Sue Sendelbach

Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest Evaluation of a Regional System to Increase Access to Cooling

Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA.Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA. # Clinical Perspective {#article-title-40}

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.

Effects of variation in temperature management on cerebral performance category scores in patients who received therapeutic hypothermia post cardiac arrest.

AIM To assess differences in cerebral performance category (CPC) in patients who received therapeutic hypothermia post cardiac arrest by time to initiation, time to target temperature, and duration of therapeutic hypothermia (TH). METHODS A secondary data analysis was conducted using hospital-specific data from the international cardiac arrest registry (INTCAR) database. The analytic sample included 172 adult patients who experienced an out-of-hospital cardiac arrest and were treated in one Midwestern hospital. Measures included time from arrest to ROSC, arrest to TH, arrest to target temperature, and length of time target temperature was maintained. CPC was assessed at three points: transfer from ICU, discharge from hospital, and post discharge follow-up. RESULTS Average age was 63.6 years and 74.4% of subjects were male. Subjects had TH initiation a mean of 94.4 min (SD 81.6) after cardiac arrest and reached target temperature after 309.0 min (SD 151.0). In adjusted models, the odds of a poor neurological outcome increased with each 5 min delay in initiating TH at transfer from ICU (OR=1.06, 95% C.I. 1.02-1.10). Similar results were seen for neurological outcomes at hospital discharge (OR=1.06, 95% C.I. 1.02-1.11) and post-discharge follow-up (OR=1.08, 95% C.I. 1.03-1.13). Additionally the odds of a poor neurological outcome increased for every 30 min delay in time to target temperature at post-discharge follow-up (OR=1.17, 95% C.I. 1.01-1.36). CONCLUSION In adults undergoing TH post cardiac arrest, delay in initiation of TH and reaching target temperature differentiated poor versus good neurologic outcomes. Randomized trials assessing the range of current recommended guidelines for TH should be conducted to establish optimal treatment protocols.

Personal Use of Complementary and Alternative Medicine (CAM) by U.S. Health Care Workers

OBJECTIVE To examine personal use of complementary and alternative medicine (CAM) among U.S. health care workers. DATA Data are from the 2007 Alternative Health Supplement of the National Health Interview Survey. We examined a nationally representative sample of employed adults (n = 14,329), including a subsample employed in hospitals or ambulatory care settings (n = 1,280). STUDY DESIGN We used multivariate logistic regression to estimate the odds of past year CAM use. PRINCIPAL FINDINGS Health care workers are more likely than the general population to use CAM. Among health care workers, health care providers are more likely to use CAM than other occupations. CONCLUSIONS Personal CAM use by health care workers may influence the integration of CAM with conventional health care delivery. Future research on the effects of personal CAM use by health care workers is therefore warranted.

Temperature Measurement in Patients Undergoing Colorectal Surgery and Gynecology Surgery: A Comparison of Esophageal Core, Temporal Artery, and Oral Methods

Maintaining perioperative normothermia reduces postoperative complications. An accurate, noninvasive method to take temperatures representative of core temperature is needed. Oral thermometry is accepted as the most accurate means of non-core temperature assessment, but poses challenges in patients who are intubated or wearing oxygen masks. The purpose of this study was to determine the difference, if any, between core temperature as measured by an esophageal thermometer and temperatures measured by oral and temporal artery methods in patients undergoing colorectal or gynecology surgery. A repeated-measures design was used with a convenience sample of 23 patients undergoing colorectal or gynecology surgery. Two series of intraoperative temperatures were taken (oral and temporal artery thermometry) and compared with core temperature measured by esophageal probe. Repeated-measures analysis of variance tested for biases of oral or temporal temperatures versus core temperatures. Bland-Altman plots were drawn to test dependence of bias on actual core temperature. A priori, a temperature difference >0.4 degrees C was defined as clinically significant. Oral temperature was biased high relative to esophageal temperature by 0.12 degrees C on average (P = .0008; 95% confidence interval [0.061, 0.187]). Temporal artery temperature was biased high relative to esophageal, by 0.074 degrees C on average (P = .03; 95% confidence interval [0.010, 0.133]). Differences between core (esophageal) thermometry and oral or temporal artery thermometry were statistically significant but much smaller than the 0.4 degrees C identified as clinically acceptable. Oral and temporal artery temperatures are within the 0.4 degrees C of core (esophageal) temperatures, a difference that is considered clinically acceptable. Temperatures taken orally or by temporal artery thermometry are acceptable as noninvasive core measures for adult patients undergoing colorectal or gynecology surgery.

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

Background and Purpose: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records. Methods: Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning. Results: The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research. Conclusions: Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.

Computer-Assisted Interventions To Improve QTc Documentation in Patients Receiving QT-Prolonging Drugs

BACKGROUND Many medications commonly used in hospitals can cause prolonged corrected QT interval (QTc), putting patients at risk for torsade de pointes (TdP), a potentially fatal arrhythmia. However, documentation of QTc for hospitalized patients receiving QT-prolonging medications is often not consistent with American Heart Association standards. OBJECTIVE To examine effects of education and computerized documentation enhancements on QTc documentation. METHODS A quasi-experimental multisite study among 4011 cardiac-monitored patients receiving QTc-prolonging medications within a 10-hospital health care system was conducted to compare QTc documentation before (n=1517), 3 months after (n = 1301), and 4 to 6 months after (n = 1193) an intervention. The intervention included (1) online education for 3232 nurses, (2) electronic notifications to alert nurses when a patient received at least 2 doses of a QT-prolonging medication, and (3) computerized calculation of QTc in electronic health records after nurses had documented heart rate and QT interval. RESULTS QTc documentation for inpatients receiving QTc-prolonging drugs increased significantly from baseline (17.3%) to 3 months after the intervention (58.2%; P < .001) within the 10 hospitals and had increased further 4 to 6 months after the intervention (62.1%, P = .75). Patients at larger hospitals were significantly more likely to have their QTc documented (46.4%) than were patients at smaller hospitals (26.2%; P < .001). CONCLUSION A 3-step system-wide intervention was associated with an increase in QTc documentation for patients at risk for drug-induced TdP, and improvements persisted over time. Further study is needed to assess whether increased QTc documentation decreases occurrence of drug-induced TdP. (American Journal of Critical Care. 2015;24:e6-e15).

Changing practice, one clinical question at a time.

E vidence-based practice (EBP) fosters an environment of clinical inquiry that will summon professional growth, influence the lives of patients, help nurses develop a unique professional legacy, and contain costs.1,2 In addition, grounding nursing practice in evidence rather than tradition will solidify credibility among other healthcare disciplines and cultivate a nursing knowledge base that can be used to influence professional, agency, and federal policy.3,4 The World Health Organization has challenged healthcare providers to create environments conducive to EBP by recommending that healthcare researchers and providers collaborate more closely in formulating research agendas that address current care delivery barriers and include translational activities that will directly and rapidly improve care delivery and health outcomes.5 One approach to integrating evidence into practice is a nursing practice fellowship designed to support nurses in answering a relevant clinical question. We discuss the development of an EBP fellowship program for nurses practicing in a large, metropolitan hospital, describing the framework, resources, educational curriculum, and initial experience of the program.

Challenges of implementing a feasibility study of acupuncture in acute and critical care settings

A majority of people in the United States use complementary and alternative therapies, and this use is increasing. With the increasing interest, providers must evaluate potential risks and benefits of these therapies. This article describes challenges of a feasibility study of acupuncture as a potential therapeutic adjunct to prevent atrial fibrillation following coronary artery bypass graft surgery. Institutional review board approval, consent logistics, implementation issues, and rapid changes in clinical practice were the primary challenges faced. Unique technological features of the institution helped address these challenges. The study protocol was acceptable to staff, patients, and family and was considered safe for these patients. However, the protocol was not feasible as designed; therefore, the efficacy of acupuncture could not be determined. Continued research is needed to evaluate the effectiveness of acupuncture to prevent atrial fibrillation following coronary artery bypass graft surgery. Recommendations for future studies of complementary and alternative therapies in acute and critical care settings are offered.

APRN Consensus Model Implementation: The Minnesota Experience

In 2015, more than 16 years of strategic work resulted in the removal of statutory barriers to Minnesota advanced practice registered nurse (APRN) practice. Keys to the passage of the legislation were the creation of a formal infrastructure (Minnesota APRN Coalition) to manage financial and communication strategies, cohesion among all four roles of APRNs, engagement of strong legislative authors and bipartisan support, and valuable partnerships among the coalition and external stakeholders, such as the Minnesota Board of Nursing. The rapid implementation of the law presented the board with distinct challenges. The purpose of this article is to present the experience of implementing the 2008 APRN Consensus Model to assist other states.