Background: Telemetry is utilized on high risk cardiac patients for monitoring of arrthymias. Guidelines providing clear monitoring indications have been published by AHA to reduce overuse of this resource, which can lead to increased care costs and false positive alerting. Despite the above evidence, our hospital has a high volume of patients on telemetry causing bottlenecks in patient flow. Our overall aim was to promote evidence based practice of telemetry use through an integrated multidisciplinary approach using order entry, analytics, and education.
Methods: Open discussion among multidisciplinary stakeholder group elicited several improvement opportunities. Findings include large volume telemetry ordered without indication or diagnosis and utilized ED bed preference request instead of admitting provider order. Physicians were not routinely reassessing the need for continued or removal at 24 to 48 hours after application. Based on analysis, plan developed to decrease telemetry overuse by leveraging change management from ED admission process, telemetry order with required indication, removal of order in non-applicable diagnosis sets, and education program. Telemetry orders included a list of approved indications but also included an “other” option for which providers had to enter a reason in a free text field.
Results: Data were obtained from 5 individual medical/surgical units within the hospital.
Telemetry orders for the 3 months preceding (N=1231) and 3 months post-implementation (N=1720) of the new order system were retrieved and analyzed. There was no statistically significant difference in telemetry utilization across medical/surgical units.
Using the new order set, specific approved indications were given in 90% of cases (1540/1720); the ‘other indication’ option was used for 10% of cases (176/1720). On the date of electronic system changes requiring indication, 4 telemetry orders did not have indications captured due to the system timing changes.
Of the 10% who selected the “other indication” option, the most common diagnoses were GI bleed, COPD, hypoxia, anemia, alcohol withdrawal. Analysis across four hospital provider groups conducted with respect to selection of the “other indication” option revealed similar utilization practices.
Conclusions: Effective change in appropriate telemetry utilization involves deployment of organizational multidisciplinary team based communication and education structure, embedding evidenced based content in order sets, and leveraging power of analytics.
Although we saw an increase in the number of post implementation telemetry orders, this is most likely a reflection of enhanced analytics systems to capture data rather than an actual increase in volume. The pre-implementation number would not take in account volume without a provider telemetry order. These enhanced systems allow us to continually analyze data at the unit level and by individual provider to monitor changes over time and develop targeted educational interventions. Qualitative analysis of the free text indications has revealed diagnosis related patterns which allows opportunity for direct education.
A robust ongoing education program and data transparency are needed for all healthcare providers and stakeholders to fully implement best practice in telemetry utilization. It is very encouraging that the system was adopted quickly. Although the ‘other’ option for medical indication was utilized in 10% of cases, we anticipate that this should decrease across time.