Introduction to Cardiac Monitoring

Cardiovascular disease remains a primary cause of morbidity and mortality worldwide. Cardiac monitoring using an electrocardiograph device continues to be a critical component in the assessment and care of patients at risk for cardiac problems or who are experiencing acute cardiac symptoms. Preparing the patient, correctly applying electrocardiography leads and monitor their cardiac rhythm are common direct care nursing tasks. Evidence indicates that a nurse's ability to competently monitor, quickly identify and respond to a lethal cardiac arrhythmia can be the difference between life and death for the patient.

While professional nursing education includes foundational knowledge of cardiac electrophysiology, research continues to demonstrate that the ability to accurately interpret an ECG is a skill that requires ongoing training and continuous practice. Evidence indicates that additional education can improve accuracy, but the when a moderate level of skill was achieved it was rarely retained.

• A controlled study of medical students was conducted, starting with a pre-test to evaluate the participants' baseline ECG interpretation skills. Following this, an intervention group received an online ECG tutorial, while the control group did not undergo any additional training. Participants were randomly assigned for skill testing at either 2-4 weeks, 8 weeks, or 16 weeks. The study revealed that the online ECG tutorial effectively enhanced the interpretation skills of the intervention group compared to the control group. However, the skill improvements were reduced by half within 2-4 weeks. Nonetheless, a residual skill enhancement persisted for up to 16 weeks following the initial training (Rolskov Bojsen 2015).
• The Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial involved a 2-part educational intervention comprising an interactive online ECG education program and unit-based nurse champions to support change. The trial included a majority of nurses with a Bachelor's degree or higher (73%, n = 2188) and an average of 12 years of nursing experience. Despite these factors, the intervention did not show sustained knowledge retention beyond 15 months.
• In a 2020 study conducted by Giannetta et al., experienced Italian nurses (n = 387, 80%) and nursing students (n = 97, 20%) participated. The pooled scores on a validated ECG knowledge test were poor, averaging 6.9 ± 2.12 out of 10. Interestingly, nursing students generally scored higher on the test compared to experienced nurses (Giannetta et al., 2020)."
• A 2021 study conducted by Chen et al. revealed that among graduating nursing students, there was a significant variation in ECG knowledge based on the type of arrhythmia. The study found that fewer than 15% of students were able to interpret critical arrhythmias such as junctional rhythm and paced rhythms (Chen et al., 2021).
• In a 2023 study involving a diverse sample of medical professionals (n=1206), the overall accuracy of 12-lead ECG interpretation was found to be 56.4% ± 17.2%. The study also revealed that Primary Care Providers had an accuracy of 58.1%, Advanced Practice Providers had an accuracy of 50.6%, and nurses had an accuracy of 46.8%, with statistically significant differences (P < 0.01) among them (Kashou 2023)..

The American Heart Association (AHA), published the 2017 Updated Practice Standards for Electrocardiographic Monitoring in Hospital Settings, identifies 4 rationales for electrocardiographic monitoring, including:

1. increased survival from sudden cardiac arrest with prompt recognition and treatment of life-threatening arrhythmias;
2. early identification of conditions like drug induced long QT interval, early afterdepolarization (EAD), and premature beats that can predispose an individual to a life-threatening arrhythmia;
3. facilitation of the management of arrhythmias that are not immediately life-threatening.
4. facilitation of the diagnosis and treatment of cardiovascular conditions of chect pain, syncope and palpitations, e.g.,  Atrial fibrillation (AFib), Ventricular tachycardia (VT), Supraventricular tachycardia (SVT), Bradycardia, Structural Heart Disease, Cardiac Ischemia and Heart Attack, Long QT Syndrome, Orthostatic Hypotension, Pulmonary Hypertension.

The AHA emphasizes that unmonitored inpatients who experience sudden cardiac arrest often face decreased survival due to delayed defibrillation. They recognize that Nurse-to-patient ratios are the most significant predictor of survival following an in-hospital arrest and that sufficient staffing enhances nurses' capability to promptly respond to monitor-identified alarms. Identifying inpatient populations at risk of cardiac arrest necessitates monitoring to enhance survival (Sandau, K. E., et al. 2017).

Instant Feedback:
Nurses outside the critical care settings do not need to master EKG dysrhythmia interpretation.

References

Chen, Y., Kunst, E., Nasrawi, D., Massey, D., Johnston, A. N., 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

Giannetta, N., Campagna, G., Di Muzio, F., Di Simone, E., Dionisi, S., & Di Muzio, M. (2020). Accuracy and knowledge in 12-lead ECG placement among nursing students and nurses: a web-based Italian study. Acta bio-medica : Atenei Parmensis, 91(12-S), e2020004. https://doi.org/10.23750/abm.v91i12-S.10349

Kashou AH, Noseworthy PA, Beckman TJ, Anavekar NS, Cullen MW, Angstman KB, Sandefur BJ, Shapiro BP, Wiley BW, Kates AM, Huneycutt D, Braisted A, Smith SW, Baranchuk A, Grauer K, O'Brien K, Kaul V, Gambhir HS, Knohl SJ, Albert D, Kligfield PD, Macfarlane PW, Drew BJ, May AM. ECG Interpretation Proficiency of Healthcare Professionals. Curr Probl Cardiol. 2023 Oct;48(10):101924. doi: 10.1016/j.cpcardiol.2023.101924. Epub 2023 Jul 1. PMID: 37394202.

Ng, Laurel K., "Improving an Electrocardiogram Competency Assessment Tool for Registered Nurses" (2021). Master's Projects and Capstones. 1265. https://repository.usfca.edu/capstone/1265

Rolskov Bojsen S, Räder SB, Holst AG, Kayser L, Ringsted C, Hastrup Svendsen J, Konge L. The acquisition and retention of ECG interpretation skills after a standardized web-based ECG tutorial-a randomised study. BMC Med Educ. 2015 Mar 7;15:36. doi: 10.1186/s12909-015-0319-0. PMID: 25889642; PMCID: PMC4356122.

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. (2017). Update to practice standards for electrocardiographic monitoring in hospital settings: A scientific statement from the American Heart Association. Circulation, 136(19). https://doi.org/10.1161/cir.0000000000000527

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