Harnessing the Electronic Health Record to Actively Support Providers with Guideline-Directed Telemetry Use

Abstract

Background: Overuse of cardiac telemetry monitoring (telemetry) can lead to alarm fatigue, discomfort for patients, and unnecessary medical costs. Currently there are evidence-based recommendations describing appropriate telemetry use, but many providers are unaware of these guidelines.

Objectives: At our multihospital health system, our goal was to support providers in ordering telemetry on acute care in accordance with evidence-based guidelines and discontinuing telemetry when it was no longer medically indicated.

Methods: We implemented a multipronged electronic health record (EHR) intervention at two academic medical centers, including: (1) an order set requiring providers to choose an indication for telemetry with a recommended duration based on American Heart Association guidelines; (2) an EHR-generated reminder page to the primary provider recommending telemetry discontinuation once the guideline-recommended duration for telemetry is exceeded; and (3) documentation of telemetry interpretation by telemetry technicians in the notes section of the EHR. To determine the impact of the intervention, we compared number of telemetry orders actively discontinued prior to discharge and telemetry duration 1 year pre- to 1 year post-intervention on acute care medicine services. We evaluated sustainability at years 2 and 3.

Results: Implementation of the EHR initiative resulted in a statistically significant increase in active discontinuation of telemetry orders prior to discharge: 15% (63.4-78.7%) at one site and 13% at the other (64.1-77.4%) with greater improvements on resident teams. Fewer acute care medicine telemetry orders were placed on medicine services across the system (1,503-1,305) despite an increase in admissions and the average duration of telemetry decreased at both sites (62 to 47 hours, p < 0.001 and 73 to 60, p < 0.001, respectively). Improvements were sustained 2 and 3 years after intervention.

Conclusion: Our study showed that a low-cost, multipart, EHR-based intervention with active provider engagement and no additional education can decrease telemetry usage on acute care medicine services.

Fig. 1

Electronic health record telemetry order set requiring providers to choose an indication for telemetry with guideline-recommended duration of telemetry monitoring.

Fig. 2

Telemetry ordering practices by month for all medicine services by hospital (site 1 = HMC, site 2 = UWMC). ( A ) A greater percentage of telemetry orders was discontinued before hospital discharge after the EHR intervention but there was significant month-to-month variation at both hospitals. ( B ) Trend of average hours of telemetry use shows a decrease in average hours of use over time at both hospitals with significant month-to-month variation. EHR, electronic health record; HMC, Harborview Medical Center; UWMC, University of Washington Medical Center.