Association of Implementation of Practice Standards for Electrocardiographic Monitoring With Nurses' Knowledge, Quality of Care, and Patient Outcomes: Findings From the Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial.

BACKGROUND: Although continuous electrocardiographic (ECG) monitoring is ubiquitous in hospitals, monitoring practices are inconsistent. We evaluated implementation of American Heart Association practice standards for ECG monitoring on nurses' knowledge, quality of care, and patient outcomes. METHODS AND RESULTS: The PULSE (Practical Use of the Latest Standards of Electrocardiography) Trial was a 6-year multisite randomized clinical trial with crossover that took place in 65 cardiac units in 17 hospitals. We measured outcomes at baseline, time 2 after group 1 hospitals received the intervention, and time 3 after group 2 hospitals received the intervention. Measurement periods were 15 months apart. The 2-part intervention consisted of an online ECG monitoring education program and strategies to implement and sustain change in practice. Nurses' knowledge (N=3013 nurses) was measured by a validated 20-item online test, quality of care related to ECG monitoring (N=4587 patients) by on-site observation, and patient outcomes (mortality, in-hospital myocardial infarction, and not surviving a cardiac arrest; N=95 884 hospital admissions) by review of administrative, laboratory, and medical record data. Nurses' knowledge improved significantly immediately after the intervention in both groups but was not sustained 15 months later. For most measures of quality of care (accurate electrode placement, accurate rhythm interpretation, appropriate monitoring, and ST-segment monitoring when indicated), the intervention was associated with significant improvement, which was sustained 15 months later. Of the 3 patient outcomes, only in-hospital myocardial infarction declined significantly after the intervention and was sustained. CONCLUSIONS: Online ECG monitoring education and strategies to change practice can lead to improved nurses' knowledge, quality of care, and patient outcomes. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01269736.

El Holter toma protagonismo ante la indicación definitiva de estimulación cardíaca / Holter takes cente stage into final indication of cardiac stimulation

El estudio se realiza con miras a obtener datos concretos que confirmen la influencia en el diagnóstico de muchas patologías cardiacas detectadas por el Holter de frecuencia cardiaca. El Holter de frecuencia cardiaca de 24 horas es un dispositivo electrónico, de pequeño tamaño, que registra y almacena un trazado electrocardiográfico de dos o tres derivaciones, mientras el paciente realiza sus actividades de la vida cotidiana. La causa de esta investigación es el aumento de solicitudes en nuestro hospital y los numerosos informes que han ayudado en el diagnóstico de nuestros pacientes. El estudio se fundamenta en datos estadísticos. Se han fabricado dos bases de datos, una que recoge el total de estudios que se realizaron en 2013 y otra con los pacientes diagnosticados con necesidad de estimulación cardiaca y que se remiten a ello. Al cruzar estas dos bases de datos se obtiene una tercera con los pacientes enviados a estimulación cardiaca con Holter de frecuencia cardiaca realizado. Podemos con estos datos afirmar que, cuando se solicita esta prueba, tiene una gran influencia en el diagnóstico final (el 87 %) y existe una probabilidad alta de encontrar hallazgos significativos, sin olvidarnos de la clínica y con los aspectos personales de cada paciente (AU)

The study was performed in order to obtain specific data confirming the influence in the diagnosis of many cardiac pathologies detected by Holter heart rate. Holter heart rate of 24 hours is an electronic device, of small size, which records and stores an electrocardiographic tracing two or three leads, while the patient activities of daily life. It leads us to conduct this study increased requests we’ve had in our hospital and the numerous reports that have helped in the diagnosis of our patients. We base the study with statistical data, therefore, produce two databases, one that reflects the total of studies conducted in 2013 and another with patients diagnosed with cardiac stimulation and need to refer to it. Crossing these two databases get third with patients referred for cardiac stimulation Holter heart rate realized. With these data we can say that, when this test is requested, it has a great influence on the final diagnosis (87%) and there is a high probability of finding significant findings, without forgetting the clinical and personal aspects of each patient (AU)

QT longo desmascarado pela flouxetina / Long QT unmasked by fluoxetine

A síndrome do QT longo induzida por fármacos é uma condição potencialmente fatal, capaz decausar morte súbita como primeira manifestação clínica. Relatamos o caso de paciente jovem que evoluiu comparada cardiorrespiratória em fibrilação ventricular durante internação hospitalar, 24 horas após nefrolitotripsiaextracorpórea. Durante a avaliação foi observado intervalo QT corrigido aumentado de 580 ms e uso de fórmulapara emagrecer que continha fluoxetina 30 mg. Após suspensão da medicação houve normalização do QT,optando-se pelo uso de cardiodesfibrilador implantável pelo alto risco de recorrência da fibrilação ventricular.A síndrome do QT longo pode se manifestar após o uso de fármacos para o tratamento de outras afecções,ressaltando a importância da anamnese rigorosa em busca de antecedentes de morte súbita, assim como darealização de eletrocardiografia antes da introdução de fármacos específicos, de forma a identificar possíveis casosassintomáticos de síndrome do QT longo.

Drug-induced long QT syndrome is a potentially fatal condition that can cause sudden death as a firstclinical manifestation. We report the case of a young patient evolved with cardiorespiratory arrest in ventricularfibrillation during hospitalization, 24 hours after extracorporeal nephrolithotripsy. The patient had an increasedcorrected QT interval of 580 ms and was on weight loss medication containing fluoxetine 30 mg. The QT intervalnormalized after withdrawal of the medication and we chose to use an implantable cardioverter defibrillator dueto the high risk of reoccurrence of ventricular fibrillation. Long QT syndrome may manifest after drug therapyfor other diseases, highlighting the importance of obtaining a through family history of sudden death as well asan ECG before using specific drugs, to identify possible asymptomatic cases of long QT syndrome.

Teste ergométrico em portadores de dispositivos cardíacos eletrônicos implantáveis / Exercise testing in patients with cardiac implantable electronic devices

O número de pacientes com dispositivos eletrônicos vem crescendo substancialmente nos últimos anos. Marca-passos com inúmeras programações e desfibriladores com ou sem ressincronizadores, cada vez mais comuns, apresentam-se com traçados eletrocardiográficos confundidores. Assim, é necessária a compreensão de princípios básicos e técnicos pelos clínicos, além da integração entre estes e os eletrofisiologistas. O conhecimento de tais princípios básicos é fundamental na condução desses pacientes, de modo que o ergometrista deve estar ciente do tipo de dispositivo, programação, frequência mínima e máxima de comando, presença de desfibrilador, bem como suas frequências de terapias e desfibrilação. Assim, promover-se-á maior segurança durante provas funcionais (teste ergométrico e ergoespirométrico) e programas de treinamento físico. Este artigo de revisão tem por objetivo descrever diversos pontos de interesse na realização do teste ergométrico em portadores de dispositivos eletrônicos.

The number of patients fitted with cardiac implantable electronic devices has grown substantially over the past few years. Pacemakers with countless programming options and defibrillators with or without resynchronization devices are increasingly more common, with confusing electrocardiographic findings. Consequently, general practitioners must understand their basic principles and techniques, in addition to developing stronger links with electrophysiologists. Knowledge of these basic principles is crucial for managing these patients, meaning that people administering ergometric testing must be aware of the type of device and its programming, minimum and maximum command frequency and defibrillator, as well as its treatment and defibrillation frequencies. This will ensure greater safety during ergometric and ergospyrometric exercise testing and exercise programs. This paper describes several points of interest in ergometric testing for patients fitted with cardiac implantable electronic devices.

Telemetry heightens nurses' vigilance, patients' mobility.

Telemetry monitoring yields better workflow and enhanced productivity.

Looking for clues. A discussion of cardiac event recorders in home healthcare practice.

Home healthcare nurses have a unique opportunity to observe patients closely as they go about their activities of daily living within their own environment. But nurses must be alert to assess for all signs and symptoms and not ignore those that do not relate solely to the primary diagnosis care.

Frequency of silent myocardial ischemia with 12-lead ST segment monitoring in the coronary care unit: are there sex-related differences?

BACKGROUND: Ischemia that occurs in the coronary care unit (CCU), whether symptomatic or silent, is associated with significant in-hospital and out-of-hospital complications. Studies have reported that more than 90% of ischemic episodes are silent in patients with unstable angina who are treated in the CCU with maximal medical therapy. Prior reports indicate that women complained more frequently of chest pain than men did. PURPOSE: The aim of this study was to compare the frequency of silent myocardial ischemia in men versus women with use of continuous 12-lead ST segment monitoring in the CCU. A secondary goal was to determine whether silent ischemia was associated with less ST segment deviation as compared with symptomatic ischemia. METHOD: Patients admitted for treatment of acute coronary syndrome in the CCU and who subsequently had 1 or more ischemic events during their monitoring period were selected for this analysis. All patients were continuously monitored (42.5 hours +/- 37.6) in the CCU with the EASI (Zymed Medical Instruments, Camarillo, Calif) 12-lead electrocardiogram (ECG) system that derives 12 leads with use of 3 information channels and 5 electrodes. RESULTS: Of 491 patients, 128 (91 men and 37 women) had at least 1 episode of transient myocardial ischemia. Men and women did not differ in their proportion of chest pain during ischemia (men 27% and women 21%, NS). For both men and women, ST segment deviation was significantly greater during symptomatic ischemia compared with silent ischemia. CONCLUSION: There are no sex-related differences in ischemic events in the CCU in regards to the variables of chest pain and ST magnitude. Therefore, because chest pain is not a reliable indicator of myocardial ischemia in the CCU, regardless of sex, patients should be adequately monitored for ischemic events.

Ambulatory blood pressure monitors.

ABPM automatically records blood pressure at preset intervals over a 24-hour period. By establishing average blood pressure, cases of white-coat hypertension and borderline hypertension can be identified. The use of ABPM is likely to increase in the near future, therefore it is important that nurses become more aware of the technique.