• Intraoperative Anesthesia Care of Patients with Cardiovascular Implantable Electronic Devices

      Nwankwo, Chioma U.; Gutchell, Veronica (2020-05)
      Problem and Purpose: Cardiovascular Implantable Electronic Devices (CIED), commonly referred to as pacemakers or implantable cardioverter defibrillators (ICD), are lifesaving devices placed subcutaneously in patients with recurrent life-threatening bradyarrhythmias and tachyarrhythmias (Crossley et al., 2011). In the United States, more than 3 million patients have pacemakers and more than 300,000 patients have ICDs (Ellis et al., 2017). Electromagnetic interference during the intraoperative period is the most significant problem encountered with these patients during surgeries (Crossley et al., 2011). Therefore, anesthesia providers need to understand how to manage these devices perioperatively (Neubauer et al., 2018). The purpose of this scholarly project is to develop a clinical practice guideline (CPG) for consistent intraoperative anesthesia care of the patients with CIEDs at a hospital in Baltimore, Maryland. Methods: Institutional Review Board approvals at the school and the hospital facility were obtained prior to DNP project implementation. An expert panel was assembled: two CRNAs, an Anesthesiologist and a Cardiac Electrophysiologist. The expert panel utilized the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool to evaluate the CPG developed by the student. Revisions were made to the CPG based on feedback from the AGREE II tool. A PowerPoint presentation on the CPG was delivered to the anesthesia staff during ground rounds by the student. Following the presentation, the anesthesia staff completed the Practitioner Feedback Questionnaire (PFQ), an anonymous survey that assessed for clarity of the presentation and ease of CPG adaptability to clinical practice. Results: Domain scores from the AGREE II tool results ranged from the lowest score of 70.8% to the highest score of 97.9%. Of the PFQ distributed, 80% were returned and analyzed. Results indicated that 94% of the providers recommended adoption of the CPG, and 90% indicated they would adapt the CPG recommendations to their practice once approved. Qualitative data on the anesthesia providers’ years of experience and provider type were collected from the PFQ responses, and results indicated that 50% of the providers had less than five years of experience and 47% were CRNAs. A finalized CPG was approved by the chief anesthesiologist, and the CPG became an official policy at this anesthesia department. Conclusion: The cumulative results revealed anesthesia providers’ future intention to use the CPG policy during their care of patients with CIEDs. Adoption of this CPG in daily clinical practice will mean a reduction in electromagnetic interference, and the use of evidence-based care by anesthesia providers during the intraoperative care for this patient population.

      Solomon-Adenola, Oluwanife; Gutchell, Veronica (2020-05)
      Problem Statement: Currently, in the United States, there are approximately 3 million patients with Cardiovascular Implantable Electronic Devices (CIEDs). Annually, more than 1 million CIEDs are implanted and 2% of patients with CIEDs undergo cardiac/non-cardiac surgical procedures. With the increase in surgical patients with CIEDs, CIED variations and CIED risk of complications, anesthesia providers must have current knowledge about preoperative and postoperative management of this patient population. Purpose: The purpose of this Doctor of Nursing Practice (DNP) project was to develop an evidence-based clinical practice guideline (CPG) for standardizing the preoperative and postoperative anesthesia management of surgical patients with CIEDs at a large, teaching, level two trauma hospital in Baltimore, Maryland. Currently, there is no existing evidence-based practice for anesthesia management of these patient populations at this facility which provided an educational opportunity to improve patient safety. Methods: An expert panel was convened and included two Certified Registered Nurse Anesthetists (CRNAs), one anesthesiologist, an interventional cardiologist, and a chief information officer. A comprehensive review of literature was conducted. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) Tool was utilized by the expert panels to assess the quality of the CPG. After the dissemination of the CPG via an educational PowerPoint presentation to anesthesia providers at Grand Rounds, the practitioner feedback questionnaire (PFQ) was completed. The PFQ is a 3-point Likert-scale used to assess the accuracy and transparency of the development of the CPG. Results: The domain scores of the AGREE II tool ranged from 70 to 100%. The domain “Editorial Independence” rated highest with a score of 100%. The domain “Stakeholder Involvement” rated lowest with a score of 70% and “Applicability” with a score of 81%. 80% of anesthesia providers (n=30) completed PFQ. Overall, 94% of the anesthesia providers agreed that the guideline should be approved for practice and it would be applied in their practice. Conclusion: This CPG impacted the knowledge deficit among anesthesia providers at this facility to increase awareness and improve patient safety of surgical patients with CIEDs. Even though this CPG was designed based on the need of this institution’s anesthesia providers, stakeholders permitted the application and usability of this CPG at other sister hospitals under this facility’s health system.