Zaremba, Jennifer L. MSN, RN; Carroll, Karen MS, RN, CCNS, CCRN PCCN; Manley, Kathleen MSN, RN, CCRN, CCNS-CSC
In 2004 and again in 2006, practice standards for electrocardiographic (ECG) monitoring were published describing the need for hospitals to expand monitoring beyond heart rate and rhythm to include diagnosis of complex arrhythmias, identification of prolonged QT intervals, and the detection of ischemia. Research surrounding ECG monitoring practices is present, but in limited quantity. The American Association of Critical Care Nurses (AACN) has published 3 practice alerts designed to guide nurses with the best evidence available to monitor patients safely. The Dysrhythmia Monitoring practice alert focused on proper lead selection to detect and diagnose wide QRS dysrhythmias. This practice alert also recommends QT-interval monitoring for a select type of patient. In addition, ST-segment monitoring was released to guide the detection of ischemia in monitored patients. Recently, a practice alert was issued on Alarm Management that describes the importance of minimizing excessive alarms, proper ECG electrode placement, and customizing alarm parameters. Although these practice alerts assist in guiding safe practices, a continued lack of ECG standardizations occurs in hospitals, along with a lack of a formalized training.
Over the years, the technology surrounding ECG monitoring vastly has changed and advanced. The need for human interpretation and supervision remains the critical element in providing safe, effective, and efficient care. The ECG survey was developed as a quality improvement project to determine the extent to which practice standards have been developed and adopted within the Veterans Healthcare Administration (VHA). This report aims to improve care processes and patient outcomes.
The survey data were developed and used to identify the differences between actual practice and evidence-based standards. This quality improvement project used Select Survey for process development and design. The study tool was developed by the Cardiovascular Field Advisory Committee (CFAC) and the Office of Nursing Service Intensive Care Unit Workgroup (ICUW). The CFAC is composed of experienced nurses and nurse practitioners, and the Office of Nursing Service ICUW is composed of a panel of experienced nurses, managers, clinical nurse specialists, clinical nurse leaders, and educators. The CFAC piloted the audit, and the ICUW evaluated the pilot data and refined the survey for national distribution. The survey was distributed to VHA facilities across the country via e-mail in late 2011. A total of 777 participants from 100 VHA facilities voluntarily completed the survey. The participants were from various areas of the country and from varying types of facilities, from small rural hospitals to large urban centers. Participants worked in intensive care, emergency department, telemetry, or progressive care units. The members of the ICUW collected and analyzed the data into total responses and percentages for each question.
The demographics of the respondents are depicted in Table 1. The majority of the respondents were staff nurses. The respondents were asked the number of years in practice; 20% had fewer than 6 years of practice, and 30% had greater than 25 years in service. The type of degree and certifications were also requested. Almost half of the sample held a bachelor’s degree, and the majority held at least 1 type of certification. The types of units are shown in Table 2; the majority of the respondents worked in an intensive care unit.
The survey questions explored practice regarding ECG electrode application, lead selection, alarm limits, monitoring capabilities, monitoring during transportation, and the type of competencies required for staff responsible for ECG monitoring. Samples questions include the following:
Question 1: What is the default lead when monitoring is indicated?
Question 2: What are your unit qualifications for ECG monitoring?
Question 3: Skin is prepared for continuous ECG monitoring by which of the following?
Question 4: Does your area have competencies for cardiac monitoring?
Question 5: Which of the following best describes your method for setting monitor alarm limits?
In this report, an electrode is the adhesive patch placed on the patient to which the ECG monitoring wire is attached to provide a view of the rhythm. Lead placement or selection refers to the position of the electrode and the lead displayed on the monitor such as V1, V3, I, II, III, aVF, and aVL.
Respondents were asked about skin preparation prior to ECG electrode application. Seventy-two percent of respondents used no skin preparation when applying electrodes. Twelve percent used alcohol wipes, and only 4% used soap and water. Seventy-nine percent of respondents report using a 5-lead system, and 10% were using a derived 12-lead system. Only 7% of respondents report using a 3-lead system.
Evidence has consistently shown the importance of washing the electrode area with soap and water, wiping with a rough washcloth and gauze, or using the sandpaper supplied on some electrodes packaging to promote the electrode-skin interface, limit artifact, and potentially decrease the occurrence of erroneous rhythm analysis.1 Twelve percent of nurses used alcohol to prepare the skin; this is not recommended as it can dry out the skin.1 The lack of skin preparation results in a higher occurrence of false alarms, alarm fatigue, and potentially misdiagnosis of rhythms, resulting in unnecessary tests and delay in discharge.1,2 Proper skin preparation prior to electrode application may be perceived as time consuming, but then nurses should consider the time involved in unnecessary reapplication of electrodes and the time it takes to respond to false alarms. The benefit of preventing false alarms and electrode disconnection with proper skin preparation can be emphasized in education and competencies as a time-saving measure.
The respondents were asked about lead selection for patient monitoring. Seventy-seven percent stated that the primary default lead was II, and 4% use V1. Twenty-eight percent of respondents report the secondary default choice was VI. Twenty-nine percent of the sample was unsure of the secondary lead choice or did not use a second lead to monitor. Respondents were asked, “If you change the default lead, what determines the lead choice for patient monitoring?” The most common reasons for changing the default lead were to get a better view, interference, patient diagnosis, patient history, patient symptoms, and provider determined, respectively.
The AACN practice alert on dysrhythmia monitoring recommends that lead selection be based on patient presentation.2 The practice alert for the detection of ischemia recommends lead selection based on patient presentation as well.3 The survey demonstrates that nurses are aware of the importance of lead selection based on patient presentation. However, better view and interference were the most commonly selected reasons for changing the default lead. In Table 3 are the study results for lead selection.
Lead selection determined by patient presentation may require the nurse to determine whether the primary goal of monitoring is to detect arrhythmias or ischemia; this depends on monitoring capabilities and the current technology available.
Alarm Limits and Monitoring Capabilities
Monitoring capabilities and the limits surrounding those measures are essential to providing safe, efficient, and effective care. Ninety-six percent of respondents state that basic ECG alarms, such as dysrhythmia and heart rate, are always enabled. Respondents were asked to best describe how alarm limits were selected. Thirty-four percent selected limits based on patient presentation, 22% relied on unit-specific defaults, 17% selected manufacturer default settings, and 14% were based on provider orders. It is recommended that alarms be individualized for the patient and set within 1 hour of assuming care and reevaluated with changes in the patient’s condition.1
The use of QT-interval and ST-segment monitoring was also explored. Twenty percent of the survey respondents do not know if they had the capability to monitor QT-intervals or never determine QT-intervals. Thirty-two percent of the respondents do not calculate the corrected QT.
Monitoring the QT and corrected QT at a consistent interval and in a lead with a well-defined T-wave is recommended for patients at risk for torsades de pointes.2 The American Heart Association recommends that the following patients be monitored for long QT; patients receiving a new or increased dose of a QT prolonging drug, new-onset bradyarrhythmias, severe hypokalemia or hypomagnesemia, and in drug overdose, particularly overdose with a QT prolonging or proarrhythmic agents.4 The American Heart Association also recommends that hospitals establish protocols to determine monitoring capabilities and select the best approach to consistent and accurate QT-interval monitoring in high-risk patients.4
The VHA has adopted advanced technologies, such as ST-segment monitoring to detect ischemia, and is using these tools. Table 4 illustrates the use of ST-segment monitoring. Fifty-eight percent of the respondents answered “yes, we use it,” 22% have ST capability, but did not use it, 6% do not have the capability, and 13% were unsure.
The AACN recommends that ST-segment monitoring based on the patient’s needs and risk for ischemia be monitored accurately.3 Funk and colleagues5 report both undermonitoring and overmonitoring of ST-segment. Several protocols have been published to guide lead selection for ischemia monitoring.6,7 A thoughtful approach to implementing ST-segment monitoring requires an assessment of monitoring capabilities, lead and patient selection, if ST-segment will be enabled for patients, and, if so, identifying when to disable for conditions that result in false alarms. An institution may determine that ST-segment monitoring will be activated by the nurse for only selected patients; this has the potential of resulting in undermonitoring and missed ischemic events. Safe ST-segment monitoring requires competent staff and interdisciplinary involvement and use of a protocol.
Monitoring During Patient Transport
Patient transportation occurs continually in hospitals and can place a patient at risk if monitoring practices are not adequate. Sixty-nine percent of respondents report that monitored patients are allowed to be transported without ECG monitoring. Thirty percent never transport patients without an ECG monitor. Twenty-eight percent report that patient transports occur with unlicensed personnel.
According to Mayer8, hospitals can safely determine when it is appropriate to transport select stable patients, close to discharge, or transferring to a lower level of care to travel without monitoring. Some facilities have developed algorithms to determine the need for ECG monitoring during transport.8 Algorithm development needs to address the competencies and licensure of staff transporting monitored patients and identify patients requiring a registered nurse and when a patient requires additional clinicians such as a respiratory therapist or a physician. Determining standards for safe transport practices can improve patient care and safety and may reduce the time away nurses spend from the unit and other patient responsibilities.8 Transporting patients with monitoring needs requires procedures or protocols to be a priority to ensure patient safety and protection of staff and the facility.
Education and Competencies
The survey showed that VHA facilities do have education and competencies in place for ECG monitoring. Fifty-five percent of staff responsible for ECG monitoring completed a formal training course, and 80% completed an ECG examination. Competencies were completed for 67% of the VHA facilities, whereas 30% had none or were unsure of ECG competencies. Cardiac monitoring occurs in a variety of hospital units and staff needs to be proficient in understanding ECG abnormalities, generalized ECG concepts, and monitoring skills.9
Competency validation for ECG monitoring varies across settings. Drew et al9 recommend “periodic” competency validation but do not define how often that periodic validation be performed. Approaches to training include traditional classroom study, computer training, and on-unit practice.
Ray and Berger10 studied the difference in outcomes of a blended classroom and computer instruction and traditional instructor-led classes and found comparable outcomes. Length of instruction for computer instruction is also variable, requiring a few hours to a few weeks. A study of 1 such program and its effect on competency development aimed to evaluate the strategy of computer instruction for ECG interpretation and found the method sound.11 Other programs have utilized a blended approach and organized structure to teach both technicians and nursing staff in ECG interpretation.12 An online basic arrhythmia course was combined with a live classroom discussion, including interpretation of rhythms, telemetry monitoring procedures and roles, and responsibilities. The training is customized to the role of the technician or registered nurse with additional shadowing and simulation for the technician in training.
Undergraduate education has embraced dysrhythmia education as part of the curriculum, as a survey published in 2008 of 33 associate degree in nursing and 24 bachelor of science in nursing programs demonstrated.13 The opinion concluded by the authors was that “current health care practice trends dictate that nurses be competent in dysrhythmia management regardless of their nursing unit.”
The use of scenarios to reinforce concepts of ECG interpretation has also been described in the literature, mainly for medical education.14 Whichever method is chosen, an evidence-based approach is the key to provide safe, standardized monitoring of patients at risk for dysrhythmias.15
DISCUSSION AND RECOMMENDATIONS FOR PRACTICE
After an in-depth evaluation of the ECG survey data and the related literature, several recommendations for practice emerge. A thorough evaluation of the current facilities equipment and monitoring practices is needed. It is recommended that facilities determine the capability of current monitoring equipment and examine current practices prior to purchasing new monitoring equipment. Electrode application should include preparing the skin by clipping or shaving excess hair and/or wiping away oils/dry skin with soap and water in an effort to prevent false alarms, alarm fatigue, and erroneous rhythm interpretation. Marking the skin where the electrodes are placed will promote continuity in ECG monitoring particularly when placing 1 or more chest leads.2 A periodic, interdisciplinary evaluation of default alarm limits should occur to ensure patient safety. Lead selection and alarm limits should be driven by patient presentation. Protocols are needed for lead selection and ST-segment and QT monitoring that are both patient and unit specific. With the development of specific protocols, facilities can formalize the process of ECG monitoring and ensure continuity of patient care.
The need for patient monitoring during transport requires an interdisciplinary approach with procedures or protocols to delineate who can transport monitored patients based on staff licensure, competency, and patient presentation. It is recommended that hospitals routinely analyze resuscitation data, rapid response calls, and patient event reports to determine when monitoring procedures need modification. In doing this, facilities can track trends, identify safety concerns, make changes to improve safety, and determine if evidenced-based practices are occurring.
Education is essential in the development and maintenance of ECG monitoring skills and knowledge. It is recommended that annual competencies and ECG courses focus beyond rhythm interpretation to include ECG electrode placement, lead selection, and protocols to guide ST and QT monitoring for all levels of staff involved in monitoring.
In developing this report, recommendations for future study include determining the best method of ECG application, lead selection, and the efficacy of ST-segment and QT-interval monitoring. This quality improvement report has highlighted the current monitoring practices in VHA facilities and demonstrates a lack of consistent ECG evidence-based practices.
The authors thank Veterans Healthcare Administration Cardiovascular Field Advisory Committee, Veterans Healthcare Administration Office of Nursing Service Intensive Care Unit Workgroup.