From the 2021 HVPAA National Conference
Trushar Dungarani (Johns Hopkins Community Physicians at Howard County Community Hospital), Tiffany Mast
Background
Many reasons contribute to over-usage of telemetry: unawareness of patients on telemetry, unfamiliar with current guidelines, lack of standard work to discontinue telemetry are among some. Nurses spend excessive time dealing with false alarms instead of value-added patient care. Patient safety organizations have shown decreased patient mobility with telemetry use.
Objective
The aim of our study was to reduce inappropriate initiation and duration of telemetry. We attempted this process through education, nursing engagement and EMR changes. A reduction of telemetry duration to 24-29 hours for most medical/surgical floors would be more aligned with national guidelines.
Methods
The study took place at a community hospital in Columbia, Maryland. Only 2 of 6 telemetry floors had lower patient/nurse ratios with the remaining floors having the traditional 5-6 patients/nurse ratio regardless of telemetry needs.
On our adult medicine hospitalist service, we implemented a telemetry reduction intervention through lean process methodology that involved a multi-disciplinary team between April 2017 and January 2020. A team comprising of a physician, nursing leadership, executive champion and lean coach were put together to create a solution that would eventually be rolled out to the entire hospital.
Physician education was provided yearly during staff meetings. Nursing engagement and education improved through telemetry pocket cards which highlighted when patients could come off telemetry and night staff auditing which helped with nursing handoffs in the morning for why the patient is on telemetry. Nursing would discuss telemetry needs every day during multi-disciplinary rounds.
EMR changes included a plan to remove telemetry order from our general admission order set and also create a new telemetry order set with specific AHA conditions instead of a free text option. The primary outcome was reducing inappropriate telemetry duration, measured as the number of hours a patient was on telemetry and reducing inappropriate telemetry initiation. We also analyzed RRT/code event rates during this study.
Results
Among hospitalist service patients, telemetry duration was reduced between 30-40%. We also had a decrease in telemetry orders by around 30%. There were no significant changes in mortality and code event rates as well as patient volumes during this time period. Through extensive chart reviews, a trend toward lowered inappropriate telemetry for non-AHA conditions (Pneumonia, Sepsis, GI bleeds, AMS, etc.) was seen. “The estimated total daily cost to deliver telemetry was $53.44 per telemetry patient.1” We estimate a reduction in just over 6,000 patient/days per year by reducing both total hours and initial orders. TThe yearly cost savings, which included nursing time and equipment cost, was $324,810 per year.
Conclusions
Our results demonstrate that a multi-faceted approach and team led to an improvement in appropriate telemetry utilization. Staff engagement, leadership support, continuous process improvement and EMR changes were all critical to the success of this project.
Clinical Implications
Unnecessary telemetry monitoring is a top patient safety concern as stated by multiple patient safety organizations(IHI, Choosing Wisely, Joint Commission). Appropriate utilization of telemetry will help focus front line staff on higher value patient care activities while making sure there is a more focused effort on those patients who need telemetry.
