November 16, 2018 - The Physician & CIO Forum, hosted by MEDITECH in Foxborough, MA on October 17-18, featured numerous presentations addressing industry topics. Breakout sessions fostered discussion around healthcare innovations and how we can further drive EHR sophistication.
On day one of the Forum, Associate Vice President Janet Desroche, Client Services, MEDITECH, introduced the presenter — Dr. Ginny Kwong, MD, FAAFP, CMIO, of Halifax Health. Dr. Kwong led the discussion on telemetry utilization in community-based hospitals — which in this case, is defined as electronic data transmissions of cardiac rhythm being monitored with real-time measurements over certain periods of time. She elaborated on telemetry use guidelines, results, and how inappropriate telemetry use can cause patient discomfort, prolonged hospital stays, alarm fatigue, and increased healthcare costs. In an effort to champion telemetry improvement, Dr. Kwong’s work was published in The Journal of Hospital Medicine and featured in the October 2018 issue of Today’s Hospitalist — creating necessary dialogue surrounding telemetry use.
Dr. Kwong referenced the AHA, American Heart Association, best practice guidelines for identifying and managing patients for whom telemetry is indicated. The dozen or so physician leaders in the room were in agreement that these are the guidelines to be used when working on a telemetry process improvement project. By grouping patients into classes of (1) monitoring required, (2) non-essential, and (3) non-beneficial, clinical personnel can determine which patients truly need telemetry. At Halifax Health, this clinical re-evaluation is every 48 hours — including the following:
Based on the need to re-evaluate telemetry use, Halifax Health decided to involve leadership, clinicians, decision support, informaticists, and others to analyze areas for improvement.
The overutilization program’s objective is to promote evidence-based telemetry practice with integrated electronic ordering functionality and analytics. Dr. Kwong aims to achieve the following goals:
After a multidisciplinary committee evaluated Halifax Health’s telemetry use, Dr. Kwong mentioned the following solutions:
The results showed that 90% of the telemetry patients had indications given. The other 10% had no indications defined, but through documentation, it was inferred they accounted for GI bleeds, COPD, Hypoxia, Anemia, alcohol, and withdrawal. Effective change in utilizing telemetry correctly involves a few steps — multidisciplinary team-based deployment of education and communication within the organization, embedded evidence-based content within order sets, and leverage on data analytics.
Clinicians are concerned with the potential for adverse events if telemetry is not used. However, Dr. Kwong believes the evidence-based reinforced education should overcome that fear-driven culture since evidence has assisted in clinical decision support and proven beneficial in Halifax Health’s retrospective analysis. Nonetheless, telemetry use challenges remain throughout community hospitals. One small community hospital physician reported bedside nurses make recommendations while three case managers and a directos assess the appropriate level of care utilizing telemetry. Here, telebed management ratio is reviewed daily. Another participant reported mandatory documentation of telemetry results in progress notes for the cardiologist before moving forward with telemetry continuation or discontinuation. Within this scenario, managing telemetry on ED hold patient lists becomes challenging.
With MEDITECH, healthcare organizations can discontinue telemetry based on time intervals with a discontinuation order signed by the physician. Furthermore, by investigating clinical indications, quality reporting and surveillance, timely assessment, and active and passive clinical decision support, Janet envisions a streamlined Telemetry Toolkit:
Tracked by clinical staff/nurses, the Surveillance product monitors patients while pulling in past data from across the EHR, features real-time functionality, and individual profile watchlists with role-based criteria populating patients with telemetry orders. By recycling this functionality along with streamlining order indication times via Status Boards, MEDITECH has the ability to include appropriate content for decision support on continuing or discontinuing telemetry:
The overall consensus — a toolkit with appropriate rules, analytics, and alerts will better manage telemetry use and patient care, as well as save hospitals thousands of dollars.