Inpatient Telemetry Does Not Need To Be Used in the Management of Older Patients Hospitalized With Chest Pain at Low Risk for In-Hospital Coronary Events and Mortality

Telemedicine in Cardiology: Modern Technologies to Improve Cardiovascular Patients’ Outcomes—A Narrative Review

The registration of physical signals has long been an important part of cardiological diagnostics. Current technology makes it possible to send large amounts of data to remote locations. Solutions that enable diagnosis and treatment without direct contact with patients are of enormous value, especially during the COVID-19 outbreak, as the elderly require special protection. The most important examples of telemonitoring in cardiology include the use of implanted devices such as pacemakers and defibrillators, as well as wearable sensors and data processing units. The arrythmia detection and monitoring patients with heart failure are the best studied in the clinical setting, although in many instances we still lack clear evidence of benefits of remote approaches vs. standard care. Monitoring for ischemia is less well studied. It is clear however that the economic and organizational gains of telemonitoring for healthcare systems are substantial. Both patients and healthcare professionals have expressed an enormous demand for the further development of such technologies. In addition to these subjects, in this paper we also describe the safety concerns associated with transmitting and storing potentially sensitive personal data.

Monitoring the Use of Telemonitor: A Resident-run Quality Improvement Initiative Decreases Inappropriate Use of Telemonitor in a Community Hospital

Background Cardiac telemetry is an important tool to detect life-threatening conditions in hospitalized patients but is used widely and inappropriately. We sought to assess current usage and improve the appropriate use of telemetry in a community hospital. Methods We conducted a quality improvement project on patients who were admitted on telemetry floors between January and March 2017 (pre-intervention). The indication(s) and duration of telemonitor use, event(s) recorded on telemonitor and outcome of the event(s) were documented. A six-month educational intervention was undertaken and the effect of intervention was assessed among patients admitted between December 2017 and February 2018 (post-intervention). Results In the pre-intervention group, 329 patients qualified for the study, with a median age of 78 years. The post-intervention group had 383 qualified patients with a median age of 77 years. Mean duration of telemonitor use was four days in both groups. In the pre-intervention group, 54% had class I, 32% had class II, and 14% had class III indications. In post-intervention group, 46% had class I, 42% had class II, and 12% had class III indications. The educational intervention resulted in a trend towards less inappropriate use of telemetry, particularly in teaching service. Telemonitor events were recorded in 22 (7%) of the pre-intervention patients and 13 (4%) of the post-intervention group. Two patients died in the pre-intervention group and one in the post-intervention group from non-cardiac causes. Conclusion Our results highlight that change in practice requires sustained education interventions.

Comprehensive in-hospital monitoring in acute heart failure: applications for clinical practice and future directions for research. A statement from the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

This paper provides a practical clinical application of guideline recommendations relating to the inpatient monitoring of patients with acute heart failure, through the evaluation of various clinical, biomarker, imaging, invasive and non-invasive approaches. Comprehensive inpatient monitoring is crucial to the optimal management of acute heart failure patients. The European Society of Cardiology heart failure guidelines provide recommendations for the inpatient monitoring of acute heart failure, but the level of evidence underpinning most recommendations is limited. Many tools are available for the in-hospital monitoring of patients with acute heart failure, and each plays a role at various points throughout the patient's treatment course, including the emergency department, intensive care or coronary care unit, and the general ward. Clinical judgment is the preeminent factor guiding application of inpatient monitoring tools, as the various techniques have different patient population targets. When applied appropriately, these techniques enable decision making. However, there is limited evidence demonstrating that implementation of these tools improves patient outcome. Research priorities are identified to address these gaps in evidence. Future research initiatives should aim to identify the optimal in-hospital monitoring strategies that decrease morbidity and prolong survival in patients with acute heart failure.

Guideline-based intervention to reduce telemetry rates in a large tertiary centre

BACKGROUND

Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs.

AIM

To evaluate the outcomes of guideline-based application of cardiac telemetry.

METHODS

Phase I involved a prospective audit (March to August 2011) of telemetry use at a tertiary hospital. Data were collected on indication for telemetry and clinical outcomes. Phase II prospectively included patients more than 18 years under general medicine requiring ward-based telemetry. As phase II occurred at a time remotely from phase I, an audit similar to phase I (phase II - baseline) was completed prior to a 3-month intervention (May to August 2015). The intervention consisted of a daily telemetry ward round and an admission form based on the American Heart Association guidelines (class I, telemetry indicated; class II, telemetry maybe indicated; class III, telemetry not indicated). Patient demographics, telemetry data, and clinical outcomes were studied. Primary endpoint was the percentage reduction of class III indications, while secondary endpoint included telemetry duration.

RESULTS

In phase I (n = 200), 38% were admitted with a class III indication resulting in no change in clinical management. A total of 74 patients was included in phase II baseline (mean ± standard deviation (SD) age 73 years ± 14.9, 57% male), whilst 65 patients were included in the intervention (mean ± SD age 71 years ± 18.4, 35% male). Both groups had similar baseline characteristics. There was a reduction in class III admissions post-intervention from 38% to 11%, P < 0.001. Intervention was associated with a reduction in median telemetry duration (1.8 ± 1.8 vs 2.4 ± 2.5 days, P = 0.047); however, length of stay was similar in both groups (P > 0.05).

CONCLUSION

Guideline-based telemetry admissions and a regular telemetry ward round are associated with a reduction in inappropriate telemetry use.

Does cardiac rhythm monitoring in patients with elevated troponin levels lead to changes in management?

BACKGROUND

We sought to identify the frequency of arrhythmias in patients with elevated cardiac troponin levels and without ST-segment elevation myocardial infarction or a primary arrhythmia, and to determine whether detection of an arrhythmia leads to management changes.

METHODS

A review of 1381 consecutive patients admitted from the emergency department for rhythm monitoring with an elevated cardiac troponin T (cTnT) level was performed. Patients admitted to an intensive care unit and those with an initial primary arrhythmia were excluded. Troponin values were obtained on admission, at 3 hours and at 6 hours. Electronic medical records and all rhythm recordings were reviewed for documentation of an arrhythmia and any changes in management.

RESULTS

An arrhythmia was detected in 26% of the 330 patients who met the inclusion criteria. Those with arrhythmias had higher rates of coronary artery disease and prior percutaneous coronary intervention ( p = 0.02 and p = 0.01, respectively). Those with arrhythmias had higher mean cTnT values compared to those without arrhythmias ( p = 0.02 at 3 hours and p = 0.006 at 6 hours) even after controlling for a discharge diagnosis of acute coronary syndrome. Changes in management in response to the detection of arrhythmias were infrequent (6.3%) and usually included only changes in medication doses.

CONCLUSIONS

Patients admitted with an elevated cTnT level to a non-intensive care unit rhythm-monitored bed without ST-segment elevation myocardial infarction or primary arrhythmia have a high incidence of arrhythmias; however, changes in management are infrequent.

Telemetry bed usage for patients with low-risk chest pain: review of the literature for the clinician

BACKGROUND

Telemetry monitoring in patients with low-risk chest pain is highly utilized, despite the lack of quality data to support its use.

STUDY OBJECTIVES

To review the medical literature on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians.

METHODS

A PubMed literature search was performed and limited to human studies written in English language articles with keywords of "telemetry" and "chest pain." Studies identified then underwent a structured review from which results could be evaluated.

RESULTS

There were 114 paper abstracts on telemetry monitoring screened; 30 articles were considered relevant. Twelve appropriate articles were rigorously reviewed and recommendations given.

CONCLUSIONS

Insufficient data exist to support telemetry use in low-risk chest pain patients. Telemetry monitoring is unlikely to benefit low-risk chest pain patients with a normal/nondiagnostic electrocardiogram, a normal first set of cardiac enzymes, and none of the following: hypotension, rales above the bases, or pain worse than baseline angina.

Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value

BACKGROUND

In an effort to lead physicians in addressing the problem of overuse of medical tests and treatments, the American Board of Internal Medicine Foundation developed the Choosing Wisely campaign. The Society of Hospital Medicine (SHM) joined the initiative to highlight the need to critically appraise resource utilization in hospitals.

METHODS

The SHM employed a staged methodology to develop the adult Choosing Wisely list. This included surveys of the organization's leaders and general membership, a review of the literature, and Delphi panel voting.

RESULTS

The 5 recommendations that were subsequently approved by the SHM Board are: (1) Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). (2) Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. (3) Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke. (4) Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. (5) Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.

CONCLUSIONS

Hospitalists have many opportunities to impact overutilization of care. The adult hospital medicine Choosing Wisely recommendations offer an explicit starting point for eliminating waste in the hospital.

A clinical decision rule to identify which chest pain patients can safely be removed from cardiac monitoring in the emergency department

STUDY OBJECTIVE

We determine the rate of serious arrhythmias in a cohort of monitored emergency department (ED) chest pain patients and derive a clinical decision rule that can identify which patients can safely be taken off continuous cardiac monitoring at initial physician assessment.

METHODS

A secondary analysis of a prospectively collected cohort was completed in a university-affiliated tertiary care center. Consecutive patients with a primary complaint of chest pain who underwent cardiac monitoring in the ED in January to April 2000 were included. Serious arrhythmias were defined as those requiring treatment in the ED. Multivariate recursive partitioning analysis was undertaken to derive a decision rule.

RESULTS

Nine hundred ninety-two consecutive chest pain patients were monitored in the ED during the study period, of whom 14% and 12% had myocardial infarction and unstable angina, respectively. There were 17 patients (1.7%) with serious arrhythmias detected in the ED. The following decision rule was derived: patients can be removed from cardiac monitoring if they are pain free at the initial physician assessment and have a normal or nonspecific ECG result. The rule had 100% sensitivity (95% confidence interval 80% to 100%) for serious arrhythmias. Applying this rule would have allowed physicians to immediately remove 29% of patients from cardiac monitoring.

CONCLUSION

Serious arrhythmias are uncommon in monitored ED chest pain patients. A simple clinical decision rule could be used to safely identify low-risk patients who can be removed from continuous monitoring if its performance is prospectively validated in an independent patient population.