Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

Markov model for detection of ECG instability prior to cardiac arrest in single-ventricle patients

OBJECTIVES

Assess the degree of instability in the electrocardiogram (ECG) waveform in patients with single-ventricle physiology before a cardiac arrest and compare them with similar patients who did not experience a cardiac arrest.

METHODS

Retrospective control study in patients with single-ventricle physiology who underwent Norwood, Blalock-Taussig shunt, pulmonary artery band, and aortic arch repair from 2013 to 2018. Electronic medical records were obtained for all included patients. For each subject, 6 h of ECG data were analyzed. In the arrest group, the end of the sixth hour coincides with the cardiac arrest. In the control group, the 6-h windows were randomly selected. We used a Markov chain framework and the likelihood ratio test to measure the degree of ECG instability and to classify the arrest and control groups.

RESULTS

The study dataset consists of 38 cardiac arrest events and 67 control events. Our Markov model was able to classify the arrest and control groups based on the ECG instability with an ROC AUC of 82% at the hour preceding the cardiac arrests.

CONCLUSION

We designed a method using the Markov chain framework to measure the level of instability in the beat-to-beat ECG morphology. Furthermore, we were able to show that the Markov model performed well to distinguish patients in the arrest group compared to the control group.

Improvements in Accuracy and Confidence in Rhythm Identification After Cardiac Surgery Using the AtriAmp Signals

Objectives: Following cardiac surgery, 50% to 60% of patients with congenital heart disease will experience an arrhythmia. These arrhythmias are associated with increased morbidity and mortality. Therefore, rapid and accurate identification is paramount to the improvement of patient outcome. We hypothesize that the AtriAmp, a device which allows atrial electrogram (AEG) display on the bedside monitors, will increase provider accuracy and confidence in arrhythmia diagnosis. Design: A prospective observational study. Electrograms were collected from post-operative patients from the bedside monitors surface ECG and an AEG using the AtriAmp. A 12-question online survey was given to critical care and cardiology providers at 9 different programs across the country as well as being posted to the AAP SOCC fall newsletter. Six questions displayed signals from only the surface leads, while the other 6 showed the same arrhythmias with an AEG obtained from the AtriAmp. Answers were then evaluated for confidence and accuracy. A paired t-test along with mixed method modeling was used to assess the data. Setting: Cardiac pediatric ICU. Subjects: Providers in pediatric cardiology and pediatric critical care were evaluated on their ability to diagnose arrhythmias on surface ECG and AEG obtained from bedside monitor. Interventions: The accuracy and confidence of diagnosis of both surface and AEG signals were evaluated through an on-line survey. Results: Eighty-eight providers completed the survey. The study showed that interpreting with the AtriAmp signal, compared to the surface ECG only, significantly increased the accuracy (P = .002) and confidence in provider rhythm diagnosis (P < .001). Junctional ectopic tachycardia, sinus tachycardia, and complete heart block had the most significant increase in accuracy of diagnose when using the AtriAmp signal (P < .001, P = .002, P = .010, respectively). Conclusion: Use of the AtriAmp increased provider accuracy and confidence in post-operative rhythm diagnosis when compared to diagnosis using the surface electrograms only.

An old diagnostic tool for new indications: inpatient Holter ECG for conditions other than syncope or stroke

Holter electrocardiography (ECG) assists in the diagnosis of arrhythmias. Its use in the inpatient setting has been described solely for the evaluation of stroke and syncope. Our aim was to assess its diagnostic value for other conditions in the internal medicine department. We included all hospitalized patients between 2018 and 2021 in a tertiary referral center. The primary outcome was a diagnostic Holter recording a new arrhythmia that led to a change in treatment. Overall, 289 patients completed a 24-h inpatient Holter ECG for conditions other than syncope or stroke, with 39 (13%) diagnostic findings. The highest diagnostic value was found in patients admitted for pre-syncope (19%), palpitations (18%), and unexplained heart failure exacerbation/dyspnea (17%). A low diagnostic yield was found for the evaluation of chest pain (5%). Heart failure with preserved ejection fraction (adjusted OR 2.3, 95% CI 1.1-5.4, p = 0.04), and baseline ECG with either a bundle branch block (AOR 4.2, 95% CI 1.9-9.2, p < 0.01) or atrioventricular block (first or second degree, AOR 5, 95% CI 2.04-12.3, p < 0.01) were among the independent predictors for a diagnostic test. Inpatient Holter ECG monitoring may have value as a diagnostic tool for selected patients with conditions other than syncope or stroke.

Evaluation of premature ventricular complexes during in-hospital ECG monitoring as a predictor of ventricular tachycardia in an intensive care unit cohort

In-hospital electrocardiographic (ECG) monitors are typically configured to alarm for premature ventricular complexes (PVCs) due to the potential association of PVCs with ventricular tachycardia (VT). However, no contemporary hospital-based studies have examined the association of PVCs with VT. Hence, the benefit of PVC monitoring in hospitalized patients is largely unknown. This secondary analysis used a large PVC alarm data set to determine whether PVCs identified during continuous ECG monitoring were associated with VT, in-hospital cardiac arrest (IHCA), and/or death in a cohort of adult intensive care unit patients. Six PVC types were examined (i.e., isolated, bigeminy, trigeminy, couplets, R-on-T, and run PVCs) and were compared between patients with and without VT, IHCA, and/or death. Of 445 patients, 48 (10.8%) had VT; 11 (2.5%) had IHCA; and 49 (11%) died. Isolated and run PVC counts were higher in the VT group (p = 0.03 both), but group differences were not seen for the other four PVC types. The regression models showed no significant associations between any of the six PVC types and VT or death, although confidence intervals were wide. Due to the small number of cases, we were unable to test for associations between PVCs and IHCA. Our findings suggest that we should question the clinical relevance of activating PVC alarms as a forewarning of VT, and more work should be done with larger sample sizes. A more precise characterization of clinically relevant PVCs that might be associated with VT is warranted.

Clinician Perspectives on Specifications for Metrics to Inform Pediatric Alarm Management

Background: Ongoing management of monitor alarms is important for reducing alarm fatigue among clinicians (e.g., nurses, physicians). Strategies to enhance clinician engagement in active alarm management in pediatric acute care have not been well explored. Access to alarm summary metrics may enhance clinician engagement. Objective: To lay the foundation for intervention development, we sought to identify functional specifications for formulating, packaging, and delivering alarm metrics to clinicians. Methods: Our team of clinician scientists and human factors engineers conducted focus groups with clinicians from medical-surgical inpatient units in a children's hospital. We inductively coded transcripts, developed codes into themes, and grouped themes into "current state" and "future state." Results: We conducted five focus groups with 13 clinicians (eight registered nurses and five doctors of medicine). In the current state, information exchanged among team members about alarm burden is initiated by nurses on an ad hoc basis. For a future state, clinicians identified ways in which alarm metrics could help them manage alarms and described specific information, such as alarm trends, benchmarks, and contextual data, that would support decision-making. Conclusion: We developed four recommendations for future strategies to enhance clinicians' active management of patient alarms: (1) formulate alarm metrics for clinicians by categorizing alarm rates by type and summarizing alarm trends over time, (2) package alarm metrics with contextual patient data to facilitate clinicians' sensemaking, (3) deliver alarm metrics in a forum that facilitates interprofessional discussion, and (4) provide clinician education to establish a shared mental model about alarm fatigue and evidence-based alarm-reduction strategies.

Added value of patient- and drug-related factors to stratify drug-drug interaction alerts for risk of QT prolongation: Development and validation of a risk prediction model

AIMS

Many clinical decision support systems trigger warning alerts for drug-drug interactions potentially leading to QT prolongation and torsades de pointes (QT-DDIs). Unfortunately, there is overalerting and underalerting because stratification is only based on a fixed QT-DDI severity level. We aimed to improve QT-DDI alerting by developing and validating a risk prediction model considering patient- and drug-related factors.

METHODS

We fitted 31 predictor candidates to a stepwise linear regression for 1000 bootstrap samples and selected the predictors present in 95% of the 1000 models. A final linear regression model with those variables was fitted on the original development sample (350 QT-DDIs). This model was validated on an external dataset (143 QT-DDIs). Both true QTc and predicted QTc were stratified into three risk levels (low, moderate and high). Stratification of QT-DDIs could be appropriate (predicted risk = true risk), acceptable (one risk level difference) or inappropriate (two risk levels difference).

RESULTS

The final model included 11 predictors with the three most important being use of antiarrhythmics, age and baseline QTc. Comparing current practice to the prediction model, appropriate stratification increased significantly from 37% to 54% appropriate QT-DDIs (increase of 17.5% on average [95% CI +5.4% to +29.6%], p_adj  = 0.006) and inappropriate stratification decreased significantly from 13% to 1% inappropriate QT-DDIs (decrease of 11.2% on average [95% CI -17.7% to -4.7%], p_adj  ≤ 0.001).

CONCLUSION

The prediction model including patient- and drug-related factors outperformed QT alerting based on QT-DDI severity alone and therefore is a promising strategy to improve DDI alerting.

Wireless Single-Lead versus Standard 12-Lead ECG, for ST-Segment Deviation during Adenosine Cardiac Stress Scintigraphy

Wearable wireless electrocardiographic (ECG) monitoring is well-proven for arrythmia detection, but ischemia detection accuracy is not well-described. We aimed to assess the agreement of ST-segment deviation from single- versus 12-lead ECG and their accuracy for the detection of reversible ischemia. Bias and limits of agreement (LoA) were calculated between maximum deviations in ST segments from single- and 12-lead ECG during 82Rb PET-myocardial cardiac stress scintigraphy. Sensitivity and specificity for reversible anterior-lateral myocardial ischemia detection were assessed for both ECG methods, using perfusion imaging results as a reference. Out of 110 patients included, 93 were analyzed. The maximum difference between single- and 12-lead ECG was seen in II (-0.019 mV). The widest LoA was seen in V5, with an upper LoA of 0.145 mV (0.118 to 0.172) and a lower LoA of -0.155 mV (-0.182 to -0.128). Ischemia was seen in 24 patients. Single-lead and 12-lead ECG both had poor accuracy for the detection of reversible anterolateral ischemia during the test: single-lead ECG had a sensitivity of 8.3% (1.0-27.0%) and specificity of 89.9% (80.2-95.8%), and 12-lead ECG a sensitivity of 12.5% (3.0-34.4%) and a specificity of 91.3% (82.0-96.7%). In conclusion, agreement was within predefined acceptable criteria for ST deviations, and both methods had high specificity but poor sensitivity for the detection of anterolateral reversible ischemia. Additional studies must confirm these results and their clinical relevance, especially in the light of the poor sensitivity for detecting reversible anterolateral cardiac ischemia.

Utility of short-term telemetry heart rhythm monitoring and CHA2DS2-VASc stratification in patients presenting with suspected cerebrovascular accident

BACKGROUND

Inpatient telemetry heart rhythm monitoring overuse has been linked to higher healthcare costs.

AIM

To evaluate if CHA2DS2-VASc score could be used to indicate if a patient admitted with possible cerebrovascular accident (CVA) or transient ischemic attack (TIA) requires inpatient telemetry monitoring.

METHODS

A total of 257 patients presenting with CVA or TIA and placed on telemetry monitoring were analyzed retrospectively. We investigated the utility of telemetry monitoring to diagnose atrial fibrillation/flutter and the CHA2DS2-VASc scoring tool to stratify the risk of having CVA/TIA in these patients.

RESULTS

In our study population, 63 (24.5%) of the patients with CVA/TIA and telemetry monitoring were determined to have no ischemic neurologic event. Of the 194 (75.5) patients that had a confirmed CVA/TIA, only 6 (2.3%) had an arrhythmia detected during their inpatient telemetry monitoring period. Individuals with a confirmed CVA/TIA had a statistically significant higher CHA2DS2-VASc score compared to individuals without an ischemic event (3.59 vs 2.61, P < 0.001).

CONCLUSION

Given the low percentage of inpatient arrhythmias identified, further research should focus on discretionary use of inpatient telemetry on higher risk patients to diagnose the arrhythmias commonly leading to CVA/TIA. A prospective study assessing event rate of CVA/TIA in patients with higher CHA2DS2-VASc score should be performed to validate the CHA2DS2-VASc score as a possible risk stratifying tool for patients at risk for CVA/TIA.

Can triage nurses accurately interpret the electrocardiogram in the emergency department to predict acute cardiovascular events? A prospective observational study

AIMS

The prompt recording of the electrocardiogram (ECG) and its correct interpretation is crucial to the management of patients who present to the emergency department (ED) with cardiovascular symptoms. Since triage nurses represent the first healthcare professionals evaluating the patient, improving their ability in interpreting the ECG could have a positive impact on clinical management. This real-world study investigates whether triage nurses can accurately interpret the ECG in patients presenting with cardiovascular symptoms.

DESIGN

Prospective, single-centre observational study conducted in a general ED of General Hospital of Merano in Italy.

METHODS

For all patients included, the triage nurses and the emergency physicians were asked to independently interpret and classify the ECGs answering to dichotomous questions. We correlated the interpretation of the ECG made by the triage nurses with the occurrence of acute cardiovascular events. The inter-rater agreement in ECG interpretation between physicians and triage nurses was evaluated with Cohen's kappa analysis.

RESULTS

Four hundred and ninety-one patients were included. The inter-rater agreement between triage nurses and physicians in classifying an ECG as abnormal was good. Patients who developed an acute cardiovascular event were 10.6% (52/491), and in 84.6% (44/52) of them, the nurse accurately classified the ECG as abnormal, with a sensitivity of 84.6% and a specificity of 43.5%.

CONCLUSION

Triage nurses have a moderate ability in identifying alterations in specific components of the ECG but a good ability in identifying patterns indicative of time-dependent conditions correlated with major acute cardiovascular events.

IMPACT FOR NURSING

Triage nurses can accurately interpret the ECG in the ED to identify patients at high risk of acute cardiovascular events.

REPORTING METHOD

The study was reported according to the STROBE guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

The study did not involve any patients during its conduction.

Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system

BACKGROUND

Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing.

METHODS

This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system. The electronic health record intervention involved the addition of a mandatory indication in the telemetry order and a best practice advisory (BPA) that would fire after the recommended time period for reassessment had passed.

RESULTS

The average telemetry hours per patient encounter went from 60.1 preintervention to 48.4 postintervention, a 19.5% reduction (p < .001). When stratified by the 11 hospitals, decreases ranged from 9% to 30%. The BPA had a 53% accept rate and fired 52,682 times, with 27,938 "discontinue telemetry" orders placed. The true accept rate was 50.4%, as there was a 2.6% 24-h reorder rate. There was variation based on clinician specialty and clinician type (attending, fellow, resident, physician associate, nurse practitioner).

CONCLUSION

We successfully reduced telemetry monitoring across a multisite safety net system using solely an electronic health record (EHR) intervention. This expands on previous telemetry monitoring reduction initiatives using EHR interventions at single academic sites. Further study is needed to investigate variation across clinician type, specialty, and post-acute sites.

Electrophysiological properties and heart rate variability of patients with thalassemia major in Jakarta, Indonesia

Beta thalassemia major (TM) is a common hereditary disease in Indonesia. Iron overload due to regular transfusion may induce myocardial iron deposition leading to electrophysiological dysfunction and functional disorders of the heart. Ventricular arrhythmia is one of the most common causes of sudden cardiac death in thalassemia patients. This cross-sectional study of 62 TM patients aged 10-32 years in Cipto Mangunkusumo General Hospital was done to assess their electrophysiological properties and heart rate variability, including 24- hour Holter monitoring, signal averaged electrocardiogram (SAECG) for detection of ventricular late potential (VLP), and determination of heart rate variability (HRV). We also assessed their 12-lead ECG parameters, such as P wave, QRS complex, QT/ QTc interval, QRS dispersion, and QT/ QTc dispersion. Iron overload was defined by T2-star magnetic resonance (MR-T2*) values of less than 20 ms or ferritin level greater than 2500 ng/mL. Subjects were grouped accordingly. There were significant differences of QTc dispersion (p = 0.026) and deceleration capacity (p = 0.007) between MR-T2* groups. Multivariate analysis showed an inverse correlation between QTc dispersion and MR-T2* values. There was a proportional correlation between heart rate deceleration capacity in the low MR-T2* group (p = 0.058) and the high ferritin group (p = 0.007). No VLPs were detectable in any patients. In conclusion, prolonged QTc dispersion and decreased heart rate deceleration capacity were significantly correlated with greater odds of iron overload among patients with Thalassemia major.

Determinants of Medical Equipment Alarm Fatigue in Practicing Nurses: A Systematic Review

Objective

This study aimed to systematically evaluate the level of medical equipment alarm fatigue and its influencing factors among clinical nurses.

Methods

PubMed, Embase, CNKI, and Wanfang databases were systematically searched to identify articles on alarm fatigue of clinical nurses published before September 25, 2022. According to the evaluation criteria of prevalence studies recommended by JBI Evidence-Based Health Care Center, the quality of the literature meeting the inclusion criteria was evaluated, and Stata MP17 software was used for meta-analysis.

Results

A total of 14 cross-sectional studies were included, with a total sample of 2,848 nurses. The results showed that the alarm fatigue score of clinical nurses was 21.76 (95% CI [20.27, 23.25]). Subgroup analysis showed that the nurses who worked night shift and had lower professional title had higher alarm fatigue.

Conclusion

The alarm fatigue of clinical nurses was at a moderate level. To reduce the alarm fatigue level of clinical nurses, nursing managers should strengthen the alarm safety awareness of nurses, rationally arrange nurse manpower, carry out training to actively improve the alarm management ability of nurses, and optimize the alarm level and frequency of alarm equipment.

Association of QT interval-prolonging drugs with clinical trial eligibility in patients with advanced cancer

Introduction

Drug-induced prolongation of the heart rate-corrected QT interval (QTc) is associated with increased risk for the potentially fatal arrhythmia torsades de pointes. Due to arrhythmia risk, clinical trials with cancer therapeutics often exclude patients based on thresholds for QTc prolongation. Our objective was to assess associations between prescriptions for QT-prolonging drugs and the odds of meeting cancer trial exclusionary QTc thresholds in a cohort of adults with advanced cancer.

Methods

Electronic health records were retrospectively reviewed for 271 patients seen at our institutional molecular solid tumor clinic. Collected data included demographics, QTc measurements, ventricular arrhythmia-related diagnoses, and all inpatient and outpatient prescriptions. Potential associations were assessed between demographic and clinical variables, including prescriptions for QT-prolonging drugs, and QTc measurements.

Results

Women had longer median QTc measurements than men (p = 0.030) and were prescribed more QT-prolonging drugs during the study (p = 0.010). In all patients, prescriptions for QT-prolonging drugs were associated with longer median and maximum QTc measurements at multiple assessed time points (i.e., for QT-prolonging drugs prescribed within 10, 30, 60, and 90 days of QTc measurements). Similarly, the number of QT-prolonging drugs prescribed was correlated with longer median and maximum QTc measurements at multiple time points. Common QTc-related exclusionary criteria were collected from a review of ClinicalTrials.gov for recent cancer clinical trials. Based on common exclusion criteria, prescriptions for QT-prolonging drugs increased the odds of trial exclusion.

Conclusion

This study demonstrates that prescriptions for QT-prolonging drugs were associated with longer QTc measurements and increased odds of being excluded from cancer clinical trials.

Decreasing Inappropriate Telemetry Use via Nursing-Driven Checklist and Electronic Health Record Order Set

Introduction: Telemetry is ubiquitous in many hospitals despite widely acknowledged limitations, waste, and potential harm associated with inappropriate use. To curb overuse, guidelines such as the 2017 American Heart Association/American College of Cardiology (AHA/ACC) continuous telemetry monitoring practice standards have outlined appropriate telemetry use standards. This study aimed to perform two “plan-do-study-act” (PDSA) cycles and assess whether a nursing (RN)-driven checklist addressing appropriate telemetry use, combined with just-in-time education delivered via an electronic health record (EHR) order set modification, was efficacious in reducing inappropriate telemetry use within a level 1a Veterans Health Administration hospital.

Methods: This is a quality improvement intervention study that took place between March 2019 and August 2020. Three cohorts were sequentially studied: a control cohort without any intervention (n = 100), a cohort with only the RN-driven checklist (n = 100), and a cohort with both the RN-driven checklist and an EHR order set modification that provided just-in-time education about telemetry indications (n = 100). Telemetry records were reviewed by a physician to determine indication, duration for each telemetry order, and appropriateness. An order was deemed “appropriate” if it met AHA/ACC classification grade I (telemetry recommended) or IIa/b (telemetry may be considered) and “inappropriate” if it fell under class III (telemetry not recommended). Data were compared between the control cohort and the two intervention cohorts, as well as between intervention cohorts, using Pearson chi-square analysis. A p-value < 0.05 was considered statistically significant.

Results: Within the control group, 37% of telemetry orders were deemed inappropriate. After implementation of the RN checklist, a non-statistically significant lower proportion (26%) of orders was deemed inappropriate (p = 0.09). Implementation of the RN checklist, along with the EHR order set, was associated with a significantly lower proportion of inappropriate orders (17%) in comparison to the control cohort (p = 0.001) but not in comparison to the RN checklist cohort (p = 0.12). There was no significant difference in the duration of telemetry use across cohorts.

Conclusions: An RN-driven checklist and EHR telemetry order set modification were associated with a decrease in inappropriate telemetry use from 37% to 17%. By prompting the review of telemetry orders via a daily nursing checklist reviewed during bedside interdisciplinary rounds, clinicians received reinforcement regarding appropriate telemetry indications. This education was strengthened by the just-in-time training provided via the EHR order set.

Patients With Acute Coronary Syndromes Admitted to Contemporary Cardiac Intensive Care Units: Insights From the CCCTN Registry

BACKGROUND:

With the improvement in outcomes for acute coronary syndrome (ACS), the practice of routine admission to cardiac intensive care units (CICUs) is evolving. We aimed to describe the epidemiology of patients with ACS admitted to contemporary CICUs.

METHODS:

Using the CCCTN (Critical Care Cardiology Trials Network) Registry for consecutive medical CICU admissions across 26 advanced CICUs in North America between 2017 and 2020, we identified patients with a primary diagnosis of ACS at CICU admission and compared patient characteristics, resource utilization, and outcomes to patients admitted with a non-ACS diagnosis and across sub-populations of patients with ACS, including by indication for CICU admission.

RESULTS:

Of 10 118 CICU admissions, 29.4% (n=2978) were for a primary diagnosis of ACS, with significant interhospital variability (range, 13.4%–56.6%). Compared with patients admitted with a diagnosis other than ACS, patients with ACS had fewer comorbidities, lower acute severity of illness with less utilization of advanced CICU therapies (41.3% versus 66.1%, P <0.0001), and lower CICU mortality (5.4% versus 9.9%, P <0.0001). Monitoring alone, without another CICU indication at the time of admission, was the most frequent admission indication in patients with ACS (53.8%); less common indications in patients with ACS included respiratory insufficiency, shock, or the need for vasoactive therapy. Of patients with ACS admitted for monitoring alone, 94.8% did not subsequently require advanced intensive care unit therapies and had a low CICU length of stay (1.5 days [0.9–2.4] versus 2.6 [1.4–5.1], P <0.0001) and CICU mortality (0.6% versus 11.0%, P <0.0001), compared with patients with ACS with an admission indication beyond monitoring.

CONCLUSIONS:

In a registry of tertiary care CICUs, ACS represent ≈1/3 of all admissions with significant variability across hospitals. More than half of the ACS admissions to the CICU were for routine monitoring alone, with a low rate of complications and mortality. This observation highlights an opportunity for prospective studies to refine triage strategies for lower risk patients with ACS.

Validation of Dozee, a Ballistocardiography-based Device, for Contactless and Continuous Heart Rate and Respiratory Rate Measurement

Long-term acquisition of respiratory and heart signals is useful in a variety of applications, including sleep analysis, monitoring of respiratory and heart disorders, and so on. Ballistocardiography (BCG), a non-invasive technique that measures micro-body vibrations caused by cardiac contractions as well as motion caused by breathing, snoring, and body movements, would be ideal for long-term vital parameter acquisition. Turtle Shell Technologies Pvt. Ltd.'s Dozee device, which is based on BCG, is a contactless continuous vital parameters monitoring system. It is designed to measure Heart Rate (HR) and Respiratory Rate (RR) continuously and without contact in a hospital setting or at home. A validation study for HR and RR was conducted using Dozee by comparing it to the vitals obtained from the FDA-approved Patient Monitor. This was done in a sleep laboratory setting over 110 nights in 51 subjects to evaluate HR and over 20 nights in 17 subjects to evaluate RR at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Approximately 789 hours data for HR and approximately 112 hours data for RR was collected. Dozee was able to achieve a mean absolute error of 1.72 bpm for HR compared to the gold standard ECG. A mean absolute error of ∼1.24 breaths/min was obtained in determining RR compared to currently used methods. Dozee is ideal for long-term contactless monitoring of vital parameters due to its low mean absolute errors in measuring both HR and RR. Clinical Relevance- Continuous and long-term vitals monitoring is known to enable early screening of clinical deterioration, improve patient outcomes and reduce mortality. Current methods of continuous monitoring are overly complex, costly, and rely heavily on patient compliance. The proposed remote vitals monitoring solution based on BCG was found to be at par with gold standard methods of recording HR and RR. As a result, clinicians can use it to effectively monitor patients in both the hospital and at home.

Electroacupuncture Ameliorates Acute Myocardial Ischemic Injury and Long QT Interval in Mice through the α1A-Adrenergic Receptor: Electrophysiological, Morphological, and Molecular Evidence

Acute myocardial ischemia (AMI) is a condition caused by a decrease in blood flow to the heart that can sometimes predispose to acquired long QT syndrome (LQTS), thereby resulting in sudden cardiac death. Recent evidence indicates that electroacupuncture (EA) can alleviate MI injury, but its specific mechanism remains unclear. This study was aimed at investigating the efficacy of EA, which utilizes α_1A-adrenergic receptors (α_1A-AR) in alleviating MI injury as well as the resulting LQTS. The AMI model was established by ligating the left anterior descending arteries (LAD) of both the wild-type and α_1A gene-knockout mice and treating them with EA for three consecutive days. A PowerLab 16 physiological recorder was used to collect the electrocardiogram (ECG) while the serum creatine kinase isoenzymes (CK-MB), lactate dehydrogenase (LDH), and norepinephrine (NE) levels in myocardial tissue were determined by using the enzyme-linked immunosorbent assay (ELISA) kit. Moreover, TTC staining was used to observe the myocardial ischemic area, while H&E and TUNEL staining determined the pathological morphology of the myocardium. Quantitative real-time PCR (qRT-PCR) was used to detect the α_1A mRNA, and Western blot was used to detect the specific proteins, such as α_1A, cleaved caspase-3, Gq, PLC, p-PKCα, and p-hERG. Our results showed that EA could effectively reduce elevated ST-segment, shorten the extended QT interval, and reduce the serum myocardial enzyme content and the degree of pathological injury in wild mice with MI. EA can also decrease the expression of α_1A-AR, PLC, p-PKCα, and NE content in myocardial tissues of wild mice, while those of p-hERG increased in ischemic myocardial tissue. These findings suggested that α_1A-AR is involved in the development of MI as well as LQTS. Additionally, EA treatment improves the cardiac function and ischemic long QT interval and plays an important role in reducing the hERG inhibition through the α_1A-AR-mediated Gq/PLC/PKCα pathway and myocardial apoptosis. Hence, it is suggested that α_1A-AR might become a potential target for EA in treating AMI treatment of myocardial ischemia injury and acquired long QT intervals caused by MI.

Environmental monitoring and health assessment in an industrial town in central India: A cross-sectional study protocol

Background

Textile industry has been widely implicated in environmental pollution. The health effects of residing near manufacturing industries are not well documented in India, especially in central India. Hence, a cross-sectional environmental monitoring and health assessment study was initiated as per directions of the local authorities.

Methods

Comprehensive exposure data about the concentrations of relevant pollutants in the ambient air and ground water samples in the study area will be collected over one year. Using stratified random sampling, 3003 apparently healthy adults will be selected from the study area. Sociodemographic and anthropometric information, relevant medical and family history, and investigations including spirometry, electrocardiogram, neurobehavioral tests, and laboratory investigations (complete blood count, lipid profile and random blood glucose) will be conducted. Finally Iodine azide test and heavy metal level detection in urine and blood samples respectively will be conducted in a subset of selected participants to assess individual pollution exposure. Ethics approval has been obtained from the Institutional Ethics Committee of the National Institute for Research in Environmental Health (No: NIREH/IEC-7-II/1027, dated 07/01/2021).

Discussion

This manuscript describes the protocol for a multi-disciplinary study that aims to conduct environmental monitoring and health assessment in residential areas near viscose rayon and associated chemical manufacturing industries. Although India is the second largest manufacturer of rayon, next only to China, and viscose rayon manufacturing has been documented to be a source of multiple toxic pollutants, there is a lack of comprehensive information about the health effects of residing near such manufacturing units in India. Therefore implementing this study protocol will aid in filling in this knowledge gap.

Premature ventricular complexes during continuous electrocardiographic monitoring in the intensive care unit: Occurrence rates and associated patient characteristics

AIMS AND OBJECTIVES

This study examined the occurrence rate of specific types of premature ventricular complex (PVC) alarms and whether patient demographic and/or clinical characteristics were associated with PVC occurrences.

BACKGROUND

Because PVCs can signal myocardial irritability, in-hospital electrocardiographic (ECG) monitors are typically configured to alert nurses when they occur. However, PVC alarms are common and can contribute to alarm fatigue. A better understanding of occurrences of PVCs could help guide alarm management strategies.

DESIGN

A secondary quantitative analysis from an alarm study.

METHODS

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was followed. Seven PVC alarm types (vendor-specific) were described, and included isolated, couplet, bigeminy, trigeminy, run PVC (i.e. VT >2), R-on-T and PVCs/min. Negative binomial and hurdle regression analyses were computed to examine the association of patient demographic and clinical characteristics with each PVC type.

RESULTS

A total of 797,072 PVC alarms (45,271 monitoring hours) occurred in 446 patients, including six who had disproportionately high PVC alarm counts (40% of the total alarms). Isolated PVCs were the most frequent type (81.13%) while R-on-T were the least common (0.29%). Significant predictors associated with higher alarms rates: older age (isolated PVCs, bigeminy and couplets); male sex and presence of PVCs on the 12-lead ECG (isolated PVCs). Hyperkalaemia at ICU admission was associated with a lower R-on-T type PVCs.

CONCLUSIONS

Only a few distinct demographic and clinical characteristics were associated with the occurrence rate of PVC alarms. Further research is warranted to examine whether PVCs were associated with adverse outcomes, which could guide alarm management strategies to reduce unnecessary PVC alarms.

RELEVANCE TO CLINICAL PRACTICE

Targeted alarm strategies, such as turning off certain PVC-type alarms and evaluating alarm trends in the first 24 h of admission in select patients, might add to the current practice of alarm management.

An Overview of the Sensors for Heart Rate Monitoring Used in Extramural Applications

This work presents an overview of the main strategies that have been proposed for non-invasive monitoring of heart rate (HR) in extramural and home settings. We discuss three categories of sensing according to what physiological effect is used to measure the pulsatile activity of the heart, and we focus on an illustrative sensing modality for each of them. Therefore, electrocardiography, photoplethysmography, and mechanocardiography are presented as illustrative modalities to sense electrical activity, mechanical activity, and the peripheral effect of heart activity. In this paper, we describe the physical principles underlying the three categories and the characteristics of the different types of sensors that belong to each class, and we touch upon the most used software strategies that are currently adopted to effectively and reliably extract HR. In addition, we investigate the strengths and weaknesses of each category linked to the different applications in order to provide the reader with guidelines for selecting the most suitable solution according to the requirements and constraints of the application.

Evaluation of MINOCA syndrome and HEART score in patients presenting to the emergency department with panic attack and chest pain complaints

BACKGROUND

Patients presenting with chest pain may or may not be experiencing a panic attack. Is chest pain caused by a panic attack or myocardial infarction with non-obstructive coronary arteries (MINOCA) syndrome?

AIM

In this study, we evaluated both MINOCA syndrome and HEART score in patients who presented to the emergency department with panic attacks and chest pain.

METHOD

Patients who applied to the emergency department with panic disorder and chest pain complaints were included. Patients who met the MINOCA diagnostic criteria were identified. The study was completed with 143 eligible patients out of a total of 217 patients evaluated. The patients were divided into two groups. The first group was those whose symptoms and test results were consistent with MINOCA. The second group was composed of those whose chest pain was considered non-specific. The HEART score of all patients was calculated. The demographic characteristics, symptoms, and HEART scores were compared between the groups.

RESULTS

Of the 143 patients evaluated in the study, 62 (43.3%) were male and 81 (56.7%) were female. While the mean HEART score was 4.7 ± 1.5 in the MINOCA group, it was 2.0 ± 1.0 in the non-cardiac group, a statistically significant difference.

CONCLUSION

Clinicians should pay attention to the patient's age, gender, number of attacks per week, HEART score, and which symptoms (palpitations, shortness of breath, and fear of death) are present in patients who meet the panic attack diagnostic criteria. Clinicians should be alert to the MINOCA syndrome in panic attack patients.

Effects of Electrocardiographic Monitoring Education on Nurses' Confidence and Psychological Stress: An Online Cross-Sectional Survey in Japan

We aimed to investigate the association between nurses’ electrocardiographic (ECG) monitoring education and their confidence and psychological stress regarding ECG monitoring. In 2019, a web-based cross-sectional study was conducted among Japanese nurses. A multivariable logistic regression analysis was performed to evaluate the effects of education on nurses’ confidence and psychological stress regarding ECG monitoring. In total, 1652 nurses were included in the study. Factors significantly associated with nurses’ confidence were post-graduate education experience (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6–3.6), ≥11 post-graduate years (OR, 2.2; 95% CI, 1.5–3.1), male gender (OR, 4.4; 95% CI, 2.9–6.6), ≥5 helpful experiences with ECG monitoring (OR, 10.7; 95% CI, 6.0–19.1), work experience in an intensive care unit (OR, 2.3; 95% CI, 1.5–3.7), and work experience in a cardiology department (OR, 1.7; 95% CI, 1.2–2.4). Factors significantly associated with nurses’ psychological stress were male gender (OR, 1.9; 95% CI, 1.2–2.9), ≥5 helpful experiences with ECG monitoring (OR, 1.9; 95% CI, 1.2–2.9), and work experience in an emergency room (OR, 2.4; 95% CI, 1.3–4.8). These results suggest that nurses’ post-graduate ECG monitoring education enhanced their confidence, but did not reduce psychological stress regarding ECG monitoring.

Electrocardiogram Monitoring Practices for Hospitalized Adults Receiving Antipsychotics: A Retrospective Cohort Study

OBJECTIVE

Antipsychotics are frequently used for managing both acute and chronic neuropsychiatric disorders. While antipsychotics are known to be associated with increased mortality due to cardiac arrhythmia, there is a lack of consensus on the timing and frequency of electrocardiogram (ECG) monitoring.  The goal of this study was to examine current ECG monitoring practices for adults receiving antipsychotics, specifically during hospital admission.

METHODS

The study involved a multisite retrospective chart review of adults admitted across 8 hospitals between January 2010 and December 2015 who received antipsychotics during hospitalization. The primary outcome was the presence of an ECG after receiving an antipsychotic.

RESULTS

During the study period, there were 26,353 hospitalizations during which adults received antipsychotic medication; the average age of the patients was 61.4 years, 50.1% were female, and 64.8% were white. The average comorbidity score was 1.4 with a median length of stay of 8.3 days. Of the 26,353 patients who were hospitalized, 60.6% (n=15,977) of patients in the sample had an ECG during their hospitalization, and 41.2% (n=10,865) had the ECG following antipsychotic administration. Patients who received a follow-up ECG had a longer length of stay (median: 11.3 d) compared with those who did not receive a follow-up ECG (median: 7.0 d). Follow-up ECGs were more likely among patients who had a history of heart failure [odds ratio (OR)=1.17, 95% confidence interval (CI): 1.06-1.30, P=0.002], who were receiving multiple antipsychotics (OR=1.3, 95% CI: 1.24-1.36, P<0.001) or other QT-prolonging medications (OR=1.09, 95% CI: 1.07-1.1, P<0.001), who were receiving risperidone (OR=1.12, 95% CI: 1.004-1.25, P=0.04), and who showed an increase in QTc duration (OR per 10 ms increase=1.02, 95% CI: 1.01-1.04, P=0.003). Follow-up ECGs were less likely to be administered to patients who were receiving antipsychotics before admission (OR=0.93, 95% CI: 0.87-0.997, P=0.04).

CONCLUSIONS

This study demonstrated that, in a large health system, ECG monitoring is not routinely practiced for hospitalized patients receiving antipsychotics. Further studies are needed to identify patients who would most benefit from ECG monitoring in the acute care setting.

Utility of continuous electrocardiographic monitoring in pregnant women with cardiovascular disease

Background

Arrhythmias are a common complication in pregnant women with heart disease. While continuous electrocardiographic monitoring is a useful tool for diagnosis, it also has significant associated costs, and identifying which pregnant women are most likely to benefit from monitoring is an important goal.

Methods

This is a retrospective observational study of pregnant adult women with heart disease cared for at an academic medical center between 2016 and 2020. Clinical information and ambulatory and inpatient monitoring results were abstracted from the electronic health record and descriptive statistics and T-tests were used to characterize the population.

Results

A total of 258 pregnancies in 202 unique women were included. The most common type of cardiovascular disease was congenital heart disease (56.6%), followed by cardiomyopathy (11.2%). An ambulatory monitor was ordered in 26.7% of pregnancies in the antepartum period, and 26.1% of these had clinically significant findings. 46.4% of monitors resulted in a clinical management change, with the most common changes being no recommendation for intrapartum electrocardiographic monitoring (20.3%) and starting a new medication (14.5%). Continuous electrocardiographic monitoring was used in 54.8% of deliveries, and detected a significant arrhythmia in only 2 cases (0.1%).

Conclusions

A symptom driven protocol for ambulatory monitoring in pregnancy yields abnormal findings in a significant proportion of patients, and nearly half trigger a change in clinical management. Intrapartum electrocardiographic monitoring has a low yield, with a significant arrhythmia detected in less than 1% of pregnancies in this cohort.

Improving Corrected QT Interval Monitoring in Critical Care Units: A Single Center Report

BACKGROUND

Corrected QT (QTc) interval prolongation is a type of ventricular tachyarrhythmia. Recommendations for QTc interval monitoring for critical care nurses are limited and variable.

LOCAL PROBLEM

The intensive care unit at the study institution had no policies for QTc interval monitoring. A quality improvement initiative for identifying and monitoring at-risk patients was begun.

METHODS

A QTc interval monitoring protocol was developed according to current recommendations for electrocardiogram monitoring and input from experts. Nursing staff received education on the QTc monitoring protocol. Numbers of patients with indications for monitoring were collected for 60 days before and 60 days after implementation. The rate of protocol adherence was collected for 60 days after implementation. Aknowledge assessment was administered to nurses at baseline, immediately after education, and 4 months after education.

RESULTS

Before protocol implementation, 537 patients had indications for monitoring. No QTc intervals were documented by nurses. After protocol implementation, 544 patients had indications for monitoring. Protocol adherence was higher during day shifts than during night shifts (45.3% and 38.4%, respectively). Of 170 documented QTc prolongation events, 26 (15%) were reported to physicians. Nurses' knowledge significantly improved after education and was retained 4 months after education (correct responses to assessment questions: 59% at baseline, 96% immediately after education, and 86% at 4 months after education).

CONCLUSIONS

This QTc interval monitoring protocol improved nurses' ability to identify and monitor patients with increased risk of QTc interval prolongation. Adherence was less than desired, suggesting that further protocol revisions are required.

Prevalence and Risk Factors of QTc Prolongation During Pregnancy

Background

Prolonged QT intervals have been observed in pregnant women, which predispose them to a higher risk of potentially lethal ventricular arrhythmias. This study was designed to evaluate the prevalence of QTc prolongation in Chinese hospitalized parturient women with single and twin pregnancies, and to explore potential risk factors associated with QTc prolongation.

Methods

This retrospective study included 1,218 patients from a large Chinese population between January 2014 and October 2020. Data from parturient women with single and twin pregnancies without pre-pregnancy cardiac diseases were collected. QTc was corrected by the Fridericia formula [QTc = QT/RR(1/3)], and QTc ≥ 460 ms for females was defined as prolonged QTc, QTc ≥ 500 ms was defined as severely prolonged QTc. The prevalence and common risk factors of QTc prolongation during pregnancy were analyzed in this cohort. Uni- and multivariable logistic regression analysis were performed to identify clinical parameters associated with QTc prolongation in this population.

Results

The prevalence of QTc prolongation was 48.19% among this population, 10.56% in single pregnancy, 89.44% in twin pregnancies. The prevalence of severely prolonged QTc was 23.48% among the total cohort, 0.49% in single pregnancy, and 46.47% in twin pregnancies. The mean QTc interval was significantly longer in twin pregnancies than in single pregnancy (498.65 ± 38.24 vs. 424.96 ± 27.67 ms, P < 0.001). Systolic blood pressure, diastolic blood pressure, total cholesterol, serum uric acid, gestational hypertension and twin pregnancies were associated with QTc prolongation in parturient women.

Conclusion

This is the first study to assess the prevalence and risk factors of QTc prolongation between single and twin pregnancies. QTc prolongation is more prevalent, and QTc intervals are significantly longer in twin pregnancies as compared to single pregnancy.

Nurses' competency in electrocardiogram interpretation in acute care settings: A systematic review

AIMS

Identify and synthesize evidence of nurses' competency in electrocardiogram interpretation in acute care settings.

DESIGN

Systematic mixed studies review.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature, Medline, Scopus and Cochrane were searched in April 2021.

REVIEW METHODS

Data were selected using the updated Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. A data-based convergent synthesis design using qualitative content analysis was adopted. Quality appraisal was undertaken using validated tools appropriate to study designs of the included papers.

RESULTS

Forty-three papers were included in this review. Skills and attitudes were not commonly assessed, as most studies referred to 'competency' in the context of nurses' knowledge in electrocardiogram interpretation. Nurses' knowledge levels in this important nursing role varied notably, which could be partly due to a range of assessment tools being used. Several factors were found to influence nurses' competency in electrocardiogram interpretation across the included studies from individual, professional and organizational perspectives.

CONCLUSION

The definition of 'competency' was inconsistent, and nurses' competency in electrocardiogram interpretation varied from low to high. Nurses identified a lack of regular training and insufficient exposure in electrocardiogram interpretation. Hence, regular, standard training and education are recommended. Also, more research is needed to develop a standardized and comprehensive electrocardiogram interpretation tool, thereby allowing educators to safely assess nurses' competency.

IMPACT

This review addressed questions related to nurses' competency in electrocardiogram interpretation. The findings highlight varying competency levels and assessment methods. Nurses reported a lack of knowledge and confidence in interpreting electrocardiograms. There is an urgent need to explore opportunities to promote and maintain nurses' competency in electrocardiogram interpretation.

Cardiac Telemetry Downtime and Contingency Plan Development: A Review of Downtime Events Reported in the Veterans Health Administration

BACKGROUND

Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety.

PROBLEM

Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime.

APPROACH

This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020.

OUTCOMES

Of 98 events, no patient harm was reported; 13% (n = 13) were planned downtime, 82% (n = 80) were unplanned downtime, 18% (n = 18) reported contingency plan use, 78% (n = 76) did not specify contingency plan use, and 32% (n = 31) reported events lasting 31 minutes to 6 hours in duration.

CONCLUSIONS

The majority of reported cardiac telemetry downtime events were unplanned and without documented contingency plans. A robust contingency plan with defined staff roles and responsibilities will serve to lessen anxiety during downtimes and mitigate potential risk of patient harm.

Stimulant Drugs of Abuse and Cardiac Arrhythmias

Nonmedical use of prescription and nonprescription drugs is a worldwide epidemic, rapidly growing in magnitude with deaths because of overdose and chronic use. A vast majority of these drugs are stimulants that have various effects on the cardiovascular system including the cardiac rhythm. Drugs, like cocaine and methamphetamine, have measured effects on the conduction system and through several direct and indirect pathways, utilizing multiple second messenger systems, change the structural and electrical substrate of the heart, thereby promoting cardiac dysrhythmias. Substituted amphetamines and cocaine affect the expression and activation kinetics of multiple ion channels and calcium signaling proteins resulting in EKG changes, and atrial and ventricular brady and tachyarrhythmias. Preexisting conditions cause substrate changes in the heart, which decrease the threshold for such drug-induced cardiac arrhythmias. The treatment of cardiac arrhythmias in patients who take drugs of abuse may be specialized and will require an understanding of the unique underlying mechanisms and necessitates a multidisciplinary approach. The use of primary or secondary prevention defibrillators in drug abusers with chronic systolic heart failure is both sensitive and controversial. This review provides a broad overview of cardiac arrhythmias associated with stimulant substance abuse and their management.

Diagnostic and prognostic significance of premature ventricular complexes in community and hospital-based participants: A scoping review

BACKGROUND

While there are published studies that have examined premature ventricular complexes (PVCs) among patients with and without cardiac disease, there has not been a comprehensive review of the literature examining the diagnostic and prognostic significance of PVCs. This could help guide both community and hospital-based research and clinical practice.

METHODS

Scoping review frameworks by Arksey and O'Malley and the Joanna Briggs Institute (JBI) were used. A systematic search of the literature using four databases (CINAHL, Embase, PubMed, and Web of Science) was conducted. The review was prepared adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR).

RESULTS

A total of 71 relevant articles were identified, 66 (93%) were observational, and five (7%) were secondary analyses from randomized clinical trials. Three studies (4%) examined the diagnostic importance of PVC origin (left/right ventricle) and QRS morphology in the diagnosis of acute myocardial ischemia (MI). The majority of the studies examined prognostic outcomes including left ventricular dysfunction, heart failure, arrhythmias, ischemic heart diseases, and mortality by PVCs frequency, burden, and QRS morphology.

CONCLUSIONS

Very few studies have evaluated the diagnostic significance of PVCs and all are decades old. No hospital setting only studies were identified. Community-based longitudinal studies, which make up most of the literature, show that PVCs are associated with structural and coronary heart disease, lethal arrhythmias, atrial fibrillation, stroke, all-cause and cardiac mortality. However, a causal association between PVCs and these outcomes cannot be established due to the purely observational study designs employed.

Prognostic Significance of Prolonged Corrected QT Interval in Acute Ischemic Stroke

Background and Purpose: The aim of this study was to determine the relationship between the heart rate-corrected QT (QTc) interval and the risk of incident long-term mortality in patients with acute ischemic stroke (AIS), considering the impact of sex differences on clinical characteristics, outcomes, and QTc intervals.

Methods: We analyzed prospectively registered data included patients with AIS who visited the emergency room within 24 h of stroke onset and underwent routine cardiac testing, such as measurements of cardiac enzymes and 12-lead ECG. QTc interval was corrected for heart rate using Fridericia's formula and was stratified by sex-specific quartiles. Cox proportional hazards models were used to examine the association between baseline QTc interval and incident all-cause death.

Results: A total of 1,668 patients with 1,018 (61.0%) men and mean age 66.0 ± 12.4 years were deemed eligible. Based on the categorized quartiles of the QTc interval, cardiovascular risk profile, and stroke severity increased with prolonged QTc interval, and the risk of long-term mortality increased over a median follow-up of 33 months. Cox proportional hazard model analysis showed that the highest quartile of QTc interval (≥479 msec in men and ≥498 msec in women; hazard ratio [HR]: 1.49, 95% confidence interval [CI]: 1.07–2.08) was associated with all-cause death. Furthermore, dichotomized QTc interval prolongation, defined by the highest septile of the QTc interval (≥501 ms in men and ≥517 m in women: HR: 1.33, 95% CI: 1.00–1.80) was significantly associated with all-cause mortality after adjusting for all clinically relevant variables, such as stroke severity.

Conclusions: Prolonged QTc interval was associated with increased risk of long-term mortality, in parallel with the increasing trend of prevalence of cardiovascular risk profiles and stroke severity, across sex differences in AIS patients.

Influence of baseline QTc on sotalol-induced prolongation of ventricular repolarization in men and women

The extent of sotalol-induced QTc prolongation on the electrocardiogram, is variable among subjects and influenced by sex. However, the influence of baseline QTc on the extent of drug-induced QTc prolongation remains unclear. This was studied around peak plasma concentration in a large cohort of 376 healthy male and 614 healthy female subjects who received 80 mg of sotalol orally. Baseline QTc was 379±16ms in men and 393±15ms in women (p<0.0001). The change in QTc from baseline was highly variable among both sexes and was greater in women than in men (26.5±13.2 vs.13.0±10.8ms; <0.0001). The slope of the regression line between QTc on sotalol and baseline QTc did not significantly differ from unity in men and in women indicating that the extent of QTc prolongation with sotalol was not influenced by baseline QTc. Assessing QTc after administration of an I_Kr blocker may be more important than measuring a baseline QTc.

Electrocardiogram monitoring in the prone position in coronavirus disease 2019 acute respiratory distress syndrome

Aims

Prone positioning is increasingly used for treating coronavirus disease 2019 (COVID-19)-induced acute respiratory distress syndrome (ARDS). In these high-risk patients for cardiovascular events who may spend more than 16 h a day in the prone position, an adequate monitoring of electrocardiogram (ECG) is mandatory. However, effects of prone positioning on the ECG are unknown as is the validity of the ECG recorded with electrodes placed dorsally. We aimed to compare ECG data obtained in the prone position from five electrodes positioned conventionally and dorsally, and to assess the effects of the change of position (from supine to prone) on the ECGs in patients with COVID-19 ARDS.

Methods and results

In patients with COVID-19 ARDS for whom the prone position was indicated, seven-lead ECG (frontal plane leads and V6) performed in the supine and the prone position with electrodes positioned conventionally and dorsally were compared. A total of 22 patients [20 (91%) males] were included. Among them, 10 (45%) patients had structural or ischaemic heart disease. After prone positioning, PR duration significantly increased and QRS duration significantly decreased whereas QT interval did not significantly change. In the prone position, there were excellent correlations between QRS axis, PR, RR, QRS, and QT intervals durations measured with electrodes placed on the torso and dorsally (with no change in the position of V6).

Conclusion

Prone positioning induced significant change in the ECG. In the prone position, ECG can be reliably monitored with four electrodes translated from conventional position to the back and with a precordial electrode left in V6 position.

Inappropriate Telemetry Use Is Increased during the COVID-19 Era

Due to the unprecedented COVID-19 pandemic, there may be overuse of telemetry monitoring compared to the pre-pandemic period. We compared the frequency of inappropriate telemetry use in the pre-COVID-19 period (1 November 2019 to 28 February 2020) versus the peri-COVID-19 period (1 March 2020 to 30 June 2020) at a major academic hospital in Honolulu, Hawaii, by a retrospective chart review to assess for the appropriateness of the telemetry orders during this period, based on the 2017 American College of Cardiology/American Heart Association guidelines. Compared to the pre-COVID-19 period, there was a significant increase in inappropriate telemetry use during the peri-COVID-19 period (X2 (1, N = 11,727) = 6.59, p = 0.0103). However, there was no increase in the proportions of respiratory failure (4.0%) or pneumonia (2.7%) during the peri-COVID-19 period. The increase in inappropriate telemetry use may be related to the uncertainty in clinical care and decision making amid the pandemic of the new virus. Appropriate utilization of telemetry monitoring is increasingly important during the pandemic due to the limited availability of resources. Further investigation is needed to clarify the relationship between the pandemic and trends in telemetry ordering.

Content Validation of an Algorithm for the Assessment, Management and Monitoring of Drug-Induced QTc Prolongation in the Psychiatric Population

BACKGROUND

QTc interval (QTcI) prolongation leads to serious complications, making it a concern for clinicians. Assessing the risk of QTcI prolongation in the psychiatric population is important because they are exposed to multiple medications known to increase the risk of life-threatening arrhythmias.

AIM

The study aims to validate the content of an algorithm for the assessment, management and monitoring of drug-induced QTc prolongation in the psychiatric population.

METHODOLOGY

Qualitative semi-structured interviews of cardiologists, to gather information regarding their approach in assessing the risk of drug-induced QTc prolongation at the time of prescribing. After the interview, an orientation to the algorithm was provided with a link to a cross-sectional, anonymous survey. The online survey included quantitative and qualitative components to gather feedback on the relevance and appropriateness of each step in the algorithm.

RESULTS

Interview responses were incorporated into 4 themes. Responses indicated a lack of a unified protocol when assessing QTcI prolongation, which supports the need of an algorithm that includes a verified risk scoring tool. Quantitative survey results showed a mean score ranging from 3.08 to 3.67 out of 4 for the appropriateness of the algorithm's steps, 3.08 to 3.58 for the safety and 3.17 to 3.75 for the reliability of references used. Additional analysis using the modified kappa and I-CVI statistical measures indicate high validity of contents and high degree of agreement between raters. As per the open-ended questions, cardiologists supported the implementation of the algorithm; however, they recommended simplification of the steps as they appear to be cumbersome.

CONCLUSION

The results demonstrate that the implementation of the algorithm after minor alterations can prove to be useful as a tool for the risk assessment of QTc prolongation. Further validation of the algorithm with mental health pharmacists and clinicians will be conducted as a separate phase of the study.

Benefit of continued noninvasive cardiac monitoring in geriatric trauma: A retrospective review of geriatric pelvis, hip, and femur fractures and analysis of cardiac events during immediate post-traumatic course

Objective

The geriatric population suffers from a predisposition to cardiac events due to physiologic changes commonly associated with aging. The majority of the trauma population seen at our facility is within the geriatric population (greater than 65 years old). Therefore, this study was aimed to determine which of those preexisting factors were associated with an increased risk for developing cardiac event. By assessing those risks, we hoped to determine a timeline for the highest risk of cardiac event occurrence, in order to identify a safe period of when cardiac monitoring was indicated.

Methods

A retrospective study performed over 6 months reviewing geriatric trauma patients with hip, pelvis, or femur fractures, n = 125. A list of predetermined risk factors including comorbidities, pathologies, laboratory values, electrocardiogram findings, and surgery was crossed with the patient's records in order to identify factors for increased risk of cardiac event. Once patients who had documented cardiac events were identified, a temporal pattern of cardiac event occurrence was analyzed in order to determine a period when noninvasive cardiac monitoring should remain in place.

Results

In 125 patients, 40 cardiac events occurred in 30 patients. The analyzed variables with statistically significant associations for having a cardiac event were comorbidities (p = 0.019), elevated body mass index (p = 0.001), abnormal initial phosphorus (p = 0.002), and an electrocardiogram finding of other than normal sinus rhythm (p = 0.020). Of the identified cardiac events, we found that by hospital day 3 68% of cardiac event had occurred, with 85% by hospital day 4, 95% by day 5, and 100% within the first 7 days of admission.

Conclusion

Patient history of cardiac comorbidities, elevated body mass index, abnormal phosphorus, and abnormal electrocardiogram findings were found to be significant risk factors for cardiac event development in geriatric trauma. All recorded events in our study occurred within 7 days of the initial trauma.

Reducing Cardiac Telemetry Nuisance Alarms Through Evidence-Based Interventions

BACKGROUND

Cardiac telemetry nuisance alarms due to leads off and poor signal increase staff workflow interruptions, decrease staff trust in technology, and can compromise patient safety.

LOCAL PROBLEM

Interventions were directed at reducing nuisance alarms on a 32-bed, non-intensive care - a cardiac telemetry unit.

METHODS

A nursing staff education module with evidence-based practices for reducing nuisance alarms, a daily care protocol for patients on cardiac telemetry monitoring, and daily audits of protocol adherence were implemented.

RESULTS

Staff pre- and posttest comparisons on their knowledge relating to nuisance alarms and the evidence-based protocol demonstrated a significant mean increase of 3.02 (95% CI, 2.55-3.48). Daily audits for 7 weeks demonstrated an average of 58.46% staff adherence. Telemetry technician call volume reduction was 16% postimplementation, while nuisance alarms were not reduced significantly.

CONCLUSIONS

This rapid-cycle, quality improvement process resulted in minimal reduction in nuisance alarms but improved staff awareness of the issue and reduced workflow interruptions.

Empowering nurses and residents to improve telemetry stewardship in the academic care setting

AIMS AND OBJECTIVES

Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource with limited success. Clinical-effectiveness studies have thus far not included care settings in which resident-physicians are the primary caregivers.

METHODS

We implemented two interventions on general internal medicine units of an academic hospital. The first intervention, or nurse-discontinuation protocol, allowed nurses to trigger the discontinuation of telemetry once the appropriate duration had passed according to practice standards. The second intervention, or physician-discontinuation protocol, instituted a best-practice advisory that notified the resident-physician via the electronic medical record when the appropriate telemetry duration for each patient had elapsed and suggested termination of telemetry. Data collection spanned 8 months following the implementation of the nurse-discontinuation protocol and 12 months following the physician-discontinuation protocol.

RESULTS

During the control period, the average time spent on telemetry was 86.29 hours/patient/month. During the nurse-discontinuation protocol, patients spent, on average, 70.86 hours/patient/month on telemetry. During the physician-discontinuation protocol, patients spent, on average, 81.6 hours/patient/month on telemetry. During the nurse-discontinuation protocol, there was no significant change in the likelihood that a patient was placed on telemetry throughout their admission when compared with the control period. During the physician-discontinuation protocol, there was a significant decrease of 56.1% in the likelihood that a patient would be put on telemetry when compared with the control time period.

CONCLUSIONS

These findings expand our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers. Furthermore, these findings represent an important addition to the telemetry and patient monitoring literature by demonstrating the impact that nurse-managed protocols can have on telemetry use and by highlighting effective strategies to improve telemetry use by physicians in training.

The clinical impact of paroxysmal arrhythmias on the hospital outcomes of patients admitted with cirrhosis: propensity score matched analysis of 2011-2017 US hospitals

BACKGROUND

We evaluate the effects of paroxysmal arrhythmia on the hospital outcomes of patients admitted with cirrhosis.

RESEARCH DESIGN AND METHODS

2011-2017 National Inpatient Sample was used to isolate patients with decompensated/compensated cirrhosis, stratified by paroxysmal arrhythmia (supraventricular: PSVT and ventricular: PVT). The cohorts were matched using propensity-score matching and compared to mortality, length of stay, cost, and cardiac complications (cardioversion, cardiogenic shock, cardiac arrest, and ventricular fibrillation).

RESULTS

In compensated cirrhosis, 2,453 had PSVT with matched controls; 5,274 had PVT with matched controls. Those with PSVT had higher mortality (aOR 1.55 95%CI 1.23-1.95) and higher rates of cardioversion and cardiogenic shock; likewise, those with PVT had higher mortality (aOR 2.41 95%CI 2.09-2.78) and higher rates of all complications. In decompensated cirrhosis, 1,598 had PSVT with matched controls; 4,178 had PVT with matched controls. Those with PSVT had higher mortality (aOR 1.57 95%CI 1.28-1.93) and higher rates of cardioversion, cardiogenic shock, cardiac arrest; those with PVT had higher mortality (aOR 2.25 95%CI 1.98-2.56) and higher rates of all complications.

CONCLUSION

The findings from this study show that in either decompensated or compensated cohort, those with paroxysmal arrhythmias are at a higher risk of in-hospital mortality and adverse cardiac outcomes.

ECG alarms during left ventricular assist device (LVAD) therapy in the ICU

BACKGROUND

In hospitalized patients with left ventricular assist device (LVAD), electrical interference and low amplitude QRS complexes are common, which could impact the accuracy of electrocardiographic (ECG) arrhythmia detection and create technical alarms. This could contribute to provider alarm fatigue and threaten patient safety.

OBJECTIVES

We examined three LVAD patients in the cardiac intensive care unit (ICU) to determine: 1) the frequency and accuracy of audible arrhythmia alarms; 2) occurrence rates of technical alarms; and 3) alarm burden (# alarms/hour of monitoring) METHODS: Secondary analysis.

RESULTS

During 593 h, there were 549 audible arrhythmia alarms and 98% were false. There were 25,232 technical alarms and 93% were for artifact, which was configured as an inaudible text alert.

CONCLUSION

False-arrhythmia and technical alarms are frequent in LVAD patients. Future studies are needed to identify both clinical and algorithm-based strategies to improve arrhythmia detection and reduce technical alarms in LVAD patients.

The HEART score to identify emergency department patients suspected of an acute coronary syndrome who can be removed from cardiac monitoring: A retrospective chart review

OBJECTIVE

Continuous cardiac monitoring has been recommended for ED patients being evaluated for possible acute coronary syndrome (ACS) due to concern for arrhythmia, although evidence suggests this risk is low. Indiscriminate use of monitored beds restricts access for other critically unwell patients and contributes to overcrowding. The objective of the present study was to determine if a low/intermediate-risk HEART score identified patients at very low risk for a clinically important arrhythmia who could be removed from cardiac monitoring.

METHODS

This was a single centre, retrospective, cohort study of consecutive ED patients in a tertiary referral hospital evaluated for possible ACS from July to August 2017. Patients with ST-elevation myocardial infarction or an arrhythmia at presentation which would mandate monitoring were excluded. Data was obtained by medical chart review. The primary outcome was the occurrence of an arrhythmia requiring treatment while in ED.

RESULTS

Inter-rater reliability for data extraction demonstrated very strong agreement (kappa 0.87, 95% confidence interval 0.83-0.91). There were 653 participants included with 83 (12.7%) having a final diagnosis of ACS. Three (0.5%) clinically important arrhythmias occurred. There were no cases of ventricular tachycardia, ventricular fibrillation or cardiac arrest. Five hundred and forty (82.7%) participants were low/intermediate-risk HEART score and one (0.2%) clinically important arrhythmia occurred (this was supraventricular tachycardia treated by a valsalva manoeuvre).

CONCLUSION

Among ED patients presenting with a possible ACS, a low/intermediate-risk HEART score identified those at very low risk for having a clinically important arrhythmia while in ED.

Medication safety in a pandemic: A multicentre point prevalence study of QTc monitoring of hydroxychloroquine for COVID-19

What is known and Objective

A pandemic can strain all aspects of the healthcare system, including the ability to monitor the safety of medication use. Reviewing the adequacy of medication safety practices during the COVID‐19 pandemic is critical to informing responses to future pandemics. The purpose of this study was to evaluate medication safety practices at a height of both COVID‐19 cases and hydroxychloroquine use.

Methods

This was a multicentre observational point prevalence study. Adult inpatients receiving hydroxychloroquine for COVID‐19 between March 22 and 28, 2020 were included. The primary outcome was the percentage of patients receiving appropriate QTc monitoring. Secondary outcomes included QTc prolongation, early discontinuation of hydroxychloroquine and ventricular arrhythmias.

Results and discussion

A total of 59% (167/284) of patients treated with hydroxychloroquine received appropriate QTc monitoring. QTc prolongation occurred in 25%. Hydroxychloroquine was prematurely discontinued in 1.4% of patients, all due to QTc prolongation. Ventricular arrhythmia occurred in 1.1%.

What is new and Conclusion

Medication safety practices were suboptimal with regard to hydroxychloroquine monitoring at the height of the COVID‐19 pandemic. Preparation for future pandemics should devote considerable attention to medication safety.

The sensitivity of graphic trends in differentiating sinus and supraventricular tachycardia

BACKGROUND

The use of cardiac telemetry in the inpatient setting is widespread and has become integral in managing hospitalized patients. Telemetry is used to monitor patients with brady- and tachyarrhythmias. While most of the focus is on the rhythm strip data, a significant utility remains in analyzing the graphic heart rate trends. We specifically focused on the shape of the curve (rectangle or bell) of the heart rate over time to differentiate sinus tachycardia (ST) and supraventricular tachycardia (SVT). We hypothesized that identifying the shape of the graphic trend would improve the accuracy of diagnosis.

METHODS

To demonstrate the simplicity of employing this method for improving the diagnosis of arrhythmia, we had senior medical students evaluate the telemetry strips and graphical trends. We gathered data from the medical student interpretation of 82 strips of in-hospital cardiac telemetry and asked them to differentiate ST and SVT based on the shape of the graphic trend. Each rhythm strip and the graphic trend was interpreted by two clinical cardiac electrophysiology attending physicians and confirmed on a 12‑lead electrocardiogram.

RESULTS

When students were asked to choose between ST and SVT based on the telemetry rhythm strip without graphic trends, 73% of their answers were correct. Diagnostic accuracy improved to 96% correct with the addition of the graphic trend. Depending on the telemetry rhythm strip alone, sensitivity to detect SVT was 75%, with 68% specificity. With the addition of the graphical trend, sensitivity improved to 98% and specificity 100%.

CONCLUSION

Review of graphical trends, specifically the analysis of onset and offset, allows novice ECG readers to improve the ability to distinguish between ST and SVT.