Out of the Comfort Zone

Imagine the following experience: Your are a student nurse working with other health care providers in the obstetric unit of your facility. A fifteen-year-old Haitian girl, along with her grandmother, arrives seeking help because her two-day-old, eight-pound baby boy is having difficulty breathing..

Analysis of Patient Alarms in Adult Intensive Care Units

...Our study aims were pretty straight-forward. We concentrated quite a bit on arrhythmia alarms, which is a little different than the parameter alarms we\u27ve been talking about so far today. We decided we were going to assess the alarm prevalence of patient\u27s physiological monitor alarms. We\u27ll identify the alarm burden, analyze a select high priority number of arrhythmia alarms and determine patient characteristics that may be associated with the frequent alarms

Heart Rate Variability Measured Early in Patients with Evolving Acute Coronary Syndrome and 1-year Outcomes of Rehospitalization and Mortality

Objective: This study sought to examine the prognostic value of heart rate variability (HRV) measurement initiated immediately after emergency department presentation for patients with acute coronary syndrome (ACS). Background: Altered HRV has been associated with adverse outcomes in heart disease, but the value of HRV measured during the earliest phases of ACS related to risk of 1-year rehospitalization and death has not been established. Methods: Twenty-four-hour Holter recordings of 279 patients with ACS were initiated within 45 minutes of emergency department arrival; recordings with �18 hours of sinus rhythm were selected for HRV analysis (number [N] �193). Time domain, frequency domain, and nonlinear HRV were examined. Survival analysis was performed. Results: During the 1-year follow-up, 94 patients were event-free, 82 were readmitted, and 17 died. HRV was altered in relation to outcomes. Predictors of rehospitalization included increased normalized high frequency power, decreased normalized low frequency power, and decreased low/high frequency ratio. Normalized high frequency �42 ms2 predicted rehospitalization while controlling for clinical variables (hazard ratio [HR] �2.3; 95% confidence interval [CI] �1.4–3.8, P�0.001). Variables significantly associated with death included natural logs of total power and ultra low frequency power. A model with ultra low frequency power �8 ms2 ( HR �3.8; 95% CI �1.5–10.1; P�0.007) and troponin �0.3 ng/mL (HR �4.0; 95% CI �1.3–12.1; P�0.016) revealed that each contributed independently in predicting mortality. Nonlinear HRV variables were significant predictors of both outcomes. Conclusion: HRV measured close to the ACS onset may assist in risk stratification. HRV cut-points may provide additional, incremental prognostic information to established assessment guidelines, and may be worthy of additional study

Heart Rate Variability Measurement and Clinical Depression in Acute Coronary Syndrome Patients: Narrative Review of Recent Literature

Aim: We aimed to explore links between heart rate variability (HRV) and clinical depression in patients with acute coronary syndrome (ACS), through a review of recent clinical research literature. Background: Patients with ACS are at risk for both cardiac autonomic dysfunction and clinical depression. Both conditions can negatively impact the ability to recover from an acute physiological insult, such as unstable angina or myocardial infarction, increasing the risk for adverse cardiovascular outcomes. HRV is recognized as a reflection of autonomic function. Methods: A narrative review was undertaken to evaluate state-of-the-art clinical research, using the PubMed database, January 2013. The search terms “heart rate variability” and “depression” were used in conjunction with “acute coronary syndrome”, “unstable angina”, or “myocardial infarction” to find clinical studies published within the past 10 years related to HRV and clinical depression, in patients with an ACS episode. Studies were included if HRV measurement and depression screening were undertaken during an ACS hospitalization or within 2 months of hospital discharge. Results: Nine clinical studies met the inclusion criteria. The studies’ results indicate that there may be a relationship between abnormal HRV and clinical depression when assessed early after an ACS event, offering the possibility that these risk factors play a modest role in patient outcomes. Conclusion: While a definitive conclusion about the relevance of HRV and clinical depression measurement in ACS patients would be premature, the literature suggests that these measures may provide additional information in risk assessment. Potential avenues for further research are proposed

Patient Characteristics Associated with False Arrhythmia Alarms in Intensive Care

Introduction A high rate of false arrhythmia alarms in the intensive care unit (ICU) leads to alarm fatigue, the condition of desensitization and potentially inappropriate silencing of alarms due to frequent invalid and nonactionable alarms, often referred to as false alarms. Objective The aim of this study was to identify patient characteristics, such as gender, age, body mass index, and diagnosis associated with frequent false arrhythmia alarms in the ICU. Methods This descriptive, observational study prospectively enrolled patients who were consecutively admitted to one of five adult ICUs (77 beds) at an urban medical center over a period of 31 days in 2013. All monitor alarms and continuous waveforms were stored on a secure server. Nurse scientists with expertise in cardiac monitoring used a standardized protocol to annotate six clinically important types of arrhythmia alarms (asystole, pause, ventricular fibrillation, ventricular tachycardia, accelerated ventricular rhythm, and ventricular bradycardia) as true or false. Total monitoring time for each patient was measured, and the number of false alarms per hour was calculated for these six alarm types. Medical records were examined to acquire data on patient characteristics. Results A total of 461 unique patients (mean age =60±17 years) were enrolled, generating a total of 2,558,760 alarms, including all levels of arrhythmia, parameter, and technical alarms. There were 48,404 hours of patient monitoring time, and an average overall alarm rate of 52 alarms/hour. Investigators annotated 12,671 arrhythmia alarms; 11,345 (89.5%) were determined to be false. Two hundred and fifty patients (54%) generated at least one of the six annotated alarm types. Two patients generated 6,940 arrhythmia alarms (55%). The number of false alarms per monitored hour for patients’ annotated arrhythmia alarms ranged from 0.0 to 7.7, and the duration of these false alarms per hour ranged from 0.0 to 158.8 seconds. Patient characteristics were compared in relation to 1) the number and 2) the duration of false arrhythmia alarms per 24-hour period, using nonparametric statistics to minimize the influence of outliers. Among the significant associations were the following: age ≥60 years (P=0.013; P=0.034), confused mental status (P\u3c0.001 for both comparisons), cardiovascular diagnoses (P\u3c0.001 for both comparisons), electrocardiographic (ECG) features, such as wide ECG waveforms that correspond to ventricular depolarization known as QRS complex due to bundle branch block (BBB) (P=0.003; P=0.004) or ventricular paced rhythm (P=0.002 for both comparisons), respiratory diagnoses (P=0.004 for both comparisons), and support with mechanical ventilation, including those with primary diagnoses other than respiratory ones (P\u3c0.001 for both comparisons). Conclusion Patients likely to trigger a higher number of false arrhythmia alarms may be those with older age, confusion, cardiovascular diagnoses, and ECG features that indicate BBB or ventricular pacing, respiratory diagnoses, and mechanical ventilatory support. Algorithm improvements could focus on better noise reduction (eg, motion artifact with confused state) and distinguishing BBB and paced rhythms from ventricular arrhythmias. Increasing awareness of patient conditions that apparently trigger a higher rate of false arrhythmia alarms may be useful for reducing unnecessary noise and improving alarm management

Living with Significant Other is Associated with Lower Risk for Emergency Readmission after Unstable Angina & Non-ST Elevation Myocardial Infarction [Poster 12064]

Introduction: Patients who are diagnosed with unstable angina (UA) or non-ST elevation myocardial infarction (non-STEMI) are at risk for repeated acute cardiac episodes resulting in emergent rehospitalization. American Heart Association/American College of Cardiology practice guidelines recommend use of risk stratification prior to hospital discharge; however, the importance of identifying patients’ social support for follow-up planning is not emphasized. Hypothesis: UA and non-STEMI patients who live with significant others are less likely to return to the Emergency Department (ED) for acute cardiac-related events within one year. Methods: Secondary analysis was conducted of data from a prospective clinical trial (IMMEDIATE AIM Study, RO1HL69753), in which patients presenting to the ED with chest pain were enrolled and followed for one year. A total of 166 patients with UA or non-STEMI and 1-year outcome data were included in the present analysis. Hazard over time analyses were performed to assess whether living with a significant other was associated with cardiac-related ED readmission during the follow-up period. Significant other was defined as spouse, partner, child, or other care provider. Results: Multivariate Cox Regression analyses controlling for gender, race, discharge diagnosis, and Thrombolysis in Myocardial Infarction (TIMI) risk score revealed that patients who lived with a significant other were less likely to return to the ED for an acute cardiac event within one follow-up year. Living with a significant other was a significant independent contributor to the statistical model (hazard ratio =.47, 95% confidence interval .29 - .75, p=.002). Overall sensitivity and specificity of the model was 73% (C-statistic=.73). Conclusions: In patients with UA or non-STEMI, living without a significant other confers a 2 times greater relative risk of ED cardiac-related readmittance compared with patients who live with a significant other. Prospective clinical trials are needed to identify what the beneficial “active ingredients” are in living with a significant other and to develop interventions to reduce risk for patients who do not have a significant other living arrangement

Living with Significant Other is Associated with Lower Risk for Emergency Readmission after Unstable Angina & Non-ST Elevation Myocardial Infarction. [Abstract 12064]

Patients who are diagnosed with unstable angina (UA) or non-ST elevation myocardial infarction (non-STEMI) are at risk for repeated acute cardiac episodes resulting in emergent rehospitalization. American Heart Association/American College of Cardiology practice guidelines recommend use of risk stratification prior to hospital discharge; however, the importance of identifying patients’ social support for follow-up planning is not emphasized

Heart Rate Turbulence in Patients with Respiratory Failure. [Abstract]

We sought to determine the feasibility of measuring heart rate turbulence (HRT) derived from electrocardiographic (ECG) bedside monitors in critically ill respiratory failure patients, receiving mechanical ventilation. In addition, we aimed to determine whether or not a normal HRT response was associated with patients\u27 successful return to spontaneous breathing, also called ventilator weaning, and survival to discharge

Patient Characteristics Associated with False Arrhythmia Alarms in Intensive Care [Abstract 19717]

Introduction: A high rate of false arrhythmia alarms leads to clinical alarm fatigue, i.e. desensitization and inappropriate silencing of alarms