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 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 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 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 % B % C % D % E87223 G % Total %

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 1/4 th 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