EKG Literature Review

Introduction to cardiac monitoring

Practice Gap

In 2004, the American Heart Association (AHA) published the Practice Standards for Electrocardiographic Monitoring in Hospital Settings. Their purpose was to provide ‘best practices’ for hospital ECG monitoring. Among other reasons they cited:

a continuing need for human oversight of the ubiquitous, automated and computerized ECG monitoring systems in place across hospital departments.
evidence supporting improved patient outcomes with, prevention, early detection and treatment of myocardial ischemia in acute coronary syndromes.
the need for healthcare professionals technically capable of analyzing ECG monitoring data for evidence of device malfunction and nonoptimal device programming.
recognition of the patient safety risk of drug induced prolonged QT interval and prodromal polymorphic ventricular ectopy that can result in sudden death from the malignant ventricular arrhythmia torsades de pointes.
acknowledgment that hospitals have, by design, reduced specialty cardiac care units in favor of multipurpose units. As a result the patients with increased cardiac risk may be assigned to a nurse with limited, outdated, or no cardiac critical care experience.
When limited cardiac expertise is compounded by a perpetual nursing shortage, the patient risk for a cardiac adverse event is compounded.

In 2017, the AHA published the Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. These standards continue to highlight the importance of appropriate inpatient cardiac monitoring and interpretation in initiating care escalation and interventions. Particular attention is directed toward: the overuse of arrhythmia monitoring in some patient populations, the underuse of QT-interval and ST-segment monitoring among select populations, alarm fatigue, and documentation in electronic health records. Furthermore, the increasing integration of artificial intelligence (AI) into cardiac monitoring systems necessitates that healthcare professionals maintain and enhance their ECG interpretation skills, as AI is intended to augment, not replace, human expertise.

Recent research continues to raise questions regarding the ability of healthcare providers to monitor and accurately interpret inpatient ECGs.

Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial by Funk et al. was a 6-year multi-site randomized clinical intervention trial that used a validated ECG test to obtain the baseline ECG knowledge data of 3013 nurses from cardiac and non-cardiac units.
- The baseline testing results of nurse ECG knowledge found a mean test score below 50%.
- Follow-up post-intervention testing revealed that nurse ECG knowledge gains were not sustanied 15 months after the intervention, but accurate electrode placement, accurate rhythm interpretation, appropriate monitoring, and ST-segment monitoring and in-hospital MI outcome improvement was sustained
According to Chen et al. (2022), acute care nurse competence in electrocardiogram (ECG) interpretation varies widely. Their analysis of 43 publications undertaken in multiple settings and countries. Here are some examples of studies looking at ECG competence, rhythm interpretation, and the effect of interventions reported by U.S. nurses:

Authors	Nursing experience	Intervention	Findings
Blakeman et al. (2015) US	cardiovascular nurses	Online PowerPoint education	Intervention significantly increased nurse ECG knowledge and comfort level
Brooks et al. (2016) US	Nurses new to ECG monitoring who passed stanardized ECG test	A 2-day ECG interpretation course •Test on week3 •Test on week 8	Nurse competence decreased from wk 3 to wk 8
Chronister, (2014) US	RNs from CVICU and IPCU	Educational content for ST-segment monitoring guidelines, practices, and case studies	Significant improvement in total knowledge of ST-segment monitoring, clinical decision-making ability, and lead placement for V3 and V5 after the educational session
Crimlisk et al. (2015) US	RNs from: Med/Surg, ED, PICU, L&D	Cardiac dysrhythmia workshop and a follow-up clinical orientation	After intervention, staff were more knowledgeable and better able to care for their patients. Staff felt more confident talking to the physicians about cardiac dysrhythmias and the appropriateness of the order for telemetry
Hernandez et al. (2019) US	RNs mainly from ED, but included ICU, 23-hour observation, and Med/surg	A 1-hour YouTube video	Significant post-test improvement for recognition of STEMI, the need for 12-lead monitoring and J-point importance.
Nickasch, (2016) US	RNs from Med/Surg and cardiac step-down units	None	Nurses reported inability to retain working knowledge (use it or lose it), uncertainty about ECG interpretation and rhythm severity. Nurses felt unable to work independent of telemetry techs

Conclusions:

a long-standing ECG practice gap continues to exist in the treatment of hospitalized patients.
nurses play a significant role in ECG application and continuous monitoring of cardiac inpatients.
nurses in all hospital departments may need to apply, troubleshoot, continuously monitor, interpret, and assess the ECGs of patients with cardiac risk.
continuing professional development can improve the ECG confidence and competence of nurses.
effective continuing development can include:

cardiac anatomy, physiology
proper application, and use of ECG devices
critical assessment of ECG rhythm strips.
recognition of arrhythmia including heart block, aberrant conduction, tachyarrhythmias, etc.
interpretation of risk
treatment.

while continuing professional development interventions can improve the ECG confidence and competence the gains wane with time
lastly, the increasing use of AI in cardiac monitoring adds another layer of complexity, requiring nurses to understand and effectively utilize AI-driven data while maintaining their own ECG interpretation skills.

Instant Feedback:

Nurse identification and interpretation of ECG dysrhythmia can be improved with continuing professional development courses, but studies also indicate that such impovement wanes with time, necessitating commitment to continued learning and application of monitoring skills.

References:

Chen, Y., Kunst, E., Nasrawi, D., Massey, D., Johnston, A. N. B., Keller, K., & Fengzhi Lin, F. (2022). Nurses' competency in electrocardiogram interpretation in acute care settings: A systematic review. Journal of advanced nursing, 78(5), 1245–1266. https://doi.org/10.1111/jan.15147

Funk, M., Fennie, K. P., Stephens, K. E., May, J. L., Winkler, C. G., Drew, B. J., & PULSE Site Investigators (2017). Association of Implementation of Practice Standards for Electrocardiographic Monitoring With Nurses' Knowledge, Quality of Care, and Patient Outcomes: Findings From the Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial. Circulation. Cardiovascular quality and outcomes, 10(2), e003132. https://doi.org/10.1161/CIRCOUTCOMES.116.003132

Sandau, K. E., Funk, M., Auerbach, A., Barsness, G. W., Blum, K., Cvach, M., Lampert, R., May, J. L., McDaniel, G. M., Perez, M. V., Sendelbach, S., Sommargren, C. E., Wang, P. J., & American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Cardiovascular Disease in the Young (2017). Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation, 136(19), e273–e344. https://doi.org/10.1161/CIR.0000000000000527