Interventions to Decrease Overuse of Cardiac Monitoring (Telemetry) When Transitioning from the Intensive Care Unit to the Regular Nursing Floor

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.

Reducing All-cause 30-day Hospital Readmissions for Patients Presenting with Acute Heart Failure Exacerbations: A Quality Improvement Initiative

Background

Congestive heart failure (CHF) is the most common cause of hospitalization in the US for people older than 65 years of age. It has the highest 30-day re-hospitalization rate among medical and surgical conditions, accounting for up to 26.9% of the total readmission rates. We conducted a quality improvement project at our hospital with the objective to reduce the 30-day all-cause readmissions of patients with CHF by improving the transition of care and setting up scheduled follow-up appointments within two weeks of patient discharge.

Method

Retrospective data were collected to understand the pattern of admission for CHF during November 2017. Data on 30-day readmission post-discharge was also collected to understand readmission rates. Similarly, all patients who were admitted with acute CHF exacerbation to our hospital during the month of November 2018 were included in our intervention cohort. The 30-day readmission rates of these patients post-intervention were calculated and compared to the initial cohort.

Results

As part of our study, we ensured that 58% of the enrolled patients had a follow-up appointment scheduled within two weeks of discharge compared to only 30% in 2017. Also, 56% of the enrolled patients kept their follow-up appointments compared to 37% in 2017. The 30-day readmission rate of CHF patients was reduced in half after the implementation of our project, with a 14% readmission rate for our study patients compared to 28% in 2017.

Conclusion

Patient education and measures to augment post-discharge follow-up appointments can lead to substantial reductions in the readmission rates of heart failure (HF) patients.