Clinical significance of premature ventricular contraction among adult patients: protocol for a scoping review

Alarm fatigue occurs when clinicians are desensitized by excessive numbers of alarms. As a result, the alarm sounds become “white noise” that is perceived as part of the typical working environment in the intensive care unit (ICU). Consequently, alarms might be silenced without checking the patient, adjusted by turning the volume down, or in extreme cases permanently disabling to minimize the burden to the nurse and patient. These responses have been recognized as a significant patient safety hazard leading to unintended consequences for patients, including death, due to missed true alarms [1]. The Association for the Advancement of Medical Instrumentation (AAMI) and the U.S. Food & Drug Administration (FDA) have warned of deaths due to alarm silencing on patient monitoring devices [2]. Likewise, several other agencies and national organizations, such as the Emergency Care Research Institute (ECRI) and The Joint Commission, have issued alerts about alarm fatigue being a major patient safety concern [3, 4]. The American Association of Critical-Care Nurses (AACN) recently published a practice alert as an evidence-based tool to guide both nurse clinicians and leaders in reducing false or nonactionable alarms with the goal of preventing alarm fatigue [5].

In clinical settings, one of the most common rhythms detected from electrocardiographic (ECG) monitoring in the ICU are premature ventricular contractions or PVCs [1]. When ECG monitoring was first introduced in the late 1960s, PVCs were thought to cause lethal arrhythmias (i.e., ventricular tachycardia [VT] and/or ventricular fibrillation [VF]); hence, PVCs were carefully monitored for and treated [6]. However, such practices changed when in the late 1980s, the Cardiac Arrhythmia Suppression Trial (CAST) showed that treatment for PVCs with antiarrhythmic drugs was associated with more deaths compared to placebo [7]. As a result of this important study, PVCs became considered a nonactionable arrhythmia alarm [1].

Despite being considered nonactionable, PVC alarms in many institutions are still turned on (audible or inaudible) during continuous ECG monitoring. In a recently published study, Drew and colleagues found 2,558,760 alarms were generated from bedside monitors [1]. Of the total number of alarms, 854,901 (33%) were for PVCs. While the PVC alarms were configured as in-audible text messages during this study, we believe that flashing warnings on the bedside monitor, while inaudible, still distract nurses and lead to alarm fatigue. Simpson and Lyndon, in their recently published study, described how neonatal ICU nurses “…hate seeing flashing…” (p. 4), with regard to inaudible text messages as they felt that there was something wrong with the patient [8]. This study illustrates that not only audible but also inaudible text alarm significantly contributes to alarm fatigue.

In the recently updated American Heart Association (AHA) Practice Standards for ECG Monitoring in Hospital Setting, recommendation for PVC monitoring states “PVCs and nonsustained VT are not immediately life-threatening, and in the absence of other indications for monitoring in hospitalized patients, continued arrhythmia monitoring may be considered but is not required” (p. e300) [9]. However, benefit or usefulness of this recommendation in clinical practice is less well-established (class IIb), and this practice is mainly based on expert opinion or standard of care (level of evidence: C) [9]. Considering the high volume of nonactionable PVC alarm, it is fair to say that PVC alarms contribute to alarm fatigue. Thus, turning off PVC monitoring completely from the bedside monitor seems to be reasonable since it will reduce a large number of nonactionable alarms. In reality, however, clinicians generally feel uncomfortable about the idea of removing/disabling PVC monitoring from routine continuous ECG monitoring. For example, there is a concern of potentially missing patients who are at high risk for developing torsade de pointes. In these patients, bradycardia followed by PVCs following a compensatory pause are a marker for TdP [1]. PVCs can also occur in patients with electrolyte disturbances, such as hypokalaemia and magnesium deficiency [9]. Unfortunately, there is no concrete evidence to support either approach (i.e., the need to monitor or turn off).

Because PVC monitoring practices and recommendations are uncertain, a thorough review of the literature regarding the clinical significance of PVCs is imperative. Furthermore, it is evident that there is a critical conflict between establishing evidence-based practice and the empirical evidence in this area. Assessing what is known and unknown on this topic may provide a more precise understanding of how to interpret the clinical significance of PVCs in general and how PVCs may differ between patients in the outpatient and inpatient settings. A preliminary search of the literature of major databases (i.e., PROSPERO, the Cochrane Library, and the JBI Database of Systematic Reviews and Implementation Reports) indicated that there are no current or underway systematic reviews on this topic. Ongoing reviews related to PVCs in the PROSPERO registry focus on predictive factors of ejection fraction after cardiac ablation intervention and PVC ablation among children. Therefore, in this review, we seek to describe what it means clinically when a patient has PVCs. Specifically, this scoping review will examine the clinical significance of PVCs in terms of their potential prognostic and diagnostic importance among adult patients in both outpatient and inpatient settings.

This protocol has been registered in the Open Science Framework (OSF), DOI: https://​doi.​org/​10.​17605/​OSF.​IO/​GAVT2. In preparing this protocol manuscript, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [10] was used, as well as the PRISMA-P Checklist (Additional file 1). This proposed scoping review will adopt the scoping review framework by Arksey and O’Malley [11], which involves the following stages:

Stage 1: Identifying the research question

Stage 2: Identifying relevant studies

Stage 3: Study selection

Stage 4: Charting the data

Stage 5: Collating, summarizing and reporting the results

In parallel, we will also adapt the scoping review protocol outlined by The Joanna Briggs Institute (JBI) [12].

We believe this scoping review will provide foundational knowledge and evidence on the potential clinical significance of PVC among the adult patient population. Interestingly, since the 1989 CAST study report [7], PVCs are generally viewed as a low priority arrhythmia and do not require treatment. However, in a recent meta-analysis by Ataklte and colleagues [15], they found a significantly increased risk for sudden cardiac death and total cardiac death among the general population who had frequent PVCs (i.e., at least one PVC on a 2-min ECG recording). We suspect that there may be differences in evidence on the significance of PVCs between the general population without cardiac disease to patients with cardiac disease and to patients who are hospitalized. Mapping out the evidence that exists on the significance of PVCs on patient care in different settings will provide insights on the knowledge gaps and potentially inform future research in this area. In addition, this scoping review will also inform our current project in assessing the utilization of continuous ECG monitoring for PVC among the adult patient population in the ICU. By knowing the current state of the evidence on the clinical significance of PVC, we will have a better direction in assessing the importance and relevancy of PVC monitoring, how it may impact patient care and patient outcomes, and how to better monitor for PVCs without overburdening clinicians with excessive alarms. Finally, to our knowledge, scoping review is the best approach to address the uncertainty of evidence in this topic, considering that this method allows us to conduct an in-depth exploration of the existing evidence.