Not Wanting to Miss a Beat – Is it
Costing Us?
Analysis of Appropriate Use of Cardiac Monitoring for ICU transfers
Kimberly Truong | Feb 2016, Doctoring Skill Rotation 2
Acknowledgements: Michelle Le, Jerry Yu, Asad Qasim
Cardiac Monitoring
• Introduced >40 years ago to the inpatient setting
• Allows remote monitoring of cardiac rhythm and pulse ox
• Logistically, determines which floor pt can be transferred to and
nursing ratio
2
The drawbacks
• Telemetry is expensive: 1998 study estimates cost at $683 per
patient per day (bill of $9,108 /day in 2012 at UCI
• Deliberately set for high sensitivity at the expense of specificity
• Consequently telemetry can give false-positive alarms: misinterpretation of
artifacts as arrhythmia
• When and how telemetry should be used has been a matter of
debate. Some physicians not aware of indications.
• Known shortage of telemetry beds available at UCI can often
impede transfer of patients
3
Guidelines
4
2004 AHA Guidelines for Cardiac Monitoring
Class I: Telemetry indicated for nearly all patients
Class II: Telemetry MAY be indicated in some patients
Class III: Telemetry is NOT indicated
5
6
7
8
Current UCIMC non-ICU telemetry capacity
T5: 28 beds
T3: 28 beds
DH 78: 15 beds
DH 66: 15 beds
DH 68: 15 beds
Total = 101 telemetry beds
Non-telemetry beds: T4: 25
9
Most Recent Project – Analyzed Medicine Admissions
6 UCI ward teams
42 patient’s charts were reviewed
27% of patients were found to not have class I or II indications for
telemetry (similar to year before)
Improvement from 2012, when 39% of patients were found to not
have class I or II indications for telemetry
Most common indications for cardiac monitoring
1. Sepsis with risk for hypotension
2. Syncope
3. ACS rule out
4. EtOH withdrawal
10
This Project -- Methods
• Looked at ICU transfers
• Medicine residents have more control
• Chart reviewed ICU transfers for 7 days
• Level of care documented – Med Surg vs Telemetry
• Indication for telemetry documented, then classified as Class I,
II or III indications based on AHA Guidelines
• Class I is definitely indicated
• Class II means may be indicated
• Class III means definitely NOT indicated
• Summary statistical analysis used
11
Results – Summary Table
Overall Diagnosis
COPD/asthma exacerbation
Upper GI Bleed
Pneumonia
DKA
Chronic afib, rate controlled
New onset afib
Recent severe sepsis or septic shock
First degree AV block
History of CAD
Tracheal stenosis
Obstructive sleep apnea
Prostate cancer
Decompensated congestive heart failure
Acute ischemic cardiac disease
Total
12
N
%
6
4
3
3
3
2
2
1
1
1
1
1
1
1
30
20.0%
13.3%
10.0%
10.0%
10.0%
6.7%
6.7%
3.3%
3.3%
3.3%
3.3%
3.3%
3.3%
3.3%
100%
Results – Summary Table
Overall Transfers
N
%
Med Surg
7
23.3%
Telemetry
23
76.7%
Total
30
13 Department Name | Month X, 201X
Med Surg Transfers: Summary Table
N
%
DKA
3
42.9%
Upper GI Bleed
1
14.3%
Chronic atrial
fibrillation
1
14.3%
Pneumonia
1
14.3%
Prostate cancer
1
14.3%
Total
7
14 Department Name | Month X, 201X
Telemetry Transfers: Summary Table
N
15
Indication
Class
%
COPD/Asthma exacerbation
Upper GI Bleed
Pneumonia
New onset afib
6
3
2
2
26.1%
13.0%
8.7%
8.7%
2
3
2
2
Chronic afib, rate controlled
Severe sepsis, septic shock
2
8.7%
8.7%
3
Tracheal stenosis
2
1
4.3%
2
2
Sleep apnea
first degree AV block
1
1
4.3%
4.3%
3
3
Acute decompensated heart failure
1
4.3%
1
1
1
23
4.3%
4.3%
1
3
Acute ischemic heart disease
History of CAD
Total
Telemetry Transfers, by Indication Class
Indication
Class
N
%
1
2
8.7%
2
13
56.5%
3
8
34.8%
23
16 Department Name | Month X, 201X
Cost Analysis
Estimated excess cost to hospital for telemetry use and
nursing:
•
•
•
$53/day1
With our 8 patients that had non-indicated monitoring excess of
$424 for 7 days
If we continue this for a year  $22,048 per year
Estimated cost to patient for telemetry bed (2012):
• General Med/Surg Bed: $5,359 /day
• Monitored (Tele) Bed: $9,108 /day
– Excess Cost per day: $3,750 / day
– With our 8 patients that had non-indicated cardiac monitoring  excess
of $30,000 in 7 day
– If we continue this for 365 days  $1.6 million in 1 year
17 Department Name | Month X, 201X
Limitations
Small sample size.
Only a 7-day cross-section look at teams’ census.
May be resident and attending dependent
Subjective assessment (classification bias) in applying AHA
guidelines and categorization of indications or lack of indication
18 Department Name | Month X, 201X
Conclusion
• First study to look at telemetry orders where internal medicine
residents have responsibility over
• Rate of inappropriate telemetry use may be higher than
medicine admission telemetry use (35% vs 27%)
• There is room for housestaff education and possible technology
integration (ie: pop-up or order expiration) in Quest
19 Department Name | Month X, 201X
References
1) Benjamin EM, Klugman RA, Luckmann R, Fairchild DG,
Abookire SA. Impact of Cardiac Telemetry on Patient Safety
and Cost. AJMC 2013;19(6):e225-32
20 Department Name | Month X, 201X