Any ED patient with symptoms worrisome enough to require cardiac monitoring reasonably expects that somebody is paying close attention. It does not always happen.
“It is not uncommon to discover at some point in the patient encounter that the patient has been removed from the cardiac monitor,” says Andrew P. Garlisi, MD, MPH, MBA, VAQSF, medical director of Geauga County (OH) EMS and University Hospitals EMS Training & Disaster Preparedness Institute.
The same is true of patients who need frequent blood pressure monitoring, or those with signs and symptoms of sepsis. In some cases, patients deteriorate without anyone realizing.
“There have been septic patients who have presented relatively intact and viable, who expire right under the noses of the healthcare team who are too busy to notice,” Garlisi reports.
Problems happen when a closely monitored patient leaves the ED, usually for a CT or MRI. “Patients who are transported to the radiology department, in my experience, are highly likely to return to the ED without being placed back on the cardiac and vital sign monitoring systems,” Garlisi observes.
ED nurses assume the radiology technologists are going to put the patient back on the monitor. Radiology assumes the ED nurses will do it. The same issue happens when ED patients are removed from cardiac monitors to go to the bathroom. “They are at risk for not being placed back on the monitors,” says Garlisi, who is aware of two bathroom-related situations in EDs that resulted in unexpected patient deaths.
EDs do not always maintain good systems to ensure any patient temporarily removed from the cardiac monitor is placed back on the monitor. To alert the staff that a patient is off-monitor, Garlisi suggests placing a red “X” on the patient’s room door. “This visual cue, hopefully, triggers someone to place the patient back on the monitor and remove the X from the door,” he offers.
Solving the problem of taking ED patients off monitors requires somebody to take ownership of it, Garlisi stresses. Hospital administrators may expect the ED staffing company to address it, and vice versa. Likewise, ED medical directors may believe it falls under the purview of nursing.
“Who would be held accountable for wrongful death, if and when a family member discovers that their loved one’s death could have been prevented with appropriate cardiac monitoring and frequent vital sign assessment?” Garlisi asks. Despite the unnecessary loss of lives in many EDs due to this problem, Garlisi says “the issue remains unresolved to this day.”
When a plaintiff attorney is evaluating a potential lawsuit arising from an ED visit, the monitoring data from the electronic medical record (EMR) is a key consideration, says Sean P. Byrne, JD, managing partner of Richmond, VA-based Byrne Legal Group. “Any abnormalities in that data will need to be evaluated in light of the patient’s baseline, presenting complaint, and suspected diagnosis,” Byrne says.
Cardiac monitors capture valuable data on the patient’s condition over time. “It is important that the insightful data from these monitors makes its way into the version of the EMR that will be produced later in response to a subpoena,” Byrne stresses.
The plaintiff attorney will examine trends in the data, and whether the EP acknowledged those trends. “If medications are given or other interventions are performed, the reviewing expert and attorney will look to see whether the monitor data demonstrated the expected and desired response,” Byrne explains.
The plaintiff’s expert also will look for evidence that ED providers responded appropriately if data fell outside the reference range of alarm parameters. “If there are unexpected periods of time where monitoring data are absent because of equipment issues, monitor detachment, or something else, that may raise questions in the mind of the reviewing expert,” Byrne cautions.
The chart should contain good answers to all these questions. “If litigation later ensues, providers should be able to explain the significance of all the data and numbers that appear in the record,” Byrne offers.
Sometimes, the problem is not that patients are taken off monitors. It is that nobody pays attention when they go off incessantly. Recently, Carilion Clinic providers studied how often alarms were going off in the ED. They knew it was happening all the time, but just how often surprised them. “During a one-month period, we had over 350,000 alarms per month in the three main units, across 50 beds,” says John Burton, MD, chair of the Carilion Clinic’s department of emergency medicine in Roanoke, VA.
That came down to more than 400 alarms per hour. “In summary, the alarm fatigue was astounding,” Burton reports. “It was happening to the point that no one was paying attention to them at all — except the patients.” It became clear the alarms were constantly going off because they were far too sensitive. This was especially true for respiratory rate. “The alarms have this built into them by the manufacturers, who I assume have no clue as to how bad they are in the ED,” Burton notes. Based on their own internal data showing the extent of the alarm problem, the ED made some important changes. “We adjusted the alarm parameter sensitivities where we could, and in some cases even shut a few down,” Burton says.
Whenever patients moved, or when ED staff changed their positions for minor procedures such as IV placement or blood draws, it often set off monitor alarms because the data fell outside the expected alarm range. “When a device is created to measure a patient parameter, such as respiratory rate, there seems to be some imperative by manufacturers to engineer an alarm in the device,” Burton observes.
This does not always make sense for the ED setting. “Shutting down some alarms and adjusting others substantially reduced the number of alarms, noise in the ED, and resultant staff alarm fatigue,” Burton adds.