,From the 2024 HVPA National Conference
Charlie Magee MD, MPH (University of Virginia), David Ling MD, Quang Le MD, Kelley Mark MD, Scott Austin BSN
Background
Inpatient cardiac monitoring (“telemetry”) is useful to identify clinically important arrhythmias and cardiac ischemia. This monitoring has indication-specific practice standards set in 2004 and updated in 2017 by the American Heart Association (AHA). Yet excess telemetry monitoring contributes to care burden and alarm fatigue for healthcare personnel and comes at a cost to patients and institutions and telemetry stewardship has remained a focus of the Choosing Wisely campaign since 2013. Prior to January 2022, University of Virginia (UVA) Medical Center lacked an active stewardship practice on acute care medicine units and at times exceeded cardiac monitoring (“telemetry”) capacity on these units.
Objective
Using a Plan-Do-Study-Act (PDSA) approach, a single, acute care medicine unit sought to align telemetry monitoring to the 2017 AHA Practice Standard using a multi-modal approach.
Methods
The first PDSA cycle included consolidation of the 2017 AHA Practice Standard into a simple, easy-to-follow infographic (figure 1), coupled with education by the unit medical director and integration into daily interdisciplinary rounds on a single acute care medicine unit. Analysis of telemetry utilization included data 8 months before and after the intervention. Escalation to intensive care was used as a balancing measure. The second cycle included development and implementation of a time-triggered, indication-specific automated alert to discontinue latent telemetry orders exceeding Practice Standard durations, adapted from Krouss et al (Krouss M, Israilov S, Alaiev D, et al. Tell‐a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system. J Hosp Med. 2023;18:147‐153. doi:10.1002/jhm.13030.). This PDSA cycle began on a single unit and disseminated across all acute care medicine units in the UVA Medical Center due to interim analysis.
Results
During the first PDSA cycle, a 48% reduction in total monthly unit-hours of telemetry monitoring (table 1; 847 hours before, 437 hours after; p=0.04) was achieved with no significant change in escalations to intensive care. The second cycle included 3 months of implementation on a single acute care medical unit from November 2023 through January 2024. During this time, the automated alert achieved a telemetry order discontinuation over 66% of the time it was triggered. All stewardship interventions were subsequently disseminated to all acute care medicine units beginning in February 2024. From February through March 2024, treating providers received 244 automated alerts and discontinued orders over 62% of the time, with a BPA burden under one alert per unit per day. Initial feedback from operational leadership informed of immediate operational cost deferment of over $225,000 in additional equipment purchase and remote cardiac monitoring reduced by 3.4 telemetry technician full-time equivalents. Interim analysis at 3- and 6-month intervals and formal cost analysis is planned to assess per-unit and per-patient telemetry hours following dissemination to all acute care medicine units in February 2024.
Conclusions
A multi-modal approach to telemetry stewardship achieved improvement and automated alert engagement exceeding that previously reported by Krouss et al.
Clinical Implications
Best-in-class telemetry stewardship was achieved through a multi-modal intervention. Additional study is necessary to further characterize the relationship and benefits of a multimodal approach to telemetry stewardship.