American association of critical-care nurses

DYSRHYTHMIA MONITORING

Expected Practice:
Select the monitoring lead based on the patient’s dysrhythmia. o Lead V1 to distinguish VT from SVT with aberrant conduction; left or right BBB Lead II or III to monitor atrial activity Use Lead V1 for primary monitoring if no history of, or potential for, atrial dysrhythmias. Proper location of the leads for ECG monitoring is critical for optimal identification of problems. Properly prepare the patient’s skin before attaching the ECG electrodes. Monitor the QT interval for patients at high risk for Torsades de Pointe. o Patients begun on antidysrhythmic drugs known to cause Torsades de Pointe (quinidine, procainamide, disopyramide, sotalol, dofetilide, ibutilide) Overdoses of potentially prodysrhythmic drugs
Supporting Evidence:
ƒ Studies show that nurses will use a standard monitoring lead regardless of diagnosis.1-3 ƒ Studies show that the leads of choice for differentiating ventricular tachycardia from supraventricular tachycardia are leads V1 and V6. A five lead monitoring system is recommended. MCL1 in a 3 lead monitoring system has been shown to differ in QRS morphology as compared to V1 in 40% of patients with ventricular tachycardia.4-7 ƒ Research has shown that when an electrode is misplace by 1 intercostal space, the morphology of the QRS can change dramatically and missed or miss diagnosis may occur (i.e., ventricular tachycardia can be misinterpreted as supraventricular tachycardia.8 ƒ Failure to properly prep the skin before placing the electrodes may cause the monitoring alarms to sound erroneously. Preparation may include shaving areas where electrodes are to be placed and/or cleaning the skin with alcohol to remove skin oils.9-12 ƒ Studies show that a prolonged QT interval (QTc>0.50sec.) can be a contributing factor in the development of Torsades de Pointe. Some medications and electrolyte abnormalities can cause an increase in the QT interval.13-
What You Should Do:
ƒ Review organization policies and procedures related to cardiac monitoring to assure same standard of care ƒ Develop proficiency standards for all staff involved in the monitoring process to ensure patient safety and effective ƒ Provide appropriate ECG education for staff. Include didactic content and “hand-on” practice with return demonstration of lead placement. ƒ Conduct an audit for placement of Lead V1. ƒ Conduct an audit of the central monitor and ECG strip documentation to determine which lead is being assessed. ƒ If compliance for either is <90%, develop a plan to improve compliance: Consider forming a multidisciplinary task force (nurses, physicians, respiratory therapist, monitor technician) or a unit core group of staff to address ECG monitoring practice changes. Educate staff about the significance of correct placement of electrodes and skin preparation. Incorporate content into orientation programs, initial and annual competency verifications. Develop a variety of communication strategies to alert and remind staff of the importance of ECG monitoring. Need More Information or Help?
ƒ Talk with a clinical practice specialist for additional information / assistan) then select PRN.
REFERENCES:
AACN Quick Poll 2003. Available at: July 9, 2004. Thomason TR, Riegel B, Carlson B, Gocka I. Monitoring electrocardiographic changes: results of a national survey. J Cardiovasc Nurs. July 1995;9:1-9. Drew BJ, Ide B, Sparacino PS. Accuracy of bedside electrocardiographic monitoring: a report on current practices of critical care nurses. Heart Lung. 1991;20(6):597-607. Drew BJ, Ide B. Differential diagnosis of wide QRS complex tachycardia. prog Cardiovasc Nurs. Summer 1998;13(3):46-47. Drew BJ, Scheinman MM. ECG criteria to distinguish between aberrantly conducted supraventricular tachycardia and ventricular tachycardia: practical aspects for the immediate care setting. Pacific clin Electrophysiol. 1995;18(12 pt 1):2194-2208. Fabius DB. Diagnosing and treating ventricular tachycardia. J Cardiovasc nurs. April 1993;7:8-25. Drew BJ, Scheinman MM. Value of electrocardiographic leads MCL1, MCL6 and other selected leads in the diagnosis of wide complex QRS complex tachycardia. J Am Coll Cardiol. 1991;18(4):1025-1033. Drew BJ. Celebrating the 100th birthday of the electrocardiogram: lessons learned from research in cardiac monitoring. Am J Crit Care. 2002;11(4):378-388. Leeper B. Continuous ST-segment monitoring. AACN Clin Issues. 2003;14(2):145-154. Pelter MM, Adams MG, Drew B. Transient myocardial ischemia is an independent predictor of adverse in-hospital outcomes in patients with acute coronary syndromes treated in the telemetry unit. Heart Lung. 2003;32(2):71-78. Clochesy JM, Cifani L, Howe K. Electrode site preparation techniques: a follow-up study. Heart Lung. 1991;20:27-30. Medina V, Clochesy JM, Omery A. Comparison of electrode site preparation techniques. Heart Lung. 1989;18:456-460. Lo SL, Drew BJ. Lead selection for QT interval measurement for bedside ECG monitorning [abstract]. Circulation. 2002;106(suppl):489. Passman R, Kadish A. Polymorphic ventricular tachycardia, long Q-T syndrome, and torsades de pointes. Med Clin North Am. 2001;85:321-341. Crouch MA, Limon L, Cassano AT. Clinical relevance and management of drug-related QT interval prolongation. Pharmacotherapy. 2003;23:881-908. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation. In press.

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