Prognostic Value of BEFAST vs. FAST to Identify Stroke in a Prehospital Setting.

BACKGROUND: Use of prehospital stroke scales may enhance stroke detection and improve treatment rates and delays. Current scales, however, may lack detection accuracy. As such, we examined whether adding coordination (Balance) and diplopia (Eyes) assessments increase the accuracy of the Face-Arms-Speech-Time (FAST) scale in a multisite prospective study of emergency response activations for presumed stroke. METHODS: This was a prospective study of emergency response activations for presumed stroke in Santa Clara County, California. Emergency medical responders were trained in the Balance-Eyes-Face-Arms-Speech-Time (BEFAST) scale and administered the scale on scene to all patients who were within 6 hours of onset of neurological symptoms. Each patient's final diagnosis (stroke vs. no stroke) was based on review of hospital records. We compared the performance of the BEFAST and FAST scales for stroke detection. RESULTS: Three hundred fifty-nine patients were included in our analysis. Compared to nonstroke patients (n = 200), stroke patients (n = 159) more often scored positive on each of the five elements of the BEFAST scale (p < 0.05 for each). In multivariable analysis, only facial droop and arm weakness were independent predictors of stroke (p < 0.05). BEFAST and FAST scale accuracy for stroke identification was comparable (area under the curve [AUC] = 0.70 vs. AUC = 0.69, p = 0.36). Optimal cutoff for stroke detection was ≥1 for both scales. At this threshold, the positive predictive value (PPV) was 0.49 for the BEFAST and 0.53 for the FAST scale, and the negative predictive value (NPV) was 0.93 for BEFAST and 0.86 for FAST. CONCLUSION: Adding coordination and diplopia assessments to face, arm, and speech assessment does not improve stroke detection in the prehospital setting.

QT Corrections for Long QT Risk Assessment: Implications for the Preparticipation Examination.

BACKGROUND: Because sudden cardiac death (SCD) in the young mainly occurs in individuals with structurally normal hearts, improved screening techniques for detecting inherited arrhythmic diseases are needed. The QT interval is an important screening measurement; however, the criteria for detecting an abnormal QT interval are based on Bazett formula and older populations. OBJECTIVE: To define the normal upper limits for QT interval from the electrocardiograms (ECGs) of healthy young individuals, compare the major correction formula and propose new QT interval thresholds for detecting those at risk of SCD. METHODS: Young active individuals underwent ECGs as part of routine preparticipation physical examinations for competitive sports or community screening. This was a nonfunded study using de-identified data with no follow-up. RESULTS: There were 31 558 subjects: 2174 grade school (7%), 18 547 high school (59%), and 10 822 college (34%). Mean age was 17 (12-35 years), 45% were female, 67% white, and 11% of African descent. Bazett performed least favorably for removing the effect of heart rate (HR), whereas Fridericia performed the best. Fridericia correction also closely fit the raw data best (R of 0.65), and at percentile values applicable to screening. The recommended risk cut points using Bazetts correction identified less than half of the athletes in the 99th or 99.5th percentiles of the uncorrected QT by HR range. Use of Fridericia correction increased capture rates by over 50%. CONCLUSION: Our results support the application of the Fridericia-corrected threshold of 460 for men and 470 milliseconds for women (and 485 milliseconds for marked prolongation) rather than Bazett correction for the preparticipation examination.

Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology.

INTRODUCTION: The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services' (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms. OBJECTIVES: The purpose of this secondary analysis was to determine differences in patients presenting the ED for possible ACS who arrive by ambulance versus self-transport on: 1) time-to-initial hospital electrocardiogram (ECG), 2) presence of ischemic ECG changes, and 3) patient characteristics. METHODS: Initial 12-lead ECGs acquired upon patient arrival to the ED were evaluated for ST-elevation, ST-depression, and T-wave inversion. ECG signs of ischemia were analyzed both individually and collapsed into an independent dichotomous variable (ED ECG ischemia yes/no) for statistical analysis. Patient characteristics tested included: gender, age, race, ethnicity, English speaking, living alone, mode of transport, and presenting symptoms (chest pain, jaw pain, shortness of breath, nausea/vomiting, syncope, and clinical history). RESULTS: In 1299 patients (mean age 63.9, 46.7% male), 384 (29.6%) patients arrived by ambulance to the ED. The mean time-to-initial ECG was 47minutes for ambulance patients versus 53minutes for self-transport patients (p<0.001). Mode of transport was found to be an independent predictor for time-to-initial ECG controlling for age, gender, and race (p=0.004). There were significantly higher rates of ECG changes of ischemia for patients who arrived by ambulance versus self-transport (p=0.02), and patient characteristics differed by mode of transport to the ED. DISCUSSION: Our findings indicate that less than 30% of individuals with symptoms of ACS activate the EMS '911' system for ambulance transport to the ED. Individuals more likely to activate 911 have timelier ECG but higher rates of ischemic changes, specifically ST-depression and T-wave inversion. Individuals least likely to activate 911 are women, younger individuals, Latino ethnicity, live with a significant other, and those experiencing chest or jaw pain.

A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon.

OBJECTIVE: The aim of this study is to evaluate the effect of 2 hospital-wide interventions on achieving a discharge-before-noon rate of 40%. BACKGROUND: A multidisciplinary team led by administrative and physician leadership developed a plan to diminish capacity constraints by minimizing late afternoon hospital discharges using 2 patient flow management techniques. METHODS: The study was a preintervention/postintervention retrospective analysis observing all inpatients discharged across 19 inpatient units in a 484-bed, academic teaching hospital measuring calendar month discharge-before-noon percentage, patient satisfaction, and readmission rates. Patient satisfaction and readmission rates were used as baseline metrics. RESULTS: The discharge-before-noon percentage increased from 14% in the 11-month preintervention period to an average of 24% over the 11-month postintervention period, whereas patient satisfaction scores and readmission rates remained stable. CONCLUSIONS: Implementation of the 2 interventions successfully increased the percentage of discharges before noon yet did not achieve the goal of 40%. Patient satisfaction and readmission rates were not negatively impacted by the program.

Intensive Care Utilization for Hematopoietic Cell Transplant Recipients.

Blood and marrow transplantation (BMT) is a potentially curative therapy for a number of malignant and nonmalignant diseases. Multiple variables, including age, comorbid conditions, disease, disease stage, prior therapies, degree of donor-recipient matching, type of transplantation, and dose intensity of the preparative regimen, affect both morbidity and mortality. Despite tremendous gains in supportive care, BMT remains a high-risk medical therapy. A critically ill BMT recipient may require transfer to an intensive care unit (ICU) and the specialized medical and nursing care that can be provided, such as mechanical ventilation and vasopressor support. Mortality for BMT recipients requiring care in an ICU is high. This paper will describe the experience of the Stanford Blood and Marrow Transplant Program in developing and implementing guidelines to maximize the benefit of intensive care for critically ill BMT recipients.

Pre-participation screening for athletes and the role of advanced practice providers.

Pre-participation screening of athletes for underlying cardiovascular disease is recommended by the AHA/ACC. However, vigorous debate continues as to whether the ECG should be used as part of a broad-based screening program. The AHA/ACC "do not support national mandatory screening ECGs of athletes, because the logistics, manpower, financial and resource considerations make such a program inapplicable to US". In an effort to address these impediments and to increase access for communities, we explore the use of advanced practice providers (Nurse Practitioners and Physician Assistants) in providing pre-participation screening to athletes with ECG interpretation. In the current healthcare environment with limited primary care resources, advanced practice providers are an important new element in improving access to care. Pre-participation screening with ECG interpretation is currently within an advanced practice provider's scope of practice. Emerging data shows that advanced practice providers perform care that is within acceptable patient care standards, safely, and cost effectively, compared to physician counterparts. To further improve pre-participation screening, a national education and certification program on 12-lead ECG interpretation is needed. Standardized screening tools and mass screening protocols that include screening ECGs for targeted athlete populations who are at high risk for SCD are needed. These recommendations are aimed at addressing some of the barriers raised by the AHA/ACC group to pre-participation screening with ECG.

Are the QRS duration and ST depression cut-points from the Seattle criteria too conservative?

BACKGROUND: Screening athletes with ECGs is aimed at identifying "at-risk" individuals who may have a cardiac condition predisposing them to sudden cardiac death. The Seattle criteria highlight QRS duration greater than 140 ms and ST segment depression in two or more leads greater than 50 µV as two abnormal ECG patterns associated with sudden cardiac death. METHODS: High school, college, and professional athletes underwent 12 lead ECGs as part of routine pre-participation physicals. Prevalence of prolonged QRS duration was measured using cut-points of 120, 125, 130, and 140 ms. ST segment depression was measured in all leads except leads III, aVR, and V1 with cut-points of 25 µV and 50 µV. RESULTS: Between June 2010 and November 2013, 1595 participants including 297 (167 male, mean age 16.2) high school athletes, 1016 (541 male, mean age 18.8) college athletes, and 282 (mean age 26.6) male professional athletes underwent screening with an ECG. Only 3 athletes (0.2%) had a QRS duration greater than 125 ms. ST segment depression in two or more leads greater than 50 µV was uncommon (0.8%), while the prevalence of ST segment depression in two or more leads increased to 4.5% with a cut-point of 25 µV. CONCLUSION: Changing the QRS duration cut-point to 125 ms would increase the sensitivity of the screening ECG, without a significant increase in false-positives. However, changing the ST segment depression cut-point to 25 µV would lead to a significant increase in false-positives and would therefore not be justified.

Limitations of Current AHA Guidelines and Proposal of New Guidelines for the Preparticipation Examination of Athletes.

OBJECTIVE: To examine the prevalence of athletes who screen positive with the preparticipation examination guidelines from the American Heart Association, the AHA 12-elements, in combination with 3 screening electrocardiogram (ECG) criteria. DESIGN: Observational cross-sectional study. SETTING: Stanford University Sports Medicine Clinic. PARTICIPANTS: Total of 1596 participants, including 297 (167 male; mean age, 16.2 years) high school athletes, 1016 (541 male; mean age, 18.8 years) collegiate athletes, and 283 (mean age, 26.3 years) male professional athletes. MAIN OUTCOME MEASURES: Athletes were screened using the 8 personal and family history questions from the AHA 12-elements. Electrocardiograms were obtained for all participants and interpreted using Seattle criteria, Stanford criteria, and European Society of Cardiology (ESC) recommendations. RESULTS: Approximately one-quarter of all athletes (23.8%) had at least 1 positive response to the AHA personal and family history elements. High school and college athletes had similar rates of having at least 1 positive response (25.9% vs 27.4%), whereas professional athletes had a significantly lower rate of having at least 1 positive response (8.8%, P < 0.05). Females reported more episodes of unexplained syncope (11.4% vs 7.5%, P = 0.017) and excessive exertional dyspnea with exercise (11.1% vs 6.1%, P = 0.001) than males. High school athletes had more positive responses to the family history elements when compared with college athletes (P < 0.05). The percentage of athletes who had an abnormal ECG varied between Seattle criteria (6.0%), Stanford criteria (8.8%), and ESC recommendations (26.8%). CONCLUSIONS: Many athletes screen positive under current screening recommendations, and ECG results vary widely by interpretation criteria. CLINICAL RELEVANCE: In a patient population without any adverse cardiovascular events, the currently recommended AHA 12-elements have an unacceptably high rate of false positives. Newer screening guidelines are needed, with fewer false positives and evidence-based updates.

Lean Manufacturing Improves Emergency Department Throughput and Patient Satisfaction.

A multidisciplinary team led by nursing leadership and physicians developed a plan to meet increasing demand and improve the patient experience in the ED without expanding the department's current resources. The approach included Lean tools and engaged frontline staff and physicians. Applying Lean management principles resulted in quicker service, improved patient satisfaction, increased capacity, and reduced resource utilization. Incorporating continuous daily management is necessary for sustainment of continuous improvement activities.

Health behaviors and needs of melanoma survivors.

PURPOSE: Little is known about melanoma survivors' long-term symptoms, sun protection practices, and support needs from health providers. METHODS: Melanoma survivors treated at Stanford Cancer Center from 1995 through 2011 were invited to complete a heath needs survey. We compared responses of survivors by sex, education, time since diagnosis (long-term vs. short-term survivors), and extent of treatment received (wide local excision (WLE) alone versus WLE plus additional surgical or medical treatment (WLE+)). RESULTS: One hundred sixty melanoma survivors (51 % male; 61 % long-term; 73 % WLE+) provided evaluable data. On average, patients were 62 years of age (SD = 14), highly educated (75 % college degree), and Caucasian (94 %). Overall, participants rated anxiety as the most prevalent symptom (34 %). Seventy percent reported that their health provider did not address their symptoms, and 53 % requested education about melanoma-specific issues. Following treatment, women spent significantly less time seeking a tan compared with men (p = 0.01), had more extremity swelling (p = 0.014), and expressed higher need for additional services (p = 0.03). Long-term survivors decreased their use of tanning beds (p = 0.03) and time spent seeking a tan (p = 0.002) and were less likely to receive skin screening every 3-6 months (p < 0.001) compared with short-term survivors. WLE+ survivors reported greater physical long-term effects than WLE survivors (p ≤ 0.001) following treatment. CONCLUSIONS: Melanoma survivors experience continuing symptoms long after treatment, namely anxiety, and they express a need for information about long-term melanoma effects, psychosocial support, and prevention of further skin cancer.

Comparison of three ECG criteria for athlete pre-participation screening.

UNLABELLED: Controversy regarding adding the ECG to the evaluation of young athletes centers on the implications of false positives. Several guidelines have been published with recommendations for criteria to distinguish between ECG manifestations of training and markers of risk for cardiovascular (CV) sudden death. With an athlete dataset negative of any CV related abnormalities on follow-up, we applied three athlete screening criteria to identify the one with the lowest rate of abnormal variants. METHODS: High school, college, and professional athletes underwent 12L ECGs as part of routine physicals. All ECGs were recorded and processed using CardeaScreen (Seattle, WA). The European (2010), Stanford (2011), and Seattle criteria (2013) were applied. RESULTS: From March 2011 to February 2013 1417 ECGs were collected. Mean age was 20±4years (14-35years), 36% female, 38.5% non-white (307 high school, 836 college and 284 professional). Rate of abnormal variants differed by criteria, predominately due to variation in interval thresholds for QT interval and QRS duration. There was a four-fold difference in abnormal variants between European and Seattle criteria (26% v 6%). CONCLUSION: The Seattle criterion was the most conservative resulting in 78% fewer abnormal variants than the European criteria. Variation was most evident with thresholds for QT prolongation, short QT interval, and intraventricular conduction delay. Continued research is needed to further understand normal training related adaptations and to improve modern ECG screening criteria for athletes.

Electrocardiographic abnormalities in the first year after heart transplantation.

STUDY AIM: Describe ECG abnormalities in the first year following transplant surgery. METHODS: Analysis of 12-lead ECGs from heart transplant subjects enrolled in an ongoing multicenter clinical trial. RESULTS: 585 ECGs from 98 subjects showed few with abnormal cardiac rhythm (99% of ECGs were sinus rhythm/tachycardia). A majority of subjects (69%) had either right intraventricular conduction delay (56%) or right bundle branch block (13%). A second prevalent ECG abnormality was atrial enlargement (64% of subjects) that was more commonly left atrial (55%) than right (30%). CONCLUSIONS: Right intraventricular conduction delay or right bundle branch block is prevalent in heart transplant recipients in the first year following transplant surgery. Whether this abnormality is related to acute allograph rejection or endomyocardial biopsy procedures is the subject of the ongoing clinical trial. Atrial enlargement ECG criteria (especially, left atrial) are also common and are likely due to transplant surgery with subsequent atrial remodeling.

Hyperglycemia is associated with corrected QT prolongation and mortality in acutely ill patients.

BACKGROUND: The QT interval on an electrocardiogram represents ventricular repolarization time. Increased length of this interval, known as corrected QT (QTc) prolongation, can be a precursor to torsade de pointes, a potentially life-threatening ventricular dysrhythmia. An association exists between blood glucose and QTc interval in ambulatory populations. Because both hyperglycemia and QTc prolongation are common in critically ill patients, we sought to examine the relationship between blood glucose, QTc interval prolongation, and all-cause mortality in critically ill patients. METHODS: We studied adult patients admitted to cardiac monitoring units. Blood glucose and other clinical variables were abstracted from the medical record. Corrected QT measurements were automatically derived from continuous bedside cardiac monitoring systems. RESULTS: Twenty-five percent (233/940) of the patients had QTc prolongation, and 53% had elevated blood glucose (>140 mg/dL) during hospitalization. Adjusted odds for QTc prolongation were 2.1 (95% confidence interval, 1.5-3.1) for moderately elevated blood glucose (140-180 mg/dL) and 3.7 (95% confidence interval, 2.5-5.4) for severely elevated blood glucose (>180 mg/dL). Mortality rate was highest (16%) in patients experiencing both severely elevated blood glucose (>180 mg/dL) and QTc interval prolongation. CONCLUSIONS: Hyperglycemia is linked with QTc prolongation, and both are associated with increased odds of mortality in critically ill patients. Further studies are needed to extrapolate the relationship between glucose and ventricular repolarization, as well as appropriate glucose control parameters and QTc interval monitoring in critical care units.

High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality: results of the QT in Practice (QTIP) Study.

OBJECTIVE: To test the potential value of more frequent QT interval measurement in hospitalized patients. DESIGN: We performed a prospective, observational study. SETTING: All adult intensive care unit and progressive care unit beds of a university medical center. PATIENTS: All patients admitted to one of six critical care units over a 2-month period were included in analyses. INTERVENTIONS: All critical care beds (n = 154) were upgraded to a continuous QT monitoring system (Philips Healthcare). MEASUREMENTS AND MAIN RESULTS: QT data were extracted from the bedside monitors for offline analysis. A corrected QT interval >500 msecs was considered prolonged. Episodes of QT prolongation were manually over-read. Electrocardiogram data (67,648 hrs, mean 65 hrs/patient) were obtained. QT prolongation was present in 24%. There were 16 cardiac arrests, with one resulting from Torsade de Pointes (6%). Predictors of QT prolongation were female sex, QT-prolonging drugs, hypokalemia, hypocalcemia, hyperglycemia, high creatinine, history of stroke, and hypothyroidism. Patients with QT prolongation had longer hospitalization (276 hrs vs. 132 hrs, p < .0005) and had three times the odds for all-cause in-hospital mortality compared to patients without QT prolongation (odds ratio 2.99 95% confidence interval 1.1-8.1). CONCLUSIONS: We find QT prolongation to be common (24%), with Torsade de Pointes representing 6% of in-hospital cardiac arrests. Predictors of QT prolongation in the acutely ill population are similar to those previously identified in ambulatory populations. Acutely ill patients with QT prolongation have longer lengths of hospitalization and nearly three times the odds for mortality then those without QT prolongation.

Remote noninvasive allograft rejection monitoring for heart transplant recipients: study protocol for the novel evaluation with home electrocardiogram and remote transmission (NEW HEART) study.

BACKGROUND: Acute allograft rejection is a major cause of early mortality in the first year after heart transplantation in adults. Although endomyocardial biopsy (EMB) is not a perfect "gold standard" for a correct diagnosis of acute allograft rejection, it is considered the best available test and thus, is the current standard practice. Unfortunately, EMB is an invasive and costly procedure that is not without risk. Recent evidence suggests that acute allograft rejection causes delays in ventricular repolarization and thereby increases the cellular action potential duration resulting in a longer QT interval on the electrocardiogram (ECG). No prospective study to date has investigated whether such increases in the QT interval could provide early detection of acute allograft rejection. Therefore, in the Novel Evaluation With Home Electrocardiogram And Remote Transmission (NEW HEART) study, we plan to investigate the potential benefit of daily home QT interval monitoring to predict acute allograft rejection. METHODS/DESIGN: The NEW HEART study is a prospective, double-blind, multi-center descriptive research study. A sample of 325 adult heart transplant recipients will be recruited within six weeks of transplant from three sites in the United States. Subjects will receive the HeartView™ ECG recorder and its companion Internet Transmitter, which will transmit the subject's ECG to a Core Laboratory. Subjects will be instructed to record and transmit an ECG recording daily for 6 months. An increase in the QTC interval from the previous day of at least 25 ms that persists for 3 consecutive days will be considered abnormal. The number and grade of acute allograft rejection episodes, as well as all-cause mortality, will be collected for one year following transplant surgery. DISCUSSION: This study will provide "real world" prospective data to determine the sensitivity and specificity of QTC as an early non invasive marker of cellular rejection in transplant recipients during the first post-transplant year. A non-invasive indicator of early allograft rejection in heart transplant recipients has the potential to limit the number and severity of rejection episodes by reducing the time and cost of rejection surveillance and by shortening the time to recognition of rejection. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01365806.

Time dependent history improves QT interval estimation in atrial fibrillation.

PURPOSE: It is not recommended to perform QTc estimation in patients with atrial fibrillation (AF). We evaluated multiple QT interval correction formulas, including a novel time-dependent history approach, in an effort to identify the best method for correcting the QT interval in patients with AF. The ideal correction results in independence between the QTc estimate and HR. METHODS: Per-beat characteristics were derived using SuperECG (Mortara Instrument). Offline beat-to-beat QTc interval estimates were constructed using standard formulae and averaged (2-10) groups constructed. RESULTS: Seventy-one patients were included, age 67 ± 10 years, 69% men. Mean-mean QTc intervals varied by correction (range 394-459 ms). Averaging resulted in the same mean-mean QTc estimate, but significantly reduced variability by up to 55%. Time-dependent RR interval history reduced variability the most (Δ 80%), increased QT/RR dynamics (m=.03 vs .17), and was independent with HR (m = 0.0008). CONCLUSIONS: Our data suggests that QTc interval estimation in patients with AF can be performed reliably using time-dependent history (RRc) outperforming other correction methods.

How many patients need QT interval monitoring in critical care units? Preliminary report of the QT in Practice study.

UNLABELLED: Recent Scientific Statement from the American Heart Association (AHA) recommends that hospital patients should receive QT interval monitoring if certain conditions are present: QT-prolonging drug administration or admission for drug overdose, electrolyte disturbances (K, Mg), and bradycardia. No studies have quantified the proportion of critical care patients that meet the AHA's indications for QT interval monitoring. This is a prospective study of 1039 critical care patients to determine the proportion of patients that meet the AHA's indications for QT interval monitoring. Secondary aim is to evaluate the predictive value of the AHA's indications in identifying patients who actually develop QT interval prolongation. METHODS: Continuous QT interval monitoring software was installed in all monitored beds (n = 154) across 5 critical care units. This system uses outlier rejection and median filtering in all available leads to construct an root-mean-squared wave from which the QT measurement is made. Fridericia formula was used for heart rate correction. A QT interval greater than 500 milliseconds for 15 minutes or longer was considered prolonged for analyses. To minimize false positives all episodes of QT prolongation were manually over read. Clinical data was abstracted from the medical record. RESULTS: Overall 69% of patients had 1 or more AHA indications for QT interval monitoring. More women (74%) had indications than men (64%, P = .001). One quarter (24%) had QT interval prolongation (>500 ms for ≥15 minutes). The odds for QT interval prolongation increased with the number of AHA indications present; 1 indication, odds ratio (OR) = 3.2 (2.1-5.0); 2 indications, OR = 7.3(4.6-11.7); and 3 or more indications OR = 9.2(4.8-17.4). Positive predictive value of the AHA indications for QT interval prolongation was 31.2%; negative predictive value was 91.3%. CONCLUSION: Most critically ill patients (69%) have AHA indications for QT interval monitoring. One quarter of critically ill patients (24%) developed QT interval prolongation. The AHA indications for QT interval monitoring successfully captured the majority of critically ill patients developing QT interval prolongation.

Pressure Injury Prevention Practices in the Intensive Care Unit: Real-world Data Captured by a Wearable Patient Sensor.

BACKGROUND: Compliance with turning protocols in the intensive care unit (ICU) is low; however, little is known about the quality of turning, such as turn angle magnitude or depressurization time. Wearable sensors are now available that provide insight into care practices. OBJECTIVE: This secondary descriptive study describes the turning practices of nurses from 2 ICUs at an academic medical center among consecutive ICU patients. MATERIALS AND METHODS: A wearable patient sensor was applied to patients on hospital admission. The sensor continuously recorded position data but was not visible to staff. A qualified turn was one that reached > 20° angle and was held for 1 minute after turning. The institution's clinical research repository provided clinical data. RESULTS: A total of 555 patients were analyzed over a 5-month period (September 2015-January 2016); 44 870 hours of monitoring data (x- = 73 hours ± 97/patient) and 27 566 individual turns were recorded. Compliant time was recorded as 54%, with 39% of observed turns reaching the minimum angle threshold and 38% of patients remaining in place for > 15 minutes (depressurization). Turn magnitude was similar for medical and surgical patients. Factors associated with lower compliant time included male sex, high body mass index, and low Braden score. Patients were supine for 72% of the observed time. CONCLUSIONS: The investigators found dynamically measured turning frequency, turn magnitude, and tissue depressurization time to be suboptimal. This study highlights the need to reinforce best practices related to preventive turning and to consider staff and patient factors when developing individualized turn protocols.

Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study).

IMPORTANCE: Though theoretically sound, studies have failed to demonstrate the benefit of routine repositioning of at-risk patients for the prevention of hospital acquired pressure injuries. OBJECTIVE: To assess the clinical effectiveness of a wearable patient sensor to improve care delivery and patient outcomes by increasing the total time with turning compliance and preventing pressure injuries in acutely ill patients. DESIGN: Pragmatic, investigator initiated, open label, single site, randomized clinical trial. SETTING: Two Intensive Care Units in a large Academic Medical Center in California. PARTICIPANTS: Consecutive adult patients admitted to one of two Intensive Care Units between September 2015 to January 2016 were included (n = 1564). Of the eligible patients, 1312 underwent randomization. INTERVENTION: Patients received either turning care relying on traditional turn reminders and standard practices (control group, n = 653), or optimal turning practices, influenced by real-time data derived from a wearable patient sensor (treatment group, n = 659). MAIN OUTCOME(S) AND MEASURE(S): The primary and secondary outcomes of interest were occurrence of hospital acquired pressure injury and turning compliance. Sensitivity analysis was performed to compare intention-to-treat and per-protocol effects. RESULTS: The mean age was 60 years (SD, 17 years); 55% were male. We analyzed 103,000 h of monitoring data. Overall the intervention group had significantly fewer Hospital Acquired Pressure Injuries during Intensive Care Unit admission than the control group (5 patients [0.7%] vs. 15 patients [2.3%] (OR = 0.33, 95%CI [0.12, 0.90], p = 0.031). The total time with turning compliance was significantly different in the intervention group vs. control group (67% vs 54%; difference 0.11, 95%CI [0.08, 0.13], p < 0.001). Turning magnitude (21°, p = 0.923) and adequate depressurization time (39%, p = 0.145) were not statistically different between groups. CONCLUSIONS AND RELEVANCE: Among acutely ill adult patients requiring Intensive Care Unit admission, the provision of optimal turning was greater with a wearable patient sensor, increasing the total time with turning compliance and demonstrated a statistically significant protective effect against the development of hospital acquired pressure injuries. These are the first quantitative data on turn quality in the Intensive Care Unit and highlight the need to reinforce optimal turning practices. Additional clinical trials leveraging technologies like wearable sensors are needed to establish the appropriate frequency and dosing of individualized turning protocols to prevent pressure injuries in at-risk hospitalized patients.