Marjorie Funk

Prevention of Torsade de Pointes in Hospital Settings A Scientific Statement From the American Heart Association and the American College of Cardiology Foundation

Cardiac arrest due to torsade de pointes (TdP) in the acquired form of drug-induced long-QT syndrome (LQTS) is a rare but potentially catastrophic event in hospital settings. Administration of a QT-prolonging drug to a hospitalized population may be more likely to cause TdP than administration of the same drug to an outpatient population, because hospitalized patients often have other risk factors for a proarrhythmic response. For example, hospitalized patients are often elderly people with underlying heart disease who may also have renal or hepatic dysfunction, electrolyte abnormalities, or bradycardia and to whom drugs may be administered rapidly via the intravenous route. In hospital units where patients’ electrocardiograms (ECGs) are monitored continuously, the possibility of TdP may be anticipated by the detection of an increasing QT interval and other premonitory ECG signs of impending arrhythmia. If these ECG harbingers of TdP are recognized, it then becomes possible to discontinue the culprit drug and manage concomitant provocative conditions (eg, hypokalemia, bradyarrhythmias) to reduce the occurrence of cardiac arrest. The purpose of this scientific statement is to raise awareness among those who care for patients in hospital units about the risk, ECG monitoring, and management of drug-induced LQTS. Topics reviewed include the ECG characteristics of TdP and signs of impending arrhythmia, cellular mechanisms of acquired LQTS and current thinking about genetic susceptibility, drugs and drug combinations most likely to cause TdP, risk factors and exacerbating conditions, methods to monitor QT intervals in hospital settings, and immediate management of marked QT prolongation and TdP. The term torsade de pointes was coined by Dessertenne in 1966 as a polymorphic ventricular tachycardia characterized by a pattern of twisting points.1 Several ECG features are characteristic of TdP and are illustrated in Figure 1. First, a change in the amplitude and morphology (twisting) of the QRS …

Practice Standards for Electrocardiographic Monitoring in Hospital Settings: An American Heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses

The goals of electrocardiographic (ECG) monitoring in hospital settings have expanded from simple heart rate and basic rhythm determination to the diagnosis of complex arrhythmias, myocardial ischemia, and prolonged QT interval. Whereas computerized arrhythmia analysis is automatic in cardiac monitoring systems, computerized ST-segment ischemia analysis is available only in newer-generation monitors, and computerized QT-interval monitoring is currently unavailable. Even in hospitals with ST-monitoring capability, ischemia monitoring is vastly underutilized by healthcare professionals. Moreover, because no computerized analysis is available for QT monitoring, healthcare professionals must determine when it is appropriate to manually measure QT intervals (eg, when a patient is started on a potentially proarrhythmic drug). The purpose of the present review is to provide ‘best practices’ for hospital ECG monitoring. Randomized clinical trials in this area are almost nonexistent; therefore, expert opinions are based upon clinical experience and related research in the field of electrocardiography. This consensus document encompasses all areas of hospital cardiac monitoring in both children and adults. The emphasis is on information clinicians need to know to monitor patients safely and effectively. Recommendations are made with regard to indications, timeframes, and strategies to improve the diagnostic accuracy of cardiac arrhythmia, ischemia, and QT-interval monitoring. Currently available ECG lead systems are described, and recommendations related to staffing, training, and methods to improve quality are provided.

Gender Differences in Symptom Presentation Associated With Coronary Heart Disease

This study explores gender differences in symptom presentation associated with coronary heart disease (CHD). In this prospective study, nurse data collectors directly observed 550 patients as they presented to the Emergency Department (ED) of Yale-New Haven Hospital. The final sample included 217 patients (41% women) diagnosed with CHD (acute coronary ischemia or myocardial infarction). Chest pain was the most frequently reported symptom in women (70%) and men (71%). Unadjusted analyses revealed that women were more likely than men to present with midback pain (odds ratio [OR] 9.61, 95% confidence interval [CI] 2.10 to 44.11, p = 0.001), nausea and/or vomiting (OR 2.29, 95% CI 1.19 to 4.42, p = 0.012), dyspnea (OR 1.82, 95% CI 1.05 to 3.16, p = 0.032), palpitations (OR 3.42, 95% CI 1.02 to 11.47, p = 0.036), and indigestion (OR 2.13, 95% CI 1.03 to 4.44, p = 0.040). After adjustment for age and diabetes, women were more likely to present with nausea and/or vomiting (OR 2.43, 95% CI 1.23 to 4.79, p = 0.011) and indigestion (OR 2.13, 95% CI 1.10 to 4.53, p = 0.048). Women (30%) and men (29%) were equally likely to present without chest pain, and dyspnea was the most common non-chest pain symptom. In the subgroup of patients without chest pain, unadjusted analyses revealed that women were more likely to report nausea and/or vomiting compared with men (OR 4.40, 95% CI 1.30 to 14.84, p = 0.013). Although we found some significant gender differences in non-chest pain symptoms, we conclude that there were more similarities than differences in symptoms in women and men presenting to the ED with symptoms suggestive of CHD who were later diagnosed with CHD.

Prevention of Torsade de Pointes in Hospital Settings: A Scientific Statement From the American Heart Association and the American College of Cardiology Foundation Endorsed by the American Association of Critical-Care Nurses and the International Society for Computerized Electrocardiology

TdP is an uncommon but potentially fatal arrhythmia that can be caused by drugs that cause selective prolongation of action potential durations in certain layers of the ventricular myocardium, which creates dispersion of repolarization and a long, distorted QT-U interval on the ECG. A summary of key points to remember is provided in Table 3. Table 3 Summary of Key Points For patients who receive QT-prolonging drugs in hospital units with continuous ECG monitoring, TdP should be avoidable if there is an awareness of individual risk factors and the ECG signs of drug-induced LQTS. Particularly important are the ECG risk factors for TdP, including marked QTc prolongation to >500 ms (with the exception of amiodarone- or verapamil-induced QT prolongation), marked QT-U prolongation and distortion after a pause, onset of ventricular ectopy and couplets, macroscopic T-wave alternans, or episodes of polymorphic ventricular tachycardia that are initiated with a short-long-short R-R cycle sequence (typically, PVC– compensatory pause–PVC). Recognition of these ECG harbingers of TdP allows for treatment with intravenous magnesium, removal of the offending agent, and correction of electrolyte abnormalities and other exacerbating factors, including the prevention of bradycardia and long pauses with temporary pacing if necessary.

Practice Standards for Electrocardiographic Monitoring in Hospital Settings

The goals of electrocardiographic (ECG) monitoring in hospital settings have expanded from simple heart rate and basic rhythm determination to the diagnosis of complex arrhythmias, myocardial ischemia, and prolonged QT interval. Whereas computerized arrhythmia analysis is automatic in cardiac monitoring systems, computerized ST-segment ischemia analysis is available only in newer-generation monitors, and computerized QT-interval monitoring is currently unavailable. Even in hospitals with ST-monitoring capability, ischemia monitoring is vastly underutilized by healthcare professionals. Moreover, because no computerized analysis is available for QT monitoring, healthcare professionals must determine when it is appropriate to manually measure QT intervals (eg, when a patient is started on a potentially proarrhythmic drug). The purpose of the present review is to provide ‘best practices’ for hospital ECG monitoring. Randomized clinical trials in this area are almost nonexistent; therefore, expert opinions are based upon clinical experience and related research in the field of electrocardiography. This consensus document encompasses all areas of hospital cardiac monitoring in both children and adults. The emphasis is on information clinicians need to know to monitor patients safely and effectively. Recommendations are made with regard to indications, timeframes, and strategies to improve the diagnostic accuracy of cardiac arrhythmia, ischemia, and QT-interval monitoring. Currently available ECG lead systems are described, and recommendations related to staffing, training, and methods to improve quality are provided.

Consequences of clinical situations that cause critical care nurses to experience moral distress

Little is known about the consequences of moral distress. The purpose of this study was to identify clinical situations that caused nurses to experience moral distress, to understand the consequences of those situations, and to determine whether nurses would change their practice based on their experiences. The investigation used a descriptive approach. Open-ended surveys were distributed to a convenience sample of 204 critical care nurses employed at a university medical center. The analysis of participants’ responses used an inductive approach and a thematic analysis. Each line of the data was reviewed and coded, and the codes were collapsed into themes. Methodological rigor was established. Forty-nine nurses responded to the survey. The majority of nurses had experienced moral distress, and the majority of situations that caused nurses to experience moral distress were related to end of life. The nurses described negative consequences for themselves, patients, and families.

Alarm Fatigue A Patient Safety Concern

Research has demonstrated that 72% to 99% of clinical alarms are false. The high number of false alarms has led to alarm fatigue. Alarm fatigue is sensory overload when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarms and missed alarms. Patient deaths have been attributed to alarm fatigue. Patient safety and regulatory agencies have focused on the issue of alarm fatigue, and it is a 2014 Joint Commission National Patient Safety Goal. Quality improvement projects have demonstrated that strategies such as daily electrocardiogram electrode changes, proper skin preparation, education, and customization of alarm parameters have been able to decrease the number of false alarms. These and other strategies need to be tested in rigorous clinical trials to determine whether they reduce alarm burden without compromising patient safety.

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.

Factors associated with pressure ulcers in patients in a surgical intensive care unit.

PURPOSE: We sought to describe the occurrence of pressure ulcers in patients managed in a surgical intensive care unit (ICU) and report preliminary work toward development of a pressure ulcer risk assessment tool for use in this population that incorporates comorbidities and other factors not addressed in previous instruments. SUBJECTS AND SETTINGS: Three hundred sixty-nine patients managed in the surgical ICU at Yale-New Haven Hospital comprised the sample. METHODS: Demographic and clinical data, including Braden Scale scores, were collected in this prospective, 2-phase study. The principal investigator (G.C.S.) performed skin assessments on all patients. We used chi-square analysis and t tests to determine variables to include in a stepwise logistic regression analysis to determine factors independently associated with the development of pressure ulcers. INSTRUMENT: We collected data, using a form we developed that contained demographic and clinical factors found in previous research and in our clinical practice to be associated with pressure ulcers. RESULTS: Eighty-eight out of 369 patients (23.9%) experienced a hospital-acquired pressure ulcer. Braden Scale scores ranged from 6 to 21, with a mean score of 11.9 ± 2.2. A lower Braden Scale score, the presence of diabetes mellitus, and patient age 70 years or older independently predicted the development of a pressure ulcer. These factors have been incorporated into the preliminary Surgical ICU Pressure Ulcer Risk Assessment scale. CONCLUSIONS: Findings from this study suggest that, in addition to a low Braden Scale score, age >70 years and a diagnosis of diabetes may represent clinically relevant pressure ulcer risk factors in the surgical intensive care population and that patients with these factors may benefit from more aggressive preventive care. In addition, the Surgical ICU Pressure Ulcer Risk Assessment scale requires additional psychometric testing before its use can be recommended for the research or practice settings.

Practice Standards for Electrocardiographic Monitoring in Hospital Settings An American Heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young

The goals of electrocardiographic (ECG) monitoring in hospital settings have expanded from simple heart rate and basic rhythm determination to the diagnosis of complex arrhythmias, myocardial ischemia, and prolonged QT interval. Whereas computerized arrhythmia analysis is automatic in cardiac monitoring systems, computerized ST-segment ischemia analysis is available only in newer-generation monitors, and computerized QT-interval monitoring is currently unavailable. Even in hospitals with ST-monitoring capability, ischemia monitoring is vastly underutilized by healthcare professionals. Moreover, because no computerized analysis is available for QT monitoring, healthcare professionals must determine when it is appropriate to manually measure QT intervals (eg, when a patient is started on a potentially proarrhythmic drug). The purpose of the present review is to provide ‘best practices’ for hospital ECG monitoring. Randomized clinical trials in this area are almost nonexistent; therefore, expert opinions are based upon clinical experience and related research in the field of electrocardiography. This consensus document encompasses all areas of hospital cardiac monitoring in both children and adults. The emphasis is on information clinicians need to know to monitor patients safely and effectively. Recommendations are made with regard to indications, timeframes, and strategies to improve the diagnostic accuracy of cardiac arrhythmia, ischemia, and QT-interval monitoring. Currently available ECG lead systems are described, and recommendations related to staffing, training, and methods to improve quality are provided.