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Improving Accuracy of Cardiac Electrode Placement

Outcomes of Clinical Nurse Specialist Practice

DiLibero, Justin MSN, RN, CNS, CCRN, ACCNS-AG; DeSanto-Madyea, Susan PhD, RN, CNS; O’Dongohue, Sharon MSN, CNS

doi: 10.1097/NUR.0000000000000172
Feature Article

Purpose: The purpose of this quality improvement project was to facilitate a sustainable improvement in the accuracy of cardiac electrode placement for continuous bedside monitoring in intensive care unit patients.

Background: Continuous cardiac electrocardiograph monitoring is a standard of practice in critical care areas and is essential to accurate interpretation of cardiac dysrhythmias and early detection of myocardial ischemia. Accurate assessment of electrocardiographs depends on precise placement of electrodes; however, electrodes are often placed inaccurately.

Rationale: Evaluation of baseline practice revealed that cardiac electrodes were placed correctly in only 12.5% of patients. The most frequently misplaced electrode was the V lead, followed by lower limb leads.

Description: This project was conducted between July 1, 2013, and October 31, 2013, and involved a multifaceted education program for registered nurse and patient care technician staff on the physiologic basis and technical procedures for cardiac electrode placement. The clinical nurse specialist served as an informal leader, role model, and mentor by developing and empowering unit champions to perform real-time auditing and provide real-time feedback to colleagues.

Outcome: At 3 months after intervention, the accuracy of cardiac electrode placement was sustained at greater than 85%, representing a 6-fold improvement above the preintervention baseline.

Conclusion: Sustainable improvement in quality requires creation of a culture that supports quality improvement initiatives. As experts in clinical practice, evidence-based practice, and leadership, clinical nurse specialists are optimally positioned to function as change agents whose initiatives measurably improve outcomes.

Implications: This quality improvement project serves as a model for improving accuracy of cardiac electrode placement at the nursing staff level. Future research is necessary to improve outcomes related to accuracy of cardiac electrode placement on the patient and systems levels.

Author Affiliations: Clinical Nurse Specialists (Mr DiLibero and Ms O’Donoghue), Critical Care, Beth Israel Deaconess Medical Center, and Doctor of Nursing Practice Students at Northeastern University; Associate Clinical Professor, Wm. F. Connell School of Nursing, Boston College, and Beth Israel Hospital Nurses’ Alumnae Association Endowed Nurse Scientist, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Dr DeSanto-Madeya).

This study has no sources of funding.

The authors report no conflicts of interest.

Correspondence: Justin DiLibero, MSN, RN, CNS, CCRN, ACCNS-AG, Trauma and Surgical Critical Care, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA 02215 (

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