AHA scientific statement: practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized electrocardiology and the American Association of Critical-Care Nurses

The goals of electrocardiographic (ECG) monitoring in hospital settings have expanded from simple heart rate and basic rhythm determination to the diagnosis of complex arrhythmias, myocardial ischemia, and prolonged QT interval. Whereas Computerized arrhythmia analysis is automatic in cardiac monitoring systems, computerized ST-segment ischemia analysis is available only in newer-generation monitors, and computerized QT-interval monitoring is currently unavailable. Even in hospitals with ST-monitoring capability, ischemia monitoring is vastly underutilized by healthcare professionals. Moreover, because no computerized analysis is available for QT monitoring, healthcare professionals must determine when it is appropriate to manually measure QT intervals (eg, when a patient is started on a potentially proarrhythmic drug). The purpose of the present review is to provide "best practices" for hospital ECG monitoring. Randomized clinical trials in this area are almost nonexistent; therefore, expert opinions are based upon clinical experience and related research in the field of electrocardiography. This consensus document encompasses all areas of hospital cardiac monitoring in both children and adults. The emphasis is on information clinicians need to know to monitor patients safely and effectively. Recommendations are made with regard to indications, time frames, and strategies to improve the diagnostic accuracy of cardiac arrhythmia, ischemia, and QT-interval monitoring. Currently available ECG lead systems are described, and recommendations related to staffing, training, and methods to improve quality are provided.

Burnout, perceived stress, and depression among cardiology residents in Argentina

OBJECTIVE

Because medical residency is a stressful time for training physicians, placing residents at increased risk for psychological distress, the authors studied the prevalence of burnout, perceived stress, and depression in cardiology residents in Argentina and examined the association between sociodemographic characteristics and these syndromes.

METHODS

The authors conducted a cross-sectional observational study of 106 cardiology residents in Argentina and a comparison group of 104 age- and gender-matched nonmedical professionals. The main outcome measures included the prevalence of burnout with the Maslach Burnout Inventory, distress with the Perceived Stress Scale, and depression with the Beck Depression Inventory.

RESULTS

One hundred six residents completed the survey. Of these, 31.3% were women, the mean age was 29.1 years old, and half were married. Respondents worked an average of 64 hours per week, and 60% of the residents needed a second job. High emotional exhaustion and depersonalization was found in the majority of respondents. Significant depressive symptoms were found in less than half of residents, and stress was on average 21.7 points on the Perceived Stress Scale. Residents who had a second job showed high levels of depersonalization. No other association was found with sociodemographic characteristics. There were no differences in sociodemographic characteristics of residents compared with nonmedical professionals, but nonmedical professionals worked less hours per week, had a lower percentage of second jobs, and higher salary. Burnout, depressive symptoms, and perceived stress were significantly lower in the reference group.

CONCLUSION

Cardiology residents in Argentina exhibit high levels of burnout, perceived stress, and depressive symptoms, which warrants greater attention to the psychological needs of residents.

Teaching cardiac auscultation: effectiveness of a patient-centered teaching conference on improving cardiac auscultatory skills

OBJECTIVES

To assess the cardiac auscultatory skills of health care professionals before and after an actual (not simulated) patient-centered cardiac auscultation conference and to determine the effectiveness of this clinical teaching method on Improving diagnostic proficiency.

SUBJECTS AND METHODS

Seventy-eight participants at a conference on cardiac auscultation completed preconference and postconference examinations on their ability to diagnose a wide variety of heart sounds and murmurs. Among those tested, 46 (59%) were physicians: 17 (22%) were cardiologists, 19 (24%) were medical Interns or residents, 7 (9%) were cardiology fellows, 2 (3%) were general practitioners, and 1 (1%) was a pediatrician. Thirty-two (41%) of this group of respondents were nonphysicians: 14 (18%) were nurse practitioners, 9 (12%) were nurses, 6 (8%) were physician assistants, 2 (3%) were medical students, and 1 (1%) was a nonmedical professional. All participants were tested on 14 clinically Important cardiac auscultatory events directly recorded from actual (not simulated) patients and transmitted via wireless Infrared stethophones. The auscultatory events tested were wide physiologic splitting of S2 in right bundle branch block, fixed S2 splitting and systolic murmur in atrial septal defect, midsystolic click and late systolic murmur of mitral valve prolapse, S4 gallop, S3 gallop, opening snap of mitral stenosis, innocent systolic murmur, systolic murmur of mitral regurgitation, systolic murmur of tricuspid regurgitation, systolic murmur of hypertrophic obstructive cardiomyopathy, continuous murmur of patent ductus arteriosus, pericardial friction rub, prosthetic valve sounds, and alternation of heart sounds, heart murmurs, and the S3 gallop in congestive heart failure.

RESULTS

On the basis of the analysis of the 78 participants who completed preconference and postconference evaluations of the 14 selected cardiac auscultatory events, a preconference Identification score of 26.3% and a postconference score of 44.7% were observed. This represents a statistically significant overall Improvement in diagnostic proficiency (P < .001).

CONCLUSIONS

Cardiac auscultatory skills among today's health care professionals are extremely poor, regardless of the level and/or type of training of the professional. An actual (not simulated) patient-centered teaching conference is an effective clinical method of improving cardiac auscultatory skills and diagnostic proficiency of health care professionals.

Monitoring the performance of residents during training in off-pump coronary surgery

OBJECTIVE

Control charts (eg, cumulative sum charts) plot changes in performance with time and can alert a surgeon to suboptimal performance. They were used to compare performance of off-pump coronary artery bypass surgery between a consultant and four resident surgeons and to compare performance of off-pump coronary artery bypass surgery and conventional coronary artery bypass grafting within surgeons.

METHODS

Data were analyzed for consecutive patients undergoing coronary artery bypass grafting who were operated on by one consultant or one of four residents. Conversions were analyzed by intention to treat. Perioperative death or one or more of 10 adverse events constituted failure. Predicted risks of failure for individual patients were derived from the study population. Variable life-adjusted displays and risk-adjusted sequential probability ratio test charts were plotted.

RESULTS

Data for 1372 patients were analyzed; 769 of the procedures were off-pump coronary artery bypass operations (56.0%). The consultant operated on 382 patients (293 off-pump, 76.7%), and the residents operated on 990 (474 off-pump, 47.9%). Patients operated on by residents tended to be older, more obese, more likely to require an urgent operation, and more likely to need a circumflex artery graft but less likely to have triple-vessel disease. There were 7 conversions (consultant 5, residents 2). The overall failure rate was 8.5% (9.2% for consultant's operations and 8.2% for residents' operations), including 10 deaths (0.7%). Predicted and observed risks of failure were similar for all five surgeons. After 100 off-pump coronary artery bypass operations, performance was the same or better for the residents as for the consultant. For all surgeons, performance was the same or better for off-pump as for conventional coronary artery bypass grafting.

CONCLUSIONS

Off-pump coronary artery bypass surgery can be safely taught to cardiothoracic residents. Implementation of continuous performance monitoring for residents is practicable.

The acquisition and retention of ECG interpretation skills after a standardized web-based ECG tutorial-a randomised study

BACKGROUND

Electrocardiogram (ECG) interpretation is of great importance for patient management. However, medical students frequently lack proficiency in ECG interpretation and rate their ECG training as inadequate. Our aim was to examine the effect of a standalone web-based ECG tutorial and to assess the retention of skills using multiple follow-up intervals.

METHODS

203 medical students were included in the study. All participants completed a pre-test, an ECG tutorial, and a post-test. The participants were also randomised to complete a retention-test after short (2-4 weeks), medium (10-12 weeks), or long (18-20 weeks) follow-up. Intragroup comparisons of test scores were done using paired-samples t-test. Intergroup comparisons of test scores were performed using independent-samples t-test and ANOVA, whereas demographic data were compared using ANOVA and Chi-squared test.

RESULTS

The overall mean test score improved significantly from 52.7 (SD 16.8) in the pre-test to 68.4 (SD 12.3) in the post-test (p < 0.001). Junior and senior students demonstrated significantly different baseline scores (45.5 vs. 57.8 points; p < 0.001), but showed comparable score gains (16.5 and 15.1 points, respectively; p = 0.48). All three follow-up groups experienced a decrease in test score between post-test and retention-test: from 67.4 (SD 12.3) to 60.2 (SD 8.3) in the short follow-up group, from 71.4 (SD 12.0) to 60.8 (SD 8.9) in the medium follow-up group, and from 66.1 (SD 12.1) to 58.6 (SD 8.6) in the long follow-up group (p < 0.001 for all). However, there were no significant differences in mean retention-test score between the groups (p = 0.33). Both junior and senior students showed a decline in test score at follow-up (from 62.0 (SD 10.6) to 56.2 (SD 9.8) and from 72.9 (SD 11.4) to 62.5 (SD 6.6), respectively). When comparing the pre-test to retention-test delta scores, junior students had learned significantly more than senior students (junior students improved 10.7 points and senior students improved 4.7 points, p = 0.003).

CONCLUSION

A standalone web-based ECG tutorial can be an effective means of teaching ECG interpretation skills to medical students. The newly acquired skills are, however, rapidly lost when the intervention is not repeated.

Sex-based differences in physiology: what should we teach in the medical curriculum?

An abundance of recent research indicates that there are multiple differences between males and females both in normal physiology and in the pathophysiology of disease. The Refresher Course on Gender Differences in Physiology, sponsored by the American Physiological Society Education Committee at the 2006 Experimental Biology Meeting in San Franciso, CA, was designed to provide teachers of medical physiology with the background necessary to include the most important aspects of sex-based differences in their curricula. The presentations addressed sex-based differences in the physiology and pathophysiology of the cardiovascular, musculoskeletal, and immune systems as well as the cellular mechanisms of sex steroid hormone actions on non-reproductive tissues. The slides and audio files for these presentations are available at http://www.the-aps.org/education/refresher/index.htm. This overview highlights the key concepts relevant to the topic of sex-based differences in physiology: why these differences are important, their potential causes, and examples of prominent differences between males and females in normal physiological function for selected organ systems.

A history of pediatric specialties: the development of pediatric cardiology

Pediatric cardiology, as a discipline, arose from early descriptive studies of congenital cardiac defects. The development of the stethoscope allowed some clinical diagnoses to be made during life. Cardiology as a medical specialty was limited, mainly, to internists. When Robert Gross ligated a patent ductus in 1938, pediatric cardiology, as a discipline, was born. Physiologic studies, angiography, and the development of extracorporeal circulation allowed congenital cardiac lesions previously considered a curiosity to be diagnosed and treated successfully. The few pediatricians who were interested in cardiology taught themselves, and soon pediatric cardiology training programs developed. By 1961, pediatric cardiology became the first subspecialty board in pediatrics. The past 60 y has brought enormous progress. Cardiac ultrasound, color-flow Doppler, and magnetic resonance imaging have made diagnostic cardiac catheterization almost unnecessary. Instead, interventional cardiac catheterization rapidly developed and is already able to replace surgery in the treatment of a number of cardiac defects. The first 50 y of cardiology has been focused on patient care, education, and clinical research, but the last 10 y has added exciting, basic research discoveries, which are elucidating the cause of cardiac defects with hope for prevention in the future. As a discipline, pediatric cardiology has always required a team-pathologists, physiologists, cardiologists, surgeons, intensivists, interventionists, and anesthesiologists-all playing an important role in the treatment of children with cardiac problems. Today the geneticists, molecular biologists, and other basic scientists are joining the team to ensure an exciting future for pediatric cardiology and the children yet to be born.

Neural network assisted cardiac auscultation

Traditional cardiac auscultation involves a great deal of interpretive skill. Neural networks were trained as phonocardiographic classifiers to determine their viability in this rôle. All networks had three layers and were trained by backpropagation using only the heart sound amplitude envelope as input. The main aspect of the study was to determine what topologies, gain and momentum factors lead to efficient training for this application. Neural networks which are trained with heart sound classes of greater similarity were found to be less likely to converge to a solution. A prototype normal/abnormal classifier was also developed which provided excellent classification accuracy despite the sparse nature of the training data. Future directions for the development of a full-scale computer-assisted phonocardiographic classifier are also considered.

Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores?

PURPOSE

Faculty development programs and faculty incentive systems have heightened the need to validate a connection between the quality of teaching and students' learning. This study was designed to determine the association between attending physicians' and residents' teacher ratings and their students' examination scores.

METHOD

From a database of 362 students, 138 faculty, and 107 residents in internal medicine, student-faculty (n = 476) and student-resident (n = 474) pairs were identified. All students were in their third year, rotating on inpatient general medicine and cardiology services, July 1994 through June 1996, at a single institution. The outcome measure for students' knowledge was the NBME Subject Examination in internal medicine. To control for students' baseline knowledge, the predictors were scores on the USMLE Step 1 and a sequential examination (a clinically-based pre- and post-clerkship examination). Teaching abilities of faculty and residents were rated by a global item on the post-clerkship evaluation. Faculty's ratings used only scores from prior to the study period; residents' ratings included those scores students gave during the study period.

RESULTS

Multivariate analyses showed faculty's teaching ratings were a small but significant predictor of the increase in students' knowledge. Residents' teaching ratings did not predict an increase in students' knowledge.

CONCLUSION

Attending faculty's clinical teaching ability has a positive and significant effect on medical students' learning.

Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK

This report addresses the needs and problems of grown-up congenital heart (GUCH) patients and makes recommendations on organisation of national medical care, training of specialists, and education of the profession. The size of the national population of patients with grown-up congenital heart disease (GUCH) is uncertain, but since 80-85% of patients born with congenital heart disease now survive to adulthood (age 16 years), an annual increase of 2500 can be anticipated according to birth rate. Organisation of medical care is haphazard with only three of 18 cardiac surgical centres operating on over 30 cases per annum and only two established specialised units fully equipped and staffed. Not all grown-ups with congenital heart disease require the same level of expertise; 20-25% are complex, rare, etc, and require life long expert supervision and/or intervention; a further 35-40% require access to expert consultation. The rest, about 40%, have simple or cured diseases and need little or no specialist expertise. The size of the population needing expertise is small in comparison to coronary and hypertensive disease, aging, and increasing in complexity. It requires expert cardiac surgery and specialised medical cardiology, intensive care, electrophysiology, imaging and interventions, "at risk" pregnancy services, connection to transplant services familiar with their basic problem, clinical nurse specialist advisors, and trained nurses. An integrated national service is described with 4-6 specialist units established within adult cardiology, ideally in relation or proximity to university hospital/departments in appropriate geographic location, based in association with established paediatric cardiac surgical centres with designated inpatient and outpatient facilities for grown-up patients with congenital heart disease. Specialist units should accept responsibility for educating the profession, training the specialists, cooperative research, receiving patients "out of region", sharing particular skills between each other, and they must liaise with other services and trusts in the health service, particularly specified outpatient clinics in district and regional centres. Not every regional cardiac centre requires a full GUCH specialised service since there are too few patients. Complex patients need to be concentrated for expertise, experience, and optimal management. Transition of care from paediatric to adult supervision should be routine, around age 16 years, flexibly managed, smooth, and explained to patient and family. Each patient should be entered into a local database and a national registry needs to be established. The Department of Health should accept responsibility of dissemination of information on special needs of such patients. The GUCH Patients' Association is active in helping with lifestyle and social problems. Easy access to specialised care for those with complex heart disease is crucial if the nation accepts, as it should, continued medical responsibility to provide optimal medical care for GUCH patients.

Comparison of two educational interventions on pediatric resident auscultation skills

OBJECTIVE

Multiple cross-sectional physician surveys have documented poor cardiac auscultation skills. We evaluated the impact of 2 different educational interventions on pediatric resident auscultation skills.

METHODS

The auscultation skills of all first-year (PGY1; n = 20) and second-year pediatric residents (PGY2; n = 20) were evaluated at the beginning and end of the academic year. Five patient recordings were presented: atrial septal defect, ventricular septal defect, pulmonary valve stenosis, bicuspid aortic valve with insufficiency, and innocent murmur. Residents were asked to classify the second heart sound, identify a systolic ejection click, describe the murmur, and provide a diagnosis. All PGY1 and most PGY2 (14 of 20) participated on the inpatient cardiology service for 1 month. PGY2 on the cardiology service also attended outpatient clinic. PGY1 did not attend outpatient clinic but were allotted 2 hours/week to use a self-directed cardiac auscultation computer teaching program.

RESULTS

Resident auscultation skills on initial evaluation were dependent on training level (PGY1: 42 +/- 15% correct; PGY2: 53 +/- 13% correct), primarily as a result of better classification of second heart sound (PGY1: 45%; PGY2: 63%) and diagnosis of an innocent murmur (PGY1: 35%; PGY2: 65%). There was no difference in the ability to identify correctly a systolic ejection click (20% vs 23%) or to arrive at the correct diagnosis (35% vs 40%). At the end of the academic year, the PGY1 scores improved by 21%, primarily as a result of improved diagnostic accuracy of the innocent murmur (35% to 65%). PGY2 scores remained unchanged (53% vs 51%), regardless of participation in a cardiology rotation (cardiology rotation: 50%; no cardiology rotation: 51%). Combined, diagnostic accuracy was best for ventricular septal defect (55%) and innocent murmur (60%) and worst for atrial septal defect (18%) and pulmonary valve stenosis (15%). However, 40% identified the innocent murmur as pathologic and 21% of pathologic murmurs were diagnosed as innocent.

CONCLUSIONS

Pediatric resident auscultation skills were poor and did not improve after an outpatient cardiology rotation. Auscultation skills did improve after the use of a self-directed cardiac auscultation teaching program. These data have relevance given the American College of Graduate Medical Education's emphasis on measuring educational outcomes and documenting clinical competencies during residency training.

The future of cardiovascular imaging and non-invasive diagnosis: A joint statement from the European Association of Echocardiography, the Working Groups on Cardiovascular Magnetic Resonance, Computers in Cardiology, and Nuclear Cardiology, of the European Society of Cardiology, the European Association of Nuclear Medicine, and the Association for European Paediatric Cardiology

Advances in medical imaging now make it possible to investigate any patient with cardiovascular disease using multiple methods which vary widely in their technical requirements, benefits, limitations, and costs. The appropriate use of alternative tests requires their integration into joint clinical diagnostic services where experts in all methods collaborate. This statement summarizes the principles that should guide developments in cardiovascular diagnostic services.

Ethical issues for invasive cardiologists: Society for cardiovascular angiography and interventions

In view of the major impact of medical economic forces, rapidly changing technology, and other pressures on invasive cardiologists, the Society for Cardiovascular Angiography and Interventions determined that a statement of the ethical issues confronting the modern invasive cardiologist was needed. The various conflicts presented to the cardiologist in his or her roles as practicing clinician, administrator of the catheterization laboratory, educator, or clinical researcher were reviewed. In all instances, the major concern was determined to be the welfare of the patient no matter how forceful the pressures from various outside force or concerns for personal advancement might be.

How cardiologists learn about echocardiography. A reminder for medical educators and legislators

Mandatory continuing medical education, because of the need to validate participation, rewards classroom activities but not self-education. To determine if self-education is still a major study method for practicing physicians, we surveyed 158 cardiologists to learn how they first heard of, and continued their education in, echocardiography, a technique in which 81% of the physician-sample receiving no training in medical school, residency, or fellowship. Initial and continuing sources of information included professional journals and literature, meetings and conferences, discussion with colleagues, and courses. Professional journals ranked first in use; individual and group learning activities were used about equally by physicians. Recent legislation requiring validation of attendance may cause educators and legislators to ignore the self-learner. This study should remind educators and legislators that variations in learning style must be considered when planning and legislating approaches in continuing medical education.