A Minnesota hospital is addressing the problem of overmonitoring patients with an order set in the electronic health record (EHR) that prompts clinicians to limit monitoring and unit assignments to only what is needed. Introducing the system was not without challenges, however.
Excessive and unnecessary electrocardiogram (ECG) monitoring of patients is a common problem in hospitals, says Sue Sendelbach, PhD, APRN CNS, who retired recently from her position as director of nursing research at Abbott Northwestern Hospital in Minneapolis. She worked at that time with Allina Health colleagues at nearby United Hospital/Allina Health Leaders in St. Paul, MN, to reduce unnecessary monitoring so that care could be improved for patients and resources could be used more appropriately for those needing more monitoring, she says.
“A lot of times, patients would be monitored for days without an assessment to determine if they really needed to have that monitoring continued. Hospitalists would put patients on our telemetry units for progressive care and say the patient doesn’t need to be monitored, but then the nurses thought they needed to be monitored because it was a telemetry unit,” she says. “There was a lot of confusion around who needed to be monitored. It was not without risks, either, because the literature has shown that patients who are monitored will have a higher risk of adverse outcomes.”
Excessive and unnecessary ECG monitoring can contribute to alarm fatigue and has even been tied to fatalities, Sendelbach notes. The best practice for ECG monitoring calls for it to be used outside of the ICU only with a program that includes continuing assessment of its value, with the option to discontinue it while the patient remains outside of the ICU, she says.
Guidelines Available for Monitoring
The goal was to have ECG monitoring outside the ICU only for those patients who truly needed it, Sendelbach says. To accomplish that, she worked with Kristin Sandau, PhD, RN, staff nurse at United Hospital/Allina Health and professor of nursing at Bethel University in St. Paul. Sandau chaired the 2017 American Heart Association (AHA) team that updated the ECG monitoring practice standards. (The standards are available online at: https://bit.ly/2V9lv2V. See the related story in this issue for a report on how some hospitals address overuse of cardiac monitoring.)
Sandau says the overuse of ECG monitoring is a side effect of the rapid proliferation of technology in healthcare over recent years.
“We have come to a point where we have more technology than needs to be used sometimes with our patients. So we need to pause and take time to review the evidence and determine what really needs to be used for patients in a way that will help them,” Sandau says. “A lot of this monitoring has been grandfathered into patient care without any studies. Some of it makes sense, because if someone is having a heart attack, we don’t need a randomized, controlled trial to tell us that monitoring is appropriate. But there are quite a few populations for which we don’t have the evidence indicating they need to be monitored.”
Way Too Much Monitoring
To address the problem, the team at Allina Health began by getting a baseline assessment of how many patients outside the ICU were monitored. An assessment of charts suggested that, according to the AHA guidelines, the system might have been overmonitoring by as much as 50%, Sandau says.
“That first informal assessment was to determine if we had an actual problem that justified investing resources in this, and we found out that indeed we seemed to have an incredible amount of overmonitoring of patients who were receiving remote monitoring on a noncritical care, nonprogressive care telemetry unit,” Sandau says.
“They might be in with a foot ulcer or a GI bleed. But you can have a GI bleed and be very stable or you can be in an ICU, so we can’t just use diagnoses.”
Instead, clinical judgment and guidelines are necessary to dictate when ECG monitoring is necessary, she says. The team at the hospital determined that an order set would be the most effective way to guide decision-making on ECG monitoring, but implementing an order set often is no easy task, says Steven Hanovich, MD, MS, an intensivist at United Hospital/Allina Health in St. Paul.
When introducing any new order set or other clinical guidance, resistance from physicians is to be expected, Hanovich says. They respond by saying they already know how to take care of patients, so why are you telling them what to do and what monitoring to order?
Physicians responded to the call for better monitoring decisions more positively than expected.
“The challenge is always to get them to listen to you, to educate them on why this is good for patient care. In this particular case, we had the advantage of saying there are some very specific practice guidelines on when to use cardiac monitoring,” Hanovich explains. “They were excited to learn these existed, and there was a thirst for the knowledge because they all realized we were using cardiac monitoring as a babysitter. A lot of doctors thought we were overdoing it. I knew we were.”
Monitoring Does Not Mean More Care
Sandau says physicians who overprescribe ECG monitoring often are under the impression that the monitoring means their patients receive more care from nurses, that they are checked more often, and that any type of problem will be discovered sooner.
That’s not the case, she says. Physicians may think their patients will receive more attention with monitoring because those units have more staff, but even that is not true across all shifts, Sandau explains.
“They see the cardiac monitoring as a proxy for higher staffing levels, and we need to be helping physicians understand it just does not work that way. Putting your patient on a cardiac monitor does not mean they receive the more attentive care that you think they should have and would have if we had more staff available,” Sandau says. “But not monitoring does not mean that your patient receives inadequate care, either. We do need the right staffing levels, but it also is important that the patients be on the unit where they need to be.”
Hanovich confirms that it can be common wisdom among physicians that ordering cardiac monitoring, whether the patient truly needs it or not, is an effective way to get better care for your patient. “It’s a line you hear over and over throughout your training and residencies — just admit them to a telemetry unit, and they’ll get closer care up there,” Hanovich says. “That’s just accepted as a real-world strategy, so you have to start by explaining to them that’s not true.”
EHR Integration Was Challenging
The hospital team developed the order set using the AHA guidelines and gained approval to introduce it throughout the Allina health system, but integrating it into the care process was not easy. The EHR was the biggest challenge, Hanovich says. He had recently been trained by the vendor in programming the hospital’s EHR, so he was able to build a dashboard for ECG monitoring into the existing system.
A primary concern was to make it user-friendly, which for clinicians means not having to click through too many options and enter too much information to get to what you want, he explains. In his training on the EHR platform, he had seen how a few other hospitals were implementing cardiac monitoring protocols.
“Some hospitals had decided their criteria for cardiac monitoring and placed the onus on the nurses to decide when to stop monitoring because the indications were gone. But we had decided early on that it would be the doctor making that decision; the doctors were going to own this,” Hanovich says. “So I had to come up with a way to achieve that and the best way still to decrease the amount of clicks.”
He determined that the best approach when the physician entered an indication for cardiac monitoring was for the EHR to present a menu of orders appropriate for that indication.
“We built the order such that they only saw a few things on the screen at a time, and based on what they ordered, they would see another few things to click on,” Hanovich says. “The doctor had to give the indication for the order, which made the doctor think about why telemetry was being ordered.”
That still added a few more clicks to an EHR process that many clinicians already found bothersome, so the order set team had to sell physicians on the reasons behind the change.
“I told them yes, we have a couple more clicks on here, but if you think about what we’re doing and how the end result is better patient care, you’ll feel better about what you’re thinking of as unnecessary, extra clicks,” Hanovich says.
“We implemented this with a road show. Sue and I went to every hospital in our system and met with the hospitalists, the primary ordering teams for cardiac monitoring, for a half hour to an hour at a time. It was the interpersonal relationships that got all of this going with a surprisingly small amount of guff from the physicians.”
Sell the Reason for Changing
Sandau also points out that clinicians are more likely to bristle at being told by upper-level administrators or even top physician leaders how to care for their patients. The new order set was presented more as the result of a collaboration among many clinicians looking for the best solution that would provide better care, she says.
“You have to be wise in understanding that people don’t like receiving a top-down mandate for change, at least not without having some personal involvement in the decisions leading to that change,” Sandau says. “At the same time, you also have to gauge how much people at different hospitals or in different areas want to be involved and respond accordingly. We had some hospitals where people wanted to be involved in the process and provide input, so you have to take some time and exchange emails with them. But we also had some other smaller sites that more often just wanted it handed to them, ready to plug in.”
Sendelbach points out that the team also trained all the nurses and cardiac technicians responsible for cardiac monitoring. At Abbott Northwestern, she visited them often during the implementation of the new order set to see whether they had any questions.
“We made a very concerted effort to involve stakeholders and keep communication lines open so that people could call you up and ask, ‘What about this patient or what about this situation?’” Sendelbach says. “It also was important to have clinical champions who could make this work by supporting it among their peers. We had champions who were cardiologists, intensivists, hospitalists, [and] nurses, and they made a big difference in moving this forward.”
It also was important to have a team member from the EHR department to help with introducing the order set and tweaking the EHR component after implementation, as well as a project manager to help coordinate the contributions of all the members, Sendelbach says.
Gradual Introduction to Health System
Allina Health introduced the order set at just a few hospitals at first, giving the team time to fine-tune it before rolling it out across the system’s 13 hospitals and 90-plus clinics in Minnesota and western Wisconsin.
“You can build what you think works great, but you don’t know until you actually go live with it what works and what doesn’t. Our order was very successfully implemented without any major difficulties at the first hospitals, but there are always a few little things you find when you first roll out something like this,” Sandau says. “Be sensitive, listen to your end users, and respond to what they’re saying.”
Sendelbach, Sandau, Hanovich, and their colleagues recently reported on their use of the order set, saying the proportion of appropriately monitored patients increased from 48% before implementation to 61.2% after.
“Hospitalists, none of whom completed the formal education, had no statistically significant improvement in adherence to the practice standards (51.6% appropriate monitoring before intervention vs. 56.6% after intervention; P = .51), whereas medical residents, who received mandatory education, had a statistically significant improvement in ordering compliance, from 30.8% appropriate monitoring before intervention to 76.5% after the intervention,” they reported.
“Most striking was the difference between hospitalists and medical residents in their participation in education and correct use of the electronic order set. Although education alone does not change practice, our results indicate that education may provide a key element to understanding the rationale for a practice change and may increase adherence to the practice change.” (The report is available online at: https://bit.ly/2UXoHhQ.)
Some Patients Still Hard to Classify
Sandau notes that they found no increase in adverse outcomes for the patients who were not monitored under the new protocol, although she suggests that is an area that could use further study. Other remaining questions involve patients who may not seem to fit easily into one category for ECG monitoring.
For example, what do you do with a patient who has an indication for monitoring when the potassium level is very low, but then that level comes up the next day, and then goes down the following day?
The team at United Hospital/Allina Health includes those patients in the protocol for ECG monitoring, but Sandau says fine-tuning the guidelines and order sets for difficult cases like that will be an ongoing effort.
“If it’s an orthopedic issue but they’re in a rapid atrial fibrillation, is the solution to be on a cardiac step-down so the nurse can manage the AFib after surgery [even if the nurse is] perhaps less familiar with the orthopedic care?” Sandau says. “Or is it better to have them on an orthopedic unit and remotely monitored by nurses who are not at that station? Those are questions that we still need to answer, and we’d like sites that are building remote monitoring to look at the evidence for that and share with each other.”
Nurses on some units may be made uncomfortable by caring for patients on their unit with remote monitoring overseen by nurses elsewhere, Hanovich says.
He and Sandau say that is an issue that hospitals must address if they use remote monitoring, particularly if they are trying to place patients on more appropriate units to reduce overmonitoring.
“We have a lot of stakeholders who truly want the best for their patients, so if they don’t feel qualified or ready, they will balk at these patients being admitted to their units. It’s not that they don’t want to do the work, but rather that they don’t want to take on a patient for whom they cannot provide proper care,” Sandau says.
“A lot of conversations have to take place to get patients in the right units with the right monitoring, but also to make the nurses and other caregivers comfortable with what you’re doing.”
- Steven Hanovich, MD, MS, Intensivist, United Hospital/Allina Health, St. Paul, MN. Phone: (651) 241-8000.
- Kristin Sandau, PhD, RN, Professor of Nursing, Bethel University, and Staff Nurse, United Hospital/Allina Health, St. Paul, MN. Phone: (651) 241-8000. Email: firstname.lastname@example.org.
- Sue Sendelbach, PhD, APRN CNS (retired), St. Paul, MN.