Incremental Prognostic Value of Guideline-Directed Medical Therapy, Transradial Access, and Door-to-Balloon Time on Outcomes in ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: Systems to improve ST-segment-elevation myocardial infarction (STEMI) care have traditionally focused on improving door-to-balloon time. However, prompt guideline-directed medical therapy and transradial primary percutaneous coronary intervention (PCI) are also associated with reduced STEMI mortality. The incremental prognostic value of each facet of STEMI care on clinical outcomes within a STEMI system of care is unknown. METHODS AND RESULTS: We implemented systems-based strategies at our hospital to improve 3 STEMI care metrics: (1) prompt guideline-directed medical therapy before sheath insertion for PCI, (2) use of transradial primary PCI, and (3) door-to-balloon time. We assessed the incremental association of metrics achieved with in-hospital adverse events and 30-day mortality. Of 1272 consecutive patients with STEMI treated with PCI at our hospital (January 1, 2011, to December 31, 2016), the percentage with achievement of zero, 1, 2, or 3 STEMI care metrics was 7.1%, 24.1%, 43.8%, and 25.1%; and 30-day mortality was 15.6%, 8.6%, 3.6%, and 3.2%, respectively (log-rank P<0.001). After adjusting for known clinical predictors of STEMI in-hospital mortality, achievement of at least 2 STEMI care metrics was associated with significantly reduced in-hospital mortality (odds ratio, 0.39; 95% CI, 0.16-0.96; P=0.041). Each metric provided incremental prognostic value when modeled in stepwise order of their occurrence in clinical practice (final model C statistic, 0.677; P<0.001). CONCLUSIONS: Prompt guideline-directed medical therapy before sheath insertion for PCI, transradial primary PCI, and door-to-balloon time add incremental prognostic value in STEMI care. Expanding STEMI systems of care from a singular focus on door-to-balloon time to a comprehensive focus on multifaceted STEMI care offers an opportunity to further improve STEMI outcomes.

4-Step Protocol for Disparities in STEMI Care and Outcomes in Women.

BACKGROUND: Women with ST-segment elevation myocardial infarction (STEMI) receive suboptimal care and have worse outcomes than men. Whether strategies to reduce STEMI care variability impact disparities in the care and outcomes of women with STEMI is unknown. OBJECTIVES: The study assessed the care and outcomes of men versus women with STEMI before and after implementation of a comprehensive STEMI protocol. METHODS: On July 15, 2014, the authors implemented: 1) emergency department catheterization lab activation; 2) STEMI Safe Handoff Checklist; 3) immediate transfer to an immediately available catheterization lab; and 4) radial first approach to percutaneous coronary intervention (PCI). The authors prospectively studied consecutive patients with STEMI and assessed guideline-directed medical therapy (GDMT) before PCI, median door-to-balloon time (D2BT), in-hospital adverse events, and 30-day mortality stratified by sex before (January 1, 2011 to July 14, 2014; control group) and after (July 15, 2014 to December 31, 2016) implementation of the STEMI protocol. RESULTS: Of 1,272 participants (68% men, 32% women), women were older with more comorbidities than men. In the control group, women had less GDMT (77% vs. 69%; p = 0.019) and longer D2BT (median 104 min; [interquartile range (IQR): 79 to 133] min vs. 112 [IQR: 85 to 147] min; p = 0.023). Women had more in-hospital stroke, vascular complications, bleeding, transfusion, and death. In the comprehensive 4-step STEMI protocol, sex disparities in GDMT (84% vs. 80%; p = 0.32), D2BT (89 [IQR: 68 to 106] min vs. 91 [IQR: 68 to 114] min; p = 0.15), and in-hospital adverse events resolved. The absolute sex difference in 30-day mortality decreased from the control group (6.1% higher in women; p = 0.002) to the comprehensive 4-step STEMI protocol (3.2% higher in women; p = 0.090). CONCLUSIONS: A systems-based approach to STEMI care reduces sex disparities and improves STEMI care and outcomes in women.

Association Between Off-site Central Monitoring Using Standardized Cardiac Telemetry and Clinical Outcomes Among Non-Critically Ill Patients.

IMPORTANCE: Telemetry alarms involving traditional on-site monitoring rarely alter management and often miss serious events, sometimes resulting in death. Poor patient selection contributes to a high alarm volume with low clinical yield. OBJECTIVE: To evaluate outcomes associated with an off-site central monitoring unit (CMU) applying standardized cardiac telemetry indications using electronic order entry. DESIGN, SETTING, AND PARTICIPANTS: All non-intensive care unit (ICU) patients at Cleveland Clinic and 3 regional hospitals over 13 months between March 4, 2014, and April 4, 2015. EXPOSURES: An off-site CMU applied standardized cardiac telemetry when ordered for standard indications, such as for known or suspected tachyarrhythmias or bradyarrhythmias. MAIN OUTCOMES AND MEASURES: CMU detection and notification of rhythm/rate alarms occurring 1 hour or less prior to emergency response team (ERT) activation, direct CMU-to-ERT notification outcomes, total telemetry census, and cardiopulmonary arrests in comparison with the previous 13 months. RESULTS: The CMU received electronic telemetry orders for 99,048 patients (main campus, 72,199 [73%]) and provided 410,534 notifications (48% arrhythmia/hemodynamic) among 61 nursing units. ERT activation occurred among 3243 patients, including 979 patients (30%) with rhythm/rate changes occurring 1 hour or less prior to the ERT activation. The CMU detected and provided accurate notification for 772 (79%) of those events. In addition, the CMU provided discretionary direct ERT notification for 105 patients (ventricular tachycardia, n = 44; pause/asystole, n = 36; polymorphic ventricular tachycardia/ventricular fibrillation, n = 14; other, n = 11), including advance warning of 27 cardiopulmonary arrest events (26%) for which return of circulation was achieved in 25 patients (93%). Telemetry standardization was associated with a mean 15.5% weekly census reduction in the number of non-ICU monitored patients per week when compared with the prior 13-month period (580 vs 670 patients; mean difference, -90 patients [95% CI, -82 to -99]; P < .001). The number of cardiopulmonary arrests was 126 in the 13 months preintervention and 122 postintervention. CONCLUSIONS AND RELEVANCE: Among non-critically ill patients, use of standardized cardiac telemetry with an off-site central monitoring unit was associated with detection and notification of cardiac rhythm and rate changes within 1 hour prior to the majority of ERT activations, and also with a reduction in the census of monitored patients, without an increase in cardiopulmonary arrest events.

A comparative study of fluid management education before hospital discharge.

OBJECTIVES: We examined if an education intervention [EduI] based on the Common Sense Model theoretical framework and 3-step action plan to control fluid-related symptoms and weight gain, decreased 6-month health care consumption. BACKGROUND: Heart failure (HF) morbidity is often related to fluid overload. METHODS: A 2-group comparative design with convenience sampling was used to assess rehospitalization (Hosp), emergency department (ED) and unplanned office visits. Analyses included regression models. RESULTS: Of 122 usual care [UC] and 122 EduI patients, mean (standard deviation) age was 65.8 (12.6) years. In multivariate analyses, first HF Hosp, total ED visits and ED visits for HF decompensation were lower in EduI compared to UC; p = 0.039, p = 0.025, and p = 0.001 respectively. There were no reductions in 6-month total Hosp or HF-related unplanned office visits. CONCLUSIONS: An EduI with a 3-step action plan to control fluid-related symptoms and weight gain reduced first Hosp, total ED and HF-ED visits.

Diabetes teaching is not for the faint of heart: are cardiac nurses up to the challenge?

BACKGROUND: Patient education of self-care is an integral component of nursing care. Promoting self-care is important for patients with diabetes because day-to-day decision making has a tremendous impact on health. PURPOSE: To examine diabetes knowledge of nurses working on medical cardiology and cardiovascular surgical intermediate care units. METHODS: In this prospective, cross-sectional, correlational study, 90 registered nurses working on medical cardiology and cardiovascular surgical units completed a 20-item survey on diabetes survival skill education. Correlational and comparative statistics were used to analyze data. RESULTS: Subjects (N = 90) were more often female (n = 73; 83.0%) and worked full time (n = 76; 84%); mean (SD) RN experience was 5.6 years (SD, 7.6 years). Total mean score on the Diabetes Survival Skills Knowledge Test (DKSST) was 10.4 (SD, 2.6), reflecting 50% mastery of diabetes survival skill content. Test scores were higher in nurses with greater general comfort in teaching patients about diabetes (P =.04), more years of experience as a nurse (P =.004), more years of work at the current workplace (P <.001), and more years in their current work unit (P <.001). By age, nurses in the oldest quartile (> or =37 years) had higher DKSST content area scores in oral glucose-lowering agents (P =.02) and symptom management (P =.01) and had a trend toward higher overall DKSST score (P =.06) and score on blood glucose self-monitoring (P =.06). Sex, formal education level, work commitment, and previous diabetes education were not associated with higher DKSST scores. CONCLUSION: Nurse's knowledge and comfort related to diabetes survival skill teaching were low. The strongest correlate of higher DKSST score was length of time as a nurse. Because previous education and other nurse characteristics were not associated with higher test scores, nurse educators and advanced practice nurses must modify education delivery modalities to improve retention of information used in the delivery of patient education about diabetes survival skills.