Overuse of telemetry monitoring is a target of the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign, which recommends that hospitals develop a protocol to limit telemetry use. The American Heart Association has published guidelines on appropriate indications and duration for telemetry. Despite these efforts, telemetry overuse persists. It is associated with ER overcrowding due to scarce telemetry beds, over‐treatment of clinically irrelevant events, limited patient mobility and sleep due to frequent adjustment of monitoring equipment, and the cost of nurse and physician time responding to false alarms.
Our project goals are to sustain: 1) a 15% reduction in total telemetry hours on the Medicine service (normalized to the number of patients discharged), 2) a 15% reduction in the proportion of telemetry‐monitored patients who remain on monitor until the moment of discharge (and who have a length of stay greater than 48 hours). The project timeline is October 2013 to June 2014 and the team consists of a faculty mentor and three senior residents with a strong interest in high‐value care.
Our project has four components:
A lunchtime presentation, given by our resident team, that describes evidence‐based telemetry use to the house staff in the internal medicine program.
A messaging campaign, designed by our resident team, that consists of widely distributed reference cards listing appropriate telemetry monitoring indications and duration, posters featuring recognizable faculty endorsing evidence‐based telemetry use, and note cards for daily house staff use featuring reminders about discontinuing telemetry.
E‐mail feedback from our resident team to their fellow house staff describing the latter’s telemetry use in order to encourage reflection and competition.
A change to our Epic electronic medical record (EMR) system that automatically discontinues a telemetry order after a specified elapsed time. This time is dictated by the indication for telemetry provided in the initial order. This change will roll out in early 2014 as we first sought buy‐in from nursing leadership and the chiefs of the top five departments that use telemetry: Hospital Medicine, Cardiology, Neurology, Cardiothoracic Surgery, and Vascular Surgery.
We gathered data from EMR reports that reflect monthly telemetry use across the Medicine service. In August 2013, the telemetry hours per discharge and percent of patients on telemetry until discharge were 20 hours and 52% respectively. In September 2013, these measures were 26 hours and 43%, notably with two outlying patients who were on telemetry for months. Finally, in October 2013 these measures dropped to 16 hours and 32% respectively.
Hospitals can effectively reduce wasteful telemetry use through a resident‐led educational, messaging, feedback and electronic medical record intervention as detailed in this study.