From the 2019 HVPAA National Conference
Dr. Sara Patrawala (University of Rochester), Mr. Eric Rankin (University of Rochester), Dr. Katherine Nicholson (University of Rochester), Ms. Kristy Filmore (University of Rochester)
Telemetry over-utilization is well documented despite clear guidelines and hospital protocols. This can lead to unnecessary downstream testing, increased length of stay, and costs to the patient.
To study the effect of a multifaceted intervention including changes to the electronic medical record, provider and nursing education as well as strengthening an existing nursing protocol.
A quality improvement project was developed to reduce unnecessary telemetry on one medical-surgical unit in our hospital.
Manual chart review was performed pre and post intervention to determine the type of order (Continuous versus 48H) as well as whether telemetry usage was appropriate. Appropriate was defined as whether the patient met the initial indication and telemetry was discontinued when that indication had expired.
A first PDSA cycle of this project included 3 interventions:
The first intervention was a change to the telemetry order panel in the EMR. For this, a multidisciplinary group (Cardiology, Neurology, Emergency Medicine, Hospital medicine) agreed to hard stop parity between the orders for continuous and 48H telemetry (previously the order required no indication or hard stops to order continuous while it did for 48H) as well as unify the list of indications for telemetry (each order had different indication lists despite clearly outlined indications in the hospital policy).
The second part of the intervention was reinforcing a nursing protocol requiring the charge nurse to document daily patients on telemetry and send a non-urgent page to the covering provider requesting review.
Finally, email notifications with discussion at resident-nursing teaching sessions regarding telemetry were implemented.
Our pre-intervention chart review revealed that more continuous orders were placed than 48H. Additionally, more inappropriate telemetry stemmed from failing to discontinue telemetry once the indication had expired. Chart review 1-month post intervention showed that continuous orders accounted for 82% (pre) versus 72% (post) indicating a reduction. We found that 76% of patients were placed on inappropriate telemetry (pre) versus 24% (post). Our sample size was too small to determine if the reduction in inappropriate telemetry overall came from reducing orders on patients who did not meet indication or from reduction in inappropriate continuation.
We reduced inappropriate telemetry usage on our unit. The current sample size is insufficient to determine if the EMR intervention played a role. Our initial hypothesis was that a reduction in inappropriate telemetry could be achieved by targeting those patients who met the indication but due to the presence of a continuous telemetry order (and not a self-expiring 48H order), were continued too long. We are collecting more data that will be used in our analysis to determine the effect our intervention had on reducing inappropriate telemetry. What we have learned thus far is that reducing telemetry is possible but not without a multidisciplinary team including both sub-specialists and importantly, nursing. Furthermore, understanding an institution’s barriers to the appropriate use of telemetry is essential in designing an intervention that will lead to the desired result.
Implication for patient care
Thus far our intervention appears to reduce unnecessary telemetry on a single unit. In addition to benefits such as reducing alarm fatigue, cost reduction, and preventing unnecessary downstream testing, patients often report dissatisfaction with wearing telemetry due to limitations on activity and sleep disturbance. By reducing unnecessary telemetry, we are improving the patient experience.