Utilization of Continuous Cardiac Monitoring on Hospitalist-led Teaching Teams

An old diagnostic tool for new indications: inpatient Holter ECG for conditions other than syncope or stroke

Holter electrocardiography (ECG) assists in the diagnosis of arrhythmias. Its use in the inpatient setting has been described solely for the evaluation of stroke and syncope. Our aim was to assess its diagnostic value for other conditions in the internal medicine department. We included all hospitalized patients between 2018 and 2021 in a tertiary referral center. The primary outcome was a diagnostic Holter recording a new arrhythmia that led to a change in treatment. Overall, 289 patients completed a 24-h inpatient Holter ECG for conditions other than syncope or stroke, with 39 (13%) diagnostic findings. The highest diagnostic value was found in patients admitted for pre-syncope (19%), palpitations (18%), and unexplained heart failure exacerbation/dyspnea (17%). A low diagnostic yield was found for the evaluation of chest pain (5%). Heart failure with preserved ejection fraction (adjusted OR 2.3, 95% CI 1.1-5.4, p = 0.04), and baseline ECG with either a bundle branch block (AOR 4.2, 95% CI 1.9-9.2, p < 0.01) or atrioventricular block (first or second degree, AOR 5, 95% CI 2.04-12.3, p < 0.01) were among the independent predictors for a diagnostic test. Inpatient Holter ECG monitoring may have value as a diagnostic tool for selected patients with conditions other than syncope or stroke.

Decreasing Inappropriate Telemetry Use via Nursing-Driven Checklist and Electronic Health Record Order Set

Introduction: Telemetry is ubiquitous in many hospitals despite widely acknowledged limitations, waste, and potential harm associated with inappropriate use. To curb overuse, guidelines such as the 2017 American Heart Association/American College of Cardiology (AHA/ACC) continuous telemetry monitoring practice standards have outlined appropriate telemetry use standards. This study aimed to perform two “plan-do-study-act” (PDSA) cycles and assess whether a nursing (RN)-driven checklist addressing appropriate telemetry use, combined with just-in-time education delivered via an electronic health record (EHR) order set modification, was efficacious in reducing inappropriate telemetry use within a level 1a Veterans Health Administration hospital.

Methods: This is a quality improvement intervention study that took place between March 2019 and August 2020. Three cohorts were sequentially studied: a control cohort without any intervention (n = 100), a cohort with only the RN-driven checklist (n = 100), and a cohort with both the RN-driven checklist and an EHR order set modification that provided just-in-time education about telemetry indications (n = 100). Telemetry records were reviewed by a physician to determine indication, duration for each telemetry order, and appropriateness. An order was deemed “appropriate” if it met AHA/ACC classification grade I (telemetry recommended) or IIa/b (telemetry may be considered) and “inappropriate” if it fell under class III (telemetry not recommended). Data were compared between the control cohort and the two intervention cohorts, as well as between intervention cohorts, using Pearson chi-square analysis. A p-value < 0.05 was considered statistically significant.

Results: Within the control group, 37% of telemetry orders were deemed inappropriate. After implementation of the RN checklist, a non-statistically significant lower proportion (26%) of orders was deemed inappropriate (p = 0.09). Implementation of the RN checklist, along with the EHR order set, was associated with a significantly lower proportion of inappropriate orders (17%) in comparison to the control cohort (p = 0.001) but not in comparison to the RN checklist cohort (p = 0.12). There was no significant difference in the duration of telemetry use across cohorts.

Conclusions: An RN-driven checklist and EHR telemetry order set modification were associated with a decrease in inappropriate telemetry use from 37% to 17%. By prompting the review of telemetry orders via a daily nursing checklist reviewed during bedside interdisciplinary rounds, clinicians received reinforcement regarding appropriate telemetry indications. This education was strengthened by the just-in-time training provided via the EHR order set.

Harnessing the Electronic Health Record to Actively Support Providers with Guideline-Directed Telemetry Use

BACKGROUND

Overuse of cardiac telemetry monitoring (telemetry) can lead to alarm fatigue, discomfort for patients, and unnecessary medical costs. Currently there are evidence-based recommendations describing appropriate telemetry use, but many providers are unaware of these guidelines.

OBJECTIVES

At our multihospital health system, our goal was to support providers in ordering telemetry on acute care in accordance with evidence-based guidelines and discontinuing telemetry when it was no longer medically indicated.

METHODS

We implemented a multipronged electronic health record (EHR) intervention at two academic medical centers, including: (1) an order set requiring providers to choose an indication for telemetry with a recommended duration based on American Heart Association guidelines; (2) an EHR-generated reminder page to the primary provider recommending telemetry discontinuation once the guideline-recommended duration for telemetry is exceeded; and (3) documentation of telemetry interpretation by telemetry technicians in the notes section of the EHR. To determine the impact of the intervention, we compared number of telemetry orders actively discontinued prior to discharge and telemetry duration 1 year pre- to 1 year post-intervention on acute care medicine services. We evaluated sustainability at years 2 and 3.

RESULTS

Implementation of the EHR initiative resulted in a statistically significant increase in active discontinuation of telemetry orders prior to discharge: 15% (63.4-78.7%) at one site and 13% at the other (64.1-77.4%) with greater improvements on resident teams. Fewer acute care medicine telemetry orders were placed on medicine services across the system (1,503-1,305) despite an increase in admissions and the average duration of telemetry decreased at both sites (62 to 47 hours, p < 0.001 and 73 to 60, p < 0.001, respectively). Improvements were sustained 2 and 3 years after intervention.

CONCLUSION

Our study showed that a low-cost, multipart, EHR-based intervention with active provider engagement and no additional education can decrease telemetry usage on acute care medicine services.

'Utilization of telemetry monitoring for non-cardiac conditions in non-critical patients: what are the trends and perceptions amongst medical residents?'

Background & Objective

Current evidence shows that telemetry monitoring is commonly overutilized for 'non-cardiac' diseases such as COPD exacerbation, pneumonia, pulmonary embolism and sepsis. This issue has not been addressed clearly in the recent American Heart Association (AHA) guidelines and no standard recommendations on the use of telemetry in non-cardiac conditions exist; therefore, clinicians continue to make such decisions based on personal preferences.As medical residency is an important phase during which young physicians develop clinical skills and habits for their future practice, the aim of this study was to understand the prevalent trends related to inappropriate telemetry use amongst the medical residents at a community hospital and the associated factors which influence the use of telemetry monitoring in non-cardiac patients.

Methods

All the residents undergoing internal medicine training at a community hospital were surveyed with the help of a questionnaire regarding the utility of telemetry in non-critical patients admitted with non-cardiac conditions.

Results

Survey was completed by 37 residents. Analysis of the responses showed that despite the frequent use of telemetry in non-cardiac conditions, majority of the medical residents are unaware of the correct indications. Seventy-three percent choose 'continuous' telemetry when placing the order while only 16% (often or always) discontinue telemetry after 24 hours of uneventful use. Although 84% residents admitted that telemetry is overutilized, still 49% felt that it leads to better patient care while 70% considered it superior to frequent vitals monitoring for early detection of hemodynamic instability. Possible causes of inappropriate use included 'Lack of knowledge about the related literature' and 'Following trends set by the peers'.

Conclusion

Majority of the medical residents overutilize telemetry in non-cardiac conditions due to lack of knowledge, perceived sense of security and inappropriate trends set by their colleagues. In order to abolish these tendencies, we propose the provision of adequate educational resources to the clinical staff at every level along with other system-based strategies.