American Journal of Critical Care. 2007;16: 358-359
Copyright © 2007 by the American Association of Critical-Care Nurses.
Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attendees review and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General and specific questions such as those outlined in the "Discussion Points" box aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 350–356, consider the questions and discussion points outlined in the "Discussion Points" box. Visit www.ajcconline.org to discuss the article online.
Evidence-Based Review and Discussion Points
By
Ruth Kleinpell, RN, PhD.
Ruth Kleinpell is contributing editor of the Evidence-Based Review section. She is a professor in the Rush University College of Nursing, a teacher-practitioner at the Rush University Medical Center, and a nurse practitioner with Our Lady of the Resurrection Medical Center, Chicago, Illinois.
This study, "Atrial Electrograms After Cardiac Surgery: Survey of Clinical Practice," by Miller and Drew, reports on a national survey of nurses working in intensive or progressive care units who had experience treating patients after cardiac surgery. Its goal was to assess current practices related to the recording of atrial electrograms (AEGs), a practice recommended by the American Heart Association (AHA) for monitoring of tachycardia of unknown origin in patients following cardiac surgery. A convenience sample of 247 nurses subscribing to the American Association of Critical-Care Nurses (AACN) eNewsletter responded to the survey. Although most respondents (92%) reported that atrial epicardial pacing wires were left in place following cardiac surgery, only 10% recorded AEGs often in patients; more than 30% had never recorded one. The findings identify a gap in practice despite published evidence-based standards highlighting the diagnostic value of AEGs in patients after cardiac surgery.
 |
Information From the Authors
|
|---|
Jane N. Miller, RN, MS, CNS, CCRN, lead author of this EBR article, reports that the research team identified a knowledge gap with respect to the use of AEGs after cardiac surgery. She notes: "During discussions regarding postoperative dysrhythmia management, we found inconsistent and conflicting information despite published guidelines from national leaders and experts. Use of AEGs seemed especially site- and knowledge-specific, so the survey was developed to determine the current state of practice."
Miller explains that the survey was intentionally constructed to focus on nurses having experience with cardiac surgery patients. "The postoperative arrhythmia statistic was drawn from recent literature. Also, we used a national survey tool, Survey-monkey, and provided "logic progression" within the survey to ensure that only cardiac surgery nurses who worked with patients with epicardial atrial wires replied. We provided a ‘yes vs no’ reply capability on use of AEGs by nurses, allowing qualitative responses at the end."
Miller reports that the study did not assess the performance of AEGs by advanced practice nurses (APNs). "We did not specify that APNs or nurse practitioners answer separately," she explains, "but this would be a wonderful follow-up research question. Not all facilities with APNs have them available 24/7 to perform AEGs whenever the arrhythmias occur; staff RNs still desire the education and the skill."
Subjects were not asked whether they had a specific policy guiding nursing performance of AEGs, but Miller responds: "This also would be a wonderful follow-up research focus since policy, education, and skill provide parallels in expectation and competence."
|
Implications for Practice
|
|---|
According to the study results, the vast majority of nurses who participated in the survey reported that they were not routinely performing AEGs for tachycardia of unknown origin in patients after cardiac surgery. "AEGs are part of a documented national standard from the AHA1 for differentiating specific postoperative dysrhythmias," says Miller. "The survey demonstrates that current practice has not met the national standard, yet nurses are interested to learn and effectively institute the practice."
Miller believes the study’s implications for clinical practice are significant. "What is known is that the occurrence of postoperative atrial arrhythmias is high nationally, and consequences of incorrect or delayed treatment of the arrhythmias create higher incidences of complications, prolonged hospital stay, and increased mortality." Additional information is needed to determine whether other factors have an impact, however, such as whether APNs have assumed the role of performing AEGs in indicated clinical situations.
Readers of AJCC can use the information from the study in several ways. "Many resources and references are listed within the article," says Miller, "including AHA practice standards for ECG monitoring in hospital settings1 and educational/skill references such as AACN’s Procedure Manual for Critical Care.2 Readers can use our article and references to champion a collaborative practice so there is more institutional support for nurses, APNs, and physicians who perform this important skill."
Such collaborative practice should include "basic and comprehensive educational and practice sessions so there is proficiency and competency, plus ongoing dialogue with management regarding the effectiveness of the skill to aid in development of a policy that supports the intervention for continued evidence-based practice," Miller explains.
|
Investigator Spotlight
|
|---|
This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.
Jane N. Miller, a graduate of the University of California, San Francisco (UCSF), has been involved in critical care nursing for more than 30 years. Her interest in research began in Boise, Idaho, where she worked as a staff nurse, but it peaked in graduate school. "Our research on atrial electrograms (AEGs) was not related to a school project or work initiative," she notes, "but developed from inquiry and conversations having to do with postoperative cardiac surgery ‘emergencies’ and word-of-mouth assumptions leading to inconsistencies in treatment."
Miller’s coauthor on this article, Barbara J. Drew, is a professor of nursing and clinical professor of medicine at UCSF. The goal of Dr Drew’s ongoing research program has been to improve electrocardiogram monitoring techniques and clinical practices for accurate diagnosis of cardiac arrhythmias, myocardial ischemia, and drug-induced prolonged QT syndrome.
Miller and Drew were concerned about an assumed trend of decreasing use of AEGs for postoperative cardiac surgical patients (despite evidence-based recommendations) when rapid decompensating arrythmias occurred. They worked together to narrow and refine the research question, perform a thorough literature search, and choose the most effective research tools.
"It was a wonderful, challenging, and fullfilling process," notes Miller. "Dr Drew’s expertise and guidence were invaluable. Nurses who cared for these cardiac patients were passionate about providing the best care possible and using evidence-based practice. Those who had positive collaborative experiences and support from physicians, educators, and management for AEGs were strong advocates for their appropriate use. Dr Drew and I share enthusiasm for quality education and support for cardiac nursing and research. We created the time and energy to pursue a mutual area of passion."
|
Discussion Points
|
|---|
- Description of the Study
What are the advantages of atrial electrograms over routine electrograms?
- Why is the problem significant for those working in critical and high acuity care?
- Literature Evaluation
- What previous research has been conducted assessing the use of atrial electrograms after cardiac surgery?
- Sample
- How representative was the study sample?
- Methods and Design
- How were the data collected?
- How were nurses who did work with epicardial pacemaker wires excluded from the study?
- Results
- What were the findings of the research?
- What information was obtained from the qualitative responses?
- Clinical Significance
- What are the implications of this study for clinical practice?
eLetters
Now that you’ve read the EBR article and accompanying features, discuss them with colleagues. To begin an online discussion using eLetters, just visit www.ajcconline.org, select the article in its full-text or .pdf form from the table of contents, and click "Respond to This Article" from the list on the right side of the screen. All eLetters must be approved by the journal’s coeditors prior to publication.
|
REFERENCES
|
|---|
- Drew B, Califf RM, Funk M, et al. Practice standards for ECG monitoring in hospital settings: an American Heart Association scientific statement from the councils on cardiovascular nursing, clinical cardiology, and cardiovascular disease in the young. Circulation. 2004;110:2721–2746.[Abstract/Free Full Text]
- Preuss T, Wiegand DL. Atrial electrograms. In: Wiegand DJL, Carlson KK, eds. AACN Procedure Manual for Critical Care. 5th ed. St Louis, MO: Elsevier Saunders; 2005:296–303.
Top
Information From the Authors
Implications for Practice
