Although the use of monitor watchers did not diminish nurses’ knowledge of electrocardiographic monitoring, it also did not increase the accuracy of arrhythmia detection. More hospitals are moving toward centralized monitoring, despite the lack of research to guide this practice. Each hospital has its own culture and geographic layout and the use of monitor watchers may be appropriate. Quality improvement projects that consider the context of the hospital environment when evaluating centralized monitoring would be valuable. Future research should address the use of monitor watchers for non-cardiac patients, the cost effectiveness of monitor watchers, and the association between the use of monitor watchers and adverse patient outcomes and missed clinically important events. Determining the amount of human surveillance of technology needed to maintain patient safety is crucial.

The PULSE Trial was funded by the National Heart, Lung and Blood Institute (R01 HL081642) and the Beatrice Renfield – Yale School of Nursing Clinical Research Initiative Fund.

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Primary challenges of a system of monitor watching are 1) ineffective communication, 2) fragmented patient care, and 3) the mesmerizing effect of watching rhythms of too many patients. First, it is essential that monitor watchers communicate effectively with bedside clinicians when a potentially serious event occurs. Communication between the monitor watcher and nurse should start at the beginning of the shift and include why the patient is being monitored and a review of previous alarms. A clear closed-loop communication protocol that identifies backup coverage and escalating alert procedures when the patient’s nurse is not available is essential. Dire consequences of a lack of an effective closed-loop communication protocol have been reported.1,10 Dependable closed-loop communication between monitor watchers and clinicians in the patient-care area is critical.

The second challenge is to avoid fragmented patient care, given that the staff responsible for assessment and care of the patient is different from the personnel directly responsible for the patient’s electrocardiographic monitoring. Because of the frequency of false and clinically irrelevant alarms, alarms often need to be validated by a clinician directly observing and assessing the patient. Timely patient assessment is key. With monitor watchers at a remote location, responsibility for setting appropriate alarm parameters must be clear. Customizing alarm settings cannot be done without awareness of the patient’s clinical condition and tolerance for arrhythmias. In addition to the monitor watcher not having critical information about the patient, the bedside nurse may lack information on the patient’s rhythm history, how the patient is tolerating a given rhythm, or the effect of an antiarrhythmic medication. Neither the bedside nurse nor the monitor watcher has complete contextual information about the patient. However, Palchauhuri et al.11 demonstrated that monitor watchers could decrease the alarm burden on nurses by using relevant contextual information to intercept alarms that they deemed invalid or irrelevant.

For accuracy of arrhythmia detection, 1 of the 3 PULSE research nurses, who were experienced ICU nurses with expertise in electrocardiographic monitoring and trained on the PULSE protocol, collected data at each hospital. Over 5 consecutive days at each hospital, the research nurse compared the occurrence of non-life-threatening arrhythmias stored in the full disclosure memory feature of the monitor with bedside nurses’ documentation of these arrhythmias in the patient’s medical record for accuracy of detection. We considered incorrect documentation and lack of documentation as not accurate.

Clickbait headline? Especially coming from a dedicated fountain pen user, who at one point would regularly lament how the ballpoint and the gel pen contributed to the downfall of polite civilization by driving the fountain pen to the brink of extinction? But from a sheer numbers and longevity perspective, you can easily make the case. Bic has sold over 100 billion of these pens since they were first launched in 1950. The pen sits in the permanent collection of the Museum of Modern Art. And it’s become the gold standard for how a basic ballpoint pen should look and write.

Evaluate the association of the use of monitor watchers with 1) nurses’ knowledge of electrocardiographic monitoring and 2) accuracy of arrhythmia detection.

The purpose of our study was to evaluate the association of the use of monitor watchers with 1) nurses’ knowledge of electrocardiographic monitoring and 2) the accuracy of arrhythmia detection. We hypothesized that on units that use monitor watchers, nurses would have a lower level of knowledge related to electrocardiographic monitoring. However, the use of monitor watchers would result in better detection of arrhythmias.

Among the 1189 patients in the non-ICU areas, the PULSE research nurses found 185 non-life-threatening arrhythmia events in the memory of the monitor during the 5 days of observation. Of the 185 arrhythmia events, 102 (55.1%) agreed with the research nurse’s findings, 14 (7.6%) did not agree, and 69 (37.3%) were not documented in the medical record (Figure 1).

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Though Europe gets the awesome orange barrels, in the States we’re “stuck” with what to me is the "classic" Bic Cristal, featuring a clear plastic hexagonal barrel and a plastic cap that matches the ink color. The design hasn’t changed much in the nearly 70 years this pen has been in existence, and the history of the Bic Cristal makes for fascinating reading.

People tend to hate cheap ballpoint pens for one of two reasons: they require too much pressure to write, and/or the ink won’t leave a solid line. The oil-based ink in really cheap ballpoints can also blob and smear all over the page (or in your pocket), making a serious mess. Of all the pure ballpoints out there on the market, however, I consider Bic Cristal and the Schmidt Easyflow 9000 to be the best options, because you don’t usually see any of these issues. (As with any mass-produced product at a lower price point, there are exceptions.)

Halley Ruppel, Kaiser Permanente Northern California Division of Research, Oakland, CA. Current affiliation: University of Pennsylvania School of Nursing and Children’s Hospital of Philadelphia Research Institute, Philadelphia, PA.

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Monitor watchers were technicians or nurses who were assigned to watch a central bank of telemetry monitors and notify bedside nurses of meaningful events. On each unit, PULSE research nurses noted if monitor watchers were used; and if so, whether they were on the unit or in a remote location.

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Though it certainly doesn’t write the same dark line as a gel or hybrid-gel pen, the Bic Cristal performs pretty well for a ballpoint. Bic’s shade of blue ink is much more vibrant than what you’ll find in a Papermate Write Bros., or the various store-brand generics. The 1.0mm “medium” tip can even show some line variation, depending on the pressure you use. For this reason, many artists use Bic pens to draw insanely detailed portraits. While I find gel pens pretty much unusable in tip sizes above .7mm, I have no trouble writing relatively small with the 1.0mm Bic Cristal, since oil-based ink doesn't feather and bleed.

Though ballpoint ink is never going to be as dark as gel, liquid rollerball, or most other types of ink, Bic's formulation is among the best. It also dries near-instantaneously on non-coated paper, including cheap office-supply stock.

Scores on the validated test of nurses’ knowledge were low (<50% correct) with or without monitor watchers. This is consistent with findings of a qualitative study in which medical-surgical and cardiac step-down nurses identified confusion and uncertainty regarding electrocardiographic rhythm analysis and intervention.9 Nursing experience and older age were more important contributors to knowledge than having direct responsibilities related to electrocardiographic monitoring.

Although the use of monitor watchers was not associated with diminished nurses’ knowledge of electrocardiographic monitoring, it also was not associated with more accurate arrhythmia detection. If implementing a monitor watcher program, critical safety points, such as ensuring closed-loop communication, must be considered.

These monitor watchers are “personnel whose job it is to watch the central cardiac monitor and alert clinicians of patient events.”2 In some hospitals, nurses are monitor watchers, whereas more frequently, technicians, who are usually supervised by a registered nurse or lead technician, serve in this role.1 National surveys have shown that monitor watchers are used in 47% to 61% of hospitals.2–4 They are stationed at a bank of monitors on the patient care unit, elsewhere in the hospital, or in a separate location. Remote telemetry monitoring may be a growing trend as hospitals are consolidated into larger health systems and may even occur in another geographic location.1

To evaluate the association between the use of monitor watchers and scores on the electrocardiographic monitoring knowledge test, we used an independent t-test, followed by stepwise multiple regression. To evaluate the association of the use of monitor watchers with accurate detection of arrhythmias, we used chi square analysis. We conducted all analyses using SAS software v9.4 (SAS Institute, Cary, NC). A p value of <.05 was considered statistically significant.

The rhythms evaluated were atrial fibrillation or flutter, non-sustained ventricular tachycardia (≥6 consecutive premature ventricular contractions), asymptomatic sustained ventricular tachycardia, supraventricular tachycardia of questionable etiology, second- or third-degree atrioventricular block (<40 beats per minute), junctional rhythm (<40 beats per minute), pacemaker failure, and pauses >2 seconds. We assumed that true life-threatening arrhythmias would be noted and documented by the bedside nurse with or without a monitor watcher present. The research nurses collected data together several times to check inter-rater reliability. The kappa coefficient was maintained at >0.90.

Despite their frequent use, the effect of monitor watchers on outcomes, such as adverse patient events, accuracy of arrhythmia detection, and nurses’ knowledge of monitoring, is not known. An early study revealed that the presence of monitor watchers was not associated with lower rates of adverse patient outcomes.5 This same study showed that the accuracy of detection of some arrhythmias was significantly better with the use of monitor watchers.6 However, a more recent study revealed that monitor watchers missed 21% of patients with detectible rhythm or rate changes on telemetry in the hour before an emergency response team was activated.7 Lastly, because nurses on a unit that uses monitor watchers do not work directly with the monitors, it is possible that they are less knowledgeable about electrocardiographic monitoring, although this has not been studied.

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Our study is limited by the secondary analysis approach. First, the parent PULSE Trial included only cardiac units. Patients with diverse diagnoses are increasingly being monitored with telemetry - often from remote locations2–4, although much work is being done to reduce inappropriate telemetry monitoring.7,8,16–20 It is possible that monitor watchers may be more useful with non-cardiac patients. Second, the focus of the PULSE Trial was on nurses, not monitor watchers, so we lacked data on characteristics of the monitor watchers, such as their training, which might have confounded the association between the use of monitor watchers and the study outcomes. Third, with a predetermined sample size of 1189 patients in the parent study, we may have lacked power to detect differences in the accurate detection of arrhythmias. Lastly, the secondary analysis approach also precluded our ability to obtain information on communication systems, fragmentation of care, and the number of patients per monitor watcher. Information addressing these issues should be included in future research.

Baseline data from 37 non-ICU cardiac patient care areas in 17 hospitals in the Practical Use of the Latest Standards for Electrocardiography (PULSE) Trial were analyzed. Nurses’ knowledge (n=1136 nurses) was measured using a validated 20-item online test. Accuracy of arrhythmia detection (n=1189 patients) was assessed over 5 consecutive days by comparing arrhythmias stored in the monitor with nurses’ documentation. Multiple regression was used to evaluate the association of use of monitor watchers with scores on the electrocardiographic monitoring knowledge test. Chi square analysis was used to examine the association of use of monitor watchers with accuracy of arrhythmia detection.

Slightly over one-third of units in this study had dedicated monitor watchers. Contrary to our hypotheses, the use of monitor watchers was not significantly associated with nurses’ knowledge of electrocardiographic monitoring, once relevant variables were considered. It was also not significantly associated with the accuracy of arrhythmia detection.

Of the 37 units, 13 (35.1%) had monitor watchers. Use of monitor watchers was not independently associated with electrocardiographic monitoring knowledge (p=.083). The presence of monitor watchers was also not significantly associated with the accuracy of arrhythmia detection (p=.935).

Reviewing centralized telemetry monitoring policies from other institutions may also be helpful. After evaluating policies from 75 Veterans Hospital Administration hospitals, George et al.14 developed a comprehensive policy that could be used at all sites. Cantillon et al.7 established and evaluated standardized cardiac telemetry with an off-site central monitoring unit. They reported detection and notification of rhythm and rate changes within 1 hour before the majority of emergency response team activations. The expense of establishing and maintaining centralized monitoring must also be addressed, especially considering that data regarding improved patient outcomes are lacking.

Third, the number of patient rhythms a monitor watcher can effectively and safely watch is not known. In their simulation study Segall et al.12 found that recognition of serious arrhythmias was significantly delayed when monitor watchers were responsible for more than 40 patient monitors. In the protocol of Cantillon et al.7, a monitor watcher provided continuous cardiac monitoring for up to 48 patients in their off-site central monitoring unit. The duration of the monitor watcher’s shift and the number and duration of breaks also may influence alertness and effectiveness. In a national survey, 68% of respondents reported that monitor watchers worked 12-hour shifts.2 Although no research has been reported on their shift-related alertness, this is a long time to remain attentive.13

The use of monitor watchers is becoming more common as hospital leaders attempt to identify effective approaches for alarm management. Many hospitals are instituting centralized telemetry monitoring, despite the lack of evidence for the safety and effectiveness of this practice. The overall impact of monitor watchers is not known.

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Of the 37 units, 13 (35.1%) had monitor watchers. In 11 (29.7%) units the monitor watchers were physically present in the patient care area and in 2 (5.4%) units they were observing the telemetry monitors from outside the patient care area. The remaining 24 (64.9%) units did not use dedicated monitor watchers.

Electrocardiographic telemetry monitors are ubiquitous in hospitals. Dedicated monitor watchers, who may be on the unit or in a centralized location, are often responsible for observing telemetry monitors and responding to their alarms. The impact of monitor watchers is not known.

Nurses on units with monitor watchers scored significantly lower on the test of electrocardiographic monitoring knowledge compared with nurses on units not using monitor watchers (46.7±10.6 with monitor watchers vs. 48.2±12.7 not using monitor watchers; p = .040). After demographic variables were entered into the stepwise multiple regression model, the use of monitor watchers was no longer significantly associated with knowledge (p value for monitor watcher variable = .083). Instead, the final multiple regression model revealed that more years worked on a cardiac unit (p < .001), more years worked as a nurse (p = .007), and older age (p = .034) were stronger predictors of greater knowledge of electrocardiographic monitoring.

Because monitor watchers do not seem to enhance safety and are expensive, monitor “watchers” of the future may not be people but rather computer algorithms. For example, Baldassano et al.15 developed and validated a platform for real-time physiological monitoring and caretaker notification via secure messaging in a neurological ICU. With advancements in the scope of physiological monitoring capabilities, more sophisticated algorithms can incorporate various types of patient data, including telemetry, to accurately identify potentially meaningful changes in patient condition and alert the nurse.

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Electrocardiographic monitors are ubiquitous in hospitals. In non-intensive care unit (ICU) areas, patients on monitors wear a portable telemetry unit that transmits to a receiver, allowing the patient’s electrocardiographic waveforms to be displayed on a central monitor bank.1

For the 185 arrhythmias, the use of monitor watchers was not significantly associated with arrhythmia detection (n=51; 54.8% accurate arrhythmia detection with monitor watchers vs. n=51; 55.4% accurate without monitor watchers; p = .935) (Figure 2).

We analyzed baseline data from the Practical Use of the Latest Standards for Electrocardiography (PULSE) Trial, a 6-year multi-site randomized clinical trial designed to evaluate the effect of implementing the American Heart Association Practice Standards for Electrocardiographic Monitoring on nurses’ knowledge, quality of care, and patient outcomes.8 The PULSE Trial took place in 65 adult cardiac units in 17 hospitals in the United States, Canada, and China. For the current study, we analyzed baseline nurses’ knowledge and quality of care data related to the use of monitor watchers in the 37 non-ICU cardiac patient care areas in the 17 hospitals. Our samples included 1136 nurses for the nurses’ knowledge aim and 1189 patients for the accuracy of arrhythmia detection aim. All hospitals received approval from their institutional review boards.

Responsibility for observing telemetry monitors and responding to their alarms varies across hospitals. At some hospitals, no specific personnel are solely assigned to watch the monitors; rather bedside nurses periodically observe the monitors and listen for alarms while also delivering patient care. In some smaller hospitals, ICU nurses are responsible for watching monitors for patients on other units, in addition to providing care to their own critically ill patients. Other hospitals have dedicated monitor watchers who observe a central bank of monitors but do not have responsibility for direct patient care.1

In a world where pen companies and big box stores are starting to charge $15 for a dozen mediocre gel pens, there’s something to be said for taking the opposite approach by picking up a pack of Bic Cristals. Sure, you'll probably lose the pen, give it away, or the plastic barrel may crack long before you use up the ink, but like the most basic woodcase pencils, sometimes you just want to get some work done with a reliable tool that presents the least amount of distraction. Moreover, with the concept of handwriting generally under attack, we should be doing all we can to preserve it by promoting the entire range of writing tools available. The Bic Cristal offers a low-cost, zero-barrier-to-entry option. Anyone can jump online or run down to the corner store, and get started handwriting.

For awesome write-anywhere portability (like in the car), I don't think you can beat the Cristal, especially if you tend to lose a lot of pens outside the house.

A majority of the 1189 patients on the 37 units when the PULSE research nurses were collecting data on arrhythmias were male (56.8%) and white (78.7%) with a mean age of 65.5 years. The most common primary admission diagnoses were arrhythmia / syncope (18.6%) and heart failure (16.5%), but 23.5% had a non-cardiac primary diagnosis (Table 2).

As I mentioned, the 1.0mm medium point will probably give you the smoothest writing experience, and is generally my recommended starting point. For editing and annotation (or if you just write really small), the “Xtra Precision” needle-tip pens are fantastic. If you write large, there's even an "Xtra Bold" 1.6mm version, though I've not tried them.

We measured nurses’ knowledge using a validated 20-item online test that covered essentials of electrocardiographic monitoring and arrhythmia, ischemia, and QT-interval monitoring. Before the PULSE Trial, we developed and pilot tested an initial version of this test. Based on an item analysis with evaluation of point biserial indices calculated for the whole test and for each item and the Kuder-Richardson reliability coefficient, we revised the test to the version used in the study.8 Test scores represented the percentage of items correctly answered (possible range 0 – 100, with higher scores indicating greater knowledge).

The 1136 nurses working in the 37 non-ICU cardiac units in the PULSE Trial were predominantly female (90.4%) and white (70.5%) with a mean age of 38 years. They had worked as a nurse for a mean of 12 years and worked on a cardiac unit a mean of 8 years; a majority had a bachelor’s degree (64.3%) (Table 1).

Monitor watchers were used less frequently than found in national surveys. In a national survey on the use of monitor watchers, nearly 61% of respondents reported that their hospital used monitor watchers on any unit.2 Response bias may account for the higher percentage reported in the earlier study. Participants who worked in hospitals that used monitor watchers (versus those whose hospitals did not) may have been more interested in responding to a survey that was marketed as a study on monitor watchers. National surveys on clinical alarms, rather than specifically focused on monitor watchers, revealed that 47% to 48% of respondents worked in hospitals that used monitor watchers.3,4 The inclusion of only cardiac units in the current study may also account for the less frequent use of monitor watchers, as these cardiac telemetry units may have been better staffed with specialized nurses and monitor watchers deemed unnecessary.

We hypothesized that the detection of arrhythmias would be better with the use of monitor watchers, whose sole responsibility was to observe the monitors and respond to alarms by determining the reason for the alarm and contacting the patient’s nurse. On units without monitor watchers, nurses must observe the monitors and listen for alarms while also delivering patient care. It defies logic that the presence of monitor watchers would not be associated with better detection of arrhythmias, as it was in an early single-site prospective study.6 Our finding that the presence of monitor watchers did not enhance the accuracy of arrhythmia detection could be related to numerous challenges in the implementation of a monitor watcher program.

Finally, if the Bic Cristal interests you from a design or historical perspective, both Philip Hensher's The Missing Ink and James Ward's The Perfection of the Paper Clip discuss the history and development of the Bic ballpoint pen in some detail (as well as diving deep into other aspects of stationery minutiae). I highly recommend both books.

Although the value of monitor watchers was not supported by our data, this does not mean that the use of monitor watchers may not be suitable for some hospitals. If hospital leaders are contemplating instituting centralized telemetry monitoring, especially from a remote location, or already have such a system in place, an interprofessional team must consider critical safety points. These safety points include the need for a detailed closed-loop communication protocol with explicit escalation strategies, plans for managing potential problems with equipment, ensuring that monitor watchers have as much contextual information as possible about the patient’s condition and clinicians have maximum contextual information from the monitor, and limiting the number of patients a monitor watcher observes.

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Two current Bic Cristal models: on the left the .8mm Xtra Precision, which sports a needle tip, and on the right, the most common Bic Cristal available, the 1.0mm "medium".