Health-Related Quality of Life in Patients With Ventricular Assist Device: Psychometric Evaluation of the German Version of the Quality of Life With a Ventricular Assist Device Questionnaire.

BACKGROUND: Ventricular assist device (VAD) implantation has become an alternative treatment for patients with end-stage heart failure. In Germany, valid and reliable instruments to assess health-related quality of life in patients with VAD are lacking. OBJECTIVE: The aim of this study was to present the psychometric validation of the German version of the Quality of Life with a Ventricular Assist Device questionnaire. METHODS: In a multicenter, cross-sectional study, 393 participants (mean age, 58.3 years; 85.8% male, 60.3% bridge to transplant, and 72.8% living with VAD for ≤2 years) completed the German Quality of Life with a Ventricular Assist Device questionnaire of physical, emotional, social, cognitive, and meaning/spiritual domains. Item and confirmatory factor analyses were conducted to test item difficulty and discrimination and the underlying structure, respectively. To examine internal consistency, Cronbach α was assessed. Convergent construct validity was tested using the Kansas City Cardiomyopathy Questionnaire and the Patient Health Questionnaire-9. Readability was examined using Flesch Reading Ease index and Vienna Factual Text Formula. RESULTS: The Quality of Life with a Ventricular Assist Device showed reasonable item difficulty (Ptotal = .67) and mostly moderate to high discriminatory power (rit > 0.30). In confirmatory factor analysis, root-mean-square error of approximation (0.07) was acceptable for model fit, but no other indices. Acceptable internal consistency was found (α ≥ 0.79), with the exception of the cognitive domain (α = 0.58). The overall questionnaire and single domains demonstrated convergent validity (r ≥ 0.45, P < .001). The questionnaire showed adequate readability (Flesch Reading Ease, 64.11; Vienna Factual Text Formula, 6.91). CONCLUSION: Findings indicate a promising standardized clinical instrument to assess health-related quality of life in patients with VAD.

Health-Related Quality of Life in Patients With a Left Ventricular Assist Device (QOLVAD) Questionnaire: Initial Psychometrics of a New Instrument.

BACKGROUND: Patients with a left ventricular assist device are a unique and growing population who deserve their own valid, reliable instrument for health-related quality of life. OBJECTIVE: We developed and tested the Health-Related Quality of Life with a Left Ventricular Assist Device (QOLVAD) questionnaire. METHODS: In a prospective, descriptive study, patients from 7 sites completed the QOLVAD and comparator questionnaires. Construct validity was tested using confirmatory factor analysis. Convergent validity was tested using correlations of QOLVAD scores to well-established measures of subjective health status, depression, anxiety, and meaning/faith. Reliability and test-retest reliability were quantified. RESULTS: Patients (n = 213) were 58.7 ± 13.9 years old; 81.0% were male, 73.7% were White, and 48.0% had bridge to transplant. Questionnaires were completed at a median time of 44 weeks post ventricular assist device. The 5 QOLVAD domains had acceptable construct validity (root mean square error of approximation = 0.064, comparative and Tucker-Lewis fit indices > 0.90, weighted root mean square residual = 0.95). The total score and domain-specific scores were significantly correlated with the instruments to which they were compared. Internal consistency reliability was acceptable for all subscales (α = .79-.83) except the cognitive domain (α = .66). Unidimensional reliability for the total score was acceptable (α = .93), as was factor determinacy for multidimensional reliability (0.95). Total test-retest reliability was 0.875 (P < .001). CONCLUSION: Our analysis provided initial support for validity and reliability of the QOLVAD for total score, physical, emotional, social, and meaning/spiritual domains. The QOLVAD has potential in research and clinical settings to guide decision making and referrals; further studies are needed.

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.

Use of the Minnesota Living With Heart Failure Questionnaire among elderly patients with aortic stenosis: results from a pilot study.

BACKGROUND: Past studies of health-related quality of life (HRQL) in aortic stenosis (AS) have focused on valve replacement, using generic or heart failure measures because no disease-specific measure exists. The literature is lacking in both performance of these measures among patients with AS and HRQL outcomes in the nonsurgical elderly AS population. OBJECTIVE: The aims of this study were to measure HRQL and test the reliability of the Minnesota Living With Heart Failure Questionnaire (MLHFQ), Geriatric Depression Scale (GDS), and Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp) in persons older than 70 years with AS receiving nonsurgical treatment. METHODS: The prospective, descriptive design in this study included baseline administration of questionnaires to a consecutive convenience sample of patients aged 75 to 97 years (mean, 85 years) enrolled in a clinical trial for AS (n = 25). RESULTS: Mean aortic valve area was 0.54 cm (range, 0.37-0.96 cm). Patients reported angina (52%) and light-headedness (72%); these 2 items were not included on the MLHFQ but were added as investigator-developed items. Scores for MLHFQ varied widely (median, 52; range, 7-101). Although the median GDS was 4 (range, 1-13), almost half (48%) scored higher than 5, indicating a positive depression screen. Scores for FACIT-Sp were moderately high (median, 37.5; range, 18-45), indicating strong spiritual well-being among many participants. A significant inverse relationship (r = -0.73, P < .0001; 95% confidence interval, -0.87 to -0.48) was found between depression and spiritual well-being. Cronbach α was 0.91, 0.83, and 0.81 for the MLHFQ, GDS, and FACIT, respectively. CONCLUSIONS: The HRQL measures selected had good internal consistency reliability, but use of the MLHFQ alone would have missed common disease-specific concerns (eg, angina, light-headedness); studies for minimally invasive aortic valve replacement should include these items. Because higher spiritual well-being was associated with less depressive symptoms, both should receive further study in HRQL assessment. Larger samples may clarify appropriate education and interventions for depressive symptoms, spiritual well-being, as well as safe physical activity and fall prevention for those with light-headedness.

The patient experience of in-hospital telemetry monitoring: a qualitative analysis.

AIMS: In-hospital telemetry monitoring has been an integrated part of arrhythmia monitoring for decades. A substantial proportion of patients require arrhythmia monitoring during stays in non-intensive care units. However, studies exploring patients' experiences of telemetry monitoring are scarce. Therefore, the aim was to explore and describe patients' experiences of in-hospital telemetry monitoring in a non-intensive care setting. METHODS AND RESULTS: Twenty face-to-face, semi-structured interviews were conducted. Interviews were conducted before discharge at two university hospitals in Norway. The patients were purposively sampled, resulting in a well-balanced population comprising 11 men and nine women, mean age 62 years (range 25-83). Average monitoring time was 9 days (range 3-14). Data were audiotaped, transcribed verbatim, and coded using NVivo software. Qualitative content analysis using an inductive approach was performed. Patients expressed a need for individualized information during telemetry monitoring. Their feelings of safety were related to responses from nurses from the central monitoring station when alarms from the telemetry were triggered. Despite perceived physical restrictions and psychological limitations associated with telemetry monitoring, they found monitoring to be beneficial because it facilitated the diagnosis of arrhythmia. Moreover, they expressed a need for improvements in wearable monitoring equipment. Patients expressed ambivalent feelings about discontinuing the telemetry and their readiness for discharge. CONCLUSION: Patients need individualized information about the results of their telemetry monitoring in order to better understand the arrhythmia management and to increase their experience of safety after discharge. The limitations patients experienced should be taken into consideration in further upgrades of telemetry monitoring equipment.

Appropriateness and outcomes of hospitalized patients telemetry monitored for cardiac arrhythmias in accordance with the American Heart Association Practice Standards-A multicenter study.

BACKGROUND: To the best of our knowledge, no prospective research studies have compared clinical practice to the American Heart Association (AHA) updated practice standards for in-hospital telemetry monitoring. OBJECTIVES: Our aims were therefore (1) to investigate how patients were assigned to telemetry monitoring in accordance with the AHA's updated practice standards, (2) to determine the number and type of arrhythmic events, and (3) to describe subsequent changes in clinical management. METHODS: This prospective multicenter study included 1154 patients at three university hospitals in Norway. Data were collected 24/7 over a four-week period, with follow-up measurements from telemetry admission until hospital discharge. RESULTS: Of patients assigned to telemetry, 67 % (n = 767) met practice standards, corresponding to AHA Class I or II. Patients were predominantly men (65 %, n = 748), and the mean age was 65 years (SD ±16). The study included both patients with cardiac and non-cardiac diagnoses from various medical and surgical departments throughout the hospitals. Ninety-one percent of the patients in Class III were monitored based on indications that were reclassified from Class II to Class III (not indicated) in the updated practice standards (patients admitted with chest pain or post-percutaneous coronary intervention (PCI) without complications). Overall, arrhythmic events occurred in 37 % (n = 424) of patients, and they occurred in all classes. Eighteen percent (n = 59) of arrhythmic events occurred in Class III. Of all arrhythmias, 3 % (n = 14) were life threatening, and all of them occurring within Class I. Telemetry monitoring led to changes in clinical management in 22 % (n = 257) of patients due to clinical alarms, of which 71 % (n = 182) were related to medication management. CONCLUSIONS: Most patients were appropriately monitored according to the AHA practice standards, meeting Class I and II. Arrhythmias occurred in all classes, but life-threatening arrhythmias only occurred in patients in Class I. However, a daily re-assessment of each patient's telemetry indication is warranted.

Evidence-based practice models for organizational change: overview and practical applications.

AIM: To provide an overview, summary of key features and evaluation of usefulness of six evidence-based practice models frequently discussed in the literature. BACKGROUND: The variety of evidence-based practice models and frameworks, complex terminology and organizational culture challenges nurses in selecting the model that best fits their practice setting. DATA SOURCES: The authors: (1) initially identified models described in a predominant nursing text; (2) searched the literature through CINAHL from 1998 to current year, using combinations of 'evidence', 'evidence-based practice', 'models', 'nursing' and 'research'; (3) refined the list of selected models based on the initial literature review; and (4) conducted a second search of the literature on the selected models for all available years to locate both historical and recent articles on their use in nursing practice. DISCUSSION: Authors described model key features and provided an evaluation of model usefulness based on specific criteria, which focused on facilitating the evidence-based practice process and guiding practice change. IMPLICATIONS FOR NURSING: The evaluation of model usefulness can be used to determine the best fit of the models to the practice setting. CONCLUSION: The Johns Hopkins Model and the Academic Center for Evidence-Based Practice Star Model emphasize the processes of finding and evaluating evidence that is likely to appeal to nursing educators. Organizations may prefer the Promoting Action on Research Implementation in Health Services Framework, Advancing Research and Clinical Practice Through Close Collaboration, or Iowa models for their emphasis on team decision-making. An evidence-based practice model that is clear to the clinician and fits the organization will guide a systematic approach to evidence review and practice change.

Competency of new graduate nurses: a review of their weaknesses and strategies for success.

Because of the ongoing nursing shortage and the increasing acuity of patients, new graduate nurses must master both psychomotor and critical thinking skills rapidly. Inadequate orientation leads to high turnover rates for new graduates. Health care leaders must examine the competencies needed for new graduate nurses to succeed in this environment. A critical review of studies (n = 26) was conducted to identify crucial competencies that are needed for new graduate nurses to be successful. Six areas were identified in which new graduates lacked competence: communication, leadership, organization, critical thinking, specific situations, and stress management. Strategies were identified to improve the transition of new graduates. Hospitals should consider implementing nurse residency programs that include strategies for clear communication and conflict management, prioritization skills, and leadership development. Schools of nursing should add communication strategies to their current focus on critical thinking, clinical reasoning, and simulation scenarios and include situation-specific skills such as end-of-life scenarios. Further research should focus on stress management, leadership, clinical reasoning, and evaluation of measurement tools for new graduates.

Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem.

Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.

Stimulant Drugs of Abuse and Cardiac Arrhythmias.

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

A practical communication strategy to improve implementation of evidence-based practice.

OBJECTIVE: The purpose of this study was to determine if a consistent communication strategy for implementation of evidence-based practice (EBP), developed with input from staff nurses, improved staff nurse satisfaction with communication of practice changes. BACKGROUND: Integration of EBP knowledge into clinical practice supports optimal nursing care. Awareness of a practice change and the ability to reference the information may be problematic. METHODS: A quasi-experimental single group before-after design was used to survey all RNs of a level III neonatal ICU for satisfaction before and after implementation of the EBP communication strategy. RESULTS: Registered nurse satisfaction improved regarding the amount of communication (P < .001), frequency of communication (P < .014), method of communication (P < .001), and ease of finding information (P < .001). CONCLUSION: A consistent strategy can improve nurse satisfaction with communication of EBP changes.

Effect of a preceptor education workshop: part 2. Qualitative results of a hospital-wide study.

BACKGROUND: This study examined the hospital-wide effect of a mandatory 8-hour nurse preceptor workshop on preceptors and orientees. METHODS: A mixed-methods approach was used. The quantitative surveys were augmented with qualitative short-answer questions (QUAN + qual) to identify the perceptions of preceptorship experiences for both preceptors and orientees. RESULTS: Findings from the narrative portions of the survey are presented. Orientees were able to distinguish between poor and excellent quality in precepting, were concerned that orientation was not tailored to the needs of experienced nurses, and described three to four preceptors as being the ideal number to be assigned to an orientee. Preceptors postintervention described "being more open" to the orientee's view, "slowing down," and increasing the promotion of critical thinking strategies. CONCLUSION: According to the quantitative results, orientees postintervention did not report increased satisfaction with preceptors. Qualitative findings suggested that this was likely related to a high number of preceptors, heavy patient loads, and lack of tailoring of orientation to the needs of experienced nurses. The quantitative results showed that preceptors postintervention reported increased satisfaction and confidence for precepting in all five preceptor roles assessed quantitatively; qualitative findings further supported these findings. However, narrative findings indicated that a primary barrier to positive changes in a preceptor's practice was a heavy patient load while precepting.

Effect of a preceptor education workshop: part 1. Quantitative results of a hospital-wide study.

BACKGROUND: This study examined the hospital-wide effect of a mandatory 8-hour preceptor workshop on preceptors and orientees. METHODS: A mixed-methods approach (QUAN + qual) with a quasi-experimental design was used to test nurse preceptors' self-reported confidence and comfort (pre- to postworkshop) in five specific roles in addition to the frequency of coaching critical thinking and providing formal feedback. Additionally, survey items compared cross-sectional cohorts of preceptors and orientees pre- to postworkshop. Orientee retention rates were compared for 1 year before and 1 year after the workshop. RESULTS: Findings from the QUAN portion of the study are presented. Paired t tests showed that preceptors (n = 131) reported significantly improved results for confidence and comfort in all five specific preceptor roles measured 3 to 6 months after workshop attendance; coaching of critical thinking was increased, whereas provision of formal feedback was not. Preceptor-reported comfort and confidence were not significantly greater in the cohort who participated in the workshop compared with the noninterventional cohort (n = 74). Among orientees, satisfaction with preceptors was not significantly improved for the cohort whose preceptors had attended training (n = 53) versus the previous cohort (n = 39). Among orientee cohorts, greater confidence in critical thinking skills on completion of orientation occurred only among experienced transfer nurses. Orientees who had three to four preceptors reported the highest composite satisfaction. One year postintervention, significantly more orientees were retained (125 of 132) than in the previous year (82 of 94) (chi-square, p < .05). CONCLUSION: Preceptor workshops are effective in preparing experienced nurses to precept new nurses, as measured by self-reported development of preceptors and retention of orientees.

Critical review of health-related quality of life studies of patients with aortic stenosis.

BACKGROUND: While studies of health-related quality of life (HRQOL) are increasing among cardiovascular patients, very few have examined HRQOL in persons with aortic stenosis (AS). PURPOSE: A critical review of studies (1997-2008) of HRQOL in persons with AS was conducted to summarize findings and identify clinical and research implications. RESULTS: Twenty-eight studies were identified, all of which were quantitative and evaluated HRQOL after aortic valve replacement (AVR). No studies conducted by nurses or studies measuring HRQOL in persons who did not undergo AVR were found. The literature focused on age and type of valve as variables influencing HRQOL postoperatively. Although results varied, elderly patients often scored similar or better than comparison groups. Health-related quality of life was found to be affected by valve noise and anticoagulation rather than the specific valve type when comparing patients receiving biological versus mechanical valves. CONCLUSIONS: Selection for surgery should not be based on age alone. Early consideration should be given to symptoms prior to surgery because of evidence that patients with fewer symptoms preoperatively have better HRQOL after AVR. Anticoagulation status should be evaluated as an independent variable of HRQOL in future studies. IMPLICATIONS FOR RESEARCH AND PRACTICE: Researchers need to augment generic HRQOL measures with disease-specific items that may pertain to life areas affected by AS, such as audible valve click, wound healing, and dyspnea. Future research should be inclusive of AS patients who do not undergo surgery. Nurses in a variety of roles can work independently or within a multidisciplinary team to provide interventions for the promotion of HRQOL for patients across all stages of the AS disease process.

Guidance for cardiac electrophysiology during the COVID-19 pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association.

Coronavirus disease 2019 (COVID-19) is a global pandemic that is wreaking havoc on the health and economy of much of human civilization. Electrophysiologists have been impacted personally and professionally by this global catastrophe. In this joint article from representatives of the Heart Rhythm Society, the American College of Cardiology, and the American Heart Association, we identify the potential risks of exposure to patients, allied healthcare staff, industry representatives, and hospital administrators. We also describe the impact of COVID-19 on cardiac arrhythmias and methods of triage based on acuity and patient comorbidities. We provide guidance for managing invasive and noninvasive electrophysiology procedures, clinic visits, and cardiac device interrogations. In addition, we discuss resource conservation and the role of telemedicine in remote patient care along with management strategies for affected patients.

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.

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).