Garrett K. Chan

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.

Integration of palliative care into emergency medicine: The Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration

BACKGROUND Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. CASE REPORT We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care. DISCUSSION We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort. CONCLUSION The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.

Factors Influencing Patient Assignment to Level 2 and Level 3 Within the 5-Level ESI Triage System

INTRODUCTION Prospectively assessing factors that influence triage nurse assignment of patients to the higher risk level 2 compared to the lower risk level 3 has not previously been explored within the 5-level Emergency Severity Index (ESI) triage system. Considering the large amount of information available about the patient, less experienced triage nurses often struggle in deciding what patient information is truly relevant when assessing if a high-risk situation exists. The primary aim of this study was to identify specific factors used by triage nurses to differentiate level 2 patients from level 3 patients. METHODS A convenience sample of triage nurses was recruited from 2 ED sites. If at the completion of the nurse-patient triage interaction the nurse assigned the patient to either level 2 or level 3, the triage nurse then completed a questionnaire related to factors that influenced patient assignment. RESULTS Overall, 18 triage nurses participated in the study with a total of 334 nurse-patient triage interactions collected. Patient age, vital signs, and need for a timely intervention were found to be significant factors that influenced patient assignment to level 2 while expected number of resources influenced patient assignment to level 3. DISCUSSION Utilizing experienced triage nurses on average, this study identified specific, objective factors that, combined with factors already delineated in the ESI Version 4 Implementation Manual, have useful implications for less experienced triage nurses by providing a more comprehensive and relevant foundation for data gathering and decision making.

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 AHAs indications for QT interval monitoring. This is a prospective study of 1039 critical care patients to determine the proportion of patients that meet the AHAs indications for QT interval monitoring. Secondary aim is to evaluate the predictive value of the AHAs 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.

A Prospective Cohort Study of Acute Kidney Injury in Multi-stage Ultramarathon Runners: The Biochemistry in Endurance Runner Study (BIERS)

The purpose of the study was to evaluate the prevalence of acute kidney injury (AKI) during a multi-stage ultramarathon foot race. A prospective observational study was taken during the Gobi 2008; Sahara 2008; and Namibia 2009 RacingThePlanet 7-day, 6-stage, 150-mile foot ultramarathons. Blood was analyzed before, and immediately after stage 1 (25 miles), 3 (75 miles), and 5 (140 miles). Creatinine (Cr), glomerular filtration rate (GFR), and incidence of AKI were calculated and defined by RIFLE criteria. Thirty participants (76% male, mean age 40 + 11 years) were enrolled. There were significant declines in GFR after each stage compared with the pre-race baseline (p < 0.001), with the majority of participants (55–80%) incurring AKI. The majority of study participants encountered significant renal impairment; however, no apparent cumulative effect was observed, with resolution of renal function to near baseline levels between stages.

Integrating palliative care in the out-of-hospital setting: Four things to jump-start an EMS-palliative care initiative

Abstract Emergency medical service (EMS) is frequently called to care for a seriously ill patient with a life-threatening or life-limiting illness. The seriously ill include both the acutely injured patients (for example in mass casualty events) and those who suffer from advanced stages of a chronic disease (for example severe malignant pain). EMS therefore plays an important role in delivering realistic, appropriate, and timely care that is consistent with the patients wishes and in treating distressing symptoms in those who are seriously ill. The purpose of this article is to; 1) review four case scenarios that relate to palliative care and may be commonly encountered in the out-of-hospital setting and 2) provide a road map by suggesting four things to do to start an EMS-palliative care initiative in order to optimize out-of-hospital care of the seriously ill and increase preparedness of EMS providers in these difficult situations. Key Words: Collaboration; emergency medical service; integration; out of hospital; palliative care

Education of Advanced Practice Nurses for Emergency Care Settings: Emphasizing Shared Competencies and Domains

In a rapidly changing healthcare environment, the educational preparation for advanced practice nurses (APNs) to assume professional roles is ever-changing. Of note is that similarities as well as differences exist in the clinical competencies of clinical nurse specialists (CNSs) and nurse practitioners (NPs). Although accrediting agencies, regulatory agencies, and relevant professional organizations have proposed certain competencies, academicians need to participate more fully in the updating of these competencies, ensuring that these new competencies become an active part of curricula. The authors perceive that research assessing active CNS and NP practices focuses on institution-specific activities rather than the knowledge, skills, and behaviors taught in APN curricula. The perception of discrete areas of didactic and clinical expertise for CNSs and NPs may not be reflected in community practice. CNS and NP academic education and clinical competencies overlap in many areas such as pathophysiology, pharmacology, differential diagnosis, and patient care management, and as such, standardizing curricula in these areas makes sense. Therefore, the purpose of this article is to examine the shared and unique competencies and domains of knowledge of CNSs and NPs in emergency care settings. Where the similarities exist, the authors propose that the curricula for CNSs and NPs might continue to be integrated in academic programs when feasible. They offer new domains for APN knowledge and practice in emergency care settings. Finally, the authors advocate for future competency validation mechanisms that are based on curricular content and nationally established competencies rather than on role delineation studies alone.

A Prospective Randomized Blister Prevention Trial Assessing Paper Tape in Endurance Distances (Pre-TAPED)

OBJECTIVE Friction foot blisters are a common injury occurring in up to 39% of marathoners, the most common injury in adventure racing, and represent more than 70% of medical visits in multi-stage ultramarathons. The goal of the study was to determine whether paper tape could prevent foot blisters in ultramarathon runners. METHODS This prospective randomized trial was undertaken during RacingThePlanet 155-mile (250-km), 7-day self-supported ultramarathons in China, Australia, Egypt, Chile, and Nepal in 2010 and 2011. Paper tape was applied prerace to one randomly selected foot, with the untreated foot acting as the own control. The study end point was development of a hot spot or blister on any location of either foot. RESULTS One hundred thirty-six participants were enrolled with 90 (66%) having completed data for analysis. There were 36% women, with a mean age of 40 ± 9.4 years (range, 25-40 years) and pack weight of 11 ± 1.8 kg (range, 8-16 kg). All participants developed blisters, with 89% occurring by day 2 and 59% located on the toes. No protective effect was observed by the intervention (47 versus 35; 52% versus 39%; P = .22), with fewer blisters occurring around the tape on the experimental foot than under the tape (23 vs 31; 25.6% versus 34.4%), yet 84% of study participants when queried would choose paper tape for blister prevention in the future. CONCLUSIONS Although paper tape was not found to be significantly protective against blisters, the intervention was well tolerated with high user satisfaction.

Laser Capture Microdissection: Understanding the Techniques and Implications for Molecular Biology in Nursing Research Through Analysis of Breast Cancer Tumor Samples

Aim: The purpose of this paper is to review the techniques and implications of laser capture microdissection (LCM) to isolate tissue and DNA of interest using breast biopsy tissue as an example. Background: Tissues are a heterogeneous mix of different cell types, and molecular alterations are often specific to a single cell type. An accurate correlation of molecular and morphologic pathologies requires the ability to procure pure populations of morphologically similar cells for molecular analysis. LCM is a technique for isolating highly pure cell populations of morphologically similar cells from a heterogeneous tissue section. Method: Nine invasive, paraffin-embedded breast biopsy specimens were obtained and analyzed. Depending on the size of the lesion, 500—1,000 shots using the 7.5- or 15-µm infrared laser beam were utilized to obtain an average of 2,000 cells. DNA was isolated from normal tissue and carcinomas and polymerase chain reaction (PCR) amplification was examined by agarose gel electrophoresis. The HER2/neu gene was amplified by standard PCR. A second round of PCR using nested primers to re-amplify the HER2/neu fragment was performed. Results: Amplification of the HER2/neu gene with DNA isolated from pure cell populations by LCM was performed. The results indicated that 22% of the cases studied were positive for HER2/neu amplifications, which corresponds to the literature regarding HER2/neu amplification/overexpression. HER2/neu amplification could be detected as early as the ductal carcinoma in situ (DCIS) stage. Conclusion: LCM is an accurate and reliable method to acquire nucleic acid and protein profiles from a specific cell population in heterogeneous tissue.

Exploring the Relationship Among Moral Distress, Coping, and the Practice Environment in Emergency Department Nurses.

Emergency department (ED) nurses practice in environments that are highly charged and unpredictable in nature and can precipitate conflict between the necessary prescribed actions and the individuals sense of what is morally the right thing to do. As a consequence of multiple moral dilemmas, ED staff nurses are at risk for experiencing distress and how they cope with these challenges may impact their practice. To examine moral distress in ED nurses and its relationship to coping in that specialty group. Using survey methods approach. One hundred ninety-eight ED nurses completed a moral distress, coping, and demographic collection instruments. Advanced statistical analysis was completed to look at relationships between the variables. Data analysis did show that moral distress is present in ED nurses (M = 80.19, SD = 53.27), and when separated into age groups, the greater the age, the less the experience of moral distress. A positive relationship between moral distress and some coping mechanisms and the ED environment was also noted. This studys findings suggest that ED nurses experience moral distress and could receive some benefit from utilization of appropriate coping skills. This study also suggests that the environment in which ED nurses practice has a significant impact on the experience of moral distress. Because health care is continuing to evolve, it is critical that issues such as moral distress and coping be studied in ED nurses to help eliminate human suffering.