In 2013, Rush University Medical Center began efforts to reduce rates of blood transfusion orders. Results of their efforts effectively reduced the number of overall blood units transfused throughout the hospital by 36 percent in just 14 months. Now, three years later, Rush is putting more evidence-based Choosing Wisely recommendations into practice.
Dr. Manya Gupta, a physician and assistant professor specializing in hospital medicine at Rush, and her team have played a vital role in changing the culture of overutilization within the organization. In 2016, her team started a new effort to avoid ordering continuous telemetry monitoring outside of the ICU without a protocol that governs its continuation, per the Society of Hospital Medicine’s Choosing Wisely recommendation.
As they began their work, Dr. Gupta’s team discovered that many patients being discharged from the hospital had been on telemetry ever since their initial admittance, and the reasoning behind the order was not very clear. In many instances, telemetry orders seemed to be a continuation from the emergency room. Nurses and staff members were sometimes unaware that a patient was on telemetry, and these gaps in awareness meant that cardiac monitors were often not being checked. Furthermore, the telemetry wires restricted patients’ mobility, sometimes causing delays in participation with physical therapy and/or procedures.
Dr. Gupta and her team concluded that the usage of telemetry monitors needed to be optimized. Accomplishing this task involved two primary methods: changing electronic medical record (EMR) ordering guidelines and educating staff members. While physicians were still able to order telemetry for patients who required it, a new “renewal” order was added.
“After 24 hours have passed, telemetry has to be manually reordered if the physician believes that the order is still appropriate. The key was that the order would self-expire unless it was specifically renewed,” Dr. Gupta said.
This change in ordering guidelines took place throughout the entire hospital, with the exception of the intensive care units.
“We also educated the house staff through educational sessions during conferences and morning reports. The model that we used was very similar to the model used previously to achieve blood-use reduction success,” Dr. Gupta said.
She added that she and her colleagues felt it was crucial for the house staff to understand how these new order protocols would benefit patient health in order to ensure a positive outcome and higher physician engagement.
The results of the intervention were positive on all fronts. When measuring the overall percentage of hospital patients placed on telemetry, Dr. Gupta and her team found stark differences between pre- and post-interventions measures. Prior to the intervention, 31.2 percent of general medical patients were on telemetry. This number dropped to 6.3 percent following implementation.
Dr. Gupta and her team also saw a decrease in the total number of hours patients spent on telemetry during their stay at the hospital. Pre-intervention, patients on telemetry generally spent an average of 62 hours on the device throughout their stay—equating to nearly 2.5 days. After the intervention, this number was essentially cut in half to just 34 hours.
The team analyzed the total percentage of hours in which patients were prescribed telemetry during their hospitalization. Once again, measurements compared before and after the intervention revealed positive results: Patients placed on telemetry went from spending roughly 60 percent of their total hospital stay hooked to the device to only spending 41 percent of their time being monitored.
Notably, there was no significant increase in adverse events, cardiac or otherwise, despite the decrease in telemetry monitoring.
Dr. Gupta and her colleagues still plan to tackle more questions about telemetry use at Rush, including whether or not their intervention has led to a true decrease in overall patient length of stay.
But the initial reductions indicate to Dr. Gupta that Rush is undergoing something even more powerful than use reduction; they are undergoing culture change.
“Once culture change starts, improvements become expected,” she said.