Acute postoperative care in cardiac surgery: the importance of nurse-led interventions

This invited commentary refers to ‘Nurse-led acute care postoperative interventions in adult cardiac surgery: a systematic review’ by S. Matthews et al., https://doi.org/10.1093/eurjcn/zvag112. Open-heart surgery, specifically coronary artery bypass grafting remains the recommended treatment modality for patients with high-complexity coronary artery disease.1,2 In addition, surgical aortic valve replacement is advised for patients younger than 70 years who are assessed as having a low operative risk.3 Guidelines for perioperative care in cardiac surgery provide graded recommendations for enhanced recovery after surgery (ERAS) that are derived from an medical expert consensus–based appraisal of the current evidence, including meta-analyses, randomized controlled trials, large nonrandomized observational studies, and systematic reviews.4 ERAS constitutes a standardized, multimodal, and transdisciplinary perioperative care pathway designed to optimize postoperative recovery, reduce the incidence of complications, and shorten hospital length of stay by glycaemic control, pain management, delirium screening, prevention of hypothermia, chest tube patency, chemical thromboprophylaxis, extubation strategies, acute kidney injury, and goal-directed fluid therapy.4 Fleming et al.5 question whether a formal nurse-led postoperative, goal-directed therapy protocol can lead to improved outcomes. Specialized cardiac surgical nurses play a pivotal role for ERAS by providing continuous, around-the-clock care that includes ongoing clinical assessment, evidence-based interventions, patient education, and coordination of multidisciplinary care for patients in the acute postoperative phase following cardiac surgery.6 A major challenge is the insufficient systematic synthesis of nurse-led interventions to inform evidence-based nursing practice to optimize outcomes for patients undergoing cardiac surgery, particularly during the acute postoperative phase extending from admission to the intensive care unit (ICU) through to hospital discharge. The distinctive feature of Matthews et al. systematic review7 is its focus on evaluating randomized controlled trials of nurse-led interventions in which specialized cardiac surgical nurses, acting either autonomously or in collaboration with other health care professionals, coordinate and deliver patient care. Interventions identified were grouped into seven domains: (i) Behavioural support, (ii) temperature management and comfort strategies, (iii) pain and symptom management, (iv) wound care, (v) infection prevention, (vi) respiratory and pulmonary function, and (vii) postoperative recovery, mobilization, and hydration. As an intervention example, Alwekhyan et al.8 conducted a study involving 89 patients to evaluate nurse-guided use of incentive spirometry compared with standard postoperative care initiated 24 h after surgery. Patients allocated to the intervention group exhibited a significantly lower mean frequency of hypoxic events, as well as a reduced length of stay in both the intensive care unit and the hospital overall. Due to the heterogeneity of interventions and outcomes, the incompleteness of statistical data, and variability in reporting formats, a narrative synthesis rather than a meta-analysis was warranted. Nonetheless, a consistent direction of benefit was observed across multiple intervention domains. In Matthews et al.7 ‘Nurse-led acute care postoperative interventions in adult cardiac surgery: A systematic review’, the authors conducted rigorous methodological procedures to synthesize high-quality evidence from randomized controlled trials (RCTs) evaluating nurse-led interventions for adult patients undergoing cardiac surgery during the acute postoperative period. Firstly, an a priori protocol for the study was registered in PROSPERO to ensure research transparency, in accordance with the Joanna Briggs Institute methodology for effective systematic reviews.9 Furthermore, the conduct and reporting of this review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.10 Secondly, a comprehensive literature search was performed in the databases Medline, Embase, CINAHL, Cochrane Central, PsycINFO, and Emcare. Identified records were imported into Covidence, after which two reviewers independently screened them against the predefined inclusion criteria: adults undergoing open heart surgery, nurse-led inpatient care intervention compared with usual care and the outcomes of the review included without being limited to postoperative complications, ICU and hospital length of stay, readmissions, pain, comfort, physiological parameters, and patient-reported outcomes. Clarifications from study authors were obtained via email where necessary. This systematic review reports on relevant outcomes in accordance with the PRISMA guidelines for the conduct and reporting of systematic reviews.10 From a methodological perspective, the selection of outcomes for a systematic review should be firmly anchored in the existing body of evidence and informed by pertinent literature and clinical relevance,11 as delineated in both the registered PROSPERO protocol and the final manuscript to avoid discrepancies in outcome reporting, which in turn can result in outcome reporting bias.12 Further, this systematic review in total screened 2335 titles and abstracts, of which 19 RCT (n = 3141) across 13 countries ultimately met the inclusion criteria. Thirdly, the methodological quality of the included RCTs was evaluated using the Cochrane Risk of Bias tool,13 which revealed that only 2 of the 19 studies presented a low risk of bias. In these 19 studies, the greatest risks of bias were primarily associated with the randomization process (n = 6), deviations from the intended interventions (n = 4), missing outcome data (n = 3), and bias in outcome measurement (n = 3). The strength of the rigorous and transparent reporting of risk of bias in primary studies enhances the critical appraisal of evidence by healthcare decision makers and patients and may, in turn, promote the design and conduct of higher-quality clinical trials, thereby generating more robust and reliable evidence.13 As concluded by Matthews et al.,7 their review establishes a critical foundation for the design and implementation of future high-quality investigations, with particular relevance to advancing the evidence base on nurse-led interventions in adult cardiac surgery. Irene Lie (Conceptualization, Writing—original draft lead) None declared. This commentary does not contain new data.