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Interactive cardiac monitoring

Alan Tulloch and Michael Fieldhouse
Curtin University of Technology, Western Australia
Cardiac monitoring and cardiac rhythm determination is an essential skill of health professionals working in critical care. Due to a lack of funds and equipment, teaching this topic in the university selling is currently fraught with difficulties. This project seeks to address these difficulties by providing a self directed interactive computer package reflecting the clinical setting. This program is based upon five modules that take the student from a review of cardiac anatomy and physiology through to coordinating the health care team in a cardiac arrest. The program aims to overcome the current difficulties and take the students learning to a new level.

The problem

This project was developed to overcome difficulties that were being experienced in the School of Nursing at Curtin University in the teaching of cardiac monitoring. The students in the undergraduate program spend a semester in the critical care environment. The ability to interpret a cardiac rhythm, recognise deviations from the norm and prepare for the management of life threatening rhythms are essential skills in critical care nursing.

The teaching of these skills in a manner which reflects current advances in critical care is difficult in a school with a limited budget. It is not financially possible to supply students with monitoring equipment that reflects the state of the art critical care monitoring systems available in the hospitals where they practice. The budget permits the purchase of outdated equipment that is serviceable, but no longer of use to the hospitals. Whilst this may be of some use in teaching the basic principles of a topic such as cardiac monitoring, it deviates markedly from the ideal where students may have hands on practice with the latest in monitoring technology.

The current education of students in cardiac monitoring comprises formal lectures followed by laboratory tutorial sessions. This provides for the core information to be delivered in didactic format and followed by practice at rhythm strip identification in the laboratory. This approach has several problems. The explanation to the students of the core material in the lectures is difficult due to a lack of available technology. Cardiac rhythm strips must be demonstrated to the class via the overhead projector.

These static images are fair at best, the background graph paper required for rhythm analysis is poorly reproduced on an overhead projector. Combined with this is the distance the audience is seated from die screen. This prevents detailed analysis and explanation of the rhythm as the accurate measurement of graph paper, with boxes 1 mm in size, is not able to be demonstrated. Even when enlarged and projected, the audience is unable to appreciate the measurements undertaken. The lecture was proving to be ineffectual in transmitting the required detail.

The laboratory gives the students the opportunity to practice analysis of the cardiac rhythm strip and connect their peers to a cardiac monitor. Since the rhythms the students analyse are derived from their classmates there is a lack of opportunity for them to practice analysing abnormal rhythms. Previously discussed difficulties with equipment result in students utilising outdated monitors with very limited scope.

The solution

A solution was sought to this situation. Previous exposure to multimedia at the inaugural Perth conference [IIMS 1992] led the author to believe this would be an ideal approach to the teaching of monitoring skills in critical care. This approach would enable the student to make clinical decisions pertaining to a given patient care simulation without endangering the client. 11m student would be self directed and the non threatening environment would give the student the confidence to experiment without fear of criticism. However the researcher was computer illiterate from a programming viewpoint. This was overcome when approached by the co-author who was undertaking multimedia studies.

Our aims for this program were to provide the student with a learning environment that would provide meaning to the study of cardiac rhythms. We wanted the students to develop a clear understanding of cardiac monitoring to ensure their safe level of practice in the hospital environment. We set about achieving this through designing a 5 module program.

The program commences with a review of cardiac electrical anatomy and physiology. A colour picture of the internal anatomy of the heart is displayed. The different sections of the electrical pathway through the heart appear as on screen buttons. Clicking the mouse on any of these buttons provides text that describes the actions of the chosen section of the electrical pathway. The explanation comes alive through the simultaneous contraction of the heart and the highlighting of the transmission of impulses through the cardiac electrical system. This contraction gives rise to a cardiac waveform which is also displayed on the screen. The rate of contraction can be slowed through a menu button so the synchronisation of the waveform and the heart contraction can be examined closely. This provides the students with a visual and text explanation of the normal cardiac waveform.

The second section examines the electrical waveform in detail. This section aims to teach the students the basics of cardiac rhythm recognition through the explanation of the different components of the cardiac waveform and the dimensions of these components. The individual waves associated with cardiac contraction are described and the technique for measuring the waveform, to determine whether it is normal or not, is demonstrated. To assist in the learning of this technique the program provides a set of callipers that the student uses via the mouse to measure waveforms provided. Feedback on the accuracy of their technique is provided.

The third section examines rhythms commonly seen in the critical care environment. These rhythms are displayed on screen with an explanation of possible causes and the clinical significance. The treatment of these rhythms is discussed. Video footage, taken of a heart during cardiac surgery, is used to expound upon critical points. Pictures of the heart quivering during cardiac arrest are displayed on screen. This reinforces the point that this rhythm results in the heart being unable to pump blood and treatment needs to be initiated immediately.

Scenarios are provided to the student requiring them to identify the cardiac rhythm and determine the correct intervention required for that situation. This is achieved through interaction with the screen via the mouse. This section aims to tie together the knowledge gained from the program and test their ability to apply this knowledge to examples representing the practical setting. The scenarios aim to be similar to a computer game in format and highly interactive. The reward for successfully managing the situation is saving the patient. Entry into the scenario without any understanding of cardiac rhythms is tested for by several gate keeping questions. Inability to correctly identify the displayed rhythm results in exit from this section and redirects the learner to the appropriate rhythm section of the program.

One scenario shows the patient sitting up in bed when the heart rhythm suddenly changes to a life threatening rhythm. The patients skin colour begins to become increasingly blue in colour. Inaccurate management will result in a rapid increase in the degree of discolouration and may lead to the patient dying. Correct management can prevent this situation and reverse the discolouration of the patient. It is a race against time and delays in responding cause further deterioration in client condition.

The management of the client in these scenarios requires the assistance of several personnel. This is achieved through the screen becoming the patient's room and the student is required, through the use of the mouse, to position staff appropriately and assign them roles. Equipment is dragged to the bedside with the mouse. This provides the student the opportunity to coordinate the management of a cardiac arrest from the comfort of their desk.

The final section includes a dictionary which lists common terms involved in cardiac monitoring and the explanation of these terms.

How it was achieved

The program was supported by an Apple University Development grant. It was written on an Apple Macintosh IIci using SuperCard as the main authoring language. SuperCard was chosen because of its ease, of use. Animations were achieved by scanning patient rhythm strips into the computer, these were then synchronised with the heart animation.

In order to ensure the program maintained its interactive nature, tools were developed that enabled the student to determine the answer themselves directly on the screen.

The collaborative approach

The bringing together of content expertise and programming expertise was a critical step in determining that this program got off the ground. Through this approach the content expert was able to discover and utilise the capabilities of multimedia technology without being involved in the intricacies of programming. The programmer was able to open the content expert's mind to the limitless alternatives available through this technology and provide different ways of presenting the information.

This combination allows for the best of both worlds. Both members of the team can increase their understanding of the other's area of expertise without having to develop expertise in an area outside their domain.

The program started as a small project to examine the teaching of cardiac rhythms. As time progressed, each party became aware of the others abilities and the project expanded to a higher level. Rather than addressing one aspect of cardiac monitoring, the program now provides a comprehensive examination of the topic and caters for a higher level of learning than currently being presented. This enables the package to be suitable for a larger audience.

The future

The program is to be trialled in the undergraduate nursing program in March 1994. Evaluation will be conducted as part of this trial. It is anticipated minor modifications will he made to the program following this trial.

The experience of developing this program has made the developers aware of many possible applications of multimedia in health care teaching. This includes extensions to our program and development of new programs to meet the needs of the health industry. Multimedia is ideally suited to the educational development needs of health care personnel in remote areas. Travel to tertiary settings is both expensive and inconvenient and conventional external studies approach frequently fall by the wayside due to a lack of support and feedback. This approach through multimedia permits the learner to negotiate their own learning style within the program and instant feedback on their progress is available.

The 24 hour nature of health care delivery results in many staff being unable to attend education sessions during normal business hours. Multimedia would enable these staff access to programs at their convenience and convert quiet hours on night shift into in house education sessions without removing the staff from the ward.

The developers would recommend that further projects would need to be funded in such a way so as to permit adequate time for their development. The time factor was the main hindrance to the progress of the program as it was vastly underestimated in our initial calculations.

Both the developers have learnt a great deal from this experience and hope to be able to utilise this knowledge in future projects. The proof of the pudding will be in the tasting.

Authors: Alan Tulloch, Lecturer, School of Nursing
Curtin University of Technology
GPO Box U1987, Perth WA 6001
Tel. 09 3512064 Fax. 09 351299

Michael Fieldhouse, IMAGE Technology Research Group
Curtin University of Technology
GPO Box U1987, Perth WA 6001
Tel. 09 3334411 Fax. 09 333 4439
Email: michael@icarus.curtin.edu.au

Please cite as: Tulloch, A. and Fieldhouse, M. (1994). Interactive cardiac monitoring. In C. McBeath and R. Atkinson (Eds), Proceedings of the Second International Interactive Multimedia Symposium, 561-563. Perth, Western Australia, 23-28 January. Promaco Conventions. http://www.aset.org.au/confs/iims/1994/qz/tulloch.html

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