Management of acute myocardial infarction has dramatically changed over the past 2 decades, but one aspect of management that has not changed is that early intervention saves lives. A resource to assist in early intervention is a relatively untapped source—practicing nurses. Bedside nurses who are able to recognize ST segment–elevated myocardial infarction (STEMI), which is amendable to intervention, could improve the time it takes to initiate treatment for these critical patients. A STEMI is defined by consistent ST elevation, evident on an electrocardiogram (ECG) at the J (junction) point in at least two contiguous leads ≥ 0.1 mV in all leads other than V2 and V3 and ≥ 0.2 mV in men ≥40 years, ≥ 0.25 in men ≤ 50 years, and ≥ 0.15 mV in women (Thygesen et al., 2012). The J point is at the start of the ST segment and an example is depicted in Figure 1.
Depiction of ST elevation and J point. Reprinted with permission from https://ECGpedia.org.
Prolonged ST segment elevation typically means an occluded artery. When this is managed with expedited angioplasty, patient outcomes are vastly improved. Although 98% of U.S. citizens are within the range of a 9-1-1 emergency telephone call system, not all patients arrive by ambulances (Spencer et al., 2010). In 2011, the ACTION Registry's Get With the Goals study demonstrated that data from percutaneous coronary intervention–capable facilities had 60% of their patients transported by emergency medical services ambulances. Historically, however, geographical variations have shown that number to be closer to 23% to 53% (Brown et al., 2000). As there are limited advanced emergency medical services units in the midwestern urban area where this project occurred, many patients are brought to the emergency department (ED) by family. Educating nurses on obtaining and conducting basic screening interpretation of 12-lead ECGs can facilitate earlier STEMI recognition, which could significantly reduce the time until treatment and improve patient survival. Achieving the benchmark “door-to-balloon time” goal of 90 minutes or less—particularly without a prehospital ECG—requires meeting the American Heart Association recommendation of door-to-ECG time to be 10 minutes or less (O'Gara et al., 2013). However, time is muscle and every 30-minute delay increases the risk of mortality by 7.5% (Tra, van der Wulp, de Bruijne, & Wagner, 2015).
Although many 12-lead ECG education programs are dedicated to teaching RNs, many health care systems do not require, recognize, or use this important resource. According to the American Nurses Association and the American Association of Critical-Care Nurses, reading 12-lead ECGs is well within a nurse's scope of practice, and analyzing assessment data and outcome identification is a standard of care (American Nurses Association, 2010; Bell, 2015). Furthermore, the Institute of Medicine states that safety and quality issues occur when health professionals (such as RNs) work in organizations that neither prepare nor support their nursing staff to achieve optimal patient outcomes (Institute of Medicine, 2004). Many EDs use standing orders for triage RNs to initiate diagnostics and therapeutic regimens before being evaluated by a provider (Retezar, Bessman, Ding, Zeger, & McCarthy, 2011). When patients present with chest pain, a 12-lead ECG is included in the standing orders. Ideally, organizations should educate RNs to appropriately triage patients with chest pain, implement standing orders, and screen 12-lead ECGs to evaluate if STEMI may be present so the appropriate health care provider can make a formal diagnosis and initiate the necessary interventions.
The purpose of this practice improvement study was to increase nursing's knowledge of accurate and timely identification of an ECG suggestive of a STEMI. Specifically, the two study aims were to (a) assess the nurses' baseline knowledge of STEMI recognition on 12-lead ECGs and (b) evaluate the nurse-acquired knowledge of the educational program by using a pretest–posttest that was delivered via a social media platform.
Background and Significance
Every 42 seconds, a person experiences an acute myocardial infarction (MI) (Mozaffarian et al., 2016), and every 83 seconds, an individual dies from that event (Go et al., 2014). In addition, more than six million patients are seen annually in the ED with chest pain (Hollander & Chase, 2016). According the American Heart Association, an estimated 550,000 people experience a new MI and 200,000 people will have an acute MI recurrence (Mozaffarian et al., 2016). Of patients with reoccurring MI, 25% to 40% will have a STEMI (O'Gara et al., 2013).
RNs have an ethical responsibility to be diligent in preventing occurrences of failure to rescue. Failure to rescue is a quality indicator in health care and occurs when a patient dies from a complication that could have otherwise been avoided (Patient Safety Network, 2019). Nurse–physician collaboration is crucial in improving patient outcomes by decreasing mortality and preventing complications (Georgiou, Papathanassoglou, & Pavlakis, 2017). To have a successful collaboration, nurses must have the autonomy to make and implement interventions. To meet this need, some organizations have instituted protocols that allow nurses to order a 12-lead ECG when symptoms signal a STEMI diagnosis.
Additionally, there is a significant economic health care cost associated with STEMI. In 2010, it was estimated that if an ED treated an estimated 2,500 patients annually with chest pain, the overall cost is approximately $7.8 million, which includes a telemetry bed, staff, and observation cost time (LaSalvia, Nadkarni, & Bal, 2010). In 2008, the average cost of a patient hospitalized with a primary STEMI diagnosis was $29,840 to $22,901 based on an individual's specific hospital needs (Wang, Zhang, Ayala, Dunet, & Fang, 2013). With complications that may arise from the infarction—such as heart failure, stroke, atrial fibrillation, and cardiogenic shock—these costs may increase dramatically. The sooner the STEMI is recognized, intervention can be initiated and potential complications may be prevented, thereby decreasing potentially lengthy hospital stays and patient cost.
Knowles developed an adult learning theory and identified six different assumptions, including self-concept, past learning experience, readiness to learn, orientation to learning, need to know, and internal/external motivation (Knowles, 1984). These assumptions were based on the maturing adult and discussed the process of learning, instead of the aims of learning. Applying this to participating RNs means that they should be self-directed, motivated, ready to learn, willing to use their best judgment, and collaborate with the patient's care team. The pretest–posttest was developed based on this andragogical approach. Questions focused on understanding the process of recognizing ST elevation on an ECG suggestive of STEMI so that early intervention can be initiated. In addition, Knowles maintained that education must be flexible, as adult learners value independence and freedom to meet their goals (Rose et al., 2016). Therefore, the method of delivery was considered to increase access and ease of completion of the module. Hence, a social media platform became part of the delivery method.
Participants and Setting
This study took place at a 772-bed, midwestern U.S. urban teaching hospital with 73 private rooms in the ED. At the time of the study, the standard of practice within the organization was to have an ED technician complete the ECG if a patient arrives via walk-in or ambulance triage with the symptom of chest pain. After the ECG is done, the ED technician routes the ECG to an ED physician to interpret. This process varies in time, up to several minutes and separates the patient story information from the provider interpreting the ECG.
A convenience sample was used targeting ED nurses as there were more than 125 RNs employed, representing a large opportunity for change and significant sample. Participants were recruited mainly from the ED and a 23-hour observation unit on all shifts. However, there was a significant amount of interest from nurses outside these departments. Therefore, the decision was to open the project to any RN who wished to participate.
Phases of Development of the Education
Institutional review board approval was obtained and the board gave written consent to conduct this project. This project was exempted from requiring institutional review board approval because it was a voluntary project involving the use of educational tests. The identity of participants, as well as any pertinent demographic information, was kept confidential to protect human subjects.
This project was initially presented to the ED and 23-hour observation-unit RNs, with interest generated in daily huddles and via signage in the locker and break rooms. In addition, as research has found that nearly three quarters of U.S. adults and 94% of 18- to 24-year-old adults are active in forms of social media, including You-Tube (73%) and Facebook® (68%). A direct link to the project was given via Facebook, which had the Qualtrics® survey and YouTube video embedded (Smith & Anderson, 2018). This tactic steered participants to the project link, as well as their organizational e-mail if they desired to gain additional information. The link was available for a period of 3 weeks and took anywhere from 1 to 2 hours to complete the education program. To receive continuing education (CE) credit, participants had to watch the educational video and complete a pretest and posttest. All RNs employed during the project period who were currently active employees were included.
The 10-question pretest consisted of three basic concepts:
- Does the learner understand what ST elevation means?
- Can the learner recognize contiguous leads and elevation?
- Does the learner have knowledge of importance for early intervention?
The education intervention was reviewed by two clinical experts in the cardiology field who are both practicing providers and university faculty. At the end of the educational program, a posttest was given using the same questions as the pretest. Demographic information was also collected, including prior experience reading 12-lead ECG, age, work experience, and highest level of education.
Due to budgetary constraints, the educational program was not allowed to be mandatory for RNs, as this would require work time and compensation. Consequently, it was decided that user-friendly access through current social media platforms and free CE should encourage adult learners to participate. The objectives were written with the current ECG process in mind, and a presentation was developed and delivered as a YouTube video. Qualtrics, a software survey system, was used for the pretest and posttest development and platform. This software also had the capability of embedding the You-Tube video within the survey. For the purpose of obtaining CE to increase participant motivation, an arbitrary score of 80% of correct posttest items was required to successfully pass for CE credits.
Data were analyzed with SPSS® Base version 22.0, and the level of significance for each test was preset at .05. The participant nurses' baseline knowledge was evaluated with a pretest immediately prior to the educational program with the cut off benchmark of 80 used as this was the passing rate required on the posttest. It is important to note the score of 8 of 10 was an arbitrary number, but was consistent with the CE approval agency and used for this purpose. Additional analyses for this study included descriptive statistics and mean scores. A one-way t test was used to analyze the pretest whereas a paired t test was used to analyze the posttest.
A total of 101 RNs completed the pretest. Seventy-three percent of the participants were female and 44.1% were between 30 and 39 years old. The vast majority of participants (70.6%) had been a nurse for longer than 5 years and 52.9% held an associate degree and worked the day shift (58.8%). Furthermore, 61.8% were employed in the ED, with the remaining in the intensive care units (14.7%), 23-hour observation (8.8%), medical–surgical floors (5.9%), and 8.8% were unidentified (Table 1). Of these 101 RNs, 37 (36.67% completion rate) completed the posttest and evaluation to finish the program and obtain their CEs. The low completion rate may be attributed to the fact that participants were mandated to watch a 1 hour-long video before completing the posttest and evaluation. Data regarding viewing time were not able to be tracked. There may have been a much larger group of nurses who watched all or a portion of the video. Participants were not allowed to use work time to complete this program as it was considered a pilot program; therefore, this was all self-paced.
Demographics of the 34 Final Participants
Educational Video Effectiveness
The first objective of the study was to assess the nurses' baseline knowledge of STEMI recognition on 12-lead ECGs with a pretest immediately prior to the educational program. The mean of the 10-question pretest was 7.53 of 10 and was found to be statistically significant, with a p value of .028. As previously mentioned, 101 RNs completed the pretest. Respondents understood when to obtain an ECG (88.8%) and how to define an MI (87.9%). Questions that depicted the location of the STEMI also scored well, with 87.9% recognizing an inferior STEMI and 81.1% recognizing a lateral STEMI. Scores were poor regarding the fundamentals of STEMI recognition. Only 62.6% understood the number of contiguous leads, 63.9% defined the J point, and 50% knew the anatomy and lead correlation.
The second objective was to evaluate the nurse-acquired knowledge of the educational program in using a 10-question posttest immediately following the online program. Of the 101 RNs that participated, 37 completed the pretest and the posttest to receive their CEs and finish the program. There was a significant improvement in the pretest score to the posttest score with an average posttest score of 9.11 of 10 (t = 6.273; p = .000), with 91.3% of participants able to define an MI and 97.3% understanding when to obtain a 12-lead ECG. Scores regarding the fundamentals of STEMI recognition did improve, with 89.2% identifying the number of contiguous leads and 91.9% understanding the importance of the J point. Demonstrating the correlation between the leads and the anatomic wall improved to 75.7% but was not statistically supported (Table 2).
Pretest and Posttest Findings
The intent of this study was to increase nursing's knowledge on accurate and timely identification of an ECG suggestive of a STEMI. Overall, this program was well received. Many participants felt more comfortable looking at 12-lead ECGs for STEMI after the presentation and applying this knowledge to their patient population. In their comments, they wrote “this was a great tool,” and that they were excited to implement it into their daily patient care. The number of participants from departments other than the ED indicates that the information presented would be useful throughout the organization. The number of participants who had been a nurse for longer than 15 years, as well as the number who participated with previous ECG experience, demonstrates a need for ongoing nursing education. The high percentage of associate degree nurses, with many of them longer-term employees, supports that this 12-lead ECG training can cross various educational preparations.
Expanding the recruitment efforts to social media did increase participation rates and should be considered in future endeavors. Social media participation is a phenomenon that is heavily used and should be considered as a means of recruitment in educational programs (Ventola, 2014). The use of social media and the manner in which the program was set up for this project made the test easy to access.
Understanding nursing's baseline knowledge of STEMI recognition as the pretest was the first study aim. Participants performed well in locating where the STEMI was. However, the corresponding leads were next to each answer choice. There was a lack of understanding in the fundamentals of STEMI—locating the J point, requiring contiguous leads, anatomy, and lead correlation. These scores were lower than the other questions and would need to be emphasized when the module is updated. Most likely, having the contiguous leads included in the location of the STEMI questions did not translate well into the understanding of contiguous leads. This may have made it easier to find which part of the anatomy the STEMI occurred in and may have affected the STEMI scores.
The second study aim was to evaluate nurse-acquired knowledge of the educational program using a posttest. Based on the overall scores obtained, it can be assumed that after viewing the video, most participants sufficiently understood the STEMI information and thus scores showed improvement. However, not all key information was reflected in the results. This indicates the need for ongoing 12-lead ECG education.
There were several limitations within the structure of this project. The assumption that as adult learners RNs would participate to obtain CEs did not appear to drive this sample. Because it was not an organizational mandate and had to be done on their own time, only a small number of RNs completed the posttest. The failure to anticipate that participants could share the link with colleagues limited the ability to define the demographics of the final group accurately. However, participants could say that they saw value in the project as they shared it with colleagues. Another limitation was that the pretest and posttest were not force-linked, which could have increased the posttest completion. Because the project had a direct pretest link, there is no way to describe the group who completed the whole module or only parts. There was no data analysis to see if merely taking the pretest raised scores on the posttest without viewing the video. The final question is: Did the inclusion of the contiguous leads on the possible STEMI questions influence the improved scores? The answer is unknown.
Millions of people present to the ED every year with chest pain. Although there are several elements needed to diagnose an infarction correctly, 12-lead ECGs are one essential diagnostic tool used in the identification of STEMI. RNs are well-placed to recognize potential complications before they occur. It is well within their scope of practice to read ECGs and recognize potential lethal cardiac rhythms, such as ST segment elevation.
This study demonstrated that with education, RNs can identify STEMIs on a 12-lead ECG, and early screening of 12-leads potentially could identify true cardiac chest pain and acute myocardial infarction. Use of nurses to screen ECGs in ED triage or outside of the ED in inpatient hospital units may potentially increase early identification and potentially have a positive impact on clinical outcomes (O'Gara et al., 2013). The clinical significance of educating RNs in the use and interpretation of 12-lead ECG via educational modules throughout organizations is both feasible and wise. Using social media as a recruitment tool for participation seems to be an effective model. Tighter controls and forced viewing completions for the purpose of accuracy in evaluation would require RNs who participated to be better equipped to recognize ST elevation leading to rapid patient intervention. With ongoing nursing education, RNs could make a clinical difference in patient outcomes.
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Demographics of the 34 Final Participants
|Years as an RN|
| 0 to 5||10||29.4|
| 6 to 10||11||32.4|
| 11 to 15||5||14.7|
|Worked as a paramedic|
| Emergency department||21||61.8|
| Observation/clinical decision||3||8.8|
| Intensive care||5||14.7|
|Prior ECG education|
|Prior ECG education|
Pretest and Posttest Findingsa
|Question||Pretest Number Correct (n)||Pretest %||Posttest Number Correct (n)||Posttest %|
|Number of contiguous leads||62||62.6||33||89.2|
|Definition of MI||87||87.9||36||97.3|
|Importance of J point||62||63.9||34||91.9|
|Factors of obtaining ECG||87||88.8||36||97.3|
|First line intervention||82||82.8||35||94.6|
|Anatomy and lead correlation||49||50||28||75.7|
|Recognition of STEMI||78||81.3||31||83.8|