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Building a Program of Research: 15 Tips

Building a Program of Research: 15 Tips. From Doctoral Student to Academic Faculty. Using ECG information to improve patient care. Improving nursing practice related to ECG monitoring. Pick a topic you are passionate about from your own clinical experience. Annals of Internal Medicine 1986.

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Building a Program of Research: 15 Tips

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  1. Building a Program of Research: 15 Tips From Doctoral Student to Academic Faculty

  2. Using ECG information to improve patient care Improving nursing practice related to ECG monitoring • Pick a topic you are passionate about from your own clinical experience

  3. Annals of Internal Medicine 1986 • Determine unsolved problems by searching the literature UCSF

  4. Supraventricular Tachycardia (SVT) Drug that blocks @ AV node Ventricular Tachycardia (VT) Narrow normal QRS complex SVT with aberrant conduction Wide bizarre QRS complex

  5. Left “Rabbit Ear” Pattern = VT Right “Rabbit Ear”Pattern = SVT Lead V1 Lead V1 • Search the literature on all research directly related to the topic Wellens HJ, et al. Value of the ECG in the differential diagnosis of a tachycardia with a wide QRS complex. Am J Med 1978.

  6. Monitoring Lead V1 Requires Five Electrodes LA RA C RL LL

  7. “Of the conventional ECG leads, the one that contains the most information…is V1, which should therefore make the best lead for routine monitoring. But V1 is inconvenient, since 5 electrodes must remain constantly attached. A satisfactory compromise, conceived in theory and confirmed in practice, employs a modified V1.”

  8. Dr. Marriott’s modified V1 (MCL1) UCSF

  9. Left “Rabbit Ear” Pattern = VT MCL1 Can wide QRS tachycardia be accurately diagnosed with V1 criteria when monitoring in MCL1? UCSF

  10. In developing MCL1, I confirmed that it matched V1 in an out-patient clinic population. I did not compare these leads during arrhythmias, but I would expect them to be comparable during wide complex tachycardias. We did not evaluate MCL1 in our study. Hein Wellens, MD Henry J. L. Marriott, MD • Contact key scientists for advice about your research ideas UCSF

  11. Henry J. L. Marriott, MD Kathy Dracup, DNSc Mel Scheinman, MD • Pick renown mentors for your doctoral committees

  12. Publish on your topic (Quals papers) so your name is associated with the topic

  13. NURSING THERAPEUTICS • Determine goals of ECG monitoring (arrhythmia, ischemia, QT interval) • Monitor ECG (select appropriate lead; place electrodes accurately; evaluate monitor alarms) • Diagnose ECG • Assess patient • Notify MD • Document • Administer Rx • Evaluate efficacy POTENTIAL Health Problem ACTUAL Health Problem Health Continuum / Transitions INDIVIDUAL ENVIRONMENT • Genetics • Lifestyle (coronary risk factors) • Psychodynamic factors (anxiety) • Functional status Internal/Cellular External/Social Electrical Activity of the Heart Arrhythmias, ST segment changes of ischemia, QT interval prolongation Normal ECG Abnormal ECG • Ischemia • Acid-base • Autonomic nervous system • Electrolytes • Drugs • Work • Family • Culture • Religion Drew BJ Heart & Lung 1989;18:8-15.

  14. Conduct studies as a doctoral student; publish & present at national scientific conferences How prevalent is inaccurate lead placement?

  15. V1 II V1 II

  16. National random survey of AACN members working in critical care & telemetry units N = 302 • Average age, 35 yrs • Average yrs critical care experience, 8.5 yrs Drew, Ide, & Sparacino Heart & Lung 1991;20:597

  17. Accuracy of lead placement in a random survey of hospital nurses in the USA # RNs 77% 23% UCSF Drew BJ, et al. Heart & Lung 1999;20:597-609.

  18. Publish clinical articles as well as research articles in order to influence practice

  19. 9. Publish ALL your dissertation findings UCSF

  20. WCT’s n=133 SVT n=35 VT n=98 Drew & Scheinman, PACE 1995;18:2194

  21. VT recorded during invasive cardiac electrophysiology study (EPS)

  22. Key dissertation findings re: wide QRS tachycardia • Routinely-monitored Lead II was poor Correctly identifies only 34% of WCTs • V1 was the best single lead; MCL1 should not be substituted for V1 40% of VTs have different QRS morphology in MCL1vs V1 • 12-Lead ECG was best If it weren’t so cumbersome, it would be great to monitor all 12 leads UCSF

  23. LA RA V1 V5 RL LL Disadvantage of 12-Lead ECG for hospital monitoring V2 V6 V3 V4 UCSF

  24. Design each subsequent study to build logically upon your prior studies Apply for “friendly” funding for initial studies (e.g., Sigma Theta Tau, companies that make related products, start-up funds from your own school)

  25. Collect data for > dissertation

  26. Once you’ve published 4-5 preliminary research articles, think of the next logical research question and apply for MAJOR funding (e.g., NIH).

  27. How does EASI 12-lead monitoring compare to routine CCU monitoring for detecting acute myocardial ischemia in acute coronary syndromes? ST AnalysisTrial(STAT Study) (1993-96) n=490 Funded by NINR (R01 NR03436) UCSF

  28. STAT Study 47 y/o male awaiting cardiac cath, possible PCI 7:03 am EASI 12-Lead ECG UCSF

  29. STAT Study 7:08 am EASI 12-Lead ECG UCSF

  30. STAT Study 7:10 am EASI 12-Lead ECG UCSF

  31. STAT Study 7:13 am EASI 12-Lead ECG UCSF

  32. STAT Study 7:33 am EASI 12-Lead ECG UCSF

  33. 1. 4. Routine CCU Monitoring Leads Before During 5. 2. 3.

  34. Of 463 ischemic events detected with EASI 12-lead ST monitoring: • 67% had no evidence of ischemia in routine CCU monitoring leads • 80% were asymptomatic (“silent”) Drew et al. Am J Crit Care 1996;5:198-206. UCSF

  35. Is ST-segment monitoring valuable in patients who present to the ED with possible acute MI? ST Analysis &Monitoring ofPatients&Evaluationof aDerivedECGSTAMPEDE Study Funded by NINR (RO1NR03436), 1996-00, n=621 IschemiaMonitoring &Mapping in theEmergencyDepartmentInAppropriateTriage &Evaluation ofAcuteIschemicMyocardium IMMEDIATE AIMStudy Funded by NHLBI (RO1HL69753), 2001-2006, n=1308 UCSF

  36. IMMEDIATE AIM Study Initial ECG in 40 y/o male presenting to the ER with increasing chest pain episodes; Troponins negative 5:00 pm UCSF

  37. IMMEDIATE AIM Study 6 days following hospital discharge, patient was brought to ER after witnessed collapse on golf course UCSF

  38. IMMEDIATE AIM Study Rapidly developed profound shock, could not be resuscitated, and died UCSF

  39. ST SMART SynthesizedTwelve-leadSTMonitoringAndReal-timeTele-electrocardiography Prospective randomized clinical trial 2003-2009 Funding:NINR (RO1 NR007881), n=800 UCSF

  40. ST SMART Study Study Aim: Determine whether individuals who call “911” for chest pain will: • have shorter time to treatment when they reach the hospital • have better survival over 5 yrs if ED clinicians are provided with ECG ischemia monitoring information from the field UCSF

  41. Dominican Watsonville San Francisco 100 miles  Santa Cruz County

  42. 16 Fire Department rigs 13 AMR ambulances ST SMART Study Methods: All EMS vehicles that respond to 911 calls in the county are equipped with portable monitor-defibrillator devices with special study software

  43. ST SMART Study Special Study Software is designed to: • Synthesize a 12-lead ECG from 5 electrodes • Analyze ST segments every 30 secs & automatically transmit an ECG to the destination ED by cell phone if ischemia occurs • If the 1st transmission fails, automatic redialing occurs for a total of 3 attempts UCSF

  44. ST SMART Study Case Example 50 y/o with onset of chest pain on Sunday a.m. Attempted to drive to hospital; was found by motorist at roadside on the ground UCSF

  45. ECG Transmitted from the Field ST SMART Study

  46. 13. Become active in professional societies that put you in touch with experts in the field • International Society for Computerized Electrocardiology • American Heart Association UCSF

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