A change request was made for the Pulse/Heart beat archetype, link here:
Clinical Knowledge Manager
I can not detect any reponses yet. Is it possible to get a discussion there, or should the question be published in this forum instead?
Kind regards,
Rikard Lövström, Karolinska University Hospital, Sweden
Hi Rikard, and thank you for helping improve the international archetypes!
I think there are several reasons why there as of yet has been no response to your change request:
- Editors and CKAs working on the international CKM are few and don’t have sufficient resources to respond to change requests or archetype proposals in a timely manner
- The Pulse/heart beat archetype has a long and painful history, and there is a certain reluctance to touch it at all for fear of opening new cans of worms
- As you rightly identify, the change request notes don’t lend themselves well to having thorough discussions
Also, and only speaking for myself, I don’t understand the reasoning for the change request or the proposed solutions. I’d be happy to have a discussion about it here though 
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Hi Silje!
Thank you for your quick response! Happy to discuss here.
So, my impression is that this archetype aims to focus on the beat/no beat questions, not on the characteristics of beats. I fully understand there has been a painful history, since this is easily conjoined an then potentially confusing. I suspect previous revisions have done extensive work to separate out everything about characteristics of the beats and placed that in other archetypes. Still, there is a remainder which makes me confused, and that is why I wrote the change request (in italics below). If so, I would recommend my suggestions 1+3: 1/focus on beat/no beat and frequence, and 3/adjust entries to be focused on heat/no beat and frequency. That is, do not describe any remaining entry with any characteristics of the pulse or heart beat, leave that to other archetypes. This will in my view make a more “clean” Pulse/Heart beat archetype, and make it quite useful in our context.
Kind regards,
Rikard
Dear international community,
We are translating the archetype Pulse/Heart beat https://ckm.openehr.org/ckm/archetypes/1013.1.4295 to Swedish, and get the impression that there is both a focus on beat/no beat, but somewhere along the line more characteristics are included in the details, although the Use/Misuse clearly states that the characteristics of the individual beats are not to be recorded or interpreted.
Sepcifically, we are noting this:
There is nowhere in Use mentioned the characteristics of the heart beat, but only the presence or absence of a heart beat or peripheral pulse (so peripheral pulse dficit is included).
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There is in Misuse mentioned that the characteristics of the actual beats should be recorded, like presence/strength of peripheral pulse.
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Still, there is in the archetype entries like Character with thready, collapsing etc. and (Clinical interpretation) with “other characteristics observed on examination”.
We find that the archetype is therefore not exclusively containing data on beat/no beat, but characteristics of the beat. Then it will be difficult for us to translate this to Swedish in a clinical context.
Our suggestion:
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Make the archetype exclusively focused on beat/no beat and frequency, OR
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Make the archetype include all other characteristics of the heart beat and pulse waves, OR
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Make all entries focused on beat/no beat, like (Clinical interpretation) with “other characteristics observed on examination regarding the presences or absence of a heart beat”.
And, in the first and third case, the archetype could perhaps be named “pulse and heart rate”? In the second case it could be named “pulse and heart beats”?
This needs to be clarified, since it deeply affects the documentation of things like vital signs.
We are of course happy to discuss all of this.
Kind regards,
Hi again Rikard,
I have to admit I still struggle to understand both the reasoning and what you’re actually suggesting. Specifically I’m not sure which paragraph of ‘Misuse’ you’re referring to. Could you elaborate?
Absolutely, the point is that the archetype needs to focus on beat/no beat, not on any other characteristics, since they are better expressed by other archetypes.
So one way to do this could be, since
“Purpose
To record details about the rate and associated attributes for a pulse or heart beat.”
AND
"Misuse
Not to be used to record other details of the full cardiovascular examination or assessment. Other specific CLUSTER archetypes will be used to record characteristics such as apex beat, murmurs and bruits, or auscultatory findings.
In particular, this archetype is not intended to record the assessment of peripheral vascular disease, which requires documentation of the presence and strength of each peripheral pulse. A specific CLUSTER archetype will be used to record the general findings on examination of peripheral pulses."
Consider changing:
- “Pulse/Heart beat” → “Pulse/Heart rate”
- “Runtime name constraint:
Clinical interpretation [Generic label to allow for any or all statements about the pulse or heart beat.]
Rhythm [Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination.]”
→
“Runtime name constraint:
Clinical interpretation [Generic label to allow for any or all statements about the pulse or heart beat.]
Rhythm [Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination regarding the presence or absence of a heart beat.]”
If not, the archetype will in practice open up for “any or all statements about the pulse or heart beat” which is not constrained enough by by the expression “other characteristics observed on examination” which opens up for numerous types of descriptions of what you find during examination.
So, I believe our translation will be easier with this clarity and that this is not opposing the intent of the archetype as I interpret it.
Kind regards,
Rikard
Okay, now I think I understand what you’re proposing, but I don’t understand how it would make anything easier. If anything I think it’d make it much harder to document that an initial pulse was bounding while 15 minutes later it was thready.
Those two “Misuse” paragraphs are intended to exclude “full cardiovascular examination or assessment” and “assessment of peripheral vascular disease” from this concept, not qualitative descriptions of a simple pulse or heart beat.
(With that said, I suspect the latter’s mention of a CLUSTER archetype may be a holdout from way back in 2013, and I’m not sure how we’d do this with today’s modelling patterns. Maybe @heather.leslie can assess whether this particular sentence should be kept as is, modified or removed altogether?)
I think the discussion has helped me so that we can have a reasonable translation and that we can use other artefacts like observations, cluster archetypes etc for other aspects of heart rhythm/pulse characteristics. Maybe I just wanted something clearer in my head that is already clear enough. Let me discuss with my team again and see if we can make the translation and the connected documentation of vital signs in a good way. Thank you for your help and patience! Also, I will try to find if there are templates connecting the dots for vital signs, at least pulse/HR, respiratory rate, bp, SpO2, temperature.
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