TELEMETRY

Inappropriate telemetry monitoring increases care costs and, although there is the notion that this monitoring can provide reassurance, telemetry misuse can have negative effects on patient care and the patient experience. This is also physically restrictive and creates a barrier for treatments including physical/occupation therapies, procedures, and imaging. In 2013, the Society of Hospital Medicine launched the Choosing Wisely Campaign, which recommended all nonintensive care telemetry decisions be protocol driven to reduce waste.(1) Several institutions have yet to implement these guidelines. Telemetry best practice advisories can offer targeted intervention to reduce cost while providing high-quality care.

The American Heart Association (AHA) and the American College of Cardiology (ACC) revised their telemetry guidelines in 2017. Based on these revisions, Society of Hospital Medicine, and Journal of the American Medical Association (JAMA) have provided recommendations for decreasing inappropriate non-ICU cardiac monitoring.(2,3) Some providers are unfamiliar with these guidelines. One study showed that 42% of providers were unable to provide AHA recommended monitoring indications.(4)

Additionally, ensuring the “five rights” of clinical documentation support are imperative in producing a successful telemetry BPA. Johnson et al redesigned a telemetry BPA to restrict firing to the hours of 8am to 6pm and restricted notifications to the attending provider thus abiding by two of the CDS rights, the right time, and the right person respectively. Over 240k BPA alerts fired in epic were analyzed. The mean time on telemetry decreased from 4481 min to 4311 mins.(5)

Alarm fatigue remains an issue regarding telemetry. One study reported the average non-intensive care monitor bed has approximately 350 alerts per day and only 0.01% of telemetry alarms identified a true emergency.(6) Johnson’s BPA implementation decreased the average number of alerts from 150 and to 76 per patient.(5)

In a randomized controlled design including over 500 patients, a E-Heart BPA decreased the number of days on patient telemetry from 5.0 to 3.8 (p=0.017) and the BPA stopped telemetry in 31.7% vs 23.3% of patients. There were no significant differences in the rapid response, code blues, or mortality in the two groups.(7)

The two studies examining EMR telemetry BPA implementation above, undoubtedly had significant cost savings to the patient and the hospital. Although there is significant institutional variability, telemetry can increase daily patient care costs from $34 to $1400 per day.(8)

Finally, improved patient throughput and lower length of stays can be achieved by having fewer patients with less overall time on telemetry. Given the current health care crisis and limited bed available, 91% of patients were delayed more than three hours while awaiting cardiac monitored bed; this translates into an added hospital cost of $168k.(9)

In summary clinical documentation support in the form of a telemetry utilization BPA abiding by the AHA/ACA best practice guidelines, can ensure the appropriate indication for a duration of telemetry monitoring on our patients. Evidence based medicine suggests that implementing an AHA supported BPA which abides by the clinical decision support rights (specifically the right time and the right person as illustrated above) improve patient care and throughput, decrease alarm fatigue, and have significant cost savings to patients and institutions without compromising quality care.

Submitted by Dr. Erin Kirkegaard

1. Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):486-492. doi:10.1002/jhm.2063 2. Reducing unnecessary telemetry monitoring: an SHM choosing wisely quality improvement implementation module. (2020). https://www.shmlearningportal.org/content/reducing-unnecessary-telemetry-monitoringshm- choosing-wisely-quality-impro 3. Yeow RY, Strohbehn GW, Kagan CM, et al.: Eliminating inappropriate telemetry monitoring: an evidence based implementation guide. JAMA Intern Med. 2018, 178:971-8. 10.1001/jamainternmed.2018.2409 4. Sharma P, Tesson A, Wachter A, Thomas S, Bae JG: Physician awareness of patient cardiac telemetry monitoring. J Hosp Adm. 2016, 5:76-80. 10.5430/jha.v5n3p76 5. Johnson T, Pahwa A, Knight A et al. Abstract 261: Best Practice Advisories Effects On Telemetry Ordering Habits. 12 May 2022https://doi.org/10.1161/circoutcomes.15.suppl_1.261Circulation: Cardiovascular Quality and Outcomes. 2022;15:A261 6. Jones K: Alarm fatigue a top patient safety hazard. CMAJ. 2014, 186:178. 10.1503/cmaj.109-4696 7. Kuo-Kai Chin, David Svec, Benjamin Leung, Christopher Sharp, Lisa Shieh. Postgraduate Medical Journal, Volume 96, Issue 1139, September 2020, Pages 556–559, https://doi.org/10.1136/postgradmedj-2019-137421 8. Henriques-Forsythe MN, Ivonye CC, Jamched U, Kamuguisha LK, Olejeme KA, Onwuanyi AE: Is telemetry overused? Is it as helpful as thought?. Cleve Clin J Med. 2009, 76:368-72. 10.3949/ccjm.76a.07260 9. Bayley MD, Schwartz JS, Shofer FS, et al. The fi nancial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med 2005; 45(2):110– 117. doi:10.1016/j.annemergmed.2004.09.010