Use and Outcomes of Telemetry Monitoring on a Medicine Service

Telemetry is a powerful tool for real-time monitoring of a patient's heart rhythm and QRS pattern. Beds with telemetry monitoring are limited and expensive in most institutions; therefore, the use of this resource would ideally be evidence based.¹ American Heart Association (AHA) guidelines provide class I, II, and III indications for the use of telemetry, but the focus is almost exclusively on cardiac diagnoses, such as admissions for rule-out acute coronary syndrome or heart block.² However, there are far fewer data that describe criteria for the use of telemetry in a general medical population.³ In the largest study of telemetry to date, only 121 of 2240 patients (5%) who underwent telemetry were admitted with noncardiac diagnoses.⁴ We performed a study to better characterize the reasons why patients on a medicine service are placed on telemetry monitoring as well as the frequency of clinically significant telemetry events.

A prospective, observational study was conducted in 2010 and 2011 at the University of California, San Francisco, Medical Center, a large university-affiliated teaching hospital. The study was approved by the university's institutional review board. We enrolled a convenience sample of consecutive adult patients who were admitted or transferred to the medicine service with telemetry monitoring on a single unit of the hospital. Each day, we asked the telemetry technician for new admissions and discharges from telemetry as well as the telemetry events for all patients whom we were tracking. For each new admission to telemetry, we administered a paper or an e-mail survey to the intern, subintern, or hospitalist who admitted the patient. For each discharge from telemetry, we administered a phone survey to the intern or the subintern who was responsible for that patient. Other clinical and demographic information was elicited from the electronic medical record system.

Our primary outcomes of interest were telemetry events and management changes in response to telemetry events. A telemetry event was defined as any change in heart rhythm logged by the telemetry technician that was different from the admission heart rhythm. Management changes in response to telemetry events were identified by the primary team members when they completed the day-of-discharge surveys.

During the study period, surveys were administered for 182 patients. The response rate was 73% for admission surveys and 74% for the discharge surveys, yielding a final sample of 100 patients for whom we had complete admission and discharge survey data. The mean patient age was 66 years; 53% of the patients were women; and 18% had do-not-resuscitate orders (Table). The patients spent an average of 2.6 days on telemetry monitoring. The 3 most common admitting diagnoses were gastrointestinal bleeding (19%), renal failure (17%), and pneumonia (11%). Only 11 patients in our cohort met AHA class I indications for the use of telemetry. Most patients (57%) had no cardiac history. The initial rhythm for most patients was normal sinus rhythm or sinus tachycardia, and the most common telemetry events were sinus bradycardia, sinus tachycardia, and premature ventricular contractions. Four patients developed new atrial fibrillation or flutter. Nineteen patients had management changes in response to telemetry events. Because more than 1 intervention was possible per patient, 9 patients underwent diagnostic testing, 8 had medications changed, 7 had intravenous fluids administered, and 2 were transferred to the intensive care unit.

When asked why they chose to place their patients on telemetry, 50% of physicians responded “to detect clinical deterioration early” and 22% responded “concern for development of an arrhythmia.” Although our sample size and event rate were too small to draw meaningful statistical conclusions, neither the 2 patients who required transfer to the intensive care unit nor the 2 others who developed new atrial fibrillation or flutter met AHA class I criteria.

This study differs significantly from previous studies of telemetry in that the study population comprised patients who were admitted to a medicine service, not for a primary cardiac diagnosis.^4-7 We found that very few patients had clinically meaningful telemetry events and even fewer had events that prompted a change in therapy. None of the patients who had significant events would have met AHA criteria for an indicated use of telemetry. This suggests that perhaps the AHA criteria, which were developed for cardiac patients, may not be applicable to patients with primary medical diagnoses.

Also, few studies asked physicians why they chose telemetry. We found that a concern for clinical deterioration, rather than an explicit concern for development of arrhythmia, drove most of the telemetry use. This finding is notable because telemetry does not replace more frequent vital sign checks or lower nurse to patient ratios and may lead both nurses and physicians to feel a false sense of security regarding their patient's monitoring.

Correspondence: Dr Najafi, Division of Hospital Medicine, University of California, San Francisco, 505 Parnassus Ave, PO Box 0131, San Francisco, CA 94143 (nnajafi@medicine.ucsf.edu).

Published Online: August 13, 2012. doi:10.1001 /archinternmed.2012.3163

Author Contributions: Both authors 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: Najafi and Auerbach. Acquisition of data: Najafi and Auerbach. Analysis and interpretation of data: Najafi and Auerbach. Drafting of the manuscript: Najafi and Auerbach. Critical revision of the manuscript for important intellectual content: Najafi and Auerbach. Statistical analysis: Najafi and Auerbach. Obtained funding: Auerbach. Administrative, technical, and material support: Auerbach. Study supervision: Auerbach.

Funding/Support: Dr Auerbach is supported by grant K24 K24HL098372 from the National Heart, Lung, and Blood Institute.

Previous Presentations: This study was presented as a poster at the Society of General Internal Medicine California-Hawaii Regional Meeting; January 21, 2012; San Francisco, California; and at the Society of Hospital Medicine Annual Meeting; April 2, 2012; San Diego, California.