Background: Continuous cardiac monitoring (telemetry) is a vital but resource intensive component of patient care, allowing providers to quickly respond to signs of cardiovascular instability. Despite its importance, and existence of American Heart Association (AHA) guidelines, overreliance of telemetry is common. Since telemetry is restricted to specific units, over-use creates a bottleneck in patient flow and negative patient experience. While the guidelines recommend durations of telemetry by indication, strength of evidence is variable and guidelines do not encompass all indications observed in practice. This study evaluated the effectiveness of a clinical decision support (CDS) tool as an implementation strategy to increase fidelity to AHA telemetry guidelines and reduce overuse.
Methods: A CDS tool was developed within a 10-hospital academic health system to promote adherence to AHA guidelines for continuous cardiac monitoring in both initiation and duration. In collaboration with system stakeholders, the AHA guidelines were condensed into a series of large categories and specific indications with recommended durations and integrated into the electronic health record. This tool was followed by an interruptive best practice alert at the completion of the recommended duration. The primary measure was the total number of days with continuous cardiac monitoring per hospital admission. Secondary measures included the proportion of admissions with any cardiac monitoring, the duration of monitoring when applied, the proportion of telemetry orders that had an indication reported, and proportion of monitoring which was in excess of AHA guidelines. We assessed the impact of the CDS on patient safety measures and outcomes. This included patients with events of bradycardia (HR < 40), tachycardia (HR < 160), and hypotension (mean arterial pressure < 65) while off telemetry. We additionally measured length of stay, ICU transfer rates, in hospital and 30-day all-cause mortality, and 30-day readmission rates. We used single group interrupted time series analysis to determine the immediate impact of the CDS on outcomes and measures to adjust for temporal trends.
Results: During the 24 month pre-implementation 54,492 patients were admitted without telemetry and 52,649 (49.1%) of patients were admitted with telemetry at some time during their inpatient stay. In the 6-month post-implementation period: 16,488 admissions post implementation of which 11,025 (40.0%) were admitted with telemetry at one point in their stay. We observed significant reductions in overall telemetry days (p< 0.001), admissions with telemetry (p< 0.001), proportion of patients with a reported indication (p< 0.001). We observed no changes in ICU transfer rates, readmission rates, length of stay, or mortality. We observed an increase in proportion of patients with hypotension off telemetry monitoring (p < 0.001), but this was not associated with adverse outcomes.
Conclusions: Integrating AHA guidelines into telemetry ordering and continuation effectively reduced cardiac monitoring without worsening patient safety. While we observed increases in potential instability while off monitoring, the utility of telemetry in these cases remains to be measured. Overall, aligning clinical decision support tools with current guidelines is an effective way to promote adherence and identify important gaps in evidence.