Published in the December 2014 issue of Today’s Hospitalist
HERE’S SOME GOOD NEWS: One of the most overused diagnostic tests can be either safely eliminated or have its duration significantly reduced.
According to a new study, Christiana Care Health System in Newark, Del., was able to cut its use of cardiac telemetry by an astonishing 70% by embedding American Heart Association (AHA) guidelines for that testing into its electronic medical record. Even better: That dramatic reduction didn’t affect patient risk or outcomes.
The study, posted online in September by JAMA Internal Medicine, found no increase in mortality, code blue calls or rapid response team activation during the eight months covered by the study.
Getting there, however, entailed a massive effort. A team had to effectively remove cardiac telemetry from all order sets in non-ICU settings for conditions not supported by the guidelines. (The Christiana Care system includes more than 1,100 patient beds.) That led to “hardwiring” the guidelines into 144 existing order sets affected by the change “an idea fully supported by the system’s hospitalists, notes Robert Dressler, MD, MBA, vice chair of the department of medicine and the study’s lead author.
Over the course of the study, the number of telemetry orders dropped from a weekly mean of 1,032 to 593, while daily system-wide costs for non-ICU telemetry decreased from $18,971 to $5,772. Because those reductions have persisted since the study ended in August 2013, Dr. Dressler estimates that the intervention is saving Christiana Care about $4.8 million a year.
Keeping it simple
Under the new system, physicians who want to order cardiac telemetry must select a clinical condition among the 17 adapted from the guidelines. Each of those indications automatically includes telemetry duration and determines when monitoring will be discontinued if the patient’s clinical condition is stable.
For example, myocardial infarction and complex surgery per the AHA guidelines qualify for automatic 48- hour telemetry, while myocardial infarction rule-out warrants only 24 hours. Patients with known serious cardiac conditions can remain on telemetry throughout their hospitalization if physicians deem it appropriate.
Physicians who choose to order telemetry for conditions not addressed by the guidelines can do so by choosing “other,” says interventional cardiologist Andrew Doorey, MD, the initiative’s cardiology champion and a co-author of the study. Checking the “other” indication will trigger 24 more hours of cardiac telemetry.
“We made this simple by essentially boiling down the many pages of guidelines,” Dr. Doorey says. Doctors who want to continue telemetry, however, must renew that order daily.
The team heading up the initiative also added stroke to the list of conditions that receive 48-hour monitoring, even though it’s not addressed in the AHA guidelines. Dr. Doorey notes that studies have found a mortality benefit with monitoring in stroke patients.
But to get the design right, the intervention took a great deal of time and support from not only physicians and nurses, but the IT staff and pharmacy. (It took four months to build the revised ordering system.) The initiative’s complexity was due to the tailoring of the IT design that embedded telemetry ordering and management within the workflow of front-line staff.
“We needed to revamp how physicians order telemetry and remove their ability to order it where there was no apparent clinical benefit of monitoring heart rhythm,” Dr. Dressler says. He points to migraine as a great example of an order set that used to include cardiac telemetry but shouldn’t.
“Ninety-nine percent of patients admitted for a migraine do not need cardiac telemetry,” he explains. Now, if a migraine patient has another indication for telemetry, physicians have to “go external to that order set” to order it if they feel it’s clinically indicated.
The initiative’s eventual success doesn’t mean it went off without a hitch. Surgeons generally supported reducing telemetry duration so their patients could get up and around sooner. But nurses raised concerns “all of them valid, Dr. Doorey says.
Nurses were worried, for instance, that telemetry was being automatically discontinued without their having any physician interaction, making nurses potentially responsible for a clinically important decision. Previously, Dr. Doorey notes, nurses and physicians would discuss when patients could safely be taken off a monitor.
The fix was to build in a nursing evaluation of patients and vital-sign input to make sure patients slated for discontinuation aren’t unstable or deteriorating. To do so, nurses answer three questions embedded in the telemetry order about the patient’s status.
“When those steps were taken “and IT did a good job designing those pages in the EHR “monitoring was automatically discontinued,” Dr. Doorey says.
At the other end of the spectrum, the design team tried to accommodate situations in which discontinuing telemetry automatically might increase patient risk of poor outcomes.
“Under very rare circumstances, a cardiologist can order what we call eternal monitoring to ensure that telemetry isn’t discontinued” for serious conditions like ventricular tachycardia storm, Dr. Doorey explains. He adds that only cardiologists have the ability to order automatic continuation.
“We had to build upon the suggestions we received and, at times, negotiate things because we didn’t want this to be heavy-handed,” says Dr. Doorey. “We wanted it to be something everyone could live with, even though it was based on guidelines and good evidence.”
The team also wanted everyone to buy in beforehand, starting with the cardiologists. Team members spent time explaining the intervention and seeking input on its design, giving grand rounds presentations and holding individual meetings with nurses, specialists and other medical staff members, and pharmacists, among others.
“We spent a lot of time listening, and we spoke to anyone who would have us, from the hospitalists and nurses to the OB-GYNs,” Dr. Dressler says. “You can’t just plop down this kind of intervention. We also made a point of never discussing costs up front, and instead talked only about quality of care.”
As discussions proceeded, team members discovered another selling point: the downsides of unnecessary cardiac telemetry. Nurses had many anecdotes about telemetry’s inherent safety risks such as alarm fatigue, patients getting caught up in wires and wires sometimes getting literally crossed.
“The nurses mentioned other downsides of unnecessary monitoring, such as having to wake patients at 2 a.m. when the system malfunctions,” Dr. Doorey says. The health system’s chief nursing officer noted yet another: All patients on telemetry also must have IVs, which pose their own safety risks. “We now have less of these.”
In the wake of the study’s publication, Dr. Dressler says that he and his colleagues have been approached by many organizations that want to structure similar initiatives. The key to succeeding is getting broad-based buy-in and support from IT and pharmacy to minimize disruptions in clinician workflow.
As for the specifics of the intervention’s design, Drs. Dressler and Doorey are happy to share the details. (Dr. Dressler’s e-mail is firstname.lastname@example.org.)
“We believe it’s our mandate,” says Dr. Dressler, “to share this with others.”
Bonnie Darves is a freelance health care writer based in Seattle.