• 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.
    • Prevention and Management of Postoperative Vision Loss (POVL) in Patients Undergoing Procedures in Trendelenburg and Prone Positions

      Lee, Judith; Pellegrini, Joseph (2019-05)
      Background: Postoperative vision loss (POVL) is considered rare, but it is a devastating complication that can occur in any patient undergoing surgery and it is important for anesthesia providers to understand the prevention and management of POVL. It has been shown there has been an increase in prevalence of POVL in patients that are placed in prone and steep Trendelenburg (ST) positions for cardiac, spine, head and neck, and orthopedic procedures. The exact prevalence of POVL is unknown, however, permanent POVL associated with spine surgery has been reported in as many as 1 in 500 operations (0.2 percent) from data obtained from three centers that performed over 3,400 spine surgeries. The most common cause of postoperative ocular injuries usually involves corneal abrasion, which may be associated with vision loss, and increased ocular perfusion pressure (IOPP). The complications associated to POVL can be anything from transient blurring to complete permanent blindness. Patients who experience POVL spend an average of 8.6 days in the hospital, costing an average of $42,532 vs. 4.1 days costing an average of $22,697 for those unaffected. Local Problem: The purpose of this DNP project was to develop a clinical practice guideline (CPG) to decrease incidences of POVL at a community hospital in Baltimore, Maryland, (which renders nearly half of its cases in STP, during prone, laparoscopic, and robotic-assisted cases), that has reported a growing concern for management of POVL. Currently, the target institution has no uniform standard for the management of POVL. Therefore, the purpose of this CPG was to develop a standardization of the management of patients undergoing procedures in ST and prone positioning. Interventions: The CPG development consisted of two phases. Phase I (June 2018-August 2018) included the identification of the practice problem, target site, and appropriate stakeholders and their approval in assisting with the project. Barriers and project measures were developed and the initial draft of the CPG was made. The CPG was then presented to the stakeholders for feedback and revisions were made accordingly. The project was then submitted to the University of Maryland School of Nursing (UMSON) Institutional Review Board (IRB) for approval. Phase II (September 2018-April 2019) included the presentation of the CPG to the anesthesia staff members at the target site. The anesthesia staff in attendance was given a Provider Feedback Questionnaire (PFQ) to complete and was collected at the end of the meeting. The results from the PFQ was then synthesized and analyzed to make further revisions to the CPG with suggestions from the stakeholders. The final DNP project manuscript was then submitted for committee review. Results: Data obtained from the AGREE II tool and PFQ were analyzed with descriptive and correlational statistics. Each domain of the AGREE II tool was individually analyzed and showed that the overall quality of the guidelines was rated highly. Appraisers recommended the CPG for it to be presented to the target institution by receiving scores above 86%. There were a total of 24 persons attending the implementation presentation whom all received the PFQ and 100% of the PFQ was received in completion. The confidence interval was 95% after calculating the total percentage of agreement which was 74% and the standard deviation was 15%. The overall comparisons between CRNA and MD via chi-square analysis was 27.3156 with a p-value <0.01. The result was significant at p <0.05. The analysis of the PFQ demonstrated the acceptance of the CPG by both groups of anesthesia providers at the target site regardless of any differences. Conclusion: The results of the study showed that there is large positive feedback from the group towards the presented CPG. This CPG has great potential and usefulness in reducing the incidence of POVL in patients undergoing surgery at this facility by standardizing the practice. Lowering POVL incidence would mean less occurrences of potential devastating permanent damages to vision that could severely impact the patients’ quality of life.