[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.158.98.119. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Download PDF
Table 1.  
Alarms Before and After Revision of the Continuous Cardiac Telemetry Protocol
Alarms Before and After Revision of the Continuous Cardiac Telemetry Protocol
Table 2.  
Classification of Emergency Alarms
Classification of Emergency Alarms
1.
Dressler  R, Dryer  MM, Coletti  C, Mahoney  D, Doorey  AJ.  Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med. 2014;174(11):1852-1854.
PubMedArticle
2.
Drew  BJ, Califf  RM, Funk  M,  et al; American Heart Association; Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young.  Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation. 2004;110(17):2721-2746.
PubMedArticle
3.
Schull  MJ, Redelmeier  DA.  Continuous electrocardiographic monitoring and cardiac arrest outcomes in 8,932 telemetry ward patients. Acad Emerg Med. 2000;7(6):647-652.
PubMedArticle
4.
Estrada  CA, Rosman  HS, Prasad  NK,  et al.  Role of telemetry monitoring in the non-intensive care unit. Am J Cardiol. 1995;76(12):960-965.
PubMedArticle
5.
Bulger  J, Nickel  W, Messler  J,  et al.  Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):486-492.
PubMedArticle
Views 1,901
Citations 0
Research Letter
Less Is More
August 2015

Potential of Missing Life-Threatening Arrhythmias After Limiting the Use of Cardiac Telemetry

Author Affiliations
  • 1Department of Cardiology, Christiana Care Health System, Newark, Delaware
  • 2College of Engineering, University of Delaware, Newark, Delaware
  • 3Department of Medicine, Christiana Care Health System, Newark, Delaware
  • 4Value Institute, Christiana Care Health System, Newark, Delaware
JAMA Intern Med. 2015;175(8):1416-1418. doi:10.1001/jamainternmed.2015.2387

We previously revised our telemetry protocol by using the American Heart Association guidelines, producing a 43% decrease in telemetry initiation.1,2 After determining that there was no increase in mortality, cardiac arrest, or activation of the rapid response team, we sought to ascertain the risk of missing life-threatening arrhythmias (LTAs) with reduced telemetry use. Life-threatening arrhythmias, such as ventricular tachyarrhythmias, are the primary rationale for using telemetry, and fear of missing them likely contributes to overuse. We studied the nature and clinical outcome of our telemetry alarms. We hypothesized that alarms representing LTAs are uncommon and that few alarms affect patient management.

Methods

In March 2013, we instituted a revision of non–intensive care unit telemetry that integrated the current American Heart Association guidelines2 into our electronic ordering system. Predefined criteria (developed internally at our institution and in use for many years before our telemetry protocol revision) categorized telemetry alarms as emergency or nonemergency. Alarm events were communicated from a central monitoring department to patient care units via telephone, and a detailed log of alarms was maintained.

We selected 2 periods—before (October 19, 2012, to November 19, 2012) and after (May 22, 2013, to June 19, 2013) revision—to retrospectively review alarm logs. We tabulated the total number of alarms and studied, in detail, a random selection of alarm logs. All alarms designated as emergency in these subgroups were then evaluated with a detailed medical record review, arrhythmia analysis, and determination of whether any change in clinical management followed.

Emergency alarms were divided into 3 classes: potential LTAs, clinically important alarms, and alarms of questionable importance. Management changes included transferring to an intensive care unit, beginning use of a new medication, ordering a diagnostic study, or activating a rapid response or cardiac arrest team. The study was approved by the institutional review board at Christiana Care Health System. Informed consent was not required.

Statistical analysis was performed using the t test and χ2 test.

Results

Emergency alarms were infrequent (Table 1). All alarm logs for 1323 and 1322 randomly selected patients from the periods before and after revision, respectively, were examined in detail. The total number of alarms, examined in detail, was 4106 and 3094, respectively. There was only 1 potentially LTA alarm (0.01%) of the 7200 total alarms in these subgroups (Table 2). This patient had a self-terminated ventricular tachycardia that lasted 32 seconds. Thus, there was not a single LTA for which telemetry led to an immediate treatment during the study period. Of the 78 emergency alarms, 29 (37.2%) were classified as clinically important. However, only 14 (48.3%) of these 29 alarms led to a change in clinical management within 1 hour. Most of these alarms were for rapid atrial tachyarrhythmia. Telemetry length declined after the revision due to prespecified durations.

Discussion

Even among the alarms designated as emergency, we found episodes of clinically important arrhythmias to be very infrequent, rarely leading to a change in patient management. Life-threatening arrhythmias were exceedingly rare, occurring in 1 of 2645 patients. Previous studies3,4 have also found low rates of serious arrhythmias. In these studies, the incidence of LTA requiring immediate action was low, and there were few important changes in management or outcomes. For example, Schull et al5 reported that, of 8932 patients undergoing telemetry, only approximately 1 (0.02%) in 5000 were survivors of cardiac arrest in whom telemetry signaled the cardiac arrest.

Medicolegal concerns may contribute to telemetry overuse. We believe our system mitigates this risk as an evidence-based standard of care applied to clinical decision making through protocols. Thus, reducing unnecessary telemetry use is not likely to miss LTAs because of the very low incidence of true LTAs in contemporary telemetry monitoring settings. This finding should be reassuring to those considering the recommendation of the Choosing Wisely campaign to limit non–intensive care unit telemetry.5

Back to top
Article Information

Corresponding Author: Andrew Doorey, MD, Christiana Care Health System, 252 Chapman Rd, Ste 150, Newark, DE 19702.

Published Online: June 15, 2015. doi:10.1001/jamainternmed.2015.2387.

Author Contributions: Drs Kansara and Doorey had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kansara, Dressler, Weiner, Kerzner, Weintraub, Doorey.

Acquisition, analysis, or interpretation of data: Kansara, Jackson, Dressler, Kerzner, Weintraub, Doorey.

Drafting of the manuscript: Jackson, Dressler, Weiner, Weintraub, Doorey.

Critical revision of the manuscript for important intellectual content: Kansara, Dressler, Kerzner, Weintraub, Doorey.

Statistical analysis: Jackson, Dressler, Weintraub.

Administrative, technical, or material support: Jackson, Dressler, Weintraub.

Study supervision: Kansara, Weiner, Kerzner, Weintraub, Doorey.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Vasanth Chandrasekhar, BS (University of Delaware), contributed to the initial pilot study to determine the value of continuous cardiac telemetry at our institution, and Paul Kolm, PhD (Value Institute, Christiana Care Health System), provided statistical assistance. No financial compensation was provided.

References
1.
Dressler  R, Dryer  MM, Coletti  C, Mahoney  D, Doorey  AJ.  Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med. 2014;174(11):1852-1854.
PubMedArticle
2.
Drew  BJ, Califf  RM, Funk  M,  et al; American Heart Association; Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young.  Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation. 2004;110(17):2721-2746.
PubMedArticle
3.
Schull  MJ, Redelmeier  DA.  Continuous electrocardiographic monitoring and cardiac arrest outcomes in 8,932 telemetry ward patients. Acad Emerg Med. 2000;7(6):647-652.
PubMedArticle
4.
Estrada  CA, Rosman  HS, Prasad  NK,  et al.  Role of telemetry monitoring in the non-intensive care unit. Am J Cardiol. 1995;76(12):960-965.
PubMedArticle
5.
Bulger  J, Nickel  W, Messler  J,  et al.  Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):486-492.
PubMedArticle
×