Ann Thorac Surg 2008;85:560-561. doi:10.1016/j.athoracsur.2007.10.041
© 2008 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Constance Haan, MD, MS
Division of Cardiothoracic Surgery, University of Florida, College of Medicine - Jacksonville, 653-1 W 8th St, Jacksonville, FL 32209
(Email: connie.haan{at}jax.ufl.edu).
Bickert and colleagues [1] have presented their findings using the Neurologic Intensive Care Evaluation (NICE) patient assessment tool, in an effort to improve the clinician’s understanding of how patients wake up after cardiac surgery and the factors influencing this process, and they have drawn some early conclusions on these aspects relative to postoperative neurologic outcomes.
This is a useful first step for the NICE study, but it will be important to continue to study the use of NICE scores, exploring for differences in the time-to-score to distinguish thresholds for identifying new deficits, changes in functional outcomes, discharge, and discharge destination. It is understandable that in this initial study, the patient selection and inclusion criteria should be somewhat restrictive to ensure comparability. I believe that the benefit of the NICE tool will be better elucidated as it is more broadly studied, applying the tool to more diverse coronary and valve patients of all risk levels, and studying the differences in patient arousal and outcomes. Studies are also needed of larger numbers to develop the study power to assess the relationship of scores to infrequent outcomes, because in Bickert and colleagues’ [1] study, true differences were only achieved in the discharge destination as related to NICE scores greater than six.
There has been much done in performance improvement of care and outcomes in cardiac surgery in the past decade [2, 3]. This includes a multidisciplinary approach to smooth, early awakening and extubation after surgery. The NICE tool should continue to be assessed for the information it provides as applied to varying protocols and techniques for cardiac anesthesia, early postoperative pain management, and ventilator weaning protocols and processes.
Finally, a scoring tool is only really useful if it can be applied strategically to patient care decision-making and intervention opportunities. As presented, NICE has not yet been shown to provide a tool or threshold for determining the optimal opportunity for proactive prevention or intervention. Selection of cases, adapting perfusion, and anesthesia techniques, and adjusting or selecting hemodynamic measurements for the care team are all opportunities for improving care of patients identified as higher risk. It would be excellent to be able to follow-up on the preoperative and intraoperative decisions and techniques with addition of an informative postoperative monitoring tool that delineates how and when to apply interventions to optimize patient outcomes.
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References
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- Bickert AT, Gallagher C, Reiner A, Hager WJ, Stecker MM. Nursing neurologic assessments after cardiac operations Ann Thorac Surg 2008;85:554-561.[Abstract/Free Full Text]
- Nugent WC, Kilo CM, Ross CS, Marrin CAS, Berwick DM, Roessner J. Improving outcomes and reducing costs in adult cardiac surgeryBoston, MA: Institute for Healthcare Improvement; 1998.
- Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Circulation 2004;110:e340-e437.[Free Full Text]
Related Article
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Nursing Neurologic Assessments After Cardiac Operations
- Anna T. Bickert, Cindy Gallagher, Amy Reiner, Walter J. Hager, and Mark M. Stecker
Ann. Thorac. Surg. 2008 85: 554-560.
[Abstract]
[Full Text]
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