Prevention Decline in Older Cardiac Surgery Patients (PREDOCS) Programme

Background

Complications after cardiac surgery are common in older patients and are associated with prolonged hospital stay, a reduced quality of life (QoL), and increased costs of healthcare. High prevalent complications after cardiac surgery in older patients are delirium (11.9% - 43.1% ), depression (15% - 18% ), pressure ulcer (13% - 18% ), and infection (1.3% - 2.4%). The risk of developing postoperative complications is not the same for every older cardiac surgery patient. Frail older patients are more likely to experience postoperative complications than non-frail older patients.

Because postoperative complications occur more frequently in frail-older patients, nurses will increasingly be charged with the care for these patients. Simultaneously, sources claim that the nursing care for these patients is insufficient. Research has shown that if they optimize the preparation of older cardiac surgery patient prior to the hospital admission period, postoperative complications can be prevented.

We therefore developed a multi-component preadmission nursing intervention called ‘PREvention Decline in Older Cardiac Surgery patients’ (PREDOCS) to prepare older patients better for elective cardiac surgery and to prevent postop­erative complications. The PREDOCS programme includes a comprehensive geriatric nursing approach aimed to pre­vent four frequently occurring postoperative complica­tions in cardiac surgery: delirium, depression, pressure ulcers and infections. The programme can be offered to patients 65 years and older who are scheduled for cardiac surgery. It consists of one nursing consult, two to four weeks prior to surgery.

Method

A multicomponent preadmission intervention was developed using several previously performed studies, these are; a systematic review for effective preventive interventions; an etiological study on links between preadmission patients characteristics and the occurrence of postoperative complications; a prognostic study resulting in instruments for predicting the risk of occurrence of the four postoperative complications; interviews among cardiac surgery patients about their needs before and during hospitalization; and a survey among nurses to their views on prevention, diagnosis and treatment of the four postoperative complications. These studies resulted in five international publications. In addition, the intervention was reviewed by four experts in the areas of delirium, depression, pressure ulcer, infection, and anaesthesiology. It was also reviewed by six employees (doctors and nurses) in the hospitals participating in this multicenter study.

Before the clinical effects of such a complex multicomponent intervention can be evaluated, the feasibility was determined to detect possible problems with the acceptability, compliance and delivery. Two large cardiac surgery centres and one university hos­pital in the Netherlands participated in the assessment of feasibility. The cardiac surgery centres were St. Antonius Hospital in Nieuwegein and the Isala Clinics in Zwolle, where respectively over 1900 and 1400 cardiac surgeries are performed each year. At the University Medical Centre of Utrecht, over 800 cardiac surgeries are performed each year. This resulted in a sixth international publication.

Results

To improve the patients’ physical, social, and psychological condition in the preadmission period and thereby reduce the occurrence of delirium, depression, pressure ulcer, and infection after cardiac surgery, at preadmission the PREDOCS programme is introduced.

In February 2014 nurses at the cardiac thoracic ward at the St. Antonius Hospital started to use this program for patients 70 years and older, four weeks before admission at the preadmission.

The intervention included three parts:

1. The intervention is administered during a consultation by the nurse two to four weeks before the surgery procedure. The consultation includes three parts: a general part for all patients of 70 years and older, patients received general advice regarding nutrition, social support, pain management, and the upcoming surgery
2. A second part, in which patients with an increased risk are identified. The patients’ risk to develop postoperative delirium, depression, pressure ulcer, and infection was calculated using scorecards.
3. A third part in which selected patients are informed about how to prepare themselves for the hospital admission to reduce their risk.

Conclusions

The average time the nurses spent on the intervention is 20 minutes. This includes a social-talk and recruitment. For the nurses, the preadmission intervention is complete and concrete. There are tools for the preparation of the coming surgery for the patients. Moreover, patients and relatives appreciated the given advices. The preadmission intervention is complementary to usual care.