Telemetry overuse = ED overflow...Can anyone relate?

Trauma Columnist · Feb 1, 2010

I worked 10 years at big teaching hospital (700+) beds and worked ER:

1. We had housewide telemetry - every bed was wired so pts could be placed everywhere!

2. If they had to have REAL telemetry, it was reserved only for those who passed thru our cardiologist's review.

07302003, ASN, RN · Feb 2, 2010

I work at a small community hospital - tele IS overused. We get lots of DNR DNI's on our tele floor, CHF frequent flyers, admissions for pneumonia (with tachycardia in the 120's)

We have an automatic stop protocol AFTER 36 hours.

I can't speak to the ED, or admission criteria.

Through the grapevine I hear that MD's feel their patients are better taken care of on a tele floor (patient ratio 4-6, RN's are knowledgable.)

Best of luck!

unlvguy · Feb 2, 2010

I dont know much. I am currently in nursing school and it just seems like everything we go over, they stress that it is a good thing to hook up the cardiac monitor. example being potassium lab issues, COPD etc.. A question that I thought of is. In the med/surg area, you do need a doctors order for telemetry correct? In the ER setting you dont? This just popped into my head. Please clarify if this is correct. Thanks!!

mappers · Feb 2, 2010

TraumaRus, what is "real" telemetry?

Altra, BSN, RN · Feb 2, 2010

Hi my dear fellow nurses,
I am currently a doctoral student with a capstone project on the overuse of telemetry which impedes patient flow. I would love to hear of any experiences from across the United States if this is an issue in your practice area. Some questions are:
Does your facility use telemetry admission criteria?
Does your facility use telemetry discontinuation criteria?
Are there times your ED experiences an overflow of patients with no tele beds available?
What strategies have been used to improve patient flow?
Thank you all for any valuable information you can share!

In the small community hospital in which I have worked ... absolutely tele is overused, to the detriment of patient flow out of the ED.

Question 1: No real criteria - PMDs admit based on what they "feel" the patient "needs", including "I want the patient on Floor X with the nurses on Floor X."

Question 2: No real criteria

Question 3: Yes. But to be fair, we sometimes board med-surg patients too, though less often.

Question 4: Management operates in crisis mode, responding when the ED is screaming that 80% of beds are being occupied by boarding patients. But no real methodical approach to avoiding this type of crisis.

Thank your for focusing your research attention on this topic!

cardiacmadeline, RN · Feb 2, 2010

I am not an ER nurse so I won't be able to respond to your last two questions, but I would like to say a couple of things. Admission criteria for tele-If the MD feels it is needed, they will order it. I am not aware of admission criteria. We don't have any discontinuation criteria either, although sometimes I wish we did. We will occasionally see a DNR remain on tele, or one of our long term patients on tele when they have been in SR for the last 2 months (just think, the cost of that is around $46000!!!). Lastly, we will sometimes get transfers from a non-tele floor because they are in rate controlled a-fib, which they have had a history of for the last ten years. Or the patient that is transferred to be monitored on tele because they are in sinus tach, but once they receive pain medicine and tylenol for their increased temp, their heart rate is WNL.

cookienay · Feb 2, 2010

I work for >500 bed facility with a 50 bed ER (including the minor care area). I hope these answers are helpful...

1- We do have "criteria" which includes factors such as dx, labs, hx. There is a clause in there for physician discretion. All units except our Mental Health unit are tele capable.

2-I am sure there is criteria listed, but MD discretion plays part here as well. Mostly if they are d/c'd in the hospital it is because they are going to a lower level of care such as rehab or skilled.

3-Yes, this has been known to happen. However this has been greatly improved over the past year in part to a nursing administrator who actually gets it (having overflow areas available, expecting managers to come in and work it if necessary) as well as the addition of a good # of inpatient beds. HAving no beds available has not been a major issue these past 12 months due to several changes in our processes.

4-Strategies to improve flow are: utilizing an aditional care area for minor ER patients (we have the capabilities to put major patients in the minor area). THis is only opened on an as needed basis depending on several criteria which are spelled out. Another strategy is the use of a "clinical decision unit" which has come into popularity recently among many hospitals. Our management as well as admin keeps a close tab on the ED and our bed assignment staff. Our turn around time is monitored and both the ED and the bed assignment office is held accountable. This strategy has been the most effective in my opinion.

These strategies have greatly improved our flow and wait times. We would occasionally have boarders due to no tele beds, but I can't really speak as to whether that is from overuse or not. We have not had a real issue with no tele beds available in the past 12 months that I remember.

Sorry to have such a long post, I hope this is helpful.

llltapp · Feb 2, 2010

I worked in a small community ER with 18 beds. We were constantly holding patients in the ER because the admitting docs wanted tele for any patient that had a irregular heartbeat at any time in their lives lol (i am being sarcastic but truthful). Their dx didn't even call for tele and their condition was not cardiac related. I was told on many occasions by the docs themselves that the patient received better care on the tele floor.

Now that I work in a larger regional trauma center with extensive cardiac interventional services, beds are still tight with lots of ER overflow in the "holding area" of the ER. Non-tele beds are much easier to come by than tele beds. Tele again is overused. We do not have "tele" protocol per se, but we have instituted a new admission order: either the physician makes the call as the admission status (23 observation or full admit) OR they can now put the ownership on case management to make the call. Funny thing though, it seems those with great insurance get automatic full admit and those without get "per case management" unless its a no-brainer high acuity issue.

blessings2nurses · Feb 2, 2010

Wow...thank you all for taking your precious time to respond. Each reply is helpful and I knew I could count on the nursing community to come through with valuable information. Much of the replies are not surprises as this issue is becoming a national crisis.

TraumaRNs- smart strategy to have an all tele capability but one question that comes to mind is whether maintaining competencies become an issue?

07302003- I would love more information on the 36 hour automatic stop protocol if at all possibly!

Altra- Exactly! I know the "crisis mode" pain all too well. The goal is to develop a nurse-driven discontinuation protocol as a proactive strategy...

Thanks to all...I will keep checking back for feedback.

Blessings :)

blessings2nurses · Feb 2, 2010

Good question mappers, this may be related to differing criteria or protocols...I'm anxious to see if this is the case. If so, TraumaRUs could you explain how the telemetry works?