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\begin{document}

\title{Empowering Nurses and Residents to Improve Telemetry Stewardship in the
Academic Care Setting}



\author[1]{Eamon Duffy}%
\author[2]{Timothy Niessen}%
\author[1]{Keisha Perrin}%
\author[3]{Ariella Apfel}%
\author[4]{Amanda Bertram}%
\author[4]{Sara Keller}%
\author[3]{Leonard Feldman}%
\author[4]{Amit Pahwa}%
\affil[1]{Johns Hopkins Hospital}%
\affil[2]{Johns Hopkins}%
\affil[3]{Johns Hopkins University School of Medicine}%
\affil[4]{Johns Hopkins Medicine}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Inappropriate use of telemetry frequently occurs in the inpatient,
non-intensive care unit setting. Recent telemetry practice standards
have attempted to guide appropriate use and limit the overuse of this
important resource, with limited success. Clinical-effectiveness studies
of these practice standards have thus far not included care settings in
which resident-physicians are the primary caregivers. Furthermore,
studies of the role of nurses in appropriate telemetry use are lacking.
In this report, we describe two interventions implemented on general
internal medicine units of a large academic hospital over three years.
The first intervention, or nurse-discontinuation protocol, allowed
nurses to trigger the discontinuation of telemetry once the appropriate
duration had passed according to practice standards. The second
intervention, or physician-discontinuation protocol, instituted a Best
Practice Advisory that notified the resident-physician via the
electronic medical record when the appropriate telemetry duration for
each patient had elapsed and suggested termination of telemetry. Results
showed that the nurse-discontinuation protocol reduced mean patient time
on telemetry and the physician-discontinuation protocol reduced mean
telemetry orders per patient. These findings validate a prior study and
expand on our understanding of telemetry use in the academic care
setting in which trainees serve as the primary caregivers.%
\end{abstract}%



\sloppy


\textbf{TEXT}

\textbf{Introduction}

Telemetry is an important tool for real-time monitoring of patients in
the hospital. However, telemetry is expensive, contributes to alarm
fatigue, and may contribute to unnecessary diagnostics and
interventions.\textsuperscript{1-5} The first telemetry practice
standards were published nearly 30 years ago to guide appropriate use
outside of the intensive care unit (ICU).\textsuperscript{6} These
practice standards were updated in 2004 and again in 2017, complete with
specific telemetry durations by indication.\textsuperscript{7,8} Despite
these practice standards, telemetry is still frequently ordered
inappropriately and continued for excessively long
durations.\textsuperscript{9} Studies show that 57\% of patients on
telemetry lack an American Heart Association (AHA) Class I or II
indication and the majority of providers remain unaware that these
practice standards exist.\textsuperscript{9-12}

As part of the Choosing Wisely Campaign, the American Board of Internal
Medicine Foundation and the Society of Hospital Medicine have advocated
for the development of institution-based protocols for all non-intensive
care patients on telemetry to better incorporate evidence-based and
practice standard-driven telemetry
practices.\textsuperscript{13}However, most protocols implementing
practice standard-based approaches to improve telemetry appropriateness
are labor-intensive or ineffective.\textsuperscript{14-18} Data on
successful interventions at academic medical centers, where residents
are the primary providers, are particularly limited. Current literature
predominantly uses stand-alone educational interventions rather than
system or workflow changes, and thus the impact may not be sustained.
Additionally, few studies have examined the impact of nursing-driven
initiatives to limit telemetry use.\textsuperscript{19}

We designed a study using systems-based interventions to reduce mean
time on telemetry among patients cared for by internal medicine
residents. We hypothesized that empowering nurses with the ability to
discontinue telemetry once the recommended indication-specific duration
had elapsed would lead to a reduction in mean time spent on telemetry.
Furthermore, we hypothesized that transitioning responsibility for
telemetry discontinuation from the nurse to the resident would lead to
an increase in patient time spent on telemetry.

\textbf{Methods}

This study was conducted at a 1,154-bed quaternary hospital in the
eastern United States with 65,000 ED visits and 16,000 hospital
admissions per year. The study was implemented within the hospital's
adult general medicine units (268 beds) and excluded intensive care,
step-down, and cardiac care units. Approximately 50\% of beds on these
units are equipped with telemetry. The patients on these units are
managed by the internal medicine residents and internal medicine
faculty. The study captured 9,881 patient encounters with telemetry.

We used a before and after study design. The study involved two
interventions. The first intervention, or the nurse-discontinuation
protocol, allowed nurses to discontinue telemetry at 24 or 48 hours
depending on the practice standard-recommended duration for the specific
indication entered upon placement of the order. After daily assessment
of telemetry data using a specified protocol based on the 2004 AHA
Telemetry Practice Standards, nurses consulted with the resident to
discontinue telemetry if appropriate. Residents were able to renew the
order if telemetry was still required. The second intervention, or the
physician-discontinuation protocol, which occurred immediately after
cessation of the nurse-discontinuation protocol, residents were notified
by a best practice advisory (BPA) if a patient's telemetry order had
gone beyond the recommended duration according to the Practice Standards
and recommended discontinuation of the order.

The study was implemented using both Allscripts (Chicago, IL) and Epic
Systems (Madison, WI), as the hospital transitioned electronic medical
record (EMR) systems mid-way through the study, at the start of the
physician-discontinuation protocol. Data collection spanned eight months
following the implementation of the nurse-discontinuation protocol and
twelve months following the physician-discontinuation protocol, with
data from the six months before the nurse-discontinuation protocol
serving as the pre-intervention control.

The primary outcome was the total time spent on telemetry per patient
per month. The secondary outcome was the percentage of patients placed
on telemetry each month. All data were obtained from the electronic
medical record. Analyses of average total time spent on telemetry every
month were calculated using a t-test and, if data did not follow a
normal distribution, were confirmed with a Wilcoxon Rank-Sum Test.
Statistical computations were performed using SAS v9.4 software (SAS
Institute, Cary NC).

\textbf{Results}

During the control period, the average time spent on telemetry was 86.29
hours/patient/month. During the nurse-discontinuation protocol patients
spent on average 70.86 hours/patient/month on telemetry (Figure 1).
During the physician-discontinuation protocol patients spent on average
81.6 hours/patient/month on telemetry (Figure 1). To assess the
significance of the interventions and to determine that there was no
pre-existing trend in time on telemetry over each study period, we
performed an interrupted time series analysis that provides rates of
change in time on telemetry over each period of the study. This analysis
found a significant level drop in the mean hours on telemetry by 19.4
hours per patient per month after the nurse-discontinuation protocol
(P\textless{}0.001, Figure 1). This analysis found no significant change
in the trend of monthly time on telemetry after the
physician-discontinuation protocol (P=0.34, Figure 1). During the
nurse-discontinuation protocol, there was no significant change in the
likelihood that a patient was placed on telemetry throughout their
admission when compared with the control period (96.1\% versus 92.1\%,
P=0.59, Figure 2). During the physician-discontinuation protocol, there
was a significant decrease of 56.1\% in the likelihood that a patient
would be put on telemetry when compared with the control time period
(36.5\% versus 92.1\%, P\textless{}0.0001, Figure 2).

\textbf{Discussion}

Over a three-year period, we studied two interventions in telemetry
workflow among internal medicine services at a large academic hospital
in an attempt to improve telemetry use and resident stewardship of this
important resource. Two primary findings add to the body of pertinent
knowledge in this field. First, allowing nurses to discontinue telemetry
led to a significant reduction in mean telemetry hours per patient.
Second, implementing a BPA that notified residents of the recommended
telemetry duration for each patient did not reduce patient time on
telemetry but did lead to a significant reduction in total telemetry
orders.

The finding that the nurse-discontinuation protocol led to significantly
fewer hours spent on telemetry represents an important validation of a
prior study\textsuperscript{18} and a novel application of this
intervention to the academic care setting in which resident-physicians
are the primary caregivers. The presence or absence of telemetry
directly impacts the daily workflow and workload of the nurse. The nurse
is required to check the telemetry regularly, notify the physician of
any alarms, and physically work around the telemetry leads that rest on
the patient's chest. Therefore, nurses may be uniquely positioned to
initiate the appropriate termination of telemetry in an academic
training environment. This study represents the first trial of a
nursing-driven intervention to reduce telemetry use in an academic care
environment in which residents serve as the primary providers. Many
other in-hospital treatments use ``nurse-managed'' protocols (e.g.,
heparin continuous infusions or withdrawal scoring and
treatment).\textsuperscript{20} Our study suggests that, like these
other interventions, nurses can and should play a more integral role in
telemetry management. Additionally, proper telemetry stewardship
requires a team-based approach, and directly incorporating the nursing
staff into this process allows for such collaboration.

The physician-discontinuation protocol began immediately following the
end of the nursing-discontinuation protocol, and we expected time on
telemetry to increase with this transition of responsibility. Residents
were now solely responsible for telemetry management and the nurses
could no longer trigger the removal of telemetry from their patients.
There was, however, no significant change in mean patient time on
telemetry. We did find a significant reduction in the number of
telemetry orders placed per month. These findings suggest that
residents, knowing that the BPA would appear, were less likely to order
telemetry in the first place. However, once a patient is on telemetry,
the BPA and awareness of the Practice Standards did little to impact the
duration of telemetry. This study suggests that academic hospitals, in
which residents serve as the primary providers, likely need stricter
guidelines for telemetry use, closer monitoring for telemetry misuse,
and regular education about the appropriate use of telemetry both via
BPAs within the EMR and more traditional educational platforms.

This study has potential limitations. The start of the
physician-discontinuation protocol was also the start of Epic Systems as
the EMR at the study hospital. The switch between systems could have
impacted the use of telemetry. The process of telemetry ordering,
however, did not change between the two EMRs. Additionally, due to the
timing of the study, the practice standards followed in this study were
those from 2004, not 2017.

In conclusion, this study represents an important addition to the
literature on telemetry use by resident physicians and nurses in the
academic hospital setting. It demonstrates the impactful role that
nurses can play in promoting adherence to the telemetry practice
standards by internal medicine care teams. Additionally, it suggests
that academic care environments that prioritize training may need to
engage in more education and oversight to curb telemetry misuse.

\textbf{FIGURES}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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\textbf{Figure 1:} Mean telemetry duration per patient per month
throughout the study period.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

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\textbf{Figure 2:} Telemetry order rate by month.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MS et al. Practice
  standards for electrocardiographic monitoring in hospital settings: an
  American Heart Association scientific statement from the councils on
  Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular
  Disease in the Young: endorsed by the international Society of
  Computerized Electrocardiology and the American Association of
  Critical-Care Nurses. Circulation 2004; 110:2721-2746. {[}PMID:
  15505110{]}
\item
  Sandau KE, Funk M, Auerbach A, Barsness GW, Blum K, et al. Update to
  Practice Standards for Electrocardiographic Monitoring in the Hospital
  Setting: A Scientific Statement from the American Heart Association.
  Circulation 2017; 137(2):e1-e72. {[}PMID: 28974521{]}
\item
  Johnson AE, Knight AM, Mock CK, Maygers JM, Zakaria S. Attitudes
  Surrounding Continuous Telemetry Utilization by Providers at an
  Academic Tertiary Medical Center. J Clin Outcomes Manag 2016;
  23:127-134.
\item
  Benjamin EM, Klugman RA, Luckmann R, Fairchild DG, Abookire SA. Impact
  of cardiac telemetry on patient safety and cost. \emph{Am J Manag
  Care} . 2013;19:e225-e232. {[}PMID: 23844751{]}
\item
  McCartney PR. Clinical alarm management. \emph{MCN Am J Matern Child
  Nurs} . 2012;37(3):202. {[}PMID: 22549425{]}
\item
  AS, Atkins JM, Field JM, Francis CK, Gibson RS, et al. Recommended
  guidelines for in-hospital cardiac monitoring of adults for detection
  of arrhythmia. J Am Coll Cardiol 1991; 18:1431-1433. {[}PMID:
  1939942{]}
\item
  Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MM,
  Macfarlane PW, Sommargren C, Swiryn S, Van Hare GF.~Practice standards
  for electrocardiographic monitoring in hospital settings: an American
  Heart Association scientific statement from the Councils on
  Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular
  Disease in the Young: endorsed by the International Society of
  Computerized Electrocardiology and the American Association of
  Critical-Care Nurses.~Circulation.~2004 Oct 26;110(17):2721-46.~doi:
  10.1161/01.CIR.0000145144.56673.59.~{[}PMID: 15505110{]}
\item
  Sandau KE, Funk M, Auerbach A, Barsness GW, Blum K, Cvach M, Lampert
  R, May JL, McDaniel GM, Perez MV, Sendelbach S, Sommargren CE, Wang
  PJ.~Update to Practice Standards for Electrocardiographic Monitoring
  in Hospital Settings: A Scientific Statement From the American Heart
  Association.~Circulation.~2017 Nov 7;136(19):e273-e344.~doi:
  10.1161/CIR.0000000000000527.~Epub 2017 Oct 3.~Review.~{[}PMID:
  28974521{]}
\item
  Henriques-Forsythe MN, Ivonye CC, Jamched U, Kamuguisha LK, Olejeme
  KA, et al. Is telemetry overused? Is it as helpful as thought? Cleve
  Clin J Med 2009; 76(6):368-372. {[}PMID: 19487558{]}
\item
  Kanwar M, Fares R, Minnick S, Saravolatz L. Inpatient Cardiac
  telemetry Monitoring: Are We Overdoing It? JCOM 2008; 15(1):16-20.
\item
  Najari N, Auerbach A. Use and Outcomes of Telemetry Monitoring on a
  Medicine Service. Arch Intern Med 2012; 172(17):1349-1350. {[}PMID:
  22892708{]}
\item
  Palchaudhuri, S, Chen S, Clayton E, Accurso A, Zakaria S. Telemetry
  Monitor Watchers Reduce Bedside Nurses' Exposure to Alarms by
  Intercepting a High Number of Nonactionable Alarms.~Journal of
  Hospital Medicine. 2017;12(6):447-449. {[}PMID: 28574535{]}
\item
  Adult hospital medicine. Five things physicians and patients should
  question. 15 Aug 2013. Accessed at
  http://www.choosingwisely.org/societies/society-of-hospital-medicine-adult
  on 31 July 2017.
\item
  Gross PA, Patriaco D, McGuire K, Skurnick J, Teicholz LE. A nurse
  practitioner intervention model to maximize efficient use of telemetry
  resources. Jt Comm J Qual Improv. 2002; 28:566-573. {[}PMID:
  12369159{]}
\item
  Leighton H, Kianfar H, Serynek S, Kerwin T. Effect on electronic
  ordering system on adherence to the American College of
  Cardiology/American Heart Association guidelines for cardiac
  monitoring. Crit Pathw Cardiol. 2013; 12:6-8. {[}PMID: 23411601{]}
\item
  Boggan JC, Navar-Boggan AM, Patel V, Schulteis RD, Simel DL.
  Reductions in Telemetry Order Duration Do Not Reduce Telemetry
  Utilization. J Hosp Med 2014; 9:795-796. {[}PMID: 25263661{]}
\item
  Beier M, Morgan DJ, Gulati, M. Educating Residents Why Less Is More
  With Telemetry. JAMA Int Med. 2015; 175: 864-865. {[}PMID: 25938315{]}
\item
  Dressler R, Dryer MM, Coletti C, Mahoney D, Doorey AJ. Altering
  Overuse of Cardiac Telemetry in Non-Intensive Care Unit Settings by
  Hardwiring the Use of American Heart Association Guidelines. Jama Int
  Med. 2014; 174: 1852-1854. {[}PMID: 25243419{]}
\item
  Perrin K, Ernst N, Nelson T, Sawyer M, Pfoh E, et al. Effect of a
  Nurse-Managed Telemetry Discontinuation Protocol on Monitoring
  Duration, Alarm Frequency, and Adverse Patient Events.~Journal of
  Nursing Care Quality. 2017;32:126-133. {[}PMID: 27607847{]}
\item
  Rivey MP, Peterson JP.~Pharmacy-managed, weight-based heparin
  protocol.~Am J Hosp Pharm.~1993 Feb;50(2):279-84.~{[}PMID: 8480784{]}
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