Background: Telemetry overuse contributes to excess healthcare costs, unnecessary workup of incidentalomas, and alarm fatigue. To curb overuse, guidelines such as the 2017 AHA/ACC continuous ECG monitoring practice standards have outlined appropriate telemetry use standards. The aim of this study was to perform a rapid “plan-do-study-act” (PDSA) cycle and assess whether a nursing (RN)-driven checklist addressing appropriate telemetry use, combined with just-in-time education delivered via an electronic medical record (EMR) order set modification, was efficacious in reducing inappropriate telemetry use within a level 1a Veterans Health Administration hospital.

Methods: This is a quality improvement intervention study which took place between March 2019 and July 2020. Three cohorts were sequentially studied: a control cohort without any intervention (n=100, 3/1/2019-3/28/2019); a cohort with only the RN-driven checklist (n=100, 7/1/2019-7/30/2019); and a cohort with both the RN-driven checklist and an EMR modification which provided just-in-time education about telemetry indications (n=100; 7/1/2020-8/18/2020). Telemetry records were obtained and reviewed by a physician to determine indication, duration for each telemetry order, and appropriateness. An order was deemed “appropriate” if it met AHA classification grade I (telemetry recommended) or IIa/b (telemetry may be considered), and “inappropriate” if it fell under class III (telemetry not recommended). Data was compared between the control cohort and the two intervention cohorts, as well as between intervention cohorts, using Pearson chi-square and logistic regression analyses. We considered a p-value < 0.05 as statistically significant.

Results: Within the control group, 37% of telemetry orders were deemed inappropriate. Institution of the RN checklist showed a trend toward decreased inappropriate telemetry ordering from 37% to 26% (p = 0.09). Institution of the RN checklist along with the EMR order set decreased inappropriate telemetry ordering to 17% (p = 0.001). Comparison between the two intervention groups (RN and RN/EMR) did not meet statistical significance (p= 0.12). The same comparison was made between the control and intervention cohorts for appropriate duration of telemetry use; only appropriate initial telemetry orders were analyzed for appropriate duration of telemetry usage. No clinically or statistically significant differences were found between any of the cohorts with regard to telemetry duration.

Conclusions: Our institution was able to initiate an RN-driven checklist and EMR telemetry order set modification which decreased inappropriate telemetry usage from 37% to 17%. We propose that the just-in-time education via the order set provided real-time education regarding appropriate telemetry usage. We further propose that by incorporating telemetry usage into daily RN rounds, residents received reinforcement regarding appropriate telemetry usage. Both interventions are easy and affordable ways to encourage appropriate telemetry utilization and could be replicated at other institutions. Additional studies should include analysis of cost savings, patient experience, and effect on length-of-stay.

IMAGE 1: EMR order set modification

IMAGE 2: Effect of intervention on inappropriate telemetry utilization