Background:
In 2004, the American Heart Association (AHA) published recommendations on the use of cardiac monitoring in the hospital setting. It provided a rating system for its indications (Class I-III), which stratify the likelihood of benefit.
In June 2013, The Joint Commission approved NPSG.06.01.01, a patient safety goal on clinical alarm use in the hospital setting, making them a priority beginning in 2014. The Association for the Advancement of Medical Instrumentation has estimated that 85-99% of alarms do not require intervention, resulting in provider “alarm fatigue.” This has been cited as the root cause of the estimated 100-200 deaths per year related to monitoring devices.
Purpose:
Cardiac monitoring (telemetry) is frequently used inappropriately. In an analysis presented at the Society of Hospital Medicine’s 2015 meeting, Stewart et al found that approximately 82% of patients were continued on telemetry until discharge, with 90% of those being inappropriate. This practice leads to poor resource management, and more importantly the potential for patient harm.
While the root cause is often a lack of education of evidence-based guidelines, previous attempts to curb inappropriate telemetry use have centered on provider education, resulting in only transient success.
Description:
We implemented a solution in our EHR (called CPRS) that seamlessly integrates telemetry ordering. The previous, nonspecific and indefinite telemetry order was replaced with a new order set, which directs providers to choose an AHA Class I or II indication. Based on the indication, each individual order is associated with an expiratory time consistent with AHA guidelines. At the time of order expiration the patient’s nurse will page the team with “FYI–Re: Mr. Example-Telemetry order has appropriately expired. Monitor will be removed in 30 minutes. Please re-assess patient before considering renewal.” The nurse will then remove telemetry in 30 minutes if there is no updated order placed.
Implementation began by piloting the new order set on 2 of the inpatient medicine services. The first 17 patients with an indication for telemetry monitoring were analyzed retrospectively, by reviewing daily “telemetry monitoring” nursing notes. This cohort was actively monitored on telemetry for 80 of the 140 (57%) total patient-days with 5 of 17 (29%) monitored continuously from admission to discharge, significantly less than the 82% monitored continuously observed in 2015.
Conclusions:
Our study demonstrated the proof-of-concept and short-term improvement in the number of patient-days on appropriate telemetry with an AHA guideline based order set. More importantly, there was a significant decrease in the number of patients monitored continuously throughout their course. We expect this will allow for improved bed utilization and cost savings. Lastly, although our intervention appears successful, further improvement opportunities and optimization are required to completely eliminate inappropriate monitoring.