Thursday, January 03, 2008

Cardiac Arrests and Hospital Staffing

Time is muscle and time is brain.

So it is not a surprise to see that hospitals that fail to apply a defibrillator shock to a cardiac arrest victim quickly while in the hospital fare worse than those who receive it early. And it was surprising to see that in-hospital deaths from cardiac arrest were higher than out-of-hospital arrest survival in areas with available AED technology.

But what was most shocking to me (pun intended) was not these findings of the study, but the accompanying editorial by Leslie Saxon, MD who advocates for centralized monitoring stations "insensitive" to staffing needs in hospitals:
The automated detection system offers advantages in that it is insensitive to staffing issues and, if centralized, can track patients anywhere in the hospital. The system also allows for quicker notification of key personnel.
Who are we kidding?

I've seen such centralized stations in action, and it was scary. First, how many monitors must one person staffing these centralized station watch? 10? 20? 100? How attentive are they? (How attentive would you be after doing this for a week or a month or a year?) Then, there's notifying the staff that there's a problem: what if no one's at the nurses station to answer the "code" phone? Also, who will check to be sure the electrodes stay applied to patients or replace the monitor's batteries when they go dead?

Can we really expect that being "insensitive" to staffing needs will save lives? If no one is there competent to execute the necessary steps for successful resuscitation (including defibrillation), then few will survive.

More effective will be the hospitalist movement, where physician staff are available in-house 24 hours per day. Additionally, simple steps, like placing every patient who undergoes any surgery, especially with conscious sedation or general anesthesia, on telemetry (and perhaps pulse oximetry). After all, not all arrests are cardiac - many are respiratory first, and then become cardiac as hypoxia ensues.

Monitoring of patients in hospitals takes people. Especially people sensitive to patients' needs. Centralized monitoring stations that remain "insensitive" to staffing issues can only spell ultimate disaster to our patients.


Image credit.


Anonymous said...

I can't even fathom how our monitor techs handle 40 beds, much less more than that and spread out among the hospital. They're very good, but, they still miss things; like a person flipping in and out of a-fib, or when a heart rate goes to 180 (even with the "oh sh!t" alarm...)
Our techs are insensitive to staffing: we always have one. End of story. I would think if more places adopted this strategy then time to treatment of life-threatening arrhythmias would be better across the board. And you wouldn't have people advocating such ideas as centralized monitoring.
Just my thoughts though...

Kb said...

This all makes me wonder why when you take off your leads to take a shower how within seconds three nurses come scrambling into your room because the telemetry techs have called to alert them. They work hard staying on top of an entire floor.

Anonymous said...

Dr. Wes - thanks for pointing out the issues with something that at first glance seems like a good idea.

Can you give us some thoughts on when to request a hospitalist? I'm assuming the patient can request one at any big city hospital, but if I'm wrong and not all big city hospitals have them I'd like to know that.

Kim said...

24-hour in house hospitalists are wonderful!

Technology is a great thing, but the bottom line is that someONE (not someTHING) has to assess the patient.

View from the Trekant said...

Then there are the times that the leads come off, and the alert doesn't come . .

How many times have I seen my patient's monitor show no signal and asked if the patient was off the floor . . . only to hear "Oh,no, his monitor must just be off. I'll go check."

No replacement for bedside staff paying attention. The monitor bank is only a back up. EchoDoc

Anonymous said...

I remember hearing a story from a resident friend about being called in the middle of the night by a nurse because a patient had coffee ground emesis and because the patient was now hypotensive. The resident quickly ran to the patient's room only to find that the coffee ground emesis was dry! In other words it had been there for a while. Apparently nurses dont monitor patients as closely as we would like!