ECG for All Patients in the PACU: Some Say, Why? I Say, Why Not?

Volume 33 Issue 2 Article 6

6-1-2020

ECG for all patients in the PACU: Some say, why? I say, why not?

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Recommended Citation Foran, Paula (2020) "ECG for all patients in the PACU: Some say, why? I say, why not?," Journal of Perioperative Nursing: Vol. 33 : Iss. 2 , Article 6. Available at: https://doi.org/10.26550/2209-1092.1087 https://www.journal.acorn.org.au/jpn/vol33/iss2/6

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Author Dr Paula Foran ECG for all patients in the PACU: PhD, RN, FACORN, FACPAN, MACN Some say, why? I say, why not? Abstract Currently in many Australian hospitals, electrocardiogram (ECG) leads are removed after the operative process and, despite the machines being freely available in the Post Anaesthesia Care Unit (PACU), they are not connected to all patients. There are many evidence-based reasons why an ECG would be advantageous for perioperative patient safety, including the detection of often asymptomatic conditions such as myocardial injury after non-cardiac surgery (MINS) and new-onset atrial fibrillation, which has been shown to increase the risk of stroke. Advantages may also be seen in saving precious minutes in a cardiac arrest, and the ability for nurses to constantly observe ECG rhythms strips as a learning tool. The aim of this discussion paper is to challenge health care professionals’ thinking about the use of ECG monitoring for the entire perioperative journey and inspire readers to implement this patient safety initiative. Keywords: arrythmia detection, atrial fibrillation, monitoring, PACU, perioperative safety, stroke. Introduction safest perioperative journey for all patients without differentiation. We In October 1997, at South West assumed that when new monitoring Healthcare in Warrnambool, a became available, all other Australian Victorian regional health care health care facilities would do facility, we proudly moved into our the same. Perhaps because of our new operating suite. The new PACU regional locality, it was many years was fitted with state-of-the-art later that we realised this was not monitoring for every bay, something the case. quite new for the times. At that time, I was one of the associate While internationally commonplace, charge nurses for the PACU. In ECG monitoring is not currently consultation with the perioperative mandatory for PACU patients in service manager, we believed that Australia, despite several nursing now we were provided with this new texts recommending this practice1,2. equipment, we would connect all However, a growing number of health available monitoring capabilities, care facilities in Australia have including pulse oximetry, 3-lead recognised the great advantages electrocardiogram (ECG) and of ECG monitoring and have automatic blood pressure monitoring, implemented 3- or 5-lead ECG to our patients. Monitoring was rhythm strips as standard monitoring connected to all patients in stage 1 for all post-operative patients in PACU, regardless of age or procedure. stage 1 PACU. It was felt that if we distinguished This discussion paper will investigate between patients, this may become evidence surrounding why ECG a difficult decision for staff, and monitoring in the PACU would be with the realisation that, albeit rare, a valuable addition, providing a cardiac events can occur in healthy safer standard of care for Australian patients, we wanted to ensure the

e-26 Journal of Perioperative Nursing Volume 33 Number 2 Winter 2020 acorn.org.au patients. This will be presented under South Africa revealed comparable reminds us that, while uncommon, four themes: results to the VISION cohort5. cardiac arrests occur during the perioperative journey9. Findings 1. myocardial injury after non- New onset perioperative atrial revealed that 28 arrests occurred cardiac surgery (MINS) fibrillation (AF) and stroke intra-operatively, five in the PACU and 2. new onset perioperative atrial Salient research conducted by three post-operatively on a ward9. Of fibrillation (AF) and stroke Gialdini et al. in 2014 informed us these, 15 cases involved emergency 3. cardiac arrest that new-onset perioperative AF surgeries, three were semi-elective is the most common arrhythmia but the majority, 18 cases, occurred 4. looking and learning. reported in perioperative patients6. during routine elective surgery When commencing their research revealing that all patients are at Discussion into perioperative AF, this common risk9. These figures are not surprising The PACU was first developed in arrythmia had been viewed as a when we remember that many 1751 by surgeons who realised their self-limited transient response to of the complications seen in the immediate post-operative patients physiological stress, however the operating suite, such as hypothermia, were unstable and would require a long-term risk of stroke after AF hypoxemia and hypovolemia, are safe environment where they could was unclear6. Findings revealed known causes of cardiac arrest. be carefully monitored by specialist that from a cohort of 1 729 360 One of the core nursing nurses until they were deemed eligible patients, 24 711 (1.43%; 95% competencies that stage 1 PACU ‘ward ready’3. Despite updates in CI, 1.41%–1.45%) were diagnosed with nurses are required to meet is anaesthesia and surgery, the role new-onset perioperative AF during advanced life support (ALS), including of the PACU nurse has remained their perioperative journey with paediatric ALS if paediatric patients relatively unchanged; it requires 13 952 (0.81%; 95% CI, 0.79%–0.82%) are cared for in the PACU10. In any attention to critical evaluation and experiencing a stroke after discharge. medical emergency, early recognition stabilisation of immediate post- These findings included both cardiac is believed to be the most essential operative patients with an emphasis and non-cardiac participants6. A step to a positive outcome11. When on the need for anticipating, recent systematic review including patients are not connected to ECG recognising and, hopefully, 3 536 291 patients from fourteen in the PACU and the patient suffers preventing complications3. In many studies conducted by Australian a cardiac arrest, minutes may be health care facilities only high-risk researchers supported the previous wasted confirming an arrest has patients are connected to an ECG in findings revealing a 2.5-fold increase occurred; however, when an ECG trace the PACU. in stroke after new-onset AF in confirms a shockable rhythm such as non-cardiac patients7. Interestingly, ventricular tachycardia or ventricular Myocardial injury after non- it was revealed that an increased fibrillation, nurses immediately know cardiac surgery (MINS) trend in the AF was noted in studies what they are dealing with and vital where continuous, as opposed to A large multicentre, international minutes may be saved. Connecting ‘opportunistic’, cardiac monitoring trial conducted in 2012 (Vascular a patient to an automated external was employed7. Recent Japanese Events In Non-cardiac Surgery defibrillator (AED) at the earliest research revealed that of non-cardiac Patients Cohort Evaluation study – possible moment is vital for patients patients who experienced new- VISION) investigated the mortality who require this therapy, as survival onset AF, 92 per cent of subsequent associated with perioperative rates decrease by approximately episodes were asymptomatic8 elevated troponin levels in patients seven to ten per cent every minute providing further evidence that ECG (n=15,133) from North and South without defibrillation12. America, Australia, Europe and Asia4. monitoring of all patients in PACU The 30-day mortality was found to would provide greater patient safety Looking and learning be independently associated with in the ability to diagnose AF post- Much of the learning involved in MINS and 84 per cent of myocardial operatively. interpreting abnormal arrythmias is injury patients were asymptomatic, Cardiac arrest to first understand what is normal. resulting in missed diagnosis in the This occurs by regular observation of vast majority of patients with MINS4. The Victorian Consultative Council a normal ECG trace. When unstable More recent research conducted in on Anaesthetic Mortality and patients or those with a known Morbidity Triennial report 2015–2017 cardiac condition are admitted to the

Journal of Perioperative Nursing Volume 33 Number 2 Winter 2020 acorn.org.au e-27 PACU and staff are asked to connect throughout the entire perioperative 5. Coetzee E, Biccard B, Dyer R, Meyersfeld an ECG to a patient, if the PACU nurse journey. N, Chishala C, Mayosi B. Incidence of myocardial injury after non-cardiac surgery: has not been regularly observing This discussion paper has provided Experience at Groote Schuur Hospital, normal ECG rhythms, and maintaining information about learning Cape Town, South Africa. S Afr Med J familiarity with the diagnosis of 2018;108(5):408–412. DOI: 10.7196/SAMJ.2018. and evidence related to several arrythmias, it is likely they may have v108i5.12784. cardiovascular conditions that are lost some of their skills. 6. Gialdini G, Nearing K, Bhave P, Bonuccelli asymptomatic and may be present U, Iadecola C, Healey J et al. Perioperative There has never been a more salient in seemingly uneventful surgical atrial fibrillation and the long-term risk of time to remember that PACU nurses procedures. In many health care ischemic stroke. JAMA 2014;312(6):616–622. DOI: 10.1001/jama.2014.9143. are often asked to care for unwell facilities early signs of these 7. Koshy AN, Hamilton G, Theuerle J, Thijs V, patients. The COVID-19 pandemic is conditions may be missed as patients Farouque O. Postoperative atrial fibrillation a perfect example with many PACU are not connected to ECG monitoring following noncardiac surgery increases risk nurses being asked to upskill and in the PACU. of stroke. Am J Med 2020;133(3):311-22. DOI: work in either high dependency or doi.org/10.1016/j.amjmed.2019.07.057. Despite all the evidence, the most intensive care units. This is evidenced 8. Higuchi S, Kabeya Y, Matsushita K, Arai N, resounding and salient point in Tachibana K, Tanaka R et al. Perioperative by the funding being provided this debate for me was born from atrial fibrillation in noncardiac surgeries by the Australian government for a discussion with several health for malignancies and one-year recurrence. 20 000 eligible nurses to undertake Can J Cardiol 2019;35:1449e56. DOI: 10.1016/j. care workers, one of whom was the SURGE (Specialised Upskilling cjca.2019.07.008. a consumer representative. The and RN Growth through Education) 9. Safer Care Victoria. Victorian Consultative consumer representative asked, ‘If Council on Anaesthetic Mortality and Critical Care program13. Having been you have a piece of monitoring Morbidity: Triennial report 2015–2017. personally involved in the project that is free, does not have Melbourne: State of Victoria; 2019. and having had conversations with contraindications, and may detect 10. Australian and New Zealand College of many of my PACU colleagues, those Anaesthetists (ANZCA). PS04BP Statement abnormalities, why would all patients who have been accustomed to using on the Post-Anaesthesia Care Unit: not be allowed to benefit from Background paper[Internet]. Melbourne: ECG in the PACU are thankful for this?’ As we are all the elderly and ANZCA 2018 [cited 2020 May 9]. Available this additional skill which has made potential perioperative patients of from: www.anzca.edu.au/documents/ the transition to recognising more ps04bp-statement-on-the-post- the future, perhaps it is time for us to complex arrythmias easier. anaesthesia-care-unit.pdf. reconsider this issue as consumers. 11. Hambrecht K. Cardipulmonary resuscitation: Conclusion Basic and advanced life support. In: References Brown D, Edwards H, Buckley T, Aitken R, editors. Lewis’s Medical-Surgical Nursing. Currently, my minimal clinical 1. Foran P. Postoperative care. In: Brown D, Marrickville: Elsevier Australia; 2019, pp. workload allows me to continue Edwards H, Buckley T, Aitken R, editors. 1936–1968. my patient care in the PACU. One of Lewis’s Medical-Surgical Nursing. 12. Szabó Z, Ujvárosy D, Ötvös T, Sebestyén my first missions on commencing Marrickville: Elsevier Australia; 2019. V. Handling of ventricular fibrillation in 2. Schlick L. Assessment and monitoring of the new employment some three years the emergency setting. Front Pharmacol. perianaesthesia patient. In: Odom-Forren 2020;10(Article number 1640). DOI: 10.3389/ ago was to politely discuss the J, editor. Drain’s Perianaesthesia Nursing: A fphar.2019.01640. introduction of ECG monitoring into Critical Care Approach. 7th ed. Philadelphia: the PACU with every anaesthetist Elsevier; 2017. p. 357–384. 13. Australian Government Department of Health.Training more nurses for critical who would listen. While this often 3. Foran P, Nilsson U. Post-Anaesthesia care [press release]. Canberra: Australian Recovery. In: Aitken L, Marshall A, Chaboyer initially fell on deaf ears, after some Government Department of Health; 2020. W, editors. Critical Care Nursing. 4th ed. time the director of anaesthetics and Chatswood: Elsevier Australia; 2019. the perioperative service manager 4. Devereaux P, Chan M, Alonso-Coello P. agreed to initiate this practice Association between postoperative change. Once introduced, this was troponin levels and 30-day mortality among amazingly painless and seamless patients undergoing noncardiac surgery. JAMA 2012;307(21):2295–2304. DOI: 10.1001/ for all and has continued as routine jama.2012.5502. PACU monitoring for the past 18 months. Patients arrive in PACU with monitoring attached that has been connected from the anaesthetic room, allowing monitoring

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