Intensive and Critical Care Nursing
Volume 25, Issue 3 , Pages 109-110, June 2009

Cardiac surgery: 25 years on

Head of Postgraduate Education, Royal Brompton & Harefield NHS Trust, Sydney Street, London SW3 6NP, United Kingdom

Article Outline

 

This is the 25th Anniversary of the Journal of Intensive and Critical Care Nursing and it seems appropriate to look back over the contribution the journal has made to the developments in patient outcome following cardiac surgery. There have been enormous developments over this period with major improvements in morbidity, mortality and quality of life for people living with heart disease.

Twenty-five years ago the waiting list for cardiac surgery was lengthy, patients were sicker and their outcome poorer. The publication of the National Service Framework for Coronary Heart Disease (CHD) (2000) identified the need to improve services and today the period of time spent on the waiting list for coronary artery bypass grafting (CABG) is substantially reduced. Mortality from cardiac surgery has also reduced and the 30-day survival now stands in the region of 96–99%, although, clearly this varies according to pre-surgical risk. The number of CABG procedures has also increased substantially to around 30,000 per annum in the United Kingdom (UK). Patient profiles are also changing. With more alternative methods for revascularisation patients are now operated on sooner and consequently are less physically restricted by CHD and angina and less likely to have developed heart failure. This all contributes to the improved survival following cardiac surgery. However, these developments also reflect the increased skills of the multi-disciplinary team in providing care during the pre, intra and post-operative period.

So what has been the contribution of this journal to this changing landscape? Looking back over past issues, key themes emerge that have added to the development of the services.

The management of pain has been a key theme in the journal over past years. At the beginning of the 1990s, Ferguson (1992) highlighted the association between anxiety and pain. This theme was further developed when in 1995 Holl concluded that patients’ desire for control and anxiety predicted analgesic use. This intricate relationship is now implicit in the thinking and practice of nurses today and pre-operative information giving and pre-surgery clinics for example have become an important part of the patient journey to the intensive care unit. More recently Gélanas (2007) published the results of a study that provided some “food for thought”. Using a questionnaire study design they questioned 93 patients about their experience of pain following cardiac surgery. Seventy-seven percent of those questioned recalled pain during their intensive care unit stay and for many their pain related to the sternal incision site. Indeed a substantial number identified that their pain was severe. Pain management has received much attention in this journal and its management has improved enormously with the more widespread use of patient controlled analgesia in the intensive care unit. Whilst Gélanas concludes that the study results have not changed much over the past 17 years the study itself highlights the increased emphasis placed upon pain management today. Much of this has been a direct response to the active involvement of nurses in questioning traditional practice, developing new ides and then disseminating this to their colleagues.

Another theme developed in the journal relates to nurse led early extubation and the use of recovery units following cardiac surgery. Traditional practice meant that patients invariably spent an overnight stay in the intensive care unit, frequently remaining intubated overnight. Indeed it was not unusual for the post-operative stay to extend to between 36 and 48h. In the early 1990s, this practice started to be questioned. Whilst the initial driver may well have been the need to increase the number of cardiac surgery operations it soon became clear that omitting the overnight ICU stay and reducing the period of patient sedation could have positive benefits in terms of recovery, not least through reducing some of the psychosocial problems associated with intensive care. Amongst the leaders in this development were the John Radcliffe in Oxford and the Royal Brompton Hospital (now the Royal Brompton & Harefield NHS Trust). Audit data demonstrated no increase in complications following surgery and concluded that patients were more likely to have a reduced overall length of hospital stay (Massey and Meggit, 1994, Riley, 1995). Whilst patient selection was key to the success of such units they demonstrated benefit for low risk patients without co-morbidity. These units developed largely as nurse managed units with nurses making decisions to initiate extubation. Nurse-managed care was uncommon in the UK at that time and protocols rapidly developed to guide the nurse and reassure the medical staff. Nurses have constantly sought to meet challenges posed by a changing environment and have developed the competence to safely and effectively extend their role.

Another advance in the care of the patient following cardiac surgery relates to the post-operative recovery period. Telephone support may now be unquestioned with most hospitals providing patients with a number to phone if they have questions or concerns. Both Roebuck (1999) and Johnson (2000) writing in the journal describe services that used a structured approach to phoning patients to gauge patient progress, identify any early indicators of complications and answer any patient questions. Whilst studies have not reported a significant reduction in anxiety with either preoperative education and support or with postoperative telephone support (Roebuck, 1999, Goodman et al., 2008), they do offer patients the opportunity for increased involvement in care and increased partnership in decision making. It is likely that providing information and education to patients in both the pre- and post-operative period does provide patient benefit and that results may have been influenced by small sample sizes. This is not uncommon in nursing studies where historically funding sources have been scarce, thus limiting length of follow-up and patient recruitment. This is set to change as research funders now focus on research that can provide evidence of a direct patient benefit. The National Institute for Health Research (NIHR) appears influential in this.

Throughout its history, the journal has adopted an approach to publishing that has embraced all research methods and enabled the patient and relative experience to become central. Advances in care result from sharing ideas and along with other professional associations, the Journal of Intensive and Critical Care Nursing has been and remains influential in this, facilitating the presentation and publication of audit and research studies, providing a forum for the exchange of ideas and the development of important networks. It is likely that there will be significant changes in the development of the next generation of services for the patient undergoing cardiac surgery. These are likely to herald new and expanding roles for the specialist nurse and will form the main subjects for debate in the next 25 years of the Journal of Intensive and Critical Care Nursing.

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Reference 

  1. Department of Health. Coronary Heart Disease: National Service Framework for Coronary Heart Disease – modern standards and service models, 2000. The Stationery Office: London.
  2. Ferguson JA. Pain following coronary artery bypass grafting: an exploration of contributing factors. Intens Crit Care Nurs. 1992;8(3):153–162
  3. Gélanas C. Management of pain in cardiac surgery ICU patients: have we improved over time?. Intens Crit Care Nurs. 2007;23(5):298–303
  4. Goodman H, Parsons A, Davison J, Preedy M, Peters E, Shuldham C, et al. A randomised controlled trial to evaluate a nurse-led programme of support and lifestyle management for patients awaiting cardiac surgery ‘Fit for surgery: Fit for life’ study. Eur J Cardiovasc Nurs. 2008;7:189–195
  5. Holl RM. Surgical cardiac patient characteristics and the amount of analgesics administered in the intensive care unit after extubation. Intens Crit Care Nurs. 1995;11(4):192–197
  6. Johnson K. Use of telephone follow-up for post-cardiac surgery patients. Intens Crit Care Nurs. 2000;16(3):144–150
  7. Massey D, Meggit G. Recovery units: the future of postoperative cardiac care. Intens Crit Care Nurs. 1994;10(1):71–74
  8. Roebuck A. Telephone support in the early post-discharge period following elective cardiac surgery: does it reduce anxiety and depression levels?. Intens Crit Care Nurs. 1999;15(3):142–146
  9. Riley J. Fast track cardiac care. Nurs Stand. 1995;9(49):55–56

PII: S0964-3397(09)00026-3

doi:10.1016/j.iccn.2009.03.003

Intensive and Critical Care Nursing
Volume 25, Issue 3 , Pages 109-110, June 2009

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