Clinical Redesign: L+M Telemetry Optimization

From the 2019 HVPAA National Conference

Mrs. Alexandra Brown (Lawrence + Memorial Hospital), Mrs. Shannon Christian (Lawrence + Memorial Hospital), Ms. Linda Hickey (Lawrence + Memorial Hospital), Dr. Kenneth Donovan (Lawrence + Memorial Hospital), Dr. Mark Somers (Lawrence + Memorial Hospital), Dr. Oliver Mayorga (Lawrence + Memorial Hospital), Ms. Judy Wallquist (Lawrence + Memorial Hospital), Mrs. Melissa Swan (Lawrence + Memorial Hospital), Dr. Scott Sussman (Yale New Haven Health), Ms. Stephanie Amport (Yale New Haven Health)

Background

When Lawrence + Memorial Hospital joined the Yale New Haven Health System (YNHHS) the Clinical Redesign team felt looking at telemetry utilization at our facility could help to reduce telemetry usage thereby decreasing length of stay and ensuring telemetry was being used for the correct patient population.

Objective

By February, 2018, integrate evidence-based telemetry utilization with clinical practice to ensure the right patients are on telemetry (appropriate indication and ordering) and patients are taken off telemetry when the indication has passed (discontinuation of telemetry monitoring when no longer meet criteria).

Methods

The Clinical Redesign project cycle time kept the team focused on concrete steps to generate swift implementation of high impact change interventions. Through a series of specific interventions, which included 1. Updating the Health System-wide telemetry orders to AHA standards, 2. Removing telemetry option from ED transition orders, 3. Adding telemetry BPA when “Patient requires telemetry” is chosen in admission orders, 4. Adding a telemetry assessment nursing BPA, 5. Integration of telemetry discussion at daily interdisciplinary disposition rounds, 5 collecting information on “other” indications for tele to understand utilization of orders outside guideline. 6. Epic workbench report to track and facilitate discussions of patients on telemetry, and, 7. Shift RN telemetry order workflow from “discontinuation” to “complete” when order criteria has been met, 8. Eliminating duplicate orders. Metrics were established to monitor appropriate use (Number of Orders), reduce unnecessary telemetry, efficiency in ordering telemetry, and telemetry duration (Average Length of Stay in hours (ALOS)).

Results

see attached table

Discussion

Our data indicates an improvement with following evidence based practice utilizing the AHA practice standards to order and discontinue telemetry. After implementing several interventions an increase in the number of actual telemetry orders was noted with a continued decrease in ALOS. While reviewing data duplicate telemetry orders were identified, which was corrected in October 2018 and a dramatic decrease in both telemetry orders and ALOS was observed. Lessons learned was that data will continue to be evaluated over time since the elimination of duplicate orders and interventions will be refined accordingly. A limitation of this project was the discovery of duplicate telemetry orders, which prevents the accurate comparison of baseline to performance data.

Clinical Implications

Patient: Improved patient experience, reduction in unnecessary monitoring and decreased cost of care. Providers: Reduction in unnecessary monitoring and reduction in exposure to data that is not interpreted. Hospital: Reduced cost of care and increased provision of appropriate AHA guideline-based care. The collaborative interdisciplinary teamwork used to update system wide practice provides a framework for improving clinical processes across YNHHS. Additionally, the team charter goals meet evidence based practice.

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