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We are a group of four BSN-RN students, we assigned in this project to evaluate the nursing practice in clinical area if it evidence based or not and to identify the barriers and facilitators to the implementation of EPB into practice using different strategies to overcome the barriers.
Bed rest is recommended to patients with a diagnosis of acute myocardial infarction (AMI) upon initial hospitalization. Reasons for immobilization have included reduction in myocardial load, evidence of further malperfusion, and moderation of remodeling process. In last two decade, the influence of bed rest on patient outcomes following AMI has not been thoroughly investigated. In this project we investigate the practice of this issue in cardiac care unit at Salmaniya medical complex and compare it with the evidence based practice by review literatures, meta-analysis and clinical trials. We conclude to the final result and raise our recommendations. (Jacqueline K, 2004).
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Reason for choosing the topic:
From our experience as cardiac staff nurses we had faced a lot of difficulties to convince a patient with uncomplicated MI to be in complete bed rest especially after 12 hrs post hospitalization. [“Patients with uncomplicated MI: patients with ST elevation myocardial infarction who are free of recurrent ischemic discomfort, symptoms of heart failure, or serious disturbances of heart rhythm.”(American Heart Association, 2004). As their chest pain has been relieved, they will try to convince themselves and others that they are in a good health, and can achieve their activities of daily living. Therefore, it is difficult to obligate them to be in complete bed rest. Usually the nurse will face a dilemma whether to mobilize the patient with uncomplicated MI or not as there is no clear protocol for the mobilization. In addition, if the nurse decides to mobilize the patient she/he will be in trouble, questionable, and accountable for any risk that might be happened for the patient. On the other hands, if the nurse doesn’t mobilize the patient, the patient won’t be satisfied and his psychological demands won’t be met. Moreover, the cardiac nurses are aware about the significant impact of the psychological status of the MI patient on the heart workload, health, and efficiency. If the patient hasn’t been satisfied, he would be anxious, nervous, and agitated which in turn will stimulate the sympathetic nervous system to release adrenalin and nor-adrenalin hormones that’s lead to increase the heart rate, and vasoconstriction. Vasoconstriction will increase the venous return which means the increase of the pre load of the heart. In addition, the peripheral resistance will increase as a result of the vasoconstriction and that causes the increase of the after load of the heart. Both, increase of the preload and after load are dangerous as it will expose the MI patient for re-infarction, heart failure, and lethal arrhythmias.
Also, we have known that Mohammed Bin Khalifa cardiac center is mobilizing the patient with uncomplicated MI after 24hrs. As we aimed to try our best to standardize our care according to the accredited agencies, we have decided to find an evidence base about the mobilization of the patient with uncomplicated MI, and to apply it in our unit.
Title of our Topic:
Duration of Bed Rest for Uncomplicated Myocardial Infarction
Is prolong bed rest safer than early mobilization for uncomplicated MI patient?
Population: Uncomplicated MI patients.
*To keep a patient with uncomplicated MI at bed rest for more than 48hrs.
* To keep a patient with uncomplicated MI at bed rest for 12-24hrs
3. Comparison: comparing whether early mobilization of a patient with uncomplicated MI is safe as a mobilization after prolong bed rest.
4. Outcomes: Early mobilization (2-12 days) doesn’t harm the patient and doesn’t contribute with developing of any complication such as death, re-infarction, and arrhythmias. It is considered to be safe as prolonged bed rest.
The used guidelines for mobilization of pts after an acute MI in SMC was stated in the management of acute ST segment elevation myocardial infarction (STEMI) included in ” Evidence- Based Guideline for Management of Cardiac Cases in Secondary Case Settings in the kingdom of Bahrain” Which was developed by Dr. Anwer Jamsheer, Dr. Rashid Al Bannai and Dr. Tayseer Garadah (Consultants Cardiology) and was supervised and final reviewed by Dr. Abdul Hai Al awadi (Assistant Undersecretary for Hospitals).
It was mentioned in the above guidelines that “The patient is kept in bed rest until otherwise ordered by the physician” and the nurse should ask on daily bases about the allowed activity privileges for the pts (bed rest, bedside commode, sit out of the bed, walk around the bed, toilet bed side in the first two days and lastly the full mobilizing). It was suggested also that it is the responsibility of the nurse to ensure range of motion exercises (ROM), deep breathing and positioning while the patient is in the bed rest. Moreover, it was declared to explain to the patient the needed rest and to teach him the allowed exercises and help him, if needed. However, it was not mentioned who should do that. Guidelines explained in the “cardiac rehabilitation for patient with STEMI (phase I -in patient care)” the full carried out protocol for the mobilization of pt after an acute MI. This includes:
Full bed restrictions in the first 2 days, including bed side wash, shaving and bed pan.
Passive form of mobility for arms and foot ruling can be given at frequency of three times per day.
In uncomplicated cases the transfer to step down can be arranged on day three. With the mobilization around the bed and allow free toilet access under supervision.
On day four and five patient can walk in the corridor and allowed to go one flight or go for symptom limited exercise test.
It was noted that the source of information for these guidelines is the last literature review up to date / version 16.1: ACC and AHA, GHA pocket Guidelines and ECS2007, but actually there was no effective date rather than revision date mentioned.
This protocol was followed in most of cases but there were some exceptions. Extended bed rest was advised for pts who are unstable or had some complications after MI like lethal arrhythmias, heart failure or recurrent ischemia etc. Such cases were not mentioned specifically in the guidelines although it was mentioned in the original source of information after we have reviewed it.
The 1996 ACC/AHA Guidelines for the Management of Patients with Acute MI has found evidence on the continued practice of “coronary precautions” although it was advocated since 1960s that some of theses precautions are no longer applicable in the current practice. In the earlier years patients with STEMI were kept in bed rest for several weeks in order to decrease myocardial oxygen demand but then it was reveled that extended bed rest is more harm than good and it would delay the recovery. 2004 ACC/AHA Guidelines recommended that “Patients with STEMI who are free of recurrent ischemic discomfort, symptoms of heart failure, or serious disturbances of heart rhythm should not be on bed rest for more than 12 to 24 hours” In addition, it is mentioned that patients with hemodynamic instability or continued ischemia to have bedside commode privileges. Both practices are not seen in SMC as Pt with STEMI who described as stable will be in bed rest for 48 hours while unstable pt (complicated MI: patients who have recurrent ischemic discomfort, symptoms of heart failure, or serious rhythm disturbances) will be in bed rest for several days up to one week.
While searching for relevant data and protocol that could answer our PICO question and prove which is the safest and more beneficial for patient post uncomplicated myocardial infarction ,mobilization after 48 hours or less, we interviewed the experts in our institution (Salmaniya Medical Complex – SMC) who are consultant cardiologist in Coronary Care Unit(CCU) ,while interviewing Dr. Hayat Al-Mahroos, she stated that there is no clear protocol is being followed and mobilization depend on the patient condition, how ever the followed and common protocol is 48 hours post uncomplicated myocardial infarction which is not being reviewed long time back, although recent studies encourage early mobilization after 12 ours from bed to chair and after 24 hours pt can walk with the help of cardiac rehabilitation nurse ,in her management she stated still she is mobilizing the patient with in 48 hours because other cardiologist mobilizing the patient with in 48 hours and perhaps mobilizing the patient with in different durations may confuse the nurses ,in addition thrombolytic protocol is for 48 hours and nurses used to mobilize the patient once the protocol is finished ,so that if she asked to mobilize the patient with in 24 hours or to be shifted to step down the nurse will replay ” patient still on protocol and didn’t finish the 48 hours ” she stated we don’t discuses the issue as long there is no harm for the patient and we leave the patient till he finished the protocol to avoid confusion to the nurses ,more ever the setting of CCU doesn’t encourage early mobilization ,the room of the patient has to have comfortable chair so that patient can be early mobilized ,the role of the cardiac rehabilitation should be extended to participate in mobilization of in patient ,early mobilization will definitely improve patient confidence and moral and will help in early discharge that will allow more vacancies for needed patient.
On other hand ,Dr. Rashid stated that post uncomplicated myocardial infarction , the patient will be on bed rest for 48 hours and that according to American college of cardiology and guidelines ,he stated that he agree with current protocol and going on line with American guidelines as it is the safest practice because this institution has always consciousness about health practice and has became a reference and source of evidence based practice on international level ,however he stated no enough trial were done on 24 hours bed rest.
In contrast, Dr. Tayseer stated that he is following the British guidelines that recommended 48 hour’s protocol; he stated mobilizing the patient in the 24 hours may induce lethal arrhythmias which could be fetal.
Early mobilisation for patients following acute myocardiac infarction:
A systematic review and meta-analysis of experimental studies
Olga L. Cortes, Juan C. Villar, P.J. Devereaux, Alba DiCenso ( 2009 )
Target studies included published and unpublished experimental, controlled studies in any language.
Systematic review and meta-analysis.
Patients defined as having uncomplicated AMI, except for Abraham et al. (1975), who enrolled patients with both complicated and uncomplicated AMI. Most studies included patients aged 55-65 years, with at least 70% male participants, except for one study that included only male participants (Messin and Demaret, 1982).
The experimental intervention was similar across studies (stand up, move to chair, and walk) with the only difference being how many days post-AMI their EM intervention was initiated.
Out of 385 potentially relevant studies, 14 met the eligibility criteria (13 published before 1983). There were 149 deaths (9.3% of 1607) and 82 non-fatal reinfarctions (5.2% of 1580) among post-AMI patients receiving EM, compared with 179 deaths (11.6% of 1541) and 80 non-fatal re-infarctions (5.3% of 1518) among AMI patients receiving control treatment (RR = 0.85, 95% CI 0.68, 1.05 and RR = 1.02, 95% CI 0.75, 1.39 respectively).
This systematic review of experimental data from studies conducted in the 1970s and 1980s showed a trend towards an increased survival of AMI patients receiving EM relative to those who do not.
There is uncertainty about early mobilisation and more research should be developed having into account all kind of differences among patients receiving treatment after AMI worldwide.
Short versus prolonged bed rest after uncomplicated acute myocardial infarction.
Systematic review and meta-analysis.
Hospitalized patients with uncomplicated myocardial infarction .
Early mobilization ( 2- 12 days)
Short versus prolonged bed rest after uncomplicated acute myocardial infarction.
Early mobilization (2-12 days) doesn’t harm the patient and doesn’t contribute with developing of any complication such as death, reinfarction, and arrhythmias. Its considered to be safe as prolonged bed rest.
Bed rest for acute uncomplicated myocardial infarction (Review)
Harald Herkner,Jasmin Arrich, Christof Havel, Marcus Mullner
Measuring the incidence of cardiac death
Measuring the incidence of reinfarction
Incidence of arrythemias
patients post uncomplicated myocardial infarction
Incidence of cardiac death , There was no
evidence that bed rest duration has link or association with all cause
or cardiac death after uncomplicated myocardial infarction (RR
0.85, 95%CI 0.68 to 1.07, and RR 0.81, 95%CI 0.54 to 1.19, respectively).
Eleven papers reported on reinfarction ,ut still there was no association between the incidence of reinfarction and the
Bed rest duration (RR 1.07, 95%CI 0.79 to 1.44).
Arrhythmia was reported in seven studies There
was no effect of short or long term duration on arrhythmia rates .
Thromboembolic complications were reported in six studies.however the rate was lower in patients
with shorter duration of bed rest, but the figure was not significant statistically
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