• Clinical Practice Guideline for Management of Pulmonary Hypertension Patients Undergoing Non-Cardiac Surgery

      Woods, Kathryn A. (2017)
      that can eventually lead to heart failure and death (Strumpher & Jacobson, 2011). Due to the medical advancements made in the diagnosis and treatment of PH, not only has the incidence of PH been steadily increasing (1.1 - 2.4 new cases per million residents each year), the patient population is living longer despite the severity of their condition (Ling et al., 2012). As a result, older and sicker patients with PH have been presenting for surgery which is an area of concern for anesthesia providers. PH is a significant risk factor for perioperative adverse complications and poor outcomes with a mortality rate of 1-7% and a morbidity rate ranging from 6-42% (Kaw et al., 2010; Meyer et al., 2013; Price et al., 2010; Ramakrishna et al., 2005). Anesthesia providers have noticed an increase in patient with pulmonary hypertension requiring surgery at a mid-sized community hospital, where standardize practices are currently not in place to guide the care of this vulnerable patient population. The purpose of this scholarly project is to develop and evaluate a clinical practice guideline (CPG) that anesthesia providers can use in the perioperative management of all adult PH patients undergoing surgery. Three separate phases were utilized in the developed of the CPG. During the initial phase, a clinical practice guideline team was established and guideline revisions were made based on the AGREE II Tool quality appraisal. In the second phase, the facility’s anesthesia staff provided feedback by completing the Practitioner Feedback Questionnaire (PFQ) survey after the CPG was presented by DNP student leaders. The project’s third phase involved presenting the finalized CPG to the facility’s Chief Anesthesiologist to review and provide feedback on the site’s usability. All data was collected blindly and tabulated in Excel, where the statistical analysis was performed. The AGREE tool informed guideline revisions by identifying domains with low quality ratings, thus enhancing the quality of the guideline. The PFQ offered insight to the sample’s demographics and facilitated the CPG’s 82% approval rating among anesthesia staff. These results indicate that the CPG’s intended users support its utilization in practice, as well as the clinical setting’s need for standardize care to assist with the perioperative management of this patient population. The DNP student leaders were able to effectively collaborate with clinical experts to translate applicable evidence into the practice setting and utilize valid instruments to develop a site-specific CPG that can help facilitate management strategies that can improve perioperative outcomes for patients with pulmonary hypertension.
    • Clinical Practice Guidelines for the Anesthetic Management of Patients with Pulmonary Hyertension

      Naper, Jessica E. (2017)
      Problem: Pulmonary Hypertension (PH) is a severe, progressive, disease with limited treatment options and poor prognosis. The risk of morbidity and mortality increases significantly when patients with PH must undergo surgery. There is a reported 42% increase in morbidity of patients with PH and the rate of perioperative mortality varies between 1-18% for patients undergoing non-cardiac, non-obstetric surgery. A small, academic, secondary care hospital within Maryland has reported an increase in adverse events among patients with PH, including unexpected or prolonged ICU admissions, and respiratory failure. The hospital has identified a need to standardize the care of anesthesia providers in the areas of perioperative management of PH to maximize outcomes and reduce morbidity and mortality. Objective: The purpose of this doctor of nursing practice (DNP) project was to develop and evaluate a clinical practice guideline (CPG) for the intraoperative anesthetic management of PH patients presenting for non-cardiac, non-obstetric surgery. The anticipated outcome of implementation was a reduction in perioperative adverse events such as respiratory failure, heart failure, hemodynamic collapse, abortion of surgical procedure, and unexpected ICU admission. Methods: The project occurred in a three stage format. In the first stage, the most current literature on the intraoperative management of patients with PH was evaluated and a guideline developed using Brower’s Agree II tool. The tool consists of 23 items within 6 quality domains; each domain focuses on a specific feature of a CPG. A team of appraisers critically analyzed and scored the guideline using the Agree II tool. In the second stage, the guideline was evaluated by anesthesia providers using Brower’s practitioner feedback questionnaire (PFQ). This tool seeks and purpose (86%), stakeholder involvement (92%), clarity and presentation (85%), and editorial independence (100%). The lowest scores where in the areas of: rigour of development (80%), and applicability (60%). From the PFQ data agreement or strong agreement was indicated 88% of the time when practitioners were questioned about the need for a guideline, or agreement with the guidelines content. However, the results of the PFQ echoed weaknesses brought to light by the Agree II appraisal. Only 72% of providers agreed that the draft recommendations would make an obvious effect on patient outcomes. Implications: Based on the Agree II and PFQ results, guideline developers decided to incorporate facilitators, barriers, and implications of guideline use into the CPG. The guideline team strongly believes that it is prudent for providers to use the best evidence available to treat patients, and while PH research is limited, the sources that are available should be consulted as a guide for better outcomes. After final review, guideline recommendations were submitted to the anesthesia department as a source of quality improvement. These guidelines are not to be considered generalizable knowledge.