Purpose: Continuous cardiac monitoring (CCM) is recommended for patients who meet American Heart Association (AHA) guidelines. However, in our 156-bed community hospital, providers were ordering this intervention for over 60% of our acute, non-ICU inpatients. Upon chart review, we found that a meaningful number of these patients did not meet AHA criteria for CCM. This intervention when used inappropriately can drive up overall costs, increase the average nurse-to-patient ratio, and contribute to alarm fatigue. When reviewing room and board costs, placing patients at the appropriate level of care—intermediate level for telemetry and routine level for medical-surgical—was our hospital’s largest opportunity.
Description: Initially, the physicians were asked to follow AHA guidelines and discontinue telemetry orders when not indicated. This was unsuccessful. Registered nurses (RNs) were educated on CCM criteria. No change in outcomes was noted. After searching the literature unsuccessfully, the leadership team took an innovative approach and leveraged the telemetry technician. Telemetry technicians were utilized as experts to assist with assessing for cardiac rhythm stability over the last 24 hours as well as ensuring CCM criteria were met, ensuring orders were written and communicating with physicians and RNs. The telemetry technicians compiled a list each morning of all patients on telemetry who have been stable for over 24 hours and whose orders were expiring. The list was sorted by physician name and indicated the primary nurse caring for the patient. The telemetry technician also compiled a list of all patients and their cardiac rhythm, including any changes in the last 24 hours for the charge nurse. This list was posted on the unit and in the physician’s dictation room. RNs then followed up with the physicians.
Evaluation/outcome: In June 2020, the telemetry technician intervention was implemented, and by April 2021, a daily reduction from 60% to 40% utilization of CCM was achieved, respectively. Additionally, 40% utilization has been sustained over the last 10 months. During the Southern California COVID-19 surge from December 2020 to February 2021, this process assisted with ensuring that only appropriate patients were placed on our COVID telemetry unit with 31 beds, while allowing us to care for non-telemetry patients in surge areas where we did not have telemetry functioning, which allocated an additional 40 beds. RNs and telemetry technicians report that with a lower number of patients on CCM, they can focus and respond more quickly to alarms, and they also verbally report a reduction in alarm fatigue. The nursing ratio is 1:4 while on CCM versus 1:5 when non-CCM, which also allowed us to remain within nursing ratios for much of the surge, by allowing us to free up additional RNs.
Using an innovative method of engaging an interdisciplinary team of physicians, nurses, and telemetry technicians allowed our hospital to decrease the number of patients on inappropriate CCM, decrease room and board costs equating to $259 per case, and reduce perceived alarm fatigue amongst caregivers.