Monitoring patients’ hearts with telemetry seems innocuous enough. It’s not invasive, and it’s an extra pair of eyes keeping track of a key vital function. So what’s the problem? Apparently, telemetry can be an outright danger to some patients, tangling them up in cords and changing their center of gravity. And it can set off false alarms at a time when alarm fatigue is something that The Joint Commission has warned about.
So when Christiana Care developed a protocol for taking just about everyone off except those people who really needed the monitoring, ECRI took notice and gave them an award for technology and patient safety.
Andrew Doorey, MD, FACC, a member of the safety committee at the Christiana Care Health System in Newark, DE, believed that cardiac telemetry was "seriously overused" despite some surprisingly strict guidelines. They state that for the most part, outside intensive care, no one should be on telemetry for more than 48 hours. "If you come in with a heart attack, they recommend 48 hours, so imagine what the recommendations are for pneumonia or something less serious," he says. "But the fact is that most people are on heart monitors for their entire stay, until discharge."
They had made several attempts to change procedure by revising policies, educating physicians, and getting nurses to automatically discontinue telemetry after a certain time frame. "They all failed," he says. "And this seems to have been the case universally across the country."
The guideline at the hospital was for a limit of 72 hours, then for an automatic discontinuation. But that didn’t happen. Part of the reason was that no one wanted to be the physician whose patient wasn’t being monitored when everyone else’s was. Nurses didn’t want to be the ones responsible for disconnecting patients. No one wanted to be responsible.
Then there was the day that the telemetry control center, off campus in a building across the street, lost communication with the hospital. Very quickly, the 377 patients being monitored had to be whittled down to a much smaller number because there weren’t 377 portable machines to monitor those patients. "The nurses had to figure out who needed those portable monitors," he says. "It was after hours, there weren’t any docs around, they didn’t know who to put on the devices. It’s a complex decision, and I think even 50 cardiologists would have been hard pressed to figure it out."
A few days later, this was presented to Doorey and his committee. "The chairman asked how can we figure out who needs the monitors. I said almost none of them." And thus Doorey was volunteered to run the project.
The device may be innocuous, but being on it can cause real harm. "We got the 2004 American Heart Association guidelines, which gives ranges of duration," he says. "We made up a list of mainly cardiac diagnoses. They were blank about surgery so we asked the surgeons. They wanted the patients off as soon as possible so they would be up and walking. Simple surgeries, 24 hours, complex 48. We wanted the physicians to have autonomy, so they could always order telemetry, but that was under other,’ and it was for 24 hours."
Doorey sold the plan to the nurses, as well, worried that they would be averse. They hated telemetry. It wasn’t the safety net he thought they’d see it as. It gets caught up in other leads, patients trip, fall, they can’t get comfortable. Smaller women who hang the box around their neck can have their center of gravity altered enough to make them a fall risk. They can’t give medications to a single patient without interruptions from central monitoring.
Indeed, a study they did for the project of every alarm and every nurse analyzed thousands of alarms and found 99% were loose leads, low battery levels, or patients wandering out of coverage range. "Garbage calls," Doorey says. "Only a tiny percentage were important. And when we added up the time, it was 117 hours per day that the nurses spent dealing with telemetry alarms."
Everyone was coached and counselled in grand rounds and section meetings. "The old system was no one’s responsibility. No one ever wanted to stick their neck out or be the only one doing things differently," he says. Now, there is a checklist that the nurses fill out after 12 and 24 hours that is imported into the electronic health system. Telemetry is automatically discontinued at that time. The final question is, "Is there any reason you think this shouldn’t be disconnected?" Doorey says that’s the "hair on the back of your neck" question — the thing that you can’t explain but makes you sure a patient should still be on telemetry.
Most alarms that ring in a hospital are physiologic — like telemetry. By showing that they could reduce the average telemetry census by 70% without any change in code blue, mortality, rapid intervention team, or other data, simply by applying national guidelines, Doorey thinks he and his team have made a real dent in reducing alarm fatigue. There is also less money spent chasing false diagnoses — there are artifacts that look like arrhythmias, but are just an electrical anomaly. He knows of one man who even had a defibrillator implanted that he didn’t need because of such an anomaly.
There may be other benefits, too.
There was one patient Doorey likes to recall, who was in the hospital for a week. The 87-year-old was on telemetry the entire time. When the family came to take her home, they took her off her heart monitor and the family balked. "If she needed to be on it all that time, she still needs it!" they cried. "The nurse told them she hadn’t really needed it," Doorey says. It’s the kind of explanation that makes people distrust medicine. And it’s a good reason to revamp telemetry practices.
