Physiologic monitors are plagued with alarms that create a cacophony of sounds and visual alerts causing "alarm fatigue" which creates an unsafe patient environment because a life-threatening event ...may be missed in this milieu of sensory overload. Using a state-of-the-art technology acquisition infrastructure, all monitor data including 7 ECG leads, all pressure, SpO(2), and respiration waveforms as well as user settings and alarms were stored on 461 adults treated in intensive care units. Using a well-defined alarm annotation protocol, nurse scientists with 95% inter-rater reliability annotated 12,671 arrhythmia alarms.
A total of 2,558,760 unique alarms occurred in the 31-day study period: arrhythmia, 1,154,201; parameter, 612,927; technical, 791,632. There were 381,560 audible alarms for an audible alarm burden of 187/bed/day. 88.8% of the 12,671 annotated arrhythmia alarms were false positives. Conditions causing excessive alarms included inappropriate alarm settings, persistent atrial fibrillation, and non-actionable events such as PVC's and brief spikes in ST segments. Low amplitude QRS complexes in some, but not all available ECG leads caused undercounting and false arrhythmia alarms. Wide QRS complexes due to bundle branch block or ventricular pacemaker rhythm caused false alarms. 93% of the 168 true ventricular tachycardia alarms were not sustained long enough to warrant treatment.
The excessive number of physiologic monitor alarms is a complex interplay of inappropriate user settings, patient conditions, and algorithm deficiencies. Device solutions should focus on use of all available ECG leads to identify non-artifact leads and leads with adequate QRS amplitude. Devices should provide prompts to aide in more appropriate tailoring of alarm settings to individual patients. Atrial fibrillation alarms should be limited to new onset and termination of the arrhythmia and delays for ST-segment and other parameter alarms should be configurable. Because computer devices are more reliable than humans, an opportunity exists to improve physiologic monitoring and reduce alarm fatigue.
...episodes of drug-induced TdP usually start with a short-long-short pattern of R-R cycles consisting of a short-coupled premature ventricular complex (PVC) followed by a compensatory pause and then ...another PVC that typically falls close to the peak of the T wave (2). ...TdP episodes usually show a warm-up phenomenon, with the first few beats of ventricular tachycardia exhibiting longer cycle lengths than subsequent arrhythmia complexes.
Heart rate (HR) alarms are prevalent in ICU, and these parameters are configurable. Not much is known about nursing behavior associated with tailoring HR alarm parameters to individual patients to ...reduce clinical alarm fatigue.
To understand the relationship between heart rate (HR) alarms and adjustments to reduce unnecessary heart rate alarms.
Retrospective, quantitative analysis of an adjudicated database using analytical approaches to understand behaviors surrounding parameter HR alarm adjustments. Patients were sampled from five adult ICUs (77 beds) over one month at a quaternary care university medical center. A total of 337 of 461 ICU patients had HR alarms with 53.7% male, mean age 60.3 years, and 39% non-Caucasian. Default HR alarm parameters were 50 and 130 beats per minute (bpm). The occurrence of each alarm, vital signs, and physiologic waveforms was stored in a relational database (SQL server).
There were 23,624 HR alarms for analysis, with 65.4% exceeding the upper heart rate limit. Only 51% of patients with HR alarms had parameters adjusted, with a median upper limit change of +5 bpm and -1 bpm lower limit. The median time to first HR parameter adjustment was 17.9 hours, without reduction in alarms occurrence (p = 0.57).
HR alarms are prevalent in ICU, and half of HR alarm settings remain at default. There is a long delay between HR alarms and parameters changes, with insufficient changes to decrease HR alarms. Increasing frequency of HR alarms shortens the time to first adjustment. Best practice guidelines for HR alarm limits are needed to reduce alarm fatigue and improve monitoring precision.
Empathy, the capacity to understand and share others' emotions, can occur through cognitive and affective components. These components are different conceptually, behaviorally, and in the brain. ...Neuroimaging task-based research in adolescents and adults document that cognitive empathy associates with the default mode and frontoparietal networks, whereas regions of the salience network underlie affective empathy. However, cognitive empathy is slower to mature than affective empathy and the extant literature reveals considerable developmental differences between adolescent and adult brains within and between these three networks. We extend previous work by examining empathy's association with functional connectivity within and between these networks in adolescents. Participants (n = 84, aged 13–17; 46.4% female) underwent resting state fMRI and completed self-report measures (Interpersonal Reactivity Index) for empathy as part of a larger Nathan-Kline Institute study. Regression analyses revealed adolescents reporting higher cognitive empathy had higher within DMN connectivity. Post hoc analysis revealed cognitive empathy's association within DMN connectivity is independent of affective empathy or empathy in general; and this association is driven by positive pairwise connections between the bilateral angular gyri and medial prefrontal cortex. These results suggest introspective cognitive processes related to the DMN are specifically important for cognitive empathy in adolescence.
•Greater cognitive empathy associates with stronger default mode network connectivity.•Angular gyri and medial prefrontal pairwise connections underlie cognitive empathy.•Cognitive empathy and default mode positively relate independent of affective empathy.•Affective empathy did not significantly associate with salience network connectivity.•Our findings may suggest introspective cognition is important for cognitive empathy.
To test the potential value of more frequent QT interval measurement in hospitalized patients.
We performed a prospective, observational study.
All adult intensive care unit and progressive care unit ...beds of a university medical center.
All patients admitted to one of six critical care units over a 2-month period were included in analyses.
All critical care beds (n = 154) were upgraded to a continuous QT monitoring system (Philips Healthcare).
QT data were extracted from the bedside monitors for offline analysis. A corrected QT interval >500 msecs was considered prolonged. Episodes of QT prolongation were manually over-read. Electrocardiogram data (67,648 hrs, mean 65 hrs/patient) were obtained. QT prolongation was present in 24%. There were 16 cardiac arrests, with one resulting from Torsade de Pointes (6%). Predictors of QT prolongation were female sex, QT-prolonging drugs, hypokalemia, hypocalcemia, hyperglycemia, high creatinine, history of stroke, and hypothyroidism. Patients with QT prolongation had longer hospitalization (276 hrs vs. 132 hrs, p < .0005) and had three times the odds for all-cause in-hospital mortality compared to patients without QT prolongation (odds ratio 2.99 95% confidence interval 1.1-8.1).
We find QT prolongation to be common (24%), with Torsade de Pointes representing 6% of in-hospital cardiac arrests. Predictors of QT prolongation in the acutely ill population are similar to those previously identified in ambulatory populations. Acutely ill patients with QT prolongation have longer lengths of hospitalization and nearly three times the odds for mortality then those without QT prolongation.
Left ventricular (LV) systolic dysfunction has been reported in humans with subarachnoid hemorrhage (SAH), and its underlying pathophysiology remains controversial. Possible mechanisms include ...myocardial ischemia versus excessive catecholamine release from sympathetic nerve terminals.
For 38 months, echocardiography and myocardial scintigraphy with technetium sestamibi (MIBI) and meta-(123)Iiodobenzylguanidine (MIBG) were performed on 42 patients admitted with SAH to assess myocardial perfusion and sympathetic innervation, respectively. A blinded observer interpreted the scintigraphic images. Cardiac troponin I (cTI) was measured to quantify the degree of myocyte necrosis. Blinded observers calculated the LV ejection fraction and graded each LV segment as normal (score=1), hypokinetic (score=2), or akinetic (score=3). A wall-motion score was calculated by averaging the sum of the 16 segments. All subjects with interpretable scans (N=41) had normal MIBI uptake. Twelve subjects had either global (n=9) or regional (n=3) absence of MIBG uptake. In comparison with patients with normal MIBG uptake, those with evidence of functional denervation were more likely to have LV regional wall-motion abnormalities (92% versus 52%, P=0.030) and cTI levels >1 microg/L (58% versus 21%, P=0.029).
LV systolic dysfunction in humans with SAH is associated with normal myocardial perfusion and abnormal sympathetic innervation. These findings may be explained by excessive release of norepinephrine from myocardial sympathetic nerves, which could damage both myocytes and nerve terminals.
•Youth in need of concrete service support have a higher level of need than youth who do not require concrete services.•Concrete service spending positively associates with placement stability, a ...necessary condition for placement permanency.•Youth in out of home placements who receive concrete services as a treatment have an increase in placement stability.
Experiencing poverty and financial difficulties are significant barriers to outcomes of permanency and placement stability. This is particularly true for children who are in out of home placements. The provision of concrete services is intended to meet concrete needs of families to address this barrier. However, little is known about how concrete services meet the needs of families in need of these services or if the use of concrete services is a viable treatment for children who are in out of home placements.
The present study examined differences between those who received and those who did not receive concrete services on factors of stability, child and caregiver traumatic stress, number of placements, and current out of home placement. Regression analysis examined the association between amount of concrete service spending and permanency. Then to test concrete services as an intervention for children in a current out of home placement, we used propensity score matching to match participants on characteristics that predicted whether they would receive concrete services. We then ran a hierarchical regression to test the treatment condition of concrete services with children who are in a current out of home placement.
Participants who received concrete services were at a much higher level of need with significantly higher levels of traumatic stress and number of placements and lower levels of placement stability. The amount of money spent on concrete services was associated with increases in placement stability. And, children in a current out of home placement had an increase in placement stability when they received concrete services.
The present study is the first to evidence concrete service as a treatment for placement stability for children in current out of home placements. Spending on concrete services in addition to child welfare services improves a child’s current placement stability. This is an important finding with implications for improving child welfare services’ approach to those in their care with financial burdens.
The QT interval on an electrocardiogram represents ventricular repolarization time. Increased length of this interval, known as corrected QT (QTc) prolongation, can be a precursor to torsade de ...pointes, a potentially life-threatening ventricular dysrhythmia. An association exists between blood glucose and QTc interval in ambulatory populations. Because both hyperglycemia and QTc prolongation are common in critically ill patients, we sought to examine the relationship between blood glucose, QTc interval prolongation, and all-cause mortality in critically ill patients.
We studied adult patients admitted to cardiac monitoring units. Blood glucose and other clinical variables were abstracted from the medical record. Corrected QT measurements were automatically derived from continuous bedside cardiac monitoring systems.
Twenty-five percent (233/940) of the patients had QTc prolongation, and 53% had elevated blood glucose (>140 mg/dL) during hospitalization. Adjusted odds for QTc prolongation were 2.1 (95% confidence interval, 1.5-3.1) for moderately elevated blood glucose (140-180 mg/dL) and 3.7 (95% confidence interval, 2.5-5.4) for severely elevated blood glucose (>180 mg/dL). Mortality rate was highest (16%) in patients experiencing both severely elevated blood glucose (>180 mg/dL) and QTc interval prolongation.
Hyperglycemia is linked with QTc prolongation, and both are associated with increased odds of mortality in critically ill patients. Further studies are needed to extrapolate the relationship between glucose and ventricular repolarization, as well as appropriate glucose control parameters and QTc interval monitoring in critical care units.
Depression amongst adolescents is a prevalent disorder consisting of heterogeneous emotional and functional symptoms—often involving impairments in social domains such as empathy. Cognitive and ...affective components of empathy as well as their associated neural networks (default mode network for cognitive empathy and salience network for affective empathy) are affected by depression. Depression commonly onsets during adolescence, a critical period for brain development underlying empathy. However, the available research in this area conceptualizes depression as a homogenous construct, and thereby miss to represent the full spectrum of symptoms. The present study aims to extend previous literature by testing whether cognitive and affective empathy indirectly account for associations between brain network connectivity and heterogeneous depression symptoms in adolescents. Heterogeneous functional and emotional symptoms of depression were measured using the child depression inventory. Our results indicate that cognitive empathy mediates the association between default mode network functional connectivity and emotional symptoms of depression. More specifically, that adolescents with a stronger positive association between the default mode network and cognitive empathy show lower emotional depression symptoms. This finding highlights the importance of cognitive empathy in the relationship between brain function and depression symptoms, which may be an important consideration for existing models of depression in adolescents.
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