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Can We Monitor Our Patients Too Much?

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traumaRUs has 25 years experience as a MSN, APRN and works as a Asst Community Manager @ allnurses.

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A recent study in the American Journal of Critical Care explored the concept of overmonitoring our patients. Cardiac monitoring is the mainstay of caring for many hospitalized but should we limit this step via the use of order sets?

Can We Monitor Our Patients Too Much?

The American Journal of Critical Care recently published the results of a research study discussing which hospitalized patients should be continuously cardiac monitored and which patients would have the same outcome whether monitored or not. Their goal was to determine the outcomes of patients who had orders for cardiac monitoring utilizing the American Heart Association (AHA) guidelines. Of course the goal is to provide safe patient care and recognize arrhythmias before they cause damage.  The AHA guidelines address which patients will benefit from continuous cardiac monitoring and the main indications include an acute cardiac diagnosis or critical illness. It's interesting to also note that the guidelines also identify a "subset of patients who are unlikely to benefit from monitoring including low-risk post-operative patients, patients with rate-controlled atrial fibrillation, and patients undergoing hemodialysis without other indications for monitoring." One reason that continuous cardiac monitoring is ordered is to detect prolongation of QT interval or even ischemia. However, there have also been studies that disprove as the rate of detection of these abnormalities actually cause many false alarms and truly may not detect a genuine risk.

So, to monitor or not to monitor, that's the question!

Overmonitoring can result in alarm fatigue, increased hospital days and increased cost. Alarm fatigue is defined as, "the desensitization of a clinician to an alarm stimulus, resulting from sensory overload and causing the response of an alarm to be delayed or dismissed." In a literature review; out of 7200 total alarms from 2645 patients, only 1 potentially life-threatening alarm was noted: a self-terminated ventricular tachycardia. Among 78 “emergency” alarms, 29 (37%) were classified as clinically important. However, only 14 (48%) of the 29 alarms led to a change in clinical management within an hour.

This study took place in a Minneapolis, Minnesota 627 bed hospital and consisted of 297 adult patients on medical, surgical, neurological, oncological, and orthopedic patient care units that used remote electrocardiographic monitoring. During the study a prompt occurred in the electronic medical record to ask the provider if cardiac monitoring was appropriate. It is to be noted that the ordering provider works closely with the bedside nurse as they are the end users. The intervention consisted of the introduction of order sets in the electronic medical record prompting providers to order electrocardiographic monitoring per the American Heart Association practice standards. There were no differences in adverse outcomes which were characterized as full arrests, transfers to the ICU, or activation of rapid response teams. 

"A patient’s indications for ECG monitoring often change during the course of hospitalization. Because anecdotal evidence suggests that many patients continue to be monitored for days after they no longer have an indication for monitoring, the researchers examined indications for monitoring for up to 6 days of hospitalization. The number of days of overmonitoring decreased after implementation of the practice standards. More patients had fewer days of monitoring without an indication for monitoring."

So, overmonitoring really doesn't help detect patient changes that necessitate further care including escalating to the next level of care. 

Of course, the decision to order cardiac monitoring rests with with the ordering provider. Outside of the AHA guidelines, many patients with severe sepsis and/or the elderly are monitored without clear indication for doing so. Some patients with alcohol withdrawal may also need to be monitored as well as COPD patients in exacerbation, especially those that are elderly or have other co-morbid conditions. 

Does your hospital utilize order sets for cardiac monitoring? Is it up to the ordering provider to decide or is there an algorithm that dictates what is ordered?       

References:

Implementing Practice Standards for Inpatient Electrocardiographic Monitoring

When Should Hospitalists Order Continuous Cardiac Monitoring?

 

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ShadowNurse has 3 years experience.

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I have worked in a hospital that used order sets for continuous telemetry, which also automatically qualified them for q4h vitals (as opposed to q8h). Anecdotally, it was completely unnecessary for the majority of our patients. I had multiple patients on telemetry with pre-admission pacemakers, making cardiac monitoring quite useless. And this was not a cardiac floor (LTAC).

This is just my opinion, but I feel like we place far too much value on things like excessive routine vital signs and constant cardiac monitoring as a provider of a false sense of security. The over-monitoring placed strain on our already under-staffed floor, disturbed my patient's rest, and created resentment in me as I had to go adjust leads on a telemetry patient for the 46746th time that shift because there is zero distinction in the machine between that and an actual cardiac event. Like in the study, we only had one real cardiac event, and by a stroke of luck our cardiologist was there to witness it--a run of a-fib that was continuously correcting itself then lapsing back to a-fib. Several of these cycles and a dose of Amiodarone later the patient was golden, with plans for an eventual pacemaker. The monitor never alarmed; the cardiologist happened to be rounding and reviewing the telemetry monitor at the desk.

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JadedCPN has 13 years experience as a BSN, RN and works as a Pediatric RN.

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In Pediatric world, there definitely can be a problem with overmonitoring.

One example off the top of my head - There has been research over the years for bronchiolitis/RSV patients that continuous pulse oximetry actually increases their total hospital stay by 2-3 days unnecessarily. Standard used to be that every RSV/bronchiolitic got placed onto a continuous pulse ox, even if they weren't in respiratory distress and were just there for suctioning/rehydration. Over the years we have now gone to spot checks once they are stable based on evidence based practice.

Edited by JadedCPN
typo

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Several thoughts:

1) I don't know if you meant to post this in the critical care section, but it would seem relevant to point out that the study you posted excluded critical care patients, and the guidelines for continuous cardiac monitoring include the broadly-defined "critical illness" as appropropriate criteria for said monitor. 

2) Over- monitoring is a problem that would seem closely related to misinterpretation of monitored data and over-treatment of said data. In other words, it seems likely to me that we could address the same problem by improving the quality of clinical education among nurses. I would hazard to guess that few nurses, for example, are thoroughly familiar with the pathophysiology and relevant treatment considerations of qtc monitoring, despite being responsible for monitoring and reporting these values to physicians. This is a recipe for bad decision-making. When I look at nursing school curriculum, I see substantial potential for improved clinical education. 

3) We're discussing continuous monitoring primarily as a means to identify patient decline or emergencies, but it also offers one huge benefit not mentioned in the OP - it can provide substantial data about an event AFTER it has already occurred. This helps both in determining the best treatment regimen for a patient already in crisis, and in root cause analysis of critical failures and informing quality improvement efforts.

Considerations of cost, impaired patient mobility or comfort, over-treatment, etc, are of course important and relevant. But be careful not to leave some of the major advantages of continuous monitoring out of the equation.

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3 hours ago, Cowboyardee said:

2) Over- monitoring is a problem that would seem closely related to misinterpretation of monitored data and over-treatment of said data. In other words, it seems likely to me that we could address the same problem by improving the quality of clinical education among nurses. I would hazard to guess that few nurses, for example, are thoroughly familiar with the pathophysiology and relevant treatment considerations of qtc monitoring, despite being responsible for monitoring and reporting these values to physicians. This is a recipe for bad decision-making. When I look at nursing school curriculum, I see substantial potential for improved clinical education. 

3) We're discussing continuous monitoring primarily as a means to identify patient decline or emergencies, but it also offers one huge benefit not mentioned in the OP - it can provide substantial data about an event AFTER it has already occurred. This helps both in determining the best treatment regimen for a patient already in crisis, and in root cause analysis of critical failures and informing quality improvement efforts.

Considerations of cost, impaired patient mobility or comfort, over-treatment, etc, are of course important and relevant. But be careful not to leave some of the major advantages of continuous monitoring out of the equation.

I think we have to be very careful that the drive to improve efficiency to reduce costs doesn't result in a decrease in patient safety.

I agree that there is likely a relationship between overuse of continuous monitoring (continuously monitoring a patient when no clinical need exists) and the misinterpretation of monitored data and over-treatment of said data.

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6 hours ago, ShadowNurse said:

I have worked in a hospital that used order sets for continuous telemetry, which also automatically qualified them for q4h vitals (as opposed to q8h). Anecdotally, it was completely unnecessary for the majority of our patients. I had multiple patients on telemetry with pre-admission pacemakers, making cardiac monitoring quite useless. And this was not a cardiac floor (LTAC).

 

Would not the patients with pre-admission pacemakers have a history of cardiac arrhythmias such as symptomatic bradycardia or V-tach?  I'm not understanding why you think that cardiac monitoring would be useless in these patients in a LTAC, where presumably they are at risk from serious cardiac arrhythmias due to their existing heart problems, current medical problems and treatment that they are currently undergoing.

Edited by Susie2310

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ShadowNurse has 3 years experience.

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2 hours ago, Susie2310 said:

Would not the patients with pre-admission pacemakers have a history of cardiac arrhythmias such as symptomatic bradycardia or V-tach?  I'm not understanding why you think that cardiac monitoring would be useless in these patients in a LTAC, where presumably they are at risk from serious cardiac arrhythmias due to their existing heart problems, current medical problems and treatment that they are currently undergoing.

I thought that the pacemaker corrected the underlying arrhythmia, and patients were not there for heart problems (most commonly intense wound care and ventilator weaning). But then again, cardiology was never a strong suit of mine.

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24 minutes ago, ShadowNurse said:

I thought that the pacemaker corrected the underlying arrhythmia, and patients were not there for heart problems (most commonly intense wound care and ventilator weaning). But then again, cardiology was never a strong suit of mine.

Depends on the pacemaker and the arrhythmia.

Pacemakers correct bradyarrhythmias. Impanted cardioverters correct some but not all kinds of tachyarrhythmias. Implanted defibrillators can defibrillate v fib or v tach.

All are prone to failure at times. Also, many of the same conditions that lead to a need for pacemakers in the first place also cause a plethora of not-easily-fixable-but-still-significant rhythm changes that show up on monitor to a trained eye.

For whatever its worth, I certainly don't think having a pacemaker should automatically qualify you for a monitor. On the other hand, I also would never say: " at least this septic, renal failure patient with 3 vessel disease and an active GIB on three pressors doesn't need a continuous monitor - he has a pacer/aicd! Ill go grab 4 units of rbcs and the prismaflex. {whistles}." 

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ShadowNurse has 3 years experience.

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21 hours ago, Cowboyardee said:

For whatever its worth, I certainly don't think having a pacemaker should automatically qualify you for a monitor. On the other hand, I also would never say: " at least this septic, renal failure patient with 3 vessel disease and an active GIB on three pressors doesn't need a continuous monitor - he has a pacer/aicd! Ill go grab 4 units of rbcs and the prismaflex. {whistles}." 

Hah, yes. Context seems to be crucial here. For me, it would be the pressors that would have me wanting continuous monitoring. 

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