Critical pathways in cardiology
-
Sudden death due to ventricular fibrillation (VF) is a catastrophic event, especially in out-of-hospital settings. Prompt detection of VF and preparedness to intervene with cardiopulmonary resuscitation (CPR) and especially the delivery of an electrical shock is potentially lifesaving. The reliability and accuracy of automated VF detection by current versions of automated external defibrillators (AEDs) require interruption of CPR because the ECG signal, which is the source of rhythm detection, is corrupted by chest compressions. ⋯ The algorithm was validated on 33,095 electrocardiographic segments, including 8840 segments corrupted by compression artifacts from 232 patients after out-of-hospital cardiac arrest. Nine thousand one hundred eighty-seven of 10,042 VF segments and 20,884 of 23,053 non-VF segments were correctly classified, with a sensitivity of 91.5% and a specificity of 90.6%. Although the proposed algorithm has a lesser predictive value for VF detection than the uncorrupted ECGs in clinical settings, it has the major potential for automated rhythm identification to guide defibrillation without repetitive interruptions of CPR.
-
Despite the clinical importance of prompt percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction, many hospitals do not routinely achieve the guideline-recommended 90-minute door-to-balloon times. In this review, we evaluate existing evidence that identifies effective hospital strategies for reducing door-to-balloon time. We performed a computerized search of MEDLINE and Current Contents for studies conducted in the last 10 years of hospital efforts to improve door-to-balloon times. ⋯ Strategies with the strongest evidence include (1) activation of the catheterization laboratory using emergency medicine physicians rather than cardiologists, (2) effective use of prehospital electrocardiograms, (3) performance data monitoring/feedback. Reasonable evidence exists for establishing a single-call system for activating the catheterization laboratory, setting the expectation that the catheterization team be available 20-30 minutes after being paged, and having an organizational environment with strong senior management support and culture to foster changes directed at improving door-to-balloon time. In conclusion, although evidence of "what works" is based on observational studies rather than randomized trials, there is evidence on effective interventions to reduce door-to-balloon time.
-
Hospitals throughout the United States face the challenge of developing implementation systems able to sustain improved clinical care over years. The American Heart Association's Get With The Guidelines (GWTGs) program helps hospitals address this challenge with a comprehensive approach to quality improvement for patients with CAD, heart failure and stroke. The Department of Medicine at Berkshire Medical Center, a 300-bed community teaching hospital, developed a clinical care improvement implementation system called multidisciplinary rounds (MDR). We report our performance in GWTGs using MDR. ⋯ MDR at Berkshire Medical Center is a clinical quality-improvement implementation system that has driven sustained high-level performance in the American Heart Association's GWTGs. MDR has changed our culture, improved coordination of care, been flexible, and facilitated rapid and sustained process improvement. Improvement in evidence-based cardiovascular processes for CAD, stroke and heart failure have been associated with improved in hospital AMI mortality and decreased overall community cardiovascular, AMI, stroke and heart failure mortality. MDR can be used by multiple organizations to drive care improvement.