Background:
Inpatient telemetry monitoring is commonly used to identify arrhythmias, ischemia, and QT prolongation. The American College of Cardiology and American Heart Association (ACC/AHA) guidelines identify groups in which telemetry use (1) is indicated, (2) may be of benefit, and (3) is unlikely to benefit. Previous studies have determined that inappropriate usage of telemetry increases costs to the health care system. Strict adherence to ACC/AHA guidelines can improve costs without increasing adverse events.
A 2013 chart review at our academic institution found both inappropriate telemetry use and deficiencies in physician telemetry review.
Purpose:
We developed a progress note template that incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. We also provided an educational session describing ACA/AHA guidelines for internal medicine residents and clerkship students with a pretest and posttest. We evaluated the effect on appropriateness of telemetry initiation and continuation, telemetry documentation, perceptions on importance of telemetry, and ability to apply the ACA/AHA guidelines to clinical cases.
Description:
We reviewed 50 randomly selected charts of patients with telemetry orders admitted to UIHC from 12/21/14 to 01/21/15. Comparison of the chart reviews with the 2013 chart review indicated that the appropriate initiation of telemetry improved significantly (63% vs 84%, p=0.01) as did telemetry documentation (16% vs 56%, p<0.01). Inappropriate continuation rates were 30% in 2015 and 60% in 2013 (p<0.01). Telemetry initiated at night was discontinued during the day (70%).
Pretest data showed that internal medicine residents and clerkship students review telemetry order indications mainly on admission (90%) and transfer (50%); however, only 45% of trainees assessed telemetry on a daily basis and only 5% assessed telemetry indication on discharge. Trainees felt that they themselves, nursing staff, and attendings were the most likely to promote telemetry utilization review. Application of ACA/AHA guidelines was assessed with 5 scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all 5 questions correctly; on posttest, 63% answered all 5 scenario questions correctly (p<0.05).
Conclusions:
Use of standard progress note template with telemetry indications and resident-based educational session led to improved compliance with ACA/AHA guidelines and telemetry usage. We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage. We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.