A Study to Evaluate the Effectiveness of Planned

"A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED

TEACHING PROGRAMME ON THE KNOWLEDGE OF RECORDING AND INTERPRETATION OF ELECTROCARDIOGRAM(ECG) AMONG STAFF NURSES WORKING IN SELECTED INTENSIVE CARE UNITS (I.C.U) OF SELECTED HOSPITALS IN TUMKUR .”

PROFORMA FOR REGISTRATION OF SUBJECT FOR THE

DISSERTATION

SUBMITTED BY

NIDIGANTLA SUBRAHMANYAM

MEDICAL SURGICAL NURSING

2012-2014

SRI SIDDHARTHA COLLEGE OF NURSIN AGALKOTE,

B.H. ROADTUMKUR

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

1

6 BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“Cardiovascular disease (CVD) is the world's leading killer, accounting for 17 million or 30 per cent of total global deaths in 2010.1 CVD alone accounts for one-quarter of all deaths in low mortality low-income countries. Non-communicable diseases such as cancers, neuropsychiatric and cardiovascular diseases now kill greater numbers of people in the lower-income countries than they do in high-income countries.2 While deaths from heart attacks have declined more than 50 per cent since the 1960s in many industrialized countries, 80 per cent of global cardiovascular diseases related deaths now occur in low and middle-income nations, which covers most countries in Asia. In India in the past five decades, rates of coronary disease among urban populations have risen from 4 per cent to 11 per cent.1

Introduced in 1902 by Einthoven, electrocardiography is the graphical display of electrical potential differences of an electric field originating in the heart as recorded at the body surface.3 As a record of electrical activity of the heart; it is a unique technology that provides information not readily obtained by other methods. The procedure is safe, simple, and reproducible; the record lends itself to serial studies; and the relative cost is minimal.

There are numerous potential clinical uses of the 12-lead ECG. The ECG may reflectchanges associated with primary or secondary myocardial processes (e.g., those associated with coronary artery disease, hypertension, cardiomyopathy, or infiltrative disorders), metabolic and electrolyte abnormalities, and therapeutic or toxic effects of drugs or devices Electrocardiography serves as the gold standard for the noninvasive diagnosis of arrhythmias and conduction disturbances, and it occasionally is the only marker for the presence of heart disease. As a research tool, it is used in long-term population-based surveillance studies and in experimental trials of drugs with recognized or potential cardiac effects.4

The technological development of powerful personal computers enabled the development of extremely sophisticated signal processing algorithms, introducing another dimension in the usefulness of ECG recordings. Analysis of RR intervals; QRS and T-wave morphology, including late potentials; QT dispersion; and T-wave alternans are currently being evaluated as prognostic markers in patients with structural heart disease. In addition, transtelephonic monitoring of implanted devices has become a standard technique of evaluating and following patients5.

Electrocardiograms are interpreted by Physicians and Nurses in many specialties, including cardiology, internal medicine, family practice, and emergency medicine. Interpretative skills vary among specialists .An adequate knowledge base should include the ability to define, recognize, and understand the basic pathophysiology of certain electrocardiographic abnormalities6.

Ensuring correct recording of ECG is imperative on the part of Nurses and technicians. Because it helps the Physician and Nurse to correctly interpret recordings and take appropriate measures. Operators recording ECGs should ensure that chest leads are placed in the proper position and electrodes make good skin contact to minimize artifacts. Incorrect placement of pericardial leads may lead to a false diagnosis of infarction. The reversal of limb leads and the switching of precordial leads have been well-documented to cause alterations in ECGs 7

Several studies have examined the accuracy of computer ECG interpretation programs and have suggested that computer analysis cannot substitute for physician interpretation of ECGs. A systematic study of computerized ECG interpretation performed in 1991 demonstrated that computer programs were 6.6% less accurate, on average, than cardiologists at identifying ventricular hypertrophy and myocardial infarction (MI) 8. Eectrocardiographic interpretation requires a basic knowledge of electrocardiographic technology, cardiac anatomy, and cardiac physiology as well as the ability to recognize diagnostic patterns on a 12-lead tracing

.Correctly recorded and interpreted ECGs will undoubtedly unearth the hidden changes associated with primary or secondary myocardial processes, metabolic and electrolyte abnormalities, and therapeutic or toxic effects of drugs or devices and aid the Physician and the Nurse to intervene promptly and save many precious lives

6.2 Need for the study:

According to world health organization (WHO), at least twenty million people survive

heart attacks and strokes around the world every year; many require continuing costly clinical care9.

British Heart Foundation’s 2009 statistics revealed Cardio Vascular Disease (CVD)

accounted for more than 276,000 deaths in the United Kingdom (UK) in 2009. Thirty-nine percent of deaths are from CVD, and 36 percent of premature deaths in men and 27 percent in women are from CVD10

European Cardio Vascular statistics of 2008 showed that each year CVD causes over

4.85 million deaths in Europe and over 2.1 million deaths in the European Union (EU). It causes nearly half of all deaths in Europe (51 percent) and in the EU (44 percent). It is the main cause of death in women in all countries of Europe and is the main cause of death in men in all countries except France and San Marino. It is the main cause of years of life lost from early death in Europe and the EU – around a third of years of life lost are due to CVD11

Heart and Stroke Foundation of Canada web site revealed that every seven minutes, aCanadian dies of heart disease and stroke. CVD accounts for more deaths than any other disease that is, 36 percent of male deaths and 38 percent of female deaths. It costs the Canadian economy about $18.4 billion annually12

The World Health Organization (WHO) estimates that 60 per cent of the world's cardiac patients will be Indian by 2010. Dr Timothy Gill, an Asia-Pacific specialist with the International Obesity Task Force, a medical NGO that coordinates with the WHO on obesity issues feels that of all Asians, South Asians have by far the worst problems when it comes to heart disease Nearly 50 per cent of CVD-related deaths in India occur below the age of 70, compared with just 22 per cent in the West. This trend is particularly alarming because of its potential impact on one of Asia's fastest-growing economies. In 2008, for example, India lost more than six times as many years of economically productive life to cardiovascular disease than did the U.S., where most of those killed by heart disease are above retirement age1.

In India it is estimated that at least 800,000 people die of heart attacks every year. About 5 out In India it is estimated that at least 800,000 people die of heart attacks every year. About 5 out of every 11 patients die after getting heart attacks, mostly within 1 hour before medical aid can reach them 13

Coronary artery disease has progressively increased among urban Indians during the last half a century and it affects people at younger age. India has the highest incidence of CAD in the world and the incidence is expected to reach epidemic proportions in the next few decades14.

The electrocardiogram (ECG) is one of the most widely used and useful investigations in contemporary medicine. It is essential for the identification of disorders of the cardiac rhythm, in various general conditions like head injury, poisoning, accidents, drowning, surgical complications, electrolyte disturbance etc. But it is specifically useful for the diagnosis of abnormalities of the heart such as Myocardial infarction (M.I), Coronary artery disease etc Nurse working in an ICU is one of the most trained personnel who possess specialized skills to provide care for these critically ill patients. Out of the many procedures she performs, she is required to have a working knowledge on electrocardiogram (ECG) i.e. correct recording and interpretation of ECG. She is in a unique position to provide 12 lead ECG and initiate an appropriate response. Key elements of 12 lead ECG interpretations and their application to established guidelines are essential skills for nurses working in ICU’s frequented by patients with serious problems15.

The investigators during their clinical experience in TUMKUR Hospital noticed deficit in the levels of knowledge of recording and interpretation of ECG by nurses in ICUs. In view of this need, the investigators strongly felt that every nurse working in the ICU should have adequate knowledge on the recording and interpretation of ECG so that precious lives could be saved. Planned teaching programme is a logical solution for this problem and would greatly help these nurses to equip them in the correct recording and interpretation of ECG.

6.3 REVIEW OF LITERATURE:

This chapter deals with review of literature which helps to gain an insight into various aspects of the problem under study, its objectives, appropriate research design, methods, instrument measures and techniques of data collection that may prove useful in the proposed project.

The review of literature provides a basis for future investigations, justifies the need for replication, throws light on the feasibility of the study, indicates constraints of data collection and helps to relate findings of one study to another. It also helps to establish a comprehensive body of scientific knowledge in a professional discipline from which valid pertinent theories may be developed.16

In the present study, the research investigator has carried out different types of Literature review at different stages of his research process and presented under the following headings:

1. Studies supporting recording of electrocardiogram (ECG).

2. Studies supporting interpretation of electrocardiogram (ECG)

3. Studies supporting planned teaching programme

Studies supporting the recording of electrocardiogram

An observational study was done on a randomly selected sample of 185 patients in an emergency setting on the appropriate recording of the electrocardiogram, it was found that moving location of electrodes from the standard limb lead position to the trunk, by placing the arm leads on the anterior ‘acromial region’ and the leg leads in the ‘anterior superior iliac spine’ resulted in difference in amplitudes within 5% of the values of standard recordings in 99.6 of all wave forms. It is prudent that a uniform approach for placing the limb leads needs to be adopted with the provision that when a modification is used for special reasons (patients with tremors), some information is entered on the ECG record and included as part of the ECG’s interpretive

report 17

A Comparative study was done on a convenient sample of 184 patients in Kingston

hospital, New Jersey. The purpose of the study was to compare the proposed new method using a 6-lead ECG BELT for precordial application to the standard 12 lead ECG method to determine the level of agreement among automated interpretations. The results indicated that BELT and standard automated interpretations disagreed significantly more frequently than repeat standard recording automated interpretations of the cardiac rhythm. The study suggested that the ECG BELT is not adequate for clinical application in its current form 18

An Evaluative study was done on the usefulness of leads aVR and −aVR as well as on the history of the frontal leads in electrocardiography. Results revealed that Lead aVR and particularly, lead −aVR, provide useful information when systematically analyzed. In addition, if lead −aVR is examined in its anatomically logical sequence, ie, aVL, I, −aVR, II, aVF, and III, the frontal plane of the 12-lead ECG is more easily understood. The study showed that ECG interpretation would be enhanced by displaying the limb leads in an orderly arrangement that starts with lead aVL and ends with lead III, and many ECG changes would be ideally displayed by a lead −aVR at 30° 19.

An evaluative study was done on one hundred forty-nine consecutive patients admitted to neurology department of an University Hospital Geneva, Geneva, Switzerland with an acute stroke or TIA. The purpose of the study was that 7-day ambulatory ECG monitoring using an event-loop recording (ELR) device would detect otherwise occult episodes of atrial fibrillation and flutter (AF) after acute stroke or transient ischemic attack (TIA). The results revealed that Standard ECG identified AF in 2.7% of the cases at admission (4/149 patients) and in 4.1% of remaining patients within 5 days (6/145). Holter disclosed AF in 5% of patients with a normal standard ECG (7/139 patients), whereas ELR detected AF in 5.7% of patients with a normal standard ECG and normal Holter (5/88 patients). The study concluded that ELR identified patients with AF, who remained undetected with standard ECG and with Holter. ELR should, therefore, be considered in every patient in whom a cardioembolic mechanism is suspected. 21

A randomized clinical trial on 174 patients in general practice was done in Amsterdam Netherlands. The objective of the study was to test the diagnostic yield of Patient-activated memo event recorders in diagnosing episodes of cardiac arrythmias in patients with palpitations or light-headedness. The results revealed that there were fewer patients without a diagnosis in the intervention group (17% vs. 38%; RR = 0.5, 95% CI 0.3 to 0.7) and more patients with a cardiac diagnosis (67% vs. 27%: RR 2.5, CI 1.8 to 3, 5). More relevant cardiac arrhythmias were detected (22% vs 7%) with event recording than with usual care (RR 3.2, 95% CI 1.5 to 6.8). The study concluded that the Patient-activated loop recorders are feasible and effective diagnostic tools in patients with palpitations or light-headedness in primary care22.

Studies supporting interpretation of electrocardiogram

A cluster randomized controlled trial on 14, 802 patients aged 65 or over was conducted in 50 primary care centers in England. The purpose of the study was to assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening. The results revealed the detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices. Systematic and opportunistic screening detected similar numbers of new cases. The study concluded that Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography23

.

An experimental study was done on 117 persons consecutively admitted to a coronary care unit in a community hospital, Toronto, Canada. The objective of the study was to find out the usefulness of three additional electrocardiographic chest leads (V7, V8, and V9) in the diagnosis of acute myocardial infarction. The results of the study revealed that among the 46 (39%) with a proven acute myocardial infarction the electrocardiograms (ECGs) of 9 (20%) showed ST-segment elevation or abnormal Q-waves, or both, in the three additional leads. In six of the nine, such changes were associated with signs of anterolateral or inferior wall infarction (in three each) on the standard 12-lead ECG. Thus the study showed that additional chest leads are helpful in detecting myocardial injury of necrosis in areas of the heart not properly reflected on the standard 12-lead ECG. this study was performed to evaluate the sensitivity of ST-segment elevation of standard and extended ECG leads in a cohort of patients with angiographically confirmed diagnosis of AMI 25.

A Cohort study conducted on 47 patients with end stage renal failure undergoing

hemodialysis sessions with the objective to evaluate the responses of P-wave, R waves, and host of other electrocardiogram (ECG) changes to the procedure. The results showed after hemodialysis (HD), significant ECG changes precipitated by hemodialysis included an increase in the P, QRS, mean, QRS duration, maximum P-wave duration, measured in lead II. Lead II was the lead with the longest P-wave duration in 36 patients (76.5%) 26.

An evaluative study on 2112 randomly selected standard 12-lead ECGs was done inNelson’s hospital, England. The purpose of this study is to determine the accuracy of ECGC rhythm interpretation in a typical patient population. The results revealed that the ECG-C correctly interpreted the rhythm in 1858 and incorrectly identified the rhythm in 254 (overallaccuracy, 88.0%). Sinus rhythm was correctly interpreted in 95.0% of the ECGs (1666/1753) with this rhythm, whereas nonsinus rhythms were correctly interpreted with an accuracy of only 53.5% (192/359) (P < .0001). Thus the study concluded that ECG-C demonstrates frequent errors in the interpretation of non sinus rhythms. In addition, incorrect rhythm interpretation by the ECG-C was frequently further compounded by additional major inaccuracies. Expert over reading of the ECG remains important in clinical settings with a high percentage of non sinus rhythms 27.

An evaluative study on the Value of Troponin-T Test in the Diagnosis of

Acute Myocardial Infarction was conducted at Dr. SN Medical College and associated group of Hospitals in 156 patients of acute myocardial infarction reaching within 24 hours of onset of symptoms. Serial ECG changes were considered as gold standard for the diagnosis of myocardial infarction. The results of the study revealed that, sensitivity (64.7%) and specificity (71.4%) of troponin-T test was higher than CPK-MB (54.9% and 42.8%) and SGOT (31.3% and 57.0%) respectively. The study concluded that bedside troponin-T test is highly sensitive and specific in the diagnosis of acute myocardial infarction and can be used in emergency and ambulatory settings33.

An observational study on a randomized sample of 84 was done at All India Institute of Medical Sciences. The objective of the study was to determine the role of ECG in the recognition of Left septal fascicular block. The study concluded that Left septal fascicular block is a polymorphic conduction defect which may explain some previously inadequately understood electrocardiographic abnormalities34.