telemetry policy -- please help!

[alyciaboo]

i'm an rn working on a new telemetry floor. this floor is considered the step down to the step down since most of the nurses experience with cardiac monitoring is 1 year since this renovation has taken place. the acuity of the pt is not as high as those on pcu as of yet and the plan is to slowly acclamate the floor to the more critical aspects of cardiac nursing. this seems to happen much quicker than was planned seeing the demand for this type of monitoring. now where the trouble begins is when there are 4 nurses (night shift), not all rns and no aide, for a 38 bed telemetry unit. the policy has not been well defined. from one supervisor to another the staff-pt ratio for telemetry seems to change. initially 1 nurse per 6 pts was the guideline, now (since the floor is short nurses) it is the nurse can have six pts on cardiac monitor plus six that are not. when this happens it leaves quite a bit of time for the monitors to not be watched, and when an alarm rings we are not always capable to drop what we are doing and go see what is happening. something fatal can be easily missed. i havent been around to too many other hospitals to know how their pcu is run, our rules seem to change daily. is there a place i can call or look into to find a state policy on this type of pt monitoring? how does it work in your hospital? how safe is this for pts being ruled out for an mi. i feel this practice is very unsafe.

[Doey, BSN, RN]

alyciaboo I agree with you that this is not safe. I work in an 11 bed PCU and ALL three shifts have 2 RNs 99% of the time. The only times that there may be one RN with a nurses aide or LPN is on the 11-7 shift or if the census is low across the floor, (ICU,PCU,CCU is the whole floor) it will happen on the other shifts as well. But this rarely happens and when it does ICU and CCU are aware of it to give a hand if needed. Plus we always have without exception, a secretary/cardiac monitor watcher. This is extremely important especially for R/O MIs. Who's going to notice any changes (new ectopy, increased ectopy, ST/T wave changes), until it's too late and something has already happened instead of preventing it from happening in the first place. What about pts. who come in with a dx of syncope. Or if someone has been started on a new cardiac med. Who's there to see any of the changes that occur. Plus having 6 monitored pts. along with 6 regular pts. is not safe either. Granted, anything could happen to anyone, but a R/O or someone who is post-infarction is at a greater risk. That's why they're monitored in the first place. What do the physicians say about this? If they don't know make sure they do. This scenario seems even more precarious with RNs that only have 1yr. of cardiac monitoring experience. Is CCU/PCU/ICU nearby? I think in my state (Ma.), there is no rule on nurse pt. ratio or monitoring for a stepdown unit. Some of the other hospitals in the area either don't have anyone watching them all the time or have just started using monitor watchers. (some because of physician complaints). Get together with some of your co-workers and write a letter expressing your concerns. Give actual examples and be specific. Don't just say it's too much or too busy. Give a copy to your nurse manager, vice president of nursing, and risk management and keep a copy for yourself. Schedule a meeting with your nurse manager to discuss this and try to get as many nurses to attend. And I think that I would be writing out an incident report for the times the monitors are not being watched, making sure your supervisor is aware, to protect yourself. Good luck.