Are Dedicated Monitor Watchers Necessary?
ABSTRACT & COMMENTARY
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 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; and 5) ventricular fibrillation (VF).
Data were collected from the 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 (1185 patients) and monitor watcher not present (1198 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 a critical care unit, 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
In this study, absence of a monitor watcher did not appear to adversely effect five of the seven outcomes evaluated. However, three of the selected events (death, asystole, and VF) occurred infrequently. In 2383 patients during 18 months of observation, there were only six episodes of VF, seven instances 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 (e.g., lengthening QT 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 a monitor watcher, 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 group of researchers (Am J Crit Care 1997;6:312) provide evidence that a monitor watcher can improve detection of some, but not all, adverse events, a not surprising finding given the sophistication of current telemetry systems. Ultimately, the decision to use a monitor watcher depends on patient, staff, unit, and telemetry system characteristics and should be individualized in consideration of these factors. In addition, the findings of this study should not be interpreted as applying to dusrhythmia surveillance in cardiac ICUs or in other critical care settings.
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