From the 2019 HVPAA National Conference
Dr. Akanksha Kashyap (Long Island Community Hospital), Dr. Maryam Tavanaei (Long Island Community Hospital), Dr. Franklin Ugbode (Long Island Community Hospital), Dr. Ravi Gupta (Long Island Community Hospital)
Background
Telemonitoring is a powerful but limited and expensive tool used extensively through hospital systems to monitor cardiac activity. Due to a sicker, aging population and the false assurance that close monitoring leads to better clinical outcomes, there has been an overutilization of telemetry. Its clinical effectiveness is often overestimated in patients who do not meet American Heart Association (AHA) guidelines.
Objective
Our study aims to decrease the number of unwarranted telemetry admissions and the duration of time patients spend on telemetry by applying a multi-disciplinary approach in changing current hospital -based processes in order to improve patient care and costs.
Methods
The study was performed in 306- bed community hospital. Data was collected from the electronic medical record (EMR) for all adult patients admitted to telemetry from the Emergency Department. Retrospective data was obtained from January 1 to December 31, 2018 as a baseline comparison before initiating interventions on January 8, 2019.
A FMEA analysis conducted by a newly-formed telemetry committee concluded lack of physician awareness on AHA guidelines for telemonitoring, order sets defaulting to telemetry, no set process for discontinuation, and overall lack of a multi- disciplinary approach.
Based on this analysis, the sequence of admitting and discharging patients from telemetry was remodeled. Foremost, the telemetry admission order set was retired. Telemetry is now selected as a separate order in patients requiring monitoring on the Medical or Surgical Unit. These orders are valid only for 48 hours after which the patient’s nurse receives an electronic prompt to discuss its discontinuation with the physician. Once discontinued, the order appears on the nurse’s worklist requiring their acknowledgement. Unit secretaries, telemetry technicians, and bed board receive a page regarding the suspension of telemetry.
Results
The average duration of telemetry use declined to an average of 82.3 hours in 2019 compared to 103.2 in 2018(Graph 1); more patients were having telemetry discontinued after implementation of the new changes. Of the 5,412 patients admitted to telemetry in 2018, only 26.8% had an appropriate indication for monitoring (Table 1) with less patients meeting guidelines (20.8%) between January to March 2019(Image 2).
Conclusion
Our study demonstrated that up to 73.2% of patients on telemetry are without appropriate indication. Though our interventions did not target or result in less patient’s being placed on telemetry, the new process has increased awareness and helped reduce the duration of time patients spend on telemetry. Simple measures such as changes in our EMR order sets, electronic reminders, and a multi-disciplinary team approach has facilitated the transfer of patients off of telemetry with an expected improvement in patient care and economic costs.
Our study had limitations including assessing indication for telemetry based on the admitting diagnosis and not the patient’s cardiac history. The future goal of the study is to implement changes to decrease the number of admissions to telemetry through educational interventions by providing evidence -based guidelines on its proper utilization.
Clinical Implications
Expanded surveillance like telemonitoring in general care is overutilized and has decreased clinical effectiveness. Our quality improvement project decreased the average duration on telemetry leading to better patient care and reduction in patient and institutional costs via less purchases of telemetry boxes, averting cost of telemetry beds and avoiding extraneous medical work up from false telemonitoring alarms.
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