Continuous ECG Monitoring from Theatre to Recovery Assignment Sample

Continuous use of electrocardiogram (ECG) from theatre throughout recovery 

Introduction: Continuous use of electrocardiogram (ECG) from theatre throughout recovery

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The student Operating Department Practitioner (ODP) will reflect on a service improvement proposal relating to the local trust Post Anaesthetic Care Unit (PACU). Information relating to the local trust, personnel, and service users will be respected and kept confidential in line with the Health and Care Professionals Council (HCPC,2021), The General Data Protection Regulation (GDPR), and the Data Protection Act 2018 (DPA). Verbal consent was obtained from the local trust to authorize the student to conduct this proposal (HCPC, 2021).

The proposal will focus on the continuous use of an electrocardiogram (ECG) from the theatre throughout recovery to monitor the patient's cardiac rhythm (Foran, 2020). In addition, this piece of work will explore the use of preventative cardiac monitoring as a safe and reasonable measure to identify any post-anesthetic arrhythmia, even in healthier patients (Daley and Huff, 2010).

Additionally, in this reflective journal, Gibbs's Reflective model will be used to address the experiences and knowledge being gathered by the student regarding the use of ECG in anesthetic and post-surgery periods in a healthcare organization.

Discussion

Gibb’s Reflective Model

Description

The student observed a transfer and handover from theatre to recovery and noticed that the patient was connected to regular monitoring. Additionally, the student also noticed that the health care practitioner is using ECG to improve the outcome throughout the patient's recovery. In fact, on the last day case on the list went into persistent AF, and then ECG was re-applied. Here it can be mentioned that, despite the widespread use of CA or catheter ablation therapy, AF or atrial fibrillation is one of the beneficial initiatives by healthcare professionals to treat patients who are suffering from persistent AF. The benefit of using a surface electrocardiogram or ECG along with an EGM or intracardiac electrogram is to measure the characteristics of AF complexity and predict the lack of AF recurrence (Santangelo et al., 2021). However, during the recovery period, the student observed that the ECG was removed for the patient, and the practitioner recommended keeping the patient under observation with ECG monitoring at the last date. As a result, the surgeon requested that the patient be kept overnight for observation. If The Association of Anaesthetists’ Guidance (AAGBI, 2021) had been followed accordingly and the patient had come from the theatre with all recommended monitoring, the abnormality would have been recognized and addressed earlier.

The ward was phoned for a bed, but there was no space. Recovery continued to look for other options to try and accommodate the patient for overnight observation. It was discussed that the patient could be transferred to a different hospital as a last resort.

Feelings

The student felt confused as to why ECG was not utilized throughout the patient journey, as it can have a positive impact on patient safety. The student feels confident that the proposal will ensure optimal use of the equipment and will help with the early identification of complications to improve patient outcomes.

Evaluation

The AAGBI (2021) and Daley and Huff (2010) refer to ECG as an essential minimal standard of monitoring for detecting cardiac abnormalities, which can contribute to and improve patient outcomes. Additionally, Foran (2020) proposes that constantly observing ECG rhythm strips should be a valuable learning tool for nurses.

It's significant to note numerous cardiac diseases relevant to perioperative care, such as regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow blockage, and pulmonary hypertension. Considering the current clinical situation, it can be seen that after the structured training about the use of the ECG tool following the concept of enhanced recovery after surgery care model, clinicians, and other healthcare professionals can acquire proficiency in getting or performing cardiac ultrasound image acquisition.

Watkins and White (2001) claim that generally healthy patients need less monitoring due to the low risk of complications, and therefore they are fast-tracked and typically no ECG is used in their recovery. On the contrary, Daley and Huff (2010) state that ECG monitoring contributes to the early detection and diagnosis of post-anesthesia arrhythmia and other unexpected adverse outcomes and, therefore, should be used as a common practice in all adult patients, including patients ASA I (Santangelo et al., 2021). Daley and Huff (2010) argue that regardless of their ASA grade, all patients are still at risk from post-anesthesia arrhythmia or cardiac events due to these side effects of anesthesia and reversal agents.

The same argument is also supported in Foran's (2020) discussion paper, where she highlights several advantages of using ECG on all patients regardless of the ASA grade, which includes the identification of asymptomatic Cardiac conditions after non-cardiac surgery (MINS). Moreover, she states ECG can save precious minutes during a cardiac arrest (Foran, 2020). However, Daley and Huff (2010) suggest that using ECG can have negative consequences, such as device-related pressure injury, skin irritation, and damage. Some patients have a sensitivity and, in more severe cases, allergic contact dermatitis (ACD) to Acrylate, which is an adhesive present in electrode dots. Lyons and Nixon (2012) presented their case study as the first case of ACD to electrode dots reported in the literature. In addition, elder patients who have dry and frail skin are at risk of Medical adhesive-related skin injury (MARSI), which happens when the skin comes in contact with a medical adhesive like dressing, tape, and ECG dots (Coleman and Nielsen,2019). According to the American Society of Echocardiography or ASE,  the continuous oscilloscopic ECG is now considered one of the most widely used anesthetic monitoring tools. Cardiac arrhythmias nowadays occur during anesthesia and surgery in 89 percent of hospital and operative cases. The benefit of using the ECG as a tool is that it displays the arrhythmias, which can detect the onset of any myocardial ischemia or electrolytic imbalance in patients during the recovery period (Higashi et al., 2020).

Additionally, the student observation at hospital care regarding the use of ECG to measure AF or atrial fibrosis, it can be stated that ECG is also an important tool to monitor the function of a pacemaker if installed within the body of the patient. With this tool, nurses and professionals at ODP can use the simple ultrasound equipment and basic model or echo-cardiogram (B-mode, color Doppler method) and spectral Doppler straining image system to measure the cardiac status of the patient after any acute surgery (Rostagno, 2022). To evaluate the importance of using ECG monitoring in threat, as per the student observation, the 12 lead ECG recording can provide much more information about the onset of any cardiac arrest or suspected cardiac disease for the patient to his healthcare providers. 

Analysis

There is a consensus among researchers that ECG is an essential monitoring tool and it should be used as standard basic monitoring for all patients. Still, in practice, practitioners exercise their discretion in the use of this piece of monitoring (Craig and Hatfield, 2020), (AAGBI, 2013). Singh and Peter (2016, p.24) claim that ECG has proven to be a vital tool because it offers a portal into the electrical behavior of the heart. In contrast, another study argues that there is insufficient evidence of the benefits of routine ECG monitoring and raises the question if ECG should be used selectively in some instances or as routine monitoring in all cases (Schull and Redelmeier, 2000). According to Lenk et al. (2019), The heart's electrical activity is captured by the ECG. It cannot be used to measure cardiac output or blood pressure and does not offer information about the mechanical operation of the heart. Regular measures of blood pressure, pulse, oxygen saturation, peripheral perfusion, and end-tidal CO2 concentrations are typically used to evaluate cardiac function when under anesthesia. Swan Ganz catheters or oesophageal Doppler techniques are occasionally used to monitor cardiac performance directly in the operating room, but this is uncommon (Rostagno, 2022). So as per the student observation at the Anaesthetic and Acute care service, the ECG monitor should always be connected to the patient before anesthesia or when the patient is in the recovery stage after any significant surgery. This will allow the anesthetist and/or healthcare professionals to detect any changes in the appearance of ECG or AF.

A study conducted by Lyons and Nixon (2012), where acrylate-based ECG electrodes from multiple companies were patch-tested, demonstrates the occurrence of adverse reactions in patients as a result of an allergen contained within the electrodes. This can occur because medical adhesives are common skin sensitizers and can trigger an allergic reaction (Fumarola et al, 2020). However, it is argued that although the electrodes can have adverse effects in rare cases, as shown in Lyons and Nixon's (2012) study, alternative options for safer monitoring, such as acrylate-free electrodes, also exist.

In addition, Coleman and Nielsen (2019) state that another negative consequence of MARSI is preventable in way that all practitioners must exercise judgment, consider the risk factors, and record any adverse reactions to the medical adhesive to ensure that the patient is not re-introduced to the same medical adhesive. Skin care and prevention strategies are fundamental aspects of patient care. Therefore the adverse effects on the skin due to ECG monitoring usage should be avoided and minimized wherever possible (Fumarola et al, 2020).

Fumarola et al., (2020) recommend using preventative measures such as daily moisturizing skin care, skin barriers, and adhesive removers to protect skin integrity. If these recommendations are not followed, patient safety and quality of life can be compromised, which can lead to an increase in healthcare costs and prolonged hospital stays (British Journal of Nursing, 2021).

ECG monitoring is currently available if needed but applied only when the patient is classified as a high risk due to previous cardiac history (Daley and Huff, 2010). A similar view is shared by the consultants from the American Society of Anesthesiologists (ASA, 2013), who acknowledge that routine ECG monitoring may not be necessary for all patients and that all procedures depend on a case-by-case basis. In contrast, another view was identified within the same study that all patients can benefit from routine pulse rate, blood pressure, and ECG monitoring as this can detect complications and thus reduce adverse outcomes during the recovery period (ASA, 2013).

Despite ECG being highly recommended practice throughout the patient journey, there is not enough evidence in favor of cardiac monitoring being used as a good practice for all patients or against the practice not being performed consistently (Daley and Huff, 2010).

Generally, a change in practice might face some resistance initially. Still, examples such as the Australian patient safety initiative to challenge the professionals` ideas on ECG implementation policies show that once the change has been introduced and communicated well to professionals, they are willing to follow it and implement it continuously (Foran 2020).

Using ECG continuously throughout the patient’s journey from theatre to recovery will not require any extra resources or costs as applied in theatre (Wheeler et al, 2010).

Conclusion

Removing the ECG during transfer has left the student confused about why it was done even though it had to be used again later. The student felt that by keeping the ECG electrodes, practitioners would reduce waste and also reduce the reaction time in case of an emergency. Moreover, using ECG monitoring throughout the patient journey can help prevent any adverse outcomes, and it can save precious minutes during a cardiac arrest (Foran, 2020). There might be a risk of skin irritation and MARSI. However, those risks can be mitigated with proper skin care.

All in all, continuous monitoring is beneficial for all patients, as it is non-invasive, and all the perks outweigh any risks. A common arrhythmia usually occurs during the anesthetic and surgical periods. In such a period, P waves are absent, and uncoordinated atrial depolarisation is evident on ECG along with an irregular baseline. Therefore, monitoring the ECG can help professionals to detect any kind of sepsis, electrolytic disturbance, presence of myocardial diseases, or Ischaemia, during surgery or the recovery period (Lenk et al., 2019). 

As a student, it can be stated that ECG traces can be obtained by the electrodes attached in various positions. Therefore, before using ECG Post Anaesthetic and Acute care services, every nurse and healthcare professional should gather in-depth knowledge about how to use ECG monitoring tools.

Action plan

The student proposal aims to improve patient care in recovery following the 6Cs. Research suggests that embedding the vision and actions of the 6Cs into research care and management would further enhance the quality of care (British Journal of Nursing, 2015).

The student thinks the proposal can be discussed during a clinical governance meeting since the main aim of clinical governance is to continuously enhance the NHS's quality of services and maintain high standards of care (Clinical governance, 2022).

To develop more in-depth knowledge and understanding about the benefits of using ECG in Post Anaesthetic and Acute care, the student must go through a training process by following the rules:

1. Set up guidelines in the realm of echo-cardiography, echo-cardiogram, and AHA guidelines
2. Set up a training program about the preoperative assessment process for the perioperative management plan
3. Set up training to use and monitor ECG in real-time and at OPD

The student suggests that it would be good to have ECG as a preventative measure that allows practitioners to monitor patients' heart rhythms to help prevent cardiac events and post-anesthesia-developed arrhythmias (Daley and Huff, 2010). According to AAGBI (2021), ECG should be part of the minimal monitoring until the patient is discharged from PACU. It is evident that the if followed this proposal can be a long-term improvement in patient care in PACU (Foran, 2020)

Overall conclusion

This proposal is driven by a situation that the student witnessed and suggested that the ECG electrodes should be left attached to the patient during the entire patient journey. The paper outlines the benefits of the practice change, and it also examines any possible disadvantages and negative impacts on the patients' health. Different studies state that any risks can be mitigated with proper care and judgment. However, there is no hard evidence for and against that procedure change, especially for healthier patients, and at the end of the day, the interpretation of the guidance and its implementation in practice is all down to practitioners’ discretion.

Reference

British Journal of Nursing, 2015. Embedding the 6Cs into clinical research practice and management. pp.365-367.

British Journal of Nursing, 2021. Preventing medical adhesive-related skin injury (MARSI). 30(15), pp.1-5.

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