Improving DVLA advice provided to the patients with acute coronary syndrome upon discharge.

Acute coronary syndrome (ACS) and coronary intervention can significantly impair patients' ability to drive and, therefore, the Driver & Vehicle Licensing Agency (DVLA) provides relevant guidance for patients and healthcare professionals on driving in order to safeguard patients, passengers and public in general. The initial pre-teaching cohort analysis revealed that 12.9% of the discharge summaries had documented driving advice and only 3.23% were in accordance with the DVLA guidance. Our primary aim was to increase the provision of appropriate driving advice to >90%. Secondary aims were to improve the quality of the written advice and to increase junior doctors' awareness and confidence in doing so. We created a template with standardised driving advice with specific guidance for group 1 and group 2 drivers, delivered formal and informal teaching, and distributed information leaflets. These measures led to an overall improvement in provision of correct advice to >90%. We demonstrated how simple measures of introducing a standardised driving advice template and conducting formal and informal teaching could significantly improve the quality of current practice pertaining to the DVLA's driving restrictions in ACS patients. The successful strategies employed by us can be utilised by other trusts across the UK to promote person-centred care and improve patient safety.

QTc prolongation during therapeutic hypothermia: are we giving it the attention it deserves?

AIMS: Therapeutic hypothermia (TH) is used in neuroprotection following cardiac arrest due to ventricular tachycardia (VT) and ventricular fibrillation (VF). Accidental hypothermia is itself known to cause prolongation of the corrected QT interval (QTc). QTc prolongation can cause polymorphic VT and VF. If this also occurs in TH, it may induce refibrillation. We investigated the effect of TH on the QTc interval. METHODS AND RESULTS: Prospective case series of all patients undergoing TH following cardiac arrest following VT/VF at our hospital between July 2008 and January 2009. We studied the effect of temperature on QTc. All electrocardiograms (ECGs) undertaken during TH were studied and compared with the ECG prior to this. Four patients underwent TH. A total of 10 ECGs were undertaken during TH. The QTc was normal prior to TH. It became prolonged (>460 ms) in all cases during TH and normalized after cessation of TH, apart from Patient 4 who did not have an ECG post-TH since she died from cardiogenic shock. There was a negative correlation between temperature and QTc (Pearson's correlation coefficient, r= -0.71). CONCLUSION: Our series illustrates QTc prolongation during TH. This carries potential for refibrillation. Guidelines on ECG monitoring during TH are needed, especially since hypothermic myocardium is intrinsically prone to arrhythmias and commonly used antiarrythmic drugs such as amiodarone can prolong the QTc.

Cardiovascular implanted electronic devices in people towards the end of life, during cardiopulmonary resuscitation and after death: guidance from the Resuscitation Council (UK), British Cardiovascular Society and National Council for Palliative Care.

The Resuscitation Council (UK), the British Cardiovascular Society (including the British Heart Rhythm Society and the British Society for Heart Failure) and the National Council for Palliative Care recognise the importance of providing clear and consistent guidance on management of cardiovascular implanted electronic devices (CIEDs) towards the end of life, during cardiorespiratory arrest and after death. This document has been developed to provide guidance for the full range of healthcare professionals who may encounter people with CIEDs in the situations described and for healthcare managers and commissioners. The authors recognise that some patients and people close to patients may also wish to refer to this document. It is intended as an initial step to help to ensure that people who have CIEDs, or are considering implantation of one, receive explanation of and understand the practical implications and decisions that this entails; to promote a good standard of care and service provision for people in the UK with CIEDs in the circumstances described; to offer relevant ethical and legal guidance on this topic; to offer guidance on the delivery of services in relation to deactivation of CIEDs where appropriate; to offer guidance on whether any special measures are needed when a person with a CIED receives cardiopulmonary resuscitation; and to offer guidance on the actions needed when a person with a CIED dies.

A simple strategy improves prehospital electrocardiogram utilization and hospital treatment for patients with acute coronary syndrome (from the ST SMART Study).

Although the American Heart Association recommends a prehospital electrocardiogram (ECG) be recorded for all patients who access the emergency medical system with symptoms of acute coronary syndrome (ACS), widespread use of prehospital ECG has not been achieved in the United States. A 5-year prospective randomized clinical trial was conducted in a predominately rural county in northern California to test a simple strategy for acquiring and transmitting prehospital ECGs that involved minimal paramedic training and decision making. A 12-lead ECG was synthesized from 5 electrodes and continuous ST-segment monitoring was performed with ST-event ECGs automatically transmitted to the destination hospital emergency department. Patients randomized to the experimental group had their ECGs printed out in the emergency department with an audible voice alarm, whereas control patients had an ECG after hospital arrival, as was the standard of care in the county. The result was that nearly 3/4 (74%) of 4,219 patients with symptoms of ACS over the 4-year study enrollment period had a prehospital ECG. Mean time from 911 call to first ECG was 20 minutes in those with a prehospital ECG versus 79 minutes in those without a prehospital ECG (p <0.0001). Mean paramedic scene time in patients with a prehospital ECG was just 2 minutes longer than in those without a prehospital ECG (95% confidence interval 1.2 to 3.6, p <0.001). Patients with non-ST-elevation myocardial infarction or unstable angina pectoris had a faster time to first intravenous drug and there was a suggested trend for a faster door-to-balloon time and lower risk of mortality in patients with ST-elevation myocardial infarction. In conclusion, increased paramedic use of prehospital ECGs and decreased hospital treatment times for ACS are feasible with a simple approach tailored to characteristics of a local geographic region.

Pre-hospital synthesized 12-lead ECG ischemia monitoring with trans-telephonic transmission in acute coronary syndromes: pilot study results of the ST SMART trial.

INTRODUCTION: The aim of the ST SMART trial is to determine whether prehospital ST monitoring with telephone transmission to the target hospital will improve hospital time to treatment in acute coronary syndromes. The present analysis reports results of the feasibility pilot study. METHODS: All patients calling 911 for chest pain in Santa Cruz County California were monitored with a synthesized 12-lead ECG. Prehospital ECGs were printed for clinical use in the experimental group; control group patient care used only ECGs recorded after hospital arrival. RESULTS: Five patients with non-ST elevation myocardial infarction or unstable angina had normal ECGs upon hospital arrival but evidence of ischemia in their prehospital ECGs. Three patients with ST elevation myocardial infarction were treated with primary percutaneous coronary intervention, with "door to balloon" times of 47 and 65 minutes in 2 experimental group patients and 148 minutes in the one control group patient. CONCLUSION: Prehospital ST monitoring appears feasible. Its potential to improve hospital time to diagnosis and treatment in acute coronary syndromes, and the clinical benefits of such improvement will be studied in the larger, ongoing ST SMART trial.