Intentional Clinical Process Design to Improve Outcomes for Patients Who Require Emergency Surgery.

Ruptured abdominal aortic aneurysms (AAAs) are associated with a 90% overall mortality and $150 000 cost of care per patient. Despite improvements in intensive care and surgical technology, morbidity and mortality remain unchanged over the past 20 years. The most significant predictor of survival is time from the door of the hospital to the operating room. To streamline operational efficiency, a team utilized Lean Six Sigma methodologies, team training, and intentional clinical process design to institute changes in our clinical processes, enhance care coordination, and improve communication. Changes led to a $1.8 million profit on operations, 10-day reduction in length of stay, and 89% survival rate among patients with ruptured AAA.

Adaptation of cardiovascular system stent implants.

Time-consuming design and manufacturing processes are a serious disadvantage when adapting human cardiovascular implants as they cause unacceptable delays after the decision to intervene surgically has been made. An ideal cardiovascular implant should have a broad range of characteristics such as strength, viscoelasticity and blood compatibility. The present research proposes the sequence of the geometrical adaptation procedures and presents their results. The adaptation starts from the identification of a person's current health status while performing abdominal aortic aneurysm (AAA) imaging, which is a point of departure for the mathematical model of a cardiovascular implant. The computerized tomography scan shows the patient-specific geometry parameters of AAA and helps to create a model using COMSOL Multiphysics software. The initial parameters for flow simulation are taken from the results of a patient survey. The simulation results allow choosing the available shape of an implant which ensures a non-turbulent flow. These parameters are essential for the design and manufacturing of an implant prototype which should be tested experimentally for the assurance that the mathematical model is adequate to a physical one. The article gives a focused description of competences and means that are necessary to achieve the shortest possible preparation of the adapted cardiovascular implant for the surgery.

Current modalities for abdominal aortic aneurysm repair: Implications for nurses.

BACKGROUND: Abdominal aortic aneurysms (AAAs) represent a significant health problem in the United States as more than 1 million people are afflicted and the prevalence is only expected to increase. Given that AAA rupture carries a high mortality rate, there is interest in repairing the aneurysm electively before aneurysm rupture. Two approaches to aneurysm repair are open repair and endovascular repair. However, limited data comparing the outcomes of these different methods exist. OBJECTIVE: A systematic review of recent clinical trials was conducted to identify and compare the short- and long-term clinical outcomes between open and endovascular repair. METHODS: Prospective, controlled trials published in the last 5 years were acquired using PubMed, Ovid, and Scopus databases. RESULTS: Four studies were identified during the search. Study trends suggest a perioperative advantage using endovascular repair. However, this advantage does not appear to be maintained in the long term. CONCLUSIONS: Each type of repair carries its own risk profile that is likely influenced by additional factors, such as the patient's age and comorbidities. It is critical that healthcare providers are aware of the risks associated with each approach in order to provide optimal patient care.

Screening for abdominal aortic aneurysm, a one-year follow up: an interview study.

The purpose of the present study was to investigate whether screening for abdominal aortic aneurysm (AAA) and the finding of an enlarged aorta cause worries and affect the living situations of men with aneurysms or of their families within a 12-month follow-up period. Men invited to ultrasound screening and having an enlarged aorta (>or=30 mm) were invited for an interview. In total, 10 men were interviewed. The semi-structured interview was conducted by using an interview guide. Data was analyzed by using an interpretative phenomenological method. Three themes were identified: (i) feeling secure being under superintendence; (ii) living as usual, but repressing thoughts; and (iii) feeling disillusionment due to negative outcome. Being given the message that an enlarged aorta was discovered at the screening was manageable; hence, continuing growth of the aorta led to some unpleasant feelings. The men were living as usual; however, they all had some reflections about having an AAA and that something could happen when they least expected it. They reported thoughts about the consequences of the enlarged aorta itself and the surgery. In a one-year retrospective interview, men who have had an aneurysm detected in a screening program for AAA reported feeling secure being under superintendence. The one finding in our study concerning worries and effects on life situation could be interpreted as disillusionment due to negative outcomes. Decisions to introduce screening for AAA in Sweden and other countries with ongoing programs should be considered to include guidelines for how to handle disillusionment.

Intervenciones de Enfermería en pacientes con aneurisma aórtico abdominal sometidos a tratamiento endovascular / Infirmary interventions on patients with abdominal aortic aneurysm subjected to endovascular treatments", "_i": "

El tratamiento endovascular por aneurisma aórtico es la reparacióninterior de la vasculatura aórtica mediante una prótesisendovascular que se coloca dentro de la aorta enferma y formaun nuevo cauce para el flujo sanguíneo. La presente revisióntiene por objeto documentar y sistematizar las intervencionesde Enfermería en los pacientes con aneurisma aórtico abdominalsometidos a tratamiento endovascular con el fin de señalarlas intervenciones específicas de Enfermería y garantizarun cuidado eficaz y eficiente, que permita prevenir, detectar ytratar oportunamente las complicaciones que pongan en peligrola vida del paciente.

The treatment to endovascular by aortic aneurism is the innerrepair of the aortic vasculatura by means of a prosthesis to endovascularthat it is placed within the ill aorta and it forms a newchannel for the sanguineous flow. The present revision intendsto document and to systematize the interventions of Infirmary inthe patients with abdominal aortic aneurysm put under treatmentto endovascular with the purpose of to indicate the interventionsspecific of Infirmary and to guarantee an effective andefficient care, that allows to opportunely prevent, to detect and totreat the complications that put in danger the life of the patient.

The drama of being diagnosed with an aortic aneurysm and undergoing surgery for two different procedures: open repair and endovascular techniques.

The purpose of this study is to describe and interpret what it means for patients to be diagnosed with an abdominal aortic aneurysm (AAA) and how they experience treatment. AAA is usually asymptomatic and often discovered coincidentally in conjunction with a diagnostic workup for other medical problems. Twenty patients who had undergone 2 different surgical procedures were sequentially invited for interviews 1 month following surgery. A hermeneutic approach was used. For all patients three themes emerged: an inability to come to terms with a life-threatening condition, a sense of living on borrowed time, and a sense of being granted a new lease on life. The theme that emerged for patients with open repair was that diagnosis with AAA was an ordeal to endure, while the theme for patients who underwent endovascular treatment was a sense of gratitude, security, and insecurity. Once the aneurysm was discovered patients were convinced that they were both blessed and saved, along with a sense of gratitude. Pre- and postoperative nursing care strategies can be developed based on the findings from this study.

Endovascular leaks: perioperative nursing implications.

Endovascular repair is becoming the gold standard treatment for aortic aneurysm disease. With the development of new treatment modalities, however, new and unique complications arise. Endovascular stent graft leaks (ie, endoleaks) are one such complication. Endoleaks occur when blood leaks into the aneurysm sac after an endovascular stent repair. Endoleaks are divided into four categories (ie, I through IV) depending on the site of origin; perioperative nurses must become familiar with treatment options for each type of endoleak.

A comparison of novice and expert nurses' cue collection during clinical decision-making: verbal protocol analysis.

BACKGROUND: The type of cues used during clinical decision-making contexts is not well understood. Further, there are conflicting findings in relation to how novice and expert nurses use cues. OBJECTIVE: The aim of this study was to determine if there were differences between novice and expert nurses in the range and type of cues selected as well as how cues were clustered together when making clinical decisions while caring for post-operative patients in an Intensive Care Unit. METHOD: The sample consisted of four novice and four expert nurses caring for patients post Abdominal Aortic Aneurysm surgery in an Intensive Care Unit. Data were collected using a think aloud (TA) process while participants cared for patients, followed by retrospective interviewing, to generate verbal protocols. The verbal protocols were analysed using content analysis to examine various aspects of decision-making, including number and type of cues used and cue clustering. The decision tasks attended in the real world of practice were described in detail to illuminate the use of cues in context. RESULTS: Expert nurses collected a wider range of cues than novice nurses, almost twice as many different cues. The expert nurses also clustered more cues together to identify patient status when making decisions. Expert nurses were more proactive in collecting relevant cues and anticipating problems that may help identify patient problems. CONCLUSIONS: In the real world of practice expert nurses collect a broader range of cues to assess patient status than novice nurses. This differs to expert nurses cue collection in simulations where expert nurses may select only those cues that are necessary for the identified problem. This difference, if identified in other studies, may have important implications for nursing research and education.

Optimizing compliance, efficiency, and safety during surveillance of small abdominal aortic aneurysms.

BACKGROUND: Outcome data documenting safety for observation of small abdominal aortic aneurysms (AAA 4.0 to 5.4 cm) are lacking outside of large clinical trials but requires near perfect patient compliance. This study describes a clinical pathway for AAA surveillance using a prospective database utilizing a nurse practitioner oversight to provide efficient use of clinic visits while maintaining a high level of patent participation. METHODS: Over a 7-year period (June 1999 through June 2006), 334 patients were enrolled in an AAA surveillance pathway at our academic veterans hospital. To minimize patient travel, clinic visitation was reserved for an initial examination with patient education and for discussion of intervention options in patients demonstrating AAA growth (>5.4 cm or expansion >1 cm/yr) during follow-up. Biannual ultrasound or CT imaging was scheduled and results discussed (after physician review) via telephone or "same day" direct patient contact. An electronic database was used to update patient information and plan follow-up. RESULTS: Compliance with the AAA surveillance pathway was achieved in 98.5% of patients, with only three patients (0.9%) lost to follow-up and two others (0.6%) choosing early repair at civilian institutions. At a mean interval of 29 months (+/-20 mo), surgical repair was performed in 225 (67%) patients by open (n = 143) or endovascular (n = 82) techniques for AAA growth to >5.4 cm (n = 219) or expansion by >1cm/yr (n = 6). One hundred six patients currently remain in surveillance. A single AAA rupture resulting in death occurred during surveillance (0.3%) and perioperative mortality (<60 days) was 0.9% in patients needing intervention for AAA growth. Cumulative aneurysm-related mortality was 0.9% for patients compliant with the AAA surveillance pathway. CONCLUSIONS: Use of a prospectively-maintained surveillance database managed by a non-physician provider with a reliance on telephone contact resulted in a high degree of patient compliance, reduced unnecessary patient travel, and provided practical clinic use. Limited additional resources were needed to implement our pathway and a similar approach may prove useful for large volume hospital, clinic, or practice systems.

[Conventional surgery versus endovascular surgery in a patient who undergoes an abdominal aorta aneurism. Nursing treatment]. / Paciente intervenido aneurisma de aorta abdominal (AAA). Cuidados de enfermeria.

Patients diagnosed with an Abdominal Aorta Aneurism who undergo an operation using either conventional surgery or endovascular surgery require a series of different nursing treatment. The authors comparatively analyze nursing treatment applied to patients who have undergone an abdominal aorta aneurism according to the technique used; their study is retrospective, observational and comparative for all 61 patients who underwent an abdominal aorta aneurism in the Navarre Hospital in 2004. The authors describe both techniques, their advantages and inconveniences, and in a well-developed comparative manner, point out the differences in nursing treatment during post-operative care. Part of this study was presented in a poster format at the XVII National Congress on Vascular Nursing.

Paciente intervenido de Aneurisma de Aorta Abdominal (AAA). Cuidados de enfermería / Conventional surgery versus endovascular surgery in a patient who undergoes an abdominal aorta aneurism. Nursing treatment

Los pacientes diagnosticados de AAA e intervenidos con la técnica quirúrgica convencional o endovascular requieren una serie de intervenciones de enfermería diferentes. Se analizan comparativamente los cuidados de enfermería aplicados al paciente intervenido de AAA según la técnica utilizada, en un estudio retrospectivo, observacional y comparativo, de todos los pacientes intervenidos de AAA en el Hospital de Navarra durante el año 2004. Se describen ambas técnicas, sus ventajas e inconvenientes, desarrollando de manera comparativa los diferentes DdE (Diagnósticos de Enfermería) en el postoperatorio. Parte de este trabajo se presentó en formato póster en el XVII Congreso Nacional de Enfermería Vascular

Patients diagnosed with a Abdominal Aorta Aneurism who undergo an operation using either conventional surgery or endovascular surgery require a series of different nursing treatment. The authors comparatively analyze nursing treatment applied to patients who have indergone an abdominal aorta aneurism according to the technique used; their study is retrospective, observational and comparative for all 61 patients who underwent an abdominal aorta aneurism in the Navarre Hospital in 2004. The authors describew both technique, their advantages and inconveniences, and in a well-developed comparative manner, point out the differences in nursing treatment during post-operative care. Part of this study was presented in a poster format at the XVII National Congress on Vascular Nursing

[Postoperative nursing care of patients submitted to thoracoabdominal aortic surgery]. / Cuidados de enfermagem no pós-operatório do doente submetido a cirurgia da aorta toraco-abdominal.

Patients who underwent surgery of the thoracoabdominal aorta require, in the post-operative period, special nursing care, related to the specificity and complexity of the disease and surgical procedure. This paper is aimed at to describe the nurse's experience of the Intensive Care Unit of the Vascular Surgical Department at Santa Maria Hospital in the management of these critical patients.

Setting up a screening service for abdominal aortic aneurysm.

Abdominal aortic aneurysms are usually asymptomatic. Rupture is associated with a very high mortality. Ultrasound surveillance of aneurysms offers the opportunity to select patients suitable for elective repair, avoiding risk of rupture. This article reports on how an ultrasound screening programme was set up by a nurse specialist rotating through local GP surgeries.

Postoperative mobilization of patients with abdominal aortic aneurysm.

AIM: This paper reports on a study which aimed to evaluate the effects of structured written preoperative information on patients' postoperative psychological and physical wellbeing after surgery for abdominal aortic aneurysm (AAA). BACKGROUND: The possible benefits of current booklets written by professionals on postoperative psychological and physical wellbeing in patients with AAA are unknown. Previous studies have shown that preoperative information has a favourable effect on both mood state and physical mobilization. METHOD: Fifty-two patients admitted for elective repair of AAA were selected consecutively and randomized to receive only verbal (control group), or verbal and written information in booklet form (experimental group). The booklet contained procedural and sensory information about the disease and its treatment. Two questionnaires were used to establish whether the booklet had any effect on perceived health, psychological and physical wellbeing postoperatively. RESULTS: The two groups were similar regarding their perceived health but differed significantly regarding psychological wellbeing pre- and postoperatively. Patients in the experimental group were significantly sadder both pre- and postoperatively compared with those in the control group. Both groups were similar in postoperative physical wellbeing. CONCLUSION: This group of patients often has asymptomatic disease, with a short interval between diagnosis and major surgery. When patients receive an information booklet during this period, this seems to cause more worries than anticipated. Hence, a more supportive educational programme might benefit this patient group, both pre- and postoperatively.

The quality of research on physical examination for abdominal aortic aneurysm.

A review of nursing literature revealed no studies regarding physical examination or other interventions (except unit based) for abdominal aortic aneurysms (AAA). The physician literature was explored, revealing an excellent meta-analysis in 1999 of studies before that date with regard to physician accuracy in physical examination for AAA. These are reviewed for quality and recommendations made for nursing research and the role of the Society for Vascular Nursing in teaching nurses.