Help! Anyone else work cardiac stepdown and have no tele techs?

locolorenzo22, BSN, RN · Jan 11, 2012

I want to say that this is Ridiculous. I transferred to tele last year, and those monitors go off for EVERYTHING!. We have no tele techs, but only have a max of 14 patients(we are a post cath lab sheath pull floor). Any nurse will go read and check strips with alarms. We do the best we can although sometimes things are missed. I feel for you. There needs to be one person to check the central monitor at all times for a floor that big. what is your charge doing?

maelstrom143 · Jan 11, 2012

Recently, our 33 bed cardiac step-down floor changed from centralized telemetry with telemetry techs to decentralized. Which means that the RNs now carry pagers filled with our patients room numbers (usually 5 patients each-spread throughout our large unit) but the pagers go off for arrhythmias on all 33 patients. There is a central bank of monitors at the desk but no one is watching them. Already, there have been several instances where patients went into afib or had runs of vtach without anyone noticing. One patient's monitor was on standby for several hours. The problem is that the pager goes off every 2-3 minutes in our pockets, [...]

This is a recipe for disaster. We have a couple of units that are decentralized. When floated to those units, we do the best we can, but a conversion from sinus to a-fib or a change from ST to SVT can be missed at first. the monitor techs' constant monitoring ensures that these arrhythmias are caught ASAP on our other units. The reality is that we cannot monitor the tele's very well when we are doing meds, on the phone with the doctors/family members, etc.

Interrupting meds is dangerous. I have come across a couple of times that, if I had been complacent, I might not have double checked to make sure the med I pulled out of the pyxis was, in fact, the right med (drawer has several small locked compartments that pop open as needed to dispense only the med requested). A few times during this check I have come across the wrong med in with the right med (i.e. 200mg labetalol instead of 200mg cordarone! It really happened! :eek: ). If you are distracted, errors are more likely to occur.

Constant interruptions on the phone w/doctors can lead to very ticked off doctors (trust me...been there).

Interruptions on the phone w/ancillary services can lead to miscommunications that may affect the patients.

Oh, and let us not forget alarm fatigue, which can occur when too many alarms keep going off throughout the day (http://articles.boston.com/2011-09-21/lifestyle/30185391_1_alarm-fatigue-nurses-patient). I have seen this happen and it is not pretty.

I totally understand the need to cut costs wherever the facility can afford to do so, but decentralizing the tele monitors is just asking for trouble...and possible lawsuits if things go south due to this money-saving strategy:uhoh3:...JMHO.

Esme12, ASN, BSN, RN · Jan 11, 2012

Recently, our 33 bed cardiac step-down floor changed from centralized telemetry with telemetry techs to decentralized. Which means that the RNs now carry pagers filled with our patients room numbers (usually 5 patients each-spread throughout our large unit) but the pagers go off for arrhythmias on all 33 patients. There is a central bank of monitors at the desk but no one is watching them. Already, there have been several instances where patients went into afib or had runs of v tach without anyone noticing. One patient monitor was on standby for several hours. The problem is that the pager goes off every 2-3 minutes in our pockets, causing us to run and check on the patient. Some are true arrhythmias, most are artifact. Sometimes it alarms asystole with a heart rate of 70. I can't make a phone call to a doctor or pull medications without constant interruptions. I am concerned that we will become complacent and miss an arrhythmia or make a medication error with all this chaos. I have never heard of this being done before. I am sure that it is a cost cutting measure. Does anyone else work in environment like this? How have you managed this successfully?

I am going to be popular here right now. Not ALL telemetry units have monitor techs. I think the reality of "running for every alarm" is a bit extreme. If the telemetry alarm are properly set....less acute alarms can wait for a short period of time for intervention. Your management needs to develop policies with the medical staff what is an acceptable "wait" for the alarm and rhythms. I have been a nurse for 33 years and I have never had a monitor tech to watch monitors in any step down/PCCU/ED/ICU/CCU/Tele I have worked or managed.......and I have never had a patient have an untoward outcome because and alarm was not answered, or not answered in a timely manner.

The AJCC (American Journal of Critical Care) has made recommendations for both ICU and PCU nurses to accommodate these changes and improve your practice with some very good suggestions.

http://ajcc.aacnjournals.org/content/19/1/28.full.pdf

Unfortunately there are "false" alarms and yes those foolish monitors will ring all day long. I do not know what system of monitors and monitor analysis you have......and I'll admit some are better than others. I always felt that if the monitors were always right....the hospital would NOT need me anymore. I have seen one system that has the alarms notification on computerized lighted "bars" on the ceiling placed at certain points in the hallway and all you do is stick you head out the door. Of course that doesn't tell you the what the monitor actually shows.

Monitoring systems have levels of notification the only ones that need to be immediately are "red" or "emergent" alarms....v.tach, v.fib, asystole, hr>200 (or whatever limit is decided),extreme bradycardia HR150 and V.tach to be 4 beats and up for response attention as emergent alarms.

In reality, a controlled a Fib even if "new" is survival rhythm. I required my staff to look at the monitor on their patients hourly and address the alarms and "clear them" every four. I also paid the secretary the top of her scale and "monitor trained" her for that rare occurrence. I always reminded the staff that leads off/battery inoperative can be asystole misread by the computer and to NEVR SHUT OFF THE ALARMS. I also had an additional banks of monitors (just the screens) so the staff could check the monitors frequently and portable bedside monitors that certain patients used when interventions for arrhythmias needed to be monitored.

Learning to adjust is difficult, change is HARD, as us here in AN discovered with the upgrade. I think the success will depend on the motivation of your facility and your bosses active presence to ensure a safe transition. Their decision to change may have been premature as The Joint Commission and HHS are coming out with recommendations very soon...the will change the playing field completely. Telemetry "mishaps are right now "Sentinel Events" http://www.jointcommission.org/sea_issue_48/ with The JC and it will be a new focus soon.

Joint Commission: Nine ways to combat health worker fatigue - The Advisory Board Daily Briefing

[h=2]Lawmaker Urges HHS To Address 'Alarm Fatigue' Among Health Providers[/h]Rep. Edward Markey (D-Mass.) has sent a letter to HHS Secretary Kathleen Sebelius calling on her to task the Institute of Medicine to address the issue of "alarm fatigue" in health care settings, the Boston Globe's "White Coat Notes" reports.

Alarm fatigue refers to medical workers ignoring or becoming desensitized to audio and visual alerts from medical devices

Lawmaker Urges HHS To Address 'Alarm Fatigue' Among Health Providers - iHealthBeat

These changes will make the hospital address these issues for they will be apart of survey and reimbursement. This is a focus for patient and safety goals and will become a greater focus soon .......if you are feeling unsafe....you can let The JC know

http://jcwebnoc.jcaho.org/QMSInternet/IncidentEntry.aspx This subject is high on their radar.

I know that this seems overwhelming but it is done at multiple facilities across th4e nations every day. There is evidence that alarm fatigue affects even telemetry techs and ignoring an alarm has lead to an untoward event even with a monitored tech present AND has even occurred in patients being monitored by an EICU. So having a moniotred tech doesn't ensure the patients safety......hard work and diligence however does.

https://allnurses.com/nursing-news/alarm-fatigue-factor-622727.html

Whether or not this is feasable for your facility I can't tell as it depends on the monitors, the MD's the staff and the manager. I just wanted you to know that it has been done and is done all across the US sucessfully and changing is hard but it can be done. I wish you the best .....Peace!

working4change · Jan 11, 2012

Thank you for all your replies! I'm glad to hear that it has worked in some facilities and I appreciate the time that it took for everyone to respond. I, too, am an experienced nurse, who has practiced for 30 years in a variety of clinical settings throughout the country. A few comments....Since the pagers go off every few minutes with "red" inaccurate & true alarms, I don't know how the staff could just check them every 4 hours? Our secretaries are too busy initiating orders to safely monitor the telemetry. (We have computerized medication administration but not charting.) In addition, we do not have a secretary for at least 8 and often 12 hours of each day.

I am a high energy, conscientious nurse. Some of my co-workers are apathetic, others are unable to keep up with the physical demands of answering alarms up and down the hallway, so they don't. Recently a nurse, shut off the alarm on a pt who had 21 beats of vtach and went on with her current task without even checking the patient. Another did not check the patient when the heart rate was staying at 170. Many of the nurses are new and overwhelmed. Our "charge" nurse is just one of the nursing staff who rotates through the position and has a full-team of patients plus the responsibility of making bed assignments, finding staff etc. We have a clinical supervisor & a director who stay in their offices and are curiously uninvolved.

Unfortunately, the "roll-out" of this system was disorganized and chaotic. As a super-user, I was given a 2 hour meeting where no one knew the answers to any of the questions raised. They used the old telemetry monitors and mounted them adjacent to the ceiling. (I'm not kidding.) So many of the shorter nurses can not use the touch screens and of course you can't use the keyboard or mouse and see the monitor at the same time. We have strips automatically printing every 4 hours on 33 patients which need to be interpreted, plus we have reams of alarm strips currently piling up on the floor or into a conveniently located waste basket.

I have worked in an ICU setting and not had problems, but 33 patients alarming every couple of minutes, is a law suit ready to happen.

working4change · Jan 11, 2012

I really appreciate all the links that everyone supplied! Thank you so much!!!

IHeartDukeCTICU · Jan 12, 2012

The SDU at the facility I work at def had some issues with alarm fatigue. Ultimately, it's up to the RN's to hold each other accountable to set your monitor limits according to your patient's norms. I started out on the SDU, and alarms would be going off constantly and it drove me crazy. When I went to the ICU, I found that if someone had a patient who kept alarming, the other nurses would approach that nurse and tell them to adjust their alarm limits appropriately. But I can imagine how difficult it would be for the 30+ bed stepdowns though.

brainkandy87 · Jan 17, 2012

This is one of the most asinine things I've ever heard of. If we had pagers for alarms on the SDU I worked on, we'd get paged every 30 seconds. We had Space Labs, which is a giant piece of crap, so EVERYTHING alarmed. I can't imagine not having human eyes on it. Although I will say, at least for the unit I was on, most of the human eyes that were watching them were fairly useless. One of them argued with me that there was no such thing as polymorphic vtach, because she'd never heard of it. This was right after one of my pts had a run of Torsades. Sigh.

Vespertinas · Jan 21, 2012

Generally if your leads are on correctly (and boy you'd be surprised how many people can't even do that right), you shouldn't be getting TOO many false alarms if your parameters are set appropriately. Like IheartDuke said, sometimes it's one particular troublesome bed and then you can say something to that nurse. I also was connected to all 32 patients but we had a set of monitors at all 3 nursing stations and when nurses charted, one had to be sitting by the monitors to look at the rhythm before shutting off an alarm.

Like Esme said, every 4 hours we were required to print out a strip, interpret, put in the paper chart, and review all alarms. We rarely had problems this way. Also like Esme, we had different levels of alarms. The only ones that actually went through to our pagers were the life-threatening ones. The rest were coded by a variety of bells that chimed at the nursing station.

I personally always felt this responsibility was mine and I was proud to be capable at interpreting rhythms. When I started at a hospital with telemetry techs, I was (mildly) offended that they thought I couldn't take care of that on my own. I've learned to trust (most) of the telemetry techs and now I can say I'm grateful to them for being there. But before I had ever known of such a position, I did my job happily ignorant that it could be otherwise. They could have gotten away with training me to wash the windows at my first job...what AREN'T we expected to do?

brainkandy87 · Jan 21, 2012

Speaking of putting on patches correctly, just a little random story:

We had a pt with situs inversus (organs all all reversed in the thoracic cavity) and his rhythm just looked crazy. However, the tele techs didn't know that and the nurse that was assigned to him didn't know what that was in his history and didn't bother looking at it. So long story short, this poor guy had a roomful of nurses hovering over him like he's about to die until finally it clicked in someone's brain to reverse the tele patches.

Vespertinas · Jan 21, 2012

We had a pt with situs inversus (organs all all reversed in the thoracic cavity)

That's the coolest thing I've heard this week.

We play with the patches a bit too for LVADs