TELEMETRY MONITORING:

Improvement Strategies for Everyone

By Kelly R. Gipson, BSN, RN

beep… beep… beep…

Anyone who has worked in the clinical setting with telemetry monitoring recognizes this constant
sound representing a patient’s heartbeat. Just as a guard stands watch, it reassures us that a patient
is safe and well. However, over time the sounds of telemetry can also become background noise.
What happens when the noise stops? Do you notice?

Alarm fatigue occurs when individuals are desensitized to the overabundance of alarms, leading
to a delayed response to actionable alarms. The Patient Safety Authority (PSA) heard the warning
alarm and ran towards the challenge.

Telemetry monitoring became an area of focus for the PSA after data analysts identified it as a
trend in their weekly reviews of high harm events reported by facilities to the Pennsylvania Patient
Safety Reporting System(PA-PSRS)*. Subsequently, they performed a detailed analysis, which
showed that 2.9% (16 of 558) of telemetry monitoring events were categorized as serious events†
and more than 80% (13 of 16) of these serious events resulted in death.1 This review showed that
while harm associated with telemetry monitoring is rare, when it occurs it likely will be cata-
strophic. This insight helped turn the PSA’s attention to this complex and multidisciplinary topic.

Keywords: telemetry, cardiac, monitoring, alarm fatigue

*PA-PSRS is a secure, web-based system through which Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities,
and birthing centers submit reports of patient safety–related incidents and serious events in accordance with mandatory report-
ing laws outlined in the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13 of 2002). All reports submitted
through PA-PSRS are confidential, and no information about individual facilities or providers is made public.
† “Serious Event” is defined as an event, occurrence, or situation involving the clinical care of a patient in a medical facility
that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional
healthcare services to the patient2.

Patient Safety Authority



Disclosure: The author declares that they have no relevant or material financial interests.

104 I PatientSafetyJ.com I Vol. 3 No. 2 I June 2021 Patient Safety I Vol. 3 No. 2 I June 2021 I 105
beep… beep… beep…
Telemetry monitoring has been part of patient care for many years.
Beginning in 1960, telemetry was broadly implemented in hos-
pitals to detect cardiac arrhythmias in patients with myocardial
infarction, and has since been adopted in other areas, including
medical/surgical departments.3 Its usage has evolved over the years
with changes in its intent, increased application, advancements
in technology, and a rise in high-acuity patients. As the number
of patients placed on telemetry monitoring increased, so did the
number of alarms. Those who have worked on telemetry units can
relate to the frustration of working a shift when one patient’s alarm
sounded every time they moved; the multitude of beeps and alarms
from telemetry eventually become background noise that no longer
hold significance—thus the emergence of alarm fatigue. Telemetry
has become a safety net where the guard standing watch in the
doorway has become responsible for numerous patients, which
increases the likelihood of missing an adverse event.
beep… beep… beep…
When we face a challenge in healthcare, we look to the literature
for best practices. As the PSA researched telemetry, it was evident
that many articles, tools, and resources were published in prepa-
ration for the 2015 phased-in Joint Commission National Patient
Safety Goal (NPSG) to reduce patient harm associated with clinical
alarm systems. The NPSG compelled facilities to evaluate their
policies and minimize risk related to alarm fatigue, as dialogue
around the topic had increased over the prior years.4 Using this
pool of resources, the PSA formulated its Hospital Telemetry Event
Investigation Tool,5 a series of questions to guide an investigation
of a telemetry monitoring event. The tool helps facilities iden-
tify failure points and process inconsistencies to drive targeted
process improvements, while an associated resource grid offers
internet resources to aid in these efforts.
Read the following scenario and think about how you would
approach such an investigation.
CM, a 62-year-old man admitted through the emergency department
with dehydration, was ordered continuous telemetry monitoring. The
nurse in the emergency department signed the telemetry order but did
not initiate the monitoring. Two additional nurses did not notice the
order for telemetry monitoring and did not connect the patient. On the
following day, CM was found in his room on the medical/surgical unit
without a pulse and a code was called. CM was successfully resuscitated
and transferred to the ICU. CM had been unmonitored for about 18
hours and his rhythm prior to the event was unknown.1 **
** The details of the PA-PSRS event narratives in this article have been modified to
preserve confidentiality.
The Hospital Telemetry Event Investigation Tool could help you
identify your facility’s opportunities for improvement in pol-
icy, initiation, monitoring, or response. Using the information
obtained during your investigation, along with research and data,
would allow you to better target issues at your facility and work
toward effective risk reduction strategies.
beep… beep… beep…
Developing solid improvement strategies can be time consum-
ing and require trial and error. For this reason, patient safety
106 I PatientSafetyJ.com I Vol. 3 No. 2 I June 2021
professionals often ask what other facilities are doing to address
similar challenges. What initiatives have been successful? To
help disseminate stories from Pennsylvania facilities who have
achieved positive results, the PSA developed a video series called
Telemetry Monitoring in Pennsylvania6-9 which is comprised of
an introduction featuring commentary from national experts on
telemetry and three spotlights on hospitals that implemented
telemetry process improvements.
● Telemetry Monitoring in PA — Introduction6
● Good Shepherd Penn Partners — Alarm Fatigue: A
Clinical Emergency Waiting to Happen7
● Mount Nittany — Ensuring Continuous Monitoring
Through a Hospital Visit8
● Einstein Medical Center Montgomery — Eliminating
Dead Batteries & End-of-Life Alarms9
These videos share successful strategies to address common telem-
etry issues, from patient monitoring and alarm settings to commu-
nication and prioritization. The document Telemetry Monitoring in
Pennsylvania: Tips and Strategies to Combat Alarm Fatigue provides
an overview of key takeaways, some of which are highlighted below.10
1. Challenge: Overutilization or unnecessary monitoring
Solution: Integrate the American Heart Association
(AHA) practice standards into electronic order sets as so
that prescribers are required to select an AHA indication
and duration for continuous telemetry monitoring6,11
A 30% reduction of unnecessary telemetry monitoring
was achieved through innovative education,
communication, resources, and prioritization of the
AHA practice standards.12
2. Challenge: High number of false and clinically irrelevant
alarms
Solution: Incorporate skin preparation and
scheduled electrode changes, follow manufacturing
recommendations for storage of electrodes, and suspend
alarms with care, to help alleviate alarms that do not
require action
By eliminating alarms that are false, such as artifacts
from patient movement, and clinically irrelevant, such
as a low heart rate in a healthy young athlete,6 you
can elevate the significance and prioritization of the
actionable alarms that sound.
3. Challenge: Impaired communication about telemetry
alarms
Solution: Communication policies should include an
escalation process that clearly states who should be
contacted when there is no alarm response6,9
Off-site, or centralized telemetry monitoring, is the
monitoring of multiple patients by a dedicated watcher
in a central location away from the patient care area.6-9
Challenges created by this model include staff-to-patient
ratios and watcher-to-clinician communication of lethal
rhythms.6
4. Challenge: Dead batteries
Solution: Implement a standardized battery change
schedule to prevent batteries from reaching end of life
Battery issues were involved in 78 of the 558 telemetry
event reports reviewed in PA-PSRS.1 Low battery alarms
are considered a low-priority alarm, meaning they are
not a continuous sound but an occasional beep that can
be drowned out by high-priority alarms. When a battery
reaches end of life, rhythm transmission ceases. To solve
this problem, one Pennsylvania hospital tested battery
life in the simulation setting and used the resulting data
to schedule routine battery replacements.9
5. Challenge: Alarm response
Solution: Use simulation to identify potential safety
issues
Using existing hospital technology to simulate critical
alarms in patient rooms, observers collected data on staff
responses, which was used to guide process improvement
efforts.12 Simulations such as this can identify safety
issues that otherwise may not be identified, discussed, or
addressed during a meeting in a conference room.
beep… beep… beep…
Have you been ignoring the beeping in this article? Is it providing
insight to alarm fatigue? Complacency regarding current teleme-
try policy is like asking the guard to turn away from the numerous
patients that require an observant eye.
In its efforts to support the guards standing watch, the PSA con-
tinues to monitor telemetry-related events reported into PA-PSRS
and share and discuss our resources with Pennsylvania hospitals.
Use of the PSA tools and hearing the stories of facilities who have
operationalized some of these shared strategies may inspire you
to look at telemetry monitoring in a new light and work to mini-
mize the unnecessary beeping and prioritize responses to alarms.
Telemetry monitoring and alarm fatigue are not easily addressed.
This is a multidisciplinary effort involving many people and
departments, and there must be leadership support to remove
barriers and prioritize change. Leveraging innovation, research,
data, and best practices will help guide process improvements
that will help staff and support safe healthcare for all patients.
References
1. Kukielka E, Gipson KR, Jones R. A Brief Analysis of
Telemetry–Related Events. Pat Saf. 2019;1(2):36–44. doi:
10.33940/biomed/2019.12.4
2. Medical Care Availability and Reduction of Error (MCARE)
Act, Pub. L.No. 154 Stat. 13 (2002)
3. Najafi N. A Call for Evidence-Based Telemetry
Monitoring: The Beep Goes On. JAMA Intern
Med. 2014;174(11):1855–1856. Also available https://jama-
network.com/journals/jamainternalmedicine/article-ab-
stract/1906997. Accessed August 15, 2018.
4. The Joint Commission. Hospital: 2015 National Patient
Safety Goals. https://www.jointcommission.org/-/media/
deprecated-unorganized/imported-assets/tjc/system-folders/
assetmanager/2015_npsg_happdf.pdf?db=web&hash=653D-
52D69E2A1A351D7EDAA88273EF8C. Published 2020. Accessed
January 13, 2020.
5. Patient Safety Authority. Hospital Telemetry Event
Investigation Tool. Accessed January 25, 2021. Also avail-
able: http://patientsafety.pa.gov/pst/Documents/Telemetry/
TelemetryEventInvestigation_2020_10.pdf Patient Safety Authority.
6. Patient Safety Authority. Telemetry Monitoring in PA-
Introduction. 2020 [accessed 2021 Jan 25]. Also available:
https://youtu.be/cKQ5s4S7p00
7. Patient Safety Authority. Telemetry Monitoring in PA—Alarm
Fatigue: A Clinical Emergency Waiting to Happen. [Video].
YouTube. https://youtu.be/fg9MiNoBDIg. Published October 26,
2020. Accessed January 25, 2021.
8. Patient Safety Authority. Telemetry Monitoring in PA—
Ensuring Continuous Monitoring Through a Hospital Visit.
[Video]. YouTube. https://youtu.be/7BkJ-6LoGtg. Published
October 26, 2020. Accessed January 25, 2021.
9. Patient Safety Authority. Telemetry Monitoring in PA—
Eliminating Dead Batteries and End-of-Life Alarms. [Video].
YouTube. https://youtu.be/N4HYqVY6MF4. Published October
26, 2020. Accessed January 25, 2021.
10. Patient Safety Authority. Telemetry Monitoring in PA—
Tips and Strategies to Combat Alarm Fatigue. Patient Safety
Authority website. http://patientsafety.pa.gov/pst/Documents/
Telemetry/Telemetry%20Monitoring%20Tips%20and%20
Strategies.pdf. Published 2020. Accessed March 9, 2021.
11. Sandau KE, Funk M, Auerbach A, Barsness GW,
Blum K, Cvach M, et al. Update to Practice Standards for
Electrocardiographic Monitoring in Hospital Settings: A
Scientific Statement From the American Heart Association.
Circulation. 2017;136(19):e273-e344. Epub 2017/10/05
doi: 10.1161/CIR.0000000000000527. PubMed PMID:
28974521. Luo B, McLoone M, Rasooly IR, Craig S, Muthu
N, Won J, Ruppel H, Bonafide CP. Analysis: Protocol for
a New Method to Measure Physiologic Monitor Alarm
Responsiveness. Biomed Instrum Technol. 2020 Nov 1;54(6):389-
396. Accessed January 28, 2020. Also available: https://
meridian.allenpress.com/bit/article/54/6/389/449918/
ANALYSIS-Protocol-for-a-New-Method-to-Measure
12. Doyle E. Breaking the Telemetry Habit. Today’s Hospitalist.
https://www.todayshospitalist.com/breaking-telemetry-habit/.
Published 2020. Accessed December 11, 2020.
About the Author
Kelly R. Gipson (kgipson@pa.gov) is a project manager at the
Patient Safety Authority. She started with the PSA as a patient
safety liaison for the South Central region of Pennsylvania. Prior
to joining the PSA, she worked as the associate patient safety offi-
cer at WellSpan York Hospital in York, Pennsylvania. Her clinical
background includes experience in medical/surgical, critical care,
and recovery room settings, as well as on multiple hospitalwide
shared decision-making committees.
This article is published under the Creative Commons Attribution-
NonCommercial license.
Patient Safety I Vol. 3 No. 2 I June 2021 I 107