By R. Kannan Mutharasan, MD, Associate Professor of Medicine — Cardiology, Northwestern Medicine, Bluhm Cardiovascular Institute; Northwestern University Feinberg School of Medicine
As a practicing cardiologist, I see firsthand how common overutilization of telemetry monitoring is today. I also know that one of the biggest pain points for clinicians is wanting to be confident that our patients are safe and being looked after appropriately. At the same time, research shows that when adhering to American Heart Association (AHA) guidelines, 75% of physicians are comfortable with discontinuing telemetry monitoring.1
But the reality is that telemetry is frequently used unnecessarily. Eighty one percent of physicians somewhat or strongly agree that cardiac telemetry is overused.2 Even the conservative estimate that 25% of patients on cardiac monitoring do not meet AHA telemetry guidelines is too many.3
“The research findings that clinicians recognize telemetry is overused and are open to discontinuing it when appropriate signal that it’s now critical to rethink how to best serve the monitoring needs of non-cardiac patients. New methods of monitoring that also track additional parameters, notably respiratory rate, pulse rate, and saturation of peripheral oxygen (SpO2), may be a good option.” — R. Kannan Mutharasan, MD
Why telemetry overuse is commonplace today
Multiple factors contribute to the inappropriate use of cardiac monitoring. Common reasons include non-adherence to guidelines, lack of awareness,4 and monitoring beyond the recommended time frame.5 The AHA’s telemetry guidelines do not address several non-cardiac conditions that clinicians might use telemetry to monitor,6 such as COPD exacerbation, pneumonia, pulmonary embolism, and sepsis.7
Additional reasons patients who are not experiencing active cardiac conditions may be put on telemetry monitoring include end-stage renal disease, low-risk chest pain, or syncope from non-cardiac causes, according to a telemetry director writing in The New England Journal of Medicine.8
“While existing solutions to telemetry overuse include educating caregivers about the AHA guidelines for telemetry,9 and building order sets and reminders into EHRs,10 these have focused primarily on improving cardiac surveillance, not on improving ways to handle non-cardiac patients who would benefit from continuous vital signs monitoring.”
The problems telemetry overuse is currently causing
Due to the challenges created by telemetry overuse, experts have been questioning its value for non-cardiac patients for years. Is telemetry as helpful as thought?11 Does telemetry overuse impede cost-effective patient care?12
Telemetry overuse has historically been so widespread that in 2013, the Journal of Hospital Medicine published an article identifying five ways hospitals can improve healthcare value, with one of those being: “Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation.”13
More than a decade later, however, the overuse of telemetry has persisted such that ECRI, the independent organization focused on improving safety, quality, and costs of care, has ranked it among both its Top 10 Health Technology Hazards14 and Top 10 Patient Safety Risks.15 “Paradoxically, increased use of cardiac telemetry monitoring (for patients who do not require it) can lead to patients overall being less effectively monitored,” ECRI explained.16
Unnecessary telemetry monitoring can lead to a number of problems, including higher costs, diminished patient throughput, and increased length of stay.17Overuse of telemetry can also add artifacts and often unnecessary alarms to already overburdened clinicians.18 Studies show that alarm fatigue can lead to missed alarms and medical errors, increased burnout, and interference with patient recovery.19 Inappropriate use of telemetry for patients who do not need cardiac monitoring may also cause harm to those individuals.20
“Contrary to the proven benefits of telemetry in the management of cardiac diseases, an in-depth review of the medical literature doesn’t yield a compelling level of evidence on its utility in non-cardiac conditions.”21 — R. Kannan Mutharasan, MD
In fact, telemetry overuse can have a downstream impact on emergency departments (ED). Hospitals’ telemetry capacity is often limited by equipment and personnel constraints compared to overall bed capacity,22 and due to the natural ebb and flow of clinical medicine, health systems can sometimes have more patients who need telemetry than they have beds in telemetry units. That can become a big problem that then starts to bottleneck the ED and leave patients waiting in hallways.23
How implementing continuous vital signs monitoring in lower acuity units can help
To better care for non-cardiac patients who would benefit from continuous monitoring but don’t need a telemetry bed, health systems and hospitals can implement wireless and wearable devices in areas such as the ED, general medical-surgical, and other units.
From my perspective, the benefits of wireless and wearable continuous vital signs monitoring include:
- Optimizing patient care
- Reducing clinician burnout
- Driving economic advantages
Optimizing patient care. While telemetry monitoring focuses on cardiac rhythms, other vital signs can more effectively signal patient deterioration. Respiratory rate is a good indicator of impending decompensation that is often neglected,24 even though that information could create the confidence among clinicians that their patients are safe, and telemetry monitoring can be discontinued appropriately. Pulse oximetry is also effective because a single sensor can provide timely indication of changes, and patients typically tolerate the sensors well.25
Another benefit of continuous vital sign monitoring is increased patient mobility. Lightweight wireless and wearable continuous vital signs monitoring for non-cardiac patients could liberate them from their beds to meet family members in the hospital’s lobby restaurant, walk around a courtyard, or otherwise move about safely. Mobilizing patients can increase muscle strength, improve quality of life and physical outcomes, and it has been shown to do so with low rates of adverse health events.26
Reducing clinician burnout. Conventional thinking would suggest that the more parameters clinicians track, the more alarms monitoring systems will produce. But a Cleveland Clinic study published in the Journal of Clinical Anesthesia measured the respiratory rate, oxygen saturation, and pulse rate of 100 post-surgical patients with continuous monitoring. Through the use of an alarm burden analytic to optimize actionable alarms and minimize non-actionable alerts, Cleveland Clinic was able to achieve averages of less than one alarm per day for all PortraitTM Mobile patients and an average of 2.3 for patients with alarms.27
Safely reducing false alarms can help to alleviate burnout28 and free up nurses as they spend an average of 20 minutes per day on each telemetry patient.29 Instead of clinicians managing wires, replacing batteries, or troubleshooting different problems, nurses can better use that time addressing patient concerns, and answering questions about what a particular medication is for, how their condition is progressing, and what to expect in the next steps of treatment or recovery.
Driving economic advantages. Telemetry monitoring is expensive. An estimate of costs, including nursing staff and monitoring supplies, finds the average to be $82 per patient, per day.30Another study found that telemetry monitoring of non-AHA guideline patients at an urban, tertiary care teaching hospital costs the organization an additional $37,995.84 per month.31
Given the high costs of telemetry overuse, reducing unnecessary telemetry monitoring can drive significant economic advantages. A medium-sized community hospital with 175 telemetry beds saved $213,986 a year by reducing telemetry waste.32 Yet another health system that lowered the mean daily number of patients monitored with telemetry by 70% saved approximately $4.8 million annually.33
It’s time to reduce unnecessary telemetry use
It’s clear to me how monitoring non-cardiac patients with wireless and wearable devices instead of telemetry monitors can be valuable for patients, caregivers, and clinicians. Beyond the problems overutilization of telemetry causes, clinicians want to be sure that we have not missed opportunities to help patients — and to avoid having a patient crash when we could have done something to prevent it. Given the potential patient harm, alarm fatigue, clinician burnout, and high costs associated with telemetry, the time has come to address the overuse problem.
Sources:
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https://bhm.scholasticahq.com/article/37988-telemetry-practices-among-physicians-and-nurses-at-an-academic-tertiary-medical-center
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https://cdn.mdedge.com/files/s3fs-public/issues/articles/media_061144e_368.pdf
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