And this is why I hate floating to stepdown...

[calivianya, BSN, RN]

I floated to stepdown last week and I am still irritated about how things went. Our stepdown unit has patients on a tele box. There is no monitor in the room, so unless I stop by the nurses' station and intentionally find and watch my patient's rhythm, I don't see it. I got report that this patient was in normal sinus rhythm and had been his whole admission. At the times I was auscultating his heart sounds and feeling his pulses, all were regular. No murmurs, no irregularities, equal pulse strength in all four extremities, etc. I assumed the report I got was correct, and I assumed the monitor tech would let me know if something funny started happening with my patient. I have since learned that what they say about assuming is pretty darned accurate...

Four AM rolls around and I was hanging out at the nurse's station and watched the monitor for the tech while she went to use the restroom. I noticed my patient was having pretty frequent PVCs, and I dug back through the alarm review to discover he had been having frequent PVCs all night long, often going into bigeminy, and had even had a 20 beat run of V-tach once!

When the monitor tech came back, I asked her very calmly if it was normal for this floor to totally ignore a patient going into a potentially lethal rhythm. She stated the charge nurse had been watching the monitor when that happened, so I turned to her and asked her why I was the last person to know my patient was having runs of V-tach. She apologized that she silenced the alarm and didn't tell me. I asked if she at least printed a strip to put in the chart so someone could be aware this was happening, and she had not. I printed one and dug through the chart, only to find the patient had in fact been going into runs of V-tach his whole admission and yet I had gotten report that he was in perfect normal sinus rhythm.

The patient also didn't have labs ordered for the morning at all, and hadn't had labs for a couple of days despite his obvious rhythm irregularities (!!!), so I called the hospitalist to notify her of the patient's abnormal rhythm and got orders for a CMP. All of his labs came back normal, but still.

Obviously I should have been stopping by the nurses' station and watching the monitor myself more often, and I will in the future now that I have learned this lesson, but what is the point of even having a monitor tech if I have to watch my patient's rhythm myself because I won't get told if things look funny? I really can't stand having patients that aren't on monitors in the room. It's almost as bad as having patients who aren't on telemetry at all.

Am I expecting too much out of our stepdown unit, or is it common for things like abnormal heart rhythms to be ignored if a patient is not in an ICU? Everyone I have talked to on my unit states that they also hate floating to stepdown for this reason, it just seems to be the culture down there to sweep things under the rug. What are your experiences with floating to floors where you cannot see the patient's heart rhythm in the room?

[Emergent, RN]

I think that particular unit has a problem. I've worked a lot of tele and the monitor techs are on top of things.

Perhaps documenting these occurrences such as you describe, and passing it on to the unit manager, or risk management, would be the next step toward solving the problem.

[PMFB-RN, RN]

I don't understand. It's a stepdown unit and yet there are not monitors in the rooms? How can this be a stepdown unit? What makes it a stepdown unit?

FWIW I have never seen a unit labeled step down that didn't have real ICU monitors for each bed.

[CardiacKittyRN]

What does the monitor tech do if they are not there to alert the nurses of rhythm changes? I work cardiac and we have monitor in each room & a monitor tech at the desk... Our floor & ICU are the only units with monitors in the room or techs. The rest of the floors' share a monitor tech who is in a room watching all the hospital's tele pts. She has to call you to tell you

Of a change.. Or you call & ask what your pts doing on the monitor. When I have floated I didn't feel comfortable with it.. Especially when giving rate/rhythm altering drugs. I'm still new so that could be why but I want to SEE the strip, even if I need help interpreting correctly, I still wanna see it!

[calivianya, BSN, RN]

I don't understand. It's a stepdown unit and yet there are not monitors in the rooms? How can this be a stepdown unit? What makes it a stepdown unit?

FWIW I have never seen a unit labeled step down that didn't have real ICU monitors for each bed.

The difference between this unit and a traditional tele unit (as my hospital defines it) as the stepdown patients are not monitored by central monitoring, which monitors the rest of the hospital - they are monitored on their own unit. The stepdown monitor tech only sees the stepdown patients.

I've occasionally seen legit CICU patients on tele boxes instead of the monitors when I have floated to CICU, too. My facility does some interesting things. One reason of many why I'm leaving.

hollykristinxo - That's not a newbie thing, that's a smart nurse thing. It really bugs me giving those kinds of drugs if I can't see the patient's rhythm, either.

[Esme12, ASN, BSN, RN]

The difference between this unit and a traditional tele unit (as my hospital defines it) as the stepdown patients are not monitored by central monitoring, which monitors the rest of the hospital - they are monitored on their own unit. The stepdown monitor tech only sees the stepdown patients.

I've occasionally seen legit CICU patients on tele boxes instead of the monitors when I have floated to CICU, too. My facility does some interesting things. One reason of many why I'm leaving.

hollykristinxo - That's not a newbie thing, that's a smart nurse thing. It really bugs me giving those kinds of drugs if I can't see the patient's rhythm, either.

Inexcusable of the tech. Shame on the charge nurse. But never assume somone else is doing their job when it concerns your patient.

What telemerty system do they have do they not have a portable Eagle or some other portable monitor to use when giving curtain drugs?

[MunoRN, RN]

I assume you looked back to see what their ectopy trend was the night before? It's not unusual for people to have sharp increase in ventricular ectopy at night, if the patient has been there for enough time to figure this out then no, I wouldn't expect tele to call me. I've worked a few places like you describe, and to be honest it doesn't really bother me. If I do need to see the rhythm in real time in the room I just hook them up to a portable monitor. It is more difficult when you're used to ICU monitoring, which is one reason why most of us ICU nurses can't float to lower acuity floor; we feel like we need that more intense monitoring even when it's not really necessary.

[calivianya, BSN, RN]

Inexcusable of the tech. Shame on the charge nurse. But never assume somone else is doing their job when it concerns your patient.

What telemerty system do they have do they not have a portable Eagle or some other portable monitor to use when giving curtain drugs?

Absolutely with the bolded part - that's the lesson I learned this go-round, and I won't make the same mistake again.

We use the Phillips monitors, and we just don't keep portable monitors on the stepdown unit. I've only ever seen portable monitors in the ER. Our ICU units have the wonderful little mini-monitors that detach from the in-room monitors that we can use for transport, but since there are no monitors in the rooms in stepdown, we don't really have that option.

@MunoRN - I did look back through their monitoring the night and day and night before, and the patient just had a ton of ectopy the whole time, so I guess nobody thought it was noteworthy. I probably wouldn't have either if I hadn't gotten "normal sinus rhythm" in report. It was just really disconcerting to think "normal sinus" and stumble on a run of V-tach.

[Sugarcoma, RN]

Yes the monitor tech should have absolutely alerted you. The previous shift nurse should have absolutely included "runs of v-tach" in their report. It is quite possible they didn't catch it or did not understand the significance of it. It has been my experience that both nurses and doctors seem to blow off intermittent runs of V-tach. At most I will get an order to draw lytes and replace if necessary but other than that no intervention is usually undertaken. I think this attitude by the docs cause a lot of nurses to ignore runs of V-tach as well as frequent PVC's.

I hate to say this but 5 years of nursing has taught me that report is basically useless. Honestly I would rather not even get report. Just give me a few minutes with the computer/chart. I NEVER take what the previous nurse tells me as fact. Unless I know that person very well and know they have there stuff together. I will assess all body systems myself thank you. If I find an abnormal I will go back and look through previous assessments to see what has been charted. If it differs I will call a doctor to inform them. This has gotten me an ear lashing more than once, but it has also caught some issues that others had missed. I then document that I have informed someone so that following RN's can see the issue has been addressed.

Cardiac and neuro seem to be the two areas that nurses have the most issues with. NSR means NORMAL, not frequent PVC's, PAC's runs of V-tach, blocks, etc. It seems that many nurses cannot interpret telemetry appropriately. I have gotten many NSR patient's in a-fib, a-flutter, 1st degree, etc. I don't even get mad anymore, nor does it surprise me. I just call someone and go on with my day.

[SalineFlush]

It frightens me that your hospital doesn't have monitors in the room in a unit that it designates as "Step-Down". Scary. I can easily answer your question on what was my (most recent) experience floating to a floor without monitors in the room. It was Hell. Perhaps more frightening was the lack of cardiac knowledge among the nurses. I floated to one floor which is supposed to be "Progressive Care" about a month ago and before I could even get report, the charge nurse told me that I was getting a patient that had "brady'd down to 15". She said that the ICU charge nurse said they couldn't take the patient yet because the bed wasn't clean but that since I was an ICU nurse floating over I could take the patient until they did have a bed ready. I refused. The unit did not have the equipment to properly monitor a patient with those sort of arrhythmias, and I was certainly not taking a patient having those pauses with three other tele patients. Someone said "Oh, well we can transcutaneously pace him". I said, "Oh no we can't!". I don't think she had the full grasp of what that involves exactly. I was ready to walk.

[NurseMikki]

I no longer work in patient, but I worked Cardiac Stepdown for many years. What you described would have been reson for a write up and termination at my previous employers. I hope you addressed this with your manager or the chain of command. I now know why so many of the doctors I used to work with would come to the remote tele rooms and review the monitor hx themselves...I can't believe this.

[KRVRN, BSN, RN]

Forgive me I don't know adult tele. What is the purpose of a tech if the nurse can't trust him/her and needs to be watching the pt's strip themself? Why does the "only trust yourself when it concerns your pt" nurse's mindset apply?