Critical pathways in cardiology
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Comparative Study
Wireless cardiac event alert monitoring is feasible and effective in the emergency department and adjacent waiting areas.
The need for vigilance for unexpected clinical deterioration in the emergency department (ED) waiting area and in unmonitored treatment areas of the ED continues to increase. We sought to determine in an observational study the feasibility and relative false-alarm burden of, and satisfaction with, a novel wireless automated clinician alert device for cardiac rate and rhythm derangements in a teaching hospital ED. Patients presenting with a variety of complaints who after ED triage were not placed on conventional telemetric monitoring (by standard triage policy) were considered for inclusion. ⋯ There were 10 false-positive asystole or ventricular fibrillation alarms in 4 patients (1.3%), all of which were readily attributable to nonclinical origins, such as poor lead adherence. There was excellent satisfaction with the device from both patients and clinical personnel. Wireless cardiac event monitoring is feasible in the ED, and improves the throughput of ED patients with worsening vital signs, and may improve overall patient safety, without an onerous burden of nonproductive alarms.
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Comparative Study
Improvements in time to reperfusion: do women have an advantage?
Several studies demonstrate that women have greater delays in primary percutaneous coronary intervention (PCI). To improve care for women, the Women's Heart Advantage at Yale-New Haven Hospital (YNHH) developed patient- and physician-level interventions to improve knowledge about chest pain syndromes to promote early presentation, diagnosis, and timely management of ST-elevation myocardial infarction (STEMI) in women presenting to the emergency department. Specifically, we analyzed chart-abstracted data from all patients undergoing PCI for STEMI at YNHH from January 2004 to July 2007 and assessed quality of care for STEMI and trends in time to reperfusion. ⋯ In this single-site study of men and women undergoing primary PCI at a large, urban teaching hospital, where ongoing interventions to increase both patient and physician awareness regarding heart disease in women were initiated, time to reperfusion for women improved to a greater degree than in men. These results are encouraging, showing that significant improvements can be made over a relatively short time frame. It is hoped these reductions in time to reperfusion are associated with improved outcomes; however, further studies are needed to verify this potential benefit.
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Comparative Study
Appropriately screened geriatric chest pain patients in an observation unit are not admitted at a higher rate than nongeriatric patients.
Observation units may exclude geriatric patients (defined as age >or=65) due to the high rate of observation failure (admission to an inpatient unit) among these patients. We evaluated whether geriatric patients on a chest pain protocol are admitted to an inpatient unit from an emergency department (ED) observation unit at a higher rate than nongeriatric patients. ⋯ Geriatric patients without a history of coronary artery disease were admitted to an inpatient unit at a rate consistent with a generally accepted observation failure rate of 10%. When screened appropriately, these patients may be appropriate for chest pain evaluation in the ED observation unit.
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In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACSs) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which was primary percutaneous coronary intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. ⋯ We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI and provide a rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be consistently updated and revises by incorporating new evidence from clinical trials in order to maintain clinical relevance.
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Global risk assessment is the standard of care for coronary artery disease management. In this setting, sleep apnea syndrome, which includes obstructive sleep apnea and central sleep apnea, is being increasingly recognized as a potentially modifiable risk factor for coronary artery disease. ⋯ Continuous positive airway pressure has been shown to decrease inflammatory markers that are elevated in sleep apnea syndrome. Well-designed randomized controlled clinical trials are needed to better establish the role of sleep apnea in the genesis and progression of coronary artery disease.