Frailty in the cardiac intensive care unit: assessment and impact.

Frailty, a clinical syndrome of increased vulnerability, due to diminished cognitive, physical, and physiological reserves is a growing concern in the cardiac intensive care unit (CICU). It contributes to morbidity, mortality, and complications and often exerts a bidirectional association with cardiovascular disease. Although it predominately affects older adults, frailty can also be observed in younger patients <65 years of age, with approximately 30% of those admitted in CICU are frail. Acute cardiovascular illness can also impair physical and cognitive functioning among survivors and these survivors often suffer from frailty and functional declines post-CICU discharge. Patients with frailty in the CICU often have higher comorbidity burden, and they are less likely to receive optimal therapy for their acute cardiovascular conditions. Given the significance of this geriatric syndrome, this review will focus on assessment, clinical outcomes, and interventions, in an attempt to establish appropriate assessment, management, and resource utilization in frail patients during and after CICU admission.

The association of the Sequential Organ Failure Assessment score at intensive care unit discharge with intensive care unit readmission in the cardiac intensive care unit.

AIMS: Unplanned intensive care unit (ICU) readmissions contribute to increased morbidity, mortality, and healthcare costs. The severity of patient illness at ICU discharge may predict early ICU readmission. Thus, in this study, we investigated the association of cardiac ICU (CICU) discharge Sequential Organ Failure Assessment (SOFA) score with unplanned CICU readmission in patients admitted to the CICU. METHODS AND RESULTS: We retrospectively reviewed the hospital medical records of 4659 patients who were admitted to the CICU from 2012 to 18. Sequential Organ Failure Assessment scores at CICU admission and discharge were obtained. The predictive performance of organ failure scoring was evaluated by using area under the receiver operating characteristic (AUROC) curves. The primary outcome was unplanned CICU readmission. Of the 3949 patients successfully discharged from the CICU, 184 (4.7%) had an unplanned CICU readmission or they experienced a deteriorated condition but died without being readmitted to the CICU (readmission group). The readmission group had significantly higher rates of organ failure in all organ systems at both CICU admission and discharge than the non-readmission group. The AUROC of the discharge SOFA score for CICU readmission was 0.731, showing good predictive performance. The AUROC of the discharge SOFA score was significantly greater than that of either the initial SOFA score (P = 0.020) or the Acute Physiology and Chronic Health Evaluation II score (P < 0.001). In the multivariable regression analysis, SOFA score, overweight or obese status, history of heart failure, and acute heart failure as reasons for ICU admission were independent predictors of unplanned ICU readmission during the same hospital stay. CONCLUSION: The discharge SOFA score may identify patients at a higher risk of unplanned CICU readmission, enabling targeted interventions to reduce readmission rates and improve patient outcomes.

Serial Assessment of Shock Severity in Cardiac Intensive Care Unit Patients.

BACKGROUND: One-time assessment of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification robustly predicts mortality in the cardiac intensive care unit (CICU). We sought to determine whether serial SCAI shock classification could improve risk stratification. METHODS AND RESULTS: Unique admissions to a single academic level 1 CICU from 2015 to 2018 were included in this retrospective cohort study. Electronic health record data were used to assign the SCAI shock stage during 4-hour blocks of the first 24 hours of CICU admission. Shock was defined as hypoperfusion (SCAI shock stage C, D, or E). In-hospital death was evaluated using logistic regression. Among 2918 unique CICU patients, 1537 (52.7%) met criteria for shock during ≥1 block, and 266 (9.1%) died in the hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; and E, 3.3%. Patients who met SCAI criteria for shock on admission (first 4 hours) and those with worsening SCAI shock stage after admission were at higher risk for in-hospital death. Each higher admission (adjusted odds ratio, 1.36 [95% CI, 1.18-1.56]; area under the receiver operating characteristic curve, 0.70), maximum (adjusted odds ratio, 1.59 [95% CI, 1.37-1.85]; area under the receiver operating characteristic curve, 0.73) and mean (adjusted odds ratio, 2.42 [95% CI, 1.99-2.95]; area under the receiver operating characteristic curve, 0.78) SCAI shock stage was incrementally associated with a higher in-hospital mortality rate. Discrimination was highest for the mean SCAI shock stage (P<0.05). Each additional 4-hour block meeting SCAI criteria for shock predicted a higher mortality rate (adjusted odds ratio, 1.15 [95% CI, 1.07-1.24]). CONCLUSIONS: Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients by quantifying the magnitude and duration of shock.

A pragmatic lab-based tool for risk assessment in cardiac critical care: data from the Critical Care Cardiology Trials Network (CCCTN) Registry.

AIMS: Contemporary cardiac intensive care unit (CICU) outcomes remain highly heterogeneous. As such, a risk-stratification tool using readily available lab data at time of CICU admission may help inform clinical decision-making. METHODS AND RESULTS: The primary derivation cohort included 4352 consecutive CICU admissions across 25 tertiary care CICUs included in the Critical Care Cardiology Trials Network (CCCTN) Registry. Candidate lab indicators were assessed using multivariable logistic regression. An integer risk score incorporating the top independent lab indicators associated with in-hospital mortality was developed. External validation was performed in a separate CICU cohort of 9716 patients from the Mayo Clinic (Rochester, MN, USA). On multivariable analysis, lower pH [odds ratio (OR) 1.96, 95% confidence interval (CI) 1.72-2.24], higher lactate (OR 1.40, 95% CI 1.22-1.62), lower estimated glomerular filtration rate (OR 1.26, 95% CI 1.10-1.45), and lower platelets (OR 1.18, 95% CI 1.05-1.32) were the top four independent lab indicators associated with higher in-hospital mortality. Incorporated into the CCCTN Lab-Based Risk Score, these four lab indicators identified a 20-fold gradient in mortality risk with very good discrimination (C-index 0.82, 95% CI 0.80-0.84) in the derivation cohort. Validation of the risk score in a separate cohort of 3888 patients from the Registry demonstrated good performance (C-index of 0.82; 95% CI 0.80-0.84). Performance remained consistent in the external validation cohort (C-index 0.79, 95% CI 0.77-0.80). Calibration was very good in both validation cohorts (r = 0.99). CONCLUSION: A simple integer risk score utilizing readily available lab indicators at time of CICU admission may accurately stratify in-hospital mortality risk.

Palliative Care Referrals in Cardiac Disease.

OBJECTIVES: With evidence of benefits of pediatric palliative care (PPC) integration, we sought to characterize subspecialty PPC referral patterns and end of life (EOL) care in pediatric advanced heart disease (AHD). METHODS: In this retrospective cohort study, we compared inpatient pediatric (<21 years) deaths due to AHD in 2 separate 3-year epochs: 2007-2009 (early) and 2015-2018 (late). Demographics, disease burden, medical interventions, mode of death, and hospital charges were evaluated for temporal changes and PPC influence. RESULTS: Of 3409 early-epoch admissions, there were 110 deaths; the late epoch had 99 deaths in 4032 admissions. In the early epoch, 45 patients (1.3% admissions, 17% deaths) were referred for PPC, compared with 146 late-epoch patients (3.6% admissions, 58% deaths). Most deaths (186 [89%]) occurred in the cardiac ICU after discontinuation of life-sustaining therapy (138 [66%]). Medical therapies included ventilation (189 [90%]), inotropes (184 [88%]), cardiopulmonary resuscitation (68 [33%]), or mechanical circulatory support (67 [32%]), with no temporal difference observed. PPC involvement was associated with decreased mechanical circulatory support, ventilation, inotropes, or cardiopulmonary resuscitation at EOL, and children were more likely to be awake and be receiving enteral feeds. PPC involvement increased advance care planning, with lower hospital charges on day of death and 7 days before (respective differences $5058 [P = .02] and $25 634 [P = .02]). CONCLUSIONS: Pediatric AHD deaths are associated with high medical intensity; however, children with PPC consultation experienced substantially less invasive interventions at EOL. Further study is warranted to explore these findings and how palliative care principles can be better integrated into care.

Financial impact of an analgosedation protocol for mechanically ventilated patients in a cardiovascular intensive care unit.

PURPOSE: The primary objective was to evaluate the impact of an analgosedation protocol in a cardiac intensive care unit (CICU) on daily doses and costs of analgesic, sedative, and antipsychotic medications. METHODS: We conducted a single-center quasi-experimental study in 363 mechanically ventilated patients admitted to our CICU from March 1, 2011, to April 13, 2013. On March 1, 2012, an analgosedation protocol was implemented. Patients in the pre-implementation group were managed at the cardiologist's discretion, which consisted of a continuous sedative-hypnotic approach and opioids as needed. Patients in the implementation group were managed using this protocol. RESULTS: The mean ± S.D. per-patient doses (mg/day) of propofol, lorazepam, and clonazepam decreased with the use of an analgosedation protocol (propofol 132,265.7 ± 12,951 versus 87,980.5 ± 10,564 [p = 0.03]; lorazepam 10.5 ± 7.3 versus 3.3 ± 4.0 [p < 0.001]; clonazepam 9.9 ± 8.3 versus 1.1 ± 0.5 [p = 0.03]). The mean daily cost of propofol and lorazepam also significantly decreased (33.5% reduction in propofol cost [p = 0.03]; 69.0% reduction in lorazepam cost [p < 0.001]). The per-patient dose and cost of fentanyl (mcg/day) declined with analgosedation protocol use (fentanyl 2,274.2 ± 2317.4 versus 1,026.7 ± 981.4 [p < 0.001]; 54.8% decrease in fentanyl cost [p < 0.001]). CONCLUSION: The implementation of an analgosedation protocol significantly decreased both the use and cost of propofol, lorazepam, and fentanyl. Further investigation of the clinical impact and cost-effectiveness of a critical care consultation service with implementation of an analgosedation protocol is warranted in the CICU.

Step-down units are cost-effective alternatives to coronary care units with non-inferior outcomes in the management of ST-elevation myocardial infarction patients after successful primary percutaneous coronary intervention.

Percutaneous coronary interventions (PCIs) within a door-to-balloon timing of 90 min have greatly decreased mortality and morbidity of ST-elevation myocardial infarction (STEMI) patients. Post-PCI, they are routinely transferred into the coronary care unit (CCU) regardless of the severity of their condition, resulting in frequent CCU overcrowding. This study assesses the feasibility of step-down units (SDUs) as an alternative to CCUs in the management of STEMI patients after successful PCI, to alleviate CCU overcrowding. Criteria of assessment include in-hospital complications, length of stay, cost-effectiveness, and patient outcomes up to a year after discharge from hospital. A retrospective case-control study was done using data of 294 adult STEMI patients admitted to the emergency departments of two training and research hospitals and successfully underwent primary PCI from 1 January 2014 to 31 December 2015. Patients were followed up for a year post-discharge. Student t test and χ2 test were done as univariate analysis to check for statistical significance of p < 0.05. Further regression analysis was done with respect to primary outcomes to adjust for major confounders. Patients managed in the SDU incurred significantly lower inpatient costs (p = 0.0003). No significant differences were found between the CCU and SDU patients in terms of patient characteristics, PCI characteristics, in-hospital complications, length of stay, and patient outcomes up to a year after discharge. The SDU is a viable cost-effective option for managing STEMI patients after successful primary PCI to avoid CCU overcrowding, with non-inferior patient outcomes as compared to the CCU.

[The heart failure management in Sicily: cognitive analysis of clinical features.] / La gestione dello scompenso cardiaco in Sicilia: analisi conoscitiva degli aspetti clinici e organizzativi.

INTRODUCTION: Heart failure (HF) is a main issue of modern healthcare system. Patient affected are continuously growing in number and age; therefore, an integrated management between different parts of healthcare system is crucial to optimize outcome and sustainability. So far, little is known about clinical pathways of HF patients in Sicily. METHODS: On initiative of the Regional HF Group of the Italian Association of Hospital Cardiologists (ANMCO), we decided to census all the Cardiology Unit of Sicily. A simple questionnaire elaborated by the group and exploring clinical and organizational matters of HF was sent to the Units. The answer arrived on a voluntary basis. RESULTS: 41/46 Units sent back the filled questionnaire. Five typologies of units were represented, based on complexity [1. Outpatient units; 2. Units without Intensive Care Unit (ICU); 3. Units with ICU; 4. Units with ICU and Cath Lab; 5. Units with ICU, Cath lab and Cardiac Surgery). A dedicated HF unit is present only in half centers, but it is formally recognized solely in 22% of Units. These Units have scarce dedicated staff and activity is predominantly based on personal initiative. Diagnostic and therapeutic tools are used appropriately in most of them, even though congestion is judged mainly through physical exam and echocardiography. Differently from the indications of the guidelines, post discharge titration of therapy lacks in almost 30% of centers. DISCUSSION AND CONCLUSIONS: In Sicily, HF is managed on a plan mainly based on personal initiative. The quality is sufficiently good but a more appropriate and structured organization in particular of the follow-up seems a necessary and improvable requirement in view of quality measurers and economic sustainability of health care.

Start-up of a Cardiology Day Hospital: Activity, Quality Care and Cost-effectiveness Analysis of the First Year of Operation.

INTRODUCTION AND OBJECTIVES: The cardiology day hospital (CDH) is an alternative to hospitalization for scheduled cardiological procedures. The aims of this study were to analyze the activity, quality of care and the cost-effectiveness of a CDH. METHODS: An observational descriptive study was conducted of the health care activity during the first year of operation of DHHA. The quality of care was analyzed through the substitution rate (outpatient procedures), cancellation rates, complications, and a satisfaction survey. For cost-effectiveness, we calculated the economic savings of avoided hospital stays. RESULTS: A total of 1646 patients were attended (mean age 69 ± 15 years, 60% men); 2550 procedures were scheduled with a cancellation rate of 4%. The most frequently cancelled procedure was electrical cardioversion. The substitution rate for scheduled invasive procedures was 66%. Only 1 patient required readmission after discharge from the CDH due to heart failure. Most surveyed patients (95%) considered the care received in the CDH to be good or very good. The saving due to outpatient-converted procedures made possible by the CDH was € 219 199.55, higher than the cost of the first year of operation. CONCLUSIONS: In our center, the CDH allowed more than two thirds of the invasive procedures to be performed on an outpatient basis, while maintaining the quality of care. In the first year of operation, the expenses due to its implementation were offset by a significant reduction in hospital admissions.

Noncardiovascular Disease and Critical Care Delivery in a Contemporary Cardiac and Medical Intensive Care Unit.

BACKGROUND: Noncardiovascular comorbidities and critical illness are increasing in cardiovascular intensive care units (CICUs). There are limited data comparing critical care delivery, resource utilization, and costs between contemporary CICUs and medical intensive care units (MICUs). METHODS: All CICU (n = 6967; 22 748 patient-days) and MICU (n = 10 892; 39 211 patient-days) admissions to Cedars-Sinai Medical Center, a tertiary care academic medical center, between January 2011 and December 2016 were reviewed. Both the CICU and MICU admitted patients for primary cardiovascular or medical conditions during the study period, but not for postoperative surgical care. RESULTS: Patients admitted to the CICU were more frequently older, male, and had more preexisting cardiac disease ( P < .0001). More than one-fifth (21.4%) of CICU patients had a noncardiovascular primary admission diagnosis, compared to 89.2% of MICU patients. Cardiovascular intensive care unit patients had lower Acute Physiology and Chronic Health Evaluation III scores (51.1 [19.9] vs 61.1 [24.9], P < .0001) and shorter median hospital length of stay ( P < .001), but not in-unit stay, as compared to MICU patients. Mechanical ventilation, vasopressors, inotropes, renal replacement therapy, and/or blood transfusion were required in 35.0% of CICU patients compared with 62.2% of MICU patients ( P < .0001). The unit mortality rate was lower for CICU than MICU patients (4.8% vs 13.0%, P < .0001), as was the hospital mortality rate (9.3% vs 21.6%, P < .0001). The standardized mortality ratio was 0.73 for the CICU and 0.86 for the MICU. There was no difference in the mean direct cost of care per patient-day between the CICU and MICU ($4011 USD [376] vs $3990 USD [214], P = .77). CONCLUSIONS: The burden of noncardiovascular diseases and the requirement for critical care therapies are high in contemporary CICU patients but remain lower compared to the MICU population. Our findings support the growing complexity of care in tertiary CICUs. Further studies are required to explore the association between critical care delivery and outcomes in this evolving population.

Acute Coronary Syndromes and Heart Failure Critical Care Units Utilization and Outcomes in Teaching and Community Hospitals: A National Population-Based Analysis.

Acute coronary syndromes (ACS) and heart failure (HF) are the leading diagnoses in patients admitted to critical care units (CCUs). Little is known about the differences between CCU resource use and outcomes across hospital types. The Canadian Institute for Health Information was used to identify patients hospitalized with primary diagnoses of ACS or HF. CCUs were categorized as teaching, large community, medium community, and small community hospitals. Outcomes included CCU rates of admission, use of critical care therapy/procedures, and in-hospital mortality. Among 204,900 patients hospitalized with ACS or HF, 73,338 (35.8%, hospital range 0% to 81.4%) were admitted to CCUs, and it varied across hospital types: 41.0% in teaching, 30.0% in large, 45.4% in medium, and 30.9% in small community hospitals (P < 0.001). The percentage of patients admitted to CCUs who received critical care therapies in teaching, large, medium, and small hospitals were as follows: 73.6%, 50.9%, 24.6%, and 8.8% (P < 0.0001). Compared with the in-hospital mortality rate for patients admitted to CCUs in teaching hospitals (8.2%), outcomes were worse for CCU patients in large (11.0%, adjusted odds ratio [aOR] 1.50; 95% CI, 1.19-1.90), medium (10.5%, aOR 1.56; 95% CI, 1.27-1.92), and small community hospitals (9.2%, aOR 1.59; 95% CI, 1.20-2.10). Patients admitted with ACS or HF to teaching hospital CCUs had a higher observed use of critical care therapies and lower mortality compared with community hospitals. These differences highlight the need to examine differences in CCU admission thresholds, resource utilization, and outcomes across hospitals types.

The high cost of critical care unit over-utilization for patients with NSTE ACS.

BACKGROUND: There is substantial variability among hospitals in critical care unit (CCU) utilization for patients admitted with non-ST-Segment Elevation Acute Coronary Syndromes (NSTE ACS). We estimated the potential cost saving if all hospitals adopted low CCU utilization practices for patients with NSTE ACS. METHODS: National hospital claims data were used to identify all patients with a primary diagnosis of NSTE ACS initially admitted to an acute care hospital between 2007 and 2013. Hospital CCU utilization was classified as low (<30%), medium (30-70%), or high (>70%). RESULTS: Among the 270,564 NSTE ACS hospitalizations (71.6% non-ST-segment elevation myocardial infarction; 28.4% unstable angina) admitted to 261 hospitals, 41.9% (inter-hospital range 0.3%-95.1%) were admitted to a CCU. The proportion of patients admitted to a CCU in low, medium and high utilization hospitals was 16.3%, 49.5%, and high 81.1%, respectively. No differences in adjusted inpatient mortality were observed by hospital CCU utilization. The overall inpatient costs of caring for NSTE ACS were $1.1 billion. CCU care accounted for 45.2% of all hospitalization costs including 22.6%, 49.9%, and 69.0% (P < .001) of costs in low, medium and high utilization centers. The national potential direct cost savings of medium and high CCU utilization centers adopting low NSTE ACS CCU utilization practices was $113.4 million over the study period. CONCLUSIONS: In a population-based contemporary cohort, CCU utilization for patients with NSTE ACS varied widely and in-hospital mortality was similar between low, medium and high utilization centers. CCU care accounted for 45% of hospitalization costs; thus, implementing policies and admission practices to align hospital resources with patient care needs have the potential to reduce overall health care costs.

Predictive Value of the Sequential Organ Failure Assessment Score for Mortality in a Contemporary Cardiac Intensive Care Unit Population.

BACKGROUND: Optimal methods of mortality risk stratification in patients in the cardiac intensive care unit (CICU) remain uncertain. We evaluated the ability of the Sequential Organ Failure Assessment (SOFA) score to predict mortality in a large cohort of unselected patients in the CICU. METHODS AND RESULTS: Adult patients admitted to the CICU from January 1, 2007, to December 31, 2015, at a single tertiary care hospital were retrospectively reviewed. SOFA scores were calculated daily, and Acute Physiology and Chronic Health Evaluation (APACHE)-III and APACHE-IV scores were calculated on CICU day 1. Discrimination of hospital mortality was assessed using area under the receiver-operator characteristic curve values. We included 9961 patients, with a mean age of 67.5±15.2 years; all-cause hospital mortality was 9.0%. Day 1 SOFA score predicted hospital mortality, with an area under the receiver-operator characteristic curve value of 0.83; area under the receiver-operator characteristic curve values were similar for the APACHE-III score, and APACHE-IV predicted mortality (P>0.05). Mean and maximum SOFA scores over multiple CICU days had greater discrimination for hospital mortality (P<0.01). Patients with an increasing SOFA score from day 1 and day 2 had higher mortality. Patients with day 1 SOFA score <2 were at low risk of mortality. Increasing tertiles of day 1 SOFA score predicted higher long-term mortality (P<0.001 by log-rank test). CONCLUSIONS: The day 1 SOFA score has good discrimination for short-term mortality in unselected patients in the CICU, which is comparable to APACHE-III and APACHE-IV. Advantages of the SOFA score over APACHE include simplicity, improved discrimination using serial scores, and prediction of long-term mortality.

Outcomes of Nonagenarians Admitted to the Cardiac Intensive Care Unit by the Elders Risk Assessment Score for Long-Term Mortality Risk Stratification.

There are limited data on outcomes of older adults admitted to cardiac intensive care units (CICU), and there are no data on outcomes after admission to the CICU in nonagenarians. Our purpose was to identify whether the Elders Risk Assessment (ERA) index could risk stratify older adults after CICU admission. We retrospectively identified 453 nonagenarians admitted to the CICU between 2004 and 2013. End points included mortality, length of stay, incidence of delirium, and discharge disposition. Average age of the cohort was 92 ± 2 years, and the average ERA score was 13 ± 6. A total of 258 patients were female (57%). Most common admission indication was acute decompensated heart failure (57%) followed by acute myocardial infarction (49%). Loss of independence was observed after CICU admission, with 66% of patients living independently before admission, decreasing to 47% at discharge. Overall length of stay was 6 ± 5 days and CICU stay was 2 ± 2 days. Fifteen percent of patients died before hospital discharge. Median survival was 452 (interquartile range 40 to 1,371) days. ERA score effectively predicted survival (log-rank test, p = 0.002). ERA score of 16 or greater and ERA score of 9 to 15 were both associated with increased risk of mortality compared with the reference (score 4 to 8): hazard ratio 2.00, 95% confidence interval 1.37 to 2.90, p = 0.003, and hazard ratio 1.48, 95% confidence interval 1.06 to 2.08, p = 0.02, respectively. In conclusion, nonagenarians admitted to CICU experience reasonable outcomes. The ERA score effectively risk stratifies nonagenarians admitted to the CICU and may help with identification of vulnerable patients at risk of adverse outcomes.

Length of Stay, Mortality, Cost, and Perceptions of Care Associated With Transition From an Open to Closed Staffing Model in the Cardiac Intensive Care Unit.

BACKGROUND: Organizational models in the intensive care unit (ICU) have classically been described as either closed or open, depending on the presence or absence of a dedicated ICU team. Although a closed model has been shown to improve patient outcomes in medical and surgical ICUs, the merits of various care models have not been previously explored in the cardiac ICU (CICU) setting. METHODS: From November 2012 to March 2014, data were prospectively collected on all admissions before and after transition from an open to closed CICU at our institution. Baseline clinical variables, illness severity, admission and discharge diagnoses, resource use, and outcomes were recorded. Anonymous surveys were also collected from nursing and resident trainee participants to evaluate the influence of unit structure on perceptions of care. Descriptive statistics were used, and logistic regression modeling was performed to examine the impact of unit structure on mortality. RESULTS: The study consisted of 670 patients, 332 (49.6%) of whom were admitted to the open CICU model and 338 (50.4%) of whom were admitted to the closed model. Neither CICU nor hospital mortality differed between the open and closed units, though length of stay was shorter in the closed CICU. Additionally, nurses and resident trainees reported that the closed CICU allowed for better communication, collaboration, and education. CONCLUSIONS: Although there was no significant impact of unit structure on patient outcomes in this single-center study, the closed CICU model was associated with better perceptions of care.

Long-term assessment of coronary care unit patient profile and outcomes: analyses of the 12-years patient records.

BACKGROUND/AIM: The aim of this study was to determine the patient profile, treatment, and outcomes of a coronary care unit (CCU) by retrospective screening of 12-year patient records. MATERIALS AND METHODS: The data of 13,463 patients admitted to the CCU of a tertiary referral hospital between 1 January 1997 and 30 June 2008 were collected. The patients were assessed with respect to demographics, admission diagnosis, treatment, and outcomes. RESULTS: The mean age of patients was 61 ± 13 years (66.7%, male). While the diagnosis of acute coronary syndrome (ACS) accounted for 65%, the rate of ST elevation myocardial infarction (STEMI) was 43.4%. Thrombolytic therapy was administered to 48.7% of the patients with STEMI. Systolic heart failure was the most frequent disease (11.9%) among the non-ACS diagnoses. The mortality rate of the CCU was 12.7% on average; it increased gradually after 2005 when the CCU became a general intensive care unit. CONCLUSION: This study is one of the largest comprehensive analyses of patient profile and outcomes of a CCU. Despite advances in the diagnosis and treatment of cardiac emergencies, the mortality rate of the CCU was high. Serving as a general intensive care unit, the absence of a coronary angiography laboratory and lower use of thrombolytic therapy for STEMI might be responsible factors.

Geographic access to interventional cardiology services in one rural state.

OBJECTIVES: Explore (1) the characteristics of the Maine population with delayed geographic access to interventional cardiology (IC) services and (2) the effect of delayed geographic IC access on coronary mortality. BACKGROUND: Acute coronary syndrome (ACS), ST-segment elevated myocardial infarction (STEMI), and non-ST segment elevated myocardial infarction (NSTEMI) are highly prevalent. Coronary mortality is minimized when victims have prompt IC access. METHODS: The study design was (1) an exploration of census data to investigate disparities in geographic IC access and (2) a secondary analysis of administrative claims data to investigate coronary mortality relative to delayed geographic IC access. RESULTS: Delayed access was associated in the Maine population with rural residence, advanced age, high school education, and lack of health insurance. Delayed access was associated with increased unadjusted coronary mortality, but not age-adjusted coronary mortality. CONCLUSION: Delayed geographic IC access was associated with disparity but not with increased age-adjusted coronary mortality.

Discharge planning for heart failure patients in a tertiary hospital in Shanghai: a best practice implementation project.

BACKGROUND: Heart failure is a major public health concern which contributes significantly to rising healthcare costs. Comprehensive discharge planning can improve health outcomes and reduce readmission rates which, in turn, can lead to cost savings. OBJECTIVES: The aim of this project was to promote best practice in the discharge planning of heart failure patients admitted in the coronary care unit of Zhongshan Hospital. METHODS: A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System tool. Five audit criteria that represent best practice recommendations for heart failure discharge planning were used. A baseline audit was conducted followed by the implementation of multiple strategies, and the project was finalized with a follow-up audit to determine change in practice. RESULTS: Improvements in practice were observed for all five criteria. The most significant improvements were in the following: completion of a discharge checklist (from 0% to 100% compliance), comprehensive (i.e. inclusion of six topics for self-care) discharge education for patients (from 7% to 100% compliance), and conducting a telephone follow-up (from 0% to 76% compliance). The compliance rates for the two remaining criteria, completion of a structured education for patients and scheduling an outpatient clinic visit, both increased from 93% to 100%.Strategies that were implemented to achieve change in practice included development of a local discharge planning checklist, provision of training for nurses, and development of resources. CONCLUSIONS: The project demonstrated positive changes in the discharge planning practices of nurses in the coronary care unit of Zhongshan Hospital. A formalized discharge planning is currently in place and plans for sustaining practice change are underway. A continuous cycle of audit and re-audit will need to be carried out in the future to determine the impact of this evidence implementation activity on heart failure patient outcomes.