Clinical Associate Professor, Medicine - Primary Care and Population Health
Director of Research, Patient Care Services, Stanford Health Care (2013 - 2016)
Executive Director of Research, Patient Care Services, Stanford Health Care (2016 - Present)
Honors & Awards
Elected Fellow, American Heart Association (2015)
Elected Fellow, American Academy of Nursing (2018)
Boards, Advisory Committees, Professional Organizations
Member, American Heart Association (2008 - Present)
Member, International Society of Computerized Electrocardiography (2010 - Present)
Member, Institutional Review Board (IRB)- Stanford University Human Research Protection Program (2014 - Present)
Member, American Nurses Association (2015 - Present)
Member, American Academy of Nursing (2018 - Present)
Bachelor, School of Nursing and Midwifery; University of Newcastle, Australia, Nursing (pre-licensure) (2000)
Master, School of Nursing and Midwifery; University of Newcastle, Australia, Advanced Practice Nursing (2006)
Training Fellowship, Georgetown University/National Institutes of Health/National Institute of Nursing Research, Molecular Genetics in Research, Health & Society (2008)
PhD, Department of Physiological Nursing; University of California, San Francisco, Quantitative Electrocardiography (2010)
Certificate, Graduate School of Business, Stanford School of Engineering; Stanford University, Innovation & Entrepreneurship (2018)
MBA, Rotman School of Management; University of Toronto, Global Healthcare & LIfe Sciences (2020)
Optimal Patient Turning for Reducing Hospital Acquired Pressure Ulcers
The purpose of this study is to test whether optimal patient turning, strictly every 2 hours with at least 15 minutes of tissue decompression, reduces the occurrence of hospital acquired pressure ulcers.
Stanford is currently not accepting patients for this trial. For more information, please contact David Pickham, PhD, 650-701-6830.
Prognostic Value of BEFAST vs. FAST to Identify Stroke in a Prehospital Setting.
Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
BACKGROUND: Use of prehospital stroke scales may enhance stroke detection and improve treatment rates and delays. Current scales, however, may lack detection accuracy. As such, we examined if coordination and diplopia (Balance and Eyes) assessments increase the accuracy of the Face-Arms-Speech-Time (FAST) scale in a multi-site prospective study of emergency response activations for presumed stroke.METHODS: This was a prospective study of emergency response activations for presumed stroke in Santa Clara County, California. Emergency medical responders were trained in the BEFAST scale and administered the scale on scene to all patients who were within 6hours of onset of neurological symptoms. Patient's final diagnosis (stroke vs no stroke) was based on review of hospital records. We compared the performance of the BEFAST and FAST scales for stroke detection.RESULTS: Three hundred fifty-nine patients were included in our analysis. Compared to non-stroke patients (n=200), stroke patients (n=159) more often scored positive on each of the five elements of the BEFAST scale (p<0.05 for each). In multivariable analysis, only facial droop and arm weakness were independent predictors of stroke (p<0.05). BEFAST and FAST scale accuracy for stroke identification was comparable (AUC=0.70 vs. AUC=0.69, p=0.36). Optimal cutoff for stroke detection was ≥1 for both scales. At this threshold, the PPV was 0.49 for the BEFAST and 0.53 for the FAST scale, and NPV was 0.93 for BEFAST and 0.86 for FAST.CONCLUSION: Adding coordination and diplopia assessments to face, arm, and speech assessment does not improve stroke detection in the prehospital setting.
View details for DOI 10.1080/10903127.2018.1490837
View details for PubMedID 30118372
Pressure Injury Prevention Practices in the Intensive Care Unit: Real-world Data Captured by a Wearable Patient Sensor
WOUNDS-A COMPENDIUM OF CLINICAL RESEARCH AND PRACTICE
2018; 30 (8): 229–34
View details for Web of Science ID 000441910800007
ELECTROCARDIOGRAPHIC CORRELATES OF ACUTE ALLOGRAFT REJECTION AMONG HEART TRANSPLANT RECIPIENTS
AMERICAN JOURNAL OF CRITICAL CARE
2018; 27 (2): 145–50
Acute allograft rejection appears to be associated with increases in QT/QTc intervals.To determine the relationship between acute allograft rejection and electrocardiogram changes in patients undergoing an orthotopic heart transplant.The study population comprised 220 adult patients undergoing heart transplant and enrolled in the NEW HEART study. Electrocardiograms obtained within 72 hours of endomyocardial biopsy were analyzed; electrocardiograms obtained fewer than 10 days after transplant surgery were excluded. Repeated-measures analysis was performed with statistical models including effects for rejection severity (mild and moderate/severe) and time trends independent of rejection status.The 151 male and 69 female transplant recipients (mean age [SD], 54  years) had 969 biopsy/electrocardiogram pairs: 677 with no rejection, 280 with mild rejection, and 12 with moderate/severe rejection. Moderate to severe organ rejection was associated with significant increases in QRS duration (P < .001), QT (P = .009), QTc (P = .003), and PR interval (P = .03), as well as increased odds of right bundle block branch (P = .002) and fascicular block (P = .009) occurring.Moderate to severe acute allograft rejection was associated with electrocardiographic changes after transplant surgery. Studies are needed to assess the value of computerized electrocardiogram measurement algorithms for detecting acute allograft rejection.
View details for DOI 10.4037/ajcc2018862
View details for Web of Science ID 000427440300009
View details for PubMedID 29496772
- Human Technology Teamwork: Enhancing the Communication of Pain Between Patients and Providers DESIGN THINKING RESEARCH: MAKING DISTINCTIONS: COLLABORATION VERSUS COOPERATION 2018: 313–25
QT Corrections for Long QT Risk Assessment: Implications for the Preparticipation Examination.
Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine
BACKGROUND: Because sudden cardiac death (SCD) in the young mainly occur in individuals with structurally normal hearts, improved screening techniques for detecting inherited arrhythmic diseases are needed. The QT interval is an important screening measurement; however, the criteria for detecting an abnormal QT interval are based on Bazett formula and older populations.OBJECTIVE: To define the normal upper limits for QT interval from the electrocardiograms (ECGs) of healthy young individuals, compare the major correction formula and propose new QT interval thresholds for detecting those at risk of SCD.METHODS: Young active individuals underwent ECGs as part of routine preparticipation physical examinations for competitive sports or community screening. This was a nonfunded study using de-identified data with no follow-up.RESULTS: There were 31558 subjects: 2174 grade school (7%), 18547 high school (59%), and 10822 college (34%). Mean age was 17 (12-35 years), 45% were female, 67% white, and 11% of African descent. Bazett performed least favorably for removing the effect of heart rate (HR), whereas Fridericia performed the best. Fridericia correction also closely fit the raw data best (R of 0.65), and at percentile values applicable to screening. The recommended risk cut points using Bazetts correction identified less than half of the athletes in the 99th or 99.5th percentiles of the uncorrected QT by HR range. Use of Fridericia correction increased capture rates by over 50%.CONCLUSION: Our results support the application of the Fridericia-corrected threshold of 460 for men and 470 milliseconds for women (and 485 milliseconds for marked prolongation) rather than Bazett correction for the preparticipation examination.
View details for PubMedID 29035985
Clostridium difficile rates in asymptomatic and symptomatic hospitalized patients using nucleic acid testing.
Diagnostic microbiology and infectious disease
2017; 87 (4): 365-370
The Clostridium difficile rate in symptomatic patients represents both those with C. difficile infection (CDI) and those with colonization. To predict the extent of CDI overdiagnosis, we compared the asymptomatic colonization rate to the symptomatic positivity rate in hospitalized patients using nucleic acid testing.Between July 2014 and April 2015, formed stool samples were collected from asymptomatic patients after admission to 3 hospital wards at the Stanford Hospital. Stool samples from symptomatic patients with suspected CDI in the same wards were collected for testing per provider order. The GeneXpert C. difficile tcdB polymerase chain reaction (PCR) assay (Cepheid, Sunnyvale, CA, USA) was performed on all stool samples and PCR cycle threshold was used as a measure of genomic equivalents. Chart review was performed to obtain clinical history and medication exposure.We found an asymptomatic C. difficile carriage rate of 11.8% (43/365) (95% confidence interval [CI], 8.5-15.1%) and a positivity rate in symptomatic patients of 15.4% (54/351) (95% CI, 11.6-19.2%; P=0.19). The median PCR cycle thresholds was not significantly different between asymptomatic carriers and symptomatic positives (29.5 versus 27.3; P=0.07). Among asymptomatic patients, 11.6% (5/43) of carriers and 8.4% (27/322; P=0.56) of noncarriers subsequently became symptomatic CDI suspects within the same hospitalization. Single and multivariate analysis did not identify any demographic or clinical factors as being significantly associated with C. difficile carriage.Asymptomatic C. difficile carriage rate was similar to symptomatic positivity rate. This suggests the majority of PCR-positive results in symptomatic patients are likely due to C. difficile colonization. Disease-specific biomarkers are needed to accurately diagnose patients with C. difficile disease.
View details for DOI 10.1016/j.diagmicrobio.2016.12.014
View details for PubMedID 28087170
Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study)
INTERNATIONAL JOURNAL OF NURSING STUDIES
2017; 80: 12–19
Though theoretically sound, studies have failed to demonstrate the benefit of routine repositioning of at-risk patients for the prevention of hospital acquired pressure injuries.To assess the clinical effectiveness of a wearable patient sensor to improve care delivery and patient outcomes by increasing the total time with turning compliance and preventing pressure injuries in acutely ill patients.Pragmatic, investigator initiated, open label, single site, randomized clinical trial.Two Intensive Care Units in a large Academic Medical Center in California.Consecutive adult patients admitted to one of two Intensive Care Units between September 2015 to January 2016 were included (n = 1564). Of the eligible patients, 1312 underwent randomization.Patients received either turning care relying on traditional turn reminders and standard practices (control group, n = 653), or optimal turning practices, influenced by real-time data derived from a wearable patient sensor (treatment group, n = 659).The primary and secondary outcomes of interest were occurrence of hospital acquired pressure injury and turning compliance. Sensitivity analysis was performed to compare intention-to-treat and per-protocol effects.The mean age was 60 years (SD, 17 years); 55% were male. We analyzed 103,000 h of monitoring data. Overall the intervention group had significantly fewer Hospital Acquired Pressure Injuries during Intensive Care Unit admission than the control group (5 patients [0.7%] vs. 15 patients [2.3%] (OR = 0.33, 95%CI [0.12, 0.90], p = 0.031). The total time with turning compliance was significantly different in the intervention group vs. control group (67% vs 54%; difference 0.11, 95%CI [0.08, 0.13], p < 0.001). Turning magnitude (21°, p = 0.923) and adequate depressurization time (39%, p = 0.145) were not statistically different between groups.Among acutely ill adult patients requiring Intensive Care Unit admission, the provision of optimal turning was greater with a wearable patient sensor, increasing the total time with turning compliance and demonstrated a statistically significant protective effect against the development of hospital acquired pressure injuries. These are the first quantitative data on turn quality in the Intensive Care Unit and highlight the need to reinforce optimal turning practices. Additional clinical trials leveraging technologies like wearable sensors are needed to establish the appropriate frequency and dosing of individualized turning protocols to prevent pressure injuries in at-risk hospitalized patients.
View details for DOI 10.1016/j.ijnurstu.2017.12.012
View details for Web of Science ID 000430784600002
View details for PubMedID 29331656
Clinical and gender differences in heart transplant recipients in the NEW HEART study.
European journal of cardiovascular nursing
2017; 16 (3): 222-229
Little attention has focused on gender differences in cardiac comorbidities and outcomes in patients undergoing orthotropic heart transplant.The objective of this study was to investigate gender differences at baseline and during follow-up among heart transplant patients.An observational cohort within the NEW HEART study was evaluated to determine gender differences in relation to age, coexisting cardiac comorbidities, and outcomes. Differences were assessed by t-test, Fisher's exact test, and logistic regression analysis.Male transplant recipients ( n = 238) were significantly older than female recipients ( n = 92), with a greater percentage over 60 years of age (45% vs. 24%, p = 0.0006). Males were more likely to have hypertension (63% vs. 49%, p = 0.034), dyslipidemia (62% vs. 45%, p = 0.006), a history of smoking (52% vs. 35%, p = 0.009), and diabetes (42% vs. 21%, p = 0.0002). Analysis of endomyocardial biopsies obtained during the 1-year follow-up period demonstrated that women averaged more episodes of acute rejection than men (3.9 vs. 3.0, p = 0.009). While most episodes of rejection were mild, women were more likely than men to have episodes of moderate or severe rejection (14% vs. 5%, p = 0.012) and to be hospitalized for acute rejection (15% vs. 6%, p = 0.013). There were no significant differences in mortality.Men were more likely than women to be older and to have diabetes, dyslipidemia, hypertension, and a history of smoking. Women were more likely to experience moderate or severe allograft rejection and to be hospitalized for acute rejection. Future investigation of the reasons for these gender differences is warranted and may improve clinical care of women undergoing cardiac transplantation.
View details for DOI 10.1177/1474515116651178
View details for PubMedID 27189203
VITAMIN D DEFICIENCY IN HEMATOPOIETIC CELL TRANSPLANT AND A POTENTIAL BUFFERING OF ACUTE GVHD BY SUPPLEMENTATION
ONCOLOGY NURSING SOC. 2017
View details for Web of Science ID 000401160800493
- QTc prolongation may be a late biomarker of orthotopic heart transplantation (OHT) rejection (vol 49, pg 928, 2016) JOURNAL OF ELECTROCARDIOLOGY 2017; 50 (2): 268
A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon
JOURNAL OF NURSING ADMINISTRATION
2016; 46 (12): 630-635
The aim of this study is to evaluate the effect of 2 hospital-wide interventions on achieving a discharge-before-noon rate of 40%.A multidisciplinary team led by administrative and physician leadership developed a plan to diminish capacity constraints by minimizing late afternoon hospital discharges using 2 patient flow management techniques.The study was a preintervention/postintervention retrospective analysis observing all inpatients discharged across 19 inpatient units in a 484-bed, academic teaching hospital measuring calendar month discharge-before-noon percentage, patient satisfaction, and readmission rates. Patient satisfaction and readmission rates were used as baseline metrics.The discharge-before-noon percentage increased from 14% in the 11-month preintervention period to an average of 24% over the 11-month postintervention period, whereas patient satisfaction scores and readmission rates remained stable.Implementation of the 2 interventions successfully increased the percentage of discharges before noon yet did not achieve the goal of 40%. Patient satisfaction and readmission rates were not negatively impacted by the program.
View details for DOI 10.1097/NNA.0000000000000418
View details for Web of Science ID 000388955800005
View details for PubMedID 27851703
- QTc Prolongation May Be a Late Biomarker of Orthotopic Heart Transplantation (OHT) Rejection. Journal of electrocardiology 2016; 49 (6): 928-929
Optimizing QT Interval Measurement for the Preparticipation Screening of Young Athletes.
Medicine and science in sports and exercise
2016; 48 (9): 1745-1750
Sudden cardiac death is the leading cause of death in athletes. Long QT syndrome (LQTS) is one of the most common cardiogenetic diseases that can lead to sudden cardiac death and is identified by QT interval prolongation on an ECG. Recommendations for QT monitoring in athletes are adopted from nonathlete populations. To improve screening, ECG data of athletes are assessed to determine a more appropriate method for QT interval estimation.ECG (CardeaScreen) data were collected from June 2010 to March 2015. ECG data with HR greater than 100 bpm were excluded. Fiducial points of outliers were manually corrected if the QRS onset or the T wave offset was misidentified. A model of best fit was determined and compared across four QT correction factors. Classification analysis was used to compare the Bazett's corrected QT interval to the 99th percentile of uncorrected QT interval.High school (n = 597), college (n = 1207), and professional athletes (n = 273) (N = 2077) were analyzed. Mean age was 19 ± 3.5 yr. QT interval varied by cohort (HS = 388 ± 30, Col = 410 ± 33, Pro = 407 ± 27, p < 0.0001). A nonlinear power function with a cubic exponent of -0.349 fit the data the best (R = 0.64). Of the four common correction factors, Fridericia had the lowest residual dependence to HR (m = -0.10). With standard screening, 75% of athletes within the top 1% for QT interval were not identified for further investigation for LQTS.Up to 75% of athletes possessing an uncorrected QT interval greater than 99% of the population are not identified for investigation for LQTS using the recommended criteria. We propose a new method of risk stratification that replaces QT interval correction. Further study is needed to establish QT interval distributions and risk thresholds in athletes.
View details for DOI 10.1249/MSS.0000000000000962
View details for PubMedID 27116644
Basic Cardiac Electrophysiology and Common Drug-induced Arrhythmias.
Critical care nursing clinics of North America
2016; 28 (3): 357-371
Drugs can be a double-edged sword, providing the benefit of symptom alleviation and disease modification but potentially causing harm from adverse cardiac arrhythmic events. Proarrhythmia is the ability of a drug to cause an arrhythmia, the number one reason for drugs to be withdrawn from the patient. Drug-induced arrhythmias are defined as the production of de novo arrhythmias or aggravation of existing arrhythmias, as a result of previous or concomitant pharmacologic treatment. This review summarizes normal cardiac cell and tissue functioning and provides an overview of drugs that effect cardiac repolarization and the adverse effects of commonly administered antiarrhythmics.
View details for DOI 10.1016/j.cnc.2016.04.007
View details for PubMedID 27484663
Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology.
Journal of electrocardiology
The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services' (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms.The purpose of this secondary analysis was to determine differences in patients presenting the ED for possible ACS who arrive by ambulance versus self-transport on: 1) time-to-initial hospital electrocardiogram (ECG), 2) presence of ischemic ECG changes, and 3) patient characteristics.Initial 12-lead ECGs acquired upon patient arrival to the ED were evaluated for ST-elevation, ST-depression, and T-wave inversion. ECG signs of ischemia were analyzed both individually and collapsed into an independent dichotomous variable (ED ECG ischemia yes/no) for statistical analysis. Patient characteristics tested included: gender, age, race, ethnicity, English speaking, living alone, mode of transport, and presenting symptoms (chest pain, jaw pain, shortness of breath, nausea/vomiting, syncope, and clinical history).In 1299 patients (mean age 63.9, 46.7% male), 384 (29.6%) patients arrived by ambulance to the ED. The mean time-to-initial ECG was 47minutes for ambulance patients versus 53minutes for self-transport patients (p<0.001). Mode of transport was found to be an independent predictor for time-to-initial ECG controlling for age, gender, and race (p=0.004). There were significantly higher rates of ECG changes of ischemia for patients who arrived by ambulance versus self-transport (p=0.02), and patient characteristics differed by mode of transport to the ED.Our findings indicate that less than 30% of individuals with symptoms of ACS activate the EMS '911' system for ambulance transport to the ED. Individuals more likely to activate 911 have timelier ECG but higher rates of ischemic changes, specifically ST-depression and T-wave inversion. Individuals least likely to activate 911 are women, younger individuals, Latino ethnicity, live with a significant other, and those experiencing chest or jaw pain.
View details for DOI 10.1016/j.jelectrocard.2016.08.008
View details for PubMedID 27614946
View details for PubMedCentralID PMC5159244
Evaluating optimal patient-turning procedures for reducing hospital-acquired pressure ulcers (LS-HAPU): study protocol for a randomized controlled trial
Pressure ulcers are insidious complications that affect approximately 2.5 million patients and account for approximately US$11 billion in annual health care spending each year. To date we are unaware of any study that has used a wearable patient sensor to quantify patient movement and positioning in an effort to assess whether adherence to optimal patient turning results in a reduction in pressure ulcer occurrence.This study is a single-site, open-label, two-arm, randomized controlled trial that will enroll 1812 patients from two intensive care units. All subjects will be randomly assigned, with the aid of a computer-generated schedule, to either a standard care group (control) or an optimal pressure ulcer-preventative care group (treatment). Optimal pressure ulcer prevention is defined as regular turning every 2 h with at least 15 min of tissue decompression. All subjects will receive a wearable patient sensor (Leaf Healthcare, Inc., Pleasanton, CA, USA) that will detect patient movement and positioning. This information is relayed through a proprietary mesh network to a central server for display on a user-interface to assist with nursing care. This information is used to guide preventative care practices for those within the treatment group. Patients will be monitored throughout their admission in the intensive care unit.We plan to conduct a randomized control trial, which to our knowledge is the first of its kind to use a wearable patient sensor to quantify and establish optimal preventative care practices, in an attempt to determine whether this is effective in reducing hospital-acquired pressure ulcers.ClinicalTrials.gov, NCT02533726 .
View details for DOI 10.1186/s13063-016-1313-5
View details for Web of Science ID 000373488900003
View details for PubMedID 27053145
View details for PubMedCentralID PMC4823913
DESIGN AND VALIDATION OF A DYNAMIC DIGITAL RULER FOR HANDS-FREE CHRONIC WOUND ASSESSMENT
AMER SOC MECHANICAL ENGINEERS. 2016
View details for Web of Science ID 000379883900085
- Design Thinking in Health IT Systems Engineering: The Role of Wearable Mobile Computing for Distributed Care DESIGN THINKING RESEARCH: TAKING BREAKTHROUGH INNOVATION HOME 2016: 87–100
Limitations of Current AHA Guidelines and Proposal of New Guidelines for the Preparticipation Examination of Athletes
CLINICAL JOURNAL OF SPORT MEDICINE
2015; 25 (6): 472-477
To examine the prevalence of athletes who screen positive with the preparticipation examination guidelines from the American Heart Association, the AHA 12-elements, in combination with 3 screening electrocardiogram (ECG) criteria.Observational cross-sectional study.Stanford University Sports Medicine Clinic.Total of 1596 participants, including 297 (167 male; mean age, 16.2 years) high school athletes, 1016 (541 male; mean age, 18.8 years) collegiate athletes, and 283 (mean age, 26.3 years) male professional athletes.Athletes were screened using the 8 personal and family history questions from the AHA 12-elements. Electrocardiograms were obtained for all participants and interpreted using Seattle criteria, Stanford criteria, and European Society of Cardiology (ESC) recommendations.Approximately one-quarter of all athletes (23.8%) had at least 1 positive response to the AHA personal and family history elements. High school and college athletes had similar rates of having at least 1 positive response (25.9% vs 27.4%), whereas professional athletes had a significantly lower rate of having at least 1 positive response (8.8%, P < 0.05). Females reported more episodes of unexplained syncope (11.4% vs 7.5%, P = 0.017) and excessive exertional dyspnea with exercise (11.1% vs 6.1%, P = 0.001) than males. High school athletes had more positive responses to the family history elements when compared with college athletes (P < 0.05). The percentage of athletes who had an abnormal ECG varied between Seattle criteria (6.0%), Stanford criteria (8.8%), and ESC recommendations (26.8%).Many athletes screen positive under current screening recommendations, and ECG results vary widely by interpretation criteria.In a patient population without any adverse cardiovascular events, the currently recommended AHA 12-elements have an unacceptably high rate of false positives. Newer screening guidelines are needed, with fewer false positives and evidence-based updates.
View details for Web of Science ID 000364310700003
View details for PubMedID 25915146
Intensive Care Utilization for Hematopoietic Cell Transplant Recipients
BIOLOGY OF BLOOD AND MARROW TRANSPLANTATION
2015; 21 (11): 2023-2027
Blood and marrow transplantation (BMT) is a potentially curative therapy for a number of malignant and nonmalignant diseases. Multiple variables, including age, comorbid conditions, disease, disease stage, prior therapies, degree of donor-recipient matching, type of transplantation, and dose intensity of the preparative regimen, affect both morbidity and mortality. Despite tremendous gains in supportive care, BMT remains a high-risk medical therapy. A critically ill BMT recipient may require transfer to an intensive care unit (ICU) and the specialized medical and nursing care that can be provided, such as mechanical ventilation and vasopressor support. Mortality for BMT recipients requiring care in an ICU is high. This paper will describe the experience of the Stanford Blood and Marrow Transplant Program in developing and implementing guidelines to maximize the benefit of intensive care for critically ill BMT recipients.
View details for DOI 10.1016/j.bbmt.2015.07.026
View details for Web of Science ID 000363357200024
View details for PubMedID 26238809
Lean Manufacturing Improves Emergency Department Throughput and Patient Satisfaction.
journal of nursing administration
2015; 45 (9): 429-434
A multidisciplinary team led by nursing leadership and physicians developed a plan to meet increasing demand and improve the patient experience in the ED without expanding the department's current resources. The approach included Lean tools and engaged frontline staff and physicians. Applying Lean management principles resulted in quicker service, improved patient satisfaction, increased capacity, and reduced resource utilization. Incorporating continuous daily management is necessary for sustainment of continuous improvement activities.
View details for DOI 10.1097/NNA.0000000000000228
View details for PubMedID 26252725
Are the QRS duration and ST depression cut-points from the Seattle criteria too conservative?
JOURNAL OF ELECTROCARDIOLOGY
2015; 48 (3): 395-398
Screening athletes with ECGs is aimed at identifying "at-risk" individuals who may have a cardiac condition predisposing them to sudden cardiac death. The Seattle criteria highlight QRS duration greater than 140 ms and ST segment depression in two or more leads greater than 50 μV as two abnormal ECG patterns associated with sudden cardiac death.High school, college, and professional athletes underwent 12 lead ECGs as part of routine pre-participation physicals. Prevalence of prolonged QRS duration was measured using cut-points of 120, 125, 130, and 140 ms. ST segment depression was measured in all leads except leads III, aVR, and V1 with cut-points of 25 μV and 50 μV.Between June 2010 and November 2013, 1595 participants including 297 (167 male, mean age 16.2) high school athletes, 1016 (541 male, mean age 18.8) college athletes, and 282 (mean age 26.6) male professional athletes underwent screening with an ECG. Only 3 athletes (0.2%) had a QRS duration greater than 125 ms. ST segment depression in two or more leads greater than 50 μV was uncommon (0.8%), while the prevalence of ST segment depression in two or more leads increased to 4.5% with a cut-point of 25 μV.Changing the QRS duration cut-point to 125 ms would increase the sensitivity of the screening ECG, without a significant increase in false-positives. However, changing the ST segment depression cut-point to 25 μV would lead to a significant increase in false-positives and would therefore not be justified.
View details for DOI 10.1016/j.jelectrocard.2015.02.009
View details for Web of Science ID 000354343100019
View details for PubMedID 25796099
Pre-participation screening for athletes and the role of advanced practice providers
JOURNAL OF ELECTROCARDIOLOGY
2015; 48 (3): 339-344
Pre-participation screening of athletes for underlying cardiovascular disease is recommended by the AHA/ACC. However, vigorous debate continues as to whether the ECG should be used as part of a broad-based screening program. The AHA/ACC "do not support national mandatory screening ECGs of athletes, because the logistics, manpower, financial and resource considerations make such a program inapplicable to US". In an effort to address these impediments and to increase access for communities, we explore the use of advanced practice providers (Nurse Practitioners and Physician Assistants) in providing pre-participation screening to athletes with ECG interpretation. In the current healthcare environment with limited primary care resources, advanced practice providers are an important new element in improving access to care. Pre-participation screening with ECG interpretation is currently within an advanced practice provider's scope of practice. Emerging data shows that advanced practice providers perform care that is within acceptable patient care standards, safely, and cost effectively, compared to physician counterparts. To further improve pre-participation screening, a national education and certification program on 12-lead ECG interpretation is needed. Standardized screening tools and mass screening protocols that include screening ECGs for targeted athlete populations who are at high risk for SCD are needed. These recommendations are aimed at addressing some of the barriers raised by the AHA/ACC group to pre-participation screening with ECG.
View details for DOI 10.1016/j.jelectrocard.2015.03.003
View details for Web of Science ID 000354343100009
View details for PubMedID 25791248
Hands-Free Image Capture, Data Tagging and Transfer Using Google Glass: A Pilot Study for Improved Wound Care Management
2015; 10 (4)
Chronic wounds, including pressure ulcers, compromise the health of 6.5 million Americans and pose an annual estimated burden of $25 billion to the U.S. health care system. When treating chronic wounds, clinicians must use meticulous documentation to determine wound severity and to monitor healing progress over time. Yet, current wound documentation practices using digital photography are often cumbersome and labor intensive. The process of transferring photos into Electronic Medical Records (EMRs) requires many steps and can take several days. Newer smartphone and tablet-based solutions, such as Epic Haiku, have reduced EMR upload time. However, issues still exist involving patient positioning, image-capture technique, and patient identification. In this paper, we present the development and assessment of the SnapCap System for chronic wound photography. Through leveraging the sensor capabilities of Google Glass, SnapCap enables hands-free digital image capture, and the tagging and transfer of images to a patient's EMR. In a pilot study with wound care nurses at Stanford Hospital (n=16), we (i) examined feature preferences for hands-free digital image capture and documentation, and (ii) compared SnapCap to the state of the art in digital wound care photography, the Epic Haiku application. We used the Wilcoxon Signed-ranks test to evaluate differences in mean ranks between preference options. Preferred hands-free navigation features include barcode scanning for patient identification, Z(15) = -3.873, p < 0.001, r = 0.71, and double-blinking to take photographs, Z(13) = -3.606, p < 0.001, r = 0.71. In the comparison between SnapCap and Epic Haiku, the SnapCap System was preferred for sterile image-capture technique, Z(16) = -3.873, p < 0.001, r = 0.68. Responses were divided with respect to image quality and overall ease of use. The study's results have contributed to the future implementation of new features aimed at enhancing mobile hands-free digital photography for chronic wound care.
View details for DOI 10.1371/journal.pone.0121179
View details for Web of Science ID 000353331500009
View details for PubMedID 25902061
View details for PubMedCentralID PMC4406552
- Prevalence of Vitamin D Deficiency in Mlogeneic HCT Recipients and Its Association with Graft Versus Host Disease ELSEVIER SCIENCE INC. 2015: S280
TEACHING NURSES CAD: IDENTIFYING DESIGN SOFTWARE LEARNING DIFFERENCES IN A NON-TRADITIONAL USER DEMOGRAPHIC
DESIGN SOC. 2015
View details for Web of Science ID 000366977500033
Health behaviors and needs of melanoma survivors
SUPPORTIVE CARE IN CANCER
2014; 22 (11): 2973-2980
Little is known about melanoma survivors' long-term symptoms, sun protection practices, and support needs from health providers.Melanoma survivors treated at Stanford Cancer Center from 1995 through 2011 were invited to complete a heath needs survey. We compared responses of survivors by sex, education, time since diagnosis (long-term vs. short-term survivors), and extent of treatment received (wide local excision (WLE) alone versus WLE plus additional surgical or medical treatment (WLE+)).One hundred sixty melanoma survivors (51 % male; 61 % long-term; 73 % WLE+) provided evaluable data. On average, patients were 62 years of age (SD = 14), highly educated (75 % college degree), and Caucasian (94 %). Overall, participants rated anxiety as the most prevalent symptom (34 %). Seventy percent reported that their health provider did not address their symptoms, and 53 % requested education about melanoma-specific issues. Following treatment, women spent significantly less time seeking a tan compared with men (p = 0.01), had more extremity swelling (p = 0.014), and expressed higher need for additional services (p = 0.03). Long-term survivors decreased their use of tanning beds (p = 0.03) and time spent seeking a tan (p = 0.002) and were less likely to receive skin screening every 3-6 months (p < 0.001) compared with short-term survivors. WLE+ survivors reported greater physical long-term effects than WLE survivors (p ≤ 0.001) following treatment.Melanoma survivors experience continuing symptoms long after treatment, namely anxiety, and they express a need for information about long-term melanoma effects, psychosocial support, and prevention of further skin cancer.
View details for DOI 10.1007/s00520-014-2286-0
View details for Web of Science ID 000343053700012
Comparison of three ECG criteria for athlete pre-participation screening
JOURNAL OF ELECTROCARDIOLOGY
2014; 47 (6): 769-774
Controversy regarding adding the ECG to the evaluation of young athletes centers on the implications of false positives. Several guidelines have been published with recommendations for criteria to distinguish between ECG manifestations of training and markers of risk for cardiovascular (CV) sudden death. With an athlete dataset negative of any CV related abnormalities on follow-up, we applied three athlete screening criteria to identify the one with the lowest rate of abnormal variants.High school, college, and professional athletes underwent 12L ECGs as part of routine physicals. All ECGs were recorded and processed using CardeaScreen (Seattle, WA). The European (2010), Stanford (2011), and Seattle criteria (2013) were applied.From March 2011 to February 2013 1417 ECGs were collected. Mean age was 20±4years (14-35years), 36% female, 38.5% non-white (307 high school, 836 college and 284 professional). Rate of abnormal variants differed by criteria, predominately due to variation in interval thresholds for QT interval and QRS duration. There was a four-fold difference in abnormal variants between European and Seattle criteria (26% v 6%).The Seattle criterion was the most conservative resulting in 78% fewer abnormal variants than the European criteria. Variation was most evident with thresholds for QT prolongation, short QT interval, and intraventricular conduction delay. Continued research is needed to further understand normal training related adaptations and to improve modern ECG screening criteria for athletes.
View details for DOI 10.1016/j.jelectrocard.2014.07.019
View details for Web of Science ID 000344311800001
View details for PubMedID 25155389
Hyperglycemia Is Associated With Corrected QT Prolongation and Mortality in Acutely Ill Patients
JOURNAL OF CARDIOVASCULAR NURSING
2014; 29 (3): 264-270
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.
View details for DOI 10.1097/JCN.0b013e31827f174c
View details for Web of Science ID 000337681400012
View details for PubMedID 23364575
Electrocardiographic abnormalities in the first year after heart transplantation
JOURNAL OF ELECTROCARDIOLOGY
2014; 47 (2): 135-139
Describe ECG abnormalities in the first year following transplant surgery.Analysis of 12-lead ECGs from heart transplant subjects enrolled in an ongoing multicenter clinical trial.585 ECGs from 98 subjects showed few with abnormal cardiac rhythm (99% of ECGs were sinus rhythm/tachycardia). A majority of subjects (69%) had either right intraventricular conduction delay (56%) or right bundle branch block (13%). A second prevalent ECG abnormality was atrial enlargement (64% of subjects) that was more commonly left atrial (55%) than right (30%).Right intraventricular conduction delay or right bundle branch block is prevalent in heart transplant recipients in the first year following transplant surgery. Whether this abnormality is related to acute allograph rejection or endomyocardial biopsy procedures is the subject of the ongoing clinical trial. Atrial enlargement ECG criteria (especially, left atrial) are also common and are likely due to transplant surgery with subsequent atrial remodeling.
View details for DOI 10.1016/j.jelectrocard.2013.09.006
View details for Web of Science ID 000333438400001
View details for PubMedID 24119878
- Understanding and Documenting QT Intervals CRITICAL CARE NURSE 2013; 33 (4): 73-75
- WOMAN WITH RISKS FOR TORSADES DE POINTES DYING WITHIN HOURS OF LEAVING THE EMERGENCY DEPARTMENT JOURNAL OF EMERGENCY NURSING 2013; 39 (1): 53-56
- Measurement and rate correction of the QT interval. AACN advanced critical care 2013; 24 (1): 90-96
Time dependent history improves QT interval estimation in atrial fibrillation
JOURNAL OF ELECTROCARDIOLOGY
2012; 45 (6): 556-560
It is not recommended to perform QTc estimation in patients with atrial fibrillation (AF). We evaluated multiple QT interval correction formulas, including a novel time-dependent history approach, in an effort to identify the best method for correcting the QT interval in patients with AF. The ideal correction results in independence between the QTc estimate and HR.Per-beat characteristics were derived using SuperECG (Mortara Instrument). Offline beat-to-beat QTc interval estimates were constructed using standard formulae and averaged (2-10) groups constructed.Seventy-one patients were included, age 67 ± 10 years, 69% men. Mean-mean QTc intervals varied by correction (range 394-459 ms). Averaging resulted in the same mean-mean QTc estimate, but significantly reduced variability by up to 55%. Time-dependent RR interval history reduced variability the most (Δ 80%), increased QT/RR dynamics (m=.03 vs .17), and was independent with HR (m = 0.0008).Our data suggests that QTc interval estimation in patients with AF can be performed reliably using time-dependent history (RRc) outperforming other correction methods.
View details for DOI 10.1016/j.jelectrocard.2012.08.052
View details for Web of Science ID 000310763300004
View details for PubMedID 23040546
Feasibility and compliance with daily home electrocardiogram monitoring of the QT interval in heart transplant recipients
HEART & LUNG
2012; 41 (4): 368-373
Recent evidence suggests that acute allograft rejection after heart transplantation causes an increased QT interval on electrocardiogram (ECG). The aims of this pilot study were to (1) determine whether heart transplant recipients could achieve compliance in transmitting a 30-second ECG every day for 1 month using a simple ECG device and their home telephone, (2) evaluate the ease of device use and acceptability by transplant recipients, and (3) evaluate the quality of transmitted ECG tracings for QT-interval measurement.A convenience sample of adult heart transplant recipients were recruited and trained to use the device (HeartOne, Aerotel Medical Systems, Holon, Israel). Lead II was used with electrodes that were easy to slip on and off (expandable metal wrist watch-type electrode for right wrist and C-shaped band electrode for left ankle). Patients used a toll-free number with automated voice prompts to guide their ECG transmission to the core laboratory for analysis.Thirty-one subjects (72% were male; mean age of 52 ± 17 years; 37% were nonwhite) achieved an ECG transmission compliance of 73.4% (daily) and 100% (weekly). When asked, how difficult do you think it was to record and transmit your ECG by phone, 90% of subjects replied "somewhat easy" or "extremely easy." Of the total 644 ECGs that were transmitted by subjects, 569 (89%) were acceptable quality for QT-interval measurement. The mean QTc was 448 ± 44 ms (440 ± 41 ms for male subjects and 471 ± 45 ms for female subjects). Eleven subjects (35%) had an extremity tremor, and 19 subjects (55%) had ≥ 1+ left leg edema. Neither of these conditions interfered with ECG measurements.Transplant recipients are compliant with recording and transmitting daily and weekly ECGs.
View details for DOI 10.1016/j.hrtlng.2012.02.012
View details for Web of Science ID 000306204900008
View details for PubMedID 22459508
QUASI-EXPERIMENTAL STUDY TO IMPROVE NURSES' QT-INTERVAL MONITORING: RESULTS OF QTIP STUDY
AMERICAN JOURNAL OF CRITICAL CARE
2012; 21 (3): 195-200
A collaboration led by the American Heart Association recently released the scientific statement "Prevention of Torsade de Pointes in Hospital Settings." Patients receiving proarrhythmic drugs, who have electrolyte disturbances, or who have bradyarrhythmias require QT-interval monitoring. Prior studies have demonstrated that physicians have a poor level of proficiency at calculating QT intervals. The ability of nurses at calculating QT intervals remains untested.To evaluate nurses' knowledge and ability to perform QT/QTc interval monitoring.At a single institution, 47 QT-education classes were provided to 480 eligible nurses who regularly perform cardiac monitoring. All nurses completed a researcher-developed knowledge test at baseline and after the QT-related education intervention.Overall 379 nurses participated (mean age 39 [SD, 10] years), 71% had more than 5 years' nursing experience. Total test scores increased after intervention (46% vs 77%, P < .001). Education significantly improved marking of the QT/RR intervals (QT: 65% vs 91%, RR: 83% vs 90%, P ≤ .001 and P = .02) and measurement of the QT/RR intervals (QT: 47% vs 84%, RR: 35% vs 71% P ≤ .001 and P ≤ .001). Calculation of the QTc interval also increased significantly (6% vs 52%, P ≤ .001).Our study results demonstrate that nurses' baseline ability to perform QT interval monitoring is extremely poor. An unacceptable amount of error persists after an educational intervention. Accurate computer-assisted methods are needed to reduce the error associated with manual QT-interval monitoring.
View details for DOI 10.4037/ajcc2012245
View details for Web of Science ID 000310641300014
View details for PubMedID 22549576
Remote noninvasive allograft rejection monitoring for heart transplant recipients: study protocol for the novel evaluation with home electrocardiogram and remote transmission (NEW HEART) study
BMC CARDIOVASCULAR DISORDERS
Acute allograft rejection is a major cause of early mortality in the first year after heart transplantation in adults. Although endomyocardial biopsy (EMB) is not a perfect "gold standard" for a correct diagnosis of acute allograft rejection, it is considered the best available test and thus, is the current standard practice. Unfortunately, EMB is an invasive and costly procedure that is not without risk. Recent evidence suggests that acute allograft rejection causes delays in ventricular repolarization and thereby increases the cellular action potential duration resulting in a longer QT interval on the electrocardiogram (ECG). No prospective study to date has investigated whether such increases in the QT interval could provide early detection of acute allograft rejection. Therefore, in the Novel Evaluation With Home Electrocardiogram And Remote Transmission (NEW HEART) study, we plan to investigate the potential benefit of daily home QT interval monitoring to predict acute allograft rejection.The NEW HEART study is a prospective, double-blind, multi-center descriptive research study. A sample of 325 adult heart transplant recipients will be recruited within six weeks of transplant from three sites in the United States. Subjects will receive the HeartView™ ECG recorder and its companion Internet Transmitter, which will transmit the subject's ECG to a Core Laboratory. Subjects will be instructed to record and transmit an ECG recording daily for 6 months. An increase in the QTC interval from the previous day of at least 25 ms that persists for 3 consecutive days will be considered abnormal. The number and grade of acute allograft rejection episodes, as well as all-cause mortality, will be collected for one year following transplant surgery.This study will provide "real world" prospective data to determine the sensitivity and specificity of QTC as an early non invasive marker of cellular rejection in transplant recipients during the first post-transplant year. A non-invasive indicator of early allograft rejection in heart transplant recipients has the potential to limit the number and severity of rejection episodes by reducing the time and cost of rejection surveillance and by shortening the time to recognition of rejection.ClinicalTrials.gov: NCT01365806.
View details for DOI 10.1186/1471-2261-12-14
View details for Web of Science ID 000302544000001
View details for PubMedID 22386040
High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality: Results of the QT in Practice (QTIP) Study
CRITICAL CARE MEDICINE
2012; 40 (2): 394-399
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.
View details for DOI 10.1097/CCM.0b013e318232db4a
View details for Web of Science ID 000299313500004
View details for PubMedID 22001585
High Prevalence of QT Interval Prolongation in Hospitalized Patients is Linked to Mortality: Results of the QT in Practice (QTIP) Study
LIPPINCOTT WILLIAMS & WILKINS. 2010
View details for Web of Science ID 000208231603417
How many patients need QT interval monitoring in critical care units? Preliminary report of the QT in Practice study
35th Annual Conference of the International-Society-for-Computerized-Electrocardiology
CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2010: 572–76
Recent Scientific Statement from the American Heart Association (AHA) recommends that hospital patients should receive QT interval monitoring if certain conditions are present: QT-prolonging drug administration or admission for drug overdose, electrolyte disturbances (K, Mg), and bradycardia. No studies have quantified the proportion of critical care patients that meet the AHA's indications for QT interval monitoring. This is a prospective study of 1039 critical care patients to determine the proportion of patients that meet the AHA's indications for QT interval monitoring. Secondary aim is to evaluate the predictive value of the AHA's indications in identifying patients who actually develop QT interval prolongation.Continuous QT interval monitoring software was installed in all monitored beds (n = 154) across 5 critical care units. This system uses outlier rejection and median filtering in all available leads to construct an root-mean-squared wave from which the QT measurement is made. Fridericia formula was used for heart rate correction. A QT interval greater than 500 milliseconds for 15 minutes or longer was considered prolonged for analyses. To minimize false positives all episodes of QT prolongation were manually over read. Clinical data was abstracted from the medical record.Overall 69% of patients had 1 or more AHA indications for QT interval monitoring. More women (74%) had indications than men (64%, P = .001). One quarter (24%) had QT interval prolongation (>500 ms for ≥15 minutes). The odds for QT interval prolongation increased with the number of AHA indications present; 1 indication, odds ratio (OR) = 3.2 (2.1-5.0); 2 indications, OR = 7.3(4.6-11.7); and 3 or more indications OR = 9.2(4.8-17.4). Positive predictive value of the AHA indications for QT interval prolongation was 31.2%; negative predictive value was 91.3%.Most critically ill patients (69%) have AHA indications for QT interval monitoring. One quarter of critically ill patients (24%) developed QT interval prolongation. The AHA indications for QT interval monitoring successfully captured the majority of critically ill patients developing QT interval prolongation.
View details for DOI 10.1016/j.jelectrocard.2010.05.016
View details for Web of Science ID 000284514700015
View details for PubMedID 21040827
- QT/QTC INTERVAL MONITORING IN THE EMERGENCY DEPARTMENT JOURNAL OF EMERGENCY NURSING 2008; 34 (5): 428-434