Overuse of telemetry...anyone relate?????

nursej22, MSN, RN · Feb 3, 2010

I work on a cardiac telemetry unit and we have admission guidelines for medical versus cardiac telemetry, however admitting physicians can order telemetry outside of these guidelines, and often do. Medical telemetry patients must have a rhythm not requiring IV meds (bolus or continuous), is often ordered for new onset CVA/TIA to rule/out Afib. They get a lot of respiratory because their pulse ox is centrally monitored.

Cardiac telemetry is meant for those patients being treated for acute cardiac conditions, i.e. acute MI, symptomatic bradycardia, tachycardias, decompensated CHF, OHS, etc. We will often get non-cardiac patients because we have a slightly better staffing ratio 4:1 versus 5:1 and some MDs think that we can "watch them closer". So we get a lot of respiratory, r/o sepsis, rhabdo, GI bleeds, syncope and the like.

We do not have a discontinuation policy; some of the more experienced hospitalists will dc telemetry on their own, but we are continually calling MDs to request a dc order, so we can move patients off to make room for more admits. We are a 29 bed unit and typically change out 50-75% of our census every 24 hours. Sometimes it comes down to "if you want your ED pt on our floor, then you will have to move someone else off."

Our team leaders and staff nurses try to be proactive when notified about admits to screen if they are really appropriate for cardiac tele, unfortunately medical tele is not. They will fill up and then we take their overflow. Their staff is so green they don't feel comfortable asking.

Rarely, maybe 3 times in the last year, have cardiac tele pts stayed in ED, and this is only after ICU has taken as many as they can.

Good thing, because orders don't get processed, labs aren't drawn, meds aren't given, pts get left laying cold, wet and hungry.

blessings2nurses · Feb 10, 2010

Thank you nursej22, what you describe is what I have experienced as well. When patient overflow occurs there may be a delay in care which is the primary concern to develop this protocol which would prompt those newer nurses.

RNcDreams · Feb 11, 2010

Good thing, because orders don't get processed, labs aren't drawn, meds aren't given, pts get left laying cold, wet and hungry.

I feel badly about this comment; I often take care of "tele holds" in the ED, and I try to ensure they are on a regular schedule as they would be on the floor. I provide peri care, clean linens, meals, meds, treatments, and draw labs, all to the best of my ability while caring for 3 or 4 other critical/emergency patients. Remember what it's like on the other side. I try to!

Ideally this "holding" thing would never happen, but it does. Sometimes, when the hospitalist is told "There are no more tele beds," they'll think for a minute and say "Ehh she can go to med surg, d/c the tele orders." It's doctor dependent, mostly.

I do think that a lot of patients are put on tele purely because the MD's feel on some level that it's "closer" observation. While this is true in terms of monitoring, I think it translates to jam-packed cardiac floors, stressed nurses, and overall a backup in patient flow.

nursej22, MSN, RN · Feb 12, 2010

If you are providing for your patients then obviously my comment wasn't directed at you. Our ED is not set up to accommodate inpatients: they have stretchers only(no beds); the staff does not use the EMR so they don't know what meds are due when or how to chart them; they have no tray service; it's cold and drafty; and they have limited toilet facilities and certainly no bathing. And as you stated the staff priority is emergencies.

blessings2nurses · Feb 16, 2010

RNcDreams,

You stated you care for the tele holds to the best of your ability while caring for several other patients. I am sure yourself and many others do your best to provide quality care...but there is only so much one can do. At some point, care may be delayed and the priority most likely will not be the 'holding' patient but the more acute. In fact, research has shown the impact on ED nurses (and patients) as they try to care for criitically ill patients when the ICU's are full and cannot transfer a patient to step-down because of the tele back log.

The issue of overusing telemetry simply because a physician 'prefers' their patient there needs addressed. This practice not only impacts our patients but the workload of nurses.

Thank you for striving to give your all to every patient!

RNcDreams · Feb 16, 2010

RNcDreams,
You stated you care for the tele holds to the best of your ability while caring for several other patients. I am sure yourself and many others do your best to provide quality care...but there is only so much one can do. At some point, care may be delayed and the priority most likely will not be the 'holding' patient but the more acute. In fact, research has shown the impact on ED nurses (and patients) as they try to care for criitically ill patients when the ICU's are full and cannot transfer a patient to step-down because of the tele back log.
The issue of overusing telemetry simply because a physician 'prefers' their patient there needs addressed. This practice not only impacts our patients but the workload of nurses.
Thank you for striving to give your all to every patient!

Thanks! Sorry if my response came out weird.... it's a touchy topic. Makes the nurses stressed and spread to thin. And it's true, at some point you end up having to ignore them for the acute, new patients. It's a terrible way to work, feeling as if you are falling short no matter what!

lkwashington · Mar 30, 2010

I can really relate to this I work on telemetry/progressive care unit. We are an 28 bed unit. When the other units are full we have to take the admits because the other units are smaller. When have you worked and med-surg unit is less than 25 beds. At this moment I am working prn. I am planning on traveling because of the hospital politics. Just a thought.

AggieNurse99, BSN, RN · Mar 30, 2010

Our hospital is different in the fact that all RNs are required to have ACLS. Med/Surg often has our Tele overflow and our Tele often has med/surg overflow. When all are full then PCU has tele overflow, then ICU. ED often has to hold pts 6-10 hrs when all are full, and routine nursing care often depends on the philosophy of the ED charge nurse for the shift.

General E. Speaking, RN, RN · Apr 13, 2010

does your facility use telemetry admission criteria? we have a protocol but i rarely see it used. seems the only thing that matters is an order for "tele"
does your facility use telemetry discontinuation criteria? we have a protocol for that too but ultimately it requires that we call the doctor and then usually say "no" so what's the point?
are there times your ed experiences an overflow of patients with no tele beds available? yes, we frequently have patients holding because of no beds or no tele boxes
what strategies have been used to improve patient flow? not so far. i would like for some education to be done for the doctors as to why they want to place a 98 year old dnr admitted with cellulites with no previous cardiac history on the monitor

hope this helps!