Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Telemetry Monitoring Issues 

VA Eastern Colorado Health Care System 

Denver, Colorado 

Report No. 09-01047-69 January 21, 2010

VA Office of Inspector General 

Washington, DC 20420 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General i 

Executive Summary 

The purpose of this review was to determine the validity of allegations regarding 

inadequate telemetry heart monitoring practices and lack of staff training that related to 

two patient deaths at the VA Eastern Colorado Health Care System (the system), Denver, 

Colorado. The complainant specifically alleged that despite notifying system 

management of concerns regarding the telemetry program, including incompetency and 

lack of training of telemetry staff, no action was taken to improve processes until patient 

deaths occurred. Our report addresses the complainant’s allegations regarding processes 

at the time of the patients’ deaths. 

We concluded that both patients had multiple medical problems that contributed to their 

deaths, and it would be difficult to determine whether delays in response to abnormal 

cardiac rhythms led to their demise. We did not substantiate the allegation that the deaths 

were a result of inadequate telemetry monitoring or lack of staff training. However, 

delays in notification of abnormal cardiac rhythms and in physical assessment could 

make a difference for other patients. 

We substantiated the allegation that management had been informed of problems with the 

telemetry program prior to the death of the first patient. Memorandums and electronic 

messages, dated as early as July 2007, demonstrate that concerns were brought forward to 

nursing management. While nursing management acknowledged suggestions made in 

the messages they received, there was no clear course of action assigned to address 

concerns raised in these messages. 

We substantiated the allegation that there were competency and training issues with 

medical support assistants and registered nurses assigned to telemetry prior to the death 

of the first patient. Although telemetry staff had initial telemetry training, there was no 

formal process to assess ongoing competency until after the Root Cause Analysis (RCA) 

was conducted following the death of the first patient. Medical support assistants that 

performed telemetry monitoring did not have appropriate clinical supervision. 

At the time of our site visit, the system was in the process of implementing changes based 

on recommendations from the RCAs they had conducted regarding the two patients. 

Temporary measures were enacted to ensure safe patient care following the first patient’s 

death. The VISN had been actively involved in monitoring the system’s progress in 

implementing changes following their receipt of the first RCA report. 

The VISN and System Directors concurred with our recommendations to evaluate the 

telemetry program in its entirety, require that all staff complete competency assessments 

for their specific positions and that training be provided as needed to maintain 

competency, and that there be clinical oversight of medical support assistants. 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, VA Rocky Mountain Network (10N19) 

SUBJECT: Healthcare Inspection – Telemetry Monitoring Issues, VA Eastern 

Colorado Health Care System, Denver, Colorado 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections conducted 

an inspection to determine the validity of allegations regarding inadequate telemetry heart 

monitoring practices and lack of staff training that related to two patient deaths at the VA 

Eastern Colorado Health Care System (the system), Denver, Colorado. 

Background 

The system is in the VA Rocky Mountain Network – Veterans Integrated Service 

Network (VISN) 19. The system provides comprehensive healthcare through primary 

care, tertiary care, and long-term care in the areas of medicine, surgery, psychiatry, 

physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics, and 

extended care. It is affiliated with the medical, pharmacy, and nursing schools of the 

University of Colorado Health Sciences Center. Residency programs are maintained in 

internal medicine, surgery, psychiatry, neurology, physical medicine and rehabilitation, 

anesthesia, pathology, radiology, and dentistry. 

The OIG Hotline Division received a complaint that there have been two patient deaths 

related to the inadequacy of telemetry heart monitoring at the system. The complainant 

specifically alleged that despite notifying system management of concerns regarding the 

telemetry program, including incompetency and lack of training of telemetry staff, no 

action was taken to improve processes until patient deaths occurred. The system 

conducted Root Cause Analyses (RCAs) following the patient deaths and at the time of 

our site visit, was in the process of implementing changes based on the RCA 

recommendations. This report addresses the complainant’s allegations regarding 

processes at the time of the patients’ deaths and prior to the RCAs. 

The centralized telemetry monitoring station was located in the medical intensive care 

unit (MICU). The actual telemetry beds were located on two units remotely located from 

VA Office of Inspector General 1 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

the monitoring station. Twelve telemetry beds were located on an acute care medical unit 

(in the process of expanding to 16 beds) and 4 telemetry beds were located on a surgical 

unit. When the medical center changed their organizational structure from traditional 

services to service lines in the late 1990s, ward clerks received training that consisted of a 

3-day electrocardiogram (EKG) class. Upon passing the required test at the end of the 

class, these ward clerks were reclassified from General Schedule (GS) grade 5 to medical 

support assistants (MSAs) at a GS grade 6. In addition to ward clerk duties such as 

answering telephones, timekeeping, maintaining medical records, ordering supplies, and 

responding to patients and family members, each qualified MSA served as a telemetry 

technician. Any newly hired MSA also completed the EKG training and test. Telemetry 

technicians maintained surveillance of the central monitoring station at all times. There 

is a ceiling for 28 full-time MSAs with a current staff of 25, including 2 light duty 

registered nurses (RNs). Two lead MSAs, who report to an administrative supervisor 

program specialist, provide direct supervision. The MSA positions are organizationally 

structured under the Associate Director for Patient Care Services (ADPS), who is a RN. 

According to local policy, MSAs are responsible for registering patients into the main 

telemetry monitoring system and continuously monitoring the patient’s cardiac rhythm. 

They are to ensure that parameter alarms are on when the patient is monitored and set the 

ordered alarm rates. If there are significant rate changes, they are responsible for 

notifying a RN on the unit where the patient is located. There are telephones located on 

the medical and surgical unit that are only used for communication from the central 

telemetry monitoring station. The charge RNs on the units are also required to carry 

digital pagers. 

RNs on the two units are responsible for routine patient care for telemetry patients, as 

well as other medical/surgical patients located there. Their telemetry responsibilities 

include: placing cardiac leads on patients; notifying telemetry MSAs if patients are 

discontinued from monitoring for any period of time; giving reports to the telemetry 

MSAs on all new telemetry patients; verifying rhythms and taking appropriate actions; 

and entering progress notes every shift, at the times of any rhythm changes, and upon 

discontinuation of telemetry monitoring. 

Scope and Methodology 

We interviewed the complainant by telephone to obtain clarification of the allegations 

prior to our site visit. We conducted a site visit at the system February 17–18, 2009, and 

interviewed system management, MSAs, supervisors, quality management, and other 

staff. We reviewed policies, procedures, training records, directives, electronic messages, 

quality management documents, and medical records. The clinical case reviews in this 

report are abbreviated and limited to telemetry events. System physicians addressed 

specific clinical issues identified through peer reviews, and RCAs were conducted for 

both patient deaths. 

VA Office of Inspector General 2 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 3 

We conducted the review in accordance with Quality Standards for Inspections published 

by the President’s Council on Integrity and Efficiency.

Inspection Results 

Clinical Case Reviews 

Patient 1

The patient was a male in his seventies with a history of a liver transplant in 1990, a 

kidney transplant in 2003, and a major stroke with resulting partial paralysis in late April 

2008. He was transferred to the system from a private hospital the first week in May, for 

ongoing treatment related to his stroke. On admission to the medical unit, physicians 

placed the patient on telemetry to monitor for arrhythmias, specifically atrial fibrillation.1

 

Physicians wrote orders to notify them if the patient’s heart rate was less than 60 beats 

per minute. Over the next few days, the patient’s heart rate ranged from 60-90 in a 

normal sinus rhythm or atrial fibrillation. The patient had complications related to his 

stroke that required blood thinning medications for treatment. On hospital day 5, a 

physician’s order changed the telemetry monitoring parameters to notify the physician for 

a heart rate of 50 or lower. 

On hospital day 6, a nursing note documents that the patient was in atrial flutter2

 and an 

EKG was completed. The physician noted that the patient had been in and out of atrial 

fibrillation and ordered continued telemetry monitoring. 

On hospital day 7 at 7:07 a.m., the patient had a low heart rate of 49. A telemetry MSA 

called the medical unit to inform a RN of the low rate, but according to notes from the 

MSA, no one answered the telephone. At 7:08 a.m., the patient’s heart rate had 

decreased to 24 and was still dropping. The MSA again called the medical unit and 

informed the medical unit MSA who answered the telephone that the patient was having 

bradycardia.3

 The RN assigned to care for the patient was not in the immediate area so 

the unit MSA went to find the RN and inform her of the change in heart rate. By 7:10 

a.m. the patient’s heart rate was less than 20 when the telemetry MSA called the medical 

unit again and spoke with an RN who answered the telephone. According to progress 

notes, the RN immediately sent a licensed vocational nurse (LVN) to assess the patient. 

Progress notes document that a cardiac arrest code was called after the LVN assessed the 

patient. Telemetry monitoring strips document that at 7:13 a.m. the patient’s heart did 

not show any electrical activity and resuscitation was initiated at that time. Following 

 

1

 Atrial fibrillation is an irregular heart rate that can cause inadequate blood circulation in the heart, resulting in 

pooling of blood and eventual clots that can lead to stroke. 

2

 Atrial flutter is an abnormal heart rate (arrhythmia) similar to atrial fibrillation that occurs when electrical impulses 

take an abnormal path through the upper chambers of the heart. 

3

 Bradycardia is an abnormally slow heart rate, normally defined as less than 60 beats per minute. 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 4 

resuscitation efforts, a pulse and blood pressure were obtained and the patient was 

transferred to the MICU but was non-responsive and on mechanical ventilation. The 

patient had to be resuscitated a second time in the MICU. Physicians consulted with the 

family and the patient was removed from mechanical ventilation at 1:52 p.m. and 

pronounced dead at 1:57 p.m. There was no autopsy, but the cause of death was 

determined to be most likely from a retroperitoneal bleed.4

 

 Patient 2

 

The patient was a male in his sixties admitted from the Emergency Department in the 

first week of January 2009, for shortness of breath, lower extremity swelling, recent 10 

pound weight gain and reduced urine output. He had multiple medical problems that 

included coronary artery disease with bypass surgery in 1998, aortic stenosis, mitral 

regurgitation, chronic atrial fibrillation, lung disease, acute renal failure, chronic renal 

insufficiency, and diabetes mellitus. For the fist 4 days of hospitalization his clinical 

treatment focused on diuresis and electrolyte management. Both nephrology and 

cardiology services were consulted regarding the patient’s treatment. 

 

The patient had complained of nausea and vomiting for several days and had irregular 

heart rhythms that were noted on daily telemetry monitoring strips. On hospital day 7 at 

8:35 p.m., the telemetry MSA noted a 6-beat run of ventricular tachycardia and called the 

unit RN. After speaking with the MSA, the unit RN attempted to page the medical 

resident. At 8:42 p.m., notes written on the telemetry monitoring strip state that the 

telemetry MSA contacted the medical unit RN of additional episodes of irregular wide 

complex rhythms. At 8:43 p.m., telemetry monitoring strips further note that the patient 

had continued runs of ventricular tachycardia and attempts were made to call the medical 

unit but no one answered the telephone. The medical unit RN documented that she spoke 

with the medical resident on the hallway telephone and reported the arrhythmia at 8:55 

p.m. The resident told the RN he wanted to see the telemetry monitoring strips and 

would be on the unit shortly, after completing other patient admissions. At 9:03 p.m., a 

cardiac arrest code was called. Attempts to resuscitate the patient failed, and he was 

pronounced dead at 9:35 p.m. An autopsy was conducted and noted the cause of death as 

acute myocardial infarction5

 that occurred approximately 6–8 hours before death. 

Issue 1: Deaths Related to Telemetry Monitoring Practices 

We did not substantiate that the two patient deaths were a result of inadequate telemetry 

monitoring or lack of telemetry staff training. Both of these cases were reviewed through 

the system’s peer review processes and management took appropriate actions as needed. 

 

4

 The retroperitoneum is the space in the abdominal cavity behind the peritoneum, which is the lining of the 

abdominal cavity. 

5

 Heart attack. 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 5 

Consistent with training and per protocol, the telemetry MSA called the medical unit to 

report bradycardia for Patient 1. There were reports that two RNs were available to 

answer the dedicated telephone when it was ringing to notify staff of Patient 1’s 

bradycardia but they waited for the unit MSA to answer the telephone. The unit MSA 

then had to go find the patient’s RN to assess his condition. Although local policy 

requires that a RN assess a patient’s condition, the RN sent either a LVN or nursing 

assistant (reports vary as to who actually went into the room) to check on the patient. 

For Patient 2, the telemetry MSA called the unit per protocol to report the ventricular 

tachycardia and a RN answered the telephone. According to system managers, while this 

RN was paging the physician, a second RN was at the bedside assessing and attending to 

the patient. The second RN was experienced in critical care and had Advanced Cardiac 

Life Support (ACLS) certification. 

The resident physician was questioned about the 20 minute delay to see Patient 2 after the 

RN called him. He stated that he remembered being told about the patient’s nausea and 

vomiting but he did not remember being told about non-sustained ventricular 

tachycardia.6

 

We asked the Chief of Medicine if he was aware of any complaints from cardiology 

physicians regarding the quality of telemetry MSAs or nursing staff. He stated nothing 

had been brought to his attention but that the highest risk patients were routinely admitted 

to the ICUs. While our review of the deaths raised serious concerns about deficiencies in 

the telemetry program, it is unlikely that these deaths were the result of a delay in 

response to arrhythmias. Although the patients’ outcomes might not have changed, 

delays in notification of abnormal cardiac rhythms and in physical assessment could 

make a difference for other patients. 

Issue 2: Attempts to Notify Management of Telemetry Concerns 

We substantiated that management had been informed of problems with the telemetry 

program. Memorandums and electronic messages, dated as early as July 2007, 

demonstrate that concerns were brought forward to nursing management. 

Emails document that in 2007 issues were reported to nursing management related to 

adherence to telemetry policies and procedures and the need to update procedures. 

Concerns were raised regarding communication from the MSAs at the telemetry 

monitoring station to the unit nursing staff. It was reported that unit nursing staff did not 

respond in a timely manner to the dedicated telephone when telemetry MSAs called to 

communicate potential problems. If the RNs were not in the nurses’ station where the 

dedicated telephone was located, there was no direct communication for the telemetry 

MSA to contact them. Although local policy requires the unit charge RNs to carry 

 

6

 Ventricular tachycardia is an arrhythmia with three or more beats in succession that originate in the lower 

chambers of the heart. It can potentially be life-threatening. 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

pagers, they did not know they were supposed to and did not know where the pagers were 

located. In response to the July 2007 emails, management notified nurse managers via 

email that the unit charge RNs must carry the telemetry pager at all times, per local 

policy. The medical unit is generally an active and very busy unit. If RNs are caring for 

other patients, they are not available to answer the unit telephones or return pages. A 

paging system requires the RN to go to a telephone to call the telemetry MSA rather than 

a true immediate two-way communication system. For this reason, the email messages 

had recommended cell phones for the RNs but this mode of communication was not 

adopted. 

Another concern the complainant raised was related to the actual telemetry equipment. 

Although there was a secondary monitor viewing station on the units, there was no ability 

to print out rhythm strips for the RNs to review. The telemetry MSAs could print strips 

and provide them to the RNs but were located at a significant distance from the units. 

Additional concerns were raised regarding incorrect cardiac rhythm interpretation by 

telemetry MSAs and the unit RNs and the need for training (discussed in Issue 3 of this 

report). Since there was no printing capability for rhythm strips, nursing staff were 

unable to perform measured interpretations and the opportunity to learn from other staff 

and supervisors was lost. 

While nursing management acknowledged suggestions made in the 2007 messages they 

received from a light duty RN assigned as Telemetry/Clinical/Administrative Support, 

there was no clear course of action or assigned responsibility to address concerns raised 

in these messages. The day after the death of Patient 1, a memorandum/safety report was 

submitted through email to nursing management that noted concerns about 

communication between the centralized telemetry monitoring station and the medical 

unit. Nursing management followed the advice of the Chief of Human Resources 

Management Service and conducted a fact finding review because there was a potential 

“failure of duty to perform”. The fact finding review was sent to the System Director on 

August 15, 2008. A RCA was chartered on September 11, 2008. 

Issue 3: Competency, Training, and Supervision of Telemetry Program Staff 

We substantiated that there were competency and training issues with MSAs and RNs 

assigned to telemetry. There was no formal process to assess competency until after the 

RCA was conducted following the death of Patient 1. 

The MSAs’ supervisor reported that other than an initial certification when MSAs were 

hired, there had been no annual skills reassessment or competency evaluation. For over 

10 years, the Joint Commission (JC) has required annual competency evaluations for all 

employees. A Human Resources Management Service employee relations specialist, 

nursing staff, and administrative supervisors verified that there was no process in place 

for competency assessment. According to supervisors, there had been very little turnVA Office of Inspector General 6 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

over in MSA staff. It had been years since the majority of them had received any formal 

training or competency evaluation. 

After the 2007 messages to nursing management (referred to in Issue 2), the light duty 

Telemetry/Clinical/Administrative Support RN volunteered to perform a basic skills 

assessment examination for the telemetry MSAs. Nursing management approved the 

suggestion and instructed the RN to proceed but the examination was not mandated or 

formally required. The pass rate was poor for those who took it, emphasizing the need 

for training. System managers reported to us that the examination covered content that 

was not included in the initial EKG training and testing and was too advanced for the 

knowledge required of a telemetry technician. For this reason, a new supervisor program 

specialist did not support the continuation of this specific skills assessment. However, no 

other competency assessment was developed. Additionally, not all RNs had completed 

the EKG course, taken the examination, or had annual competency evaluations. We were 

told the charge RN on duty at the time of both deaths had never received specialized 

telemetry training. 

After Patient 1’s death, it was recommended that all telemetry staff be required to take an 

examination that would test their cardiac rhythm interpretation skills. The MSAs and 

RNs took the examination in October 2008. Both groups had very poor initial passing 

rates. Only 4 (14 percent) of 26 MSAs and 1 (4 percent) of 28 RNs passed the basic 

interpretation examination. 

An emergency room RN with extensive cardiac background offered and provided 

training classes for MSAs in November 2008. The course was 3 days in length with a 

final examination given on the last day. Of the 22 MSAs listed on a final scoring sheet, 6 

passed, 3 passed with contingency, 7 failed with recommendation for more intensive 

instruction, and 6 failed with the concern raised that they would not grasp material even 

with more instruction. The RN who conducted the classes wrote a memorandum to 

nursing management with copies sent to the Director Quality Management and Education 

Department, and the Patient Safety Manager voicing concerns about telemetry program 

needs and staff assigned to the area. Nursing management developed a strategy to 

provide a focused review session and re-testing. 

To maintain cardiac rhythm interpretation skills, it is important to perform them on a 

regular basis. We evaluated the MSA staffing levels and determined that if all day shift 

MSAs rotated assignments equally, they could only be in the telemetry station 2.3 days 

per month. One light duty RN is assigned solely to telemetry, leaving very few 

opportunities for other day shift staff to be at the telemetry monitoring station. Rotation 

for evening shift MSAs would be 3 days per month and night shift MSAs 4 days per 

month. Some MSAs have not been at the telemetry monitoring station for months at a 

time. At a minimum, annual competency reviews need to be performed. Telemetry 

MSA staffing needs to be analyzed to determine if all MSAs should have telemetry 

responsibility. 

VA Office of Inspector General 7 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

There was no clinical supervision of MSAs despite the fact that they were 

organizationally structured under the ADPS, who is responsible for nursing care. 

Without some clinical supervision it would be difficult to assess telemetry competency on 

an ongoing basis and to identify training needs. In addition, if MSAs have clinical 

questions, they need to have a formal process to address those needs. 

There had been a proposal to hire a master’s prepared nurse to serve as a dedicated 

educator for the cardiac/telemetry education program. This specialty nurse would be 

responsible for clinical oversight of the program, developing and updating policies and 

procedures, assessing competencies, performing ongoing education, and developing 

preceptor ships. Senior managers did not approve this position and planned to 

reprioritize current resources to achieve the same goal. At the time of our site visit, it 

was unclear who was responsible for telemetry training and staff were not aware that 

policies had been updated. We were provided an updated local policy, dated November 

4, 2008, that defines roles and responsibilities but it was not finalized. 

Conclusions 

We concluded that both patients had multiple medical problems that contributed to their 

deaths, and it would be difficult to determine whether delays in response to abnormal 

rhythms led to their demise. Recognition of the importance of rapid response to critical 

medical situations and timely intervention are well documented in recent literature and a 

focus of JC patient safety goals. 

Temporary measures were enacted to ensure safe patient care following the RCA and 

after the review of competency examination results. An ICU RN has been assigned to the 

remote telemetry units for dedicated response to critical situations and contract telemetry 

technicians were utilized to provide telemetry monitoring. A project has been 

implemented to improve the telemetry monitoring equipment on the units. Cordless 

phones had been purchased for unit nursing staff but some areas of the units have poor or 

no reception. The VISN had been monitoring the system’s processes since the first RCA 

results were reported to them. 

Recommendations 

Recommendation 1. We recommended that the VISN Director ensures that the System 

Director evaluates the telemetry program in its entirety. 

Recommendation 2. We recommended that the VISN Director ensures that the System 

Director requires that all staff complete competency assessments for their specific 

positions and that training be provided as needed to maintain competency. 

Recommendation 3. We recommended that the VISN Director ensures that the System 

Director requires clinical oversight of MSAs. 

VA Office of Inspector General 8 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 9 

Comments 

The VISN and System Directors concurred with the findings and recommendations of 

this inspection and provided acceptable improvement plans (see Appendixes A & B, 

pages 10─15, for the full text of the Directors’ comments). We will follow up on the 

planned actions until they are completed. 

 (original signed by:) 

JOHN D. DAIGH, JR., M.D.

Assistant Inspector General for 

Healthcare Inspections 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 10 

Department of 

Veterans Affairs Memorandum

Date: January 8, 2010 

From: Director, Rocky Mountain Network (10N19) 

Subject: Healthcare Inspection – Telemetry Monitoring Issues, VA 

Eastern Health Care System, Denver, Colorado 

To: Director, Chicago and Kansas City Offices of Healthcare 

Inspections (54CH/KC) 

Attached are the responses from VA Eastern Colorado Health Care System 

to OIG Health Care Inspection – Telemetry Monitoring Issues. Although I 

have reviewed and concur with these responses, it should be noted that VA 

Eastern Colorado HCS had completed Root Cause Analyses with 44 action 

items after the two incidences. Included in those action items were the use 

of Critical Care RNs to monitor the land phone lines and a temporary move 

of the surgical telemetry patients to the SICU for 2.5 months pending the 

installation of the central computer station with printing capability. 

 (original signed by:)

Glen W. Grippen, FACHE 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

Appendix B 

System Director Comments 

VA Office of Inspector General 11 

Department of 

Veterans Affairs Memorandum

Date: January 6, 1010 

From: Director, VA Eastern Colorado Health Care System (554/00) 

Subject: Healthcare Inspection – Telemetry Monitoring Issues, VA 

Eastern Health Care System, Denver, Colorado 

To: Director, Rocky Mountain Network (10N19) 

I concur with the recommendations from the Healthcare Inspection 

conducted on February 17-18, 2009. The recommendations cover areas 

where we had placed great emphasis and were improving prior to the 

Healthcare Inspection visit. 

Based on the actions taken to date by the medical center, I respectfully 

request that OIG Recommendations # 1 and 2 be closed. 

Eastern Colorado Health Care System (ECHCS) leadership continues to 

monitor processes and outcomes and take action when indicated to 

strengthen our telemetry monitoring program. 

(original signed by:)

Lynette A. Roff 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

Appendix B 

System Director Comments 

VA Office of Inspector General 12 

System Director’s Comments 

to Office of Inspector General’s Report 

The following System Director’s comments are submitted in response to 

the recommendations in the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensures 

that the System Director evaluates the telemetry program in its entirety. 

Concur Target Completion Date: Completed 

This recommendation covers an area where we had placed great emphasis 

and were improving prior to the Healthcare Inspection visit. After these 

two incidences it was determined that Critical Care RNs were to be 

assigned to the land phone lines. Additionally, the surgery telemetry 

patients were temporarily (mid- February through April 2009) housed in the 

SICU pending the installation of the central computer station with printing 

capability. Most recently, the System Director requested that the VISN 19 

Patient Safety Officer review and evaluate the improvements in the 

telemetry program. This review and evaluation of quality and safety was 

conducted on October 27- 30, 2009. 

To insure timely notification of abnormal rhythms, in October 2008 charge 

nurse’ pagers were replaced with cellular telephones to be carried 24/7. 

Unit staff nurses were also issued cordless telephones. Managers 

developed and disseminated guidelines for the communication process 

using the dedicated cordless and cellular telephones that included 

documentation expectations for shift-to-shift handoffs. In addition, a 

process for testing the functionality of each cellular and cordless telephone 

at the beginning of each shift was developed and implemented. Per policy, 

unit nurses are expected to answer their cordless telephone within 4 rings. 

If the cordless telephone is not answered within 4 rings, the telemetry 

technician is to call the charge nurse who is expected to answer the cellular 

telephone within 4 rings. Managers implemented a process for continuous 

tracking and reporting of unit nurse and charge nurse response times for 

answering telemetry telephones. Compliance for answering the telephone 

has consistently met policy.
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 13 

The current cordless and cellular telephone system will be replaced with a 

“state of the art” wireless communication system in FY10 Q-2. An 

interdisciplinary, interdepartmental task force was formed to evaluate 

wireless communication systems to allow real-time, two-way 

communication among telemetry technicians and the nurses caring for 

patients. The task force made a selection after evaluating systems from four 

vendors. The telephones have been received and the wireless 

communication system is being installed through-out the medical center. 

We anticipate activation of the system in February 2010. 

The ECHCS Telemetry Policy (11-14) was revised in November 2008 to 

standardize and clarify communication channels. During the course of the 

past year, as practice changes were implemented, standard operating 

procedures were developed to provide guidelines for staff to follow. The 

current policy was posted in December 2009 (attachment A). The policy 

directs the telemetry technician to immediately call a “COR O” for lethal

dysrhythmias. In addition to assigning responsibility and describing the 

procedure for telemetry monitoring, this policy includes the attachments 

defining the telemetry phone process, the standard operating procedure for 

telemetry monitoring, roles for both the telemetry technician and the RN, 

and the telemetry hand-off communication document. 

To insure rapid response to critical medical events, a Rapid Response Team 

(RRT) was implemented in February 2009 following education of staff 

through-out the medical center. Outcomes are being monitored and have 

demonstrated favorable results. Subsequent to implementation, the number 

of inpatient “COR 0” calls decreased from 3-4 to 1 per month. There have 

been only 2 inpatient “COR 0” incidents in FY10 Q-1. 

Central station computers with printing capabilities were purchased and the 

telemetry monitoring equipment was installed on the telemetry units in 

April 2009. The telemetry monitoring function was relocated from the 

remote location in MICU to the 5N acute care nursing unit. Both nursing 

and telemetry technicians were trained by the vendor subsequent to 

installation. 

Recommendation 2. We recommended that the VISN Director ensures 

that the System Director requires that all staff complete competency 

assessments for their specific positions and that training be provided as 

needed to maintain competency. 

Concur Target Completion Date: Completed 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 14 

This recommendation covers an area where we had placed great emphasis 

and were improving prior to the Healthcare Inspection visit. All staff had 

competency assessed prior to working in telemetry. 

The telemetry training was redesigned. In November 2008, telemetry

technicians were retrained and retested. Only those MSAs who achieved a 

passing score were assigned to telemetry monitoring functions. An 

additional in-depth competency assessment, developed by the telemetry 

resource nurse has been completed on all of the telemetry technicians. 

Auditing of telemetry technician’s interpretations of rhythms was initiated 

on April 2009. Technicians with scores below 90% on rhythm 

interpretation audits have not been assigned to telemetry monitoring 

functions and are scheduled to attend the Essentials of Critical Care 

Orientation (ECCO) class. 

The Critical Care Nurse Educator redesigned the telemetry education 

program for RNs following a survey of community and VA medical centers 

to determine best practice for telemetry education, certification, and 

ongoing competency validation. The redesigned program, based on the 

ECCO was implemented in February 2009. Almost all of the RNs have 

completed the course and are ECCO certified. Classes will now be 

provided quarterly.

The ECHCS ACLS/BLS policy was revised in May 2009 to require that 

RNs on the telemetry units be ACLS certified, with non-certified nurses 

expected to attain certification within one year of hire. As of December 

2009, most of the RNs on the telemetry units are ACLS certified. The 

remaining RNs are compliant with policy and will achieve ACLS 

certification within one year of hire date. 

The Critical Care Nurse Educator designed an eight-hour preceptorship for 

ECCO certified RNs. This preceptorship was implemented in November 

2009 and consists of 1:1 training by a qualified telemetry technician, to 

include monitoring of and performing rhythm interpretations on telemetry 

patients, accurate electrode placement, and operation of the monitoring 

equipment. The Educator has also developed a process for ongoing 

monitoring and verification of competency to include technical, critical 

thinking, and interpersonal skills. The annual competency validation 

process is offered quarterly. 

Recommendation 3. We recommended that the VISN Director ensures 

that the System Director requires clinical oversight of MSAs. 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 15 

Concur Target Completion Date: 03/31/10 

The ACNS for Inpatient Care is currently responsible for the clinical 

oversight of telemetry technicians. Responsibilities include insuring that 

the telemetry technicians adhere to the telemetry policy and maintain 

competency in telemetry skills, providing clinical resource assistance to the 

telemetry technicians, reviewing competency/proficiency data and taking 

action as appropriate, and reporting results of initial, quarterly, and annual 

competency/proficiency data to the Patient Safety Committee. 

In addition, nursing management is working with HRMS to create 12.0 

FTEE dedicated Health Technician/Telemetry Technician positions, 

classify those positions and recruit for a RN Telemetry Clinical Manager, 

who will have supervisory responsibility and accountability for 

performance management. The Health Technicians will be assigned to 

clinical duties only, to include telemetry monitoring functions on the acute 

medicine (5N) and acute surgical (4S) units. 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 16 

OIG Contact and Staff Acknowledgments 

OIG Contact Verena Briley-Hudson, MN, RN 

Director, Chicago and Kansas City Offices of Healthcare 

Inspections 

(708) 202-2672 

Acknowledgments Dorothy Duncan, BSN, MHA, RN, CPHQ 

Michael Shepherd, MD 

Judy Brown 
Telemetry Monitoring Issues, VA Eastern Colorado Health Care System, Denver, Colorado 

VA Office of Inspector General 17 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Rocky Mountain Network (10N19) 

Director, VA Eastern Health Care System (554/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Michael F. Bennet, Mark Udall 

U.S. House of Representatives: Diana DeGette, Doug Lamborn, Betsy Markey, Ed 

Perlmutter, Jared Polis, John T. Salazar, Mike Coffman 

This report is available at http://www.va.gov/oig/publications/reports-list.asp.