To Be (Monitored) or Not To Be (Monitored)

Should all ICU and tele patients be monitored when leaving the unit for procedures? If not, which absolutely should be monitored and for which patients may the requirement be waived? My aim is to stimulate thinking about best and most sustainable practices: best for the patients who need monitoring, and sustainable when losing a nurse for two hours creates a hardship in the unit.

To Be (Monitored) or Not To Be (Monitored)

Old-school RN here. Studied for Boards (before they were called NCLEX) while traveling West in a wagon train, fighting dinosaurs along the way. Cut my teeth in several ICUs, when Swan-Ganz catheters were becoming all the rage. Have seen trends and treatments come and go, the pendulum of nursing practice swing first one way then the other way.

Background: I worked in IR (Interventional Radiology, which included staffing the Cardiac Cath Lab) for 21 years. Most recently (past 10 years) I work exclusively in Cardiology: Cath Lab, Stress Lab and Cardiology Case Management.

Current Issue: Two recent encounters blew dust off a few dendrites, and got me wondering about the practice of transporting cardiac patients from either the ICU or tele unit to various procedure areas.

Encounter One

Patient with NSTEMI (non-ST-elevated MI, the "less" dangerous form of MI) and +chest pain in the past 24 hours arrived via bed to our Cath Lab. He is not on a cardiac monitor. Say what???

Repeat: He is not on a cardiac monitor. His accompanying nurse reported "the doctor said he could go unmonitored."

Encounter Two

Waiting for my next patient to enter the Stress Lab, I heard a familiar beep-beep-beep and turned toward the door expecting to see a gurney roll through, patient attached to the monitor, RN in attendance.

What rolled through the door: Nuclear Med tech pushing a wheelchair, on which sits a patient with the transport monitor in his lap. Beep-beep-beep. No RN.

My question: WHO is monitoring the patient???

And now I ask you, gentle readers

  1. Do you know your OFFICIAL hospital policy regarding transporting cardiac patients (or any ICU or telemetry patient, for that matter) off the unit for procedures?
  2. How old is the policy?
  3. Is it reasonable, sensible and sustainable (i.e., is there sufficient trained staff to accompany a monitored patient off the unit for two hours, while other nurses cover the transport nurse's patients)?
  4. Do ALL tele patients and ICU patients require RN attendance and monitoring for transport for procedures?
  5. Is it time for re-evaluation of said policy?

I offer food for thought in the form of four articles my newly-dusted dendrites found when I did an online search for "monitoring patients going off the unit."

First is a short thread from our own allnurses.com, in which members describe a wide range of policies and how they are implemented: Transporting Telemetry Patients off the unit - page 2

Next I found a 2004 article - a statement of practice guidelines! - from the American Heart Association: Practice Standards for Electrocardiographic Monitoring in Hospital Settings

(make some popcorn and settle down for serious reading with this one)

Patients are divided into three classifications according to diagnosis and condition, to determine the need for monitoring. Lots to consider and ponder.

I was pleased the website search revealed a wonderful small article outlining how one facility empowered nurses to formulate an algorithm to use that "enables safe patient transport without an RN or monitoring."

The article is written by Nancy J. Mayer, MBA, BSN, RN, and published in the AJN Nov 2009. The algorithm is simple to use, takes a lot of guesswork out of the decision-making and requires a second nurse's (usually the charge nurse) approval for the transport plan.

Look up Transporting Telemetry Patients -Aligning Forces for Quality (pdf)

And finally, a short article about, well, exactly what the title says:

Telemetry monitoring during transport of low-risk chest pain patients from the emergency department: is it necessary?

Targeted mainly for patients being transported from the ED to a tele or ICU unit, this is a thoughtful study. Lots of ideas here.

Oh, and the encounters I described earlier?

Encounter One

I respectfully requested the nurse re-evaluate each transport situation. Patient with NSTEMI and chest pain within 24 hours who is going to the Cath Lab (which means, we don't yet know for sure the extent of coronary disease but he just had an MI, so it is quite possible he has cardiac disease!), no matter what the MD writes --- I will transport him on a cardiac monitor!

Encounter Two

Think about it: Yes the patient was sent on a monitor. However, is sending the patient on a monitor, without an RN in attendance to watch the monitor, really carrying through with the intent of the policy of monitoring a patient during transport? IMO,either send him on a monitor with an RN or obtain an MD order to transport without monitoring.

Ah, my old dendrites are tired now. Hopefully your patients who need watching (to paraphrase the Bard, [mis-]quoted in the article title) "must not unwatch'd go."

Thank you for your attention, and I wish your patients EXCELLENT care!

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dianah

About dianah, ASN

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CA girl, born in Hawaii, raised in Northern CA, live in So. Cal last 35 yr.

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Specializes in Quality, Cardiac Stepdown, MICU.

Two options we have: wireless and "lifepak" monitors.

On our (PCU/pre-&post-interventional) cardiac unit, all pts wear wireless monitors that fit in the gown pocket. They do not display rhythms on the box but are transmitted to our monitor tech, which we have 24/7. If a pt is ordered to be monitored they are monitored at all times. This means they may not come off the monitor for a bed bath (techs must remove one electrode at a time) and may not shower unless they have an MD order. They also need an order to come off telemetry if they need radiation treatments, which are done across the street.

All patients come to and from our floor by non-nursing transport personnel, unless they are an emergent ICU transfer, in which the rapid response team, RN, respiratory, whoever takes them.

Most patients come up from the ED on one of ED's wireless monitors, which means their monitor tech (or whoever watches down there, I dunno) is supposedly monitoring them until we switch over to our box. Sometimes they come up on what we call a "lifepak" monitor, which is a large box that shows the rhythm and will beep loudly if there is a problem. These are similar to the ones seen on crash carts. I think the only rationale as to why a pt comes up on one or the other is supply of wireless boxes. The main difference between the two: The wireless box does not show anything to the transporter, but the monitor tech can see it, though unless we know the name of the transport person (we don't) we can't call them on our Vocera if we see a problem. The lifepak will beep if there is a serious rhythm, and though the transporter is not nursing, they can push the nearest code blue button or use their Vocera to call for help.

When a pt transfers to us from the ICU, we tube our wireless monitor over to them so we can watch the pt on the way over, but we do not send them to other units. I had a pt transfer to my floor from the non-tele respiratory floor because he had a PE, and I met the pt down in CT and applied the monitor there until he could come up.

Lately there have been issues on our floor with pts being off the monitor too long, hence the new rules about not taking pts off for bed baths, etc., but I don't know how hard and fast our policies are other than that. I will definitely look into it, thank you!

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Specializes in RETIRED Cath Lab/Cardiology/Radiology.

Thanks!

Our transports are done with a portable monitor (much like the LifePak you describe, delphine22).

I will have to ask how far away from the monitored display the wireless tele boxes will transmit.

Also, if the patient is on the 3rd floor for a procedure or test, box is transmitting, and the tech at the monitor station on the 4th floor sees a rhythm problem, what then?? Lots of phone calls?

For patient safety these questions need to be asked. :)

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Specializes in Quality, Cardiac Stepdown, MICU.

Only the monitor tech at the station that "owns" the box can see the rhythms. Each floor watches their own, we do not have "centralized" monitoring. That's why it's so important (and we are sometimes lax about it) to call the monitor tech and read the pt identifiers with the box number when we apply a monitor, because it has happened in the past that the wrong patient was alarming.

Transport signs pts out with the monitor tech, who will mark the monitor screen with a certain color to indicate that while the pt is monitored, they are off the floor, and will type in a note on where they are. I have never heard of an instance when they'd had to call down to, say, CT and tell them there's a problem. Though of course our pts are totally off the monitor for MRIs.

We are on the 7th floor, and the hospital is 1/4-mile long end to end, and our monitors reach the whole facility. The radiation center I mentioned is across the street, and they do not reach there. Side note: on the med-tele side (not PCU) they have new wireless monitors with a small screen on the unit itself, you can press a button and view the rhythm right there with the patient. It's a great tool, also for teaching the pt as well, wish we had them on the floor that actually gets the weird rhythms all the time! :-P

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Where I worked as a CVICU nurse we transported patients on monitors 99 percent of the time. Not only that, we also carried a bag of code medications just in case. There was a 1 percent where we did not transfer on monitors and those patients were going to regular med/surg floors and didn't require monitoring.

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I work in a cardiac unit. We have an algorithm that we use to determine when patients need to be monitored (telemetry by an ACLS certified RN) for off-floor procedures. For example, any patients with positive cardiac enzymes have to be transported on monitor. Any patients receiving IV anti-arrythmic drip would need to be monitored, and etc.

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Specializes in RETIRED Cath Lab/Cardiology/Radiology.

mufinurbhai, how was the algorithm developed or how did it come about?

And, would you care to share it here?

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Medical errors are rampant these days. Some of them go UN-reported and swept under the wrong. You rarely hear about multiple code blues and one of them losing their lives because of either short staffed, failure to monitor properly or not following proper protocol to insure each patient experiencing a code blue gets Rapid Response and Timely care to increase their chances of living and not cause any adverse events. My father did not have that chance. There is a slight twist to the "To Be (Monitored) or Not To Be (Monitored) with my father. Here is my story:

A multiple code blue took place on September 9, 2012 in ICU. While one patient was being attended to, my father and others went UN-monitored. I left the room around 4 am came back around 4:45 am and found him unresponsive. I ran for help. This resulted in Anoxic Encephalopathy, Right Hamiparesis/Hemiplegia, Coma, Global Cerebral Ischemia, Necrosis and death. I gleaned those terms from his medical records in order to educate myself. They referred to absence of oxygen. There is eight hours of missing mount sheets, before the code. I’ve asked for evidence of the machines working properly, why didn't they know there was a second code, did the machines go off, could they have been muted, was he connected properly, what was the nurse/patient ratio then, how was it that they caught the other patient’s code, but not his, his room was right at the nurse’s station, why didn't they see visually what was happening, and why wasn’t "Rapid Response” or "Timely Care given to prevent further harm?

How do you be on the floor of ICU surrounded by monitors, but yet you have a multiple code but not be equipped to handle it? My father went Unmonitored and while everyone was away, including me his plea for help went Unheard...

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Specializes in ICU.
How do you be on the floor of ICU surrounded by monitors, but yet you have a multiple code but not be equipped to handle it? My father went Unmonitored and while everyone was away, including me his plea for help went Unheard...

It's a money thing. I could easily see that happening where I work now. Management is trying to convince us that we do not need a monitor tech in our ICU because we are all RNs and can monitor rhythms for ourselves, and monitor techs have to be paid. However, if someone codes, many nurses from the unit will rush into that room to help because a code takes a lot of hands. There have to a couple of people at least rotating for compressions, someone has to push meds, someone has to record, someone has to manage the airway, etc. Full staffing for us is 12 nurses. Let's say eight of them are in the code - that only leaves four nurses for the rest of the floor, which is up to 23 other patients since we have 24 beds. If there is no monitor tech and those other four nurses are busy doing things for their own patients, well... I could see a situation exactly like what happened to your father happening.

It's really not a problem of not being equipped to handle multiple codes, because we certainly can and have done so before... it's nobody watching the other patients because everyone is in the first code. A code has to be recognized as a code before it can be handled, and if nobody is watching the monitors it might never get acknowledged in the first place. ICU patients are only monitored in their own ICU here, there is no central monitoring for ICU patients, so - if nobody is watching inside of our ICU, no one period will see the development of a lethal heart rhythm. It is a dangerous setup for the other patients if you ask me. Yes, the monitors alarm loudly if a lethal rhythm develops, but the way our ICU is set up if that lethal rhythm alarm is going off at the end of the hall, people on the opposite side of the hall would not be able to hear it. There really needs to be someone on the same side of the hall to know what's going on.

I really love getting the experience that comes with going to codes, but if both of my coworkers on either side of me have already gone, I won't go just to make sure there is someone on my side of the floor noticing what is going on with the other patients exactly because I am afraid of something like what happened to your father happening while we are all down the hall. Incidents like this are a strong argument for have a dedicated monitor tech in ICU, but as long as management views monitor techs as an expense and not a necessary part of the healthcare team, adverse outcomes are going to happen.

Heck, let's not even talk codes - what happens if my other patient starts alarming a lethal rhythm while I am elbow deep in poop and can't immediately leave a room? I might hear an alarm but I might not have any clue that the patient alarming is mine because I can't see the monitor. If there is a monitor tech, they can page me in the room to let me know, and I can ask them alert another nurse to check on my second patient. If there isn't a monitor tech, well... I really hope someone happens to notice.

In regards to telemetry patients being transported, only critical patients here are transported with ICU RNs with them. The others are just hooked to telemetry boxes with central monitoring.

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Specializes in Cardiology, Cardiothoracic Surgical.

My institution has a specialty team of ACLS-certified RNs that transport to and monitor patients in procedures. To be transported, they must meet certain criteria (most often on cardiac monitoring, have extensive cardiac histories, and potentially fatal dysrhythmias) and/or require additional care and monitoring of IV drips, seizure activity, stable trachs or various drains. The RNs may or may not carry medications, but carry basic airway management equipment and other supplies. Basically, the goal is to keep the patient stable enough until further help can be called (Rapid Response, Code Team). They take some LVAD patients, but generally defer ICU level of care.

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It's a money thing. I could easily see that happening where I work now. Management is trying to convince us that we do not need a monitor tech in our ICU because we are all RNs and can monitor rhythms for ourselves, and monitor techs have to be paid. However, if someone codes, many nurses from the unit will rush into that room to help because a code takes a lot of hands. There have to a couple of people at least rotating for compressions, someone has to push meds, someone has to record, someone has to manage the airway, etc. Full staffing for us is 12 nurses. Let's say eight of them are in the code - that only leaves four nurses for the rest of the floor, which is up to 23 other patients since we have 24 beds. If there is no monitor tech and those other four nurses are busy doing things for their own patients, well... I could see a situation exactly like what happened to your father happening.

It's really not a problem of not being equipped to handle multiple codes, because we certainly can and have done so before... it's nobody watching the other patients because everyone is in the first code. A code has to be recognized as a code before it can be handled, and if nobody is watching the monitors it might never get acknowledged in the first place. ICU patients are only monitored in their own ICU here, there is no central monitoring for ICU patients, so - if nobody is watching inside of our ICU, no one period will see the development of a lethal heart rhythm. It is a dangerous setup for the other patients if you ask me. Yes, the monitors alarm loudly if a lethal rhythm develops, but the way our ICU is set up if that lethal rhythm alarm is going off at the end of the hall, people on the opposite side of the hall would not be able to hear it. There really needs to be someone on the same side of the hall to know what's going on.

I really love getting the experience that comes with going to codes, but if both of my coworkers on either side of me have already gone, I won't go just to make sure there is someone on my side of the floor noticing what is going on with the other patients exactly because I am afraid of something like what happened to your father happening while we are all down the hall. Incidents like this are a strong argument for have a dedicated monitor tech in ICU, but as long as management views monitor techs as an expense and not a necessary part of the healthcare team, adverse outcomes are going to happen.

Heck, let's not even talk codes - what happens if my other patient starts alarming a lethal rhythm while I am elbow deep in poop and can't immediately leave a room? I might hear an alarm but I might not have any clue that the patient alarming is mine because I can't see the monitor. If there is a monitor tech, they can page me in the room to let me know, and I can ask them alert another nurse to check on my second patient. If there isn't a monitor tech, well... I really hope someone happens to notice.

In regards to telemetry patients being transported, only critical patients here are transported with ICU RNs with them. The others are just hooked to telemetry boxes with central monitoring.

Very true! In the hospital I used to work at, if you knew you were going to be in a patient's room a while, you could go to that patients monitor and pull up your other patient's monitor as a mini screen. It would flash too if it was alarming. I miss those monitors! Also, each one was portable and so you didn't have to unplug your patient to help them to the bathroom or to go down for a procedure, you just unhooked the monitor from the wall and away you went. Now we have to unplug patients from the monitor to help the to the bathroom and either stay with them or pray nothing happens to your seemingly stable patient ?

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You are awesome! Thanks for the thought provoking questions and articles.

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