Telemetry Monitoring: Are Admission Criteria Based on Evidence?

Telemetry monitoring is a powerful tool for real-time monitoring of heart rhythm. Telemetry beds are limited in number and expensive1–3; therefore, their use should be evidence based.4,5 The 2004 American Heart Association (AHA) practice standards for electrocardiographic (ECG) monitoring are often not followed and rigorous criteria for inpatient telemetry admissions are often not systematically used, resulting in overcrowding in emergency departments and inpatient monitored beds1,3,6–9 (Table 1). Monitored beds are often occupied by patients who require only frequent nursing care rather than cardiac monitoring.5,6 Few studies have been done to determine whether inpatient telemetry monitoring is beneficial3 and accurately confirms the initial clinical impression, facilitating ongoing treatment plans.3,10 The PICO (problem, intervention, control, outcome) question crafted for this review was, “For hospitalized adults, what criteria are used for admission to a telemetry unit and/or telemetry monitoring?”A comprehensive search strategy was used to identify evidence reported between January 2000 and August 2014 or open search if few results were obtained. The Figure outlines the databases, key search terms, and relevant articles matching the inclusion and exclusion criteria. The final evidence matrix included 1 expert consensus statement,8 3 retrospective studies,2,7,11 2 prospective observational studies5,10 and 1 randomized clinical trial9 (Tables 2 and 3).Although the 2004 AHA practice standards were groundbreaking, few studies have validated their effectiveness. In most of the studies2,5,7,9,11 in this review, researchers reported that patients who had telemetry ordered did not meet class I and class II indications. Furthermore, arrhythmic events were infrequent and clinically insignificant. Table 4 shows common diagnoses used in ordering telemetry. These results suggest that the practice standards do not address several noncardiac conditions that physicians often monitor on telemetry units5,6,8 and thus may not apply to patients with primary medical diagnoses.5 For example, in a randomized controlled trial by Funk et al,9 28.2% of patients admitted to cardiac units from 17 hospitals had a noncardiac primary diagnosis; these patients may not be appropriate for monitoring for arrhythmia, ischemia, and increased QT interval. Of the 7 diagnoses common to both hospital admission via the emergency department and telemetry unit admission, pulmonary disease and respiratory distress (ie, chronic obstructive pulmonary disease or pneumonia)11,13 are 2 conditions without indications for ECG monitoring per AHA practice standards. Yet, patients are still admitted to telemetry units for these conditions.5,6 Causes for overmonitoring and undermonitoring may be lack of awareness and/or nonadherence to practice standards by clinicians, or a combination of other factors such as technology, equipment, and condition-specific formula calculations.3,9 Furthermore, a method to easily identify low-risk patients (class III) within the current AHA practice standards does not exist.1Other authors reviewed earlier publications for evidence of the need to monitor specific diagnoses. Five diagnoses were highlighted as having no evidence for telemetry monitoring (Table 5).1,3,6 Further research is needed for telemetry utilization and understanding nuances for overmonitoring and undermonitoring of cardiac and noncardiac patients.5,9,11,13 Research could further the validation and revision of current AHA practice standards and promote an evidence-based approach to clinical practice.4Most institutions and clinicians use the 2004 AHA practice standards to structure monitoring decisions. However, these practice standards are 11 years old and may need to be updated to address primary noncardiac conditions often monitored on telemetry units1,6,8,9 or patients often considered “low risk.”1,3,6,10 A stratification tool, coupled with telemetry guidelines and admission criteria, can increase efficient resource utilization and reduce unnecessary admissions and telemetry use.1,3 Goldman and colleagues14 developed the most widely studied risk stratification protocol for chest pain, stratifying patients with suspected acute coronary syndrome into high, moderate, low, and very low risk on the basis of 5 variables.1 Other tools include the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument and Thrombolysis in Myocardial Infarction risk scores. The assessment of high-risk patients without the benefit of a risk stratification protocol may result in allocation of more high-risk patients to unmonitored beds. However, wide variability remains in management decisions and resource utilization via the use of risk stratification protocols and tools. The threat of litigation represents a formidable obstacle to the widespread implementation of standardized risk-stratification methods and appropriate criteria for telemetry monitoring.1Another issue uncovered in this review is the monitoring of patients in deteriorating condition. These patients are often placed on telemetry simply to ensure frequent nurse surveillance, rather than for dysrhythmias that require ECG monitoring.1,5,6 Researchers in multiple studies1,4 have reported that widespread monitoring does not change medical management or produce a substantial survival benefit, even in cardiac arrest patients. (However, the high-risk subset of patients did show potential benefit.1) The time and effort required to monitor “nonindicated” patients takes nurses away from other patients’ needs and caring for telemetry-indicated patients.2,9 Telemetry does not replace frequent observation and vital signs, nor should it be used to influence nurse-to-patient staffing ratios through inappropriate use.5 Over-monitoring increases the risk of artifacts and false alarms and the risk of their misinterpretation, and it also desensitizes monitor watchers, leading to missed meaningful alarms and errors in clinical management.1,3,4,9 Additional safety concerns include alert fatigue and interruptions that adversely affect patient care and outcomes.2,9 The overall clinical value of ECG monitoring is often overestimated1,4 and may lead both nurses and physicians to feel a false sense of security about monitoring of patients.5The simple recognition of low-risk patients not needing monitoring has both clinical and financial implications related to reduced adverse outcomes for patients, increased monitoring capacity, and effective use of limited resources.1–4,6 Clinicians must ensure consistency between initial symptoms and final diagnoses.10 Additionally, current patient diagnosis should be used to determine if telemetry monitoring is indicated each day.10 It must be noted that class II indications give clinicians the opportunity to examine and uniquely evaluate each patient to decide whether continued ECG monitoring is warranted. Some institutions have reexamined best evidence and enlisted the consensus of clinical experts to supplement the existing 2004 AHA practice standards to reflect the current practice environment and include populations not specially addressed. This work includes indications, exclusion criteria, and discharge criteria for telemetry monitoring.2,7 These supplements to practice may minimize ECG overmonitoring and undermonitoring, prevent overcrowding in the emergency department and ambulance diversion, and enhance clinical outcomes.1,6,7Determining appropriate admission, monitoring, and discharge of patients on telemetry units ultimately depends on interprofessional teamwork. Nurse involvement is key for the ideal functioning of modified criteria systems.2 Nurses play a pivotal role in reviewing the need for telemetry on a daily basis and consulting with the treatment team.7 Physicians are uniquely positioned to determine which patients need ECG monitoring, as supported by nursing staff, evidence-based tools and guidelines, and their own clinical expertise.1,3,6–8,10 Eight clinical considerations1–7,9–11 (Table 5) have the potential to influence decision making by nurse-physician interprofessional teams as they collaboratively provide the best possible care for patients, whether or not those patients are being monitored.