The importance of maintaining high expectations and standards related to electrocardiographic interpretation skills among nurses in the acute care setting
Year: 2025
Type: article
Abstract: This invited commentary refers to ‘Nurse educators’ expectations, training, and assessments of electrocardiogram interpretation among Australian acute care nurses: a national survey’, by Y. Chen et al., https://doi.org/10.1093/eurjcn/zvaf088. In the article published by Chen et al.1 entitled ‘Nurse educators ‘expectations, training, and assessments of electrocardiogram interpretation among Australian acute care nurses: a national survey’, the investigators address a very important aspect of clinical care in the acute care setting—electrocardiographic (ECG) interpretation. Continuous ECG monitoring was initially introduced into coronary care units (CCUs) in the 1960s to monitor patients diagnosed with (or suspected) acute coronary syndrome (ACS). Nurses working in the CCU were highly trained in both ECG monitoring procedures and interpretation skills, the latter mainly focused on identification and interpretation of lethal arrhythmias associated with ACS. In speaking with CCU nurses who worked during this era, one can appreciate the expertise these nurses possessed, and the many patient lives saved due to their accurate interpretation skills and quick action to reverse a lethal arrhythmia (i.e. initiate a code blue, advanced cardiac life support, call a physician, etc.) Their expertise was deeply rooted in education, both in the classroom and, more importantly, over the course of working in clinical care. Seasoned CCU nurses mentored newer nurses on ECG monitoring practices and interpretation; thus, education was built into the unit culture. In clinical practice today, introductory and often ongoing education regarding ECG interpretation is typically provided by nurse educators, which makes the study by Chen et al., very relevant for informing acute care clinical practice. Electrocardiographic monitoring was eventually added to other ICU types and as ECG technologies improved, wireless ‘telemetry’ ECG monitoring was expanded into step-down units and eventually many other unit types (i.e. emergency department, medical–surgical, operating room, radiology, diagnostic/procedural areas, etc.). While many nurses working in these hospital settings welcomed ECG monitoring because it was non-invasive, included alarms/alerts and visualization (heart rate, rhythm) of a patient’s cardiac status, other nurses were not as enthusiastic. In our interactions with medical–surgical nurses who had ECG monitoring introduced into their hospital units, many stated ‘I don’t want to be a critical care nurse!’ This is reflected in the findings by Chen et al.,1 based on the nurse educators’ perception that medical/surgical nurses ‘often show less interest’ and ownership in ECG interpretation. It was reassuring that 96% of the nurse educators who participated in the Chen et al. study had ‘high expectations of nurses’ competency in ECG interpretation.’ At the same time, nurse educators perceived that only 50% of clinical nurses were ‘comfortable’ caring for cardiac-monitored patients, and less than one-third considered ECG interpretation their responsibility; rather, this belonged to physicians/providers. This likely reflects the challenges, which are real, when a nurse is faced with interpreting an ECG generated from a monitor, which often requires speed and a high degree of accuracy. Discomfort with interpretation may also reflect the overwhelming number and varied ECG abnormalities that require interpretation. Modern-day ECG devices generate more than 25 individual arrhythmia alarm types, ST-segment alarms for myocardial ischaemia detection, and QT-interval alarms to assess risk for torsades de point, just to name a few. Add a multitude of other physiologic parameters included in ECG monitoring systems [Sp02, vital signs (invasive and non-invasive), etc.], and one can appreciate the complexity of ‘monitoring’ a patient. This can be, and often is, overwhelming for busy nurses who are tasked with a multitude of other assessments and documentation—it is alarm/alert fatigue on full display. Unfortunately, patient-centred care can be lost, and alarm fatigue can increase patient safety concerns. Adding to interpretation challenges are false alarms, which predominate over true alarms. In a seminal study published in 2014, Drew et al.2 examined 461 consecutive ICU patients and found that there were an astonishing 2 558 760 unique alarms in the 31-day study period, 45% were arrhythmia alarms (24%) parameter (i.e. too high, too low); and 31% technical (i.e. ECG leads off, artefact, line/probe disconnect). The audible alarm burden was 187/bed/day and of 12 671 annotated ECG arrhythmia alarms, 90% were false positive. This means that most ECG arrhythmia alarms are false, which interrupts clinical care and increases nurses’ frustration with ECG interpretation. Building on this work our group has found that the vast majority of false arrhythmia alarms is rooted in sub-optimally designed algorithms, thus, nursing interventions (i.e. changing skin electrodes, customizing alarm settings, and education) will have little impact on this problem.3 Key to solving this problem is collaborations between nurses, who work with ECG monitors and engineers (both scientists and industry) who develop algorithm-based solutions. While there are examples of this related to improving the accuracy of ventricular tachycardia detection,4 a recent bibliometric analysis showed that among 50 engineering studies that tested new ECG/physiologic monitoring algorithms, only 1% included a nurse co-author.5 While this highlights a significant gap in alarm fatigue research, it identifies a huge opportunity to make meaningful progress in this area of research and clinical practice. Imagine the day when a nurse hears an arrhythmia alarm and it is true—this will make ECG interpretation meaningful and maybe even fun for nurses. One solution to this significant issue is for there to be in-depth discussions among nurses at all levels of care (bedside and leadership) and physician/providers regarding what ECG parameters are truly clinically significant and require action. Our group has been at the forefront of examining false vs. true ECG and physiologic alarms and based on our research, we have coined a phrase ‘Just because we can turn an alarm on, doesn’t mean we should.’ For example, do we really need to have audible alarms and/or inaudible flashing alerts for premature ventricular complexes (PVCs)? In a study of 445 ICU patients with >800 000 PVC alarms, we found that none of the six PVC types we examined, i.e. isolated PVC, bigeminy, trigeminy, couplet, R-on-T, and run PVC were associated with ventricular tachycardia or in-hospital death.6 We concluded that turning ‘on’ PVC alarms does not appear to be clinically meaningful, which is in line with the American Heart Association’s (AHA) Practice Standards for ECG Monitoring in Hospital Settings.7 Having the phrase above ‘Just because we can’ at the forefront of these discussions should be a central theme to guide ECG device alarm settings. Educational efforts could then be focused on how to interpret clinically meaningful ECG findings. One has to question if ECG monitoring should return to its original intention in the 1960s, i.e. heart rate and lethal arrhythmia detection, especially in non-critical care settings. For instance, if medical–surgical nurses need only learn how to interpret asystole, ventricular fibrillation, ventricular tachycardia, and atrial fibrillation, would their comfort level with ECG interpretation be improved? This idea was reported in Chen et al.,1 by the nurse educators who stated that there is a need to ‘tease out the difference in ECG knowledge and skills between general [ward] nurses and those working on acute care areas.’ Highly trained ECG monitor watchers, ideally nurses, are another possible solution, which some hospitals employ. This design creates a buffer for busy clinical nurses who are still ultimately responsible for the final ECG interpretation and determining what action(s) need to be taken, but creates a collaborative dimension that is key to ECG interpretation—it’s a team sport. We agree wholeheartedly with Chen et al.,1 in their suggestion regarding the utilization of advanced practice nurses as another solution for enhancing ECG interpretation skills of bedside/clinical nurses. This would require, however, that advanced practice nurses have ECG interpretation skills included in their curriculum in graduate school and maintain these skills in their clinical practice. All of these possible solutions require a culture of excellence and commitment from leadership, which were identified as barriers among the nurse educators that participated in the Chen et al. study. The authors are to be commended for their research on this topic and for their thoughtful implications for practice. Michele M. Pelter (Conceptualization [lead], Writing—original draft [lead]), and Mary G. Carey (Writing—review & editing [supporting]) No funding associated with this commentary.
Authors: Michele M Pelter, Mary G Carey
Language: English
Subfield: Family Practice
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4412741231