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

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.

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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.

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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.

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.

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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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).

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.

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.

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.

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 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).

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.

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.

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.

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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.

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

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).

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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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.

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.

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.

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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.

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.

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).

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

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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.

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.

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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.

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

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).

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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

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).

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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.

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.

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.

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.

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