Association of Implementation of Practice Standards for Electrocardiographic Monitoring With Nurses' Knowledge, Quality of Care, and Patient Outcomes: Findings From the Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial.
Although continuous electrocardiographic (ECG) monitoring is ubiquitous in hospitals, monitoring practices are inconsistent. We evaluated implementation of American Heart Association practice standards for ECG monitoring on nurses' knowledge, quality of care, and patient outcomes.



The PULSE (Practical Use of the Latest Standards of Electrocardiography) Trial was a 6-year multisite randomized clinical trial with crossover that took place in 65 cardiac units in 17 hospitals. We measured outcomes at baseline, time 2 after group 1 hospitals received the intervention, and time 3 after group 2 hospitals received the intervention. Measurement periods were 15 months apart. The 2-part intervention consisted of an online ECG monitoring education program and strategies to implement and sustain change in practice. Nurses' knowledge (N=3013 nurses) was measured by a validated 20-item online test, quality of care related to ECG monitoring (N=4587 patients) by on-site observation, and patient outcomes (mortality, in-hospital myocardial infarction, and not surviving a cardiac arrest; N=95 884 hospital admissions) by review of administrative, laboratory, and medical record data. Nurses' knowledge improved significantly immediately after the intervention in both groups but was not sustained 15 months later. For most measures of quality of care (accurate electrode placement, accurate rhythm interpretation, appropriate monitoring, and ST-segment monitoring when indicated), the intervention was associated with significant improvement, which was sustained 15 months later. Of the 3 patient outcomes, only in-hospital myocardial infarction declined significantly after the intervention and was sustained.



Online ECG monitoring education and strategies to change practice can lead to improved nurses' knowledge, quality of care, and patient outcomes.



URL: http://www.clinicaltrials.gov. Unique identifier: NCT01269736.
From the School of Nursing, Yale University, West Haven, CT (M.F.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami (K.P.F.); Department of Pharmacology and Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD (K.E.S.); Yale Center for Clinical Investigation, School of Medicine, Yale University, New Haven, CT (J.L.M.); Western Connecticut Medical Group, Danbury (C.G.W.); and Department of Physiological Nursing, School of Nursing, University of California San Francisco (B.J.D.). marjorie.funk@yale.edu.
Marjorie
M
Funk
From the School of Nursing, Yale University, West Haven, CT (M.F.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami (K.P.F.); Department of Pharmacology and Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD (K.E.S.); Yale Center for Clinical Investigation, School of Medicine, Yale University, New Haven, CT (J.L.M.); Western Connecticut Medical Group, Danbury (C.G.W.); and Department of Physiological Nursing, School of Nursing, University of California San Francisco (B.J.D.).
Kristopher P
KP
Fennie
From the School of Nursing, Yale University, West Haven, CT (M.F.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami (K.P.F.); Department of Pharmacology and Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD (K.E.S.); Yale Center for Clinical Investigation, School of Medicine, Yale University, New Haven, CT (J.L.M.); Western Connecticut Medical Group, Danbury (C.G.W.); and Department of Physiological Nursing, School of Nursing, University of California San Francisco (B.J.D.).
Kimberly E
KE
Stephens
From the School of Nursing, Yale University, West Haven, CT (M.F.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami (K.P.F.); Department of Pharmacology and Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD (K.E.S.); Yale Center for Clinical Investigation, School of Medicine, Yale University, New Haven, CT (J.L.M.); Western Connecticut Medical Group, Danbury (C.G.W.); and Department of Physiological Nursing, School of Nursing, University of California San Francisco (B.J.D.).
Jeanine L
JL
May
From the School of Nursing, Yale University, West Haven, CT (M.F.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami (K.P.F.); Department of Pharmacology and Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD (K.E.S.); Yale Center for Clinical Investigation, School of Medicine, Yale University, New Haven, CT (J.L.M.); Western Connecticut Medical Group, Danbury (C.G.W.); and Department of Physiological Nursing, School of Nursing, University of California San Francisco (B.J.D.).
Catherine G
CG
Winkler
From the School of Nursing, Yale University, West Haven, CT (M.F.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami (K.P.F.); Department of Pharmacology and Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD (K.E.S.); Yale Center for Clinical Investigation, School of Medicine, Yale University, New Haven, CT (J.L.M.); Western Connecticut Medical Group, Danbury (C.G.W.); and Department of Physiological Nursing, School of Nursing, University of California San Francisco (B.J.D.).
Barbara J
BJ
Drew
D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D002309:Cardiology / Q000193:education* / Q000592:standards; D016507:Cardiology Service, Hospital; D002983:Clinical Competence; D018592:Cross-Over Studies; D004509:Education, Nursing, Continuing / Q000379:methods* / Q000592:standards; D004522:Educational Status; D015716:Electrocardiography, Ambulatory / Q000451:nursing* / Q000592:standards; D005260:Female; D019983:Guideline Adherence; D007722:Health Knowledge, Attitudes, Practice; D006323:Heart Arrest / Q000175:diagnosis / Q000401:mortality / Q000451:nursing; D006331:Heart Diseases / Q000175:diagnosis* / Q000401:mortality / Q000451:nursing*; D006723:Hong Kong; D017052:Hospital Mortality; D006801:Humans; D007318:Inservice Training; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000451:nursing; D009741:Nursing Staff, Hospital / Q000193:education* / Q000523:psychology; D009864:Ontario; D017063:Outcome Assessment, Health Care / Q000592:standards; D017410:Practice Guidelines as Topic / Q000592:standards; D011237:Predictive Value of Tests; D011379:Prognosis; D058996:Quality Improvement; D019984:Quality Indicators, Health Care / Q000592:standards; D013997:Time Factors; D014481:United States; D055815:Young Adult
electrocardiography; nursing; outcome assessment (health care); quality of health care; randomized controlled trial