A Delaware healthcare system was able to reduce its use of cardiac telemetry by 70% without affecting patient safety by integrating American Heart Association guidelines into their electronic ordering system (EOS), saving the provider millions of dollars.
Non-intensive-care use of cardiac telemetry to detect arrhythmia is among the most overused diagnostic tests in cardiovascular medicine, as evidenced by its appearance in March of 2013 on the ' list of top five tests and practices that are widely performed but have questionable value to patients.
Action Points
- The Choosing Wisely campaign advocates the use of a protocol to govern the continuation of telemetry monitoring and suggests AHA guidelines be used to determine appropriate telemetry guidelines.
- Using these guidelines to set limits on telemetry monitoring outside the ICU and incorporating these guidelines into the inpatient electronic ordering system markedly reduced the number of patients monitored with telemetry without a significant increase in adverse outcomes.
When the Newark, Delaware-based provider Christiana Care Health System implemented their revised EOS based on the AHA recommendations there was an "immediate and sustained reduction" in weekly, non-ICU telemetry orders and per patient telemetry duration, , and colleagues wrote in published online Sept. 22.
"This intervention is estimated to save our organization $4.8 million annually, suggesting that efforts addressing opportunities listed in the 'Choosing Wisely' campaign can be an effective strategy to enhance value-added health care," the researchers wrote.
Earlier Telemetry Reduction Efforts Failed
In 2004 the American Heart Association published that stratified patients into the categories of 'telemetry is indicated, 'may provide benefit', or 'is unlikely to provide benefit.'
Dressler and colleagues noted that earlier efforts within their 1,100-bed tertiary care system to reduce the use of cardiac telemetry proved largely unsuccessful. These efforts relied on educating healthcare providers about the AHA recommendations.
"It turns out this is not a particularly effective strategy," Dressler told 51˶, adding that hardwiring AHA guidelines into the system's EOS removed clinical conditions not supported by the guidelines from the cardiac telemetry order set.
"If the condition is complicated and the physician thinks the patient requires telemetry, they can still go find the order and order it," he said.
Under the revised system, orders for cardiac telemetry also require providers to select a telemetry duration, determined by the AHA recommendations, based on clinical indication.
Indications for 24-hour telemetry include:
- ruling out MI
- implantation of an automatic defibrillator lead or a pacemaker lead
- uncomplicated ablation or an arrhythmia
- major surgery
Indications for 48-hour telemetry include:
- acute MI
- acute and subacute congestive heart failure
- thoracic surgery
- acute stroke
- complex major surgery
Bedside nurses are also authorized to discontinue cardiac telemetry within the EOS. When they determine that termination might be unsafe -- such as when a patient had unstable blood pressure -- the nurse can contact the physician to override the EOS.
Daily Telemetry Costs Dropped by $13,199
In an effort to assess the safety and efficacy of the redesigned telemetry orders, Dressler and colleagues reviewed data for non-ICU, adult patients from December 31, 2012 to August 12, 2013. The redesigned orders went into effect on March 18, 2013.
Measured outcomes included a mean weekly number of patients with telemetry orders, mean duration of telemetry, and rapid response activation, codes and deaths.
In the weeks following the implementation, weekly telemetry orders fell from 1032.3 to 593.2, and the mean duration of telemetry fell from 57.8 hours to 30.9 (reductions of43% and 47%, respectively; P<0.001).
The mean daily number of patients monitored with telemetry decreased 70% from 357.5 to 109.1, but hospital census, code blue, mortality and rapid response team activation rates did not change throughout the observation period.
"Nurses spent a mean of 19.75 minutes per patient on telemetry-related tasks daily (>115 hours system wide)," the researchers wrote. "The estimated total daily cost to deliver telemetry was $53.44 per telemetry patient; thus, our mean daily cost for non-ICU cardiac telemetry decreased from $18,971 to $5772 (a $13,199 per day reduction)."
The revised ordering saved the system money and it also appeared to improve patient safety by freeing nurses to perform critical bedside care instead of dealing with telemetry issues, Dressler said. He added that about 70% of telemetry alarms are battery related.
Some Telemetry Practices 'Clinically Irrational'
In a related editorial, of the University of California, San Francisco called for a randomized trial of telemetry including non-ICU patients without known cardiac conditions. He said the exclusion of such patients was a limitation of the AHA guidelines.
He argued that many widespread telemetry practices, such as monitoring patients until the moment of hospital discharge, are "clinically irrational."
Najafi wrote that the dramatic decrease in telemetry use with no significant increase in adverse outcomes was "remarkable," adding that two findings were suggested by the study results.
"First, telemetry is overused, and the AHA guidelines, imperfect as they may be, can safely rein in unnecessary monitoring," he wrote. "Second, since the guidelines exclude patients who do not have a primary cardiac condition, the intervention must have safely reduced or nearly eliminated monitoring for these patients."
Primary Source
JAMA Internal Medicine
Dressler R, et al "Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines" JAMA Intern Med 2014; Sept. 22.