1. Not Wanting to Miss a Beat – Is it Costing Us?
Analysis of Appropriate Use of Cardiac Monitoring for ICU transfers
Kimberly Truong | Feb 2016, Doctoring Skill Rotation 2
Acknowledgements: Michelle Le, Jerry Yu, Asad Qasim

2. Cardiac Monitoring
Introduced >40 years ago to the inpatient setting
Allows remote monitoring of cardiac rhythm and pulse ox
Logistically, determines which floor pt can be transferred to and nursing ratio

3. Deliberately set for high sensitivity at the expense of specificity
The drawbacks
Telemetry is expensive: 1998 study estimates cost at $683 per patient per day (bill of $9,108 /day in 2012 at UCI
Deliberately set for high sensitivity at the expense of specificity
Consequently telemetry can give false-positive alarms: misinterpretation of artifacts as arrhythmia
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

4. Guidelines

5. 2004 AHA Guidelines for Cardiac Monitoring
Class I: Telemetry indicated for nearly all patients Class II: Telemetry MAY be indicated in some patients Class III: Telemetry is NOT indicated

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. Most Recent Project – Analyzed Medicine Admissions
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 (similar to year before)
Improvement from 2012, when 39% of patients were found to not have class I or II indications for telemetry
Most common indications for cardiac monitoring
Sepsis with risk for hypotension
Syncope
ACS rule out
EtOH withdrawal

11. This Project -- Methods
Looked at ICU transfers
Medicine residents have more control
Chart reviewed ICU transfers for 7 days
Level of care documented – Med Surg vs Telemetry
Indication for telemetry documented, then classified as Class I, II or III indications based on AHA Guidelines
Class I is definitely indicated
Class II means may be indicated
Class III means definitely NOT indicated
Summary statistical analysis used

12. Results – Summary Table
Overall Diagnosis N %
COPD/asthma exacerbation 6
20.0%
Upper GI Bleed 4
13.3%
Pneumonia 3
10.0%
DKA
Chronic afib, rate controlled
New onset afib 2
6.7%
Recent severe sepsis or septic shock
First degree AV block 1
3.3%
History of CAD
Tracheal stenosis
Obstructive sleep apnea
Prostate cancer
Decompensated congestive heart failure
Acute ischemic cardiac disease
 Total 30
100%

13. Results – Summary Table
Overall Transfers N %
Med Surg 7
23.3%
Telemetry 23
76.7%
Total 30
Department Name | Month X, 201X

14. Med Surg Transfers: Summary Table%
DKA 3
42.9%
Upper GI Bleed 1
14.3%
Chronic atrial fibrillation
Pneumonia
Prostate cancer
 Total 7
Department Name | Month X, 201X

15. Telemetry Transfers: Summary Table%
Indication Class
COPD/Asthma exacerbation 6
26.1% 2
Upper GI Bleed 3
13.0%
Pneumonia
8.7%
New onset afib
Chronic afib, rate controlled
Severe sepsis, septic shock
Tracheal stenosis 1
4.3%
Sleep apnea
first degree AV block
Acute decompensated heart failure
Acute ischemic heart disease
History of CAD
  Total 23

16. Telemetry Transfers, by Indication Class% 1 2
8.7% 13
56.5% 3 8
34.8% 23
Department Name | Month X, 201X

17. Estimated excess cost to hospital for telemetry use and nursing:
Cost Analysis
Estimated excess cost to hospital for telemetry use and nursing:
$53/day1
With our 8 patients that had non-indicated monitoring excess of $424 for 7 days
If we continue this for a year  $22,048 per year
Estimated cost to patient for telemetry bed (2012):
General Med/Surg Bed: $5,359 /day
Monitored (Tele) Bed: $9,108 /day
Excess Cost per day: $3,750 / day
With our 8 patients that had non-indicated cardiac monitoring  excess of $30,000 in 7 day
If we continue this for 365 days  $1.6 million in 1 year
Department Name | Month X, 201X

18. Only a 7-day cross-section look at teams’ census.
Limitations
Small sample size.
Only a 7-day cross-section look at teams’ census.
May be resident and attending dependent
Subjective assessment (classification bias) in applying AHA guidelines and categorization of indications or lack of indication
Department Name | Month X, 201X

19. Conclusion
First study to look at telemetry orders where internal medicine residents have responsibility over
Rate of inappropriate telemetry use may be higher than medicine admission telemetry use (35% vs 27%)
There is room for housestaff education and possible technology integration (ie: pop-up or order expiration) in Quest
Department Name | Month X, 201X

20. References
Benjamin EM, Klugman RA, Luckmann R, Fairchild DG, Abookire SA. Impact of Cardiac Telemetry on Patient Safety and Cost. AJMC 2013;19(6):e225-32
Department Name | Month X, 201X