Using the Zwolle Risk Score at Time of Coronary Angiography to Triage Patients With ST-Elevation Myocardial Infarction Following Primary Percutaneous Coronary Intervention or Thrombolysis.

Background The Zwolle Risk Score was designed to identify the risk of complications in patients with ST-segment‒elevation myocardial infarction (STEMI) following percutaneous coronary intervention (PCI). Its utility following PCI in STEMI treated with thrombolysis is unknown. The objective was to evaluate the safety of using the Zwolle Risk Score to triage patients with STEMI following PCI, including patients receiving thrombolysis. Methods and Results Patients aged ≥18 years with STEMI and primary PCI or PCI after thrombolysis were included. A triage protocol was developed, with high-risk patients those with Zwolle Risk Score ≥4 triaged to the cardiac intensive care unit. A prospective evaluation of the triaging protocol was performed on 452 patients, mean age 65±12 years, 73% men. Median Zwolle Risk Score was 3 (interquartile range, 2‒5), with 257 low-risk (57%), and 195 high-risk (43%) patients. Adherence to the protocol was 91%. In-hospital mortality was 0.4% in low-risk and 13% in high-risk patients (P<0.001). Seventy-two patients (16%) received thrombolysis. Median time post-thrombolysis to PCI was 281 minutes (interquartile range, 219‒376). In-hospital mortality was 0% versus 9% (P=0.083) for low- and high-risk patients, respectively. High-risk patients had higher rates of cardiogenic shock (34% versus 1%, P<0.001), pulmonary edema (60% versus 9%, P<0.001), arrhythmia (25% versus 2%, P<0.001), blood transfusion (10% versus 2%, P<0.001), and stroke (4% versus 0.4%, P=0.011). Median hospital costs decreased by $1419 per low-risk patient after protocol implementation. Conclusions For patients with STEMI following primary PCI or PCI following thrombolysis, a Zwolle-based triaging system is safe and may decrease cardiac intensive care unit usage costs.

Using the Donabedian framework to examine transitional care for cardiac patients and family caregivers.

PURPOSE: This study aims to examine how health-care managers in acute care and post-acute care facilities support and plan to improve transitional care for cardiac patients and their family caregivers, to better manage care in the home. DESIGN/METHODOLOGY/APPROACH: A qualitative descriptive approach, guided by appreciative inquiry was used in this study. A purposive sample of 16 participants were engaged in the study. Participants completed a demographic questionnaire, the caregiver policy lens questionnaire and participated in one of four focus group interviews. The semi-structured focus group interviews were audio-recorded and analyzed using thematic analysis. FINDINGS: Using Donabedian's framework, six major themes contributed to how health-care managers can improve transitional care: structure included supporting personnel and continuing education; process included enacting approaches of care, coordinating care among the health-care team and calling to work upstream; and outcomes included needing to clarify expectations of home care services and witnessing the impact of the caregiver role. ORIGINALITY/VALUE: These findings demonstrate the importance of Donabedian's core dimensions of structure and processes in influencing caregiver outcomes. These results emphasize the central role of the manager in influencing system change to improve transitional care.

Examining Patient Outcome Quality Indicators Based on Wait Time From Referral to Entry Into Cardiac Rehabilitation: A PILOT OBSERVATIONAL STUDY.

PURPOSE: The purpose of this study was to examine whether meeting the Canadian Cardiovascular Society (CCS) ≤60-day wait time from cardiac rehabilitation (CR) referral to enrollment is associated with CCS patient-level quality indicator outcomes. METHODS: This pilot observational study consisted of 69 participants entering CR separated into 2 groups based on wait time (≤60-day, n = 45; >60-day, n = 24). Data were collected at baseline, and 1, 4 (CR completion), 6, and 12 months after baseline. Quality indicators for achieving a 0.5 peak metabolic equivalent (MET) improvement at CR completion, physical activity of 150 min/wk of moderate-vigorous physical activity, and CR adherence were assessed. Depressive symptoms were assessed with the Patient Health Questionnaire. RESULTS: Sixty participants completed the study (≤60-day, n = 40; >60-day, n = 20). In the ≤60-day group, 92% of participants achieved the 0.5 MET improvement upon CR completion; whereas 60% of the >60-day group met this criteria (P ≤ .05). For the 150 min/wk of moderate-vigorous physical activity and CR adherence, both groups were not significantly different at any time. Elevated depressive symptoms were initially observed in 45% of participants in the ≤60-day group and 35% in the >60-day group (NS) and decreased to 8% in the ≤60-day group compared with 30% in the >60-day group at 12 months (P ≤ .05). CONCLUSIONS: Meeting the CCS 60-day acceptable wait time is associated with improvements in METs and depressive symptoms, but not with physical activity or CR adherence. A larger observational study is warranted to explore patient-level CCS quality indicators during and after CR.

Protocol for the PREHAB study-Pre-operative Rehabilitation for reduction of Hospitalization After coronary Bypass and valvular surgery: a randomised controlled trial.

INTRODUCTION: Frailty is a geriatric syndrome characterised by reductions in muscle mass, strength, endurance and activity level. The frailty syndrome, prevalent in 25-50% of patients undergoing cardiac surgery, is associated with increased rates of mortality and major morbidity as well as function decline postoperatively. This trial will compare a preoperative, interdisciplinary exercise and health promotion intervention to current standard of care (StanC) for elective coronary artery bypass and valvular surgery patients for the purpose of determining if the intervention improves 3-month and 12-month clinical outcomes among a population of frail patients waiting for elective cardiac surgery. METHODS AND ANALYSIS: This is a multicentre, randomised, open end point, controlled trial using assessor blinding and intent-to-treat analysis. Two-hundred and forty-four elective cardiac surgical patients will be recruited and randomised to receive either StanC or StanC plus an 8-week exercise and education intervention at a certified medical fitness facility. Patients will attend two weekly sessions and aerobic exercise will be prescribed at 40-60% of heart rate reserve. Data collection will occur at baseline, 1-2 weeks preoperatively, and at 3 and 12 months postoperatively. The primary outcome of the trial will be the proportion of patients requiring a hospital length of stay greater than 7 days. POTENTIAL IMPACT OF STUDY: The healthcare team is faced with an increasingly complex older adult patient population. As such, this trial aims to provide novel evidence supporting a health intervention to ensure that frail, older adult patients thrive after undergoing cardiac surgery. ETHICS AND DISSEMINATION: Trial results will be published in peer-reviewed journals, and presented at national and international scientific meetings. The University of Manitoba Health Research Ethics Board has approved the study protocol V.1.3, dated 11 August 2014 (H2014:208). TRIAL REGISTRATION NUMBER: The trial has been registered on ClinicalTrials.gov, a registry and results database of privately and publicly funded clinical studies (NCT02219815).

Looking past the heart rhythm: continuous ST-segment monitoring for adults.

Clinical practice guidelines and expert consensus statements are available to guide nursing practice. Research suggests care gaps exist between best practice standards and the clinical reality of day-to-day nursing practice. The purpose of this column is to review the rationale for ST-segment monitoring, indications, preparation and implications for direct patient care.

Clinical nurse specialist practice in evidence-informed multidisciplinary cardiac care.

Care gaps exist in the management of cardiac patients throughout the care continuum. The clinical nurse specialist (CNS) is paramount in the development, implementation, and evaluation of tools to assist care providers in the use of evidence-informed therapies to maximize patient outcomes. The purpose of this article was to describe the CNS practice in terms of these evidence-informed initiatives for defined cardiac populations. Putting evidence into practice is one of the primary responsibilities for the CNS practice. Evidence-informed tools such as clinical pathways have been implemented throughout the healthcare region to reduce care gaps for the acute myocardial infarction and cardiac surgery populations. These tools equip care providers with a standards document, physician order sets, cardiac rehabilitation referral process, care guide, depression screening tool, and patient education material. By incorporating interventions known to reduce avoidable adverse events in the cardiac population into the clinical pathways, patient outcomes have been impacted. Ongoing evaluation of the evidence-informed tools through regular tracking of key indicators has enabled refinement of existing processes and care. It is the CNS practice that ensures not only patient care standards, but also daily routine care are underpinned by scientific evidence. Bridging research with clinical practice remains the stronghold for CNS practice.

Reperfusion times for ST elevation myocardial infarction: a prospective audit.

BACKGROUND: New published guidelines recommend treatment of ST elevation myocardial infarction (STEMI) within 30 minutes of first medical contact to thrombolysis and 90 minutes to primary percutaneous coronary intervention (PCI). OBJECTIVES: To determine how a tertiary care center compares to these new guidelines and to evaluate the success of measures directed to shorten delays. METHODS: This was a prospectively designed audit loop using retrospective chart review. Specific time intervals were evaluated: 1) T2 (ER presentation to diagnostic EKG; 2) T ER (ER presentation to reperfusion); and 3) T AHA (first medical contact to reperfusion). Results of the initial 12-month data were conveyed to Emergency Room staff and a dedicated EKG machine was placed in the ER for the subsequent 12 months, and the results were then re-analyzed. RESULTS: In 2003-4, 58 patients with STEMI were identified, with 41 (70.7%) receiving reperfusion. Of those receiving thrombolysis, median T AHA was 54 [37-72] minutes, with 12.0%<30 minutes, while those receiving PCI, median T AHA was 58 [43-78] minutes, with 25.0%<90 minutes. In 2004-5, 52 patients had STEMI, with 40 (76.9%) receiving reperfusion. The percentage of patients meeting the guidelines was 14.3% for the thrombolysis group and 11.1% for the PCI group. Introduction of a dedicated EKG machine led to a strong trend towards improvement in median T2 (22 vs 10 minutes; P=0.07), but other treatment times remained unchanged. CONCLUSIONS: Treatment times are longer than recommended guidelines. More comprehensive strategies and improved coordination of medical services are required to shorten pre-contact and post-contact response times.

Effects of a tailored lifestyle self-management intervention in patients with type 2 diabetes.

OBJECTIVES: The aim of the present study was to develop, implement and evaluate a brief intervention to improve adherence to the recommended lifestyle changes for patients with Type 2 diabetes, in particular to help patients to reduce the total amount of fat consumed and to increase lifestyle physical activity levels. DESIGN AND METHOD: A brief, tailored lifestyle self-management intervention for patients with Type 2 diabetes was evaluated in a randomized controlled trial. One hundred participants (aged 40 - 70 yrs) completed assessments at three time points- baseline, three months and one year. Participants were allocated to either an intervention group who received the brief tailored intervention including follow-up telephone calls, or a usual care control group. RESULTS: Results indicate that the intervention was successful in helping patients to reduce fat intake and, to a lesser extent, increase lifestyle physical activity levels. These self-reported changes in behaviour were reflected in the objective data with weight maintenance in the intervention group compared to the control group, together with a significant reduction (2 cm) in waist circumference. CONCLUSIONS: These results provide further evidence of the effectiveness of tailored interventions for lifestyle change.