occur. Decreased renal perfusion may lead to fluid overload, decreased urine output, increased levels of serum urea nitrogen, and weight gain.27–29 S.B. had continued signs of heart failure as indicated by his increased weight, peripheral edema, and crackles in the lung bases.
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CASE STUDY 2 |
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TopREVIEW OF THE LITERATURECLINICAL PATHWAYS AND VALVULAR...CASE STUDY 1CASE STUDY 2EVALUATIONSUMMARYReferences |
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Immediately after surgery, J.G. was transferred to the CTICU, accompanied by the cardiothoracic surgeon and anesthesiologist. The surgeon initiated use of the CTICU standing order sets. The nurse initiated the protocol for preventing pressure ulcers. Postoperative intravenous medications included dobutamine for inotropic support and nitroglycerine to prevent coronary artery spasm. Epicardial atrioventricular pacing was initiated in the operating room because of complete heart block. J.G. met the criteria outlined in the early extubation protocol; he was successfully extubated 10 hours postoperatively and was given oxygen via nasal cannula at 5 L/min.
On the first postoperative day, J.G. was able to dangle his legs by 16 hours after surgery, in accordance with the activity/ambulation protocol and the clinical pathway. J.G. was weaned off intravenous medications. The pulmonary artery catheter and the pericardial, mediastinal, and left pleural chest tubes were removed. The bowel protocol was initiated by administering a stool softener, encouraging J.G. to take clear liquids by mouth, and doing a routine abdominal assessment every shift. The assessment included monitoring for bowel sounds, watery diarrhea, and abdominal discomfort or distention. J.G.’s complete heart block persisted, requiring continuation of atrioventricular pacing. He was not transferred to a step-down unit because of the arrhythmia.
On postoperative day 2, J.G. got out of bed and into a chair with the assistance of 2 registered nurses. J.G. was evaluated by a physical therapist; however, ambulation was deferred because of the cardiac monitoring and pacing. Marching in place for 1 minute was done in lieu of ambulation. The central venous and Foley catheters were discontinued. Because J.G. was elderly and had a tissue valve replacement, antiplatelet therapy rather than anticoagulation with warfarin was initiated. Oxygen was decreased to 2 L/min via nasal cannula, with oxygen saturations greater than 90%.
On postoperative day 3, J.G. remained in the CTICU because of his arrhythmia. The atrial pacing wire failed, and the ventricular pacing wire was not sensing properly. A 12-lead electrocardiogram revealed a ventricular rate of 60 beats per minute. J.G.’s hemodynamic condition remained stable. The cardiac arrhythmia prompted discussion of the need for a permanent pacemaker. The physical therapist continued to follow J.G.’s progress. However, J.G. could not ambulate because of the need for constant cardiac monitoring. He continued marching in place and received instruction about the active range of motion of both the upper and lower extremities. With the assistance of a registered nurse, J.G. got out of bed for each meal. He was weaned off the oxygen supplied via nasal cannula. Because he did not have a bowel movement, he was given a suppository, which yielded no results. He then received 30 mL of milk of magnesia. J.G. was proceeding with all aspects of the valve pathway with the exception of the need for continued cardiac monitoring and the inability to transfer to a step-down unit because of the arrhythmia.
On postoperative day 4, J.G. had a bowel movement after receiving an enema as per the bowel protocol. The heparin lock was not discontinued because of the arrhythmia.
On postoperative day 5, J.G. continued with his activities: getting out of bed for all meals and marching in place. He could not shower or climb stairs because of his cardiac arrhythmia, which required continuous cardiac monitoring.
On the sixth postoperative day, an electrocardiogram revealed complete heart block with a ventricular response rate of 50 beats per minute. The decision was made to insert a permanent pacemaker.
On the seventh postoperative day, J.G. was taken to the operating room and a dual-chamber permanent pacemaker was inserted with local anesthesia. He returned to the CTICU for monitoring. His rhythm was stable, and that afternoon he was transferred to a step-down unit. The standing order sets for the step-down unit were initiated.
On the eighth postoperative day, the pacemaker was tested and was deemed to be functioning properly. With the assistance of the physical therapist, J.G. ambulated in the hall. However, J.G.’s gait was unsteady, and he did not climb stairs or take a shower. The healthcare team determined that after discharge J.G. would continue to need nursing and physical therapy support to safely complete all activities of daily living. Therefore, the social worker made a referral for home health and physical therapy services in anticipation of J.G.’s discharge the following day. J.G. and his family demonstrated an understanding of his pacemaker and medications. They were also instructed about safety measures and the use of a rolling walker. The physical therapist indicated that J.G. was safe for discharge so long as home physical therapy was used.
On postoperative day 9, J.G. was discharged home with his family after an electrocardiogram revealed proper functioning of the pacemaker. He was to have follow-up with home health nursing and physical therapy the next day.
Atrioventricular block may occur after cardiac surgery, especially after aortic valve surgery, when dense calcification is present and encroachment of the conduction system is possible. Development of second- or third-degree atrioventricular block is an indication for temporary pacing by use of epicardial wires. Permanent conduction abnormalities develop in less than 5% of patients. However, if resolution of the block does not occur, a permanent pacemaker is required.30 J.G. had complete heart block that did not resolve, thus requiring placement of a permanent pacemaker.
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EVALUATION |
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TopREVIEW OF THE LITERATURECLINICAL PATHWAYS AND VALVULAR...CASE STUDY 1CASE STUDY 2EVALUATIONSUMMARYReferences |
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Since they began using the pathway and protocols, nurses have been able to provide more timely care. Before, nurses were required to notify a physician for all orders or wait until a physician wrote individual orders. This process led to delays in care. In addition, creation of the pathway and protocols, which require a single order to initiate the entire process, has provided for more consistent care. Nurses implement all aspects of the pathway and protocols and notify a physician only when variances occur.
Use of the pathway and protocols has also allowed the care patients receive to be condensed into a shorter time frame. Previously, patients were intubated for an average of 24 hours. With the use of the early extubation protocol, the mean time to extubation is now 13 hours. Patients were maintained on bed rest for 48 to 72 hours before development of the pathway and the activity/ambulation protocol. Most patients are now allowed to dangle their legs and get out of bed on postoperative day 1. In addition, this increased progression of care has increased satisfaction among patients and their families. Patients can communicate with their families sooner and are more comfortable. Patients and their families can see measurable improvement in care sooner and realize the success of the surgery earlier in the postoperative course.
With the increased consistency of care, the quality of care has improved, and patients progress more quickly in their rehabilitation. The healthcare team has noted a decrease in length of stay and a decrease in the utilization of resources. The average length of stay for patients after valve surgery has decreased 2.60 days, from 11.04 days to 8.44 days, since initiation of the valve clinical pathway. Some patients are discharged on postoperative day 7, as outlined in the pathway. However, some patients continue to require longer hospitalizations because of variances from the pathway.
The most common variances are atrial arrhythmias and activity intolerance. Previously, numerous drug therapies were used to treat atrial arrhythmias. Management of atrial arrhythmias has been adjusted in an attempt to provide a more consistent approach. Protocols for the continuous infusion of potassium and magnesium were also used with varied success. Atrial arrhythmias continue to occur frequently and result in delays in discharge. Despite increases in activity as outlined in the activity/ambulation protocol, activity intolerance continues to be a variance and results in delays in discharge. Increases in physical therapy coverage were instituted to assist with improving activity intolerance in these patients. Referrals to a rehabilitation facility are made as early as possible, preferably by postoperative day 3.
Patients’ outcomes are also monitored. The readmission rate has not increased since use of the pathway began. Causes of readmission vary; no single complication has been found consistently. The team thinks that no predischarge interventions or extensions of the length of stay would have prevented these readmissions.
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SUMMARY |
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TopREVIEW OF THE LITERATURECLINICAL PATHWAYS AND VALVULAR...CASE STUDY 1CASE STUDY 2EVALUATIONSUMMARYReferences |
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Acknowledgments |
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References |
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