From the 2018 HVPAA National Conference
Fatima Shahid (Cleveland Clinic), Nabil Madhun (Cleveland Clinic), Susan Vehar (Cleveland Clinic), Shailee Shah (Cleveland Clinic), Anne Harwood (Cleveland Clinic), Rabel Misbah (Cleveland Clinic), Jason Wheeler (Cleveland Clinic), Tamara Sussman (Cleveland Clinic), Shruti Gandhy (Cleveland Clinic), Dianna Copley (Cleveland Clinic), Jessica Donato (Cleveland Clin)
Approximately $250,000 is spent on unnecessary cardiac monitoring in an average hospital annually. In 2004, the American Heart Association (AHA) published guidelines for cardiac monitoring, yet physicians continue to place patients on telemetry when it is not indicated. Overuse of telemetry results in waste, over-treatment, patient discomfort and alarm fatigue.
This resident-led multi-disciplinary quality improvement project aimed to reduce inappropriate ordering of telemetry by residents rotating through General Internal Medicine (GIM) teaching service by 20% over 3 months by implementing a multipronged intervention targeting resident knowledge of telemetry guidelines and awareness of telemetry status.
A baseline survey was conducted to assess trainee knowledge regarding indications for telemetry and the associated cost. Review of the electronic medical record was used to determine telemetry status and indications for patients on GIM teaching service between January 2018 and March 2018. Cleveland Clinic Health System Telemetry Guidelines, which are based largely on the AHA Telemetry Guideline’s class I and II indications, were used to determine appropriateness of telemetry orders. After baseline data collection, a series of interventions were implemented. In order to increase resident awareness of telemetry status, residents were instructed to add a telemetry status column to their patient rounding lists in the electronic medical record (EPIC). This was followed by discussion of overuse of telemetry at an educational conference and distribution of telemetry guidelines in the conference handout. Statistical analysis was performed using χ2 test.
Only 13 % of residents checked orders for telemetry, 32% were not aware that the AHA telemetry guidelines existed and 61% were somewhat familiar with the guidelines. Prior to our interventions, 32% of patients were on telemetry, of which 67% were inappropriately on telemetry. After implementation of use of the telemetry column on resident Epic patient lists, 28% of patients were on telemetry, out of which 34 % did not have an appropriate indication. This resulted in 33% reduction in inappropriate use (p= 0.008). After discussion regarding overuse of telemetry at the program educational conference, 40% of patients were on telemetry, out of which 37% had inappropriate indications, resulting in 30% reduction of inappropriate usage from baseline (p= 0.012).
A significant proportion of general medicine patients are placed inappropriately on telemetry. This occurs despite institutional-level interventions to incorporate telemetry indications into the telemetry order. The physician culture of ordering telemetry as a safety net, lack of awareness of telemetry status, and limited knowledge regarding telemetry guidelines contribute to overuse. Our intervention to increase physician awareness of telemetry status through inclusion of the telemetry column on Epic patient list was effective in reducing inappropriate use. Subsequent resident education on telemetry guidelines was effective in helping to maintain a reduction in inappropriate telemetry orders but did not result in further reductions in inappropriate orders.
Implications for the Patient
Lack of physician awareness regarding patients’ telemetry status contributes to inappropriate telemetry use. This can be mitigated by incorporating telemetry status into resident patient lists in the electronic medical record. Our study was effectively able to reduce inappropriate telemetry use by 33% (p= 0.008).