Memo For Change in Policy Nu 708

CONFIDENTIAL
Memorandum
To: CNO Glenda Powell, MSN, RN

From: Joseph H Mitchell BSN, RN
Date: November 11, 2018
Re: Policy Brief for Perioperative Beta (β) Blockers Use
Message
Knowledge is ever changing in the world of nursing in accenting patient-centered care.
Building on this paradigm, we must sometimes adjust clinical practices to strengthen our
roles as patient advocates. This model includes changing policies regarding the way we
prepare patients for surgery.
Atrial fibrillation is a substantial concern for post-surgical patients and is one of the most
significant complications after surgical intervention. During my tenure on this vascular/
endovascular unit, a clinical conundrum broached itself. Does the administration of a
beta blocker preoperatively as compared to not administering a beta blocker reduce the
risk of atrial fibrillation postoperatively in surgical patients?
A critical undertaking of evidence arose to answer this question to appraise its'

application in practice. Evidence suggested that an essential change in policy was
required regarding the administration of a beta-blocker peri-operatively to reduce the
incidence of post-surgical atrial fibrillation. Through this search for knowledge, multiple
articles were discovered that substantiate this necessity for change. Asernault et al.
(2013), in a systematic review of 118 randomized control trials, found that beta-blockers
significantly reduce post-surgical atrial fibrillation. We can be confident that the
evidence is credible since is it at the highest level of the evidence hierarchy with a
confidence interval of 95%.
Another source that validates this change is a single-blind, randomized control trial
executed by Skiba et al. (2013). In this level two research design, several methods were
used to conduct measurements on 215 cardiac patients which included logistic
regression analysis, intention to treat analysis, per protocol analysis, and ECG
monitoring. During the study, they found that metoprolol had a significant reduction of
atrial fibrillation post-surgically with an occurrence rate of 0.31 and a p-value of 0.048,
which suggests a robust evidentiary correlation. Lastly, another single-blind, randomized
control trial executed by Horikoshi et al. (2017) investigated the inhibitory effects of
landiolol on new-onset atrial fibrillation.
CONFIDENTIAL
Memorandum
CNO Powell, MSN, RN August 11, 2018 page 2
Through instrumenting Chi-square testing using GraphPad 6 software, the incidence of

atrial fibrillation observed in the interventional group receiving landiolol found only one
of the nineteen participants experienced new-onset atrial fibrillation post-surgery.
From the evidence presented, there is a clinical recommendation suggested for your
evaluation. Grounded in the information provided, every surgical patient should receive
the opportunity to be administered a β-blocker before elective interventions to reduce
the risk of atrial fibrillation post-surgically. During my employment on this vascular/
endovascular surgical unit, there have been patients who have experienced this
anomaly. As an experienced healthcare provider, multiple years practice, and an array of
background work in both medical/ surgical units and intensive care settings, reducing
known associated risks is one of the preferred ways in which we can provide a sound
care model for our patients. For assertion of the best practice during this process, a
collective inventory of my clinical skills was undertaken to provide the most accurate
measure of the information disseminated to the patients on this unit (Melnyk & Fineout-
Overholt, 2015). In consideration of this proposed change in policy, it is important to also
engage the patient in this decision process. Following the Institute for Healthcare
Improvement recommendations, the patient will take center stage as we acclimate the
policy changes around their beliefs and predilections (Melnyk & Fineout-Overholt, 2015).
Thank you for your contemplation in completing this change in policy. My hope is that
the information presented will offer insight into making the most relevant decision in
support of this change. Together, we can make a difference in the lives of the operative
individuals by providing them with the best, most inclusive level of quality care.
References
Arsenault, K., Yusuf, A., Crystal, E., Healey, J., Morillo, C., Nair, G., & Whitlock, R. (2013, January 31).
Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery.
Cochrane Database of Systematic Reviews, 2021(4), 1-196. doi: 10.1002/14651858.cd003611.pub3
Horikoshi, Y., Goyagi, T., Kudo, R., Kodama, S., Horiguchi, T., & Nishikawa, T. (2017). The suppressive
effects of landiolol administration on the occurrence of postoperative atrial fibrillation and
tachycardia, and plasma IL-6 elevation in patients undergoing esophageal surgery: A randomized
controlled clinical trial. Journal of clinical anesthesia, (38). 111–116. doi://doi-org.lib-
proxy.jsu.edu/10.1016/j.jclinane.2017.01.036
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide
to best practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
Skiba, M., Pick, A., Chaudhuri, K., Bailey, M., Krum, H., Kwa, L., & Rosenfeldt, F. (2013). Prophylaxis
against atrial fibrillation after cardiac surgery: Beneficial Effect of perioperative metoprolol. Heart,
Lung & Circulation, 22(8), 627-633. doi: 10.1016/j.hlc.2012.12.017

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CONFIDENTIAL

To: CNO Glenda Powell, MSN, RN

A critical undertaking of evidence arose to answer this question to appraise its'

CNO Powell, MSN, RN August 11, 2018 page 2

Through instrumenting Chi-square testing using GraphPad 6 software, the incidence of

Cochrane Database of Systematic Reviews, 2021(4), 1-196. doi: 10.1002/14651858.cd003611.pub3

effects of landiolol administration on the occurrence of postoperative atrial fibrillation and

controlled clinical trial. Journal of clinical anesthesia, (38). 111–116. doi://doi-org.lib-

to best practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.

Lung & Circulation, 22(8), 627-633. doi: 10.1016/j.hlc.2012.12.017

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