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).