When an alarm goes off every six seconds, at some point, the urgency it was designed to convey fades. Clinicians can be overwhelmed by the sound of recurring alarms and not respond quickly when one is triggered. For the patient, this increases anxiety and impacts care.
“Alarm fatigue” is a concern at hospitals across the country and is often associated with the overuse of telemetry monitoring, which records the electrical activity of the heart. Recognizing this, the American Board of Internal Medicine’s Choosing Wisely campaign selected telemetry as one of the five tests and treatments which should be carefully considered prior to use.
An encouragement for “careful consideration” is not enough to change habits, however. So New Hanover Regional Medical Center undertook a systematic study of how telemetry monitoring is used and which processes needed to change to hardwire new behaviors, ensuring the right patients are on telemetry, for the right duration of time. The results were dramatic.
Using Lean problem-solving techniques, a team came together to begin exploring the issue in February 2015. The team included hospitalists with NHRMC Physician Group, as well as representatives from the telemetry department, nursing, clinical informatics, pharmacy, and information technology.
The Lean process took us throughout the hospital to look at each step in ordering and discontinuing telemetry. Our goal was to find wasted steps in the system. We quickly realized there were no standard guidelines for the appropriate use of telemetry outside the intensive care unit (ICU). An evaluation of the electronic medical records revealed that three different orders could initiate telemetry, but only a multi-step process could discontinue it.
The challenge for providers and staff to understand which patients required telemetry led to considerable overuse. NHRMC Physician Group Hospitalists averaged 59 patients on telemetry each day, more than 42 percent of the group’s daily census. The cost, meanwhile, averaged $82.44 a day per patient. The patient never sees this cost, but the hospital is paying for the service as part of a patient’s overall stay.
Setting Goals and Establishing Countermeasures
In defining our “desired state” we set a goal to bring the hospitalist group’s average percentage of patients on telemetry to 37, with a stretch goal of bringing it down to 30 percent. Our strategy revolved around two types of initiatives: identifying the right patients for telemetry and monitoring for the right duration of time.
The first step was to ensure hospitalists were following the same guidelines. During a monthly meeting of NHRMC Physician Group hospitalists, we reviewed standards published by the American Heart Association/American College of Cardiology. Then we developed a telemetry icon that would flag patients on telemetry on the daily patient census roster. The icon made it easier for the physician taking care of the patient to see that a patient had orders for telemetry and take action. In addition, a physician champion could easily review the chart for appropriateness.
To prevent telemetry from being used longer than required, we eliminated duplicate orders through the development of a single non-ICU inpatient telemetry order with consistent nomenclature. The order includes a question on expected duration. In the near future, a “best practice advisory” will alert the physician to either discontinue telemetry or update the order. To make it easier to discontinue, we streamlined the process to just one step. To prevent orders from automatically transferring from the emergency department to the unit, we initiated a special emergency department-only telemetry order set.
For eight consecutive months after implementation, the team hit the target goal of having just 37 percent of our patient census on telemetry, and frequently achieved the stretch goal of 30 percent.
The impact of this reduction is significant. The hospital avoided 4,264 days on telemetry, 533 days a month, for non-ICU patients. This saved at least $227,882 for the eight-month period, eliminating unnecessary costs of care for NHRMC. More relieving for staff and patients: this prevented more than 243,000 alarms from sounding.
As a physician, I was shocked when I learned of the burden the frequent alarms created for staff and patients. We tend to see monitoring as a comforting measure to track a patient’s heart rhythm and notify of issues. But its effectiveness is certainly compromised when overused. The Lean process, with its focus on why a situation exists and its clear direction for eliminating wasteful steps and standardizing the system to ensure success, has delivered results beneficial for our patients, staff and physicians.