Decreasing Inappropriate Telemetry Utilization in the Non-ICU Setting

Telemetry monitoring is known to be over-utilized outside of the ICU, rarely leads to a change in management, and has never been shown to improve clinical outcomes. We demonstrate that implementation of a system-wide change to the EMR telemetry ordering process has, thus far, led to a 15% decrease in overall telemetry utilization, while a simultaneous multi-faceted intervention within the hospitalist group led to a reduction of 54%.

Decreasing Inappropriate Telemetry Utilization in the Non-ICU Setting Karli Edholm MD, Jason Carr MD, David Gill MD, Austin Rupp MD, Jack Morshedzadeh MD Department of Internal Medicine, University of Utah, Salt Lake City, UT Background • Telemetry monitoring is known to be over-utilized outside of the ICU, rarely leads to a change in management, and has never been shown to improve clinical outcomes • Telemetry monitoring increases cost and is associated with numerous potential harms, including frequent false positives • As part of the ABIM's Choosing Wisely campaign, SHM highlighted telemetry monitoring as a target for improving value in inpatient medicine • Our institution did not previously have a standardized approach to telemetry monitoring or a protocol that governed continuation Purpose • Decrease overall telemetry utilization by 30% and increase guidelinecongruent monitoring from 14 to 75% by hard-wiring the American Heart Association (AHA) guidelines into our EMR, and evaluate the additional effect of a more robust intervention on the hospitalist service Telemetry Process Map System-Wide Intervention - Modification of the EMR order requiring selection of a clinical indication and duration for monitoring, based on AHA guidelines - Decision support within the order providing guidance on common clinical conditions for which monitoring is not indicated Hospitalist Group Multifaceted Intervention - Educational component - Removal of telemetry order from admission order sets without a clinical indication - Regular feedback - Financial incentive to the division (not individual providers) from a cost-savings program through the University - Renewed emphasis of the rounding checklist to address telemetry on rounds daily • Based on initial data, system-wide utilization has decreased 15%, from a baseline of 1626 telemetry days per month, to a mean over the past 5 months of 1383 days • System-wide duration of monitoring remains about the same (3.18 vs 3.05 days) • Hospitalist service utilization has decreased by 54%, from a baseline of 294 telemetry days per month, to a mean over the past 5 months of 134 days • Among hospitalist service patients, mean duration of monitoring has decreased by 19%, from 2.52 to 2.04 days Conclusions We demonstrate that implementation of a system-wide change to the EMR telemetry ordering process has, thus far, led to a 15% decrease in overall telemetry utilization, while a simultaneous multi-faceted intervention within the hospitalist group led to a reduction of 54%. Major Limitations: • Telemetry days are not expressed as a rate (no denominator), therefore changes in overall census are not accounted for • No automatic discontinuation. Once the chosen duration for monitoring time is reached, the order expires and the clinician must renew or discontinue the order Baseline EMR order did not require indication for monitoring, and continued indefinitely Methods • Baseline analysis of 100 consecutive charts 51% of patients met an indication for monitoring at the time of initiation 14% of all telemetry days met indications for monitoring • Baseline analysis of all telemetry days over the preceding 15 months (Jan 2014 - Mar 2015) demonstrated a mean of 1626 telemetry days per month (SD 148) with an average duration of 3.13 days (SD 0.20) • Highest utilization services are Cardiology with 24.8% of all telemetry days, Hospitalist 22.5%, CT surgery 11.6%, Neurology 10.8% and Neurosurgery 8.0% New EMR Order Requiring "Indication" and "Duration" Next Steps: • Implementation of a system-wide process to standardize expiring telemetry orders, in order to limit inappropriate renewal • Expansion of the educational component to additional high utilization services • Repeat chart review evaluating for increased proportion of guideline-congruent monitoring • Ongoing monitoring for sustainability References • Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circ 2004;110:2721-2746 • Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med 2013;8(9):486-92 • Henriques-Forsythe MN, Ivonye CC, Jamched U, et al. Is telemetry overused? Is it as helpful as thought? Cleve Clin J Med 2009; 76(6):368-372 • Dressler R, Dryer MM, Coletti C, et al. Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med 2014; 174:1852-1854