Updated Practice Standards for ECG Monitoring: Impact at the Bedside

Abstract

Any trigger for notifying the health care provider depends on the patient, as well as the expectations for a given setting. Patients vary in their responses to arrhythmias. A consistent message is that any hemodynamically unstable patient should have continuous electrocardiographic (ECG) monitoring. Each unit should consider having preset default heart rate parameters to guide provider notification. These decisions are based on discussion with all stakeholders, including providers and nurses.Consider why your patient may have an elevated cardiac troponin level and no chest pain. Does the patient have neuropathy and, therefore, may not sense angina? Is the patient unable to communicate because of impaired mental status, a language barrier, intubation, or sedation? If the answer to any of these questions is yes, your patient may benefit from continuous ST-segment monitoring. The current highest recommendation for continuous ST-segment monitoring is a IIa (ie, it is reasonable to perform the procedure, but more evidence is needed) in selected patients in a nursing unit with technology for continuous 12-lead ST-segment monitoring and related education and protocols that facilitate reduction of false and nonactionable alarm signals.Because the QT interval can often be measured successfully in all leads, prioritize monitoring the ST segment in the lead with known ST-segment depression or elevation. For example, if the patient had ST-segment changes in a particular lead during a myocardial infarction or balloon inflation during percutaneous coronary intervention, choose that lead; if the patient returns after a successful revascularization, select the lead in which the patient had previously demonstrated ST changes. If the patient is having wide QRS tachycardia, monitor lead V1 to distinguish ventricular tachycardia from supraventricular tachycardia with aberrancy.Dispelling this belief requires a change in unit culture. This change includes considering other types of monitoring such as continuous pulse oximetry instead of ECG monitoring using telemetry. Also consider changing the name of a unit from telemetry unit to progressive care unit or step-down unit. Patients may not need telemetry monitoring on these units, but still need qualified nurses who can provide care for complex airway issues and vascular procedures.