Registered nurses' knowledge and interpretation of ECG rhythms: A cross-sectional study.

BACKGROUND: Electrocardiographic (ECG) monitoring and recording are seen as the most commonly used non-invasive diagnostic tool to identify cardiac arrhythmia and myocardial damage in the clinical setting. There is an expectation that critical care nurses are ideally trained to interpret abnormalities and morphology in the ECG more proficiently than nurses from general ward areas. However, the ability to interpret and recognise ECG abnormalities is dependent on which critical care area nurses are currently working in and their level of experience. AIM: The aim of this study was to investigate registered nurses' knowledge in being able to identify and interpret select electrocardiographic rhythms. STUDY DESIGN: This was a cross-sectional study that evaluated registered nurses' knowledge of electrocardiogram rhythm identification and interpretation. A convenience sample of 105 registered nurses currently enrolled in a 2-year Master's programme leading to critical care specialism and advanced practice nurse award were recruited. A 20-item multiple choice questionnaire that provided examples of electrocardiogram rhythm (n=14) abnormalities and rhythm abnormalities caused by electrolyte disturbances (n=6) RESULTS: The study included registered nurses from critical care and general ward areas. The overall results were poor with only 55% of questions answered correctly. Coronary care nurses scored the highest in identifying ECG rhythms (12/20 ± 1.58; p < .001). When ECG abnormalities associated with electrolyte imbalances were analysed, both groups were unable to identify the effects of hypokalaemia and hypomagnesaemia effectively (p = .748). Length of time as a registered nurse (r = -0.304, p = .002) and length of time in current work environment were weakly correlated (r = -0.328, p = .001). Having a critical care background showed a positive relationship with nursing knowledge of ECG rhythm identification (r = 0.614, p < .001). CONCLUSION: The results of this study demonstrate that nurses have a poor knowledge of ECG rhythm identification and interpretation, a consistent finding from other work. A possible solution is a revamp of education and training associated with ECG recognition and morphology. RELEVANCE TO CLINICAL PRACTICE: Monitoring and assessing ECG morphology provide important details about cardio-electroconductive stability, especially with fluctuations in serum electrolyte levels seen in critical illness or trauma. For this, critical nurses must improve their proficiency through education/training or internal quality improvement activities in detecting abnormalities associated with ECG changes beyond those most easily recognizable rhythms such as atrial fibrillation or ventricular tachycardia.

Transcutaneous Pacing: An Emergency Nurse's Guide.

Transcutaneous pacing is commonly performed in emergency departments to treat patients with cardiac dysrhythmias. Although emergency nurses are required to complete a standardized course that reviews components of transcutaneous pacing, such as Advanced Cardiac Life Support, performing transcutaneous pacing on patients may be done infrequently in some facilities and can lead to anxiety and fear for bedside emergency nurses, especially novice emergency nurses and nurses who infrequently care for patients requiring external pacing. This manuscript provides a practical guide for emergency nurses to care for patients who require transcutaneous pacing. Key information found in this manuscript includes indications for transcutaneous pacing, the nurse's role when performing transcutaneous pacing, and transcutaneous pacing troubleshooting information.

["Arrhythmia Reading": A Diverse Teaching Approach to Improve the Ability of 2 Year NPGY Nurses to Interpret and Manage Arrhythmias].

BACKGROUND: The author of this paper works in the critical care ward of an internal medicine department. During the study period, current trainees in a nurse post graduate year (NPGY) program joined our nurse team. While at our ward, they were required to demonstrate clinical nursing competencies in intensive care units in the facets of nursing knowledge, equipment use, prediction of emergencies, emergency response, and patient evaluation and management. The ability to interpret arrhythmias is critical to connecting and coordinating these competencies. However, arrhythmia interpretation is usually the most difficult skill for nurses to master. PURPOSE: This study was developed to improve the knowledge of NPGY trainees regarding arrhythmia interpretation, the accuracy of their arrhythmia interpretation and management, and their confidence in caring for patients with arrhythmia. RESOLUTION: The period of this study spanned from April 5th to June 18th, 2018. After surveying the current capabilities of the NPGY trainees to provide a reference for improvement, several teaching strategies were adopted. These strategies included: (1) provision of arrhythmia clinical scenarios; (2) establishment of multimedia teaching and interactive e-books; (3) development of memory strategies; and (4) mind mapping. RESULTS: The accuracy of the trainees' knowledge regarding arrhythmia interpretation increased from 52.5% pretest to 92.5% posttest, while their arrhythmia interpretation skill improved from 56.3% pretest to 92.5% posttest. Furthermore, their caring-for-patients-with-arrhythmia confidence score increased from 5.5 to 9.1. All of the objectives of this study were achieved. CONCLUSIONS: The diverse teaching approach employed in this study enhanced the ability of trainees to remember and recall relevant theories as well as improved their related practical skills. Furthermore, posttest, the trainees were significantly less nervous during encounters with patients with arrhythmia and demonstrated improved problem-solving abilities. Participation in this intervention significantly improved the confidence of trainees to serve as critical care nurses and to pursue a career in critical care nursing.

Electrocardiograms: a guide to rhythm recognition for emergency nurses.

Electrocardiogram (ECG) is one of the most commonly performed investigations in emergency departments (EDs), and is an extremely useful adjunct that guides diagnosis, prognosis and treatment. In most cases nurses are the first healthcare professional to assess patients and record an ECG, yet anecdotal evidence suggests that few emergency nurses review, interpret and act on ECG findings. Research suggests this may be due to lack of confidence in, or knowledge about, interpretation of results, often because of inadequate training. This article aims to help emergency nurses understand and interpret the cardiac rhythms commonly encountered on ECGs in EDs, to enable them to support earlier diagnosis and treatment. It describes a simple, five-step method for evaluating the main components of cardiac rhythm.

Nursing-Based Dysrhythmia Detection on a Dedicated Stroke Unit Using a Unit-Based Cardiac Telemetry Monitoring System.

BACKGROUND: Acute stroke care includes cardiac rhythm monitoring in the first 24 hours. The method of monitoring varies, as do the reported findings. The nurses' role in this process can be intensive, including primary response and review of all data. Competency is critical as the acute stroke setting can be associated with life-threatening dysrhythmias as well as the detection of atrial fibrillation that affects therapy. Limited studies exist to evaluate the effectiveness of a unit-based cardiac monitoring system for which the bedside nurse has primary responsibility. OBJECTIVE: The goal was to determine if a unit-based cardiac monitoring system for which the bedside nurse was responsible detected clinically significant dysrhythmias. METHODS: Stroke unit nurses completed a mandatory education program on identifying common dysrhythmias and using the monitoring equipment along with a structured algorithm for cardiac dysrhythmia detection. The nurse was responsible for all alarms as well as review of their patients' data. Their findings were recorded and reviewed by a cardiology team after the 24-hour monitoring was completed. A total of 300 consecutive stokes, transient ischemic attack, and possible stroke patients were enrolled. RESULTS: Nurses identified 96% of all significant dysrhythmias. Twenty-eight percent of the stroke patients had a dysrhythmia, of which 79% were atrial fibrillation/atrial flutter. The bedside nurses did identify all 8 new atrial fibrillation cases. CONCLUSION: Stroke unit nurses who complete an educational program can identify dysrhythmias on their patients' unit-based cardiac monitoring systems and can improve patient outcomes.

Accuracy of EASI 12-lead ECGs in monitoring ST-segment and J-point by nurses in the Coronary Care Units.

AIMS AND OBJECTIVES: To confirm the accuracy of the EASI system compared to the standard 12-lead electrocardiogram, which is the gold standard, in monitoring the two major parameters used in the Coronary Care Units to detect myocardial ischaemia: ST-segment and J-point. BACKGROUND: Continuous electrocardiograph monitoring is used in the Coronary Care Units to detect cardiac conduction abnormalities and to show the morphology of electrocardiographic waves and tracts. Its accuracy is essential for efficient nursing vigilance, particularly for monitoring the ST segment and the J-point, in which alterations may indicate the onset of myocardial ischaemia. DESIGN: An observational study was conducted. METHODS: The enrolled patients (n = 253) simultaneously underwent standard electrocardiogram (10 electrodes) and EASI electrocardiogram (five electrodes). Data were collected by the Coronary Care Units nurses. Tests to compare differences in means and medians between the two sets of measurements were performed, and the Bland-Altman plots were used to illustrate their agreement. RESULTS: All 6·072 electrocardiographic leads (3·036 standard and 3·036 EASI) were recorded and analysed. Between the two measurement methods, very small statistically significant differences were found in some leads which are not clinically relevant for both the ST-segment or the J-point. CONCLUSIONS: This study confirms that the accuracy of the EASI 12-leadelectrocardiogram, compared to the standard 12-leadelectrocardiogram, which is the gold standard, is acceptable for clinical practice to monitor the two major parameters used in the Coronary Care Units for detecting myocardial ischaemia: ST-segment and J-point. RELEVANCE TO CLINICAL PRACTICE: The EASI system ensures: (1) ease of use and comfort for patients admitted to Coronary Care Units because it only requires five electrodes; (2) increased efficacy of nursing vigilance in the early detection of changes in ST-segment and J- point measurements.

Using health psychology techniques to manage chronic physical symptoms.

Chest pain and palpitations, non-malignant pain, breathlessness and fatigue often endure despite the receipt of appropriate nursing and medical care. This is distressing for patients, impacts on their quality of life and ability to function and is associated with high healthcare usage and costs. The cognitive behavioural approach offers nurses a model to understand how people's perceptions and beliefs and their emotional, behavioural and physiological reactions are linked. Common 'thinking errors' which can exacerbate symptom severity and impact are highlighted. Understanding of this model may help nurses to help patients cope better with their symptoms by helping them to come up with alternative more helpful beliefs and practices. Many Improving Access to Psychological Therapy services offer support to people with chronic physical symptoms and nurses are encouraged to sign post patients to them.

Factors associated with health-related quality of life among patients with implantable cardioverter defibrillator: identification of foci for nursing intervention.

AIM: To explore factors associated with health-related quality of life of patients with implantable cardioverter defibrillators. BACKGROUND: Substantial evidence indicates that implantable cardioverter defibrillator is proven to increase survival rate by terminating life-threatening arrhythmia. However, this device can negatively affect health-related quality of life. Little is known about factors associated with health-related quality of life of patients with implantable cardioverter defibrillators, particularly in Asian population. DESIGN: A transversal descriptive design was used. METHODS: Data were collected from a convenience sample of 139 adult patients with implantable cardioverter defibrillators from 4 January-30 April 2012 using the structured questionnaires administered by the researcher and medical record reviews. The Short Form-36 Health Survey version 2 was used to measure health-related quality of life. RESULTS: A total of 139 Chinese patients, including 107 (77·0%) males with a mean age of 63·0 (14·6) years, were selected. The physical component summary was relatively lower, whereas the mental component summary was relatively higher than that of the general Hong Kong Chinese population. Multivariable regression analysis revealed gender, self-care dependence, educational level, atrial fibrillation, diabetes mellitus, anxiety and depression significantly associated with physical or mental quality of life. CONCLUSIONS: Depression was a common factor affecting physical and mental quality of life. Self-care dependence, atrial fibrillation, diabetes mellitus, depression and anxiety could be improved. Our findings expand existing knowledge on identifying at-risk patients for having lower quality of life, thus allowing development of appropriate interventions targeting risk factors for improving health-related quality of life of patients with implantable cardioverter defibrillator.

Workload and usefulness of daily, centralized home monitoring for patients treated with CIEDs: results of the MoniC (Model Project Monitor Centre) prospective multicentre study.

AIM: Automated, daily Home Monitoring (HM) of pacemaker and implantable cardioverter-defibrillator (ICD) patients can improve patient care. Yet, HM introduction to routine clinical practice is challenged by resource allocation for regular HM data review. We tested the feasibility, safety, workload, and clinical usefulness of a centralized HM model consisting of one monitor centre and nine satellite clinics. METHODS AND RESULTS: Having no knowledge about patients' clinical data, a telemonitoring nurse (TN) and a supporting physician at the monitor centre screened and filtered HM data in 62 pacemaker and 59 ICD patients from nine satellite clinics for over 1 year. Basic screening of arrhythmic and technical events required 25.7 min (TN) and 0.7 min (physician) per working day, normalized for 100 patients monitored. Communication of relevant events to satellite clinics per email or phone required additional 4.3 min (TN) and 0.4 min (physician). Telemonitoring nurse also screened for abnormal developments in longitudinal data trends weekly for 3 months after implantation, and then monthly; one patient session lasted 4.0 ± 2.9 min. To handle transmission-gap notifications, TN needed additional 2.8 min daily. Satellite clinics received 231.3 observations from the monitor centre per 100 patients/year, which prompted 86.3 patient contacts or intensive HM screening periods by the satellite clinic itself (37.3% response rate), 51.7 extra follow-up controls (22.3%), and 30.1 clinical interventions (13.0%). CONCLUSION: Centralized HM was feasible, reliable, safe, and clinically useful. Basic screening and communication of relevant arrhythmic and technical events required a total of 30 min (TN) and 1.1 min (physician) daily per 100 patients monitored.

Treatment of inherited cardiac conditions.

Inherited cardiac conditions are difficult to detect and screen for Part 2 of our six part series on rare diseases explains why health professionals need to be aware of the symptoms associated with inherited cardiac conditions so they can make swift referrals to expert services.

Benefits of arrhythmia care coordinators.

Arrhythmias (abnormal heartbeats) are common but can be life threatening. Symptoms can be severe and include palpitations, dizziness, blackouts, breathlessness and even chest pain. These can be highly distressing for patients, causing them severe anxiety and depression if they are not well supported. Early diagnosis is essential to reduce mortality and improve quality of life--the most common arrhythmia--atrial fibrillation--can cause a stroke if left untreated or inadequately treated. While sudden cardiac death is less common in a young person, it is usually due to an inherited cardiac condition that has resulted in a critical arrhythmia. Screening family members at risk can provide timely assessment, psychological support through counselling and treatment with the implantation of a cardioverter defibrillator if necessary. In 2005, a chapter setting out best practice for arrhythmia care was added to the National Service Framework for Coronary Heart Disease. This highlights the need for early diagnosis and expert patient support. In response, the British Heart Foundation launched a pilot programme to fund specialist nurses as arrhythmia care coordinators. Its aim was to develop and improve care pathways, and provide continuity and support for patients diagnosed with an arrhythmia to improve clinical care and emotional wellbeing. An independent evaluation by the University of York showed that these posts significantly improved patients' experiences of arrhythmia services, prevented thousands of readmissions and cut costs for the NHS. This article explains how the new role was successfully implemented.

Evaluation of basic arrhythmia knowledge retention and clinical application by registered nurses.

The purpose of this descriptive study was to evaluate knowledge retention over time and clinical application of basic arrhythmia knowledge following exposure to an orientation program. Data showed significant differences in knowledge retention at 4 weeks and clinical application in rhythm identification using simulation at 3 months.

Evidence-based strategies for teaching dysrhythmia monitoring practices to staff nurses.

Standards for dysrhythmia monitoring were established by the American Heart Association in 2004, but they have not been fully implemented in everyday nursing practice. Nurses working on units with cardiac monitoring must be able to prepare the skin and place electrodes correctly, monitor in the appropriate lead, and identify potentially lethal dysrhythmias. This article presents a literature review of evidence-based strategies for educating staff nurses on dysrhythmia monitoring practices. Based on the findings of this literature review, there is evidence to support the use of an interactive web-based learning format combined with unit-based collaborative activities and competency validation. The program should incorporate Chickering and Gamson's seven principles for good practice in undergraduate education. More research is needed with randomized controlled studies to determine the most effective strategies.

A Case of Heart Palpitations and Shortness of Breath.

Editor's note: This is the next installment in a series on electrocardiogram (ECG) interpretation. Nurses in all settings should know the basics, as medications and physiological changes can cause cardiac arrhythmias. Each article will start with a brief case scenario and an ECG strip and then take you step by step through analyzing the heart rhythm.

A nurse-led palpitations clinic: a 2-year experience.

OBJECTIVE: To investigate the role of a nurse-led clinic in the assessment of patients with palpitations. DESIGN: Prospective descriptive study. SETTING: Nurse-led palpitations clinic in a UK district general hospital. PARTICIPANTS: Patients referred from primary care or the emergency department with palpitations. METHODS: Referral letters were screened, and only patients without high-risk features or a documented arrhythmia were diverted to the palpitations clinic. Patients were evaluated using a protocol. All patients had an ECG and ambulatory ECG monitoring and were discussed with a cardiologist. RESULTS: Over 15 months, 389 patients were seen. The mean time from referral to assessment was 38 days (range 3-142). The most common diagnoses were symptomatic extrasystoles (42%) and sinus rhythm (22%). Significant arrhythmias were diagnosed in 15% (atrial fibrillation/flutter, 8%; supraventricular arrhythmias, 6%). Only 52 (13%) were subsequently referred to a cardiologist, including 20 with high-risk features. These 20 patients waited on average an additional 70 days to be seen by a cardiologist compared with patients who were seen directly by a cardiologist after referral by primary care or the emergency department. CONCLUSIONS: For low-risk patients, a nurse-led palpitations clinic may provide a viable alternative to the traditional cardiology outpatient service. Despite attempts to exclude them, some high-risk patients were seen. This was unforeseen and led to a clinically important delay in their appropriate assessment. Hence, before adopting a nurse-led palpitations service, a rigorous pathway for the early assessment of high-risk patients needs to be agreed.

Incidence of arrhythmias in ASA I patients in the phase I PACU.

Cardiac monitoring is routinely performed on all adult patients in the immediate postoperative period in the Phase I PACU, regardless of the surgery/procedure or type of anesthesia given. This practice is based on the premise that there may be a possibility of a postanesthesia arrhythmia or cardiac event that would need to be recognized and treated. The purpose of this study was to explore whether routine cardiac monitoring is a valid practice for healthy individuals (ASA I) or merely a tradition of postanesthesia nursing care.

Introduction to electrocardiogram interpretation: part 2.

Twelve-lead electrocardiograms (ECGs) record 12 different views of cardiac electrical activity, or leads. They therefore provide more information than bedside monitors, which usually record one or sometimes two leads. Many acutely ill patients have 12-lead ECGs recorded either on admission to hospital, before undergoing operations or when specific cardiac concerns have arisen. Traditionally, ECGs have aided clinical diagnoses and, by learning how to understand and interpret them, nurses will know when they need to summon expert help. This article describes what each of the 12 leads represents, outlines the main indications for recording 12-lead ECGs and identifies likely causes of error in interpreting them.

Acute Care Nurses' Arrhythmia Knowledge: Defining Competency.

BACKGROUND: Most methods of evaluating arrhythmia knowledge acquisition are internally developed by nursing professional development practitioners and are institution specific. This approach has resulted in assessing nurses' minimal qualifications for rhythm recognition as defined by the facility but does not result in describing basic, intermediate, and advanced competency levels for practice. METHOD: This quantitative study with a convenience sample of 85 acute care nurses refined an instrument to assess varying levels of arrhythmia recognition competency for acute care nurses. RESULTS: The final instrument, called the Cardiac Arrhythmia Recognition Tool (CART), consisted of 33 items divided into basic, intermediate, and advanced subscales, with an overall Cronbach's alpha of .84. CONCLUSION: This study significantly contributes to defining arrhythmia competency in nurses caring for electrocardiographically monitored patients. [J Contin Educ Nurs. 2020;51(1):39-45.].

Effectiveness of the CRISP Method on the Primary Cardiac Arrhythmia Interpretation Accuracy of Nurses.

BACKGROUND: Accurate electrocardiogram (ECG) interpretation is key to quickly providing attention to patients, and the first health staff who evaluate ECGs are nurses. METHOD: This was a prospective study with a pre-posttest design. The study test included 15 ECGs related to primary cardiac arrhythmias. After pretest nurses were instructed on arrhythmia interpretation using the Cardiac Rhythm Identification for Simple People (CRISP) method, posttests were completed. RESULTS: There was a significant difference between the pretest scores of nurses who had postgraduate education on ECG interpretation and who did not (p = .002). Median test score increased from 3 (interquartile range [IQR] = 2-5) to 7 (IQR = 5-9) (p < .001). Participants mostly missed questions about heart blocks and were most successful with questions about fatal arrhythmias after education. CONCLUSION: The CRISP method is an effective, simple, and easy method for accurate ECG interpretation by nurses. The posttest scores of the participants, especially accurate interpretation of fatal arrhythmias, increased significantly after training. [J Contin Educ Nurs. 2020;51(12):574-580.].