Accuracy of cardiac monitoring (electrode placement, lead selection, interval assessment, and rhythm interpretation) is an important component of patient safety in hospitalized patients who meet the criteria for dysrhythmia monitoring. Quality dysrhythmia monitoring requires nurses to have high levels of knowledge and skill for accuracy and effective clinical decision-making. Gaps in practice related to dysrhythmia monitoring have been documented.14  Inaccurate placement of electrodes can affect the morphology (shape) of the QRS complex and result in misinterpretation of a rhythm.5,6 

General

  1. Ensure proper placement of electrodes to obtain accurate diagnosis of cardiac rhythm (see Figure). Palpate patient to ensure proper intercostal spaces. Electrodes should be placed under the breast tissue in women. [level B]

  2. Provide proper skin preparation for electrocardiography (ECG) electrodes. Change ECG electrodes daily. [level B]

  3. Individualize limits on heart-rate alarms and other alarm settings on the basis of the goals of patient care. [level D]

    graphic

    graphic

  4. Do not transport patients for diagnostic testing who have a corrected QT interval (QTc) of 0.50 seconds (500 milliseconds) or greater while in the hospital until the prolonged QTc has been addressed. [level B]

  5. Provide continuous uninterrupted cardiac monitoring for the first 48 hours from admission for patients with an ST-segment elevation myocardial infarction and in high-risk patients with non– ST-elevation acute coronary syndrome (ejection fraction ≤ 40%, hemodynamic instability, unsuccessful revascularization/awaiting revascularization) because of the risk for life-threatening ventricular arrhythmias. [level A]

  6. Identify leads on posted rhythm strips. [level D]

Figure

Placement of electrodes.

Figure

Placement of electrodes.

Close modal

Dysrhythmia Identification

  1. Document the onset and offset of new dysrhythmias. [level D]

  2. Select the best monitoring leads for identifying dysrhythmia (see Table) according to the needs of the patient (display 2 leads when possible). Lead selection requires critical thinking and may require integration of leads for ST-segment monitoring with leads for dysrhythmia monitoring. See the American Association for Critical-Care Nurses (AACN) Practice Alert: Ensuring Accurate ST-Segment Monitoring. [level B]

  3. Obtain 12-lead ECG in a stable wide complex tachycardia to provide additional information to aid in interpretation. [level B]

  4. Report episodes of paroxysmal atrial fibrillation in patients with no documented history of atrial fibrillation, as paroxysmal atrial fibrillation increases stroke risk. [level A]

  5. Report a short PR interval of less than 0.12 seconds (120 milliseconds). This short an interval may represent the presence of an accessory pathway. [level B]

  6. Request consultation for device interrogation in patients with a permanent device who have paced rhythms that are difficult to interpret. [level D]

Table

Lead selection

Lead selection
Lead selection

QT-Interval Monitoring

  1. Measure QT interval and calculate QTc (rate-adjusted QT interval) by using the same lead where there is a T-wave amplitude of at least 2 mm and a clearly identified T-wave end. [level C]

  2. Do not include a distinctly separate U wave in the measurement of the QT interval. [level C]

  3. Assess and document QTc at least once per shift in patients who meet criteria for QT interval monitoring as identified in the American Heart Association Scientific Statement: Practice Standards for Electrocardiographic Monitoring in Hospital Settings.7  Also consider QTc monitoring as a routine practice in patients with 1 or more high-risk features for torsades de pointes. [level D]

  4. Assess QTc more frequently in patients with baseline QTc prolongation, the initiation or dosage increase of a drug that prolongs QTc, or in patients with other warning signs for torsades de pointes observed on the monitor. [level B]

  5. Assess QTc before and after administration of a drug that prolongs the QTc by using the same lead, the same device, and the same formula for heart-rate correction. [level D]

  6. Use QTc to differentiate torsades de pointes from polymorphic ventricular tachycardia with normal QT interval. [level B]

  7. Report a QTc greater than 0.50 seconds (500 milliseconds) or any increase in the QTc of more than 0.06 seconds (60 milliseconds) after administration of a QTc-prolonging medication. Report any new finding of a QTc greater than 0.50 seconds (500 milliseconds). [level D]

  8. Review the patient’s medication list for actual or potential QT-prolonging medications whenever QT prolongation is a concern. Consider collaboration with a clinical pharmacist when reviewing the medication profile. [level D]

General

  1. Selection of patients for dysrhythmia monitoring is important for the detection of and intervention in both life-threatening and other cardiac rhythm disturbances.7  Some evidence indicates overuse of dysrhythmia monitoring according to current recommendations.812  Use of cardiac monitoring in patients without a clear clinical indication may have adverse unintentional patient-specific (eg, aggravation of delirium13 ) and organizational (eg, increased cost11 ) consequences. Conversely, beneficial unintentional consequences may occur when patients who do not meet current recommended criteria (eg, detection and stroke prevention treatment in paroxysmal atrial fibrillation14  and early intervention and improved outcomes in patients with cardiac arrest1519 ) are monitored. Cardiac monitoring is used in a wide variety of patient care settings within hospitals. Nurses in all areas should be prepared to respond appropriately to all cardiac monitor alarms and events.7  [level B]

  2. Staffing practices may affect response times to cardiac alarms and potentially affect patient safety.20  [level C]

  3. Dysrhythmia monitoring is complex and requires a high level of clinical decision-making. Initial training, continuing education, and competency assessment are important criteria for safe and high-quality cardiac monitoring. Additionally, accurate interpretation of cardiac rhythm involves a specific set of knowledge and skills. Gaps in knowledge and skills related to cardiac monitoring are evident.1,2,2128  [level A]

  4. Electrode site preparation includes clipping excessive hair and cleansing oily skin with alcohol. Failure to prepare skin properly before electrode placement may cause inappropriate monitoring alarms.2931  Electrodes should be changed daily as a strategy for reducing alarms.32  Additional strategies can be effective in reducing alarm fatigue and facilitating appropriate response to monitor alarms.3236  See the AACN Practice Alert: Alarm Management. [level A]

Dysrhythmia Monitoring and Identification

  1. Two leads should be displayed whenever available to aid in accurate rhythm interpretation. Nurses do not always use 2 leads for bedside monitoring when appropriate and the leads are available.3,37  [level C]

  2. Chest leads V1, V2, and V4 require palpation to locate the correct intercostal space. Current guidelines recommend electrode placement under breast tissue in women. When an electrode is misplaced by as little as 1 intercostal space, QRS morphology can change and misdiagnosis may occur (eg, ventricular tachycardia may be misidentified as supraventricular tachycardia or vice versa).4,5  [level B]

  3. Document onset and offset of dysrhythmias.7  [level C]

  4. A short PR interval on a resting ECG may be associated with the presence of an accessory pathway.28  [level B]

  5. The percentage of patients with acute coronary syndrome who have life-threatening ventricular arrhythmias has decreased with the use of reperfusion in ST-segment elevation myocardial infarction and with the use of evidence-based medications in all patients with acute coronary syndrome (with and without ST-segment elevation).38,39  Still, patients with acute coronary syndrome (ST-segment elevation myocardial infarction and high-risk non–ST-elevation presentation) are at higher risk for ventricular arrhythmias, with the vast majority of life- threatening arrhythmias occurring within 48 hours of the event.38,40,41  High-risk features in a patient with non–ST-segment elevation acute coronary syndrome include arrhythmias, hemodynamic instability, ejection fraction less than 40%, and failed reperfusion or pending revascularization of major coronary arteries.42  Life- threatening arrhythmias early in the hospital course are associated with worse short-term outcomes. However, patients who have a late ventricular arrhythmia (> 48 hours from time of event) have a higher long-term risk for sudden cardiac death and will need an electrophysiology referral for possible use of a wearable cardioverter defibrillator and subsequent use of an implantable defibrillator.38  Additionally, the presence of ventricular arrhythmias in a patient with acute coronary syndrome is used to stratify risk, and risk stratification is used to guide treatment.42,43  [level A]

  6. Paroxysmal atrial fibrillation is a risk factor for stroke, and anticoagulation for stroke prevention is warranted because of the patient’s stroke risk.4451  Paroxysmal atrial fibrillation may be an incidental finding while a patient is receiving inpatient hospital monitoring. Reporting of paroxysmal atrial fibrillation may lead to treatment for stroke prevention, a reduction in stroke risk, and improved outcomes for patients. [level A]

  7. Accurate interpretation of wide complex tachycardias is important for patient safety because supraventricular tachycardia with bundle branch block and ventricular tachycardia are treated differently. Inappropriate treatment can lead to adverse outcomes.5254  [level B]

  8. ECG criteria are needed for the differentiation of ventricular tachycardia from supraventricular tachycardia with bundle branch block because clinical tolerance of the rhythm is insufficient for differentiation.55  [level C]

  9. Several algorithms for the interpretation of wide complex tachycardias (differentiating ventricular tachycardia from supraventricular tachycardia with bundle branch block) have been proposed. The algorithms involve criteria that require the completion of a 12-lead ECG to determine cardiac axis, QRS morphology in multiple leads, and the presence of concordance in the precordial leads.5660  [level B]

  10. The criterion of atrioventricular (AV) dissociation for the diagnosis of ventricular tachycardia does not require any specific monitoring lead. However, P waves are not always visible in a wide complex tachycardia, and thus the nurse cannot rely on the presence of AV dissociation to confirm ventricular tachycardia. Additionally, not all ventricular tachycardias have AV dissociation. Some ventricular tachycardias will conduct retrograde, resulting in a P wave after each QRS complex.5661  [level B]

  11. Lead aVR and lead II have been proposed as useful leads for differentiating wide complex tachycardias. However, lead aVR and lead II are not recommended leads for the differentiation of right and left bundle branch block patterns.21,60,6264  [level B]

  12. Leads V1 and V6 are 2 leads referenced in several algorithms for the differentiation of wide complex tachycardias. Leads V1 and V6 are also components of published criteria for the recognition of patterns of right and left bundle branch block (in sinus rhythm or during a supraventricular tachycardia). V1 is the preferred bedside monitoring lead for dysrhythmia monitoring. When V1 electrode placement is not possible (eg, in a patient with a surgical dressing at that spot), V6 may be used. When 2 chest leads are available, the combination of V1 and V6 is preferred for dysrhythmia monitoring.7,5659,62,6576  [level A]

  13. A 5- or 6-lead monitoring system is required to monitor true V (chest) leads. MCL leads are modified chest leads. True chest leads should be used rather than modified chest leads whenever available. A 5-lead monitoring system provides the ability to monitor in 1 true V lead. When a 5-lead system is used, lead V1 should be the monitoring lead of choice for dysrhythmia monitoring. If a true V lead is not available (as with a 3-lead monitoring system), an MCL1 lead may be used. A 6-lead monitoring system provides the ability to monitor in 2 true V leads at the same time. In a 6-lead system, V1 and V6 could be simultaneously monitored for dysrhythmia monitoring or V1 and V3 could be simultaneously monitored for combined dysrhythmia monitoring and ST-segment monitoring. When using a 5-lead monitoring system, V1 and an MCL6 may be used for dysrhythmia monitoring. Nurses must be aware that limb lead placement is altered (and thus the accuracy of limb lead recordings is altered) when modified chest leads are used. For example, using an MCL6 for dysrhythmia monitoring would prohibit the simultaneous monitoring of lead III for ST-segment monitoring.68,69  [level C]

  14. When a derived ECG monitoring system is being used at the bedside, the full-disclosure view allowing 12 leads to be displayed should be used to aid in the interpretation of any wide complex tachycardia.77  The derived ECG may have limitations in morphology assessment compared with the standard ECG.78,79  [level B]

  15. Obtain an atrial electrogram in cardiac surgical patients with atrial epicardial wires to assist in identifying atrial activity.8082  Use the Lewis lead in patients without epicardial pacing wires to identify atrial activity when P waves are not clear. The Lewis lead takes a close-up look at right atrial activity and can identify P waves in atrial tachycardia or flutter waves in atrial flutter that are not otherwise seen in other monitoring leads. The Lewis lead has also been used to identify AV dissociation during a wide complex tachycardia.83  [level C]

QTc Interval Monitoring

  1. The QTc interval should be measured once per shift in patients who meet criteria for QT-interval monitoring. More frequent assessment is indicated on the basis of additional ECG and clinical high-risk features. Use a consistent lead, and document the lead that is being used for QT-interval monitoring.84,85  [level C]

  2. Measurement of the QT interval has some technical considerations. U waves that are distinctly separate from the T wave should not be included in the measurement. Additionally, an increase in QRS duration as seen with bundle branch blocks will prolong the QT/QTc. However, an increased QT/QTc from a conduction delay does not carry the same risk for torsades de pointes as does a prolonged QT/QTc caused by a delay in repolarization (the T wave is associated with ventricular repolarization).84,86  [level C]

  3. The QT interval should be corrected for heart rate (QTc). There are several formulas (Bazett, Fridericia, Framingham) for correcting the QT interval for heart rate in patients with a regular R-R interval. No consensus has been reached regarding one optimal method to be used in clinical practice.84,8689  Additionally, it is difficult to assess the QTc in patients with atrial fibrillation because of the irregular R-R interval. Several methods have been proposed, including standard heart correction formulas, identifying the longest and shortest R-R intervals, using each to calculate the QTc and taking the average; additionally, a long rhythm strip can be printed to assess if the interval from R wave to the peak of the following T wave is more than half of the preceding R-R interval. (Note: this method does not provide an actual QTc but rather an indicator for a QT interval that is too long.) [level B]

  4. QTc prolongation in hospitalized patients is associated with adverse clinical outcomes. QTc greater than 0.50 seconds (500 milliseconds) is dangerously prolonged and associated with risk for torsades de pointes. A QTc of more than 0.50 seconds (500 milliseconds) or more than 0.06 seconds (60 milliseconds) from baseline is reportable. The time frames for and duration of assessment of the QTc after administration of a QT-prolonging drug will vary depending on the onset, peak, and duration of the drug. Ideally, the QTc should be measured when there is peak plasma concentration. Multiple medications carry the risk for QTc prolongation, and the risk may be dependent on other clinical features. High-risk clinical features for torsades de pointes include genetic predisposition, severe bradycardia, long pauses, any drug overdose, hypokalemia, hypomagnesemia, hypocalcemia, advanced age, female sex, low ejection fraction, left ventricular hypertrophy, renal or hepatic dysfunction, history of stroke, hyperglycemia, and hypothyroidism.7,74,8487,90104  [level A]

  5. In addition to clinical features and QTc prolongation, additional warning signs for torsades de pointes can be observed on the cardiac monitor, including T-wave or U-wave distortion, visible T-wave alternans, new-onset ventricular ectopy, and nonsustained polymorphic ventricular tachycardia often occurring after a pause.84,85,105  [level B]

  6. The QTc can be used to differentiate torsades de pointes from polymorphic ventricular tachycardia with a normal QT interval. The treatment differs for these 2 dysrhythmias.106  [level B]

Monitor patients for dysrhythmias according to the recommendations in the American Heart Association Scientific Statement: Practice Standards for Electrocardiographic Monitoring in Hospital Settings.

When replacing current bedside monitoring equipment, evaluate for the number of chest leads and for the technology related to continuous assessment of the QT interval.

Review organizational policies and protocols related to cardiac monitoring to ensure the same standard of care across settings. Ensure that monitoring policies and protocols are based on needs of the patient and integrate both dysrhythmia monitoring priorities and ST-segment monitoring priorities.

Determine a consistent method for QT heart-rate correction to be used for bedside monitoring in hospital- or unit-based protocols. Determine the method for QT heart-rate correction in patients with atrial fibrillation.

Provide appropriate initial and continuing education for staff, including but not limited to electrode placement, lead selection, recognition of right and left bundle branch block patterns, identification of heart blocks, recognition of QRS morphology seen in ventricular tachycardia, criteria for differentiating wide complex tachycardias, heart rate correction methods for QT interval, warning signs for torsades de pointes, reportable conditions, and emergency response to life-threatening arrhythmias. Include didactic content and “hands-on” practice with return demonstration of lead placement.

Develop competency standards for all staff involved in dysrhythmia monitoring to ensure patient safety related to implementation of cardiac monitoring standards and accurate cardiac rhythm interpretation.

Consider cardiac monitoring responsibilities in staffing assignments.

Conduct audits at regular intervals to ensure actual practice matches recommended practice for dysrhythmia monitoring: accurate electrode placement, appropriate lead selection, accurate rhythm interpretation and QT assessment, and appropriate documentation.

  1. Go to www.aacn.org, click Clinical Resources, and scroll down to select AACN Practice Resource Network.

  2. Review the standards. AHA Scientific Statement: Practice Standards for Electrocardiographic Monitoring in Hospital Settings. http://circ.ahajournals.org/content/110/17/2721.full.pdf+html. Accessed July 14, 2016.

  3. AACN Practice Alert: Alarm Management. http://www.aacn.org/wd/practice/content/practicealerts/alarm-management-practice-alert.pcms?menu=practice.

1
McCann
K
,
Holdgate
A
,
Mahammad
R
,
Waddington
A
.
Accuracy of ECG electrode placement by emergency department clinicians
.
Emerg Med Aust
.
2007
;
19
(
5
):
442
448
.
2
Zaremba
JL
,
Carroll
K
,
Manley
K
.
Electrocardiographic practices: the current report of monitoring and education in Veterans Affairs facilities
.
Dimens Crit Care Nurs
.
2014
;
33
(
2
):
82
87
.
3
Drew
BJ
,
Ide
B
,
Sparacino
PS
.
Accuracy of bedside electrocardiographic monitoring: a report on current practices of critical care nurses
.
Heart Lung
.
1991
;
20
(
6
):
597
607
.
4
Kligfield
P
,
Gettes
LS
,
Bailey
JJ
, et al
.
Recommendations for the standardization and interpretation of the electrocardiogram: Part I: The electrocardiogram and its technology a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society endorsed by the International Society for Computerized Electrocardiology
.
J Am Coll Cardiol
.
2007
;
49
(
10
):
1109
1112
.
5
Drew
BJ
.
Celebrating the 100th birthday of the electrocardiogram: lessons learned from research in cardiac monitoring
.
Am J Crit Care
.
2002
;
11
(
4
):
378
388
.
6
Bond
RR
,
Finlay
D
,
Nugent
C
,
Breen
C
,
Guldenring
D
,
Daly
M
.
The effects of misplacement on clinicians’ interpretation of the standard 12-lead electrocardiogram
.
Eur J Intern Med
.
2012
;
23
(
7
):
610
615
.
7
Drew
BJ
,
Califf
RM
,
Funk
M
, et al
.
Practice standards for electrocardiographic monitoring in hospital settings: An American Heart Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses
.
Circulation
.
2004
;
110
(
17
):
2721
2746
.
8
Dhillon
SK
,
Rachko
M
,
Hanon
S
,
Schweitzer
P
,
Bergmann
SR
.
Telemetry monitoring guidelines for efficient and safe delivery of cardiac rhythm monitoring to noncritical hospital inpatients
.
Crit Pathways Cardiol
.
2009
;
8
(
3
):
125
126
.
9
Funk
M
,
Winkler
CG
,
May
JL
, et al
.
Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest Standards for Electrocardiography trial
.
J Electrocardiol
.
2010
;
43
(
6
):
542
547
.
10
Leighton
H
,
Kianfar
H
,
Serynek
S
,
Kerwin
T
.
Effect of an electronic ordering system on adherence to the American College of Cardiology/American Heart Association guidelines for cardiac monitoring
.
Crit Pathways Cardiol
.
2013
;
12
(
1
):
6
8
.
11
Dressler
R
,
Dryer
MM
,
Coletti
C
,
Mahoney
D
,
Doorey
AJ
.
Altering overuse of cardiac telemetry in non–intensive care unit settings by hardwiring the use of American Heart Association Guidelines
.
JAMA Intern Med
.
2014
;
174
(
11
):
1852
1854
.
12
Crawford
CL
,
Halm
MA
.
Telemetry monitoring: are admission criteria based on evidence?
Am J Crit Care
.
2015
;
24
(
4
):
360
364
.
13
Chen
S
,
Zakaria
S
.
Behind the monitor—the trouble with telemetry: a teachable moment
.
JAMA Intern Med
.
2015
;
175
(
6
):
894
.
14
Najafi
N
,
Auerbach
A
.
Use and outcomes of telemetry monitoring on a medicine service
.
Arch Intern Med
.
2012
;
172
(
17
):
1349
1350
.
15
Chan
PS
,
Krumholz
HM
,
Nichol
G
,
Nallamothu
BK
.
Delayed time to defibrillation after in-hospital cardiac arrest
.
N Engl J Med
.
2008
;
358
(
1
):
9
17
.
16
Larkin
GL
,
Copes
WS
,
Nathanson
BH
,
Kaye
W
.
Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation
.
Resuscitation
.
2010
;
81
(
3
):
302
311
.
17
Brady
WJ
,
Gurka
KK
,
Mehring
B
,
Peberdy
MA
,
O’Connor
RE
.
In-hospital cardiac arrest: impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge
.
Resuscitation
.
2011
;
82
(
7
):
845
852
.
18
Cleverley
K
,
Mousavi
N
,
Stronger
L
, et al
.
The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients
.
Resuscitation
.
2013
;
84
(
7
):
878
882
.
19
Do
DH
,
Hayase
J
,
Tiecher
RD
,
Bai
Y
,
Hu
X
,
Boyle
NG
.
ECG changes on continuous telemetry preceding in-hospital cardiac arrests
.
J Electrocardiol
.
2015
;
48
(
6
):
1062
1068
.
20
Segall
N
,
Hobbs
G
,
Granger
CB
, et al
.
Patient load effects on response time to critical arrhythmias in cardiac telemetry: a randomized trial
.
Crit Care Med
.
2015
;
43
(
5
):
1036
1042
.
21
Surawicz
B
,
Childers
R
,
Deal
BJ
,
Gettes
LS
.
AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: Part III: Intraventricular conduction disturbances a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; The American College of Cardiology Foundation; and the Heart Rhythm Society endorsed by the International Society for Computerized Electrocardiology
.
J Am Coll Cardiol
.
2009
;
53
(
11
):
976
981
.
22
Evenson
L
,
Farnsworth
M
.
Skilled cardiac monitoring at the bedside: an algorithm for success
.
Crit Care Nurse
.
2010
;
30
(
5
):
14
22
.
23
Webner
C
.
Applying evidence at the bedside: a journey to excellence in bedside cardiac monitoring
.
Dimens Crit Care Nurs
.
2011
;
30
(
1
):
8
18
.
24
Funk
M
,
Fennie
KP
,
Stephens
K
, et al
.
The Practical Use of the Latest Standards of Electrocardiography (PULSE) trial: nursing-focused intervention improves nurses’ knowledge and quality of ECG monitoring
.
Circulation
.
2014
;
130
(
suppl 2
):
A16320
.
25
Pitcher
D
.
Who should learn cardiac rhythm interpretation and how?
Resuscitation
.
2014
;
85
(
2
):
163
164
.
26
Scruth
EA
.
Cardiac rhythm monitoring: competency, accuracy, and meaningful Use
.
Clin Nurse Spec
.
2014
;
28
(
2
):
86
88
.
27
Crimlisk
JT
,
Johnstone
DJ
,
Winter
MR
.
Cardiac monitoring: hospital-wide education and staff competence
.
Dimens Crit Care Nurs
.
2015
;
34
(
3
):
170
175
.
28
Page
RL
,
Joglar
JA
,
Caldwell
MA
, et al
.
2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society
.
J Am Coll Cardiol
.
2016
;
67
(
13
):
1575
1623
.
29
Medina
V
,
Clochesy
JM
,
Omery
A
.
Comparison of electrode site preparation techniques
.
Heart Lung
.
1989
;
18
(
5
):
456
460
.
30
Clochesy
JM
,
Cifani
L
,
Howe
K
.
Electrode site preparation techniques: a follow-up study
.
Heart Lung
.
1991
;
20
(
1
):
27
30
.
31
Walsh-Irwin
C
,
Jurgens
CY
.
Proper skin preparation and electrode placement decreases alarms on a telemetry unit
.
Dimens Crit Care Nurs
.
2015
;
34
(
3
):
134
139
.
32
Cvach
MM
,
Biggs
M
,
Rothwell
KJ
,
Charles-Hudson
C
.
Daily electrode change and effect on cardiac monitor alarms: an evidence-based practice approach
.
J Nurs Care Quality
.
2013
;
28
(
3
):
265
271
.
33
Graham
KC
,
Cvach
M
.
Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms
.
Am J Crit Care
.
2010
;
19
(
1
):
28
34
.
34
Cvach
MM
,
Frank
RJ
,
Doyle
P
,
Stevens
ZK
.
Use of pagers with an alarm escalation system to reduce cardiac monitor alarm signals
.
J Nurs Care Qual
.
2014
;
29
(
1
):
9
18
.
35
Drew
BJ
,
Harris
P
,
Zègre-Hemsey
JK
, et al
.
Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients
.
PLoS One
.
2014
;
9
(
10
):
e110274
.
36
Whalen
DA
,
Covelle
PM
,
Piepenbrink
JC
,
Villanova
KL
,
Cuneo
CL
,
Awtry
EH
.
Novel approach to cardiac alarm management on telemetry units
.
J Cardiovasc Nurs
.
2014
;
29
(
5
):
E13
E22
.
37
Thomason
TR
,
Riegel
B
,
Carlson
B
,
Gocka
I
.
Monitoring electrocardiographic changes: results of a national survey
.
J Cardiovasc Nurs
.
1995
;
9
(
4
):
1
9
.
38
Steg
PG
,
James
SK
,
Atar
D
, et al
.
ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
.
Eur Heart J
.
2012
;
33
(
20
):
2569
2619
.
39
Winkler
C
,
Funk
M
,
Schindler
DM
,
Hemsey
JZ
,
Lampert
R
,
Drew
BJ
.
Arrhythmias in patients with acute coronary syndrome in the first 24 hours of hospitalization
.
Heart Lung
.
2013
;
42
(
6
):
422
427
.
40
Cricri
P
,
Trachsel
LD
,
Müller
P
,
Wäckerlin
A
,
Reinhart
WH
,
Bonetti
PO
.
Incidence and time frame of life-threatening arrhythmias in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention
.
Swiss Med Wkly
.
2012
;
142
:
w13604
.
41
Ohlow
MA
,
Geller
JC
,
Richter
S
, et al
.
Incidence and predictors of ventricular arrhythmias after ST-segment elevation myocardial infarction
.
Am J Emerg Med
.
2012
;
30
(
4
):
580
586
.
42
Roffi
M
,
Patrono
C
,
Collet
JP
, et al
.
2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
.
Eur Heart J
.
2016
;
37
(
3
):
267
315
.
43
Harkness
JR
,
Morrow
DA
,
Braunwald
E
, et al
.
Myocardial ischemia and ventricular tachycardia on continuous electrocardiographic monitoring and risk of cardiovascular outcomes after non–ST-segment elevation acute coronary syndrome (from the MERLIN-TIMI 36 Trial)
.
Am J Cardiol
.
2011
;
108
(
10
):
1373
1381
.
44
Elijovich
L
,
Josephson
SA
,
Fung
GL
,
Smith
WS
.
Intermittent atrial fibrillation may account for a large proportion of otherwise cryptogenic stroke: a study of 30-day cardiac event monitors
.
J Stroke Cerebrovasc Dis
.
2009
;
18
(
3
):
185
189
.
45
Hidalgo
RM
,
Campello
AR
,
Santiago
ÁO
,
Godia
EC
,
Sunyer
CP
,
Roquer
J
.
Cardiac monitoring in stroke units: importance of diagnosing atrial fibrillation in acute ischemic stroke
.
Rev Esp Cardiol
.
2009
;
62
(
5
):
564
567
.
46
Seet
RC
,
Friedman
PA
,
Rabinstein
AA
.
Prolonged rhythm monitoring for the detection of occult paroxysmal atrial fibrillation in ischemic stroke of unknown cause
.
Circulation
.
2011
;
124
(
4
):
477
486
.
47
Lazzaro
MA
,
Krishnan
K
,
Prabhakaran
S
.
Detection of atrial fibrillation with concurrent Holter monitoring and continuous cardiac telemetry following ischemic stroke and transient ischemic attack
.
J Stroke Cerebrovasc Dis
.
2012
;
21
(
2
):
89
93
.
48
Rizos
T
,
Güntner
J
,
Jenetzky
E
, et al
.
Continuous stroke unit electrocardiographic monitoring versus 24-hour Holter electrocardiography for detection of paroxysmal atrial fibrillation after stroke
.
Stroke
.
2012
;
43
(
10
):
2689
2694
.
49
Sposato
LA
,
Klein
FR
,
Jáuregui
A
, et al
.
Newly diagnosed atrial fibrillation after acute ischemic stroke and transient ischemic attack: importance of immediate and prolonged continuous cardiac monitoring
.
J Stroke Cerebrovasc Dis
.
2012
;
21
(
3
):
210
216
.
50
Gladstone
DJ
,
Spring
M
,
Dorian
P
, et al
.
Atrial fibrillation in patients with cryptogenic stroke
.
N Engl J Med
.
2014
;
370
(
26
):
2467
2477
.
51
Rabinstein
AA
.
Prolonged cardiac monitoring for detection of paroxysmal atrial fibrillation after cerebral ischemia
.
Stroke
.
2014
;
45
(
4
):
1208
1214
.
52
Dancy
M
,
Camm
AJ
,
Ward
D
.
Misdiagnosis of chronic recurrent ventricular tachycardia
.
The Lancet
.
1985
;
326
(
8450
):
320
323
.
53
Stewart
RB
,
Bardy
GH
,
Greene
HL
.
Wide complex tachycardia: misdiagnosis and outcome after emergent therapy
.
Ann Intern Med
.
1986
;
104
(
6
):
766
771
.
54
Buxton
AE
,
Marchlinski
FE
,
Doherty
JU
,
Flores
B
,
Josephson
ME
.
Hazards of intravenous verapamil for sustained ventricular tachycardia
.
Am J Cardiol
.
1987
;
59
(
12
):
1107
1110
.
55
Morady
F
,
Baerman
JM
,
DiCarlo
LA
,
DeBuitleir
M
,
Krol
RB
,
Wahr
DW
.
A prevalent misconception regarding wide-complex tachycardias
.
JAMA
.
1985
;
254
(
19
):
2790
2792
.
56
Marriott
HJ
.
Differential diagnosis of supraventricular and ventricular tachycardia
.
Cardiology
.
1990
;
77
(
3
):
209
220
.
57
Brugada
P
,
Brugada
J
,
Mont
L
,
Smeets
JL
,
Andries
EW
.
A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex
.
Circulation
.
1991
;
83
(
5
):
1649
1659
.
58
Wellens
HJ
.
Ventricular tachycardia: diagnosis of broad QRS complex tachycardia
.
Heart
.
2001
;
86
(
5
):
579
585
.
59
Wellens
HJ
,
Bär
FW
,
Lie
KI
.
The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex
. In:
Smeets
JL
,
Doevendans
PA
,
Josephson
ME
,
Kirchhof
CH
,
Vos
MA
, eds.
Professor Hein J. J. Wellens
.
Netherlands
:
Springer
;
2000
:
173
181
.
60
Vereckei
A
,
Duray
G
,
Szénási
G
,
Altemose
GT
,
Miller
JM
.
Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia
.
Eur Heart J
.
2007
;
28
(
5
):
589
600
.
61
Edhouse
J
,
Morris
F
.
ABC of clinical electrocardiography: broad complex tachycardia—Part I
.
BMJ
.
2002
;
324
(
7339
):
719
.
62
Willems
JL
,
de Medina
EO
,
Bernard
R
, et al
.
Criteria for intraventricular conduction disturbances and pre-excitation
.
J Am Coll Cardiol
.
1985
;
5
(
6
):
1261
1275
.
63
Pava
LF
,
Perafán
P
,
Badiel
M
, et al
.
R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias
.
Heart Rhythm
.
2010
;
7
(
7
):
922
926
.
64
Baxi
RP
,
Hart
KW
,
Vereckei
A
, et al
.
Vereckei criteria as a diagnostic tool amongst emergency medicine residents to distinguish between ventricular tachycardia and supra-ventricular tachycardia with aberrancy
.
J Cardiol
.
2012
;
59
(
3
):
307
312
.
65
Sandler
IA
,
Marriot
HJ
.
The differential morphology of anomalous ventricular complexes of RBBB-type in lead V1 ventricular ectopy versus aberration
.
Circulation
.
1965
;
31
(
4
):
551
556
.
66
Dongas
J
,
Lehmann
MH
,
Mahmud
R
,
Denker
S
,
Soni
J
,
Akhtar
M
.
Value of preexisting bundle branch block in the electrocardiographic differentiation of supraventricular from ventricular origin of wide QRS tachycardia
.
Am J Cardiol
.
1985
;
55
(
6
):
717
721
.
67
Kindwall
KE
,
Brown
J
,
Josephson
ME
.
Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias
.
Am J Cardiol
.
1988
;
61
(
15
):
1279
1283
.
68
Drew
BJ
,
Scheinman
MM
.
Value of electrocardiographic leads MCL1, MCL6 and other selected leads in the diagnosis of wide QRS complex tachycardia
.
J Am Coll Cardiol
.
1991
;
18
(
4
):
102
.
69
Drew
BJ
,
Scheinman
MM
,
Dracup
K
.
MCL1 and MCL6 compared to V1 and V6 in distinguishing aberrant supraventricular from ventricular ectopic beats
.
Pacing Clin Electrophysiol
.
1991
;
14
(
9
):
1375
1383
.
70
Fabius
DB
.
Diagnosing and treating ventricular tachycardia
.
J Cardiovasc Nurs
.
1993
;
7
(
3
):
8
25
.
71
Drew
BJ
,
Scheinman
MM
.
ECG criteria to distinguish between aberrantly conducted supraventricular tachycardia and ventricular tachycardia: practical aspects for the immediate care setting
.
Pacing Clin Electrophysiol
.
1995
;
18
(
12 pt 1
):
2194
2208
.
72
Drew
BJ
,
Ide
B
.
Differential diagnosis of wide QRS complex tachycardia
.
Prog Cardiovasc Nurs
.
1998
;
13
(
3
):
46
47
.
73
Edhouse
J
,
Morris
F
.
ABC of clinical electrocardiography: broad complex tachycardia—part II
.
BMJ
.
2002
;
324
(
7340
):
776
.
74
Drew
BJ
,
Funk
M
.
Practice standards for ECG monitoring in hospital settings: executive summary and guide for implementation
.
Crit Care Nurs Clin North Am
.
2006
;
18
(
2
):
157
168
.
75
Garmel
GM
.
Wide complex tachycardias: understanding this complex condition—Part 1, Epidemiology and electrophysiology
.
West J Emerg Med
.
2008
;
9
(
1
):
28
39
.
76
Nikoo
MH
,
Aslani
A
,
Jorat
MV
.
LBBB: state-of-the-art criteria
.
Int Cardiovasc Res J
.
2013
;
7
(
2
):
39
40
.
77
Jahrsdoerfer
M
,
Giuliano
K
,
Stephens
D
.
Clinical usefulness of the EASI 12-lead continuous electrocardiographic monitoring system
.
Crit Care Nurse
.
2005
;
25
(
5
):
28
37
.
78
Drew
BJ
,
Finlay
DD
.
Standardization of reduced and optimal lead sets for continuous electrocardiogram monitoring: where do we stand?
J Electrocardiol
.
2008
;
41
(
6
):
458
465
.
79
Gregg
RE
,
Zhou
SH
,
Lindauer
JM
,
Feild
DQ
,
Helfenbein
ED
.
Where do derived precordial leads fail?
J Electrocardiol
.
2008
;
41
(
6
):
546
552
.
80
Kern
LS
,
McRae
ME
,
Funk
M
.
ECG monitoring after cardiac surgery: postoperative atrial fibrillation and the atrial electrogram
.
AACN Adv Crit Care
.
2007
;
18
(
3
):
294
304
.
81
Miller
JN
,
Drew
BJ
.
Atrial electrograms after cardiac surgery: survey of clinical practice
.
Am J Crit Care
.
2007
;
16
(
4
):
350
356
.
82
McRae
ME
,
Chan
A
,
Imperial-Perez
F
.
Cardiac surgical nurses’ use of atrial electrograms to improve diagnosis of arrhythmia
.
Am J Crit Care
.
2010
;
19
(
2
):
124
133
.
83
Bakker
AL
,
Nijkerk
G
,
Groenemeijer
BE
, et al
.
The Lewis lead making recognition of P waves easy during wide QRS complex tachycardia
.
Circulation
.
2009
;
119
(
24
):
e592
e593
.
84
Drew
BJ
,
Ackerman
MJ
,
Funk
M
, et al
.
Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation endorsed by the American Association of Critical-Care Nurses and the International Society for Computerized Electrocardiology
.
J Am Coll Cardiol
.
2010
;
55
(
9
):
934
947
.
85
Pickham
D
.
Understanding and documenting QT intervals
.
Crit Care Nurse
.
2013
;
33
(
4
):
73
75
.
86
Al-Khatib
SM
,
LaPointe
NM
,
Kramer
JM
,
Califf
RM
.
What clinicians should know about the QT interval
.
JAMA
.
2003
;
289
(
16
):
2120
2127
.
87
Sommargren
CE
,
Drew
BJ
.
Preventing torsades de pointes by careful cardiac monitoring in hospital settings
.
AACN Adv Crit Care
.
2007
;
18
(
3
):
285
293
.
88
Pai
GR
,
Rawles
JM
.
The QT interval in atrial fibrillation
.
Br Heart J
.
1989
;
61
(
6
):
510
513
.
89
Berling
I
,
Isbister
GK
.
The half RR rule: a poor rule of thumb and not a risk assessment tool for QT interval prolongation
.
Acad Emerg Med
.
2015
;
22
(
10
):
1139
1144
.
90
Passman
R
,
Kadish
A
.
Polymorphic ventricular tachycardia, long Q-T syndrome, and torsades de pointes
.
Med Clin North Am
.
2001
;
85
(
2
):
321
341
.
91
Crouch
MA
,
Limon
L
,
Cassano
AT
.
Clinical relevance and management of drug-related QT interval prolongation
.
Pharmacotherapy
.
2003
;
23
(
7
):
881
908
.
92
Yap
YG
,
Camm
AJ
.
Drug-induced QT prolongation and torsades de pointes
.
Heart
.
2003
;
89
(
11
):
1363
1372
.
93
Gupta
A
,
Lawrence
AT
,
Krishnan
K
,
Kavinsky
CJ
,
Trohman
RG
.
Current concepts in the mechanisms and management of drug-induced QT prolongation and torsade de pointes
.
Am Heart J
.
2007
;
153
(
6
):
891
899
.
94
Kannankeril
PJ
,
Roden
DM
.
Drug-induced long QT and torsade de pointes: recent advances
.
Curr Opin Cardiol
.
2007
;
22
(
1
):
39
43
.
95
Åström-Lilja
C
,
Odeberg
JM
,
Ekman
E
,
Hägg
S
.
Drug-induced torsades de pointes: a review of the Swedish pharmacovigilance database
.
Pharmacoepidemiol Drug Saf
.
2008
;
17
(
6
):
587
592
.
96
Ghosh
S
,
Apte
P
,
Maroz
N
,
Broor
A
,
Zeineh
N
,
Khan
IA
.
Takotsubo cardiomyopathy as a potential cause of long QT syndrome and torsades de pointes
.
Int J Cardiol
.
2009
;
136
(
2
):
225
227
.
97
Funk
M
,
Winkler
CG
,
May
JL
,
Stephens
K
,
Fennie
KP
,
Rose
LL
,
Turkman
YE
,
Drew
BJ
.
Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest Standards for Electrocardiography trial
.
J Electrocardiol
.
2010
;
43
(
6
):
542
547
.
98
Bunch
TJ
,
Mahapatra
S
.
Implications of continuous QT monitoring in the intensive care setting
.
Crit Care Med
.
2012
;
40
(
2
):
658
659
.
99
Pickham
D
,
Helfenbein
E
,
Shinn
JA
, et al
.
High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality: results of the QT in Practice (QTIP) Study
.
Crit Care Med
.
2012
;
40
(
2
):
394
399
.
100
Beach
SR
,
Celano
CM
,
Noseworthy
PA
,
Januzzi
JL
,
Huffman
JC
.
QTc prolongation, torsades de pointes, and psychotropic medications
.
Psychosomatics
.
2013
;
54
(
1
):
1
13
.
101
Trinkley
KE
,
Lee Page
R
,
Lien
H
,
Yamanouye
K
,
Tisdale
JE
.
QT interval prolongation and the risk of torsades de pointes: essentials for clinicians
.
Curr Med Res Opin
.
2013
;
29
(
12
):
1719
1726
.
102
Hoogstraaten
E
,
Rijkenberg
S
,
van der Voort
PH
.
Corrected QT-interval prolongation and variability in intensive care patients
.
J Crit Care
.
2014
;
29
(
5
):
835
839
.
103
Shah
AA
,
Aftab
A
,
Coverdale
J
.
QTc prolongation with antipsychotics: is routine ECG monitoring recommended?
J Psychiatr Pract
.
2014
;
20
(
3
):
196
206
.
104
Barrett
T
.
Why are we prolonging QT interval monitoring?
Dimens Crit Care Nurs
.
2015
;
34
(
3
):
130
133
.
105
Kirchhof
P
,
Franz
MR
,
Bardai
A
,
Wilde
AM
.
Giant T–U waves precede torsades de pointes in long QT syndrome: a systematic electrocardiographic analysis in patients with acquired and congenital QT prolongation
.
J Am Coll Cardiol
.
2009
;
54
(
2
):
143
149
.
106
Zipes
DP
,
Camm
AJ
,
Borggrefe
M
, et al
.
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)
.
J Am Coll Cardiol
.
2006
;
48
(
5
):
e247
e346
.

Footnotes

Original Author: Barbara Drew, RN, MS, PhD, FAAN, FAHA, CNS-BC August 2004

Contributing Authors: Cynthia Webner, RN, DNP, CCNS, CCRN-CMC, CHFN and Karen Marzlin, RN, DNP, CCNS, CCRN-CMC, CHFN April 2016

Annette M. Bourgault, PhD, RN, CNL, Maureen A. Seckel, MSN, APRN, ACNS-BC, CCRN CCNS, Debra L. Kramlich, PhD, RN, CNE, CCRN-K and Nancy M. Richards, RN, MSN, CCRN, CCNS, APRN-CNS April 2008

Reviewed and approved by the AACN Clinical Resources Task Force, 2016.

Financial Disclosures

None reported..

Correction: This article was corrected on June 12, 2023, to include more contributing authors.