Background: Telemetry monitoring is known to be over-utilized outside of the ICU, rarely leads to a change in management, and has never been shown to improve clinical outcomes. Telemetry monitoring increases cost and is associated with numerous potential harms, including frequent false positives. As part of the ABIM’s Choosing Wisely campaign, the Society of Hospital Medicine highlighted telemetry monitoring as a target for improving value in inpatient medicine. Published interventions aimed at decreasing inappropriate telemetry utilization have had varying degrees of success, but have never been shown to compromise patient safety. Our institution did not previously have a standardized approach to telemetry monitoring or a protocol that governed continuation.
Purpose: To decrease inappropriate telemetry utilization by hard-wiring the American Heart Association (AHA) guidelines for telemetry monitoring into our electronic medical record (EMR), and evaluate the additive effect of a multi-faceted intervention on the hospitalist service.
Description: A baseline analysis of 100 charts indicated that 51% of patients met an indication for monitoring at the time of initiation of telemetry, and only 14% of all telemetry days met indications for monitoring, suggesting significant over-utilization.
We modified the telemetry order in the Epic EMR at the University of Utah, to require ordering providers to select a clinical indication and duration for monitoring, based on AHA guidelines. Decision support was added to the order to provide education on common clinical conditions for which monitoring is not indicated. Once the chosen duration for monitoring is reached, the order expires and the clinician must renew or discontinue the telemetry order.
Simultaneously, we instituted an intervention on the hospitalist service that included an educational component, removal of the telemetry order from admission order sets without a clinical indication for monitoring, regular feedback on telemetry utilization, a financial incentive with a cost-savings program through the University, and renewed emphasis of the rounding checklist to address telemetry on rounds daily.
System-wide non-ICU telemetry days and mean duration of telemetry monitoring were evaluated for 15 months prior to invention, and continue to be tracked monthly. Based on initial data, system-wide telemetry utilization has decreased by 15%, from a baseline of 1626 telemetry days per month to 1392 telemetry days, four months after implementation of the new order. Mean duration of telemetry monitoring remains about the same (3.18 days vs 3.12 days). However, utilization on the hospitalist service has decreased by 66%, from a baseline of 294 telemetry days per month, to 101 telemetry days, with continued decreases seen monthly. Mean duration of telemetry decreased from 2.52 to 2.02 days among hospitalist service patients.
Conclusions: We demonstrate that implementation of a system-wide change to the EMR telemetry ordering process has, thus-far, led to a 15% decrease in overall telemetry utilization, while a simultaneous multi-faceted intervention within the hospitalist group led to a reduction of 66%. Future directions include monitoring for sustainability of the decreases, expansion of the educational component to additional high utilization services, and implementation of a system-wide process to standardize expiring telemetry orders, in order to decrease inappropriate renewal of orders.