Central Telemetry, Single Coverage: A 22-Second Wide-Complex Run
You are the house telemetry surveillance RN at a 420-bed community hospital, covering three medical units from the central station. Tonight one monitor tech called out, so you are working alone with a tech who is in week three of orientation; the house supervisor has told you no relief will come before 0600. At 0240 the tech flags bed 312: a 72-year-old man, postoperative day 2 after a right hemicolectomy with a history of paroxysmal atrial fibrillation, who has just had a 22-second run of wide-complex tachycardia at 186 beats/min that terminated spontaneously into sinus rhythm at 96. His last documented vital signs, 35 minutes ago, were 108/64 and SpO2 95% on 2 L nasal cannula. The primary nurse is in another room with a postoperative patient who is bleeding. You have never assessed bed 312 in person. Hospital policy permits only the RN, not the monitor tech, to interpret rhythms or notify providers.
1. What is your immediate priority, and in what sequence do you act in the first five minutes?
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Verify, then escalate - neither alone is enough.
- Look at the stored strip yourself before doing anything else. A 22-second wide-complex run at 186 is either ventricular tachycardia or atrial fibrillation with aberrancy; the two carry very different urgency, and you are the only person in the building permitted to make that call. Confirm the complexes are truly wide (over 120 ms), whether the rhythm is regular, and whether he has had earlier runs this admission.
- Get a human being to the bedside. The primary nurse is managing an active bleed, so waiting is not a safe option. Activating the rapid response team is the fastest route. A patient who has just sustained 22 seconds of wide-complex tachycardia can recur at any moment, and there is currently a gap between your screen and a physical assessment.
- In parallel, pull the last potassium, magnesium, and QT-relevant medications (ondansetron, fluoroquinolones, any antiemetic stack) plus the most recent 12-lead. Postoperative hypokalemia or hypomagnesemia is a common and correctable trigger - and it changes what you say to the hospitalist.
- Notify the hospitalist with SBAR once the bedside assessment is underway, not before. Reason: reporting a rhythm you have not verified and a patient you have not assessed invites a wrong disposition, either over-treatment or dismissal.
2. The house supervisor confirms no relief before 0600. How do you manage the assignment across 68 monitored beds, and what can you delegate to the orienting tech?
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Triage by risk, delegate by task type, and escalate in writing.
The tech's orientation week limits her to non-interpretive tasks: printing and storing strips, calling out alarms, confirming lead placement on the video, paging the assigned nurse, and documenting alarm times in the surveillance log. She cannot interpret, cannot call a provider, and cannot be the only person watching the board while you are on the phone. Structure her shift so she never leaves the station unattended; if a strip must be hand-carried, you carry it.
For the 68 beds, sort by actual risk rather than alarm volume: patients with a new arrhythmia in the last 12 hours, electrolyte replacement in progress, or QT-prolonging meds get reviewed every 30 minutes; stable sinus rhythm on day 4 gets hourly. Explicitly ask each unit charge nurse to free one nurse for a single 15-minute focused check on the highest-risk patients.
Document the staffing gap and your mitigation to the house supervisor in a timed note, and file the safe-staffing concern per policy. The reason is not bureaucratic: if a second event occurs at 0400, the record must show that you identified the risk, escalated it, and took defined action within your authority.
3. How do you document and hand off this event so that the next shift and the provider act on it rather than rediscover it?
Read the worked answer
Two records, two audiences.
Your surveillance log gets a timed entry: 0240 wide-complex run, 22 seconds, rate 186, spontaneous termination, who was notified and when, what was pulled and reviewed, and what the bedside assessment found. Attach the stored strips to that entry. You generally do not write in the patient's chart from a central station, so the primary or rapid response nurse owns the EHR assessment note - confirm that it was actually written before shift change rather than assumed.
The provider notification follows SBAR and ends with a specific ask: a 12-lead, electrolyte repletion parameters, and a decision about a monitored bed on a unit with continuous bedside capability. Close the loop by reading back whatever is ordered.
For handoff, do not bury this in report. At the 0645 huddle, name bed 312, state the event, and state the open item ('hospitalist deciding on magnesium replacement; repeat ECG pending'). Give the oncoming surveillance RN the saved strips and note that this patient is now permanently in the every-30-minute risk tier until the workup is complete.
Finally, call the patient's own nurse and explain what was seen, so the patient is not told nothing happened overnight.