Continuous pulse oximetry monitoring and COVID

[macleod340, BSN]

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]

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]

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]

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]

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]

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]

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]

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]

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.

[JKL33]

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]

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.

[Crystal-Wings, LVN]

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?