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

BACKGROUND AND PURPOSE: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records. METHODS: Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning. RESULTS: The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research. CONCLUSIONS: Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.

American Heart Association Response to the 2015 Institute of Medicine Report on Strategies to Improve Cardiac Arrest Survival.

The American Heart Association (AHA) commends the recently released Institute of Medicine (IOM) report, Strategies to Improve Cardiac Arrest Survival: A Time to Act (2015). The AHA recognizes the unique opportunity created by the report to meaningfully advance the objectives of improving outcomes for sudden cardiac arrest. For decades, the AHA has focused on the goal of reducing morbidity and mortality from cardiovascular disease though robust support of basic, translational, clinical, and population research. The AHA also has developed a rigorous process using the best available evidence to develop scientific, advisory, and guideline documents. These core activities of development and dissemination of scientific evidence have served as the foundation for a broad range of advocacy initiatives and programs that serve as a foundation for advancing the AHA and IOM goal of improving cardiac arrest outcomes. In response to the call to action in the IOM report, the AHA is announcing 4 new commitments to increase cardiac arrest survival: (1) The AHA will provide up to $5 million in funding over 5 years to incentivize resuscitation data interoperability; (2) the AHA will actively pursue philanthropic support for local and regional implementation opportunities to increase cardiac arrest survival by improving out-of-hospital and in-hospital systems of care; (3) the AHA will actively pursue philanthropic support to launch an AHA resuscitation research network; and (4) the AHA will cosponsor a National Cardiac Arrest Summit to facilitate the creation of a national cardiac arrest collaborative that will unify the field and identify common goals to improve survival. In addition to the AHA's historic and ongoing commitment to improving cardiac arrest care and outcomes, these new initiatives are responsive to each of the IOM recommendations and demonstrate the AHA's leadership in the field. However, successful implementation of the IOM recommendations will require a timely response by all stakeholders identified in the report and a coordinated approach to achieve our common goal of improved cardiac arrest outcomes.

Evidence-Based Teaching Practice in Nursing Education: Faculty Perspectives and Practices.

PURPOSE: This national online study was conducted to describe nursing faculty perspectives and practices about evidence-based teaching practice (EBTP). BACKGROUND: Professional standards for nurse educator practice stress the importance of EBTP; however, the use of evidence by faculty in curriculum design, evaluation and educational measurement, and program development has not been reported. METHOD: Nurse administrators of accredited nursing programs in the United States (N = 1,586) were emailed information about the study, including the research consent form and anonymous survey link, and invited to forward information to nursing faculty. RESULTS: Respondents (551 faculty and nurse administrators) described the importance of EBTP in nursing education, used multiple sources of evidence in their faculty responsibilities, and identified factors that influence their ability to use EBTP. CONCLUSION: EBTP in nursing education requires sustained institutional, administrative, and collegial support to promote faculty effectiveness and student learning.

Therapeutic hypothermia after out-of-hospital cardiac arrest: evaluation of a regional system to increase access to cooling.

BACKGROUND: Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. METHODS AND RESULTS: The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non-ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non-ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. CONCLUSIONS: A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA.

Staffing patterns of scheduled unit staff nurses vs. float pool nurses: a pilot study.

In this study, the differences in patient assignments between float pool nurses versus scheduled unit staff nurses were examined. Although there was a tendency for float pool nurses to receive more difficult patient assignments, this was not statistically significant (at alpha=0.05).

Decreasing pressure ulcers across a healthcare system: moving beneath the tip of the iceberg.

The authors describe a pressure ulcer prevention program implemented across a large healthcare system in Minnesota. An interprofessional team of representatives from 10 hospitals developed a bundle of interventions directed at measurement standardization, provider education, patient/family education and point-of-care resources for providers, timely nutritional assessment, and a novel Skin Day event intended to increase awareness. The number of pressure ulcers reported to the State of Minnesota decreased 33% after implementation of the program with a potential cost savings of up to $430,000.

Temperature measurement in patients undergoing colorectal surgery and gynecology surgery: a comparison of esophageal core, temporal artery, and oral methods.

Maintaining perioperative normothermia reduces postoperative complications. An accurate, noninvasive method to take temperatures representative of core temperature is needed. Oral thermometry is accepted as the most accurate means of non-core temperature assessment, but poses challenges in patients who are intubated or wearing oxygen masks. The purpose of this study was to determine the difference, if any, between core temperature as measured by an esophageal thermometer and temperatures measured by oral and temporal artery methods in patients undergoing colorectal or gynecology surgery. A repeated-measures design was used with a convenience sample of 23 patients undergoing colorectal or gynecology surgery. Two series of intraoperative temperatures were taken (oral and temporal artery thermometry) and compared with core temperature measured by esophageal probe. Repeated-measures analysis of variance tested for biases of oral or temporal temperatures versus core temperatures. Bland-Altman plots were drawn to test dependence of bias on actual core temperature. A priori, a temperature difference >0.4 degrees C was defined as clinically significant. Oral temperature was biased high relative to esophageal temperature by 0.12 degrees C on average (P = .0008; 95% confidence interval [0.061, 0.187]). Temporal artery temperature was biased high relative to esophageal, by 0.074 degrees C on average (P = .03; 95% confidence interval [0.010, 0.133]). Differences between core (esophageal) thermometry and oral or temporal artery thermometry were statistically significant but much smaller than the 0.4 degrees C identified as clinically acceptable. Oral and temporal artery temperatures are within the 0.4 degrees C of core (esophageal) temperatures, a difference that is considered clinically acceptable. Temperatures taken orally or by temporal artery thermometry are acceptable as noninvasive core measures for adult patients undergoing colorectal or gynecology surgery.

Implementing Practice Standards for Inpatient Electrocardiographic Monitoring.

BACKGROUND: Although electrocardiographic monitoring is common in hospitalized patients, many patients receive unnecessary monitoring, contributing to patients' inconvenience, clinicians' alarm fatigue, and delayed admissions. OBJECTIVE: To evaluate the impact of implementation of an electronic order set based on the American Heart Association practice standards for electrocardiographic monitoring on the occurrence of appropriate monitoring. METHODS: The sample for this preintervention-to-postintervention quasi-experimental study consisted of 297 adult patients on medical, surgical, neurological, oncological, and orthopedic patient care units that used remote electrocardiographic monitoring in a 627-bed hospital in Minneapolis, Minnesota. The intervention was the introduction into the electronic health record of order sets prompting physicians to order electrocardiographic monitoring per the American Heart Association practice standards. Indications for monitoring according to the practice standards and adverse outcomes (unexpected transfer to intensive care unit, death, code blue events, and call for the rapid response team) were compared before and after implementation of the order set. RESULTS: Implementation of the order set was associated with an increase in appropriate monitoring (48.0% to 61.2%; P = .03); the largest increase was in ordering by medical residents (30.8% to 76.5%; P = .001). No significant increase in adverse patient outcomes was noted. CONCLUSIONS: Implementation of the practice standards via an electronic order set was associated with a statistically significant increase in appropriate monitoring, with no increase in adverse events. Use of electronic order sets is an effective and safe way to enhance appropriate electrocardiographic monitoring.

Delirium in the orthopaedic patient.

Published incidence of delirium in orthopaedic patients ranges from 5.1% to 61%. Delirium may present before or after the patient undergoes the surgical procedure and has demonstrated increased risk, including mortality. Yet, delirium goes unrecognized by both physicians and nurses. This article focuses on the literature on delirium in the orthopaedic patient, including incidence, how to identify those patients at risk, patient outcomes, nonpharmacological and pharmacological interventions, and provides an example of how one tertiary care hospital implemented a prevention and management program of delirium in orthopaedic patients.

Postoperative complications of coronary artery bypass grafting surgery.

Coronary artery bypass grafting (CABG) surgery continues to be an effective and well-used intervention for coronary artery disease. Older patients and those with sicker hearts will become the norm. In spite of increased risk for patients undergoing CABG, overall mortality rates have decreased. Nursing contributions to these improved outcomes cannot be overestimated. Continued understanding and appreciation of these complications will be necessary to effectively care for patients and create optimal outcomes.

Maximizing safety of hospitalized elders.

The safety of elders in acute care settings has been a long-standing nursing concern; it is well known that elders are at a higher risk for injury and adverse events during hospitalization. Common sensory changes, comorbidities, and frailty of elders may contribute to injury and poorer outcomes. Confusion, delirium, falls, or adverse drug events experienced by hospitalized elderly also may contribute to injury and adverse hospital outcomes. Nurses may use strategies to protect hospitalized elderly from injury and optimize their outcomes by establishing a culture of safety. Approaches to foster safe hospital stays for elderly patients are outlined, and recommendations for institutional management and administration, policy and nursing practice, education, and research are identified.

Place Atrium to Water Seal (PAWS): Assessing Wall Suction Versus No Suction for Chest Tubes After Open Heart Surgery.

BACKGROUND: Traditionally chest tubes are set to -20 cm H2O wall suctioning until removal to facilitate drainage of blood, fluid, and air from the pleural or mediastinal space in patients after open heart surgery. However, no clear evidence supports using wall suction in these patients. Some studies in patients after pulmonary surgery indicate that using chest tubes with a water seal is safer, because this practice decreases duration of chest tube placement and eliminates air leaks. OBJECTIVE: To show that changing chest tubes to a water seal after 12 hours of wall suction (intervention) is a safe alternative to using chest tubes with wall suction until removal of the tubes (usual care) in patients after open heart surgery. METHODS: A before-and-after quality improvement design was used to evaluate the differences between the 2 chest tube management approaches in chest tube complications, output, and duration of placement. RESULTS: A total of 48 patients received the intervention; 52 received usual care. The 2 groups (intervention vs usual care) did not differ significantly in complications (0 vs 2 events; P = .23), chest tube output (H1 = 0.001, P = .97), or duration of placement (median, 47 hours for both groups). CONCLUSION: Changing chest tubes from wall suction to water seal after 12 hours of wall suction is a safe alternative to using wall suctioning until removal of the tubes.

Correlates of neurocognitive function of patients after off-pump coronary artery bypass surgery.

BACKGROUND: Decreases in neurocognitive function have been reported in patients who have undergone off-pump coronary artery bypass surgery; however, few investigators have examined the correlates of the decreases. OBJECTIVES: To explore and determine the correlates of neurocognitive function at the time of discharge from the hospital in patients undergoing off-pump coronary artery bypass surgery. METHODS: Patients undergoing off-pump coronary artery bypass surgery at Abbott Northwestern Hospital, Minneapolis, Minn, were administered tests of neuro-cognition (cognition and motor function), anxiety, depression, and quality of life preoperatively (within 72 hours of surgery) and postoperatively (at least 72 hours after surgery but before discharge from the hospital). RESULTS: A total of 54 patients (79.6% men), mean age 64.5 years, completed tests both preoperatively and postoperatively. When baseline function was controlled for, increased age and new-onset atrial fibrillation (F(3,40)=42.97; P<.001) were associated with decreases in postoperative cognitive function; increased age and anxiety (F(3,35)=15.83; P<.001) were associated with decreases in postoperative motor function. CONCLUSION: Older patients, anxious patients, and patients with new-onset atrial fibrillation are at risk for neurocognitive changes after off-pump coronary artery bypass surgery. Further studies with larger sample sizes should be done to examine interventions to reduce preoperative anxiety in these patients. Interventions to prevent postoperative atrial fibrillation should be explored to determine whether the interventions prevent a decline in neurocognitive function.

Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery.

BACKGROUND: Cardiac surgery is a common interventional procedure for ischemic and valvular heart disease. Cardiac surgery is accompanied by postoperative pain and anxiety. The use of music therapy has been shown to reduce pain, anxiety, and physiological parameters in patients having surgical procedures. OBJECTIVES: To compare the effects of music therapy versus a quiet, uninterrupted rest period on pain intensity, anxiety, physiological parameters, and opioid consumption after cardiac surgery. SUBJECTS AND METHODS: An experimental design was used. A total sample of 86 patients (69.8% males) were randomized to 1 of 2 groups; 50 patients received 20 minutes of music (intervention), whereas 36 patients had 20 minutes of rest in bed (control). Anxiety, pain, physiologic parameters, and opioid consumption were measured before and after the 20-minute period. RESULTS: A significant reduction in anxiety (P < or = .001) and pain (P = .009) was demonstrated in the group that received music compared with the control group, but no difference was observed in systolic blood pressure (P = .17), diastolic blood pressure (P = .11), or heart rate (P = .76). There was no reduction in opioid usage in the 2 groups. CONCLUSIONS: Patients recovering from cardiac surgery may benefit from music therapy.

Assessing the Impact of Acupuncture on Pain, Nausea, Anxiety, and Coping in Women Undergoing a Mastectomy.

PURPOSE/OBJECTIVES: To compare the effect of acupuncture to a standard-of-care (control) group on pain, nausea, anxiety, and ability to cope. 
. DESIGN: Pilot randomized, controlled trial. 
. SETTING: Abbott Northwestern Hospital, a large, urban, tertiary care hospital in Minneapolis, Minnesota.
. SAMPLE: 30 adult women undergoing surgery for breast cancer.
. METHODS: Women were randomly assigned to two hospital-based acupuncture treatments versus usual care after breast cancer surgery. Pain, nausea, anxiety, and the patient's ability to cope pre- and post-treatment were compared within and between groups at two different time points postoperatively.ʉ۩. MAIN RESEARCH VARIABLES: Mean change in pain, nausea, anxiety, and ability to cope by treatment group.
. FINDINGS: Compared to women assigned to the control group, women who received acupuncture reported a statistically significant greater reduction in pain, nausea, anxiety, and increase in ability to cope on the first postoperative day and in pain on the second postoperative day following mastectomy surgery.
. CONCLUSIONS: Acupuncture delivered postoperatively in the hospital after mastectomy can reduce the severity of symptoms experienced, as well as increase the patient's ability to cope with her symptoms. However, before implementation as a standard of care, further research needs to be conducted.
. IMPLICATIONS FOR NURSING: Acupuncture adds a nonpharmacologic intervention for symptom management in women undergoing mastectomies for breast cancer.

Use of complementary and alternative therapies: a national survey of critical care nurses.

BACKGROUND: Demand for complementary and alternative therapies is increasing and is affecting all healthcare settings, including critical care. METHODS: A random sample of members of the American Association of Critical-Care Nurses was surveyed to determine the members' attitudes, knowledge, perspectives, and use of complementary and alternative therapies. RESULTS: Most of the 726 respondents were using one or more complementary and alternative therapies in practice. The most common therapies used were diet, exercise, relaxation techniques, and prayer. A majority of the nurses had some knowledge of more than half of the 28 therapies listed on the survey, and a majority desired additional training for 25 therapies. Respondents generally required more evidence judged as essential to use or recommend conventional therapy than to use or recommend complementary and alternative therapies. Nurses viewed complementary and alternative therapies positively overall, were open to use of the therapies, and perceived them as legitimate and beneficial to patients. Nurses judged the therapies helpful for treatment of a variety of symptoms. A majority of nurses desired an increase in the availability of the therapies for patients, patients' families, and nursing staff. Nurses' professional use of the therapies was related to having more knowledge of them, perceiving benefits of them, total number of therapies they recommended to patients, personal use, and affiliation with a mainstream religion. CONCLUSIONS: Educational programs that provide information about use of complementary and alternative therapies and the underlying evidence base most likely will increase the appropriate use of the therapies to achieve desired outcomes.

Early neurocognitive function of patients after off-pump coronary artery bypass surgery.

DESIGN: This was a prospective, descriptive study. SETTING: The study took place in cardiovascular units at a large urban metropolitan, midwestern tertiary care hospital. SAMPLE: Fifty-four patients undergoing off-pump coronary artery bypass surgery were included. OUTCOME MEASURES: Outcome measures were neurocognition preoperatively at baseline (within 72 hours of surgery) and postoperatively (at least 72 hours after surgery but before discharge). RESULTS: In neurocognitive tests of cognition (memory, language, and attention) there was an improvement in the cognitive composite from the preoperative baseline to the postoperative follow-up (P < .001). However, in tests of motor function (motor speed and information processing speed) there was a decline in the motor composite (P = .006). CONCLUSIONS: After off-pump coronary artery bypass surgery, patients had an overall improvement in tests of memory, language, and attention (cognitive composite), but a decline in tests of motor speed and information processing speed (motor composite).

Stop the Noise: A Quality Improvement Project to Decrease Electrocardiographic Nuisance Alarms.

BACKGROUND: As many as 99% of alarm signals may not need any intervention and can result in patients' deaths. Alarm management is now a Joint Commission National Patient Safety Goal. OBJECTIVES: To reduce the number of nuisance electrocardiographic alarm signals in adult patients on the medical cardiovascular care unit. METHODS: A quality improvement process was used that included eliminating duplicative alarms, customizing alarms, changing electrocardiography electrodes daily, standardizing skin preparation, and using disposable electrocardiography leads. RESULTS: In the cardiovascular care unit, the mean number of electrocardiographic alarm signals per day decreased from 28.5 (baseline) to 3.29, an 88.5% reduction. CONCLUSION: Use of a bundled approach to managing alarm signals decreased the mean number of alarm signals in a cardiovascular care unit.

Computer-assisted interventions to improve QTc documentation in patients receiving QT-prolonging drugs.

BACKGROUND: Many medications commonly used in hospitals can cause prolonged corrected QT interval (QTc), putting patients at risk for torsade de pointes (TdP), a potentially fatal arrhythmia. However, documentation of QTc for hospitalized patients receiving QT-prolonging medications is often not consistent with American Heart Association standards. OBJECTIVE: To examine effects of education and computerized documentation enhancements on QTc documentation. METHODS: A quasi-experimental multisite study among 4011 cardiac-monitored patients receiving QTc-prolonging medications within a 10-hospital health care system was conducted to compare QTc documentation before (n=1517), 3 months after (n = 1301), and 4 to 6 months after (n = 1193) an intervention. The intervention included (1) online education for 3232 nurses, (2) electronic notifications to alert nurses when a patient received at least 2 doses of a QT-prolonging medication, and (3) computerized calculation of QTc in electronic health records after nurses had documented heart rate and QT interval. RESULTS: QTc documentation for inpatients receiving QTc-prolonging drugs increased significantly from baseline (17.3%) to 3 months after the intervention (58.2%; P < .001) within the 10 hospitals and had increased further 4 to 6 months after the intervention (62.1%, P = .75). Patients at larger hospitals were significantly more likely to have their QTc documented (46.4%) than were patients at smaller hospitals (26.2%; P < .001). CONCLUSION: A 3-step system-wide intervention was associated with an increase in QTc documentation for patients at risk for drug-induced TdP, and improvements persisted over time. Further study is needed to assess whether increased QTc documentation decreases occurrence of drug-induced TdP. (American Journal of Critical Care. 2015;24:e6-e15).