Cardiac surgical nurses' use of atrial electrograms to improve diagnosis of arrhythmia

Improvements in Accuracy and Confidence in Rhythm Identification After Cardiac Surgery Using the AtriAmp Signals

Objectives: Following cardiac surgery, 50% to 60% of patients with congenital heart disease will experience an arrhythmia. These arrhythmias are associated with increased morbidity and mortality. Therefore, rapid and accurate identification is paramount to the improvement of patient outcome. We hypothesize that the AtriAmp, a device which allows atrial electrogram (AEG) display on the bedside monitors, will increase provider accuracy and confidence in arrhythmia diagnosis. Design: A prospective observational study. Electrograms were collected from post-operative patients from the bedside monitors surface ECG and an AEG using the AtriAmp. A 12-question online survey was given to critical care and cardiology providers at 9 different programs across the country as well as being posted to the AAP SOCC fall newsletter. Six questions displayed signals from only the surface leads, while the other 6 showed the same arrhythmias with an AEG obtained from the AtriAmp. Answers were then evaluated for confidence and accuracy. A paired t-test along with mixed method modeling was used to assess the data. Setting: Cardiac pediatric ICU. Subjects: Providers in pediatric cardiology and pediatric critical care were evaluated on their ability to diagnose arrhythmias on surface ECG and AEG obtained from bedside monitor. Interventions: The accuracy and confidence of diagnosis of both surface and AEG signals were evaluated through an on-line survey. Results: Eighty-eight providers completed the survey. The study showed that interpreting with the AtriAmp signal, compared to the surface ECG only, significantly increased the accuracy (P = .002) and confidence in provider rhythm diagnosis (P < .001). Junctional ectopic tachycardia, sinus tachycardia, and complete heart block had the most significant increase in accuracy of diagnose when using the AtriAmp signal (P < .001, P = .002, P = .010, respectively). Conclusion: Use of the AtriAmp increased provider accuracy and confidence in post-operative rhythm diagnosis when compared to diagnosis using the surface electrograms only.

Nurses' competency in electrocardiogram interpretation in acute care settings: A systematic review

AIMS

Identify and synthesize evidence of nurses' competency in electrocardiogram interpretation in acute care settings.

DESIGN

Systematic mixed studies review.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature, Medline, Scopus and Cochrane were searched in April 2021.

REVIEW METHODS

Data were selected using the updated Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. A data-based convergent synthesis design using qualitative content analysis was adopted. Quality appraisal was undertaken using validated tools appropriate to study designs of the included papers.

RESULTS

Forty-three papers were included in this review. Skills and attitudes were not commonly assessed, as most studies referred to 'competency' in the context of nurses' knowledge in electrocardiogram interpretation. Nurses' knowledge levels in this important nursing role varied notably, which could be partly due to a range of assessment tools being used. Several factors were found to influence nurses' competency in electrocardiogram interpretation across the included studies from individual, professional and organizational perspectives.

CONCLUSION

The definition of 'competency' was inconsistent, and nurses' competency in electrocardiogram interpretation varied from low to high. Nurses identified a lack of regular training and insufficient exposure in electrocardiogram interpretation. Hence, regular, standard training and education are recommended. Also, more research is needed to develop a standardized and comprehensive electrocardiogram interpretation tool, thereby allowing educators to safely assess nurses' competency.

IMPACT

This review addressed questions related to nurses' competency in electrocardiogram interpretation. The findings highlight varying competency levels and assessment methods. Nurses reported a lack of knowledge and confidence in interpreting electrocardiograms. There is an urgent need to explore opportunities to promote and maintain nurses' competency in electrocardiogram interpretation.

Atrial Electrography for Postoperative Tachyarrhythmia Analysis in Patients

The over 400,000 cardiac surgeries performed in the United States each year hold a risk for the postoperative complication of arrhythmias. Currently, bedside monitoring of surface electrocardiogram leads is used to interpret arrhythmias despite the evidence that atrial electrograms (AEGs) offer superior rhythm discrimination. This hesitancy to use the AEG may be due to a lack of training for practitioners in interpreting AEGs; therefore, our goal was to create an algorithm for the diagnosis of tachyarrhythmia using an AEG that can be utilized by any health care practitioner. Our algorithm classifies the most prevalent type of tachyarrhythmias following cardiac surgery. To allow rhythm identification, we categorized them based on their atrial to ventricular signal ratio, which is uniquely apparent on AEGs. Other considerations were given to rhythm regularity, consistency, P-wave axis, and rate. The algorithm includes the most common postoperative arrhythmias differentiated based on a unique branch-point approach, which walks through the steps in arrhythmia discrimination. Both rendered and collected AEGs are included as references for further understanding and interpretation of tachyarrhythmias. The utility of AEGs for rhythm discrimination post-cardiac surgery is established and recent technology can provide real-time and continuous monitoring; however, practitioner training may be inadequate. To bridge this divide, we created an algorithm so that existing atrial wires can be better used for an enhanced rhythm interpretation via AEGs.

Insertion and Management of Temporary Pacemakers

Temporary pacemakers are used in a variety of critical care settings. These life-saving devices are reviewed in 2 major categories in this review: first, the insertion and management of epicardial pacemakers after and during cardiac surgery; and second, the insertion of transvenous temporary pacemakers for the emergent treatment of bradyarrhythmias. Temporary epicardial pacemakers are used routinely in patients recovering from cardiac surgery. Borrowing from advances in cardiac resynchronization therapy there are many theoretical and untested benefits to pacing the postoperative cardiac surgery patient. Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients suffering from hemodynamically unstable bradyarrhythmia. We review the traditional and expanding use of transvenous pacemakers inside and outside the operating room.