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

[dianah]

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!

[NewICU]

I work in a medical ICU, and we (the primary RN or charge RN) transport our patients any time they leave the unit. They are switched to the lifepak monitor, and we are expected to monitor them throughout any procedure. We have no central monitoring, so we have to make sure that we can see the monitor at all times. We actually have a new policy with an algorithm that is supposed to determine how many other people (RN, RT, tech, etc.) should go with us on our trip and forces a sort of cost/benefit analysis of how stable the patient is and how important the off-unit procedure is. This policy was added about 2 years ago after a sentinel event occurred. My biggest concern when I leave the unit with a patient is the monitoring of my other patient. We are often short staffed, and while another RN will look out for my other patient, I know that they don't know them nearly as well as I do and probably aren't watching as closely as I would.

[That Guy, BSN, RN, EMT-B]

Speaking from the ER here. All tele pts must be transferred to the floor by an ER tech, if they are on cardiac drips then an RN must go instead and on the monitor every time. Every ICU pt requires monitor to go up and at least one RN goes with them.

If our main MRI is down and we have to go to the "outpatient" one, two RNs must go, usually one of us and a flight nurse

If they go for a procedure ( cath, GI, IR, whatever ) then the dept that is getting the pt does the monitoring

[Lev, MSN, RN, NP]

From ER as well. All ICU or stepdown patients go with RN on Zoll monitor + vitals machine. Tele patients go off monitor with patient transport, unless they are on a drip. (M/S patients on heparin drip can go with patient transport).

[dexm]

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.

We also do this in the ICU I work in, minus the code meds (don't get me started on that one ). All patients are hooked up to the portable monitor and VS are continuously monitored by the RN when transporting patients to a procedure off the unit or to a med/surg floor if they have tele orders. We also can't travel alone - either a tech, RT, another RN, or MD must travel with us. A patient going to the floor that doesn't have tele orders isn't hooked up to the portable monitor and a tech can transport them without an RN. Our RN to patient ratio is 2:1, so when I leave the unit with one of my patients I give report to another RN on my other patient, and I try to give report to a nurse who's patients are relatively stable.

When tele patients are transported to the ICU they are disconnected from their tele monitor, connected to the lifepak monitor from the floor's crash carts, and transported to the ICU being continuously monitored by the rapid response RN.

The primary population in our ICU is surgery/trauma, so many of our patients are younger and often without extensive cardiac history or other comorbidities. However, I have never thought twice about putting any of my patients on the monitor when leaving the unit.

[icuRNmaggie, BSN, RN]

If you are using telemetry packs to monitor your non ICU patients being transported, check with your monitor tech first about dead zones within the hospital.

Be aware that some hospitals are not 100% wired with telemetry transmitters and that the lead walls in radiology can interfere with the signal.

If the telemetry central monitor says no signal for a pt off the unit, it is simply not transmitting for whatever reason and that should be investigated.

We are ultimately responsible if the pt becomes unstable while off the unit. I don't take chances and I prefer to travel with them whenever possible even if they are just a stable telemetry patient.

[Julius Seizure]

Our patients (pediatric CVICU) not only go monitored and with an RN, but ALSO a provider (NP or Fellow) must come too! Needless to say, many tests end up cancelled due to lack of providers available to come on the trip.

[msannie]

I don't know why it took almost a year to see this response. I didn't know I actually got a response. Thank You. After reading it, it was like ibuprofen to my pain. I like reading the truth about monitoring of patients. If you know where I can find stories specifically on monitoring or lack there of, please let me know.

I sincerely appreciate your thoughts on this.

[valx92]

At my hospital there's an order whether the patient needs to be transported on tele or not. There's a protocol in place they must be transported on tele if they're on a drip like amio, lido, cardizem, primacor, etc. Usually those are the only patients that we transport on tele, but sometimes they are considered very high risk for some other reason and the doc will place the order. If there's no order to be transported on tele, but I feel it necessary, I do it anyway. Someone with a nstemi going to the cath lab wouldn't be considered high risk and wouldn't need to be transported on tele. However, if they are being transported on tele then they are accompanied by someone who is both ECG and ACLS certified. This is 99.99999% of the time a nurse; however, we have one PCT who has both certs.

As for patients being monitored.. when a code is called at my hospital our code team is 1-2 micu nurses, 2 doctors, an anesthesiologist, a pharmacist, a respiratory therapist, the nursing supervisor, and the nurse responsible for that patient. any other nurses from that floor will start off the code until the code team arrives, then they go back to watching the floor. We also get one nurse from another floor who's responsibility is not to be a part of the code, but just to watch the floor and the monitors. It has happened before that i have been the staff nurse responding to a code on another floor and as i was watching the monitor another patient went into a stable vt and required immediate attention as well but that's why i was there. Everyone is there for a reason and needs to be monitored, can't ignore the rest of the patient when a code goes on.