Reorganisation reaps benefits in Canada

Cameron Shantz, a principal with one of Canada's largest architectural firms, Parkin Architects, and project architect for a major reconfiguration and reorganisation of clinical and other spaces at the St. Mary's General Hospital in Kitchener, Ontario, describes the rationale behind the project, and highlights the resulting benefits for patients, staff and visitors.

Digital assessment of the epicardial electrocardiogram: novel methodology for a core laboratory for clinical studies

BACKGROUND

The epicardial electrocardiogram (ECG) is a sensitive marker for cardiac ischemia and has been used as a measure of ischemia in clinical trials. We sought to examine the utility of a central ECG laboratory for determining ischemic-type ST-segment shifts from epicardial ECG recordings obtained from multiple clinical sites.

HYPOTHESIS

We speculated that an operator-assisted digital ECG core laboratory is feasible, reliable, and efficient, with the ability for rapid and accurate interpretation of the epicardial ECG.

METHODS

The epicardial ECG was recorded via an angioplasty guidewire placed in a coronary artery of a patient undergoing angioplasty. Site investigators visually determined the time-to-onset of 0.1 and 0.3 mm ST-segment elevation, and the maximal ST-segment elevation during balloon inflation, and then compared the measurements with those made at an operator-assisted digital ECG core laboratory.

RESULTS

Agreement between the two methods occurred in 78% of the time-to-onset measurements, but in only 39% of the maximal ST-segment measurements. Overall, the visual measurements of the clinical investigators of time-to-onset differed from the digital core laboratory by 11.8 +/- 11.6 s for 0.1 mV, and 15.8 +/- 20.6 s for 0.3 mV. Recorded maximal ST-segment shifts differed by a mean of 0.47 +/- 0.69 mV.

CONCLUSION

The magnitude of inconsistency between the ECG core laboratory results using an operator-assisted digital method and the interpretations of clinical investigators using manual caliper-type analysis was surprisingly large. These results support the need for an ECG core laboratory in clinical trials where ECG ST-segment shifts are used as a response variable.

[Too many coronary intervention centres in the Netherlands]

The Dutch Minister of Health's decision to expand the number of specialised treatment centres for percutaneous cardiac interventions (PCI) will reduce the volume per centre and per cardiologist. Hospitals and cardiologists have overestimated their adherence region and this will result in too few interventions per cardiologist to allow them to maintain their skills and guarantee optimal quality. Several studies show that there is a strong relationship between volume and complications. In acute PCI, experienced cardiologists have 42% (95% CI: 0.39-0.86) less mortality than their less experienced colleagues. The minister has defended his policy by stating that quality of care is the responsibility of cardiologists, directors of hospitals and health insurance companies. However, the branch is not able to control the distribution of complicated interventions. Although they know that there is a strong relation between the number of interventions and outcome they refuse to accept this and ignore the importance of forming strong alliances and collaborative networks.

Computer-mediated mobile messaging as collaboration support for nurses

Collaboration in hospitals is coordinated mainly by communication, which currently happens by face-to-face meetings, phone calls, pagers, notes and the electronic patient record. These habits raise problems e.g., delayed notifications and unnecessary interruptions. Dealing with these problems could save time and improve the care. Therefore we designed and prototyped a mobile messaging solution based on two specific scenarios coming from observations at a cardiology department of a Norwegian hospital. The main focus was on supporting the work of nurses. One prototype supported patient management while another one dealt with messages related to medication planning. The evaluation of the prototypes suggested that messaging-based collaboration support is worth to explore and also gave ideas for improvement.

[Implementation and use of an electronic medical record in a department of cardiology: ten-year experience]

The rising of healthcare and hospital efficiency has underlined the necessity of clinical information systems. Hospitals represent complex organizations requiring control of different types of data for the management of patients and resources. A project was developed at the CNR Institute of Clinical Physiology of Pisa to produce an integration system to manage healthcare in its technological, administrative and clinical aspects, in respect of high quality in healthcare and cost-effectiveness evaluation. A networked computer-based information system was implemented to integrate different heterogeneous sources of patient data, both administrative and clinical (texts, signals, images), reaching a total integration. Data are stored into a relational database, processed and presented to healthcare personnel by network-connected clinical workstations. Epidemiological components are integrated to continuously offer evaluation processes to clinical components. From 1998 to August 2007 more than 300 stations were connected. The electronic medical records of more than 20 000 patients were recorded; more than 100 000 procedures were digitally integrated and the entire health file record and cost calculation could be obtained for each patient. In conclusion, the use of electronic medical records allowed a complete clinical data integration with improvement of overall structure efficiency and healthcare quality.

Health-related quality of life measurement in patients admitted with coronary heart disease and heart failure to a cardiology department of a secondary urban hospital in Greece

INTRODUCTION

The aim of this study was to measure the quality of life in patients with coronary heart disease and heart failure, who make up the majority of admissions to an acute hospital cardiology unit.

METHODS

The study was undertaken in the General Hospital of Agios Nikolaos, Crete, and recruited 153 patients. The SF-36 and EQ-5D questionnaires were administered to evaluate health-related quality of life at hospital admission, discharge and one month after the discharge date.

RESULTS

The analysis indicates that the quality of life of coronary disease patients is quite low and improved very marginally between admission and one month post discharge. The same applies for heart failure patients, who are associated with even lower quality of life scores.

CONCLUSION

As illness affects all aspects of life, such as physical functioning, emotional balance, social role and general wellbeing, measurement of quality of life is considered to be an important factor in the assessment of the objective and subjective status of the individual's health. It appears in this context that patients with cardiac conditions suffer a significant deterioration in their quality of life status.

Physicians' and Nurses' Perceptions of Patient Involvement in Myocardial Infarction Care

BACKGROUND

Patients' involvement in their healthcare has been associated with better health outcomes. However, few studies have examined whether patient involvement affects the work of healthcare professionals. A better understanding of professionals' views and behaviour is necessary for improving clinical practice and optimizing patient involvement.

AIM

To measure perceptions and behaviour regarding patient involvement among physicians and nursing staff caring for patients with acute myocardial infarction.

METHODS

A questionnaire study conducted in 2005 among cardiology staff at twelve Swedish hospitals. The questionnaire included six scales measuring staff views and behaviour.

RESULTS

Physicians, registered nurses, and practical nurses did not differ significantly in their views of patient involvement, but did differ significantly in behaviour (p<.001). All three groups felt that an actively involved patient enriched their work, at the same time increasing their work load and taking time from other tasks. Physicians discussed daily activities and lifestyle changes with myocardial infarction patients before hospital discharge to a greater extent than nursing staff (p<.001).

CONCLUSION

Physicians and registered nurses viewed time constraints as a hinder for patient involvement, while practical nurses felt unsure in communicating with patients. Considering these organizational and professional issues may improve patient involvement and health outcomes in myocardial infarction care.

[Direct referral of patients with ST-elevation acute myocardial infarction to primary percutaneous coronary intervention. Pre-hospital use of telemedicine and risk stratification]

INTRODUCTION

Primary percutaneous coronary intervention (PCI) is recommended for revascularisation of patients with ST-elevation acute myocardial infarction (STEMI) with a duration of symptoms less than 12 hours. Primary PCI is recommended even if the patient is to be transported from a non-invasive hospital to an invasive centre. Normally this transport requires an attending physician. This transport strategy is associated with an increased treatment delay. The aim of this study was to assess pre-hospital tele-transmitted electrocardiogram (tele-ECG) and risk stratification by using a questionnaire in order to assess if selected patients with STEMI can be transported safely to primary PCI without an attending physician.

MATERIALS AND METHODS

Since January 2005 Fyn Svendborg Hospital has received pre-hospital tele-ECG recorded in patients with suspected acute coronary syndrome (ACS) with simultaneous risk stratification by using a questionnaire. Transportable STEMI patients were referred directly to an invasive centre without an attending physician.

RESULTS

During a period of 17 months tele-ECGs were recorded from 1,148 patients. 82 patients had STEMI and 71 patients were transported to an invasive centre without an attending physician. In this group, 1 case of resuscitated ventricular fibrillation was reported. 11 patients were transported to the nearest hospital: 2 to invasive centres, 7 patients were inter-hospital transported with a physician, and transport was not relevant/possible for 2 patients.

CONCLUSION

Pre-hospital tele-ECG and risk stratification can select patients with STEMI and transport them safely to an invasive PCI centre without an attending physician.

Evaluation of the electrocardiographic criteria for left ventricular hypertrophy

OBJECTIVE

Left ventricular hypertrophy (LVH) is an independent predictor of cardiovascular (CV) mortality. This study compared different criteria including Sokolow-Lyon and Cornell, in terms of voltage and voltage-QRS-duration products, as well as point-scoring systems such as the Romhilt-Estes, Perugia and Glasgow-Royal-Infirmary modified Romhilt-Estes score.

METHODS

Patients undergoing echocardiography were recruited from the cardiology department in Glasgow Royal Infirmary. Echocardiographically derived left ventricular mass was indexed to body surface area and using sex dependent thresholds, LVH was determined. Electrocardiograms (ECG) were processed using The University of Glasgow Analysis Program, permitting different LVH criteria to be calculated and evaluated. Inclusion criteria for this study were that the patients had a technically adequate echocardiogram and ECG.

RESULTS

The main analysis used 51 male and 76 female patients. At published thresholds, the Lewis index gave the greatest sensitivity of the voltage criteria (12%). However, adjusted to 95% specificity, the Cornell index produced the greatest sensitivity at 19%. The best voltage-duration product was the Cornell product that gave 15% sensitivity and 19% when adjusted to 95% specificity. The point scoring systems proved to be the most accurate with the Perugia score being 22% sensitive and the Glasgow Royal Infirmary modified Romhilt-Estes score 24 % sensitive, both at 95% specificity.

CONCLUSION

This study finds that ECG criteria for LVH that use only voltage are relatively poor predictors of LVH. This study also finds that the best criteria for assessing LVH are the point scoring criteria, in particular the Glasgow Royal Infirmary Modified Romhilt-Estes score.

Cognitive analysis of physicians and nurses cooperation in the medication ordering and administration process

The objective of this study was to analyse physician-nurse cooperation in the medication ordering and administration process from a cognitive point of view. In this paper, we compared two work organizations characterized by: (1) a synchronous cooperation engendered by common doctor-nurse medical rounds and (2) an asynchronous situation characterized by split physician's and nurse's rounds. Both organizations worked with paper-based documentation systems. We relied on a cooperation cognitive architecture model and used specific methods from cognitive ergonomics to analyse physicians' and nurses' activity, communications and cooperation. The analysis of doctor-nurse dialogues during the medical rounds demonstrated that in the synchronous situation, the nurses actively participated in the medication ordering process. Such dialogues supported the elaboration of shared knowledge in the form of a common frame of reference (COFOR) which both actors rely on to control the entire medication process, and more precisely the coordination of their actions. Document analysis showed that the orders were far from exhaustively documented. However, self-confrontation interviews with the nurses demonstrated that, except for a small number of ill-documented orders, they were able to accurately retrieve the physician's complete intended orders. In this work organization, the nurse was able to control the medication administration process at a high level, because she understood the highest level of strategic control of the medication ordering carried out by the physician. In the asynchronous situation, the results were reversed. The nurses no longer participated in the decision making phase of the medication process. Doctor-nurse communications were rare, and their shared knowledge about the patient was weakened. Although written orders proved to be better documented, the nurses suffered from a lack of knowledge on the patient's medical case and the particular context of the medical decision making when confronted with incomplete or ambiguous orders. In this work organization, the nurse would find herself restrained to low level process control and confined in a reactive, instead of anticipative, management mode. This latter work organization is very similar to the CPOE situation we observed in previous studies, where the coordination of physicians' and nurses' actions was delegated to the system. We suggest that it is essential to take these organizational and cognitive aspects into account when (re-)designing CPOE applications.

Transradial access in a cath lab with moderate procedural volume: a single operator's experience

AIM

The transradial access (TRA) for cardiovascular interventions has become increasingly popular and was shown to be effective in many clinical settings, including acute coronary syndromes. Despite offering many advantages, such as a striking reduction in access site complications, the penetration of TRA in routine practice is still low. One reason for this could be that many studies about TRA were performed in high-volume centers by expert operators, making their results not fully applicable to the real world. In order to assess the efficacy of TRA, we retrospectively reviewed the caseload of a single operator working in a community hospital with moderate procedural volume.

METHODS

We considered 873 consecutive procedures, of which 406 percutaneous coronary interventions (PCI), performed by a single operator (S.R.) who had previously completed the learning curve in TRA at a high volume center.

RESULTS

TRA was selected in 48.3% of patients, transfemoral approach (TFA) in 50.9% and transbrachial approach in 0.8%. TFA was used more frequently in PCI (62.5% vs 37.5%; P<0.001), largely because it was the access of choice in primary PCI. The overall procedural success rate was 94% in TRA and 98% in TFA (P=0.035); access failure was more frequent in TRA (5.9% vs 1.1%; P<0.001), whereas an increased rate of access-related vascular complications was observed in TFA as compared to TRA (1.1% vs 0%; P=0.029).

CONCLUSION

After an adequate training period, the overall performance of TRA is good even in moderate-volume hospitals. Despite reducing access site complications, TRA is limited by a slightly higher rate of procedural failure as compared to TFA.

Outcomes of Myocardial Infarction in Hospitals With Percutaneous Coronary Intervention Facilities

BACKGROUND

Despite evidence on the efficacy and safety of percutaneous coronary intervention (PCI) for patients with acute myocardial infarction, it is unclear whether patients admitted to hospitals with on-site PCI facilities (herein after, PCI hospitals) have improved outcomes in routine practice.

METHODS

We compared processes of care, hospital outcomes, and 1-year mortality rate for 1176 consecutive patients admitted to 126 PCI hospitals and 738 patients admitted to 190 non-PCI hospitals in France from November 1 to November 30, 2000.

RESULTS

Patients admitted to PCI hospitals were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications and to undergo PCI within 48 hours of admission than those admitted to non-PCI hospitals (54% vs 6.2%; P<.001). Despite comparable rates of in-hospital stroke (0.9% vs 1.1%; P=.75) and reinfarction (1.7% vs 2.5%; P=.25), patients admitted to PCI vs non-PCI hospitals had lower in-hospital (7.5% vs 12%; P=.001) and 1-year (13% vs 20%; P<.001) mortality rates. Admission to PCI hospitals was associated with decreased hazard ratios of mortality after adjusting for baseline characteristics (0.75; 95% confidence interval, 0.57-0.98) or propensity score (0.76; 95% confidence interval, 0.59-0.97). Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications.

CONCLUSIONS

In this prospective observational study, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidence-based medications and with improved 1-year survival. Although we cannot exclude the possibility that some unmeasured confounding factors might explain the survival benefit of admission to PCI hospitals, our findings support routine use of PCI and evidence-based medications for these patients.

Real-time three-dimensional echocardiography: a pilot feasibility study in an Italian cardiologic center

BACKGROUND

The majority of studies demonstrating the diagnostic potential of three-dimensional (3-D) echocardiography have been conducted on selected series of patients in research laboratories.

AIM

To investigate the feasibility and usefulness of real-time 3-D transthoracic echocardiography in daily routine practice.

METHODS

Two hundred consecutive patients underwent standard two-dimensional (2-D) transthoracic echocardiography (TTE) and real-time (RT) 3-D TTE with a commercially available ultrasound system (Sonos 7500 LIVE 3D, Philips Medical Systems). The quality of 3-D acquisitions and post-processed images was graded as: bad, satisfactory, good and demo. In each case, the results of 3-D TTE were compared with 2-D images to disclose additional qualitative information provided by 3-D examination. An additional qualitative information score was given for each cardiac structure.

RESULTS

The mean time of the 3-D examination was 11+/-4 min. The mean time of 2-D transthoracic studies in our laboratory is 25 min and the total time in this series was therefore approximately 36 min. The mean number of acquisitions in our series was 11.5 per patient. The quality was evaluated as bad/insufficient in 7.0%, satisfactory/sufficient in 29.6%, good in 40.2% and demo in 23.2% of all datasets and reconstructions. The structures with greater additional qualitative information scores comprise the anterior and posterior mitralic leaflets, antero-lateral and postero-medial papillary muscles and leaflets of tricuspid valve. The intra- and interobserver reproducibility of quality grading was good and there are few interobserver discrepancies, which were resolved by two physicians, experienced in 3-D echocardiography, not involved in the study.

CONCLUSIONS

RT 3-D TTE may be used in clinical settings with high feasibility rate and may provide additional, clinically quite relevant qualitative information. This technique may expand the abilities of non-invasive cardiology and open new doors for the evaluation of cardiac disease.

Cardiac centre lights up Blackpool

A new cardiac centre at Blackpool's Victoria Hospital is described as an excellent example of how the ProCure21 process can work.

Telemedicine in pediatric and perinatal cardiology: Economic evaluation of a service in English hospitals

Objectives:Pediatric cardiology has an expanding role in fetal and pediatric screening. The aims of this study were to observe how district hospitals use a pediatric telecardiology service, and to compare the costs and outcomes of patients referred to specialists by means of this service or conventionally.

Methods:A telemedicine service was set up between a pediatric cardiac center in London and four district hospitals for referrals of second trimester women, newborn babies, and older children. Clinicians in each hospital decided on the role for their service. Clinical events were audited prospectively and costed, and patient surveys were conducted.

Results:The hospitals differed in their selection of patient groups for the service. In all, 117 telemedicine patients were compared with 387 patients seen in London or in outreach clinics. Patients selected for telemedicine were generally healthier. For all patients, the mean cost for the initial consultation was £411 for tele-referrals and £277 for conventional referrals, a nonsignificant difference. Teleconsultations for women and children were significantly more expensive because of technology costs, whereas for babies, ambulance transfers were much more costly. After 6-months follow-up, the difference between referral methods for all patients was nonsignificant (telemedicine, £3,350; conventional referrals, £2,172), and nonsignificant within the patient groups.

Conclusions:Telemedicine was perceived by cardiologists, district clinicians, and families as reliable and efficient. The equivocal 6-month cost results indicate that investment in the technology is warranted to enhance pediatric and perinatal cardiology services.

[Performance indicators: INCA (cardiovascular indicators) project]

The objective of INCA project was the development and implementation of Acute Myocardial Infarction (AMI type ST elevation) process and outcome indicators for the regional cardiology units, testing the possibility of using regional healthcare information data to evaluate the quality of provided healthcare within the regional healthcare accreditation process. The project is introduced by an overview of major concepts of evaluating and managing quality of healthcare. We performed a literature review of structure, process and outcome indicators in cardiology and of accreditation standards for cardiology at national and international level. Through consensus procedures and according to international evidence based literature a set of 18 process and outcome indicators for AMI was defined. A specific procedure for data collection has been developed. Education and training of participants on procedures, quality and accreditation was achieved. Expected verifiable end-points have been achieved over a three months period of data collecting throughout 21 cardiology units, differentiated for level of complexity and location, for a total of 409 clinical observed cases of AMI. Analysis of data was followed by the diffusion of results. Successful data collection of clinical performance indicators on a regional basis was achieved. Participants have been trained to quality sciences. Results will be useful to evaluate and design implementation strategies of regional accreditation of health care services within a shared framework. Benchmarking within Regional hospital cardiology care services will be developed following self evaluation and continuous quality improvement cycle activities.

Herbals in cardiovascular practice: are physicians neglecting anything?

BACKGROUND

Herbal products have been widely used by many patients with cardiovascular problems solely expecting benefit out of them. Since, it is important to consider patients' needs and believes to prevent breaking off the relationship of patients and physicians, we conducted a survey on patients admitted to our outpatient Cardiology department.

METHODS

A questionnaire was prepared including 49 questions. After giving informed consent, 310 participants were enrolled into our survey. Participants were asked about disease states, use of herbal products and their tendencies.

RESULTS

There were 169 male (mean age: 54.7+/-13.3 years) and 141 female participants (mean age: 56.2+/-14.7 years). 54.5% (n=169) had hypertension (HT), 48.7% (n=151) had coronary artery disease (CAD). Among all participants, 38.7% (n=120) stated that they have used herbals in part of their lives. Presence of dyslipidemia was associated with herbal use. Three fourths of herbal users (73.3%, n=88) stated that they thought they benefited some extent from the use of herbals, and 25% (n=30) of herbal users stated that they did not take their medicine regularly. Herbal users more frequently agreed the statement "herbals are beneficial when added to medicine" compared to nonusers (20.8% vs. 15.8%, p<0.001).

CONCLUSION

Considering the facts that increasing interest on herbals is likely to continue by the people and the potentially hazardous interactions between the herbals and the drugs might be risky for the patients, there seems a need for closer, careful and respectful look for physicians onto herbal users and herbals themselves for the safety of population.

Second reading of coronary angiograms by radiologists

BACKGROUND

In many hospitals in the provinces of Quebec and Nova Scotia, as well as in some hospitals in the rest of Canada, coronary angiograms are performed and interpreted by invasive cardiologists, and are later reinterpreted and reported by radiologists.

OBJECTIVE

To evaluate the value of second readings of coronary angiograms by radiologists.

METHODS

Cardiology and radiology reports of a total of 160 consecutive coronary angiograms were compared from patients at three hospitals. Ten segments of the coronary tree were considered and 1582 segments were included. Agreement between cardiology and radiology interpretations was evaluated using per cent agreement, Pearson correlation and Bland-Altman limits of agreement. Agreement was calculated for each arterial segment and for each hospital.

RESULTS

Excellent agreement was found between cardiology and radiology interpretations of coronary angiograms. Per cent agreement ranged from 94.9% to 100%, Pearson correlation ranged from 0.83 to 0.97 and Bland-Altman limits of agreement ranged from -18.1 to 19.4. Agreement was similar for each segment and for each hospital. Agreement remained excellent after exclusion of normal angiograms (n=348 segments), with a per cent agreement of 96.3%. Secondary analyses demonstrated a mean time delay of 13 days between angiograms and the subsequent radiology reports.

CONCLUSIONS

There are minimal differences between the cardiology and radiology interpretations of coronary angiograms. Routine second reading by a radiologist may be redundant.

Impact of antenatal screening on the presentation of infants with congenital heart disease to a cardiology unit

AIM

Antenatal diagnosis of congenital heart disease (CHD) facilitates prenatal treatment and optimal perinatal care. This has been demonstrated to improve perinatal mortality and morbidity in neonates with CHD. Thus, antenatal diagnosis of CHD is most likely to benefit patients who require surgery in early infancy. We aimed to examine the frequency of antenatal diagnosis in neonates presenting to The Royal Children's Hospital severe CHD.

METHODS

Main outcome measures were antenatal diagnosis and whether the individual lesion would have been expected to be detected on a four-chamber view or four-chamber and outflow tract view during a routine obstetric anomaly ultrasound. Poisson regression was used to estimate the average trend over the study period.

RESULTS

A total of 610 patients met the inclusion criteria, of whom 164 had an antenatal diagnosis (26.8%). If routine ultrasound screening was ideal, we would have expected 63.9% of cases to be detected on four-chamber view and 83.6% on four-chamber and outflow tract view. Trend analysis demonstrated an annual rate of improvement of 9% in actual versus expected antenatal diagnosis of CHD. Malformation-specific analysis showed that antenatal detection was the highest for double inlet/outlet ventricle (51.3%, 95% confidence interval 34.8-67.6%) and the lowest for simple transposition of the great arteries (15.6%, 95% confidence interval 9.0-24.5).

CONCLUSION

Despite mass screening for congenital malformations in Victoria with routine antenatal ultrasounds, a large proportion of neonates with severe congenital heart disease still present without an antenatal diagnosis.