心电图监测实践标准的实施与护士知识、护理质量及患者结局的关联：心电图最新标准实际应用（PULSE）试验的结果
Association of Implementation of Practice Standards for Electrocardiographic Monitoring With Nurses' Knowledge, Quality of Care, and Patient Outcomes: Findings From the Practical Use of the Latest Standards of Electrocardiography (PULSE) Trial.
作者信息
Funk Marjorie, Fennie Kristopher P, Stephens Kimberly E, May Jeanine L, Winkler Catherine G, Drew Barbara J
机构信息
From the School of Nursing, Yale University, West Haven, CT (M.F.); Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami (K.P.F.); Department of Pharmacology and Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD (K.E.S.); Yale Center for Clinical Investigation, School of Medicine, Yale University, New Haven, CT (J.L.M.); Western Connecticut Medical Group, Danbury (C.G.W.); and Department of Physiological Nursing, School of Nursing, University of California San Francisco (B.J.D.).
出版信息
Circ Cardiovasc Qual Outcomes. 2017 Feb;10(2). doi: 10.1161/CIRCOUTCOMES.116.003132.
BACKGROUND
Although continuous electrocardiographic (ECG) monitoring is ubiquitous in hospitals, monitoring practices are inconsistent. We evaluated implementation of American Heart Association practice standards for ECG monitoring on nurses' knowledge, quality of care, and patient outcomes.
METHODS AND RESULTS
The PULSE (Practical Use of the Latest Standards of Electrocardiography) Trial was a 6-year multisite randomized clinical trial with crossover that took place in 65 cardiac units in 17 hospitals. We measured outcomes at baseline, time 2 after group 1 hospitals received the intervention, and time 3 after group 2 hospitals received the intervention. Measurement periods were 15 months apart. The 2-part intervention consisted of an online ECG monitoring education program and strategies to implement and sustain change in practice. Nurses' knowledge (N=3013 nurses) was measured by a validated 20-item online test, quality of care related to ECG monitoring (N=4587 patients) by on-site observation, and patient outcomes (mortality, in-hospital myocardial infarction, and not surviving a cardiac arrest; N=95 884 hospital admissions) by review of administrative, laboratory, and medical record data. Nurses' knowledge improved significantly immediately after the intervention in both groups but was not sustained 15 months later. For most measures of quality of care (accurate electrode placement, accurate rhythm interpretation, appropriate monitoring, and ST-segment monitoring when indicated), the intervention was associated with significant improvement, which was sustained 15 months later. Of the 3 patient outcomes, only in-hospital myocardial infarction declined significantly after the intervention and was sustained.
CONCLUSIONS
Online ECG monitoring education and strategies to change practice can lead to improved nurses' knowledge, quality of care, and patient outcomes.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01269736.
背景
尽管连续心电图（ECG）监测在医院中普遍存在，但监测方法并不一致。我们评估了美国心脏协会心电图监测实践标准的实施对护士知识、护理质量和患者结局的影响。
方法与结果
PULSE（心电图最新标准的实际应用）试验是一项为期6年的多中心交叉随机临床试验，在17家医院的65个心脏科室进行。我们在基线、第1组医院接受干预后的第2阶段以及第2组医院接受干预后的第3阶段测量结局。测量期相隔15个月。两部分干预措施包括一个在线心电图监测教育项目以及在实践中实施和维持变革的策略。通过一项经验证的20项在线测试评估护士的知识（n = 3013名护士），通过现场观察评估与心电图监测相关的护理质量（n = 4587名患者），并通过查阅行政、实验室和病历数据评估患者结局（死亡率、院内心肌梗死以及心脏骤停未存活；n = 95884例住院患者）。两组干预后护士的知识立即有显著提高，但15个月后未持续。对于大多数护理质量指标（电极放置准确、心律解读准确、监测适当以及在有指征时进行ST段监测），干预与显著改善相关，且这种改善在15个月后得以维持。在3项患者结局中，只有院内心肌梗死在干预后显著下降且得以维持。
结论
在线心电图监测教育和改变实践的策略可提高护士的知识、护理质量和患者结局。
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