HH adherence of junior practitioners improved under the supervision of adherent role models. These results suggest that HH behavior of senior practitioners plays a crucial influence on other staff. Senior healthcare practitioners should consider the important role they may play in reinforcing or weakening a culture of patient safety and proper HH.

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OBJECTIVE: To identify preoperative, intraoperative, and postoperative predictors of early (6 hours or less after surgery) and delayed (more than 6 hours) extubation after coronary artery bypass graft surgery. METHODS: The sample for this prospective nonrandomized study consisted of 116 consecutive patients in a 12-bed cardiothoracic ICU who had coronary artery bypass graft surgery in a 6-month period and were followed up prospectively until transfer to an observation unit. RESULTS: Age and the presence of early hemodynamic instability (within the first 3 hours after ICU admission) were independent predictors of intubation times of more than 6 hours when each was considered in separate multivariate models of preoperative, intraoperative, and postoperative variables. In a combined model, when considered with age and ejection fraction, the presence of early hemodynamic instability increased the odds by 4.7 times that extubation would occur more than 6 hours after surgery. For every 1 year increase in age, the odds of extubation occurring more than 6 hours after surgery increased by 6.5%. CONCLUSIONS: Older age and the presence of early hemodynamic instability are associated with postoperative intubation periods of more than 6 hours after coronary artery bypass graft surgery. Clinicians should evaluate extubation goals in older patients carefully. Clinical management of hemodynamic instability should be aimed at prompt optimization of myocardial oxygen supply to limit ischemia and its sequelae.

BackgroundThe practice standard for electrocardiographic monitoring in hospitals recommends use of atrial electrograms after cardiac surgery to help diagnose cardiac arrhythmias. Objectives To determine whether use of atrial electrograms significantly improves nurses' ability to diagnose cardiac arrhythmias and to assess nurses' perceptions of the ease of obtaining and interpreting electrograms, the frequency of use of atrial electrograms, and the correlation between nurses' experience with the technique and arrhythmia scores. Methods In total, 282 nurses completed a test consisting of 5 electrocardiographic rhythms for which use of atrial electrograms might improve interpretation. A standardized educational session on obtaining and interpreting atrial electrograms was given to 165 nurses who had not previously received such education. In a second test, the same rhythms were provided along with atrial electrograms to 261 nurses. Overall changes in total test scores and individual changes in interpreting rhythms were analyzed. Demographic information, perceptions of the ease of obtaining and interpreting atrial electrograms, and the frequency of use were collected. Correlation between scores on the second test and nurses' years of experience in interpreting atrial electrograms was determined. Results Use of atrial electrograms significantly increased overall arrhythmia interpretation scores. Nurses rated obtaining atrial electrograms as easy and interpreting the findings as moderately easy. Despite this reported ease, 57.1% of nurses obtained atrial electrograms less than monthly and only 3.4% obtained them daily. Correlation between experience with atrial electrograms and arrhythmia test scores was not significant. Conclusions Nurses' use of atrial electrograms improves diagnoses of cardiac arrhythmias. (American Journal of Critical Care. 2010;19:124-134) CARDIAC SURGICAL NURSES' USE OF ATRIAL ELECTROGRAMS TO IMPROVE DIAGNOSIS OF ARRHYTHMIA C E 1.0 Hour Notice to CE enrollees:A closed-book, multiple-choice examination following this article tests your under standing of the following objectives:1. Identify clinical indications for the use of atrial electrograms (AEGs). 2. Describe the process for obtaining an AEG. 3. Discuss 3 rhythms that an AEG would assist the nurse in interpreting. AEGs record cardiac activity directly from the surface of the right atrium via pacemaker wires. The AEG waveform provides a distinct spike representing atrial depolarization. AEGs can be recorded from the right atrial lead of permanent pacemakers to assess the origin of an arrhythmia.In postoperative cardiac surgical patients, AEGs can be recorded via the atrial pacemaker wires that are routinely placed at the conclusion of many cardiac surgical procedures. In tachycardic rhythms that are common postoperatively, the p wave on the surface electrocardiogram (ECG) may be obscured by the preceding t wave, and evaluation for the presence, quality, or absence of atrial activity can be difficult. AEGs can facilitate diagnosis of cardi...