Catherine Winkler

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

PURPOSE The purpose of the study was to examine the appropriate use of arrhythmia, ischemia, and QTc interval monitoring in the acute care setting. METHODS We analyzed baseline data of the Practical Use of the Latest Standards for Electrocardiography (PULSE) trial, a multisite randomized clinical trial evaluating the effect of implementing electrocardiographic monitoring practice standards. Research nurses reviewed medical records for indications for monitoring and observed if arrhythmia, ischemia, and QT interval monitoring was being done on 1816 patients in 17 hospitals. RESULTS Almost all (99%) patients with an indication for arrhythmia monitoring were being monitored, but 85% of patients with no indication were monitored. Of patients with an indication for ischemia monitoring, 35% were being monitored; but 26% with no indication were being monitored for ST-segment changes. Only 21% of patients with an indication for QT interval monitoring had a QTc documented, but 18% of patients with no indication had a QTc documented. CONCLUSION Our data show evidence of inappropriate monitoring: undermonitoring for ischemia and QTc prolongation and overmonitoring for all 3 types of monitoring, especially arrhythmia monitoring.

Arrhythmias in patients with acute coronary syndrome in the first 24 hours of hospitalization

OBJECTIVES In patients with acute coronary syndrome (ACS), we sought to: 1) describe arrhythmias during hospitalization, 2) explore the association between arrhythmias and patient outcomes, and 3) explore predictors of the occurrence of arrhythmias. METHODS In a prospective sub-study of the IMMEDIATE AIM study, we analyzed electrocardiographic (ECG) data from 278 patients with ACS. On emergency department admission, a Holter recorder was attached for continuous 12-lead ECG monitoring. RESULTS Approximately 22% of patients had more than 50 premature ventricular contractions (PVCs) per hour. Non-sustained ventricular tachycardia (VT) occurred in 15% of patients. Very few patients (≤ 1%) had a malignant arrhythmia (sustained VT, asystole, torsade de pointes, or ventricular fibrillation). Only more than 50 PVCs/hour independently predicted an increased length of stay (p < .0001). No arrhythmias predicted mortality. Age greater than 65 years and a final diagnosis of acute myocardial infarction independently predicted more than 50 PVCs per hour (p = .0004). CONCLUSIONS Patients with ACS seem to have fewer serious arrhythmias today, which may have implications for the appropriate use of continuous ECG monitoring.

Association of Implementation of Practice Standards for Electrocardiographic Monitoring With Nurses’ Knowledge, Quality of Care, and Patient Outcomes: Findings From the Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial

Background— Although continuous electrocardiographic (ECG) monitoring is ubiquitous in hospitals, monitoring practices are inconsistent. We evaluated implementation of American Heart Association practice standards for ECG monitoring on nurses’ knowledge, quality of care, and patient outcomes. Methods and Results— The PULSE (Practical Use of the Latest Standards of Electrocardiography) Trial was a 6-year multisite randomized clinical trial with crossover that took place in 65 cardiac units in 17 hospitals. We measured outcomes at baseline, time 2 after group 1 hospitals received the intervention, and time 3 after group 2 hospitals received the intervention. Measurement periods were 15 months apart. The 2-part intervention consisted of an online ECG monitoring education program and strategies to implement and sustain change in practice. Nurses’ knowledge (N=3013 nurses) was measured by a validated 20-item online test, quality of care related to ECG monitoring (N=4587 patients) by on-site observation, and patient outcomes (mortality, in-hospital myocardial infarction, and not surviving a cardiac arrest; N=95 884 hospital admissions) by review of administrative, laboratory, and medical record data. Nurses’ knowledge improved significantly immediately after the intervention in both groups but was not sustained 15 months later. For most measures of quality of care (accurate electrode placement, accurate rhythm interpretation, appropriate monitoring, and ST-segment monitoring when indicated), the intervention was associated with significant improvement, which was sustained 15 months later. Of the 3 patient outcomes, only in-hospital myocardial infarction declined significantly after the intervention and was sustained. Conclusions— Online ECG monitoring education and strategies to change practice can lead to improved nurses’ knowledge, quality of care, and patient outcomes. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01269736.