The use of cardiac telemetry in the hospital setting became commonplace in American medicine in the 1960s.1 The American College of Cardiology (ACC) first published evidence-based indications for use of telemetry in 1991 and this remains the seminal source for telemetry guidelines.2 (See Table 1.) More recently, the American Heart Association (AHA) published its own set of guidelines for continuous cardiac monitoring in 2004.3 Despite the publication of indications for appropriate telemetry use by the ACC and AHA, widespread misuse of telemetry is prevalent in the hospital setting, specifically in the general medical-surgical level where continuous cardiac monitoring isn't commonly the standard of care.
Reasons for overuse include the perceived or actual existence of better nursing ratios, misunderstanding or lack of awareness by medical staff of the differing levels of care and associated standard of care, administrative deference to physician clinical decision-making and autonomy, and physician preference to concentrate patients on single units to ease physician rounding. Although these reasons may not be applicable to all hospitals, it's widely accepted that telemetry is an overused service.4 What may not be realized is that the overuse of telemetry can cause issues for patients and efficient hospital operations.5 Overuse of telemetry can result in alarm fatigue; unnecessary transferring of patients to various levels of care or units; and wasted financial resources in equipment and infrastructure, such as telemetry packs, wiring/cabling, and human resources to monitor the patient. Telemetry may be a scarce resource in many hospital settings, and lack of evidence-based use may result in bottlenecks.
The intent of this quality improvement project was to directly align the ordering process for telemetry with the ACC indications for appropriate telemetry use, chosen by the cardiology group as a matter of preference. Both ACC and AHA guidelines are based on expert opinion and widely accepted in evidence-based literature. Desired outcomes included improved patient experience, patient safety, and throughput/capacity management; reduced nursing workload; and better stewardship of scarce patient resources. The primary driver for the initial project was to improve capacity and eliminate the need to purchase additional telemetry monitoring equipment and infrastructure. As the key metric for this project, our focus was placed on the overall reduction of telemetry hours at the medical-surgical level of care.
Key drivers for change
Alarm fatigue. The purpose of telemetry is to observe continuous electronic cardiac waveforms in patients at risk for sudden cardiac deterioration. The actual use of telemetry over time has evolved as a proxy for closer observation and monitoring of heart rate. The overuse of telemetry may seem to have a benign overall effect on patient safety; however, research findings suggest that there are many unintended consequences of overmonitoring. One such well-studied and documented consequence is alarm fatigue.6
On any given hospital unit, there are numerous sights, sounds, and activities that may consequently mute or muffle important alarms. Telemetry monitoring comes with various alarms, some signaling critical events that require clinical intervention. Telemetry can also trigger nuisance alarms, such as low battery, artifact, and improperly set limits, contributing to alarm fatigue and increased workload. At Massachusetts General Hospital, a patient death was directly attributed to overmonitoring in 2010. The patient had a falling heart rate during a 20-minute timespan in which 10 nurses on duty failed to see or hear repeated alarms. The Centers for Medicare and Medicaid Services attributed desensitization to alarms as a factor in the patient's death.7
Although the process of continuously individualizing alarm settings for patients is tedious and time-consuming if done correctly, accuracy is key to preventing unnecessary alarms. In addition, orders may exist to remove a patient from telemetry for showering or transport to testing or procedures. These exceptions should be pause for inquiry of the true need for telemetry.
Capacity. Given the overuse of telemetry and the potential scarcity of telemetry-capable beds in the medical-surgical setting, capacity management becomes a patient safety and operational concern. Patients may be held in the ED, postanesthesia care unit (PACU), or other settings while waiting for a telemetry-capable bed, leading to potential care delays or alternate workflows.
This project was conducted at an inner-city tertiary care center with 386 beds and three levels of care. Telemetry-capable medical-surgical units totaling 70 beds were consistently running at near 100% capacity and patients were waiting for placement in the ED and PACU. Medical-surgical non-telemetry-capable units were running at 75% to 85% capacity. This often meant that there were available beds for pending patients; however, telemetry capacity wasn't available. Bottlenecks created by overuse of telemetry resulted in multiple patient moves and reprioritization of patients who were waiting for a telemetry-capable bed. Patient movement from one area to another increases the opportunity for errors related to handoff of care. The non-value-added work for nursing, environmental services, and other ancillary services (such as bed placement and transport) adds costs and creates delays, which contribute to decreased capacity.
Equipment and infrastructure. The cost of a telemetry pack, a portable heart monitor worn by patients, is between $3,500 and $5,000. Additionally, cabling, wi-fi infrastructure, and monitor screens to view the rhythm all generate thousands of dollars in infrastructure and maintenance costs, creating an unnecessary financial burden. Even further, human capital is required to observe and document the telemetry intervention. Organizations often choose to add infrastructure and equipment to solve the capacity issues identified rather than attempting to curtail unnecessary resource use. The long-term impact of this decision may negatively impact patient flow and outcomes and add significant amounts of unnecessary costs.
Staffing and culture. Inconsistent labeling of levels of care throughout the industry creates confusion for benchmarking purposes and contributes to the belief that patients receive additional nursing care if telemetry is ordered. Organizations commonly use similar naming conventions for ICU and medical-surgical areas. Variability in naming comes at the intermediate level of care, often called progressive cardiac care, telemetry, or step-down. Due to the inconsistency in nomenclature, it's critical to assess the organizational guidelines for patient placement as they relate to level of care.
Organizations may base level of care decisions on staffing ratios rather than actual workload. Patients on telemetry are perceived as sicker and are, therefore, assumed to require additional nursing care. Another scenario is that it's assumed the middle level of care requires telemetry as an expected standard regardless of patient diagnosis. The cultural aspect of patient placement shouldn't be minimized. Physician comfort with nursing care and staff familiarity contribute significantly to patient placement decisions, ultimately influencing the use of telemetry.
Setting the stage
For this project, patients admitted to a cardiologist were excluded from the initial project work based on the assumption that most would meet an ACC evidence-based reason for telemetry. The employed hospitalist group was approached as a first partner and recognized as a key stakeholder in driving change. The ACC guidelines were provided, along with several examples of non-evidence-based telemetry use. In addition, examples demonstrating the patient safety impact related to falls, handoff of care, and capacity management were provided to the hospitalist group. Information was shared regarding nurse staffing, which dispelled the belief that additional nursing hours were provided for telemetry.
To further bolster the concept that telemetry was an overused service, 30 patient records were chosen for a retrospective chart review by two physician leaders in the hospitalist group. The physicians received the ACC recommendations for telemetry use, reviewed the patient record, and documented on a spreadsheet which ACC recommendation was met. (See Table 2.) This review supported the theory of misalignment with evidence-based guidelines for telemetry use. Based on the ACC indications, the hospitalists performing the audit found only 57% of patients placed on telemetry were appropriate for the service. These data provided a foundation from which to begin our work and aligned with the evidence presented by Chen and colleagues, which concluded that one-fifth of telemetry patients are monitored for noncardiac conditions.6
Changing the culture
Telemetry wasn't seen as an intervention; rather, culturally it was viewed as a level of care associated with a misguided belief that the patient received additional nursing care or increased staffing. If a patient required telemetry, the initial order was placed for a monitored medical-surgical bed and no additional physician order for telemetry was required. Patients on telemetry had vital signs taken every 4 hours and the rhythm strips were documented each shift, contributing to nursing workload.
Cardiologists aided in the development of the change design, and the cardiology medical director navigated the change through the medical staff approval process. The first desired process for restructuring telemetry required adding a separate and distinct order in the electronic health record. Telemetry is no longer considered a standard of care based on admission to certain units. This reinforced the notion that telemetry is a distinct intervention. As part of the initial order for telemetry, physicians are required to select an ACC indication of telemetry use.
The second key function is an automatic telemetry order expiration at 48 hours. Evidence supports the removal of telemetry after 24 to 48 hours with no documented dysrhythmia.8 The physician is alerted at 24 hours that the patient has an expiring telemetry order and to assess and discontinue the order if necessary. Once the order has expired at 48 hours, the nurse receives an alert that the patient has an expired telemetry order and to assess and call the physician to discontinue the order or reorder if evidence-based reasons exist.
On August 20, 2018, the new telemetry ordering process for medical-surgical patients was implemented. This ordering process requires selection of an ACC indication for appropriate telemetry use at the time of the telemetry order and expires at 48 hours unless renewed. The hospital has demonstrated a reduction in monthly telemetry hours from 39,272 in July 2018 to 10,955 hours in October 2019. (See Figure 1.) A 72% decrease in telemetry hours has been sustained, with increased patient volume in the same time period. There have been zero adverse patient outcomes attributed to this project. No increase in rapid response team or code blue calls have been noted, which aligns with the study outcomes of Chong-Yik and colleagues.5
Before the project's implementation, the organization planned on hiring three additional telemetry technicians to monitor patients. As a result of these efforts, no additional resources were needed to centrally monitor patients. Telemetry usage before implementation ranged from 48 to 70 patients daily on the general medical-surgical units, with additional patients waiting for admission in the ED and PACU, at home, or at other regional hospitals transferring to a higher level of care. Postimplementation, our telemetry pack use ranges from 7 to 30 patients daily on general medical-surgical units. Opportunity remains on the progressive care units, which currently maintain telemetry as a standard of care.
Although not a new lesson, “culture eats strategy for lunch” should be emphasized.9 The commonly held belief that patients on telemetry receive more nursing care or additional staffing is a key driver in patient placement and the intervention of telemetry. Frequent, consistent communication and sharing the “why” and early wins are critical to leveraging change. Monthly reporting is distributed to nursing and physician leadership, demonstrating the sustained results in an easy-to-read format. Further, the daily house supervisor report shows the number of telemetry patients on the medical-surgical units. This reporting keeps the project in the spotlight and can visualize if a creep in practice change may be occurring. Real-time data feeds, such as a monthly report and house supervisor report, allow leadership to appropriately monitor the change and implement interventions when necessary to ensure continuous improvement.
To remain conservative, initial focus was placed only on the medical-surgical level of care. Leveraging the culture change on the progressive care units simultaneously would've been advantageous because there's likely equal opportunity for improvement at this level of care. Instituting a requirement for a telemetry order rather than assuming telemetry as a standard of care on the progressive care units will further reduce telemetry use. Elimination of telemetry as a standard of care will decrease nursing workload and aid in bringing focus to a patient-centric rather than a technology-centric environment. Examination of alerts to decrease alert fatigue may enhance physician and nurse satisfaction. Considerations include an alert at 48 hours to both the nurse and physician indicating that the order has expired and the ability for nursing to remove telemetry monitoring under certain conditions without notifying physicians. Examples of conditions for continued use with an appropriate order may include specific medications intended for cardiac intervention and evidence of a dysrhythmia in the last 48 hours.
Principles of change management and quality improvement combined to elevate clinical decision-making and reduce a costly intervention in this quality improvement project. Telemetry use was reduced by over 70%, and these gains have been sustained for the past year. Continual data transparency with key stakeholders ensures that the overuse of telemetry doesn't resume. The project also demonstrated to physicians and staff the potential to create widespread change quickly, efficiently, and safely. Organizational capacity realized immediate benefits, reducing the need for use of overflow areas by 95% and maximizing all beds within the hospital.
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