Cardiac telemetry monitoring

Our columnist discusses “alarm fatigue.”.

Your patient's telemetry alarm rings for the tenth time in the last 30 minutes. A quick glance shows wide complex tachycardia. You race into the room, as you have done multiple times already, to find your patient tapping on his chest lead again. This time, he demands, “Where's my sleeper?”

All technology has its downfalls. Monitoring patients for life-threatening conditions has saved many lives, but the price for vigilance is false alarm after false alarm. We trade specificity for sensitivity, trying to minimize the risk of not responding fast enough that one time when the alarm is real.

“Alarm fatigue” is a safety issue. According to an April 3, 2010 Boston Globe article, a patient died at Massachusetts General Hospital when staff neglected to notice cardiac monitor alarms indicating a problem. Ten nurses did not remember hearing the alarm or seeing the scrolling tickertape warning of progressive bradycardia over 20 minutes.

In Pennsylvania, there were 277 reports of errors related to alarm response during medical telemetry monitoring in 2004-2006, according to a 2008 report by the Pennsylvania Patient Safety Authority (PPSA). All described inconsistent monitoring for physiologic conditions, and three events reportedly resulted in patient death. According to an analysis, the causes of these events included:

  • patient misidentification,
  • human/equipment error (i.e., telemetry transceiver not connected to patient, signal drop out),
  • alarm condition not detected,
  • alarm condition not detected by electrocardiography (ECG)-qualified staff,
  • ECG-qualified staff not available,
  • detection of alarm condition delayed,
  • verification of alarm condition delayed,
  • locating patient delayed and
  • intervention for alarm condition delayed

Suggested actions to prevent these events from occurring include placing slave displays and alarm enunciators in strategic locations throughout a telemetry care area; setting the volume level of an alarm to higher than the minimum audible level (the level will vary based on the noise level of the environment); and developing standardized practices for periodic ECG-electrode and lead-set inspection and replacement and proper electrode-site skin preparation. Other suggestions by the PPSA include:

  • requiring prompt response for all alarm conditions (i.e. low-, medium-, and high-priority alarms),
  • establishing alarm limit default settings based on a particular patient population in a given care area,
  • establishing criteria for when and how to adjust alarm default limits based on a patient's condition and
  • delineating responsibility for primary alarm response and establishing tiers of backup alarm coverage.

On the other hand, hypervigilance to alarms can cause inefficient patient care, increased patient and family anxiety, and staff burnout. Patients and families become upset when an alarm rings, especially if a staff member doesn't come into the room immediately to check the patient. Patients get annoyed at the frequent noise interrupting sleep, quiet time and conversations.

Staff and patients are bombarded with multiple alarms from other monitors, too: bed alarms, pulse oximetry alarms, IV pump alarms, bathroom alarms, respiration alarms, blood pressure monitor alarms, etc.

The problem may be that we're using telemetry too often. In a November 2003 Anesthesia and Analgesia study of telemetry use and effectiveness, strict monitoring criteria found telemetry was not indicated on 345 of 735 telemetry-patient days comprising 236 admissions. Only nine arrhythmic events occurred on those “non-indicated” days. Excessive use of telemetry impedes patient flow, reduces availability to appropriate candidates and increases costs.

Hospitalists can take action to reduce the risks of alarm fatigue and hypervigilance. Auditing and developing criteria for appropriate telemetry use based on the American College of Cardiology guidelines is an excellent quality improvement project, and has been shown to improve resource utilization.

Other ideas to optimize monitoring are to:

  • develop rigorous start and stop criteria for telemetry monitoring,
  • change electrodes at least every 24 hours,
  • know the default alarm settings of monitors,
  • set “reasonable” alarm settings,
  • install “teachable” monitors,
  • hire monitor technicians,
  • cross-train nursing assistants, unit secretaries and patient care technicians in basic rhythm interpretation and
  • instill a culture of paying attention to alarms in all clinicians.