Tushar Sharma, MD

 Inappropriate use of telemetry monitoring is associated with alarm fatigue, an increase in health care expenditures, and the potential for patient harm from interventions in clinically inconsequential arrhythmias. We explored adherence to current guidelines for appropriateness of (1) initial telemetry assignment and (2) duration of the assignment.

 After institutional review board approval, 695 consecutive adult patients (≥ 18 years) who were admitted with any diagnosis to general medical floors and assigned telemetry at the time of admission over 3 months were enrolled. Patients on surgical service and transferred from critical care were excluded. Data were collected from electronic health records (EHRs).

 We observed that 155 of 695 (22.3%) patients had been inappropriately assigned telemetry at the time of initial assignment. Of the 540 patients appropriately assigned telemetry, 56.3% of patients had longer than the recommended duration of telemetry monitoring with a median (interquartile range) of 3 (2-4) nonindicated days per patient. The annualized additional cost of telemetry monitoring due to the inefficient utilization was found to be more than $500,000 per year.

 Our data further support the need for frequent reassessment of telemetry indication, which can be facilitated by the utilization of EHR-based automated monitoring.

Rising health care costs necessitate process and quality improvement. We explored the contribution of inappropriate guideline-directed telemetry monitoring to health care expenditures.

Retrospectively, 695 adult patients were evaluated for appropriate assignment and duration of telemetry. We found that 22.3% had an inappropriate assignment and 56.3% had longer than recommended use of telemetry.

The overuse resulted in more than $500,000 per year of wasted health care expenditures. Electronic health record prompts for telemetry reassessment may improve adherence and reduce health care waste.

Inappropriately implemented telemetry monitoring can lead to potential harms to patients and increased unnecessary costs to health care. Several studies report that the decision to initiatetelemetry monitoring is driven by concerns of overall patient clinical deterioration as opposed to concerns for monitoring for arrhythmias.

 The inappropriate use of telemetry can lead to overdiagnoses and detection of artifacts resulting in unnecessary invasive interventions.

 Hence, the benefits of utilizing a tele­metry monitoring system in detecting clinically indicated cardiac arrhythmias need to be balanced with the risk of potential harm to patients. In addition, telemetry monitoring requires telemetry technicians, trained nursing staff, and instruments, increasing cost burden if not used efficiently.

The 2017 American Heart Association scientific statement divides the indications for telemetry use into 3 classes—class I (monitoring is indicated), class II (monitoring may be of some benefit), and class III (monitoring is not indicated)—and expounds upon the duration of its use in different clinical settings.

 We hypothesized inappropriate initial assignment of telemetry monitoring and continuation of telemetry longer than indicated in a large community hospital. After institutional review board approval, we conducted a retrospective chart review of 695 consecutive adult patients (≥ 18 years), over 3 months, admitted under medicine service and assigned telemetry at the time of admission. Data on indication of telemetry monitoring were extracted from the (1) electronic health record (EHR) order, (2) emergency department note, and/or (3) admission note. All statistical analyses were performed with IBM SPSS Statistics 22.

The mean (SD) age was 68 (10) years, and 59% of patients were women. In the total population, the median (interquartile range [IQR]) days of telemetry were 3 (2-4) per patient. Overall, 155 of 695 (22.3%) patients had been inappropriately assigned telemetry at the time of initial assignment (class III) (

). Diagnoses among patients with inappropriate initial assignment were community-acquired pneumonia (24%), urinary tract infection (21%), mild exacerbation of chronic obstructive pulmonary disease (18%), and others (37%). Of the 540 patients appropriately assigned telemetry, 37.2% of patients had class I and 62.8% patients had class II indications. Of the 540 patients with appropriately assigned telemetry, 304 (56.3%) had longer than recommended duration of monitoring. Their median (IQR) number of nonindicated days was 3 (2-4) per patient. Diagnoses among patients with more than the indicated duration of telemetry were congestive heart failure (22%), chest pain (20%), drug/metabolic disturbances (18%), and others (40%). No invasive procedures were noted in patients with either inappropriate initial assignment of telemetry or additional nonindicated days of telemetry. The annualized additional cost of telemetry monitoring due to the inappropriate utilization was more than $500,000 per year (including time from technicians and nurses, as well as costs of instrument battery).

Our study demonstrates the importance of efficient and appropriate telemetry utilization in both the initial assignment and timely discontinuation when no longer indicated. These findings support the need for frequent reassessment of telemetry indication, which can be facilitated by the utilization of EHR-based automated tracking. 


 Deakin University (RoC), Melbourne, Australia; Mayo Clinic (TK, RaC), Rochester, MN; Sinai Hospital of Baltimore (SS), Baltimore, MD; MercyOne Des Moines Pulmonary & Infectious Disease Care (JC), Des Moines, IA; The Medical Center at Bowling Green (GMSP), Bowling Green, KY; Dartmouth-Hitchcock Medical Center (TS), Lebanon, NH; Medical College of Wisconsin (JG), Milwaukee, WI.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (RoC, TK, SS, JC, JG, RaC); acquisition of data (SS, JC, GMSP, TS); analysis and interpretation of data (RoC, TK, SS, JC, GMSP, TS, JG, RaC); drafting of the manuscript (RoC, SS, GMSP, TS); critical revision of the manuscript for important intellectual content (TK, JC, TS, JG, RaC); statistical analysis (RoC, RaC); provision of patients or study materials (JC); and supervision (JG, RaC).

 Rahul Chaudhary, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email: Chaudhary.rahul@mayo.edu.

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. 2012;172(17):1349-1350. doi:10.1001/archinternmed.2012.3163

2. Chen DW, Park R, Young S, Chalikonda D, Laothamatas K, Diemer G. Utilization of continuous cardiac monitoring on hospitalist-led teaching teams. 

. 2018;10(9):e3300. doi:10.7759/cureus.3300

3. Knight BP, Pelosi F, Michaud GF, Strickberger SA, Morady F. Clinical consequences of electrocardiographic artifact mimicking ventricular tachycardia. 

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4. Sandau KE, Funk M, Auerbach A, et al; American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young. Update to practice standards for electrocardiographic monitoring in hospital settings: a scientific statement from the American Heart Association. 

. 2017;136(19):e273-e344. doi:10.1161/CIR.0000000000000527

Articles

The authors report overutilization of telemetry monitoring in a community setting, increasing the cost of health care and potential harm to patients with unnecessary interventions.

Telemetry: Appropriateness of Initial Assignment and Duration in Nonintensive Setting

Guidelines recommend a door-to-balloon time (DTBT) of less than 90 minutes for patients with ST-segment elevation myocardial infarction.

We identified specific interventions using a Six Sigma approach that led to reduction in the overall mean (SD) DTBT (from 79 [52] to 57 [19] minutes; 

 <.001), with 99.4% (from 76.2%) of patients having a DTBT of less than 90 minutes. The reduction was sustained 3 years post interventions.

The results now exceed the national and state average of 94% to 96% of patients having a DTBT of less than 90 minutes.

Institutions in a community setting struggling to reduce their DTBT can adopt community hospital—specific interventions from this study to improve compliance.

Each year, more than 300,000 patients worldwide experience an ST-segment elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PPCI) is the gold standard for these patients, with a recommended door-to-balloon time (DTBT) of less than 90 minutes.

 In a community-based hospital, we observed that only 76% of patients had a DTBT of less than 90 minutes despite CMS reporting a national average of 96%.

 Subsequently, several individual steps from the emergency department arrival of a patient to deployment of the balloon in the catheterization lab were identified. Interventions were then designed based on the Six Sigma ideology to improve performance at each step by reducing SD. Here, we report the specific interventions and their impact on the DTBTs specific to the community setting.

We collected data on 243 consecutive adult patients (≥18 years) who presented with out-of-hospital STEMI between October 1, 2013, and December 31, 2017. In addition to the total DTBT, data were collected on time durations for several steps as outlined in the 

. These data were collected using the CathPCI registry of the National Cardiovascular Data Registry after approval by the Institutional Review Board at Sinai Hospital of Baltimore in Baltimore, Maryland.

 The patients were divided into 3 groups: group 1 (preintervention group; n = 63; October 1, 2013, to September 30, 2014), group 2 (transition group; n = 14; October 1, 2014, to December 31, 2014; excluded from analysis), and group 3 (postintervention group; n = 166; January 1, 2015, to December 31, 2017). A Six Sigma approach was used for the primary end point of reduction in DTBT and the proportion of patients with DTBT less than 90 minutes and secondary end points of improvement in the time duration of each of the 7 steps mentioned in the Table. All analyses were conducted using IBM SPSS Statistics for Windows version 22.0 (IBM Corp; Armonk, New York).

The mean age of patients was 63 years; 69% were male and 50% were black. Overall, the baseline demographics, comorbidities (including cardiovascular risk factors), and cardiac catheterization data were similar in group 1 and group 3. The individual steps, specific interventions targeting them, and their impact with reductions in mean and SD are noted in the Table. These interventions led to an overall reduction in DTBT from a mean (SD) of 79 (52) minutes in group 1 to 57 (19) minutes in group 3 (

 <.0001), with 99.4% of patients in group 3 (vs 76.2% in group 1; 

 <.0001) achieving a DTBT of less than 90 minutes. No differences were observed in 48-hour postprocedure mortality or need for intra-aortic balloon pump.

DTBT has 3 key intervals—time from door to electrocardiogram (ECG), time from ECG to catheterization laboratory, and time from laboratory arrival to device&mdash;all of which are dependent on system factors that vary across institutions.

 In this study, we demonstrate successful customization of the generalized recommendations for STEMI DTBT reduction in the community setting using a Six Sigma approach. Although the change did not translate to decreases in postprocedural 48-hour mortality, the results now exceed the national and state average of 94% to 96% of patients receiving PPCI within 90 minutes. We anticipate that specific measures implemented at our institution will help other struggling community-based centers improve their DTBT and increase the percentage of patients receiving angiography within 90 minutes of arrival.&ensp;

 Sinai Hospital of Baltimore (TS), Baltimore, MD; Deakin University (RoC), Melbourne, Australia; Medical College of Wisconsin (JG, DM), Milwaukee, WI; Michigan State University (AK), Garden State, MI; Mayo Clinic (RaC), Rochester, MN.

 Concept and design (TS, RoC, JG, AK, DM, RaC); acquisition of data (TS, RaC); analysis and interpretation of data (RoC, JG, DM, RaC); drafting of the manuscript (TS); critical revision of the manuscript for important intellectual content (JG, AK, DM, RaC); statistical analysis (RoC, RaC); provision of patients or study materials (TS); and supervision (JG, AK, RaC).

 Rahul Chaudhary, MD, Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email: Chaudhary.rahul@mayo.edu.

1. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 

. 2013;61(4):e78-e140. doi: 10.1016/j.jacc.2012.11.019.

2. Hospital profile: timely & effective care. Medicare.gov website. medicare.gov/hospitalcompare/profile.html#profTab=2&ID=210012&loc=21215&lat=39.3416271&lng=-76.6816962&name=sinai. Accessed July 20, 2019.

3. Moussa I, Hermann A, Messenger JC, et al. The NCDR CathPCI Registry: a US national perspective on care and outcomes for percutaneous coronary intervention. 

. 2013;99(5):297-303. doi: 10.1136/heartjnl-2012-303379.

4. Bradley EH, Herrin J, Wang Y, et al. Door-to-drug and door-to-balloon times: where can we improve? time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI). 

. 2006;151(6):1281-1287. doi: 10.1016/j.ahj.2005.07.015.&ensp;

Specific measures using a Six Sigma approach led to sustained reduction of door-to-balloon times among patients with ST-segment elevation myocardial infarction (STEMI) in a community setting.

Tushar Sharma, MD

Articles

Telemetry: Appropriateness of Initial Assignment and Duration in Nonintensive Setting

Six Sigma Approach to Reduce Door-to-Balloon Time for Patients With STEMI