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

Abstract

Purpose-To examine the appropriate use of arrhythmia, ischemia, and QTc interval monitoring in the acute care setting.Methods-We analyzed baseline data of the PULSE Trial, a multi-site randomized clinical trial evaluating the effect of implementing ECG monitoring practice standards. Research nurses reviewed medical records for indications for monitoring and observed if arrhythmia, ischemia, and QT interval monitoring were being done on 1,816 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 Corresponding Author: Marjorie Funk, PhD, RN, Professor, Yale University School of Nursing, 100 Church Street South, PO Box 9740, New Haven, CT 06536-0740, Telephone: 203-737-2346, marjorie.funk@yale.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access MethodsThe PULSE Trial is a 5-year (2008-2013) multi-site randomized clinical trial to evaluate the implementation of the AHA Practice Standards for ECG Monitoring 6 on nurses' knowledge, quality of care including the appropriateness of monitoring, and patient outcomes. The intervention consists of an online ECG monitoring education program and strategies to implement and sustain change in practice, led by nurse champions on each unit. The study takes place in 17 hospitals: 15 in the United States, 1 in Ottawa, Canada, and 1 in Hong Kong, China (Table 1). All hospitals received institutional review board approval. Sites include both academic medical centers and community hospitals. Hospital units involved in the study are primarily for the treatment of cardiac surgical and medical patients. They include both intensive care units (ICUs) with "hard-wire" bedside cardiac monitoring and step-down units with "wireless" telemetry monitoring.For the baseline quality of care data, our sample consisted of 2,744 observations on 1,816 patients on these adult cardiac units. One of three research nurses, who were experienced ICU nurses with expertise in ECG monitoring, visited each site for 5 days. If time permitted, they observed patients more than once during their 5-day visit. They collected data on the use and appropriateness of monitoring by reviewing the current medical records to determine if the patient had a Class I or II indication for arrhythmia, ischemia, or QT interval monitoring. The AHA Practice Standards 6 used the following rating system for indicati...

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“…In most of the studies 2,5,7,9,11 in this review, researchers reported that patients who had telemetry ordered did not meet class I and class II indications. Furthermore, arrhythmic events were infrequent and clinically insignificant.…”

“…These results suggest that the practice standards do not address several noncardiac conditions that physicians often monitor on telemetry units 5,6,8 and thus may not apply to patients with primary medical diagnoses. 5 For example, in a randomized controlled trial by Funk et al, 9 28.2% of patients admitted to cardiac units from 17 hospitals had a noncardiac primary diagnosis; these patients may not be appropriate for monitoring for arrhythmia, ischemia, and increased QT interval. Of the 7 diagnoses common to both hospital admission via the emergency department and telemetry unit admission, pulmonary disease and respiratory distress (ie, chronic obstructive pulmonary disease or pneumonia) 11,13 are 2 conditions without indications for ECG monitoring per AHA practice standards.…”

“…Significantly more arrhythmia events in "telemetry indicated" vs "not indicated" group No clinically significant arrhythmias required change in patient management in "not indicated" group 3,9 Furthermore, a method to easily identify low-risk patients (class III) within the current AHA practice standards does not exist. 1 Other authors reviewed earlier publications for evidence of the need to monitor specific diagnoses.…”

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“…6 Among patients with an indication for ischemia monitoring, only 34.5% had the ST-segment monitoring feature activated on the monitor, but 26.3% of patients with no indication for ischemia monitoring also had this feature activated.…”

“…18 Baseline data on quality of care showed substandard practice related to ECG monitoring, including incorrect electrode placement, inaccurate rhythm interpretation, overmonitoring for arrhythmias, underuse of ischemia monitoring, and failure to monitor for QTc prolongation when indicated. 6,19 In the current phase of the PULSE trial, we are testing whether the online ECG monitoring education program and the strategies to implement and sustain changes in practice will enhance nurses' knowledge and the quality of ECG monitoring, ultimately leading to improved outcomes for patients.…”