From the 2022 HVPA National Conference
Trent Johnson MS, MD (Johns Hopkins Hospital), Niloo Latifi MD, Amy Knight MD, Trushar Dungarani DO, Sammy Zakari MD, Amit Pahwa MD
Inpatient telemetry detects dysrhythmias. However, there is a low incidence of clinically significant arrhythmias on days telemetry is continued without a practice standard indication1, and telemetry is often continued beyond the recommended duration by AHA best practice standards leading to excess cost2,3. Prior interventions have incorporated electronic health record (HER) decision support tools to limit telemetry use with evidence of tailored alarms leading to a significant reduction in telemetry duration4. We have conducted a multi-center evaluation of the effects of a targeted EHR best practice advisory (BPA) on EHR alert burden and telemetry duration.
To study the effectiveness of a targeted BPA on daily EHR alert burden on the providers and average duration of telemetry monitoring at three Johns Hopkins Health System (JHHS) sites.
We performed a retrospective analysis of the number of telemetry BPA alerts encountered by providers and the duration of time on telemetry from October 2018 through December 2021 at Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, and Howard County General Hospital. We redesigned a previously existing telemetry BPA based on AHA telemetry duration guidelines to restrict firing to the hours of (8 AM to 6 PM) and to target notifications to only the first call and Attending providers. This intervention was implemented across the EHR system in October 2019 at the three JHHS sites.
We used Epic-generated data from 121, 621 BPA alerts and 88, 832 unique patient telemetry orders from the three sites. From the BPA alert data, we excluded patients with duplicate BPA alerts and limited the study to general medicine, general surgery, and medicine observation floors. From telemetry duration data, we excluded patients who had multiple simultaneous telemetry orders and chose to analyze encounters with the longest time on telemetry. The data was normalized for variation in total number of patients hospitalized over time using admission contact serial numbers (CSN) and inpatient admission orders.
Prior to targeted BPA implementation, the mean daily alerts per patient admission per month was 1.69 and decreased to 1.53 (p value <0.0001) [Figure 1]. The Pre-BPA implementation mean time to telemetry discontinuation per patient admission per month was 4223.79 minutes. The Post-BPA implementation mean time to telemetry discontinuation per patient admission per month was 3465.28 minutes corresponding to a 12.6 hour reduction (p value <0.001) [Figure 2]. Variations in the number of patient admissions over 24 months was not statistically significant (p 0.0899).
Despite practice standards, telemetry use outside of the ICU varies widely amongst providers and a non-targeted EHR best practice advisory alert can reduce the efficacy of this intervention. Targeting EHR BPA alerts to first call and attending providers responsible for patient care during the day can significantly reduce number of EHR alerts and duration of telemetry use.
Targeted EHR interventions that lead to a reduction in duration of unindicated telemetry monitoring can reduce costs of care and improve patient comfort without an increase in clinician EHR alert burden. This multicenter study shows the feasibility and efficacy of this intervention at various institutions with the potential for scalability to other EHRs.
Figure 1- Mean daily EHR BPA alerts triggered per patient admission per month. JHH and BMC time interval Oct. 2018-Dec. 2021. HCGH time interval Oct. 2019 – Dec. 2021. Intervention date Oct. 2019 (p value <0.0001).
Figure 2- Mean time to telemetry discontinuation per patient admission per month. Time interval Oct. 2018-Dec. 2021. Intervention date Oct. 2019 (p value <0.001).
1 Curry JP, Hanson CW 3rd, Russell MW, Hanna C, Devine G, Ochroch EA. The use and effectiveness of electrocardiographic telemetry monitoring in a community hospital general care setting. Anesth Anal. 2003;97(5):1483-1487 2 Sandau KE, Funk M, Auerbach A, et al. Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation. 2017;136(19):e273-e344. doi:10.1161/CIR.0000000000000527 3 Benjamin EM, Klugman RA, Luckmann R, Fairchild DG, Abookire SA. Impact of cardiac telemetry on patient safety and cost. Am J Manag Care. 2013;19(6):e225-e232. Published 2013 Jun 1. 4 Najafi N, Cucina R, Pierre B, Khanna R. Assessment of a Targeted Electronic Health Record Intervention to Reduce Telemetry Duration: A Cluster-Randomized Clinical Trial. JAMA Intern Med. 2019;179(1):11-15. doi:10.1001/jamainternmed.2018.5859