Do all hospital inpatients need cardiac telemetry?

TELEMETRY IS OVERUSED

Off-site telemetry monitoring can identify significant arrhythmias during hospitalization. It also saves time on nursing staff to focus on bedside patient care. However, its convenience can lower the threshold for ordering it. This can lead to overuse with a major impact on healthcare costs.

Routine use of cardiac telemetry is associated with increased hospitalization costs with little benefit.⁸ The use of off-site services for continuous monitoring can activate many alarms throughout the day, triggering unnecessary workups and leading to densensitization to alarms (“alarm fatigue”).⁹

Despite the precise indications outlined in the AHA updated practice standards for inpatient electrocardiographic monitoring,¹⁰ telemetry use is expanding to non-ICU units without evidence of benefit,⁸ and this overuse can result in harmful clinical outcomes and a financial burden. Telemetry monitoring of low-risk patients can cause delays in emergency department and ICU admissions and transfers^8,11 of patients who may be sicker and need intensive care.

In a prospective observational study,¹² only 11 (6%) of 182 patients admitted to a general medical floor met AHA class I criteria for telemetry; very few patients developed a significant telemetry event such as atrial fibrillation or flutter that necessitated a change in management. Most overprescribers of telemetry monitoring reason that it will catch arrhythmias early.¹² In fact, in a study of patients in a cardiac unit, telemetry detected just 50% of in-house cardiac arrest cases, with a potential survival benefit of only 0.02%.¹³

Another study showed that only 0.01% of all telemetry alarms represented a real emergency. Only 37.2% of emergency alarms were classified as clinically important, and only 48.3% of these led to a change in management within 1 hour.¹⁴

Moreover, in a report of trauma patients with abnormal results on ECG at the time of admission, telemetry had negligible clinical benefit.¹⁵ And in a study of 414 patients, only 4% of those admitted with chest pain and normal initial ECG had cardiac interventions.¹⁶

Another study⁸ showed that hospital intervention to restrict the use of telemetry guided by AHA recommendations resulted in a 43% reduction in telemetry orders, a 47% reduction in telemetry duration, and a 70% reduction in the mean daily number of patients monitored, with no changes in hospital census or rates of code blue, death, or rapid response team activation.⁸

The financial cost can be seen in the backup of patients in the emergency department. A study showed that 91% of patients being admitted for chest pain were delayed by more than 3 hours while waiting for monitored beds. This translated into an annual cost of $168,300 to the hospital.¹⁷ Adherence to guidelines for appropriate use of telemetry can significantly decrease costs. Applying a simple algorithm for telemetry use was shown⁸ to decrease daily non-ICU cardiac telemetry costs from $18,971 to $5,772.

CURRENT GUIDELINES ARE LIMITED

The current American College of Cardiology and AHA guidelines are based mostly on expert opinion rather than randomized clinical trials, while most telemetry trials have been performed on patients with a cardiac or possible cardiac diagnosis.³ Current guidelines need to be updated, and more studies are needed to specify the optimal duration of cardiac monitoring in indicated cases. Many noncardiac conditions raise a legitimate concern of dysrhythmia, an indication for cardiac monitoring, but precise recommendations for telemetry for such conditions are lacking.

RECOMMENDATIONS


Raising awareness of the clinical and financial burdens associated with unwise telemetry utilization is critical. We suggest use of a pop-up notification in the electronic medical record to remind the provider of the existing telemetry order and to specify the duration of telemetry monitoring when placing the initial order. The goal is to identify patients in true need of a telemetry bed, to decrease unnecessary testing, and to reduce hospitalization costs.