Case presentation, current practices of telemetry management, root cause analysis, goals for improvement, proposed intervention and next steps

Eckman, BS, BA, Susannah

Feldman, RN, Sarah

Heckel, BS, Brittany

Jaffe, MD, Rebecca C.

Panakos, MD, Andrew W.

Ragupathi, MD, Loheetha

English

Case presentation, current practices of telemetry management, root cause analysis, goals for improvement, proposed intervention and next steps.https://jdc.jefferson.edu/patientsafetyposters/1006/thumbnail.jp

Heckel, Brittany

Eckman, Susannah

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsHouse Staff Quality Improvement and PatientSafety Posters GME Quality and Safety6-10-2016To Fib or not to Fib: Misdiagnosis of AtrialFibrillation on Telemetry: Case Presentation andRoot Cause AnalysisAndrew W. Panakos, MDThomas Jefferson University Hospital, andrew.panakos@jefferson.eduLoheetha Ragupathi, MDThomas Jefferson University Hospital, Loheetha.ragupathi@jefferson.eduSarah Feldman, RNThomas Jefferson University Hospital, sarah.feldman@jefferson.eduBrittany HeckelThomas Jefferson University Hospital, brittany.heckel@jefferson.eduSusannah EckmanThomas Jefferson University Hospital, susannah.eckman@jefferson.eduSee next page for additional authorsFollow this and additional works at: http://jdc.jefferson.edu/patientsafetypostersPart of the Medicine and Health Sciences CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inHouse Staff Quality Improvement and Patient Safety Posters by an authorized administrator of the Jefferson Digital Commons. For more information,please contact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationPanakos, MD, Andrew W.; Ragupathi, MD, Loheetha; Feldman, RN, Sarah; Heckel, Brittany; Eckman, Susannah; and Jaffe, MD,Rebecca C., "To Fib or not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry: Case Presentation and Root Cause Analysis"(2016). House Staff Quality Improvement and Patient Safety Posters. Poster 5.http://jdc.jefferson.edu/patientsafetyposters/5AuthorsAndrew W. Panakos, MD; Loheetha Ragupathi, MD; Sarah Feldman, RN; Brittany Heckel; SusannahEckman; and Rebecca C. Jaffe, MDThis poster is available at Jefferson Digital Commons: http://jdc.jefferson.edu/patientsafetyposters/5CASE PRESENTATION ROOT CAUSE ANALYSIS  CURRENT PRACTICES OF TELEMETRY MANAGEMENT GOALS FOR IMPROVEMENT  PROPOSED INTERVENTION To Fib or Not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry  Case Presentation and Root Cause Analysis    Brittany Heckel, Sarah Feldman RN, Andrew W. Panakos MD, Loheetha Ragupathi MD, Susannah Eckman, Rebecca Jaffe MD Thomas Jefferson University Hospital, Philadelphia, PA  Summary of Error : The patient was started on anticoagulation for atrial fibrillation; however atrial fibrillation was not present .         A patient with a complex past medical history was admitted to a community hospital with symptoms of stroke, and he was found to have multiple acute cerebral infarctions on MRI.  He was transferred to Jefferson for further management, and he was admitted to a telemetry unit.  Morning and afternoon EKGs showed normal sinus rhythm. PGYI notes atrial fibrillation on review of telemetry alerts. Heparin infusion started.  Cardiology was consulted, and they determined that the atrial fibrillation alert was actually from the day prior to when this patient was admitted.        Day 0   Day 1     Day 2 Admission Process ● Patient is connected to a telemetry unit. ● Entering information is optional (except for patient last name), but there is space for several identifiers. ● These can be updated at any time.  Discharge Screen Admit Screen Patient inappropriately started on heparin infusion for atrial fibrillation, since atrial fibrillation was not truly present in this patient. Discharge Process ● Patient is disconnected from telemetry unit. ● Click one of the discharge buttons.  ● Patient data may be saved (stored remotely by vendor for 24 -72 hours) or discarded. RN/MD communication Supervision/Double check models Confirmation bias Health literacy Patient education and advocacy for themselves Practice variation between telemetry units  No dedicated personnel for management of telemetry No standard protocol for admitting/discharging patients Patient name can be changed without having to discharge patient from telemetry. Adding patient identifiers is not mandatory for monitor to function. Typically only last name is used. High index of suspicion for AF due to embolic stroke 12-lead EKGs showed sinus rhythm – lack of confirmation of telemetry findings Lack of formal telemetry training in medical education  Previous patient was not discharged from telemetry. GOALS:  (1)  To standardize the process for telemetry admission and discharge so that patients are always correctly identified on telemetry.   (2) To incorporate telemetry interpretation into medical education curricula so that providers can accurately identify arrhythmia events.  SMART Aims: By the end of the 2017 academic year:  (1) 90-percent of nursing staff on the inpatient medicine units will know the procedure for telemetry admission and discharge; (2) 90-percent of internal medicine residents will be able to describe a process for telemetry interpretation.   NEXT STEPS  (1) Create a standardized module for nurses which will teach the telemetry admission and discharge process   (2) Develop an algorithm  for telemetry interpretation to be used by house staff. No WHO Identify patient name. WHEN Search telemetry for the time period that you are interested in analyzing. WHAT What is the clinical question/reason that the patient is on telemetry in the first place?  WHERE Where is your patient? Is the telemetry being transmitted while they are in the room, or elsewhere?  Trends Alarms WHY Will the information you found have a significant clinical impact?  Consider discontinuing telemetry NO YES Yes 1.Partner with nursing leadership on telemetry units to implement education sessions on the telemetry admission/discharge process. 2. Incorporate telemetry interpretation into intern orientation and signoff requirements. 3.Survey medical staff to assess completion of the training module as well as its implementation in clinical practice. 4.Continue to encourage providers to report telemetry errors through the Error Reporting System, and ask those who interpret telemetry often (i.e. cardiology) for their assessment of the type and frequency of telemetry errors to monitor future issues. 

To Fib or not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry: Case Presentation and Root Cause Analysis

Name not available

To Fib or Not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry Case Presentation and Root Cause Analysis

CASE PRESENTATION ROOT CAUSE ANALYSIS  CURRENT PRACTICES OF TELEMETRY MANAGEMENT GOALS FOR IMPROVEMENT  PROPOSED INTERVENTION To Fib or Not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry  Case Presentation and Root Cause Analysis    Brittany Heckel, Sarah Feldman RN, Andrew W. Panakos MD, Loheetha Ragupathi MD, Susannah Eckman, Rebecca Jaffe MD Thomas Jefferson University Hospital, Philadelphia, PA  Summary of Error : The patient was started on anticoagulation for atrial fibrillation; however atrial fibrillation was not present .         A patient with a complex past medical history was admitted to a community hospital with symptoms of stroke, and he was found to have multiple acute cerebral infarctions on MRI.  He was transferred to Jefferson for further management, and he was admitted to a telemetry unit.  Morning and afternoon EKGs showed normal sinus rhythm. PGYI notes atrial fibrillation on review of telemetry alerts. Heparin infusion started.  Cardiology was consulted, and they determined that the atrial fibrillation alert was actually from the day prior to when this patient was admitted.        Day 0   Day 1     Day 2 Admission Process ● Patient is connected to a telemetry unit. ● Entering information is optional (except for patient last name), but there is space for several identifiers. ● These can be updated at any time.  Discharge Screen Admit Screen Patient inappropriately started on heparin infusion for atrial fibrillation, since atrial fibrillation was not truly present in this patient. Discharge Process ● Patient is disconnected from telemetry unit. ● Click one of the discharge buttons.  ● Patient data may be saved (stored remotely by vendor for 24 -72 hours) or discarded. RN/MD communication Supervision/Double check models Confirmation bias Health literacy Patient education and advocacy for themselves Practice variation between telemetry units  No dedicated personnel for management of telemetry No standard protocol for admitting/discharging patients Patient name can be changed without having to discharge patient from telemetry. Adding patient identifiers is not mandatory for monitor to function. Typically only last name is used. High index of suspicion for AF due to embolic stroke 12-lead EKGs showed sinus rhythm – lack of confirmation of telemetry findings Lack of formal telemetry training in medical education  Previous patient was not discharged from telemetry. GOALS:  (1)  To standardize the process for telemetry admission and discharge so that patients are always correctly identified on telemetry.   (2) To incorporate telemetry interpretation into medical education curricula so that providers can accurately identify arrhythmia events.  SMART Aims: By the end of the 2017 academic year:  (1) 90-percent of nursing staff on the inpatient medicine units will know the procedure for telemetry admission and discharge; (2) 90-percent of internal medicine residents will be able to describe a process for telemetry interpretation.   NEXT STEPS  (1) Create a standardized module for nurses which will teach the telemetry admission and discharge process   (2) Develop an algorithm  for telemetry interpretation to be used by house staff. No WHO Identify patient name. WHEN Search telemetry for the time period that you are interested in analyzing. WHAT What is the clinical question/reason that the patient is on telemetry in the first place?  WHERE Where is your patient? Is the telemetry being transmitted while they are in the room, or elsewhere?  Trends Alarms WHY Will the information you found have a significant clinical impact?  Consider discontinuing telemetry NO YES Yes 1.Partner with nursing leadership on telemetry units to implement education sessions on the telemetry admission/discharge process. 2. Incorporate telemetry interpretation into intern orientation and signoff requirements. 3.Survey medical staff to assess completion of the training module as well as its implementation in clinical practice. 4.Continue to encourage providers to report telemetry errors through the Error Reporting System, and ask those who interpret telemetry often (i.e. cardiology) for their assessment of the type and frequency of telemetry errors to monitor future issues. 

Case presentation, current practices of telemetry management, root cause analysis, goals for improvement, proposed intervention and next steps.http://jdc.jefferson.edu/patientsafetyposters/1006/thumbnail.jp

http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1006&context=patientsafetyposters

To Fib or Not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry Case Presentation and Root Cause Analysis

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