Causes and Timing of Unplanned ICU Admissions Among Trauma Patients at a Level 1 Trauma Center

BACKGROUND

Unexpected ICU admissions are a key quality metric in trauma care. The purpose of this study is to identify the most common causes of unplanned ICU admissions among trauma patients at an ACS-verified level 1 trauma center.

METHODS

A retrospective review was conducted of all trauma patients with unplanned admission to the ICU at a level 1 trauma center between 2019 and 2021. Unplanned ICU admissions were categorized into (1) "bounce-backs," patients previously admitted to the ICU and (2) "upgrades," patients who had not previously been cared for in the ICU.

RESULTS

Of 300 unexpected ICU transfers, bounce-backs accounted for 69% and upgrades 31%. The most common injuries were traumatic brain injuries (40%) and rib fractures (41.3%). In-hospital mortality rate was 10% and did not significantly differ between bounce-backs and upgrades (12 vs 5%, P = .92). Respiratory distress was the most common cause of transfer (41.1%), followed by neurologic (29.6%) and cardiovascular decline (21.2%). Patients were on average 928 mL fluid positive 72 hours prior to transfer (t > 0, P < .0001), and 295 mL fluid positive in the 24 hours prior to transfer (t > 0, P .0003). Patients transferred for respiratory distress were no more fluid over-balanced than those transferred for other reasons.

CONCLUSION

We found a large percent of unplanned transfers occurring within 48 hours of admission or transfer out of the ICU suggesting under-triage as a leading cause of bounce-backs and upgrades. Respiratory distress was the leading cause of transfer. These findings highlight opportunities for targeted interventions.

Valvular Heart Disease

Valvular heart disease is a common abnormality seen in the primary care setting. There are many causes of valvular heart disease including congenital, degenerative, infectious, traumatic, and many more. There is a wide variety of types of valvular heart disease with each valve having the ability to develop both regurgitation and stenosis by multiple mechanisms. All these complexities make diagnosis and management of valvular heart disease complicated, especially in the context of comorbidities. For this reason, it is important for primary care physicians to have a thorough understanding of how these diseases present and when interventions are indicated.

Atherosclerosis Vindicated: A Case of Chest Pain Due to Capecitabine-Induced Coronary Artery Spasm

BACKGROUND Capecitabine and other 5-fluorouracil prodrugs are medications widely employed in treating solid tumors, including breast and colorectal cancer. However, they carry a notable risk for cardiotoxicity, including coronary vasospasm, possibly related to their impact on vascular endothelium and smooth muscle. CASE REPORT We present a case of a 45-year-old male with a pancreatic neuroendocrine tumor who developed exertional chest pain after starting capecitabine. Initial evaluations in the emergency department, including a 12-lead electrocardiogram and cardiac enzymes, were normal, but suspicion for coronary vasospasm persisted due to the temporal relationship with drug initiation and symptom characteristics. A graded exercise test reproduced his symptoms, accompanied by hyperacute peaked T waves and subsequent ST segment elevations in the inferior leads. Coronary angiography revealed patent coronary arteries, rendering provocative testing unnecessary due to a high clinical suspicion of capecitabine-induced vasospasm. Discontinuing the patient's medication was a more efficient approach than continuing additional cardiac workup while the drug was still administered. After multidisciplinary discussion, capecitabine was discontinued, leading to symptom resolution and a negative repeat graded exercise test. CONCLUSIONS This case underscores the potential for capecitabine to induce coronary artery vasospasm, emphasizing the importance of prompt medication cessation. Patients receiving capecitabine therapy and experiencing chest pain should undergo an evaluation with consideration of capecitabine-induced vasospasm in the differential diagnosis. Prompt recognition and medication cessation are critical to prevent serious cardiovascular complications including death. In our patient, discontinuing capecitabine resolved his symptoms, emphasizing the significance of discontinuing the causative drug and seeking alternative chemotherapy regimens.

Neurocognitive Profiles of 22q11.2 and 16p11.2 Deletions and Duplications

Rare recurrent copy number variants (CNVs) at chromosomal loci 22q11.2 and 16p11.2 are among the most common rare genetic disorders associated with significant risk for neuropsychiatric disorders across the lifespan. Microdeletions and duplications in these loci are associated with neurocognitive deficits, yet there are few studies comparing these groups using the same measures. We address this gap in a prospective international collaboration applying the same computerized neurocognitive assessment. The Penn Computerized Neurocognitive Battery (CNB) was administered in a multi-site study on rare genomic disorders: 22q11.2 deletion (n = 397); 22q11.2 duplication (n = 77); 16p11.2 deletion (n = 94); and 16p11.2 duplication (n = 26). Domains examined include executive functions, episodic memory, complex cognition, social cognition, and sensori-motor speed. Accuracy and speed for each neurocognitive domain were included as dependent measures in a mixed-model repeated measures analysis, with locus (22q11.2, 16p11.2) and copy number (deletion/duplication) as grouping factors and neurocognitive domain as a repeated measures factor, with age and sex as covariates. We also examined correlation with IQ and site effects. We found that 22q11.2 deletions were associated with greater deficits in overall performance accuracy than 22q11.2 duplications, while 16p11.2 duplications were associated with greater deficits than 16p11.2 deletions. Duplications at both loci were associated with reduced speed. Performance profiles differed among the groups with particularly poor performance of 16p11.2 duplication on non-verbal reasoning and social cognition. Average accuracy on the CNB was moderately correlated with Full Scale IQ. No site effects were observed. Deletions and duplications of 22q11.2 and 16p11.2 have varied effects on neurocognition indicating locus specificity, with performance profiles differing among the groups. These profile differences can help inform mechanistic substrates to heterogeneity in presentation and outcome. Future studies could aim to link performance profiles to clinical features and brain function.

What techniques are recommended to undertake procedures that require asepsis? Content and cluster analysis of information supplied in international guidance

BACKGROUND

Health professionals frequently conduct procedures requiring asepsis but there is no definitive evidence-based guidance on how aseptic technique should be undertaken.

OBJECTIVE

To undertake content and cluster analysis to compare and contrast information relating to the conduct of aseptic technique in national and international guidance.

METHODS

Content and hierarchical cluster analysis.

RESULTS

We identified 16 sources of information from: organizations that generate infection prevention guidelines, provide advice about infection prevention in addition to other topics, generate guidance for procedures (e.g., wound care); practice manuals; MeSH and Wikipedia. Content related to: theory underpinning aseptic technique; terminology used; how and when it should be undertaken; and equipment. The nature and amount of information varied widely. Most frequently stated information related to: environment or equipment (N = 13), followed by the absolute nature of asepsis and the importance of hand hygiene (N = 10); general personal protective equipment, the significance of pathogens, and no-touch techniques (N = 8); that it is risk-based (N = 7); the existence of key parts or sites, and that there are different types of aseptic technique (N = 6). The most comprehensive sources were a wound care organization in the USA, and a British internationally used textbook. Least information was provided in some general infection prevention guidelines.

CONCLUSION

Progress with research and practice in relation to aseptic technique suffers through lack of common goals and understanding. This study is one step towards establishing what constitutes aseptic technique, how and when it should be conducted, and the equipment necessary. This is required to support practice, policy and education, and may improve sustainability of healthcare resources.

A soldier's return to duty after minimally invasive correction of complex congenital cardiovascular disease

We report a case of incidental detection of severe aortic coarctation, severe secundum atrial septal defect, and bicuspid aortic valve in an active-duty military service member. A single complex minimally invasive procedure successfully corrected his coarctation and atrial septal defect allowing this patient to continue military service.

Using a co-designed, self-delivered, Avatar-based patient discharge education application to improve acute coronary syndrome patient knowledge

Background

30-day rehospitalisation following heart event among acute coronary syndrome (ACS) patients remains high and is largely contributed by poor disease-related knowledge and self-management, especially in the disadvantaged patient groups such as those with low education levels and inadequate health literacy. Traditional patient education methods fail to address these issues.

Purpose

This study aimed to test a unique consumer co-designed discharge education application (app) on patients' knowledge and its acceptability.

Methods

ACS patients (unstable angina, non-STEMI or STEMI) were recruited from Royal Adelaide Hospital at South Australia during admission, provided with the app via tablet for one-month self-delivered education. The app has undergone a rigorous development process with the substantial engagement of consumers (Figure 1). App content includes the Heart Foundation Six Steps to Cardiac Recovery including disease-related knowledge, risk factor management, and ACS responses, assessed at baseline, followed by first use at discharge and one month later. Patients and cardiac nurses rated the acceptability of the app.

Results

Among 22 Participants 81.8% were male (n=18), with a mean age of 59.7 (10.3) years, 45.5% (n=10) had not completed high school and nearly a quarter of the participants had marginal or below marginal health literacy. The diagnosis included STEMI (n=16, 72.7%) and non-STEMI (n=5, 22.7%). The majority of participants underwent percutaneous coronary intervention (PCI) (n=21, 95.5%)

Significant improvements were observed for overall coronary artery disease knowledge at one month (p=0.003) and the exercise and nutrition domains at discharge (p=0.029; p&lt;0.001) and one month (p=0.02; p=0.003) (Figure 2). Significant improvements were also observed for ACS knowledge and beliefs at discharge (p=0.008; p=0.038) and one month (p&lt;0.001; p=0.025) when ACS response attitude was also significantly improved at one month (p=0.036). Overall acceptability was high at 7.7/10 (n=22 nurses) and 8.3/10 (patients). The participants described the app as `clear, simple, easy to understand, as well as stimulating and interactive, better than a live person'.

Conclusion

This novel, self-delivered Avatar-based ACS discharge education App has the potential to provide discharge education for ACS patients even for those who have low education levels or inadequate health literacy. Results need to be confirmed in a randomised controlled trial.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The National Heart Foundation Australia

Mortality, morbidity, and cardiovascular risk factor outcomes from cardiac rehabilitation, in ethnic minorities: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Abstract

Background

Cardiac rehabilitation (CR) is a secondary prevention intervention for coronary heart disease that has well-established efficacy in reducing mortality, morbidity, and cardiovascular risk factors. However, outcomes from CR are known to differ between population groups, with ethnic minorities reported to have health outcome disparities. However, there is no synthesis of these CR outcomes for ethnic minority populations.

Purpose

The main purpose of this study was to evaluate the impact of CR on rates of mortality, morbidity, and important cardiovascular risk factor outcomes including exercise performance, exercise capacity, low-density lipoproteins, cholesterol levels, body mass index, weight, waist circumference and systolic blood pressure, within ethnic minority groups.

Methods

Four electronic databases (Medline, EMBASE, CINAHL, Scopus) were searched from February to September 2021, for studies that reported CR outcomes of ethnic minorities. Potential papers were independently screened by two reviewers, and discrepancies were resolved by a third reviewer. Data was extracted from the studies using an electronic data extraction form. Meta-analyses for eligible studies were performed using Revman 5.4. Risk of bias were assessed using the Cochrane Tool.

Results

Across 13 studies (n = 132,109 participants), the 10,494 participants of ethnic minority groups achieved significant improvements in mortality, morbidity, and most cardiovascular risk factor outcomes including exercise performance, exercise capacity, body mass index, waist circumference, and systolic blood pressure. However, while ethnic minority groups achieved equivalent outcomes from CR for exercise performance and low-density lipoproteins, some outcomes were worse (exercise capacity, body mass index, waist circumference, systolic blood pressure). In addition, minority participants had greater reductions in cholesterol levels.

Conclusion

Ethnic minority groups achieve important improvements in mortality, morbidity, and cardiovascular risk factor outcomes from CR, although to a lesser extent than majority groups. Therefore, this information can be used to support efforts to improve participation in CR and prompt changes to the delivery of CR services for ethnic minority participants.

Pushing to keep going, scared: a qualitative study exploring why transcatheter aortic valve implantation to treat aortic stenosis is a highly acceptable intervention to patients and carers

Funding Acknowledgements

Type of funding sources: None.

Background

Contemporary options to treat severe, symptomatic aortic stenosis (AS) include transcatheter and surgical approaches (TAVI and SAVR). Evidence continues to accumulate for minimally invasive TAVI to be used to treat AS for expanding patient groups, however patients experiences are seldom investigated.

Purpose

The aim of this study was to explore patients and carers perspectives of the acceptability of TAVI as a treatment option for AS, in the context of their values, attitudes, and the burden and effectiveness of intervention, to better guide expectations and management of recovery.

Methods

Older patients (n=18) and their carers (n= 8) were interviewed 4-6 months post TAVI. Data was themed deductively by applying the theoretical framework of acceptability (1) as an analytic lens, followed by inductive analysis to identify any further emergent themes.

Results

The mean age of patient participants was 85 ± 5 years and 33% were women. Patients experiences of severe AS symptoms (e.g., breathlessness and fatigue) resulted in growing emotions of ‘struggling and pushing to keep to going’ in their daily lives, a few thought they were ‘nearly gone’ and expressed feelings of being scared. Debilitating AS symptoms, and a challenge to the values of this older patient group were the major influencing factors informing high prospective acceptability of the TAVI. Patients and their carers perceived the TAVI procedure to be a ‘good operation’ because of a short hospital stay and minimal disruption to their lives. Low burden resulted in high levels of concurrent acceptability of TAVI. Most patients experienced gradual symptom relief and being able to ‘get back to normal’, be independent and reconnect with valued pastimes, leading to high retrospective acceptability of the intervention for both patients and carers.

Conclusion

Patients and carers perceive TAVI to have high prospective, concurrent, and retrospective acceptability as improved symptoms restored mental wellbeing, the procedure was uncomplicated and operative burden was low, and most patients regained functional capacity and a return to their normal lives. The need to assess acceptability of interventions, such as TAVI, from the perspectives of patients and carers is increasingly becoming important in health care, not only better support patients and carers but to inform effective implementation and sustainability of treatment modalities.

I really want to know what is wrong with my heart and what should I do a qualitative study of information needs among Chinese immigrants

Funding Acknowledgements

Type of funding sources: None.

Background

The health information needs of immigrants who have heart disease are poorly understood, despite the important role of patient knowledge in improving symptom recognition and control, prevention, and health-rated outcomes.

Purpose

This study explored disease-related information needs among Chinese immigrants with heart disease.

Methods

The study followed an exploratory qualitative design. Immigrants with heart disease from Chinese community associations in Sydney, Australia were recruited to participate in the interviews. Data were analysed using thematic analysis.

Results

Participants (n=20) were aged mean 75±7 years and had lived in Australia for mean 16 ± 8 years. The majority were female (65%), and had poor English language proficiency (95%), poor self-reported health (90%).

Two main themes generated from interviews were related to culture and language influence in terms of accessing and interpreting health information. Other themes were primarily related to deficits, in heart disease-related knowledge, understanding of the healthcare system, and health information resources.

Conclusions

Immigrants with heart disease in this study have multiple health information and education needs related to personal and system factors inadequately addressed by healthcare services. Culturally and linguistic appropriate health information and support services are recommended to improve disease knowledge and appropriate use of healthcare services.

Remote delivery of cardiac rehabilitation can achieve equivalent health-related quality of life outcomes to in-person methods in patients with coronary heart disease: a multi-site study

Funding Acknowledgements

Type of funding sources: None.

Background In-person exercise-based cardiac rehabilitation (CR) has well-established benefits for health-related quality of life (HRQL) for patients with coronary heart disease (CHD). During COVID-19 pandemic restrictions, remote delivery replaced in-person CR, but the impact on HRQL is unclear. This study addresses this gap.

Methods Consecutive patients commencing CR at four sites in one Local Health District in Sydney were recruited (n = 194), recruited from December 2019 to October 2020. Remote delivery from March 2020 created a natural comparison group to in-person CR. HRQL was measured at CR entry and completion using the SF-12v2 and linear regression was used for analyses.

Results Participants were aged mean 65.94 (SD 10.45) years, were 80.9% male and diagnoses included elective PCI (37.9%), CABG (26.7%), and MI (34.9%) either with PCI (23.6%) or alone (11.3%). Participants received remote (n = 103, 53.1%) or in-person (n = 91, 46.9%; ≥ assessment + 2 sessions) CR, with more completions for in-person (75.8% vs 63.1%, p=.03). Remote participants were more likely to be white than ethnic minority (35.2% vs 13.6% p&lt;.001), however, there were no differences in baseline HRQL for delivery group after adjustment.

HRQL improved from CR entry to completion regardless of delivery mode (adjusted). Most improvements occurred in physical function (SMD 6.37, 95% CI 4.81,7.92), role physical (SMD 5.72, 95% CI 4.29. 7.16) and physical component (SMD 5.77 95% CI 4.43, 7.12) scores. Least improvement occurred in mental component scores (SMD 1.65, 95%CI .53, 2.78).

Conclusion Remotely delivered CR provides comparable HRQL outcomes to in-person delivery, thus providing a promising alternative. Data are needed on cost-effectiveness, as well as staff and patient preferences.

Womens health-related quality of life substantially improves with tailored cardiac rehabilitation: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Women have poorer outcomes from coronary heart disease (CHD) compared to men and participation in exercise-based cardiac rehabilitation (EBCR) offers an opportunity for improvement. However, synthesised evidence for women-specific patient-reported outcomes are often lacking. We aimed to synthesise HRQL outcomes from EBCR in women with CHD.

Methods

Four electronic databases (PUBMED, CINAHL, SCOPUS and Cochrane) were searched for studies reporting HRQL using validated measures in women attending EBCR. Two reviewers independently screened papers and extracted data. Random effects model (RevMan v5.4) was used for analysis.

Results

Eleven studies (1292 women participants) were included: six observational, three randomised controlled trials, and two quasi-experimental design. Seven studies were included in the meta-analyses. EBCR participation was associated with HRQL benefits in several domains of the Short-Form (SF-12 or 36). Improvements were greatest in Role Physical (MD 19.09 95% CI 2.37, 35.81), Physical Functioning (MD 10.43, 95% CI 2.60, 18.27) and Vitality (MD 9.59, 95% CI 0.31, 18.86). When tailored components were added to traditional EBCR, gains in HRQL were also observed, specifically in Bodily Pain (MD 9.82, 95% CI 4.43, 15.21), Role Physical (MD 8.48, 95% CI 1.31, 9.97), Vitality (MD 8.17, 95% CI 3.79, 12.55), General Health (MD 5.64, 95% CI 1.31, 9.97), and Physical Function (MD 5.61, 95% CI 0.83, 10.40) domains.

Conclusion

Women attending EBCR achieve clinically meaningful improvements in multiple areas of HRQL, and additional benefits were seen when strategies tailored to their needs and preferences were included. Future research should focus on promoting EBCR uptake in women.

Human connection: a valuable element for health-related quality of life outcomes in cardiac rehabilitation during COVID-19

Funding Acknowledgements

Type of funding sources: None.

Background The COVID-19 pandemic restrictions have pivoted in-person cardiac rehabilitation (CR) to remote delivery via telehealth. Patient perceptions on their CR participation in these models can guide CR coordinators improve program elements.

Purpose To qualitatively explore patient perceptions and experiences on how CR influenced their health-related quality of life (HRQL).

Methods A purposive sample of 16 patients were recruited, ensuring representation from four participating CR sites, gender, age, and mode of CR delivery. Semi-structured telephone or video interviews were conducted at six months following CR completion. Interviews were audio-recorded, transcribed verbatim and analysed using Braun and Clarke’s six-step thematic analysis.

Results Perceptions and experiences of patients were positive overall and similar between the two models. Three main themes were identified: value of human connection, benefits of exercise and need for more individualised approaches, and importance of telehealth as an adjunct to in-person CR. Patients have expressed the value of interacting with health care professionals and socialising with peers in similar circumstances; and the absence of these interactions was palpable to those who attended telehealth. Exercises were beneficial but needed to be tailored to individual capabilities and preferences. Telehealth offered convenience and was generally accepted. However, telehealth should be complementary and not a replacement to in-person CR. 

Conclusions Meaningful personal interactions with health care providers and other CR participants are most appreciated by patients in both in-person and telehealth models. Exercises are perceived to be more beneficial when individualised. Long-term outcomes from alternative CR delivery models should be evaluated.

Fit, Female or Fifty - is cardiac rehabilitation fit for purpose? A systematic review and meta-analysis with meta-regression

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac rehabilitation (CR) is a multi-disciplinary, evidence-based intervention, aimed to address modifiable risk factors for coronary artery disease. It is recommended worldwide for patients following myocardial infarction (MI), Percutaneous Coronary Intervention (PCI) and cardiac surgery. A growing body of evidence points towards a lack of uptake in CR in females and younger people.

Purpose

To examine the effectiveness of contemporary CR programs and assess whether they cater for all patients regardless of age, gender and prior level of fitness, via systematic review, meta-analysis and meta-regression.

Methods

MEDLINE was examined for studies involving exercise prescription or CR following MI, PCI and cardiac surgery from January 2010 to May 2020. RCTs and cohort studies of ≥10 patients were included for programs delivering phase II or III CR. Primary outcome measures were peakVO2max, 6-minute walk test (6MWT) and Metabolic Equivalent of Task (METs). Data were extracted using random effects meta-analysis. Epidemiological data were analysed for age, proportion of males to females and prior level of fitness. Baseline level of fitness was assessed by peakVO2max, 6MWT and METs values on entry into CR programs. Meta-regression was then used to determine change in fitness and the influence of age or gender.

Results

Thirty-three of the 713 studies (13 RCT, 20 cohort) were eligible and included in the review. Participants had a mean age of 60.0 years and 6/49 (12%) of study groups had a mean age &lt;55 years. Male participants comprised 81.9% of those who completed CR and 41/58 (71%) participants were below average for cardiorespiratory fitness (CRF) when compared to normative values for those aged 60-69 years on entering CR.

CRF improved in all study groups by the end of CR programs (mean improvement in peakVO2 3.3mL/kg/min, 6MWT 90.8m and METs 1.7). Meta-regression analysis showed that males were more likely to have an increase in 6MWT distance compared to females (mean difference 3.16m (95% CI 0.44-5.89). However, gender and age did not independently affect peakVO2max or METs.

Conclusion

CR following MI, PCI or cardiac surgery improved mean CRF in all study groups. While males were more likely to show an improvement in 6MWT there was no appreciable difference in effect in other outcomes after controlling for age or gender differences.

Females, younger people and those of average or above CRF appear to be under-represented in data and attendance at cardiac rehabilitation. Given that CR outcomes are equal across gender and age, more effort should be made to encourage female and younger patients to attend. A ‘Precision Medicine’ model of exercise prescription may assist in this aim.

Impact of cardiac rehabilitation on 3 year outcomes amongst patients after acute coronary syndrome: (ACS) SNAPSHOT ACS follow-up study

Background

Cardiovascular disease is the leading cause of disease burden globally. With advancements in medical and surgical care more people are surviving initial acute coronary syndrome (ACS) and are in need of secondary prevention and cardiac rehabilitation (CR). Increasing availability of high quality individual-level data linkage provides robust estimates of outcomes long-term.

Purpose

To compare 3 year outcomes amongst ACS survivors who did and did not participate in Australian CR programs.

Methods

SNAPSHOT ACS follow-up study included 1806 patients admitted to 232 hospitals who were followed-up by data linkage (cross-jurisdictional morbidity, national death index, Pharmaceutical Benefit Schedule) at 6 and 36 months to compare those who did/not attend CR.

Results

In total, the cohort had a mean age of 65.8 (13.4) years, 60% were male, only 25% (461/1806) attended CR. During index admission, attendees were more likely to have had PCI (39% v 14%, p&lt;0.001), CABG (11% v 2%, p&lt;0.001) and a diagnosis of STEMI (21% v 5%, p&lt;0.001) than those who did not attend. However, there was no significant difference between CR attendees/non-attendees for risk factors (LDL-cholesterol, smoking, obesity). Only 19% of eligible women attended CR compared to 30% of men (p&lt;0.001). At 36 months, there were fewer deaths amongst CR attendees (19/461, 4.1%) than non-attendees (116/1345, 8.6%) (p=0.001). CR attendees were more likely to have repeat ACS, PCI, CABG at both 6 and 36 months (Table). At 36 months, CR attendees were more likely to have been prescribed antiplatelets (78% v 53%, p&lt;0.001), statins (91% 73%, p&lt;0.001), beta-blockers (11% v 13%, p=0.002) and ACEI/ARBs (72% v 61%, p&lt;0.001) than non-attendees.

Conclusions

Amongst Australian ACS survivors, participation in CR was associated with less likelihood of death and increased prescription of pharmacotherapy. However, attendance at CR was associated with higher rates of repeat ACS and revascularisation.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): New South Wales Cardiovascular Research Network, National Heart Foundation

Being married/having an intimate partner/being has protective effects for mild cognitive impairment in acute coronary syndrome patients

Background

Cardiovascular disease (CVD) is a leading cause of mortality and morbidity and is known to contribute to cognitive impairment, a condition common in CVD patients. Cognitive impairment (CI) is important to detect, manage and accommodate because it limits the capacity of CVD patients to learn about secondary prevention and engage in appropriate self-care including lifestyle change.

Purpose

Therefore this study aimed to determine the prevalence and predictors of cognitive impairment in acute coronary syndrome (ACS) patients during hospital admission.

Methods

ACS (myocardial infarction, unstable angina) inpatients (n=81) who did not have a neurocognitive diagnosis were recruited to a prospective descriptive study in 2019. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) and the Hopkins Verbal Learning Test (HVLT).

Results

The sample had an age mean of 63.49±10.86 (range 40–89) years, was mostly male (82.7%) and 50.6% were university educated. MI occurred in 56.8%, equally STEMI (28.4%) and nSTEMI (28.4%) with 70.4% treated by coronary intervention.

The mean education adjusted MOCA score was 25.73±3.05 (range 18–31) and 48.1% were classified as having mild CI (18–26). The domain with the worst performance was delayed recall/memory domain at mean 2.58±1.77 (of potential 0–5 points). The mean unadjusted recall score on HVLT was 19.56±6.18 (range 0–32), the mean z-score −0.69±1.21 (range −4.59–1.87) and 40.7% were classified as having mild CI (age and education adjusted Z-score ≥−1). Mild CI was classified by both MOCA and HVLT (both adjusted) in 24.7%.

Patients classified as having mild CI (MOCA) were significantly older (66.87 versus 60.36 years, p=0.006) and less likely and to be married or have an intimate partner (21% versus 32% p=0.039). When all factors were taken into account using multiple linear regression, higher MOCA scores in patients who were married/partnered (B=1.6) and lower scores with advancing age (B=−0.08).

Conclusions

Mild CI and decreased delayed recall is prevalent in ACS patients and patient education strategies need to be accommodate this. Being married/partnered may have protective effects, therefore additional support may need to be directed to single patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Heart Foundation of Australia Vanguard Award

National quality indicators to promote cardiac rehabilitation service effectiveness in Australia

Background/Introduction

Comprehensive exercise-based cardiac rehabilitation (CR) has well-established efficacy and effectiveness for improving patients' outcomes. There is substantial variability in terms of clinical effectiveness and quality measurement of CR programs internationally which limits service improvement initiatives. In Australia in 2018 a the Australian Cardiovascular Health and Rehabilitation Association (ACRA) and the National Heart Foundation of Australia (NHFA) combined forces to develop nationally-agreed, internationally-consistent, locally-relevant quality indicators (QI).

Purpose

To provide a minimum set of standardised national-level QI that should be collected and reported on by CR programs to determine the quality of delivery and associated outcomes, benchmark performance and support improvement processes.

Methods

We formed the National Cardiac Rehabilitation Measurement (NCRM) Taskforce led by ACRA and NHF and used the National Institute for Health and Care Excellence (NICE) UK guidelines to develop high quality QIs. The process included topic overview, prioritising areas for quality improvement, drafting and consultation, validation and consistency checking.

Results

Eleven preliminary QIs were circulated for ranking and comment to all ACRA members (predominately multidisciplinary CR providers) (68 responses), and to leading national multidisciplinary CR experts from cardiology, research, physiotherapy, nursing, epidemiology and register backgrounds (7 responses). Ratings, comments and suggestions were collated and discussed by the NCRM Taskforce, and the indicators rated most important, useful and feasible were retained, resulting in 10 QIs. These 10 QIs were presented at the ACRA national conference and then discussed at a workshop (55 participants) for this purpose. Ten QIs and accompanying data dictionary with definitions, evidence and allowable values is the final product.

Conclusions

A minimum set of locally relevant, internationally recognised, national QIs for CR is now available for CR providers, health service managers and researchers in Australia, which may be relevant internationally. The QIs will best serve national interests incorporated within a national cardiac registry but will also be useful for site audits and have strong potential to be aggregated across sites, health districts and states. The definitive test of the QIs will be how useful they are for CR program coordinators and funders of such programs; a key consideration for building sustainable business models and ensuring long-term implementation.

Funding Acknowledgement

Type of funding source: None

223Atrial fibrillation screen, management and guideline recommended therapy (AF SMART II) in the rural primary care setting: eHealth tools to support all stages of screening

Funding Acknowledgements

National Heart Foundation of Australia: CVRN Grant and Vanguard Grant; investigator-initiated grant from Pfizer-BMS; AliveCor provided free devices

BACKGROUND

Internationally, most atrial fibrillation (AF) management guidelines recommend screening for AF in people aged ≥65 years, as well as treatment with oral anticoagulants (OAC) for those at high stroke risk ( CHA2DS2-VA ≥2). However, in practice, gaps remain in both screening and treatment. In Australian general practice in 2017, the estimated rate of AF screening was 11%, and only about 60% of diagnosed AF patients received guideline-based OAC. Our 2018 screening study using eHealth tools in metropolitan general practices increased screening to 16% of eligible patients, leading to further refinement of the eHealth tools.

PURPOSE

To investigate the impact of an AF screening program in rural general practices, using a suite of custom-designed eHealth tools designed to increase the proportion screened and treated for AF in accordance with guidelines.

METHODS

General practices (n = 8) in rural New South Wales, Australia participated in the study between September 2018 – June 2019. General practitioners (GPs) and practice nurses conducted opportunistic screening of eligible patients (i.e. aged ≥65 years without existing AF diagnosis) using a smartphone electrocardiogram during practice visits. Practices were also provided with 1) an electronic screening prompt (which appeared when an eligible patient’s file was opened); 2) electronic decision support based on ESC/Australian treatment guidelines; and 3) regular customised data reports aimed at quality improvement (Figure 1). A clinical audit tool was used to extract deidentified data from practices.

RESULTS

A total of 3,103 eligible patients (mean age 75.1 ± 6.8 years, 47% male) who attended the 8 practices during the study period were screened (median screening period 4.6 months). Practices screened a median of 35% of eligible patients (range 9-51% per practice), with 4/8 practices screening &gt;40% of eligible patients. 36 (1.2%) new cases of AF were confirmed (mean age 77.0 years, 64% male, mean CHA2DS2-VA = 2.9). GPs (n = 22) screened 30% (range 1-182 per GP) of patients and nurses (n = 40) screened 70% (range 1-192 per nurse). OAC treatment rates of patients with AF with CHA2DS2-VA≥2 were 82% (screen-detected), 78% (clinically-detected during study period) and 75% (pre-existing AF), with no significant differences between groups.

CONCLUSIONS

In the rural general practice setting, an AF screening program supported by eHealth tools resulted in 35% of eligible people screened, which is substantially higher than the 16% achieved in our previous study. Half the practices screened 40-50% of eligible patients, suggesting this may represent a ‘ceiling’ of patients captured by opportunistic AF screening programs. OAC treatment rates were higher than previous studies at baseline and were trending upwards during the study. eHealth tools, particularly including customised data reports as part of an audit and feedback system, may be a valuable addition to future screening programs.

Abstract Figure 1 - screening process

P202 Are Chinese immigrants with CVD ready to use web-based health information: a comparative study in Australia

Background

Immigrant populations often have poor access to cardiovascular disease (CVD) secondary prevention due to linguistic and cultural barriers. Web-based interventions are effective in risk reduction and lifestyle modification and may reach those hard-to-reach populations such as Chinese immigrants. However, less is known about the current use of web-based health information and confidence in use.

Purposes

We compared the use of web-based health information and confidence in use between Chinese immigrants with CVD to those with and without another chronic condition; and explored the factors associated with the confidence in utilization.

Methods

Chinese immigrants with CVD, musculoskeletal conditions, or no chronic condition were recruited from Chinese communities across New South Wales, Australia. E-health literacy scale was used to explore the perceptions of web-based health information and confidence in use. Demographic, clinical data and use of web-based health information were collected and health literacy was measured using a validated single screening question.

Results

Participants (n = 90 CVD, n = 87 musculoskeletal, n = 154 no chronic conditions) were aged mean 59 ± 16 years, mostly female (69%), 75% reported fair to poor English proficiency, and 51% had completed university. The most accessed web-based health information concerned lifestyle (60%), health resources (45%), diseases (35%), and medications (30%). More than half (54%) were confident in using web-based health information.

Participants with CVD were the oldest (71 vs 65 vs 49 years, p&lt;.001) and participants with any chronic condition had less education (p&lt;.001) and English proficiency (p&lt;.001) than the healthy group. Approximately half of the participants with CVD perceived web-based health information as useful (48%) and important (46%), and the most accessed information concerned lifestyle and medication (56% and 32%). Participants with CVD accessed medication information more often than musculoskeletal group (32% vs 23%), but there was no difference in accessing other information. Both chronic groups showed no difference in accessing web-based medication and lifestyle information compared with the healthy group. Confidence in using web-based health information was similar for CVD and musculoskeletal groups and lower than the healthy group (p&lt;.001).

Participants with the least confidence to use web-based health information were older (p=.016), female (p=.014), had less than university level education (p&lt;.001), and lower health literacy (p=.001) after adjusting for age, gender, education, English proficiency, employment status, social support, health literacy, and number of chronic conditions.

Conclusions

There is a strong potential to provide web-based medication and lifestyle information for Chinese immigrants with CVD if support is provided to improve confidence in this technology for older, women, and those with less education and/or health literacy.

Development of consensus-based international antimicrobial stewardship competencies for undergraduate nurse education

BACKGROUND

There is growing recognition by national and international policymakers of the contribution nurses make towards antimicrobial stewardship. Although undergraduate education provides an ideal opportunity to prepare nurses for antimicrobial stewardship roles and activities, only two-thirds of undergraduate nursing programmes incorporate any antimicrobial stewardship teaching and only 12% cover all the recommended antimicrobial stewardship principles. Nurses also report that they do not have a good knowledge of antibiotics, and many have not heard of the term antimicrobial stewardship.

AIM

To provide international consensus on the antimicrobial stewardship competency descriptors appropriate for undergraduate nurse education.

METHODS

A modified Delphi approach comprising two online surveys delivered to an international panel of 15 individuals reflecting expertise in prescribing and medicines management in the education and practice of nurses; and antimicrobial stewardship. Data collection took place between February and March 2019.

FINDINGS

A total of 15 participants agreed to become members of the expert panel, of whom 13 (86%) completed round 1 questionnaire, and 13 (100%) completed round 2. Consensus was achieved, with consistently high levels of agreement across panel members, on six overarching competency domains and 63 descriptors, essential for antimicrobial stewardship practice.

CONCLUSION

The competency descriptors should be used to direct undergraduate nurse education and the antimicrobial stewardship practices of qualified nurses (including those working in new roles such as Nursing Associates) due to the high levels of agreement reached on competency descriptors.