Conference: 2011 PH Professional Network Symposium
Release Date: 09.22.2011
Presentation Type: Abstracts
L Savage, MSN, RN, PCCN, K Ratcliffe, RN, BSN, PCCN
Virginia Commonwealth University Health Systems, Richmond, VA
BACKGROUND: Pulmonary arterial hypertension (PAH) is defined as a mean pulmonary pressure of greater than 25 mm of mercury. Patients often present to critical care units with debilitating dyspnea at rest, high oxygen requirements and limited reserve. Research has begun to unlock the mysteries of the pathophysiology of PAH. Endothelial cell dysfunction appears to play a key role in PAH. Additionally, impaired production of vasodilators such as nitric oxide and prostacyclin, an excess of vasoconstrictors such as endothelin-1 and thromboxane A2 vascular changes such as vasoconstriction, smooth muscle cell and endothelial cell proliferation, as well as thrombosis contribute to the vascular changes. Treatment strategies are directed to these factors. As a result, there are many options for patients with PAH.
The decision was made to manage these patients on the progressive care unit. The unit consists of 16 monitored (telemetry) beds. The ratio of patients to nurses is generally 3:1. Resources available to nursing staff include an advanced practice nurse (CNS), charge/resources nurses (clinical coordinators) and experienced staff nurses ("senior" nursing staff with greater than 2 years of clinical experience caring for PAH patients).
PURPOSE: The purpose of this approach to patient care was to ensure a consistent method for training patients with pulmonary arterial hypertension (PAH) and to develop competent staff to manage complex PAH patients in progressive care.
METHODS/DESIGN: The Clinical Nurse Specialist, progressive care nurses and the pulmonary team worked collaboratively to develop a Center of Excellence for patients with PAH. The pulmonary team consists of pulmonologists and the nurse practitioner. Unlike other centers where teaching is taken on by a specialty pharmacy, our progressive care nurses train patients and their families to manage all aspects of this complex care. Nursing staff attend a 4 hour training session annually to learn drug therapy, mixing techniques, management of delivery systems and central line care. Didactic content is covered for 2 hours. This content includes the pathophysiology of PAH, WHO classification, diagnostic studies and current drug therapies. Oral, inhaled, intravenous and subcutaneous therapies are discussed. Indications for each drug are reviewed as well as side effects and nursing implications for patient care. Staff then rotates through hands on stations where they mix drug, program pumps and demonstrate central line care over the next 2 hours. A core group of senior staff are then assigned to care for PAH patients with the support of the CNS or clinical coordinator. Nursing staff also receive "just in time" reviews as patients present. For example, new patients are generally elective admissions. Staff is often pre assigned to care for the new PAH patient. Prior to admission, staff is able to review the protocols for the specific drug therapy that will be initiated with the CNS or clinical coordinator. Novice staff attend training after ~ 6 months to 1 year on the progressive care unit and are resourced by the senior staff.
Patients are admitted only to the cardiothoracic progressive care unit or if they are deemed more critical, to the medical respiratory ICU (MRICU). Recently, the MRICU worked in collaboration with pharmacy to implement the use of syringe pumps. Patients on epoprostenol are switched from their CADD pump to the hospital syringe pump in order to maintain a consistent concentration of drug. Once patients are stable and able to transition back to progressive care, they are placed back on their CADD pumps and patient and family teaching resumes.
FINDINGS/CONCLUSIONS: The average pt. length of stay (LOS) in our center where nurses provide all training is 3 days as benchmarked with other PAH centers where LOS is 7 to 10 days. Additionally, patients have not been readmitted within 30 days as a result of training issues. Specialty pharmacies do provide home follow up for these patients upon discharge
When staff are educated, mentored and resourced, cost effective, efficient care is provided to complex PAH patients on a progressive care unit. Staff satisfaction is high as nurses see their patients progress from "novice" to "expert".