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Closed-loop communication (CLC) is a fundamental aspect of effective communication, critical in the cardiac catheterization laboratory (cath lab) where physician orders are verbal. Complete CLC is typically a hospital and national mandate. Deficiencies in CLC have been shown to impair quality of care. Single center observational study, CLC for physician verbal orders in the cath lab were assessed by direct observation during a 5-year quality improvement effort. Performance feedback and educational efforts were used over this time frame to improve CLC, and the effects of each intervention assessed. Responses to verbal orders were characterized as complete (all important parameters of the order repeated, the mandated response), partial, acknowledgment only, or no response. During the first observational period of 101 cases, complete CLC occurred in 195 of 515 (38%) medication orders and 136 of 235 (50%) equipment orders. Complete CLC improved over time with various educational efforts, (p < 0.001) but in the final observation period of 117 cases, complete CLC occurred in just 259 of 328 (79%) medication orders and 439 of 581 (76%) equipment orders. Incomplete CLC was associated with medication and equipment errors. CLC of physician verbal orders was used suboptimally in this medical team setting. Baseline data indicate that physicians and staff have normalized weak, unreliable communication methods. Such lapses were associated with errors in order implementation. A subsequent 5-year quality improvement program resulted in improvement but a sizable minority of unacceptable responses. This represents an opportunity to improve patient safety in cath labs.

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OBJECTIVES: To assess closed-loop communications (readback), a fundamental aspect of effective communication, among cardiovascular teams and assess improvement efforts. BACKGROUND: Effective communication within teams is essential to assure safety and optimal outcomes. Readback of verbal physician orders is a hospital and national requirement. METHODS: Single-center observational study, where the readback responses to physician verbal orders in the catheterization laboratory were characterized over three distinct time intervals from 2015 to 2017. Performance feedback and focused education on the value of readbacks was provided to the teams in two waves, with subsequent remeasurement. Responses to verbal orders were characterized as complete (all important parameters of the order repeated for verification), partial, acknowledgement only, or no response. Changes in readback performance after quality interventions were assessed. RESULTS: During the first-observational period of 101 cases, complete readback occurred in 195 of 515 (38%) medication orders and 136 of 235 (58%) equipment orders. After initial quality improvement efforts, 102 cases were observed. In these, 298 of 480 (62%) medication orders had complete readback, and 210 of 420 (50%) equipment orders had complete readback. After additional quality improvement efforts, 168 cases were observed. In these, 506 of 723 (70%) medication orders had complete readback, and 630 of 1,061 (59%) equipment orders had complete readback. Overall, medication order readback improved over time (correlation = 0.26 [-0.30, -0.21]; p < 0.001), but equipment order readback did not (correlation = 0.02 [-0.07, 0.03]; p = 0.44). CONCLUSIONS: Closed-loop communication of physician verbal orders was used infrequently in this medical team setting and proved difficult to fully improve. This is an important safety gap.

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BACKGROUND: Benzodiazepines and opioids are commonly used for conscious sedation (CS) in cardiac catheterization laboratory (CCL) patients. Both drugs are known to predispose to hypoxemia, apnea and decreased responsiveness to PCO2, resulting in decreased arterial pH and PO2, as well as increased PCO2. We want to determine the effects of CS on arterial blood gas (ABG) in CCL patient, and identify if pulse oximetry monitoring is adequate. METHODS: We enrolled 18 subjects undergoing elective catheterization. Measurement of ABGs at one-minute intervals was done from the moment of arterial access until case end. The results of ABGs were not available to the clinician who administered sedation. Relationships of pH, PCO2, PaO2 and SaO2 were studied by plotting time series graphs. Significant changes were defined as pH <7.30, SaO2 < 90, and PCO2 > 50 mmHg. RESULTS: No significant change in pH, PCO2, PaO2 and SaO2 was noted in 4/18 (22%) subjects. A significant drop in SaO2 was noted in 4/18 (22%). A significant change in PCO2 and/or pH was noted in 10/18 (55%) cases. Among the 16 (16/18) subjects receiving supplemental oxygen, 7 (7/18, 39%) had no drop in SaO2, but developed respiratory acidosis. At the end of the case, 5/18 (28%) subjects had respiratory acidosis with normal PaO2. CONCLUSION: Significant hypercarbia and acidosis occurred frequently in this small study during CS in patients undergoing cardiac catheterization. Relying on pulse oximetry alone especially with patients on supplemental oxygen may lead to failure in detecting respiratory acidosis in a significant number of patients.

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BACKGROUND: Accurate assessment of Cardiac Output (CO) is a critical measurement in the calculation of aortic valve area (AVA). Due to the known inaccuracy of estimated Fick calculations, many measure thermodilution (TD) CO as well due to previous studies showing better correlation with the gold standard direct CO. Previous studies showed suboptimal correlation between both methods. Most physicians assume that the TD CO is chosen by catheterization laboratory software for AVA evaluation. Our study was performed to check which CO method is assigned by our popular computer software system [Philips Xper Connect (XIM)] for the AVA calculation and the impact of that on clinical decision. METHODS: We studied one hundred consecutive patients who underwent right and left heart catheterization from 2009 to 2012 for assessment of AVA and who had both estimated Fick and TD CO calculated. Correlation of direct continuous VO2, assumed VO2 and TD based CO measurements were assessed by linear regression analysis and by variance component analysis. RESULTS: We found that whichever CO calculation was entered first to the software system became the determinative output used to calculate the AVA appearing on the final report. This was the estimated Fick method in 32 patients and TD in 68 patients. The CO used for the final report depended solely on the timing of the oxygen saturation samples. The Correlation between AVA based on both methods correlated poorly (Pearson R=0.73, Intra-Class Correlation (ICC) =0.72). This discrepancy affects recommendation for surgery (AVA <1.0 cm2) in 18 cases (18% of patients). CONCLUSION: Our widely used software has an arbitrary method of selecting the determinative CO to calculate the final AVA. For TD CO to 'trump' the Fick CO a complex series of computer commands needs to be performed. None of the physicians or technicians was aware of this software selection process, which affects critical treatment decisions.

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BACKGROUND: Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of aortic valve area (AVA). Estimation of oxygen consumption (VO2) and Thermodilution (TD) is employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO and AVA. METHODS AND MATERIALS: Seventeen consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate. RESULTS: Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R= 0.57; ICC =0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R= 0.51; ICC=0.60). Similarly AVA derived from direct continuous VO2 correlated poorly with those of assumed VO2 (R= 0.68; ICC=0.55) and TD (R=0.66, ICC=0.60). Repeated direct continuous VO2 CO and AVA measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) and (R=0.99; ICC>0.99) respectively], suggesting that this was the most reliable measurement of CO. CONCLUSIONS: CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO and AVA measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results.

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BACKGROUND: Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of valvular heart disease. Estimation of oxygen consumption (VO2) and thermodilution (TD) are employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO. METHODS AND MATERIALS: Thirty consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate. RESULTS: Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R=0.57; ICC=0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R=0.51; ICC=0.60). Repeated direct continuous VO2 CO measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) suggesting that this was the most reliable measurement of CO. CONCLUSIONS: CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results.

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OBJECTIVES: The goal of this article is to examine the correlation of catheter (cath) based and echocardiographic assessment of aortic stenosis (AS) in a community-based academic hospital setting, particularly in the degree that decision to refer for surgery is altered. BACKGROUND: Current guidelines discourage AS evaluation by invasive pressure measurement if echocardiography (echo) is adequate, but several studies show sizable differences between echo and cardiac catheterization lab (CCL) measurements. We examine this correlation using high quality CCL techniques. METHODS: Sequential patients with suspected AS by echo (n = 40) aged 61-94 underwent catheterization with pressure gradients via left ventricular pressure wire and ascending aorta catheter. The echos leading to the catheterization were independently reviewed by an expert panel to assess the quality of community-based readings. RESULTS: CCL changed assessment of severity of aortic valve area (AVA) by more than 0.3 cm(2) in 25% and 0.5 cm(2) in 8%. Values changed to over or under the surgical threshold of AVA < 1 cm(2) in 30% of the patients. Pearson correlation of 0.35 between measurements of AVA by echo and CCL is lower than earlier studies, which often reported correlation values of 0.90 or greater. Echo expert reviews provided minimal improvement in discrepancies (Pearson correlation of 0.46), suggesting quality of initial interpretation was not the issue. CONCLUSIONS: Cath-echo correlation of AS severity is lower in contemporaneous practice than previously assumed. This can alter the decision for aortic valve replacement. Sole reliance on echo-derived assessment of AS may at times be problematic.

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OBJECTIVE: To assess the impact of an aggressive protocol to decrease the time from hospital arrival to onset of reperfusion therapy ("door to balloon [DTB] time") on the incidence of false-positive (FP) diagnosis of ST-segment elevation myocardial infarction (STEMI) and in-hospital mortality. PATIENTS AND METHODS: The study population included 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization between July 1, 2008, and December 1, 2012, On July 1, 2009, we instituted an aggressive protocol to reduce DTB time. A quality improvement (QI) initiative was introduced on January 1, 2011, to maintain short DTB while improving outcomes. Outcomes were compared before and after the initiation of the DTB time protocol and similarly before and after the QI initiative. Outcomes were DTB time, the incidence of FP-STEMI, and in-hospital mortality. A review of the emergency catheterization database for the 10-year period from January 1, 2001, through December 31, 2010, was performed for historical comparison. RESULTS: Of the 1031 consecutive patients with presumed STEMI who were assessed, 170 were considered to have FP-STEMI. The median DTB time decreased significantly from 76 to 61 minutes with the aggressive DTB time protocol (P=.001), accompanied by an increase of FP-STEMI (7.7% vs 16.5%; P=.02). Although a nonsignificant reduction of in-hospital mortality occurred in patients with true-positive STEMI (P=.60), a significant increase in in-hospital mortality was seen in patients with FP-STEMI (P=.03). After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality. CONCLUSION: Aggressive measures to reduce DTB time were associated with an increased incidence of FP-STEMI and FP-STEMI in-hospital mortality. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures that may delay other appropriate therapies in critically ill patients.

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Door-to-balloon (DTB) time is an important quality measure for ST-segment myocardial elevation infarction (STEMI). Aggressive measures to reduce DTB time can increase the incidence of false positive-STEMI and may increase mortality in that group. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures especially in critically ill patients who don't have STEMI and may benefit from other appropriate therapies in timely manner. We report two cases where trying to achieve an aggressive DTB time may have led to unwarranted outcomes.

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INTRODUCTION: Oral anticoagulants (OAC) are the therapy of choice to prevent thromboembolism in patients at risk. Discontinuation of OAC prior to elective medical and surgical procedures may reduce the risk of bleeding, but may expose patients to increased risk of thromboembolism and ischemic stroke. The current public health burden of ischemic strokes associated with OAC discontinuation is unknown. We aimed to study the prevalence OAC discontinuation in patients who presented with acute ischemic stroke as well as the outcomes of these strokes. METHODS: Retrospective cross-sectional study by intensive chart review of all acute ischemic stroke patients over 6 months in a large tertiary care community hospital. RESULTS: A total of 431 patients with acute ischemic stroke were admitted during study period, of which 11 (2.6%) had OAC discontinuation within 120 days prior to the index admission. Several strokes occurred after relatively brief discontinuations. The patient group with discontinuation was older, had higher comorbidities and also had a clinically significant stroke and resulting higher mortality and morbidity. CONCLUSION: About 2.6% or 1 in every 38 of all ischemic stokes occurred after OAC discontinuation. Strokes occurring after OAC discontinuation also have higher mortality and morbidity. Our data suggest that any planned discontinuation of OAC, however brief, should be carefully considered.

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BACKGROUND: Our goal was to define the prevalence of radiation-induced valvular heart (RIVD) disease among patients undergoing cardiac valve surgery in a community-based, regional academic medical center. Mediastinal radiation is a treatment modality for various hematologic and solid malignancies; however, long-term cardiac complications, including radiation-induced valvular heart disease, can occur years after the radiation treatments. HYPOTHESIS: Mediastinal radiation exposure is an independent risk factor for valvular heart disease often necessitating valve replacement in patients without other risk factors for valve disease. METHODS: Between January 1, 1998 and September 1, 2007, we retrospectively analyzed our institution's cardiac surgical database over a 10 year period and identified 189 consecutive patients ≤ 50 years of age who underwent valve surgery. Using case-control matching, we assessed the prevalence of mediastinal radiation among these young patients with valve disease necessitating surgery and to their matched controls from all patients admitted to the hospital. RESULTS: Nine individuals (4.8%) were identified as having received previous mediastinal radiation, significantly increased from controls (p<0.0001), and 8 of whom had surgical or pathologic findings consistent with radiation damage. Compared with a matched case-control population, individuals who had severe valve disease and underwent valve replacement had a markedly increased prevalence of prior mediastinal radiation therapy. CONCLUSIONS: In conclusion, cardiologists must remain aware of the potential long term valvular complications in patients treated with mediastinal radiation. Increased surveillance for RIVD may be considered in the decades following radiation therapy.

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Mental stress increases cardiovascular morbidity and mortality. Although laboratory mental stress often causes less myocardial ischemia than exercise stress (ES), it is unclear whether mental stress is intrinsically different or differences are due to less hemodynamic stress with mental stress. We sought to evaluate the hemodynamic and ischemic response to intense realistic mental stress created by modern flight simulators and compare this response to that of exercise treadmill testing and conventional laboratory mental stress (CMS) testing in pilots with coronary disease. Sixteen airline pilots with angiographically documented coronary disease and documented myocardial ischemia during ES were studied using maximal treadmill ES, CMS, and aviation mental stress (AMS) testing. AMS testing was done in a sophisticated simulator using multiple system failures as stressors. Treadmill ES testing resulted in the highest heart rate, but AMS caused a higher blood pressure response than CMS. Maximal rate-pressure product was not significantly different between ES and AMS (25,646 vs 23,347, p = 0.08), although these were higher than CMS (16,336, p <0.0001). Despite similar hemodynamic stress induced by ES and AMS, AMS resulted in significantly less ST-segment depression and nuclear ischemia than ES. Differences in induction of ischemia by mental stress compared to ES do not appear to be due to the creation of less hemodynamic stress. In conclusion, even with equivalent hemodynamic stress, intense realistic mental stress induced by flight simulators results in significantly less myocardial ischemia than ES as measured by ST-segment depression and nuclear ischemia.

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