THE USE OF CARDIAC MONITORING
FOR NON-ICU MEDICINE PATIENTS AT
UCI: A FOLLOW UP
Jerry Yu
DSR2
Cardiac Monitoring
• Introduced >40 years ago to the inpatient setting
• Now include computerized arrhythmia detection, ST
segment monitoring, noise reduction, multi-lead
monitoring
The drawbacks of telemetry
• Deliberately set for high sensitivity at the expense of
•
•
•
•
specificity (frequent arrhythmia alarms, ST segment
alarms)
Consequently telemetry can give false-positive alarms:
misinterpretation of artifacts as arrhythmia
Telemetry is expensive: 1998 study estimates cost at
$683 per patient per day
When and how telemetry should be used has been a
matter of debate
Known shortage of telemetry beds available at UCI can
often impede transfer of patients from higher levels of
care
2004 AHA Guidelines for Cardiac
Monitoring
• Separation of patients into 3 risk classes:
• Class I: Telemetry indicated for nearly all patients
• Class II: Telemetry MAY be indicated in some patients
• Class III: Telemetry is NOT indicated
• Guidelines are based on expert opinion consensus
Class I Indications
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Patients resuscitated from cardiac arrest
Patients in early ACS
Patients with ACS and newly diagnosed high-risk coronary lesions
Adults who undergone cardiac surgery
Child who undergone cardiac surgery
Patients who undergone non-urgent PCI w/ complications
Patients undergone DF or PM placement and are pacer dependent
Patients with temporary pacemaker
Patients with AV block (mobitz 2 or higher)
Patients with arrhythmias complicating WPW with rapid conduction
Patients with long QT syndrome and associated ventricular arrhythmia
Patients receiving Intraaortic balloon counterpulsation
Patients with Acute heart failure/pulmonary edema
Patients with hemodynamically unstable arrhythmia
Patients with indications for intensive care
•
•
•
•
•
•
•
Sepsis
Acute Respiratory Failure
Shock
Acute PE
Major non-cardiac surgery
Renal failure with electrolyte abnormalities
Drug overdose (esp with known arrhythmogenics)
Class II Indications
• Patients with postacute MI
• Patients with chest pain syndromes
• Patients undergone uncomplicated non urgent PCI
• Patients with chronic atrial tachyarrhythmias receiving antiarrhythmic rx
• Patients undergone PM who are not PM dependent
• Patients who undergone uncomplicated ablation of arrhythmia
• Patients who undergone routine coronary angiography
• Patients with subacute heart failure
• Patients who are being evaluated for syncope
• Patients who are DNR with arrhythmias that causediscomfort
Class III indications
• Postoperative patients at low risk for arrhythmias
• Obstetric patients unless heat disease is present
• Patients with permanent rate controlled atrial fibrillation
• Patients undergoing hemodialysis w/o Class I/II indications
• Stable patients with chronic ventricular premature beats
Some Background literature
• Estrada CA, Young MJ. Role of Telemetry monitoring in the non-intensive
care unit. Am J Cardiol. 1995 Nov 1;76(12):960-5
• Prospective Cohort study n=2240
• Telemetry lead to change in management of 7% of patients
• Telemetry was useful but did not change management in 5.7% of patients
• Estrada CA, Young MJ. Evaluation of Guidelines for the Use of Telemetry in
the Non-Intensive-care setting. J Gen Intern Med. 2000 January; 15(1): 51–
55.
• Subgroup analysis based on previous study
• Telemetry detected arrhythmia resulting in ICU transfer for:
• 0.4% of the Class I patients
• 1.6% of the Class II patients
• 0% of the Class III patients
The Prior Project- 2012
• Conducted at UCI inpatient medicine service- 4 ward
teams
• Classified patients on telemetry into class I, II, or III based
on 2004 AHA guidelines
• Determined % of patients who received telemetry w/o
class I or II indications
Results of 2012 study
• 54 patient charts were reviewed
• 39% of patients were found to not have class I or II
indications for telemetry
• Most common reasons to be on telemetry:
• Stable GI bleeding
• Chest pain r/o
• Respiratory compromise
• Acute decompensated Heart failure
Current UCIMC non-ICU telemetry
capacity
• T5: 28 beds
• T3: 28 beds
• DH 78: 15 beds
• DH 66: 15 beds
• DH 68: 15 beds
• Non-telemetry beds:
• T4: 25
• DH 32: 15
• “On any given day, all telemetry beds are full and we have
patients waiting for telemetry beds” -SPPO
This Project
• Review of 6 ward Teams at UCI
• Review of all patients on cardiac monitoring on a
telemetry unit (T3, T5, DH78, NSDU, SDU)
• Classify patients into Class I, II, or III indications for
cardiac monitoring based on 2004 AHA guidelines
• Compare current % of Class III patients to 2012
Results
• Total 53 patient’s charts were reviewed
• Most common indications for cardiac monitoring
• 1. Syncope
• 2. A fib/A flutter w/ RVR
• 3. Sepsis with hypotension
• 4. Acute Decompensated Heart Failure
Results
Team
# of pts
on tele
unit
# of
patients
w/
cardiac
monitor
# of
Class I
# of
Class II
# of
class III
% of
patients
on tele
w/ class
III
A
8
7
3
2
1
14%
B
6
4
1
2
1
25%
C
5
5
2
2
1
20%
D
13
12
6
1
5
42%
E
8
7
2
2
3
42%
G
13
10
9
1
0
0%
Total
53
45
23
10
11
24.4%
Results
• 24.4% of patients on cardiac monitoring did not have
indications
• Most commonly observed: Hemodynamically stable patients with
infections (UTI, CAP, infectious colitis)
• Compared to 2012, observed a 14.6% reduction in non-
indicated cardiac monitoring use
Limitations
• Small sample size
• Bias (me) in applying AHA guidelines and categorization
• No AHA category for “clinical judgement”
Discussion
• We observed a substantial improvement over telemetry
use from 2 years prior of 14.6%
• Yet, still have nearly 1/4th of all telemetry use not fulfilling
AHA criteria
• This is an understatement given that not ALL class II
patients require telemetry use
Areas for improvements at UCI
• Continued daily examination of telemetry use during
morning rounds with RN staff
• Early cessation of cardiac monitoring when indications are no
longer met
• Continued need to educate house staff and attending
alike regarding AHA recommendations