Remote telemetry and graham crackers: U-M nurses describe cuts to patient care
Megan Duncan, a cardiology nurse at the University of Michigan Hospital, began filing reports with her superiors detailing concerns with the hospital’s new remote heartbeat monitoring program in Summer 2017. She was met with little-to-no response from the Michigan Medicine administration.
Beginning in July 2017, Michigan Medicine moved almost all cardiology patients — outside of the intensive care unit — to a remote heart rate monitoring system, referred to as remote telemetry, that largely replaced licensed nurses with technicians. Before then, almost all hospital patients with heart monitors had their heart rates monitored by live nurses; outside of eight patients linked to a limited remote screening program monitored by a single nurse.
As soon as Michigan Medicine remote telemetry was rolled out in scale, Duncan and other nurses in her unit began experiencing issues with the technicians.
“Sometimes I found myself having to educate (the technicians) when they didn’t report an incident in time or didn’t report it at all,” Duncan said. “We noticed lags. Sometimes a heart rhythm would change and they would never call or call much later. Often, they didn’t know what it was, which was alarming. They’re supposed to be trained.”
Duncan explained technicians are stationed in the basement of their respective unit to watch the heart monitors and report back to the nurses when changes occur; she added there were no sentinel events in her unit, but there was still concern about harm coming to the patients.
Technicians within the remote telemetry unit typically monitor 40 patients at a time and are allowed to monitor up to 64 patients, according to Duncan, a stark contrast to the personalized attention nurses could offer patients when they were only able to see three at a time. Before the hospital began employing the technicians, only eight of the unit’s patients were monitored remotely by a single nurse in the cardiology unit basement for the cardiology unit, while all the other patients with heart monitors had in-person monitoring by nurses.
While the technicians work in the basement, technicians and nurses within the hospital do not interact personally. Duncan explained the only contact the nurses within her unit had with the technicians was over the phone. The lack of contact within the cardiology unit resulted in hostility between the two groups.
“I think the technicians thought we didn’t trust them after we started filing incident reports,” Duncan said.
Many nurses such as Duncan believe the hospital’s implementation of remote telemetry with technicians reflects a devaluation of nurses under a management culture at Michigan Medicine that has become increasingly profit-driven at the expense of staff and patients. Ian Robinson, the president of the Huron Valley Area Labor Federation — who was involved in the recent nurses’ strike — said he has seen a drastic shift at Michigan Medicine toward a corporate mindset.
“It’s a new model that is taking place at the University,” Robinson said. “It is a model that has moved from focusing on the interests of the public to profit.”
In an email statement, Michigan Medicine senior communications representative Beata Mostafavi said the hospital’s new remote telemetry practices were intended to improve patient care by enabling immediate, continuous monitoring and by facilitating greater collaboration across hospital staff.
“Remote telemetry provides real-time monitoring of patients who are at risk for cardiac events, significantly improving the ability to observe and monitor hospitalized patients’ hearts around-the-clock,” Mostafavi wrote. “A skilled, highly trained team of registered nurses, cardiac technicians and other Michigan Medicine staff monitor patients in every unit that has cardiac monitoring. These teams collaborate to interpret patient cardiac rhythms and identify patients who require clinical attention, which helps improve patient care and outcomes.”
Despite Michigan Medicine’s claims, Duncan fears the practice has actually created a barrier for communication at the hospital and the lapses of communication that seem to accompany the practice could negatively impact patients’ health.
“Overall, we feel that remote telemetry is a barrier to interdisciplinary communication, and can result in delay of care; both of which can result in negative outcomes for the patients and family,” Duncan wrote.
Though the University invested a significant amount of money in the change — it remodeled a level of the basement and purchased new monitors — Duncan believes this was part of a long-term strategy by Michigan Medicine to cut costs by reducing the number of nurses needed, at the expense of patient care.
“Remote telemetry isn’t a cutback issue,” she said. “They spent a significant amount of money on it, but in the long run it’s speculated they invested in remote telemetry in order to possibly down-staff nursing in the future. If they don’t need a nurse to monitor a patient’s heart and a technician can monitor more hearts at once then they can staff less nurses.”
While staffing has been a key issue in the 100 days of bargaining leading to the University of Michigan Professional Nurse Council’s tentative contract agreement with Michigan Medicine, nurses also cite cutbacks Michigan Medicine has made in other aspects of patient care.
Allison Carroll, a nurse in the pediatric hematology and oncology unit at C.S. Mott Children’s Hospital, said budget cuts inhibit her role as a caregiver to her patients.
“As nurses, we feel devalued,” Carroll said. “We really aren’t asking for anything we didn’t have before.”
Carroll explained the hospital used to keep graham crackers on her floor for diabetic patients or patients undergoing chemotherapy who struggle to find their appetite, but the budget cuts have eliminated important amenities like this.
“We can order them through food services but it can take up to an hour, and by then the patient undergoing chemotherapy might have lost their appetite,” Carroll said. “It sounds insignificant but patients in the oncology unit struggle to keep down food.”
Similarly, Lynn Detloff, a nurse within the Brandon Newborn Intensive Care unit at Mott Children’s Hospital, said Michigan Medicine’s cutbacks on programs designed to support nurses in providing personal care to patients have negatively impacted her role as a caregiver.
Detloff explained the hospital has significantly cut back on bereavement trays — trays of food that are brought to families following the loss of a loved one.
“If there was a death in our unit or any other unit, we would set them up for the family so they wouldn’t have to leave the bedside,” Detloff, the chair of the bereavement tray committee in her unit, said.
Until a cutback on bereavement trays in May 2018, nurses could provide food to up to 15 family members per patient. Bereavement trays included anything from bagels, cereal, pastries, oatmeal or yogurt and juice for breakfast or an array of sandwiches and cookies. Now, the nurses are limited to offering 8 trays with a limited menu of a blueberry muffin and orange juice for breakfast or a granola bar and a piece of fruit. Michigan Medicine did not respond to a question about how much these bereavement trays cost, or how much was saved in cutting the choice of food.
“The bereavement trays are just one of the things we do in the hospital to show empathy for families going through a difficult time,” Detloff said. “(Michigan Medicine) has a surplus of $103 million for the 2018 budget. It seems heartless for them to cut back on bereavement trays when it is our job to care for families.”
Bereavement trays are not the only patient care item Michigan Medicine has dropped from their budget.
Carroll explained the hospital also eliminated meal passes, certificates given to family members of patients, typically patients who had been in the hospital for a long period of time.
“Social workers would give the vouchers to families because they know what families will be there for a while,” Carroll said. “It was a way to look out for families of extremely sick patients and help cut down on their personal expenses.”
Ultimately, Detloff said the hospital has made it more difficult for nurses to provide genuine, personalized care. Ironically, when Michigan Medicine launched its Victors Care concierge care service in Spring 2018 — which offered more personalized medical attention for patients willing to pay a costly membership view — it drew criticism from many hospital staff for being elitist and exclusionary.
“Michigan Medicine puts nurses at a disadvantage when they take away things like meal passes,” Detloff said. “We want to take care of them. We want to comfort the crying child, offer to send them down for food or give them something, but we can’t. We want to buy them food with our own money but we’d get in trouble for that too.”
While Detloff and Carroll explained cutbacks by Michigan Medicine have made it more difficult to care for their patients both physically and emotionally, Duncan said the nurses in her unit fear for their patients’ health and feel obligated to hold the hospital accountable. As a result, these nurses took a stand against the practice of having technicians conduct remote telemetry.
According to Duncan, when she and other nurses expressed their fears of patients’ heart arrhythmias going unnoticed by the technicians, they were told by their managers to write up incident reports detailing their safety concerns. The nurses documented the lapses in the technicians’ responses to irregular heart rhythms with forms called Assignment Despite Objection. ADOs allow the nurses to notify management of a potential issue that could be detrimental to patients as well as maintain documentation for their own job safety.
“It was really alarming for all of us once (remote telemetry with technicians) started that this was happening,” Duncan said. “We would print a copy of the rhythm strip, go back through the monitor and find the event, print it and attach it to an incident report. We must have filed dozens over the course of months.”
Due to the strong response from nurses within Duncan’s unit, 7C, Michigan Medicine temporarily suspended the practice of remote telemetry in Fall 2017, but only from 7C. The hospital maintained the practice throughout the hospital and in other cardiology units like 7B. The practice was reinstated in Duncan’s unit in January 2018.
After that reinstatement, nurses began filling reports on the same issues again, to which they received no response from the hospital once more.
In May 2018, the nurses within 7C took a new approach. They sent in ADOs to the union representing the 6,000 registered nurses in University of Michigan Hospitals — the UMPNC — instead of solely to Michigan Medicine. This escalation began to bear fruit.
“We noticed once we got the union involved that’s when (Michigan Medicine) began to listen to us,” Duncan said.
As a result of the 7C nurses’ reports and the union’s support, the hospital relented and remote telemetry was removed from 7C in July 2018. However, the practice was not removed from any other units within the hospital, including the 7B cardiology units.
“Remote telemetry was implemented in other units in the hospital and is still used today,” Duncan continued. “It’s just an example of the squeaky wheel getting the oil because other units haven’t filed reports.”
When remote telemetry with technicians was first implemented at Michigan Medicine in July 2017, it was used across the hospital — not just for monitoring patients within the cardiology unit.
Duncan explained remote telemetry is not used on every patient because not every patient within the hospital needs to have his or her heart monitored, but many patients outside the cardiology unit are monitored for potential complications — now through remote telemetry.
“An example of a patient on a general care unit that may require cardiac monitoring could possibly be someone who came into the hospital for knee surgery but is having complications from the surgery that may result in dehydration and electrolyte imbalances which can cause heart arrhythmias (an abnormal rhythm) or maybe that patient who just had knee surgery has a history of some irregular heart rhythm so the doctors might want to monitor their heart more closely while they recover from that surgery,” Duncan wrote.
As far as Duncan knows, her unit was the only unit within the hospital to file incident reports detailing the negative effects of remote telemetry.
Duncan owes her unit’s prompt response to the faulty practice to the remaining monitors in her unit. When remote telemetry was implemented, other units in the hospital lost their heart monitors. Their only source of information on a patient’s heart rhythm was through the technicians.
Therefore, other units would not be able to see any lapses in the reports from the technicians. The failure to address heart arrhythmias could lead to other medical complications, Duncan explained. If a nurse is never informed of the heart arrhythmia or is not informed in a timely manner, the nurse has no way of reacting appropriately to the arrhythmia, nor of correlating the abnormal heart rhythm to its corresponding complication.
While Detloff, Carroll, Duncan and 6,000 other UMPNC nurses continue to detail other cutbacks by Michigan Medicine such as the elimination of parking passes for families and cutting the patient sitter budget in half, the three nurses agree they will continue to fight for safer staffing, a better contract and the importance of thoughtful patient care.
“It started out with taking away graham crackers,” Detloff said. “Now it’s meal tickets and bereavement trays. What are they going to cut next?”