Background: The Society of Hospital Medicine’s Choosing Wisely guidelines recommend regular assessment of inpatients’ need for urinary catheters and telemetry monitoring. Since studies suggest clinicians are not aware which patients have an indwelling catheter or are on telemetry, we aimed to use the electronic patient list to improve cognitive awareness of unnecessary urinary catheters and telemetry utilization.
Methods: As part of an institutional challenge to promote Choosing Wisely projects, we inserted a passive indicator on the electronic patient list that signaled an active telemetry or urinary catheter order for each patient (Fig. 1) in the Epic electronic health record (EHR). Clicking on the indicator enabled the provider to cancel the order. During the 6-month intervention, monthly e-mail education about the new feature and the Choosing Wisely recommendations were sent to residents and attendings at the start of their general medicine rotation. We utilized an interrupted time-series analysis to estimate changes in utilization. The pre-intervention period was defined as 9 months prior to the intervention. We excluded patients with hospital stays >14 days, had an ICU stay, or a catheter on admission. Utilization rates were obtained through the EHR and analyzed with R, v3.3.2.
Results: In total, 1,213 and 7,901 patients with a catheter and telemetry were assessed, respectively. Assuming pre-intervention trends, 29% fewer catheters were ordered (8.5% vs. 6.0%; p<0.05) (Fig.2), though no change in catheter duration was found (41.5 vs. 35.8 hrs; p>0.05). While no absolute difference in the percentage of patients who received telemetry orders was seen, a significant decrease in the ordering trend for telemetry (p<0.01) (Fig. 2) was noted after implementation. Additionally, patients receiving telemetry orders spent 18% less time on telemetry (42.5 vs. 34.9 hrs; p<0.01). The average monthly case mix index increased from 1.64 to 1.88 (p<0.05) and 1.25 to 1.40 (p>0.05) for patients who received a catheter or telemetry order, respectively.
Conclusions: Following implementation of this tool, we demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients. While it remains unclear whether the benefits were due to educational reminders or the electronic indicator, teaching alone is unlikely to lead to sustained practice changes. This intervention is highly generalizable as it involved a simple modification to one of the most widely used EHRs in the US.
