Sammy Zakaria, MD, MPH

Cardiac telemetry, designed to monitor hospitalized patients with active cardiac conditions, is highly utilized outside the intensive care unit (ICU) and generates a large number of automated alarms. Telemetry is also costly and requires substantial time and attention commitments from nursing and technician staff, who place and maintain the recording devices and address monitoring results. ^1,2 The staff address and dismiss invalid alarms caused by telemetry artifacts, ² such as the misreporting of patient movement as ventricular tachycardia/fibrillation (VT/VF) or the mimicking of asystole by a lead disconnection.

One strategy for addressing telemetry alarms is to have dedicated staff observe telemetry monitors and notify nurses with any events or findings. Studies conducted in the 1990s showed that dedicated monitor watchers, compared with automatically generated alarms alone, did not affect most outcomes ³ but can improve accuracy of arrhythmia detection. ⁴ Since then, given the advances in telemetry detection software, the effect of monitor watchers has not been evaluated. Mindful of the perceived burden of nonactionable telemetry alerts, we wanted to quantify the frequency of automated telemetry alerts in the wards and analyze the proportion of alerts deemed nonactionable by monitor watchers.

METHODS

We conducted this retrospective study at a 545-bed urban academic hospital in the United States. We reviewed the cases of all non-ICU patients with telemetry monitoring ordered. The telemetry order requires providers specify the indication for monitoring and adjust alert parameters for variables such as heart rate (preset to 60 and 100 beats per minute) and baseline rhythm (preset to normal sinus). Once a telemetry order is received, 5 leads are attached to the patient, and electrocardiographic data begin transmitting to a portable wireless telemetry monitor, or telemeter (Philips Intellispace Telemetry System), which in turn transmits to a central monitoring station in the progressive care unit (PCU; cardiac/pulmonary unit). The majority of patients on telemetry are in the PCU. Telemeters are also located in the general medicine, surgical, and neurologic non-ICU units. Data from a maximum of 96 telemeters in the hospital are simultaneously displayed in the central monitoring station.

At all times, two dedicated monitor watchers oversee the central monitoring station. Watchers are certified medical assistants with extra telemetry-specific training. Each receives a salary of $17 per hour (no benefits), or about $800 per 24-hour day for two watchers. Their role is to respond to audiovisual alerts triggered by the monitoring system—they either contact the bedside nurse or intercept the alert if deemed nonactionable. Consistent with the literature, ⁵ nonactionable alerts and alarms were defined as either “invalid” or “nuisance.” Invalid alerts and alarms misrepresent patient status (eg, patient motion is electronically interpreted as VT/VF), and nuisance alerts and alarms do not require clinical intervention (eg, persistent sinus tachycardia has already been communicated to the nurse or provider). Monitor watchers must intercept the alert within a limited amount of time: 15 seconds for suspected lethal alerts (asystole, VT/VF), 30 seconds for extreme tachycardia/bradycardia, and 60 seconds for lead displacement or low battery.

If a watcher does not intercept an alert—either intentionally or because time ran out—the alert generates an alarm, which automatically sends a text message to the patient’s nurse’s wireless phone. The nurse acknowledges the alarm and decides on further action. If the bedside nurse does not acknowledge the alarm within the same time frames as mentioned, the alarm is escalated, first to the unit charge nurse and then to the monitoring station charge nurse (Figure). All alerts are available for provider review at the central monitoring station for the duration of the telemetry order, and select telemetry strips are printed and filed in the patient’s paper chart.

For this study, we analyzed telemetry system data for all monitored non-ICU ward patients from August 1 through September 30, 2014. We focused on the rate and relevance of alerts (system-generated) and alarms (text message to nurse). As cardiac arrhythmias leading to cardiopulmonary arrest can potentially be detected by telemetry, we also reviewed all code team activations, which are recorded in a separate database that details time of code team activation, to evaluate for correlation with telemetry alerts.

 

RESULTS

Within the 2-month study period, there were 1917 admissions to, and 1370 transfers to, non-ICU floors, for a total of 3287 unique patient-admissions and 9704 total patient-days. There were 1199 patient admissions with telemetry orders (36.5% of all admissions), 4044 total patient-days of telemetry, and an average of 66.3 patients monitored per day. In addition, the system generated 20,775 alerts, an average of 341 per day, 5.1 per patient-day, 1 every 4 minutes. Overall, 18,051 alerts (87%) were intercepted by monitor watchers, preventing nurse text-alarms. Of all alerts, 91% were from patients on medicine services, including pulmonary and cardiology; 6% were from patients on the neurology floor; and 3% were from patients on the surgery floor.

Forty percent of all alerts were for heart rates deviating outside the ranges set by the provider; of these, the overwhelming majority were intercepted as nuisance alerts (Table). In addition, 26% of all alerts were for maintenance reasons, including issues with batteries or leads. Finally, 34% (6954) were suspected lethal alerts (asystole, VT/VF); of these, 74% (5170) were intercepted by monitor watchers, suggesting they were deemed invalid. None of the suspected lethal alerts triggered a code team activation, indicating there were no telemetry-documented asystole or VT/VF episodes prompting resuscitative efforts. During the study period, there were 7 code team activations. Of the 7 patients, 2 were on telemetry, and their code team activation was for hypoxia detected by pulse oximetry; the other 5 patients, not on telemetry, were found unresponsive or apneic, and 4 of them had confirmed pulseless electrical activity.

DISCUSSION

In small studies, other investigators have directly observed nurses for hours at a time and assessed their response to telemetry-related alarms. ^1,2 In the present study, we found a very large number of telemetry-detected alerts over a continuous 2-month period. The large majority (87%) of alerts were manually intercepted by monitor watchers before being communicated to a nurse or provider, indicating these alerts did not affect clinical management and likely were either false positives or nonactionable. It is possible that repeat nonactionable alerts, like continued sinus tachycardia or bradycardia, affect decision making, but this may be outside the role of continuous cardiac telemetry. In addition, it is likely that all the lethal alarms (asystole, VT/VF) forwarded to the nurses were invalid, as none resulted in code team activations.

Addressing these alerts is a major issue, as frequent telemetry alarms can lead to alarm fatigue, a widely acknowledged safety concern. ⁶ Furthermore, nonactionable alarms are a time sink, diverting nursing attention from other patient care needs. Finally, nonactionable alarms, especially invalid alarms, can lead to adverse patient outcomes. Although we did not specifically evaluate for harm, an earlier case series found a potential for unnecessary interventions and device implantation as a result of reporting artifactual arrhythmias. ⁷

Our results also highlight the role of monitor watchers in intercepting nonactionable alarms and reducing the alarm burden on nurses. Other investigators have reported on computerized paging systems that directly alert only nurses, ⁸ or on escalated alarm paging systems that let noncrisis alarms self-resolve. ⁹ In contrast, our study used a hybrid 2-step telemetry-monitoring system—an escalated paging system designed to be sensitive and less likely than human monitoring to overlook events, followed by dedicated monitor watchers who are first-responders for a large number of alarms and who increase the specificity of alarms by screening for nonactionable alarms, thereby reducing the number of alarms transmitted to nurses. We think that, for most hospitals, monitor watchers are cost-effective, as their hourly wage is lower than that of registered nurses. Furthermore, monitor watchers can screen alerts faster because they are always at the monitoring station. Their presence reduces the amount of time that nurses need to divert from other clinical tasks in order to walk to the monitoring station to evaluate alerts.

Nonetheless, there remains a large number of nonactionable alerts forwarded as alarms to nurses, likely because of monitor watchers’ inability to address the multitude of alerts, and perhaps because of alarm fatigue. Although this study showed the utility of monitor watchers in decreasing telemetry alarms to nurses, other steps can be taken to reduce telemetry alarm fatigue. A systematic review of alarm frequency interventions ⁵ noted that detection algorithms can be improved to decrease telemetry alert false positives. Another solution, likely easier to implement, is to encourage appropriate alterations in telemetry alarm parameters, which can decrease the alarm proportion. ¹⁰ An essential step is to decrease inappropriate telemetry use regarding the indication for and duration of monitoring, as emphasized by the Choosing Wisely campaign championing American Heart Association (AHA) guidelines for appropriate telemetry use. ¹¹ At our institution, 20.2% of telemetry orders were for indications outside AHA guidelines, and that percentage likely is an underestimate, as this was required self-reporting on ordering. ¹² Telemetry may not frequently result in changes in management in the non-ICU setting, ¹³ and may lead to other harms such as worsening delirium, ¹⁴ so it needs to be evaluated for harm versus benefit per patient before order.

Cardiac telemetry in the non-ICU setting produces a large number of alerts and alarms. The vast majority are not seen or addressed by nurses or physicians, leading to a negligible impact on patient care decisions. Monitor watchers reduce the nursing burden in dealing with telemetry alerts, but we emphasize the need to take additional measures to reduce telemetry-related alerts and thereby reduce alarm-related harms and alarm fatigue.

 

Acknowledgments

The authors thank Torberg Tonnessen, who was instrumental in providing the telemetry and clinical data used in this study, as well as the numerous Johns Hopkins Bayview Medical Center nurses, patient care technicians, and monitor watchers who answered questions about telemetry processes and allowed their work to be observed.

Disclosure

Nothing to report.

 

Cardiac telemetry, designed to monitor hospitalized patients with active cardiac conditions, is highly utilized outside the intensive care unit (ICU) and generates a large number of automated alarms. Telemetry is also costly and requires substantial time and attention commitments from nursing and technician staff, who place and maintain the recording devices and address monitoring results. ^1,2 The staff address and dismiss invalid alarms caused by telemetry artifacts, ² such as the misreporting of patient movement as ventricular tachycardia/fibrillation (VT/VF) or the mimicking of asystole by a lead disconnection.

One strategy for addressing telemetry alarms is to have dedicated staff observe telemetry monitors and notify nurses with any events or findings. Studies conducted in the 1990s showed that dedicated monitor watchers, compared with automatically generated alarms alone, did not affect most outcomes ³ but can improve accuracy of arrhythmia detection. ⁴ Since then, given the advances in telemetry detection software, the effect of monitor watchers has not been evaluated. Mindful of the perceived burden of nonactionable telemetry alerts, we wanted to quantify the frequency of automated telemetry alerts in the wards and analyze the proportion of alerts deemed nonactionable by monitor watchers.

METHODS

We conducted this retrospective study at a 545-bed urban academic hospital in the United States. We reviewed the cases of all non-ICU patients with telemetry monitoring ordered. The telemetry order requires providers specify the indication for monitoring and adjust alert parameters for variables such as heart rate (preset to 60 and 100 beats per minute) and baseline rhythm (preset to normal sinus). Once a telemetry order is received, 5 leads are attached to the patient, and electrocardiographic data begin transmitting to a portable wireless telemetry monitor, or telemeter (Philips Intellispace Telemetry System), which in turn transmits to a central monitoring station in the progressive care unit (PCU; cardiac/pulmonary unit). The majority of patients on telemetry are in the PCU. Telemeters are also located in the general medicine, surgical, and neurologic non-ICU units. Data from a maximum of 96 telemeters in the hospital are simultaneously displayed in the central monitoring station.

At all times, two dedicated monitor watchers oversee the central monitoring station. Watchers are certified medical assistants with extra telemetry-specific training. Each receives a salary of $17 per hour (no benefits), or about $800 per 24-hour day for two watchers. Their role is to respond to audiovisual alerts triggered by the monitoring system—they either contact the bedside nurse or intercept the alert if deemed nonactionable. Consistent with the literature, ⁵ nonactionable alerts and alarms were defined as either “invalid” or “nuisance.” Invalid alerts and alarms misrepresent patient status (eg, patient motion is electronically interpreted as VT/VF), and nuisance alerts and alarms do not require clinical intervention (eg, persistent sinus tachycardia has already been communicated to the nurse or provider). Monitor watchers must intercept the alert within a limited amount of time: 15 seconds for suspected lethal alerts (asystole, VT/VF), 30 seconds for extreme tachycardia/bradycardia, and 60 seconds for lead displacement or low battery.

If a watcher does not intercept an alert—either intentionally or because time ran out—the alert generates an alarm, which automatically sends a text message to the patient’s nurse’s wireless phone. The nurse acknowledges the alarm and decides on further action. If the bedside nurse does not acknowledge the alarm within the same time frames as mentioned, the alarm is escalated, first to the unit charge nurse and then to the monitoring station charge nurse (Figure). All alerts are available for provider review at the central monitoring station for the duration of the telemetry order, and select telemetry strips are printed and filed in the patient’s paper chart.

For this study, we analyzed telemetry system data for all monitored non-ICU ward patients from August 1 through September 30, 2014. We focused on the rate and relevance of alerts (system-generated) and alarms (text message to nurse). As cardiac arrhythmias leading to cardiopulmonary arrest can potentially be detected by telemetry, we also reviewed all code team activations, which are recorded in a separate database that details time of code team activation, to evaluate for correlation with telemetry alerts.

 

RESULTS

Within the 2-month study period, there were 1917 admissions to, and 1370 transfers to, non-ICU floors, for a total of 3287 unique patient-admissions and 9704 total patient-days. There were 1199 patient admissions with telemetry orders (36.5% of all admissions), 4044 total patient-days of telemetry, and an average of 66.3 patients monitored per day. In addition, the system generated 20,775 alerts, an average of 341 per day, 5.1 per patient-day, 1 every 4 minutes. Overall, 18,051 alerts (87%) were intercepted by monitor watchers, preventing nurse text-alarms. Of all alerts, 91% were from patients on medicine services, including pulmonary and cardiology; 6% were from patients on the neurology floor; and 3% were from patients on the surgery floor.

Forty percent of all alerts were for heart rates deviating outside the ranges set by the provider; of these, the overwhelming majority were intercepted as nuisance alerts (Table). In addition, 26% of all alerts were for maintenance reasons, including issues with batteries or leads. Finally, 34% (6954) were suspected lethal alerts (asystole, VT/VF); of these, 74% (5170) were intercepted by monitor watchers, suggesting they were deemed invalid. None of the suspected lethal alerts triggered a code team activation, indicating there were no telemetry-documented asystole or VT/VF episodes prompting resuscitative efforts. During the study period, there were 7 code team activations. Of the 7 patients, 2 were on telemetry, and their code team activation was for hypoxia detected by pulse oximetry; the other 5 patients, not on telemetry, were found unresponsive or apneic, and 4 of them had confirmed pulseless electrical activity.

DISCUSSION

In small studies, other investigators have directly observed nurses for hours at a time and assessed their response to telemetry-related alarms. ^1,2 In the present study, we found a very large number of telemetry-detected alerts over a continuous 2-month period. The large majority (87%) of alerts were manually intercepted by monitor watchers before being communicated to a nurse or provider, indicating these alerts did not affect clinical management and likely were either false positives or nonactionable. It is possible that repeat nonactionable alerts, like continued sinus tachycardia or bradycardia, affect decision making, but this may be outside the role of continuous cardiac telemetry. In addition, it is likely that all the lethal alarms (asystole, VT/VF) forwarded to the nurses were invalid, as none resulted in code team activations.

Addressing these alerts is a major issue, as frequent telemetry alarms can lead to alarm fatigue, a widely acknowledged safety concern. ⁶ Furthermore, nonactionable alarms are a time sink, diverting nursing attention from other patient care needs. Finally, nonactionable alarms, especially invalid alarms, can lead to adverse patient outcomes. Although we did not specifically evaluate for harm, an earlier case series found a potential for unnecessary interventions and device implantation as a result of reporting artifactual arrhythmias. ⁷

Our results also highlight the role of monitor watchers in intercepting nonactionable alarms and reducing the alarm burden on nurses. Other investigators have reported on computerized paging systems that directly alert only nurses, ⁸ or on escalated alarm paging systems that let noncrisis alarms self-resolve. ⁹ In contrast, our study used a hybrid 2-step telemetry-monitoring system—an escalated paging system designed to be sensitive and less likely than human monitoring to overlook events, followed by dedicated monitor watchers who are first-responders for a large number of alarms and who increase the specificity of alarms by screening for nonactionable alarms, thereby reducing the number of alarms transmitted to nurses. We think that, for most hospitals, monitor watchers are cost-effective, as their hourly wage is lower than that of registered nurses. Furthermore, monitor watchers can screen alerts faster because they are always at the monitoring station. Their presence reduces the amount of time that nurses need to divert from other clinical tasks in order to walk to the monitoring station to evaluate alerts.

Nonetheless, there remains a large number of nonactionable alerts forwarded as alarms to nurses, likely because of monitor watchers’ inability to address the multitude of alerts, and perhaps because of alarm fatigue. Although this study showed the utility of monitor watchers in decreasing telemetry alarms to nurses, other steps can be taken to reduce telemetry alarm fatigue. A systematic review of alarm frequency interventions ⁵ noted that detection algorithms can be improved to decrease telemetry alert false positives. Another solution, likely easier to implement, is to encourage appropriate alterations in telemetry alarm parameters, which can decrease the alarm proportion. ¹⁰ An essential step is to decrease inappropriate telemetry use regarding the indication for and duration of monitoring, as emphasized by the Choosing Wisely campaign championing American Heart Association (AHA) guidelines for appropriate telemetry use. ¹¹ At our institution, 20.2% of telemetry orders were for indications outside AHA guidelines, and that percentage likely is an underestimate, as this was required self-reporting on ordering. ¹² Telemetry may not frequently result in changes in management in the non-ICU setting, ¹³ and may lead to other harms such as worsening delirium, ¹⁴ so it needs to be evaluated for harm versus benefit per patient before order.

Cardiac telemetry in the non-ICU setting produces a large number of alerts and alarms. The vast majority are not seen or addressed by nurses or physicians, leading to a negligible impact on patient care decisions. Monitor watchers reduce the nursing burden in dealing with telemetry alerts, but we emphasize the need to take additional measures to reduce telemetry-related alerts and thereby reduce alarm-related harms and alarm fatigue.

 

Acknowledgments

The authors thank Torberg Tonnessen, who was instrumental in providing the telemetry and clinical data used in this study, as well as the numerous Johns Hopkins Bayview Medical Center nurses, patient care technicians, and monitor watchers who answered questions about telemetry processes and allowed their work to be observed.

Disclosure

Nothing to report.

 

Cardiac telemetry, designed to monitor hospitalized patients with active cardiac conditions, is highly utilized outside the intensive care unit (ICU) and generates a large number of automated alarms. Telemetry is also costly and requires substantial time and attention commitments from nursing and technician staff, who place and maintain the recording devices and address monitoring results. ^1,2 The staff address and dismiss invalid alarms caused by telemetry artifacts, ² such as the misreporting of patient movement as ventricular tachycardia/fibrillation (VT/VF) or the mimicking of asystole by a lead disconnection.

One strategy for addressing telemetry alarms is to have dedicated staff observe telemetry monitors and notify nurses with any events or findings. Studies conducted in the 1990s showed that dedicated monitor watchers, compared with automatically generated alarms alone, did not affect most outcomes ³ but can improve accuracy of arrhythmia detection. ⁴ Since then, given the advances in telemetry detection software, the effect of monitor watchers has not been evaluated. Mindful of the perceived burden of nonactionable telemetry alerts, we wanted to quantify the frequency of automated telemetry alerts in the wards and analyze the proportion of alerts deemed nonactionable by monitor watchers.

METHODS

We conducted this retrospective study at a 545-bed urban academic hospital in the United States. We reviewed the cases of all non-ICU patients with telemetry monitoring ordered. The telemetry order requires providers specify the indication for monitoring and adjust alert parameters for variables such as heart rate (preset to 60 and 100 beats per minute) and baseline rhythm (preset to normal sinus). Once a telemetry order is received, 5 leads are attached to the patient, and electrocardiographic data begin transmitting to a portable wireless telemetry monitor, or telemeter (Philips Intellispace Telemetry System), which in turn transmits to a central monitoring station in the progressive care unit (PCU; cardiac/pulmonary unit). The majority of patients on telemetry are in the PCU. Telemeters are also located in the general medicine, surgical, and neurologic non-ICU units. Data from a maximum of 96 telemeters in the hospital are simultaneously displayed in the central monitoring station.

At all times, two dedicated monitor watchers oversee the central monitoring station. Watchers are certified medical assistants with extra telemetry-specific training. Each receives a salary of $17 per hour (no benefits), or about $800 per 24-hour day for two watchers. Their role is to respond to audiovisual alerts triggered by the monitoring system—they either contact the bedside nurse or intercept the alert if deemed nonactionable. Consistent with the literature, ⁵ nonactionable alerts and alarms were defined as either “invalid” or “nuisance.” Invalid alerts and alarms misrepresent patient status (eg, patient motion is electronically interpreted as VT/VF), and nuisance alerts and alarms do not require clinical intervention (eg, persistent sinus tachycardia has already been communicated to the nurse or provider). Monitor watchers must intercept the alert within a limited amount of time: 15 seconds for suspected lethal alerts (asystole, VT/VF), 30 seconds for extreme tachycardia/bradycardia, and 60 seconds for lead displacement or low battery.

If a watcher does not intercept an alert—either intentionally or because time ran out—the alert generates an alarm, which automatically sends a text message to the patient’s nurse’s wireless phone. The nurse acknowledges the alarm and decides on further action. If the bedside nurse does not acknowledge the alarm within the same time frames as mentioned, the alarm is escalated, first to the unit charge nurse and then to the monitoring station charge nurse (Figure). All alerts are available for provider review at the central monitoring station for the duration of the telemetry order, and select telemetry strips are printed and filed in the patient’s paper chart.

For this study, we analyzed telemetry system data for all monitored non-ICU ward patients from August 1 through September 30, 2014. We focused on the rate and relevance of alerts (system-generated) and alarms (text message to nurse). As cardiac arrhythmias leading to cardiopulmonary arrest can potentially be detected by telemetry, we also reviewed all code team activations, which are recorded in a separate database that details time of code team activation, to evaluate for correlation with telemetry alerts.

 

RESULTS

Within the 2-month study period, there were 1917 admissions to, and 1370 transfers to, non-ICU floors, for a total of 3287 unique patient-admissions and 9704 total patient-days. There were 1199 patient admissions with telemetry orders (36.5% of all admissions), 4044 total patient-days of telemetry, and an average of 66.3 patients monitored per day. In addition, the system generated 20,775 alerts, an average of 341 per day, 5.1 per patient-day, 1 every 4 minutes. Overall, 18,051 alerts (87%) were intercepted by monitor watchers, preventing nurse text-alarms. Of all alerts, 91% were from patients on medicine services, including pulmonary and cardiology; 6% were from patients on the neurology floor; and 3% were from patients on the surgery floor.

Forty percent of all alerts were for heart rates deviating outside the ranges set by the provider; of these, the overwhelming majority were intercepted as nuisance alerts (Table). In addition, 26% of all alerts were for maintenance reasons, including issues with batteries or leads. Finally, 34% (6954) were suspected lethal alerts (asystole, VT/VF); of these, 74% (5170) were intercepted by monitor watchers, suggesting they were deemed invalid. None of the suspected lethal alerts triggered a code team activation, indicating there were no telemetry-documented asystole or VT/VF episodes prompting resuscitative efforts. During the study period, there were 7 code team activations. Of the 7 patients, 2 were on telemetry, and their code team activation was for hypoxia detected by pulse oximetry; the other 5 patients, not on telemetry, were found unresponsive or apneic, and 4 of them had confirmed pulseless electrical activity.

DISCUSSION

In small studies, other investigators have directly observed nurses for hours at a time and assessed their response to telemetry-related alarms. ^1,2 In the present study, we found a very large number of telemetry-detected alerts over a continuous 2-month period. The large majority (87%) of alerts were manually intercepted by monitor watchers before being communicated to a nurse or provider, indicating these alerts did not affect clinical management and likely were either false positives or nonactionable. It is possible that repeat nonactionable alerts, like continued sinus tachycardia or bradycardia, affect decision making, but this may be outside the role of continuous cardiac telemetry. In addition, it is likely that all the lethal alarms (asystole, VT/VF) forwarded to the nurses were invalid, as none resulted in code team activations.

Addressing these alerts is a major issue, as frequent telemetry alarms can lead to alarm fatigue, a widely acknowledged safety concern. ⁶ Furthermore, nonactionable alarms are a time sink, diverting nursing attention from other patient care needs. Finally, nonactionable alarms, especially invalid alarms, can lead to adverse patient outcomes. Although we did not specifically evaluate for harm, an earlier case series found a potential for unnecessary interventions and device implantation as a result of reporting artifactual arrhythmias. ⁷

Our results also highlight the role of monitor watchers in intercepting nonactionable alarms and reducing the alarm burden on nurses. Other investigators have reported on computerized paging systems that directly alert only nurses, ⁸ or on escalated alarm paging systems that let noncrisis alarms self-resolve. ⁹ In contrast, our study used a hybrid 2-step telemetry-monitoring system—an escalated paging system designed to be sensitive and less likely than human monitoring to overlook events, followed by dedicated monitor watchers who are first-responders for a large number of alarms and who increase the specificity of alarms by screening for nonactionable alarms, thereby reducing the number of alarms transmitted to nurses. We think that, for most hospitals, monitor watchers are cost-effective, as their hourly wage is lower than that of registered nurses. Furthermore, monitor watchers can screen alerts faster because they are always at the monitoring station. Their presence reduces the amount of time that nurses need to divert from other clinical tasks in order to walk to the monitoring station to evaluate alerts.

Nonetheless, there remains a large number of nonactionable alerts forwarded as alarms to nurses, likely because of monitor watchers’ inability to address the multitude of alerts, and perhaps because of alarm fatigue. Although this study showed the utility of monitor watchers in decreasing telemetry alarms to nurses, other steps can be taken to reduce telemetry alarm fatigue. A systematic review of alarm frequency interventions ⁵ noted that detection algorithms can be improved to decrease telemetry alert false positives. Another solution, likely easier to implement, is to encourage appropriate alterations in telemetry alarm parameters, which can decrease the alarm proportion. ¹⁰ An essential step is to decrease inappropriate telemetry use regarding the indication for and duration of monitoring, as emphasized by the Choosing Wisely campaign championing American Heart Association (AHA) guidelines for appropriate telemetry use. ¹¹ At our institution, 20.2% of telemetry orders were for indications outside AHA guidelines, and that percentage likely is an underestimate, as this was required self-reporting on ordering. ¹² Telemetry may not frequently result in changes in management in the non-ICU setting, ¹³ and may lead to other harms such as worsening delirium, ¹⁴ so it needs to be evaluated for harm versus benefit per patient before order.

Cardiac telemetry in the non-ICU setting produces a large number of alerts and alarms. The vast majority are not seen or addressed by nurses or physicians, leading to a negligible impact on patient care decisions. Monitor watchers reduce the nursing burden in dealing with telemetry alerts, but we emphasize the need to take additional measures to reduce telemetry-related alerts and thereby reduce alarm-related harms and alarm fatigue.

 

Acknowledgments

The authors thank Torberg Tonnessen, who was instrumental in providing the telemetry and clinical data used in this study, as well as the numerous Johns Hopkins Bayview Medical Center nurses, patient care technicians, and monitor watchers who answered questions about telemetry processes and allowed their work to be observed.

Disclosure

Nothing to report.

 

From the Johns Hopkins Bayview Medical Center, Baltimore, MD (Drs. Johnson, Knight, Maygers, and Zakaria), and Duke University Hospital, Durham, NC (Dr. Mock).

 

Abstract

• Objective: To determine patterns of telemetry use at a tertiary academic institution and identify factors contributing to noncompliance with guidelines regarding telemetry use.
• Methods: Web-based survey of 180 providers, including internal medicine residents and cardiovascular disease fellows, hospitalists, non-hospitalist teaching attending physicians, nurse practitioners, and physician assistants.
• Results: Of the 180 providers surveyed, 67 (37%) replied. Most providers (76%) were unaware of guidelines regarding appropriate telemetry use and 85% selected inappropriate diagnoses as warranting telemetry. Only 21% routinely discontinued the telemetry order within 48 hours.
• Conclusions: Many providers at a tertiary academic institution utilize continuous telemetry inappropriately and are unaware of telemetry guidelines. These findings should guide interventions to improve telemetry utilization.

 

For many decades, telemetry has been widely used in the management and monitoring of patients with possible acute coronary syndromes (ACS), arrhythmias, cardiac events, and strokes [1]. In addition, telemetry has often been used in other clinical scenarios with less rigorous data supporting its use [2–4]. As a result, in 2004 the American Heart Association (AHA) issued guidelines providing recommendations for best practices in hospital ECG monitoring. Indications for telemetry were classified into 3 diagnosis-driven groups: class I (indicated in all patients), class II (indicated in most patients, may be of benefit) and class III (not indicated, no therapeutic benefit) [2]. However, these recommendations have not been widely followed and telemetry is inappropriately used for many inpatients [5,6].

There are several reasons why clinicians fail to adhere to guidelines, including knowledge deficits, attitudes regarding the current guidelines, and institution-specific factors influencing practitioner behaviors [7]. In response to reports of widespread telemetry overuse, the Choosing Wisely Campaign of the American Board of Internal Medicine Foundation has championed judicious telemetry use, advocating evidence-based, protocol-driven telemetry management for patients not in intensive care units who do not meet guideline-based criteria for continuous telemetry [8].

In order to understand patterns of telemetry use at our academic institution and identify factors associated with this practice, we systematically analyzed telemetry use perceptions through provider surveys. We hypothesized that providers have misperceptions about appropriate use of telemetry and that this knowledge gap results in overuse of telemetry at our institution.

Methods

Setting

Johns Hopkins Bayview Medical Center is a 400-bed academic medical center serving southeastern Baltimore. Providers included internal medicine residents and cardiovascular disease fellows who rotate to the medical center and Johns Hopkins Hospital, hospitalists, non-hospitalist teaching attending physicians, nurse practitioners (NPs), and physician assistants (PAs).

Current Telemetry Practice

Remote telemetric monitoring is available in all adult, non-intensive care units of the hospital except for the psychiatry unit. However, the number of monitors are limited and it is not possible to monitor every patient if the wards are at capacity. Obstetrics uses its own unique cardiac monitoring system and thus was not included in the survey. Each monitor (IntelliVue, Philips Healthcare, Amsterdam, Netherlands) is attached to the patient using 5 lead wires, with electrocardiographic data transmitted to a monitoring station based in the progressive care unit, a cardio-pulmonary step-down unit. Monitors can be ordered in one of 3 manners, as mandated by hospital policy:

1. Continuous telemetry – Telemetry monitoring is uninterrupted until discontinued by a provider.
2. Telemetry protocol – Within 12 hours of telemetry placement, a monitor technician generates a report, which is reviewed by the nurse caring for the patient. The nurse performs an electrocardiogram (ECG) if the patient meets pre-specified criteria for telemetry discontinuation, which includes the absence of arrhythmias, troponin elevations, chest pain, or hemodynamic instability. The repeat ECG is then read and signed by the provider. After these criteria are met, telemetry can be discontinued.
3. Stroke telemetry protocol – Telemetry is applied for 48 hours, mainly for detection of paroxysmal atrial fibrillation. Monitoring can be temporarily discontinued if the patient requires magnetic resonance imaging, which interferes with the telemetric monitors.

When entering any of the 3 possible telemetry orders in our computerized provider order entry system (Meditech, Westwood, MA), the ordering provider is required to indicate baseline rhythm, pacemaker presence, and desired heart rate warning parameters. Once the order is electronically signed, a monitor technician notes the order in a logbook and assigns the patient a telemeter, which is applied by the patient’s nurse.

If a monitored patient develops any predefined abnormal rhythm, audible alerts notify monitor technicians and an alert is sent to a portable telephone carried by the patient’s assigned nurse. Either the monitoring technician or the nurse then has the discretion to silence the alarm, note it in the chart, and/or contact the patient’s provider. If alerts are recorded, then a sample telemetry monitoring strip is saved into the patient’s paper medical chart.

 

Survey Instrument

After approval from the Johns Hopkins institutional review board, we queried providers who worked on the medicine and cardiology wards to assess the context and culture in which telemetry monitoring is used (see Appendix). The study was exempt from requiring informed consent. All staff had the option to decline study participation. We administered the survey using an online survey software program (SurveyMonkey, Palo Alto, CA), sending survey links via email to all internal medicine residents, cardiovascular disease fellows, internal medicine and cardiology teaching attending physicians, hospitalists, NPs, and PAs. Respondents completed the survey anonymously. To increase response rates, providers were sent a monthly reminder email. The survey was open from March 2014 to May 2014 for a total of 3 months.

Analysis

The survey data were compiled and analyzed using Microsoft Excel (Mac version 14.4; Microsoft, Redmond, WA). Variables are displayed as numbers and percentages, as appropriate.

Results

Of the 180 invited providers, 67 replied, for a response rate of 37%. Residents were the largest group of respondents (42%), followed by non-hospitalist teaching attending physicians (31%), hospitalists (21%), fellows (4%), and one PA (1%) (Table).

All providers reported having ordered telemetry, but almost all were either unaware of (76%) or only somewhat familiar with (21%) the AHA guidelines for appropriate telemetry use. Notably, the vast majority of fellows and residents reported that they were not at all familiar with the guidelines (100% and 96%, respectively). When asked why providers do not adhere to telemetry guidelines, lack of awareness of and lack of familiarity with the guidelines were the top 2 choices among respondents (Figure 1). 

Despite acknowledging unfamiliarity with the guidelines, 60% (40/67) felt their own ordering practices were consistent with the guidelines the majority of the time. The majority of respondents (64%, 43/67) felt that telemetry was not being appropriately utilized at their institution.

Additionally, most providers acknowledged experiencing adverse effects of telemetry: 86% (57/66) had experienced delayed patient transfers from the emergency department to inpatient floors due to telemetry unavailability and 97% (65/67) had experienced some delay in obtaining tests or studies for their telemetry-monitored patients. Despite acknowledging the potential consequences of telemetry use, only 21% (14/66) of providers routinely (ie, > 75% of the time) discontinued telemetry within 48 hours. Fifteen percent (10/65) routinely allowed telemetry to continue until the time of patient discharge. When discontinued, it was mainly due to the provider’s decision (57%); however, respondents noted that nurses prompted telemetry discontinuation 28% of the time.

Finally, providers viewed a list of 14 diagnoses, only 3 of which met criteria for telemetry use per AHA guidelines—myocardial infarction/ACS, myocarditis, and ingestion of a cardiotoxic drug (Figure 2). Participants were asked to select the diagnoses for which they would order telemetry. Eighty-five percent (57/67) selected at least 1 inappropriate diagnosis. The most commonly selected inappropriate diagnoses in descending order were substance withdrawal (57%), gastrointestinal bleed (43%), pulmonary embolus with normal heart rate and blood pressure (37%), altered mental status (33%), acute renal failure with normal electrolytes (18%), and exacerbation of obstructive lung disease (12%). Seven respondents (10%) selected only the guideline-supported diagnoses.

The majority of providers (40/67) agreed that “better provider education” would be the most effective method for improving communication between providers and nurses regarding telemetry use. Rather than choosing one of the available answer choices (Figure 3), some providers offered write-in suggestions for improving communication about telemetry, especially with regard to limited telemeter availability. Examples included: “The biggest barrier to compliance with tele guidelines is that providers don’t know which of their patients are on tele; especially when taking over care from another colleague.” Similarly, another provider wrote, “I wish… there was a prompt or sign that the patient is on tele… When we encounter tele shortages, I have to ask [the charge nurse] if there is any patient who no longer needs tele… We need to pay more attention.”

 

Discussion

Consistent with previous studies [3–5,9–15], the majority of providers at our institution do not think continuous telemetry is appropriately utilized. Most survey respondents acknowledged a lack of awareness surrounding current guideline recommendations, which could explain why providers often do not follow them. Despite conceding their knowledge deficits, providers assumed their practice patterns for ordering telemetry were “appropriate”(ie, guideline-supported). This assertion may be incorrect as the majority of providers in our survey chose at least 1 non–guideline-supported indication for telemetry. Other studies have suggested additional reasons for inappropriate telemetry utilization. Providers may disagree with guideline recommendations, may assign lesser importance to guidelines when caring for an individual patient, or may fall victim to inertia (ie, not ordering telemetry appropriately simply because changing one’s practice pattern is difficult) [7].

In addition, the majority of our providers perceived telemetry overuse, which has been well-recognized nationwide [4]. While we did not assess this directly, other studies suggest that providers may overuse telemetry to provide a sense of reassurance when caring for a sick patient, since continuous telemetry is perceived to provide a higher level of care [6,15–17]. Unfortunately, no study has shown a benefit for continuous telemetry when placed for non-guideline-based diagnoses—whether for cardiac or non-cardiac diagnoses [3,9–11,13,14]. Likewise, the guidelines suggest that telemetry use should be time-limited, since the majority of benefit is accrued in the first 48 hours. Beyond that time, no study has shown a clear benefit to continuous telemetry [2]. Therefore, telemetry overuse may lead to unnecessarily increased costs without added benefits [3,9–11,13–15,18].

Our conclusions are tempered by the nature of our survey data. We recognize that our survey has not been previously validated. In addition, our response rates were low. This low sample size may lead to under-representation of diverse ideas. Also, our survey results may not be generalizable, since our study was conducted at a single academic hospital. Our institution’s telemetry ordering culture may differ from others, therefore making our results less applicable to other centers.

Despite these limitations, our results aid in understanding attitudes that surround the use of continuous telemetry, which can shape formal educational interventions to encourage appropriate guideline-based telemetry use. Since our providers agree on the need for more education about the guidelines, components such as online modules or in-person lecture educational sessions, newsletters, email communications, and incorporation of AHA guidelines into the institution’s automated computer order entry system could be utilized [17]. Didactic interventions could be designed especially for trainees given their overall lack of familiarity with the guidelines. Another potential intervention could include supplying providers with publically shared personalized measures of their own practices, since providers benefit from reinforcement and individualized feedback on appropriate utilization practices [19]. Previous studies have suggested that a multidisciplinary approach to patient care leads to positive outcomes [20,21], and in our experience, nursing input is absolutely critical in outlining potential problems and in developing solutions. Our findings suggest that nurses could play an active role in alerting providers when patients have telemetry in use and identifying patients who may no longer need it.

In summary, we have shown that many providers at a tertiary academic institution utilized continuous telemetry inappropriately, and were unaware of guidelines surrounding telemetry use. Future interventions aimed at educating providers, encouraging dialogue between staff, and enabling guideline-supported utilization may increase appropriate telemetry use leading to lower cost and improved quality of patient care.

 

Acknowledgment: The authors wish to thank Dr. Colleen Christmas, Dr. Panagis Galiatsatos, Mrs. Barbara Brigade, Ms. Joetta Love, Ms. Terri Rigsby, and Mrs. Lisa Shirk for their invaluable technical and administrative support.

Corresponding author: Amber Johnson, MD, MBA, 200 Lothrop St., S-553 Scaife Hall, Pittsburgh, PA 15213, amberjohn@gmail.com.

Financial disclosures: None.

From the Johns Hopkins Bayview Medical Center, Baltimore, MD (Drs. Johnson, Knight, Maygers, and Zakaria), and Duke University Hospital, Durham, NC (Dr. Mock).

 

Abstract

• Objective: To determine patterns of telemetry use at a tertiary academic institution and identify factors contributing to noncompliance with guidelines regarding telemetry use.
• Methods: Web-based survey of 180 providers, including internal medicine residents and cardiovascular disease fellows, hospitalists, non-hospitalist teaching attending physicians, nurse practitioners, and physician assistants.
• Results: Of the 180 providers surveyed, 67 (37%) replied. Most providers (76%) were unaware of guidelines regarding appropriate telemetry use and 85% selected inappropriate diagnoses as warranting telemetry. Only 21% routinely discontinued the telemetry order within 48 hours.
• Conclusions: Many providers at a tertiary academic institution utilize continuous telemetry inappropriately and are unaware of telemetry guidelines. These findings should guide interventions to improve telemetry utilization.

 

For many decades, telemetry has been widely used in the management and monitoring of patients with possible acute coronary syndromes (ACS), arrhythmias, cardiac events, and strokes [1]. In addition, telemetry has often been used in other clinical scenarios with less rigorous data supporting its use [2–4]. As a result, in 2004 the American Heart Association (AHA) issued guidelines providing recommendations for best practices in hospital ECG monitoring. Indications for telemetry were classified into 3 diagnosis-driven groups: class I (indicated in all patients), class II (indicated in most patients, may be of benefit) and class III (not indicated, no therapeutic benefit) [2]. However, these recommendations have not been widely followed and telemetry is inappropriately used for many inpatients [5,6].

There are several reasons why clinicians fail to adhere to guidelines, including knowledge deficits, attitudes regarding the current guidelines, and institution-specific factors influencing practitioner behaviors [7]. In response to reports of widespread telemetry overuse, the Choosing Wisely Campaign of the American Board of Internal Medicine Foundation has championed judicious telemetry use, advocating evidence-based, protocol-driven telemetry management for patients not in intensive care units who do not meet guideline-based criteria for continuous telemetry [8].

In order to understand patterns of telemetry use at our academic institution and identify factors associated with this practice, we systematically analyzed telemetry use perceptions through provider surveys. We hypothesized that providers have misperceptions about appropriate use of telemetry and that this knowledge gap results in overuse of telemetry at our institution.

Methods

Setting

Johns Hopkins Bayview Medical Center is a 400-bed academic medical center serving southeastern Baltimore. Providers included internal medicine residents and cardiovascular disease fellows who rotate to the medical center and Johns Hopkins Hospital, hospitalists, non-hospitalist teaching attending physicians, nurse practitioners (NPs), and physician assistants (PAs).

Current Telemetry Practice

Remote telemetric monitoring is available in all adult, non-intensive care units of the hospital except for the psychiatry unit. However, the number of monitors are limited and it is not possible to monitor every patient if the wards are at capacity. Obstetrics uses its own unique cardiac monitoring system and thus was not included in the survey. Each monitor (IntelliVue, Philips Healthcare, Amsterdam, Netherlands) is attached to the patient using 5 lead wires, with electrocardiographic data transmitted to a monitoring station based in the progressive care unit, a cardio-pulmonary step-down unit. Monitors can be ordered in one of 3 manners, as mandated by hospital policy:

1. Continuous telemetry – Telemetry monitoring is uninterrupted until discontinued by a provider.
2. Telemetry protocol – Within 12 hours of telemetry placement, a monitor technician generates a report, which is reviewed by the nurse caring for the patient. The nurse performs an electrocardiogram (ECG) if the patient meets pre-specified criteria for telemetry discontinuation, which includes the absence of arrhythmias, troponin elevations, chest pain, or hemodynamic instability. The repeat ECG is then read and signed by the provider. After these criteria are met, telemetry can be discontinued.
3. Stroke telemetry protocol – Telemetry is applied for 48 hours, mainly for detection of paroxysmal atrial fibrillation. Monitoring can be temporarily discontinued if the patient requires magnetic resonance imaging, which interferes with the telemetric monitors.

When entering any of the 3 possible telemetry orders in our computerized provider order entry system (Meditech, Westwood, MA), the ordering provider is required to indicate baseline rhythm, pacemaker presence, and desired heart rate warning parameters. Once the order is electronically signed, a monitor technician notes the order in a logbook and assigns the patient a telemeter, which is applied by the patient’s nurse.

If a monitored patient develops any predefined abnormal rhythm, audible alerts notify monitor technicians and an alert is sent to a portable telephone carried by the patient’s assigned nurse. Either the monitoring technician or the nurse then has the discretion to silence the alarm, note it in the chart, and/or contact the patient’s provider. If alerts are recorded, then a sample telemetry monitoring strip is saved into the patient’s paper medical chart.

 

Survey Instrument

After approval from the Johns Hopkins institutional review board, we queried providers who worked on the medicine and cardiology wards to assess the context and culture in which telemetry monitoring is used (see Appendix). The study was exempt from requiring informed consent. All staff had the option to decline study participation. We administered the survey using an online survey software program (SurveyMonkey, Palo Alto, CA), sending survey links via email to all internal medicine residents, cardiovascular disease fellows, internal medicine and cardiology teaching attending physicians, hospitalists, NPs, and PAs. Respondents completed the survey anonymously. To increase response rates, providers were sent a monthly reminder email. The survey was open from March 2014 to May 2014 for a total of 3 months.

Analysis

The survey data were compiled and analyzed using Microsoft Excel (Mac version 14.4; Microsoft, Redmond, WA). Variables are displayed as numbers and percentages, as appropriate.

Results

Of the 180 invited providers, 67 replied, for a response rate of 37%. Residents were the largest group of respondents (42%), followed by non-hospitalist teaching attending physicians (31%), hospitalists (21%), fellows (4%), and one PA (1%) (Table).

All providers reported having ordered telemetry, but almost all were either unaware of (76%) or only somewhat familiar with (21%) the AHA guidelines for appropriate telemetry use. Notably, the vast majority of fellows and residents reported that they were not at all familiar with the guidelines (100% and 96%, respectively). When asked why providers do not adhere to telemetry guidelines, lack of awareness of and lack of familiarity with the guidelines were the top 2 choices among respondents (Figure 1). 

Despite acknowledging unfamiliarity with the guidelines, 60% (40/67) felt their own ordering practices were consistent with the guidelines the majority of the time. The majority of respondents (64%, 43/67) felt that telemetry was not being appropriately utilized at their institution.

Additionally, most providers acknowledged experiencing adverse effects of telemetry: 86% (57/66) had experienced delayed patient transfers from the emergency department to inpatient floors due to telemetry unavailability and 97% (65/67) had experienced some delay in obtaining tests or studies for their telemetry-monitored patients. Despite acknowledging the potential consequences of telemetry use, only 21% (14/66) of providers routinely (ie, > 75% of the time) discontinued telemetry within 48 hours. Fifteen percent (10/65) routinely allowed telemetry to continue until the time of patient discharge. When discontinued, it was mainly due to the provider’s decision (57%); however, respondents noted that nurses prompted telemetry discontinuation 28% of the time.

Finally, providers viewed a list of 14 diagnoses, only 3 of which met criteria for telemetry use per AHA guidelines—myocardial infarction/ACS, myocarditis, and ingestion of a cardiotoxic drug (Figure 2). Participants were asked to select the diagnoses for which they would order telemetry. Eighty-five percent (57/67) selected at least 1 inappropriate diagnosis. The most commonly selected inappropriate diagnoses in descending order were substance withdrawal (57%), gastrointestinal bleed (43%), pulmonary embolus with normal heart rate and blood pressure (37%), altered mental status (33%), acute renal failure with normal electrolytes (18%), and exacerbation of obstructive lung disease (12%). Seven respondents (10%) selected only the guideline-supported diagnoses.

The majority of providers (40/67) agreed that “better provider education” would be the most effective method for improving communication between providers and nurses regarding telemetry use. Rather than choosing one of the available answer choices (Figure 3), some providers offered write-in suggestions for improving communication about telemetry, especially with regard to limited telemeter availability. Examples included: “The biggest barrier to compliance with tele guidelines is that providers don’t know which of their patients are on tele; especially when taking over care from another colleague.” Similarly, another provider wrote, “I wish… there was a prompt or sign that the patient is on tele… When we encounter tele shortages, I have to ask [the charge nurse] if there is any patient who no longer needs tele… We need to pay more attention.”

 

Discussion

Consistent with previous studies [3–5,9–15], the majority of providers at our institution do not think continuous telemetry is appropriately utilized. Most survey respondents acknowledged a lack of awareness surrounding current guideline recommendations, which could explain why providers often do not follow them. Despite conceding their knowledge deficits, providers assumed their practice patterns for ordering telemetry were “appropriate”(ie, guideline-supported). This assertion may be incorrect as the majority of providers in our survey chose at least 1 non–guideline-supported indication for telemetry. Other studies have suggested additional reasons for inappropriate telemetry utilization. Providers may disagree with guideline recommendations, may assign lesser importance to guidelines when caring for an individual patient, or may fall victim to inertia (ie, not ordering telemetry appropriately simply because changing one’s practice pattern is difficult) [7].

In addition, the majority of our providers perceived telemetry overuse, which has been well-recognized nationwide [4]. While we did not assess this directly, other studies suggest that providers may overuse telemetry to provide a sense of reassurance when caring for a sick patient, since continuous telemetry is perceived to provide a higher level of care [6,15–17]. Unfortunately, no study has shown a benefit for continuous telemetry when placed for non-guideline-based diagnoses—whether for cardiac or non-cardiac diagnoses [3,9–11,13,14]. Likewise, the guidelines suggest that telemetry use should be time-limited, since the majority of benefit is accrued in the first 48 hours. Beyond that time, no study has shown a clear benefit to continuous telemetry [2]. Therefore, telemetry overuse may lead to unnecessarily increased costs without added benefits [3,9–11,13–15,18].

Our conclusions are tempered by the nature of our survey data. We recognize that our survey has not been previously validated. In addition, our response rates were low. This low sample size may lead to under-representation of diverse ideas. Also, our survey results may not be generalizable, since our study was conducted at a single academic hospital. Our institution’s telemetry ordering culture may differ from others, therefore making our results less applicable to other centers.

Despite these limitations, our results aid in understanding attitudes that surround the use of continuous telemetry, which can shape formal educational interventions to encourage appropriate guideline-based telemetry use. Since our providers agree on the need for more education about the guidelines, components such as online modules or in-person lecture educational sessions, newsletters, email communications, and incorporation of AHA guidelines into the institution’s automated computer order entry system could be utilized [17]. Didactic interventions could be designed especially for trainees given their overall lack of familiarity with the guidelines. Another potential intervention could include supplying providers with publically shared personalized measures of their own practices, since providers benefit from reinforcement and individualized feedback on appropriate utilization practices [19]. Previous studies have suggested that a multidisciplinary approach to patient care leads to positive outcomes [20,21], and in our experience, nursing input is absolutely critical in outlining potential problems and in developing solutions. Our findings suggest that nurses could play an active role in alerting providers when patients have telemetry in use and identifying patients who may no longer need it.

In summary, we have shown that many providers at a tertiary academic institution utilized continuous telemetry inappropriately, and were unaware of guidelines surrounding telemetry use. Future interventions aimed at educating providers, encouraging dialogue between staff, and enabling guideline-supported utilization may increase appropriate telemetry use leading to lower cost and improved quality of patient care.

 

Acknowledgment: The authors wish to thank Dr. Colleen Christmas, Dr. Panagis Galiatsatos, Mrs. Barbara Brigade, Ms. Joetta Love, Ms. Terri Rigsby, and Mrs. Lisa Shirk for their invaluable technical and administrative support.

Corresponding author: Amber Johnson, MD, MBA, 200 Lothrop St., S-553 Scaife Hall, Pittsburgh, PA 15213, amberjohn@gmail.com.

Financial disclosures: None.

From the Johns Hopkins Bayview Medical Center, Baltimore, MD (Drs. Johnson, Knight, Maygers, and Zakaria), and Duke University Hospital, Durham, NC (Dr. Mock).

 

Abstract

• Objective: To determine patterns of telemetry use at a tertiary academic institution and identify factors contributing to noncompliance with guidelines regarding telemetry use.
• Methods: Web-based survey of 180 providers, including internal medicine residents and cardiovascular disease fellows, hospitalists, non-hospitalist teaching attending physicians, nurse practitioners, and physician assistants.
• Results: Of the 180 providers surveyed, 67 (37%) replied. Most providers (76%) were unaware of guidelines regarding appropriate telemetry use and 85% selected inappropriate diagnoses as warranting telemetry. Only 21% routinely discontinued the telemetry order within 48 hours.
• Conclusions: Many providers at a tertiary academic institution utilize continuous telemetry inappropriately and are unaware of telemetry guidelines. These findings should guide interventions to improve telemetry utilization.

 

For many decades, telemetry has been widely used in the management and monitoring of patients with possible acute coronary syndromes (ACS), arrhythmias, cardiac events, and strokes [1]. In addition, telemetry has often been used in other clinical scenarios with less rigorous data supporting its use [2–4]. As a result, in 2004 the American Heart Association (AHA) issued guidelines providing recommendations for best practices in hospital ECG monitoring. Indications for telemetry were classified into 3 diagnosis-driven groups: class I (indicated in all patients), class II (indicated in most patients, may be of benefit) and class III (not indicated, no therapeutic benefit) [2]. However, these recommendations have not been widely followed and telemetry is inappropriately used for many inpatients [5,6].

There are several reasons why clinicians fail to adhere to guidelines, including knowledge deficits, attitudes regarding the current guidelines, and institution-specific factors influencing practitioner behaviors [7]. In response to reports of widespread telemetry overuse, the Choosing Wisely Campaign of the American Board of Internal Medicine Foundation has championed judicious telemetry use, advocating evidence-based, protocol-driven telemetry management for patients not in intensive care units who do not meet guideline-based criteria for continuous telemetry [8].

In order to understand patterns of telemetry use at our academic institution and identify factors associated with this practice, we systematically analyzed telemetry use perceptions through provider surveys. We hypothesized that providers have misperceptions about appropriate use of telemetry and that this knowledge gap results in overuse of telemetry at our institution.

Methods

Setting

Johns Hopkins Bayview Medical Center is a 400-bed academic medical center serving southeastern Baltimore. Providers included internal medicine residents and cardiovascular disease fellows who rotate to the medical center and Johns Hopkins Hospital, hospitalists, non-hospitalist teaching attending physicians, nurse practitioners (NPs), and physician assistants (PAs).

Current Telemetry Practice

Remote telemetric monitoring is available in all adult, non-intensive care units of the hospital except for the psychiatry unit. However, the number of monitors are limited and it is not possible to monitor every patient if the wards are at capacity. Obstetrics uses its own unique cardiac monitoring system and thus was not included in the survey. Each monitor (IntelliVue, Philips Healthcare, Amsterdam, Netherlands) is attached to the patient using 5 lead wires, with electrocardiographic data transmitted to a monitoring station based in the progressive care unit, a cardio-pulmonary step-down unit. Monitors can be ordered in one of 3 manners, as mandated by hospital policy:

1. Continuous telemetry – Telemetry monitoring is uninterrupted until discontinued by a provider.
2. Telemetry protocol – Within 12 hours of telemetry placement, a monitor technician generates a report, which is reviewed by the nurse caring for the patient. The nurse performs an electrocardiogram (ECG) if the patient meets pre-specified criteria for telemetry discontinuation, which includes the absence of arrhythmias, troponin elevations, chest pain, or hemodynamic instability. The repeat ECG is then read and signed by the provider. After these criteria are met, telemetry can be discontinued.
3. Stroke telemetry protocol – Telemetry is applied for 48 hours, mainly for detection of paroxysmal atrial fibrillation. Monitoring can be temporarily discontinued if the patient requires magnetic resonance imaging, which interferes with the telemetric monitors.

When entering any of the 3 possible telemetry orders in our computerized provider order entry system (Meditech, Westwood, MA), the ordering provider is required to indicate baseline rhythm, pacemaker presence, and desired heart rate warning parameters. Once the order is electronically signed, a monitor technician notes the order in a logbook and assigns the patient a telemeter, which is applied by the patient’s nurse.

If a monitored patient develops any predefined abnormal rhythm, audible alerts notify monitor technicians and an alert is sent to a portable telephone carried by the patient’s assigned nurse. Either the monitoring technician or the nurse then has the discretion to silence the alarm, note it in the chart, and/or contact the patient’s provider. If alerts are recorded, then a sample telemetry monitoring strip is saved into the patient’s paper medical chart.

 

Survey Instrument

After approval from the Johns Hopkins institutional review board, we queried providers who worked on the medicine and cardiology wards to assess the context and culture in which telemetry monitoring is used (see Appendix). The study was exempt from requiring informed consent. All staff had the option to decline study participation. We administered the survey using an online survey software program (SurveyMonkey, Palo Alto, CA), sending survey links via email to all internal medicine residents, cardiovascular disease fellows, internal medicine and cardiology teaching attending physicians, hospitalists, NPs, and PAs. Respondents completed the survey anonymously. To increase response rates, providers were sent a monthly reminder email. The survey was open from March 2014 to May 2014 for a total of 3 months.

Analysis

The survey data were compiled and analyzed using Microsoft Excel (Mac version 14.4; Microsoft, Redmond, WA). Variables are displayed as numbers and percentages, as appropriate.

Results

Of the 180 invited providers, 67 replied, for a response rate of 37%. Residents were the largest group of respondents (42%), followed by non-hospitalist teaching attending physicians (31%), hospitalists (21%), fellows (4%), and one PA (1%) (Table).

All providers reported having ordered telemetry, but almost all were either unaware of (76%) or only somewhat familiar with (21%) the AHA guidelines for appropriate telemetry use. Notably, the vast majority of fellows and residents reported that they were not at all familiar with the guidelines (100% and 96%, respectively). When asked why providers do not adhere to telemetry guidelines, lack of awareness of and lack of familiarity with the guidelines were the top 2 choices among respondents (Figure 1). 

Despite acknowledging unfamiliarity with the guidelines, 60% (40/67) felt their own ordering practices were consistent with the guidelines the majority of the time. The majority of respondents (64%, 43/67) felt that telemetry was not being appropriately utilized at their institution.

Additionally, most providers acknowledged experiencing adverse effects of telemetry: 86% (57/66) had experienced delayed patient transfers from the emergency department to inpatient floors due to telemetry unavailability and 97% (65/67) had experienced some delay in obtaining tests or studies for their telemetry-monitored patients. Despite acknowledging the potential consequences of telemetry use, only 21% (14/66) of providers routinely (ie, > 75% of the time) discontinued telemetry within 48 hours. Fifteen percent (10/65) routinely allowed telemetry to continue until the time of patient discharge. When discontinued, it was mainly due to the provider’s decision (57%); however, respondents noted that nurses prompted telemetry discontinuation 28% of the time.

Finally, providers viewed a list of 14 diagnoses, only 3 of which met criteria for telemetry use per AHA guidelines—myocardial infarction/ACS, myocarditis, and ingestion of a cardiotoxic drug (Figure 2). Participants were asked to select the diagnoses for which they would order telemetry. Eighty-five percent (57/67) selected at least 1 inappropriate diagnosis. The most commonly selected inappropriate diagnoses in descending order were substance withdrawal (57%), gastrointestinal bleed (43%), pulmonary embolus with normal heart rate and blood pressure (37%), altered mental status (33%), acute renal failure with normal electrolytes (18%), and exacerbation of obstructive lung disease (12%). Seven respondents (10%) selected only the guideline-supported diagnoses.

The majority of providers (40/67) agreed that “better provider education” would be the most effective method for improving communication between providers and nurses regarding telemetry use. Rather than choosing one of the available answer choices (Figure 3), some providers offered write-in suggestions for improving communication about telemetry, especially with regard to limited telemeter availability. Examples included: “The biggest barrier to compliance with tele guidelines is that providers don’t know which of their patients are on tele; especially when taking over care from another colleague.” Similarly, another provider wrote, “I wish… there was a prompt or sign that the patient is on tele… When we encounter tele shortages, I have to ask [the charge nurse] if there is any patient who no longer needs tele… We need to pay more attention.”

 

Discussion

Consistent with previous studies [3–5,9–15], the majority of providers at our institution do not think continuous telemetry is appropriately utilized. Most survey respondents acknowledged a lack of awareness surrounding current guideline recommendations, which could explain why providers often do not follow them. Despite conceding their knowledge deficits, providers assumed their practice patterns for ordering telemetry were “appropriate”(ie, guideline-supported). This assertion may be incorrect as the majority of providers in our survey chose at least 1 non–guideline-supported indication for telemetry. Other studies have suggested additional reasons for inappropriate telemetry utilization. Providers may disagree with guideline recommendations, may assign lesser importance to guidelines when caring for an individual patient, or may fall victim to inertia (ie, not ordering telemetry appropriately simply because changing one’s practice pattern is difficult) [7].

In addition, the majority of our providers perceived telemetry overuse, which has been well-recognized nationwide [4]. While we did not assess this directly, other studies suggest that providers may overuse telemetry to provide a sense of reassurance when caring for a sick patient, since continuous telemetry is perceived to provide a higher level of care [6,15–17]. Unfortunately, no study has shown a benefit for continuous telemetry when placed for non-guideline-based diagnoses—whether for cardiac or non-cardiac diagnoses [3,9–11,13,14]. Likewise, the guidelines suggest that telemetry use should be time-limited, since the majority of benefit is accrued in the first 48 hours. Beyond that time, no study has shown a clear benefit to continuous telemetry [2]. Therefore, telemetry overuse may lead to unnecessarily increased costs without added benefits [3,9–11,13–15,18].

Our conclusions are tempered by the nature of our survey data. We recognize that our survey has not been previously validated. In addition, our response rates were low. This low sample size may lead to under-representation of diverse ideas. Also, our survey results may not be generalizable, since our study was conducted at a single academic hospital. Our institution’s telemetry ordering culture may differ from others, therefore making our results less applicable to other centers.

Despite these limitations, our results aid in understanding attitudes that surround the use of continuous telemetry, which can shape formal educational interventions to encourage appropriate guideline-based telemetry use. Since our providers agree on the need for more education about the guidelines, components such as online modules or in-person lecture educational sessions, newsletters, email communications, and incorporation of AHA guidelines into the institution’s automated computer order entry system could be utilized [17]. Didactic interventions could be designed especially for trainees given their overall lack of familiarity with the guidelines. Another potential intervention could include supplying providers with publically shared personalized measures of their own practices, since providers benefit from reinforcement and individualized feedback on appropriate utilization practices [19]. Previous studies have suggested that a multidisciplinary approach to patient care leads to positive outcomes [20,21], and in our experience, nursing input is absolutely critical in outlining potential problems and in developing solutions. Our findings suggest that nurses could play an active role in alerting providers when patients have telemetry in use and identifying patients who may no longer need it.

In summary, we have shown that many providers at a tertiary academic institution utilized continuous telemetry inappropriately, and were unaware of guidelines surrounding telemetry use. Future interventions aimed at educating providers, encouraging dialogue between staff, and enabling guideline-supported utilization may increase appropriate telemetry use leading to lower cost and improved quality of patient care.

 

Acknowledgment: The authors wish to thank Dr. Colleen Christmas, Dr. Panagis Galiatsatos, Mrs. Barbara Brigade, Ms. Joetta Love, Ms. Terri Rigsby, and Mrs. Lisa Shirk for their invaluable technical and administrative support.

Corresponding author: Amber Johnson, MD, MBA, 200 Lothrop St., S-553 Scaife Hall, Pittsburgh, PA 15213, amberjohn@gmail.com.

Financial disclosures: None.