ECG monitoring? The lack thereof--that's what's alarming!

Dr Marjorie Funk from the Yale School of Nursing was quoted in Shelley Wood's piece: "We know there have been a number of deaths reported, and we thought that a contributor to 'alarm fatigue' may be unnecessary ECGs. The number of false alarms is substantial, and if we could eliminate unnecessary monitoring, that could result in a higher proportion of clinically meaningful alarms and maybe a faster response time. This is a potential way to decrease sentinel events."

As a cardiologist, I could not disagree more.

I recall many years ago, entering the office of our late CEO DeWayne Moss, concerned because I'd just attended to an elderly patient with rapid atrial fibrillation. She was in florid pulmonary edema and by the nursing vital sign records, her heart rate had been elevated for hours. Since she was on the surgical floor, the nursing staff understandably expected mild tachycardia as a postsurgical norm, but in this case, whatever the substrate, she had crashed, narrowly avoiding a ventilator. A simple cardiac telemetry device would have heralded a change from normal sinus rhythm to atrial fibrillation many hours earlier and would likely have prevented the need for another three or four days of hospitalization.

Because of Dewayne's quick response to conversation and common sense, within just a few weeks, we had run multiple telemetry tracks all over the hospital. Remote monitoring devices were available to provide O_2sat monitoring and other lifesaving information in those who were at the extremes of risk, ie, receiving high doses of pain medication, those with obvious sleep apnea due to body habitus, the elderly, the smokers, the frail, and of course, our cardiac patients who were having noncardiac procedures or other medical problems.

By far, throughout the course of my career, more patients have suffered from the lack of monitoring than from those suffering from "monitoring fatigue." As a matter of fact, I'm so pro monitor that I took great offense at this study. I think we should monitor folks who are just walking around Wal-Mart. As a matter of fact I do monitor folks walking around Wal-Mart — with off-site telemetry, event monitors, loops, and Holters. I monitor them (now say it with the same cadence of Dr. Seuss's Green Eggs and Ham): In their beds, in their yard, in their homes, near and far, in the store, at a bar, at their work, near and far — everywhere but the swimming pool and the shower. Grant you, these folks came with shortness of breath, chest pain, dizziness, syncope, palpitation, the entire spectrum of complaints, but every single day of the week, we obtain information that affects the health or longevity of at least one patient. Compare this population to those undergoing the stresses and rigors of an inpatient admission.

There will be lost opportunities if facilities decrease the number of inpatients who are monitored. We don't just rejoice over the one in 1000 who are saved from V-fib. What if they are found to have intermittent atrial fibrillation, for instance? The CHA₂DS₂-VASc score is calculated; the patient is sent home on anticoagulation and avoids a stroke, almost by accident. What about asymptomatic ST elevation? In an old study, up to one-third of patients with a prior MI by echo had no recollection of pain or an event. We are blessed when ST changes are detected and appropriate therapies delivered as prevention. Any cardiovascular healthcare provider can surely relate to just how many people are saved in the long run (not nearly so often in the "short run") by arrhythmia detection.

As for the guidelines, we must ask ourselves regardless, "Who is really at risk of an occult arrhythmia?" According to a 2004 Circulation article, "Lifetime risks for development of AF are one in four for men and women 40 years of age and older. Lifetime risks for AF are high (one in six), even in the absence of antecedent congestive heart failure or myocardial infarction." In other words, if you are alive and an adult, you may be someone at risk.

The US spends $43 billion per year on stroke care. Doing our part to monitor patients in-hospital might significantly affect that cost, but more than that, quality of life; a concern that should trump all concerns. To prevent disaster, all we need to do in many instances is to use that monitoring system that's six feet above our patient's head as they lie in their hospital beds thinking all is well.

The answer is not fewer cardiac monitors. It's more monitor techs and better staffing. If hospital workers don't know the indications for a cardiac monitor, retrain. If they don't have time to keep up with all the alarms, the CEO should close the unit and send the patient somewhere else where they can be safe. Period. As healthcare providers, we must stave off the national trend to just get 'em in, get 'em out, and head 'em up, Rawhide! Our mission is to prevent, detect, and treat, not to just get them home safely and pray we can get them through the next 30 days.

I ♥ monitors!

Your comments

	ECG monitoring? The lack thereof--that's what's alarming!
	# 1 of 4	March 10, 2013 12:25 (EDT)
	thomas metkus	Great comments! Agree wholeheartedly! Diagnosing, preventing and treating disease is what medicine is all about. Tried and true modalities must be used and appreciated. This is not "old school", just good medicine. Bravo to you Dr Walton-Shirley, love your work. Author's disclosure (Mar 10, 2013) I have no relevant disclosures to make in connection with this topic.
	# 2 of 4	March 10, 2013 06:41 (EDT)
	David Gee	Monitoring should be selective I'm also a cardiologist and I can not disagree more with your comments and I commend the poster presentation. Monitoring selective patients, with certain conditions, is very effective for detecting significant arrhythmias. However, there are a number of studies that have shown that ECG monitoring does little to reduce morbidity or mortality in most patients. In fact, there are studies that show cardiac monitoring increases morbidity because of false positive findings and subsequent unnecessary procedures such as EP studies and pacermakers and ICDs placed. All of us have stories that shape our judgement. However, we should really base our practice upon solid evidence and published data. Author's disclosure (Mar 10, 2013) I have no relevant disclosures to make in connection with this topic.
	# 3 of 4	March 10, 2013 08:14 (EDT)
	Rajesh Gupta	Wholeheartedly agree The "crying wolf" piece by Wood was poorly thought through and reflected a mindset in healthcare that has got us to the current state where quality medical attention is locked up and parsimoniously dispensed by a system designed to only look after catastrophic events. Author's disclosure (Mar 10, 2013) I have no relevant disclosures to make in connection with this topic.
	# 4 of 4	March 24, 2013 03:33 (EDT)
	Vince miraglia	How about the patient... Its time that evidence actual is in the equation.....if in fact as was mentioned by David Gee..."studies that have shown that ECG monitoring does little to reduce morbidity or mortality in most patients. In fact, there are studies that show cardiac monitoring increases morbidity because of false positive findings" Than this practice rather than simply increase the cost of care ;a not undesirable result from the provider side; also carries the potential to harm. Better care not necessarily more should be the goal. The Choice wisely initiative recommends against many "tried and true practices" Author's disclosure (Mar 24, 2013) I have no relevant disclosures to make in connection with this topic.

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