Background: Inpatient telemetry monitoring is a limited resource. The value of telemetry monitoring in hospitalized patients with high risk for cardiac arrhythmia is high. However, telemetry monitoring is often ordered for inpatients at low risk for cardiac arrhythmia. The SHM’s Choosing Wisely campaign recommended avoiding continuous telemetry monitoring in non-ICU patients without a protocol. Ordering inpatient telemetry monitoring for low- risk patients is associated with various negative impacts such as increased cost of care and length of stay, false alarms leading to unnecessary management, and alarm fatigue for nurses, etc.
Purpose: This quality improvement project aimed to safely reduce inappropriate ordering of inpatient telemetry monitoring by updating the telemetry indications, in accordance with the 2017 American Heart Association’s (AHA) scientific statement on inpatient telemetry monitoring recommendations.
Description: Our health system’s inpatient telemetry orders included short-term monitoring (Daily 24hr Telemetry) and long-term monitoring (Continuous Telemetry). It was noted that “Acute Medical Illness” accounted for about 70% patients under telemetry monitoring. Acute Medical Illness was not a recommended indication for inpatient telemetry monitoring according to the AHA’s scientific statement. In addition, some of the other indications in our orders were not consistent with AHA’s recommendation. For example, “CHF” was listed as an indication for daily telemetry monitoring, when the AHA statement suggested telemetry monitoring in acutely decompensated CHF. The indications for telemetry orders were reviewed based on the 2017’s AHA scientific statement. After revision to the Daily and Continuous Telemetry orders, education was provided to all relevant inpatient teams (ED, HM, FM, Surgery, IM residents, cardiology). After the implementation of new telemetry orders, 3-month pre- (May-July 2023) and post- (August – October) intervention telemetry utilization data were compared. Code Blue events without telemetry order was the primary safety metric monitored. There was a 12% reduction in Med/Surg telemetry bed requests upon admission despite a 2% increase in admission volume during the post-intervention period. The Daily Telemetry order was reduced by 36%. This reduction was achieved by reduced initial ordering of Daily Telemetry monitoring and less renewal of the Daily Telemetry orders. It was noted that there was an approximately 30% (a significant lower denominator compared to the Daily telemetry orders) increase in Continuous Telemetry orders. Overall, there was still a significant net reduction in telemetry monitoring days. There was no increase of inpatient Code Blue events without pre-arrest telemetry monitoring (6 cases pre vs 3 cases post).
Conclusions: Revising our network’s telemetry monitoring indications based on the AHA’s 2017 scientific statement significantly reduced unnecessary telemetry orders and reduced Med/Surg telemetry bed requests. Despite significantly fewer telemetry monitoring orders post-intervention, there was no increase of Code Blue events on patients without pre-arrest telemetry orders during their inpatient hospital stay, which affirmed the safety of the intervention.