For all its benefits, cardiac monitoring also has its downsides, such as discouraging patient mobility and often producing clinical noise rather than useful signals, said Nader Najafi, MD, director of the UCSF division of hospital medicine's Data Core, an electronic health record (EHR) data acquisition and analysis service. To alert physicians when telemetry is no longer needed, his team created a real-time EHR decision support tool.
How it works
The team used American Heart Association guidelines and expert consensus at UCSF to determine recommended durations of cardiac monitoring for various indications (e.g., sepsis, electrolyte abnormality). Then, they built an alert into the background of the EHR, where it constantly checks all non-ICU patients who have active orders for cardiac monitoring, Dr. Najafi said. “The moment that the duration of that order being alive exceeds the anticipated duration, based on the indication that was chosen in the order, it pops up an alert to the primary physician,” he said.
After reporting that telemetry has exceeded the recommended duration, the alert offers physicians three choices: discontinue the current order, reorder with a new indication, or dismiss the alert. “Nothing is automatic. The physician has to make that decision themselves, and they have more information, obviously, than the alert has,” said Dr. Najafi, also an associate clinical professor at UCSF.
To test the alert's effects, the research team randomized six of 12 hospital medicine teams to receive the alert, while the other half received no alerts pertaining to telemetry. Compared to patients cared for by the control teams, those whose teams received alerts had 8.7 fewer hours of monitoring per hospitalization, according to results published online in December 2018 by JAMA Internal Medicine. There was no significant change in rapid-response calls or medical emergency events.
Overall, in response to 200 alerts, physicians discontinued telemetry 62% of the time, reordered telemetry 21% of the time, and dismissed the alert without taking action 7% of the time. “I'm proud that the alert seemed clinically appropriate, given that most physicians agreed with it,” said Dr. Najafi.
The first challenge was determining the appropriate duration for telemetry, especially since guidelines do not cover many diagnoses for which general medicine patients are admitted, he said. “But we were able to meet with a lot of leadership at UCSF and put together our indication table using that expert opinion,” Dr. Najafi said. A second challenge was that it also took some work to build the alert into the EHR and get it to identify the appropriate patients in the trial, he said. But one challenge that never came up was having to do clinician education or announcements. “We've done telemetry-reduction efforts at UCSF before, so I don't think there were very many hospitalists who would've thought to themselves, ‘Why is this even important?’ I think they already knew,” Dr. Najafi said.
Clinician researchers should conduct more randomized trials of this type, according to Dr. Najafi. “Decision support in EHRs is really common. It's a really hot topic, and there are whole teams at hospitals that work on building decision support,” he said. “It's really important, and if we're going to be scientific and academic, then we should study whether that decision support is doing what we want it to do.”
The alert was removed from the EHR when the trial ended in May 2017, but Dr. Najafi has future plans for an improved version 2.0. The EHR now allows alerts to appear on the side of the screen, rather than popping up front and center. “I think a pop-up alert is not the ideal alerting system [for non-emergencies],” he said. “What I want it to look like is a sidebar notification, so physicians see that their patient has had telemetry duration that exceeds the UCSF guidelines, but they can continue with their work if they're doing something urgently important, and their work doesn't get interrupted by the alert.”
Words of wisdom
“Overuse of telemetry is an important issue. I think this study is extra impetus to other institutions that you can use your EHR to help reduce unnecessary cardiac monitoring, and it can be done safely,” Dr. Najafi said.