Abstract 891: Substandard Quality of ECG Monitoring in Current Clinical Practice: Preliminary Results of the Practical Use of the Latest Standards for Electrocardiography (PULSE) Trial
Although electrocardiographic (ECG) monitoring is the cornerstone of care in hospital cardiac units, no studies have evaluated its quality.
Purpose: To examine the quality of ECG monitoring by evaluating electrode placement, accuracy of rhythm interpretation, use of ischemia and QT interval monitoring, and appropriateness of monitoring.
Methods: We analyzed baseline data of the PULSE Trial, a multi-site randomized clinical trial evaluating the effect of implementing American Heart Association practice standards for ECG monitoring on nurses’ knowledge, quality of care, and patient outcomes. Three research nurses observed patients for electrode placement and reviewed the full disclosure feature of the monitor and current medical records from patients on adult cardiac units in 15 hospitals in the US and Canada 7/08 –5/09.
Results: The sample of 1,684 patients had a mean age of 64.7±15.4 years and was 58% male and 80% white. Electrodes were frequently in the incorrect place: 15%–27% of the time for limb electrodes and 77% of the time for chest electrodes. Research nurses compared rhythm changes from full disclosure with documentation by unit nurses. Of the 258 occurrences of a rhythm change, the nurses documented it correctly only 49% of the time. The practice standards specify indications for arrhythmia, ischemia, and QT interval monitoring. Of the 139 patients with an indication for ischemia monitoring, 48% were monitored continuously for ST segment changes. Only 19% of the 179 patients with an indication for QTc monitoring had a QTc value documented by the nurses. Of the 421 patients with no indication for monitoring, 82% were on a monitor.
Conclusions: Our findings revealed substandard ECG monitoring, including incorrect electrode placement, inaccurate rhythm interpretation, underutilization of ischemia monitoring, failure to monitor for QT interval prolongation when indicated, and over-monitoring. The next phase of the PULSE Trial will test whether an online ECG monitoring education program based on the practice standards and strategies to implement and sustain change in practice will enhance nurses’ knowledge and the quality of ECG monitoring, ultimately leading to improved patient outcomes.