Jump to content

Continuous pulse oximetry monitoring and COVID

Updated | Posted

Specializes in Progressive Care - Respiratory. Has 5 years experience.

how-to-rate-reliability-on-a-continuous-pulse-oximetry.jpg.c2261beb8d7002929956c4e24f6dc577.jpg

Hello Allnurses,

I am attempting to troubleshoot some issues we have been having at our hospital that have resulted in patient harm while monitoring patients on continuous pulse oximetry.  I work in ICU stepdown and we have seen a dramatic increase in the number of patients being monitored for continuous pulse oximetry with COVID.  Understanding that that loose connections, a sweaty finger or patient conditions like afib/PVD/DM impact circulation and ability to monitor pulse oximetry, what type of system do you use and how to rate it's reliability?

 We have had more than one patient die while supposedly being monitored on continuous pulse oximetry without anyone even knowing and this seems completely unacceptable to me.

Any comments or suggestions appreciated.

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 40 years experience.

Do you set the pulse oximeter alarms? It should have a high rate alarm, a low rate alarm, a high O2 alarm, and a low O2 alarm. If these are correctly set, then you will know before a patient dies. 

Perhaps you need to tighten your alarms.

JadedCPN, BSN, RN

Specializes in Pediatrics, Pediatric Float, PICU, NICU. Has 15 years experience.

1 hour ago, Kitiger said:

Do you set the pulse oximeter alarms? It should have a high rate alarm, a low rate alarm, a high O2 alarm, and a low O2 alarm. If these are correctly set, then you will know before a patient dies. 

Perhaps you need to tighten your alarms.

To piggy back on that, are you pulse oximeters connected to a central monitoring system that someone monitors (usually unit secretary who will alert you that they alarming) or that directly alerts you via your work phone/voalte/vocera/device, or do you just have to “listen out” for the alarm in order to catch it?
If it’s not attached to some sort of central monitoring/alert system, that’s part of the problem. An alarm isn’t going to do any good if the nurse isn’t aware it’s alarming while they’re in another room. 

macleod340, BSN

Specializes in Progressive Care - Respiratory. Has 5 years experience.

Yup alarms are set.  It's more that we get so many sensor malfunctions, poor pleth waves and false alarms due to poor signal quality.  I have had setups where I've had to put over six new pulse ox probes on one patient over a 12hr shift.  I think our adapter cords are faulty and we are so short of supplies, the faulty ones stay in service because we don't have extra.  We upgraded our system 2 years ago and we have just accepted the fact that its not at all reliable.  We ran a report and are getting over 1000 alarms for a 500 bed hospital with less than 100 pts on monitors in a 4hr period.  The only thing I can think of is to use opaque tape over the probe to stop outside light sources from interfering.  Our alarm fatigue has directly led to patient deaths that I can't accept.

macleod340, BSN

Specializes in Progressive Care - Respiratory. Has 5 years experience.

We have a centralized monitoring system with at least two dedicated monitor techs present at all times and they are completely overwhelmed.   Our new system has 4 connections that nurses are trying to troubleshoot and just mess around with them until they work for another 15 minutes until the patient batts an eyelash.  I've timed it and sometimes I've spent over an hour troubleshooting our systems.  It seems like a very bad design and is making my job harder.  But, you gotta love those Philips touch screens that make the boxes run through 3 AA batteries ever 6 hrs. 

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

I can't really say I've ever had an experience with continuous pulse oximetry that wasn't as you describe.

They are extremely sensitive to movement, they work great on comatose patients, but on patients who might move now and then they are effectively a source of a constant alarm.

One thing that helps is to place the sensor where it will be least affected by movement.  Sometimes toes work better than fingers.  If you can get a good pleth with a forehead sensor that might be better than either fingers or toes.

Another thing is to lower the alarm thresholds to more meaningful limits.  We set our lower limit on the general ICU population at 87%, for Covid-land it's 85%.  

macleod340, BSN

Specializes in Progressive Care - Respiratory. Has 5 years experience.

Thank you MunoRN,

Being a respiratory RN I am pretty aware of the issues with getting a good pleth that is consistent, reliable and the best thing is to have eyes on your patient.  We used to have pagers that Nurses would carry and this placed the ability to silence alarms directly at the bedside and in the hands of someone who has eyes on the patient.  I'm guessing we are just experiencing issues due to the rapid influx we have had of our COVID population and with our Nurses that are not as keen at troubleshooting issues in an efficient way.  Also with our move to centralized monitoring, we took the ability to interpret an alarm away from Nurses at the bedside and placed it in the hands of our monitor techs (who do an amazing job). I will definitely push for the alarms for our COIVD patients to be set at a lower threshold.

Thanks a lot for you response

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

2 hours ago, macleod340 said:

  We ran a report and are getting over 1000 alarms for a 500 bed hospital with less than 100 pts on monitors in a 4hr period.  

Woah, that seems incredible. Getting a good pleth can be hard but shouldn't be THAT hard. Leadership needs to pick another product for you guys to use for your continuous pulse ox monitoring or else they may be looking at making quite a few legal settlements in the future. Maybe that's how you all should present it to them.

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 40 years experience.

8 hours ago, macleod340 said:

Yup alarms are set.  It's more that we get so many sensor malfunctions, poor pleth waves and false alarms due to poor signal quality.  I have had setups where I've had to put over six new pulse ox probes on one patient over a 12hr shift.  I think our adapter cords are faulty and we are so short of supplies, the faulty ones stay in service because we don't have extra.  We upgraded our system 2 years ago and we have just accepted the fact that its not at all reliable.  We ran a report and are getting over 1000 alarms for a 500 bed hospital with less than 100 pts on monitors in a 4hr period.  The only thing I can think of is to use opaque tape over the probe to stop outside light sources from interfering.  Our alarm fatigue has directly led to patient deaths that I can't accept.

You could point out that it is cost effective to replace the adapter cords instead of running through the probes.

I use earlobes and foreheads when having trouble with pleth, another key being to stabilize the cord along it's length if using one of these two sites so that it is isn't pulling. I see people put wads of tape over the sensor area (on ears, for instance) but that's just a bigger wad of tape, still being pulled by the same weight of the cord. Same w/ foreheads. If you don't do something about the weight of the cord there's pulling that pulls the sensor enough to affect good contact. (My theories/observations). So, I create a tiny bit of slack and then stabilize the cord below it with silk tape running both lengthwise and across the cord.

You are probably good at getting a reliable waveform, though. So...what is your management saying about all of these problems?

At some point they're the key, not nurses trying to come up with more and more voodoo to get a poor product or a poor system to work.

And...I'd fill out incident reports. Also, if you believe the equipment is malfunctioning make sure to file service requests to your biomed people. Worst thing is that because we are so harried we often don't do these things and then there is deniability on the facility's part.

Sorry, nothing else other than the issues everyone else has stated (alarm parameters, etc.)

macleod340, BSN

Specializes in Progressive Care - Respiratory. Has 5 years experience.

Thank you everyone for your comments and suggestions, that really helps a lot!!  I have a meeting with our equipment reps and I am so lucky to work at a hospital that has leadership that is supportive and listens to their Nurses.  

COVID has led us into a state of harried impulsivity and I think a lot of our med/surg units that have been forced to change into COVID units are experiencing frustration, burnout, and an overall, loss of control.  We are all being forced to work outside of our comfort zone and are not always able to stay focused, grounded, and mindful of what we are doing.  I am so thankful that I work in an area where I still have someone to handoff my patients to at the end of a 12hr shift and have been fully vaccinated.

I'm sure we will address our problems shortly, I just hope we don't have another event in the meantime.

Thank you for your suggestions, 

I will definitely include them in our Practice Alert.

If they have conditions that impact circulation, why aren’t their fingers/toes that have the clip on them checked more frequently? To me it would make sense to change the finger/toe that the clip is on more frequently for these types of patients if it’s possible. Also, do they have alarms? 

JBMmom, MSN

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

So sorry for your frustrations, and for the tragic losses suffered potentially unnecessarily. You've already gotten some good feedback from others, I don't have much to add. But I can definitely sympathize with your situation. Our hard wired cords in the ICU seem slightly less finicky, but the small remote telemetry boxes with the portable set are notoriously unreliable. They are also monitored at a remote desk and the monitor coordinators can't even get off the phone due to the frequency of calls to notify RNs/PCTs about low O2 alarms. 

In our ICU, we use the neonatal pulse ox set ups that look like a band-aid to wrap around the finger, toe or earlobe. We find those much better than the regular sticker type for adults. I hope you can find something that works for your hospital, good luck!

Honestly, I think the only thing you can do is to push for more reliable equipment.  That won't solve all the false alarms, but hopefully it will cut down on them. 

I can 100% relate to alarm fatigue. The number of COVID patients with dementia and/or AMS is through the roof, so I never know if the low O2 alarm is because the patient's O2 needs are increasing, the patient removed the oxygen, or the patient removed the sensor.  There's only so much time I can spend donning/doffing PPE to troubleshoot tech problems without other nursing matters slipping through the cracks.  I feel terrible about it, but I've had to do a lot of restraints lately to make sure the patients keep their O2 on and their sensors attached, and even then I've had a ton of false alarms.  It's worse when I'm dealing with PUI/PUM patients because it's fresh gown and gloves for every patient; at least on the + unit, I can just change my outer gloves and get into the next room faster.

The other wrinkle here is that the O2 sensors attach to our telemetry boxes, and the monitor techs send alerts to our phones. It's a good system in theory, but in reality, I can't access my phone while I'm in a COVID isolation room.  So if I'm in a room with another patient when a message comes through, it could be quite some time before I'm out of there and able to see the alert.  

macleod340, BSN

Specializes in Progressive Care - Respiratory. Has 5 years experience.

Thanks for all the replies, so many good points and a good all-around discussion.  We are also having issues similar to that TurtlesRcool explains and there is nothing quite like trying to log into your rooms on Vocera with an N95 or PAPR or CAPR on.  "Did you mean Mechanical Plant Boiler #3???"  Just glad I passed my fit test and and don't have to deal with wearing a helmet anymore.  

I think now more than ever, it's important to address problems in a logical manner and not give into frustration, alarm fatigue, burnout and the chaos of being a Nurse in a pandemic.  I see so many of our nurses that are overwhelmed, fatigued and doing thinks like not logging into their rooms on Vocera or a phone system, so that they aren't able to receive notifications about their patient's wonky pleth wave or V lead that has lifted off a hairy man's chest again. 

Unfortunately, in one of our sentinel events, the alarms were blaring, fatigue and burnout was present, no one could get a hold of the nurse and the patient with a "bad Pleth wave" or a sensor off was decompensating and died without anyone knowing.  This is the very, very, unfortunate reality of a global pandemic and my heart hurts for that patient and their family members.

As Nurses we should always respect that

Airway is always first,

Alarms are there for a reason and not to be ignored, no matter how fatigued we are, we have a responsibility to at least lay eyes on our patients.

 

I will post our recommendations included in our practice alert and let you know how it goes with the equipment reps.

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

1 hour ago, macleod340 said:

Thanks for all the replies, so many good points and a good all-around discussion.  We are also having issues similar to that TurtlesRcool explains and there is nothing quite like trying to log into your rooms on Vocera with an N95 or PAPR or CAPR on.  "Did you mean Mechanical Plant Boiler #3???"  Just glad I passed my fit test and and don't have to deal with wearing a helmet anymore.  

I think now more than ever, it's important to address problems in a logical manner and not give into frustration, alarm fatigue, burnout and the chaos of being a Nurse in a pandemic.  I see so many of our nurses that are overwhelmed, fatigued and doing thinks like not logging into their rooms on Vocera or a phone system, so that they aren't able to receive notifications about their patient's wonky pleth wave or V lead that has lifted off a hairy man's chest again. 

Unfortunately, in one of our sentinel events, the alarms were blaring, fatigue and burnout was present, no one could get a hold of the nurse and the patient with a "bad Pleth wave" or a sensor off was decompensating and died without anyone knowing.  This is the very, very, unfortunate reality of a global pandemic and my heart hurts for that patient and their family members.

As Nurses we should always respect that

Airway is always first,

Alarms are there for a reason and not to be ignored, no matter how fatigued we are, we have a responsibility to at least lay eyes on our patients.

 

I will post our recommendations included in our practice alert and let you know how it goes with the equipment reps.

That is so unfortunate, I really hope your employer doesn't throw the nurse under the bus. We all know that alarm fatigue leads to complacency, and while I agree we must not allow our selves to become complacent, it is easier said than done during extraordinary times. Hopefully your employer will see this as evidence that they need to address the technology their using.

nursemike, ASN, RN

Specializes in Rodeo Nursing (Neuro). Has 12 years experience.

What kind of ratios are you running? Early in the pandemic, we were making all Covid patients 1:1. I believe that's still the case in our ICUs. It's a bear to staff, but there's just no substitute for eyes on a patient.

 

On 1/26/2021 at 3:44 PM, macleod340 said:

I am so lucky to work at a hospital that has leadership that is supportive and listens to their Nurses.  

Not to be a total Debbie Downer but, you know, being supportive (with regard to this particular topic) means action, pronto. Like, if we can't fix our alarm system immediately then we are going to implement temporary plan B such as increased staffing...now. It should not have taken a death or one nurse's commitment to this issue to recognize widespread nurse fatigue or problems with monitoring patients' SpO2 or to recognize that the monitor techs are overwhelmed. These are problems that are routinely ignored or left for those on the ground to deal with in real time and then those same ones will eventually be vilified since no explanation or excuse is good enough when someone has had a bad outcome.

I hope your leadership is indeed supportive and I hope that they are actively demonstrating that--not waiting for you to meet with equipment reps and write up a big report. Though those actions are obviously also important.

👍🏽

Good luck!