QT MONITORING IN THE ICU A BENCHMARK PROJECT

QT MONITORING IN THE ICU: A BENCHMARK PROJECT JEFFREY WOODWARD NURS 5382: CAPSTONE APRIL 2020

PICOT QUESTION In adult Intensive Care Unit (ICU) patients, does QT/QTc monitoring compared to no QT/QTc monitoring affect mortality or ventricular tachyarrhythmia rates during their ICU stay?

RATIONALE • QT interval: how well ventricles depolarize and repolarize • QTc = QT interval corrected for heart rate • Prolonged QT/QTc interval: • > 500 ms • Increase > 60 ms from baseline (Pham, Banks, Narotsky, & Dorman, 2016) • Most common cause: • Medication administration (Etchegoyen, Keller, Mrad, Cheng, & Di. Girolamo, 2017) QT Interval Image

RATIONALE (CONT. ) In the United States each year, approximately: Torsades de Pointes picture • 300, 000 deaths from sudden cardiac events • 15, 000 from Torsades de Pointes (Td. P) (Dave et al. , 2017) • QTc prolongation rates: 2. 6%-24% (Sandau et al. , 2017) • Td. P from QTc prolongation: up to 3. 8% (Hoogstraaten, Rijkenberg, & van der Voort, 2014 ) • Td. P Annual Incidence rate: 0. 1% (Michels, Kochanek, & Pfister, 2016)

LITERATURE SYNTHESIS • Nurses unaware of need • Risk factors for QT/QTc prolongation: • Baseline prolongation with new med risk (Sandau et al. , 2017) • Older age • Low BMI • Electrolyte abnormalities • QTc prolongating meds (Hoogstraaten et al. , 2014 ) • 35% to 84% patients (George et al. , 2015; Hoogstraaten et al. , 2014) • crediblemeds. org Nurse picture clip art

LITERATURE SYNTHESIS (CONT. ) • Classes of medications • Drug-Drug Interactions (DDIs) • Pharmacodynamic • Pharmacokinetic (Armahizer et al. , 2013) • Clinical Decision Support System (CDSS) to manage Pills clip art

LITERATURE SYNTHESIS (CONT. ) • ICU-level patients monitored • Recommendations • 12 -lead ECG: • Initial, repeat after 4 hours, and then daily (Scalese et al. , 2017) • QT/QTc interval with vital signs • Every 4 hours • Minimum every 8 hours Monitor clip art

STAKEHOLDERS • Nurses • Bedside • Clinical Coordinators • Managers/Directors • Physicians • Bio. Med • Facilities • IT/Informatics Puzzle People clip art

PLANNED EVALUATION Project Success • Project Management • Goals as “met”, “on-going”, or ”not met” • Physician and nurse satisfaction • System Usability Scale (SUS) • Chart audits • Patient outcome success • Decrease in cardiac arrests from Td. P Man with clipboard clip art

TIMETABLE/FLOWCHART

TIMETABLE/FLOWCHART (CONT. )

DATA COLLECTION METHODS

COST/BENEFIT Main Costs: • Replacing monitors-$80, 000 • Biomed to change monitors-$4, 000 • Building EHR flowsheet and CDSS-$99, 000 • Education-$6, 300+$4, 200 • Total= $200, 000 (approximately) Man with calculator clip art

COST/BENEFIT (CONT. ) Benefits: • Lives saved!!! Puzzle heart clip art • Preventing lawsuits • Doctrine of Respondeat Superior • One lawsuit= $750, 000 + legal fees (approximately) Money clip art

DISCUSSION • Flowsheet and CDSS not yet started • QT/QTc interval education started Talking heads clip art • Importance timely related to COVID-19 • AHA, ACC, and HRS recommend ECG/QT interval monitoring

RECOMMENDATIONS • Implement QT/QTc monitoring • Create EHR flowsheet and CDSS • Change outdated bedside monitors • QT/QTc routinely assessed • At least every 4 hours Idea clip art

CONCLUSION Man at finish line clip art

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