Weighing In On a Decade-old Subject
Submitted by Elaine S. Puricelli RN, BSN
This writing addresses a subject of great interest to me. I unearthed an article written in 2011, by Ms. Tamekia L. Thomas, MSN, RN, PCCN, as per the time of a publication article dated Spring 2011: “Who’s Watching the Cardiac Monitor? Does it Matter?” (Nursing: Spring 2011- Volume 41)
A quick background in my interest, is that I have recently retired after graduating as a registered nurse in 1988. One of the greatest joys of my nursing work, aside from the obvious patient contact and, hoping to make a difference to my patients’ experience, was working in telemetry. In several job locations, I worked telemetry intermittently, when assigned, though other duties notwithstanding.
While reading Ms. Thomas’ article with devout interest, it occurred to me that my opinion is almost diametrically opposed. The 2011 article mentions, appropriately, the possible need for additional staff to engage in watching cardiac monitors. Whether or not nursing or allied nursing personnel are entrained is a consideration. Budgetary considerations in any hospital unit is a reality. This point, as well as several others, is mentioned as part of the “Pro’s and Con’s” section of Ms. Thomas’ cogent article, and reference is given to the source, Drew BJ, Califf RM, Funk M, et al., in their article dated 2004.
I was immediately drawn to the “Pro’s and Con’s,” as they’re labeled, because I wanted to see a specific topic addressed: Whether or not the person(s) watching the cardiac monitor should be credentialed. The preamble to this section of Ms. Thomas’ work accurately mentions adequate training of those telemetry technicians and the ability of the technicians to alert a healthcare professional of alarms and alerts signaled by the monitor, within an adequate or prompt period of time. Usually chime mechanisms within the monitors, in varying audible sounds based on severity of the alarm. Institutions and specifically cardiac units will have training manuals pre-printed from which the technicians will read requirements of the telemetry monitor area. Of course, ALL persons working within the telemetry area will be expected to have a required skill level.
Be advised that I do not write this essay based on statistics or any other data associated with the use of non-professional staff in the role of telemetry technicians in a cardiac unit setting. I have not read statistics regarding safe outcomes of telemetry “techs” in a cardiac unit.
Certainly I agree that TIMELY notification of an untoward arrhythmia is essential, but MY objection speaks directly to those whom are trained to watch a cardiac monitor. I have a strong opinion about this point in that I have worked with both licensed healthcare professionals (nurses) and EMT’s or paramedics. While there is a requisite period of time for newly-hired monitor technicians, (monitor “techs,” as they may be called), to pass a test within the institution, after formal, classroom training time within an institution, I do not feel that a non-credentialed healthcare worker is adequate to ensure absolute quality care in working with the cardiac monitors in the role of a monitor tech. Be aware that I am including paramedics and EMT’s in this grouping of healthcare professionals, qualified and skilled, as well as registered nurses and licensed practical nurses.
My point is that healthcare professionals have had formal classroom settings and practical settings in which they earned credentialing. There was no requisite, 8-week or longer “training period” in the telemetry area, in which healthcare professionals engaged with a specific institution upon hiring. Certainly all new-hires who are professional personnel area afforded some measure of training time in the new environment of the telemetry area, but I am not certain as to how many registered nurses are hired by hospitals for the purpose of working exclusively in the telemetry area. Certainly I have worked with EMT’s and paramedics who were hired for this role. But never “monitor techs” with a nursing assistant background- allowing that many nursing assistants are “C.NA’s.” I have not worked with nursing assistants in the role of a monitor technician. Frankly I feel that a nursing assistant in that role is taking on an enormous responsibility so I hope that person is paid accordingly. But I worry than a direct care provider to a cardiac patient, such as myself, and R.N., would be at all comfortable with essentially handing over the role of whomever is watching his or her patients’ cardiac monitor (telemetry) rhythm to a monitor tech, a person who is non-professional by virtue of credentialing. Personally, I would not risk my own liability, I would worry that something may be getting overlooked, thus not reported to me, the nurse, on the watch of a monitor tech. This is my grave concern for the future of monitor techs whom are not professionally credentialed: Where’s the liability on the end of the monitor tech? The R.N. is responsible for reporting changes in his or her patient’s medical condition to the provider. The R.N. has ultimate responsibility. All licensed, thus, credentialed healthcare professionals, mastered proficiencies throughout the formal classroom process, evidenced practical skills during practicums required by their schools, and sat for formal exams for both classroom time and credentialing.
More importantly, and closer to my heart and passion for telemetry monitoring, credentialed healthcare professionals sought out formal instruction on the lesson at hand in the monitor technician arena; there was concentration, at some point, in formal education, on concepts vital to understanding the images seen on the telemetry screen they will observe. In my experience, fellow nurses would alert the monitor technician (always a credentialed professional) whenever the nurse is about to inject a medication such as a beta blocker or intravenous adenosine as an emergency medication. The telemetry nurse, acting in the role of monitor technician would be alert to changes in heart rhythm such as a slowing of the patient’s heart rate or a change in the atrio-ventricular conduction of the heart. It is typical to provide a detailed account of telemetry rhythm strips, and usually their interpretation, at the end of a monitoring shift, but certainly rhythm strips are needed as a graphic depiction of events in the event of an emergency with a patient. In fact, in my time in telemetry, providers will arrive into the telemetry area to obtain rhythm strips that elapsed during an emergency or interventional time in the course of a patient’s day on the unit. “Code blue” events ALWAYS result in the monitor technician or professional’s carefully acquired rhythm strips depicting tracings during an event. For example, a monitored patient who may have fainted in his bathroom, will often result in a careful review of the monitor’s rhythms strips as the nurse and provider may want to know the cardiac rhythm prior to the faint, during the faint, and at the time of recovery from the faint, for that patient. I am aware that topics such as vigilance with a nursing or emergency intervention is something for which “monitor techs” are familiarized in their hospital training period, but other conditions may not have been addressed: Do monitor technicians (excluding credentialed healthcare personnel) have an awareness of the patients’ admitting diagnoses? In my experience, there is a log kept within the telemetry area, of patients and their telemetry order “level” as well as their admitting diagnosis. The “level of telemetry” speaks to whether or not the patient may leave the unit for testing or procedures off the monitored unit without continuous monitoring en route to the patient’s destination, and is ordered by the patient’s provider. Telemetry personnel also participate in “report” which is a concept well-known to healthcare personnel, however, not, as I have seen, in the same physical location as the unit’s nurses- the monitor techs have their own, independent report in the same way nurses have shift report at a shift change. Perhaps some institutions have all-inclusive report wherein the monitor techs are present with nursing staff. Does the monitor tech understand that patients admitted for an overdose of some psychiatric medications may experience complications such as a prolonged QT-intervals, thus potentially predisposing the patient to an concerning cardiac arrhythmia? A QT-interval vigilance is also needed for an overdose of a digitalis-related medication, along with attention to heart rate.
Does the monitor tech or the healthcare professional recognize that specifically, “sinus arrhythmia” shouldn’t co-exist with a rhythm strip interpretation of “normal sinus rhythm?” An inconsistently noted rhythm may be interpreted as “sinus arrhythmia.” And what about the sudden degradation of a patient’s rhythm into “complete heart block” in which there is no atrial and ventricular association evidenced in the cardiac monitor tracing: Was this patient usually in “second degree heart block” prior to the degradation of his cardiac rhythm? Will the monitor tech promptly obtain a 12-lead EKG of the patient being monitored, when a possible change in the cardiac tracing (perhaps a specific lead picture) is noticed? Is obtaining a 12-lead EKG at this time within the job description of the monitor tech or will the tech ask the patient’s nurse to obtain a 12-lead EKG once a change is suspected? I have checked lead placement and/or obtained a 12-lead EKG when questions in rhythm or tracing patterns within a specific telemetry lead have arisen. There is obvious attention paid to changes in cardiac rhythm and certain attention and quick alarm issuance to critical alarms on the cardiac monitor, but what about the subtleties of the patient’s heart rhythm tracings? While parameters given to the nursing staff, in the form of a provider’s order regarding which alarms on the monitor qualify as alarms for which the provider will be notified, for example, “Contact provider for V-tach greater than 4 beats,” will the monitor tech include in his or her documentation that the patient has had a predominance of several 3-beat runs of PVC’s? Will precise documentation by the monitor tech convey ALL cardiac activity noted within the technician’s work shift? Will the monitor technician notate AND notify a patient’s nurse that the patient monitored whom is assigned to her has had ten minutes or greater, collectively, of PVC’s as displayed on their telemetry tracing over time? (Although this PVC parameter is usually prescribed within providers’ orders as a notification order). Monitor techs should be aware of provider’s specific telemetry orders and include the most recent, valid orders in report and/ or in the telemetry log of active patients.
Obviously displayed telemetry tracings will be noticed by the telemetry technician, such as a patient with a newly-placed pacemaker achieving “capture” of the pre-set electrical (of the heart) pathways determined by the electrophysiologist during placement – I imagine that tracing would be labeled as a “Post-Procedure” note/telemetry strip by the monitor tech. My concern is that subtle changes in heart rhythm tracings may be overlooked during the course of a monitor tech’s shift, that a seasoned healthcare professional would inherently notice as part of their professional training. As an RN I looked for trends in the cardiac tracings, from the time of a patient’s admission to the hospital, when telemetry was first placed onto the patient. I was alert to POTENTIAL arrhythmias or other tracing anomalies with the patient’s admitting diagnosis as my understanding of the disease process for which the patient was admitted, was familiar to me. Concluding overall that ALL those who watch the telemetry or cardiac monitors (not getting snagged by syntax) from whatever background they bring to their time in the telemetry area, will notice obvious alarms for which the cardiac monitor can be pre-set. But the skilled and credentialed healthcare professional will also bring with him or her the education training and understanding that comes with formal education in their profession, whether nursing or allied professional. Experience comes as a result of educational exposure of requisite curricula in a formal healthcare program, as well as inherent knowledge acquired from having a thorough understanding of an illness or procedural intervention, a patient will have, as evident by medical diagnoses. EMT’s and paramedics who have worked with cardiac patients need keen observational skills in their field of work so as to make prompt (and accurate )reporting to providers and execute interventions where appropriate. Nurses have received didactic education and practicums as a required curriculum in their nursing programs, and experiences with their working environments will lead to additional classes or training (A.C.L.S training comes to mind), and have sought out specific skills when working in specialized units within a hospital or clinical setting. In my opinion it matters a great deal, whom is watching those cardiac telemetry monitors, every day, every shift, at all times. Credentialed healthcare professionals have most likely experienced cardiac monitor rhythms and anomalies in their education and training backgrounds, as well as their backgrounds within their field of work environment. Hopefully nursing staff has specific training in telemetry if one hopes to work in the telemetry area. All those who observe cardiac telemetry monitors should have information about the illness, condition, or procedure for which the patient is admitted, when working in cardiac telemetry units, in order to understand and link what is seen on cardiac tracings as they are responsible for providing graphic strip recordings (telemetry) strips and usually, interpretations of those tracings as part of a patient’s permanent medical record. As a final note, whenever I worked in the telemetry area, as an R.N. I brought with me decades of experiential knowledge, full responsibility for reporting to the patient’s primary nurse or in the event of an emergency, reporting directly to the provider serious or alarming changes on the cardiac monitors and a shared responsibility for knowing my “stuff” along with the patient’s primary nurse assigned, which entailed FULL and timely communication with the primary nurses regarding their patients’ rhythms. And I never, for one moment, thought I knew everything about telemetry work, my reference materials were always with me while working telemetry, even if just a few steps away in my locker. I always reported to the telemetry area to do my best work for benefit of the patients.
Reference Material Used for this Essay
- Cardiac-Vascular Nursing, 4th Edition (2005). Published by The Nursing Knowledge Center. Author: Ms. Lynn W. Smith, MSN, MDiv., RN, CNE, B-C. Publisher: The Nursing Knowledge Center, www.nursingknowlegecenter.org