Overutilization of a medical technology can be a thorny issue: Instances of overuse can be difficult to detect. And they can be problematic to resolve once identified because the path to a solution can require changing perceptions about the costs versus the benefits, and also modifying behaviors. But breaking the pattern of overuse is important, especially if the problem could undermine the safety and quality of patient care. This was the challenge faced by Christiana Care Health System (Wilmington, DE), where the issue was overutilization of cardiac telemetry monitoring. To tackle the problem, Christiana Care developed a highly effective initiative—a project that earned the organization the 2014 Health Devices Achievement Award.
Keys to the success of Christiana Care's initiative included the formation of a well-functioning multidisciplinary team and the team's ability to develop a process change that (1) did not significantly interfere with physician autonomy and (2) could be "hardwired" into an already existing workflow.
Christiana Care's overutilization problem grew as an unintended consequence of a previous improvement initiative. Fifteen years ago, the health system determined that the ability to provide cardiac monitoring outside the ICU would offer several advantages: It would help address a shortage of monitored beds, it would improve monitoring and the response to alarms, and it would improve the continuity of care by reducing transfers from one care area to another.
To that end, the organization set a goal of being able to monitor any patient in any bed at any time. Christiana Care achieved that goal through an improvement initiative called the Flexible Monitoring Program. This program has added the capability to transmit ECG and other patient signals from wearable telemetry monitors via a wireless signal to a centralized monitoring room. There, the ECG signals and tracings are interpreted by trained monitor technicians, who communicate notable events to the nurses via dedicated phone lines.
For patients at risk of heart events, cardiac telemetry monitoring is a valuable tool. However, what developed over time following the launch of the Flexible Monitoring Program was the widespread use of cardiac telemetry monitoring for low-risk patients. For these patients, the technology offered little or no clinical value. In fact, Christiana Care determined that in addition to requiring resources, the use of telemetry monitoring for low-risk patients actually created multiple challenges to the delivery of safe, high-quality care.
For example, telemetry alarms that had activated for avoidable or clinically insignificant conditions created frequent interruptions, distracting nurses from necessary clinical care duties and increasing the potential for error. Also, artifacts displayed on the waveform would, on occasion, be misinterpreted as representing serious arrhythmias, sometimes leading to the activation of urgent cardiac-consultation or rapid-response teams or unnecessary follow-up testing.
In addition, wearing the telemetry pack with its associated wires is an encumbrance for the patient. "We want to get patients up and around," explained Andrew Doorey, MD, a cardiologist on the telemetry redesign team. "When wrapped in wires, patients simply can't move like they'd like. It's very frustrating for them." Furthermore, being tethered to the telemetry pack can increase the risk of patient falls, especially among the elderly. And it can disrupt patient sleep. For reasons such as these, "nurses were emphatic that telemetry can be horrible for the patient experience"—an observation that cardiologists did not appreciate at first, Doorey noted.
In short: Christiana Care concluded that "more is not always better." More monitoring and more spending do not necessarily translate into better patient outcomes. The health system needed to reconfigure its telemetry monitoring program to provide more effective, and more cost-effective, patient care.
Christiana Care formed an interdisciplinary team to examine the issue. The team—which included physicians, nurses, administrators, IT professionals, and others—established a goal of reducing the use of cardiac telemetry in non-ICU settings.
First, the team evaluated the current telemetry processes and reviewed data collected just prior to the team's formation: Call logs from the Flexible Monitoring Center were analyzed to categorize the types of calls that were received and to estimate call volume. A time-motion study (a method for observing job tasks to improve work-process efficiency) was conducted to evaluate nursing time spent on telemetry activities. An analysis of the cost to deliver telemetry was performed, taking into account both the efforts of the Flexible Monitoring Center and the nursing time associated with telemetry activities.
Data from this evaluation showed that in this 1,100-bed system, 355 patients per day were receiving cardiac telemetry, each requiring an average of 20 minutes of nursing time to manage the administrative, equipment, and patient care needs associated with the technology. Nursing activities included reviewing telemetry strip results and orders, responding to telemetry alarms, adjusting leads, changing batteries, and accompanying some patients on transports off the patient care unit.
James P. Keller, Jr., ECRI Institute’s Vice President, Health Technology Evaluation and Safety, presents the 2014 Health Devices Achievement Award to Christiana Care Health System for its cardiac telemetry redesign initiative. Pictured, from left to right: Roger Kerzner, MD; Sharon Kleban; Chris Coletti, MD; Chris Carrico; Andrew Doorey, MD; Robert Dressler, MD; James P. Keller, Jr.; Donna Mahoney; Michele Campbell; Brittney Henning; Tamekia Thomas.
Significantly, the evaluation revealed that cardiac-arrhythmia-related emergencies accounted for less than 1% of the calls from the Flexible Monitoring Center to caregivers. The vast majority of the calls (70%) resulted from technical problems—specifically, lead or reception problems (60%) and battery-related issues (10%). The evaluation also estimated the cost of telemetry to be approximately $53 per 24 hours of patient monitoring.
Based on its analysis, the team developed three strategies to address factors that were identified as contributing to the overutilization:
Alignment with national guidelines for telemetry use. Telemetry orders had been embedded in 144 predefined order sets within the organization's computer order-entry system. However, these order sets, which are used to guide care for a broad spectrum of medical conditions, had not been aligned with national telemetry guidelines. The result was that, for many conditions, telemetry was initiated even though its use was not specified in national guidelines as offering a clinical benefit. By changing its order sets to reflect national guidelines adapted from the American Heart Association and the American College of Cardiology, Christiana Care was able to remove telemetry orders from approximately 75% of these order sets.
Redesigning nursing processes. When the provider places an order for telemetry based on a clinical indication, the order automatically specifies that telemetry should be discontinued after a certain time interval—24 hours, 48 hours, or indefinite, depending on the indication. However, the team observed that nurses were often reluctant to remove patients from telemetry even after the telemetry order had expired. As a result, the duration of monitoring often exceeded the monitoring period specified in the order.
To facilitate a change in practice, Christiana Care deployed a computerized clinical decision support tool. The tool, which was specifically designed to aid nurses in safely discontinuing cardiac telemetry as ordered by the patient's provider, works as follows: One hour before a patient's telemetry monitoring order is set to expire, the assessment tool is launched for the nurse to complete. The tool displays the patient's vital signs for the previous eight hours and prompts the nurse to take the patient's vital signs again. If the patient's blood pressure, heart rate, or respiratory rate is or had been outside defined parameters, or if there is, or was, any significant change in clinical status (e.g., serious arrhythmias, clinical deterioration), a message is displayed to contact the physician to evaluate the need for a new telemetry order. On the other hand, if the patient meets the criteria of the defined parameters, the message "Ok to remove the telemetry" is displayed.
The benefit, as described by Tamekia Thomas, a nurse who was involved in the telemetry redesign process, is that the tool "helps drive the conversation" about whether a telemetry order should be extended or should be allowed to expire. Without that mechanism to prompt a reassessment, nurses were inclined to continue telemetry monitoring indefinitely, rather than seek out the physician to obtain confirmation that telemetry could be safely discontinued.
Rethinking medication leveling policies. The team noted that the organization's "medication leveling" policy required telemetry monitoring for some instances in which telemetry was not clinically indicated. (The medication leveling policy is used to guide the degree of monitoring required when certain medications are administered.)
Through collaboration with staff from pharmacy, cardiology, and the pharmacy and therapeutics committee, three new monitoring categories were developed:
a. Cardiac telemetry monitoring required—For medications in this category, an alert is issued to the prescriber, who, with one click, places an order for cardiac telemetry for 24 hours, after which the need for telemetry is reassessed.
b. Cardiac telemetry monitoring optional—For medications in this category, an alert is issued to the prescriber, who can decide whether monitoring is needed and, if so, can order telemetry for 24 hours with one click.
c. No indication for cardiac telemetry—For medications in this category, no alert is issued, although prescribers may still choose to order telemetry monitoring if they feel it is warranted.
Christiana Care observed the effect of these strategies over the period from March to August 2013. The results showed a sustained decrease in telemetry use over the study period, including a 43% decrease in the mean weekly number of patients monitored with telemetry (from 1,032 to 592), and a 47% reduction in average number of hours of telemetry per monitored patient. Significantly, the changes had no adverse impact on patient safety, as determined by events such as rapid response team calls, code-blue alerts, or deaths during the period in which use of cardiac telemetry was decreased.
The team also calculated that the reduction in the number of patients on telemetry, in conjunction with a decrease in telemetry durations, resulted in a 70% reduction in total hours of telemetry utilization, dramatically reducing costs—an estimated annual saving of $4.8 million.
The success of any initiative of this scale requires buy-in from the various stakeholders, something that can be difficult to achieve. But members of the Christiana Care team report that they experienced little resistance once stakeholders were educated about the issue. "When you make people's lives easier while increasing the value to the patient, the resistance goes away," noted Robert Dressler, MD, vice chair and director of patient safety and quality at Christiana Care Health System.
Doorey noted the extensive efforts made to educate staff about the changes and to obtain feedback: "We gave many grand rounds and visited every clinical group in the hospital to explain the new protocol. People made suggestions and expressed concerns, but everybody bought into it (1) because it was evidence-based and (2) because nurses felt strongly that it was good for patients." From the nurses' perspective, it was helpful to see that the cardiologists were on board and that "it was a true collaborative effort," Thomas said.
The team at Christiana Care offered the following specific observations:
- The manner in which the nationally accepted professional society guidelines were adopted provided sufficient clinical flexibility so that physicians could order cardiac telemetry when they judged it was appropriate to do so, preserving physician autonomy and facilitating their acceptance of the change.
- Obtaining buy-in was supported by the fact that the process changes enhanced nursing clinical decision making, reduced wasteful steps, and rectified clinical inconsistencies (e.g., those associated with the medication leveling policy).
- "Hardwiring" a process change into an existing workflow proved to be an effective intervention for sustained change. (Education alone, by comparison, tends to be a weak intervention.)
- Extensive communication with stakeholders is crucial to support change.
Congratulations and thanks to the cardiac telemetry redesign team for submitting Christiana Care's application for the Health Devices Achievement Award.