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Open Access Publications from the University of California

Scholarly Works (7 results)

  • Article
  • Peer Reviewed
UCSF Open Access Publishing Fund (2019)
    • Thesis
    • Peer Reviewed
    UC San Francisco Electronic Theses and Dissertations (2021)

    Significance: Early studies showed that premature ventricular complexes (PVCs) were associated with lethal arrhythmias (ventricular tachycardia (VT) and ventricular fibrillation (VF)) and death in patients with acute myocardial infarction (MI). However, the Cardiac Arrhythmia Suppression Trial (CAST) showed that treatment of PVCs with antiarrhythmics was associated with death. As a result, aggressive pharmacological treatment of PVCs was no longer standard practice. Nevertheless, continuous monitoring for PVCs remains routine care in the intensive care unit (ICU), mainly due to clinicians’ fear of missing patients at risk for developing lethal arrhythmias. Although studies examining the significance of PVCs in outpatient settings exist, similar evidence is lacking in hospital settings, especially in the ICU.

    Methods: We performed a literature review of the evidence of the diagnostic and prognostic significance of PVCs utilizing the frameworks for scoping review by Arksey and O’Malley and the Joanna Briggs Institute (JBI). We synthesized the results and described the significance of PVCs in patients with and without cardiac disease in the community and hospital settings. We evaluated occurrence rates of PVC alarms in 446 ICU patients and determined whether demographics (age, sex, race) and clinical characteristics (medical history, presence of PVC and atrial fibrillation on baseline 12-lead ECGs, serum potassium, ejection fraction, and primary diagnosis) were associated with six PVC types (i.e., isolated, bigeminy, trigeminy, couplet, R-on-T, and run PVC). Using logistic regression modeling, we determined if any of the six PVC types were associated with the occurrence of lethal arrhythmias (ventricular tachycardia and ventricular fibrillation), code blue, and death.

    Results: Existing evidence largely examined the prognostic value of PVCs in the outpatient settings on several patient outcomes, such as left ventricular dysfunction, arrhythmia development, and mortality. Only three studies, done in the 1970s, evaluated the significance of PVCs in acute MI. Isolated PVCs were the most common type, accounting for 81.3% (646,666 out of 797,072 individual PVC alarms), and were concentrated in a small subgroup of patients. We found that none of the six PVC types were associated with VT events and death. Due to the small sample size, we could not determine a similar association for VF and code blue outcomes.

    Conclusion: This dissertation represents current “real-world” clinical practice regarding PVC monitoring from a large time-series dataset during continuous ECG monitoring in the ICU. PVC monitoring was shown to be non-specific and likely not clinically meaningful, leading to an increased alarm burden and alarm fatigue. Therefore, the clinical team should strategize and develop different alarm strategies to minimize nuisance (i.e., true but not clinically significant) PVC alarms.

      Cover page: Evaluation of Premature Ventricular Complexes (PVCs) during In-Hospital ECG Monitoring in the ICU
      • Thesis
      • Peer Reviewed
      UC San Francisco Electronic Theses and Dissertations (2016)

      Background: Current evidence shows that an open visitation policy can benefit patients and families during ICU stays. Therefore, an unrestricted visitation policy in ICU has been proposed as part of patient-centered care. Purpose: the purpose of this secondary analysis is to explore the likelihood of an ICU with a CNS having an open visitation policy when compared to an ICU without a CNS. Design: A survey was conducted between 2008 and 2009, describing the ICU visitation practices in more than 600 hospitals across the United States. A limited number of ICUs has open visitation policies in place, and the clinical nurse specialist (CNS) was identified as one of the clinical leadership roles available within the units. Methods: Chi-square analysis was performed, with a p-value of <0.05 considered statistically significant. Results: No significant correlation was found between a CNS being present in the ICU and open visitation policy (OR 0.93, p = 0.83), regardless of hospital geographic regions. Conclusion: Although CNS presence was not associated with open visitation in this study, given the strong evidence to support the benefits to patients and the CNS role as change agent in the hospital system, liberalization of visitation in ICU is an area that could benefit from CNS advocacy.

        Cover page: Association between the Presence of Clinical Nurse Specialist and Open Visitation Policy in US Intensive Care Units
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2019)

        Background

        Excessive electrocardiographic alarms contribute to "alarm fatigue," which can lead to patient harm. In a prior study, one-third of audible electrocardiographic alarms were for accelerated ventricular rhythm (AVR), and most of these alarms were false. It is uncertain whether true AVR alarms are clinically relevant.

        Objectives

        To determine from bedside electrocardiographic monitoring data (1) how often true AVR alarms are acknowledged by clinicians, (2) whether such alarms are actionable, and (3) whether such alarms are associated with adverse outcomes ("code blue," death).

        Methods

        Secondary analysis using data from a study conducted in an academic medical center involving 5 adult intensive care units with 77 beds. Electronic health records of 23 patients with 223 true alarms for AVR were examined.

        Results

        The mean age of the patients was 62.9 years, and 61% were white and male. All 223 of the true alarms were configured at the warning level (ie, 2 continuous beeps), and 215 (96.4%) lasted less than 30 seconds. Only 1 alarm was acknowledged in the electronic health record. None of the alarms were clinically actionable or led to a code blue or death.

        Conclusions

        True AVR alarms may contribute to alarm fatigue. Hospitals should reevaluate the need for close monitoring of AVR and consider configuring this alarm to an inaudible message setting to reduce the risk of patient harm due to alarm fatigue. Prospective studies involving larger patient samples and varied monitors are warranted.
          Cover page: Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2021)

          Background

          While there are published studies that have examined premature ventricular complexes (PVCs) among patients with and without cardiac disease, there has not been a comprehensive review of the literature examining the diagnostic and prognostic significance of PVCs. This could help guide both community and hospital-based research and clinical practice.

          Methods

          Scoping review frameworks by Arksey and O'Malley and the Joanna Briggs Institute (JBI) were used. A systematic search of the literature using four databases (CINAHL, Embase, PubMed, and Web of Science) was conducted. The review was prepared adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR).

          Results

          A total of 71 relevant articles were identified, 66 (93%) were observational, and five (7%) were secondary analyses from randomized clinical trials. Three studies (4%) examined the diagnostic importance of PVC origin (left/right ventricle) and QRS morphology in the diagnosis of acute myocardial ischemia (MI). The majority of the studies examined prognostic outcomes including left ventricular dysfunction, heart failure, arrhythmias, ischemic heart diseases, and mortality by PVCs frequency, burden, and QRS morphology.

          Conclusions

          Very few studies have evaluated the diagnostic significance of PVCs and all are decades old. No hospital setting only studies were identified. Community-based longitudinal studies, which make up most of the literature, show that PVCs are associated with structural and coronary heart disease, lethal arrhythmias, atrial fibrillation, stroke, all-cause and cardiac mortality. However, a causal association between PVCs and these outcomes cannot be established due to the purely observational study designs employed.
            Cover page: Diagnostic and prognostic significance of premature ventricular complexes in community and hospital-based participants: A scoping review
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2020)

            Background

            Ventricular tachycardia (V-tach) is the most common lethal arrhythmia, yet 90% of alarms are false and contribute to alarm fatigue. We hypothesize that some true V-tach also causes alarm fatigue because current criteria are too sensitive (i.e., ≥6 beats ≥100 beats/min [bpm]).

            Purpose

            This study was designed to determine (1) the proportion of clinically actionable true V-tach events; (2) whether true actionable versus nonactionable V-tach differs in terms of heart rate and/or duration (seconds); and (3) if actionable V-tach is associated with adverse outcomes.

            Methods

            This was a secondary analysis in 460 intensive care unit (ICU) patients. Electronic health records were examined to determine if a V-tach event was actionable or nonactionable. Actionable V-tach was defined if a clinical action(s) was taken within 15 minutes of its occurrence (i.e., new and/or change of medication, defibrillation, and/or laboratory test). Maximal heart rate and duration for each V-tach event were measured from bedside monitor electrocardiography. Adverse patient outcomes included a code blue event and/or death.

            Results

            In 460 ICU patients, 50 (11%) had 151 true V-tach events (range 1-20). Of the 50 patients, 40 (80%) had only nonactionable V-tach (97 events); 3 (6%) had both actionable and nonactionable V-tach (32 events); and 7 patients (14%) had only actionable V-tach (23 events). There were differences in duration comparing actionable versus nonactionable V-tach (mean 56.19 ± 116.87 seconds vs. 4.28 ± 4.09 seconds; P = 0.001) and maximal heart rate (188.81 ± 116.83 bpm vs. 150.79 ± 28.26 bpm; P = 0.001). Of the 50 patients, 3 (6%) had a code blue, 2 died, and all were in the actionable V-tach group.

            Conclusions

            In our sample, <1% experienced a code blue following true V-tach. Heart rate and duration for actionable V-tach were much faster and longer than that for nonactionable V-tach. Current default settings typically used for electrocardiographic monitoring (i.e., ≥6 beats ≥100 bpm) appear to be too conservative and can lead to crisis/red level nuisance alarms that contribute to alarm fatigue. A prospective study designed to test whether adjusting default settings to these higher levels is safe for patients is needed.
              Cover page: Actionable Ventricular Tachycardia During In-Hospital ECG Monitoring and Its Impact on Alarm Fatigue.
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2023)
              In-hospital electrocardiographic (ECG) monitors are typically configured to alarm for premature ventricular complexes (PVCs) due to the potential association of PVCs with ventricular tachycardia (VT). However, no contemporary hospital-based studies have examined the association of PVCs with VT. Hence, the benefit of PVC monitoring in hospitalized patients is largely unknown. This secondary analysis used a large PVC alarm data set to determine whether PVCs identified during continuous ECG monitoring were associated with VT, in-hospital cardiac arrest (IHCA), and/or death in a cohort of adult intensive care unit patients. Six PVC types were examined (i.e., isolated, bigeminy, trigeminy, couplets, R-on-T, and run PVCs) and were compared between patients with and without VT, IHCA, and/or death. Of 445 patients, 48 (10.8%) had VT; 11 (2.5%) had IHCA; and 49 (11%) died. Isolated and run PVC counts were higher in the VT group (p = 0.03 both), but group differences were not seen for the other four PVC types. The regression models showed no significant associations between any of the six PVC types and VT or death, although confidence intervals were wide. Due to the small number of cases, we were unable to test for associations between PVCs and IHCA. Our findings suggest that we should question the clinical relevance of activating PVC alarms as a forewarning of VT, and more work should be done with larger sample sizes. A more precise characterization of clinically relevant PVCs that might be associated with VT is warranted.
                Cover page: Evaluation of premature ventricular complexes during in‐hospital ECG monitoring as a predictor of ventricular tachycardia in an intensive care unit cohort
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