Evaluating optimal patient-turning procedures for reducing hospital-acquired pressure ulcers (LS-HAPU): study protocol for a randomized controlled trial.

BACKGROUND: Pressure ulcers are insidious complications that affect approximately 2.5 million patients and account for approximately US$11 billion in annual health care spending each year. To date we are unaware of any study that has used a wearable patient sensor to quantify patient movement and positioning in an effort to assess whether adherence to optimal patient turning results in a reduction in pressure ulcer occurrence. METHODS/DESIGN: This study is a single-site, open-label, two-arm, randomized controlled trial that will enroll 1812 patients from two intensive care units. All subjects will be randomly assigned, with the aid of a computer-generated schedule, to either a standard care group (control) or an optimal pressure ulcer-preventative care group (treatment). Optimal pressure ulcer prevention is defined as regular turning every 2 h with at least 15 min of tissue decompression. All subjects will receive a wearable patient sensor (Leaf Healthcare, Inc., Pleasanton, CA, USA) that will detect patient movement and positioning. This information is relayed through a proprietary mesh network to a central server for display on a user-interface to assist with nursing care. This information is used to guide preventative care practices for those within the treatment group. Patients will be monitored throughout their admission in the intensive care unit. DISCUSSION: We plan to conduct a randomized control trial, which to our knowledge is the first of its kind to use a wearable patient sensor to quantify and establish optimal preventative care practices, in an attempt to determine whether this is effective in reducing hospital-acquired pressure ulcers. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02533726 .

Quasi-experimental study to improve nurses' QT-interval monitoring: results of QTIP study.

BACKGROUND: A collaboration led by the American Heart Association recently released the scientific statement "Prevention of Torsade de Pointes in Hospital Settings." Patients receiving proarrhythmic drugs, who have electrolyte disturbances, or who have bradyarrhythmias require QT-interval monitoring. Prior studies have demonstrated that physicians have a poor level of proficiency at calculating QT intervals. The ability of nurses at calculating QT intervals remains untested. OBJECTIVES: To evaluate nurses' knowledge and ability to perform QT/QTc interval monitoring. METHODS: At a single institution, 47 QT-education classes were provided to 480 eligible nurses who regularly perform cardiac monitoring. All nurses completed a researcher-developed knowledge test at baseline and after the QT-related education intervention. RESULTS: Overall 379 nurses participated (mean age 39 [SD, 10] years), 71% had more than 5 years' nursing experience. Total test scores increased after intervention (46% vs 77%, P < .001). Education significantly improved marking of the QT/RR intervals (QT: 65% vs 91%, RR: 83% vs 90%, P ≤ .001 and P = .02) and measurement of the QT/RR intervals (QT: 47% vs 84%, RR: 35% vs 71% P ≤ .001 and P ≤ .001). Calculation of the QTc interval also increased significantly (6% vs 52%, P ≤ .001). CONCLUSIONS: Our study results demonstrate that nurses' baseline ability to perform QT interval monitoring is extremely poor. An unacceptable amount of error persists after an educational intervention. Accurate computer-assisted methods are needed to reduce the error associated with manual QT-interval monitoring.

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.

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

The Clinical Nurse Leader: impact on practice outcomes in the Veterans Health Administration.

The Clinical Nurse Leader (CNL) role was designed to meet an identified need for expert clinical leadership at the point of care. The Veterans Health Administration (VHA) became early adopters of the CNL role, foreseeing the value of this pivotal clinical leader at the point of care to meet the complex health care needs of America's veterans and shape health care delivery. Impact data were collected and assimilated from seven Veterans Administration Medical Centers to support how CNLs impact the delivery of quality and safe patient care and how practice changes could be sustained. Data collection and analyses resulted in many lessons learned. The new CNL role was implemented in a variety of settings in the VHA system. Integration of the CNL role in all areas of practice in every care setting has the promise of streamlining coordination of care for veterans across all spectrums in the provision of care.

Implantable left ventricular assist devices.

The first bridge to transplant with a left ventricular assist device (LVAD) was preformed over 20 years ago. Since that time, the devices have continued to evolve and now patients are being supported with devices as an alternative to transplantation. The primary indication of end-stage heart failure remains the same but increased knowledge about patient selection, the timing of implant, and patient management have contributed to improved outcomes with decreasing adverse events. Multiorgan failure, right ventricular failure, bleeding, infection, thromboembolism, and device malfunction continue to be the most serious threats to long-term survival in these patients. Despite that, patients who do well are now able to be discharged from the hospital and resume relatively normal lives with the devices. The article reviews 3 of the most widely used LVADs for bridge to transplant therapy: the Thoratec; HeartMate vented electric; and the Novacor Left Ventricular Assist System. Indications, mechanism of operation, clinical problems, and out-of-hospital preparation are outlined.