Bill Klaproth (Host): This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. And with me is Cindy Welsh, Strategic Consultant and Advisory board member for Phillips Healthcare North America; and Jacob Turmell, Chief Clinical Officer, Phillips Hospital Patient Monitoring as we discuss centralized telemetry monitoring through CMUs, allowing nurses to operate at the top of their license while boosting signal to noise and high acuity environments. Cindy and Jacob, welcome.

Cindy Welsh, RN, MBA, FACHE: Thank you for having us.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah, excited to be here, Bill. Thank you.

Host: Yeah, thank you, Cindy. Thank you, Jacob. So Cindy, let me start with you. When you think about a CMU that has gone from good to great, what is different in the day-to-day experience for nurses, monitor techs, and patients?

Cindy Welsh, RN, MBA, FACHE: Sure. When I think about that situation, it really, for me, is time, because time equals trust. And trust is so important to being successful and having this remote function outside of a hospital organization. Because if you imagine a central monitoring unit, it's typically offsite from the hospital, the staff don't necessarily have never met each other.

So, they really need to get to know each other remotely, so to speak. So, it's really over time they get to understand what the skills of the technicians are, and then they trust that when they're being called and told that something's happening with their patients, there really is something going on.

Host: Yeah. Time equals trust. So, that's really important to remember in all of this.

Cindy Welsh, RN, MBA, FACHE: Yes, I think so.

Host: So, Cindy, what are the clearest signs that a CMU is functioning well on paper but not yet performing at a truly high level in practice?

Cindy Welsh, RN, MBA, FACHE: So many organizations in healthcare today are very data-driven. So for us, in my former organization, we really watched patient safety events related to patients on telemetry as kind of our true North Monitor. So when we started to see that fewer patients were having serious safety events like deaths or permanent harm, we knew that we had made it right. We knew that we had gotten to the point that our patients truly were benefiting from the workflows that we had in place, and the communication and trust that had been built up with the bedside.

Host: Absolutely.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah, I agree, Cindy. And it's really about getting those workflow efficiencies too that lead to that patient safety. It's the workflow efficiencies that really make a CMU that's been optimized stand out. They're able to give that time back, like you said, to nursing staff. So, I think that's really important.

Host: Yeah. Good thought on that. So Cindy, what have you seen organizations do to make alarms more meaningful and actionable. And what were the challenges and what were the benefits?

Cindy Welsh, RN, MBA, FACHE: Yeah. So, that's where the time and trust thing comes in, right? When we first started, we believed, and we worked very closely with Phillips. They were a great partner to us in terms of helping us understand what we should be looking at in terms of workflows and alarm management. But we really believe turn every alarm on, because that's going to make our patients as safe as possible, because everything will go off them. But we learned really quickly that that added to a lot of noise. That meant if I was taking my eyes off to look at what we'll call a nuisance alarm, an alarm that probably wasn't indicative of an event for a patient, then it was making me miss when the other patient I'm watching, because our staff have a one to 48 tech-to-patient ratio. So, it's really important they can keep their eyes on the monitors. So, it was really learning which alarms were important to have and which type of patients it was important to keep the alarms that we decided to turn off for.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah. And I've worked in alarm management since 2014, since the National Patient Safety Goal came out. And one of the things I see organizations doing is exactly what Cindy described. We're turning on more because more is better. And there's actually literature that would say less is better. And it's really using data to drive those conversations to say, "What alarms is it safe to turn off? What alarms is it safe to keep on?" and using data in that way to make these new standard configurations and looking at best practices from other organizations to say, "What alarms are you leaving on and does that make sense for our patient population?"

Host: So, smarter decisions when it comes to the alarms then?

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Absolutely, and that's what I see. Organizations back whenever Joint Commission told us, "Do something about your alarms" in 2014, that work needed to be refreshed, and that's what's happening now is a lot of organizations are saying, "Let's take our standard configuration, our standard defaults, dust them off, and make sure that they still make sense, and using data that they now have access to make those decisions."

Host: Yeah. And Jacob, how important is role clarity between the bedside nurse and the monitor tech, and where do organizations usually get that wrong?

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah, that's a great question. And it's something that I see a lot of organizations struggle with. How do we bring that monitor tech who is working in collaboration with the nursing staff? They are an extension of that nursing staff. How do we bring them together with that nurse? And that trust that Cindy talked about is so important. And a lot of times they haven't ever met, they've never worked together. They're a phone call away. And so when it comes to that communication around alarms, it's really important to have that trust embedded. So, I think the monitor tech has to realize they are an extension of that nursing staff and nursing needs to understand the work and the services that that monitor tech is providing.

Cindy Welsh, RN, MBA, FACHE: Yeah, I would agree. And I think vice versa, the nurse has to understand that the tech has a role that is really important, that they're consistent with. So, it isn't helpful if the nurse turns alarms off that we've requested that they not, so that the tech can, you know, have their attention drawn to it. So, like Jacob said, it's really so important that there's bidirectional communication all the time.

Host: So, Cindy, let me ask you this. What communication and escalation practices make the biggest difference between the CMU and the bedside team?

Cindy Welsh, RN, MBA, FACHE: I think that goes again to when you have workflows. We have developed an escalation algorithm that we thought was really going to be just a guideline for our techs to use. And very quickly, it became kind of the Bible by which communication and success was judged. So, I think that having the ability, one of the things that we learned early was we have to be able to call medical codes and rapid response teams from the CMU, because time is hard, right?

I mean, it's so important that, if the patient's having a lethal arrhythmia that someone get there to intervene. So, I think that it's really important to have everybody able to act when it's appropriate.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah.

Host: Yeah

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: And it's interesting, Cindy, that escalation pathway is so critical to the success of a CMU that those monitor techs know their chain of command, who they need to call next to make sure that the patients get the care that they need. I think it's great that you all implemented that they can call a code. What I have seen work really well for this escalation process is something very simple. You know, keep it as simple as possible, so those monitor techs can remember it.

Where I used to work, we had a very, very convoluted algorithm, you could call it. And the techs couldn't remember it. They were constantly referring to it instead of just knowing what to do, which is time wasted as well. So, keeping it simple is really important.

Cindy Welsh, RN, MBA, FACHE: And that was another, you know, lesson learned with time and. As you good to great kind of thing, you learn to simplify pretty quickly, because it is so important that it just becomes muscle memory that this is, you know, "I need to call a code now, because this is what I see on the monitor."

Host: Yeah. And Jacob, a common challenge with telemetry is patients staying and monitoring longer than warranted. What role can CMU play in helping address that?

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: So, I think CMUs have a big role in this and telemetry overuse is a huge problem everywhere today. And it's not so much that we're trying to get patients off so that we're not monitoring them. We want these patients off of telemetry so that we can get that next patient on so that we can help with throughput because patients are waiting in the ED for these monitored beds.

So if we can get a patient off, it means another patient is ready to go. And the CMU can really drive that conversation. I look at these monitor techs really as experts when it comes to monitoring. And so, they're able to say, "This patient meets criteria. They've not had any arrhythmias. Nurse, I think it's time for them to come off of telemetry."

But it goes back to what Cindy says with communication and trust. We can't emphasize that enough. The nurse has to trust the information that that monitor tech is giving and there needs to be communication back to that monitor tech to say, "Yes, I followed up with the physician. We're going to get the patient off of the monitor now." So, there's a big role for the CMU monitor tech in that.

Cindy Welsh, RN, MBA, FACHE: I love what Jacob suggests, is having the monitor tech be kind of the gatekeeper, so to speak, of it's time for the patient to come off, but that also requires the cooperation of the staff at the bedside in that, let's say for example, a patient has discharge orders, which means they no longer need telemetry. And the tech calls and says, "Hey, I see Mr. Smith has discharge orders. Can we get that box off?" And you find a lot of hesitation of removing the box before the patient's being wheeled down to the front door to get into their car. So, I think that, you know, again, as time evolves and we get to develop those relationships, that's one of the areas I think we could make a big impact on appropriate use of telemetry.

Host: Yeah. So, Jacob, what metrics actually tell you a CMU is improving, not just operating?

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah. So, Cindy's already talked about patient safety. Patient safety obviously should be the number one metric. Seeing reduction in safety events should definitely be something that organizations are looking at.

But what I find as CMU are becoming more efficient, becoming more standardized, they're looking at different metrics. And what they're looking at, especially from a CMU perspective, is time and alarms state. So, how long did it take for somebody to acknowledge that alarm and actually to respond to it is a key indicator to say that this CMU is functioning well.

Another one that could be looked at is the response rate. So as the nurse is getting those phone calls, are they having to escalate it to their buddy nurse or are they actually going in and responding to it? It's another metric that can be looked at. And that's where data comes in to be so important to really drive excellence in a CMU.

Cindy Welsh, RN, MBA, FACHE: Yeah. I'd add to that, Jacob, that I think kind of your trend over time, you see a baseline of what the serious safety events, what caused them. You know, patient on the wrong box or, you know, failure to recognize—

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: All leads off.

Cindy Welsh, RN, MBA, FACHE: Yeah. And then you fix those things, and then they shift to a different reason that you're having these safety events. So to me, that's really progress because you're using your data to drive your improvements, adjust your workflows, and then moving on to the next area of focus that needs improvement. So, you don't just stand still because, "Oh, we don't have the all leads off anymore," you know, things like that. We're looking at what the next cause is and addressing that.

Host: Yeah.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Well, it's interesting. Cindy, I talk about alarm management being a continuous process improvement. It is not a one and done project whenever you're doing alarm management or teleutilization.

Host: Always a work in progress.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Always. Always, yes.

Host: Always trying to improve.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yes.

Host: Absolutely. And Cindy, for leaders who already have a CMU in place, what is the next improvement step that usually unlocks the biggest gain?

Cindy Welsh, RN, MBA, FACHE: I think the next step is when you start to collaborate with the bedside between the CMU and, you know, an individual site.

So as much as you have to keep standard work because it's, you know, when you're watching 1400 patients out of one CMU, you have to have standard work. But you also want to support the sites and what their issues are. So if they have, you know, a specific kind of alarm that they seem to have repetitively, you want to work with them to address that. So, I think that's when you have that good relationship and rapport between your remote leader and your onsite leader, and you really collaborate to make those improvements. It makes a big difference.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah, I agree. And you mentioned something that I was going to say too is standardization. Any leader that is working within a CMU, they should be looking at standardizing their workflows. I think as CMUs are stood up, a lot of times workflows just kind of grow inherently. Organically, they may not be best practice, they may be best practice, but looking at standardization is key for a nurse leader. That's looking at optimizing their CMU.

Host: Yeah. Well, this has been great. One final question for you, Jacob. Let me start with you. What separates then a CMU that simply watches patients from one that really meaningfully improves care?

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah, I think it's all down to patient safety. Are we keeping patients safe by monitoring them? And you can have a CMU that's not doing everything they should be doing. Maybe the monitor tech isn't answering alarms like they should. Maybe the monitor tech doesn't have a good pathway to call. And you will see patient safety events. And so, I think as you're looking at that, patient safety is a key piece of that.

Host: Yeah. Cindy, your thoughts?

Cindy Welsh, RN, MBA, FACHE: Yeah, I totally agree with Jacob. I think you kind of hit the nail on the head. You've got to start to see less safety events because you are utilizing the tools that you have in front of you. And optimizing how they're implemented so that your patients don't have events.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah.

Host: Well, thank you both for stopping by today. This has really been fantastic. Thank you.

Jacob Turmell, DNP, APRN, ACNS-BC, NP-C: Yeah. Thank you, Bill. This has been great.

Host: Jacob, Cindy, thank you again.

Cindy Welsh, RN, MBA, FACHE: Thank you.

Host: Yeah. Once again, that is Cindy Welsh and Jacob Turmell. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you at aonl.org/nursing-leadership-podcast. This is Today a Nursing leadership. Thanks for listening.