Telemetry

Overview

Intern

Conference 7/30/13

Indications for Cardiac

Monitoring

Chest Pain

MI

Heart Failure

Hemodynamically compromised patient

Palpitations

Syncope

Electrolyte /metabolic abnormalities

Introduction of proarrythymic or QTc prolonging drug

Ordering Telemetry

Cardiac monitoring level

- Adult Cardiac Monitoring Med/Surg: May go off floor without

monitor - Adult Cardiac Monitoring Med/Surg: Requires monitor when

off floor

In general, patients requiring cardiac monitoring when off

floor include those patients with the following

conditions/situations:

Rule out for myocardial infarction pending cardiac enzymes

Acute Coronary Syndrome awaiting PCI or CABG who have

had chest discomfort or anginal equivalent in prior 24 hrs or

who are on IV Ntg, IV Heparin, GPIIbIIIa InhibitorCardiac

arrest where the threat of a recurrent arrest remains

VT, 2nd /3rd degree HB, AF with rapid ventricular response or

any symptomatic dysrhythmias

IV Antiarrythymic agents

Prolonged QTc ≥ than .50

Hemodynamically unstable

High flow FiO2 requirement to maintain O2 sats

Uncorrected metabolic /electrolyte abnormalities that have

potential cardiac effects until these are corrected

Alarm Histories

Graphics

Some Other Tools

Full Disclosure Strip

Full Disclosure Page

Telemetry Management

and Roles

RN At the beginning of each shift, the RN runs a rhythm strip and

documents rate, rhythm, intervals (PR, QRS, QTc).

RN is responsible for reviewing the telemetry data every 4 hours & clearing artifact

Managing all alarms

Intern Responsible for reviewing telemetry alarms /graphics while

pre rounding and circling back during day to look for changes

Printing out any significant events and bringing them to rounds (Print out as Event Strip)

Reflecting tele data/alarms in Progress Notes , reevaluating decision for telemetry with teams when rounding and reviewing tele order

Once patient rules out for example should be discontinued

A Discharge Order automatically discontinues telemetry

Audible Telemetry Alarms?

All audible three tone repetitive alarms are CRISIS ARRYTHYMIA or HR VIOLATION ALARMS RNS responds to alarm immediately Assess whether true clinically significant alarm or whether alarm false (artifact) or clinically not significant to individual patient (2 RN validation, adjust

parameter, request house staff change to order) For clinically significant event takes action, notifies MD

and documents alarm strip mounting in Progress Note for documentation

For clinically significant alarms MD reviews the alarm, discuss with RN and places event note in the chart as to action taken

HOUSE STAFF MAY NOT SILENCE ALARMS

What You May Be Asked

To raise alarm 10 above upper rate

To move AF to Message from Advisory

To move VT> than 2 to Message is known

short runs of NSVT leaving Vent Tach VT>6

To lower low rate to 40

To Reflect Change in Order

Discontinue the original adult cardiac

monitoring order

Place new adult cardiac monitoring order

incorporating the changes

Closing Thoughts

Artifact vs V-tach: how can your

tell the difference?

60 yo woman on ENC 7N with known

complete heart block and cancer being

followed by EP consult service

Pt had a stable escape rhythm and the EP

service did not want to put a venous pacer

in as she was receiving TPN – so were

considering arranging for an epicardial

pacer

Ms. T’s Baseline Rhythm

At some point the patient began having this on the monitor;

what was happening here?

14:15 “V TACH” cont…

Teaching Points Review Tele Alarms more than just pre-rounds and

respond to RN pages about new findings and the alarms they are bringing to your attention. ALWAYS LOOK AND VIEW THE RHYTHM. BE SURE TO SHARE WITH THE RN YOUR ASSESSMENT AND YOUR PLAN AND WHO YOU WILL TELL ABOUT THE RHYTHM

If you are unsure if something is artifact, show it to the your Resident , Attending or ask Cardiology for help

Remember patients with complete heart block are at increased risk of developing bradycardia dependent torsades from a long QT interval – so keep an eye on the QT interval and watch carefully for torsades

REMEMBER Alarms belong to all of us . Listen and look up to the

the visual signs and monitors when on the units . If you see something alert and check the patient.

Thanks!!