Exploring the patients' experiences of living with a subcutaneous implantable cardioverter defibrillator.

BACKGROUND: The implantable cardioverter defibrillator provides effective treatment for the prevention of sudden cardiac arrest but significant risks associated with transvenous implantation persist. The subcutaneous implantable cardioverter defibrillator has proven to be an alternative and innovative treatment option for select patients to mitigate these risks. Obtaining the patients' perspectives can provide clinicians with essential information to guide implant selection, procedural decision-making, and support patient management. Conventional implantable cardioverter defibrillator patients have reported shock-related anxiety, fear, insufficient education, and challenges adapting to physical and psychological changes. Little evidence exists to determine whether differences between the subcutaneous implantable cardioverter defibrillator and conventional implantable cardioverter defibrillator allow for the transferability of our current knowledge to the care and management of this population. AIMS: The purpose of this study was to explore patients' experiences of living with a subcutaneous implantable cardioverter defibrillator including the decision-making process, implant, and follow-up care processes. METHODS: Using an exploratory qualitative approach, semi-structured interviews were conducted by telephone with 15 participants who underwent subcutaneous implantable cardioverter defibrillator implant. RESULTS: Analysis revealed five main themes: (a) influences on decision-making; (b) unmet education needs; (c) physical impact; (d) psychological impact; and (e) recommendations. CONCLUSION: As a new technology, little knowledge of the subcutaneous implantable cardioverter defibrillator exists outside of the tertiary implanting sites, therefore developing new strategies to increase learning and dissemination is essential. Although similarities exist in our findings to those of conventional implantable cardioverter defibrillators, there are significant differences in the decision-making process and physical impact which require individualized care planning and development of strategies to provide a patient-centered approach to care.

Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury.

PURPOSE: Assess the relationship between optic nerve sheath diameter (ONSD) measured on bedside portable computed tomography (CT) scans and simultaneously measured intracranial pressure (ICP) in patients with severe traumatic brain injury. METHODS: Retrospective cohort study of 57 patients admitted between 2009 and 2013. Linear and logistic regression were used to model the correlation and discrimination between ONSD and ICP or intracranial hypertension, respectively. RESULTS: The cohort had a mean age of 40 years (SD 16) and a median admission Glasgow coma score of 7 (IQR 4-10). The between-rater agreement by intraclass coefficient was 0.89 (95 % CI 0.83-0.93, P < 0.001). The mean ONSD was 6.7 mm (SD 0.75) and the mean ICP during CT was 21.3 mmHg (SD 8.4). Using linear regression, there was a strong correlation between ICP and ONSD (r = 0.74, P < 0.001). ONSD had an area under the curve to discriminate elevated ICP (≥20 mmHg vs. <20 mmHg) of 0.83 (95 % CI 0.73-0.94). Using a cutoff of 6.0 mm, ONSD had a sensitivity of 97 %, specificity of 42 %, positive predictive value of 67 %, and a negative predictive value of 92 %. Comparing linear regression models, ONSD was a much stronger predictor of ICP (R(2) of 0.56) compared to other CT features (R(2) of 0.21). CONCLUSIONS: Simultaneous measurement of ONSD on CT and ICP were strongly correlated and ONSD was discriminative for intracranial hypertension. ONSD was much more predictive of ICP than other CT features. There was excellent agreement between raters in measuring ONSD.

The development and evaluation of a competency-based program for patients with a ventricular assist device.

The ventricular assist device (VAD) is a mechanical device that is used to provide long term support either as a bridge or as an alternative to transplantation for patients suffering from end stage heart failure. While in hospital, patients with a VAD have traditionally been taught by an educator nurse with VAD expertise in preparation for discharge. In 2004, our centre implemented a successful competency-based patient education program in post-heart transplant patients and thought that a similar program may provide increased confidence for bedside nurses to actively participate in VAD patient education prior to discharge. The purpose of this quality improvement project was to create a competency-based education program that would provide consistency in patient teaching. A questionnaire was developed and completed by 13 bedside nurses. This pre-test questionnaire indicated the need for a systematic and organized approach to VAD patient teaching. Furthermore, adequate resources, consistency in teaching methods, and feedback were seen to be essential. A pilot competency-based program was designed to lead bedside nurses and patients through a series of learning phases and has successfully been implemented. Since its implementation, the questionnaire has been repeated with results reflecting satisfaction with the revised competency-based program. Our findings and evaluation of the program through pre- and post-testing reflect an increase in organization in our teaching methods and has led to improved confidence and satisfaction for bedside nurses using this program. By redeveloping the current method of VAD education, our goal has been to improve the ways in which we deliver teaching to our patients. It is thought that, as with our experience in the post-heart transplant population, bedside nurses and team members will feel more empowered to provide teaching to patients with a VAD.