In our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” we noted that telemetry is one technology we often see overutilized in many hospitals, which may contribute to alarm fatigue. When we discuss alarm management strategies with hospitals one of the first areas of focus we recommend is telemetry, particularly that occurring outside ICU’s. The American Heart Association and American College of Cardiology (AHA/ACC) have published guidelines on telemetry monitoring and suggested criteria. Yet many hospitals have never developed local guidelines to help identify which patients should be monitored (and which should not). Moreover, criteria for continued monitoring are extremely important because all too often a physician orders telemetry and it gets continued indefinitely. Getting your physician staff involved early in developing your telemetry criteria is the key.
Researchers at Christiana Care Health System successfully implemented a system that significantly reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring.
After implementation there was a 70% reduction in the mean daily number of patients being monitored by telemetry. The mean weekly number of telemetry orders dropped 43% and the mean duration of telemetry dropped by 47%. They assessed for potential impact on patient safety and found no worsening of mortality, code blues, or rapid response team activations. Their mean daily cost for non-ICU telemetry decreased from $18,971 to $5,772, with a projected annual savings of $4.8 million. Undoubtedly, this also had a beneficial effect on the phenomenon of alarm fatigue, though they had no specific measure of the latter.
Commentary on the study points out that the AHA guidelines were primarily aimed at patients with cardiac diagnoses so their appropriateness for non-ICU patients with non-cardiac diagnoses is not fully understood (Najafi 2014). Najafi had previously done a study (Najafi 2012) of telemetry use in patients admitted to a medical service with non-cardiac diagnoses and found very few patients had meaningful telemetry events or events that led to a change in management.
This excellent work by Christiana Care Health System demonstrates that such a focus on unnecessary telemetry monitoring can lead to significant financial savings without sacrificing patient safety and likely reducing alarm fatigue.
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. (Research Letter). JAMA Intern Med 2014; published online first September 22, 2014
Najafi N. A Call for Evidence-Based Telemetry Monitoring: The Beep Goes On. JAMA Intern Med 2014; published online first September 22, 2014
Najafi N, Auerbach A. Use and Outcomes of Telemetry Monitoring on a Medicine Service. Arch Intern Med 2012; 172(17): 1349-1350
Print “PDF version”