Rigoberto Dela Cruz and Sandra Donia
Registered nurses Rigoberto Dela Cruz and Sandra Donia are learning new skills to manage post-Transcatheter Aortic Valve Implant (TAVI) patients to help get the patients home safely, faster. (Photo: UHN)

Rigoberto Dela Cruz and Sandra Donia have decades of registered nursing experience between them, but that doesn't mean they can't learn new skills. In fact, the two Peter Munk Cardiac Centre (PMCC) RNs say a recent change to their work not only energizes them – it means patients can go home safely, faster.

That's because technological advances at PMCC allow for the repair of aortic valves without opening the chest in patients who previously would have been deemed too high-risk for surgery.

Here's how it works: the Transcatheter Aortic Valve Implantation (TAVI) team identifies eligible patients who can be fast-tracked to avoid a stay on the Intensive Care Unit (ICU). Post-procedure, those patients now have a short recovery period in the Post-Anesthetic Care Unit (PACU) before moving on to Unit 5B Munk, where they are under the care of Rigoberto and Sandra.

While the patients may be coming to them quicker, the RNs have received additional technical training which enables them to monitor the patients' recovery.

"I take it as a challenge," Rigoberto says of the change. "We're given this challenge because we can manage it.

"It's empowering."

This is National Nursing Week in Canada. It culminates with International Nurses Day on May 12, the anniversary of the birth of Florence Nightingale, the Englishwoman recognized as the pioneer of modern nursing.

This year's theme for International Nurses Day, developed by the International Council of Nurses (ICN), is "Nurses: A Voice to Lead - Health for All."

"As one of the most trusted and respected health professions, nursing has a pivotal role to addressing the multiple health challenges that are being faced all over the world," ICN says in its 2019 campaign.

At UHN, this week is a time to recognize the year-round dedication and achievements of approximately 4,200 nurses working full-time, part-time and casual. A number of events are planned this week at UHN.

At PMCC, TAVI patients in the past would spend time in the ICU to recover, post-procedure.

But Linda Flockhart, Clinical Director of PMCC, says this change in process will result in improved patient outcomes, reducing the risk of complications, easing internal congestion and a cost-savings.

"This is going to be the way of the future for valve surgery," Linda says. "Our teams, including the operating room, are shifting how they provide care, and are learning new skills."

Nurses in PACU have received training and education to ensure patients are medically prepared for a transfer to Unit 5B.

This change in process provided a unique educational opportunity for Rigoberto and Sandra, who are being lauded for their ability to take on these patients.

Putting patients in the right place, at the right time

On average, Rigoberto and Sandra care for two post-procedure patients. That's because constant vigilance and closer patient monitoring is required following the procedure.

Specifically, the pair has learned how to manage cardiac sheaths and applied their expertise of post-anesthesia recovery to this patient population, including reducing the risk of delirium and improving pain management. They also monitor for signs of possible bleeding, stroke, acute kidney injury and arrhythmias. They keep a close eye on access sites, vital signs – blood pressure changes, pupil size, alertness, laboratory values, and changes in heart rhythm, among other items.

"We know what to monitor for because we know what can go wrong," explains Sandra.

But if all goes well, the patient could go home after only a day-long stay.

"Patients are happy they don't have to stay in hospital," saysSandra.

Both nurses acknowledge the support they've received as a result of taking on this patient population has been "amazing," including the clinical educator, the patient care coordinator (PCC), the TAVI physicians and nurse manager.

"All of the nurses on 5B are very skilled and experienced in managing unstable patients; we usually care for five to six patients on a day shift and our patient population becomes unstable very quickly," says Sandra.

"We can competently manage these TAVI patients because we have the critical skills and knowledge to manage emergencies," she says. "I am very lucky to work with such amazing nurses because we all work as a team on 5B.

"We would not be able to care for such complex patients with the support from our manager, educator and PCC."

Zelia Souter, Nurse Manager, Inpatient Cardiology and Cardiac Short Stay, says Rigoberto and Sandra "have demonstrated they're able to rise to the occasion to take on complex patients who require close post-procedure care monitoring.

"Their expanded scope of practice is making a difference to the patient care experience."

Clinical Director Linda Flockhart says staff in the PACU, Operating Room and 5B Munk are also all learning new skills to manage patients in a new way that is safer for patients and gets them home sooner, avoiding hospital acquired conditions and deconditioning. She also recognizes the operating room inventory team, as well as the staff at the Preadmission Clinic for their ability to adapt to these changes.

"This will help put patients in the right place, at the right time," says Monika Keri, advanced practice nurse educator on 5B.

"This aligns quite nicely with UHN's Essentials, including quality and safety – we are making meaningful and measureable progress towards zero preventable harm for patients and staff."

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