1. Lindquist, Ruth PhD,RN

Article Content

The topic of shortened length of stay for hospitalized cardiovascular patients is the focus of this issue of The Journal of Cardiovascular Nursing (14:1). Current trends in the care of cardiovascular patients can be characterized as promoting faster progression and earlier discharge from the acute care setting. Many invasive procedures are done on an outpatient basis. Cost-cutting efforts have focused on reduction of hospital admissions and length of stay for hospitalization episodes. 1 This focus has required health professionals to develop strategies to meet the needs of the patients and families who encounter care that may be provided in rapid sequence and who grapple with details of medical regimens after procedures and hospitalizations. Workable strategies are needed to achieve desired medical and health-related objectives so that complications and hospital readmission may be avoided.


Smooth transitions in care require communication, collaboration, and coordination of care across the continuum. While in the hospital, this transition may take the form of specific protocols defining essential care processes to facilitate movement through the system and to ensure standard care delivery. The documentation of these processes may provide data that may be used to evaluate care and to target problems, thereby improving both the process and outcomes of care. Through the identification of essential steps in the process, nonessential steps may also be identified and potentially eliminated to effect a cost savings to the system. So, too, the early identification of persons who are at risk for difficulty when managed by the standard processes may enable timely targeted interventions tailored to the needs of those individuals to ensure progress and optimal outcomes for all patients at an acceptable cost. When length of hospitalization is short, innovative strategies are needed to ensure that the information needed by the patient, families, and other care providers to carry out essential components of care gets transferred.


The articles in this issue document contemporary issues facing nurses in the acute care environment. These issues are addressed in the authors' accounts of experience with a variety of cardiovascular therapies in contemporary practice including pacemaker implantation, cardiac surgery, and management of heart failure and acute coronary syndromes. The authors provide insight into clinical concerns commonly faced in the context of shortened length of stay and suggest methods to more effectively address these concerns. The articles included in this issue exemplify nurse authors' sensitivity and responsiveness to the challenging issues surrounding shortened length of hospital stay. The perspectives of the authors are timely and relevant; the innovative approaches to intervention described have demonstrated the potential to improve outcomes for cardiovascular patients and families.


Edwardson has provided a perspective on current trends for shortened length of stay for cardiac patients. She cites statistics documenting shortened length of stay for a variety of cardiac conditions, procedures, and events to remind readers of the dramatic changes that have occurred over time, especially over the past decade. Hospitalization is viewed in the current business environment as one of the most expensive modes of care delivery. She describes the current trends in managed care to find ways to decrease the number of hospitalizations or when admissions are unavoidable, to find ways to shorten the length of hospitalization. She describes continued efforts to find and target factors contributing to increased hospital days.


In the search to identify factors that drive up costs, patient-related factors have not escaped scrutiny. Grady, Jalowiec, and White-Williams have examined psychosocial predictors of length of stay after heart transplantation. These investigators found that preoperative self-care disability, a history of noncompliance, and emotional disability were significant contributors to the variance in length of stay. They suggest that these psychosocial variables be included in clinical pathways for transplant patients. The authors recommend attention to psychosocial factors in periods before and after discharge and call for further research relating psychosocial variables to recovery.


Patient education is important to recovery yet learning may become difficult when amnesic agents impair the acquisition and retention of information during cardiac procedures. Schuster and colleagues note that frequently patients are discharged the day of surgery and teaching may occur during the time when the effects of drugs such as midazolam are still present. In follow-up of their observation, they examined the effects of midazolam on learning retention of 20 patients who received permanent cardiac pacemakers. In their experimental protocol, they assigned patients to receive teaching within either 1 or 3 hours after the last dose of midazolam to evaluate the potential effects of the drug on learning. When tested, those taught at 3 hours were more consistent in their responses and retained more learning relative to their counterparts who were taught at 1 hour after drug administration. The work of these authors underscores the importance of assessing learner readiness for information that is of importance to follow-up care and recovery. This would include situations where capacity to learn may be compromised as a result of the effects of drugs, stress, or other patient conditions. In such cases, nurses would need to plan to shift education to visiting nurses or family caregivers. Clearly more research is needed in this area.


Preparation of caregivers for early discharge of cardiovascular patients was the focus of the study conducted by Leske and Pelczynski. Among the variables included in their investigation were caregiver satisfaction with discharge preparation and preferences for length of stay. An interesting finding was that the majority of the 53 caregivers surveyed preferred early discharge but did not feel prepared for the patient care responsibilities in the home. The investigators emphasize the importance of communication between the hospital and the home and suggest that home care follow-up be provided when possible or that educational videos be made to reinforce the information related to postoperative care and recovery. The investigators point out that early discharge after hospitalization may be perceived positively by families just as long as they have enough information to provide care and they know where to turn if problems arise in the early days and weeks of recovery.


Naylor and McCauley highlight the potential significance of the role of advanced practice nurses in discharge planning and transition periods. They describe findings from a secondary analysis of data of a recently completed randomized clinical trial in which patients were assigned to receive a comprehensive hospital discharge planning protocol focused on elders versus "routine care." In this study, advanced practice nurses with background in the care of elders contributed to discharge planning and also provided home services and phone follow-up. Advantages to elder medical and surgical patients were demonstrated relative to the control group. Medical patients had a decrease in the numbers of multiple readmissions and a decrease in hospital days. Surgical patients had a decrease in early readmission and a total decrease in the number of readmissions.


Another example of work to ensure smooth transitions and to reduce hospital readmission is provided by Knox and Mischke. These authors describe the efforts of a multidisciplinary team to provide coordinated care across the continuum of health care for patients with heart failure. The program employs daily monitoring and telemanagement and ongoing education of patients by all members of the health care team. The integrated program comprises components of inpatient consultation and education, an outpatient clinic, home care, and a telephonic system to monitor patient compliance with recommended therapy. They view patients as "comanagers" of their disease. In their article, these authors describe the goals, operating challenges, and strides made in their efforts to improve patient outcomes and to assist patients to manage their disease after hospital discharge.


Robinson takes the topic of discharge planning further by envisioning a network of care that extends beyond the hospital walls for patients who are at high risk of poor outcomes after myocardial infarction. This interdisciplinary network of care would provide a collaborative approach to the delivery of holistic care to the myocardial infarction patient and family. The nurse in context of this network would play a key role in assessing needs and anticipating future needs. Such a network would engage a broad range of professionals and community resources to address patient and family needs and to enhance patient recovery and quality of life. In the case of recurrent events, the network would foster prompt mobilization of the patient and family and would ensure timely access to care.


To evaluate the effects of shortened hospital length of stay, Deaton recommends that appropriate patient and family outcome data be selected. Such things as the "burden of care" placed on family members resulting from early (or premature) discharge may need to be evaluated because adverse effects on family health and income or disruption of family dynamics may result. She advocates for the use of standard deviations in reporting average length of stay and potentially displaying the distribution of length of stay in a graphic form to provide nurses of a quick "visual" of length of stay of patient groups. Other patient variables (eg, comorbidities, age, rehospitalizations) that may be important to track and that might lead to important cost and quality insights are discussed.


As issue editor, I would like to thank the authors who have contributed their experience, perspective, and considerable expertise to address the topic of this issue. My thanks are also owed to Mr Shigeaki Watanuki, a graduate student in nursing at the University of Minnesota, for his instrumental support and the technical assistance in the effort to bring the issue together. These times of shortened length of stay provide opportunities for nurses to use creativity and to explore innovative new approaches to patient education, communication, and use of technology to achieve desired health outcomes for cardiovascular patients and families. I hope that readers will find the work described in this issue to be of direct relevance to their own research, teaching, or clinical practice.


-Ruth Lindquist, PhD, RN


Associate Professor and Director of Graduate Studies; University of Minnesota; School of Nursing; Minneapolis, Minnesota


Issue Editor




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