1. CCU Core Clinical Business
2013 Competency Module 2

2. What’s in Store for this Module
This module will focus on CCU’s core clinical business. This includes:
Our key patient populations (HF, ACS, and A Fib)
Our key skills (12 lead ECG, Cardiac Monitoring, Risk Factor Counseling, and HF Self Care Education)
The content will either briefly review or build on what has already been covered in competency.
The primary purpose of this module is for you to highlight examples of excellence in practice as it relates to our core clinical business

3. Building on Heart Failure Self Care Education
Heart Failure Self Care was covered in 2011 and Heart Failure Disease Management was covered in 2012.
If you would like to review any prior competency modules you can access them at
2011
2012
Building on Heart Failure Self Care Education

4. Teach-Back . . . What Is It and What Does The Evidence Say?
“Asking that patient’s recall and restate what they have been told” is one of the 11 top patient safety practices based on the strength of scientific evidence.”
- AHRQ, 2001 Report, Making Health Care Safer
The “Teach-Back” method is one way to assess if the patient understands the instructions
“Teach-Back” is asking patients to repeat in their own words what they need to know or do
“Teach-Back” is NOT a test of the patient, but of how well you explained a concept.
Studies - - with complex disease processes such as heart failure/diabetes.
Not only is teach-back a good thing to do, it is supported by research. In fact, the Agency for Healthcare Research and Quality considers teach-back one of the top 11 patient safety strategies. Another study showed that when physicians used interactive communication techniques like teach-back, diabetic patients had better glycemic control.
Another study showed teach –back education was effective in improving patient education retention and preventing readmissions in HF patients (N = 67) (2011)
Endorsed by: American Academy of Family Physicians
American College of Surgeons
American Hospital Association
American Medical Association
Joint Commission
National Quality Forum
2013

5. Why is “Teach-Back” important?..... Telling is not Teaching
We Remember:
10% of what we read
20% of what we hear
30% of what we see
50% of what we see/hear
80% of what we say
90% of what we say and apply
2013

6. Using “Teach-Back”
The teach-back technique should replace the more common practice of simply asking a patient, “Do you understand?”
Here are examples to get you started:
“I have shared a lot of information with you. So I can see how well I did in explaining things to you, will you tell me a couple of things you remember?”
“Can you tell me what you will do when you get home?”
“Show me what you would do…”
Who here has ended a conversation with the question “do you understand”? I know I have. When we use this with our patients, they most likely will nod or answer yes, even when they understand nothing. But you won’t have any idea what they really understand. Teach-back will replace this more common question and provide you with the chance to know what the patient understood from what you said.
“I want to be sure I explained everything clearly, so can you please explain it back to me so I can be sure I did.”
Rephrase if the patient is unable to repeat back the key concepts/understanding of what was taught
Asking more open-ended questions is the key to a successful teach-back.
If you use, “Do you have any questions?” - you are not using “Teach-Back”
2013

7. For Your Portfolio
Reflective statements are an opportunity to step away from the closeness of the day and evaluate our practice.
Nurses are often overwhelmed with the busyness of practice, and do not routinely build in opportunities to reflect on the outcomes of practice interventions.
Reflective statements are an opportunity to formally build reflection into practice. Reflection is a strategy for clinical and professional development and an important component of ongoing competency.
Please submit two self reflective statements indicating how you used teach back in providing education to a patient with heart failure. A worksheet is provided for you in your “2013 Competency Packets” or electronically at

8. Content of Self Reflective Statements:
Patient initials, room number, and date & shift on which you provided education.
Describe the specific question(s) you used to ask the patient teach back content to you.
Since the teach back strategy is a new skill, please discuss the barriers you experienced in using this approach.
Based on the patient response, what did you learn about the effectiveness of the education provided.
Summarize how the education you provided to the patient has the potential to impact outcomes of care.
According to the Synergy Model, patients have unique characteristics. What patient characteristics influenced outcomes of the patient education session?
According to the Synergy Model, one nurse competency is facilitator of learning. What would you like to work on to improve your competency in this area of practice?

9. Building on Cardiac monitoring knowledge and skill.
Accurate and evidence based cardiac monitoring were focus areas for both 2011 and 2012 CCU Competency.
If you would like to review any prior competency modules you can access them at
2011
2012
Building on Cardiac monitoring knowledge and skill.

10. Lead placement is the foundation for accurate cardiac monitoring
V 1 V3
When V1 lead placement is incorrect it is most frequently because it is placed above the 4th ICS.
To palpate the 4th ICS start at the patient’s sternal angle. This is the point where your sternum is most anterior. Just to the right and down slightly from the sternal angle is the 2nd ICS. From this point you can palpate down to the 4th ICS.
V3 is a difficult to lead to place. V3 is to be placed between V2 and V4. Since V2 and V4 are not actually on the chest you must visually place them in order to have accurate V3 lead placement. V2 is 4th ICS LSB and V4 is 5th ICS mid clavicular line.

11. Electrode Placement Chest (Precordial) Leads
CNEA / Key Choice
7/16/2019
Electrode Placement Chest (Precordial) Leads
Lead V1
4th ICS, RSB
Lead V2
4th ICS, LSB
Lead V3
Midway Between V2 & V4
Lead V4
L midclavicular line, 5th ICS
Lead V5
L anterior axillary line, same level as V4
Lead V6
L midaxillary line, same level as V4

12. Limb Leads The most common errors for limb lead placement are:
The left arm electrode is not pulled out toward the left arm but rather is placed too close to the mid clavicular line. REMEMBER: The left arm electrode is the “camera” looking at the high lateral wall of the left ventricle and therefore must be pulled out toward the left arm (clavicle) so it can “see” the high lateral wall.
The left leg electrode is not below the rib cage when using it as a limb lead for lead 3. This is the same principle as above. If you want the “camera” of the left leg electrode to see the inferior wall, it must be below the patient’s rib cage and toward the left hip.

13. Limb Lead Electrode Placement

14. For Your Portfolio
Please review the lead placement for five different patients at the beginning of your shift. Use the worksheet in your competency packet or download the competency packet at
This review needs to occur on at least two different calendar days.
For each patient reviewed please document the following:
Patient initials, room number, and date & shift you reviewed.
Indicate the leads being monitored via hardwire or telemetry.
Answer the following questions:
Was the patient on hardwire or telemetry?
Was the left arm electrode pulled out toward far enough to the left shoulder?
Was the right arm electrode pulled out toward far enough to the right shoulder?
Was the left leg electrode below the level of the rib cage and toward the left hip?
Was the V1 electrode precisely in the 4th ICS on the right of the sternal border?
You must palpate to verify
If on telemetry, was the V3 electrode in the position between V1 and the 5th ICS mid clavicular line on the left?
The 5th ICS mid clavicular line on the left is the location for V4.

15. Additional Examples of Accurate and Evidence Based Monitoring
Bundle branch blocks should be documented as right or left based on their morphology in lead V1.
ST segment alarms should be set at 0.6 mm above or below baseline in the limb leads.
Abnormal rhythms should be documented in the following ways:
Strip posted in the chart with onset and offset of the arrhythmias.
Rhythm interpretation should be documented in interactive flow sheet in Cerner.
Provider documentation should be documented for any clinically significant arrhythmias.
QTc intervals should be monitored. QTc intervals > 500 msec (0.5 seconds) should be reported and the MAR should be assessed for drug therapy with the potential to increase the QTc.

16. For Your Portfolio
Please submit two self reflective statements indicating how you demonstrated accurate rhythm interpretation or evidence based monitoring practice. Use the worksheet in your competency packet or download the competency packet at
The self reflective statements should include the following:
Patient initials, room number, and date & shift during which your example occurred.
The Synergy Model identifies clinical judgment and patient advocacy as two important nursing competencies. Please identify how your cardiac monitoring example demonstrates clinical judgment and advocacy.
Please describe what happened as a result of your example of excellence in practice. The purpose here is for you to connect your nursing care to patient outcomes. For example if you identified a prolonged QTc, consulted with the pharmacist regarding medications prolonging the QT, notified the provider, and as a result a medication was discontinued; the result is the discontinuation of a potentially harmful medication, the avoidance of Torsades de Pointes, and improved patient safety.
What would you like to work on to improve your competency in the area of cardiac monitoring?

17. Please see Rhonda Fleischman for any questions.
Thank You!
Please see Rhonda Fleischman for any questions.