The Evolution of a Centralized Telemetry Program
Patricia Brown Lazzara, RN, MS
Anjana Redheendran Santos, RN, MBA
Linda F. Hellstedt, APN, MSN
Rita Walter, RN, MS, NE-BC
Abstract: Northwestern Memorial Hospital, Chicago, IL, recently transitioned from a unitbased telemetry program, monitored by the existing nursing staff, to a centralized telemetry
monitoring system, utilizing a staff of telemetry monitor technicians. The process to initiate and
implement the new system is described.
With current advances in wireless technology, the capability to perform cardiac
monitoring has moved beyond the ICU and progressive care units onto general medical-surgical
floors and diagnostic testing areas1. One method of ensuring that patients are closely monitored
is through a centralized system, where monitoring is performed in a remote location by personnel
who are not directly involved with the patients’ care1,2. This twenty-four hour visualization
across multiple units relieves the nursing staff of some of the responsibilities involved in
monitoring and improves some of the inefficiencies of a unit-based monitoring system3,4.
Simultaneous developments have led to the recent implementation of a centralized remote
telemetry monitoring program at Northwestern Memorial Hospital, Chicago, Illinois:

A bed reorganization to increase sub-specialty units, geographically localize medical
coverage, and distribute telemetry capability to the necessary areas;

An increase in the demand for telemetry capability due to expanding medical technology
as well as an increase in the number of stable, acute patients requiring cardiac monitoring
but not an intensive care unit (ICU) bed;

A projected increase in the demand for additional inpatient beds and telemetry services
over the next five years.
These factors necessitated a reorganization of patient care units and movement from
decentralized telemetry monitoring to a remote centralized model. This transition was vital to
achieving strategic growth goals and advancing the vision of the medical center.
The purpose of this paper is to describe the process undertaken in converting from a unitbased telemetry program, monitored by the existing nursing staff, to a centralized telemetry
monitoring system, utilizing a staff of telemetry monitor technicians (MT).
Background to the Project
Northwestern Memorial Hospital (NMH) is an 897-bed hospital in an academic medical
center in a major metropolitan area. Prior to this transition, the hospital had 74 telemetry-
1
capable beds distributed among three patient care units, and cardiac rhythms were monitored by
the individual nursing staffs. Patients who required telemetry monitoring were admitted or
transferred to one of these telemetry-capable units. After the telemetry monitoring was
discontinued, patients were transferred to the appropriate medical or surgical unit, based on their
diagnosis and/or nursing care needs. The additional transfer produced dissatisfaction from
patients and their families, extra work for the nursing, medical and ancillary staffs, and often a
delay in the patient reaching his/her home unit due to lack of bed availability.
In 2007, NMH undertook a Capacity Project for Bed Restacking. This project included
re-distribution of telemetry monitoring to expand its availability to the sub-specialty areas and to
centralize the program under dedicated, specially-trained MT’s. The reorganized program would
provide around-the-clock cardiac monitoring for up to 110 patients over 10 units in two separate
buildings.
Initial Planning
High level administrative planning for the Centralized Telemetry Project began about 12
months prior to the planned “Go Live” date. A Steering Committee composed of selected
representatives of nursing leadership, medical leadership, and support services identified
“deliverables” and formed task-specific teams. Items requiring development and planning
included:

Centralized telemetry policy, protocol, and guidelines – including specific admitting
guidelines and tools to facilitate evaluation of continuing need for telemetry monitoring;

A billing model and supporting technology for the new Centralized Telemetry
Monitoring Center (CTMC)

MT qualifications and job description;

Centralized telemetry documentation forms;

Training plans for both Nursing and MT staffs.
Throughout discussions on the above items, primary attention was paid to ensuring that optimal
patient safety was addressed and that patient satisfaction would be improved.
Group members reviewed the current literature and embarked on site visits of institutions that
already had a centralized telemetry program in place. Project Leaders and an identified
Transition Manager maintained the timelines and data points for each team.
Central Telemetry Monitoring Center
The CTMC was constructed on the site of a vacated satellite pharmacy, located between two
patient care areas, the Medical Cardiology and Heart Failure Units. The CTMC is a fairly large
room, allowing space for breaks, lockers, and an office setup. Its most appreciated characteristic
is a large picture window. Desk chairs, tables for holding the monitoring equipment, and the
telemetry monitor screens were all chosen based on their ability to provide an ergonomicallycorrect environment. A tube system station was available at this site for sending telemetry
transmitters, cardiac rhythm strips, and other documentation between the patient care units and
2
the CTMC. A bed tracking board was installed to allow the MT to follow telemetry patients
back and forth to procedural areas.
The CTMC is staffed by a minimum of three MT’s per 12-hour shift. Each MT observes a 3screen “station” which can display up to 48 patients, but averages 30-35 patients at a time. This
staffing was determined by a best practice survey of like area hospitals. Each MT station has a
binder with documentation of arrhythmia histories for each patient. The CTMC Manager is also
the Manager of the 30-bed Heart Failure Unit. There are permanent weekday and weekend MT
staffs as well as permanent day and night staffs. MT responsibilities are listed in Table 1.
Telemetry-Capable Patient Care Units
The three previous unit-based telemetry units and seven new medical-surgical telemetry
units comprise the new centralized telemetry units. Each unit has a central monitoring console
located in the nursing station so that both medical and nursing staffs can view current tracings
and arrhythmic events. To assist with telemetry bed utilization, guidelines were developed for
patient admission to the various types of monitored beds throughout the institution (Table 2),
based on the AHA Practice Standards for ECG Monitoring in Hospitals5.
Nurses on the telemetry-capable units carry a cell phone for direct and immediate
communication with the CTMC regarding significant arrhythmia occurrence (Table 3). The
nurses also collaborate with the medical staff to assess the need for continuation of telemetry
monitoring. Twice-a-day they review an evaluation of patients with stable rhythms, generated
by the MT’s. They also complete a Cardiac Monitoring Evaluation Tool (Table 4) in the
electronic medical record, which is generated for each patient with a telemetry order. This tool
helps to assure appropriate use of telemetry. A list of telemetry nurse responsibilities can also be
found in Table 1.
Patient Transport
Separate transport monitors, equipped with wireless technology, allow the MT’s to
visualize telemetry tracings during patient transport and during many diagnostic tests and
procedures. A dedicated phone is attached to the portable monitor so that the MT can
immediately notify the transporter, technician, or procedural nursing or medical staff when a
significant arrhythmia occurs. A call is also made by the MT to the unit nurse regarding the
change in the patient’s monitor rhythm. Prior to this time, all telemetry patients were
accompanied by a nurse when they left the unit; now the CTMC can safely and seamlessly
monitor the patients centrally while they are off the unit.
Because of this change in how transport monitors would be used, training of nurses and
technical staffs in these diagnostic and procedural areas was initiated, focusing on use of the
monitors and the attached phones. Transporters were also instructed on how their work would be
impacted with the CTMC monitoring patients during transport.
Staff Training
Telemetry Monitor Technician
3
A concerted effort was made to recruit for all the budgeted MT positions and hire for one
start date, 10 weeks prior to “Go Live”. The prospective group of sixteen MT’s was hired from a
variety of backgrounds and experiences, creating a diverse and energetic team. Some were
experienced MTs or paramedics from outside institutions, some had recently completed cardiac
technician programs, but did not have work experience, and several were internal transfers who
had hospital experience in other roles but were without telemetry experience. An initial decision
was made to put everyone through the same training with attempts at individualization for the
very experienced and inexperienced.
The training program consisted of a variety of experiences (Table 5). The initial part of
the program was developed by an Education Consultant from the hospital’s training department
and a Cardiology Advanced Practice Nurse (APN). The first four weeks consisted of an online
Basic Arrhythmia course (or successfully passing all the pretests) and a formal Central
Telemetry class for MT’s. In addition, the MT’s participated in a “Shadow-a-Nurse” program
and followed nurses from the Critical Care and Telemetry Units, the Emergency Department and
diagnostic testing areas to observe the management of patients with various arrhythmias as well
as become more familiar with the hospital environment outside of the CTMC. Three Clinical
Instructors (CI) joined the program on Week Five. They were experienced staff nurses from one
of the ICU’s or a telemetry unit who had expressed interest in participating in this short term
project. With the assistance of the Cardiology APN, they provided the MT’s with additional
training on arrhythmia monitoring, role development, and preparation for “Go Live”.
The MT’s would meet as a whole and then break into three groups for one-to-one lessons
with the CI’s. Learning modalities including lectures, games, tracings and daily quizzes. Study
tools and packets were also provided to each MT. All candidates took a final MT Telemetry Post
Test and passed. Towards the end of the 10 weeks, the CI’s developed simulation exercises to
mimic the various activities and responsibilities of the MT, since the CTMC equipment
installation was not yet complete. They also organized pilot testing of the system once it was
available for use.
The training program started out with 8-hour shifts and moved to 12-hour shifts for the
last four weeks. During the last week, a CI rotated with those MT’s who had been hired to work
permanent nights to train on the night shift. An unexpected benefit of keeping the 16 MT’s
together for 10 straight weeks is that they developed a very strong group identity and continue to
demonstrate great teamwork and support for each other.
Nursing Staff Training
For the approximately 280 new telemetry nurses, a decision was made to train all of them
in the recognition of basic arrhythmias and their management, in addition to telemetry policy and
equipment. Planning and implementation of the nurse training was again developed by the
Instructor from the training department and the Cardiology APN (Table 5). Nursing staff new to
telemetry were first enrolled in an abbreviated online Basic Arrhythmia Course, which was
completed on their own unit. They then attended a four-hour Centralized Telemetry Training
Program offered at multiple times throughout the six-weeks prior to “Go Live”. MT’s assisted in
the training sessions for rhythm strip interpretation. This proved to be an invaluable experience
as the nurses could meet the MT’s and learn about their background and skill level and the MT’s
could hear the nurses’ concerns. Current cardiac telemetry nurses attended a portion of this class
4
to learn about the differences they would be experiencing with the transition to a centralized
telemetry system. The new telemetry nurses took a Nursing Staff version of the Telemetry PostTest.
After the online study and live class were completed, some nurses had a six-week wait
for telemetry patients to be admitted to their units. Additional study tools were developed to
help sustain the training, including extra rhythm strips for practice, online interactive case
studies, availability of arrhythmia texts, and continuing access to the online Basic Arrhythmia
program for review. Finally, to facilitate in the transition, each new telemetry unit was assigned
to one of the original telemetry units as a “sister unit”, to provide identified support for the new
telemetry managers as well as the staff.
Conclusion
The launch of a centralized telemetry program has expanded access of services to patients
with promotion of safety and comfort. The implementation is still a work in progress, but since
adopting the centralized telemetry model, patients are assigned to diagnosis-appropriate units
while being monitored remotely for any abnormal or adverse cardiac events. Patients are now
placed on units based upon disease, required nursing care, physician coverage, and consult
patterns, not the need for cardiac monitoring.
The extended efforts of many departments facilitated the opening of an operational
Centralized Telemetry program on the designated date. Key elements identified as essential to
the program’s successful “Go Live” were:
 timely, careful and continuous planning with attention to detail;
 continuing adherence to the timeline;
 assignment of CI’s to the MT training program; and
 the flexibility and adaptability of all in the CTMC.
The evolution from a unit-based telemetry program, monitored by the existing nursing staff, to a
centralized system, utilizing a staff of MT’s, has now been successfully realized at Northwestern
Memorial Hospital. The ongoing challenge now lies in future evolution of the program as the
needs for patient monitoring continue to change.
References
1. Reilly T & Humbrecht D. Fostering synergy: a nurse-managed remote telemetry model.
Crit Care Nurse. 2007;27:22-33.
2. Olson LA. Welcome to monitor central. Am J Nurs. 2000;100:24AA-24BB,24DD.
3. Miller W, Erickson C, Mehlbrech M. You can’t see us, but we’re watching…the design
and implementation of a centralized telemetry surveillance unit (abstract). Crit Care
Nurse. 2006;26:6.
4. Radtke A. Telemetry monitoring: a preferred solution for intermediate care. Nursing
Management. 2006;37:52A-52D.
5. Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MM, Macfarlane PW,
Sommargren C, Swiryn S & Van Hare GF. Practice standards for electrocardiographic
monitoring in hospital settings: an American Heart Association Scientific Statement from
the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular
Disease in the Young: endorsed by the International Society of Computerized
5
Electrocardiology and the American Association of Critical-Care Nurses. Circulation.
2004;110:2721-2746.
6
Table 1: Monitor Technician and Telemetry Nurse Responsibilities







Monitor Technician Responsibilities
Immediate nurse notification of an arrhythmic
event via cell phone (after 3 rings, the call is
forwarded to the Charge Nurse)
Maintenance of an updated nurse phone list
with their assigned telemetry patients – sent by
each patient care unit to the CTMC at the
beginning of every shift
Documentation of rhythm strips every eight
hours and with any new significant arrhythmia
-- sent to the patient care unit for inclusion in
the paper medical record
Provision of updates to all telemetry units
twice a day as to which patients have been in a
stable rhythm with no acute events for the prior
twelve hours
Nurse notification of significant artifact that
needs to be addressed
Manager/Off-Shift Administrator notification
of the need to initiate a “Telemetry
Decompression” page – a page that is sent to
all telemetry-capable units when the CTMC is
near its maximum number of telemetry patients
Cleaning, maintenance, and distribution of
telemetry transmitters and their wires
7








Telemetry Nurse Responsibilities
Initiation of cardiac telemetry, i.e.,
connecting the patient to the telemetry
transmitter, confirming the cardiac rhythm
with the MT, and documenting specific
identifying information
Patient assessment upon receiving arrhythmia
call from the CTMC
Ongoing evaluation of arrhythmia patient and
initiation of appropriate anti-arrhythmic
therapy
Phone communication whenever patient is
transferred on and off transport monitor
Troubleshooting monitor artifact/loss of
tracing with assistance of a Patient Care
Technician
Twice daily assessment of the need to
continue telemetry monitoring in
collaboration with the medical staff
Telemetry discontinuation and return of
telemetry transmitter with wires to the CTMC
for cleaning
Initiation of the identified protocol with any
disruption of telemetry monitoring.
Table 2: Northwestern Memorial Hospital Admitting Cardiac Monitoring Guidelines (rev. 9/08)
Cardiac Problem
General Medicine Unit with
Telemetry/Surgical Telemetry
(Need reevaluated q.12 hrs)
Observation Unit Bed
(OU)
Heart Failure and Cardiac Telemetry
Bed (medicine patient)
11 West/CVT Surgery
(Need reevaluated q.12hrs)
CCU Bed (medicine patient)
SICU/CTICU Bed
(surgical patient)
Chest Pain
If patient has
significant CAD
risk factor (prior
MI,CAD,DM),
ideally admit
patient to cardiac
unit
 OU criteria plus
accompanying condition(s)
requiring inpatient workup
and/or therapy (e.g., heart
failure, dialysis pt. with
electrolyte imbalance/fluid
overload, HTN urgency,
accompanying syncope)
 Possible MI w/true DNR
status & no aggressive
medical management
(exception)
 Class II
 ECG: normal or
non-diagnostic, or
w/ non-specific T
wave changes
 Cardiac serum
markers normal or
borderline
 Hemodynamically
& electrically stable
 Chest pain with risk
factors and nonspecific EKG
abnormalities
 Class II
 OU criteria plus accompanying
condition(s) requiring inpatient
workup and/or therapy (e.g., heart
failure, dialysis pt. with electrolyte
imbalance/fluid overload, HTN
urgency, accompanying syncope)
 Possible MI w/true DNR status & no
aggressive medical management
(exception)
 Class II
 History consistent with ACS
(STEMI, NSTEMI or
Unstable Angina)
 ECG: ST segment elevation
in 2 or more contiguous leads
or new BBB OR new
ischemic changes (ST
segment depression &/or T
wave inversion)
 Requiring IV antithrombotic/anti-ischemic
therapy (exception:
heparin/enoxaparin)
 Hemodynamically and/or
electrically unstable
 Post-op Cardiac Surgery
 Class I
Syncope neurologic to
NICU, Neuro
Step-Down
 Not attributable to lifethreatening cardiac disease
 Class II
 Non-cardiac
syncope, i.e.
orthostatic
hypotension,
hypoglycemia
 Class II
 Not attributable to life-threatening
cardiac disease
 Cardiac etiology is being
pursued/possible cardiac etiology
 Recommend cardiac monitoring for
approximately 24 hours
 Class II
 With life-threatening
arrhythmia (VT or highdegree AV block)
 Class I
 Recommend cardiac
monitoring for 12 – 24 hours
 Cardiac etiology is
being pursued (OU
or Cardiac Tele)
 Class II
 Cardiac etiology is being pursued
(OU or Cardiac Tele)
 Class II
 Malignant arrhythmias
 Class I
 Hemodynamically stable AF/AFl
requiring rate control, drug loading to
convert, or new onset AF/AFl
 Hemodynamically unstable
SVT: unable to control
ventricular response,
hypotensive
 Class I
Palpitations
 Class II
Atrial
Fibrillation (AF)/
Flutter (AFl)
Supraventricular
Tachycardia
(SVT)
 Chronic or controlled
ventricular response AF
 AF NOT requiring IV drips
or drug loading
 SVT controlled by initial
therapy or not requiring
continuous IV therapy
 Class II
 SVT controlled by
initial therapy or not
requiring continuous
IV therapy
 Class II
 SVT not controlled by initial therapy
&/or requiring continuous IV therapy
 Class II
 Admit to 11W/CVT Surgery unit
Cardiac Surgery
LVAD
 Immediately post-op
 Hemodynamically/surgically
and/or electronically unstable
 Class I
 Admit to 11W/CVT Surgery unit
Follow-up Post
Transplant
Stable Post –
LVAD
Ventricular
Tachycardia
(VT)
 Transfer to cardiac
unit
 Hemodynamically stable/nonsustained VT (no acute ischemia
requiring workup &/or treatment)
 Class I
 Class I
8
 Sustained VT
 Class I
Table 2: continued
Cardiac Problem
Symptomatic
Bradycardia –
workup &
treatment
General Medicine Unit with
Telemetry/Surgical Telemetry
(Need reevaluated q.12 hrs)
Observation Unit Bed
(OU)
 Non-life threatening rate
without significant pauses
and NOT requiring
external/temporary
transvenous pacing
 Class II
Heart Failure and Cardiac Telemetry
Bed (medicine patient)
11 West/CVT Surgery
(Need reevaluated q.12hrs)
 Non-life threatening rate without
significant pauses and NOT requiring
external/temporary transvenous
pacing
 11W/CVT accepts pacing wires
 Class II
CCU Bed (medicine patient)
SICU/CTICU Bed
(surgical patient)
 Life-threatening AV block or
sinus arrest with hypotension
&/or requiring external or
temporary transvenous
pacing
 Class I
Antiarrhythmic
Drug Therapy –
loading/ changing
dose
 No IV infusions or drug
loading
 Transfer to Cardiac
Telemetry or 11W/CVT (if
surgical patient)
 Class I
 Transfer to cardiac
unit
 Class I
 Drugs requiring hospitalization for
initiation (e.g. QT monitoring during
drug loading)
 IV infusions: diltiazem; ibutilide with
MD present at bedside; amiodarone
for AF ONLY
 Class I
Elective
Cardioversion
 No elective cardioversion
 Transfer to Cardiac
Telemetry or 11W/CVT (if
surgical patient)
 Class I
 Transfer to cardiac
unit
 Class I
 Elective inpatient cardioversion
 Elective outpatient cardioversion
(ICR/CSU preferred)
 Class I
Post-Pacemaker
&/or ICD
Implant
 Transfer to Cardiac
Telemetry
 Post-op patient with new
device transfer to 11W/CVT
 Class I
 Transfer to cardiac
unit
 Class I
 Hemodynamically stable postprocedure
 Class I
 Unstable patient
(hypotensive or significant
decrease in Hgb)
 Class I
Acute
Decompensated
Heart Failure
 Hemodynamically stable
patient requiring IV diuretic
therapy
 NO IV nesiritide or inotropes
 Class II
 Hemodynamically stable patient w/
heart failure
 Requiring IV therapy (nesiritide or
dobutamine)
 Newly diagnosed (arrhythmia risk)
 LV dysfunction requiring aggressive
IV diuretic therapy
 Class II
 Hemodynamically unstable
&/or requiring PA line
 In pulmonary edema/
requiring greater than 50%
FiO2
 Class I
Significant
Hyperkalemia
 Potassium levels greater than
6.0 mEq/L without life
threatening EKG changes
 Class I until electrolytes
correct
 Potassium levels greater than 6.0
mEq/L without life threatening EKG
changes
 Class I
 Potassium levels greater than
6.0 mEq/L with EKG
changes
 Class I
Drug Toxicity
Drug Overdose
 Low probability for lifethreatening arrhythmia
 Without respiratory
depression (not requiring
continuous pulse oximetry)
 Consider telemetry for 24
hours and reevaluate*
 Low probability for life-threatening
arrhythmia
 Without respiratory depression (not
requiring continuous pulse
oximetry)*
 High probability for lifethreatening arrhythmia or
respiratory depression (CCU
or MICU)
 Class I
*Not Classified in
Document
 Low probability for
life-threatening
arrhythmia
 Without respiratory
depression*
 IV infusions: esmolol;
ibutilide; amiodarone for VT
 Class I
Drew B, Califf R, et al. Practice Standards for Electrocardiographic Monitoring in Hospital Settings. An American Heart Association
Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology and Cardiovascular Disease in the Young. (Circulation
2004;110:2721-2746) http:www.circulationaha.org
9
Table 3: Northwestern Memorial Hospital Alarm/Arrhythmia Notification
The telemetry monitoring technician calls the patient’s nurse for the following cardiac rhythm
abnormalities:
a. Ventricular heart rate less than 50 or greater than 120 or as determined by the
physician-ordered parameters for vital signs;
b. Greater than 6 premature ventricular contractions (PVC’s) per minute or as
determined by the physician-ordered parameters for vital signs;
c. Runs of ventricular tachycardia (defined as 3 or more PVCs in a row), ventricular
fibrillation or asystole;
d. Supraventricular tachycardia – new onset or change from previous rhythm (e.g., atrial
fibrillation, atrial flutter, paroxysmal supraventricular tachycardia, junctional
tachycardia);
e. Any other new cardiac rhythm – new onset or change from previous rhythm (e.g.,
sinus pause/arrest, AV heart block, pacemaker malfunction, widened QRS,
conversion from abnormal rhythm back to normal sinus rhythm/baseline rhythm);
f.
Mechanical or persistent artifact.
10
Table 4: Northwestern Memorial Hospital Cardiac Monitoring Evaluation Tool
11
Table 5: Course Content for Monitor Technician and Telemetry Nurse Training
Monitor Technician Training
 Online Basic Arrhythmia course (11 modules)
 Pre-Course Assignment Worksheet
 5-hour “live” class
o Rhythm strip interpretation & case studies
o Telemetry policy & procedures
o Nurse & MT roles/responsibilities
o Nurse & MT communication - SBAR
o Central telemetry & transport monitors
o Personal wellness – exercises/ergonomics
 Shadow-A-Nurse program
 Additional rhythm strip interpretation,
advanced arrhythmias
 MT Post-Test (> 85%)
 Simulated practice: telemetry procedures
 Simulated practice: arrhythmia monitoring and
documentation of rhythms
 Assisted as instructors in RN classes
12






Telemetry Nurse Training
Online Basic Arrhythmia course (4 modules)
Pre-Course Assignment Worksheet
4-hour “live” class:
o Rhythm strip interpretation & case
studies
o Arrhythmia management
o Telemetry policy & procedures
o Nurse & MT roles/responsibilities
o Central telemetry & transport monitors
Telemetry Nursing Post-Test (> 85%)
Additional study tools to maintain skills
Assignment of a “sister unit”