Background Although electrocardiographic monitoring is common in hospitalized patients, many patients receive unnecessary monitoring, contributing to patients’ inconvenience, clinicians’ alarm fatigue, and delayed admissions. Objective To evaluate the impact of implementation of an electronic order set based on the American Heart Association practice standards for electrocardiographic monitoring on the occurrence of appropriate monitoring. Methods The sample for this preintervention-to-postintervention quasi-experimental study consisted of 297 adult patients on medical, surgical, neurological, oncological, and orthopedic patient care units that used remote electrocardiographic monitoring in a 627-bed hospital in Minneapolis, Minnesota. The intervention was the introduction into the electronic health record of order sets prompting physicians to order electrocardiographic monitoring per the American Heart Association practice standards. Indications for monitoring according to the practice standards and adverse outcomes (unexpected transfer to intensive care unit, death, code blue events, and call for the rapid response team) were compared before and after implementation of the order set. Results Implementation of the order set was associated with an increase in appropriate monitoring (48.0% to 61.2%; P = .03); the largest increase was in ordering by medical residents (30.8% to 76.5%; P = .001). No significant increase in adverse patient outcomes was noted. Conclusions Implementation of the practice standards via an electronic order set was associated with a statistically significant increase in appropriate monitoring, with no increase in adverse events. Use of electronic order sets is an effective and safe way to enhance appropriate electrocardiographic monitoring.

Background Many medications commonly used in hospitals can cause prolonged corrected QT interval (QTc), putting patients at risk for torsade de pointes (TdP), a potentially fatal arrhythmia. However, documentation of QTc for hospitalized patients receiving QT-prolonging medications is often not consistent with American Heart Association standards. Objective To examine effects of education and computerized documentation enhancements on QTc documentation. Methods A quasi-experimental multisite study among 4011 cardiac-monitored patients receiving QTc-prolonging medications within a 10-hospital health care system was conducted to compare QTc documentation before (n=1517), 3 months after (n = 1301), and 4 to 6 months after (n = 1193) an intervention. The intervention included (1) online education for 3232 nurses, (2) electronic notifications to alert nurses when a patient received at least 2 doses of a QT-prolonging medication, and (3) computerized calculation of QTc in electronic health records after nurses had documented heart rate and QT interval. Results QTc documentation for inpatients receiving QTc-prolonging drugs increased significantly from baseline (17.3%) to 3 months after the intervention (58.2%; P < .001) within the 10 hospitals and had increased further 4 to 6 months after the intervention (62.1%, P = .75). Patients at larger hospitals were significantly more likely to have their QTc documented (46.4%) than were patients at smaller hospitals (26.2%; P < .001). Conclusion A 3-step system-wide intervention was associated with an increase in QTc documentation for patients at risk for drug-induced TdP, and improvements persisted over time. Further study is needed to assess whether increased QTc documentation decreases occurrence of drug-induced TdP. ( American Journal of Critical Care . 2015;24:e6–e15)

Background Guidelines recommend rest periods between nursing interventions for patients with a neurologic diagnosis but do not specify a safe number of interventions. Objectives To examine the physiological stress response to clustered nursing interventions in neurologic patients receiving mechanical ventilation. Methods Prospective, comparative, descriptive design to examine effects of clustered interventions (≥6 interventions in a single nursing interaction) versus nonclustered interventions on patients’ stress. Stress response was defined as a 10% change in end-tidal carbon dioxide from before the interaction to (1) 5 and 10 minutes after the start of the interaction, (2) at the end of the interaction, and (3) 15 minutes after the interaction. Results The mean percent change in end-tidal carbon dioxide at 5 minutes differed significantly between patients with clustered interventions and patients with nonclustered interventions (6.7% vs −0.2%; P = .001). Patients with clustered interventions were significantly more likely than patients with low clustering to exhibit a stress response at 5 minutes (24.3% vs 0%; P = .01). Conclusions Neurologic patients receiving mechanical ventilation who experienced 6 or more clustered nursing interventions showed a higher mean change in end-tidal carbon dioxide than did patients who received fewer than 6 clustered interventions. These findings suggest that providing fewer interventions during 1 nursing interaction may minimize induced stress in neurologic patients receiving mechanical ventilation.

Background Continuous ST-segment monitoring can be used to detect early and transient cardiac ischemia. The American Heart Association and American Association of Critical-Care Nurses recommend its use among specific patients, but such monitoring is routine practice in only about half of US hospitals. Objective To determine cardiologists’ awareness and practice standards regarding continuous ST-segment monitoring and the physicians’ perceptions of appropriate patient selection, benefits and barriers, and usefulness of this technology. Methods An electronic survey was sent to a random sample of 915 US cardiologists from a pool of 4985 certified cardiologists. Results Of 200 responding cardiologists, 55% were unaware of the consensus guidelines. Of hospitals where respondents admitted patients, 49% had a standard of practice for using continuous ST-segment monitoring for cardiac patients. Most cardiologists agreed or strongly agreed that patients in the cardiovascular laboratory (87.5%) and intensive care unit (80.5%) should have such monitoring. Cardiologists routinely ordered ST monitoring for patients with acute coronary syndrome (67%) and after percutaneous coronary intervention (60%). The primary factor associated with higher perceptions for benefits, clinical usefulness, and past use of continuous ST-segment monitoring was whether or not hospitals in which cardiologists practiced had a standard of practice for using this monitoring. A secondary factor was awareness of published consensus guidelines for such monitoring. Conclusion Respondents (55%) were unaware of published monitoring guidelines. Hospital leaders could raise awareness by multidisciplinary review of evidence and possibly incorporating continuous ST-segment monitoring into hospitals’ standards of practice.

• Background Decreases in neurocognitive function have been reported in patients who have undergone off-pump coronary artery bypass surgery; however, few investigators have examined the correlates of the decreases. • Objectives To explore and determine the correlates of neurocognitive function at the time of discharge from the hospital in patients undergoing off-pump coronary artery bypass surgery. • Methods Patients undergoing off-pump coronary artery bypass surgery at Abbott Northwestern Hospital, Minneapolis, Minn, were administered tests of neurocognition (cognition and motor function), anxiety, depression, and quality of life preoperatively (within 72 hours of surgery) and postoperatively (at least 72 hours after surgery but before discharge from the hospital). • Results A total of 54 patients (79.6% men), mean age 64.5 years, completed tests both preoperatively and postoperatively. When baseline function was controlled for, increased age and new-onset atrial fibrillation (F 3,40 = 42.97; P < .001) were associated with decreases in postoperative cognitive function; increased age and anxiety (F 3,35 = 15.83; P < .001) were associated with decreases in postoperative motor function. • Conclusion Older patients, anxious patients, and patients with new-onset atrial fibrillation are at risk for neurocognitive changes after off-pump coronary artery bypass surgery. Further studies with larger sample sizes should be done to examine interventions to reduce preoperative anxiety in these patients. Interventions to prevent postoperative atrial fibrillation should be explored to determine whether the interventions prevent a decline in neurocognitive function.

• Background Demand for complementary and alternative therapies is increasing and is affecting all healthcare settings, including critical care. • Methods A random sample of members of the American Association of Critical-Care Nurses was surveyed to determine the members’ attitudes, knowledge, perspectives, and use of complementary and alternative therapies. • Results Most of the 726 respondents were using one or more complementary and alternative therapies in practice. The most common therapies used were diet, exercise, relaxation techniques, and prayer. A majority of the nurses had some knowledge of more than half of the 28 therapies listed on the survey, and a majority desired additional training for 25 therapies. Respondents generally required more evidence judged as essential to use or recommend conventional therapy than to use or recommend complementary and alternative therapies. Nurses viewed complementary and alternative therapies positively overall, were open to use of the therapies, and perceived them as legitimate and beneficial to patients. Nurses judged the therapies helpful for treatment of a variety of symptoms. A majority of nurses desired an increase in the availability of the therapies for patients, patients’ families, and nursing staff. Nurses’ professional use of the therapies was related to having more knowledge of them, perceiving benefits of them, total number of therapies they recommended to patients, personal use, and affiliation with a mainstream religion. • Conclusions Educational programs that provide information about use of complementary and alternative therapies and the underlying evidence base most likely will increase the appropriate use of the therapies to achieve desired outcomes.