It was reported that a fixed heart rate value appeared at a bedside monitor, even though the pt was disconnected from the ecg and a flat ecg line was displayed.
The surveillance center was configured to flexibe mode.
This bedside monitor was not currently assigned to a sector on the surveillance center because the user was attempting to use a 12 bed surveillance center in a 13 bed icu by reassigning sectors while pts were connected to the bedsides.
After reassigning the monitor to a sector on the surveillance center, the real heart rate value was correctly shown at the surveillance center and at the bedside monitor.
Upon de-assigning the monitor, the heart rate froze again.
If the heart rate is frozen at the monitor, the monitor doesn't recognize any change in ecg and therefore, does not alarm.
To address the customer's unusual use of the flexible monitoring capability, the customer was upgraded to a 16 bed surveillance center to support its 13 live bedside monitoring requirement.
To investigate the incident, the engineering team configured a 12 bed surveillance center for 12 beds, and when they de-turned the bedside monitor from the central, the bedside was still expecting the central to provide arrhythmia detection and therefore continued to display the last updated vaule from the central (be it heart rate or inop).
This condition remained until the central was either re-booted or the bedside is re-tuned to the central station.
While the bedside is in this state, however, its internal cardio-tach and basic arrhythmia detection is shut off, disabling the bedside hr and v-fib/asystole alarm.
This condition does not always occur when a monitored bed de-tunes from the central, as there appears to be a timing window that triggers this condition.
The use model employed by this hosp has been determined to be unusual: the normal model is to only de-tune beds that have no pt on them.
User and training documentation on the use of flexible monitoring capability indicates that de-tuning a bedside from the central station should be accomplished when the bedside is not in use.
The customer's use modle of tuning and de-tuning an active bedside monitor with a pt connected was determined to be rare.
The investigation determined that the static heart rate displayed on the bedside monitor was due to the customer's misapplication/misuse of the device.
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The customer has a 13 bed unit.
Each bed has a bedside monitor.
The customer has a central station with 12 pt sectors.
The customer's use model was to clear an active bedside pt from the central station (while attempting to continue monitoring the pt from the bedside) to allow them to moniotr a different pt at the central station.
As a result of this switching, which was outside the normal use model of the device, the bedside monitor displayed a static heart rate, which persisted after the ecg was disconnected from the pt.
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