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

Effect of Memantine on QT/QTc Interval in a Healthy Korean Population

Studies on the effects of memantine on QT prolongation have yielded conflicting results. For a long time, memantine was reported to be a safe drug without QT prolongation; however, several case studies have reported memantine-induced QT prolongation in Alzheimer's patients. This study evaluated the relationship between memantine blood levels, and QT interval changes. Over a 2-week period, we orally administered 20 mg of memantine daily to achieve a steady state in 57 healthy Korean subjects. We measured and analyzed the QT interval and blood memantine concentrations simultaneously before and after treatment, as well as 2 weeks after the last dosing. Correlation analysis was done between blood memantine level and QT interval. No serious adverse events occurred during the study period. Repeated dosing of memantine did not show clinically significant QT interval changes after treatment. Regression analysis was performed based on the results; there was no statistical association between memantine blood level and QT prolongation. In conclusion, the results of the present study demonstrated no clinically significant changes in the QT interval with therapeutic blood levels of memantine.

Telemetry Bed Usage for Patients with Low-Risk Chest Pain: An Updated Review of the Literature for the Clinician

BACKGROUND

Telemetry monitoring in patients with low-risk chest pain continues to be highly used despite a 2011 literature review and recommendations by the Clinical Practice Committee (CPC) of the American Academy of Emergency Medicine that did not find quality data to support its use.

OBJECTIVE

To update the medical literature review on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians.

METHODS

A PubMed literature search was performed for systematic reviews in English relevant to low-risk chest pain between 2011 and 2019 and then expanded to all citations by removing the systematic review criteria. Studies identified then underwent a structured review from which results could be evaluated in the context of the associated 2011 literature review and CPC recommendations.

RESULTS

The initial search yielded 2 potentially relevant studies, although none directly addressed telemetry. The expanded search resulted in 76 abstracts that were screened. Two addressed telemetry, including the last CPC statement, which were reviewed and recommendations given.

CONCLUSIONS

No further quality data were identified to support the use of telemetry monitoring in patients with low-risk chest pains. Telemetry monitoring is unlikely to benefit patients with low-risk chest pain with a low-risk HEART Score.

Basic surface electrocardiogram interpretation for the pharmacist

PURPOSE

The electrocardiogram (ECG) is an invaluable tool for clinicians that provides important information about a patient's heart. As clinical pharmacists play an ever-increasing role in cardiovascular care, ECG interpretation is an important skill with which to become familiar.

SUMMARY

The ECG provides information on both electrical and biomechanical aspects of the heart. Electrical information such as the rhythm, rate, and axis of the electrical activity can all be provided by the ECG. Biomechanical information about the heart, such as the presence of ventricular hypertrophy and repolarization changes that may be associated with ischemia or myocardial injury, can also easily be gleaned from the ECG. Furthermore, the ECG plays a central role in both the diagnosis and treatment of common clinical conditions such as atrial fibrillation, ischemic heart disease, and QT interval prolongation.

CONCLUSION

The ECG is one of the most commonly performed diagnostic tests, and clinicians should become familiar with its basic interpretation.

Importance Ranking of Electrocardiogram Rhythms: A Primer for Curriculum Development

INTRODUCTION

Electrocardiogram interpretation is an essential skill for emergency and critical care nurses and physicians. There remains a gap in standardized curricula and evaluation strategies used to achieve and assess competence in electrocardiogram interpretation. The purpose of this study was to develop an importance ranking of the 120 American Heart Association electrocardiogram diagnostic labels with interdisciplinary perspectives to inform curriculum development.

METHODS

Data for this mixed methods study were collected through focus groups and individual semi-structured interviews. A card sort was used to assign relative importance scores to all 120 American Heart Association electrocardiogram diagnostic labels. Thematic analysis was used for qualitative data on participants' rationale for the rankings.

RESULTS

The 18 participants included 6 emergency and critical care registered nurses, 5 cardiologists, and 7 emergency medicine physicians. The 5 diagnoses chosen as the most important by all disciplines were ventricular tachycardia, ventricular fibrillation, atrial fibrillation, complete heart block, and normal electrocardiogram. The "top 20" diagnoses by each discipline were also reported. Qualitative thematic content analysis revealed that participants from all 3 disciplines identified skill in electrocardiogram interpretation as clinically imperative and acknowledged the importance of recognizing normal, life threatening, and time-sensitive electrocardiogram rhythms. Additional qualitative themes, identified by individual disciplines, were reported.

DISCUSSION

This mixed-methods approach provided valuable interdisciplinary perspectives concerning electrocardiogram curriculum case selection and prioritization. Study findings can provide a foundation for emergency and critical care educators to create local ECG educational programs. Further work is recommended to validate the list amongst a larger population of emergency and critical care frontline nurses and physicians.

Describing Clinically Significant Arrhythmias in Postoperative Vascular Surgery Patients

BACKGROUND

The American Heart Association guidelines instruct use of postoperative telemetry (POT) should be reserved for patients undergoing cardiac procedures and/or those with ischemic cardiac symptoms, but acknowledge that major vascular procedures deserve unique consideration. Telemetry remains a limited resource in many hospitals; however, it has been poorly defined which vascular patients have greatest need for POT. The purpose of this study is to define the rates of postoperative arrhythmias (POAs) after major vascular operations using the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry, identify independent predictors of POA, and determine the effect of POA on mortality to guide the use of POT in vascular patients.

METHODS

A retrospective cohort study was performed using the following VQI modules: open abdominal aortic aneurysm repair (oAAA), complex endovascular aneurysm repair (EVAR) (thoracic endovascular aortic repair [TEVAR]/c-EVAR), EVAR, suprainguinal bypass (SIB), and infrainguinal bypass (IIB). POA was defined in the VQI as a new rhythm disturbance requiring treatment with medication or cardioversion. The incidence of POA, preoperative risk factors, and demographics were determined for each procedure.

RESULTS

A total of 121,652 procedures were identified with an overall POA event rate of 5.1% (n = 6,265). Procedure-specific event rates for POA among VQI registries are as follows: oAAA 14.4%, TEVAR/c-EVAR 8.5%, EVAR 2.7%, SIB 6.2%, and IIB 3.8%. Across all procedure types, POA was associated with emergent operations and increased procedure time. Procedure-specific multivariable regression revealed additional independent preoperative intraoperative factors associated with POA that were unique with each procedure. Across all procedural groups, the presence of POA was associated with increased rates of clinical myocardial infarction and decreased survival on Kaplan-Meier analysis.

CONCLUSIONS

Rates of POA in patients undergoing vascular procedures appear higher than previously reported, and POA is associated with decreased survival. Our study elucidated patient- and procedure-specific predictor factors associated with POA that can be used to inform the use of POT.

Factors associated with shockable versus non-shockable rhythms in patients with in-hospital cardiac arrest

AIM

To identify factors associated with the initial rhythm in patients with in-hospital cardiac arrest and to assess whether potential differences in outcomes based on the initial rhythm can be explained by patient and event characteristics.

METHODS

Adult patients (≥18 years old) with in-hospital cardiac arrest in 2017 and 2018 were included from the Danish In-Hospital Cardiac Arrest Registry (DANARREST). We used population-based registries to obtain data on comorbidities, cardiac procedures, and medications. Unadjusted and adjusted risk ratios (RRs) for initial rhythm, return of spontaneous circulation (ROSC), and survival were estimated in separate models including an incremental number of prespecified variables.

RESULTS

A total of 3422 patients with in-hospital cardiac arrest were included, of which 639 (19%) had an initial shockable rhythm. Monitored cardiac arrest, witnessed cardiac arrest, and specific cardiac diseases (i.e. ischemic heart disease, dysrhythmias, and valvular heart disease) were associated with initial shockable rhythm. Conversely, higher age, female sex, and specific non-cardiovascular comorbidities (e.g. overweight and obesity, renal disease, and pulmonary cancer) were associated with an initial non-shockable rhythm. Initial shockable rhythm remained strongly associated with increased ROSC (RR = 1.63, 95%CI 1.51-1.76), 30-day survival (RR = 2.31, 95%CI 2.02-2.64), and 1-year survival (RR = 2.36, 95%CI 2.02-2.76) compared to initial non-shockable rhythm in the adjusted analyses.

CONCLUSION

In this study, specific patient and cardiac arrest characteristics were associated with initial rhythm in patients with in-hospital cardiac arrest. However, differences in patient and cardiac arrest characteristics did not fully explain the association with survival for initial shockable rhythm compared to a non-shockable rhythm.

Direct oral anticoagulants: a review on the current role and scope of reversal agents

New guideline recommendations prefer direct oral anticoagulants (DOACs) over warfarin in DOAC-eligible patients with atrial fibrillation and patients with venous thromboembolism. As expected with all antithrombotic agents, there is an associated increased risk of bleeding complications in patients receiving DOACs that can be attributed to the DOAC itself, or other issues such as acute trauma, invasive procedures, or underlying comorbidities. For the majority of severe bleeding events, the widespread approach is to withdraw the DOAC, then provide supportive measures and "watchful waiting" with the expectation that the bleeding event will resolve with time. However, urgent reversal of anticoagulation may be advantageous in patients with serious or life-threatening bleeding or in those requiring urgent surgery or procedures. Until recently, the lack of specific reversal agents, has affected the uptake of these agents in clinical practice despite a safer profile compared to warfarin in clinical trials. In cases of life-threatening or uncontrolled bleeding or when patients require emergency surgery or urgent procedures, idarucizumab has been recently approved for reversal of anticoagulation in dabigatran-treated patients and andexanet alfa for factor Xa inhibitor-treated treated patients. The current review summarizes the current clinical evidence and scope of these agents with the potential impact on DOAC use in clinical practice.

Preliminary study between Y chromosome haplogroups and chagasic cardiomyopathy manifestations in patients with Chagas disease

INTRODUCTION

Among patients with Chagas disease, men have a higher risk of worse pathological symptoms than women. We aimed to explore the role of the Y chromosome in men diagnosed with Chagas disease and assess the relationship between their ancestry and disease status.

METHODS

In this comparative study, we analyzed 150 men with unrelated non-chagasic disease (nCD) and 150 men with unrelated chagasic disease (CD). We assessed the serological diagnosis of Chagas disease, biochemical parameters, thoracic X-rays, electrocardiogram, and transthoracic echocardiography and determined the haplogroup by analyzing a set of 17 microsatellites from the Y chromosome. We examined the associations between common Y chromosome haplogroups and the clinical parameters of risk by logistic regression.

RESULTS

For all patients, the most common haplogroups were R1b (43%), G2a (9%), and E1b1b (9%). The R1b and G2a haplogroup was more frequent in men with nCD and CD, respectively. As expected, we observed a high proportion of symptomatic patients in the CD group independent of the haplogroups. Men from both groups classified as having the R1b haplogroup showed less clinical evidence of disease. Multivariate analysis showed that CD patients without R1b were about five times more likely to have a cardio-thorax index >0.5% (OR [odds ratio] = 5.1, 95% CI [confidence interval] = 3.31-8.17). Men without the R1b haplogroup were 2.5 times more likely to show EcoCG alterations (OR = 2.50, 95% CI = 0.16-3.94).

CONCLUSIONS

Our results provided evidence that the R1b haplogroup may have a potential protective cardiovascular effect for its carriers.

The Clinical Utility of Continuous QT Interval Monitoring in Patients Admitted With COVID-19 Compared With Standard of Care: A Prospective Cohort Study

Background

QT interval monitoring has gained much interest during the COVID-19 pandemic because of the use of QT-prolonging medications and the concern about viral transmission with serial electrocardiograms (ECGs). We hypothesized that continuous telemetry-based QT monitoring is associated with better detection of prolonged QT episodes.

Methods

We introduced continuous cardiac telemetry (CCT) with an algorithm for automated QT interval monitoring to our designated COVID-19 units. The daily maximum automated heart rate-corrected QT (Auto-QTc) measurements were recorded. We compared the proportion of marked QTc prolongation (Long-QTc) episodes, defined as QTc ≥ 500 ms, in patients with suspected or confirmed COVID-19 who were admitted before and after CCT was implemented (control group vs CCT group, respectively). Manual QTc measurement by electrophysiologists was used to verify Auto-QTc. Charts were reviewed to describe the clinical response to Long-QTc episodes.

Results

We included 33 consecutive patients (total of 451 monitoring days). Long-QTc episodes were detected more frequently in the CCT group (69/206 [34%] vs 26/245 [11%]; P < 0.0001) and ECGs were performed less frequently (32/206 [16%] vs 78/245 [32%]; P < 0.0001). Auto-QTc correlated well with QTc measurement by electrophysiologists with an excellent agreement in detecting Long-QTc (κ = 0.8; P < 0.008). Only 28% of patients with Long-QTc episodes were treated with recommended therapies. There was 1 episode of torsade de pointes in the control group and none in the CCT group.

Conclusions

Continuous QT interval monitoring is superior to standard of care in detecting episodes of Long-QTc with minimal need for ECGs. The clinical response to Long-QTc episodes is suboptimal.

Team-Based Intervention to Reduce the Impact of Nonactionable Alarms in an Adult Intensive Care Unit

BACKGROUND

Nonactionable alarms comprise over 70% of alarms and contribute a threat to patient safety. Few studies have reported approaches to translate and sustain these interventions in clinical settings.

PURPOSE

This study tested whether an interprofessional team-based approach can translate and implement effective alarm reduction interventions in the adult intensive care unit.

METHODS

The study was a prospective, cohort, pre- and postdesign with repeated measures at baseline (preintervention) and post-phase I and II intervention periods. The settings for the most prevalent nonactionable arrhythmia and bedside parameter alarms were adjusted during phases I and II, respectively.

RESULTS

The number of total alarms was reduced by 40% over a 14-day period after both intervention phases were implemented. The most prevalent nonactionable parameter alarms decreased by 47% and arrhythmia alarms decreased by 46%.

CONCLUSIONS

It is feasible to translate and sustain system-level alarm management interventions addressing alarm fatigue using an interprofessional team-based approach.

Adverse events targeted by drug-drug interaction alerts in hospitalized patients

OBJECTIVE

To identify the types of adverse drug events (ADEs) that drug-drug interaction (DDI) alerts are trying to prevent in hospitalized patients.

METHODS

This was a retrospective cross-sectional study conducted in a tertiary referral hospital in Australia. All DDI alerts encountered by prescribers during a 1-month period were evaluated for potential ADEs targeted for prevention. If the same DDI alert occurred for the same patient multiple times during hospitalization, it was counted only once (i.e. first alert). This was termed a 'unique DDI alert' for a given patient. The primary outcome was the type of ADE the alerts were trying to prevent.

RESULTS

There were 715 patients who had 1599 unique DDI alerts. The two most common potential ADEs (not mutually exclusive) that the alerts attempted to prevent were QTc prolongation or torsades de pointes (n = 1028/1599, 64 %), followed by extrapyramidal symptoms or neuroleptic malignant syndrome (n = 463/1599, 29 %). Either of these two potential ADEs were present in 83 % (n = 1329/1599) of unique DDI alerts.

CONCLUSION

Alerting systems are primarily trying to prevent two types of potential ADEs, which were included in more than 80 % of DDI alerts. This has important implications for patient monitoring in hospitals.

Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association

Many widely used medications may cause or exacerbate a variety of arrhythmias. Numerous antiarrhythmic agents, antimicrobial drugs, psychotropic medications, and methadone, as well as a growing list of drugs from other therapeutic classes (neurological drugs, anticancer agents, and many others), can prolong the QT interval and provoke torsades de pointes. Perhaps less familiar to clinicians is the fact that drugs can also trigger other arrhythmias, including bradyarrhythmias, atrial fibrillation/atrial flutter, atrial tachycardia, atrioventricular nodal reentrant tachycardia, monomorphic ventricular tachycardia, and Brugada syndrome. Some drug-induced arrhythmias (bradyarrhythmias, atrial tachycardia, atrioventricular node reentrant tachycardia) are significant predominantly because of their symptoms; others (monomorphic ventricular tachycardia, Brugada syndrome, torsades de pointes) may result in serious consequences, including sudden cardiac death. Mechanisms of arrhythmias are well known for some medications but, in other instances, remain poorly understood. For some drug-induced arrhythmias, particularly torsades de pointes, risk factors are well defined. Modification of risk factors, when possible, is important for prevention and risk reduction. In patients with nonmodifiable risk factors who require a potentially arrhythmia-inducing drug, enhanced electrocardiographic and other monitoring strategies may be beneficial for early detection and treatment. Management of drug-induced arrhythmias includes discontinuation of the offending medication and following treatment guidelines for the specific arrhythmia. In overdose situations, targeted detoxification strategies may be needed. Awareness of drugs that may cause arrhythmias and knowledge of distinct arrhythmias that may be drug-induced are essential for clinicians. Consideration of the possibility that a patient's arrythmia could be drug-induced is important.

Effects of monitor alarm management training on nurses' alarm fatigue: A randomised controlled trial

BACKGROUND

Chaotic monitor alarm management generates a large number of alarms, which result in alarm fatigue. Intensive care unit (ICU) nurses are caretakers of critically ill patients, the effect of alarm management affect patient safety directly.

OBJECTIVES

To evaluate the effect of monitor alarm management training based on the theory of planned behaviour for reducing alarm fatigue in intensive care unit nurses.

DESIGN

A randomised, single-blind trial. This article follows the requirements of CONSORT statement.

PARTICIPANTS

The study was conducted from February 2019-May 2019 in a tertiary A-level hospital. 93 ICU clinical nurses were included, and they were randomly assigned into two groups.

INTERVENTION

Nurses in the experimental group (n = 47) received a 12-week alarm management training course based on the theory of planned behaviour. Nurses in the control group (n = 46) received regular training. All nurses' alarm fatigue scores were measured with a questionnaire before and after the study period. Total number of alarms, nonactionable alarms and true crisis alarms were recorded continuously throughout the study period.

RESULTS

For baseline comparisons, no significant differences were found. By the analysis of independent samples one-way ANCOVAs, the nurses' adjusted alarm fatigue scores at the post-test in the experimental group were significantly lower than those in the control group (p < .001). After the study period, adjusted total number of alarms and nonactionable alarms recorded in the experimental group were both significantly lower than those recorded in the control group (p < .001). After the study period, no significant difference between the two groups was noted in the adjusted number of true crisis alarms (p > .05). The interventions did not cause adverse events in either group of patients and did not cause adverse events in patients.

CONCLUSION

Intensive care unit nurses' alarm fatigue was effectively decreased by the monitor alarm management training based on the theory of planned behaviour.

RELEVANCE TO CLINICAL PRACTICE

(1) Monitor alarm training based on the theory of planned behaviour is effective in reducing nonactionable alarms and lowering alarm fatigue in ICU nurses. (2) The intervention considering the social psychological aspects of behaviour is effective in rebuilding the nurses' awareness and behaviour of alarm management. (3) Nurses are the direct users of monitoring technology. Hospital administrators should attach importance to the role of nurses in the medical monitoring system. We suggest that nursing managers implement training programmes in more ICUs in the future to improve alarm management ability and lower alarm fatigue in ICU nurses.

Methadone's Effect on Cardiac Repolarization: Safety in the PICU

OBJECTIVES

Opioids are routinely used in the PICU. Methadone is an effective method of preventing and treating iatrogenic opioid withdrawal; however, it carries an Food and Drug Administration Boxed Warning due to the potential to prolong the corrected QT interval and potentially lead to life-threatening arrhythmias. Guidelines on the safe use of methadone have limited applicability to children since their cardiac intervals differ from those of adults. There is little data on the electrophysiologic effects in the pediatric population. We set out to describe the safety of methadone use in the PICU, hypothesizing that methadone does not cause a significant change in corrected QT interval from baseline.

DESIGN

Retrospective cohort study.

SETTING

Children's Hospital of Wisconsin, Milwaukee, WI.

PATIENTS

Fifty-one patients, age less than or equal to 18 years old, initiated on methadone during PICU admission, over an 11-month period, for the prevention or treatment of opioid withdrawal.

INTERVENTIONS

Retrospective data queried from the electronic health record and stored telemetry waveforms obtained from an automated real-time patient data acquisition software system (BedMasterEx; Anandic Medical Systems AG, Feuerthalen, Switzerland).

MEASUREMENTS AND MAIN RESULTS

Corrected QT intervals were not significantly different at 12 hours, 96 hours, or PICU discharge (p values: 0.57, 0.54, and 0.34) when compared to baseline. The median change in corrected QT from baseline to 12 hours after the first dose of methadone was 5 ms (interquartile range, -12 to 11 ms), 0 ms to steady state (interquartile range, -18 to 18 ms), and 5 ms from baseline to 12 hours after the highest dose of methadone (interquartile range, -14 to 16 ms). The most common primary diagnosis was structural heart disease (29% of subjects) in our cohort and every subject that experienced an increase in corrected QT interval greater than or equal to 40 ms had some form of structural heart disease.

CONCLUSIONS

Methadone did not significantly prolong the corrected QT interval in a population of critically ill children, suggesting that it can be safely used in this population, although patients with structural heart disease may warrant closer monitoring.

QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry

OBJECTIVE

Several psychiatric medications have the potential to prolong the QTc interval and subsequently increase the risk for ventricular arrhythmias such as torsades de pointes (TdP). There is limited guidance for clinicians to balance the risks and benefits of treatments.

METHODS

After a review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus guidelines for ECG monitoring of the QTc interval for patients with medical and psychiatric comorbidities who are prescribed medications with the potential to prolong the QTc interval. A risk score was developed based on risk factors for QTc prolongation to guide clinical decision-making.

RESULTS

A baseline ECG may not be necessary for individuals at low risk for arrythmia. Those individuals with a risk score of two or more should have an ECG prior to the start of a potentially QTc-prolonging medication or be started on a lower risk agent. Antipsychotics are not equivalent in causing QTc prolongation. A consensus-based algorithm is presented for the management of those identified at high (QTc >500 msec), intermediate (males with QTc 450-499 msec or females with QTc > 470-499 msec), or low risk.

CONCLUSIONS

The proposed algorithm can help clinicians in determining whether ECG monitoring should be considered for a given patient. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for complex patients with medical and psychiatric comorbidities. Additional studies are needed to determine whether baseline and serial ECG monitoring reduces mortality.

A Retrospective Analysis of Hospital Electrocardiogram Auto-Populated QT Interval Calculation

Background

The current electrocardiogram (ECG) standard for rate correction of the QT interval (QTc) is a power function known as the Bazett formula (QTcB). QTc formulae are either power functions or linear functions. QTcB is known to lack reliability, as heart rate (HR) rises from or falls below 60 beats per minute (bpm). The American Heart Association (AHA), the American College of Cardiology Foundation (ACCF), and the Heart Rhythm Society (HRS) have recommended using other formulae in place of QTcB since 2009. The Epic Electronic Health Record System (Epic Systems Corporation, Verona, WI) automatically populates the Fridericia formula (QTcFri) on hospital ECG reports without any provider calculation.

Methods

We aimed to retrospectively investigate the effect of QTcFri on one year of ECGs in the Epic Electronic Health Record (EHR) at a single tertiary care center. Inclusion criteria for ECG reports specified HR 60-120 bpm without QRS duration > 120 ms. Gathered data from Epic EHR ECG reports included patient age, sex, HR, QRS duration (QRSd), QT interval, QTcB, and QTcFri. EHR documented 61,946 ECG reports for the year, with 44,566 meeting criteria for inclusion. General statistical methods included range, median, mean, and standard deviation. Confidence intervals were assessed to maintain the fidelity of analysis. The normality of data distribution was assessed with Kolmogorov-Smirnov testing. The Wilcoxon rank-sum test was then performed to confirm a statistically significant difference between the Bazett and Fridericia formulae. The ∆QTc analysis was conducted on prolonged QTc (males > 450 ms; females > 460 ms) and severely prolonged QTc > 500 ms data subsets. A value of p<0.05 was interpreted as significant. Statistical analysis was performed using SPSS statistical software (IBM Statistics, v. 26; IBM Corp, Armonk, NY).

Results

The 44,566 ECG reports demonstrated 57% female gender and a mean age of 57 ± 17.5 years. The mean HR was 83 ± 14.7 bpm and the mean ∆QTc was 23 ± 12.9 ms shorter with QTcFri. Mean data showed minimal variation between sexes: age, heart rate, uncorrected QT, QTcB, QTcFri, and ∆QTc varied by less than 2%. Mean QRS varied by 4% between sexes. The Wilcoxon rank-sum test revealed 44,127 ranks with a negative difference, 0 ranks with a positive difference, and 439 ties, p <0.001 (99% CI: 22.5 ms, 23.0 ms). QTcB identified 37.4% (16665/44566) ECGs prolonged. Using QTcFri, 21% (9371/44566) of the total ECGs corrected to normal QTc (<450 ms (men) and 460 ms (women)). QTcFri use reduced the number of ECG reports with QTc > 500 ms by 57.3%. A total of 125 ECG reports, 117 females and eight males, corrected to normal gender-specific QTc with QTcFri. The mean decrease in QTc with the Fridericia formula when QTcB > 500 ms was 31 ± 14.5 ms (99% CI: 30.4 ms, 31.7 ms).

Conclusion

Our data from the Wilcoxon rank-sum analysis indicated that the EHR QTcFri analysis yields a statistically significant difference (p < 0.001) in QTc calculation of 22 ms over 44,566 ECG reports. The data showed a 21% reduction in inaccurately documented test results. The utilization of this resource will provide the most accurate and clinically relevant data to inform clinical decision-making. Accurate QT interval calculation will better inform downstream clinical decision-making through a wider scope of therapeutic intervention. This analysis is readily available to clinicians without calculation and its awareness will benefit patient care.

The risk of QTc-interval prolongation in COVID-19 patients treated with chloroquine

Background

Chloroquine, a quinolone antimalarial drug, is known to potentially inhibit pH-dependent viral replication of the SARS-CoV‑2 infection. Therefore, chloroquine is considered as a treatment option for coronavirus disease 2019 (COVID-19). Chloroquine is known for prolonging the QT interval, but limited data are available on the extent of this QT-prolonging effect.

Objective

To assess the QTc-prolonging potential of chloroquine in COVID-19 patients and to evaluate whether this prolongation increases with the cumulative dose of chloroquine and is associated with the peak plasma concentration of chloroquine. Furthermore, the number of patients who prematurely discontinued treatment or had an adjustment in dose due to QTc-interval prolongation was established.

Methods

A retrospective, observational study was performed in patients aged over 18 years, hospitalised for a suspected or proven infection with COVID-19, and therefore treated with chloroquine, with a baseline electrocardiogram (ECG) performed prior to the start of treatment and at least one ECG after starting the treatment.

Results

In total, 397 patients were included. The mean increase in QTc interval throughout the treatment with chloroquine was 33 ms. Nineteen out of 344 patients unnecessarily had their treatment prematurely discontinued or adjusted due to a prolonged QTc interval based on the computerised interpretation of the ECG.

Conclusion

Chloroquine treatment in COVID-19 patients gradually increased the QTc interval. Due to a significant number of overestimated QTc intervals by computer analysis, it is advisable to measure the QTc interval manually before adjusting the dose or withdrawing this potentially beneficial medication.

Resuscitation outcomes of a wireless ECG telemonitoring system for cardiovascular ward patients experiencing in-hospital cardiac arrest

BACKGROUND/PURPOSE

In-hospital cardiac arrest is a serious issue for hospitalized patients. The documented initial rhythm and detected medical events have been reported to influence the survival of cardiopulmonary resuscitation. This study aimed to identify the effect of continuous real-time electrocardiogram (ECG) monitoring on the prognosis of resuscitated patients in a general cardiac ward.

METHODS

We conducted this retrospective study using medical records of hospitalized patients in a cardiovascular ward who experienced an in-hospital cardiac arrest and received cardiopulmonary resuscitation from February 2015 to December 2018. The patients who were considered to be at high risk of cardiac events such as ventricular arrhythmia would receive continuous ECG monitoring. A wireless ECG telemonitoring system was introduced to replace traditional bedside ECG monitors. The outcome measures were the initial success of resuscitation, 24-h survival after resuscitation, and survival to discharge.

RESULTS

We enrolled 115 patients with a cardiac arrest during hospitalization, of whom 73 (63%) patients received wireless ECG telemonitoring. Patients receiving continuous ECG monitoring were associated with higher opportunities of initial success of resuscitation and 24-h survival after resuscitation (67.1% vs. 40.5%, p = 0.005; and 49.3% vs. 26.2%, p = 0.015, respectively) when comparing to the non-monitoring group; but no significant difference in survival to discharge (21.9% vs. 16.7%, p = 0.498) was observed. With adjustment of the covariates, the monitoring group was associated with a higher likelihood to reach the initial success of resuscitation (odds ratios [ORs], 3.21; 95% confidence interval [CI], 1.03-9.98). However, the effect of monitoring on 24-h survival and survival to discharge was close to null after adjusting for covariates.

CONCLUSION

A wireless ECG telemonitoring system were beneficial to the initial success of resuscitation for patients at high risk of cardiovascular events suffering an in-hospital cardiac arrest; but had less impact on 24-h survival and survival to discharge.

Walk the Line-The Importance of Well-Informed Interpretation of QT Prolongation

Acute care pharmacists play an integral role in identifying drug-drug interactions that may predispose patients to QT prolongation. Although most pharmacists are equipped with a baseline understanding of drug interactions and the risks of QTc prolongation, few understand the limitations of QTc calculation and interpretation. In this commentary, we put forth the notion that at times health care providers, including pharmacists, place an overemphasis on the QTc interval. In the context of using the QTc to guide pharmacotherapy decisions, unintended consequences may include a cascade of effects leading to delays in treatment, suboptimal medication selection, alert fatigue, and overutilization of resources.

Clinical impact of multi-parameter continuous non-invasive monitoring in hospital wards: a systematic review and meta-analysis

OBJECTIVE

Delayed response to clinical deterioration as a result of intermittent vital sign monitoring is a cause of preventable morbidity and mortality. This review focuses on the clinical impact of multi-parameter continuous non-invasive monitoring of vital signs (CoNiM) in non-intensive care unit patients.

DESIGN

Systematic review and meta-analysis of primary studies. Embase, MEDLINE, HMIC, PsycINFO and Cochrane were searched from April 1964 to 18 June 2019 with no language restriction.

SETTING

The search was limited to hospitalised, non-intensive care unit adult patients who had two or more vital signs continuously monitored.

PARTICIPANTS

All primary studies that evaluated the clinical impact of using multi-parameter CoNiM in adult hospital wards outside of the intensive care unit.

MAIN OUTCOME MEASURES

Clinical impact of multi-parameter CoNiM.

RESULTS

This systematic review identified 14 relevant studies from 3846 search results. Five studies were classified as Group A - associations found between measured vital signs and clinical parameters. Nine studies were classified as Group B - comparison between clinical outcomes of patients with and without multi-parameter CoNiM. Vital signs data from CoNiM were found to associate with type of presenting complaint, level of renal function and incidence of major clinical events. CoNiM also assisted in diagnosis by differentiating between patients with acute heart failure, stroke and sepsis (with sub-clustering of septic patients). In the meta-analysis, patients on multi-parameter CoNiM had a 39% decrease in risk of mortality (risk ratio [RR] 0.61; 95% confidence interval [95% CI] -0.39-0.95) when compared to patients with regular intermittent monitoring. There was a trend of reduced intensive care unit transfer (RR 0.86; 95% CI -0.67-1.11) and reduced rapid response team activation (RR 0.61; 95% CI 0.26-1.43). A trend towards reduced hospital length of stay was also found using weighted mean difference (WMD -3.32 days; 95% CI -8.82-2.19 days).

CONCLUSION

There is evidence of clinical benefit in implementing CoNiM in non-intensive care unit patients. This review supports the use of multi-parameter CoNiM outside of intensive care unit with further large-scale RCTs required to further affirm clinical impact.

Actionable Ventricular Tachycardia During In-Hospital ECG Monitoring and Its Impact on Alarm Fatigue

BACKGROUND

Ventricular tachycardia (V-tach) is the most common lethal arrhythmia, yet 90% of alarms are false and contribute to alarm fatigue. We hypothesize that some true V-tach also causes alarm fatigue because current criteria are too sensitive (i.e., ≥6 beats ≥100 beats/min [bpm]).

PURPOSE

This study was designed to determine (1) the proportion of clinically actionable true V-tach events; (2) whether true actionable versus nonactionable V-tach differs in terms of heart rate and/or duration (seconds); and (3) if actionable V-tach is associated with adverse outcomes.

METHODS

This was a secondary analysis in 460 intensive care unit (ICU) patients. Electronic health records were examined to determine if a V-tach event was actionable or nonactionable. Actionable V-tach was defined if a clinical action(s) was taken within 15 minutes of its occurrence (i.e., new and/or change of medication, defibrillation, and/or laboratory test). Maximal heart rate and duration for each V-tach event were measured from bedside monitor electrocardiography. Adverse patient outcomes included a code blue event and/or death.

RESULTS

In 460 ICU patients, 50 (11%) had 151 true V-tach events (range 1-20). Of the 50 patients, 40 (80%) had only nonactionable V-tach (97 events); 3 (6%) had both actionable and nonactionable V-tach (32 events); and 7 patients (14%) had only actionable V-tach (23 events). There were differences in duration comparing actionable versus nonactionable V-tach (mean 56.19 ± 116.87 seconds vs. 4.28 ± 4.09 seconds; P = 0.001) and maximal heart rate (188.81 ± 116.83 bpm vs. 150.79 ± 28.26 bpm; P = 0.001). Of the 50 patients, 3 (6%) had a code blue, 2 died, and all were in the actionable V-tach group.

CONCLUSIONS

In our sample, <1% experienced a code blue following true V-tach. Heart rate and duration for actionable V-tach were much faster and longer than that for nonactionable V-tach. Current default settings typically used for electrocardiographic monitoring (i.e., ≥6 beats ≥100 bpm) appear to be too conservative and can lead to crisis/red level nuisance alarms that contribute to alarm fatigue. A prospective study designed to test whether adjusting default settings to these higher levels is safe for patients is needed.

'Utilization of telemetry monitoring for non-cardiac conditions in non-critical patients: what are the trends and perceptions amongst medical residents?'

Background & Objective

Current evidence shows that telemetry monitoring is commonly overutilized for 'non-cardiac' diseases such as COPD exacerbation, pneumonia, pulmonary embolism and sepsis. This issue has not been addressed clearly in the recent American Heart Association (AHA) guidelines and no standard recommendations on the use of telemetry in non-cardiac conditions exist; therefore, clinicians continue to make such decisions based on personal preferences.As medical residency is an important phase during which young physicians develop clinical skills and habits for their future practice, the aim of this study was to understand the prevalent trends related to inappropriate telemetry use amongst the medical residents at a community hospital and the associated factors which influence the use of telemetry monitoring in non-cardiac patients.

Methods

All the residents undergoing internal medicine training at a community hospital were surveyed with the help of a questionnaire regarding the utility of telemetry in non-critical patients admitted with non-cardiac conditions.

Results

Survey was completed by 37 residents. Analysis of the responses showed that despite the frequent use of telemetry in non-cardiac conditions, majority of the medical residents are unaware of the correct indications. Seventy-three percent choose 'continuous' telemetry when placing the order while only 16% (often or always) discontinue telemetry after 24 hours of uneventful use. Although 84% residents admitted that telemetry is overutilized, still 49% felt that it leads to better patient care while 70% considered it superior to frequent vitals monitoring for early detection of hemodynamic instability. Possible causes of inappropriate use included 'Lack of knowledge about the related literature' and 'Following trends set by the peers'.

Conclusion

Majority of the medical residents overutilize telemetry in non-cardiac conditions due to lack of knowledge, perceived sense of security and inappropriate trends set by their colleagues. In order to abolish these tendencies, we propose the provision of adequate educational resources to the clinical staff at every level along with other system-based strategies.

Delineation of Electrocardiograms Using Multiscale Parameter Estimation

The continuing interest in unobtrusive electrocardiography requires the development of algorithms, compensating for an increased number of artifacts. In previous work, we proposed a framework for robust parameter estimation of signals following a piecewise Gaussian derivative model, well suited for describing all waves of a heartbeat. The framework is based on a numeric and analytic representation of applying the Wavelet Transform at arbitrary scale to the input model. For robustly estimating model parameters, it processes lines of zero-crossings in scale-space, showing high accuracy for various noise models in synthetic signals. An initial evaluation with electrocardiography signals revealed that our basic classifier for identifying the correct lines often fails, leading to false parameter estimates. In this work, we propose a general delineation method based on a solid mathematical framework that treats each heartbeat, wave and fiducial point in the same way, tailored only by intuitive parameters and not relying on any heuristically found decision rules. The steps include a novel line classifier based on pre-filtering using domain knowledge, followed by an exhaustive search among all possible combinations of zero-crossing lines and an error-measure quantifying their agreement with the model. The combination with highest agreement is processed by the parameter estimation framework, customized to the computation of all nine fiducial points. Evaluation using the expert-annotated QT database, shows high sensitivity (P: 99.91%, QRS: 99.92%, T: 99.89%) and mean errors below 1 ms for all onset and offset fiducial points. The proposed combination of line classification and parameter estimation is well suited for delineating electrocardiograms.

Perianesthesia Implications and Considerations for Drug-Induced QT Interval Prolongation

Prolongation of the QT interval can predispose patients to fatal arrhythmias such as torsade de pointes. While arrhythmias can occur spontaneously in patients with a genetic predisposition, drugs such as ondansetron and droperidol, which are frequently used in the perioperative period, have been implicated in the prolongation of the QT interval. As the list of medications that cause QT prolongation grows, anesthesia providers and perioperative nurses must be informed regarding the importance of the QT interval. This article reviews the physiology and measurement of the QT interval, the risk factors of QT prolongation, the mechanism of drug-induced QT prolongation, and perioperative considerations for patient care.

Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital

BACKGROUND10: The Joint Commission identified inpatient alarm reduction as an opportunity to improve patient safety; enhance patient, family and nursing satisfaction; and optimise workflow. We used quality improvement (QI) methods to safely decrease non-actionable alarm notifications to bedside providers.

METHODS

In a paediatric tertiary care centre, we convened a multidisciplinary team to address alarm notifications in our acute care cardiology unit. Alarm notification was defined as any alert to bedside providers for each patient-triggered monitor alarm. Our aim was to decrease alarm notifications per monitored bed per day by 60%. Plan-Do-Study-Act testing cycles included updating notification technology, establishing alarm logic and modifying bedside workflow processes, including silencing the volume on all bedside monitors. Our secondary outcome measure was nursing satisfaction. Balancing safety measures included floor to intensive care unit transfers and patient acuity level.

RESULTS

At baseline, there was an average of 71 initial alarm notifications per monitored bed per day. Over a 3.5-year improvement period (2014-2017), the rate decreased by 68% to 22 initial alarm notifications per monitored bed per day. The proportion of initial to total alarm notifications remained stable, decreasing slightly from 51% to 40%. There was a significant improvement in subjective nursing satisfaction. At baseline, 32% of nurses agreed they were able to respond to alarms appropriately and quickly. Following interventions, agreement increased to 76% (p<0.001). We sustained these improvements over a year without a change in monitored balancing measures.

CONCLUSION

We successfully reduced alarm notifications while preserving patient safety over a 4-year period in a complex paediatric patient population using technological advances and QI methodology. Continued efforts are needed to further optimise monitor use across paediatric hospital units.

Routine Continuous Electrocardiographic Monitoring Following Percutaneous Coronary Interventions

BACKGROUND

The clinical utility of routine electrocardiographic monitoring following percutaneous coronary interventions (PCI) is not well studied.

METHODS

We prospectively evaluated the incidence, cost, and the clinical implications of actionable arrhythmia alarms on telemetry monitoring following PCI. One thousand three hundred fifty-eight PCI procedures (989 [72.8%] for acute coronary syndrome and 369 [27.2%] for stable angina) on patients admitted to nonintensive care unit were identified and divided into 2 groups; group 1, patients with actionable alarms (AA) and group 2, patients with non-AA. AA included (1) ≥3 s electrical pause or asystole; (2) high-grade Mobitz type II atrioventricular block or complete heart block; (3) ventricular fibrillation; (4) ventricular tachycardia (>15 beats); (5) atrial fibrillation with rapid ventricular response; (6) supraventricular tachycardia (>15 beats). Primary outcomes were 30-day all-cause mortality. Cost-savings analysis was performed.

RESULTS

Incidence of AA was 2.2% (37/1672). Time from end of procedure to AA was 5.5 (0.5, 24.5) hours. Patients with AA were older, presented with acute congestive heart failure or non-ST-segment-elevation myocardial infarction, and had multivessel or left main disease. The 30-day all-cause mortality was significantly higher in patients with AA (6.5% versus 0.3% in non-AA [P<0.001]). Applying the standardized costing approach and tailored monitoring per the American Heart Association guidelines lead to potential cost savings of $622 480.95 for the entire population.

CONCLUSIONS

AA following PCI were infrequent but were associated with increase in 30-day mortality. Following American Heart Association guidelines for monitoring after PCI can lead to substantial cost saving.

An observational study of the management practices and outcomes of patients with new onset atrial fibrillation in non-cardiothoracic surgeries

BACKGROUND AND OBJECTIVE

Limited data exist on characteristics and management of patients with postoperative atrial fibrillation (POAF) after noncardiothoracic surgeries and on the relationship between symptoms and outcomes. We sought to describe clinical features, in-hospital practices and outcomes in patients with new POAF by the presence or absence of clinical symptoms.

METHODS

Retrospective cohort study of adults with POAF in one tertiary center.

RESULTS

Among the 99 patients who fulfilled the eligibility criteria, median age was 75 years (IQR 64-83) and 57.6% were male. Only thirty percent of patients with POAF were symptomatic. Rate control/conversion to sinus rhythm was achieved in ≤ 4 h in 56% of the patients and in 80% was maintained for ≥ 24 h. Anticoagulation was prescribed in 50% of those discharged in AF; the CHADS2-VASc score was not associated with anticoagulation prescribed. One third of patients were readmitted and half of them were in AF. Asymptomatic patients had lower median heart rate than symptomatic patients but no other clinical characteristics, or outcomes were different.

CONCLUSIONS

Most patients with POAF were asymptomatic but their presentation or outcomes were similar with symptomatic patients. One in four discharged patients was prescribed anticoagulation and the CHADS2-VASC score was not associated with this decision. These findings have important implications for practice and future research. There is a need to better delineate the risk associated with transient versus persistent POAF, symptomatic versus asymptomatic POAF, as well as for clinical trials to determine optimal strategies to improve their outcomes.

Clinical significance of premature ventricular contraction among adult patients: protocol for a scoping review

BACKGROUND

Premature ventricular contractions (PVCs) are one of the most common arrhythmias detected from electrocardiographic (ECG) monitoring. PVCs were thought to cause lethal arrhythmias and thus were closely monitored and treated. However, in current practice, PVCs generally do not required treatment. There is also concern that PVCs contribute to excessive alarms and lead to alarm fatigue. Practice guidelines for in-hospital monitoring state that monitoring for PVCs may be indicated on some patients but do not recommend continuous ECG monitoring. Despite these recommendations, PVC monitoring practices remain part of routine care, especially in the intensive care unit, for worry of missing potentially significant arrhythmia events. A thorough scoping review of the literature regarding the clinical significance of PVC is imperative, precisely to map out the evidence on the diagnostic and prognostic values of PVCs and to identify research gaps on this issue.

METHODS

The primary question of this review is "what is the clinical significance of PVCs in adults?" Preparation of this scoping review will use the PRISMA-P statement. A scoping review framework by Arksey and O'Malley will be adopted. In identifying relevant studies, the Population-Concept-Context (PCC) framework by the Joanna Briggs Institute will be used. A search strategy will be developed, and four major electronic databases will be searched: CINAHL, Embase, PubMed, and Web of Science Core Collection. Manual searches will also be conducted. The study selection process will adopt the 2009 PRISMA flow diagram. EndNote X8 will be used to manage citations, as well as for duplicates screening in addition to Microsoft Excel 2016. Two independent reviewers will assess potential studies in detail against inclusion criteria. A standardized data extraction form will be developed. Finally, critical appraisal will be conducted using a tool adapted from the Quality Appraisal Checklist by the National Institute for Health Care Excellence (NICE).

DISCUSSION

We believe this scoping review will provide a general foundation of evidence on the potential significance of PVCs concerning its diagnostic and prognostic value among the adult patient population. The findings will allow us to map out research gaps on this topic that could shape future research and ultimately clinical practice.

SCOPING REVIEW REGISTRATION

This scoping review has been registered in the Open Science Framework (OSF), DOI: https://doi.org/10.17605/OSF.IO/GAVT2 .

Indication-specific event rates among hospitalized patients undergoing continuous cardiac monitoring

Background

Cardiac telemetry monitoring is widely utilized for a variety of clinical indications, yet indication‐specific event rates for monitored patients are seldomly reported.

Hypothesis

High‐risk hospitalized patients for clinical deterioration can be identified using standardized telemetry monitoring indications.

Methods

Adjudicated data from events triggering emergency response team (ERT) activation were systematically characterized at the Cleveland Clinic from among standardized telemetry indications ordered over a 13‐month period.

Results

Among 72 199 orders created for telemetry monitored patients, ERT activation occurred in 2677 patients (3.7%), of which 1326 (49.5%) were cardiac‐related. Patients with deep venous thrombosis or pulmonary embolism (DVT/PE) demonstrated the highest overall event rate (ERT: n = 41 of 593 pts [6.9%]; 25/41 cardiac related [61%]). Cardiac‐related events were proportionally highest among patients with coronary disease awaiting revascularization (ERT: n = 19 of 847 patients [2.2%]; 13/19 cardiac‐related [68.4%]). Arrhythmia‐specific events were highest among patients who underwent cardiac surgery (n = 78 of 193 cardiac‐related ERT [40.4%]), and patients with known or suspected tachyarrhythmias (n = 318 of 788 cardiac‐related ERT [40.4%]). Bubble plot analysis identified patients hospitalized with DVT/PE, drug or alcohol exposures, and acute coronary syndrome as among the highest overall and cardiac‐related events while identifying patients with respiratory disorder monitoring indications as carrying the highest noncardiac event rate.

Conclusion

High‐risk hospitalized patients can be identified by telemetry indication and prioritized according to concerns for cardiac, arrhythmia‐specific and noncardiac clinical deterioration. This is particularly useful when monitored bed resources are constrained.

Appropriate utilisation of cardiac telemetry monitoring: a quality improvement project

For hospitals located in the United States, appropriate use of cardiac telemetry monitoring can be achieved resulting in cost savings to healthcare systems. Our institution has a limited number of telemetry beds, increasing the need for appropriate use of telemetry monitoring to minimise delays in patient care, reduce alarm fatigue, and decrease interruptions in patient care. This quality improvement project was conducted in a single academic medical centre in Kansas City, Kansas. The aim of the project was to reduce inappropriate cardiac telemetry monitoring on intermediate care units. Using the 2004 American Heart Association guidelines to guide appropriate telemetry utilisation, this project team sought to investigate the effects of two distinct interventions to reduce inappropriate telemetry monitoring, huddle intervention and mandatory order entry. Telemetry utilisation was followed prospectively for 2 years. During our initial intervention, we achieved a sharp decline in the number of patients on telemetry monitoring. However, over time the efficacy of the huddle intervention subsided, resulting in a need for a more sustained approach. By requiring physicians to input indication for telemetry monitoring, the second intervention increased adherence to practice guidelines and sustained reductions in inappropriate telemetry use.

ECG Monitoring during End of Life Care: Implications on Alarm Fatigue

Excessive numbers of clinical alarms in the intensive care unit (ICU) contribute to alarm fatigue. Efforts to eliminate unnecessary alarms, including during end of life (EOL) care, are pivotal. This study describes electrocardiographic (ECG) arrhythmia alarm usage following the decision for comfort care. We conducted a review of electronic health records (EHR) in patients who died and had comfort care orders that were in place during our study. The occurrences of ECG arrhythmia alarms among these patients were examined. We found 151 arrhythmia alarms that were generated in 11 patients after comfort care was initiated: 72% were audible, 21% were manually muted, and 7% had an unknown audio label. Level of alarm: 33% crisis, 58% warning, 1% message, and 8% were labeled unknown. Our report shows that ECG monitoring was commonly maintained during the EOL care. Since the goal of care during this phase is for both patient and family comfort, it is important for the clinicians to weigh the benefits versus harms of the continuous ECG monitoring.

Implementation of a QTc-interval monitoring protocol by pharmacists to decrease cardiac risk in at-risk patients in an acute care inpatient psychiatric facility

Introduction

Many medications commonly prescribed in psychiatric hospitals can cause QTc-interval prolongation, increasing a patient's risk for torsades de pointes and sudden cardiac death. There is little guidance in the literature to determine when an electrocardiogram (ECG) and QTc-interval monitoring should be performed. The primary end point was improvement of the appropriateness of ECGs and QTc-interval monitoring of at-risk psychiatric inpatients at Barnabas Health Behavioral Health Center (BHBH) and Monmouth Medical Center (MMC) following implementation of a standardized monitoring protocol. The secondary end point was the number of pharmacist-specific interventions at site BHBH only.

Methods

Patients who met the inclusion criteria were assessed using a standardized QTc-prolongation assessment algorithm for ECG appropriateness. A retrospective analysis of a control group (no protocol) from January 1, 2016, to July 17, 2017, was compared with a prospective analysis of the intervention group (with protocol) from December 11, 2017, to March 11, 2018.

Results

At BHBH, appropriate ECG utilization increased 25.5% after implementation of a standardized protocol (P = .0172) and appropriate omission of ECG utilization improved by 26% (P < .00001). At MMC, appropriate ECGs decreased by 5%, and appropriate ECG omissions increased by 28%, neither of which were statistically significant (P = 1.0 and P = .3142, respectively). There was an increase in overall pharmacist monitoring.

Discussion

The study demonstrated that pharmacist involvement in ECG and QTc-interval monitoring utilizing a uniform protocol may improve the appropriateness of ECG and QTc-interval monitoring in patients in an acute care inpatient psychiatric hospital.

Navigating the Minefield of QTc Interval-Prolonging Therapy in Nursing Facility Residents

BACKGROUND

The exponential increase in the number of medications associated with clinically important prolongation of the heart rate-corrected QT interval (QTc) places older adults at increased risk of arrhythmias including life-threatening torsade de pointes (TdP) and sudden death. Risk factors, other than age older than 65 years and female sex, include multiple concurrent drugs that prolong QTc and a variety of underlying predisposing conditions. Although electronic medical records and pharmacy dispensing systems can alert clinicians to the risk of QTc-prolonging therapy, more than 95% of safety alerts are overridden, and many systems have deactivated QTc drug interaction alerts. The clinical consequences, magnitude of the effect, mitigation strategies, and recommended monitoring are not well defined for nursing facility (NF) residents.

DESIGN

Narrative review.

SETTING

NFs in the United States.

PARTICIPANTS

NF residents.

RESULTS

Medications known to prolong QTc include selected anti-infectives, antidepressants, urinary anticholinergics, antipsychotics, and cholinesterase inhibitors (eg, donepezil), used commonly in NFs. Drug-drug interactions are a risk when adding a medication that exaggerates the effect or inhibits the metabolism of a QTc-prolonging medication. The vast majority of patients in whom TdP is induced by noncardiac drugs have risk factors that are easily identifiable.

CONCLUSIONS

Recommendations are provided to improve standardization and use of drug interaction alerts, evaluate the risk of QTc-prolonging drugs in older adults receiving generally lower doses, validate a QTc risk score addressing complex multimorbidity, garner evidence to guide clinical decision making, avail NFs of access to electrocardiograms and interpretive recommendations, and develop standards of practice for hosting risk discussions with residents and their families. J Am Geriatr Soc, 1-8, 2019.

Validation of wearable textile electrodes for ECG monitoring

A highly conductive textile was woven from nano-fibers coated with the PEDOT-PSS polymer. The aim of this study was to assess the usefulness of textile electrodes for ECG recording as a smart garment. Electrode textile pads and lead wires were sewn to the lining of sportswear and their tolerability to repeated washings were tested up to 150 times. The electrical conductivity of the textile electrode remained functional for up to 50 machine washes. To assess the level of motion artifacts or noise during the daily monitoring of ECG, a single lead ECG with conventional or textile electrodes was recorded during supine rest, seated rest, upright trunk rotation (i.e., twisting), and stepping movement in 66 healthy adults. A Holter system was used for data storage and analysis. ECG patterns of P, QRS, and T waves were comparable between the conventional and textile electrodes. However, the signal-to-artifact-and/or-noise ratio (SAR) during twisting was larger in the textile electrodes than in the conventional electrodes. No skin irritation was seen in the textile electrodes. The single lead textile electrodes embedded in an inner garment were usable for continuous and/or repeated ECG monitoring in daily life except during vigorous trunk movement.

Solving alarm fatigue with smartphone technology

Alarms were developed to improve patient safety, but alarm fatigue may put patients at higher risk for harm. This article recounts one acute care institution's search for a better alarm management solution using smartphone technology to replace its beeper-based system for telemetry alarm events.

Assessment of a Targeted Electronic Health Record Intervention to Reduce Telemetry Duration: A Cluster-Randomized Clinical Trial

IMPORTANCE

Physicians frequently use cardiac monitoring, or telemetry, beyond the duration recommended by published practice standards, resulting in "alarm fatigue" and excess cost. Prior studies have demonstrated an association between multicomponent quality improvement interventions and safe reduction of telemetry duration.

OBJECTIVE

To determine if a single-component intervention, a targeted electronic health record (EHR) alert, could achieve similar gains to multicomponent interventions and safely reduce unnecessary monitoring.

DESIGN, SETTING, AND PARTICIPANTS

This cluster-randomized clinical trial was conducted between November 2016 and May 2017 on the general medicine service of the Division of Hospital Medicine at the University of California, San Francisco Medical Center and included physicians of 12 inpatient medical teams (6 intervention, 6 control).

INTERVENTIONS

The EHR alert was randomized to half of the teams on the general medicine service. The alert displayed during daytime hours when physicians attempted to place an order for patients not in the intensive care unit whose telemetry order duration exceeded the recommended duration for a given indication.

MAIN OUTCOMES AND MEASURES

The primary outcome was telemetry monitoring hours per hospitalization, which was measured using time-stamped orders data from the EHR database. Physician responses to the alert were collected using EHR reporting tools. The potential adverse outcomes of rapid-response calls and medical emergency events were measured by counting the notes documenting these events in the EHR.

RESULTS

Of the 1021 patients included in this study, in the intervention arm, there was a mean (SD) age of 64.5 (18.9) and 215 (45%) were women; in the control arm, there was a mean (SD) age of 63.8 (19.1) and 249 (46%) were women. The 12 teams were stratified to 8 house-staff teams and 4 hospitalist teams, with 499 hospitalizations analyzed in the intervention arm and 567 hospitalizations analyzed in the control arm. The alert prompted a significant reduction in telemetry monitoring duration (-8.7 hours per hospitalization; 95% CI, -14.1 to -3.5 hours; P = .001) with no significant change in rapid-response calls or medical emergency events. The most common physician response to the alert was to discontinue telemetry monitoring (62% of 200 alerts).

CONCLUSIONS AND RELEVANCE

A targeted EHR alert can safely and successfully reduce cardiac monitoring by prompting discontinuation when appropriate. This single-component electronic intervention is less resource intensive than typical multicomponent interventions that include human resources.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02529176.

Nurses' use of monitors in patient surveillance: an ethnographic study on a coronary care unit

BACKGROUND

Physiological monitors are increasingly used for patient surveillance. Although nurses play a vital role in the observation, analysis and use of information obtained from these devices, difficulties in their use, coupled with the high frequency of false and nuisance monitor alarms, can lead to negative working conditions and threaten patient safety.

AIM

With the purpose of promoting effective monitor use and ensuring patient safety, the aim was to explore both how cardiovascular nurses use monitors in patient surveillance and the effect that the monitors have on the nurses' work.

METHODS

A qualitative ethnographic design with semi-structured interviews and a field observation conducted at a 35-bed coronary care unit. A purposive sample was used in selecting participants. Data were analysed using systematic text condensation.

RESULTS

Eight registered nurses, all women, aged 27-49 years, were participants. The themes helping device, competence development and distractions and strain reflected both the knowledge on which the nurses drew in working with monitors and their influence on the nurses' work. False security and collaboration and teamwork discussed how the nurses trust and depend on each other during monitor surveillance and how poor work conditions and unclear responsibility undermine surveillance.

CONCLUSIONS

Monitors enable nurses to observe critically ill cardiac patients closely and respond quickly to life-threatening changes in their condition. Current work arrangements and limited training diminish the reliability of monitor surveillance. It is imperative to revise the structure of the surveillance and improve education in monitor surveillance to enhance nurses' clinical competence and patients' safety.