A Case of Heart Palpitations and Shortness of Breath.

Editor's note: This is the next installment in a series on electrocardiogram (ECG) interpretation. Nurses in all settings should know the basics, as medications and physiological changes can cause cardiac arrhythmias. Each article will start with a brief case scenario and an ECG strip and then take you step by step through analyzing the heart rhythm.

Interactive Learning for Nurses Through Gamification.

OBJECTIVE: The nursing professional development department purchased technology to create an innovative structure to engage nurses in educational offerings. The purpose of this study is to examine the effect of incorporating gamification on knowledge acquisition. BACKGROUND: Nursing administrators should support the use of gamification to improve the nurses' acquisition of knowledge. The clinical educators traditionally utilize lecture-based educational offerings preventing students from active participation. Gamification promotes learner engagement, critical thinking, and enjoyment. METHODS: A quasi-experimental study design with a 230-person convenience sample compared the knowledge acquisition of nurses before and after new hire orientation and basic electrocardiogram course. Technology purchased included iPad, GoPro, mobile apps, and websites. RESULTS: Incorporating gamification technology resulted in an increase in knowledge acquisition and engagement of learners. CONCLUSION: Findings demonstrate gamification as an effective way to increase knowledge acquisition when compared with traditional methods.

Effectiveness of the CRISP Method on the Primary Cardiac Arrhythmia Interpretation Accuracy of Nurses.

BACKGROUND: Accurate electrocardiogram (ECG) interpretation is key to quickly providing attention to patients, and the first health staff who evaluate ECGs are nurses. METHOD: This was a prospective study with a pre-posttest design. The study test included 15 ECGs related to primary cardiac arrhythmias. After pretest nurses were instructed on arrhythmia interpretation using the Cardiac Rhythm Identification for Simple People (CRISP) method, posttests were completed. RESULTS: There was a significant difference between the pretest scores of nurses who had postgraduate education on ECG interpretation and who did not (p = .002). Median test score increased from 3 (interquartile range [IQR] = 2-5) to 7 (IQR = 5-9) (p < .001). Participants mostly missed questions about heart blocks and were most successful with questions about fatal arrhythmias after education. CONCLUSION: The CRISP method is an effective, simple, and easy method for accurate ECG interpretation by nurses. The posttest scores of the participants, especially accurate interpretation of fatal arrhythmias, increased significantly after training. [J Contin Educ Nurs. 2020;51(12):574-580.].

Low voltage on the 12-lead ECG: A warning sign.

A 12-lead ECG showing low voltage should be a red flag to providers; it can be caused by several serious conditions. This clinical case describes how an NP correctly treated a patient with low voltage on an ECG by discerning and managing the underlying causes.

Individualized parameterization of multiparametric monitors alarms in infarcted patients.

OBJECTIVE: To measure the magnitude of the effect of an individualized parameterization protocol for hemodynamic alarms in patients with acute myocardial infarction. METHOD: Pragmatic clinical trial, open label and single arm, whose intervention was performed through a protocol validated and tested in 32 patients using multiparametric monitors. The heart rate, blood pressure, respiratory rate, oxygen saturation and ST segment-monitoring were measured and classified for clinical consistency one hour before and after the intervention, for 64 hours. RESULTS: The protocol obtained Content Validity Index of 0.92. Of the 460 registered alarms, 261 were considered inconsistent before the intervention and 47 after it. The Relative Risk of inconsistent alarms after the protocol was 0.32 (95% CI 0.23-0.43, p <0.0001). CONCLUSION: The protocol proved to be a protective factor to the appearance of inconsistent clinical alarms of multiparametric monitors.

Individualized parameterization of multiparametric monitors alarms in infarcted patients / Parametrización individualizada de alarmas de monitores multiparamétricos en pacientes infartados / Parametrização individualizada de alarmes de monitores multiparamétricos em pacientes infartados

ABSTRACT Objective: To measure the magnitude of the effect of an individualized parameterization protocol for hemodynamic alarms in patients with acute myocardial infarction. Method: Pragmatic clinical trial, open label and single arm, whose intervention was performed through a protocol validated and tested in 32 patients using multiparametric monitors. The heart rate, blood pressure, respiratory rate, oxygen saturation and ST segment-monitoring were measured and classified for clinical consistency one hour before and after the intervention, for 64 hours. Results: The protocol obtained Content Validity Index of 0.92. Of the 460 registered alarms, 261 were considered inconsistent before the intervention and 47 after it. The Relative Risk of inconsistent alarms after the protocol was 0.32 (95% CI 0.23-0.43, p <0.0001). Conclusion: The protocol proved to be a protective factor to the appearance of inconsistent clinical alarms of multiparametric monitors.

RESUMEN Objetivo: Medir la magnitud del efecto de un protocolo de parametrización individualizada de alarmas hemodinámicas en pacientes con infarto agudo de miocardio. Método: Ensayo clínico pragmático, open label y single arm cuya intervención ocurrió por medio de un protocolo validado y testado en 32 pacientes, utilizándose monitores multiparamétricos. Las alarmas de frecuencia cardíaca, presión arterial, frecuencia respiratoria, saturación de oxígeno y segmento ST fueron valorados y clasificados según su consistencia clínica, una hora antes y después de la intervención, durante 64 horas. Resultados: El protocolo obtuvo un índice de Validez de Contenido de 0,92. De las 460 alarmas registradas, 261 fueron consideradas inconsistentes antes de la intervención y 47 después. El Riesgo Relativo de las alarmas incoherentes después del protocolo fue de 0,32 (IC 95% 0.23-0.43, p <0,0001). Conclusión: El protocolo se mostró un factor protector al surgimiento de alarmas clínicas inconsistentes de monitores multiparamétricos.

RESUMO Objetivo: Medir a magnitude do efeito de um protocolo de parametrização individualizada de alarmes hemodinâmicos em pacientes com infarto agudo do miocárdio. Método: Ensaio clínico pragmático, open label e single arm, cuja intervenção ocorreu por meio de um protocolo validado e testado em 32 pacientes usando monitores multiparamétricos. Os alarmes de frequência cardíaca, pressão arterial, frequência respiratória, saturação de oxigênio e segmento ST foram mensurados e classificados quanto à consistência clínica uma hora antes e após a intervenção, durante 64 horas. Resultados: O protocolo obteve Índice de Validade de Conteúdo de 0,92. Dos 460 alarmes registrados, 261 foram considerados inconsistentes antes da intervenção e 47 após. O Risco Relativo de alarmes inconsistentes após o protocolo foi de 0,32 (IC 95% 0.23-0.43, p<0,0001). Conclusão: O protocolo mostrou-se um fator protetor ao surgimento de alarmes clínicos inconsistentes de monitores multiparamétricos.

Quando e como avaliar o risco cardiovascular global em indivíduos aparentemente normais ­ ou check-up para todos / When and how to assess global cardiovascular risk in apparently normal individuals ­ or check-up for everyone

A prevenção cardiovascular é tema fundamental, pois as doenças cardiovasculares que têm como substrato a aterosclerose, têm grande impacto na morbidade e mortalidade cardiovascular no Brasil e no mundo. Estima-se que 80% dos casos de doença arterial co-ronariana resultam da presença isolada ou em associação a fatores como as dislipidemias, tabagismo, hipertensão arterial, diabetes entre outros. Além disso, biomarcadores como história familiar de aterosclerose precoce, marcadores de inflamação de baixo grau como a proteína C reativa (PCR) e imagem da placa de ateroma (escore de cálcio coronário) ajudam a identificar e reclassificar o risco de doença cardiovascular. Estratégias como check-up cardiovascular ou os dos escores de risco são utilizadas na identificação do indivíduo assintomático com maior risco de desenvolver um evento agudo. O check-upcardiovascular, além de identificar os fatores de risco, inclui exames laboratoriais, testes funcionais e de imagem, o que pode implicar em custos excessivos dos exames que não agregarão valor discriminatório ou de reclassificação do risco cardiovascular. Apesar da escassez de dados, meta-análise recente não observou qualquer diferença na mortali-dade por todas as causas e cardiovascular, quanto à realização ou não dos exames de check-up de rotina. A partir da medicina baseada em evidência, diversos algoritmos foram criados para estratificação, de acordo com a presença dos fatores de risco e calibrados para a população estudada. Esses algoritmos são de simples realização e de baixo custo.A Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose ­ 2017 mantém a recomendação do uso do Escore Global de Risco na avalição inicial de indiví-duos assintomáticos. A revisão sistemática realizada pelo grupo Cochrane, observou que o uso dos escores de risco na prevenção primária tiveram modesto impacto na redução de eventos cardiovasculares, comparados com a não utilização. Além disso, o uso dos escores clínicos reduziu fatores de risco como colesterol elevado e hipertensão arterial, aumentou a prescrição de hipolipemiantes, anti-hipertensivos e AAS, sem evidência de danos e diminuiu a prevalência de tabagismo. Atualmente, ainda há controvérsias sobre quando e como deve ser feita a avaliação do risco cardiovascular. A literatura é clara em dizer que o uso de testes de forma indiscriminada na população não tem boa relação de custo-eficácia. Entretanto, a avaliação do risco cardiovascular pelos escores clínicos de risco pode identificar indivíduos de maior risco que serão beneficiados pela implementação de tratamentos preventivos.

Cardiovascular disease prevention is a key topic as cases with atherosclerosis as an underlying cause have a considerable impact on cardiovascular morbidity and mortality in Brazil and the rest of the world. It is estimated that 80% of coronary artery disease cases result from the individual presence or combination of factors such as dyslipidemias, smo-king, hypertension, diabetes, and others. In addition, biomarkers such as family history of early atherosclerosis, low-grade inflammatory markers such as C-reactive protein (CRP), and atheromatous plaque imaging (coronary calcium score) help identify and reclassify the risk of cardiovascular disease. Strategies such as cardiovascular check-ups or the use of risk scores are used to identify the asymptomatic patient with a higher risk of developing an acute event. Besides identifying risk factors, the cardiovascular check-up also includes laboratory, functional and imaging tests, which may involve excessive costs that will not add discriminatory value or allow the cardiovascular risk to be reclassified. Despite the lack of data, a recent meta-analysis found no difference in all-cause and cardiovascular mortality, whether or not routine check-ups were performed. According to evidence-based medicine, several algorithms have been created for stratification, depending on the presence of risk factors and calibrated for a particular study population. These algorithms are both simple and inexpensive. The Update of the Brazilian Guideline on Dyslipidemia and Atherosclerosis Prevention - 2017 recommends using the Global Risk Score in the initial assessment of asymptomatic individuals. A systematic review conducted by the Cochrane group found that the use of risk scores in primary prevention had a modest impact on the reduction of cardiovascular events compared to non-use. Furthermore, the use of clinical scores reduced risk factors such as high cholesterol and high blood pressure, increased lipid-lowering/antihypertensive drug and aspirin prescriptions, with no evidence of harmful side effects, and reduced the prevalence of smoking. There is still controversy as to when and how to assess cardiovascular risk. The literature is clear in stating that the use of indiscriminate testing in the population is not cost effective. However, the evaluation of cardiovascular risk using clinical risk scores can identify higher risk individuals who will benefit from the implementation of preventive treatments.

Continuous ECG Monitoring in Patients With Acute Coronary Syndrome or Heart Failure: EASI Versus Gold Standard.

The purpose of the study was to compare the EASI system with the standard 12-lead surface electrocardiogram (ECG) for the accuracy in detecting the main electrocardiographic parameters (J point, PR, QT, and QRS) commonly monitored in patients with acute coronary syndromes or heart failure. In this observational comparative study, 253 patients who were consecutively admitted to the coronary care unit with acute coronary syndrome or heart failure were evaluated. In all patients, two complete 12-lead ECGs were acquired simultaneously. A total of 6,072 electrocardiographic leads were compared (3,036 standard and 3,036 EASI). No significant differences were found between the investigate parameters of the two measurement methods, either in patients with acute coronary syndrome or in those with heart failure. This study confirmed the accuracy of the EASI system in monitoring the main ECG parameters in patients admitted to the coronary care unit with acute coronary syndrome or heart failure.

[New generation implantable loop recorders can be safely managed by certified nurses]. / I loop recorder impiantabili di nuova generazione possono essere gestiti in maniera sicura ed efficace da personale infermieristico formato.

. New generation implantable loop recorders can be safely managed by certified nurses. INTRODUCTION: Implantable loop recorders (ILR) are recommended for several cardiac disorders: the recent miniaturization processes eased their implant and management. AIM: To describe the advantages of the ILR implant, patients' education and remote control performed by expert certified nurses. METHODS: Retrospective analysis of consecutive ILR implants of our centre, preformed between May and December 2016: the complications occurred in patients implanted by doctors and nurses were described. Nurses were certified after a two days course and 3 implants assisted by a medical doctor. RESULTS: 157 patients were implanted with a ICM Reveal LINQ (Medtronic): 74 (47%) by physicians electrophysiologists and 83 (53%) out of the electrophysiology room, by certified nurses. The two groups of patients were not fully comparable because more complex patients were implanted by the physician. All the loop recorders were easily implanted adverse without events during the procedure and after 30 days. Two minor bleedings occurred 24 hours after the implant: 1 in a patient implanted by a physician and the other by a nurse. Both were rapidly solved by finger pressure. CONCLUSIONS: The ILR implants can be safely performed by trained nurses, out of the elettrophysiology room, with benefits for the patients and the hospital.

Emergency Nurse Competence in Electrocardiographic Interpretation in Spain: A Cross-Sectional Study.

INTRODUCTION: Electrocardiographic interpretation skills are key to provide a fast attention to patients with thoracic pain. The aim of the study was to determine the current level of competence in electrocardiographic interpretation of nurses in emergency departments. METHODS: Cross-sectional, multicenter study via an ad hoc questionnaire. Subjects were nurses from three Spanish emergency departments with at least a year experience in this area. A two-part questionnaire was created consisting of a professional profile, and 12 questions (2 theoretical questions and 10 questions on practical cases with electrocardiographic register [readout]). A pilot test was carried out to evaluate the validity of the questionnaire, the content validity index. The reliability of the questionnaire was also tested on a subsample through intraclass correlation coefficient with a value of 0.869 (CI 95% 0.712-0.941). Descriptive and bivariate analyses were conducted using an independent t-test or one-way ANOVA as appropriate. A statistical significance of P < .05 was assumed. RESULTS: Fifty-seven usable questionnaires were obtained (47.2% response rate). Women comprised 84.2% of the sample and the mean age of the sample was 40.5 (SD = 9.3) years. Slightly more than 91% had taken electrocardiographic interpretation training courses, the main modality for which was face-to-face (84.2%). The average score on our questionnaire was 8.6 (SD=1.1) points. No significant differences between nursing experience and hospitals were observed. Nurses who had received training within the previous five years scored significantly higher than those who had not (P = .031). DISCUSSION: The electrocardiographic knowledge of emergency nurses is high. Level of knowledge was not influenced by experience or hospital but was influenced by training when provided in the previous 5 years. Therefore, refreshing courses should be taken at least every 5 years. Contribution to Emergency Nursing Practice.

Screening for atrial fibrillation during influenza vaccinations by primary care nurses using a smartphone electrocardiograph (iECG): A feasibility study.

BACKGROUND: People with unknown atrial fibrillation (AF), who are often asymptomatic, have a substantially increased risk of stroke. Although recommended in European guidelines, AF screening is not routinely performed. Screening at the time of influenza vaccination presents an ideal opportunity to detect AF in large numbers in a primary care medical setting, with an existing annual recall system for patients aged ≥65 years. DESIGN: Cross-sectional pilot study of handheld smartphone electrocardiogram (iECG) screening to identify unknown AF. METHODS: General practices in Sydney, Australia, were recruited during the influenza-vaccination period of April-June 2015. Practice nurses screened patients aged ≥65 years with a 30-second iECG, which has a validated algorithm for detecting AF in real time. In order to confirm the accuracy of the algorithm, two research cardiologists reviewed de-identified iECGs. In order to explore barriers and enablers, semi-structured interviews were conducted with selected nurses, practice managers and general practitioners. RESULTS: Five general practices were recruited, and 973/2476 (39%) patients attending influenza vaccination were screened. Screening took an average of 5 minutes (range 1.5-10 minutes); however, abnormal iECGs required additional time. Newly identified AF was found in 8/973 patients (0.8%). The sensitivity of the iECG automated algorithm was 95% (95% confidence interval: 83-99%) and the specificity was 99% (95% confidence interval: 98-100%). Screening by practice nurses was well accepted by practice staff. Key enablers were the confidence and competence of nurses and a 'designated champion' to lead screening at the practice. Barriers were practice specific, and mainly related to staff time and funding. CONCLUSIONS: Screening with iECG during influenza vaccination by primary care nurses is feasible and well accepted by practice staff. Addressing barriers is likely to increase uptake.

ECG-based PICC tip verification system: an evaluation 5 years on.

In 2011, the vascular access team at East Kent Hospitals University NHS Foundation Trust safely and successfully incorporated the use of electrocardiogram (ECG) guidance technology for verification of peripherally inserted central catheters (PICC) tip placement into their practice. This study, 5 years on, compared the strengths and limitations of using this ECG method with the previous gold-standard of post-procedural chest X-ray. The study was undertaken using an embedded case study approach, and the cost, accuracy and efficiency of both systems were evaluated and compared. Using ECG to confirm PICC tip position was found to be cheaper, quicker and more accurate than post-procedural chest X-ray.

Evitar errores comunes en la realización de un electrocardiograma / Avoid common mistakes in realization of a electrocardiogram

Introducción. El electrocardiograma (ECG) es una técnica no invasiva sencilla de realizar, económica, reproducible y que aporta información valiosa que puede utilizarse para la realización del diagnóstico del paciente y para dirigir las decisiones clínicas. Es una prueba de diagnóstico utilizada con frecuencia, que puede realizarse con rapidez -puesto que se realiza generalmente con un equipo portátil- y que se efectúa normalmente en cualquier ámbito, ya sea de Atención Primaria, atención especializada o extrahospitalaria. El diagnóstico realizado mediante el ECG se considera válido en la práctica asistencial, pero solo resulta efectivo si los electrodos se colocan en las localizaciones anatómicas correctas, si se unen adecuadamente los latiguillos a sus electrodos, si el registro mantiene una buena calidad (se utilizan los filtros apropiados, se evitan interferencias y ruido eléctrico) y se comparan los ECG realizados mediante el mismo sistema de registro (ECG de 5 o 10 latiguillos) para la determinación de cambios evolutivos (como para determinar cambios en el segmento ST durante la isquemia miocárdica o para valorar los cambios producidos por las terapias de reperfusión). Objetivo. Identificar los errores más usuales en electrocardiografía, que se relacionan con las colocaciones inadecuadas de derivaciones, cruce o intercambio de latiguillos de derivaciones de miembros, registros de poca calidad y comparaciones de ECG seriadas realizados con sistemas de adquisición diferentes (10 frente a 5 latiguillos). Conclusiones. Se realizan las recomendaciones para prevenir y evitar estos errores, que pueden conducir a diagnósticos y tratamientos con resultados adversos para el paciente (AU)

Introduction. The electrocardiogram (ECG) is a noninvasive technique to perform simple, economical, reproducible and provides valuable information that can be used to make the diagnosis of the patient and to guide clinical decisions. It is a diagnostic test used frequently as it can be done quickly, since it is done with a laptop and generally is always possible implementation in any field either primary care, specialty outpatient care. The diagnosis made by the ECG is considered valid in clinical practice, but is only effective if the electrodes are placed in the correct anatomical locations, if the hoses are properly attached to the electrodes, the registry maintains a good quality (the filters are used appropriate, interference and electrical noise are avoided) and ECG compares made by the same registration system (ECG 5 or 10 lead) for determining evolutionary changes (to determine changes in the ST segment during myocardial ischemia or assess the changes caused by reperfusion therapies). Objective. To review the most common errors in electrocardiography, which are related to inappropriate placements of shunts, cross or exchange of patch cords limb leads, records of poor quality and comparisons of ECG serials made with different acquisition systems (10 vs 5 lead). Conclusions. We make the recommendations to prevent and avoid these scams that can lead to diagnosis and treatment with adverse outcomes for the patient (AU)

El Holter toma protagonismo ante la indicación definitiva de estimulación cardíaca / Holter takes cente stage into final indication of cardiac stimulation

El estudio se realiza con miras a obtener datos concretos que confirmen la influencia en el diagnóstico de muchas patologías cardiacas detectadas por el Holter de frecuencia cardiaca. El Holter de frecuencia cardiaca de 24 horas es un dispositivo electrónico, de pequeño tamaño, que registra y almacena un trazado electrocardiográfico de dos o tres derivaciones, mientras el paciente realiza sus actividades de la vida cotidiana. La causa de esta investigación es el aumento de solicitudes en nuestro hospital y los numerosos informes que han ayudado en el diagnóstico de nuestros pacientes. El estudio se fundamenta en datos estadísticos. Se han fabricado dos bases de datos, una que recoge el total de estudios que se realizaron en 2013 y otra con los pacientes diagnosticados con necesidad de estimulación cardiaca y que se remiten a ello. Al cruzar estas dos bases de datos se obtiene una tercera con los pacientes enviados a estimulación cardiaca con Holter de frecuencia cardiaca realizado. Podemos con estos datos afirmar que, cuando se solicita esta prueba, tiene una gran influencia en el diagnóstico final (el 87 %) y existe una probabilidad alta de encontrar hallazgos significativos, sin olvidarnos de la clínica y con los aspectos personales de cada paciente (AU)

The study was performed in order to obtain specific data confirming the influence in the diagnosis of many cardiac pathologies detected by Holter heart rate. Holter heart rate of 24 hours is an electronic device, of small size, which records and stores an electrocardiographic tracing two or three leads, while the patient activities of daily life. It leads us to conduct this study increased requests we’ve had in our hospital and the numerous reports that have helped in the diagnosis of our patients. We base the study with statistical data, therefore, produce two databases, one that reflects the total of studies conducted in 2013 and another with patients diagnosed with cardiac stimulation and need to refer to it. Crossing these two databases get third with patients referred for cardiac stimulation Holter heart rate realized. With these data we can say that, when this test is requested, it has a great influence on the final diagnosis (87%) and there is a high probability of finding significant findings, without forgetting the clinical and personal aspects of each patient (AU)

Improving Accuracy of Cardiac Electrode Placement: Outcomes of Clinical Nurse Specialist Practice.

PURPOSE: The purpose of this quality improvement project was to facilitate a sustainable improvement in the accuracy of cardiac electrode placement for continuous bedside monitoring in intensive care unit patients. BACKGROUND: Continuous cardiac electrocardiograph monitoring is a standard of practice in critical care areas and is essential to accurate interpretation of cardiac dysrhythmias and early detection of myocardial ischemia. Accurate assessment of electrocardiographs depends on precise placement of electrodes; however, electrodes are often placed inaccurately. RATIONALE: Evaluation of baseline practice revealed that cardiac electrodes were placed correctly in only 12.5% of patients. The most frequently misplaced electrode was the V lead, followed by lower limb leads. DESCRIPTION: This project was conducted between July 1, 2013, and October 31, 2013, and involved a multifaceted education program for registered nurse and patient care technician staff on the physiologic basis and technical procedures for cardiac electrode placement. The clinical nurse specialist served as an informal leader, role model, and mentor by developing and empowering unit champions to perform real-time auditing and provide real-time feedback to colleagues. OUTCOME: At 3 months after intervention, the accuracy of cardiac electrode placement was sustained at greater than 85%, representing a 6-fold improvement above the preintervention baseline. CONCLUSION: Sustainable improvement in quality requires creation of a culture that supports quality improvement initiatives. As experts in clinical practice, evidence-based practice, and leadership, clinical nurse specialists are optimally positioned to function as change agents whose initiatives measurably improve outcomes. IMPLICATIONS: This quality improvement project serves as a model for improving accuracy of cardiac electrode placement at the nursing staff level. Future research is necessary to improve outcomes related to accuracy of cardiac electrode placement on the patient and systems levels.

'What Do I Do Next?' Nurses' Confusion and Uncertainty with ECG Monitoring.

The prevalence of telemetry monitoring is increasing on medical- surgical units, but no evidence-based guidelines standardize nursing education. Research indicates nurses feel uncertain and report a lack of knowledge when caring for patients with telemetry monitoring.