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.