Clinical pathways were introduced a...

Clinical pathways were introduced at the University of Kentucky Hospital, Lexington, in 1994 as part of a larger effort to improve clinical and financial consequences Multidisciplinary teams identified system, clinician, and patient issues within a specified patient population that impeded the achievement of desired outcomes

The coronary artery bypass graft (CABG) clinical pathway was implemented at our hospital in January 1996 Initially, patients undergoing the minimally invasive direct coronary artery bypass (MIDCAB) transaction were placed on this pathway. It became evident, however, that the care of the MIDCAB patient and the anticipateed course of recovery were quite different from conventional CABG measures The multidisciplinary team, therefore, bring outed and implemented a clinical pathway that cogitateed the unique features of care and issues of MIDCAB patients. This article discusses the distinguishing characteristics and results of the multidisciplinary MIDCAB clinical pathway according to the principle time intervals outlined upon the pathway.

SELECTION CRITERIA

Patients principally likely to be selected for MIDCAB transactions are those with single- or double involving bottom coronary disease the left anterior descending (LAD) or right coronary artery (RCA) or both(1) Other candidates may include patients with comorbid conditions (eg chronic obstructive pulmonary disease, renal failure, advanced age, peripheral vascular disease) that make them high risks for conventional CABG surgery

PREOPERATIVE PHASE

After the patient has been determined to be suitable for the MIDCAB technique, teaching and discharge planning become the primary areas of business preoperatively.

Teaching. The MIDCAB measure is less well known among lay public; therefore, the step must be explained to patients and families in detail. There are many potentially major paradigm shifts associated with the MIDCAB approach to coronary artery revascularization. The first is the shortened postoperative extent of stay (LOS). Although conventional CABG patients increasingly are being discharged from the hospital in succession postoperative day (POD) three or four, MIDCAB patients should be prepared for hospital discharge as early as legume two. Patients need to know their postoperative activity schedule will be advanced quickly; the approximate location of the incision forward the anterior thorax; and removal of ventilatory support within a not many hours after surgery.

The greatest in number critical educational need is pain management. Pain is a major patient care issue for the MIDCAB patient, steady more so than in conventional CABG patients, especially if the anterior thoracotomy approach is used. The median sternotomy incision used in conventional CABG operations is associated with less discomfort than a thoracotomy incision.(2) In the anterior mini-thoracotomy approach, an incision 3 to 4 inches protracted is made in the fourth intercostal space.(3) Costochondral. cartilage may be resect to achieve adequate visualization of the surgical field according to the surgeon and to provide access to the left internal mammary artery, which is used to bypass the occlusion.(4) This approach has a direct impact forward the anatomical structures the patient uses during normal respiratory effort. As a deduction pain occurs not only from the surgical incision, yet also from the simple act of breathing.

Pain is a known physiologic stressor that activates the sympathetic nervous plan which places a greater workload onward the cardiovascular system.(5) Elevations in patients' heart rates and relations pressures--both of which increase myocardial oxygen demand--occur in answer to sympathetic nervous system activation. Pain also interferes with patients' abilities to engage in early postoperative mobilization and physical activity. Effective pain management, therefore, is essential to achieving desired respiratory, cardiovascular, and activity clinical outcomes

To provide a certain quantity of baseline indication of patients' perceptions of pain and their experiences with it, patients' pain management goal is assessed preoperatively using a visual analog scale (VAS). The VAS is the preferr way for assessing patients' pain objectively.(6) Patients be agreeable to to a Likert-type scale (ie, 0 = no pain, 10 = worst pain) to describe the intensity of their pain. Depending in succession the scale used, patients may make a mark forward the line, provide a number forward the line, or point to a place upon the line. Patients should understand the importance of reporting their discomfort before it reaches an intense flat and of helping caregivers evaluate their rejoinder to pain management interventions.

During this time, alternative, nonpharmacologic measures (eg music therapy, relaxation therapy, massage, meditation, imagery) that complement traditional pain management modalities may be explored. Patients also may use pain have the direction of methods that have been beneficial to them during their past experiences with pain.

Preoperatively, a thorough assessment of the nature of patients' anginal symptoms should be well documented. This is done to assist caregivers and the patient postoperatively in distinguishing the difference between discomfort associated with myocardial ischemia and that associated with incision pain.