Implementing a Nurse-Driven Telemetry Discontinuation Protocol.

Abstract

What is the best practice for implementing a nurse-driven telemetry discontinuation protocol?A Rayna Gorisek, MSN, RN, CCRN, CNL, replies:In the current climate of nurse staffing and supply shortages, nurses must take the lead in developing innovative ways to minimize waste and improve the quality of health care. Using a nurse-driven telemetry discontinuation protocol to optimize appropriate telemetry monitoring may decrease unnecessary monitoring, thereby reducing nurse workload, and it may promote patient flow through the hospital.The purpose of nursing protocols is to promote better patient outcomes, optimize patient safety, and improve quality of care. Nurse-driven protocols assist nurses in integrating evidence-based practices into patient settings, support nurses’ decision-making capacity, and increase their autonomy and accountability.1To begin developing a nurse-driven protocol for discontinuing telemetry, evaluate your organization’s existing process. Does a telemetry order set or protocol include steps to assess the need to continue telemetry? Next, conduct a comprehensive literature review, using more than one database to identify current evidence for developing a nurse-driven protocol for discontinuing telemetry. Also review any evidence-based guidelines for appropriate telemetry use, such as those from the American Heart Association, which identify 3 categories of patients and cardiac monitoring2: After reviewing the literature and guidelines, form an interdisciplinary task force that comprises all stakeholders—physicians, nurse managers, nurse directors, clinical nurse leaders, educators, risk management, and nursing staff—to produce a list of criteria for patients to be removed from telemetry. These criteria form the groundwork for developing the nurse-driven discontinuation protocol. As a team, the task force members develop a clinical research question using the PICOT (Patient, Intervention, Comparison, Outcome, and Time) method (see Table).3 Identify local problems specific to your unit or organization, such as delays in patient flow or limited availability of telemetry.Many organizations are challenged by transfer delays from emergency departments or intensive care units to acute care telemetry units. Specific metrics to consider evaluating include wait times for emergency department or intensive care unit patients to receive a bed on the telemetry unit and the total number of hours of telemetry monitoring. One opportunity for quality improvement is to assess alarm data on your unit. Nursing time and workload are impacted when nurses have to attend to unnecessary or nuisance telemetry alarms (eg, leads-off, poor connectivity, artifact, or battery failure alarms).4Initiating a 4-part iterative experiment by using the Plan-Do-Study-Act (PDSA) model offers a method of testing to achieve improvements on a small scale. With this model, a team performs a pilot to test a specific aim of improvement (see Figure).3 One of the benefits of using the PDSA model to test a nurse-driven protocol is that it does not require a lot of time or resources to fully execute the test for change. The PDSA model promotes simplicity by specifying who does what when and with what materials and supplies, ensuring that the stakeholders involved in the PDSA cycle have clear roles and responsibilities.4,5In the Plan phase of the PDSA cycle, the team establishes the specific aim or goal for change to be tested. Members of the interdisciplinary task force are assigned roles and responsibilities for the pilot, create a timetable for the pilot, and complete methods to measure and track data during the pilot. Frontline staff are given any necessary education or training during this phase. Consider ways to incorporate the nurse-driven protocol into nursing workflow, such as through the electronic health record or a checklist that would be used during nurse hand-offs or rounds.The Do phase of PDSA occurs when the pilot is implemented. Documentation is important in order to capture events—especially unanticipated ones—for future study. Listen to frontline staff and adjust the process on the basis of their feedback; making changes at this step reduces staff members’ anxiety and resistance to trying out a practice change.The Study phase is when data are analyzed. Ensure that an appropriate group and time interval are set for the comparison data that will be used to demonstrate the impact of the intervention or change. Evaluate and compare hypotheses and summarize the lessons learned.During the Act phase of PDSA, the task force decides, on the basis of the results, whether to implement, modify, or withdraw the change or idea. The team can continue the PDSA cycle if necessary.3–5Nurse-driven protocols can produce many positive outcomes. Implementing a protocol that decreases the amount of unnecessary telemetry monitoring may increase nurse autonomy, improve patient flow, and reduce costs. Using the PDSA cycle is one evidence-based way to systematically create improvement. Nurses need to be empowered and supported to lead in the development of innovations that improve processes and the outcomes of patients and the nursing profession.