Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest Standards for Electrocardiography trial

Appropriateness and outcomes of hospitalized patients telemetry monitored for cardiac arrhythmias in accordance with the American Heart Association Practice Standards-A multicenter study

BACKGROUND

To the best of our knowledge, no prospective research studies have compared clinical practice to the American Heart Association (AHA) updated practice standards for in-hospital telemetry monitoring.

OBJECTIVES

Our aims were therefore (1) to investigate how patients were assigned to telemetry monitoring in accordance with the AHA's updated practice standards, (2) to determine the number and type of arrhythmic events, and (3) to describe subsequent changes in clinical management.

METHODS

This prospective multicenter study included 1154 patients at three university hospitals in Norway. Data were collected 24/7 over a four-week period, with follow-up measurements from telemetry admission until hospital discharge.

RESULTS

Of patients assigned to telemetry, 67 % (n = 767) met practice standards, corresponding to AHA Class I or II. Patients were predominantly men (65 %, n = 748), and the mean age was 65 years (SD ±16). The study included both patients with cardiac and non-cardiac diagnoses from various medical and surgical departments throughout the hospitals. Ninety-one percent of the patients in Class III were monitored based on indications that were reclassified from Class II to Class III (not indicated) in the updated practice standards (patients admitted with chest pain or post-percutaneous coronary intervention (PCI) without complications). Overall, arrhythmic events occurred in 37 % (n = 424) of patients, and they occurred in all classes. Eighteen percent (n = 59) of arrhythmic events occurred in Class III. Of all arrhythmias, 3 % (n = 14) were life threatening, and all of them occurring within Class I. Telemetry monitoring led to changes in clinical management in 22 % (n = 257) of patients due to clinical alarms, of which 71 % (n = 182) were related to medication management.

CONCLUSIONS

Most patients were appropriately monitored according to the AHA practice standards, meeting Class I and II. Arrhythmias occurred in all classes, but life-threatening arrhythmias only occurred in patients in Class I. However, a daily re-assessment of each patient's telemetry indication is warranted.

Research Outcomes of Implementing CEASE: An Innovative, Nurse-Driven, Evidence-Based, Patient-Customized Monitoring Bundle to Decrease Alarm Fatigue in the Intensive Care Unit/Step-down Unit

INTRODUCTION

The research literature is replete with evidence that alarm fatigue is a real phenomenon in the clinical practice environment and can lead to desensitization of the need to respond among nursing staff. A few studies attest to the effectiveness of incorporating parts of the American Association of Critical-Care Nurses recommended nursing practices for alarm management. No studies could be found measuring the effectiveness of the American Association of Critical-Care Nurses recommendations in their entirety or the effectiveness of a nursing-driven, evidence-based, patient-customized monitoring bundle.

PURPOSE/RESEARCH QUESTION

The purpose of this study was to describe the effect of implementing CEASE, a nurse-driven, evidence-based, patient-customized monitoring bundle on alarm fatigue. CEASE is an acronym for Communication, Electrodes (daily changes), Appropriateness (evaluation), Setup alarm parameters (patient customization), and Education (ongoing).

RESEARCH QUESTIONS

(1) In a 36-bed intensive care unit/step-down unit (ICU/SDU) with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by the number of hemodynamic and respiratory monitoring alarms? (2) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by duration of alarms? and (3) In a 36-bed ICU/SDU with continuous hemodynamic and respiratory monitoring, does application of an evidence-based, patient-customized monitoring bundle compared with existing monitoring practice lead to less alarm fatigue as measured by nurse perception?

METHODS

This was an institutional review board approved exploratory, nonrandomized, pretest and posttest, 1-group, quasi-experimental study, without-comparators design describing difference in pretest and posttest measures following CEASE Bundle implementation. The study was conducted over a 6-month period. Convenience sample of 74 registered nurses staffing a 36-bed ICU/SDU using the CEASE Bundle participated. Preimplementation/postimplementation number of alarms and alarm duration time for a 30-day period were downloaded from the monitoring system and compared. Nurses completed an electronic 36-item Clinical Alarms Survey provided by the Healthcare Technology Foundation: 35 before implementation and 18 after implementation. Researchers measured CEASE alarm bundle adherence. χ and t-tests determined statistical significance.

RESULTS

Total number of monitoring alarms decreased 31% from 52 880 to 36 780 after CEASE Bundle implementation. Low-priority Level 1 alarms duration time significantly decreased 23 seconds (t = 1.994, P = .045). Level 2 duration time did not change. High-priority Level 3 alarms duration time significantly increased to 246 seconds (t = 4.432, P < .0001). CEASE alarm bundle adherence significantly improved to 22.4% (χ = 5.068, P = .0244). Nurses perceived a significant decrease in nuisance alarm occurrence (68% to 44%) postimplementation (χ = 3.243, P = .0417). No adverse patient events occurred.

CONCLUSIONS

Decreased total number of monitoring alarms improved nurse perception of alarm fatigue. Continued monitoring of CEASE Bundle adherence by nursing staff is required. Longer high-priority Level 3 alarms duration suggests need for further research.

Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use

Interventions guiding appropriate telemetry utilization have successfully reduced use at many hospitals, but few studies have examined their possible adverse outcomes. The authors conducted a successful intervention to reduce telemetry use in 2013 on a hospitalist service using educational modules, routine review, and financial incentives. The association of reduced telemetry use with the incidence of rapid response team (RRT) and code activations was assessed in a retrospective cohort study of 210 patients who experienced a total of 233 RRT and code events on the inpatient internal medicine services from January 2012 through March 2015 at a tertiary care center. The incidence of adverse events for the hospitalist service was not significantly different during the intervention and postintervention period as compared to the preintervention period. Reducing inappropriate telemetry use was not associated with an increase in the incidence rates of RRT and code events.

Solving alarm fatigue with smartphone technology

Alarms were developed to improve patient safety, but alarm fatigue may put patients at higher risk for harm. This article recounts one acute care institution's search for a better alarm management solution using smartphone technology to replace its beeper-based system for telemetry alarm events.

Nurses' use of monitors in patient surveillance: an ethnographic study on a coronary care unit

BACKGROUND

Physiological monitors are increasingly used for patient surveillance. Although nurses play a vital role in the observation, analysis and use of information obtained from these devices, difficulties in their use, coupled with the high frequency of false and nuisance monitor alarms, can lead to negative working conditions and threaten patient safety.

AIM

With the purpose of promoting effective monitor use and ensuring patient safety, the aim was to explore both how cardiovascular nurses use monitors in patient surveillance and the effect that the monitors have on the nurses' work.

METHODS

A qualitative ethnographic design with semi-structured interviews and a field observation conducted at a 35-bed coronary care unit. A purposive sample was used in selecting participants. Data were analysed using systematic text condensation.

RESULTS

Eight registered nurses, all women, aged 27-49 years, were participants. The themes helping device, competence development and distractions and strain reflected both the knowledge on which the nurses drew in working with monitors and their influence on the nurses' work. False security and collaboration and teamwork discussed how the nurses trust and depend on each other during monitor surveillance and how poor work conditions and unclear responsibility undermine surveillance.

CONCLUSIONS

Monitors enable nurses to observe critically ill cardiac patients closely and respond quickly to life-threatening changes in their condition. Current work arrangements and limited training diminish the reliability of monitor surveillance. It is imperative to revise the structure of the surveillance and improve education in monitor surveillance to enhance nurses' clinical competence and patients' safety.

Alarm Fatigue: Use of an Evidence-Based Alarm Management Strategy

The purpose of this article is to describe the impact of an evidence-based alarm management strategy on patient safety. An alarm management program reduced alarms up to 30%. Evaluation of patients on continuous cardiac monitoring showed a 3.5% decrease in census. This alarm management strategy has the potential to save $136 500 and 841 hours of registered nurses' time per year. No patient harm occurred during the 2-year project.

Case Report and Review of Management of Penetrating Trauma and Cardiac Pericarditis

Acute pericarditis is the most common form of pericardial disease worldwide and it has many potential etiologies. This case study examines a patient admitted for multiple gunshot wounds who developed acute pericarditis postpericardial drain removal. The initial penetrating abdominal trauma, along with facial injuries and a suspected myocardial infarction, led to confusion in which the initial etiology of pericarditis was missed, creating a delay in overall patient care and extended length of stay.

Proper skin preparation and electrode placement decreases alarms on a telemetry unit

BACKGROUND

An estimated 85% to 99% of electrocardiographic (ECG) alarms are false, leading to alarm fatigue, which is associated with increased risk of death among hospitalized patients.

OBJECTIVE

The aim of this study was to examine the effect of proper skin preparation and electrode placement on frequency of ECG alarms on a telemetry unit.

METHOD

A prospective descriptive design was used to test the effect of proper skin preparation and ECG electrode placement. Purposive sampling of patients (n = 15) admitted to a telemetry hospital in a suburban Veterans Affairs Medical Center was used. Alarms were counted for 24 hours after admission, electrodes were replaced using proper technique, and alarms were counted for 24 hours after electrode change. Bootstrapping was used to double the sample size for analysis.

RESULTS

Electrocardiographic alarms decreased significantly (P < .05) after proper skin preparation and electrode placement (95% confidence interval, 1.273-82.327).

DISCUSSION

Proper skin preparation and ECG electrode placement reduced alarms. Reducing alarm frequency is vital to decreasing alarm fatigue and increasing patient safety.

Cardiac Monitoring in the Emergency Department

Patients present to the emergency department (ED) with a wide range of complaints and ED clinicians are responsible for identifying which conditions are life threatening. Cardiac monitoring strategies in the ED include, but are not limited to, 12-lead electrocardiography and bedside cardiac monitoring for arrhythmia and ischemia detection as well as QT-interval monitoring. ED nurses are in a unique position to incorporate cardiac monitoring into the early triage and risk stratification of patients with cardiovascular emergencies to optimize patient management and outcomes.

Among Unstable Angina and Non-ST-Elevation Myocardial Infarction Patients, Transient Myocardial Ischemia and Early Invasive Treatment Are Predictors of Major In-hospital Complications

BACKGROUND

Treatment for unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) is aimed at plaque stabilization to prevent infarction. Two treatment strategies are (1) invasive (ie, cardiac catheterization laboratory <24 hours after admission) or (2) selectively invasive (ie, medications with cardiac catheterization laboratory >24 hours for recurrent symptoms). However, it is not known if the frequency of transient myocardial ischemia (TMI) or complications during hospitalization varies by treatment.

PURPOSE

We aimed to (1) examine occurrence of TMI in UA/NSTEMI, (2) compare frequency of TMI by treatment pathway, and (3) determine predictors of in-hospital complications (ie, death, myocardial infarction [MI], pulmonary edema, shock, dysrhythmia with intervention).

METHODS

Hospitalized patients with coronary artery disease (ie, history of MI, percutaneous coronary intervention/stent, coronary artery bypass graft, >50% lesion via angiogram, or positive troponin) were recruited, and 12-lead electrocardiogram Holter initiated. Clinicians, blinded to Holter data, decided treatment strategy; offline analysis was done after discharge. Transient myocardial ischemia was defined as more than 1-mm ST segment ↑ or ↓, in more than 1 electrocardiographic lead, more than 1 minute.

RESULTS

Of 291 patients, 91% were white, 66% were male, 44% had prior MI, and 59% had prior percutaneous coronary intervention/stent or coronary artery bypass graft. Treatment pathway was early in 123 (42%) and selective in 168 (58%). Forty-nine (17%) had TMI: 19 (15%) early invasive, 30 (18%) selective (P = .637). Acute MI after admission was higher in patients with TMI regardless of treatment strategy (early: no TMI 4% vs yes TMI 21%; P = .020; selective: no TMI 1% vs yes TMI 13%; P = .0004). Predictors of major in-hospital complication were TMI (odds ratio, 9.9; 95% confidence interval, 3.84-25.78) and early invasive treatment (odds ratio 3.5; 95% confidence interval, 1.23-10.20).

CONCLUSIONS

In UA/NSTEMI patients treated with contemporary therapies, TMI is not uncommon. The presence of TMI and early invasive treatment are predictors of major in-hospital complications.

ECG changes on continuous telemetry preceding in-hospital cardiac arrests

BACKGROUND

About 200,000 patients suffer from in-hospital cardiac arrest (IHCA) annually. Identification of at-risk patients is key to improving outcomes. The use of continuous ECG monitoring in identifying patients at risk for developing IHCA has not been studied.

OBJECTIVE

To describe the profile and timing of ECG changes prior to IHCA.

DESIGN

Retrospective, observational.

SETTING

Single 520-bed tertiary care hospital.

PATIENTS

IHCA in adults between April 2010 and March 2012 with at least 3 hours of continuous telemetry data immediately prior to IHCA.

MEASUREMENTS

We evaluated up to 24 hours of telemetry data preceding IHCA for changes in PR, QRS, ST segment, arrhythmias, and QTc in ventricular tachycardia cases. We determined mechanism and likely clinical cause of the arrest by chart and telemetry review.

RESULTS

We studied 81 IHCA patients, in whom the mechanism was ventricular tachycardia/fibrillation in 14 (18%), bradyasystolic in 21 (26%), and pulseless electrical activity (PEA) in 46 (56%). Preceding ECG changes were ST segment changes (31% of cases), atrial tachyarrhythmias (21%), bradyarrhythmias (28%), P wave axis change (21%),QRS prolongation (19%), PR prolongation (17%), isorhythmic dissociation (14%), nonsustained ventricular tachycardia (6%), and PR shortening (5%). At least one of these was present in 77% of all cases, and in 89% of IHCA caused by respiratory or multiorgan failure. Bradyarrhythmias were primarily seen with IHCA in the setting of respiratory or multiorgan failure, and PR and QRS prolongation with IHCA and concomitant multiorgan failure.

LIMITATIONS

This is a retrospective study with a limited number of cases; each patient serves as their own control, and a separate control population has not yet been studied.

CONCLUSIONS

ECG changes are commonly seen preceding IHCA, and have a pathophysiologic basis. Automated detection methods for ECG changes could potentially be used to better identify patients at risk for IHCA.

Electrocardiographic practices: the current report of monitoring and education in Veterans Affairs facilities

In 2004, practice standards for electrocardiographic (ECG) monitoring were published to address the need for an expanded use of ECG monitoring beyond heart rate and basic rhythm determination. This article reports the data collected from a survey distributed throughout the Veterans Healthcare Administration hospitals to determine the extent to which practice standards have been adopted. Survey data were used to identify the differences between actual practice and evidence-based standards. The results were divided into ECG electrode application, lead selection, alarm limits, monitoring capabilities, monitoring during patient transport, and education and competencies. The results confirm the need for improvement, including a thorough evaluation of facility practices and education. The data demonstrate the differences among actual practice and evidence-based recommendations.

A description of nurses' decision-making in managing electrocardiographic monitor alarms

AIMS AND OBJECTIVES

To describe the cues and factors that nurses use in their decision-making when responding to clinical alarms.

BACKGROUND

Alarms are designed to be very sensitive, and as a result, they are not very specific. Lack of adherence to the practice standards for electrocardiographic monitoring in hospital settings has been observed, resulting in overuse of the electrocardiographic monitoring. Monitoring without consideration of clinical indicators uses scarce healthcare resources and may even produce untoward circumstances because of alarm fatigue. With so many false alarms, alarm fatigue represents a symptom of a larger problem. It cannot be fixed until all of the factors that contribute to its existence have been examined.

DESIGN

This was a qualitative descriptive study.

METHOD

This study was conducted at an academic medical centre located in the Northeast United States. Eight participants were enrolled using purposive sampling. Nurses were observed for two three-hour periods. Following each observation, the nurse was interviewed using the critical decision method to describe the cognitive processes related to the alarm activities. Qualitative data from the conducted interviews were analysed via an a priori framework founded in the critical decision method.

RESULTS

This study reveals information, experience, guidance and decision-making as the four prominent categories contributing to nurses' decision-making in relation to alarm management. Managing technology was a category not identified a priori that emerged in the data analysis.

CONCLUSION

Nurses revealed a breadth of information needed to adequately identify and interpret monitor alarms, and how they used that information to put the alarms into the particular context of an individual patient's situations.

RELEVANCE TO CLINICAL PRACTICE

Understanding the cues and factors nurses use when responding to cardiac alarms will guide the development of learning experiences and inform policies to guide practice.

Improvement of in-hospital telemetry monitoring in coronary care units: an intervention study for achieving optimal electrode placement and attachment, hygiene and delivery of critical information to patients

BACKGROUND

In-hospital telemetry monitoring is important for diagnosis and treatment of patients at risk of developing life-threatening arrhythmias. It is widely used in critical and non-critical care wards. Nurses are responsible for correct electrode placement, thus ensuring optimal quality of the monitoring. The aims of this study were to determine whether a complex educational intervention improves (a) optimal electrode placement, (b) hygiene, and (c) delivery of critical information to patients (reason for monitoring, limitations in cellular phone use, and not to leave the ward without informing a member of staff).

METHODS

A prospective interventional study design was used, with data collection occurring over two six-week periods: before implementation of the intervention (n=201) and after the intervention (n=165). Standard abstraction forms were used to obtain data on patients' clinical characteristics, and 10 variables related to electrode placement and attachment, hygiene and delivery of critical information.

RESULTS

At pre-intervention registration, 26% of the electrodes were misplaced. Twelve per cent of the patients received information about limiting their cellular phone use while monitored, 70% were informed of the purpose of monitoring, and 71% used a protective cover for their unit. Post-intervention, outcome measures for the three variables improved significantly: use of protective cover (p<0.001), information about the purpose of monitoring (p=0.005) and information about limitations in cellular phone use (p=0.003). Nonetheless, 23% of the electrodes were still misplaced.

CONCLUSION

The study highlights the need for better, continued education for in-hospital telemetry monitoring in coronary care units, and other units that monitor patients with telemetry.

Evaluation of the appropriateness and outcome of in-hospital telemetry monitoring

The American Heart Association classifies monitored patients into 3 categories. The aims of this study were to (1) investigate how patients are assigned according to the American Heart Association classification, (2) determine the number and type of arrhythmic events experienced by these patients, and (3) describe subsequent changes in management. A prospective observational study design was used. All patients assigned to telemetry during a 3-month period were consecutively enrolled in our study. Data were collected 24/7. Only arrhythmias that might require a change in management were recorded. Monitor watchers at the central monitoring station completed a standard data sheet assessing 64 variables. These data, as well as medical records, were reviewed by the investigator. Overall, 1,194 patients were included. Eighteen percent of the patients were assigned to American Heart Association class I (monitoring indicated), 71% to class II (monitoring may be of benefit), and 11% to class III (monitoring not indicated). The overall arrhythmia event rate was 33%. Forty-three percent of class I patients, 28% of class II patients, and 47% of class III patients experienced arrhythmia events. Change in management occurred in 25% of class I patients, 14% of class II patients, and 29% of class III patients. Although the number of class III indications should have been reduced, nearly 1/2 of class III patients experienced arrhythmia events and 1/3 of them received management changes. This outcome challenges existing guidelines. In conclusion, most patients in this study were monitored appropriately, according to class I and II indications.

Normal standards for computer-ECG programs for prognostically and diagnostically important ECG variables derived from a large ethnically diverse female cohort: the Women's Health Initiative (WHI)

BACKGROUND

Substantial new information has emerged recently about the prognostic value for a variety of new ECG variables. The objective of the present study was to establish reference standards for these novel risk predictors in a large, ethnically diverse cohort of healthy women from the Women's Health Initiative (WHI) study.

METHODS AND RESULTS

The study population consisted of 36,299 healthy women. Racial differences in rate-adjusted QT end (QT(ea)) and QT peak (QT(pa)) intervals as linear functions of RR were small, leading to the conclusion that 450 and 390 ms are applicable as thresholds for prolonged and shortened QT(ea) and similarly, 365 and 295 ms for prolonged and shortened QT(pa), respectively. As a threshold for increased dispersion of global repolarization (T(peak)T(end) interval), 110 ms was established for white and Hispanic women and 120 ms for African-American and Asian women. ST elevation and depression values for the monitoring leads of each person with limb electrodes at Mason-Likar positions and chest leads at level of V1 and V2 were first computed from standard leads using lead transformation coefficients derived from 892 body surface maps, and subsequently normal standards were determined for the monitoring leads, including vessel-specific bipolar left anterior descending, left circumflex artery and right coronary artery leads. The results support the choice 150 μV as a tentative threshold for abnormal ST-onset elevation for all monitoring leads. Body mass index (BMI) had a profound effect on Cornell voltage and Sokolow-Lyon voltage in all racial groups and their utility for left ventricular hypertrophy classification remains open.

CONCLUSIONS

Common thresholds for all racial groups are applicable for QT(ea), and QT(pa) intervals and ST elevation. Race-specific normal standards are required for many other ECG parameters.

Nurses' response to frequency and types of electrocardiography alarms in a non-critical care setting: a descriptive study

BACKGROUND

An important role of the registered nurse is to identify patient deterioration by monitoring the patient condition and vital signs. Increasingly, this is supplemented with continuous electrocardiographic (ECG) monitoring. Continuous monitoring is inefficient in identifying deterioration because of the high number of false and nuisance alarms. Lack of strong evidence or formal guidelines for the care of patients receiving ECG monitoring has led clinicians to rely too heavily on this technology without consideration of its limitations. The nursing workload associated with alarm management remains unexamined.

OBJECTIVE

To describe nurses' routine practices related to continuous ECG monitoring, frequency and types of alarms, their associated nursing interventions, and the impact on the patient's plan of care.

METHODS

Design. Prospective, descriptive, observational study. Setting and participants. Between January 2011 and March 2011 we observed nine Registered Nurses providing care for patients receiving continuous ECG monitoring in non-critical care areas. The PI and two research assistants observed each nurse for two 3-h observation periods and recorded data on a researcher designed observation tool. At the end of each observation period, the observers printed the alarm events as recorded by the central monitoring computer.

RESULTS

Nurses responded to 46.8% of all alarms. During the observation period, there were no dysrhythmia adverse events. One patient had a change in condition requiring transfer to a higher level of care. A range of nursing interventions occurred in response to alarms.

CONCLUSION

Nurses routine practices related to monitoring continue to reveal gaps in practice related to alarm management. Observations of practice also revealed the difficulties and complexities of managing alarm systems and the range of nursing interventions associated with managing alarms.

Alarm fatigue

The number of false high alarms in the hospital setting remains a serious problem. False alarms have desensitized care providers and, at times, have led to dire consequences for patients. Efforts by both industry and clinicians are beginning to address this situation in collaborative approaches. Research is needed to establish an evidence base around issues such as which patients need to be monitored, and what the threshold settings and delay settings should be on devices. Initial and ongoing education needs to be considered for any new medical device, and be included in the hospital's annual budget.

Detecting myocardial ischemia with continuous ST-segment monitoring: two case studies

Continuous ST-segment ischemia monitoring is recommended for patients at significant risk for myocardial ischemia that, if sustained, may result in acute myocardial infarction or extension of a myocardial infarction. It is especially useful for patients who do not perceive or cannot communicate symptoms of ischemia. We report 2 case studies of young women with acute coronary syndrome who benefited from continuous ST-segment monitoring. One patient was critically ill and unresponsive, and one patient had atypical symptoms and some difficulty communicating clearly.

Individual and institutional factors affecting cardiac monitoring in coronary care units: a national survey of Chinese nurses

BACKGROUND

As cardiovascular diseases have become the leading cause of death in many countries including China, nurses are increasingly required to be abreast of technological advances and the skills necessary to manage this increasing health care problem. Chinese nurses are under pressure to provide skilled electrocardiography monitoring, and be sufficiently skilled to detect myocardial ischemia and infarction, in this large patient population. This presents a challenge for the nursing profession in China, particularly for nurses working in coronary care in a country where advancement has been so rapid, yet little research has been conducted or reported in the literature.

OBJECTIVES

The two main objectives were: to explore the demographic and educational factors that affect the use of ST-segment monitoring and correct electrode placement by CCU/ICU nurses in China; and to explore the factors both individual and institutional that affect monitoring and lead placement.

METHODS

A self-administered questionnaire was distributed to nurses in 126 randomly selected tertiary hospitals, which were stratified into three homogeneous regions across China. The instrument examined demographics, information about hospitals, electrocardiogram devices, current practice patterns and perceptions toward monitoring and lead placement. Data from 734 nurses and 59 nurse managers from 59 hospitals were analyzed using t-tests, ANOVA, Chi-square test and logistic regression.

RESULTS

Electrocardiogram monitoring was used to detect myocardial ischemia by 43.7% of respondents, and 35.1% selected leads according to electrocardiogram or angiography findings. Most (70%) agreed that monitoring for acute coronary syndrome was important, while 39.2% did so, and 15.7% were able to identify correct placement. Logistic regression revealed a significant relationship between the uses of ST-segment monitoring and number of hospital beds, continuing education and a belief in its use and ease of use. Correct electrode placement was significantly correlated with respondents from university hospitals, hospitals with more acute coronary syndrome admissions and more independent thinking nurses.

CONCLUSIONS

Despite best practice evidence, less than half of the sample used electrocardiogram monitoring to detect myocardial ischemia and the majority could not identify correct electrode placement, while ST-segment monitoring was not used routinely. This paper highlights the need for improvements in education both in universities and hospitals and discussion addresses conventions in units, which inhibit development of nurses' skills.

As health care technology advances: benefits and risks

Technology permeates every dimension of critical care. Bedside technology is integral to the assessment and monitoring of patients and to the provision of treatment. It also helps with access to vital information and can enhance communication. Although it offers extraordinary benefits to patients and clinicians, technology may also create problems. Our research addresses the wise use of technology in the care of critically ill patients. It examines the appropriate and safe use of technology, its equitable distribution, and the human-machine interface. Given that some devices are more effective and safe than others, it is important to assess the appropriateness of a specific technology in a specific situation. Just because a particular device is available, is it necessary to use it in every possible situation? Do we use it just because it is there? Do we employ "heroic" measures sometimes when it would be kinder not to? Studies on the safe use of technology in patient care lead to a consideration of the risk-benefit ratio. Our research on gender and racial differences in the use of cardiac procedures in patients with acute myocardial infarction focused on the equitable distribution of technology. The results of this line of research, along with those of numerous other studies, suggest possible racism in our health care practices. The human-machine interface, or how clinicians and patients interact with health care technology, is a crucial focus of research. Technology is at the heart of critical care. It allows clinicians to perform miracles, but is also a seductive and self-perpetuating force that needs careful monitoring by those who use it.