You are here

Article Text

Article menu

Download PDFPDF

Short report
Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival
  1. Cody McCoy1,
  2. Neil Keshvani2,
  3. Maryam Warsi3,
  4. L Steven Brown4,
  5. Carlos Girod5,6,
  6. Eugene S Chu6,7,
  7. Anita A Hegde6,7
  1. 1Division of Cardiology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
  2. 2Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
  3. 3Fred Hutchinson Cancer Research Center, Statistical Center for HIV/AIDS Research and Prevention, University of Washington School of Medicine, Seattle, Washington, USA
  4. 4Department of Health Systems Research, Parkland Health, Dallas, Texas, USA
  5. 5Division of Pulmonary & Critical Care, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
  6. 6Medicine Services, Parkland Health, Dallas, Texas, USA
  7. 7Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
  1. Correspondence to Dr Anita A Hegde; anita.hegde{at}utsouthwestern.edu

Abstract

Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.

  • Nurses
  • Communication
  • Human factors
  • Quality improvement
  • Patient safety
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2022-002220

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Introduction

    There are an estimated 292 000 adult in-hospital cardiac arrests (IHCA) in the USA yearly.1 2 Delays in treatment of IHCAs are associated with decreased survival and worsened neurological outcomes.3 Little is known on how to improve IHCA mortality aside from telemetry, for which data is mixed.4 5

    Centralised telemetry allows for efficient monitoring of higher volumes of hospitalised patients by specialised staff.6 Delays in communication between telemetry technicians and bedside nurses regarding critical arrhythmias can lead to delays in activating the IHCA response team, and subsequent code activation, resulting in increased morbidity and mortality.2 Minimising delays in code activation should reduce time to defibrillation, improving IHCA outcomes.7–10

    Communication deficiencies are a leading cause of sentinel events in hospitalised patients.11 12 Bundled interventions have been shown to improve safety outcomes.13–15 Accordingly, we created a bundled intervention to improve communication between telemetry technicians and bedside nurses, thereby decreasing the time to Advanced Cardiac Life Support (ACLS) and improve IHCA outcomes.

    Methods

    This quality improvement intervention was implemented at a 900-bed, urban, safety-net academic hospital. A retrospective chart review was performed on all IHCAs in ward patients, aged 18 or greater, on centralised telemetry for 1 year prior to the intervention (September 2015 through July 2016) and 3 years postintervention (October 2016 through September 2019). Data from the procedure rollout period were excluded.

    A telemetry hotline was implemented for telemetry technicians to alert nursing staff for critical arrhythmias, including sustained ventricular tachycardia (VT) greater than 30 s, ventricular fibrillation (VF), bradycardia less than 30 beats/min or asystole. The telemetry hotline phones in each nursing station were modified to have a unique ring tone and a red handset. Next, telemetry technicians were empowered to activate codes directly on the overhead intercommunication system for critical arrhythmias. The IHCA response team at our institution includes medical intensive care unit (ICU) residents, ICU faculty physician or fellow, rapid response nursing team, respiratory therapist and pharmacist. Finally, an escalation protocol was implemented for critical arrhythmia alerts within the hospital-issued nursing mobile phone network, escalating to the charge nurse and all unit nurses in 30 s increments.

    The primary study outcome was IHCA survival. Secondary outcomes included survival to discharge and inappropriate code activations, such as those on DNR patients and false alarms. Two distinct Cox proportional hazard regression models were used to examine the association between the outcomes and intervention group after adjusting for age, gender, race and Charlson Comorbidity Index (CCI). A χ2 testing was also performed. For comparison with the telemetry patient survival outcomes preintervention and postintervention, χ2 testing was performed to compare the proportion of non-telemetry patients who survived IHCA events and survived to discharge preintervention and postintervention. Values of p<0.05 were considered significant.

    Results

    There were 20 ward IHCAs on centralised telemetry in the preintervention period and 55 in the postintervention period. Patient demographics are reported in table 1. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced risk of death (HR 0.26, 95% CI 0.08 to 0.84) during IHCA and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge after controlling for age, gender, Caucasian race and CCI. The overall median CCI for the postintervention group was greater than the preintervention group (5.0 (IQR 3.0–6.0) vs 4.0 (IQR 3.0–4.0), p=0.041).

    View this table:
    Table 1

    Baseline characteristics of patient population (N=75)

    On χ2 analysis, overall IHCA survival improved from 60.0% to 83.6% (p=0.031), with an improvement in VT/VF IHCA survival from 50.0% to 100.0% (p=0.035). Survival to discharge did not reach statistical significance, either overall (15.0% vs 38.2%, p=0.057) or for VT/VF (0% vs 50%, p=0.197). χ2 testing of ward non-telemetry IHCA events showed no significant difference preintervention and postintervention in either IHCA survival (71.4% vs 71.3%, p=0.999) or survival to discharge (42.9% vs 22.5%, p=0.068) (table 2). Cox proportional HRs for IHCA survival and survival to discharge are shown in figures 1 and 2.

    View this table:
    Table 2

    Survival by cardiac rhythm and overall

    Figure 1
    Figure 1

    In-hospital cardiac arrest survival.

    Figure 2
    Figure 2

    Survival to discharge after in-hospital cardiac arrest.

    There was one code activation of a DNR patient in the first 3 months and four false alarm code activations by telemetry technicians for bradycardia <30. There were no false alarms called for asystole or VT/VF.

    Discussion

    Our data demonstrate that improved communication and staff empowerment may increase IHCA survival for patients on centralised telemetry. Improved communication between telemetry technicians and nursing staff has previously been shown to result in more rapid bedside care. Bonzheim et al found that bidirectional voice communication badges decreased time to first contact and closure of the communication loop between telemetry technicians and bedside nursing staff when compared with unidirectional text paging.16 In contrast, our study reports improved survival outcomes from telemetry technician empowerment to directly activate the IHCA response team for critical arrhythmias, bypassing the initial contact with the primary nurse.

    Previously, empowerment of nurses through nurse-driven protocols, bypassing the need for physician confirmation, has improved a variety of healthcare outcomes. Nurse-driven urinary catheter removal protocols, for example, have been shown to decrease catheter associated urinary tract infection prevalence.17 Similarly, nurse-driven protocols help increase compliance with bundled interventions, thereby decreasing hospital acquired infections in neonatal and surgical trauma ICUs.18 19 Nurses have also been empowered to initiate sepsis screening and sepsis bundle protocols to improve sepsis outcomes.20 21 In our study, we expanded on the paradigm of staff empowerment by permitting telemetry technicians to directly activate the IHCA response team.

    Routine review of IHCA events led us to develop and implement a bundled intervention. Bundled interventions have also been shown to improve a wide variety of conditions ranging from sepsis22 to surgical site infections23 24 to fall prevention.25 26 Schweizeret al implemented a bundled intervention including methicillin-resistant Staphylococcus aureus (MRSA) screening and, when appropriate, decolonisation, chlorhexidine gluconate bathing and MRSA targeted perioperative prophylactic antibiotics to decrease cardiac and orthopaedic surgical site infections.23 To decrease patient falls in the emergency department, Pop et al implemented a bundle including fall risk assessment, safe ambulation, safe toileting, staff communication, early warning and patient education.25 Our bundled intervention included a telemetry hotline, telemetry technician empowerment to directly activate the IHCA response team and a standardised escalation protocol for critical arrhythmia alerts within the nursing mobile phone system, addressing both structural and process gaps and resulting in improved IHCA outcomes.

    Shockable initial rhythms, pulseless VT or VF, predict more favourable outcomes after cardiac arrest than pulseless electrical activity (PEA) or asystole arrests.27–29 Our study provided comparable results with 100% code survival for VT/VF arrests postintervention, confirming that the presenting rhythm is a significant predictor of code survival.30

    This study was limited by taking place at a single centre with a small sample size. Moving to a new hospital also limited the sample size in the baseline period. The retrospective nature of this study did not allow for a randomised control group. However, for non-telemetry codes, where the bundled intervention would not apply, we found no difference in IHCA survival. We were also unable to differentiate the individual effects of each component of the bundled intervention. Future studies may focus on specific components of the intervention, such as telemetry technician empowerment to directly activate codes.

    We were also unable to measure the experiences of the various stakeholders in this quality improvement intervention. Future studies may examine the impact of improved communication and empowerment of telemetry technicians on the satisfaction of the telemetry technicians as well as the nurses and physicians with whom they work. Equity of care for IHCAs and timeliness of code activations were other dimensions of quality of care that we were unable to measure and may be amenable to future studies.

    This bundled intervention incorporating enhanced communication processes with empowerment of telemetry technicians improved overall IHCA survival, particularly for VT/VF arrests in patients on centralised telemetry.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The University of Texas Southwestern (UTSW) Institutional Review Board exempted this study.

    Acknowledgments

    We would like to acknowledge all of the Parkland Health telemetry technicialns who contribute to patient safety everyday and have the expertise to call codes directly for critical arrhythmias. We would also like to acknowledge the nursing leaders, including Judy Herrington RN, Jacob Pietersen RN, Sheila DePaola RN, and Lita Kasunuran RN, at Parkland Health who made these interventions possible. We would like to acknowledge the IT and clinical informatics teams, including Chief Medical Informatics Officer, Dr. Brett Moran, for creating the mobile phone escalation pathway and continuously working on safety improvements to our system.

    References

    1. ↵
      1. Holmberg MJ,
      2. Ross CE,
      3. Fitzmaurice GM, et al
      . Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes 2019;12:doi:10.1161/CIRCOUTCOMES.119.005580.
    2. ↵
      1. Andersen LW,
      2. Holmberg MJ,
      3. Berg KM, et al
      . In-hospital cardiac arrest. JAMA 2019;321:1200–10. doi:10.1001/jama.2019.1696
      OpenUrlCrossRefPubMed
    3. ↵
      1. Bircher NG,
      2. Chan PS,
      3. Xu Y, et al
      . Delays in cardiopulmonary resuscitation, defibrillation, and epinephrine administration all decrease survival in in-hospital cardiac arrest. Anesthesiology 2019;130:414–22. doi:10.1097/ALN.0000000000002563
      OpenUrl
    4. ↵
      1. Mohammad R,
      2. Shah S,
      3. Donath E, et al
      . Non-critical care telemetry and in-hospital cardiac arrest outcomes. J Electrocardiol 2015;48:426–9. doi:10.1016/j.jelectrocard.2015.02.003
      OpenUrl
    5. ↵
      1. Cleverley K,
      2. Mousavi N,
      3. Stronger L, et al
      . The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients. Resuscitation 2013;84:878–82. doi:10.1016/j.resuscitation.2013.01.038
      OpenUrlCrossRefPubMed
    6. ↵
      1. Drew BJ,
      2. Califf RM,
      3. Funk M, et al
      . Practice standards for electrocardiographic monitoring in hospital settings. Circulation 2004;110:2721–46. doi:10.1161/01.CIR.0000145144.56673.59
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Chan PS,
      2. Krumholz HM,
      3. Nichol G, et al
      . Delayed time to Defibrillation after in-hospital cardiac arrest. N Engl J Med 2008;358:9–17. doi:10.1056/NEJMoa0706467
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      1. Herlitz J,
      2. Aune S,
      3. Bång A, et al
      . Very high survival among patients defibrillated at an early stage after in-hospital ventricular fibrillation on wards with and without monitoring facilities. Resuscitation 2005;66:159–66. doi:10.1016/j.resuscitation.2005.03.018
      OpenUrlCrossRefPubMedWeb of Science
    9. ↵
      1. Elmer J,
      2. Callaway CW
      . The brain after cardiac arrest. Semin Neurol 2017;37:19–24. doi:10.1055/s-0036-1597833
      OpenUrl
    10. ↵
      1. Kleinman ME,
      2. Brennan EE,
      3. Goldberger ZD, et al
      . Part 5: adult basic life support and cardiopulmonary resuscitation quality. Circulation 2015;132(18_suppl_2):18 suppl 2. doi:10.1161/CIR.0000000000000259
    11. ↵
      1. Dayton E,
      2. Henriksen K
      . Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf 2007;33:34–47. doi:10.1016/s1553-7250(07)33005-5
      OpenUrlPubMed
    12. ↵
      1. The Joint Commission
      . Sentinel event data event type by year. Available: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-data-event-type-by-year [Accessed 19 Jan 2022].
    13. ↵
      1. Guo XM,
      2. Runge M,
      3. Miller D, et al
      . A bundled intervention LOWERS surgical site infection in hysterectomy for benign and malignant indications. Int J Gynaecol Obstet 2020;150:392–7. doi:10.1002/ijgo.13257
      OpenUrl
    14. ↵
      1. Payne V,
      2. Hall M,
      3. Prieto J, et al
      . Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2018;103:F422–9. doi:10.1136/archdischild-2017-313362
      OpenUrlAbstract/FREE Full Text
    15. ↵
      1. Davies PE,
      2. Daley MJ,
      3. Hecht J, et al
      . Effectiveness of a bundled approach to reduce urinary catheters and infection rates in trauma patients. Am J Infect Control 2018;46:758–63. doi:10.1016/j.ajic.2017.11.032
      OpenUrlPubMed
    16. ↵
      1. Bonzheim KA,
      2. Gebara RI,
      3. O’Hare BM, et al
      . Communication strategies and timeliness of response to life critical telemetry alarms. Telemed J E Health 2011;17:241–6. doi:10.1089/tmj.2010.0139
      OpenUrlCrossRefPubMed
    17. ↵
      1. Durant DJ
      . Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: a systematic review.am. American Journal of Infection Control 2017;45:1331–41. doi:10.1016/j.ajic.2017.07.020
      OpenUrlPubMed
    18. ↵
      1. Ceballos K,
      2. Waterman K,
      3. Hulett T, et al
      . Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. Adv Neonatal Care 2013;13:154–63; doi:10.1097/ANC.0b013e318285fe70
      OpenUrlCrossRefPubMed
    19. ↵
      1. Tyson AF,
      2. Campbell EF,
      3. Spangler LR, et al
      . Implementation of a nurse-driven protocol for catheter removal to decrease catheter-associated urinary tract infection rate in a surgical trauma ICU. J Intensive Care Med 2020;35:738–44. doi:10.1177/0885066618781304
      OpenUrl
    20. ↵
      1. Kleinpell R
      . Promoting early identification of sepsis in hospitalized patients with nurse-led protocols. Crit Care 2017;21:10. doi:10.1186/s13054-016-1590-0
    21. ↵
      1. Dobrasz G,
      2. Hatfield M,
      3. Jones LM, et al
      . Nurse-driven protocols for febrile pediatric oncology patients. J Emerg Nurs 2013;39:289–95. doi:10.1016/j.jen.2013.01.014
      OpenUrlCrossRefPubMed
    22. ↵
      1. Levy MM,
      2. Pronovost PJ,
      3. Dellinger RP, et al
      . Sepsis change bundles: converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med 2004;32(11 Suppl):S595–7. doi:10.1097/01.ccm.0000147016.53607.c4
      OpenUrlCrossRefPubMed
    23. ↵
      1. Schweizer ML,
      2. Chiang H-Y,
      3. Septimus E, et al
      . Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 2015;313:2162–71. doi:10.1001/jama.2015.5387
      OpenUrlCrossRefPubMed
    24. ↵
      1. Waits SA,
      2. Fritze D,
      3. Banerjee M, et al
      . Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery 2014;155:602–6. doi:10.1016/j.surg.2013.12.004
      OpenUrlPubMed
    25. ↵
      1. Pop H,
      2. Lamb K,
      3. Livesay S, et al
      . Tailoring a comprehensive bundled intervention for ED fall prevention. J Emerg Nurs 2020;46:225–32. doi:10.1016/j.jen.2019.11.010
      OpenUrl
    26. ↵
      1. Titler MG,
      2. Conlon P,
      3. Reynolds MA, et al
      . The effect of a translating research into practice intervention to promote use of evidence-based fall prevention interventions in hospitalized adults: a prospective pre-post implementation study in the U.S. Appl Nurs Res 2016;31:52–9. doi:10.1016/j.apnr.2015.12.004
      OpenUrlCrossRef
    27. ↵
      1. Nadkarni VM,
      2. Larkin GL,
      3. Peberdy MA, et al
      . National Registry of cardiopulmonary resuscitation investigators. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006;295:50–7. doi:10.1001/jama.295.1.50
      OpenUrlCrossRefPubMedWeb of Science
    28. ↵
      1. Brady WJ,
      2. Gurka KK,
      3. Mehring B, et al
      . American heart association’s get with the guidelines (formerly, NRCPR) investigators. in-hospital cardiac arrest: impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge. Resuscitation 2011;82:845–52. doi:10.1016/j.resuscitation.2011.02.028
      OpenUrlCrossRefPubMedWeb of Science
    29. ↵
      1. Jones P,
      2. Miles J,
      3. Mitchell N
      . Survival from in-hospital cardiac arrest in Auckland city hospital. Emerg Med Australas 2011;23:569–79. doi:10.1111/j.1742-6723.2011.01450.x
      OpenUrlPubMed
    30. ↵
      1. Saklayen M,
      2. Liss H,
      3. Markert R
      . In-hospital cardiopulmonary resuscitation. survival in 1 hospital and literature review. Medicine (Baltimore) 1995;74:163–75. doi:10.1097/00005792-199507000-00001
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • Contributors All authors have made significant contributions to the following: conception and study design or data acquisition/analysis/interpretation, drafting or revising the article for intellectual content, and final approval of the version to be submitted.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.