ECG ST-segment Monitoring

By Clement Tsui, Telemetry

Background

ECG ST-segment monitoring is one of the important steps in the elevation of a patient who presents with chest pain and possible acute coronary syndrome. This is particularly important in monitoring patient after percutaneous coronary intervention because post-stenting coronary artery related complication can also lead to ST-segment changes. However, telemetry nurses have noticed some cases of artifactual ST-segment distortion on ECG, when ST/AR Arrhythmia Algorithm with the low frequency filter set at 0.5Hz under the current monitoring system in the hospital. This abnormal finding is not affected by the change of electrode position, but it resolves when we change the algorithm to ST/AR ST Analysis Algorithm with the low frequency filter set at 0.05Hz.

Purpose and Problem Statement

The purpose of the project is to improve telemetry nurses’ knowledge and skills in conducting computerized continuous ECG ST-segment monitoring of the patient. Hence, the causes of errors are the lack of understanding in use of appropriate algorithm and filter setting for conducting ECG ST-segment monitoring resulting to confusion and unnecessary interventions.

Implementation Plan

This project used a pre-and-then-post approach to assess the knowledge and operational skills of telemetry nurses. We introduced the project to all stakeholders by providing relevant and detailed information as well as helping them build more realistic expectations. Through the process to meet these expectations, it can be easier to get more involvements from stakeholders and obtain their support to the project. We developed the pre- and post-training surveys for knowledge assessment and designed the pre- and post-training performance evaluation surveys for operational skills assessment. The pre- and post-training surveys and the pre-and post-training performance evaluation surveys were conducted before and after conducting the nursing training program for analysis. Training material were provided from the vendor technical support team in an electronic version. We started the project and ran the training program with a combination of group classes, computerized training, and in person one-to-one tutoring shortly after the pre-training period.

Results

According to the pre- and post-training survey results (pre-training average score 56.7% vs post-training average score 91.7%), there was a significant increase in the Telemetry nurses’ knowledge in screening and identifying the appropriate patients for computerized continuous ST-segment monitoring. In addition, telemetry nurses also had great knowledge improvement in using the ST/AR ST analysis algorithm to conduct the computerized continuous ST-segment monitoring as there was an 18.4% increase in the post-training survey assessment score (pre-training average score 68.3% vs post-training average score 86.7%).

The pre-and post-training performance evaluation results demonstrated that telemetry nurses have an increase of 15% in performance evaluation results in selection and use of correct monitoring mode for conducting the computerized continuous ST-segment monitoring (pre-training average score 85% vs post-training average score 100%). Furthermore, they have remarkable performance in conducting a full assessment for screening of patients before initiation of the computerized continuous ST-segment monitoring as there was an increase of 20% in performance evaluation results (pre-training average score 80% vs post-training average score 100%).

Recommendations and Next Steps

The advancement of medical technology in twentieth century has changed the healthcare milieu, and nursing is no exception. In order to provide high quality monitoring service to the patient, telemetry nurses must take steps to embed modern technology firmly in nursing education so as to reduce clinical errors that can impact the quality of care.

As an EBP fellow, the writer would like to take the following steps in enhancing the project’s sustainability:

• Invite the top-level management team to make commitment in promoting project’s sustainability as one of the major operational strategies in the hospital.
• Nurture a culture of sustainability in project designs through creating opportunity for telemetry nurses to engage in project development and management.
• Integrate the element of project’s sustainability into training and learning practices for telemetry nurses.
• Collaborate with all relevant stakeholders across the hospital to ensure the effective implementation of the sustainable project.
• Conduct periodic reviews and evaluations of the project.