When nursing leaders evaluate the appropriateness of adding cardiac monitoring to a med/surg floor, there are a number of factors to consider. "You need to decide what skill set you want to employ - a standalone monitor tech, a very large centralized monitoring center with several techs, charge nurses who are monitor certified, or a unit in which all RNs are monitor certified," Cale said. "You need to decide who covers potential problems - the charge nurses, the rapid response team, or critical care nurses. Most importantly, you need to decide what you want to monitor on a med/surg floor."
It's important to involve clinicians in the decision-making and planning process, Cale emphasized. "If an oncology unit is going to add the ability to monitor patients who are on cardiotoxic chemotherapy agents, for example, you start out working with the oncology physician leaders who have to buy into the concept," she said. "Since physicians typically want their patients to stay on their specialized unit rather than transferring to a traditional telemetry unit, it's usually easy to get their buy-in."
The next step is to obtain buy-in from nursing colleagues. "You want to bring monitor techs and nurses together to identify and overcome barriers to cardiac monitoring," Cale said. "The concerns can be everything from your own skill set to the need for a remote viewing station or a way to communicate better. It's up to the nursing councils to bring forward these concerns or barriers, and then nursing management needs to figure out a cost-effective way to address the concerns or remove the barriers from their facility."
Most healthcare organizations acknowledge the need for flexibility in units with cardiac monitoring. "It's important to use appropriate criteria when admitting patients to these units," Cale said. "Typically, that means those who are hemodynamically stable without cardiac drips, and those who have low risk cardiac conditions. The American Cardiology College, ACC, adopted guidelines that can help an organization determine what type of monitoring is appropriate for a med/surg setting."
Telemetry monitoring requires new knowledge and skills. At Good Samaritan, those needs are addressed in two different educational components.
"The first is clinical training done by our nursing education department," Vallone said. "New grads or med/surg nurses new to monitoring attend classes about the cardiovascular and respiratory systems, as well as specific about monitoring. We also have good rapport with the manufacturer of our equipment, who sends a clinical support person to provide hands-on training prior to implementation of any new system."
Sydnor emphasized the importance of ongoing support after the initial training period. "When we opened the new unit, we had new graduates as well as a nice mix of RNs experienced in telemetry or critical care," she said. "We teamed our new nurses up with a buddy, and also provide them with a clinical support nurse on the unit 24/7 who can guide their practice."
When telemetry is added to the mix on a med/surg unit, nurse leaders need to make thoughtful decisions about the number and mix of nurses. National staffing standards for med/surg units with telemetry monitoring are higher than those of unmonitored med/surg beds, Vallone explained.
"We compare ourselves nationally and annually to both the Labor Management Institute and NDNQI," she said. "It's important to compare apples to apples when you're looking at patient mix."
While the base staffing on the stroke unit at SSM is 4:1, nursing judgment is important. "We take patients fresh from tPA, neurointerventions, or neurosurgery and watch them closely," Sydnor said. "We can flex our 4:1 ratio depending on patient acuity and specific patient needs."
Sandy Keefe is a frequent contributor to ADVANCE.