Background: Cardiac telemetry is frequently overused in the hospital. Our institution requires telemetry while patients are on the Clinical Institute Withdrawal Assessment (CIWA) protocol, regardless of the presence or severity of alcohol withdrawal (AW). Telemetry use in this population has not been studied or incorporated into guidelines, however some patients may need monitoring for co-existing indications. Small studies suggest that patients with severe AW may have higher risk for coronary events. Adverse effects of telemetry include excess cost, decreased patient ambulation and satisfaction, and alarm fatigue. We investigated the rate of clinically significant AW in all-comers monitored on the CIWA protocol, the presence of co-existing indications for telemetry, and the risk of adverse cardiac events in order to evaluate the necessity of telemetry in patients on the CIWA protocol.
Methods: We retrospectively reviewed 150 charts of patients admitted to the hospital outside of the ICU and placed on the CIWA protocol. Data collection included reason for admission, medical comorbidities, severity of AW, and development of telemetry events. With documented telemetry changes, we determined clinical significance based on provider notes, medication changes, cardiac studies, and consultations.
Results: Of 150 patients assessed, 48 (32%) were admitted primarily for AW. Twenty-seven patients (18%) placed on CIWA developed severe AW during admission (CIWA score ≥ 19). Seven significant telemetry events were recorded (4.7%), five of which occurred in patients with a telemetry indication (Table 1). Twenty-nine patients (19%) did not develop clinically significant alcohol withdrawal and did not receive medication. Of these 29 patients, 21 had no indication for telemetry at admission. Only one of these patients had a significant telemetry event (AFRVR) which occurred intraoperative while patient was appropriately monitored. No telemetry events were associated with clinical instability or necessitated a higher level of care.
Conclusions: The majority of clinically significant telemetry events occurred in patients with an indication for telemetry. The most frequent event was AFRVR and no events were life threatening. While patients with AW may be at higher risk for AFRVR, this can be diagnosed with vital sign monitoring and a physical exam, particularly in patients who do not have severe AW or an impaired sensorium. Importantly, patients on the CIWA protocol who did not develop significant withdrawal and had no indication for telemetry (13% of our population), had no clinically significant telemetry events. Reduction of monitoring in this population may decrease nursing and patient burden (tethering, alarm fatigue, cost) and provide high value care.
