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 study18 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).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.