NICU monitor event review

[HeartNIC]

We recently had a change in practice requiring nurses to do a monitor event review to catch any A&B's or desaturations recorded in the monitor that were not witnessed or charted. An event log review is to be done at end of shift and documented that it was done and whether events were found or not. This is a new practice for us and compliance is really low.

Do any of your units do this and if so do have an accountability system that works?

Thanks.

[NicuGal, MSN, RN]

We have the capability to go back and look at the trends, etc and we can have them downloaded, but our docs won't do it because how do you know if they were real if they weren't witnessed? Seems to be a legal snafu.

[dixRN]

I have not encountered this before. What about those desats when the baby kicks off the sat probe, etc. ? Seems like a lot of potential for not being a real event.

[TiffyRN, BSN, PhD]

We would need monitors that are far more accurate. Particularly the ones that can never perceive the infant's resps when they are prone.

[TheMiss]

@TiffyRN

your monitor only does not pick up the babies resp when they are prone if you placed the respiratory lead incorrectly.

Most believe that the respiratory lead work by picking up respiration movement. Which it doesn't. It sends an electrical signal through the body. When resistance is high (i.e. when there is air in the lungs on inhalation, as air has a higher resistance than bodyfluids or tissue) it measures this and gives you the upwards curve. When resistance is low (i.e. on exhalation when there is less air in the lung) it displays a downwards curve. If you don't place your leads correctly it monitors superficial skin resistance bypassing the lungs and will either show anoea, shallow breathing or nonsense.

[TiffyRN, BSN, PhD]

TheMiss:

So what is the ideal placement for the leads? We have always been instructed to place the white lead and black leads approximately the same place on the upper chest with one on the right and the other on the left (avoiding the nipple). The red lead (or some monitors use green) goes on the left leg. Sometimes this is placed on the left lower abdomen but I find this sometimes does not permit a good resp reading (and gets pooped on).

Once more I'm not sure if our monitors are as advanced as others, because they DEFINITELY respond to movement that has nothing to do with the infant. Such as me touching the infant, or burping.

[RainDreamer, BSN, RN]

No, we have nothing like that in place.

I just don't see the advantage of something like this? How do you know if these events were even real if they weren't witnessed? And also, what were the circumstances around the event (baby screaming, eating, pooping, etc.) and what needed to be done.

We document every A&B. Heart rate, O2 sats, color change, circumstances, duration, and interventions. Those things can't be determined by looking through the event history of the monitor.

I can see why compliance is low. Who's idea was it to put this practice in place?

[HeartNIC]

The idea was from the medical director, our monitors are high tech and doctors were noticing A&B events recorded on monitors but not charted. The events are generally those heart rate drops that self-recover within 5 seconds or so. Sometimes a nurse many not even make it to the room to see what is happening but it happens frequently enough to cause concern and is potentially the difference of whether or not an infant is sent home on a monitor.

The expectation became that a monitor event review would be done every shift with nurses charting recorded events that are not witnessed. The HR drops recorded are reliable on our monitor, recorded as a number as well as the rythym, it is clear whether or not it's artifact or a true heart rate drop. Desats are only documented IF accompanied by a recorded HR drop because the pleth recording does have a lot of artifact. Nurses are not expected to interpret, just document factual information. The entry would say something like "0900 - HR was recorded as 72 and sats 78 per monitor event review at 1230". Nurses are reporting recorded information and physicians are expected to interpret the information on the monitor.

It's interesting no one has responded they are doing it.

[TiffyRN, BSN, PhD]

It's interesting no one has responded they are doing it.

I think it would have to be because with so many of us our monitors are just not that accurate or capable of such detailed reports.

I wouldn't feel uncomfortable noting an event if I could see an image of the event.

[NicuGal, MSN, RN]

We have brand spanking new monitors too with all those capabilities, but I can just hear the conversation from a lawyer about this running thru my head. I'd be running this past your legal team to see what they think. That is fine and dandy that it is documented, but unless they are going to print a hard copy from every monitor then how do you prove the doctor read and interpreted it, esp if you have say 30 of those events documented...do they go in and make a comment about every single one of the things you document? Take 30 events x 50 kids (what we have in our unit) and I can tell you, that after a while they would hang it up, esp if legal tells them that they have to go in and intrepret each one and write a note.

[HeartNIC]

NICU Gal -

You are right on with what legal said - physicians need to be documenting that they are reviewing and interpreting the events that we are documenting! The medical director thinks having the nurses look it up and document will decrease the docs work but it is really only creating more for them...I am with you, we'll see how long this lasts!