Does your telemetry unit need a monitor watcher?

Synopsis: In a telemetry unit, having a dedicated monitor watcher present was not associated with a lower rate of most adverse outcomes evaluated.

Source: Funk M, et al. Am J Crit Care 1997; 6:318-323.

Funk and colleagues evaluated the effects of continual telemetry observation by a monitor watcher on mortality, frequency of transfer to a critical care unit, and the occurrence of the following five life-threatening dysrhythmias:

1. bradyarrhythmia requiring pacing, administration of atropine, or a change in anti-arrhythmic therapy;

2. supraventricular tachycardia or rapid atrial fibrillation requiring cardioversion or a change in anti-arrhythmic therapy;

3. asystole requiring an intervention;

4. sustained ventricular tachycardia (VT) requiring a change in antiarrhythmic therapy, precordial thump, cardioversion, defibrillation, or overdrive pacing;

5. ventricular fibrillation (VF).

Data were collected from medical records of patients admitted to a 26-bed cardiac progressive care unit located in a university hospital during two nine-month periods: monitor watcher present (1,185 patients) and monitor watcher not present (1,198 patients). Monitor watchers were RNs who were assigned to observe a bank of 26 telemetry monitors with responsibilities for validating alarms immediately, recording significant changes in rhythm, alerting each patient’s nurse as necessary, and maintaining the integrity of the telemetry system. During the time without a monitor watcher, each staff nurse was responsible for evaluating his or her patients.

There were no significant differences in death, transfer to critical care, supraventricular tachycardia asystole, or VF when a monitor watcher was present. Significantly fewer (P < 0.047) instances of sustained VT occurred with a monitor watcher (n=73), compared to without (n+99). However, more bradyarrhythmias (P < 0.001) occurred with a monitor watcher (n=101) than without (n=60). In a multivariate logistic regression, the adjusted odds ratio indicated that having a dedicated monitor watcher present made it 0.64 times as likely for a patient to have sustained VT, after factors such as age, sex, and admitting diagnoses were taken into account. Conversely, having a monitor watcher present made it 1.6 times more likely for patients to have bradyarrhythmias, after controlling for age and admitting diagnoses.

Comment by Leslie A. Hoffman, PhD, RN, chair, department of acute/tertiary care, University of Pittsburgh School of Nursing.

Absence of a watcher did not appear to adversely affect five of the seven outcomes studied However, three of the events — death, asystole, and VF — occurred infrequently. In 2,382 patients during 18 months of observation, there were six episodes of VF, seven of asystole, and 10 deaths. Thus, statistical power was insufficient to detect differences in frequency of these three outcomes.

The presence of a monitor watcher was associated with fewer episodes of sustained VT. Most likely, this finding resulted from the monitor watcher being able to detect less serious precursor rhythms — for example, lengthening Q-T interval, widening QRS complex, increase in premature ventricular beats — and initiate preventive therapy before an alarm was activated. On the negative side, patients experienced more bradyarrhythmias with the monitor watcher present. No details were given regarding etiology or management, so it is difficult to evaluate this finding.

Should a dedicated monitor watcher be employed on telemetry units? In the absence of this position, detection of dysrhythmias depends on many factors, including patient acuity, nurse-patient ratios, staff experience, frequency and type of dysrhythmias, sophistication of the telemetry system, and the physical layout of the unit.

This study and a prior study by the same researchers (Am J Crit Care 1997; 6:312) provide evidence that a monitor watcher can improve detection of some, but not all, adverse events, which isn’t surprising given the sophistication of telemetry systems. Ultimately, the decision to use a watcher depends on patient, staff, unit, and telemetry system characteristics and should be individualized in consideration of those factors. Also, this study’s findings should not be interpreted as applying to dysrhythmias surveillance in cardiac ICUs in other critical care settings.