Subacute Care and Continuous
Cardiac Monitoring
Peggy Beeley, MD
June 7th, 2010
Objectives
• Understand Current Availability & Utilization of
Cardiac Telemetry at UH
• Understand Current Availability & Utilization of
Subacute care at UH
• Review the literature for utility of Cardiac
Telemetry in non-cardiac patients
• Develop consensus for better utilization of SAC
and Telemetry resources
Reasons to Look at Utilization of
SAC/Cardiac Telemetry
• Expensive
• Affects ED throughput, ICU availability
• Continuous Cardiac Monitoring infrequently
influences management decisions
• May lead to unnecessary testing and concern
• Decreases mobility, making VTE complications
more likely
Definitions
• Acute Care
• Intermediate Care or ‘Subacute Care’
– Nursing interventions at least every 2-4 hours
– Post surgery or procedure requiring monitoring at
least every 2-4 hours
– Continuous cardiac monitoring
• Telemetry cardiac monitoring
– {Hemodynamically stable patients with extended
ventilator weaning, or chronic ventilation}
• Intensive Care
Our Resources
• Total Adult Bed Census 296
• 72 Adult ICU beds
– Includes MICU, TSICU, NICU
• 136 SAC beds
– 7S, 6S, 5S, 4E, 4W, 3S, 3E
• 88 Med Surg
– 5S, 5W, 5E, 4S, 3N
• Patients waiting for beds vary but SAC #s
persistently higher than floor level care
Questions to the Group
• How do you decide on SAC vs. Floor
status?
• How do you decide on whether you will
use cardiac monitoring?
• How often do you reassess the need for
current level of care or telemetry?
Subacute or Intermediate Care
• Currently, a subjective process
• No UH Protocol currently, although these
were in development in the past
• Individual Floors have Unit Operational
Plans that include the types of patient
and services they can accommodate
Utilization Review
• UH uses a tool accepted by CMS and other
organizations
• Please see your handout page 1,2
• Includes criteria for Intermediate Care
• Complicated list:
– Severity of illness (at least one)
– Intensity of Service (major criteria or 3 minor criteria)
• If patient doesn’t meet criteria, then should be
changed to a lower level of care
Criteria for Intermediate Care
Common examples
• Cardiac Patients
– Acute MI ≤ 24 hrs, r/o MI
– Starting anti-arrhythmics
– Post critical care, CABG
• Non-cardiac Patients
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–
–
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Insulin/Dextrose gtts
Severe Sepsis
EtOH withdrawl requiring high Dose CAGE protocol
Severe Electrolyte disturbances
Cardiac Monitoring
• Usually requires SAC level of Care
• Subset of SAC care
• Continuous Cardiac Monitoring (CCM)
– Telemetry is CCM
– Most CCM at UH is not telemetry
Available Types of
Monitors
1. Centralized Cardiac
Monitoring
2. Cardiac ambulatory
telemetry
3. Portable Cardiac
Monitoring
4. Oxinet
5. Capnography
6. Frequent Vitals, pulse
oximetry
UNM Continuous Cardiac Monitoring (CCM)
• Centralized Monitor room
– 2 techs for ~ 100 monitors
• 7S Monitor Tech
– 20 rooms, including telemetry
• Monitoring at nurses stations
– ED Obs
– ED Main
– ICUs
Cardiac Telemetry
Centralized Monitoring
1.Centralized Monitoring Room is located on 3 North
2. Two trained monitor Techs (Basic Arrhythmia and annual
Arrhythmia Competency exam)
3. Monitor 80-90 patients at all times.
4. Max # is 90, we are at capacity most of the time.
126 adult SAC beds are monitor beds.
Individual Units
4West- 36 beds, monitor 36, 0 tele portable monitors
4 East - 20 Beds, monitor 20, 2 tele portable monitors
3 South-16 Beds, monitor 16, 0 tele portable monitors
5 East-16 beds, monitor 8, 1 tele portable monitor
5 South- 31 beds, monitor 14, 2 tele portable monitors
6 South- 20 beds, monitor 20, 0 tele pacs/ 2 portable monitors
3 East- 10 beds, monitor 10
Guidelines
• American Heart Association
• American College of Cardiology
–Expert Opinion
–Addresses primarily Cardiac
Conditions
–See pages 3 & 4 for Classes 1-3
Class I
Cardiac monitoring is indicated in nearly all patients
•
•
•
•
•
Early phase of ACS, including rule-out MI
Postop cardiac surgery
After resuscitation from cardiac arrest
Intensive Care patients
Poisoning w drugs/chemicals cardiac arrhythmic
toxicity
• During initiation and loading of typeI or III
antiarrhythmic drugs
• Immediate after percutaneous transluminal
coronary angioplasty w complications
Class I, cont
Cardiac monitoring is indicated in nearly all patients
• High-risk coronary artery lesions who are
candidates for urgent mechanical
revascularization
• Temp pacemaker or transcutaneous pacing
pads
• Pt who have undergone implantation of
automatic defibrillator lead or pacemaker lead
and are pacemaker dependent
Class I, cont
Cardiac monitoring is indicated in nearly all patients
• Mobitz type II or greater atrioventricular block,
adv 2nd degree AV block, complete heart block or
new onset left bundle branch block in the setting
of acute MI
• Acute heart failure, pulmonary edema or intraaortic balloon counterpulsion
• Procedures requiring conscious sedation or
anesthesia
• Prolonged QT syndrome w associated ventricular
arrhythmias or HD instability
Class II
Some patients may benefit
• > 3 days after acute MI
• Chest pain syndromes
• Pt with hx of potentially lethal arrhythmia,
several days after control of arrhythmia
• At risk of cardiac arrest, respiratory arrest or
development of hypotension
• Adjustment of drugs for rate control w chronic
atrial tachycardias
• Suspected or proven hemodynamically significant
paroxysmal tachy or brady arrhythmias
Class II, cont
Some patients may benefit
• Subacute heart failure or in acute phase of
pericarditis
• Unexplained syncope or TIA thigh might be due
to arrhythmias
• After uncomplicated coronary angioplasty or
ablation of arrhythmia
• Pacer implanted w/I 48-72 hr who are not pacer
depend
• Post cardiac surgery even if stable
• DNR w symptomatic arrhythmia
Class III
not indicated
• After low risk surgery
• During labor and delivery (if no significant medical
problems exist)
• Terminal illness who are not candidates for Rx of
arrhythmias
• Chronic stable atrial fibrillation
• With stable asymp PVCs or Non-sustained V tach who
are not hospitalized for cardiac or HD compromise
• Underlying cardiac disease that are stable w/o
arrhythmias on 3 consecutive days of monitoring.
Experiences in Improving Utilization
• Jackson Memorial Hospital Miami: 1,600 bed
tertiary care
• Telemetry Utilization Review project
– Evaluate whether pts currently on tele still needed
it
– Evaluate length of time pts remained on tele
– Improve emergency departments throughput
– Evaluate the potential need for additional tele
beds
Subharwal, et al
Most Commonly
Misused
Telemetry Diagnoses
Audit of 753 charts at Jackon
Memorial Hospital in Miami.
When audited: 50% of 650
patients were found to not
need or no longer need
telemetry.
Diagnoses at right were
common.
Sabharwal, et. Al
•
•
•
•
•
•
•
•
•
•
•
GI bleeding 16%
Malignancy 8%
Sepsis/Bacteremia w/o Septic Shock 8%
ARF or ESRD w normal lytes 8%
Sickle cell crisis 7%
DVT or PE w/o HD compromise 7%
COPD/Asthma/OSA 6%
EtOH abuse or withdrawl 6%
Pneumonia 6%
Cirrhosis/hepatitis/cholelithiasis 6%
AMS, uncontrolled DM, UTI, Fx or
wound infection, Pancreatitis,
dehydration comprised the other 25%
Subharwal, et al
Clinical Need
• Developed auditing tool using Guidelines by
American College of Cardiology
• Of 651 telemetry patients reviewed
– 54% no longer met criteria
– 18% did meet any criteria since admission
• Telemetry Authorization Form – 6 month
followup
– Charge nurses validated need
– Monitored bed use decreased by 60 %
Subharwal, et al
Similar quality improvement programs
• Hackensack University – reduced use by 34%
w authorization form
• Portland Veterans Med Center – incorporated
stop times
CCM & cardiac arrest outcomes
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•
•
•
Review of 5 yrs of telemetry admissions
8,932 pt were admitted to telemetry unit
20 suffered cardiac arrest
Two of three of survivors had significant
arrhythmias detected on tele before arrest
• Monitor-signaled survival rate was 0.02%
• Conclusion: Routine telemetry offers little cardiac
arrest survival benefit
Schull, et al
Does CCM alter medical management?
• Estrada, et al (Henry Ford, Detroit) 1994
– 467 patients admitted to telemetry based on ACC
guidelines
– Only 1 % of cases had ICU transfer based on tele
findings
– Majority of pts who deteriorated were identified
clinically
Does CCM alter medical
management?
• Estrada, et al (Henry Ford, Detroit) 1995
– Data collected from 2,240 pts admitted to tele
for chest pain, arrhythmias, heart failure, &
syncope
– Outcomes ICU transfer and mortality
– Telemetry was helpful in modifications of
management in only 7%
– 0.8% of all admission to tele were transferred
to ICU because of telemetry findings
Telemetry in the Elderly
• Looked pts admitted for Chest Pain with low risk
for a coronary event during hospitalization
• Excluded pts w ACS per ECG or cardiac markers
• Of the 105: about half had HTN, DM, elev lipids,
smoking and prior CAD
• Telemetry did not show significant arrhythmia or
lead to management changes in any pts
• Tele did not influence inpt mortality or 5 yr
survival
Saleem, et al
Monitoring in Low Risk Acute Chest
Pain Syndrome
• 414 consecutively admitted for suspected ACS
• Outcomes: MI, new or rapid atrial
arrhythmias, vent arrhythmias, AV nodal block
and asystole
• Intervention change in dose of medication,
cardioversion, EP study or Txn to ICU
• Results: Patient w atypical chest pain, normal
ECG findings are sign less likely to have
arrhythmias 8%
Snider, et al
Artifact
• Evaluation of monomorphic or polymorphic V
tachycardia in 12 patients
• Cardiac cath (3), Intravenous lidocaine in 7, IV
NTG in 1 and SL nitro in 1
• 2 patients were given a precordial thumb that
was interpreted as a successful cardioversion
• 1 had implantable defibrillator for “torsades”
Knight, et al
Summary
• Need for Intermediate Care should be carefully
considered.
– More options available, such as oxynet
• Continuous Cardiac Monitoring
– should not be a reflex action for non-cardiac pts who
may still need increased intensity of service.
– Studies suggest overuse
– Telemetry infrequently leads to management changes
– May cause harm when misinterpreted.
– Increases physician phone calls for telemetry artifact
or non-sustained Vtach
– Leads to increased fall risk, VTE
Recommendations
• Evaluate current use of Cardiac monitoring
and intermediate care at UH
• Develop guidelines for use based on other
institutions protocols
• Educate staff, providers, physicians on
accepted uses of Cardiac monitoring and
intermediate care.
• Encourage more thoughtful analysis of the use
of these resources