Practice Alert: Dysrhythmia Monitoring|
- 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 yorsades de pointe (quinidine, procainamide, disopyramide, sotalol, dofetilide, ibutilide)
• Overdoses of potentially prodysrhythmic drugs
• New onset bradycardias
• Severe hypokalemia or hypomagnesimia
• 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 5-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 misplaced by 1 intercostal space the morphology of the QRS can change dramatically and missed or misdiagnosis may occur (ie, 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 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.13-16
What You Should Do:
• Review organizational policies and procedures related to cardiac monitoring to ensure 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 “hands-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?
• For additional information or assistance, call the AACN Practice Resource Network at (800) 394-5995, ext. 217. Practice Alerts are online.
1. AACN Quick Poll 2003.
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. Pacing 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 monitoring [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.
Is Your Unit a Beacon of Excellence?
Apply Online Anytime for Special Award
With the first AACN Beacon Award for Critical Care Excellence presented during AACN’s National Teaching Institute and Critical Care Exposition in May, applications continue to be accepted and reviewed.
This program shines national recognition on units that attain high standards for quality, exceptional care of patients, and healthy, humane and healing work environments.
The Web-based application process asks you to evaluate your critical care unit in six criteria areas:
• Recruitment and retention
• Education, training and mentoring
• Evidence-based practices
• Patient outcomes
• Healing environments
• Leadership and organizational ethics
Applications, which may be submitted at any time, are evaluated on a quarterly basis. Awards are granted twice a year. The application fee is $1,000 per unit. There is no limit on the number of units that may apply from a single facility.
For more information, visit the AACN Website.
Critical Care Nurses Are Crucial to Organ Donation After Cardiac Death Process
Editor’s note: In April 2003, Health and Human Services Secretary Tommy G. Thompson joined with leaders and practitioners from the nation’s transplantation and hospital communities to launch the Organ Donation Breakthrough Collaborative. Intended to dramatically increase access to transplantable organs, the purpose of this initiative is clear, measurable, ambitious and achievable: to commit to saving or enhancing thousands of lives a year by spreading known best practices to the nation’s largest hospitals to achieve organ donation rates of 75% or higher in these hospitals. AACN is one of the organizations on the Leadership Coordinating Council that is providing input into and support for the success of this collaborative endeavor. Following is an account of a successful collaboration by the TEAM (together everyone achieves more) at Theda Clark Regional Medical Center, Neenah, Wis.
By Kathleen Fuller, RN, MSN
Manager of Critical Care and Respiratory Care
Theda Clark Medical Center
For many years, the critical care nurse has been a key player in the organ donation process for patients being declared brain dead. Our organization has chosen to utilize all ICU RNs as certified requesters, instead of having an organ procurement organization representative make the request in person or via the phone. Although our hospital does not perform transplants, the staff in our critical care unit (15 beds and an average daily census of eight) have been recognized nationally for their involvement with organ donation. In fact, the critical care nursing staff has successfully met additional challenges with a recent increase in donation-after-cardiac-death patients by meeting the needs of our patients and their families.
Our 240-bed hospital is accredited by the American College of Surgeons as a level II trauma center. We have been supported by an active staff of neurosurgeons and neurologists, as well as an administration committed to the organ donation process.
Having a close working relationship with the OPO team, the nursing staff and physicians consult as often as needed during the donation process. We have an average of eight to 10 patients per year whose organs have been donated after brain death, and the physicians and staff do an outstanding job supporting families and patients through this process. We also average one DCD patient per year, with the process involving the same staff as for donation after brain death.
Process Stepped Up
During 2003, we stepped up the process of using “clinical triggers” to notify the OPO of patients potentially facing brain or cardiac death. This led to calls on patients with a GCS of 5 or less, and we found ourselves involved with donations after cardiac death more frequently. In fact, in 2003, we handled a total of nine patients, with the majority in the final quarter. Already in the first quarter of 2004, we have dealt with five DCD patients.
Because the process involved discontinuation of the ventilator in the operating room, with death subsequently pronounced and organs harvested, resistance among anesthesiologists and some OR staff quickly developed. We were charged with developing a new process for the DCD patient that met patient, family and staff needs.
After consultation with the Department of Anesthesia, physicians and staff involved, the manager of critical care drafted a new protocol that involved the critical care nurse and respiratory therapist at a much higher level in the OR. They now transport and stay with the patient until death has been declared. The OR nurse and technician assist the OPO team with the organ harvest, before returning the deceased patient to the unit if the family wishes to have additional time. Previously, the critical care staff had turned over care of these patients when they were taken from the unit to the OR.
Education and case debriefing have helped the critical care team work through issues, such as analgesia and anxiolytic administration for their patients. Other hospitals’ protocols have also been reviewed for interventions that could possibly help. We have now accommodated six DCD cases using the new staffing method and feel that most issues have been appropriately addressed.
Involvement with the family and attending physician as end-of-life decisions are made helps the critical care nurses support the decision to withdraw life support. They understand that the patient will probably not survive without the ventilator and recognize that educating the family about potential organ donation may lead to the availability of organs for a recipient on a waiting list.
RNs Most Effective
Studies show that families rely heavily on the critical care nurse for support and information during organ donation.1 Donation rates are also higher when families have ample time to discuss donation questions with the healthcare team.2 This is handled effectively by the RN caring for the potential donor and received well by the family because of the relationship established.
As more families learn about the organ donation opportunities possible after cardiac death, hospitals will need to look at effective ways of meeting these requests. The critical care nurse, with the close relationship to the patient and family, is often the key to successful donations.
Additional information about organ and tissue donation is available online at
1. Pelletier Maryse L. The needs of family members of organ and tissue donors. Heart Lung. 1993;22:151-157.
1. Simonoff L, et al. Factors influencing families’ consent for donation of solid organs for transplantation. JAMA. 2001;286:71-77.
Submit Research, Creative Solutions Abstracts for the NTI
AACN is inviting research and creative solutions poster abstracts for consideration for AACN’s 2005 National Teaching Institute and Critical Care Exposition May 7 through 12 in New Orleans, La.
In addition to the posters, 16 research abstracts and 16 creative solution abstracts will be selected for oral presentation. Four of the research applicants will be selected as award recipients. The awards for research poster abstracts reflect outstanding original research, replication research or research utilization. Award recipients are presented a plaque and $1,000 to use toward NTI expenses.
Sept. 1 is the deadline to submit the abstracts.
The application, guidelines and resources are now available online.
Evidence-Based Clinical Practice Grant
This grant funds awards up to $1,000 to stimulate the use of patient-focused data and/or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice. Grant proposals are accepted twice a year and must be received by either March 1 or Oct. 1.
AACN Clinical Practice Grant
This $6,000 grant supports research focused on one or more AACN research priorities. Research conducted in fulfillment of an academic degree is acceptable. Oct. 1 is the annual application deadline for this grant.
AACN-Sigma Theta Tau Critical Care Grant
AACN and Sigma Theta Tau International cosponsor this $10,000 grant, which may be used to fund research for an academic degree. Principal investigators must be members of AACN or of Sigma Theta Tau International. The principal investigator must have at least a master’s degree. Oct. 1 is the annual application deadline for this grant.
To find out about AACN’s research priorities and grant opportunities, visit the
AACN Website or e-mail
One-Day APN Course Planned During ACCP Board Review
AACN and the American College of Chest Physicians are offering a one-day course for advanced practice nurses in critical care on Aug. 17, during the ACCP Critical Care Board Review Course in Orlando, Fla. Didactic and hands-on workshop sessions are planned.
Justine Medina, RN, MS, AACN’s director of professional practice and programs, will chair the session, which offers participants 9 hours of CE credit and 7.5 hours of CME credit.
Presentations include “Expected Outcomes for Guideline Implementation” by Richard S. Irwin, MD, FCCP; “Suturing” by Peter Lopez, MD, FCCP; “Central Line Replacement” by John P. Kress, MD, FCCP; and Ann Pohlman, RN; “Intubation in Emergent Situations” by Stephen O. Heard, MD, FCCP, and “Neuro Exam and Assessment” by Thomas P. Bleck, MD, FCCP, and Deborah Baker, RN, MSN.
The session is free to those who are registered for the ACCP course, scheduled Aug. 13 through 17. The preregistration deadline was July 30, but registration will be accepted onsite. For more information, call (800) 343-2227.
Public Policy Update
RN Groups Support Nurse Education Bill
The Americans for Nursing Shortage Relief Alliance has asked the House Committee on Education and Workforce to include funding for nursing education in the College Access and Opportunity Act (H.R. 4283). AACN, in conjunction with 40 other nursing associations that are members of the alliance, has signed a letter supporting the measure, which was introduced in May by Rep. John Boehner (R-Ohio).
The letter asked that provisions of the Teacher and Nurse Support Act of 2003 (H.R. 934), introduced by Rep. Carolyn McCarthy (D-N.Y.), be incorporated into the bill. McCarthy’s bill addresses the most critical aspect of the nursing shortage by providing loan forgiveness to nurses trained through all accredited nursing programs who agree to work in shortage areas, as well as to those individuals who teach in accredited nursing programs.
For more information on these and other bills that AACN supports, visit the
House Passes Stroke Care Bill
Nurses and other members of stroke care teams would have access to the latest and best treatments and technologies for stroke patients, under a bill authored by Rep. Lois Capps (D-Calif.). H.R. 3658, the Stroke Treatment and Ongoing Prevention Act, would create a national, multimedia campaign to promote stroke prevention and encourage stroke patients to seek immediate treatment. The bill would also establish the Paul Coverdell Stroke Registry and Clearinghouse to collect data about care for stroke patients and foster the development of effective stroke care systems. The act would also provide grants to create statewide stroke care systems. For more information, contact Capp’s office at (202) 225-3601.
JCAHO Issues Rules to Reduce Surgical Errors
Rules issued by the Joint Commission on Accreditation of Healthcare Organizations to prevent surgeons from operating on the wrong body part or patient went into effect on July 1. Before operating, surgeons will be required to sign the incision site with a marker that will not wash off in the operating room. Whenever possible, the marks are to be made while a patient is awake and cooperative, the rules say. In addition, the operating team will be required to go through a checklist before the surgery to ensure the correct patient is on the operating table, and team members must agree on which procedure is being done and on which body part. Any hospital or other surgery center that does not comply with the new safety regulations risks losing JCAHO accreditation.
The rules come in the wake of “growing reports of wrong-site, wrong-procedure and wrong-patient surgeries.” JCAHO has received 275 reports of wrong surgeries since 1999, and the number of incidents has steadily increased each year. Because JCAHO only receives such reports on a voluntary basis, it is not known exactly how many wrong surgeries occur each year.
National Foundation for Infectious Diseases Issues Influenza Report
The National Foundation for Infectious Diseases recently issued a comprehensive report stressing the importance of annual influenza vaccination among healthcare workers and urging healthcare institutions to help facilitate annual employee influenza immunization programs. The report was issued in response to dismal influenza immunization rates among healthcare workers, despite long-standing recommendations from the Centers for Disease Control and Prevention.
Unvaccinated healthcare workers can transmit the highly contagious influenza virus to patients in their care. According to William Schaffner, MD, NFID board member and professor and chair of the department of preventive medicine at Vanderbilt University School of Medicine, only 36% of U.S. healthcare workers are immunized against influenza each year.
The comprehensive report, titled “Improving Influenza Vaccination Rates in Health Care Workers: Strategies to Increase Protection for Workers and Patients,” provides details about the overall impact of influenza among healthcare workers and shares data regarding the lack of knowledge among healthcare workers about influenza immunization and its impact on patient safety. The report highlights effective strategies and best practice models that healthcare institutions can employ to improve, update or establish their own employee vaccination programs or policies.
NFID developed this comprehensive resource from proceedings of an expert roundtable meeting in November in Washington, D.C. Representatives of more than 20 of the nation’s top health and labor organizations, hospital chains and government institutions reviewed policies and practices to reach a consensus on the best ways employers and professional organizations can positively affect influenza vaccination rates of healthcare workers.
The healthcare worker influenza immunization document can be accessed via
NFID’s Web site.
New AHRQ Evidence Report Helps Hospitals Respond to Mass Casualty Emergencies
As part of its public health and emergency preparedness portfolio, the Agency for Healthcare Research and Quality has released a new evidence report titled “Training of Hospital Staff to Respond to a Mass Casualty Incident.” Developed by AHRQ’s Johns Hopkins University Evidence-Based Practice Center in Baltimore, the report identifies key elements to be used in evaluating hospital disaster drills. It provided the science behind another recently released AHRQ tool titled “Evaluation of Hospital Disaster Drills: A Module-Based Approach.” Both can be accessed online at
HHS Issues ‘Blueprint for Action’ to Build Healthier Nation
Health and Human Services Secretary Tommy G. Thompson has announced a “Blueprint for Action” to reduce and prevent chronic diseases. The blueprint outlines steps that individuals, groups, communities and other organizations can take to help improve the overall health of Americans.
The blueprint lists action steps for individuals and families; communities; schools; employers; health insurers; healthcare providers and professionals; researchers and health professions educators; the media; and state, local and tribal governments. It notes that the most immediate and effective changes in people’s lives are controlled by individuals themselves. By taking small, deliberate actions, individuals can improve their lives.
The summit addressed the nation’s chronic disease epidemic and the department’s latest efforts to prevent chronic diseases such as obesity, diabetes, asthma, heart disease, stroke and cancer, and the risk factors that cause them, namely, physical inactivity, poor nutrition, and tobacco use and brought together representatives of federal, state and local governments. It builds on President George W. Bush’s HealthierUS Initiative that addresses the key areas of physical activity, nutrition, preventive screenings and making healthy choices.
The blueprint is available at
aspe.hhs.gov > Health Policy Issues.
Public Policy Snapshot
Palliative care is an increasingly common discussion topic among healthcare officials. In January 2003, the American Hospital Association reported that the number of U.S. hospitals with palliative care programs rose 20% in one year’s time, from 668 in 2000 to 806 in 2001. Five years ago, the study noted, there were almost no hospital-based palliative programs. The American Academy of Hospice and Palliative Medicine reported that approximately 1,200 physicians are now certified in hospice-palliative care. The group says it expects palliative care to become an accredited subspecialty within the next five to 10 years.
A recent report by Virginia Commonwealth University showed that palliative care units save millions of dollars in hospital costs. The table below shows the average cost for terminally ill patients in palliative and nonpalliative programs during their final five days at one hospital.
Cost of Palliative vs. Nonpalliative Care
|Drugs and Chemotherapy Lab||
|Room and nursing||
(Source: Virginia Commonwealth University Medical Center)
Measure Creates Anesthesiology Assistants
Anesthesiology assistants will be allowed to practice in Florida, helping doctors anesthetize patients for surgery, under a measure signed by Gov. Jeb Bush. The bill (CS SB 626) has been before lawmakers for several years and has been fought stringently by nurse anesthetists, who say assistants are lesser-trained to administer anesthesia and argue they will endanger patients. Nurses had argued that certified registered nurse anesthetists have critical care experience before they’re allowed to administer anesthesia that assistants don’t necessarily have when they finish their education. Anesthesiology assistants are already allowed to practice at some level in 12 other states.
Safe Patient Care Initiative
The Michigan Nurses Association has released a comprehensive commissioned research report showing that Safe Patient Care legislation, Senate Bill 1190, will save lives and cut healthcare costs for Michigan patients and hospitals in the future. The legislation requires hospitals to meet minimum registered patient-to-nurse staffing ratios and places limits on the practice of mandatory overtime for nurses.
The Safe Patient Care legislation amends the Public Health Code to prohibit the practice of mandatory overtime, which forces exhausted nurses in short-staffed facilities to work long consecutive hours. The bill also requires hospitals to develop staffing plans and implement minimum patient-to-nurse ratios to promote the safe care of patients throughout Michigan hospitals.
Staffing Bill Shelved for 1 Year
Massachusetts advocates for a safe nurse staffing bill say they will continue to fight for more nursing manpower in acute care hospitals, despite being left out of the recent state budget. A scaled-down version of the original bill that passed the Senate failed to make it out of the House and Senate Budget Conference Committee.
The Massachusetts Nurses Association, as well as 70 healthcare and consumer advocacy groups, will refocus efforts on passing the original staffing bill, H.1282-Safe RN Staffing, now being considered by the House Ways and Means Committee.
For more information about these and other issues, visit the
Volunteer Groups to Begin Work on Initiatives
AACN work groups will meet later this month to continue work on association initiatives in specific subject areas. The group members were selected from the pool of volunteers registering in AACN’s new just-in-time Volunteer Profile Database online.
Following are the appointments, including the chairs and board liaisons, of the four work groups called in February:
Advanced Practice Work Group
This group will review and make recommendations on resources to support advanced nursing practice. Members will also evaluate topics and speakers for the Advanced Practice Institute at AACN’s annual National Teaching Institute and Critical Care Exposition, and write articles for AACN News. The members are:
John J. Whitcomb, RN, MSN, CCRN (chair)
Jodi E. Mullen, RN, CNS, MS, CCRN, CCNS (board liaison)
Carolyn Diane Byrum, RN, MSN, CCRN, CCNS
Marilyn P. Hravnak, RN, MN, PhD, CCRN, APRN, NP, FCCM
Laurie S. Finger, RN, CNS, MN, MS, CCRN, CCNS, APRN
Barbara L. Leeper, RN, CNS, MN, CCRN, FAHA
Patricia A. Radovich, RN, CNS, MS, MSN, FCCM
Kelly A. Thompson-Brazill, RN, MSN, AP
Ethics Work Group
Members of this group will identify or produce resources, including Practice Alerts related to the ethical issues of informed consent, advance directives and advocacy; end-of-life care, and decision making and symptom management; and moral distress on the caregiver. The members are:
Cynda H. Rushton, RN, DNS, PhD, FAAN (chair)
John F. Dixon, Jr., RN, MS, MSN (board liaison)
Henry B. Geiter Jr., RN, ADN, CCRN
Andrea M. Kline, RN, MS, MSN, CCRN, APRN, NP, NP-C, APRN-BC
Diane J. Mick, RN, CNS, DNS, PhD, CCNS, CS, APRN, NP, APRN-BC
Denise C. Thornby, RN, MS, MSN
M. Terese Verklan, RN, CNS, MSN, PhD, CCNS
NTI Work Group
This group will review and analyze evaluation and program data from NTI 2004 and review abstract submissions to make recommendations for program topics and sessions for NTI 2005. The members, who will also be part of the NTI 2005 onsite staff, are:
Dennis J. Cheek, RN, MSN, PhD, FAHA (chair)
Caryl A. Goodyear-Bruch, RN, MS, MSN, CCRN (board liaison)
Lisa N. Gingerich, RN, BS, BSN, CCRN
Shawn M. McCabe, RN, MS, MSN
Karen A. McQuillan, RN, MS, MSN, CCRN, CNRN
Nancy L. Munro, MN, MS, CCRN, APRN, APRN-BC
Kristine J. Peterson, RN, MS, MSN, CCRN, CCNS
Marcheta Lynn Rodgers, RN, MN, CCRN, APRN-BC
Alisa T. Shackelford, RN, BS, CCRN
Research Work Group
This group will identify, prioritize and produce evidence-based Practice Alerts, position statements, fact sheets and other materials regarding AACN’s platforms that excellence in critical care nursing practice is driven by the needs of the patients and their families and that critical care work environments must be safe, healing, humane and respectful to promote the creation of cultures of inquiry, broad sharing and evidence-based practice. The members are:
Mary Lou Sole, RN, PhD, CCNS, FAAN (chair)
Janie Heath, RN, MS, ACNP, ANP (board liaison)
Sherill A. Cronin, RN, DSN, PhD
Patricia A. Daansen, RN, BS, BSN, CCRN
Susan B. Fowler, RN, MSN, PhD, CCRN, CNRN
Joanne M. Kuszaj, RN, MS, MSN, CCRN
Christine L. Schulman, RN, MS, MSN, CCRN
Cathy J. Thompson, RN, CNS, MSN, PhD
For more information about volunteer opportunities, visit the