Practice Standards for Electrocardiographic Monitoring in Hospital Settings

Drew, Barbara J.; Califf, Robert M.; Funk, Marjorie; Kaufman, Elizabeth S.; Krucoff, Mitchell W.; Laks, Michael M.; Macfarlane, Peter W.; Sommargren, Claire E.; Swiryn, Steven; Hare, George F. Van

doi:10.1161/01.cir.0000145144.56673.59

Cited by 524 publications

(250 citation statements)

References 136 publications

(41 reference statements)

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“…3,4 In 1991, the American College of Cardiology published guidelines for telemetry use, which were later revised by the American Heart Association in 2004. 5,6 Notably, the guidelines are based on expert opinion and on research data in electrocardiography. 7 The guidelines divide patients into 3 classes based on clinical condition: recommending telemetry monitoring for almost all class I patients, stating possible benefit in class II patients, and discouraging cardiac monitoring for the low-risk class III patients.…”

Section: Discussionmentioning

confidence: 99%

“…7 The guidelines divide patients into 3 classes based on clinical condition: recommending telemetry monitoring for almost all class I patients, stating possible benefit in class II patients, and discouraging cardiac monitoring for the low-risk class III patients. 5,6 The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine and the Society of Hospital Medicine, highlights telemetry monitoring as 1 of the top 5 interventions that physicians and patients should question when determining tests and procedures. 8 Choosing Wisely suggests using a protocol to govern continuation of telemetry outside of the intensive care unit (ICU), as inappropriate monitoring increases care costs and may result in patient harm.…”

Section: Discussionmentioning

confidence: 99%

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Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost

Svec

Ahuja

Evans

et al. 2015

Journal of Hospital Medicine

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BACKGROUND Telemetry monitoring is a widely used, labor‐intensive, and often‐limited resource. Little is known of the effectiveness of methods to guide appropriate use. OBJECTIVE Our intervention for appropriate use included: (1) a hospitalist‐led, daily review of bed utilization, (2) hospitalist‐driven education module for trainees, (3) quarterly feedback of telemetry usage, and (4) financial incentives. DESIGN/METHODS Hospitalists were encouraged to discuss daily telemetry utilization on rounds. A module on appropriate telemetry usage was taught by hospitalists during the intervention period (January 2013–August 2013) on medicine wards. Pre‐ and post‐evaluations measured changes regarding telemetry use. We compared hospital bed–use data between the baseline period (January 2012–December 2012), intervention period, and extension period (September 2014–March 2015). During the intervention period, hospital bed–use data were sent to the hospitalist group quarterly. Financial incentives were provided after a decrease in hospitalist telemetry utilization. SETTING Stanford Hospital, a 444‐bed, academic medical center in Stanford, California. RESULTS Hospitalists saw reductions for both length of stay (LOS) (2.75 vs 2.13 days, P = 0.005) and total cost (22.5% reduction) for telemetry bed utilization in the intervention period. Nonhospitalists telemetry bed utilization remained unchanged. We saw significant improvements in trainee knowledge of the most cost‐saving action (P = 0.002) and the least cost‐saving action (P = 0.003) in the pre‐ and post‐evaluation analyses. Results were sustained in the hospitalist group, with telemetry LOS of 1.93 days in the extension period. CONCLUSIONS A multipronged, hospitalist‐driven intervention to improve appropriate use of telemetry reduces LOS and cost, and increases knowledge of cost‐saving actions among trainees. Journal of Hospital Medicine 2015;10:627–632. © 2015 Society of Hospital Medicine

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost

Svec

Ahuja

Evans

et al. 2015

Journal of Hospital Medicine

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“…2 The existing literature documents the timing in which arrhythmias occur after cardiac surgery or myocardial infarction, and therefore is limited in guiding patient care outside intensive care unit settings. 3,4 As such, hospitalists and inpatient providers have little data directing additional telemetry decisions for these patients, and none for patients requiring telemetry for other indications.…”

Section: Discussionmentioning

confidence: 99%

“…1 Current guidelines for cardiac monitoring use recommend minimum durations for all adult class I and most class II indications. 2 However, telemetry ordering often fails to include timing or criteria for discontinuation. We determined the impact of a reduction in telemetry order duration within our hospital, hypothesizing this reduction would lead to earlier reassessment of telemetry need and therefore decrease overall utilization.…”

mentioning

confidence: 99%

Reductions in telemetry order duration do not reduce telemetry utilization

Boggan

Navar-Boggan

Patel

et al. 2014

Journal of Hospital Medicine

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Wisely measures include not ordering "continuous telemetry monitoring outside of the ICU [intensive care unit] without using a protocol that governs continuation." 1 Current guidelines for cardiac monitoring use recommend minimum durations for all adult class I and most class II indications. 2 However, telemetry ordering often fails to include timing or criteria for discontinuation. We determined the impact of a reduction in telemetry order duration within our hospital, hypothesizing this reduction would lead to earlier reassessment of telemetry need and therefore decrease overall utilization. METHODS SettingDurham Veterans Affairs Medical Center (DVAMC) is a 151-bed tertiary care hospital within Veterans Affairs (VA) Integrated Services Network Region 6 (VISN 6) serving as the primary VA hospital for >54,000 patients and a referral hospital for VISN 6. Twenty-five telemetry units are available for use on 2 wards with 48 potential telemetry beds. All nonintensive care wards contain general medical and surgical patients, without a primary inpatient cardiology service. Most orders are written by housestaff supervised by attending physicians. InterventionPrior to our intervention, the maximum allowable duration of telemetry orders was 72 hours. The duration was enforced by nursing staff automatically discontinuing telemetry not renewed within 72 hours. For our intervention, we reduced the duration of telemetry within our electronic ordering system in November 2013 so that orders had to be renewed within 48 hours or they were discontinued. No education regarding appropriate telemetry use was provided. This intervention was created as a qualityimprovement (QI) project affecting all telemetry use within DVAMC and was exempt from institutional review board review. OutcomesOutcomes included the mean number of telemetry orders per week, mean duration of telemetry orders, mean duration of telemetry per episode, and the ratio of time on telemetry relative to the total length of stay. As a balancing measure, we examined rates of rapid response and "code blue" events. All measures were compared for 12 weeks before and 16 weeks after the intervention. Telemetry orders and durations were obtained using the Corporate Data Warehouse. AnalysisAll outcome measurements were continuous variables and compared using the Student t test in Stata version 9.2 (StataCorp, College Station, TX). RESULTSFollowing the intervention, overall order duration decreased by 33% from 66.6 6 8.3 hours to 44.5 6 2.3 hours per order (P < 0.01), mirroring the reduction in the maximum telemetry order duration from 72 to 48 hours (Table 1). However, an increase in telemetry order frequency after the intervention resulted in no significant change in telemetry duration per episode or the proportion of the hospitalization on telemetry (59.3 vs 56.3 hours per patient, P 5 0.43; and 66.4% vs 66.2% of hospitalization, P 5 0.58). Rapid response and code blue events did not differ significantly relative to the intervention (2.8 events per week before and 3.1 events...

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“…According to estimates, 23,24 clinically important cardiac arrhythmias will develop in approximately 1 in 5 ICU patients. The incidence of aLQTS and torsades de pointes may be high in hospitalized patients, especially ICU patients, because of the multiple classes of QT-prolonging medications prescribed and an increase in the incidence of other potential risk factors.…”

Section: Discussionmentioning

confidence: 99%

Acquired Long QT Syndrome: Frequency, Onset, and Risk Factors in Intensive Care Patients

Kozik

Wung

2012

Critical Care Nurse

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Background Acquired long QT syndrome is a reversible condition that can lead to torsades de pointes and sudden cardiac death. Objective To determine the frequency, onset, frequency of medications, and risk factors for the syndrome in intensive care patients. Methods In a retrospective chart review of 88 subjects, hourly corrected QT intervals calculated by using the Bazett formula were collected. Acquired long QT syndrome was defined as a corrected QT of 500 milliseconds or longer or an increase in corrected QT of 60 milliseconds or greater from baseline level. Risk factors and medications administered were collected from patients’ medical records. Results The syndrome occurred in 46 patients (52%); mean time of onset was 7.4 hours (SD, 9.4) from time of admission. Among the 88 patients, 52 (59%) received a known QTc-prolonging medication. Among the 46 with the syndrome, 23 (50%) received a known QT-prolonging medication. No other risk factor studied was significantly predictive of the syndrome. Conclusions Acquired long QT syndrome occurs in patients not treated with a known QT-prolonging medication, indicating the importance of frequent QT monitoring of all intensive care patients.

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Practice Standards for Electrocardiographic Monitoring in Hospital Settings

Cited by 524 publications

References 136 publications

Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost

Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost

Reductions in telemetry order duration do not reduce telemetry utilization

Acquired Long QT Syndrome: Frequency, Onset, and Risk Factors in Intensive Care Patients

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