NR 721 Week 5 Workaround Case Study Example

Workaround Case Study: The Paper "Keep on Tele" List at the Monitor Desk, Written Step by Step and Priced Against the Route It Replaced

Student Name

College of Nursing, Chamberlain University

NR 721: Topics in Healthcare Systems Leadership II

Instructor Name

Month Day, Year

Workaround Case Study: The Paper "Keep on Tele" List at the Monitor Desk, Written Step by Step and Priced Against the Route It Replaced

The Workaround in One Sentence

On 5 West, a handwritten sheet stuck beside the monitor station, titled "keep on tele," lets nurses answer the 07:00 telemetry discontinuation reminder with the default "continue, provider preference" for any listed patient, without assessing the patient or contacting a provider.

The Second Version, in Steps

The workaround runs alongside the designed protocol and has its own steps, which no document records.

1. At the evening huddle, about 19:30, the night charge nurse asks each nurse whether any monitored patient should stay on telemetry, and writes those names on the list.

2. During the night, a hospitalist who wants a patient kept on monitoring sometimes tells the nurse or adds a name directly.

3. At 07:00, when the reminder fires, the nurse answering it walks to the monitor desk or calls the technician and asks whether the patient is on the list.

4. If the patient is listed, the nurse selects "continue, provider preference" in about five seconds.

5. Names are crossed off when a patient is discharged or transferred; otherwise they stay, sometimes for several days.

The list needs a sheet of paper, a pen, tape and the evening huddle. It takes the charge nurse about two minutes a night and the answering nurse about ten seconds a reminder. What it produces that the designed route does not is a way to honor a hospitalist's wish to keep a patient monitored without paging the hospitalist at 07:00, when the hospitalists are themselves in handoff.

How the List Began

The list is about eleven months old. Night nurses date it to November 2026, when two hospitalists complained at a medical staff meeting that nurses were removing telemetry from patients the hospitalists had wanted monitored, and one removal had been followed, an hour later, by a run of atrial fibrillation that a box would have caught. The removal had met the criteria and the arrhythmia caused no harm, but the episode left night nurses wary. A night charge nurse started the list as a courtesy to the hospitalists, so their wishes would be visible at 07:00. Within a month it had become the default route for any patient anyone was unsure about. Its origin matters: it was built to protect nurses and to respect physicians, not to avoid work.

What Staff Said About It

Five nurses and two monitor technicians described the list when asked. All of them knew it was not part of the protocol. Three nurses said it saved them from paging a hospitalist at the worst moment of the morning. Two said they used it for patients they were unsure about, "to be safe." Both technicians said the list was often out of date and that they crossed off names only when someone told them a patient had left. Nobody described it as a shortcut; everyone described it as a safety measure.

Pricing the Designed Route Too

The designed route, for a patient a provider wants kept on telemetry, is longer. The nurse assesses the patient against the criteria, about two to three minutes; finds the criteria met but the provider's wish unclear; pages the hospitalist and waits for a reply, which in September took a median of 18 minutes at 07:00 and often arrived mid-medication pass; then documents the reason given. For the 81 September reminders answered by the list, the designed route would have cost roughly 81 pages to hospitalists during their handoff and about four hours of nurse assessment and documentation time, plus the interruptions of 81 replies arriving during medication passes. Pricing only the workaround's shortcuts and not the designed route's burden would make the list look like laziness. It is not; it is a cheaper route to an answer the designed route makes expensive (Debono et al., 2013).

What the Shortcut Gives Up

Three things are lost. First, the assessment: the patient is not checked against the criteria at all. Second, the documented reason: "provider preference" says who wanted monitoring, not why, so no one can later tell whether the indication still held. Third, expiry: names stay on the list until someone crosses them off. To test what this costs, the manager reviewed 46 patient-days in September on which a listed patient's reminder was answered with the default. On 19 of the 46, 41%, the patient met the protocol's criteria for stopping and the chart held no reason a provider had given for continuing. The national monitoring standards treat telemetry beyond its indication as overuse that adds alarm burden without benefit (Sandau et al., 2017).

Ward Currency

Table 1

Designed Route and Workaround Compared for a Patient a Provider Wants Kept on Telemetry

Note. Note. Times from observation in September 2027; page reply time from the paging system log.

Three Possible Endings

The unit could forbid the list. That is the simplest ending and probably the least durable: the pressure that produced the list, pages at 07:00 and interruptions mid-medication pass, would remain, and a new informal route would likely appear.

The unit could formalize the list. A hospitalist who wants a patient kept on telemetry past 48 hours would enter a short order, "continue telemetry," with a required reason and a 24-hour expiry. The reminder would then show that order and its reason, and the nurse would neither page nor guess. This keeps what the list does well, letting a provider's wish travel without a page, and restores the reason and the expiry it lost.

The unit could redesign the moment that created the list. Moving the reminder from 07:00 to 10:00 would place it after handoff, after the medication pass and after hospitalists have started rounds, when a question can be asked in person.

The recommendation is to formalize and redesign together, and to remove the paper list only once both are in place, so that staff are never left without a route. Removing a practice works best when something fills the space it leaves (Norton & Chambers, 2020).

References

Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J. C., Black, D., Johnson, J., & Braithwaite, J. (2013). Nurses' workarounds in acute healthcare settings: A scoping review. BMC Health Services Research, 13, Article 175. https://doi.org/10.1186/1472-6963-13-175

Norton, W. E., & Chambers, D. A. (2020). Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Science, 15, Article 2. https://doi.org/10.1186/s13012-019-0960-9

Sandau, K. E., Funk, M., Auerbach, A., Barsness, G. W., Blum, K., Cvach, M., Lampert, R., May, J. L., McDaniel, G. M., Perez, M. V., Sendelbach, S., Sommargren, C. E., & Wang, P. J. (2017). Update to practice standards for electrocardiographic monitoring in hospital settings: A scientific statement from the American Heart Association. Circulation, 136(19), e273-e344. https://doi.org/10.1161/CIR.0000000000000527