TTUHSC Impact of CDC Classification for Patients with SWI On Medical Treatment and Outcomes of Patients Paper

TTUHSC Impact of CDC Classification for Patients with SWI On Medical Treatment and Outcomes of Patients Paper TTUHSC Impact of CDC Classification for Patients with SWI On Medical Treatment and Outcomes of Patients Paper Need help with my Nursing question – I’m studying for my class. Critique 3 articles using an appropriate template. Each article will be either quantitative, qualitative or integrative. Match the appropriate article to the templates provided and complete the template. Articles are provided as well at the templates. article_3.pdf article_1.pdf article_2.pdf appraisal_c_integrative_review__3_.docx appraisal_e_qualitative_review__1_.docx appraisal_f_quanitative_review.docx articles.zip ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Open access Protocol Dumbor Ngaage,1 Natasha Mitchell,2 Alexandra Dean,2 Claire Hirst,2 Enoch Akowuah,3 Patrick Joseph Doherty ? ?,4 Caroline Fairhurst,2 Kate Flemming,4 Catherine Hewitt,2 Sebastian Hinde ? ?,5 Alex Mitchell,2 Simon Nichols ? ?,6 Judith Watson ? ?2 To cite: Ngaage D, Mitchell N, Dean A, et al. Feasibility study of early outpatient review and early cardiac rehabilitation after cardiac surgery: mixed-­ methods research design—a study protocol. BMJ Open 2019;9:e035787. doi:10.1136/ bmjopen-2019-035787 ?? Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http://?dx.?doi.?org/?10.?1136/?bmjopen-?2019-?035787). Received 15 November 2019 Revised 28 November 2019 Accepted 02 December 2019 © Author(s) (or their employer(s)) 2019. Re-­use permitted under CC BY. Published by BMJ. For numbered affiliations see end of article. Correspondence to Dumbor Ngaage;[email protected]?hey.?nhs.u? k Abstract Introduction Following cardiac surgery, patients currently attend an outpatient review 6 weeks after hospital discharge, where recovery is assessed and suitability to commence cardiac rehabilitation (CR) is determined. CR is then started from 8 weeks. Following a median sternotomy, cardiac surgery patients are required to refrain from upper body exercises, lifting of heavy objects and other strenuous activities for 12 weeks. A delay in starting CR can prolong the recovery process, increase dependence on family/carers and can cause frustration. However, current guidelines for activity and exercise after median sternotomy have been described as restrictive, anecdotal and increasingly at odds with modern clinical guidance for CR. This study aims to examine the feasibility of bringing forward outpatient review and starting CR earlier. Methods and analyses This is a multicentre, randomised controlled, open feasibility trial comparing postoperative outpatient review 6 weeks after hospital discharge, followed by CR commencement from 8 weeks (control arm) versus, postoperative outpatient review 3 weeks after hospital discharge, followed by commencement of CR from 4 weeks (intervention arm). The study aims to recruit 100 eligible patients, aged 18–80 years who have undergone elective or urgent cardiac surgery involving a full median sternotomy, over a 7-­month period across two centres. Feasibility will be measured by consent, recruitment, retention rates and attendance at appointments and CR sessions. Qualitative interviews with trial participants and staff will explore issues around study processes and acceptability of the intervention and the findings integrated with the feasibility trial outcomes to inform the design of a future full-­scale randomised controlled trial. Ethics and dissemination Ethics approval was granted by East Midlands—Derby Research Ethics Committee on 10 January 2019. The findings will be presented at relevant conferences disseminated via peer-­reviewed research publications, and to relevant stakeholders. Trial registration number ISRCTN80441309 Introduction Following cardiac surgery, patients currently attend their first outpatient review 6 weeks after Strengths and limitations of this study ?? This is one of the first studies to look at the timing of follow-­up and cardiac rehabilitation after cardiac surgery. ?? This feasibility study is a small multicentre randomised controlled trial (RCT). ?? The study will collect both qualitative and quantitative data. ?? If it is determined that a larger scale RCT is feasible, this study will generate valuable data to enable its design. ??TTUHSC Impact of CDC Classification for Patients with SWI On Medical Treatment and Outcomes of Patients Paper This feasibility study is not large enough to determine effectiveness or cost-­effectiveness and is limited to assessing the feasibility of a larger trial. hospital discharge, where recovery is assessed and ability to commence cardiac rehabilitation (CR) is determined. CR is then started from 8 weeks. In a 2017 survey, 35 of the 42 UK cardiac centres who responded, confirmed this as current practice.1 This interval before review and CR extends the period of inactivity of patients, and medical attention for surgery-­ related complications is often sought during this period.2–4 Our prospective observational study (FORCAST6) found that 39% of patients reported surgery-­related complications in the 6 weeks following discharge, with the majority occurring in the first 4 weeks; 15% required hospital readmission. Although the majority of patients were satisfied with the 6 weeks interval, 44% felt it was too long and would have liked an earlier review.1 The standard access for heart operations is through a median sternotomy.5–8 In the UK, 35 158 heart operations were performed in 2015.9 Following a median sternotomy, patients are required to refrain from upper body exercises, lifting of heavy objects and other strenuous Ngaage D, et al. BMJ Open 2019;9:e035787. doi:10.1136/bmjopen-2019-035787 1 BMJ Open: first published as 10.1136/bmjopen-2019-035787 on 29 December 2019. Downloaded from http://bmjopen.bmj.com/ on July 7, 2020 by guest. Protected by copyright. Feasibility study of early outpatient review and early cardiac rehabilitation after cardiac surgery: mixed-­methods research design—a study protocol Open access Methods and analysis Study design A multicentre, randomised controlled, open feasibility trial using mixed methods to establish the feasibility of conducting a study where: 2 Participants have a postoperative outpatient review 6 weeks after hospital discharge, followed by commencement of CR from 8 weeks (control arm) or ?? Participants have a postoperative outpatient review 3 weeks after hospital discharge, followed by commencement of CR from 4 weeks (intervention arm). The study is detailed in figure 1: study flow chart and the protocol follows the Standard Protocol Items: Recommendations for Interventional Trials reporting guidelines.25 ?? Study aim To establish the feasibility of delivering and evaluating a definitive randomised controlled trial (RCT) of the current 8th vs 4th week CR commencement pathways, reducing the period over which patients are required to refrain from usual physical activities following cardiac surgery. Study objectives The primary objective is to determine the feasibility of delivering outpatient review 3 weeks after discharge postcardiac surgery, followed by CR from 4 weeks. Secondary objectives Assess surgeons’ and surgical practitioners’ willingness to conduct outpatient review 3 weeks after discharge and refer patients to CR. ?? Examine barriers to patient enrolment. ?? Identify recruitment rates and drop-­out to follow-­up. ?? Identify the most appropriate outcome measures. ?? Test follow-­ up procedures and data collection tools and management. ?? Assess the feasibility of conducting an economic evaluation of any future definitive RCT. ?? Gather outcome data for power and sample size calculations for the RCT. ?? Inform any necessary redesign of a new recovery pathway in light of information gained. ?? Study population and setting Patients attending for cardiac surgery at Hull University Teaching Hospitals National Health Service (NHS) Trust, UK and South Tees Hospitals NHS Foundation Trust, UK will be approached regarding study participation. Inclusion criteria Undergone elective or urgent cardiac surgery, including the following procedures (isolated or combined): –– Coronary artery bypass graft (CABG). –– Aortic valve replacement. –– Mitral valve repair or replacement. –– Atrial fibrillation ablation. –– Left atrial appendage occlusion. ?? Has had a full median sternotomy. ?? Willing and capable of giving informed consent. ?? Aged 18–80 years at the time of giving consent. ?? Ngaage D, et al. BMJ Open 2019;9:e035787. doi:10.1136/bmjopen-2019-035787 BMJ Open: first published as 10.1136/bmjopen-2019-035787 on 29 December 2019. TTUHSC Impact of CDC Classification for Patients with SWI On Medical Treatment and Outcomes of Patients Paper Downloaded from http://bmjopen.bmj.com/ on July 7, 2020 by guest. Protected by copyright. activities for 12 weeks.10–13 These ‘sternal precautions’ (SP) are intended to aid healing of the sternum. CR, which has significant short-­term and long-­term benefits after cardiac surgery,14 15 is therefore delayed. The delay can mitigate the benefits of CR,16 contributing to physical deconditioning, and hinder the ability of CR to facilitate timely recovery of fitness and physical activity status.17 However, current guidelines for activity and exercise after median sternotomy have been described as restrictive, conflicting, sometimes arbitrary, frequently anecdotal and frequently at odds with modern clinical guidance.11 Following surgery, there are variations in types of exercises permitted, limits for weight of objects that can be lifted, guidelines for activities and timeline for resumption of driving. Parker et al18 demonstrated that the force elicited on the breastbone by coughing far exceeded lifting above the recommended limit. Adams et al11 investigated forces associated with 32 activities of daily living and reported that the majority not restricted by SP, such as opening and closing doors, generated forces greater than the allowed weight limit. While SP may help to support bone healing, the optimal nature and duration are unclear especially since sternal bone healing occurs by 5 weeks.12 According to the 2013 UK national audit of CR, late commencement contributes to a substantial number of heart surgery patients declining to participate.19 Adverse outcomes following heart operations and other forms of surgery have been shown to be reduced by early patient review after hospital discharge.20 21 The FORCAST6 study showed a high incidence of postoperative complications with the current 6-­week patient review after heart surgery. This was the highest in the first week after hospital discharge and declined to lowest levels by 4 weeks.1 It, therefore, seems logical to conduct patient reviews after hospital discharge sooner than current practice to enable early CR from the period of postoperative stability and sternal bone healing at 5 weeks after surgery (4 weeks after hospital discharge). The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) Standards and Core Components22 and the National Certification Programme for CR23 recommend early commencement of CR. This is monitored by the National Audit of CR 2018.19 A delay in starting CR can prolong the recovery process, increase dependence on family/carers and can cause frustration. This may contribute to anxiety and depression that is reported in patients recovering after cardiac surgery.24 This study aims to examine the feasibility of bringing forward outpatient review and CR in order to facilitate recovery, physical fitness and quality of life. Open access FARSTER study flow chart. PIS, Patient Information Sheet. ?? ?? were ‘out of area’ impacting on their ability to attend study CR locations. With the funder’s approval, a substantial amendment was submitted to the ethics committee. The original criteria had only included patients who had undergone CABG, had an upper age limit of 75 years and a maximum BMI limit of 40 kg/m2. This amendment was approved on 30 October 2019. Amendment to eligibility criteria During the initial recruitment period, fewer patients than anticipated were meeting the eligibility criteria, and many Sample size This study is a feasibility RCT and therefore does not have a primary outcome measure to inform a power calculation. Sample sizes of between 24 and 70 have been recommended for feasibility trials to allow for the reliable estimation of an SD for use in future sample size calculations.26 27 The plan is to recruit 100 eligible patients, allowing for a 30% attrition rate in order to still have ?? ?? Able to self-­complete the English language outcome measure tools (or can complete with assistance). Able to follow detailed verbal instructions required for clinical assessments. Exclusion criteria Body mass index (BMI) >45 kg/m2.TTUHSC Impact of CDC Classification for Patients with SWI On Medical Treatment and Outcomes of Patients Paper Heart failure with left ventricular ejection fraction of <30% before surgery. ?? Early postoperative sternal wound complications (eg, deep sternal wound infection, wound dehiscence and/or sternal instability). ?? Postoperative complications resulting in prolonged hospital stay >14 days after surgery. Ngaage D, et al. BMJ Open 2019;9:e035787. doi:10.1136/bmjopen-2019-035787 3 BMJ Open: first published as 10.1136/bmjopen-2019-035787 on 29 December 2019. Downloaded from http://bmjopen.bmj.com/ on July 7, 2020 by guest. Protected by copyright. Figure 1 Open access Participant recruitment Patients scheduled for elective cardiac surgery will be given the study leaflet prior to surgery. Patients undergoing urgent cardiac surgery will receive it following surgery. All patients will undergo surgery as normal, receiving standard in-­hospital postoperative care. Eligibility and consent After discharge from intensive care to the ward following surgery, the medical staff will review patients’ routine clinical examination results, including sternal stability and postoperative tests. Those identified as potentially eligible, interested and willing, will have their eligibility confirmed by the research nurse using an eligibility checklist and written informed consent will be obtained according to Good Clinical Practice guidelines. Consent will also be sought to contact participants who are interested in being interviewed as part of an embedded qualitative study. Patients screened as eligible, but who develop complications between being considered ready for discharge and going home, will not proceed to consent until deemed well enough (if remain in hospital for >14 days after surgery, as per exclusion criteria they will not proceed at all). Randomisation Following surgery, consent and completion of baseline data collection and assessments, participants will be randomised to either the control or intervention arm. Randomisation will be performed by a remote, centralised randomisation service provided by York Trials Unit (YTU), and the allocation sequence generated by a statistician not involved in the study. Participants will be individually randomised and stratified according to study site on a 1:1 basis using variable block sizes. Authorised site research staff will telephone the randomisation service to obtain the participant’s allocation. Outcomes Participant self-­reported data will be collected at baseline, prior to CR commencement, following CR completion and at final follow-­up assessment (up to 26 weeks postrandomisation): 1. Demographics (baseline only). 2. EQ-­5D-­5L (EuroQol-5 dimensions-5 levels): a validated generic patient-­reported outcome measure.28 3. NHS resource use. The following clinical data will be collected: 1. Height, weight, BMI, preoperative presentation (baseline only). 2. Heart rate, blood pressure, oxygen saturation at baseline, outpatient review and pre-­CR as per usual practice. 4 3. Physical fitness assessed by dynamic testing with incremental shuttle walk test (ISWT) for both study arms at commencement and end of CR, and at final follow-­up. 4. Cardiopulmonary fitness assessed by cardiopulmonary exercise testing (CPET) at baseline and at final follow-­ up, for up to 25 patients in each study arm (Hull study site only). 5. 30 and 90-­day mortality, surgical site complications and hospital readmission rates. In line with the objectives of a feasibility study, we will also gather information on: 6. Recruitment rates and drop-­out to follow-­up. 7. Compliance to treatment arm allocation. 8. Acceptability of patient recruitment, early outpatient review and CR to patients, clinicians and NHS organisations. Cardiopulmonary exercise testing Maximal CPET provides a holistic assessment of the cardiovascular, ventilatory and metabolic responses to exercise and is a powerful diagnostic and prognostic tool.29 Maximal CPET is the gold-­standard method of assessing changes in aerobic fitness, which is potentially important if we are to assess the beneficial/not harmful effects of early CR. Maximal CPET will be conducted on a cycle ergometer with patients pedalling at 50 revolutions per minute throughout the test. The test workload will start at 0watts and increase in 10watts/minute increments until the patient reaches volitional exhaustion (ideally 8–12 min29). Maximal CPET will only be carried out (after randomisation) in up to 25 participants in each arm in the Hull site only due to costs and logistics, but also to ensure that test procedures and data interpretation are consistent. CPET will be completed once a participant is deemed clinically stable and conducted within 14 days after surgery. It will be repeated at the final follow-­up. Postoperative outpatient review As standard practice, all participants will have a postoperative outpatient clinical review in order to be certified suitable to commence CR. This clinical decision is usually based on the absence of limiting complications. This review will take place at 6 weeks posthospital discharge in the control arm, and 3 weeks postdischarge in the intervention arm. Participants considered unfit for CR will be given a second review appointment for approximately 1 week later and if necessary, a third review appointment 2 weeks later. Reason(s) they were deemed unfit will be documented.TTUHSC Impact of CDC Classification for Patients with SWI On Medical Treatment and Outcomes of Patients Paper If they are deemed unfit for CR at the third review, they will not commence CR as part of the Feasibility Study of Early Outpatient Review and Early Cardiac Rehabilitation After Cardiac Surgery: Mixed Methods Research Design (FARSTER) study. They will, however, continue to be monitored as per usual practice and be sent all study questionnaires for completion. Ngaage D, et al. BMJ Open 2019;9:e035787. doi:10.1136/bmjopen-2019-035787 BMJ Open: first published as 10.1136/bmjopen-2019-035787 on 29 December 2019. Downloaded from http://bmjopen.bmj.com/ on July 7, 2020 by guest. Protected by copyright. 70 patients in the final analysis. There will be a 7-­month recruitment period across two centres. Open access CR programme This will consist of supervised low-­to-­moderate intensity exercise performed once (South Tees) or twice (Hull) a week for 8 weeks (as is standard UK practice). Exercise will be prescribed according to standards published by BACPR.22 Attendance at these sessions and session content will be recorded for each participant. Post-CR appointment Following completion of the CR programme (16 weeks postdischarge for the control arm and 12 weeks postdischarge for the intervention arm), all participants will have a repeat ISWT. If a participant misses this appointment, they will be sent another. A discharge letter will be sent to participants’ general practitioners summarising their treatment. Final follow-up assessment At final follow-­up (up to 26 weeks after randomisation), participants will have a repeat CPET (if appropriate), undergo a final ISWT, have an end-­ of-­ study consultation and be examined for sternal wound complications, including sternal instability. Medical history will be taken to establish hospital readmissions and accident & emergency department attendance for surgery-­related complications. If a participant misses this appointment, they will be sent another. Data collection CR and post-­ CR appointments and the final At pre-­ up assessment, participants will be asked to follow-­ complete quality of life (EQ-­5D-­ 5L) and resource use questions (see table 1). If a participant does not attend, the questionnaire will be posted out to them, with two reminders subsequently sent if no response (1 and 2 weeks later as necessary). Qualitative data collection After the outpatient review, we will conduct semis … Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool’s honor code & terms of service . Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Read more
Enjoy affordable prices and lifetime discounts
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Order Now Order in Chat

Start off on the right foot this semester. Get expert-written solutions at a 20% discount