Attitudes Surrounding Continuous Telemetry Utilization by Providers at an Academic Tertiary Medical Center

Survey Instrument

After approval from the Johns Hopkins institutional review board, we queried providers who worked on the medicine and cardiology wards to assess the context and culture in which telemetry monitoring is used (see Appendix). The study was exempt from requiring informed consent. All staff had the option to decline study participation. We administered the survey using an online survey software program (SurveyMonkey, Palo Alto, CA), sending survey links via email to all internal medicine residents, cardiovascular disease fellows, internal medicine and cardiology teaching attending physicians, hospitalists, NPs, and PAs. Respondents completed the survey anonymously. To increase response rates, providers were sent a monthly reminder email. The survey was open from March 2014 to May 2014 for a total of 3 months.

Analysis

The survey data were compiled and analyzed using Microsoft Excel (Mac version 14.4; Microsoft, Redmond, WA). Variables are displayed as numbers and percentages, as appropriate.

Results

Of the 180 invited providers, 67 replied, for a response rate of 37%. Residents were the largest group of respondents (42%), followed by non-hospitalist teaching attending physicians (31%), hospitalists (21%), fellows (4%), and one PA (1%) (Table).

All providers reported having ordered telemetry, but almost all were either unaware of (76%) or only somewhat familiar with (21%) the AHA guidelines for appropriate telemetry use. Notably, the vast majority of fellows and residents reported that they were not at all familiar with the guidelines (100% and 96%, respectively). When asked why providers do not adhere to telemetry guidelines, lack of awareness of and lack of familiarity with the guidelines were the top 2 choices among respondents (Figure 1). 

Despite acknowledging unfamiliarity with the guidelines, 60% (40/67) felt their own ordering practices were consistent with the guidelines the majority of the time. The majority of respondents (64%, 43/67) felt that telemetry was not being appropriately utilized at their institution.

Additionally, most providers acknowledged experiencing adverse effects of telemetry: 86% (57/66) had experienced delayed patient transfers from the emergency department to inpatient floors due to telemetry unavailability and 97% (65/67) had experienced some delay in obtaining tests or studies for their telemetry-monitored patients. Despite acknowledging the potential consequences of telemetry use, only 21% (14/66) of providers routinely (ie, > 75% of the time) discontinued telemetry within 48 hours. Fifteen percent (10/65) routinely allowed telemetry to continue until the time of patient discharge. When discontinued, it was mainly due to the provider’s decision (57%); however, respondents noted that nurses prompted telemetry discontinuation 28% of the time.

Finally, providers viewed a list of 14 diagnoses, only 3 of which met criteria for telemetry use per AHA guidelines—myocardial infarction/ACS, myocarditis, and ingestion of a cardiotoxic drug (Figure 2). Participants were asked to select the diagnoses for which they would order telemetry. Eighty-five percent (57/67) selected at least 1 inappropriate diagnosis. The most commonly selected inappropriate diagnoses in descending order were substance withdrawal (57%), gastrointestinal bleed (43%), pulmonary embolus with normal heart rate and blood pressure (37%), altered mental status (33%), acute renal failure with normal electrolytes (18%), and exacerbation of obstructive lung disease (12%). Seven respondents (10%) selected only the guideline-supported diagnoses.

The majority of providers (40/67) agreed that “better provider education” would be the most effective method for improving communication between providers and nurses regarding telemetry use. Rather than choosing one of the available answer choices (Figure 3), some providers offered write-in suggestions for improving communication about telemetry, especially with regard to limited telemeter availability. Examples included: “The biggest barrier to compliance with tele guidelines is that providers don’t know which of their patients are on tele; especially when taking over care from another colleague.” Similarly, another provider wrote, “I wish… there was a prompt or sign that the patient is on tele… When we encounter tele shortages, I have to ask [the charge nurse] if there is any patient who no longer needs tele… We need to pay more attention.”