Our Expert Today Is Darlene Hutton.  Darlene has worked in CCU, ICU, PACU, and Emergency as a bedside nurse, educator, and manager. She is currently working as a Clinical Research Manager at Rouge Valley Metabolic Research Associates in Toronto. Darlene also is an Educational Consultant providing workshops, seminars, and conferences on such topics as ECG Interpretation, Dysrhythmia Interpretation, Acute Coronary Syndromes and Cardiology Drugs. She is also an ACLS Course Director and runs courses throughout the province. Her company, QRS Educational Services, founded 18 years ago, provides education to nurses and other health care professionals throughout Canada. She is also the Department Head for Emergency Preparedness in the O.R. in the American College of Plastic Surgical Nursing journal.

 

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Answer:

This is a great question and one that has been trialed a few different ways over the past 20 years by me.

At QRS Educational Services, we provide a one-day ECG Course that facilitates issues with time-constraint. This course nicely supplements the 12 week Coronary Care Level II offered at a few of the community colleges in the province on Ontario. This course also is a great stand alone for novices to experts. I stress that the novices will learn about a normal vs abnormal ecg. They may not be able to "label" or "diagnose"; however, they will be able to call the physician at 2am and describe what it is they see. For them, the objective is to learn the recognition and anticipated treatment of ST segment elevation, depression, T wave inversion. They will also learn the anticipated complications of the big inferior and anterior MIs. For those who are intermediate, I stress that their objective for the day is to get a better understanding of the bundle branch blocks, and the "why" of what they do. For example: why do you give saline boluses to the inferior MI who's blood pressure is low, but you have to give an inotropic drug to someone having an anterior MI with a low blood pressure. For the advanced nurses, mentors, educators who attend this day, they get another perspective of how to teach these concepts to newer staff, a Train the Trainer approach.

I have decided many years ago to drop the Axis determination component on the day for a few reasons. It takes about 15 minutes out of other concepts I feel are more important for the patient having an ACS and I feel that the relevance of an abnormal axis is so rarely a big deal. I do mention that for those who are more advanced in their ECG skills, I can gladly add the axis content at the end of the day, and sometimes a few people do stay behind to go over it. For those who are advanced, I explain what axis is and I explain the conditions that can make it become abnormal (many of which are not life-threatening) and I end with a quick and very easy method to assess if the axis is normal, right, left, or extreme. I have stopped using the approach of determining the actual degree of axis after working with many cardiologists who seemed to be just concerned with the fact it was abnormal not what the actual degree of abnormality was. I truly believe that for people to understand the important concepts of axis determination, we need to keep the topic as uncomplicated as possible. Easily done.

So to recap, this is what I feel are the important concepts to include in a day of ECG interpretation

 

-a systematic approach to ECG assessment (I use the RIRI approach: rate, intervals, rhythm, ischemia/infarction). The day follows this approach

 

-importance of a quick interval determination (normal or abnormal, is it a concern? AV Blocks, Bundle Branch Blocks, Long QT Interval)

 

-St segment determination

 

-what is ACS and how to treat

-what are the anticipated complications of the anterior and inferior MIs and why

 

-lots of practice

 

Last, I emphasize that for the novice, they will walk away with at 20% more information that what they walked in with. Many times, these people will take the year to put into place what they have learned. Then, I see them again the following year and despite the course being pretty much the same, they feel it's different. To them, it feels different because they're now learning the next 20% from what they've retained the previous year.

 

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