Think Outside the Box: Using a Multi-Disciplinary Approach to Reduce the Overutilization of Telemetry

From the 2018 HVPAA National Conference

Brittany Katz (NewYork-Presbyterian/Weill Cornell Medical Center), Yasin Hussain (NewYork-Presbyterian/Weill Cornell Medical Center), Derek Mazique (NewYork-Presbyterian/Weill Cornell Medical Center), Lia Logio (Drexel University College of Medicine)

Background

Inappropriate remote telemetry is linked to increased healthcare costs and alarm fatigue. On the Internal Medicine service at NYPH/WCMC, a telemetry order remains active until a provider discontinues it or it “”auto-expires”” after five days. Beyond auto-expiration, there are no institutional methods for when to consider or to discontinue telemetry.

Objectives

1. Reduce the total number of telemetry-days among patients who are admitted to the Internal Medicine service by at least 30% within 12 months

2. Increase the number of provider discontinuations of telemetry (compared to auto-expiration) in the same population

Methods

From 7/1/2017 to 8/31/2017 (Phase 0, baseline), a daily automated report extracted demographic and order information (including admission date, telemetry start and stop dates, and discharge date) from all patients who were admitted or transferred to the adult inpatient General Medicine service. From 9/4/2017 to 11/2/2017 (Phase 1), we began our patient-driven protocol, which involved modifying our existing telemetry boxes to have a label in both English and Spanish that encouraged patients to discuss their need for telemetry with providers daily. After 11/3/2017 (Phase 2), we began distributing educational material to Internal Medicine resident physicians, physician assistants, and nurses regarding appropriate indications for telemetry based upon the American Heart Association practice guidelines. Before receiving any educational material, resident physicians and physician assistants were surveyed about their use and awareness of telemetry. On 3/19/2018 (Phase 3), the computerized order entry system was changed for auto-expiration to occur after two days (as opposed to five days) – data collection from that change is ongoing.

Results

We identified 196 patient encounters for remote wireless telemetry from Phases 0, 1, and 2 (Phase 3 is currently ongoing). Among those three phases, the average duration of telemetry for all patients was 3.51 days. Since 9/4/2017, 2870 stickers (approximately 19 per day) were applied to telemetry boxes. After our sticker and educational intervention, there was a non-significant decrease on duration of telemetry days (3.63 to 3.33, p = 0.19). Comparing baseline data to the end of Phase 2, the percentage of telemetry orders that auto-expired after five days was significantly decreased from 42.4% to 33.5% (p=0.02) Comparing the pre-intervention period to the end of Phase 2 (stickers and education), the number of transfers to a higher level of care were not significantly impacted by each arm of the intervention (p = 0.20).

Conclusion

Our patient-centered and educational interventions resulted in a non-significant decrease in the number of telemetry-days among eligible patients. The intervention also significantly decreased the number of telemetry orders that auto-expired after five days (i.e. long-term use of telemetry). Furthermore, this change in telemetry ordering did not result in patient transfers to higher levels of care (i.e. clinical deterioration)

Implications for the Patient

Through a multimodal and novel intervention, we were able to decrease the use of long-term use of telemetry (up to five days), which for most patients on a general Internal Medicine service is a low-value intervention