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In our numerous columns on alarm fatigue and
alarm management, we’ve emphasized that one of the interventions strongly
recommended to reduce alarm fatigue is to eliminate unnecessary telemetry
monitoring. Far too many patients are placed on telemetry monitoring without
appropriate indications or are unnecessarily continued on telemetry monitoring
after a legitimate need is no longer present. See our What's New in the Patient
Safety World columns for October 2014 “Alarm
Fatigue: Reducing Unnecessary Telemetry” and
December 2018 “Cost Savings
from Eliminating Unnecessary Telemetry Monitoring” and
our April 16, 2019 Patient Safety Tip of the Week “AACN
Practice Alert on Alarm Management”.
But what about when use of telemetry monitoring
is appropriate? What can go wrong? Actually, lots can go wrong and the result
is often devastating.
One of our earliest
Patient Safety Tips of the Week “Unintended Consequences of Technological
Solutions”
described one such event. A hospital purchased such a remote telemetry system
in which the transmitter could be placed on a patient on one floor of a
hospital and the receiver/monitor was in the CCU as part of a bank of telemetry
screens that were continuously viewed by a nurse assigned to that duty. One
day, right around nursing change of shift, two patients were admitted to the
remote floor and telemetry was ordered on both. A nurse took two transmitters
with him and hooked the patients up, then called the CCU monitoring nurse to
tell her about the two patients just hooked up. About an hour later the CCU
monitoring nurse called the remote floor because one of the patients was in
ventricular fibrillation. A code was called and the floor staff and code team
ran to the patient’s room, only to find him sitting up in bed, watching TV and
eating a meal. Only after several minutes of fiddling with his EKG leads and
talking to the nurse in the CCU did anyone realize that the patient several
rooms down the hall was really the one in ventricular fibrillation. The transmitters
obviously had been transposed! This is a variation of the “two in a box”
phenomenon we talked about in the April 23, 2007 Tip of the Week “Predictable Errors”. And, of course, the system was poorly
designed in that it allowed the first nurse to take out two remote telemetry
transmitters at the same time.
In our July 2011 “What's
New in the Patient Safety World” column we noted that the
ECRI PSO issued a Patient Safety E-lert on the very same issue (ECRI
PSO 2011). They did not provide details of the cases
in their database but did discuss contributing factors identified and made
several good recommendations. They noted lack of good policies and procedures
and lack of orientation and training plus communications failures as important
contributory factors. They specifically noted things like change of shift,
inexperienced staff, lack of familiarity with procedure, and distractions. They
also note technological issues and workflow issues.
They recommend patient identification be
verified each time a patient is hooked up to telemetry (and that means
verification at both the patient’s end and the remote monitoring site). They
stress that the telemetry receivers should incorporate a display with the
patient identifiers to reconcile the telemetry transceiver with the correct
patient (and to be especially cautious about patients with similar names). That
patient identification needs to be done independently at the two sites to avoid
confirmation bias. To their recommendations we would reiterate that your system
should also use the constraint function of preventing anyone from taking out
two transceivers simultaneously. Allowing more than one at a time to be
taken simply increases the probability of such transposition.
Incidents related to telemetry often occur during
intrahospital transports. Many of our columns highlighting the dangers
of the Radiology Suite stress that the dangers often have no relation to the
radiology procedure. Our May 22, 2018 Patient Safety Tip of the Week “Hazardous
Intrahospital Transport” discussed a report from the California
Department of Public Health (CDPH 2018) that
illustrates the problem. A patient had been admitted after being found on the
floor and noted to be in atrial fibrillation. He was placed on telemetry and
had orders for serial EKG’s and cardiac enzymes. It is not clear from the
report whether the atrial fibrillation was persistent but subsequent EKG’s
apparently showed PVC’s with trigeminy. A nurse notified his physician about
the trigeminy and he was begun on oxygen 2 L/min. He was scheduled for an MRI
scan of the head (reason not provided in report). The nurse apparently
contacted the physician, who ok’d sending the patient for the MRI, though it
did not appear the physician realized the patient would be transported without
telemetry monitoring. No RN accompanied the patient to the MRI suite and he was
not monitored in transit nor connected to telemetry on arrival at the MRI
suite. The MRI technician did call the telemetry unit and asked a nurse whether
the patient needed monitoring and the answer was “no”. The patient was
initially advanced into the MRI machine but was pulled out when he complained
of shortness of breath. He sat up and was placed on high flow oxygen again but
agreed to attempt the MRI again. He then asked to be pulled from the MRI again.
As the MRI tech moved the patient back to the hallway and assisted him getting
back in bed, the patient had a cardiac arrest. A code was called but attempts
at resuscitation were unsuccessful.
The hospital’s policy on intrahospital
transports had been revised about two years earlier to enable registered nurses
to utilize clinical criteria to discontinue telemetry for select patients for
transport to and during a test. The hospital, in its POC (plan of correction),
again revised its policy and protocol for transport of monitored patients. It
would require a physician’s order stating that the patient could be transported
without monitoring. If telemetry or other form of monitoring is to be
continued, an RN must accompany the patient to the receiving area. The POC also
included appropriate dissemination of the revised policy, inservice training,
and an audit of subsequent transports of telemetry patients. Though the
hospital POC mentions the hospital uses patient safety tools like the Lean
Daily Management Huddle on each nursing unit and multidisciplinary hospital
Safety Huddles, there is no mention whether the hospital utilizes checklists
like the “Ticket to Ride”. We have highlighted “Ticket to Ride” in multiple
columns (see list below). It was originally started to ensure that patients
being transported had adequate oxygen supplies, since some studies showed that
over half of patients transported to sites like the radiology suite ran out of
oxygen. But the “Ticket to Ride” checklist is a good way to remind
everyone to address what should be done about remote monitoring when patients
are transported.
Our February 4, 2014
Patient Safety Tip of the Week “But What If the Battery Runs Low?” highlighted another issue related to remote
monitoring: battery drainage. A patient was being monitored by remote
telemetry (CDPH
2014).
The battery charge on the 9-volt battery on the remote unit was running low. The
audible alarms for low battery status had been turned off and the only ones
working were the visual ones. A low battery warning appeared as a yellow alarm
on the screen. It later turned red but once the battery is dead no tracing at
all appears on the remote monitor screen. The nurse who was manning the remote
monitoring station (because no monitor tech was available) had multiple other
distractions and did not see the yellow or red low battery alerts. The patient
has a fatal event not picked up by monitoring.
Our February 23, 2010
Patient Safety Tip of the Week “Alarm Issues in the News Again” reminds us not to forget that monitoring
and alarm systems consist of much more than pieces of medical equipment. The Pennsylvania
Patient Safety Authority’s “Alarm
Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects
Analysis”
analyzed data on alarm-related incidents from the Pennsylvania Patient Safety
Reporting System and identified 29 steps involved in the telemetry monitoring
process (see our April 1, 2008 Patient Safety Tip of the Week “Pennsylvania
PSA’s FMEA on Telemetry Alarm Interventions”). They provide excellent recommendations
regarding patient identification, optimal display location, ensuring the power
source of the telemetry receivers, protocols for when monitoring is temporarily
suspended or on standby (eg. during transport or while electrodes are being
manipulated), protocols for alarm volume levels, electrode placements and
inspection and maintenance, making alarm parameters appropriate to both the
individual patient and the setting, and protocols for responding to all alarms
(whether low- or high-priority alarms) including establishment of a tiered
backup response system. They also point out a very important question easily overlooked
in a FMEA “Is telemetry monitoring indicated in this patient at all?”.
A more recent report from the Pennsylvania
Patient Safety Authority (Kukielka
2019) analyzed 558 events reported to the Patient
Safety Reporting System (PA-PSRS) over a 5-year period. These events specifically
involving interruptions or failures associated with telemetry monitoring
equipment or with the healthcare providers responsible for setting up and
maintaining proper functioning of that equipment.
Almost half (47.1%) the events were
attributed to user errors. But other errors included:
Common scenarios were not keeping patients on
telemetry when they left the floor for testing or forgetting to reconnect
telemetry when they returned, poor handoffs at transfers, unsuccessful attempts
by the monitoring nurse to reach the nursing staff on the floor when a
significant arrhythmia occurred, dead batteries, and the classic error: alarm
disabled or volume reduced to inaudible levels. And, yes, just as in our
earliest case, the problem of two or more patient having their telemetry
monitoring equipment switched happened again. In one such case, they provided
details. Two patients in the same room were being monitored via telemetry. At
some point their equipment was disconnected and mixed up before being
reconnected. One of the patients then developed a rapid heart rate and an
intravenous medication was ordered. Fortunately, as they were about to
administer that medication, they identified the mix up and avoided what could
have been a serious outcome.
The authors point out that harm associated
with telemetry monitoring is rare but potentially catastrophic, with death
being the most frequent outcome among serious events. Communication breakdowns,
battery issues, and improper alarm settings rounded out their top 4 take home
points.
Our own take home points:
See
also our July 2, 2013 Patient Safety Tip of the Week “Issues
in Alarm Management” and
our many columns on alarm-related issues listed below.
Some of our prior
columns on the hazards associated with telemetry:
Prior
Patient Safety Tips of the Week pertaining to alarm-related issues:
Some
of our prior columns on the “Ticket to Ride” concept:
References:
(Note: some of the links to the publications
prior to 2015 listed below may no longer be valid)
ECRI PSO. Patient Safety E-Alerts. Patient
Identification Prevents Life-Threatening Events. Did you Double-Check the
Cardiac Monitor? May 2011
https://www.ecri.org/PatientSafetyOrganization/Documents/E-lert_Patient_Identification.pdf
CDPH (California Department of Public
Health). Complaint CA00221802. Accessed 2/2/14
CDPH (California Department of Public
Health). 2018. Intake Number CA00462998. Accessed April 21, 2018
PPSA (Pennsylvania Patient Safety Authority).
Patient Safety Advisory supplement “Alarm Interventions During Medical
Telemetry Monitoring: A Failure Mode and Effects Analysis”. March 2008
Kukielka E, Gipson KR, Jones R. A Brief
Analysis of Telemetry-Related Events. Patient Safety 2019; 1(2): 36-44 December
2019
https://patientsafetyj.com/index.php/patientsaf/article/view/telemetry/67
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