Background: Inappropriate telemetry use has been associated with increased health care cost and unnecessary diagnostic procedures. For these reasons, the Society of Hospital Medicine’s Choosing Wisely campaign promoted use of both American Heart Association (AHA) telemetry guidelines and protocol-driven discontinuation of telemetry. Despite these measures, an estimated 59% of patients are placed on telemetry due to non-AHA indications. Subsequently, our institution developed a facility-wide order set for improving clinically appropriate telemetry use. The purpose of this study is to evaluate the effectiveness of this electronic order set in minimizing inappropriate telemetry.
Methods: An inpatient telemetry order set congruent with the 2004 AHA telemetry guidelines was created in our electronic medical record (CPRS) in November 2015. It was piloted and then instituted in February and April 2016, respectively. The order set prompts physicians to select an evidence-based indication for telemetry, which continues only for a predetermined time interval. Telemetry automatically discontinues, but can be reordered prior to expiration if indicated. Pre- and post-intervention utilization rates from the 28-bed telemetry unit were analyzed. Additionally, 294 post-intervention charts were reviewed to analyze the duration of cardiac monitoring and to verify that the cited indication for telemetry was present on admission.
Results: Of the 294 charts reviewed, 265 (90.1%) had an appropriate indication for telemetry, and 287 telemetry days were saved in these patients (1.08 tele days/admission). In the 29 patients with an inappropriate indication for telemetry, 84 telemetry days were saved (2.16 tele days/admission). In the first two months after institution, the percentage of patients initiated on telemetry fell by 11.4% and 10.4%, respectively. There was a transient year-over-year increase in July through September, followed by a 21.8% drop in telemetry initiation in October 2016. (Figure 1)
Conclusions: Implementation of an electronic order set congruent with AHA guidelines improved evidence-based telemetry use at our institution. Protocoled discontinuation shortened the duration of telemetry use for inpatient admissions. Additionally, given that the number of telemetry days saved was higher in the inappropriate group is suggestive of a possible cultural change where patients with a “borderline” indication were more likely to have telemetry actively discontinued or at least auto-expire sooner. There was no change in the number of inpatient cardiac arrests or medical codes observed since order set institution. The effects on direct costs and indirect quality measures remains to be investigated.
