Staff perspectives of a cardiology short stay unit

Objective To evaluate staff perceptions about working environment, efficiency and the clinical safety of a cardiovascular intervention short stay unit (SSU) during the first year of operation. Design Postal questionnaire. Setting Cardiac catheterisation laboratory (CCL), coronary care unit (CCU), general cardiology ward (GCW) and the short stay unit (SSU) of a tertiary referral hospital situated in the mid coastal region of NSW. Subjects Cardiologists (including visiting medical officers [VMO]), cardiology fellows, cardiology advanced trainees and nurses. Results Responses on the working environment of the SSU and the discharge process were statistically significant. A substantial proportion of both nurses and doctors had concerns about patient safety, even though no adverse events were formally recorded in the database. Conclusions Though the participants of the survey agree on the efficiency of the SSU in providing beds to the hospital, they disagree on aspects that are important in the functioning of the SSU, including the working environment, patient selection and clinical safety. The results highlight potential issues that could be improved or addressed and are relevant to the rollout of SSUs across NSW.

Development and use of risk adjusted statistical process control tools for the monitoring and improvement of clinical outcomes in interventional cardiology

This thesis explored the development of statistical methods to support the monitoring and improvement in quality of treatment delivered to patients undergoing coronary angioplasty procedures. To achieve this goal, a suite of outcome measures was identified to characterise performance of the service, statistical tools were developed to monitor the various indicators and measures to strengthen governance processes were implemented and validated. Although this work focused on pursuit of these aims in the context of a an angioplasty service located at a single clinical site, development of the tools and techniques was undertaken mindful of the potential application to other clinical specialties and a wider, potentially national, scope.

Cholesterol-lowering management of stroke : inconsistencies of evidence and practice

Cholesterol-lowering treatment by statins is an important and costly issue; however, its role in stroke has not been well documented. The aim of the present study was to review literature and current practice regarding cholesterol-lowering treatment for stroke patients. A literature review was conducted on lipids in stroke and their management with both statins and diet, including the cost-effectiveness of medical nutrition therapy. Qualifying criteria and prescription procedures of the Pharmaceutical Benefits Scheme (PBS) were also reviewed. Data on lipid levels and statin prescriptions were analysed for 468 patients admitted to a stroke unit. The literature shows that management with both medication and diet can be effective, especially when combined; however, 60% of patients with an ischaemic event had fasting total cholesterol measures ≥4 mmol/L (n = 231), with only 52% prescribed statins on discharge (n = 120). Hypercholesterolaemia is an underdiagnosed and undertreated risk factor within the stroke population. It appears that the PBS has not kept pace with advances in the evidence in terms of statin use in the stroke population, and review is needed. The present review should address the qualifying criteria for the stroke population and recommendations on referral to dietitians for dietary advice. Cholesterol-lowering treatment for both stroke patients and the wider population is an area that needs awareness raising and review by the PBS, medical practitioners and dietitians. The role of dietary and pharmacological treatments needs to be clearly defined, including adjunct therapy, and the cost-effectiveness of medical nutrition therapy realised.

Initial CFD investigation of an MR fluid in a bicycle ergometer

A bicycle ergometer is a scientific device used by exercise physiologists which attempts to mimic on-road cycling characteristics such as foot technique, EMG activity, VO2, VCO2 and rider cardiology in a laboratory environment. Presently there are no known useful scientific ergometers that mimic these characteristics and are able to provide a satisfactory controlled resistance that is independent of speed. Previous research has suggested the use of a Magneto-Rheological (MR) Fluid as part of the ergometer design, as when used in a rotary brake application it is able to be controlled electronically to increase resistance instantly and independent of speed. In the target application, MR fluids are subject to immense tribological wear and temperature during viscous shearing, and will eventually show some degree of deterioration which is usually manifested as an increase in off-state viscosity. It is not known exactly how the fluid fails, however the amount of deterioration is related to the shear rate, temperature and duration and directly related to the power dissipation. Currently, there is very little literature that investigates the flow and thermal characteristics of MR fluid tribology using CFD. In this paper, we present initial work that aims to improve understanding of MR fluid wear via CFD modelling using Fluent, and results from the model are compared with those obtained from a experimental test rig of an MR fluid-based bicycle ergometer.

P2 purinergic receptor mRNA in rat and human sinoatrial node and other heart regions.

It is known that adenosine 5'-triphosphate (ATP) is a cotransmitter in the heart. Additionally, ATP is released from ischemic and hypoxic myocytes. Therefore, cardiac-derived sources of ATP have the potential to modify cardiac function. ATP activates P2X(1-7) and P2Y(1-14) receptors; however, the presence of P2X and P2Y receptor subtypes in strategic cardiac locations such as the sinoatrial node has not been determined. An understanding of P2X and P2Y receptor localization would facilitate investigation of purine receptor function in the heart. Therefore, we used quantitative PCR and in situ hybridization to measure the expression of mRNA of all known purine receptors in rat left ventricle, right atrium and sinoatrial node (SAN), and human right atrium and SAN. Expression of mRNA for all the cloned P2 receptors was observed in the ventricles, atria, and SAN of the rat. However, their abundance varied in different regions of the heart. P2X(5) was the most abundant of the P2X receptors in all three regions of the rat heart. In rat left ventricle, P2Y(1), P2Y(2), and P2Y(14) mRNA levels were highest for P2Y receptors, while in right atrium and SAN, P2Y(2) and P2Y(14) levels were highest, respectively. We extended these studies to investigate P2X(4) receptor mRNA in heart from rats with coronary artery ligation-induced heart failure. P2X(4) receptor mRNA was upregulated by 93% in SAN (P < 0.05), while a trend towards an increase was also observed in the right atrium and left ventricle (not significant). Thus, P2X(4)-mediated effects might be modulated in heart failure. mRNA for P2X(4-7) and P2Y(1,2,4,6,12-14), but not P2X(2,3) and P2Y(11), was detected in human right atrium and SAN. In addition, mRNA for P2X(1) was detected in human SAN but not human right atrium. In human right atrium and SAN, P2X(4) and P2X(7) mRNA was the highest for P2X receptors. P2Y(1) and P2Y(2) mRNA were the most abundant for P2Y receptors in the right atrium, while P2Y(1), P2Y(2), and P2Y(14) were the most abundant P2Y receptor subtypes in human SAN. This study shows a widespread distribution of P2 receptor mRNA in rat heart tissues but a more restricted presence and distribution of P2 receptor mRNA in human atrium and SAN. This study provides further direction for the elucidation of P2 receptor modulation of heart rate and contractility.

A pilot randomised control trial of general practitioner and exercise physiologist interventions to reduce primary cardiovascular risk in overweight patients [Abstract]

Aims & Rationale/Objectives: With the knowledge that overweight is a major public health concern in Australia, that a multidisciplinary team approach to the management of lifestyle-related conditions is supported, and that the Australian Government recently recognised the role of the exercise physiologist (EP) in reducing the health burden of disease by their inclusion for reimbursement under the Medicare Plus scheme, this study sought to undertake a pilot RCT to compare GP and EP interventions to reduce primary cardiovascular risk in the overweight general practice population. Methods and Measures: Overweight patients recruited by a convenience sample of GPs were randomised into one of three arms: the control group, or the GP or EP intervention group (in which patients received either five GP or five EP consultations over 24 weeks). Patients had baseline, 12- and 24-week measures of body composition and cardio-respiratory fitness, and completed baseline and end-of-study surveys, fasting lipids and glucose. GPs and EPs completed an end-of-study survey. Results:Sixty-seven patients attended the baseline assessment. Overall retention rate was 67%. Patients were generally satisfied with the effectiveness of the interventions and their weight reduction. Favourable trends in BMI, weight, glucose and exercise levels for GP and EP intervention groups and in physical activity levels for all groups Conclusions: This study supports the feasibility of a RCT of GP and EP interventions for decreasing primary cardiovascular risk in the overweight general practice population.

The intra-aortic balloon pump in heart failure management : implications for nursing practice

Management of acute heart failure is an important consideration in critical care. Mechanical support of the failing heart is crucial for improving health outcomes. The most common Australasian application of intraaortic balloon counterpulsation (IABP) is in the setting of cardiogenic shock. High end users of IABP (>37/annum) demonstrate significantly lower mortality for cardiogenic shock managed with IABP (p <0.001) in contrast to hospitals which employ limited IABP (<4/annum). This underscores the importance of proficiency in managing patient receiving IABP support. Nurses play a crucial role in carding for patients with acute heart failure. This paper summarises care considerations for management of the IABP.

Central venous oxygen saturation monitoring

It has been established that mixed venous oxygen saturation (SvO2) reflects the balance between systemic oxygen deliver y and consumption. Literature indicates that it is a valuable clinical indicator and has good prognostic value early in patient course. This article aims to establish the usefulness of SvO2 as a clinical indicator. A secondary aim was to determine whether central venous oxygen saturation (ScvO2) and SvO2 are interchangeable. Of particular relevance to cardiac nurses is the link between decreased SvO2 and cardiac failure in patients with myocardial infarction, and with decline in myocardial function, clinical shock and arrhythmias. While absolute values ScvO2 and SvO2 are not interchangeable, ScvO2 and SvO2are equivalent in terms of clinical course. Additionally, ScvO2 monitoring is a safer and less costly alternative to SvO2 monitoring. It can be concluded that continuous ScvO2 monitoring should potentially be undertaken in patients at risk of haemodynamic instability.

Anger and depression predict hospital use among chronic heart failure patients

Costly hospital readmissions among chronic heart failure (CHF) patients are expected to increase dramatically with the ageing population. This study investigated the prognostic ability of depression, anger and anxiety, prospectively, and after adjusting for illness severity, on the number of readmissions to hospital and the total length of stay over one year. Participants comprised 175 inpatients with CHF. Depression, anger, anxiety, and illness severity were measured at baseline. One year later, the number of readmissions and length of stay for each patient were obtained from medical records. Depression and anger play a detrimental role in the health profile of CHF patients.

Comprehensive standardized data definitions for acute coronary syndrome research in emergency departments in Australasia

Patients with chest discomfort or other symptoms suggestive of acute coronary syndrome (ACS) are one of the most common categories seen in many Emergency Departments (EDs). While the recognition of patients at high-risk of ACS has improved steadily, identifying the majority of chest pain presentations who fall into the low-risk group remains a challenge. Research in this area needs to be transparent, robust, applicable to all hospitals from large tertiary centres to rural and remote sites, and to allow direct comparison between different studies with minimum patient spectrum bias. A standardised approach to the research framework using a common language for data definitions must be adopted to achieve this. The aim was to create a common framework for a standardised data definitions set that would allow maximum value when extrapolating research findings both within Australasian ED practice, and across similar populations worldwide. Therefore a comprehensive data definitions set for the investigation of non-traumatic chest pain patients with possible ACS was developed, specifically for use in the ED setting. This standardised data definitions set will facilitate ‘knowledge translation’ by allowing extrapolation of useful findings into the real-life practice of emergency medicine.

Future developments in chest pain diagnosis and management

Much of the focus of research on patients with chest pain is directed at technological advances in the diagnosis and management of acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic dissection (AAD), despite there being no significant difference at 4 years as regards mortality, ongoing chest pain, and quality of life between patients presenting to the emergency department with noncardiac chest pain and those with cardiac chest pain. This article examines future developments in the diagnosis and management of patients with suspected ACS, PE, AAD, gastrointestinal disease, and musculoskeletal chest pain.

QUT Medical Engineering Research Facility (MERF) annual report 2009

DIRECTOR’S OVERVIEW by Professor Mark Pearcy This report for 2009 is the first full year report for MERF. The development of our activities in 2009 has been remarkable and is testament to the commitment of the staff to the vision of MERF as a premier training and research facility. From the beginnings in 2003, when a need was identified for the provision of specialist research and training facilities to enable close collaboration between researchers and clinicians, to the realisation of the vision in 2009 has been an amazing journey. However, we have learnt that there is much more that can be achieved and the emphasis will be on working with the university, government and external partners to realise the full potential of MERF by further development of the Facility. In 2009 we conducted 28 workshops in the Anatomical and Surgical Skills Laboratory providing training for surgeons in the latest techniques. This was an excellent achievement for the first full year as our reputation for delivering first class facilities and support grows. The highlight, perhaps, was a course run via our video link by a surgeon in the USA directing the participants in MERF. In addition, we have continued to run a small number of workshops in the operating theatre and this promises to be an avenue that will be of growing interest. Final approval was granted for the QUT Body Bequest Program late in 2009 following the granting of an Anatomical Accepting Licence. This will enable us to expand our capabilities by provide better material for the workshops. The QUT Body Bequest Program will be launched early in 2010. The Biological Research Facility (BRF) conducted over 270 procedures in 2009. This is a wonderful achievement considering less then 40 were performed in 2008. The staff of the BRF worked very hard to improve the state of the old animal house and this resulted in approval for expanded use by the ethics committees of both QUT and the University of Queensland. An external agency conducted an Occupational Health and Safety Audit of MERF in 2009. While there were a number of small issues that require attention, the auditor congratulated the staff of MERF on achieving a good result, particularly for such an early stage in the development of MERF. The journey from commissioning of MERF in 2008 to the full implementation of its activities in 2009 has demonstrated the potential of this facility and 2010 will be an exciting year as its activities are recognised and further expanded building development is pursued.

Caveat Anicula! Beware of the Quiet Little Old Ladies : Demographics, Pharmacotherapy, Survival and Readmissions in a 10 Year Cohort of Heart Failure Patients with Preserved Systolic Function

Objective--To determine whether heart failure with preserved systolic function (HFPSF) has different natural history from left ventricular systolic dysfunction (LVSD). Design and setting--A retrospective analysis of 10 years of data (for patients admitted between 1 July 1994 and 30 June 2004, and with a study census date of 30 June 2005) routinely collected as part of clinical practice in a large tertiary referral hospital.Main outcome measures-- Sociodemographic characteristics, diagnostic features, comorbid conditions, pharmacotherapies, readmission rates and survival.Results--Of the 2961 patients admitted with chronic heart failure, 753 had echocardiograms available for this analysis. Of these, 189 (25%) had normal left ventricular size and systolic function. In comparison to patients with LVSD, those with HFPSF were more often female (62.4% v 38.5%; P = 0.001), had less social support, and were more likely to live in nursing homes (17.9% v 7.6%; P < 0.001), and had a greater prevalence of renal impairment (86.7% v 6.2%; P = 0.004), anaemia (34.3% v 6.3%; P = 0.013) and atrial fibrillation (51.3% v 47.1%; P = 0.008), but significantly less ischaemic heart disease (53.4% v 81.2%; P = 0.001). Patients with HFPSF were less likely to be prescribed an angiotensin-converting enzyme inhibitor (61.9% v 72.5%; P = 0.008); carvedilol was used more frequently in LVSD (1.5% v 8.8%; P < 0.001). Readmission rates were higher in the HFPSF group (median, 2 v 1.5 admissions; P = 0.032), particularly for malignancy (4.2% v 1.8%; P < 0.001) and anaemia (3.9% v 2.3%; P < 0.001). Both groups had the same poor survival rate (P = 0.912). Conclusions--Patients with HFPSF were predominantly older women with less social support and higher readmission rates for associated comorbid illnesses. We therefore propose that reduced survival in HFPSF may relate more to comorbid conditions than suboptimal cardiac management.