Deborah J. DeWaay, MD, FACP and Kenneth P. Steinberg, MD, FACP, Editor
Dr. DeWaay and Dr. Steinberg report no financial relationships in this field of study.
: The hospitals in this study outsourced their cardiac telemetry to an off-site central monitoring center without an increase in adverse events.
: Cantillon D, et al. Association between off-site central monitoring using standardized cardiac telemetry and clinical outcomes among non-critically ill patients. JAMA 2016;316(5):519-524.
Telemetry is traditionally monitored on-site in hospitals and is associated with high levels of alarm fatigue since most alerts do not have clinical relevance. Alarm fatigue has been associated with an increase in severe adverse events since real events are missed and resources are wasted on false-positive events. As a result, the 2014 National Patient Safety Goal was written by The Joint Commission mandating that this problem will be addressed by 2016. In addition, to address the global overutilization of telemetry, the Society of Hospital Medicine advocated that non-intensive care unit cardiac telemetry monitoring must be protocol-driven. When telemetry is utilized according to the 2004 American Heart Association recommendations, there is a 70% reduction in use without an increase in deaths. In addition, having a trained nurse devoted to continuous rhythm monitoring is associated with increased reliability rhythm interpretation. The current study sought to determine if an off-site central monitoring unit (CMU) could maintain high quality, standardized telemetry monitoring.
The Cleveland Clinic main campus and 3 regional hospitals had a dedicated off-site facility which delivered telemetry monitoring before there was telemetry standardization. Within this system, 48 patients are monitored by 1 technician. There are also lead technicians that assist with oversight during events in real time. Patient monitoring is a shared responsibility between CMU and the nursing staff with the patients. A phone system is used for protocol-driven CMU communication to nursing staff of events. Nursing is responsible for informing the CMU of staff rosters during each shift. The authors of the study estimated the costs based on institutional contracts with the particular vendors and the vendor specific technologies used. A ratio of 5.2 full-time employees per 48 monitored patients was used to estimate personnel costs.
All CMU notifications were categorized as arrhythmia or hemodynamic notification or non-arrhythmia and hemodynamic notifications (includes low battery, lead failures etc). When a patient was suspected of declining precipitously, both nursing and the emergency response team (ERT), made up of a physician, nurse and respiratory therapist, were contacted simultaneously. Beginning in 2014, this health system implemented a protocol for telemetry usage based upon the 2004 American Heart Association (AHA) guidelines. When the telemetry order is entered, the nurse electronically notes the order, applies the electrodes and submits a task completion notification. Within the CMU, the technician begins monitoring per the parameters. Every 72 hours, there is notification by the health record for the telemetry order to be reevaluated and reordered as necessary.
Data was collected for the 13 months after telemetry standardization was put in place and then compared to the previous 13 months. Specifically, throughout the study period, authors looked to see if there was accurate identification and notification of rhythm and rate alarms within the 1 hour prior to ERT activation. In addition, during the study period and the previous 13 months, all cardiopulmonary arrest events on monitored and unmonitored patients were counted. A lead technician entered all ERT activations into the study database with the rhythm strips of the event and the 1 hour prior. There was an independent audit of the database.
99,048 patients were put on telemetry during the study period. The most common indications were known or suspected atrial or ventricular tachyarrhythmias. Metabolic derangement, respiratory disorders, seizure monitoring, stroke, deep vein thrombosis/pulmonary embolism, and drug exposure are not recommended reasons for the use of telemetry by the AHA yet they were common reasons for utilization in this study. The cost of implementing the CMU was between $2.3 and 4.7 million.
Compared to the prior 13 months, the implementation of standardized cardiac telemetry decreased the weekly telemetry census by a mean of 15.5% immediately and consistently across the study period. There were 126 cardiopulmonary arrests in the pre-intervention phase and 122 in the post-intervention phase. During the study period, 410,534 notifications were sent to 61 nursing units across all of the campuses. Lead failure was the predominant reason (80%) of non-arrhythmia or hemodynamic notification. 57%, 3243 patients, of ERT events occurred on monitored patients. Of these activations, 30%, 979 patients, had a rhythm or rate change within 1 hour of ERT being called. The CMU detected 79% of these patients accurately. Of the 21%, 207 patients, that were not detected, 85% were missed events, 8% were simultaneous alarm events with ERT activation and 7% were process failures. On the main campus, CMU directly notified the ERT in conjunction with nursing 105 times for findings including monomorphic ventricular tachycardia (n=44), asystole (n=36), polymorphic ventricular tachycardia or fibrillation (n=14), and other (n=11). 27 of these patients had cardiopulmonary arrest events, 25 of which had a return of spontaneous circulation. The 10 patients who met criteria for defibrillation received it within 3 minutes. There were 2 deaths.
COMMENTARY
In this study, the CMU offered centralized monitoring without an increase in adverse events. The implementation of a guideline driven protocol decreased the census of telemetry patients, which mirrors other studies in the literature. In addition, CMU allowed for increased oversight with lead technicians in order to mitigate lapses in monitoring. Finally, this study demonstrated that it is possible to integrate a CMU with the ERT team. The primary limitations to this study are that there was no randomization, that it was a pre-post study design that might not have accounted for other temporal changes occurring in the system, and that 2 changes were employed concurrently making it difficult to ascribe the results to one or the other.
This study demonstrates that centralized telemetry can take place off-site and this model may be of interest to hospital systems. The start-up cost is significant and may be prohibitive for some systems. It is unclear if the cost savings is in the implementation of the CMU or of the guideline based protocol. The CMU appears to increase quality of the monitoring delivered. This ongoing discussion regarding the best way to implement telemetry is important for hospitalists since they are key stake holders in this process as physicians to these patients and leaders in quality improvement.
