702 revised Nov 2017

Policy Title: Guidelines for Continuous Cardiac Monitoring from a Remote Monitoring Station Location: Nursing Practice Council Department: Patient Care Services Policy Number: 702 Review Date: June 2017November 2017 Original Effective Date: August 2006 Current Effective Date: November 2014 Scope This policy applies throughout Patient Care Services Purpose To maintain a constant graphic display of the electrical activity of the patient’s heart To provide an automatic alarm if the cardiac rate exceeds or falls below desired and or ordered limits To record the electrocardiogram (ECG) pattern Definitions TT – Telemetry Technicians LIP – Licensed Independent Practitioner PCT – Patient Care Technician Policy Statement Central telemetry monitoring will provide 24-hour surveillance of patients requiring continuous cardiac monitoring TTs. Telemetry Technicians (TTs)TTs who have passed the George Washington University Hospital Comprehensive Dysrhythmia Exam will continuously observe the cardiac monitors. The ratio for number of patients being watched on the monitor to each telemetry technician is 36:1. Telemetry is not to be discontinued during transfer from ED or between units. If a portable monitor is used, the patient should be observed until a telemetry pack is obtained and placed on the patient. To maintain patient safety, no more than one telemetry box will should be issued to the same unit at a time. Nurses must should follow the guidelines for Cerner Downtime to initiate continuous cardiac monitoring. for Bariatric patients using the GE Solar bedside monitor. If the central monitoring room printer malfunctions, nurses must enter a “Telemetry Box Setup” order in the medical record and bring a patient label to the central monitoring room to obtain a telemetry box. Equipment ECG Monitor Electrodes, pre-gelled and disposable Lead wires Hospital approved disinfectant Procedure Initiation of Continuous Cardiac Monitoring COURSE OF ACTION POINTS OF EMPHASIS The transferring nurse verifies that a physician order for cCardiac mMonitoring is entered in Cerner. The transferring nurse will enter a “Telemetry Box Setup” order in Cerner and obtain a telemetry box from the monitoring room. A requisition will print to the central monitoring room. The telemetry technicianTT will prepare the telemetry box for the patient and enter the patient information into the central monitoring system after receiving requisition. The nNurse, PCT or LIP places the telemetry box on the patient. The receiving nurse will verify patient information, room number and telemetry box number by when completing the “Telemetry Box Setup Verification Form” from the Task List in Cerner. The receiving nurse must will call the central monitoring room, ext. 5622 in order to complete this step. Initiation of Continuous Cardiac Monitoring during Cerner Downtime COURSE OF ACTION POINTS OF EMPHASIS The nurse verifies that a physician order is placed in Cerner for cardiac monitoring. The nurse or PCT brings one patient label to the central monitoring room and obtains a telemetry monitor. No more than one telemetry box per person will be issued to the same unit at a time. The TT enters the patient information into the central monitoring system. The nurse, PCT or LIP places the telemetry monitor on the patient and verifies the reading is registering in the central monitoring room by calling extension 5622. The Chain of Command for Battery or Lead Change COURSE OF ACTION POINTS OF EMPHASIS The Telemetry Technician should: Immediately notify the primary nurse of the patient. If the patient is away from the unit for a test or procedure, notify the department where the patient is located. The primary nurse should notify the TT where the patient is located if the patient leaves the unit. Call the charge nurse of the unit where the patient is located, if there is no response from the primary nurse. Call the House Operations Supervisor (HOS), if there is no response from the charge nurse. The TT should escalate to HOS within 10 minutes if unable to reach charge nurse of the unit. Document on the Arrhythmia Flow Sheet. The Chain of Command for Change in Baseline Rhythm COURSE OF ACTION POINTS OF EMPHASIS The Telemetry Technician should: Immediately notify the primary nurse of the patient. The primary nurse should notify the TT where the patient is located if the patient leaves the unit. Call the charge nurse of the unit where the patient is located; if there is no response from the primary nurse. Call the House Operations Supervisor (HOS), if there is no response from the charge nurse. The TT should escalate to HOS within 10 minutes if unable to reach charge nurse of the unit. Print a strip of the event and document on the Arrhythmia Flow Sheet. The Chain of Command for a Lethal Dysrhythmia COURSE OF ACTION POINTS OF EMPHASIS The Telemetry Technician should: Initiate a CODE BLUE with the presence of a lethal dysrhythmia unless the patient is a DNR. Initiate Rapid Response for an acute change in heart rate less than 40 or greater than 140 beats/minutes. Print a strip of the event and document on the Arrhythmia Flow Sheet. Central Monitor Telemetry Technician Intervention COURSE OF ACTION POINTS OF EMPHASIS The Telemetry Technician should: Set monitor alarm at a low rate of 50 and a high rate of 120, unless the LIP specifies different parameters. Alert appropriate nurse by telephone if telemetry monitor batteries are low or leads need to be reconnected. The nursing unit that the patient is located on is responsible for changing the battery. AA batteries should be kept on each unit. Complete documentation of the Arrhythmia Flow Sheet every 4 hours documenting the following: duration of PRI, QRS, QT, rate, rhythm, presence of ectopy, and ST changes. The PM shift TT will compile all strips run in a 24-hour period and attach them to the Arrhythmia Flow Sheet and place them in the appropriate patient medical record. Clean telemetry monitor between each patient with a hospital-approved disinfectant. Registered Nurse Responsibilities COURSE OF ACTION POINTS OF EMPHASIS Nurse should check Cerner for “Cardiac Monitoring” order. Nurse or LIP should place “Telemetry Box Setup” order in Cerner. Nurse must should call telemetry room within 30 minutes of patient being placed on telemetry to verify the patient’s name, FIN#, room#, telemetry box# and to notify the TT if the patient is a DNR or limited code. The TT will record the code status information on the Arrhythmia Flow Sheet. If no call from the nursing unit within 30 minutes the TT will call the unit’s charge nurse to verify appropriate information. The Nurse must should call the TT to verify patient rhythm and confirm patient’s name, FIN#, room#, telemetry box # and code status a minimum of once per shift. TT will call charge nurse at each shift change, if no call received from the primary nurse. The nurse must should notify the TT of: LIP ordered changes in the rate or rhythm parameters. LIP order to be off monitoring and when telemetry is reactivated (Nurse nurse must should notify TT every time patient is to be taken off the monitor ( i.e. showering, discharge, off unit for test or procedure). LIP order to discontinue telemetry. Patient movement from unit to another area of the hospital. For new admissions and transfers, the sending unit must notify the TT of the room number. When the receiving unit admits the patient, they must call the TT to confirm the room number. Nurses caring for patients requiring continuous telemetry monitoring must have passed the approved Dysrhythmia exam. Failure to trace rhythm (with patient off the monitor) may result in overhead rapid response or code blue being called. The nurse should reassess patient’s need for continuous telemetry monitoring every shift. The telemetry monitor should be returned to the central monitoring room immediately after it is discontinued. The nurse should document the following, during each shift: The telemetry section of the complete assessment, including rhythm, heart rate, interpretation and presence of ectopy as provided by the TT. In the event of notification of a cardiac arrhythmia or change from baseline status, the nurse should: Immediately assess the patient Notify the LIP of the event and respond as ordered. Verbally inform TT of the patient status. Obtain strip of the event from the central monitor room for interpretation by the LIP. Document the event and any intervention in the patient’s medical record. Procedure for System Failure (One Telemetry Technician) COURSE OF ACTION POINTS OF EMPHASIS TT should immediately notify the 3South Charge Nurse. 3 South Charge Nurse should notify the HOS and the charge nurses of the other floors. Designated personnel notify the unit nurses for mandatory rounding during system failure. TT contacts BioMed. Procedure for System Failure (Two Telemetry Technicians) COURSE OF ACTION POINTS OF EMPHASIS One TT will immediately contact BioMed. The second TT will immediately notify the 3South Charge Nurse, HOS and the charge nurses of the other floors with patients being monitored. Designated personnel notify the unit nurses for mandatory rounding during system failure References Created: August 2006 Revised: June 2008 Revised: June 2010 Revised: June 2011 Revised: November 2012 Revised: November 2014 Revised: November 2017 Johnny Veal, MSN, RN Chief Nursing Officer