A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study

Background

Systematically targeting modifiable risk factors for delirium may reduce its incidence. However, research interventions have not become part of routine clinical practice. Particular approaches to the education of clinical staff may improve their practice and patient outcomes.

Objectives

To evaluate the effectiveness of a multifaceted educational program in preventing delirium in hospitalised older patients and improving staff practice, knowledge and confidence.

Design

A before and after study.

Setting

A 22-bed general medical ward of a district hospital in Sydney, Australia.

Participants

Patients were aged 65 years and over and not delirious upon admission. Of 568 eligible patients, 129 were recruited pre-intervention (3 withdrew initial consent) and 129 patients post-intervention.

Methods

Prior to the intervention, in order to establish a baseline, patients were assessed early after admission and again at discharge. The intervention was a one-hour lecture on delirium focusing on prevention for medical and nursing staff followed by weekly interactive tutorials with delirium resource staff and ward modifications. Following the initial education session, data were gathered in a second group of medical ward patients at the same time-points to ascertain the effectiveness of the intervention. Pre and post-intervention data were analysed to determine change in staff objective knowledge and self-ratings of confidence and clinical practice in relation to delirium. The main outcome measures were incident delirium and change in staff practice, confidence and knowledge.

Results

The mean age of patients was 81. The pre and post-intervention groups were comparable, aside from greater co morbidity in the pre-intervention group (F(1, 253) = 9.20, p = 0.003). Post-intervention there was a significant reduction in incident delirium (19% vs. 10.1%, X² = 4.14, p = 0.042), and improved function on discharge (mean improvement 5.3 points, p < 0.001, SD 13.31, 95% CI −7.61 to −2.97). Staff objective knowledge of delirium improved post-intervention and their confidence assessing and managing delirious patients. Staff addressed more risk factors for delirium post-intervention (8.1 vs. 9.8, F(1, 253) = 73.44, p < 0.001).

Conclusions

A low-cost educational intervention reduced the incidence of delirium and improved function in older medical patients and staff knowledge and practice addressing risk factors for delirium. The program is readily transferable to other settings, but requires replication due to limitations of the before and after design.     

Factors associated with delayed activation of medical emergency team and excess mortality: An Utstein-style analysis

Aim

We used the Utstein template, with special reference to patients having automated patient monitoring, and studied the factors which are associated with delayed medical emergency team (MET) activation and increased hospital mortality.

Design and setting

A prospective observational study in a tertiary hospital with 45 of 769 general ward beds (5.9%) equipped with automated monitoring.

Cohort

569 MET reviews for 458 patients.

Results

Basic MET review characteristics were comparable to literature. We found that 41% of the reviews concerned monitored ward patients. These patients’ vitals had been more frequently documented during the 6 h period preceding MET activation compared to patients in normal ward areas (96% vs. 74%, p < 0.001), but even when adjusted to the documentation frequency of vitals, afferent limb failure (ALF) occurred more often among monitored ward patients (81% vs. 53%, p < 0.001). In MET population, factors associated with increased hospital mortality were non-elective hospital admission (OR 6.25, 95% CI 2.77–14.11), not-for-resuscitation order (3.34, 1.78–6.35), ICD XIV genitourinary diseases (2.42, 1.16–5.06), ICD II neoplasms (2.80, 1.59–4.91), age (1.02, 1.00–1.04), preceding length of hospital stay (1.04, 1.01–1.07), ALF (1.67, 1.02–2.72) and transfer to intensive care (1.85, 1.05–3.27).

Conclusions

Documentation of vital signs before MET activation is suboptimal. Documentation frequency seems to increase if automated monitors are implemented, but our results suggest that benefits of intense monitoring are lost without appropriate and timely interventions, as afferent limb failure, delay to call MET when predefined criteria are fulfilled, was independently associated to increased hospital mortality.     

Impact of a standardized nurse observation protocol including MEWS after Intensive Care Unit discharge

Background

Analysis of in-hospital mortality after serious adverse events (SAE's) in our hospital showed the need for more frequent observation in medical and surgical wards. We hypothesized that the incidence of SAE's could be decreased by introducing a standard nurse observation protocol.

Aim

To investigate the effect of a standard nurse observation protocol implementing the Modified Early Warning Score (MEWS) and a color graphic observation chart.

Methods

Pre- and post-intervention study by analysis of patients records for a 5-day period after Intensive Care Unit (ICU) discharge to 14 medical and surgical wards before (n = 530) and after (n = 509) the intervention.

Results

For the total study population the mean Patient Observation Frequency Per Nursing Shift (POFPNS) during the 5-day period after ICU discharge increased from .9993 (95% C.I. .9637–1.0350) in the pre-intervention period to 1.0732 (95% C.I. 1.0362–1.1101) (p = .005) in the post-intervention period. There was an increased risk of a SAE in patients with MEWS 4 or higher in the present nursing shift (HR 8.25; 95% C.I. 2.88–23.62) and the previous nursing shift (HR 12.83;95% C.I. 4.45–36.99). There was an absolute risk reduction for SAE's within 120 h after ICU discharge of 2.2% (95% C.I. −0.4–4.67%) from 5.7% to 3.5%.

Conclusion

The intervention had a positive impact on the observation frequency. MEWS had a predictive value for SAE's in patients after ICU discharge. The drop in SAE's was substantial but did not reach statistical significance.     

A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients

Aim

To determine whether the introduction of a multi-faceted intervention (newly designed ward observation chart, a track and trigger system and an associated education program, COMPASS^©) to detect clinical deterioration in patients would decrease the rate of predefined adverse outcomes.

Methods

A prospective, controlled before-and-after intervention of trial was conducted in all consecutive adult patients admitted to four medical and surgical wards during a 4 month period, 1157 and 985, respectively. A sub-group of patients underwent vital sign and medical review analysis pre-intervention (427) and post-intervention (320). The outcome measures included: number of unplanned admissions to the intensive care unit (ICU), Medical Emergency Team (MET) reviews and unexpected hospital deaths, vital sign documentation frequency and incidence of a medical review following clinical deterioration. This study is registered, ACTRN12609000808246.

Results

Reductions were seen in unplanned admissions to ICU (21/1157 [1.8%] vs. 5/985 [0.5%], p = 0.006) and unexpected hospital deaths (11/1157 [1.0%] vs. 2/985 [0.2%], p = 0.03) during the intervention period. Medical reviews for patients with significant clinical instability (58/133 [43.6%] vs. 55/79 [69.6%] p < 0.001) and number of patients receiving a MET review increased (25/1157 [2.2%] vs. 38/985 [3.9%] p = 0.03) during the intervention period. Mean daily frequency of documentation of all vital signs increased during the intervention period (3.4 [SE 0.22] vs. 4.5 [SE 0.17], p = 0.001).

Conclusion

The introduction of a multi-faceted intervention to detect clinical deterioration may benefit patients through increased monitoring of vital signs and the triggering of a medical review following an episode of clinical instability.     

Senior charge nurses’ leadership behaviours in relation to hospital ward safety: A mixed method study

Background

High standards of quality and patient safety in hospital wards cannot be achieved without the active role of the nursing leaders that manage these units. Previous studies tended to focus on the leadership behaviours of nurses in relation to staff job satisfaction and other organizational outcomes. Less is known about the leadership skills of senior charge nurses that are effective for ensuring safety for patients and staff in their wards.

Objectives

The aim of the two studies was to identify the leadership behaviours of senior charge nurses that are (a) typically used and, (b) that relate to safety outcomes.

Methods

In study one, semi-structured interviews were conducted with 15 senior charge nurses at an acute NHS hospital. Transcribed interviews were coded using Yukl's Managerial Practices Survey (MPS) framework. In study two, self ratings of leadership (using the MPS) from 15 senior charge nurses (SCN) and upward ratings from 82 staff nurses reporting to them were used to investigate associations between SCNs’ leadership behaviours and worker and patient-related safety outcomes.

Results

The interviews in study one demonstrated the relevance of the MPS leadership framework for nurses at hospital ward level. The SCNs mainly engaged in relations-oriented (n = 370, 49%), and task-oriented (n = 342, 45%) behaviours, with fewer change-oriented (n = 25, 3%), and lead by example behaviours (n = 26, 3%). In demanding situations, more task-oriented behaviours were reported. In study two, staff nurses’ ratings of their SCNs’ behaviours (Monitoring and Recognizing) were related to staff compliance with rules and patient injuries (medium severity), while the self ratings of SCNs indicated that Supporting behaviours were linked to lower infection rates and Envisioning change behaviours were linked to lower infection and other safety indicators for both patients and staff.

Conclusion

This study provides preliminary data on the usability of a standard leadership taxonomy (Yukl et al., 2002), and the related MPS questionnaire, on a nursing sample. The findings indicate the relevance of several leadership behaviours of SCNs for ensuring a safer ward environment and contribute to the evidence base for their leadership skills training.     

A multi-professional full-scale simulation course in the recognition and management of deteriorating hospital patients

Introduction

Recognition and management of deteriorating patients is often suboptimal, resulting in adverse events that may be avoided if a unified understanding of the signs and needs of deteriorating patients is secured through the education of staff. This paper describes the planning and evaluation of a multi-professional, full-scale simulation-based course for hospital professionals.

Methods

A systematic approach to course development was used and the programme was introduced on four general wards in a university hospital. Experts from the wards were trained as educators and participated in the course development. A needs assessment consisting of an observational study, questionnaires and interviews resulted in the creation of learning objectives to provide the road map for content and teaching methods. A 1-day multi-professional ward-specific educational programme with full-scale simulations, mini-lectures, case discussions and practical training was planned. Course material, a manual for educators and questionnaires for evaluation of the course were developed.

Results

A 1-day full-scale simulation-based educational programme was developed and 50% of the medical staff and 70% of the nursing staff on four wards were trained in a 5-month period. The course was highly rated in terms of content and teaching methods.

Discussion

The systematic approach for developing the course resulted in a relevant, highly rated course, deeply rooted in the wards, implying the opportunity to facilitate local improvements and adjust the content to local needs.

Conclusion

The use of a systematic approach was successful in the development of this multi-professional full-scale simulation-based educational programme, which has proven to be easily applicable and usable.     

The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients

Objective

Since the introduction of telemetry over a half century ago, it has expanded to various units and wards within health care institutions outside of the traditional critical care setting. Little is known on whether routine telemetry use is beneficial in this patient population. The aim of this study was to determine the impact of telemetry monitoring on survival of in-hospital cardiac arrests in patients admitted to non-critical care units.

Methods

A retrospective study of cardiac arrests in patients admitted to non-critical care units within the Winnipeg Regional Health Authority from 2002 to 2006 inclusive was performed. Baseline demographic, cardiac arrest, and outcome data were collected.

Results

Of the total 668 patients, the mean age was 70 ± 14 years with 404 (61%) males. Patients presenting with asystole or pulseless electrical activity (PEA) demonstrated an increased mortality as compared to those presenting with ventricular tachycardia (VT) or ventricular fibrillation (VF). Overall, 268 of 668 patients (40%) survived their initial arrest, 66 (10%) survived to hospital discharge and 49 (7%) survived transfer to another facility. Patients on telemetry vs. no telemetry had higher survival rates immediately following cardiac arrest (66% vs. 34%, OR = 3.67, p = 0.02), as well as higher survival to hospital discharge (30% vs. 6%, OR = 7.17, p = 0.01). Finally, patients with cardiac arrest during the night and early morning benefited proportionally the greatest from telemetry use.

Conclusion

Regardless of whether cardiac arrest was witnessed or unwitnessed, telemetry use was an independent and strong predictor of survival to hospital discharge.     

Increasing pediatric resident simulated resuscitation performance: A standardized simulation-based curriculum

Aim

Studies demonstrating the impact of resuscitation simulation curricula on performance are limited. Our objective was to create and evaluate a simulation-based resuscitation curriculum's impact on pediatric residents’ performance in a simulated resuscitation.

Methods

We developed a standardized simulation-based pediatric resident resuscitation curriculum consisting of nine modules, incorporating four domains (basic skills, airway/breathing, circulation and team management) and specific topics (e.g., anaphylaxis). Each module was presented four times over the academic year.Evaluation of the curriculum consisted of pre- and post-intervention video-recorded performances of a simulated pediatric resuscitation by 10 resident resuscitation teams, scored using the Simulation Team Assessment Tool (STAT). The effectiveness of the standardized curriculum on medical (basics, airway/breathing, circulation) and team management, and on knowledge test scores was evaluated by comparing pre- and post-intervention STAT scores using unpaired two-sided T-test. The impact of group curriculum participation on team performance (STAT scores) was analyzed using linear regression.

Results

Overall team performance STAT scores increased post-intervention (mean pre-test 0.61, post-test 0.74, p < 0.001), as did management of the basics of resuscitation, airway/breathing and teamwork (mean basics: pre 0.46, post 0.62, p = 0.001; mean airway/breathing: pre 0.63, post 0.76, p = 0.01; mean teamwork: pre 0.61, post 0.79, p = 0.003). Regression analysis provided evidence for a training “dose–response” among the post-intervention teams, with teams exposed to more training achieving higher performance scores (p = 0.004).

Conclusions

We created a standardized simulation-based pediatric resuscitation curriculum that increased pediatric residents’ scores on medical management and teamwork skills in a dose dependent relationship.     

Evaluation of the effect of Benson's relaxation technique on pain and quality of life of haemodialysis patients: A randomized controlled trial

Background

Haemodialysis patients may suffer from pain and impairment of quality of life. Some complementary interventions, such as relaxation therapy, might affect the pain and quality of life. The present study aimed to identify the effectiveness of Benson's relaxation technique in relieving pain and improving the quality of life in haemodialysis patients.

Study design

The study was a randomized controlled trial.

Setting and participants

The data were collected in two haemodialysis units affiliated to Shiraz University of Medical Sciences. A total of 86 haemodialysis patients were randomly assigned to either the intervention (receiving Benson's relaxation technique) or the control group (routine care) from 2011 to 2012.

Intervention

The patients in the intervention groups listened to the audiotape of relaxation technique twice a day each time for 20 min for eight weeks.

Measurements and outcomes

The pain numeric rating scale and Ferrans and Powers Quality of Life Index-dialysis version questionnaire were completed at baseline and 8 weeks after the intervention. The data were analyzed using independent t-test and ANCOVA.

Results

The results of ANCOVA showed a significant difference between the intervention and the control group concerning the mean score of the intensity of pain (F = 6.03, p = 0.01). Moreover, a significant difference was found between the intervention and the control group regarding the total quality of life (F = 10.20, p = 0.002) and health-functioning (F = 8.64, p = 0.004), socioeconomic (F = 12.45, p = 0.001), and family (F = 8.52, p = 0.005) subscales of quality of life.

Conclusion

These findings indicated that Benson's relaxation technique might relieve the intensity of pain and improve the quality of life in haemodialysis patients. Thus, Benson's relaxation technique could be used as part of the care practice for relieving the pain intensity and improvement of the quality of life in haemodialysis patients.     

Unscheduled Return Visits With and Without Admission Post Emergency Department Discharge

Background

Monitoring unscheduled return visits to the Emergency Department (ED) is useful to identify medical errors.

Objective

To investigate the differences between unscheduled return visit admissions (URVA) and unscheduled return visit no admissions (URVNA) after ED discharge.

Methods

From January 1, 2008 to March 31, 2008, URVA and URVNA patients who returned within 3 days after ED discharge were enrolled in the study. We compared the clinical characteristics, underlying diseases, ED crowding indicators, staff experience at the patient's first visit, and several other risk factors. We used multivariate logistic regression to evaluate differences between the two groups and to identify predictors of admission from unscheduled return visits.

Results

The unscheduled return visit rate was 3.1%. Of the 413 patients included, 147 patients (36%) were admitted, and had a mortality rate of 4.1%. The most common reason for the return visit was an illness-based factor (47.9%). Compared to URVNA patients, unscheduled return visit admissions had higher prevalence rates for old age, non-ambulatory status, high-grade triage, and underlying diseases (e.g., malignancy, diabetes mellitus, hypertension, coronary artery disease, heart failure, and chronic obstructive pulmonary disease). The independent predictors for URVA were: age ≥ 65 years (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4–3.5); high-grade triage (adjusted OR 2.1, 95% CI 1.3–3.2); and doctor-based factors (adjusted OR 3.5, 95% CI 2.0–6.1). More advanced staff experience (p = 0.490) and ED crowding were not significant predictors (p = 0.498 for whole-day number of patients, p = 0.095 for whole-shift number of patients).

Conclusion

Old age, high-grade triage, and doctor-based factors were found to be significant predictors for URVA, whereas advanced staff experience and ED crowding were not.     

Rapid response team calls to patients with a pre-existing not for resuscitation order

Objective

Compare and contrast rapid response team (RRT) calls to patients with, and those without, a pre-existing not for resuscitation (NFR) order.

Methods

Retrospective medical record and database review of adult inpatients with a hospital stay greater than 24 h.

Results

198 (15.7%) of 1258 patients with a RRT call, had a pre-existing NFR order. Patients with, compared to those without a pre-existing NFR, were older (median years, 81 vs 70, p < 0.01), similar gender (males, 56.6% vs 54.3%, p = 0.55), the trigger be the worried criterion (48.5% vs 33.9%, p < 0.01) and have had a prior RRT call (30.8% vs 18.0%, p < 0.01).At time of RRT attendance, NFR patients had a higher respiratory rate (24 vs 20, p < 0.01), lower SaO2 (93% vs 97%, p = 0.02) and just as likely to receive a critical care (24.2% vs 25.8%, p = 0.63) or ward type (88.9% vs 90.1%, p = 0.61) intervention. NFR patients were less likely to be admitted to an ICU (2.0% vs 9.4%, p < 0.01), more likely to be left on the ward (92.4% vs 80.3%, p < 0.01), and be documented not for further RRT calls (2.5% vs 0.9%, p = 0.06), but have a similar mortality (5.6% vs 3.5%, p = 0.16), at time of RRT call.

Conclusions

RRT calls to patients with pre-existing NFR orders are not uncommon. The worried criterion is more often the trigger, they have abnormal respiratory observations at time of call, a similar level of intervention, less likely to be admitted to the ICU and more likely to be documented not for further RRT calls.     

The effectiveness of a self-efficacy-enhancing intervention for Chinese patients with colorectal cancer: A randomized controlled trial with 6-month follow up

Background

Colorectal cancer is a major public health problem. There is growing support for colorectal cancer survivors who are experiencing problems after cancer treatment to engage in self-management programs to reduce symptom distress. However, there is inconclusive evidence as to the effectiveness of such program especially in Asian region.

Objectives

This study tested the effects of a six-month nurse-led self-efficacy-enhancing intervention for patients with colorectal cancer, compared with routine care over a six-month follow up.

Design

A randomized controlled trial with repeated measures, two-group design.

Setting

Three teaching hospitals in Guangzhou, China.

Participants:

One hundred and fifty-two Chinese adult patients with a diagnosis of colorectal cancer were recruited. The intervention group (n = 76) received self-efficacy-enhancing intervention and the control group (n = 76) received standard care.

Method

The participants were randomized into either intervention or control group after baseline measures. The outcomes of the study (self-efficacy, symptom distress, anxiety, depression and quality of life) were compared at baseline, three and six months after the intervention.

Results

Sixty-eight participants in the intervention group and 53 in the control group completed the study. Their mean age was 53 (SD = 11.3). Repeated measure MANOVA found that the patients in the intervention group had significant improvement in their self-efficacy (F = 7.26, p = 0.003) and a reduction of symptom severity (F = 5.30, p = 0.01), symptom interference (F = 4.06, p = 0.025), anxiety (F = 6.04, p = 0.006) and depression (F = 6.96, p = 0.003) at three and six months, compared with the control group. However, no statistically significant main effect was observed in quality of life perception between the two groups.

Conclusions

The nurse-led self-efficacy enhancing intervention was effective in promoting self-efficacy and psychological well-being in patients with colorectal cancer, compared with standard care. The intervention can be incorporated into routine care. Future empirical work is required to determine the longer term effects of the intervention.     

Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: Observational study of neurological and infectious outcomes

Introduction

Neuromuscular blockade (NMB) is widely used during therapeutic hypothermia (TH) after cardiac arrest but its effect on patient outcomes is unclear. We compared the effects of NMB on neurological outcomes and frequency of early-onset pneumonia in cardiac-arrest survivors managed with TH.

Methods

We retrospectively studied consecutive adult cardiac-arrest survivors managed with TH in a tertiary-level intensive care unit between January 2008 and July 2013. Patients given continuous NMB for persistent shivering were compared to those managed without NMB. Cases of early-onset pneumonia and vital status at ICU discharge were recorded. To avoid bias due to between-group baseline differences, we adjusted the analysis on a propensity score.

Results

Of 311 cardiac-arrest survivors, 144 received TH, including 117 with continuous NMB and 27 without NMBs. ICU mortality was lower with NMB (hazard ratio [HR], 0.54 [0.32; 0.89], p = 0.016) but the difference was not significant after adjustment on the propensity score (HR, 0.70 [0.39; 1.25], p = 0.22). The proportion of patients with good neurological outcomes was not significantly different (36% with and 22% without NMB, p = 0.16). Early-onset pneumonia was more common with NMB (HR, 2.36 [1.24; 4.50], p = 0.009) but the difference was not significant after adjustment on the propensity score (HR, 1.68 [0.90; 3.16], p = 0.10).

Conclusions

Continuous intravenous NMB during TH after cardiac arrest has potential owns effects on ICU survival with a trend increase in the frequency of early-onset pneumonia. Randomised controlled trials are needed to define the role for NMB among treatments for TH-induced shivering.     

Regular in situ simulation training of paediatric Medical Emergency Team improves hospital response to deteriorating patients

Aim of the study

The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.

Methods

Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.

Results

Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).

Conclusions

These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.     

ECG signs of acute myocardial ischemia in the prehospital setting of a suspected acute coronary syndrome and its association with outcomes

Aims

The aims of this study were (a) to determine the prehospital prevalence of electrocardiographic (ECG) signs of acute myocardial ischemia in patients with suspected acute coronary syndrome and (b) to describe the relationships between the various ECG patterns and the diagnosis of acute myocardial infarction (AMI) and outcomes.

Methods

Prospective cohort study using data from an interventional trial in acute chest pain patients transported by the emergency medical services. These patients were classified into 3 groups: patients with ECG showing signs of acute myocardial ischemia, patients with ECG showing other abnormal changes (bundle-branch block, pacemaker rhythm, Q-wave or T-wave inversion) and patients without significant pathologic findings. All P values are age-adjusted.

Results

Among 1546 patients, 312 (20%) had ECG signs of acute myocardial ischemia. Of them, 57% had a final diagnosis of AMI versus 26% of those with other abnormal ECGs and 12% of those with ECG without significant pathologic findings (P < .0001). In all, 53% of all AMI cases involved patients without ECG signs of acute myocardial ischemia. Although ECG signs of acute myocardial ischemia predicted heart failure and ventricular tachyarrhythmias both prior to and after hospital admission, there was no significant difference in 30-day mortality between the 3 patient groups (4.3%, 3.7%, and 1.2%, respectively, P = .11).

Conclusion

Among patients with a clinical suspicion of AMI in the prehospital setting, the prevalence of ECG signs suggesting AMI was low, as was the ability to identify AMI patients using ECG findings only. We therefore need better instruments in the prehospital triage of patients with acute chest pain.     

Myocardial infarction is a frequent cause of exercise-related resuscitated out-of-hospital cardiac arrest in a general non-athletic population

Background

Performing exercise is shown to prevent cardiovascular disease, but the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during strenuous activity. We examined the etiology and outcome after successfully resuscitated OHCA during exercise in a general non-athletic population.

Methods

Consecutive patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at hospital arrival (2002–2011). Patient charts were reviewed for post-resuscitation data. Exercise was defined as moderate/vigorous physical activity.

Results

A total of 1393 OHCA-patients were included with 91(7%) arrests occurring during exercise. Exercise-related OHCA-patients were younger (60 ± 13 vs. 65 ± 15, p < 0.001) and predominantly male (96% vs. 69%, p < 0.001). The arrest was more frequently witnessed (94% vs. 86%, p = 0.02), bystander CPR was more often performed (88% vs. 54%, p < 0.001), time to ROSC was shorter (12 min (IQR: 5–19) vs. 15 (9–22), p = 0.007) and the primary rhythm was more frequently shock-able (91% vs. 49%, p < 0.001) compared to non-exercise patients. Cardiac etiology was the predominant cause of OHCA in both exercise and non-exercise patients (97% vs. 80%, p < 0.001) and acute coronary syndrome was more frequent among exercise patients (59% vs. 38%, p < 0.001). One-year mortality was 25% vs. 65% (p < 0.001), and exercise was even after adjustment associated with a significantly lower mortality (HR = 0.40 (95%CI: 0.23–0.72), p = 0.002).

Conclusions

OHCA occurring during exercise was associated with a significantly lower mortality in successfully resuscitated patients even after adjusting for confounding factors. Acute coronary syndrome was more common among exercise-related cardiac arrest patients.     

A simple solution for improving reliability of cardiac arrest equipment provision in hospital

Introduction

Effective and safe cardiac arrest care in the hospital setting is reliant on the immediate availability of emergency equipment. The patient safety literature highlights deficiencies in current approaches to resuscitation equipment provision, highlighting the need for innovative solutions to this problem.

Methods

We conducted a before–after study at a large NHS trust to evaluate the effect of a sealed tray system and database on resuscitation equipment provision. The system was evaluated by a series of unannounced inspections to assess resuscitation trolley compliance with local policy prior to and following system implementation. The time taken to check trolleys was assessed by timing clinicians checking both types of trolley in a simulation setting.

Results

The sealed tray system was implemented in 2010, and led to a significant increase in the number of resuscitation trolleys without missing, surplus, or expired items (2009: n = 1 (4.76%) vs 2011: n = 37 (100%), p < 0.001). It also significantly reduced the time required to check each resuscitation trolley in the simulation setting (12.86 (95% CI: 10.02–15.71) vs 3.15 (95% CI: 1.19–4.51) min, p < 0.001), but had no effect on the number of resuscitation trolleys checked every day over the previous month (2009: n = 8 (38.10%) vs 2011: n = 11 (29.73%), p = 0.514).

Conclusion

The implementation of a sealed tray system led to a significant and sustained improvement in resuscitation equipment provision, but had no effect on resuscitation trolley checking frequency.     

Assessment of risk factors for post-rewarming “rebound hyperthermia” in cardiac arrest patients undergoing therapeutic hypothermia

Introduction

The outcomes associated with therapeutic hypothermia (TH) after cardiac arrest, while overwhelmingly positive, may be associated with adverse events. The incidence of post-rewarming rebound hyperthermia (RH) has been relatively unstudied and may worsen survival and neurologic outcome. The purpose of this study was to determine the incidence and risk factors associated with RH as well as its relationship to mortality, neurologic morbidity, and hospital length of stay (LOS).

Methods

A retrospective, observational study was performed of adult patients who underwent therapeutic hypothermia after an out-of-hospital cardiac arrest. Data describing 17 potential risk factors for RH were collected. The primary outcome was the incidence of RH while the secondary outcomes were mortality, discharge neurologic status, and LOS.

Results

141 patients were included. All 17 risk factors for RH were analyzed and no potential risk factors were found to be significant at a univariate level. 40.4% of patients without RH experienced any cause of death during the initial hospitalization compared to 64.3% patients who experienced RH (OR: 2.66; 95% CI: 1.26–5.61; p = 0.011). The presence of RH is not associated with an increase in LOS (10.67 days vs. 9.45 days; absolute risk increase = −1.21 days, 95% CI: −1.84 to 4.27; p = 0.434). RH is associated with increased neurologic morbidity (p = 0.011).

Conclusions

While no potential risk factors for RH were identified, RH is a marker for increased mortality and worsened neurologic morbidity in cardiac arrest patients who have underwent TH.     

Clinical significance of serum mitochondrial DNA in lung cancer

Objectives

The aim of the study was to investigate the clinical significance of serum mitochondrial DNA (mtDNA) in lung cancer.

Design and methods

Serum mtDNA from 65 lung cancer patients, 20 patients with benign lung diseases and 55 healthy individuals was quantified using real-time fluorescent quantitative polymerase chain reaction (FQ-PCR). Data were analyzed using statistical software SPSS 13.0.

Results

Serum mtDNA levels in lung cancer patients were significantly higher, compared to those in patients with benign lung diseases and healthy individuals (u = 108, p = 0.000; u = 293, p = 0.000), and closely associated with TNM stage (p = 0.01). The use of serum mtDNA facilitated detection of lung cancer at a cutoff value of 0.74 × 10⁴ copies/μL with a sensitivity of 86.2% and specificity of 80.7%. However, serum mtDNA levels were not associated with patient age, gender, histological type, and lymph node metastasis (p > 0.05).

Conclusions

Quantification of serum mtDNA using FQ-PCR potentially serves as a novel complementary tool to improve the clinical screening and detection of lung cancer.     

Elevated telomerase activity in essential thrombocythemia with extreme thrombocytosis

Introduction

We performed a comparative analysis of telomerase activity (TA) in patients with myeloproliferative neoplasm (MPN) and myelodysplastic syndrome (MDS). The relationships between TA and known prognostic factors were also analyzed.

Materials and methods

A telomeric repeat amplification protocol was performed with bone marrow hematopoietic cells from 96 normal controls, 44 MPNs, and 40 MDSs.

Result

TA (measured as molecules/reaction) showed no correlation with age in the control group (R² = 0.0057, p = 0.464). MPN showed elevated TA compared with controls (15,537.57 vs. 7775.44, p = 0.020). Patients with essential thrombocythemia showed markedly elevated TA (22,688.56, p = 0.030), particularly in cases with extreme thrombocytosis versus those without extreme thrombocytosis (34,522.19 vs. 9375.71, p = 0.041). MDS patients showed a TA value of 7578.50.

Conclusion

There was no association between age and TA in bone marrow hematopoietic cells. TA was elevated in MPN but borderline in MDS, probably because of differences in the nature of the diseases. Elevated TA in patients with essential thrombocythemia, especially those with extreme thrombocytosis, suggests that an anti-telomerase strategy could be beneficial in the prevention of thrombotic complications.