Spent Telemetry Batteries Cited in Flatline

By Walter F. Roche Jr.


Telemetry failures due to spent batteries and the failure of staff to monitor equipment have been cited in two recent cases at the same Philadelphia area hospital where one patient was found pulseless and another coded.
In a 17-page report, Pennsylvania Health Department surveyors found that staff at the Crozer-Chester Medical Center in Chester, PA. failed to monitor alarms showing whether cardiac monitors were functioning. properly.
As a result monitors for two patients failed to operate for as long as an hour and forty five minutes before staffers responded.
In the first case a nurse noted that on reporting for her shift on Aug. 16 at 11:45 p.m. she went to print a patient's cardiac monitor strip and found the monitor displaying the message "Replace Battery."
When she went to that patient's room the patient "was noted to have no pulse and no resp."
The monitoring strip showed a flatline (no cardiac tracing) from 9:43 p.m. to 10:45 p.m. when the patient was found pulseless."
The report concludes staffers did not respond to the "Replace Battery" message at either the nursing station or hallway telemetry. As a result the alarm was not functioning for 62 minutes.
The inspectors, who conducted a review of hospital records from Oct. 12 to Oct. 24, of hospital records, determined that no staffer was specifically assigned to watch telemetry monitors at the nursing station on all four telemetry units."
In addition, though the batteries were supposed to be changed every eight hours, no specific person was assigned that task.
The inspectors also learned that the hospital had switched battery suppliers in June and nurses had noted that the new batteries sometimes didn't last the expected eight hours.
In the second case, which came just two days after the first, the report states that the telemetry unit in question had "no cardiac tracing for one hour and 45 minutes prior to the patient's code due to a dead battery."
"Further interviews confirmed that (Patient 1 and Patient 2) patients' rights to care in a safe setting were not met," the report states.
Noting that none of the nurses were equipped with telemetry linked phones, the report concludes, "All of these factors led to an unsafe setting."
Asked to respond to the report a spokesman said that the hospital itself had reported the incidents to the state but he did not respond to questions about the outcome for the two patients.
"As part of our ongoing quality control efforts, we identified a possible issue with our telemetry monitoring process and self-reported it to the Pennsylvania Department of Health," spokesman Andrew Bastin wrote in an e-mail response to questions.
He added that the hospital worked with state health officials to develop an acceptable plan of correction and that the plan finally implemented went beyond the department's recommendations. He said the change in battery brands was due to a change of vendors.
"There was no meaningful difference in the cost of the new batteries," the email stated.
According to the statement, additional staff have been hired to monitor all telemetry operations and a central telemetry monitoring system was established at the Crozer-Chester Medical Center.
According to the plan of correction, logs will also be kept to ensure that the required monitoring is taking place.
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