Case Objectives

• Describe current hospital practices for continuous telemetry monitoring.
• Appreciate key recommendations from the Update to Practice Standards for Electrocardiographic Monitoring from the American Heart Association.
• Recognize risky practices and common errors related to telemetry monitoring, especially when done from a remote location.
• List approaches to enhance closed-loop communication between remote telemetry monitoring staff and bedside nurses.
• Identify critical safety points to consider during initial decision-making about incorporation of remote telemetry monitoring.

Case and Commentary—Part 1

A 78-year-old woman with a history of advanced dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the hospital from a nursing facility with fevers and confusion. At baseline, she was minimally verbal and required assistance with all her activities of daily living.

In the emergency department, the patient had a fever and met criteria for sepsis. She had a mild leukocytosis, evidence of mild acute kidney injury, and a urinalysis positive for infection. Her other laboratory values were normal. Her admission electrocardiogram was unchanged from a prior one and showed no evidence of cardiac ischemia. She was given intravenous fluids and antibiotics. Because of her history of CHF, she was admitted to a unit with telemetry monitoring. At this institution, telemetry monitoring was done remotely, with the monitoring equipment and team stationed in another part of the hospital.

When the patient arrived on the telemetry unit, the nurse performed a full evaluation. The patient had a low-grade fever (38.2°C) and a heart rate of 102 beats per minute, but her vital signs were otherwise normal. She was awake but neither communicating nor following commands. The nurse checked to make sure the patient had received the intravenous fluids and antibiotics.

Continuous monitoring of a patient's electrocardiographic (ECG) waveform is ubiquitous in hospitals. In an intensive care unit (ICU), the patient is hard-wired to a cardiac monitor at the bedside. On non-ICU units, patients typically wear a portable telemetry monitor that transmits to a receiver, allowing the patient's ECG waveforms to be displayed on a central monitor bank. The central monitor with the tracings is sometimes on the same unit as the patient and sometimes in another part of the hospital (as in this case). Most non-ICU patients on telemetry are hemodynamically stable, whereas those in ICU may not be.

This patient seemed to be hemodynamically stable and did not need to be in an ICU, but did she need to be on telemetry? As a general principle, patients should only be placed on telemetry if they meet specific indications for monitoring. According to the Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings (a consensus set of recommendations from several key professional organizations societies) (1), although acute decompensated heart failure is an indication for ECG monitoring, a history of heart failure is not. However, because this patient met the criteria for sepsis and was receiving aggressive fluid resuscitation, she was at risk for fluid overload and decompensation of her heart failure. Therefore, telemetry monitoring was appropriate for her, though surveillance monitoring with continuous pulse oximetry may have been considered instead.

Who was watching the monitors? Responsibility for observing telemetry monitors varies across hospitals. At some hospitals, no one person is solely assigned to watch the monitors; instead, bedside nurses periodically observe the monitors and listen for alarms while also delivering patient care. Some smaller hospitals require ICU nurses to be responsible for watching monitors for patients on other units, in addition to providing care to their own critically ill patients. Other hospitals have dedicated monitor watchers who watch a bank of monitors but do not have responsibility for direct patient care. Monitor watchers have been described as "personnel whose job it is to watch the central cardiac monitor and alert clinicians of patient events."(2) In some hospitals, nurses are monitor watchers, whereas in others technicians (supervised by a registered nurse) serve in this role. In all circumstances, personnel assigned to watch telemetry monitors should receive appropriate training.(2)

The use of monitor watchers may be increasing. In 2011 and 2016 national surveys on clinical alarms, the Healthcare Technology Foundation found that 47% and 48% of respondents, respectively, reported that they worked in hospitals that use monitor watchers.(3,4) One national survey specifically addressing the use of monitor watchers found that 61% of respondents worked at hospitals that used monitor watchers.(2) In this case, the monitor watchers were "stationed in another part of the hospital." In the same national survey, 62% of respondents who worked at hospitals that used monitor watchers reported that those monitor watchers were stationed off the patient care unit—either in a centralized location elsewhere in the hospital (56%) or in a separate building (6%).(2) Remote telemetry monitoring may be a growing trend as hospitals are consolidated into larger health systems and may even occur in another geographic area. Evidence is lacking to guide the use of remote telemetry monitoring.

One benefit of having monitor watchers on the clinical unit is their ability to review and validate an alarm with immediate patient assessment.(5) They also may be more likely than busy bedside nurses to ensure proper electrode placement and the setting of appropriate alarm parameters. However, given the frequency of false-positive alarms, many alarms need to be validated by a qualified clinician laying eyes on the patient. With monitor watchers at a remote location, timely patient assessment, proper electrode placement, and appropriate alarm settings may be less likely.

Other risks related to remote telemetry monitoring include the potential mesmerizing effect of viewing multiple monitor screens simultaneously, causing fatigue and decreased vigilance. One study (6) reported that responsibility for more than 40 patients at a time significantly delays identification of serious arrhythmias. A second risk is the potential for fragmented care. If the responsible health care provider has questions about a patient's rhythm history, how the patient is tolerating a given rhythm, or the effect of an antiarrhythmic medication, the bedside nurse may not be able to provide this information expeditiously.

Case and Commentary—Part 2

After entering the patient’s room to check morning vital signs 6 hours later, the nurse found her to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, and chest compressions were initiated. The patient was found to be in asystole and after about 20 minutes of resuscitation efforts with no return of spontaneous circulation, she was pronounced dead.

The nurse manager for the unit led a root cause analysis to determine what had happened. The group reviewed the telemetry tracings and discovered that the technician who was remotely watching the telemetry monitor recognized progressive bradycardia and called the hospital floor several minutes before the code. The nurse caring for the patient was busy with another patient, so the technician was placed on hold. He continued to wait; while on hold, he observed worsening bradycardia on the telemetry monitor, eventually transitioning to asystole. He tried to call back the unit and no one answered. He wondered if either they were already caring for the patient or maybe it wasn't truly asystole. By that point, the nurse had discovered the patient and initiated the Code Blue.

The institution wanted to explore this incident and the other common safety issues with telemetry monitoring, particularly remote monitoring, and identify best practices for preventing such errors in the future.

Do we assume that no one saw this patient for 6 hours until this nurse came to obtain vital signs? Six hours is a long time to go without observing a patient. Unfortunately, as is possibly true in this case, telemetry monitoring may be seen by the prescriber or bedside nurse as a surrogate for closer observation or a solution to inadequate staffing. The primary purpose of telemetry monitoring is to observe ECG waveforms, not serve as a substitute for assessment of breathing, trends in vital signs, neurological status, or numerous other assessments. Each hospital has standards of care, which include frequency of checking a patient's vital signs or performing certain assessments. A full assessment of the hospital's standards for patient assessment should have been part of the root cause analysis. (Consideration of the patient safety issues related to frequency of patient assessment in the hospital is beyond the scope of this commentary.)

The frequency of harm related to remote telemetry monitoring is not known. The Joint Commission does not currently collect data on telemetry monitoring errors as part of their sentinel event reporting (J. Aleccia, written communication, November 2018).

The remote telemetry monitoring technician's phone call to the unit went unanswered. Thus, essential information was not communicated and the patient died. This case illustrates a clear breakdown in communication. Organizations must develop and implement an effective communication process that begins with the remote telemetry monitoring system and ends with appropriate assessment and care provided to the patient.(7) A communication protocol that identifies backup coverage and ensures notification of other staff—for example, a rapid response team—when the patient's bedside nurse is not available is essential. The communication process must be clear, with escalating alert procedures and backup methods.

Some hospitals have incorporated a bidirectional voice communication badge system (8) that employs a two-way communication device that bedside nurses wear clipped to their clothing or on a lanyard around the neck as an alternative to relying on phones for primary communication, but this can be distracting to both nurses and patients. Alternatively, the voice badge system could serve as a secondary notification strategy when no one on the unit is answering the phone or for select life-threatening arrhythmias. The fact that no one answered the phone in this case also raises the issue of the adequacy of staffing.

Leaders at institutions considering implementing remote telemetry monitoring must incorporate perspectives from an interprofessional team, including bedside nurses, clinical nurse specialists or educators, cardiologists, hospitalists, monitor watchers, biomedical engineers, risk management personnel, and hospital administrators. Practical aspects of safety in the use of remote telemetry monitoring can only be identified by structured procedures to "walk through" the process of telemetry monitoring, from the moment the monitor is placed on the patient to the moment the bedside nurse is notified of the abnormal rhythm. Such an interprofessional team should discuss all potential problems including lack of staff availability to answer a phone call, phone outage, incorrect phone numbers, computer downtime, and printer malfunction (if relying on print-outs for new admissions).

Reviewing remote telemetry monitoring policies from other institutions can also be helpful. After evaluating policies for remote monitoring from 75 Veterans Health Administration hospitals, George and colleagues (9) developed a comprehensive policy that could be used at all sites. It specified that bedside nurses are required to respond immediately to any STAT calls or requests from the remote telemetry monitoring personnel. Each facility is responsible for identifying the response process.

The Table outlines critical safety points to consider when deciding whether to incorporate remote telemetry monitoring or as part of an ongoing evaluation of its effectiveness. These points are based primarily on clinician expertise, as evidence to support specific practices is limited.

To maximize the benefits and minimize the risks of telemetry monitoring, the Practice Standards for Electrocardiographic Monitoring (1) specify which patient populations should be monitored and for how long. In addition, these standards provide recommendations for the education of nursing and monitoring staff and for alarm management and documentation that is accessible interprofessionally.

A risk of telemetry monitoring is alarm fatigue, or desensitization from overexposure to alarms that are false (inaccurate) and nonactionable (accurate, but clinically irrelevant). Alarm fatigue has resulted in missed patient events and preventable deaths. An observational study (10) suggested that, by intercepting alarms, monitor watchers could reduce nurses' exposure to alarms and the resulting alarm fatigue. Determining the validity and relevance of an alarm to a particular patient is a complex task requiring contextual information about the patient, which necessitates close communication between the monitor watcher and the bedside nurse.(11) Close communication clearly did not happen in this case. When the technician tried to call the unit a second time and no one answered, he "wondered if either they were already caring for the patient or maybe it wasn't truly asystole." Because no one answered the phone, he could only surmise contextual information.

Likewise, the bedside nurse and other clinicians need the contextual information provided on the monitor. A method should be in place for them to see a patient's waveform, especially when a life-threatening rhythm is suspected. Auxiliary monitor screens in convenient locations around the unit or a waveform display on the patient's telemetry box would provide essential information on the unit. An alarm that is audible on the patient care unit could be useful if set to sound only for life-threatening rhythms verified by the remote telemetry monitoring staff.

In their implementation of a remote telemetry monitoring unit at four hospitals, Cantillon and colleagues (12) included the following: (i) designated lead technicians on-site for real-time rhythm interpretation and management for escalation to "charge nursing personnel," (ii) a telephone system with continuously updated nurse assignments that were reviewed each change of shift, and (iii) direct mobile phone for nurses as well as a crisis phone for emergencies.

Implemented thoughtfully by an interprofessional team with ongoing evaluation, remote telemetry monitoring may be an effective way to monitor patients at risk for deterioration; however, more evidence is needed. This case illustrates the challenges of remote telemetry monitoring and the need for a detailed closed-loop communication protocol with explicit escalation strategies.

Take-Home Points

• Risks of remote telemetry monitoring include the mesmerizing effect of multiple monitor screens, unanswered calls from the monitoring staff, and fragmented care when the overall patient assessment is separate from the waveform analysis.
• Determining the validity and relevance of an alarm to a particular patient requires that the remote telemetry monitoring staff have contextual information about the patient's clinical condition and clinicians have contextual information from the monitor.
• A detailed closed-loop communication protocol with explicit escalation strategies is essential.
• Organizations must have an effective communication process that begins with the remote telemetry monitoring system and ends with appropriate assessment and care of the patient.

Kristin E. Sandau, PhD, RN Professor of Nursing Bethel University Staff Nurse United Hospital, Allina Health St. Paul, MN

Marjorie Funk, PhD, RN Helen Porter Jayne and Martha Prosser Jayne Professor Emerita of Nursing Yale School of Nursing New Haven, CT

Faculty Disclosures: Dr. Funk serves as a consultant to Philips Healthcare about monitors and alarms. Dr. Sandau has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. The commentary does not include information regarding investigational or off-label use of products or devices. All conflicts of interest have been resolved in accordance with the ACCME Updated Standards for commercial support.

References

1. Sandau KE, Funk M, Auerbach A, et al; American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young. Update to practice standards for electrocardiographic monitoring in hospital settings: a scientific statement from the American Heart Association. Circulation. 2017;136:e273-e344. [go to PubMed]

2. Funk M, Ruppel H, Blake N, Phillips J. Use of monitor watchers in hospitals: characteristics, training, and practices. Biomed Instrum Technol. 2016;50:428-438. [go to PubMed]

3. Funk M, Clark JT, Bauld TJ, Ott JC, Coss P. Attitudes and practices related to clinical alarms. Am J Crit Care. 2014;23:e9-e18. [go to PubMed]

4. Ruppel H, Funk M, Clark JT, et al. Attitudes and practices related to clinical alarms: a follow-up survey. Am J Crit Care. 2018;27:114-123. [go to PubMed]

5. Drew BJ, Califf RM, Funk M, et al; American Heart Association; Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation. 2004;110:2721-2746. Erratum in Circulation. 2005;111:378. [go to PubMed]

6. Segall N, Hobbs G, Granger CB, et al. Patient load effects on response time to critical arrhythmias in cardiac telemetry: a randomized trial. Crit Care Med. 2015;43:1036-1042. [go to PubMed]

7. Connecting remote cardiac monitoring issues with care areas. PA-PSRS Patient Saf Advis. September 2009;6:79-83. [Available at]

8. Bonzheim KA, Gebara RI, O'Hare BM, et al. Communication strategies and timeliness of response to life critical telemetry alarms. Telemed J E Health. 2011;17:241-246. [go to PubMed]

9. George KJ, Walsh-Irwin C, Queen C, Heuvel KV, Hawkins C, Roberts S. Development of evidence-based remote telemetry policy guidelines for a multifacility hospital system. Dimens Crit Care Nurs. 2015;34:10-18. [go to PubMed]

10. Palchaudhuri S, Chen S, Clayton E, Accurso A, Zakaria S. Telemetry monitor watchers reduce bedside nurses' exposure to alarms by intercepting a high number of nonactionable alarms. J Hosp Med. 2017;12:447-449. [go to PubMed]

11. Ruppel H, Funk M. Monitor watchers and alarm fatigue: cautious optimism. J Hosp Med. 2017;12:481-482. [go to PubMed]

12. Cantillon DJ, Loy M, Burkle A, et al. Association between off-site central monitoring using standardized cardiac telemetry and clinical outcomes among non-critically ill patients. JAMA. 2016;316:519-524. [go to PubMed]

Table

Table. Critical Safety Points to Consider When Deciding Whether to Incorporate Remote Telemetry Monitoring.*

*At a minimum, includes bedside nurses, clinical nurse specialists or educators, cardiologists, hospitalists, monitor watchers, biomedical engineers, risk management personnel, and hospital administrators.