RESUMO
BACKGROUND: Recently, our institution adopted a weight-based nurse-driven heparin titration protocol that relies on nurses ordering laboratories, adjusting doses, and initiating boluses. Numerous institutions have implemented similar protocols with reported success. METHODS: A single-center retrospective analysis was conducted at the Brigham and Women's Hospital in Boston, Massachusetts that included all patients who were initiated on the weight-based nurse-driven heparin nomogram during a 30-day period. Nomogram compliance was defined as the rate of correct titrations per nomogram encounter and further separated into laboratory, titration, or dosing compliance. Spearman's coefficient was utilized to determine the correlation between noncompliance and percentage of activated partial thromboplastin time (aPTT) values in range. RESULTS: Overall, 211 patients were evaluated for inclusion, of which 95 patients were determined to meet criteria for evaluation. The total nomogram compliance rate was 84.6% ± 10.5%. Laboratory, titration, and dosing compliances were 77.6% ± 19.2%, 87.2% ± 14.5%, and 91.8% ± 10.6%, respectively. The percent of aPTT values in therapeutic range was 39.6% ± 24.6%. A moderate negative correlation between the percentage of aPTT values in range and the nomogram error rate was observed (r = -0.452, P < 0.001). This relationship was found to be driven by the rate of dosing error, which showed the strongest correlation with percentage of aPTT values out of range (r = -0.465, P = 0.001). CONCLUSIONS: Implementation of a nurse-driven heparin titration nomogram relies on compliance with the prescribed protocol. Dosing compliance had the lowest error rate, whereas dosing noncompliance had the strongest impact on percentage of aPTT values in range.
Assuntos
Anticoagulantes/administração & dosagem , Peso Corporal , Fidelidade a Diretrizes/estatística & dados numéricos , Heparina/administração & dosagem , Nomogramas , Enfermeiras e Enfermeiros , Centros Médicos Acadêmicos , Síndrome Coronariana Aguda/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Papel do Profissional de Enfermagem , Tempo de Tromboplastina Parcial , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Centros de Atenção Terciária , Tromboembolia Venosa/tratamento farmacológicoRESUMO
Weight-based, nurse-driven heparin nomograms are reported in the medical literature to improve the time it takes to reach a minimum threshold for anticoagulation without compromising patient safety in specific indications or patient populations. This is the first report in the literature of an institution-wide protocol implementation and evaluation of effectiveness with simultaneous transition to an electronic health record. The purpose of implementing this practice change at our institution was to standardize practice, improve time to reach therapeutic anticoagulation, and improve patient safety. We conducted a retrospective analysis utilizing a pre/postimplementation design to compare outcomes. The primary end point evaluated was the time to reach minimum threshold value for therapeutic anticoagulation. Additionally, we assessed the percentage of patients who reached minimum threshold therapeutic anticoagulation within 24 hours, the percentage of patients with a critically supratherapeutic activated partial thromboplastin time (aPTT) value (≥120 seconds) during therapy, and a description of heparin titration for the first 4 aPTT results with nomogram use. Overall time to therapeutic anticoagulation decreased from a mean 18.7 to 11.7 hours (hazard ratio [HR] 1.59; 95% confidence interval 1.22-2.08; P < .0005). Percentage of patients receiving therapeutic anticoagulation within 24 hours increased from 74.4 to 88.5 (odds ratio [OR 2.97, P = .002) and the percentage of patients with an aPTT ≥120 seconds remained constant at 49.9 versus 46.8 (OR 0.92, P = .73). This practice change reduced time to therapeutic anticoagulation without an increase in the proportion of patients with a critically supratherapeutic aPTT at our institution.
Assuntos
Centros Médicos Acadêmicos/métodos , Heparina/uso terapêutico , Nomogramas , Tempo de Tromboplastina Parcial , Idoso , Anticoagulantes/farmacocinética , Feminino , Heparina/farmacocinética , Humanos , Masculino , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Estudos Retrospectivos , Centros de Atenção TerciáriaRESUMO
Clinical outcomes in acute myocardial infarction (AMI) worsen with increasing delay between symptom onset and clinical presentation. Previous studies have shown that black patients with AMI have longer presentation delays. The objective of this analysis is to explore the potential contribution of community factors to presentation delays in black patients with AMI. We linked clinical data for 346,499 consecutive patients with AMI from Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines™ (2007-2014) to socioeconomic and community information from the American Community Survey. Black patients with AMI had longer symptom onset to first medical contact times than white patients (114 vs 101 minutes, p <0.0001) regardless of ambulance versus self-transport. Compared with white patients, black patients were younger and more likely to have clinical co-morbidities such as hypertension, diabetes, previous heart failure, and stroke. They were also more likely to live in urban communities with lower socioeconomic status, lower rates of long-term residence, and higher proportion of single-person households than white patients. In sequential linear regression models adjusting for patient demographic and clinical characteristics, logistic barriers to prompt presentation, and community socioeconomic and composition factors, black patients had a persistent 9% greater time from symptom onset to presentation compared with white patients (95% CI 8% to 11%, p <0.0001). In conclusion, the longer delay in time to presentation in black patients with AMI compared with white patients persists after accounting for a number of both patient and community factors.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Infarto do Miocárdio/epidemiologia , Tempo para o Tratamento , População Branca/estatística & dados numéricos , Distribuição por Idade , Idoso , Comorbidade , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Revascularização Miocárdica/estatística & dados numéricos , Sistema de Registros , Pessoa Solteira/estatística & dados numéricos , Classe Social , Terapia Trombolítica/estatística & dados numéricos , Troponina/sangue , Estados Unidos/epidemiologia , População UrbanaRESUMO
BACKGROUND: We explored the risks/benefits of revascularization versus medical management in syncope patients with obstructive coronary artery disease (CAD). METHODS: We retrospectively examined Medicare patients ≥65 years undergoing percutaneous coronary intervention (PCI) for syncope at 539 CathPCI Registry hospitals with ≥70% stenosis in at least 1 coronary artery, excluding those with ST-segment elevation myocardial infarction (MI), cardiogenic shock, left main disease, and coronary artery bypass grafting. In a propensity-matched population, we compared short-term (90-day) all-cause readmission risk and long-term (3-year) risks of readmission for syncope and MI, as well as mortality in those receiving PCI versus medical management. RESULTS: Among 14,674 syncope patients, 9,549 (65%) had at least 1-vessel obstructive CAD. After exclusions, 3,196 of 7,338 patients (44%) underwent PCI. In the propensity-matched cohort, there was no significant difference in 90-day all-cause readmission risk (28.2% vs 30.3%, adjusted hazard ratio [HR] 0.92, 95% CI 0.83-1.02) or long-term risks of readmission for syncope (7.0% vs 6.1%, adjusted HR 1.06, 95% CI 0.83-1.35). PCI-treated patients had significantly higher risk of readmission for MI (5.6% vs 4.0%, adjusted HR 1.56, 95% CI 1.18-2.06) but lower risk of long-term mortality (27.0% vs 30.3%, adjusted HR 0.86, 95% CI 0.77-0.97) than medically managed patients. CONCLUSIONS: In patients presenting with syncope and obstructive CAD, PCI was not associated with significant improvements in the risk of readmission but was associated with lower long-term mortality compared with medical therapy, suggesting the need to more definitively assess the benefit of PCI among elderly syncope patients.
Assuntos
Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Síncope , Idoso , Fármacos Cardiovasculares/uso terapêutico , Angiografia Coronária/métodos , Angiografia Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Readmissão do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Síncope/diagnóstico , Síncope/epidemiologia , Síncope/etiologia , Síncope/terapia , Estados Unidos/epidemiologiaAssuntos
Hipotireoidismo/diagnóstico , Rim/patologia , Nefrose Lipoide/diagnóstico , Tiroxina/urina , Diagnóstico Diferencial , Edema/etiologia , Humanos , Hiponatremia/etiologia , Hipotireoidismo/etiologia , Perna (Membro) , Linfoma Folicular , Masculino , Pessoa de Meia-Idade , Nefrose Lipoide/complicações , Neoplasias da Glândula Tireoide , Tireotropina/sangue , Tiroxina/sangueAssuntos
Blastomyces/isolamento & purificação , Blastomicose/patologia , Pulmão/patologia , Nariz/microbiologia , Nariz/patologia , Idoso , Antígenos de Fungos/urina , Asma/complicações , Asma/diagnóstico , Blastomyces/imunologia , Blastomicose/complicações , Carcinoma de Células Escamosas/patologia , Diagnóstico Tardio , Diagnóstico Diferencial , Dispneia/etiologia , Glucocorticoides/uso terapêutico , Humanos , Pulmão/diagnóstico por imagem , Masculino , Neoplasias Nasais/patologia , Embolia Pulmonar/diagnóstico por imagem , Radiografia , Trombose Venosa/complicaçõesAssuntos
Sangue/parasitologia , Febre/etiologia , Malária Vivax/diagnóstico , Plasmodium vivax/isolamento & purificação , Adulto , Antimaláricos/uso terapêutico , Cloroquina/uso terapêutico , Ritmo Circadiano , Diagnóstico Diferencial , Humanos , Malária Vivax/complicações , Malária Vivax/tratamento farmacológico , Masculino , Parasitemia , ViagemAssuntos
Estenose da Valva Mitral/diagnóstico por imagem , Complicações na Gravidez/diagnóstico , Síndrome do Desconforto Respiratório/etiologia , Cardiopatia Reumática/diagnóstico por imagem , Adulto , Alcalose Respiratória , Valvuloplastia com Balão , Diagnóstico Diferencial , Eletrocardiografia , Feminino , Humanos , Pulmão/diagnóstico por imagem , Estenose da Valva Mitral/complicações , Estenose da Valva Mitral/terapia , Gravidez , Complicações na Gravidez/terapia , Edema Pulmonar/etiologia , Radiografia , Cardiopatia Reumática/complicações , Cardiopatia Reumática/terapia , Taquicardia/diagnóstico , Taquicardia/etiologia , UltrassonografiaAssuntos
Adenocarcinoma/diagnóstico , Neoplasias Gástricas/diagnóstico , Tromboflebite/diagnóstico , Adenocarcinoma/complicações , Adenocarcinoma/patologia , Vesícula , Diagnóstico Diferencial , Edema/etiologia , Insuficiência Cardíaca/complicações , Humanos , Coeficiente Internacional Normatizado , Isquemia/diagnóstico , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Estômago/patologia , Neoplasias Gástricas/complicações , Neoplasias Gástricas/patologia , Trombofilia/etiologia , Tromboflebite/etiologia , Trombose Venosa/diagnósticoAssuntos
Dor Abdominal/etiologia , Hipertensão/etiologia , Infarto/diagnóstico , Rim/irrigação sanguínea , Poliarterite Nodosa/diagnóstico , Adulto , Sedimentação Sanguínea , Diagnóstico Diferencial , Humanos , Infarto/etiologia , Rim/diagnóstico por imagem , Rim/patologia , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Poliarterite Nodosa/complicações , RadiografiaRESUMO
BACKGROUND: Current practice guidelines advocate delaying assessment of primary prevention implantable cardioverter/defibrillator (ICD) candidacy at least 40 days after an acute myocardial infarction (AMI) because early ICD implantation after AMI has not demonstrated survival benefit. The rate at which interval reassessment of left ventricular ejection fraction (LVEF) occurs in potential primary prevention ICD candidates is unknown. METHODS: We examined patients with AMI in the TRIUMPH registry with inhospital LVEF <40% discharged alive after their index presentation, excluding patients with a prior ICD and those who declined ICD during the index admission or were discharged to hospice. We conducted multivariable Poisson modeling to identify independent factors associated with LVEF reassessment by 6 months after AMI. RESULTS: Of the 533 patients meeting the inclusion criteria, only 187 (35.1%) reported LVEF reassessment in the first 6 months after AMI and only 13 patients (2.4%) underwent ICD implantation by 1 year. In multivariable analysis, early cardiology follow-up after AMI was associated with a higher likelihood of LVEF reassessment (odds ratio 1.16, 95% confidence interval 1.06-1.28), whereas uninsured status and cardiologist-driving inpatient medical decision making were associated with a lower likelihood of LVEF reassessment (odds ratios 0.84 [95% CI 0.74-0.96] and 0.78 [95% CI 0.68-0.91], respectively). CONCLUSIONS: In contemporary practice, almost 2 of 3 potential primary prevention ICD candidates did not report follow-up LVEF evaluation, with a very low rate of ICD implantation at 1 year. These results suggest an important gap in quality, highlighting the need for better transitions of care.
Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Infarto do Miocárdio/complicações , Prevenção Primária/métodos , Sistema de Registros , Medição de Risco , Volume Sistólico/fisiologia , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/etiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Razão de Chances , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Pesquisa Translacional Biomédica/métodos , Resultado do Tratamento , Estados Unidos/epidemiologiaAssuntos
Cardiomiopatia Chagásica/diagnóstico , Síncope/etiologia , Taquicardia Ventricular/diagnóstico , Trypanosoma cruzi , Bloqueio de Ramo/diagnóstico , Cardiomiopatia Chagásica/complicações , Diagnóstico Diferencial , Eletrocardiografia , Humanos , Masculino , Tomografia por Emissão de Pósitrons , Taquicardia Ventricular/complicaçõesAssuntos
Artralgia/etiologia , Febre Reumática/diagnóstico , Streptococcus pyogenes , Doença Aguda , Adulto , Antiestreptolisina/sangue , Diagnóstico Diferencial , Ecocardiografia , Fadiga/etiologia , Feminino , Febre/etiologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etiologia , Humanos , Contagem de Leucócitos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/etiologia , Estenose da Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/etiologia , Edema Pulmonar/diagnóstico , Edema Pulmonar/etiologia , Febre Reumática/complicaçõesAssuntos
Transtornos Neurológicos da Marcha/etiologia , Hepatite B/complicações , Nervo Fibular/patologia , Poliarterite Nodosa/diagnóstico , Idoso , Ponte de Artéria Coronária , Febre/etiologia , Antígenos do Núcleo do Vírus da Hepatite B/imunologia , Humanos , Masculino , Debilidade Muscular/etiologia , Condução Nervosa , Dor/etiologia , Poliarterite Nodosa/complicaçõesAssuntos
Fibrilação Atrial/etiologia , Cardiomegalia/diagnóstico por imagem , Doença de Fabry/diagnóstico , alfa-Galactosidase/genética , Amiodarona/uso terapêutico , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Cardiomegalia/complicações , Cardiomegalia/genética , Códon sem Sentido , Ecocardiografia Doppler , Eletrocardiografia , Doença de Fabry/complicações , Doença de Fabry/genética , Humanos , Hipertensão/complicações , Transplante de Rim , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/cirurgia , Vômito/etiologiaRESUMO
Management strategies for ventricular arrhythmias are guided by the risk of sudden death and severity of symptoms. Patients with a substantial risk of sudden death usually need an implantable cardioverter defibrillator (ICD). Although ICDs effectively end most episodes of ventricular tachycardia or ventricular fibrillation and decrease mortality in specific populations of patients, they have inherent risks and limitations. Generally, antiarrhythmic drugs do not provide sufficient protection from sudden death, but do have a role in reducing arrhythmias that cause symptoms. Catheter ablation is likewise important for reducing the frequency of spontaneous arrhythmias and is curative for some patients, usually those with idiopathic arrhythmias and no heart disease. Arrhythmia surgery is now infrequent, offered by only a few specialised centres for refractory arrhythmias. Advances in understanding of genetic arrhythmia syndromes and in technology for mapping and ablation of ventricular arrhythmias, and enhanced algorithms in implantable devices for rhythm management, have contributed to improved outcomes.
Assuntos
Morte Súbita Cardíaca/etiologia , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia , Displasia Arritmogênica Ventricular Direita/genética , Displasia Arritmogênica Ventricular Direita/fisiopatologia , Displasia Arritmogênica Ventricular Direita/terapia , Síndrome de Brugada/fisiopatologia , Síndrome de Brugada/terapia , Reanimação Cardiopulmonar , Ablação por Cateter , Desfibriladores Implantáveis , Eletrocardiografia , Humanos , Síndrome do QT Longo/fisiopatologia , Síndrome do QT Longo/terapia , Taquicardia Ventricular/complicações , Taquicardia Ventricular/genética , Taquicardia Ventricular/fisiopatologia , Fibrilação Ventricular/complicações , Fibrilação Ventricular/genética , Fibrilação Ventricular/fisiopatologiaRESUMO
BACKGROUND: The left ventricular ejection fraction (LVEF) has prognostic and therapeutic utility after acute myocardial infarction (AMI). Although LVEF assessment is a key performance measure among AMI patients, contemporary rates of in-hospital assessment and its association with therapy use have not been well characterized. METHODS AND RESULTS: We examined rates of in-hospital LVEF assessment among 77 982 non-ST-elevation myocardial infarction patients and 50 863 ST-elevation myocardial infarction patients in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines between January 2007 and September 2009, after excluding patients who died in-hospital or who were transferred to another acute care facility, discharged to end-of-life care, or had missing LVEF assessment status. LVEF assessment increased significantly over time, with higher rates among ST-elevation myocardial infarction than non-ST-elevation myocardial infarction patients (95.1% versus 91.6%; P<0.001). Excluding patients with prior heart failure did not alter these observations. Significant interhospital variability in LVEF assessment rates was observed. Compared with patients with in-hospital LVEF assessment, patients who did not have LVEF assessed were older and more likely to have clinical comorbidities. In multivariable modeling, lower overall hospital quality of AMI care was also associated with lower likelihood of LVEF assessment (odds ratio for failure to assess LVEF, 1.09; 95% confidence interval, 1.05-1.13 per 10% decrease in defect-free care). Patients with in-hospital LVEF assessment were more likely to be discharged on evidence-based secondary prevention medication therapies compared with patients without LVEF assessment. CONCLUSIONS: The assessment of LVEF among patients with AMI has improved significantly over time, yet significant interhospital variability exists. Patients who did not have in-hospital LVEF assessment were less likely to receive evidence-based medications at discharge. These patients represent targets for future quality improvement efforts.