Is Nurse Interpretation of the ECG QRS Width Reliable?

Tonia Zimmerman, Michael C. Beuhler, William Kerns

Electrocardiogram (ECG) data are critical in formulating management strategies following sodium channel antagonist overdose. Poison centers frequently rely on verbal reports of the ECG obtained from bedside nurses. No previous study has addressed the quality of ECG data obtained in this manner. Therefore, we sought to test the ability of nurses to recognize and measure a widened QRS complex, the hallmark of myocardial sodium channel toxicity. Thirty-six emergency department and critical care nurses employed at a tertiary care hospital participated in this prospective study. The study subjects were divided into three groups and asked to interpret 12 ECGs (five normal and seven wide QRS). For each ECG, participants (1) determined if the QRS was narrow or wide and (2) measured the QRS duration. The groups differed in delivery of instruction regarding QRS measurement. Group 1 received visual instructions; group 2 received scripted verbal instructions, and group 3 served as controls, receiving no specific QRS measurement instructions. The nurse data was compared with physician interpretation (consensus of three physicians). Between-group analysis tested for impact of potential real-time educational intervention. Overall, the nurses identified a wide QRS complex most of the time (77%), but had difficulty in accurately measuring the QRS duration (44%). Real-time visual or verbal instruction did not improve accuracy (p = NS between groups). The results suggest that verbal ECG data from nurse callers is not sufficient to make an accurate clinical assessment in the setting of sodium channel poisoning.