Utilization of Continuous Cardiac Monitoring on Hospitalist-led Teaching Teams

Abstract

Guidelines for continuous cardiac monitoring (CCM) have focused almost exclusively on cardiac diagnoses, thus limiting their application to a general medical population. In this study, a retrospective chart review was performed to identify the reasons that general medical patients, cared for on hospitalist-led inpatient teaching teams between April 2017 and February 2018, were initiated and maintained on CCM, and to determine the incidence of clinically significant arrhythmias in this patient population. The three most common reasons for telemetry initiation were sepsis (24%), arrhythmias (12%), and hypoxia (10%). Most patients remained on telemetry for more than 48 hours (62%) and a significant number of patients were on telemetry until they were discharged from the hospital (39%). Of the cumulative total of more than 20,573 hours of CCM provided to this patient population, 37% of patients demonstrated only normal sinus rhythm and 3% had a clinically significant arrhythmia that affected management.

‘Utilization of telemetry monitoring for non-cardiac conditions in non-critical patients: what are the trends and perceptions amongst medical residents?’

“…Lastly, we observed that 57% residents are compelled to 'often' order telemetry for patients requiring only continuous pulse oximetry (CPO). Similarly, Chen et al [6] reported that concerns for hypoxia resulted in the initiation of telemetry in 10% of the cases. This situation arises because, in some hospitals, CPO is integrated into the cardiac surveillance system and cannot be performed without placing patients in such specialized units.…”

“…A significant problem associated with overutilization of telemetry on general medical floor is its use for inappropriately long intervals. Curry et al [12] reported that TM was continued for more than 48 hours in almost one-fifth of their study population while in another clinical trial, 39% of patients remained on telemetry till their discharge [6]. The likely reasons behind this issue are an initial lack of clinical judgement and subsequent poor follow-up; for example, when asked to specify the duration upon initiation of monitoring, 73% of the residents would choose 'continuous telemetry' while only 16% would (either 'often' or 'always') discontinue it after 24-48 hours of uneventful use.…”

“…Despite this, it has been observed that TM is more likely to be ordered in patients who are primarily admitted for non-cardiac conditions. Chen et al [6] identified sepsis as the most common non-cardiac condition prompting telemetry initiation by the physicians (24%) while another study [7] observed that majority of the patients being monitored were admitted with gastrointestinal bleeding (19%), renal failure (17%) or pneumonia (11%). Similarly, in our survey, a significant proportion of the medical residents admitted ordering telemetry for patients with pulmonary embolism, COPD exacerbation and severe anemia.…”

Physiological Adaptions to Acute Hypoxia

“…Using this measurement, important parameters such as partial pressure of oxygen, partial pressure of carbon dioxide, acidity (pH), oxyhaemoglobin saturation and bicarbonate concentration in arterial blood can be assessed [68]. Management and treatment of persons under hypoxia should be started as soon as the evaluation has been successfully finished, and follows three categories: maintaining patent airways, increasing the oxygen content of the inspired air and improving the diffusion capacity [69][70][71]. Without adequate adaption processes and management, an imbalance between oxygen demand and oxygen delivery will occur leading to impaired homeostasis within the body.…”

Harnessing the Electronic Health Record to Actively Support Providers with Guideline-Directed Telemetry Use

“…Cardiac telemetry monitoring in accordance with evidencebased standards predicts cardiac events, 1 but inappropriate overuse leads to alarm fatigue, patient discomfort, and unnecessary resource utilization including unnecessary work-up potentially adversely impacting patient safety and increasing costs of care. [2][3][4] The American Heart Association (AHA) has published guidelines on appropriate telemetry use 1 and the Society of Hospital Medicine's Choosing Wisely initiative recommends against using continuous telemetry monitoring outside the intensive care unit (ICU) without a protocol that governs its continuation. 5 Many providers are unaware of these guidelines and recommendations and few receive education about guideline-directed telemetry use.…”