Reducing Over-utilization of Cardiac Telemetry Monitoring Among Patients on the Teaching Service

From the 2019 HVPAA National Conference

Dr. Malek Mushref (Piedmont Athens Regional Medical Center), Dr. Muhammad Mufty (Piedmont Athens Regional Medical Center), Dr. James Pippim (Piedmont Athens Regional Medical Center, AU/UGA medical partnership program), Dr. Remus Popa (University of California Riverside)

Background

In hospital cardiac telemetry monitoring is intended for the detection of malignant arrhythmias in high risk patients. Telemetry is frequently over-utilized and this may impact the patient, the provider and the health care organization (HCO). It may lead to alarm fatigue in providers, higher hospital costs for HCO and unnecessary interventions in patients.

Objectives

To identify and reduce the rate of inappropriate use of telemetry monitoring in non-ICU patients admitted to the teaching service. We aimed to reduce inappropriate use by 20% over six months duration.

Methods

At Piedmont Athens Regional Medical Center (PARMC), we performed a chart review of 50 random patients on telemetry to identify potential areas of over-use. The possible reviewed areas were appropriate indication and duration of monitoring.The appropriateness was based on the American Heart Association (AHA) guidelines.

We performed two interventions targeting the internal medicine residents ,namely noon conferences and daily periodic review. The noon conferences discussed the AHA telemetry guidelines and strategies to reduce over-utilization. The second intervention was changing the residents’ daily progress notes template to require documentation of the indication and duration of telemetry monitoring.

We then calculated the average duration of telemetry monitoring per patient. We also calculated the number of hospital telemetry orders adjusted for the census during this period.

Results

The initial chart review showed that only 10% of patients had inappropriate indication while 31% of patients had at least one day of unnecessary monitoring. In January 2019 ( Pre-intervention), the teaching service’s census was 522 patients with 83 telemetry orders and 320 total telemetry days. The overall average duration of telemetry was 3.8 days per monitored patient. In February 2019 ( Post intervention 1), the census was 447 with 96 telemetry orders and 307 telemetry days. This correlated with 3.1 telemetry days per patient. In March 2019 ( Post intervention 2), the census was 534 with 91 telemetry orders and 258 telemetry days. The estimated average duration of telemetry was 2.8 days per patient. The overall reduction of telemetry duration was one day per patient after applying the two interventions. The estimated cost saving was:

53.44 (The estimated total daily cost to deliver telemetry per telemetry patient x 300 (Average hospital census)= $16067 per month.

The overall hospital telemetry utilization (Number of telemetry orders/overall census) was 26% in January, 33% in February and 28% in March.

Conclusions

After evaluating the current condition of telemetry utilization at PARMC, we found a low rate of inappropriate initial indication but a longer duration of monitoring in a significant percentage of patients. We chose the resident’s group for the first PDSA cycle. The first cycle showed fewer telemetry days among teaching service’s patients. This project is ongoing and we aim to continue monitoring results for 6 months and eventually apply the intervention to other hospitalized patients if the results are sustained.

Clinical Implications

Education of providers and applying daily periodic review of telemetry monitoring in non -ICU patients may reduce over-utilization. This has the potential to increase the number of available telemetry boxes, decrease alarm fatigue and potentially reduce hospital costs by saving $190,000 per year if the results are sustained.

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