The use of telemetry cardiac monitoring on inpatient wards at UCI The use of telemetry cardiac monitoring on inpatient wards at UCI. Where are we now in 2019? Fady Gabra, MD. PGY-2

OBJECTIVES Identify causes for overuse of telemetry monitoring at UCI To assess the progress we made since 2012 in reducing the number of unnecessary telemetry monitoring To identify new ways to continue to improve on reducing telemetry monitoring when not needed. Review indications for telemetry monitoring

Background A telemetry unit is a unit in a hospital where patients are under continuous electronic monitoring.  At tower, tele units are T5 and T3 Nursing ration is 1 nurse per up to 4 patients Med/surg nursing ratio tends to be 1 nurse per up to 5 patients. Average cost of a tele bed per day: $9200 Average cost of Med/Surg bed per day: $5300 Net cost difference: $3900 per patient per day.

Guidelines for the use of telemetry were first published in 1991 by the American College of Cardiology (ACC) in response to concerns raised by its increasing use in noncritical care settings. The latest revision of the guidelines was published in 2004 by the American Heart Association (AHA). The Guidelines classify patients into 3 risk-based classes I: Telemetry indicated for nearly all patients II: Telemetry MAY be indicated in SOME patients III: Telemetry is NOT indicated These guidelines were based mostly on expert opinion

Cardiac monitoring indicated for:

Cardiac monitoring may be indicated for:

Cardiac monitoring is not indicated for:

What progress have we made so far? In 2012, by Asad Qasim

At this time - We made guidelines known by posting them in team rooms, and in the ED Made Cardiac monitoring self-expiring (72 hours maximum)

4 years later; project by Michelle Le

Where are we at now?! Team Total number of patients Number of pts w/ cardiac monitoring Class I indication Class II indication Class III indication % of patients on tele without indication A 15 12 4 5 3 25% B 9 2 44% C 16 22% D 13 8 1 12.5% E 18 G 11 36% Total 90 57 19 23 26%

Daily unnecessary cost: $58500 Yearly burden: $21,352,000

What do those patients tend to have? Severe sepsis with hemodynamic stability; or resolved sepsis Patient’s with chronic arrhythmias admitted for other reasons (chronic Atrial fibrillation) GI bleeding with stable vitals AKI with normal electrolytes

Why do we tend to overuse tele at UCI? Our own residents’ opinion: 1) Fear of the unknown (especially with night admits) 2) Being too busy on wards to evaluate the appropriateness of the level of care on a daily basis 3) Feeling that some patients need the higher nursing ratio for reasons other than the guidelines indications (i.e, altered patients) GOOD NEWS: most residents do know the guideline indications to cardiac monitoring

What can we do now? Residents to be reminded to assess the appropriateness of patients’ level of care before sign out, DAILY. Attendings/Chief residents to assist in suggesting downgrading patients who do not need tele monitoring to Med/Surg. Reminder posters to be posted in team rooms.

Thank you