Cardiac Monitoring/Strip Interpretation

[Kiwi82, BSN, RN]

Hey everyone,

As part of our performance improvement project we are attempting to increase compliance of printing and interpreting EKG rhythm strips for each patient with an active cardiac monitoring order. We are currently (very) non compliant. We have been working on this for almost 2 years and have had many barriers.

What does your Department do? Do you have a unit specific "policy"? How frequently do you print and interpret rhythm strips?

Is is this acceptable for TJC?

Any input is great!

Thank you!

[Wuzzie]

Are you talking about rhythm strips from the EKG machine or the monitor?

[Kiwi82, BSN, RN]

The cardiac monitor

[Wuzzie]

When I worked in the ED if you needed monitoring you got an EKG. It was read and documented by the MD. The remainder of the time the rhythm on the monitor was documented with vitals. We did not print strips unless there was a significant change. What's the rationale behind routinely printing slips on an ED patient? And with most placed using EMR's what would you do with the strips?

[Kiwi82, BSN, RN]

Same here. All patients get an EKG right when they walk in the door if they meet the criteria. But we are supposed to print the strips and then scan in the EMR. Apparently is a TJC thing... interpret and scan... I guess because otherwise it would just be having the patient on the monitor but no one really "looking at it".

we also have an area under the cardiac assessment where the rhythm is documented but apparently that is not enough.

[amzyRN]

At the ER's I've worked at if the patient was on the monitor they usually also got an EKG that is shown to the MD who interprets it (the EKG machine also interprets it too), the MD compares it to the last one if the patient had one.

If a patient is tachy from pain or dehydration (a young patient for example) might be on the monitor but not get an EKG. We don't have to print a strip and chart it, but there's a place to document what rhythm shows up when the monitor is applied in the EMR. To have to print a strip on every patient would be annoying to me, can you try to get that policy changed? On the other hand, maybe it's easy enough, but there can be so much to do in ER, to add another task can be a lot.

[Wuzzie]

I guess because otherwise it would just be having the patient on the monitor but no one really "looking at it".

But that doesn't make sense if there is documentation of what the rhythm is. Are you certain this is a Joint Commission requirement?

Or just some administrator's "good" idea.

[Lunah, MSN, RN]

We always did this back in the day, there were mounting forms just for this purpose. I always thought it was a good habit, we'd always get a baseline strip. It was an amazing day when we could start printing a page of strips from the central monitor - no more mounting! Lol

I think this might actually be a thing, I heard something the other day in my hospital about strips being required in addition to the EKG, but it sounded like it was our cardiologists asking for it, which I thought sounded weird. Hmmmm.

[CX_EDRN]

We do the same as others, and this has been standard in the several other EDs I have previously worked. Initial EKG, hook up to monitor for rest of time. Repeat/serial EKGs are sometimes done with evolving CP but the only time we print from the monitor is when we've caught significant runs of something, i.e. VT. But that's not very often because we'll just get another EKG. We also document current rhythm in with VS, minimally q30 for anything possibly cardiac related, i.e. dizziness/SOB.

[JKL33]

OP, I do think you need to understand the impetus for your department's PIP.

If JC has something to say about this, we're all ears to hear about it. It wouldn't surprise me, though, if someone has correctly (or even erroneously) figured out how they think they can submit additional billings for rhythm strips.

IMVHO one of the chief reasons people are less than enthusiastic about working hard on some of these projects is because appropriate/verifiable rationales are often not offered. I think it's quite unacceptable to be worried about/working on outcomes of a PIP without knowing a solid reason why it is being undertaken. It just becomes another one of those things that must be JC's fault. Meanwhile, the real reason might be because someone simply misunderstood something.

Sorry to make a mountain out of a molehill, but we do have enough things to do without working hard on PIPs with sketchy rationales.

[Kiwi82, BSN, RN]

No one misunderstood anything. This is a PIP because obviously there was a fall out at some point. I didn't get into much detail in my first post...

All I'm asking is if other ED's do this and if so how is it working for your department? Just trying to get ideas since it doesn't seem to work for us.

I've worked in other ED's and it was the same issue.

We are one of the busiest ED's in the COUNTRY.

We see way too many patients for our department size. We have acquired monitors for overflow spaces. But that component of the strip interpretation is a huge barrier. And yes, of course, we do document... or ... SHOULD document the rhythm.

And the EKG process I'm sure is the same across the board.

[Kuriin, BSN, RN]

We do not, but the previous tele floor I worked on would do this every shift. Print out the rhythm, interpret it, and place it in the patient's chart.