Even when patients are on telemetry monitoring according to appropriate guidelines, "there are very few things they tell us that we can't find out in other ways," researcher says.
Andrew Doorey, MD |
Analysis of one large healthcare system's care practices has found that 70% or more of non-ICU, non-cardiac patients were tethered to telemetry monitors even though they didn't have conditions requiring it.
"The wires get tangled all the time, people trip over them, and in elderly patients their center of balance is disturbed by the box, [onto] which they roll over in their sleep and endure a big metal thing crushing their chest," says Andrew Doorey, MD, a cardiologist at Christiana Care Health System, in Newark, DE.
Moreover, most of these patients had conditions such as simple pneumonia, which by themselves don't require telemetry monitoring, he says.
The one-year cost of avoidable complications and potential injuries due to telemetry overuse in the 1,100-bed hospital system were estimated by researchers to be $4.8 million.
Doorey says that clinicians—not just at his hospital but across the country—have gotten into a "habit," a kind of "default action," of putting non-cardiac, and non-ICU patients who aren't at risk for cardiac events or stroke on telemetry monitors "for liability reasons." This practice goes against specific guidelines set up by the American College of Cardiology/American Heart Association.
"No one wants their patient to not be on a monitor, because if something went wrong, you'd look horrible," Doorey says. But Christiana clinicians determined that conclusion was "ridiculous."
Doorey and four other Christiana providers published their findings as in Monday's JAMA Internal Medicine. Their research garnered Christiana the 2014 Health Devices Achievement Award from ECRI Institute, announced on Thursday.
As a result of the telemetry project, Christiana changed its practice last year to reduce monitoring in order sets, and has not had any cases of non-monitored patients who have suffered an event and died or required a rapid response team intervention for lack of it ever since, he says.
"We've made this the standard of care, and we still have not identified anybody with a bad outcome which would have been better had they been on telemetry," Doorey says. Now, prompts in the system's electronic health record remind clinicians when guidelines say any particular patient might be taken off telemetry after 24 or 48 hours.
The revised telemetry order sets led to a reduction in telemetry use from 1,032 per week to 593 and the mean duration fell from 57.8 to 30.9 hours. "The mean daily number of patients monitored with telemetry decreased 70%, from 357.5 to 109.1," the clinicians wrote in their paper. The mean daily total cost to deliver telemetry fell from $18,971 to $5,772.
Initially, clinicians thought that front line nurses would be upset because they typically regard telemetry units as "an extra set of eyes or a backup" in the event a patient develops a significant arrhythmia or heart attack.
"It was our biggest surprise," he said. "Instead of objecting, they said "Oh my God; this is overdue. Get rid of these darn things" for those patients that guidelines say don't need to be on them.
In their study, the physicians and their nursing collaborators tracked nursing time on several telemetry floors and found that the time required for each nurse to answer signals from telemetry units was about 20 minutes per unit per day.
Almost always, the cause was loose wires, a low battery, or a motion artifact that can resemble atrial fibrillation. "They get called a lot. The patient may be dying, but they may also be brushing their teeth."
Doorey says the analysis did not take into consideration the many hours a day devoted to telemetry nurses who must accompany patients to get a CT or an MRI in another part of the hospital, which they often have to do, staying there until the test is done and returning the patient to the unit. "These are the best nurses we have, basically wasting time doing trivial stuff."
Also, Doorey says, the hospital system realized that the ED was sometimes backed up with patients waiting until a bed with telemetry came available, a common reason for ED boarding nationally. With the new policy, that went away as well.
The project, which was conducted by the Christiana safety committee, came almost by accident, after a problem that occurred one night with a communications breakdown between the units and the central command center that monitors them. There was an alert, which was in all likelihood not a real alert, but clinicians couldn't determine which patient needed attention. There were 377 patients on telemetry, more than half of the non-ICU patients in the hospital that day.
The new policy does not tell clinicians that they have to remove patients from telemetry when they don't specifically meet the guidelines. "There is what we call a 'hair on the back of the neck' box, which you can check when you just don't feel comfortable taking the patient off of telemetry," Doorey says. "If they feel it's not right, it's not right."
An upcoming paper from Doorey and the Christiana quality committee looks at actual events, such as ventricular tachycardia, ventricular fibrillation, and asystole, that occur among patients assigned to telemetry and finds them "exceedingly rare," Doorey says.
Even when patients are on telemetry monitoring according to appropriate use of the AHA/ACC guidelines, "there are very few things they tell us that we can't find out in other ways, and we can wait for those other ways."
UCSF's Nader Najafi, MD, wrote in JAMA Internal Medicine that the Christiana report has two conclusions:
"First, telemetry is overused, and the AHA guidelines, imperfect as they may be, can safely rein in unnecessary monitoring. 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. It is a reminder of the absence of known clinical benefit of using telemetry on medical and surgical services."
"Technology often overtakes scientific evidence in the race to the bedside," he added. We must remain vigilant against this outcome in the name of patient safety and cost."