The PULSE online education program features animations, such as this interactive screen that asks the nurse to drag and drop ECG electrodes onto their correct anatomic locations.
Research Associate Jeanine May Ramonas and Principal Investigator Marjorie Funk examine a patient's ECG tracings.
Jeanine May Ramonas collects ECG monitoring data in the Cardiac ICU at Yale-New Haven Hospital with the help of staff nurse Betsy Hine.
The PULSE Research Team: Back row (left to right): Chelsea Hoffman, Jeanine May Ramonas, Kris Fennie, Kim Stephens, Elisabeth Hurley. Front row: Marjorie Funk and Barbara Drew.
"Despite the advances in monitoring technology, the need for human oversight in the interpretation of ECG monitoring data remains crucially important."
- Marjorie Funk |
Imagine: You are preparing for work in the morning when you feel some discomfort in your chest. You call 911, an ambulance brings you to the emergency department, and you are admitted to the cardiac intensive care unit (ICU) for a possible heart attack. So far, initial tests for heart damage show nothing abnormal, but as you wait for more information, you think about your risk factors. You have mild diabetes, you take medication for elevated blood pressure and cholesterol, and your family physician has warned that you are a bit overweight and don't exercise as much as you should. Just when you're really starting to worry, you find out that you are in good hands.
It turns out your ICU nurse is up to date on the latest Practice Standards for Electrocardiographic (ECG or EKG) Monitoring. Knowing what the equipment can do, she sets up the optional software to detect cardiac ischemia, or lack of blood and oxygen supply to the heart muscle. In fact, the ECG monitor will detect signs of trouble even before you do, which is good news, since approximately 80% of patients do not experience chest pain or other symptoms during a cardiac episode. While you are napping, the monitor alarm sounds. Your nurse checks the monitor and sees evidence of ischemia in the ST segment of your electrocardiogram. She arranges to rush you to the cardiac catheterization lab for an emergency procedure to open your blocked coronary artery.
You have just averted a massive heart attack, thanks in part to a nurse who had the skills and knowledge to make full use of ECG monitoring software. You were fortunate that your ICU nurse had this expertise--it may have saved your life! Although ischemia monitoring technology has been available since the 1980s, many nurses do not use it because they find the software too difficult and the potential false alarms too bothersome. A new line of research is working to change that trend.
Yale University School of Nursing Professor Marjorie Funk PhD, '84 MSN, RN, FAHA, FAAN, was recently awarded a $3.9 million research grant--the largest ever awarded to a YSN researcher--to test the effect of implementing practice standards for ECG monitoring. This funding from the National Heart, Lung, and Blood Institute of the National Institutes of Health will enable Funk and her co-investigator, Professor Barbara Drew of the University of California–San Francisco School of Nursing, to evaluate whether educating nurses on the latest advances in ECG monitoring will improve the quality of care and outcomes for patients.
Over the next five years, the PULSE (Practical Use of the Latest Standards in Electrocardiography) trial will include 15 hospitals across the United States, one in Canada, and one in China, with advanced practice nurses at each hospital serving as site investigators. PULSE will provide an interactive online ECG monitoring education program for nurses developed by Professors Funk and Drew, along with Kimberly Scheibly and Jim Duber from California, based on the practice standards. Site investigators will appoint "champions" on each unit to answer questions and to support what the nurses have learned online. "For instance, champions will look at where the electrodes are placed on a patient's chest and reinforce the way it should be done," said Funk.
ECG technology has changed dramatically since it was first introduced on hospital units 45 years ago. Its uses have expanded from tracking heart rate and the basic heart rhythm, to the diagnosis of complex arrhythmias and the detection of cardiac ischemia. Today, the technology allows access to a wealth of diagnostic information obtained in a noninvasive and inexpensive way, and it is used routinely in hospitals to guide clinical decision making.
"Despite the advances in monitoring technology, the need for human oversight in the interpretation of ECG monitoring data remains crucially important," Funk said. "Modern ECG monitoring equipment is complex and has the capacity to do so much that often nurses do not take full advantage of all the features."
In hospitals, it is nurses who are responsible for ECG monitoring. They place the ECG electrodes in precise positions on the patient's chest, determine the goals of monitoring based on the patient's diagnosis and risk factors, and select the leads to be displayed on the monitor. They select alarm parameters, choose whether to employ the ischemia monitoring option, watch the monitor, and evaluate alarms. Nurses also administer anti-arrhythmic drugs and evaluate the effectiveness of treatment. "Errors and omissions can occur at any step in this process," Funk said. "Nurses need sufficient expertise to carry out all these responsibilities."
Currently, the investigators are collecting baseline data on nurses' knowledge, quality of care, and patient outcomes. In May 2009 the study will randomly assign hospitals to either an experimental or a control group. Nurses at hospitals in the experimental group will receive the online education, which the champions will reinforce. The investigators will then look for improvements in the experimental group. Nurses in the control group will get the intervention at a later point in the study.
Funk said that most nurses are very knowledgeable and skilled in ECG monitoring, but it's tough for even the most dedicated to keep up with the explosion of information and research, adding, "We expect that improved ECG monitoring will result in more accurate diagnosis and more timely treatment, which may lead to better outcomes for patients."
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