Coronary Care Unit Patients Research Articles

Clinical quality improvement: eliminating unplanned extubation in the CCU

This article aims to explore coronary care unit (CCU) extubation structures, processes and outcomes. There were 13 unplanned-extubation cases (UE) among 251 intubated patients (5.2 per cent) in a cardiologist-led CCU in 2008. Seven did not require re-intubation, implying possible earlier extubation. A quality improvement project was undertaken with a goal to eliminate CCU UE within 12 months. Using the clinical practice improvement (CPI) method, the most significant root causes were missing sedation/analgesia protocol, no ventilator weaning protocol and absent respiratory therapist during the CCU morning rounds. Non-physician directed sedation/analgesia and ventilation weaning protocols were created and put on trial in Plan-Do-Study-Act cycles before formal implementation. Arrangements were made to allocate a respiratory therapist to the CCU daily for morning rounds. For 12 months after fully implementing the interventions, UE incidence dropped from 5.2 per cent to 0.9 per cent (p = 0.006). There were no adverse outcomes, re-intubation and/or readmission to CCU within 48 hours. Through a multi-disciplinary CPI approach, adopting non-physician directed protocols has successfully streamlined and improved airway management in mechanically ventilated patients in a cardiologist-led CCU. There is little published data on improving intubated patient care in cardiologist-led CCUs. Previous studies centered on intensive care units managed by critical care specialists.

Urinary Interleukin 18 for Detection of Acute Kidney Injury: A Meta-analysis

Interleukin 18 (IL-18) has been proposed as a biomarker for the early detection of acute kidney injury (AKI), but a broad range of its predictive accuracy has been reported. Meta-analysis of diagnostic test studies. Various clinical settings of AKI, including after cardiac surgery, after contrast infusion, in the emergency department, or in the intensive care unit. Prospective studies that investigated the diagnostic accuracy of IL-18 level to predict AKI. Increasing or increased urinary IL-18 excretion. The primary outcome was AKI development, mainly based on serum creatinine level (definition varied across studies). The other outcome was in-hospital mortality. We analyzed data from 23 studies and 7 countries involving 4,512 patients. Of these studies, 18 could be included in the meta-analysis. Across all settings, the diagnostic odds ratio (DOR) for urinary IL-18 level to predict AKI was 4.22 (95% CI, 2.90-6.14), with sensitivity and specificity of 0.58 and 0.75, respectively. The area under the receiver operating characteristic curve (AUROC) of urinary IL-18 level to predict AKI was 0.70 (95% CI, 0.66-0.74). Subgroup analysis showed the DOR/AUROC of urinary IL-18 was 5.32 (95% CI, 2.92-9.70)/0.72 (95% CI, 0.68-0.76) in cardiac surgery patients and 3.65 (95% CI, 1.88-7.10)/0.66 (95% CI, 0.62-0.70) in intensive care unit or coronary care unit patients. After stratification for age, IL-18 level had better diagnostic accuracy in children and adolescents versus adults: 8.12 (95% CI, 3.79-17.41)/0.78 (95% CI, 0.75-0.82) versus 3.31 (95% CI, 2.28-4.80)/0.66 (95% CI, 0.62-0.70). There was no significant difference in predictive performance of urinary IL-18 level among various times. Various clinical settings; different definition of AKI and serum creatinine level as the reference standard test for the diagnosis of AKI. Urinary IL-18 is a useful biomarker of AKI with moderate predictive value across all clinical settings.

Massage Therapy and Vital Signs of Patients in Coronary Care Units

In the first issue of Nursing and Midwifery Studies, AdibHajbaghery et al. have published the results of a study on the effects of massage therapy by the patient’s relative on vital signs of males admitted in critical care unit (1). Ischemic heart disease is estimated to be the leading cause of mortality in the country and worldwide (2). Tachycardia and high blood pressure in these patients can have dangerous consequences, especially in their acute phase. Then, treating tachycardia and lowering the high blood pressure may help to control the dangerous consequences in this phase. Due to the side effects of drugs, the study of Adib-Hajbaghery et al. (1) can draw the nurses’ attention to the use of non-pharmacological treatments for balancing the vital signs of patients in the CCU. This study has a good design and the results are presented in clear and expressive way. Also massage therapy was done by the patient’s relatives and this may be viewed as an innovation in research and practice and is strength for this study. However, it could be better if the time between the two consecutive measurements of vital signs (before and after the intervention) in the intervention and control Published by Kowsar Corp, 2012. cc 3.0.

Acute Kidney Injury Biomarkers for Patients in a Coronary Care Unit: A Prospective Cohort Study

BackgroundRenal dysfunction is an established predictor of all-cause mortality in intensive care units. This study analyzed the outcomes of coronary care unit (CCU) patients and evaluated several biomarkers of acute kidney injury (AKI), including neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18) and cystatin C (CysC) on the first day of CCU admission.Methodology/Principal FindingsSerum and urinary samples collected from 150 patients in the coronary care unit of a tertiary care university hospital between September 2009 and August 2010 were tested for NGAL, IL-18 and CysC. Prospective demographic, clinical and laboratory data were evaluated as predictors of survival in this patient group. The most common cause of CCU admission was acute myocardial infarction (80%). According to Acute Kidney Injury Network criteria, 28.7% (43/150) of CCU patients had AKI of varying severity. Cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.05) between patients with AKI versus those without AKI. For predicting AKI, serum CysC displayed an excellent areas under the receiver operating characteristic curve (AUROC) (0.895±0.031, p<0.001). The overall 180-day survival rate was 88.7% (133/150). Multiple Cox logistic regression hazard analysis revealed that urinary NGAL, serum IL-18, Acute Physiology, Age and Chronic Health Evaluation II (APACHE II) and sodium on CCU admission day one were independent risk factors for 6-month mortality. In terms of 6-month mortality, urinary NGAL had the best discriminatory power, the best Youden index, and the highest overall correctness of prediction.ConclusionsOur data showed that serum CysC has the best discriminative power for predicting AKI in CCU patients. However, urinary NGAL and serum IL-18 are associated with short-term mortality in these critically ill patients.

Accuracy, Precision, and Validity of Fever Detection using Non-invasive Temperature Measurement in Adult Coronary Care Unit Patients with Pulmonary Catheters

To investigate the accuracy, precision and validity of fever detection of tympanic membrane (TM), temporal artery (TA) and axillary temperature (AT) compared with pulmonary artery temperature (PA). Repeated-measures design was conducted for one year on 83 adult cardiac care unit patients with pulmonary artery catheters after open heart surgery. Sequential temperature measurements were taken three times at 20-minute intervals. Accuracy, precision, repeatability, and validity of fever detection were analyzed. Mean pulmonary artery temperature was 37.04°C (SD 0.70°C). The mean (SD) offsets from PA, with the mean reflecting accuracy and SD reflecting precision, were -1.31°C (0.75°C) for TA, -0.20°C (0.24°C) for TM, and -0.97°C (0.64°C) for AT. Percentage of pairs with differences within ±0.5°C was 9.6% for TA, 19.7% for AT, and 91.6% for TM. Repeated measurements with all three methods had mean SD values within 0.04°C. Sensitivity, specificity, and positive and negative predictive values of tympanic measurements were 0.76, 1.0, and 1.0, and 0.90, respectively. Results show that TM best reflects PA, and is most consistent, accurate, and precise. AT tends to underestimate PA, and TA is least accurate and precise. Therefore tympanic membrane measurement is a reliable alternative to other non-invasive methods of measuring temperatures.

Screening for abdominal aortic aneurysm in coronary care unit patients with acute myocardial infarction using portable transthoracic echocardiography

Patients with acute myocardial infarction (AMI) represent a high-risk population in which screening for abdominal aortic aneurysm (AAA) is recommended but only occasionally performed. Transthoracic echocardiography (TTE) may offer the unique opportunity to evaluate the cardiac function and to screen for AAA during the same examination. We aimed to evaluate the feasibility of AAA screening at bedside using a portable cardiac ultrasound (US) echo machine and to determine the prevalence of AAA in population with AMI. The AA diameter was measured at bedside at the end of a regular TTE performed in consecutive patients admitted for AMI in the coronary care unit using a portable echo machine (Vividi, General Electric). AAA was defined by a transverse diameter of ≥ 30 mm. We prospectively enrolled 193 patients (65 ± 11 years, 77% male). Measurement of the AA diameter was feasible in 93% and the duration was 3 ± 1 min. An AAA was observed in nine patients (4.7%) and the prevalence increased with age (7.7% after 60 years and 9.2% after 65 years). No AAA was observed in patients under 50 years old. Inter-observer variability between cardiologists using the portable US system was excellent (mean difference 1.8 ± 2.0 mm) as well as the accuracy compared with measurements performed by a radiologist using a dedicated vascular US system (mean difference 1.5 ± 1.3 mm). Overall, the prevalence of AAA was 4.7%, increased with age, and seems higher than expected in the 'same-aged population'. In regard to the simplicity, accuracy, and feasibility, screening for AAA during TTE (one cardiovascular shot) may be of value after AMI especially in elderly patients.

Establishing a Culture of Blood Management Through Education

Blood management strategies are crucial in light of transfusion-related health risks to patients and the relative scarcity and cost of blood products. The authors describe a collaborative quality initiative to reduce blood use in their coronary artery bypass graft (CABG) population and other cardiovascular intensive care unit (CVICU) patients. A multidisciplinary team was engaged at all levels of patient care. The 2-part initiative involved a direct educational component emphasizing transfusion risk awareness and patient-centered blood management strategies accompanied by a data-based component that included monthly dissemination of blood product use to the relevant service lines. The authors observed a reduction in postoperative blood product use among CABG patients (14.3% decrease in the first year; 30.6% from 2006 to 2008) and an 18.2% reduction in blood product volume used in the entire CVICU, with no additional harm to patients and a trend toward better outcomes. This team-driven paradigm change has made blood management everyone's initiative.

Does the relation between red blood cell transfusion and mortality vary according to transfusion indication? A case–control study among patients with acute coronary syndromes

Red blood cell (RBC) transfusions are common among patients with acute coronary syndromes (ACS). We sought to determine their impact on mortality according to indication. We conducted a case-control analysis of ACS patients admitted to a single coronary care unit. Transfused patients were matched to nontransfused patients for age, estimated glomerular filtration rate, and nadir hematocrit. Conditional logistic regression analysis was used to determine the independent relationship between RBC transfusion and inhospital mortality. Results were stratified according to the indication for transfusion. Of the 3190 patients admitted with ACS, 206 (6.4%) received at least one RBC transfusion. Of these, 103 patients were matched to 185 nontransfused patients. The most common indications for transfusion were nonspecific anemia (48%) and overt blood loss (42%). Transfused patients had a significantly lower ejection fraction and were more likely to present in Killip class IV, undergo pulmonary artery catheterization, and require an intra-aortic balloon pump. On univariate analysis, RBC transfusion was associated with a doubling of the risk of inhospital mortality [odds ratio: 2.0; 95% confidence interval: 1.0-3.9; P=0.046]. However, after adjustment for confounders, transfusion was no longer significantly associated with higher inhospital mortality (odds ratio: 1.8; 95% confidence interval: 0.6-5.1; P=0.3). On stratified analysis, RBC transfusion was not significantly associated with inhospital mortality among patients transfused for either nonspecific anemia or overt blood loss. Among coronary care unit patients with ACS, RBC transfusion does not seem to have a significant impact on inhospital mortality irrespective of the indication for transfusion.

Cluster of Parvovirus Infection Among Hospital Staff Working in Coronary Care Units

Parvovirus B19 is associated with erythema infectiosum in children or arthralgia and arthritis in adults. The virus is relatively conserved and nucleotide identity is expected in viruses that are epidemiologically related. Here, we describe the first cluster of parvovirus infection among hospital staff documented in Taiwan. Active surveillance was conducted in coronary care units (CCUs) at a 2200-bed teaching hospital for 1 month in 2007. A case defined clinically as occurring in a patient or staff in CCUs with new onset of fever or rash. Serum was tested for parvovirus B19 IgM and IgG by immunoblotting and DNA by nested polymerase chain reaction. When viremia was detected, nucleotide sequences were analyzed and compared with those of two clinical isolates. The attack rate was defined as the cumulative incidence of acute infection in CCU staff and patients during the study period. Among 57 staff and 15 patients, five nurses met the clinical case definition. Three had acute infection as demonstrated by viral DNA and IgM. The attack rate was 5.3% for the staff and zero for patients. Seroprevalence rate was lower in staff than in patients (26.3%vs. 53.3%). The isolates collected from three cases were highly similar to a community isolate, and they varied with each other by 2-6 nucleotides. The isolate collected from a nurse was identical to that from her friend 3 weeks apart and was concordant with mutual transmission. A sequence with 45 nucleotide variations was identified from a staff member with chronic infection who was negative for IgM and had only weak IgG anti-VP1 reaction with immunoblotting. We did not find any patient as the source of infection. We identified a cluster of parvovirus infection that was caused by three circulating strains which did not support the hypothesis of transmission of a single strain in CCUs.

Venous thromboembolism risk assessment and thromboprophylaxis among hospitalized acute medical patients in China – the RAMP study

Background In developed countries, hospitalized patients with acute medical conditions are at significant risk for venous thromboembolism (VTE). Little is known about VTE risk and prophylaxis practices in China. Objective To determine the VTE risk and the frequency of recommended VTE prophylaxis in hospitalized Chinese patients with acute medical conditions. Methods Multi-center, cross-sectional, observational study. Eligibility criteria: ≥ 30 years, admitted to an intensive care unit (ICU)/coronary care unit (CCU) for acute medical illness, had ≥ 1 VTE risk factor/1 disease that predisposes to VTE, and provided informed consent. We used 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines to assess VTE risk and the frequency of recommended VTE prophylaxis. Results 1247 patients from 19 hospitals in 11 cities across 11 provinces of China were enrolled from July 2007 to June 2008. 57.3% patients had > 2 VTE risk factors. Only 20.2% received ACCP-recommended VTE prophylaxis (CCU patients: 22.7%, ICU patients: 16.9%, p = 0.0117). Limitations Excluding some patients with VTE risk factors did not allow assessment of the prevalence of VTE risk in the acute hospital-care setting. We could not determine whether the duration of prophylaxis complied with the ACCP recommendations. Our results may not be representative of hospitals in small cities/rural areas in China. Conclusions The prevalence of VTE risk factors in Chinese patients was similar to that in developed countries; however, only a small proportion of eligible patients received the recommended VTE prophylaxis. Our findings highlight the need for dissemination and implementation of appropriate VTE prophylaxis guidelines in China.

The Accuracy of the Central Venous Blood Gas for Acid-Base Monitoring

Routine use of central venous blood gases (VBGs) may reduce complications from prolonged arterial cannulation. We investigated the reliability of the VBG as a substitute for arterial blood gas (ABG) in multiple care settings. We developed a VBG adjustment rule of ABG pH = VBG pH + 0.05, ABG CO(2) = VBG PCO(2) -5 mm Hg from prior studies and validated this relationship with simultaneous venous and arterial blood obtained from 187 medical/surgical intensive care, cardiac catheterization laboratory, and coronary care unit patients with central venous access. The overall accuracy of a normal adjusted VBG (aVBG) to predict a normal ABG was 90%. After adjustment, the mean systematic difference (bias) between ABG and VBG pH decreased from 0.035 +/- 0.02 to -0.015 +/- 0.02 and PCO(2) bias decreased from -4.5 +/- 3.5 to 0.5 +/- 3.5. Intraclass correlation coefficients for agreement improved after applying the adjustment rule to venous pH (from 0.84 to 0.93, P < .001) and PCO(2) (from 0.66 to 0.84, P < .001). Overall diagnostic accuracy of VBG improved from 45% to 74% after adjustment. Multiple logistic regression demonstrated that the factor independently associated with discrepancy between VBG and ABG diagnoses was an abnormal aVBG (OR 6.8, 95% CI 2.8-16.5). Because of the high agreement between a normal aVBG with a normal ABG and the small bias between these tests, we recommend use of the adjusted central VBG.

The application of risk management in the nursing of elderly patients in CCU

Objective This study is aimed to reduce the incidence of nursing risk and avoid the occurrence of defects of nursing in order to improve the quality of nursing of elderly patients in Coronary Care Unit(CCU).Methods Between December 2007 and December 2008,risk management has been applied to the nursing of elderly patients in CCU.The risk of nursing was assessed and relative protocols of prevention of nursing risk werle established and brought into routine nursing practice.The effectiveness of this protocol has also been evaluated.30 patients were selected from CCU every quarter(totally 120patients were selected).These patients fulfilled the indacing format made by PLA General Hospital.The rate of satisfactory.complaints and defect were compared before and after the implement of management.Results After application of risk management,the satisfaction rate of patients raised from 87.50%to 98.33%(P<0.01).Compared to pieapplication,the rate of complaint of nursing(10.83%,3.33%;P<0.05)and defects(14.17%,5%;P<0.01)have both dropped significandy.Conclusions The application of risk management play an important role to prevent the occurrence of nursing defects,enhance the ability of nursing staff recognizing and copping with risks,reduce the risk rate and improve the nursing safety in CCU. Key words: Risk management; Elderly; Coronary care unit; Nursing management

The role of continuous monitoring in a 24/7 telecardiology consultation service—a feasibility study

Today's coronary care unit patients include those with complicated and uncomplicated myocardial infarction, decompensated heart failure and frank cardiogenic shock, severe valvular heart disease, high-grade conduction disturbances, and incessant ventricular arrhythmias. Increasingly in modern medicine, these conditions are not seen in isolation but rather in connection with a series of additional medical comorbidities. Increased life expectancy results in an increase in the prevalence of chronic cardiovascular diseases and an increased demand for health care services. Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of a patient. Telecardiology is one of the oldest applications in telemedicine and has been largely applied during the last 10 to 20 years. This study evaluated the feasibility of remote surveillance of coronary care unit and cardiology ward patient monitoring data by a “telecardiologist” with access to electronic health care record data and digitally stored 12-lead electrocardiograms. The remote access to the hospital intranet proved to be technically feasible. Also, the server applications used over the remote connection proved to be reliable and showed robustness against network performance variations. Extending remote patient surveillance to other hospitals is possible, provided that similar electrocardiogram and electronic health care record applications are available and a remote access can be arranged to them. However, the usability from cardiologist's perspective may be degraded if connecting with multiple applications and hospital networks is needed. The study indicated potential for speeding up the diagnostic and therapeutic processes in the hospital, although the study was limited in that the telecardiologist played a passive role and did not acutely impact patient care. In the future, the system could be expanded to surveillance of smaller hospitals. Telemedicine has the potential to aid in solving the conflict between aging of population, rise in the demand for critical care services, and shortage of professional personnel. This might, however, require a more active remote surveillance than the one tested in this study. Privacy- and security-related aspects are major components of building trust and confidence in telemedicine systems. In telecardiology, the real-time interactive telemedicine model with 24/7 service has potential superior performance compared with a store-and-forward telemedicine model.

Innovative self‐management programme for diabetics following coronary care unit admission

Evidence indicates self-management programmes based on improving self-efficacy in managing diabetes can reduce the risk of a further cardiac event. Many current cardiac rehabilitation or diabetes self-management programmes do not address the needs of people with both type 2 diabetes and a critical cardiac condition in their transition from coronary care unit (CCU) to home. The aim was to develop and pilot test a Cardiac-Diabetes Self-Management Program (CDSMP) using an experimental design. Results demonstrated the feasibility of the CDSMP for CCU patients with type 2 diabetes in their transition to home, and a full study is warranted.

Pre-event Cardiovascular Risk in Coronary Care Unit Patients

Pre-event Cardiovascular Risk in Coronary Care Unit Patients

Akut koroner sendrom ve stabil koroner arter hastalarında sigara içiciliği ve nikotin bağımlılığı

Amac: Sigara icmek, kalp damar hastal›klar› icin onemli bir risk faktorudur; koroner kalp hastal›¤› riskini iki kat art›rmaktad›r. Bu cal›flma, kararl› koroner arter hastalar›n›n ve akut koroner sen- drom nedeniyle youn bak›ma yatanlar›n sigara icme durumunu ve nikotin ba¤›ml›l›¤›n› saptamay› amaclamaktad›r. Yontem: Akut koroner sendrom tan›s›yla youn bak›m gorenler ile kardiyoloji polikliniinde kontrol muayenesi olan stabil koroner arter hastalar›na bir soru formu uyguland›. Klinik ozellikleri kayde- dildi. Bu kesitsel tan›mlay›c› cal›flmada sigara icme al›flkanl›¤› geri- ye donuk olarak sorguland›. Hastalar›n bilgilendirilmifl onam› al›- narak Fagerstrom nikotin ba¤›ml›l›¤› testi uyguland›. Summary Objective: Smoking is an important risk factor for cardiovascular diseases. Our aim was to determine the status of smoking and degree of nicotine addiction. Methods: In the study a questionnaire was performed on patients who were admitted to the coronary care unit and stable coronary artery disease patients who were followed-up at the outpatient clinic. The clinical characteristics were noted. In this descriptive cross-sectional study, smoking habits of the patients' were evalu- ated retrospectively. The nicotine addiction status was determined by Fagerstrom test. Results: In the acute coronary syndrome patients group (group 1) there were a total of 50 patients (41 male/9 female). The mean age was 61±11.1 year. The stable coronary artery disease patients group (group 2) included 48 cases (36 male/12 female) and the mean age was 62.7±9.0. The number of patients who were cur- rent smokers in group 1 and group 2 were 22 (%44) and 5 (%10, 4) respectively (p<0.05). The number of passive smokers were 47 (%94) in group 1 and 19 (%39.6) in group 2 (p<0.05). Conclusions: Smoking was more prevalent in acute coronary syn- drome patients compared to patients with stable coronary artery disease. For primary and secondary prevention of coronary artery disease; programs for quitting smoking and prevention of non- smokers from smoke are important.

Current Management of Anemia in Critically Ill Patients: Analysis of a Database of 139 Hospitals

This analysis focused on three objectives: 1) to measure packed red blood cell (pRBC) use across different critical care settings; 2) to characterize transfused and nontransfused critically ill patients; and (3) to identify potential predictors of transfusion use. A retrospective analysis of critically ill patients from 139 hospitals across the United States was conducted. Hospital administrative and laboratory data were collected for patients 18 years of age and older admitted to the intensive care unit (ICU) (including coronary care unit and intermediate care units) from January 1, 2004, to May 31, 2005. Multivariate analyses controlling for patient and hospital heterogeneity evaluated the association between pRBC transfusions and patients' ICU or hospital length of stay. A total of 180,221 patients met all inclusion criteria, with 29,331 (16.3%) receiving pRBCs during their ICU stay. There was differential use of pRBCs by ICU/coronary care unit setting (ie, 23% of general ICU patients versus 7% of intermediate coronary care unit patients). Increasing age [odds ratio (OR), 1.007; 95% confidence interval (CI), 1.006-1.008], declining hemoglobin concentrations (OR, 2.315; 95% CI, 2.288-2.342), mechanical ventilation (OR, 1.338; 95% CI, 1.287-1.392), dialysis (OR, 2.071; 95% CI, 1.913-2.242), and presence of acute renal failure (OR, 1.259; 95% CI, 1.193-1.329), congestive heart failure (OR, 1.156; 95% CI, 1.106-1.208), or septicemia (OR, 1.143; 95% CI, 1.071-1.221) were associated with a higher likelihood of pRBC use. Each pRBC transfusion significantly increased hospital length of stay (1.6, 0.5, and 2.7 additional days for patients with 1, 2, and 3 or more transfusions, respectively, P < 0.0001) as compared with nontransfused patients. Multiple factors increased the likelihood of pRBC use in ICU patients. In addition, pRBC transfusion was associated with increased length of stay. Clinicians should evaluate the risk-benefit ratio and consider interventions to limit any unnecessary pRBC use in the critically ill.

Audit of patients with type 2 diabetes following a critical cardiac event

Evidence indicates that type 2 diabetes leads to complications such as a cardiac event, which often requires admission to a coronary care unit (CCU). Although there is a considerable body of knowledge about the management and characteristics of people with type 2 diabetes and myocardial infraction, there are few reports of the disease and demographic characteristics of the entire group of patients with diabetes admitted to a CCU. To gain greater understanding of the characteristics of patients with diabetes hospitalized for a critical cardiac event in order to assist in the development of an appropriate self-management programme for CCU patients with diabetes. Data were collected retrospectively from computerized records and charts of all patients with diabetes admitted to the CCU from 1 January 2000 to 31 December 2003. The proportion of type 2 diabetic patients admitted to CCU with a critical cardiac event over the 4-year study period was consistent at 14.7%, 233 in 1589 patients. More than 22% of CCU patients with diabetes were readmitted to hospital within 28 days compared with only 6% of CCU patients without diabetes. Predictors for readmission and length of stay were also examined. A considerable proportion of a CCU population had type 2 diabetes and these patients had significantly higher readmission rates. The implications of this study for the development of a self-management programme for patients with diabetes who experienced a critical cardiac event are discussed. Innovative programmes are required to reduce the rate of readmission for patients with both diabetes and a critical cardiac event. These should: 1 ensure transition programmes, such as self-management, commence within the CCU environment and continue following discharge, and 2 integrate diabetes and cardiac self-management programmes to condense the large amount of information provided to patients for managing two serious conditions.

A model of recovering medical errors in the coronary care unit

The purpose of this study was to explore the thoughts, interpersonal processes, and actions used by nurses who had recently intervened to protect coronary care unit (CCU) patients from potential medical errors. The study used semistructured interviews conducted with 18 very experienced CCU nurses in two academic medical centers. Content analysis was used to code and analyze text segments. Core codes were used for developing an empirically derived model. There were more than 1000 data bits of accounts of involvement in the near-miss events, thought processes and actions surrounding the events, communication strategies used, feelings, outcomes, reflection about the event and consequences, and environment/context in which the events occurred. A three-stage temporally ordered model illustrates the process of recovering medical errors. In stage one, the presence of the evolving clinical scenario and nursing knowledge and expertise plus the CCU context are the antecedents that lead to processes and actions of identification, interruption, and correction of the error in stage two. Outcomes of whether or not the near miss was recovered lead to an adverse event (or not), and reflections on the process and outcome lead to the nurse's feelings about the event in stage three. The model can guide nursing administration, practice, education, and research to recognize and value this responsibility, to teach others, and to test strategies to enhance the vital nursing role of recovering near-miss events that leads to safer and better patient care.

Effects of healthcare acoustics on medical outcomes

Although considerable research has examined detrimental effects of noise on patient sleep quality in healthcare buildings, few studies have investigated the extent to which noise may worsen other types of patient clinical outcomes. Studies are also scarce concerning the effects of noise and poor acoustics on healthcare staff. The presentation describes a prospective controlled study conducted with colleagues in Sweden that examined the impact of higher versus lower noise levels, and longer in contrast to shorter reverberation times, on several patient and staff outcomes in a hospital coronary critical care unit (CCU). Acoustics were altered during the study period by changing the ceiling tiles throughout the CCU from sound-reflecting tiles to sound-absorbing tiles of similar appearance. Regarding patients, an improved acoustics environment significantly reduced physiological stress, increased satisfaction with quality of care, improved sleep quality, and lessened incidence of costly re-hospitalizations following discharge. Better acoustics also improved speech intelligibility, and healthcare staff experienced reduced work demands and less pressure and strain. The discussion concludes by outlining research directions, including the need for more outcomes studies to enable development of a strong business case for better healthcare acoustics.