Changes in paced signals may predict in-hospital cardiac arrest.

BACKGROUND: An increasing number of patients with chronic illnesses have implanted cardiac rhythm devices such as pacemakers and implantable cardioverter-defibrillators (ICDs). This study was conducted to identify potentially useful predictors of in-hospital cardiac arrest (I-HCA) within paced electrocardiogram (ECG) signals from cardiovascular patients with implanted medical devices. METHODS: In this retrospective study of 17 subjects, full-disclosure ECG traces prior to the time of documented I-HCA were analyzed to determine R-R intervals and QRS durations (QRSd). RESULTS: Ventricular paced QRSd prolongation was observed prior to I-HCA in 10/16 (63%) subjects. QRSd was significantly greater immediately preceding cardiac arrest than during each of the 8 hours prior to cardiac arrest (P < 0.05). Heart rate changes (measured using standard deviation) within 15 minutes of cardiac arrest were significantly greater in subjects with pulseless electrical activity (PEA)/asystolic arrest compared to those with cardiac arrests due to ventricular tachycardia/ventricular fibrillation (VT/VF) (10.13 vs 3.31; P  =  0.024). Significant differences over the 8 hours preceding cardiac arrest in heart rate (74 vs 86 beats/min; P  =  0.002) and QRS duration (172 ms vs 137 ms; P < 0.001) were observed between subjects with initial rhythms of VT/VF and those with initial rhythms of PEA/asystole. CONCLUSIONS: Patterns of diagnostic ECG features can be extracted from the telemetry data of patients with implanted medical devices prior to adverse events including I-HCA. The detection of these significant changes might have an immediate prognostic impact on the timely treatment of some patients at risk of adverse events.

Effect of morbidity and mortality peer review on nurse accountability and ventilator-associated pneumonia rates.

OBJECTIVE: This program was designed to evaluate the effect of morbidity and mortality peer review conferences (MMPRCs) for ventilator-associated pneumonia (VAP) on nurse accountability and compliance with evidence-based VAP prevention practices. BACKGROUND: Ventilator-associated pneumonia is associated with longer average length of stay (ALOS), greater cost, and increased morbidity and mortality. Traditionally, passive or punitive methods have been used to reduce undesirable outcomes. The MMPRC is not a conventional nursing intervention. METHODS: Each MMPRC included case history, relevant hospital course, diagnostic comorbidities, and compliance with VAP prevention strategies. The preventability of each VAP was determined by RN peers. Ventilator days, VAP bundle compliance, VAP incidence, ICU ALOS, cost, and satisfaction data were collected. RESULTS: Nurse accountability improved significantly (chi(2)= 24.041, P < .001), and VAP incidence was reduced. Data demonstrated satisfaction with the MMPRC. Number of ventilator days and ALOS did not change significantly, although VAP bundle compliance improved from 90.1% to 95.2%. CONCLUSIONS: The nonpunitive MMPRC process was cost-effective and should be considered for other nurse-sensitive indicators to increase nurse accountability and improve outcomes.

The tried, true, and new: a traditional approach to critical care education with a new twist.

The training of a new critical care nurse is not solely the transmission of a determined body of knowledge or skill set. When one begins to consider what actually makes a critical care nurse a critical care nurse, one realizes that the training is much more complex. It involves the teaching of appropriate thought processes, and use of the body of knowledge and/or skill set in application with respect to a specific patient, disease state, or a group of symptoms. Teaching a new critical care nurse to think, talk, act, and respond like a critical care nurse is just as important as sharing knowledge--that is what makes a critical care nurse. This article summarizes one hospital's critical care training program and orientation for new critical care nurses with and without critical care experience. This is done in pursuit of excellence in patient care, by providing a comprehensive and complete, full-service training program. All nurses deserve the very best education and training-our patients demand it.

Innovations in the management of cerebral injury.

During the past decade, brain tissue oxygen monitoring has been studied predominantly in Europe. Cerebral oxygenation monitoring was implemented in many intensive care units and correlations of intracranial pressure, cerebral perfusion pressure, end-tidal carbon dioxide monitoring, fever and partial pressure of brain tissue oxygenation (Pbto2) have been described (Crit Care Nurse. 2003;23[4, pt 1]:17-27). The monitoring of brain tissue oxygen is now being done and researched in the United States. This article will discuss the history of treatment of traumatic brain injury and how treatment interventions are changing with the latest technological advances in monitoring of cerebral oxygen levels and suggested interventions and factors that affect brain tissue oxygenation. It is clear that by understanding the causes of hypoxia and ischemia--along with the interventions to treat them--the critical care team will be better able to prevent low oxygen states in the brain and optimize treatment, thus improving patient outcome.

Traumatic brain injury: a review.

Traumatic brain injury (TBI) is defined as "a blow or jolt to the head ...which can disrupt the function of the brain" (CDC. Traumatic brain injury [TBI]: Topic Home. 2004 [http://www.cdc.gov]). TBI changes the lives of approximately 2 million persons each year in the United States. Rapid diagnosis and treatment are imperative to promote optimum outcomes. The critical care clinician who is able to identify and treat appropriately utilizing best practice guidelines may significantly reduce the morbidity and mortality of TBI. This article describes the classification, mechanism of injury, pathophysiology, and clinical therapeutic management strategies identified as best practice for TBI.

Code gray--an organized approach to inpatient stroke.

This article reviews the need for planning and implementation of an organized emergency response to stroke as a secondary diagnosis. Patients who are admitted to hospitals with a diagnosis other than stroke and experience stroke symptoms warrant immediate identification and rapid intervention. Code Gray is an emergency team response for inpatient stroke. Modeled after the response for Code Blue, this team quickly assesses, obtains further diagnostic studies, and provides appropriate intervention to patients who experience stroke symptoms while being hospitalized for some other diagnosis or problem. This emergency team response provides the ingredients for improved patient outcomes and promotes quality patient care.