Continuous ST-segment monitoring: protocol for practice

The effectiveness of nurse education and training for clinical alarm response and management: a systematic review

AIMS AND OBJECTIVES

To identify the effectiveness of education interventions provided for nurses for clinical alarm response and management.

BACKGROUND

Some education has been undertaken to improve clinical alarm response, but the evidence for evaluating effectiveness for nurse education interventions is limited.

DESIGN

Systematic review.

METHODS

A systematic review of experimental studies published in English from 2005-2015 was conducted in four computerised databases (MEDLINE, EMBASE, CINAHL and Scopus). After identification, screening and appraisal using Joanna Briggs Institute instruments, quality research papers were selected, data extraction and analysis followed.

RESULTS

Five studies met the inclusion criteria for alarm response and no articles were concerned with clinical alarm education for management. All had different types and methods of interventions and statistical pooling was not possible. Response accuracy, response time and perceptions were consistent when different interventions were adopted. A positive effect was identified when learning about general alarms, single alarms, sequential alarms and medium-level alarms for learning as the primary task. Nurses who were musically trained had a faster and more accurate alarm response. Simulation interventions had a positive effect, but the effect of education provided in the care unit was greater. Overall, clinical alarm awareness was improved through education activities.

CONCLUSIONS

Nurses are the main users of healthcare alarms and work in complex environments with high numbers of alarms, including nuisance alarms and other factors. Alarm-related adverse events are common. The findings of a small number of experimental studies with diverse evidence included consideration of various factors when formulating education strategies. The factors which influence effectiveness of nurse education are nurse demographics, nurse participants with musical training, workload and characteristics of alarms. Education interventions based in clinical practice settings increase education effectiveness, although simulation can be effective. No study shows any type of intervention results in sustained improvement.

RELEVANCE TO CLINICAL PRACTICE

There are workload implications in education and the matching of load, number and type of alarms with nurse demographics which should be evaluated. There also needs to be a connection between education and the clinical setting to contribute to clinical alarm awareness for undergraduate nurses and practicing nurses. Education solely supported by employers is insufficient. Patient safety and long-term effects must be further explored.

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.

Signal Quality Analysis of Ambulatory Electrocardiograms to Gate False Myocardial Ischemia Alarms

OBJECTIVE

The objective of this study is to propose and validate an alarm gating system for a myocardial ischemia monitoring system that uses ambulatory electrocardiogram. The PeriOperative ISchemic Evaluation study recommended the selective administration of β blockers to patients at risk of cardiac events following noncardiac surgery. Patients at risk are identified by monitoring ST segment deviations in the electrocardiogram (ECG); however, patients are encouraged to ambulate to improve recovery, which deteriorates the signal quality of the ECG leading to false alarms.

METHODS

The proposed alarm gating system computes a signal quality index (SQI) to quantify the ECG signal quality and rejects alarms with a low SQI. The system was validated by artificially contaminating ECG records with motion artifact records obtained from the long-term ST database and MIT-BIH noise stress test database, respectively.

RESULTS

Without alarm gating, the myocardial ischemia monitoring system attained a Precision of 0.31 and a Recall of 0.78. The alarm gating improved the Precision to 0.58 with a reduction of Recall to 0.77.

CONCLUSION

The proposed system successfully gated false alarms with future work exploring the misidentification of fiducial points by myocardial ischemia monitoring systems.

SIGNIFICANCE

The reduction of false alarms due to the proposed system will decrease the incidence of the alarm fatigue condition typically found in clinicians. Alarm fatigue condition was rated as the top patient safety hazard from 2012 to 2015 by the Emergency Care Research Institute.

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.

Improving Nurses’ Knowledge of Continuous ST-Segment Monitoring

Background:

Continuous ST-segment monitoring can result in detection of myocardial ischemia, but in clinical practice, continuous ST-segment monitoring is conducted incorrectly and underused by many registered nurses (RNs). Many RNs are unable to correctly institute ST-segment monitoring guidelines because of a lack of education.

Purpose:

To evaluate whether an educational intervention, provided to 32 RNs, increases knowledge and correct clinical decision making (CDM) for the use of continuous ST-segment monitoring.

Methods:

At a single institution, an ST-segment monitoring class was provided to RNs in 2 cardiovascular units. Knowledge and correct CDM instruments were used for a baseline pretest and subsequent posttest after ST-segment monitoring education.

Results:

Statistical significance between pretest and posttest scores for knowledge and correct CDM practice was noted with dependent t tests (P = .0001).

Conclusions:

Many RNs responsible for electrocardiographic monitoring are not aware of evidence-based ST-segment monitoring practice guidelines and cannot properly place precordial leads needed for ST-segment monitoring. Knowledge and correct CDM with ST-segment monitoring can be improved with focused education.

Continuous ST-segment monitoring: nurses' attitudes, practices, and quality of patient care

BACKGROUND

Continuous ischemia monitoring helps identify patients with acute, but often silent, myocardial ischemia. Evidence suggests nurses do not activate ischemia monitoring because they think it is difficult to use. ST-Map software incorporates graphic displays to make monitoring of ongoing ischemia easier.

OBJECTIVES

To determine if nurses' use of and attitude toward ischemia monitoring and the quality of patient care improve with use of ST-Map.

METHODS

The study included 61 nurses and 202 patients with acute coronary syndrome in a cardiac intensive care unit. Baseline data on nurses' use of and attitude toward ischemia monitoring and quality of care were obtained. Education was then provided and ST-Map software was installed on all monitors. Follow-up data were obtained 4 months later.

RESULTS

The percentage of nurses who had ever used ischemia monitoring was 13% before ST Map and 90% afterward (P < .001). The most common reason for not using ischemia monitoring before ST Map was inadequate knowledge (62%). The most common reason for liking ischemia monitoring after ST Map was knowing when a patient has ischemia (80%). Time to acquisition of a 12-lead electrocardiogram in response to symptoms or ST-segment changes was 5 to 15 minutes before ST Map and always less than 5 minutes afterward (P < .001). Time to return to the catheterization laboratory did not differ before and after ST Map.

CONCLUSIONS

ST Map was associated with more frequent use of ischemia monitoring, improved attitudes of nurses toward ischemia monitoring, and shorter time to obtaining 12-lead electrocardiograms.

National survey of cardiologists' standard of practice for continuous ST-segment monitoring

BACKGROUND

Continuous ST-segment monitoring can be used to detect early and transient cardiac ischemia. The American Heart Association and American Association of Critical-Care Nurses recommend its use among specific patients, but such monitoring is routine practice in only about half of US hospitals.

OBJECTIVE

To determine cardiologists' awareness and practice standards regarding continuous ST-segment monitoring and the physicians' perceptions of appropriate patient selection, benefits and barriers, and usefulness of this technology.

METHODS

An electronic survey was sent to a random sample of 915 US cardiologists from a pool of 4985 certified cardiologists.

RESULTS

Of 200 responding cardiologists, 55% were unaware of the consensus guidelines. Of hospitals where respondents admitted patients, 49% had a standard of practice for using continuous ST-segment monitoring for cardiac patients. Most cardiologists agreed or strongly agreed that patients in the cardiovascular laboratory (87.5%) and intensive care unit (80.5%) should have such monitoring. Cardiologists routinely ordered ST monitoring for patients with acute coronary syndrome (67%) and after percutaneous coronary intervention (60%). The primary factor associated with higher perceptions for benefits, clinical usefulness, and past use of continuous ST-segment monitoring was whether or not hospitals in which cardiologists practiced had a standard of practice for using this monitoring. A secondary factor was awareness of published consensus guidelines for such monitoring.

CONCLUSION

Respondents (55%) were unaware of published monitoring guidelines. Hospital leaders could raise awareness by multidisciplinary review of evidence and possibly incorporating continuous ST-segment monitoring into hospitals' standards of practice.