Dysrhythmia Monitoring

American Association of Critical Care Nurses- August 2004 Download the .pdf

Expected Practice:

  •  Select the monitoring lead based on the patient’s dysrhythmia.
    • 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.
    • Patients begun on antidysrhythmic drugs known to cause Torsades de Pointe (quinidine, procainamide, disopyramide, sotalol, dofetilide, ibutilide)
    • Overdoses of potentially prodysrhythmic drugs
    • New onset bradycardias
    • Severe hypokalemia or hypomagnesimia

Supporting Evidence

  •  Studies show that nurses will use a standard monitoring lead regardless of diagnosis.1-3
  • 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
  • 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
  • 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
  • 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.13-17

What You Should Do:

  •  Review organization policies and procedures related to cardiac monitoring to assure same standard of care across settings.
  • Develop proficiency standards for all staff involved in the monitoring process to ensure patient safety and effective monitoring.
  • Provide appropriate ECG education for staff.
    • Include didactic content and “hand-on” practice with return demonstration of lead placement.
  • Conduct an audit for placement of Lead V1.
  • Conduct an audit of the central monitor and ECG strip documentation to determine which lead is being assessed.
  • 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.
    • Ensure that practice changes continue.

Need More Information or Help?

Talk with a clinical practice specialist for additional information / assistance at www.aacn.org then select PRN.

References:

  1.  AACN Quick Poll 2003. Available at: http://www.aacn.org/aacn/surveys.nsf/c24308e92a041cdc8825681900762e80/eccf2eaca259ec76b88256cb4007ab5ef?opendocument. Accessed July 9, 2004.
  2. Thomason TR, Riegel B, Carlson B, Gocka I. Monitoring electrocardiographic changes: results of a national survey. J Cardiovasc Nurs. July 1995;9:1-9.
  3. 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.
  4. Drew BJ, Ide B. Differential diagnosis of wide QRS complex tachycardia. prog Cardiovasc Nurs. Summer 1998;13(3):46-47.
  5. 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.
  6. Fabius DB. Diagnosing and treating ventricular tachycardia. J Cardiovasc nurs. April 1993;7:8-25.
  7. 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.
  8. 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.
  9. Leeper B. Continuous ST-segment monitoring. AACN Clin Issues. 2003;14(2):145-154.
  10. 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.
  11. Clochesy JM, Cifani L, Howe K. Electrode site preparation techniques: a follow-up study. Heart Lung. 1991;20:27-30.
  12. Medina V, Clochesy JM, Omery A. Comparison of electrode site preparation techniques. Heart Lung. 1989;18:456-460.
  13. Lo SL, Drew BJ. Lead selection for QT interval measurement for bedside ECG monitorning [abstract]. Circulation. 2002;106(suppl):489.
  14. Passman R, Kadish A. Polymorphic ventricular tachycardia, long Q-T syndrome, and torsades de pointes. Med Clin North Am. 2001;85:321-341.
  15. Crouch MA, Limon L, Cassano AT. Clinical relevance and management of drug-related QT interval prolongation. Pharmacotherapy. 2003;23:881-908.
  16. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation. In press.