1. THE USE OF CARDIAC MONITORING FOR NON-ICU MEDICINE PATIENTS AT UCI: A FOLLOW UP OF A FOLLOW UP Michelle Le – PGY2 DSR2 Cost Conscious Project

2. Cardiac Monitoring Introduced >40 years ago to the inpatient setting Includes computerized arrhythmia detection, ST segment monitoring, noise reduction, multi-lead monitoring Will determine which floor pt can be transferred and nursing ratio/level of care

3. The drawbacks Deliberately set for high sensitivity at the expense of specificity 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 (bill of $9,108 /day in 2012 at UCI) When and how telemetry should be used has been a matter of debate. Some physicians not aware of indications. Known shortage of telemetry beds available at UCI can often impede transfer of patients

5. 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

9. Current UCIMC non-ICU telemetry capacity T5: 28 beds T3: 28 beds DH 78: 15 beds DH 66: 15 beds DH 68: 15 beds Total = 101 telemetry beds Non-telemetry beds: T4: 25

10. Prior Projects – 2012 4 UCI ward teams 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

11. Prior Projects – 2015 6 UCI ward teams 53 patient’s charts were reviewed 24.4% of patients were found to not have class I or II indications for telemetry (14.6% reduction in non-indicated cardiac monitoring use) Most common indications for cardiac monitoring 1. Syncope 2. A fib/A flutter w/ RVR 3. Sepsis with hypotension 4. Acute Decompensated Heart Failure

12. 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 A8732114% B6412125% C5522120% D131261542% E87223 G13109100% Total534523101124.4% Prior Projects – 2015

13. Current Results – 2016 6 UCI ward teams 42 patient’s charts were reviewed 27% of patients were found to not have class I or II indications for telemetry (2.6% increase in non-indicated cardiac monitoring use compared to last year) Most common indications for cardiac monitoring 1. Sepsis with risk for hypotension 2. Syncope 3. ACS rule out 4. EtOH withdrawal

14. Team# of pts on tele unit # of patients w/ cardiac monitor # of Class I # of Class II # of class III or no indication % of patients on tele w/ class III or no indication A10924333.3% B7722342.9% C882600% D2201150% E7403125% G8714228.6% Total423772010 Average: 27% Current Results – 2016

15. Let’s look at the costs! Estimated Average Bill at UCIMC for 2012 General Med/Surg Bed: $5,359 /day Monitored (Tele) Bed: $9,108 /day Excess Cost per day: $3,750 / day With our 10 patients that had non-indicated cardiac monitoring  excess of $37,500 in 1 day If we continue this for 365 days  $13.7 million in 1 year True value is likely higher given increased cost of healthcare since 2012

16. Limitations Small sample size. Only a 1-day cross-section look at teams’ census. Subjective assessment (classification bias) in applying AHA guidelines and categorization of indications or lack of indication Some patient charts were excluded due to lack of H&P/progress note or level of care order not yet entered

17. 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 Make telemetry orders self-expiring every X hours requiring active renewing for use Continued need to educate house staff and attending alike regarding AHA recommendations

18. Thank you! Asad Qasim and Jerry Yu for establishing the ground work for this project Dr. Swaroop and Dr. Rucker for this DSR2 rotation