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ARTICLE CONTRIBUTORS

Nerys Louise Conway

Stephen Hutchison

Annie Frances Evans

Clinical Articles, Lead Article

An audit of telemetry monitoring in a district general hospital

Abergavenny healthcare professionals review the use of telemetry monitoring in their hospital, focusing on inappropriate requests and the lack of evidence based guidelines…

We conducted an audit of telemetry requests in Nevill Hall Hospital, Abergavenny. We reviewed telemetry requests over one month resulting in the local guidelines and request form being amended and subsequently re-audited one month later. We discuss the reasons why there are so many inappropriate requests for telemetry and unintended consequences, due to the lack of evidence based guidelines for a popular service.

Introduction

Our audit of telemetry monitoring was conducted at Nevill Hall Hospital, Abergavenny- a busy district general hospital serving South Powys and North Gwent. There are a total of 499 beds (including 165 acute medical beds and 6 acute cardiac care unit beds). All eight ambulatory wireless monitoring devices were in use most of the time; although there were several reasons to conduct this audit, the main reason was to determine if further monitoring devices were required to cope with demand or simply whether the requests for monitoring were appropriate.

291934_635c7783The original telemetry request and local guidelines were published in 2000 when the Acute Cardiac Care Unit opened. The local guidelines were based on a variety of international and national cardiac societies (e.g. American College of Cardiology). There had been no audit conducted of telemetry monitoring within this time period.

Method

We reviewed all the requests for telemetry during September 2011 New guidelines and a new request form were produced following the initial audit. These were based upon literature reviews and agreement between medical and nursing staff. We then re-audited this during the month of October 2011. Further changes were made to the request form as a consequence of the re-audit.

Results

Results of Initial Audit (Figure 1)

  • There were 79 telemetry requests throughout the hospital.
  • Doctors could request telemetry for any given reason.
  • The most common reason for requesting telemetry was collapse.
  • The most common age group for requesting telemetry was 70-89.
  • The most common place where telemetry was initiated was the emergency assessment unit.
Figure 1 - Results of initial audit

Figure 1 - Results of initial audit

Changes Implemented

  • New local guidelines and request form were produced.
  • Doctors could request telemetry for the following reasons; unstable atrial fibrillation/ tachyarrhythmia/ bradyarrhythmia; IV infusions; cardiotoxic overdose; collapse of likely cardiac  cause; possible malfunctioning implantable cardiac defibrillator and other causes (to be discussed with the acute cardiac care unit).

Results of Re-audit (Figure 2)

  • There were 62 telemetry requests throughout the hospital.
  • The most common reason for requesting telemetry was unstable atrial fibrillation/ tachyarrhythmia/ bradyarrhythmia.
  • There were 3 requests in the ‘other’ category that included 2 for possible malfunctioning pacemaker and another for light-headedness.
  • The most common age group was 70-89.
  • The most common place for initiating telemetry was the emergency assessment unit.
  • There were no requests for a possible malfunctioning implantable cardiac defibrillator.
  • Only 8 patients had their time period of telemetry monitoring recorded.
Figure 2 - Results of re-audit

Figure 2 - Results of re-audit

Further Developments

  • Adaptions were made to the telemetry request form.

- “Possible malfunctioning ICD” was changed to “possible malfunctioning device”.

- All patients who had collapsed required a lying and standing blood pressure before a request was made

- All request for collapse and arrhythmias had to be discussed with CCU

  • The time period of monitoring had to be documented on the request form after monitoring had ceased.

Discussion

Telemetry originates from the Greek word Tele (remote) and metron (measure). Telemetry is another term for ambulatory wireless cardiac monitoring. Each patient has a three-lead ECG recording telemetry box. The system is wireless and signal is received by several antennae located throughout the hospital. The central monitoring system (that records any event or arrhythmia) is located within CCU. The central monitoring system has an alarm system that informs the nurses of any significant change in rate or rhythm (i.e. if the heart rate drops below 30 beats per minute or a patient develops a broad complex tachycardia). Before its use in hospital, telemetry was used during spaceflight in the 1960s and was developed by spacelabs medical.1

Telemetry requires both trained personnel and specialised equipment. Remote monitoring is often inappropriately used and patients are kept on devices for a significant amount of time. This is probably due to the lack of evidence based guidelines for the initiation and discontinuation of telemetry.2 In a hospital in Penysylvannia a nurse managed service of telemetry issued guidelines for the initiation and discontinuation of telemetry that were approved by their medical, nursing and bed management staff.3

Each telemetry box used within our hospital costs £400. The system was installed (along with the stationary cardiac monitoring system) in 2010 and will the system be reviewed again in eight years time. Following the implementation of our new guidelines and request form, there has been a significant reduction of inappropriate requests allowing us to cope with the demand for telemetry.

In our hospital telemetry is a cardiac care nurse-led service. Every shift, there is a cardiac care unit nurse responsible for issuing telemetry devices, interpreting any arrhythmias or events and notifying the appropriate ward or clinician if this is the case. After telemetry monitoring has ceased, a report of any arrhythmias or events is issued within the patients notes. If the dedicated nurse has any issues or concerns then they can be addressed with the cardiology registrar/consultant or on call medical registrar. Benezet-Mazuecos J et al emphasised the importance of trained nurses in the detection and management of arrhythmias.4

We discovered that most of our inappropriate requests were either related to collapse or arrhythmias. For example, clinicians may request telemetry for patient with rate-controlled atrial fibrillation just simply because they had atrial fibrillation. There were also numerous requests for collapse in those patients with a clear neurological cause.

It is difficult to determine which patients with collapse and arrhythmias will require telemetry. Locally, we felt it was important that those with an abnormal ECG, significant cardiac risk factors or the elderly that were admitted with a collapse required telemetry monitoring. Benezet-Mazueous J et al concluded that in unexplained syncope telemetry monitoring was particularly useful in the older generation and those with heart failure.4 We also concluded that those with haemodynamically compromised arrhythmias required monitoring, but it was not required in for example the septic patient with a sinus tachycardia.

Clearly, those patients that had taken an overdose that may induce a lethal arrhythmia such as tricyclic antidepressants absolutely require cardiac monitoring.5

We noted that as there were less inappropriate requests, there was consequently no waiting time for a telemetry device and no need for further investment. It would not be easy to demonstrate significant savings but avoiding unnecessary monitoring is likely to have a modest benefit on overall performance. We felt that overall clinical care of the patient improved as there were more appropriate requests, a reduction in waiting time for a device and prompt diagnosis in the smaller numbers studied.

Within our hospital we have improved practice and educated junior medical and nursing staff. However, our re-audit has shown that we must now concentrate on adapting guidelines for the time we monitor patients on telemetry. The updated request form has also been implemented in other hospitals throughout our trust.

Key Messages

  • In many hospitals telemetry is inappropriately used and patients are kept on monitors for a considerable amount of time.
  • After our local guidelines and request forms were amended there was a significant reduction of inappropriate telemetry requests.
  • Our Acute Cardiac Care Unit has a dedicated staff nurse on every shift responsible for telemetry.
  • We will continue to re-audit practice to maintain a high standard of care.

Conflicts of Interest

None declared

Acknowledgements

This audit was awarded best poster prize at the National Audit Of Cardiac Services, 2011.

References

1. Henriques-Forsythe MN, Ivonye CC, Jamched U et al. Is telemetry overused? Is it helpful as thought? Cleveland Clinical Journal of Medicine 2009;76(6):368–72.

2. Dawson S, Ruck JA.  Right patient? Right bed? A question of appropriateness. AACN Clin Issues 2000;11:375–85.

3. Reilly T, Humbrecht D.  Fosetring synergy: A nurse-managed remote telemetry model.  Crit care nurse 2007;27: 22–3

4. Benezet-Mazuscos J, Ibanez B, Rubio JM et al. Utility of in-patient cardiac telemetry in patients with unexplained syncope. Europace 2007;9: 1196–201.

5. Pentel PR, Benowitz NL. Tricyclic antidepressant poisoning. Management of arrhythmias. Med Toxicol 1986;1(20):101–21

Nerys_Conway

Dr Nerys Louise Conway, Speciality Registrar Cardiology

Authors

Dr Nerys Louise Conway (lead author)
Speciality Registrar Cardiology
(
nerys.conway@doctors.org.uk)

Dr Stephen Hutchison
Consultant Cardiologist

Annie Frances Evans
Acute Cardiac Care Unit Sister

Department of Cardiology, Nevill Hall Hospital, Abergavenny, NP7 7EG

<span style=”font-size: 20px; font-weight: bold;”><strong>Citation</strong></span>
George A, John J, Chattopadhyay S.  Dronedarone: a new therapeutic option for atrial fibrillation.  <em>BJC </em><em>Arrhythmia Watch</em> 2012;Issue 21 (Feb)

Citation

Conway NL, Hutchison S, Evans AF.  An audit of telemetry monitoring in a district general hospital.  BJC Arrhythmia Watch 2012;Issue 22 (Mar)

Published on: March 9, 2012

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