From the 2024 HVPA National Conference
Rupesh Prasad MD, MBA (Advocate Health) Tulay Aksoy MD, Sue Harvey MS, BSN, Elizabeth Mounir DNP, RN, Julie Schintgen BSN, RN
Background
Ours is an inner-city safety net hospital, part of a multi-hospital integrated health system. Each unit in our hospital has daily multidisciplinary team rounds (MDR) where there is discussion among patient care team members about all the patients on the unit.
It was identified that there is overutilization of telemetry monitors in patients admitted to the hospital, with telemetry monitoring reaching capacity on 6-8 days a month. This has contributed to boarding patients in the Emergency Department while awaiting telemetry box availability, also delaying care in the inpatient unit. Patients were noted to remain on telemetry beyond ACC AHA guidelines for indications, with no ongoing discussions of indication or need to continue it. The Hospital Telemetry Utilization Committee previously developed a nurse-driven protocol for discontinuing telemetry monitoring in appropriate patients, but it was not followed.
Objective
- To ensure discussion of telemetry indication and duration during multidisciplinary team rounds.
- To ensure timely discontinuation of telemetry, if not indicated, after the multidisciplinary team rounds.
Methods
A series of Plan-Do-Study-Act (PDSA) cycles were conducted to address the issue of telemetry utilization. As part of the MDR redesign and standardization, patient care team members were assigned various tasks related to telemetry monitoring. The nurse caring for the patient would report on telemetry findings during the MDRs. This report would be followed by the attending providers sharing the indication and planned duration of monitoring. The case managers would enter the room numbers of the telemetry discontinuations in the multidisciplinary teams’ communication channels on Microsoft Teams. This information on the communication channel served two purposes:
1- A reminder for providers to discontinue telemetry orders on their patients, and
2- A method for auditing the process of whether the orders were discontinued on patients who no longer required telemetry monitoring.
If the telemetry orders were not discontinued after one hour of MDRs, the RNs would send a secure chat message to the attending provider using the electronic medical records.
The quality management department was tasked with collecting and analyzing the data on telemetry order discontinuation. The tele discontinuation compliance rate was reported based on patients whose tele orders were discontinued by 3:00 pm the same day. They used the MDR communication channel for the room numbers and reviewed EMR records for order discontinuation.
Results
A review of the data over eight weeks revealed an uptrend in telemetry indications and duration discussion in MDRs and an improvement in the discontinuation rate of telemetry orders by 3 pm. The hospital reached capacity only twice during this period compared to 6 times in the preintervention period.
Conclusions
Discussion of telemetry indication and duration during multidisciplinary team rounds leads to early discontinuation of telemetry monitoring on inpatient units, thus freeing up telemetry for patients admitted from the Emergency Department.
Clinical Implications
Our project focuses on the appropriateness of use of telemetry monitoring in hospitalized patients that impacts patient outcomes including length of stay and cost of care. Targeting one of the key recommendations under the Choosing Wisely campaign of the ABIM and the Society of Hospital Medicine, the project is likely to serve as a guide for interventions towards optimizing telemetry monitoring.