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Patient Safety Tip of the Week
February 7, 2023
Reducing
Unnecessary Telemetry
When hospitals ask Where should we
start? in addressing alarm fatigue, we always tell them the first place to
look is at unnecessary telemetry. There are two key elements in programs to
reduce such use:
·
Only begin telemetry in patients who meet
accepted guidelines for telemetry use
·
Stop telemetry once patients no longer meet
criteria for continued use
A hospital system recently did just that (Patidar
2022). They did 2 key interventions across 4 hospitals (a large academic
quaternary center, a tertiary care center, a small community hospital, and a
large community hospital) with a total of 1700 beds. The 2 key elements were:
·
Hardwiring the 2017 American Heart Association
practice guidelines on the appropriate use of telemetry into their EHR-based
protocol for telemetry
·
Developing a nursing-driven discontinuation protocol
with an electronic nursing screening task form for safe discontinuation of
telemetry
There was a statistically and clinically significant 24%
decrease in telemetry duration between pre- and post-intervention time periods
(P < 0.0001). Mean telemetry duration was 4.11 and 2.36 days in pre- and
post-intervention periods, respectively, a 1.75 day reduction
across each of the four hospitals.
The authors projected a substantial cost avoidance from this
project. Though they did not measure it, there was also likely also a
substantial reduction in alarm fatigue as a result of
the project.
The Patidar article details the project planning by a
multidisciplinary team and the communication rollout that was important in
preparing for the implementation of the automated protocol.
The results are
remarkably similar to a program we highlighted in our October 2014 What's New
in the Patient Safety World column Alarm
Fatigue: Reducing Unnecessary Telemetry Monitoring, in which researchers at Christiana
Care Health System successfully 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%.
Another striking reduction in telemetry was achieved on a
hospitalist service (Edholm
2018). Interventions included education, process change, routine
feedback, and a financial incentive. A system-wide change to the telemetry
ordering process was also introduced without the other components. Among
hospitalist service patients, telemetry utilization was reduced by 69%. On the
non-hospitalist services the reduction was a less marked 22%. There were no
significant increases in mortality, code event rates, or care escalation, and
there was a trend toward improved utilization appropriateness. The EHR
telemetry order was modified to discourage unnecessary telemetry monitoring. The
new order required providers ordering telemetry to choose a clinical indication
and select a duration for monitoring, after which the order would expire and
require physician renewal or discontinuation. These were the only changes that
occurred for nonhospitalist providers.
The authors also noted there had been an immediate decrease
in telemetry orders after removing the telemetry order from their admission
order set. They also attributed success on the
hospitalist service to standardization of rounds to include daily discussion of
telemetry and the provision of routine feedback. They could not discern whether
other components of the program (such as the financial incentives) contributed more or less to the program, though the sum of these
interventions produced an overall program that required substantial buy in and
sustained focus from the hospitalist group.
Our own take on these programs is that there are some key
success factors:
·
A multidisciplinary team must be involved in
planning and implementation
·
There should be clinical champions from both
your medical and nursing staffs
·
Evidence-based guidelines for telemetry use need
to be integrated into your electronic health record ordering process
·
A strong communication program prior to rollout
·
Your medical staff must buy into the concept of either
automatic discontinuation or a nurse-driven discontinuation process
·
Your nursing staff must be confident in that
nurse-driven discontinuation process and not fear retribution from medical staff
·
You need to measure desired outcomes and give
feedback to all stakeholders
Though such programs likely achieve
significant financial savings, you staffs are more likely interested in outcomes
other than financial ones. Though measurement of alarm fatigue is difficult,
you can at least do informal surveys of stakeholders about the perceived
benefit as it pertains to alarm fatigue.
Prior Patient Safety
Tips of the Week pertaining to alarm-related issues:
·
March 5, 2007 Disabled Alarms
·
March 26, 2007 Alarms Should Point to the
Problem
·
April 2, 2007 More Alarm Issues
·
June 19, 2007 Unintended Consequences of
Technological Solutons
·
April 1, 2008 Pennsylvania PSAs FMEA on
Telemetry Alarm Interventions
·
February 23, 2010 Alarm Issues in the News
Again
·
March 2, 2010 Alarm Sensitivity: Early
Detection vs. Alarm Fatigue
· March 16, 2010 A
Patient Safety Scavenger Hunt
·
November 2010 Alarms in the Operating Room
· February 22, 2011 Rethinking
Alarms
· February 2013 Joint
Commission Proposes New 2014 National Patient Safety Goal
· May 2013 Joint
Commission Sentinel Event Alert: Alarm Safety
· July 2, 2013 Issues
in Alarm Management
· August 2013 Joint
Commission Formalizes 2014 NPSG on Alarm Management
· February 4, 2014 But
What If the Battery Runs Low?
· October 2014 Alarm
Fatigue: Reducing Unnecessary Telemetry Monitoring
· December 15, 2015 Vital
Sign Monitoring at Night
· February 9, 2016 It was just a matter of
time
· August 16, 2016 How
Is Your Alarm Management Initiative Going?
· February 21, 2017 Alarm Fatigue in the ED
· April 18, 2017 Alarm Response and Nurse
Shift Duration
· April 25, 2017 Dialysis and Alarm Fatigue
· October 17, 2017 Progress on Alarm Management
· November 21, 2017 OSA, Oxygen, and Alarm
Fatigue
· May 1 2018 Refrigerator Alarms
· April 16, 2019 AACN Practice Alert on Alarm
Management
· September 2019 Alarm Fatigue in the Emergency
Room
· October 8, 2019 Another Freezer Accident
· June 23, 2020 Telemetry Incidents
· August 2020 Pulse Oximetry in Children
· September 15, 2020 An Eerily Familiar Incident
· January 26, 2021 This Freezer Accident May
Cost Lives
Some of our prior columns on the hazards associated with
telemetry:
·
June 19, 2007 Unintended Consequences of
Technological Solutions
·
April 1, 2008 Pennsylvania PSAs FMEA on
Telemetry Alarm Interventions
·
February 23, 2010 Alarm Issues in the News
Again
·
July 2011 What's New in the Patient
Safety World
·
February 4, 2014 But What If the Battery Runs
Low?
·
May 22, 2018 Hazardous
Intrahospital Transport
·
June 23, 2020 Telemetry Incidents
References:
Patidar V, Park JM, Khasnavis T,
et al. Evaluation of a Multifaceted Protocol in Reducing Unnecessary Telemetry
Monitoring Across a Large Healthcare System. South Med J 2022; 115(12):
930-935
Dressler R, Dryer MM, Coletti C,
et al. Altering Overuse of Cardiac Telemetry in NonIntensive Care Unit
Settings by Hardwiring the Use of American Heart Association Guidelines.
(Research Letter). JAMA Intern Med 2014; 174(11): 1852-1854 published online
first September 22, 2014
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1906998
Edholm K, Kukhareva
P, Ciarkowski C, et al. Decrease in Inpatient
Telemetry Utilization Through a System-Wide Electronic Health Record Change and
a Multifaceted Hospitalist Intervention. Journal of Hospital Medicine 2018; 13:
531-536
https://shmpublications.onlinelibrary.wiley.com/doi/abs/10.12788/jhm.2933
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