implementing american heart association practice standards for inpatient ecg monitoring: an...
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Implementing American Heart Association Practice Standards for Inpatient ECG Monitoring:An Interventional Study at Abbott-Northwestern Hospital
Sue Sendelbach, PhD, RN1
Kristin Sandau, PhD RN2,3
Marjorie Funk, PhD, RN4
Lisa Smith, RN3
Mark Frederickson, BS1
Steve Hanovich, MD5
1Abbott Northwestern Hospital/Minneapolis Heart Institute, Minneapolis, MN; 2Bethel University, St. Paul, MN 3United Hospital, St. Paul, MN; 4Yale University, New Haven, CT; 5Unity Hospital, Fridley, MN
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For their expertise and collaboration:• Bob Miner, MD• Bill Dickey, MD• Alex Campbell, MD• Katie Scheel, RN
For their generous support:• Abbott Northwestern Hospital Foundation
Acknowledgments:
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• Background: Although ECG monitoring is common in hospitalized patients, studies demonstrate that many patients receive unnecessary monitoring, contributing to inconvenience to patients, alarm fatigue for clinicians, and cost for institutions.
• Objective: To evaluate the impact of implementation of the 2004 AHA Practice Standards for arrhythmia monitoring of hospitalized adult patients on non-cardiac units with remote ECG monitoring.
• Methods: A pre-to-post interventional study implementing electronic health provider order sets will be conducted to evaluate the impact of implementation of Practice Standards for arrhythmia monitoring of hospitalized patients on non-critical care/non-cardiac units. A total sample of 300 patients (alpha = .05 and power = 0.90) medical/surgical units receiving remote ECG monitoring will be examined at pre- and post-intervention.
• Outcomes (pending): Primary outcome: percentage of patients appropriately monitored for arrhythmia according to the Practice Standards pre- and post-implementation. Secondary outcomes: percentage of patients appropriately monitored for QTc prolongation; and differences in ECG monitoring among provider groups (e.g., hospitalists vs. residents). Safety will be reported percentage of cardiac arrests and all-cause mortality from pre-to-post- intervention.
Abstract (Sendelbach, Sandau, et al. study in progress)
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1. Background
Although ECG monitoring is common in hospitalized patients, studies demonstrate that many patients receive unnecessary monitoring, contributing to:• inconvenience to patients• distraction for nurses; alarm fatigue for all clinicians• cost for institutions.
Recently, several facilities have published results of research or quality improvement (QI) projects describing how increased implementation of the American Heart Association (AHA) Practice Standards for ECG Monitoring reduced telemetry use with no adverse effect on cardiac arrest.
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Background: Practice Standards for ECG Monitoring (AHA Scientific Statement)
Types of ECG monitoring– Arrhythmia– Ischemia– QT interval
Drew B. et al. (2004). Practice standards for ECG monitoring…Circulation, 110, 2721-2746.
Classifications:• Class I: Cardiac monitoring is indicated in most, if not all, patients in this
group• Class II: Cardiac monitoring may be of benefit in some patients but is
not considered essential for all patients• Class III: Cardiac monitoring is not indicated because a patient’s risk of a
serious event is so low that monitoring has no therapeutic benefit
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Background: Past Studies to Implement Practice Standards
• Kanwar et al. (2008) (Retrospective study)– Lectures to MD residents and faculty, NPs, PAs, and unit clerks;
reminders via email, laminated cards and posting. Unit clerks encouraged to call to confirm tele indication.
– Class I/II indications for monitoring from pre- (57%) to post- (71%) intervention
• Benjamin et al. (2013) (Retrospective, 4 hospital study)– Telemetry bed use was examined for 1 week. In 35% of
telemetry days, ECG monitoring was not supported by clinical indication for monitoring.
– Implementation of appropriate ECG monitoring associated with a savings of $53-$88 per patient/day
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Background: Past Studies to Implement Practice Standards
• Dressler et al. (2014) (Prospective study)– Revised telemetry order sets based on AHA Practice Standards in which
prescribers were required to select from a list of clinical indications, each with a predetermined duration of monitoring.
– Mean daily number of patients with telemetry ordered decreased by 70%, with cost savings noted.*
– Safety: code blue, mortality, rapid response team activation rates remained stable.
• Rayo et al. (2015) (Prospective study)– ECG monitoring decreased by 53.2% per day.– Monitored transport rate decreased by 15.5% per day.– ED patient boarding rate decrease 36.6%.– Percentage of false alarms decreased from 18.8% to 9.6%. – Safety: neither LOS nor mortality changed significantly with this practice
change.
*Generalizeability is limited for Dressler et al. due to their very low adherence to Practice Standards at baseline; consider site differences with remote monitoring station
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Background: Allina-Specific Data that Motivated our Study
We need to do better:• Abbott Northwestern Hospital (audit): 120 charts of non-cardiac patients who
received remote telemetry monitoring were reviewed by a cardiologist; of these, an estimated 54% did not have an indication for ECG monitoring.
And we can!• Allina-wide (published study by Sandau et al., 2015): Nurse-led interventional
study (10 hospitals) to improve adherence to QTc monitoring for patients receiving ECG monitoring who were on QT-prolonging medications.– Intervention: (Multi-Disciplinary Computer Alerts + Education + Automatic QTc
Calculation for End-user RN) was followed by a significant improvement in QTc documentation according to AHA practice standards among monitored inpatients (n=4,011) receiving QT-prolonging medications.
Sandau, KE, Sendelbach S …Funk, M. (2015). Computer-assisted interventions improve QTc documentation in hospital patients receiving QT-prolonging drugs. American Journal of Critical Care, 24:000-000.
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Background: Rationale for Appropriate Telemetry Monitoring
Aligns with national goals:• Aligns with Joint Commission National Safety Goal to reduce alarm
fatigue• Aligns with Choosing Wisely CampaignContributes toward our goal to:• Reduce unavailability of monitored beds which impacts transfers out
of ICU or telemetry• Reduce delay for ED admissions & avoids diverts• Impact inpatient and ED length of stay• Work toward Allina-wide computerized order entry with decision tools
that are aligned with practice standards for ease of ordering (long-term goal)
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Objective: To evaluate the impact of implementation of the 2004 AHA Practice Standards for arrhythmia monitoring of hospitalized adult patients on non-cardiac units with remote ECG monitoring.
2. Objective
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Methods: A pre-to-post interventional study implementing electronic health provider order sets will be conducted to evaluate the impact of implementation of Practice Standards for arrhythmia monitoring of hospitalized patients on non-critical care/non-cardiac units. A total sample of 300 patients (alpha = .05 and power = 0.90) medical/surgical units receiving remote ECG monitoring will be examined at pre- and post-intervention.
3. Methods
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October 2014 • 4th quarter: Pre-implementation data (n = 150)2015• Physician education piloted at UH during separate QI project2016• Feb: Excellian® (electronic health record) orders implemented for
intervention pilot for ANW’s medical-surgical patients receiving remote ECG-monitoring.
• 2nd quarter: Post-implementation data (n = 150)• 3rd and 4th quarter: Review, clean, analyze data. Travel to Allina sites to
communicate practice change.2017• 1st quarter, 2017 online education for nurses and any technicians working
with monitored patients
3. Methods: Timeline
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• Computerized Order Entry• Face-to-Face Introduction of Implementation to
providers at sites (Sendelbach, Sandau)• Online education for nurses and any technicians
working with monitored patients• Telemetry Indications Quick Reference (See
electronic copy which will be on the AKN)
Methods: Interventions Include…
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Methods: UH Telemetry Indications Quick Reference (Adults)
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In order to understand the Telemetry Indications Quick Reference, it is helpful to point out a few things:• In attempt to provide simplicity, patient indications are presented in the
following categories: • No indication• No ST-segment monitoring• Cardiac: Artery Disease• Cardiac: Rhythm• Non-cardiac
• Under each indication, the recommended DURATION of monitoring is provided, reminding us we need to reassess each day why telemetry is still needed.
• Note that for some patient conditions, arrhythmia monitoring should be supplemented by continuous ST-segment monitoring. This is indicated by +ST.
• Similarly, +QT notes a diagnosis for which supplemental QTc monitoring is indicated.
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Methods: Computerized Order Entry with AHA Practice Standards Imbedded
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Methods: Computerized Order Entry with AHA Practice Standards Imbedded
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Methods: Computerized Order Entry with AHA Practice Standards Imbedded
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Primary outcome: • Percentage of patients appropriately monitored for
arrhythmia according to the Practice Standards pre- and post-implementation. • Secondary outcomes: percentage of patients
appropriately monitored for QTc prolongation; and differences in ECG monitoring among provider groups (e.g., hospitalists vs. residents).• Safety will be reported percentage of cardiac arrests
and all-cause mortality from pre-to-post- intervention.
4. Outcomes (pending)
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• Data analysis is underway.• Submission of manuscript to peer-reviewed journal;
national conference.• Allina-wide implementation of EHR order sets.• Generalize findings appropriately (e.g., percentages of
appropriately monitored patients on cardiac step-down/telemetry/progressive care units are already higher than for the remotely monitored patients on this study)• Use these data to help make decisions about ECG
monitoring practices at Allina
What’s Next?
