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2010 QUALITY IMPROVEMENT INITIATIVES

Clinical Improvement Project: Implementation of Central and Telemetry Monitoring Capability
 
Time Frame:  March 2010 and ongoing

Project Description
To improve patient safety and quality of care, Grace Cottage Hospital purchased a central monitoring system which can simultaneously receive and display information and waveforms it receives from four separate patients.  The system utilizes two portable bedside monitors and two telemetry monitoring units which can be placed on any patient within the hospital’s Emergency Department and/or Inpatient Care Unit.  The central monitor, or Clinical Information Center(CIC), is housed at the Inpatient Unit Nurses’ Station and receives the patient’s data wirelessly from these four remote monitoring devices.  In addition to sending information back to the CIC, the two bedside monitors have their own display capability.  You can see what they are monitoring at both the patient’s bedside and at the nurses’ station:  they are able to continuously monitor the patient’s heart rhythm, heart rate, respiratory rate and oxygen level, and can be programmed to automatically measure and display the patient’s blood pressure at physician or nurse defined time intervals. The telemetry units, which are small and fit into a patient’s pocket, allowing for unrestricted patient movement, provide continuous remote monitoring of a patient’s heart rhythm and heart rate at the CIC. The CIC stores the information it receives for up to 24 hours and can be printed out for placement into the patient’s chart.  Through interfaces, which will be purchased at a later date, the CIC information can be uploaded and integrated into the patient’s electronic medical record.  

Problem
Grace Cottage Hospital’s 3-bed Emergency Department (ED) sees approximately 3,000 patients per year (about 8 a day) with one registered nurse on each shift.  Due to the physical design of the ED, it is not possible to view all 3 beds simultaneously.  Therefore when a patient was being continuously monitored, either a nurse needed to remain with the patient, or relied on auditory monitor alarms if the nurse needed to leave the monitored patient to attend to another patient.  Additionally, the monitored patient was attached to one machine to monitor heart rhythm and rate and a second machine to monitor blood pressure.  The nurse then had to make a manual entry into the patient’s chart to document the findings on the monitors.  If a patient required admission into the hospital for (non-ICU level) heart monitoring, there was no capability to do so on the inpatient unit and those patients would be transferred to another facility - even though Grace Cottage’s physicians and nurses had the clinical competence to care for the patient.       

Goals:
1.  To improve the quality of care and safety of ED patients being continuously monitored.
2.  To provide the equipment necessary to allow (non-ICU level) patients requiring inpatient admission for heart monitoring to receive care from their primary care provider in their local community hospital.
3.  To improve documentation of continuous assessments for monitored patients.

Intervention:
1. Opened discussions with Medical Staff and Board of Trustees regarding the need for Central and Telemetry monitoring – summer 2009
2. Funds from the Hospital’s annual “Fair day” designated for system purchase – August 2009.
3. System demonstrations from various vendors – F all 2009
4. Inpatient Unit nursing staff education on cardiac rhythm interpretation – January 2010
5. Policy and procedure development (patient selection criteria for inpatient admission, telemetry implementation and utilization policy and pre printed telemetry monitoring physician order set) – January & February 2010
6. Medical Staff review and final approval of policies – early March 2010
7. Purchase and Installation of CIC, bedside monitors and telemetry units – March 2010
8. Staff training on use of system and policies – March 2010
9. Go Live – late March 2010

Evaluation:
1.  All ED patients that need continuous cardiac monitoring are now placed on one of the new portable bedside monitors which displays its information and waveforms at both the bedside and on the CIC at the Inpatient Unit Nurses’ Station.  Now when the ED nurse needs to leave his/her monitored patient’s bedside, there is still someone watching the patient’s monitor - not just listening for an auditory alarm. 
2.  Clutter is reduced at the ED patient’s bedside.  One compact portable bedside monitor (on a rolling stand) replaces the two monitors previously needed.
3.  Patients requiring non-ICU level inpatient admission, who meet Grace Cottage Hospital’s Medical Staff approved criteria, do not have to be transferred to another facility.  They are admitted to Grace Cottage where their own primary care provider can take care of them.
4.  Documentation of continuous assessments has improved by using the print out capability of the CIC.