Debora Cale, MHA, RN, nurse director for telemetry services at Sutter Health, Sacramento, believes more and more nurses will see the addition of telemetry capability on their general nursing units as one way to improve patient outcomes.

"As time goes on, the demand for telemetry monitoring continues to grow along with the aging population," she said. "We've steadily increased our monitoring capacity to speed patient flow, reduce bottlenecks and allow patients to remain within the specialty clinical environments where they receive the best medical and nursing care while receiving another layer of observation to ensure optimal outcomes. For example, when construction is completed on the Anderson Lucchetti Women's and Children's Center here in Sacramento, we'll be able to provide telemetry monitoring for high-risk obstetric inpatients."

Developing Basic Processes

Cale, who currently oversees the telemetry monitoring of 144 patients housed in nursing units at Sutter Medical Center, Sacramento (including the Sutter General and Sutter Memorial campuses); Sutter Davis Hospital; and Sutter Solano Medical Center, Vallejo, talked about the changes needed when telemetry comes into the picture. "We start out developing basic processes that begin with the understanding that nurses on the units we're monitoring have to be able to read ECG strips and interpret arrhythmias," she said. "They attend a training program - usually a community-based critical care class that includes 3 days of arrhythmia interpretation - and it's up to their nurse manager to ensure they demonstrate the appropriate competencies."

Once they've demonstrated competency, nurses visit the monitoring center at Sutter Memorial Hospital. "They can see all the technology used for monitoring their patients," Cale said. "A central monitoring system like ours can track not only cardiac rhythms, but noninvasive blood pressure, continuous pulse oximetry and even invasive blood pressure. On med/surg units, nurses are often more interested in the oxygen saturation that will identify patients at risk of respiratory distress. Increasing monitoring capability allows facilities this option."

It's important to pay attention to end-users. "Each little community has its own nuances, and it is important to incorporate those preferences right up front," Cale said. "One unit may want their parameters set by the physician and never changed, while staff on another unit may want the monitor techs to change the rate to plus or minus 20 percent of the patient's baseline rhythm so they're not constantly called for variations. It's important to understand the culture on the other side."

A Learning Curve

While telemetry units are often characterized by the cardiac monitoring equipment they display, telemetry nursing is actually a combination of nursing science and art, of high-tech and high-touch that involves a fairly steep learning curve. "It's a process of experience, getting used to it day after day," said Christanne Kurtz, BA, RN, charge nurse at the University of California, San Diego Medical Center. "Telemetry nursing is not something you pick up in a day, a week or even a month. You learn by doing - reading those ECG strips every shift, going over them with the telemetry tech or the physician, and discussing what the implications are for your patient and his nursing care. That's how you become comfortable over time.

"When I first started as a telemetry nurse 8 years ago, I wasn't totally comfortable with A-V blocks, atrial fibrillation and other arrhythmias," Kurtz acknowledged. "Now I can look at one of the monitors at our nurses stations, or in the back room, and know what's going on with my patients."

Cale emphasized the importance of building confidence not only for the nurses at the bedside, but among the attending physicians as well. "We hired monitor techs who have come from various medical backgrounds," she noted. "This includes nursing assistants, as well as those who have been EMTs or paramedics, and even some LVNs. We share the message that the techs are there to watch patients as an extra set of eyes and ears, and that they won't take over patient care on the nursing units. This message helps to build trust from the very beginning."