Electrocardiographic monitoring (telemetry) is often ordered without an appropriate clinical indication1
Telemetry (continuous remote cardiac rhythm monitoring) can detect arrhythmias, abnormal QT intervals, and electrocardiographic changes suggestive of myocardial ischemia.2 Studies show that between 30% and 90% of noncritical care telemetry use is inappropriate or is continued longer than recommended. 1 Patients monitored without an appropriate indication (such as chronic, stable atrial fibrillation or asymptomatic hemodynamically stable sinus bradycardia) rarely have arrhythmias identified that change management.1,2
Inpatient telemetry is recommended for patients at high risk of arrhythmia, such as those with acute coronary syndrome or suspected cardiac syncope
In patients with moderate to high risk of acute coronary syndrome, telemetry should be continued for 24 to 48 hours until there is no evidence of modifiable ischemia or electrical instability.2 When cardiac syncope is suspected using clinical decision tools, a minimum of 24 hours of monitoring is warranted until cause and treatment is identified. Other indications include acute stroke, drug overdose, or substantial electrolyte abnormalities. The American Heart Association’s Practice Standards acknowledge no Level A evidence supporting the benefit of telemetry.2
Telemetry is not benign
Monitoring leads are physically restrictive for patients. Incidental or artifactual telemetry findings may lead to unnecessary diagnostic or therapeutic cascades.1 Telemetry can also lead to delirium, alarm fatigue, and increased health care expenditures.3,4
Mandates and staff education can improve appropriateness of telemetry ordering1,4
Requiring clinicians to select a Practice Standards–based indication when ordering telemetry and providing education on appropriate reasons to order telemetry leads to substantial reductions in inappropriate telemetry orders without increasing mortality, code blue events, or activation rates of critical care outreach teams.1,4
Embedding expiration times into telemetry orders or reviewing telemetry use daily are evidence-based interventions that facilitate timely discontinuation4,5
Even when ordered for an appropriate indication, telemetry is often maintained for longer than is recommended. Quality-improvement initiatives that standardize discontinuation of telemetry into routine practice safely and sustainably reduce duration of inappropriate telemetry monitoring.5
Footnotes
Competing interests: Sanket Dhruva reports receiving research grants from the United States Department of Veterans Affairs and Arnold Ventures. William Silverstein reports receiving a stipend as lead of the Students and Trainees Advocating for Resource Stewardship, Choosing Wisely Canada. No other competing interests were declared.
This article has been peer reviewed.
References
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