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Background: A policy statement recommending that healthcare providers (HCPs) encourage cardiac patients to enroll in cardiac rehabilitation (CR) was recently endorsed by 23 medical societies. This study describes the development and evaluation of a guideline implementation tool., Methods: A stepwise multiple-method study was conducted. Inpatient cardiac HCPs were recruited between September 2018-May 2019 from two academic hospitals in Toronto, Canada. First, HCPs were observed during discharge discussions with patients to determine needs. Results informed selection and development of the tool by the multidisciplinary planning committee, namely an online course. It was pilot-tested with target users through a think-aloud protocol with subsequent semi-structured interviews, until saturation was achieved. Results informed refinement before launching the course. Finally, to evaluate impact, HCPs were surveyed to test whether knowledge, attitudes, self-efficacy and practice changed from before watching the course, through to post-course and 1 month later., Results: Seven nurses (71.4% female) were observed. Five (62.5%) initiated dialogue about CR, which lasted on average 12 s. Patients asked questions, which HCPs could not answer. The planning committee decided to develop an online course to reach inpatient cardiac HCPs, to educate them on how to encourage patients to participate in CR at the bedside. The course was pilot-tested with 5 HCPs (60.0% nurse-practitioners). Revisions included providing evidence of CR benefits and clarification regarding pre-CR stress test screening. HCPs did not remember the key points to convey, so a downloadable handout was embedded for the point-of-care. The course was launched, with the surveys. Twenty-four HCPs (83.3% nurses) completed the pre-course survey, 21 (87.5%) post, and 9 (37.5%) 1 month later. CR knowledge increased from pre (mean = 2.71 ± 0.95/5) to post-course (mean = 4.10 ± 0.62; p ≤ .001), as did self-efficacy in answering patient CR questions (mean = 2.29 ± 0.95/5 pre and 3.67 ± 0.58 post; p ≤ 0.001). CR attitudes were significantly more positive post-course (mean = 4.13 ± 0.95/5 pre and 4.62 ± 0.59 post; p ≤ 0.05). With regard to practice, 8 (33.3%) HCPs reported providing patients CR handouts pre-course at least sometimes or more, and 6 (66.7%) 1 month later., Conclusions: Preliminary results support broader dissemination, and hence a genericized version has been created ( http://learnonthego.ca/Courses/promoting_patient_participation_in_CR_2020/promoting_patient_participation_in_CR_2020EN/story_html5.html ). Continuing education credits have been secured.

Purpose: Cardiac rehabilitation (CR) is a recommendation in international clinical practice guidelines given its benefits; however, use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrollment and adherence into implementable recommendations., Methods: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patients' utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A Web call was convened to achieve consensus and confirm strength of the recommendations (based on Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review and public comment., Results: The 3 drafted recommendations were that to increase enrollment, health care providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence, part of CR could be delivered remotely (weak). Ratings (mean ± SD) for the 3 recommendations were 5.95 ± 0.69, 5.33 ± 1.12, and 5.64 ± 1.08, respectively., Conclusions: Interventions can significantly increase utilization of CR and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization and to ensure that CR programs are adequately resourced to serve enrolling patients and support them to complete programs.

Background: Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its' benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations., Methods: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was convened to achieve consensus and confirm strength of the recommendations (based on GRADE). The draft underwent external review and public comment., Results: The 3 drafted recommendations were that to increase enrolment, healthcare providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence part of CR could be delivered remotely (weak). Ratings for the 3 recommendations were 5.95 ± 0.69 (mean ± standard deviation), 5.33 ± 1.12 and 5.64 ± 1.08, respectively., Conclusions: Interventions can significantly increase utilization of CR, and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization, and to ensure CR programs are adequately resourced to serve enrolling patients and support them to complete programs., (Copyright © 2019. Published by Elsevier B.V.)

Objective: Coronary artery disease (CAD) is frequently accompanied by white matter hyperintensities and executive dysfunction. Because acetylcholine is important in executive function, these symptoms may be exacerbated by subcortical hyperintensities (SH) located in cholinergic (CH) tracts. This study investigated the effects of SH on cognitive changes in CAD patients undergoing a 48-week cardiac rehabilitation program., Methods: Fifty patients (age 66.5 ± 7.1 years, 84% male) underwent the National Institute of Neurological Disorders and Stroke - Canadian Stroke Network neurocognitive battery at baseline and 48 weeks. Patients underwent a 48-week cardiac program and completed neuroimaging at baseline. Subcortical hyperintensities in CH tracts were measured using Lesion Explorer. Repeated measures general linear models were used to examine interactions between SH and longitudinal cognitive outcomes, controlling for age, education, and max VO 2 change as a measure of fitness., Results: In patients with SH in CH tracts, there was a significant interaction with the Trail Making Test (TMT) part A and part B over time. Patients without SH improved on average 16.6 and 15.0% on the TMT-A and TMT-B, respectively. Patients with SH on average showed no improvements in either TMT-A or TMT-B over time. There were no significant differences in other cognitive measures., Conclusion: These results suggest that CAD patients with SH in CH tracts improve less than those without SH in CH tracts, over 48 weeks of cardiac rehabilitation. Thus, SH in CH tracts may contribute to longitudinal cognitive decline following a cardiac event and may represent a vascular risk factor of cognitive decline. © 2017 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons Ltd., (© 2017 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons Ltd.)

Objective: Coronary artery disease (CAD) is associated with an increased risk of cognitive decline. Although cerebral white matter (WM) damage predicts cognitive function in CAD, conventional neuroimaging measures only partially explain the effect of CAD on cognition. The purpose of this study was to determine if WM microstructural integrity and CAD using diffusion tensor imaging (DTI) correlates with cognitive function in older adults with CAD., Methods: Forty-nine CAD patients (66 ± 7 years old, 86% male) underwent neurocognitive assessments using the cognitive battery recommended by the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network for the study of vascular cognitive impairment. Composite scores for each cognitive domain were calculated. Microstructural integrity in normal-appearing WM was quantified as fractional anisotropy (FA) using DTI in nine bilateral and two interhemispheric WM tracts from the Johns Hopkins University WM Tractography Atlas. Linear regression models examined associations between FA and cognitive performance, controlling for age, sex, and education, with correction for multiple comparisons using a false discovery rate of 5%., Results: Executive function was most significantly associated with FA in the left parahippocampal cingulum (β = 0.471, t = 3.381, df = 44, p = 0.002) and left inferior fronto-occipital fasciculus (β = 0.430, t = 2.984, df = 44, p = 0.005). FA was not associated with memory in any of the WM tracts examined., Conclusion: These results suggest that WM microstructural integrity may be an important neural correlate of executive function even in cognitively intact CAD patients. This study suggests WM damage may be relevant to subtle cognitive decline in a population that may have early neural risk for dementia., (Copyright © 2015 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Clinicians frequently encounter and grapple with complex ethical issues and perplexing moral dilemmas in critical care settings. Intensive care unit (ICU) clinicians often experience moral distress in situations in which the ethically right course of action is intuitively known, but cannot be acted on. Most challenging cases pertain to end-of-life issues. Researchers have shown that moral distress and moral residue are common among critical care nurses. It is, therefore, essential that all ICU clinicians (and nurses, in particular) have an ongoing opportunity to work safely through these ethical dilemmas and conflicts. In this article, we describe the medical surgical intensive care unit (MSICU) experience with its monthly ethics initiative and explore the next steps to enhance its use through maximizing attendance and value to MSICU clinicians. To optimize attendance of staff a small group discussion among critical care clinicians (n = 8) was conducted asking about their perceptions of the debriefing sessions and their suggestions on how to promote their use. Process changes were implemented based on the group's suggestions. The process changes resulted in increased awareness of the benefits, increased frequency of sessions and demonstrated utility. Lessons learned from the MSICU experience will inform the development of education curricula to help critical care nurses with challenging end-of-life situations.