From the 2019 HVPAA National Conference
Dr. Sarah Snow (UCLA Health/David Geffen School of Medicine), Dr. Jonathan Barthelet (UCLA Health/David Geffen School of Medicine), Dr. Caleb Wilson (UCLA Health/David Geffen School of Medicine), Dr. Sun Yoo (UCLA Health/David Geffen School of Medicine)
Despite the existence of practice standards for inpatient use of cardiac monitoring and time-expiration for orders, patients are often inappropriately monitored, remaining on cardiac monitor longer than 48 to 72 hours and even until discharge. Inappropriate use of cardiac monitoring may increase fall risk and decrease sleep quality for patients, contribute to alarm fatigue by nursing, lead to further unnecessary testing, and drive up the overall cost of care. Improving resident education regarding the appropriate duration of cardiac monitoring for certain indications and utilizing nurse-driven discontinuation protocols may supplement automatically expiring orders to reduce the duration of cardiac monitoring.
To decrease the number of patients remaining on cardiac monitor at the time of discharge by 20% at 6 months.
We are using a LEAN A3 model to address the problem of inappropriate use of cardiac monitoring. We have performed a root-cause analysis, identified key stakeholders, and formed a multi-disciplinary team. We performed a chart review of all patients admitted to one medical-surgical unit at Ronald Reagan-UCLA hospital over a one-week period to obtain baseline cardiac monitoring data. Two months later, we re-reviewed these charts to obtain total cardiac monitoring days and percentage of patients with active cardiac monitor orders at discharge. We excluded patients with a history of prior heart or lung transplant or those who received heart or lung transplant during their hospital stay.
During the one-week period, 25 patients were monitored on telemetry, excluding four patients with heart or lung transplants. Each day, between 37.5% and 62.5% (mean 50%, median 50%) of patients on the medical-surgical unit were monitored on telemetry. The majority (80%) of patients had a cardiac monitor order that automatically expired at 72 hours with the option for renewal. The average length of stay for patients on cardiac monitor was 22.5 days (median 10 days). The average duration of cardiac monitoring was 20.9 days (median 10 days). Thirteen patients (52%) were monitored for ten or more days. Seventeen patients (68%) had an active cardiac monitor order at the time of discharge.
We will next implement plan-do-study-act (PDSA) cycle 1, surrounding resident education of appropriate duration of cardiac monitoring for various indications, and PDSA cycle 2, involving a nurse-driven discontinuation protocol. Following each PDSA cycle, we will re-examine cardiac monitoring data for the same medical-surgical unit.
The majority of patients remain on telemetry until discharge, despite the presence of automatically expiring orders. Further efforts are needed to reduce the duration of cardiac monitoring, including improved resident education and input from nursing.
Reducing the duration of cardiac monitoring may prevent additional harms to patients by decreasing fall risk, improving sleep quality, and preventing adverse outcomes related to alarm fatigue or further unnecessary testing related to false alarms.