When a patient presents at the emergency department (ED) with chest pain, a hospitalist's first instinct might be to order continuous cardiac monitoring. But while that course of action may set the physician's mind at ease, it can also lead to inappropriate use of the resource-intensive telemetry unit and huge backlogs in the ED.
“Physicians tend to automatically send patients to telemetry with any kind of chest pain,” said Sandeep K. Dhillon, MD, a cardiologist at Beth Israel Medical Center in New York City. “But our guidelines say you have to get the clinical story and have the admission make sense.”
Dr. Dhillon and her colleagues developed simple criteria for guiding physicians' decisions about telemetry admission. They followed up with a retrospective study to validate the system, which showed that the 562 patients who were admitted to telemetry based on the guidelines had a higher number of arrhythmias than patients who were not admitted, and that patients who were not admitted did not experience worse outcomes.
“We showed that if patients didn't meet the guidelines criteria, the chance of them having any significant arrhythmia was slim to none,” said Dr. Dhillon, lead author of the study, which was published in the September 2009 Critical Pathways in Cardiology. Dr. Dhillon's findings are in line with the most recent recommendations on cardiac monitoring in the hospital by the American Heart Association and the American College of Cardiology (see “Telemetry Resources” sidebar, page 24).
Yet inappropriate use of telemetry is still a problem in many hospitals. To address the issue, Beth Israel and other hospitals have concentrated on educating hospitalists and residents about the appropriate use of telemetry and ensuring that the units are monitored continuously to facilitate movement in and out.
Identifying patients at risk
One factor leading to overuse of telemetry is physicians' tendency to view the unit as an “intermediary between the ICU and the medical floor,” said Neil Winawer, MD, FACP, director of the hospital medicine unit at Grady Memorial Hospital in Atlanta.
Several years ago, a task force led by Dr. Winawer concluded that clearer guidelines for admission to and transfer out of the telemetry unit, along with an efficient transfer process, would cut down on misuse of telemetry and ease ED overcrowding (the April 2010 issue of ACP Hospitalist has more on Grady's initiative) .
“If there are no uniform policies or procedures, decisions about telemetry are left up to the whims of treating providers, who might have varying levels of comfort with different clinical conditions,” said Dr. Winawer. “At the end of the day, a lot of people end up being on cardiac monitors who don't necessarily meet the criteria.”
A typical example is a patient who presents with pneumonia and needs oxygen but is otherwise stable with no cardiac problems, he said. Even though the patient is at low risk for arrhythmia based on the criteria, a physician might send the patient to telemetry with the idea that he is more likely to be informed about any changes in heart rate than if the patient were in an unmonitored bed.
“Really, patients with heart failure should only be on telemetry if they are suspected of having an ischemic precipitant or have severe valvular disease,” said Dr. Winawer. “But a lot of physicians struggle with that and look at heart failure as a blanket reason to be on telemetry.”
“What we have to know is which patients are at highest risk of arrhythmia in the near future,” said cardiologist Elizabeth S. Kaufman, MD, professor at Case Western University School of Medicine in Cleveland who helped write the AHA recommendations on cardiac monitoring. A patient who presents with syncope of suspected cardiac origin, for example, should be placed on monitoring for at least 24 hours. However, many patients with syncope who do not have heart disease do not require hospitalization.
Some patients may be temporarily at high risk for arrhythmias due to very low potassium, electrolyte disorders or an overdose of a proarrhythmic drug, added Dr. Kaufman. The AHA consensus statement includes a list of antiarrhythmic drugs that are known to put patients at risk for torsade de pointes, one of the most common acute arrhythmias, and an indication for monitoring. Patients with newly implanted pacemakers or temporary pacing wires also should be monitored, she said.
Setting—and enforcing—clear guidelines
Grady's task force used the existing AHA/ACC recommendations on telemetry, along with input from senior cardiologists, to create its own criteria, which are posted prominently in the unit as well as in the ED and on the medical floors. The hospital also authorized the physician directors of the telemetry unit to transfer patients based on criteria instead of waiting for the primary medical team to initiate transfers during regular rounds.
“When I downgrade patients off telemetry, there are two types: patients who no longer meet criteria for cardiac monitoring and those that never should have been on it in the first place,” said Dr. Winawer. “It's the director's job to oversee the unit and have daily checks on whether patients are still meeting the criteria.”
At Beth Israel, Dr. Dhillon and her colleagues created inclusion and exclusion criteria to help doctors decide which patients needed monitoring. They also drew up a list of suggestions to help physicians decide when patients should be moved out of telemetry.
Since the criteria were adopted six years ago, “the number of days patients stay on telemetry has decreased dramatically, as have admissions to telemetry,” said Dr. Dhillon. “We used to have telemetry backups from Saturday night until Monday afternoon but now we can have a telemetry bed available on Sunday and beds are available for patients who actually needed [telemetry].”
Once patients have been admitted to telemetry, they must be assessed continuously to determine whether they continue to meet criteria, she said. At Beth Israel, telemetry patients are assessed every morning by a multidisciplinary team, including hospitalists and cardiologists, which decides if a patient should be kept on monitoring, moved to another unit or considered for discharge. In order to keep a patient on telemetry, physicians must submit a renewal order every 24 hours.
Hospitalists must be prepared to explain why they are continuing telemetry, especially when the unit fills up and patients are waiting for beds, she added. “If they can't justify telemetry, a cardiologist will discontinue it.”
Stanford University Hospital in Palo Alto, Calif., also assesses its telemetry patients during daily interdisciplinary team rounds, said Peg Albrets, case management manager for the hospital. “That's the forum to have pointed conversations about patients who should be moved out of telemetry based on criteria,” she said. The hospital uses McKesson's Interqual criteria for determining level of care.
Stanford's five telemetry units with a total of about 100 beds are always full and case managers keep a close eye on turnover, said Ms. Albrets. Case managers are critical to keeping patients moving in and out of the telemetry unit, she said. They continuously update physicians on whether their patients still meet the criteria for telemetry and provide other useful information, such as feedback from payers that may be questioning the length of a patient's stay.
Physician has final say
Clear guidelines help categorize patients, but determining whether or not to place a patient on telemetry is not always a cut-and-dried decision, noted Dr. Winawer. Even though other medical staff such as physician assistants or nurses can assess patients according to criteria, a final decision calls for the clinical expertise of a physician, he said.
For example, a patient who is low risk with normal EKG results and bloodwork can be taken off cardiac monitoring quickly, he said. However, if that patient is 60 years old, has numerous cardiovascular risk factors and a convincing chest pain story, he should stay on telemetry until an angiogram is performed. Similarly, patients with pulmonary emboli or syncope do not uniformly require telemetry monitoring, Dr. Winawer said.
“The subtleties of making sure we do things right dictate that someone with real knowledge and expertise in the area make these types of decisions because they're not made lightly,” he said.
Guidelines are a valuable tool to inform decision-making but cannot determine the final plan of care, agreed Dr. Kaufman. Physician judgment is a critical factor in making the right call.
“We can't be too dogmatic about guidelines,” she said. “There are times when we don't always have an objective criterion to defend our decisions about where to put a patient, but sometimes an experienced clinician can know when a patient is at increased risk and might benefit from increased monitoring.”