1. ECG INTERPRETATION Lisa Donaghy MSc. P.Grad Dip. BSc. CNM1 St. James Hospital Supervisor: Ms. Thelma Begley (TCD) November 2015

2. Overview Introduction and background to the study Review of existing literature Methodology Data analysis and discussion of findings Limitations, implications and recommendations Conclusion

3. Introduction to the study 1.2 million patients attend EDs in Ireland annually (average 3,000 per day) (McCarthy et al. 2013) Cardiovascular diseases most common cause of mortality worldwide – ¼ of all deaths (Zareba et al. 2008) 80% of Ischemia is silent (Evenson and Farnsworth 2010) Prompt diagnosis and treatment decreases mortality rates relating to ACS ( Varvaroussis et al. 2014)

4. Competency Requires appropriate training, adequate exposure and constant practice Incorrect ECG interpretation Doctors rotating frequently Doctor preoccupied with other patients

5. Question…. Who is responsible for interpreting an ECG?

6. Answer… The healthcare professional recording the ECG is responsible for acting upon the interpreted ECG (Litwin 2008).

7. Review of existing literature (2001-2015) Numerous studies have been conducted to investigate doctor’s competency levels. No previous studies specifically targeting ED nurse’s assessment of interpreting ECG’s and perceptions of ECG interpretation in the ED. Literature on nurses – educational articles

8. Existing literature: Nurses McCarthy et al. (2013) – Irish study which measured the most common ED nursing procedures and identifying relating competency levels. 403 ED nurses over 11 hospitals were invited. - 92% attach ECG monitoring - 90.6% obtain a 12-lead ECG - 51.4% interpret the 12-lead ECG.

9. “ A study to investigate Emergency Nurses’ current knowledge and perceptions of ECG interpretation in the Emergency Department” Donaghy (2015)

10. Methodology Quantitative Descriptive Design Two large urban academic teaching EDs, with a combined annual presentation of 90,000 patients and the employment of over 100 ED nurses (n=100). Response rate 60% (n=60) Access to the study locations. Inclusion/Exclusion Criteria Gatekeeper Anonymous questionnaire – structured & unstructured questions. 4 weeks.

11. Questionnaire design Section 1 - demographic information. Section 2 - basic ECG interpretation skills such as the function of the ECG, what the QRS complex represents, the normal QTC interval and lead placement of a 12-lead ECG. Section 3 - 5 different ECGs. Previous studies have indicated a poor accuracy rate with CHB, STEMI and VT, thus these were included in this section (Hals 2009, Hoyle et al. 2007, O’Brien et al. 2009).

12. Data analysis and discussion

13. Section 1 Descriptive profile of participants

15. Previous ECG interpretation training Most participants reported attending training on ECG interpretation. 70% of these were one hour or less in length. No participants attended a training day greater than one day. As previously stated, competency in ECG interpretation requires appropriate training, adequate exposure and constant practice. 77% completed ACLS course.

16. Current competency level and recommendations for future education and training

17. Emergency Nurses perceptions interpreting ECGs

19. Section 2: Basic interpretation skills

21. Position of ECG leads 13.3% - 0 correct 43.3% got all 10 limb leads correct Over 50% got one or all limb leads incorrect

22. Section 3: Interpreting ECGs 5 ECGs were distributed to participants to interpret independently.

23. ECG No. 1

24. ECG No. 2

25. ECG No. 3

26. ECG No. 4

27. ECG No.5

28. Summary of ED nurses knowledge competency rates from Section 3 ECG NumberPercentage of correctly answered ECGs ECG 1: Complete Heart Block21.7% ECG 2: VT58.3% ECG 3: STEMI81.7% ECG 4: LBBB36.7% ECG 5: SVT68.3% TOTAL AVERAGE53.34%

29. Limitations Confined to ED nurses Two urban hospitals in Ireland The researcher obtained a response rate of 60% which is average. Despite these limitations, it is an important study and it is anticipated the findings can be used to enhance the current knowledge surrounding ED nurses and ECG interpretation.

30. Implications for practice and research Nurse education – monthly staff education in the form of lectures and practical sessions in conjunction with competency book Nursing practice - cardiovascular diseases are considered the most common cause of mortality worldwide. Competency in ECG interpretation is of upmost importance to provide and maintain high standards of patient care, which is in accordance with the NMBI. Nursing management - Nurse managers will be asked to facilitate and support further education regarding ECG interpretation. Additionally, the Nurses and Midwives Act (2011) outlines that the employer should ensure to facilitate the maintenance of professional competence by a registered nurse by providing learning opportunities in the workplace. This is supported by the National Emergency Medicine Programme (2012).

31. Recommendations for future First national and international study - further research is required incorporating a larger sample population. Qualitative approach - attitudes and potential barriers affecting same. Exam rather than an anonymous questionnaire. Examine ED doctors competency levels - develop an interdisciplinary education programme. Identifying the most appropriate means of delivering education and training of ECGs to ED nurses specifically.

32. Standardised national guidelines - minimum number of ECGs to be conducted by ED nurses in order to gain and maintain proficiency. Acquisition of ECGs and the potential effects of poor acquisition to the interpretation of an ECG.

33. Conclusion The 12-lead ECG is considered the gold standard for the identification of any cardiac or metabolic abnormalities. ED nurses record ECGs on a daily basis. They rate their competency level of interpreting ECGs independently as average, which was demonstrated by the interpretation of the five ECGs in the questionnaire. A consistent finding to emerge from this study is that ED nurses require further training and education on ECG interpretation. Furthermore, the data highlights that ED nurses would benefit from both a competency book and lectures/practical classes on ECG interpretation and this is also their chosen method of education. They take an interest – improving waiting times and prioritising care.

34. The findings of this study illustrate that ED nurses are not competent at acquiring an ECG and the overall ECG interpretation competency rate was average. Thus, it is acknowledged that the outcomes of this study has implications for professional practice and improvements need to be made in order for all ED nurses to achieve the same competency level and ultimately improve patient outcomes.

35. Thank you for your attention! Any questions?