Cardiac Unit Research Articles

P391 THE DIAGNOSTIC CHALLENGE BETWEEN CHRONIC PULMONARY EMBOLISM AND PULMONARY ARTERY SARCOMA: A CASE REPORT

Abstract We report the case of a 63–year–old obese and hypertensive woman, admitted in hospital with worsening dyspnea for 2 weeks and syncope. A suspected chronic thromboembolism was diagnosed nine months before for a similar clinical picture; hematologic screening excluded thrombophilia and NOACs were prescribed. Two–dimensional transthoracic echocardiography showed enlargement of right chambers, the interventricular septum shifted to the left ventricle, showing “D” sign. Color Doppler flow imaging showed moderate regurgitation in tricuspid valve, with indirect pulmonary pressure estimation 90 mmHg. Left ventricle was normal for dimensions and function. ECG evidenced sinus tachycardia and no specific ST–T alterations. Blood exams evidenced anemia (Hb 9 mg/dl), negative neoplastic markers and absence of occult blood in feces, mildly elevated inflammatory markers, T–Troponin and D–dimer. Naso–pharyngeal swab for SARSCoV2 infection was negative. Chest computed tomography with contrast revealed a large filling defect within bilateral main pulmonary arteries. No lymph nodes or pulmonary pneumonia were detected. Lower extremity venous ultrasound was positive for right popliteal deep vein thrombosis. The global clinical picture suggested an acute pulmonary embolism recurrence, with a severe right ventricle impairment and a concomitant deep vein thrombosis. Some factors were not completely clear: chronic anemia, only mildly increased D–dimer, no specific increase of inflammatory markers. The patient was referred to Cardiac Surgery Unit of IRCCS Foundation Policlinico San Matteo in Pavia, for pulmonary endarterectomy. Unexpectedly the surgical finding was a bilateral pulmonary artery sarcoma, confirmed by histological exam. We thus clarified some uncertain clinical aspects, explainable in the context of a severe neoplastic picture. There were no immediate complications, and a chemotherapy was initiated after a period of cardio–pulmonary rehabilitation. Pulmonary artery intimal sarcoma is a very rare disease, its prevalence is about 0.001–0.003%, it can originate from the left and right pulmonary arteries and intimal layer of pulmonary arteries, forming a tumor growing in the nodular cavity or spreading along the intimal surface. PAS is often misdiagnosed as acute or chronic pulmonary thromboembolism due to its clinical presentation and radiological findings. Thus, early diagnosis is very crucial and may improve patient outcome.

P373 IN SUPPORT OF THE NEED FOR P.E.R.T. (PULMONARY EMBOLISM RESPONSE TEAMS) IN PULMONARY EMBOLISM (PE)

Abstract Pulmonary embolism (PE) is one of the leading causes of cardiovascular death with a wide range of criticality and complex and varied pathogenesis. A rapid therapeutic decision reverses the rapid progression towards a fatal outcome. A 64 years old patient, obese and hypertensive, returning from an intercontinental flight, went to the emergency room because of worsening dyspnoea and chest pain, which he had been suffering for a week; he arrived tachycardic, tachypnoic and with 91% O2 saturation in ambient air. A CT angiography showed extensive thrombosis of both main branches of the pulmonary artery (PA). Echocardiography confirmed right ventricular involvement, which was already hypokinetic and with a RV/LV ratio double than normal, which corresponds to a progressive drop in pressure and for which he was transferred to the cardiac intensive unit. The patient‘s history, comorbidities, risk of haemorrhage, imaging and laboratory data were analysed, leading to an evaluation of high risk PE, hemodynamic instability and positive cardiac biomarkers. With the availability of on–site equipment and trained personnel, the patient underwent ultrasound–guided locoregional thrombolysis through the placement of dedicated catheters capable of infusing into each PA branch 1mg of rtPA/h for 12 hours and ultrasound throughout the course of the catheter to increase the penetrance of thrombolysis into old thrombi (Ultrasound Accelerated Thrombolysis). As early as 6 hours, at echocardiographic control, there was a reduction in the RV/LV ratio to below 1.5, corresponding to a restoration of pressor stability. PERT shortens the time of decision of the best medical approach, which is the most effective method available to deal with the emergency. But PERT is also useful in low–risk PE in patients with significant comorbidities that contraindicate anticoagulant therapy, or in PE that is an incidentalomas, according to the wisdom of the radiologists in the group who know how to identify inveterate thromboses or PA sarcoma occlusion which are otherwise treatable. Hence the need for a multidisciplinary team: a) able to assess the patient with PE and provide the correct treatment which includes a range of medical, surgical and endovascular therapies; b) skilled in ensuring the follow–up of the patient with PE (post–thromboembolic pulmonary hypertension; c) skilled in getting the components to communicate about the effectiveness of treatment in the individual patient.

C38 EARLY AND MID-TERM RESULTS FROM THE RESILIA AORTIC TISSUE VALVE ITALIAN REGISTRY (RES-ITA)

Abstract Objective The objective of our study is to evaluate safety, hemodynamic performance and durability of the new generation aortic bioprosthesis with Resilia Tissue. Methods RES-ITA Registry is the Italian multicenter registry created in 2017, enrolling patients who underwent isolated or combined AVR with Resilia tissue valve. The Registry was recently recognized by SICCH as the official national registry of Resilia tissue valve implantations, with Potenza’s Cardiac Surgery Unit as its coordinating center. Isolated AVR (50%) was performed predominantly through an upper J mini-sternotomy or a right anterior mini-thoracotomy, while combined procedures (50%) were performed in full sternotomy and included associated CABG, ascending aorta surgery, mitral valve repair or replacement, aortic annulus enlargement. For all patients, clinical and echocardiographic assessment were evaluated at discharge, 30 days, 6 months and every year after surgery. Results Between June 2017 and March 2022, about 1000 patients were included, coming from 13 Italian cardiac surgery centers. During last year, 6 more Italian centers have asked to join the Registry. Mean age was 57±11 years. Mean Euroscore II was 2.24±3.01%. Redo surgery was performed in 11%. Most frequently implanted valve sizes were 23 mm (30%), 25 mm (27.7%) and 27 mm (19%). Two-year freedom from all-cause mortality for isolated AVR and for all patients was 97.4±1.3% and 95.7±1.1%, respectively. Two-year freedom from major paravalvular leaks (≥2+/4) was 98.4±0.8; freedom from prosthesis thrombosis was 96.7±2 and freedom from prosthesis dysfunction (according to VARC-2 criteria) was 96.7±1.7. Mean gradient was 13.3±8.3 mmHg and maximum gradient was 23.2±16.2 mmHg at 2-year follow-up. Conclusions The new generation aortic prosthesis with RESILIA tissue demonstrates versatility of use, safety, good early and mid-term outcomes and hemodynamic performance. Further investigations and longer follow-up are needed to evaluate long-term durability.

P124 A TAKOTSUBO SYNDROME MIMICKING AN APICAL HYPERTROPHIC CARDYOMYOPATHY: A CASE REPORT

Abstract A 70–year–old woman was admitted to our Intensive Care Unit (ICU) with high levels Hs–TnT. Coronaries were normal and ventriculography was suggestive for Takotsubo Syndrome (TS). In the acute phase she developed a cardiogenic shock and transthoracic echocardiography (TTE) showed a dilated left ventricle (LV) with iperkinesia of basal segments and biventricular apex and mid –ventricular akinesia, with a severely reduced left ventricular ejection fraction (LVEF 20%). Seven days after admission to Cardiac Rehabilitation Unit, a TTE showed LV apical hypertrophy (max thickness 18 mm), hypokinesia of hypertrophic segments, hypercontractility of basal segments and LVEF 55%. These features could have been suggestive for a coexisting apical hypertrophic cardiomyopathy (HCM). The EKG showed T wave inversions in precordial and inferior leads, not present at admission, this observation being against the presence of a pre–existing unknown HCM. Cardiac Magnetic Resonance (CMR) showed T1 and T2 mapping imagines for oedema in LV infero–lateral, basal segments and apical region, a subepicardial stria of late gadolinium enhancement in infero–lateral basal segment. These patterns were reported as suggestive for myocarditis rather than TS. Recent infectious or autoimmune diseases were excluded. Further TTE showed reversed LV parameters, normal kinesis of all segments, LVEF 66%, with a persistence of negative T waves at EKG. Discussion Our patient developed a classical TS with LV apical ballooning and hyperkinesia of basal segments with uncommon right ventricular hypokinesia. A peculiar finding was the transient apical LV thickness that was seen through TTE, mimicking an apical hypertrophic cardiomyopathy. Such a finding has already been described in few case reports; however, the nature and the physiopathology of that apical thickness was never proved. Through CMR we noted that, in the same region where TTE detected apical hypertrophy, there was a consistent amount of oedema which could be the reason of pseudo–hypertrophy findings. Our experience confirms the importance of integrating CMR in the diagnostic algorithm as already supported in consensus statements. In our case CMR played a key–role in the exclusion of a coexisting apical hypertrophic cardiomyopathy.

P94 LATE–ONSET POST–INFECTIVE AORTIC PSEUDO–ANEURYSM AFTER BIOPROSTETHIC AORTIC VALVE REPLACEMENT

Abstract A 74 year–old man was admitted three months after SAVR symptomatic for dyspnea. Past medical history: DM type 2, PAD and recent SAVR after diagnosis of severe aortic stenosis, complicated by Stafilococcus Epidermidis blood culture sternal wound dehiscence, requiring Robicsek technique treatment and long–term parenteral antibiotics. He was finally discharged to our cardiac rehab unit. Blood analysis: negative blood culture at admission with negative CPR. Late positivity (after 2 weeks) for a Staphylococcus epidermidis reinfection. EKG: normal atrio–ventricular and intra–ventricular conduction with regular repolarization. TTE: Normal left ventricular volume and ejection fraction with severe aortic regurgitation secondary to suspected partial bioprosthesis detachment. TOE: valvular detachment with a newly–formed pouch located in the mitro–aortic membrane. Bioprosthetic valvular failure (BVF) is a pathological entity arising from a variety of conditions affecting prosthetic heart valves. We present the case of a late–onset partial valvular bioprosthesis detachment associated with a newly–formed pseudoaneurysm due to late infective endocarditis occurred after cardiac surgery, initially manifested with negative cultural findings and suddenly evolved in severe aortic regurgitation. Valvular detachment is an infrequent complication of infective endocarditis. Surgery is the only option capable of restoring a proper anatomy and a correct function of the valvular apparatus. Patient underwent re–do surgery and a new SAVR was needed after confirmation of diagnosis with no residual aortic regurgitation after discharged. BVF is a fearsome and severe condition presenting with a wide spectrum of clinical presentation. Our experience highlights the need of a prompt diagnosis. Late positivity of blood cultures for Stafilococcus Epidermidis probably depend on prolonged antimicrobial therapy after sternal dehiscence treatment which have probably masked laboratoristic finding in early phase (negative CPR and blood cultures). An early intervention is mandatory in order to prevent systemic dissemination or acute decompensation secondary to severe aortic regurgitation. Surgical approach in this case guaranteed a radical treatment with no residual regurgitation or sub–acute microbial infection. 4–weeks parenteral antibiotics during cardiac–rehab efficacy–controlled relapse of CPR and blood–culture (negative before final discharge).

Results and insights after 413 TAVI procedures performed by cardiac surgeons on their own.

Current evidence on transcatheter aortic valve implantation (TAVI) has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here, we describe the development of our TAVI programme and report the results of transfemoral (TF) TAVI done by cardiac surgeons on their own. This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 to July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. A total of 413 patients were included in the study. Mean patients' age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2-4.4). Eighty patients underwent transapical TAVI and 333 patients had a TF approach. We progressively moved from transapical TAVI towards TF procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After TF TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality. The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with similar results when compared with major randomized clinical trials and registries' experiences.

Atrial fibrillation after surgical aortic valve replacement: the dark side of safe procedure.

Journal Article Atrial fibrillation after surgical aortic valve replacement: the dark side of safe procedure Get access Lorenzo Giovannico, Lorenzo Giovannico Cardiac Surgery Unit, Dipartimento di Medicina di Precisione e Rigenerativa Area Jonica (DIMEPRE-J), University of Bari Medical School, Bari, Italy Search for other works by this author on: Oxford Academic PubMed Google Scholar Tomaso Bottio, Tomaso Bottio Cardiac Surgery Unit, Dipartimento di Medicina di Precisione e Rigenerativa Area Jonica (DIMEPRE-J), University of Bari Medical School, Bari, Italy Corresponding author. Cardiac Surgery Unit, University of Bari, Piazza Giulio Cesare 11, Bari, Italy. Tel: +39 335328307; e-mail: tomaso.bottio@uniba.it; tbottio@gmail.com (T. Bottio). https://orcid.org/0000-0001-7299-2983 Search for other works by this author on: Oxford Academic PubMed Google Scholar Aldo Domenico Milano Aldo Domenico Milano Cardiac Surgery Unit, Dipartimento di Medicina di Precisione e Rigenerativa Area Jonica (DIMEPRE-J), University of Bari Medical School, Bari, Italy Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, Volume 63, Issue 5, May 2023, ezad177, https://doi.org/10.1093/ejcts/ezad177 Published: 02 May 2023 Article history Received: 19 April 2023 Accepted: 29 April 2023 Published: 02 May 2023 Corrected and typeset: 12 May 2023

Sternal Wound Management in Pediatric Cardiac Surgical Patients: A Novel Strategic Interprofessional Approach.

Information on sternal wound management in children after cardiac surgery is limited. The authors formulated a pediatric sternal wound care schematic incorporating concepts of interprofessional wound care and the wound bed preparation paradigm including negative-pressure wound therapy and surgical techniques to expedite and streamline wound care in children. Authors assessed knowledge about sternal wound care among nurses, surgeons, intensivists, and physicians in a pediatric cardiac surgical unit regarding the latest concepts such as wound bed preparation, NERDS and STONEES criteria for wound infection, and early use of negative-pressure wound therapy or surgery. Management pathways for superficial and deep sternal wounds and a wound progress chart were prepared and introduced in practice after education and training. The cardiac surgical unit team members demonstrated a lack of knowledge about the current concepts of wound care, although this improved after education. The newly proposed management pathway/algorithm for superficial and deep sternal wounds and a wound progress assessment chart were introduced into practice. Results in 16 observed patients were encouraging, leading to complete healing and no mortality. Managing pediatric sternal wounds after cardiac surgery can be streamlined by incorporating evidence-based current wound care concepts. In addition, the early introduction of advanced care techniques with appropriate surgical closure further improves outcomes. A management pathway for pediatric sternal wounds is beneficial.

Determining Factors of Alarm Fatigue among Nurses in Intensive Care Units-A Polish Pilot Study.

With the development of medical technology, clinical alarms from various medical devices, which are rapidly increasing, are becoming a new problem in intensive care units. The aim of this study was to evaluate alarm fatigue in Polish nurses employed in Intensive Care Units and identify the factors associated with alarm fatigue. A cross-sectional study. The study used the nurses' alarm fatigue questionnaire by Torabizadeh. The study covered 400 Intensive Care Unit nurses. The data were collected from February to June 2021. The overall mean score of alarm fatigue was 25.8 ± 5.8. Participation in training programs related to the use of monitoring devices available in the ward, both regularly (ß = -0.21) and once (ß = -0.17), negatively correlated with nurses' alarm fatigue. On the other hand, alarm fatigue was positively associated with 12 h shifts [vs. 8 h shifts and 24 h shifts] (ß = 0.11) and employment in Intensive Cardiac Surveillance Units-including Cardiac Surgery [vs. other Intensive Care Units] (ß = 0.10). Monitoring device alarms constitute a significant burden on Polish Intensive Care Unit nurses, in particular those who do not take part in training on the operation of monitoring devices available in their ward. It is necessary to improve Intensive Care Unit personnel's awareness of the consequences of overburdening and alarm fatigue, as well as to identify fatigue-related factors.

Impact of Fetal Echocardiography on Altering Course of Action Following A Prenatal Diagnosis of Congenital Heart Disease-A Thought Analysis

Objective: To assess the impact of fetal echocardiography in altering the course of action for neonatal cardiac expertise and services available in Pakistan following an antenatal diagnosis of congenital heart defect (CHD).
 Study Design: Cross-sectional study.
 Place and Duration of Study: Pediatric Cardiology Unit, Armed Forces Institute of Cardiology & National Institute of Heart Diseases, Rawalpindi Pakistan, from Feb 2020 to Sep 2021.
 Methodology: Fetuses aged 18 to 38 weeks of gestational age referred to the Pediatric Cardiac Unit due to risk of or suspicion of congenital heart disease underwent fetal cardiac echo. Data were collected and reviewed retrospectively to seek any impact of the antenatal diagnosis on post-natal planning.Results: The mean age of the mothers was 29.79±5.24 years (range, 17-47 years), and the mean gestational age at which the fetal echocardiography examination was performed was 27.29±4.47weeks (range: 12–38 years). Of the 609 pregnancies, fetal echocardiogram evaluation was performed, and sixty-three (10.3%) fetal echocardiograms were abnormal. Of the 63, only 06(9.5%) returned to the neonatal cardiac unit for follow-up and treatment in the first ten days of life.
 Conclusion: The real impact of fetal echocardiography is possible only with the availability of well-developed, readily accessible fetal and neonatal cardiac services. Poverty and a struggling healthcare infrastructure confound the benefits.

Implementation of the Cardiac Inpatient Neurodevelopmental Care Optimization (CINCO) programme: an interdisciplinary, generalisable approach to inpatient neurodevelopmental care.

Children with CHD are at risk for neurodevelopmental delays, and length of hospitalisation is a predictor of poorer long-term outcomes. Multiple aspects of hospitalisation impact neurodevelopment, including sleep interruptions, limited holding, and reduced developmental stimulation. We aimed to address modifiable factors by creating and implementing an interdisciplinary inpatient neurodevelopmental care programme in our Heart Institute. In this quality improvement study, we developed an empirically supported approach to neurodevelopmental care across the continuum of hospitalisation for patients with CHD using three plan-do-study-act cycles. With input from multi-level stakeholders including parents/caregivers, we co-designed interventions that comprised the Cardiac Inpatient Neurodevelopmental Care Optimization (CINCO) programme. These included medical/nursing orders for developmental care practices, developmental kits for patients, bedside developmental plans, caregiver education and support, developmental care rounds, and a specialised volunteer programme. We obtained data from the electronic health record for patients aged 0-2 years admitted for at least 7 days to track implementation. There were 619 admissions in 18 months. Utilisation of CINCO interventions increased over time, particularly for the medical/nursing orders and caregiver handouts. The volunteer programme launch was delayed but grew rapidly and within six months, provided over 500 hours of developmental interaction with patients. We created and implemented a low-cost programme that systematised and expanded upon existing neurodevelopmental care practices in the cardiac inpatient units. Feasibility was demonstrated through increasing implementation rates over time. Key takeaways include the importance of multi-level stakeholder buy-in and embedding processes in existing clinical workflows.

Use of Complementary Pain Management Strategies in Postoperative Cardiac Surgical Patients.

Complementary pain management strategies are effective at reducing pain in postsurgical patients. Cardiac nurses at a large academic hospital reported inconsistent awareness of patient opioid utilization and poor implementation of complementary pain management strategies. A pre/post-quality improvement project was conducted on 2 inpatient cardiac units. Outcomes included nursing staff's perceived knowledge, confidence, and use of complementary pain management strategies and knowledge of patient postsurgical opioid utilization through calculation of morphine milligram equivalence (MME). A comprehensive education program was implemented that included increased patient access to pain management resources, nurse education about complementary pain management strategies, and nurse education and access to MME calculations using a custom electronic health record application. Nursing staff's perceived knowledge, confidence, and use of complementary pain techniques increased. Patient opioid utilization findings were inconclusive. Educational programs about complementary pain management offer promise to improve cardiac postsurgical patient care.

Implementation of Healing Touch in the Acute Care Setting

Aim -The aim of this quality improvement project was to determine the feasibility of implementing Healing Touch (HT) as a complementary therapy at the bedside and its impact on patient self-reported levels of pain, nausea, and anxiety. Healing Touch is a relaxing, heart-centered, biofield therapy. Healing Touch assists in the creation of a coherent and balanced energy field, which supports one's inherent ability to heal (Anderson et al., 2017). Methods -The project was conducted over a 2-month period (February through March, 2020) on the cardiac unit in a Midwestern, acute care hospital. Prior to the project, staff on the unit received education, which included an overview of HT and project implementation. Healing Touch therapy was available three times a week and performed by a certified HT practitioner. Any patient that gave permission to receive a treatment was considered. Forty-six patients participated. Results -Patients rated their level of pain, nausea and anxiety using a 0 to 10 rating scale pre and post treatment. A paired samples t-test revealed self-reported levels of pain: t(45)=5.35, p<0.01, nausea: t(45)=2.74, p<0.01, and anxiety: t(44)=5.88, p<0.01, significantly decreased following HT therapy. Patients were asked, “In your own words tell me how you feel following the treatment.” and “Would you be interested in receiving a Healing Touch treatment in the future?”. Content analysis of the qualitative descriptive responses indicated patients felt relaxed. Additionally, 87% of participants stated they would like another treatment. The average HT treatment was 17 minutes. Conclusions -Healing Touch had a significant impact on patient pain, nausea and anxiety. Given the average HT treatment time, a dedicated role to provide HT is now being piloted. Reference Anderson, J. G., Anselme L. C., & Hart, L. K. (2017). Foundations and practice of healing touch. Healing Beyond Borders.

Blueprints for well-being: Modeling the way through Human-Centered Leadership and Pathway to Excellence.

Blueprints for well-being: Modeling the way through Human-Centered Leadership and Pathway to Excellence.

A single-patient-use ECG system for cardiothoracic surgery admissions in the UK: A cost-consequence analysis.

Deep sternal wound infections (DSWI) are severe complications in up to 1.36% of coronary artery bypass grafting (CABG) procedures in the United Kingdom. Each event adds between £4,000 and £11,000 in healthcare costs, owing primarily to prolonged hospitalisations. ECG devices have been shown to convey infection throughout perioperative CABG. On the other hand, single-patient ECG devices (spECG) can effectively reduce the incidence of surgical site infections (SSI), including DSWI, but no assessment of spECG impact in NHS cardiac units has been conducted. To estimate the impact of spECG on NHS cardiac units, we conducted a cost-consequence analysis modeling the CABG care pathway in the United Kingdom using Simul8 software for a probabilistic, individual-patient simulation. The simulation time was 1 year, with each patient followed from admission through 30 days post-discharge. The base case simulation mirrors the cardiac unit of Bart Health NHS Trust, London. A total of 2,183 patients are generated with demographic and clinical attributes from probabilistic distributions informed by hospital-specific inputs from NHS Digital Data. The Brompton Harefield Infection Score (BHIS) is allocated to gauge the risk of SSI. Results are averaged across 50 independent and randomly seeded iterations. Simulation results indicate a base-case savings of £388 per patient, determined by the incidence of infections rather than the number of CABG procedures. In the base-case simulation, the mean cost of care with rECG was £13,096, whereas the mean cost with spECG was £12,708, resulting in a cost saving of £388 (2021 GBP). The simulation yielded an overall 8.6% SSI incidence rECG, whereas the incidence of SSIs with spECG was 6.9%. The model was most sensitive to changes in general ward and ICU costs, and infection incidence was a stronger predictor of potential per-patient savings than annual CABG volume. Single-patient ECG is a sustainable and effective alternative to reusable ECG cables and lead wires in terms of patient safety and resource allocation.

Organizational culture and barriers to change in University of Gondar Comprehensive Specialized Hospital Cardiac Unit

BackgroundCardiovascular disease is a major contributor to high mortality in Ethiopia. Hospital organizational culture affects patient outcomes including mortality rates for patients with cardiovascular disease. Therefore, the purpose of this study was to assess organizational culture and determine barriers to change in the Cardiac Unit of University of Gondar Comprehensive Specialized Hospital.MethodsWe used a mixed methods approach with a sequential explanatory design. We collected data through a survey adapted from a validated instrument measuring organizational culture (n = 78) and in-depth interviews (n = 10) with key informants from different specialty areas. We analyzed the quantitative data using descriptive statistics and the qualitative data through a constant comparative method of thematic analysis. We integrated the data during the interpretation phase to generate a comprehensive understanding of the culture within the Cardiac Unit.ResultsThe quantitative results indicated poor psychological safety and learning and problem solving aspects of culture. On the other hand, there were high levels of organizational commitment and adequate time for improvement. The qualitative results also indicated resistance to change among employees working in the Cardiac Unit as well as other barriers to organizational culture change.ConclusionMost aspects of the Cardiac Unit culture were poor or weak, signaling opportunities to improve culture through identifying culture changing needs, implying the need to be aware of the subcultures within the hospitals that influence performance. Thus, it is important to consider hospital culture in planning health policy, strategies, and guidelines.RecommendationsIt is of paramount importance to strengthen organizational culture through fostering a safe space that enables workers to express divergent views and actively considering such views to improve the quality of care, supporting multidisciplinary teams to think creatively to address problems, and investing in data collection to monitor changes in practice and patient outcomes.

Variables associated with in-hospital and postdischarge outcomes after postcardiotomy extracorporeal membrane oxygenation: Netherlands Heart Registration Cohort.

Extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiogenic shock has been increasingly used without concomitant mortality reduction. This study aims to investigate determinants of in-hospital and postdischarge mortality in patients requiring postcardiotomy ECMO in the Netherlands. The Netherlands Heart Registration collects nationwide prospective data from cardiac surgery units. Adults receiving intraoperative or postoperative ECMO included in the register from January 2013 to December 2019 were studied. Survival status was established through the national Personal Records Database. Multivariable logistic regression analyses were used to investigate determinants of in-hospital (3 models) and 12-month postdischarge mortality (4 models). Each model was developed to target specific time points during a patient's clinical course. Overall, 406 patients (67.2% men, median age, 66.0years [interquartile range, 55.0-72.0years]) were included. In-hospital mortality was 51.7%, with death occurring in a median of 5days (interquartile range, 2-14days) after surgery. Hospital survivors (n=196) experienced considerable rates of pulmonary infections, respiratory failure, arrhythmias, and deep sternal wound infections during a hospitalization of median 29days (interquartile range, 17-51days). Older age (odds ratio [OR], 1.02; 95% CI, 1.0-1.04) and preoperative higher body mass index (OR, 1.08; 95% CI, 1.02-1.14) were associated with in-hospital death. Within 12months after discharge, 35.1% of hospital survivors (n=63) died. Postoperative renal failure (OR, 2.3; 95% CI, 1.6-4.9), respiratory failure (OR, 3.6; 95% CI, 1.3-9.9), and re-thoracotomy (OR, 2.9; 95% CI, 1.3-6.5) were associated with 12-month postdischarge mortality. In-hospital and postdischarge mortality after postcardiotomy ECMO in adults remains high in the Netherlands. ECMO support in patients with higher age and body mass index, which drive associations with higher in-hospital mortality, should be carefully considered. Further observations suggest that prevention of re-thoracotomies, renal failure, and respiratory failure are targets that may improve postdischarge outcomes.

Healthcare is Demanding: Patience is a Virtue!

Healthcare is Demanding:Patience is a Virtue! Andrea Torrence Nursing is a rewarding career, but it can also be extremely challenging, depending on the type of patient you are assigned to. In my career, I have had a number of "difficult" patients, and every situation required a specific type of approach. Understanding how to interact with a difficult patient is a talent and requires a level of patience that exceeds the normal amount one may have. As a nurse, if you want to be successful, you must have patience. Along with many natural characteristics required to be successful in nursing, patience, in my opinion, is the most required quality required for nursing. The difficult patient can be an emotional burden to the care provider. These burdens are not always related to the tasks associated with care. The patient that is emotionally exhausting is far more complex than a patient who requires physical work. Nursing is a trying and risky career, but the nurse is obligated to provide the best care possible to all patients regardless of how difficult that person may be. Our cardiac surgical telemetry unit received a patient from the emergency room diagnosed with a minor psychiatric problem and tachycardia (a fast heart rate). This patient required medical clearance before going to the psychiatric unit for further evaluation. At our facility, this frequently happens, depending on how many psychiatric beds are available and on the patient's medical status. There were no clinical indications for this patient to require a bedside caregiver—a bedside caregiver is assigned to a patient that may somehow be classified as a danger to themselves or others—and the patient was not "pink-slipped." Patients who may not be safe to leave the hospital once they've been evaluated in the emergency room will be pink-slipped for an inpatient evaluation. Also, suicidal or homicidal patients are pink-slipped until they undergo an extensive evaluation and are deemed safe to leave on their own. A pink slip is a legal hold document. The patient that we received at the time of her admission required neither. The initial description of the patient revealed that she was a young, pleasant, ambulatory (able to walk with no problems) woman and completely oriented (understands and can comprehend). This patient did not have any pain or complaints documented on her emergency room assessment. She was corporative and followed instructions. As soon as we received the patient to the unit, she began to protest the need for pain medication. There were no orders for pain medication because there was no notation of pain in the emergency room. The nurse addressed the patient's pain with the admitting physician and Tylenol was ordered. When the patient heard that the physician ordered Tylenol, she became very angry. The patient wanted a stronger medication. I have a reputation for connecting with patients who become angry, and those who are classified as difficult, so the primary nurse asked me to speak to this patient. After a brief conversation, I was able to calm the patient, and she returned to her room quietly. The patient was apologetic and sincere. I used a calm approach, reassuring words of affirmation, and the perfect body language to de-escalate this patient. I was pleased with myself because only a simple combination of techniques was used to resolve the patient's anger, and at that time, a therapeutic connection was made. The nurse entered the patient's room and noticed that the roommate looked somewhat bewildered, [End Page E11] but she did not address the roommate. The nurse was focused on completing her patient's admission assessment. After the nurse completed the assessment, the order for the patient to wear telemetry was discussed. Telemetry is a physician's order to continuously monitor the heart's function while hospitalized. Because the patient was mildly tachycardic, telemetry was ordered. The patient immediately refused the order and told the nurse that she was not going to wear the monitor. The nurse explained the need and informed the patient that she would not be confined to the bed while wearing it. The nurse left the room to find me to discuss the...

The level of adherence to best-practice guidelines by interprofessional teams with and without acute care nurse practitioners in cardiac surgery: A study protocol.

Acute care nurse practitioners (ACNPs) in postoperative cardiac surgery settings provide significant benefits to patients and organizations. Recent studies have suggested that ACNPs increase the level of adherence to best-practice guidelines by interprofessional teams. It is however, unknown whether interprofessional teams with ACNP are associated with higher levels of adherence to best-practice guidelines compared to interprofessional teams without ACNPs. Furthermore, no extraction tool is available to measure the level of adherence to best-practice guidelines by interprofessional teams in postoperative cardiac surgery settings. This project aims to measure and examine the level of adherence to best-practice guidelines of interprofessional teams with and without ACNPs in a postoperative cardiac surgery setting in Québec, Canada. A retrospective observational study will be conducted of 300 patients hospitalized between January 1, 2019 and January 31, 2020 in a postoperative cardiac surgery unit in Québec, Canada. Data will be collected from patient health records and electronic databases. An extraction tool will be developed based on systematic review of the literature, and will include best-practice guidelines and confounding variables related to patient and interprofessional teams' characteristics. Content and criterion validation, and a pilot-test will be conducted for the development of the tool. A multivariate linear regression model will be developed and adjusted for confounding variables to examine the association between interprofessional teams with and without ACNPs, and level of adherence to best-practice guidelines by those teams. This project represents the first study to measure and examine the level of adherence to best-practice guidelines by interprofessional teams with and without ACNPs in a postoperative cardiac surgery setting. The findings of this project will generate empirical data focusing on the contribution of ACNPs within interprofessional teams, and ultimately enhance the delivery of high quality and evidence-based care for patients and families.

Assessment of patient satisfaction with nursing care with the Newcastle scale

Abstract Introduction. Improving the quality of provided services and increasing patient satisfaction in medical facilities is an undoubted challenge for health care institutions in Poland. A high level of nursing care increases the efficiency of the treatment process, reduces the costs of health care units and affects the patient’s sense of satisfaction and contentment. Aim. The aim of this paper was to assess the level of satisfaction with nursing care using the Newcastle scale. Material and methods. The study included 117 patients hospitalized in the cardiac rehabilitation unit. The research tool used in the study was the standardized Newcastle questionnaire to assess patients’ overall satisfaction and experiences with nursing care at the unit level. Results. The respondents’ experience of nursing care was rated at a medium level, while their level of satisfaction with nursing care was rated at a high level. The above rating was influenced by the age and educational level of the patients. Conclusions. Patients of cardiac rehabilitation units rate the experience of nursing care well, while their level of satisfaction with this care is high.