Is telemetry overused? Is it as helpful as thought?
ABSTRACTCardiac telemetry is widely used in hospitals, but it is expensive and labor-intensive. Therefore, it should be used only in those most likely to benefit. The authors review the available evidence and offer their recommendations.
KEY POINTS
- Guidelines from the American College of Cardiology (1991) and American Heart Association (2004) divide patients into three risk classes for whom telemetry is, may be, or is not indicated.
- Few studies have addressed whether telemetry is beneficial in clinical practice.
- The available evidence suggests that telemetry infrequently influences physician management decisions for patients at low risk, although it may in a relatively small subset at high risk.
- Inappropriate use of telemetry is associated with unnecessary testing and treatment and higher cost of care.
- Better risk-assessment and selection strategies are needed to identify patients for whom telemetry monitoring will be most beneficial.
TELEMETRY CAN GIVE FALSE-POSITIVE ALARMS
Inappropriate use of telemetric monitoring increases the chance of artifacts or false-positive rhythms being misinterpreted as dysrhythmias and can potentially lead to errors in management.
Cases have been reported of patients undergoing invasive procedures because of artifacts seen during telemetric monitoring. Knight et al12 described 12 patients who underwent unnecessary diagnostic or therapeutic interventions as a result of misdiagnosis of artifacts as ventricular tachycardia.
We did not discover in our review any data correlating the frequency of false-positive telemetric monitoring findings to management errors. On the other hand, it is also not possible to discern from these studies how often cardiac telemetric monitoring reaffirmed the clinical impression and facilitated ongoing therapy.
TELEMETRY IS EXPENSIVE
Telemetry requires specialized equipment and trained personnel, making it both costly and labor-intensive. The additional costs and cost-effectiveness of telemetry remain uncertain. Studies of its medical costs have found wide variations across different hospital systems. Sivaram et al,7 in an observational study published in 1998, estimated the cost per patient at $683. At our hospital, the current cost of telemetric monitoring is at least $1,400 per patient per 24 hours.
Whatever the true cost, inappropriate use of telemetry creates a financial burden on the health care system and adds to unnecessary costs incurred by patients.
POTENTIAL BARRIERS TO APPROPRIATE USE OF TELEMETRY
A number of factors contribute to the inappropriate use of telemetry. Possible causes for its overuse may be a lack of awareness of the ACC and AHA guidelines, nonadherence to the guidelines, or a combination of factors.
Even when physicians are aware of these guidelines, adherence may be suboptimal for a variety of reasons (reviewed by Mehta13). Adams et al14 revealed that most studies evaluating adherence were biased by overreporting, since the levels of adherence were self-reported.
OUR RECOMMENDATIONS
To improve on the appropriate use of telemetry, we recommend that several strategies be implemented.
Current guidelines for in-hospital cardiac monitoring need to be updated, particularly since the recommendations were based on evidence that is several decades old. Also, medical care has improved since the publication of the last guidelines, justifying an update in the guidelines.
Guidelines for cardiac monitoring should be incorporated into the curriculum for physician education to increase awareness of the guidelines. Hospitals should ensure that the emergency medicine staff is educated with regard to ensuring appropriateness of admissions to telemetry units.
Finally, the implementation of predictive models similar to that developed by Goldman et al6 and implemented in the study by Durairaj5 could help to ensure that cardiac telemetry is reserved for patients who will benefit from it the most.
