NR 721 Week 7 Continue or Stop Recommendation Example

Recommendation: Continue the Telemetry Discontinuation Protocol on 5 West in an Altered Form From 1 December 2027, With Four Named Changes and One Thing Removed

Student Name

College of Nursing, Chamberlain University

NR 721: Topics in Healthcare Systems Leadership II

Instructor Name

Month Day, Year

Recommendation: Continue the Telemetry Discontinuation Protocol on 5 West in an Altered Form From 1 December 2027, With Four Named Changes and One Thing Removed

The Position

Continue the nurse-driven telemetry discontinuation protocol on 5 West, altered in four specific ways from 1 December 2027, and remove the informal "keep on tele" list on the same date. Do not stop the protocol, and do not continue it unchanged.

The Evidence, Compressed

Over its first year the protocol cut telemetry use from 41 to 31 days per 100 patient-days, about 1,235 telemetry days, and central station alarms from 1,190 to 940 a day, with no harm found in reviews of three rapid response calls after removals. It also cost about $30,550 in lost transmitters, a cost nobody had foreseen, and its gain fell short of the 25 per 100 promised. The review of current practice found the core assessment done in a little over half of reminders, a 07:00 reminder that fires during handoff, a paper list that bypasses assessment for listed patients and a nurse-added call to the monitor technician that improves the protocol. On days the telemetry champion works, the default answer is used far less often. The national monitoring standards the protocol was built on remain current (Sandau et al., 2017).

The Four Alterations

First, the reminder moves from 07:00 to 10:00, after handoff, the medication pass and the start of hospitalist rounds, so the nurse answering it has seen the patient and can ask a provider in person.

Second, a "continue telemetry" order replaces the paper list. A provider who wants a patient monitored beyond the criteria enters it, stating why, and it lapses after 24 hours, and the reminder displays it. The default answer "continue, provider preference" is removed from the reminder.

Third, transmitter return becomes part of removal: a return bin at the nurses' station, a required checkbox in the removal note and a line on the discharge checklist, all being installed this month.

Fourth, the nurses' own addition, phoning the technician before a box comes off, is written into the protocol.

Stopping Is a Piece of Work

Removing the paper list is not a matter of taking it down. On 1 December, the night charge nurse will take the list down as the shift opens, after the continuation order has been live in the record for a week, so no patient is left without a route. The original laminated criteria cards, which still describe the 07:00 time and the default answer, will be collected from all six charging stations and replaced by new cards placed in each bedside telemetry pouch. The reminder's old answer option will be switched off by the record team on the same date. The protocol document will be reissued with a version number and date. Each of these has a named person, listed in the communication that follows this recommendation, because a removal nobody performs leaves the old practice in place beside the new one (Norton & Chambers, 2020).

Something Fills the Gap

The paper list existed because hospitalists' wishes had no route at 07:00. The continuation order gives them one, with a reason and an expiry, and the 10:00 reminder places the decision when a conversation is possible. Removing the list without these would invite a new informal route within weeks.

The Option Rejected, Argued Fairly

The strongest alternative is to stop the protocol and return telemetry discontinuation to providers. The case for it is real. The unit has spent about $30,550 on lost transmitters. Hospitalists remain uneasy, and one episode of atrial fibrillation an hour after a removal still shapes how night nurses feel about the protocol. The gain is smaller than promised, and much of it depends on one champion's daily question. Returning the decision to providers would end the reminder, the list and the lost boxes in one move.

It is rejected because it would also give back most of the gain, more than a thousand telemetry days a year and a quarter of the central station's alarms, and return the unit to a practice in which monitoring outlasted its indication by days. The costs that make stopping attractive come from a missing step and a badly timed reminder, both of which can be fixed, not from the protocol's logic. A hospital that wrote the standards into the order itself achieved a larger fall than 5 West has (Dressler et al., 2014), which suggests the unit's problem is too little structure, not too much nurse authority.

The Other Option Rejected: Continue Unchanged

Continuing as the protocol now runs has its own case: it is working in part, the transmitter fix is already under way and changing the reminder time and the answer options asks the record team for work in its busiest quarter. But the review showed that unchanged practice is drifting further, not holding steady. The default answer rose from 14% of reminders in the protocol's second month to 40.7% a year later, and drift of that kind tends to continue in the direction it is already moving. Leaving the 07:00 time and the default option in place would let the protocol slowly turn back into the practice it replaced, with a reminder that everyone clicks through.

Who Does What Before 1 December

The record team moves the reminder, removes the default option and builds the continuation order by 24 November. Clinical engineering installs the return bin by 1 November. The medical director for hospital medicine tells hospitalists about the continuation order at the November staff meeting. The unit educator prepares the new pouch cards. The nurse manager reissues the protocol document and owns the June review.

A Date, Not a Watch

The altered protocol takes effect on 1 December 2027. It will be reviewed on 1 June 2028 against three figures: telemetry days at or below 28 per 100 patient-days, transmitter losses at two or fewer a quarter and at least 80% of reminders answered with an assessment or an active continuation order. The champion's daily question becomes a duty of every day charge nurse, so the protocol no longer depends on one person's schedule.

The Default

If the June review does not take place or reaches no decision, the altered protocol continues, and the continuation order keeps its 24-hour expiry. The default protects the gain without letting any patient's monitoring continue indefinitely by inertia.

References

Dressler, R., Dryer, M. M., Coletti, C., Mahoney, D., & Doorey, A. J. (2014). Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Internal Medicine, 174(11), 1852-1854. https://doi.org/10.1001/jamainternmed.2014.4491

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