Is nurse-supervised exercise stress testing safe practice?

Objective: Nurses have been performing exercise stress tests (EST) without medical supervision since 1978 in our hospital-based cardiac rehabilitation unit. This study was conducted to examine the incidence of cardiovascular complications and to describe the competency-based training program for the nurses performing the EST. Design: Descriptive, retrospective audit of prospective data. Setting: Single comprehensive cardiac rehabilitation center in a large tertiary referral hospital in western Sydney, Australia. Subjects: Seventeen thousand, four hundred and sixty-seven patients were included in this study over a 12-year period. Method: Data were collected on all ESTs performed by the cardiac rehabilitation nurses from January 1986 to December 1997 in relation to serious cardiovascular complications and other EST parameters. Results: In this study, 17,467 ESTs were performed on 5054 patients who had 6273 separate presentations. The most common entry diagnosis was after an acute myocardial infarction (50%). The mean age was 58 ± 10.5 years (range 15 to 87 years; 80% male). The left ventricular ejection fraction (n = 2822) was 49% ± 14%. In a subgroup analysis of 14,454 patients, 14% had a positive EST (ST segment >1.9 mm depression). There were no deaths associated with the EST, and there were 13 major complications in 12 patients. This figure included no cardiac arrests, 11 episodes of conscious sustained ventricular tachycardia, 1 reinfarction, and 1 mitral valve rupture, representing a 0% mortality rate and a 0.075% major morbidity rate. Conclusion: This study shows that nurse-supervised EST of higher risk patients in the hospital-based cardiac rehabilitation setting has been a safe practice from a mortality and morbidity rate perspective. This finding may be accounted for by the high training standard and reaccreditation of the nurses on the advanced practice of performing EST. (Heart Lung® 1999;28:175-85)