Eliminating Inappropriate Telemetry Monitoring
What are the most effective ways to optimize telemetry usage in non–intensive care unit (ICU) patients?
The authors hypothesize that continuous electrocardiographic (ECG) monitoring outside the ICU (i.e., telemetry, is overutilized). They believe one reason for inappropriate usage is unfamiliarity with practice standards put forth by the American Heart Association (AHA). The authors voice concern for the consequences of routine telemetry monitoring: “alarm fatigue,” unnecessary testing based on inappropriate diagnosis of arrhythmias, and cost. They provide an overview of the AHA recommendations for monitoring and then review several studies in which the aim was to optimize ECG monitoring outside the ICU. Using these study results, they suggest an implementation blueprint to guide health care providers.
The included studies (n = 8) were quite variable, but in general utilized the AHA practice standards, which were incorporated into the local electronic medical record (EMR). Clinicians were asked to become more familiar with the standards (email reminders/presentations/rounds), to justify the indications and renew orders for continued monitoring, and to reduce the monitoring period. In two studies, financial incentives were offered to enhance compliance. In some studies, telemetry was automatically discontinued after a prespecified time. Findings of these studies were also variable: reduction in telemetry orders placed and monitoring duration, associated with cost savings in some; no change in telemetry duration; and no difference in mortality/code rates as compared to preintervention.
The authors concluded that the findings of these studies along with the AHA practice standards may be used by clinicians and administrators to develop optimal criteria for telemetry monitoring in non-ICU patients.
In the hospital setting, one may find examples of both overutilization and underutilization of telemetry monitoring. Some examples of the former include continuous monitoring of patients who do not wish to be resuscitated (DNR), and those with implantable cardiac devices admitted for noncardiac reasons. Underutilization may occur in the setting of a patient with multiple medical problems whose primary diagnosis (e.g., malignancy) may direct him/her to a specialty/nontelemetry unit, but who may also benefit from monitoring for a concomitant condition (e.g., hyperkalemia). Clinicians would be well served to review the practice standards, most of which are intuitive. However, some physicians such as medical housestaff, unless guided by a seasoned clinician, may not feel comfortable withholding telemetry in a patient with a cardiac history or potential cardiac condition, erring on the side of caution. One must also be cautious in interpreting such studies since the focus was squarely on resource utilization (for example, arbitrary reduction of the monitoring period, and automatic discontinuation of telemetry), and less so on patient safety.
Keywords: Arrhythmias, Cardiac, Cost Savings, Electrocardiography, Electronic Health Records, Hyperkalemia, Intensive Care Units, Monitoring, Ambulatory, Secondary Prevention, Telemetry
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