POLL: Should telemetry techs need to know patient Dx?

jadelpn, LPN, EMT-B · May 3, 2015

I can see that someone who is monitoring rhythms would need to know diagnosis, if only to remind the nurse when reporting changes. For instance, if the patient is admitted after converting out of a-fib for observation if they go back into a-fib, then that original diagnosis would be helpful to know. If they are admitted with a low K, again, something for the nurse to be reminded of if you report off to them a change.

I would also think it difficult to figure out a baseline if you really have no idea why they are there. So if a tech continues to report the patient is tachy, for instance, that may or may not be what the patient was admitted for.

Then there's the almighty buck. Monitoring, and having someone monitor is a charge-able function. Therefore, to have information handy on one sheet helps billing to not have to look more than one place for the information they need to bill.

I am surprised that with the ECG interpretation class, they are also not teaching general diagnosis and how it affect rhythms. I am not sure how one would establish what is going on to begin with, in order to discuss changes.

GrannyRRT · May 3, 2015

To have us write the patient Dx seems unnecessary, irrelevant and clearly outside our scope as a tele tech. Consider the fact that in most cases the tele tech position requires zero education beyond a basic ecg interpretation course.

It sounds like you did not realize you were getting hired to be part of a PATIENT CARE TEAM. You don't need a college degree to understand a few things beyond the squiggly lines on the monitor and how they pertain to the total care of the patient.

The way I see it is, it isn't my job to speculate, make assumptions about a patients condition or be anything but completely objective in the way I handle each rhythm on the screen.

No one is asking you to make assumptions. There are concrete reasons and even some speculations already made by the doctor who ordered the patient to be on tele. Your job is to support that reasoning. As you gain experience you will be amazed at what your will learn about people from watching the monitors. You will find other professionals such as RT and PT will want to know what you have been seeing on the monitor.

As an RT, I find the Tele Tech to be an invaluable part of the team and to have my back for some of the Pulmonary patients. Our tele is also capable of SpO2 and in some cases ETCO2. I sometimes let them know if I am going to be working with the patient or if I have put them on CPAP/BIPAP/AVAPS or a Continuous Albuterol nebulizer (increased HR or PVCs from K+ drop). The Tele Tech might be told when the patient is on a considerable amount of oxygen. They may document that initiation of therapy in their own notes at least to pass on to the next Tele Tech. We also provided education for OSA not only to the RNs but also to the Tele Techs since they will be directly involved when we initiate the protocol. Some Tele Techs have also told me about patients who have had rhythm changes only at night and have been placed on oxygen by nurses temporarily but still not in our protocol. This is not diagnosing or making an assumption. This is merely reporting observations to possibly initiate the proper care for the patient. What the licensed professionals choose to do with that information reported is on them.

Tele Techs may be asked to do extra documentation for certain drug studies.

Patients, especially pediatrics, will have notations that their cardiac issues will have SpO2s at a much lower range for normal. You would really have to be very task focused with a "not my job" attitude to not want more information about these conditions. If you see that dx on the charting it should be appropriate to ask for SpO2 parameters.

The Tele Tech has also been instrumental in preventing falls. They, of course, do not replace a sitter but they have watched someone's rhythm long enough to know the patient's movements. I sat at the monitors back when post op hearts in the tele wing were on major drips including lidocaine. By 0200, some of them were bat crap crazy. I got to know when someone was about to do something even without a "reportable" rhythm on the monitor. I still take my turn sitting at the monitors in the units and the RT department does the 12 Lead ECGs which we may also report to the Tele Tech to document its existence to correspond to the tele monitor.

Even the doctors will rely on the Tele Tech for information or just to know where a patient is since it is not uncommon for nothing to get past the really good Tele Techs who will know where their patients are and their tele boxes. Once the doctors get to know you, you might just find yourself having some very indepth discussions on cardiac issues and rhythm interpretation with them.

It is your choice to build on that very minimal training the ECG course gave you to function as a valued part of a patient care team and learn why patients need a Tele Tech or you can just do the task of watching squiggly lines on a monitor.

dudette10, MSN, RN · May 3, 2015

At my old job, we had a world class tele tech with which many of the cardios would discuss strips. She never knew diagnoses. She watched 80 monitors and never missed a thing.

All the the points above are indicative of a really good tele tech (interpreting pt activity from monitor tracings, asking for parameters for SpO2 monitoring, etc.), but none of them require knowing the diagnosis. Going from NSR to afib post cardioversion is reportable even without knowing the patient was converted.

Hell, I just want the tele techs where I work to pay attention. One in particular is known to change alarm parameters to something ridiculously high after the first report to the nurse without asking permission from the nurse. The first time he did that with one of my patients, I changed it back and asked him why he changed it. He said, "because it kept alarming." Without really giving a crap how I sounded, I said, "yes, that is why the alarms are on in the first place. Don't you ever change alarm parameters without discussing it with me first." If he had been the world class tech from my old place, I would have trusted him more to think through everything, and I wouldn't have had an issue with changing alarms without permission. But, he's an idiot....so, no.

GrannyRRT · May 3, 2015

but none of them require knowing the diagnosis.

I do not agree that none of them require knowing the diagnosis. Many of the alarm parameters are diagnosis based. If you have a fixed rate pacemaker your alarm settings might be different than a variable rate or regular patient. If the patient is part of the cardiac "mixers" group, you would know to get the parameters. The same for patients on a pulmonary floor or those hooked up to "breathing machines". Some nurses do not always think to pass on this information or even ask the doctor for parameters. This is why I prefer a floor with a good Tele Tech as opposed to a floor with a hodge podge group of RNs or various techs watching the monitors. It is also good to know a little about the patient whose HR is usually at 62 but goes to 98 (which still in normal limits for most alarms) if the patient is easily agitated or on a floor with no SpO2 monitoring but is on hefty O2. The monitor techs can see changes with are not necessarily outside of the alarm settings. I have seen enough Tele Techs get blasted and belittled by RNs for not knowing something even though certain information was never passed on to the Tele Techs. But then, I guess maybe it is sometimes best to just say you only watch the monitors and only report what you are told to.

Alarm fatigue is an issue. I have had RNs tell me to set my ventilator alarms way out of the parameters for that type of patient and ventilator or shut off that alarm totally. Others demand the mode be changed to PCV so there are fewer alarms. They also say probably the same thing the Tele Tech told you, "But, I'm here watching the vent (monitor)".

I could easily just call these nurses "idiots" also but I would rather explain "why" which might involve taking a few minutes to go into detail about the diagnosis.

I don't always have to go into a great amount of detail but I will tell the Tele Tech I have a brittle pulmonary patient in room X and am expecting something to do with the ABC. I also tell them to call me directly if the nurse doesn't respond or in addition to.

If we didn't have great Tele Techs, RT and the CCM doctors would be totally against BIPAP, ventilator and most trach patients being on the Tele floors. This would mean a lot of ICU time and beds tied up for otherwise stable patients.

Trauma Columnist · May 3, 2015

Okay - lets keep our terms of service in mind and debate the topic, not the poster.

icuRNmaggie, BSN, RN · May 3, 2015

I voted yes.

The following link will take you to the AHA Practice Standards for Cardiac Monitoring in the Hospital.

Circulation

I am accustomed to working with

tele techs who have expertise with cardiac diagnoses, the causes of dysrhythmias, medications and cardiac side effects as well as full access to the EMR.

They can be counted on to record and report changes to the Nurse in charge of the patient.

dudette10, MSN, RN · May 4, 2015

GrannyRRT, you misinterpreted "none of them require knowing the diagnosis." What I meant was, your examples that I put in parentheses do not require a diagnosis. In fact, they are unrelated to a diagnosis and more related to treatment of any number of diagnoses. That doesn't mean that nurses never speak to tele techs to give them info on a patient. If I start a person on diltiazem, OF COURSE I'm gonna tell the tech and ask him/her to inform me if the HR goes sustains even higher, or hits a normal rate, or changes rhythm.

mycoholic1 · May 4, 2015

It sounds like you did not realize you were getting hired to be part of a PATIENT CARE TEAM. You don't need a college degree to understand a few things beyond the squiggly lines on the monitor and how they pertain to the total care of the patient.

Hi, Granny. Yes, but you do need a college degree to treat and care for patients. I know what my part of the health care team is. A huge part of being an effective member of a team is knowing exactly what your role is. While I'm a valued part of the health care team the fact remains, I don't give care to the patients. I don't have a license to treat patients. All I have is a rhythm, name and age, a room number and a pt. dx. and you can't give care to a patient with only that information from a remote office. We work directly under the RN. They are our boss. The rhythm is what I monitor; the name, and room number are my pt. identifiers and are essential. The rest is non-essential, but nice to have in some cases, but our job doesn't rely on Dx.

My argument is based on the experience I've gained over the last 7 years as a tele tech "watching squiggly lines" and rarely, if ever have had the need cross-reference a pts rhythm with their Dx. I understand the squiggly lines well and have taught 12-lead. I know what is normal and what isn't. I know when to call the RN and maybe even more importantly, when not to. My job is to simply observe and report in a swift manner as to avoid any potential delay of treatment. Not to speculate about what a patient may or may not be doing. The Dx really doesn't help me in any way. But, lets dive down that rabbit hole for kicks and grins.

I've just received notice of a new patient going on tele. Schmoe going in room 322, 75yo male, Dx - COPD. I'm looking at the rhythm and see a bunch of different looking p' waves. I methodically analyze the rhythm and decide he has an atrial arrhythmia; WAP. I'm not surprised because I know from educational literature that WAP can correlate with COPD and hypoxia, but I call the RN and let them know that the patient was admitted in wandering atrial pacemaker, because it's abnormal. Did I need the Dx to reach my conclusion? Did it even help?

OK, pt being admitted. I have their name, age, room number and Dx is AMS. Oh! I'm glad I had that diagnosis! They have an altered mental status and might be pulling at their leads, or they might try to get out of bed and fall, or they might have tachycardia from being confused and saw spiders in their corn-flakes. Might. None of that matters because this is science, not a guessing game. If there's artifact I'll call the RN. If leads come off I call the RN. If they get tachy, call RN. I report anything notable because that's what we do for EVERY patient. I can't make judgment calls. If the RN wants to give me special parameters about when and what to be notified that's up to the RN. I can't assume anything based on the patients Dx.

This is merely reporting observations to possibly initiate the proper care for the patient. What the licensed professionals choose to do with that information reported is on them.

Yes, Granny you're exactly right and I thank you for your thoughtful reply. I wish we had RT's like you in our hospital, they never talk to us. I also love it when RNs take the time to call and give us a quick report and discuss alarm parameters, but they almost never do where I'm working now. I didn't want to come off as if I had the "it's not my job" attitude, that's not what this is about. I see it like this; If I wanted to use my understanding of arrhythmias and how they relate to the patients total condition, in a hands-on the patient capacity then I should chose another modality; be an RN, an EP doc or even paramedic. I don't like to think of my own mother or daughter in a hospital bed on continuous ecg and O2 with an un-licsenced monitor tech who's privy to their Dx.

mycoholic1 · May 4, 2015

Thanks for the link icuRNmaggie, I certainly hope my hospital follows similar high cardiac monitoring standards. I don't see how it supports your vote, though. We have techs, myself included who have a solid understanding of cardiac diseases and the associated arrhythmias, medications and side effects. As a monitor tech I still fail to see how access to the pt's Dx would influence how I perform my duties. If I just used pt diagnosis in any way to shape my actions, I've just become a nurse and am outside of my scope. I just observe and report. It's up to the RN to decide whether what I report is important and needs addressing.

Here.I.Stand, BSN, RN · May 4, 2015

I'm not sure what everyone else's experience is, or what standard every hospital has for their tele techs... But where I've worked, they are basically a CNA with some extra training in reading rhythms, so I'm basing my comment off of what I know. Are they a valued part of the team, absolutely. Is their role important, absolutely. If I set an unusual parameter, can the tech know the RN's reasoning, absolutely--not at all appropriate to tell a valued member of the team "Just do as you're told."

That said, in my experience, they knowing what drugs the pt is on or that the pt has crush injuries is irrelevant because they have not studied patho. I would want them to report peaked T-waves because it's a change in rhythm, but I can't expect them to put the pieces together that pt has crush injuries so is at risk for elevated K+ which can cause peaked T-waves. Because they haven't studied patho.

MatrixRn · May 4, 2015

My argument is based on the experience I've gained over the last 7 years as a tele tech "watching squiggly lines" and rarely, if ever have had the need cross-reference a pts rhythm with their Dx. I understand the squiggly lines well and have taught 12-lead. I know what is normal and what isn't. I know when to call the RN and maybe even more importantly, when not to. My job is to simply observe and report in a swift manner as to avoid any potential delay of treatment. Not to speculate about what a patient may or may not be doing. The Dx really doesn't help me in any way. But, lets dive down that rabbit hole for kicks and grins.

Exactly right the tele tech reports changes in rhythm and it it up to the nurse to interpret the results. I would say having the diagnosis on the strip is a time saver for the nurse. If I know part of somones history is a-fib I will be less concerned when I see that on the strip, but I will pay attention to a new bigem or trigem showing up.

POLL: Should telemetry techs need to know patient Dx?

Should tele techs be privy to PT Dx?