Is nurse-supervised exercise stress testing safe practice?

Improving Hospital Length of Stay: Results of a Retrospective Cohort Study

(1) Background: Jersey Shore University Medical Center (JSUMC) is a 646-bed tertiary medical center located in central New Jersey. Over the past several years, development and maturation of tertiary services at JSUMC has resulted in tremendous growth, with the inpatient volume increasing by 17% between 2016 and 2018. As hospital floors functioned at maximum capacity, the medical center was frequently forced into crisis mode with substantial increases in emergency department (ED) waiting times and a paradoxical increase in-hospital length of stay (hLOS). Prolonged hLOS can contribute to worse patient outcomes and satisfaction, as well as increased medical costs. (2) Methods: A root cause analysis was conducted to identify the factors leading to delays in providing in-hospital services. Four main bottlenecks were identified by the in-hospital phase sub-committee: incomplete orders, delays in placement to rehabilitation facilities, delays due to testing (mainly imaging), and delays in entering the discharge order. Similarly, the discharge process itself was analyzed, and obstacles were identified. Specific interventions to address each obstacle were implemented. Mean CMI-adjusted hospital LOS (CMI-hLOS) was the primary outcome measure. (3) Results: After interventions, CMI-hLOS decreased from 2.99 in 2017 to 2.84 and 2.76 days in 2018 and 2019, respectively. To correct for aberrations due to the COVID pandemic, we compared June-August 2019 to June-August 2020 and found a further decrease to 2.42 days after full implementation of all interventions. We estimate that the intervention led to an absolute reduction in costs of USD 3 million in the second half of 2019 and more than USD 7 million in 2020. On the other hand, the total expenses, represented by salaries for additional staffing, were USD 2,103,274, resulting in an estimated net saving for 2020 of USD 5,400,000. (4) Conclusions: At JSUMC, hLOS was found to be a complex and costly issue. A comprehensive approach, starting with the identification of all correctable delays followed by interventions to mitigate delays, led to a significant reduction in hLOS along with significant cost savings.

For Better and For Worse: Quality of Life Impaired in HF Patients as well as in Their Partners

Background: Quality of Life (QOL) is known to be impaired in patients with Heart Failure (HF). The involvement of a key person, most often the spouse, enables the HF patient to manage the medical regimen and therefore to sustain Quality of Life (QOL). Yet little is known on the impact of caring for an HF patient on the QOL of the caregiving partner. This study aims to explore the QOL of partners of HF patients compared to the QOL of the patients.

Methods: The study population consisted of 38 couples of hospitalized HF patients and their partners. The Cantril Ladder of Life was used to rate QOL during hospitalization, with regard to the month prior to hospitalization and as projected 3 years in the future. Demographic and clinical variables were collected by patient interview and chart review.

Results: On a scale from 0–10, QOL scores of partners varied from 5.9 to 6.4. At some point the QOL score of partners was even lower than the QOL scores of HF patients. In the month prior to hospital admission the QOL of partners was significantly higher in comparison to the QOL of HF patients (6.1 vs. 4.9, respectively). However, this reversed during hospital admission, with QOL scores of partners being significantly lower compared to QOL scores of HF patients (5.9 vs. 6.8, respectively), even after correcting for age and gender.

Conclusion: In our study the QOL of partners of HF patients was low. Whether this is explicitly due to having to live with a HF patient is not clear. Further research on what partners actually do and the relationship between being a caregiver and QOL is necessary in order to support these partners in giving optimal care and support.

Practical Application of Educational Rhetoric: A Pathway to Expert Cardiac Nurse Practice?

Cardiac nursing takes place within various spheres of health care, reaching into primary, secondary and tertiary care within theses, cardiac expertise falls within four domains: health promotion, cardiac prevention and rehabilitation, acute, chronic and episodic care and palliative care. This paper sets out the possibility for a staged development of the cardiac nurse, which could promote homogeneity in role, skill and practice. A framework ('Expert Cardiac Nurse Pathway') for the United Kingdom, is proposed here, and views on its usefulness throughout Europe are sought.

Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations

This systematic review examines critically "best practices" in the training of qualified exercise professionals. Particular attention is given to the core competencies and educational requirements needed for working with clinical populations. Relevant information was obtained by a systematic search of 6 electronic databases, cross-referencing, and through the authors' knowledge of the area. The level and grade of the available evidence was established. A total of 52 articles relating to best practices and (or) core competencies in clinical exercise physiology met our eligibility criteria. Overall, current literature supports the need for qualified exercise professionals to possess advanced certification and education in the exercise sciences, particularly when dealing with "at-risk" populations. Current literature also substantiates the safety and effectiveness of exercise physiologist supervised stress testing and training in clinical populations.

Early exercise stress testing is safe after primary percutaneous coronary intervention

BACKGROUND

The optimal timing of exercise stress testing post primary percutaneous coronary intervention is uncertain with anecdotal evidence suggesting an increased risk of acute myocardial infarction and/or death if performed too early. This has translated into a delayed return to normal life activities following an acute myocardial infarction resulting in an increase in socio-economic burden.

AIMS

We hypothesize that early (within 7 days of primary percutaneous coronary intervention) exercise stress testing is safe.

METHODS

A prospective study of consecutive patients enrolled into the Cardiac Rehabilitation Program at a tertiary referral centre that underwent primary percutaneous coronary intervention, and who were able to perform a treadmill stress test were recruited. Timing of exercise stress testing was within 7 days post primary percutaneous coronary intervention and outcomes of death, acute myocardial infarction and other major adverse cardiac event were assessed 24 hours post exercise stress testing.

RESULTS

Recruited patients (n=230) aged between 29 and 78 (mean age 56 ± 10 years) with 191 being males (83%) and 39 being females (17%). While 28 patients had a positive stress test (12.2%), there were no deaths, acute myocardial infarction or any other major adverse cardiac event within 24 hours of performing the exercise stress testing. Mean METS achieved were 8.1 ± 2.3.

CONCLUSIONS

Early exercise stress testing after primary percutaneous coronary intervention appears safe.

Interpretation of exercise stress test recordings: concordance between nurse practitioner and cardiologist

AIM

Cardiology nurse practitioners (NPs) conduct exercise stress tests (ESTs) for diagnosis of cardiac disease. The diagnostic concordance of NPs to cardiologists has not been assessed. The hypothesis was that an NP is as reliable as a cardiologist in determining ST-segment depression, detecting arrhythmias, and making a diagnostic assessment.

METHODS

An NP and two cardiologists (C1 and C2) were provided with 100 consecutive, anonymized ESTs, consisting of three 10-second, 12-lead tracings obtained at baseline, peak-exercise, and recovery. Interpretation was based on baseline rhythm, baseline and maximal exercise ST levels, arrhythmias, and global diagnosis (positive, negative, or inconclusive for ischemia). Raters used uniform criteria to interpret ESTs and were blinded to prior EST interpretation and computerized ST-segment analysis.

RESULTS

There was similar concordance between the NP and cardiologists as between the cardiologists, measured by Kappa coefficients (rhythm: NP vs. C1 = .92, NP vs. C2 = .84, C1 vs. C2 = .84; arrhythmias: NP vs. C1 = .77, NP vs. C2 = .73, C1 vs. C2 = .75; EST diagnosis: NP vs. C1 = .75, NP vs. C2 = .73, C1 vs. C2 = .75). Pearson correlations demonstrated concordance for baseline ST levels (NP vs. C1 = .86, NP vs. C2 = .86, C1 vs. C2 = .90) and peak exercise ST levels (NP vs. C1 = .58, NP vs. C2 = .48, C1 vs. C2 = .67).

CONCLUSIONS

Concordance among raters, and with the computer-generated algorithm, was moderate to high for all parameters of EST interpretation. This study lends support to NPs interpreting ESTs.

Reproducibility and safety of the incremental shuttle walking test for cardiac rehabilitation

The incremental shuttle walking test (ISWT) is recommended to assess the exercise capacity of patients attending cardiac rehabilitation (CR) as a cost-effective alternative to the treadmill test. We used the Bland Altman limits of agreement method on 353 paired ISWTs to explore whether the recommended practice test is necessary. The mean increase in distance from the practice to the second walk was 29.5 m (95% CI 23.0, 36.0) p<0.001, confirming the need for the practice walk when undertaking the ISWT.