Too much of a good thing: Optimizing cardiac telemetry monitoring

By Kathryn Merkeley, MHSA, RN, PMP, CPPS
Vizient Program Director, Performance Improvement Programs

First introduced in ICUs in the 1960s, telemetry provides continuous physiological monitoring for patients with cardiac disease and those with critical illness or injury. Over the past several decades, the practice of using telemetry for patients outside of the ICU has grown exponentially. Telemetry is an effective tool for improving outcomes in the presence of an cardiac disease or critical illness but research indicates utilizing telemetry as a "second set of eyes" for patients who do not meet criteria for use is an ineffective, inefficient and potentially risky practice.

Indiscriminate use of telemetry as a safety net for identifying clinical deterioration or preventing code blue events outside of the ICU strains resources for safe patient monitoring, contributes to unnecessary diagnostics and treatment and increases the frequency of "false alarms" that distract clinicians from early identification and response to actionable arrhythmias and patient deterioration. Multiple studies support that a very small percentage of telemetry alarms represent true emergencies requiring intervention or result in code blue events. Additionally, telemetry is not effective for early detection of impending clinical deterioration and should not replace frequent vital signs and assessments or use of early warning systems. Overusing telemetry also is linked to increased length of stay, higher cost of care, delayed patient flow and diminished patient experience.

Drivers of overutilization include lack of provider education on evidence-based guidelines for telemetry, inadequate controls for telemetry initiation and absence of reassessment and discontinuation criteria. Practice Standards from the American Heart Association (AHA) provide recommendations for indications, duration and implementation of telemetry. Subsequent studies demonstrated the effectiveness of these practice standards for reducing overutilization without compromising safety or patient outcomes.
Organizations should assess their current telemetry workflow and protocols to identify opportunities for improvement and prevent negative consequences from overutilization on patient safety, quality of care and organizational efficiency. Recommendations for optimizing cardiac telemetry monitoring include:

Preventing overuse of telemetry monitoring

Transforming workflow culture within a healthcare organization requires effort, yet leaders can implement models to optimize telemetry monitoring and avoid overuse.

• Set structures and processes in place to guide the change, such as those outlined in this implementation blueprint.
• Establish a clear protocol for the initiation, evaluation and removal of telemetry. All non-ICU telemetry decisions should be protocol-driven to reduce waste.
• Implement multimodal interventions aligned with AHA guidelines including indication-based ordering and duration of use, routine multidisciplinary reviews for appropriateness or discontinuation and educational efforts to reduce telemetry utilization.
• Build best practice alerts or prompts into the EHR for multidisciplinary reviews after a specified duration.

Support early recognition and response to actionable arrhythmias

Early detection and response to actionable arrhythmias is critical for patient safety and optimal outcomes. Ways to ensure the right support is provided to these patients include:  

• Explore the potential of artificial intelligence and machine learning tools in identifying actionable arrhythmias and assigning responsibility for evaluating alerts and interventions.
• Minimize nonactionable alarm signals by modifying alarm sounds according to urgency, standardizing default alarm settings for similar populations and setting up protocols to personalize alarms based on individual patient needs.
• Evaluate telemetry technician workload to ensure it does not exceed the individual's ability to watch and respond to arrhythmias. Consider additional tasks and workspace factors that distract technicians from patient monitoring.
• Establish workflows for timely and consistent documentation of waveforms and telemetry events in the electronic medical record. Electronic transmission of telemetry data into the EMR ensures information is readily available to all care team members.

Revisiting telemetry use, processes and standardization for non-ICU patients can improve patient care and experience as well as cut down on length of stay and unnecessary diagnostics and treatments that increase the cost of care.

Explore more ways your organization can improve patient safety at Vizient's Patient Safety Organization and read the Vizient blog, Improving patient safety: Early recognition and timely response to clinical deterioration.