Redesign Works to Reduce Telemetry

Five years after initiating work to redesign continuous cardiac telemetry ordering, Christiana Care Health System has sustained ordering levels that reflect evidence-based guidelines.

Led by the Department of Medicine’s Section of Cardiology, the redesign initiative started in September 2012 as baseline data was collected about telemetry ordering. This happened ahead of the release of the Society of Hospital Medicine’s recommendation to question continuous telemetry.

“The Choosing Wisely list provided further justification for what we wanted to do,” said Robert Dressler, MD, MBA, Quality and Safety Officer for Academic and Medical Affairs at Christiana Care Health System. “It signaled that we were on track with the changes we were making to address overuse.”

In 2012, researchers in the Department of Medicine discovered that nurses spent 92 hours every day managing telemetry equipment and that false alarms pulled nurses away from regular duties. But the organization’s utilization of telemetry didn’t directly incorporate the clinical indication in the telemetry ordering process. Christiana Care redesigned its ordering process by including three main elements:

• Embedding national guidelines around both indication and duration for telemetry into the computer order entry system and removing cardiac telemetry orders from disease-specific order sets where there was no clinical indication for monitoring.
• Creating a computerized, nursing-based clinical-decision support tool that included the display of patients’ vital signs in advance of discontinuing telemetry, which reduced unneeded process steps and empowered nurses to move forward with discontinuing telemetry or initiate consultations with physicians.
• Initiating conversations with other departments to identify clinical inconsistencies, which helped facilitate buy-in to the process changes.

Within a week of implementation, telemetry use decreased without any increase in adverse events. Sustained results reported in a 2014 research letter in JAMA Internal Medicine showed:

• Reduction in mean weekly telemetry orders from 1032.3 to 593.2 (43 percent)
• Reduction in mean telemetry duration from 57.8 to 30.9 hours (47 percent)
• About 250 fewer daily patients on telemetry
• Decrease in mean daily cost for non-ICU telemetry from $18,971 to $5,772

Now, a few years later, telemetry utilization rates remain constant at these levels when adjusted for an increase in hospital admissions, indicating evidence-based ordering. Since publishing their results, Dr. Dressler said that over 50 organizations have reached out to Christiana Care to learn more about reducing unneeded telemetry.

“What was unique about our implementation was its interprofessional nature. It involved cardiologists, hospitalists, pharmacists and, in particular, nurses in a vital step of a discontinuation process that made them feel more empowered to discontinue orders,” he said. “One organization that tried to replicate our approach did not take this step and was not as successful. The practice of medicine today is a team sport and multiple key individuals are needed to deliver care in an appropriate fashion.”