Overutilization of a medical technology can be a thorny issue: Instances of overuse can be difficult to detect. And they can be problematic to resolve once identified because the path to a solution can require changing perceptions about the costs versus the benefits, and also modifying behaviors. But breaking the pattern of overuse is important, especially if the problem could undermine the safety and quality of patient care. This was the challenge faced by Christiana Care Health System (Wilmington, Delaware), where the issue was overutilization of cardiac telemetry monitoring. To tackle the problem, Christiana Care developed a highly effective initiative — a project that earned the organization the 2014 Health Devices Achievement Award from ECRI Institute.
Keys to the success of Christiana Care’s initiative included the formation of a well-functioning multidisciplinary team and the team’s ability to develop a process change that (1) did not significantly interfere with physician autonomy and (2) could be “hardwired” into an already existing workflow.
Christiana Care’s overutilization problem grew as an unintended consequence of a previous improvement initiative. Fifteen years ago, the health system determined that the ability to provide cardiac monitoring outside the ICU would offer several advantages: It would help address a shortage of monitored beds, it would improve monitoring and the response to alarms, and it would improve the continuity of care by reducing transfers from one care area to another.
To that end, the organization set a goal of being able to monitor any patient in any bed at any time. Christiana Care achieved that goal through an improvement initiative called the Flexible Monitoring Program. This program has added the capability to transmit ECG and other patient signals from wearable telemetry monitors via a wireless signal to a centralized monitoring room. There, the ECG signals and tracings are interpreted by trained monitor technicians, who communicate notable events to the nurses via dedicated phone lines.
For patients at risk of heart events, cardiac telemetry monitoring is a valuable tool. However, what developed over time following the launch of the Flexible Monitoring Program was the widespread use of cardiac telemetry monitoring for low-risk patients. For these patients, the technology offered little or no clinical value. In fact, Christiana Care determined that in addition to requiring resources, the use of telemetry monitoring for low-risk patients actually created multiple challenges to the delivery of safe, high-quality care.
For example, telemetry alarms that had activated for avoidable or clinically insignificant conditions created frequent interruptions, distracting nurses from necessary clinical care duties and increasing the potential for error. Also, artifacts displayed on the waveform would, on occasion, be misinterpreted as representing serious arrhythmias, sometimes leading to the activation of urgent cardiac-consultation or rapid-response teams or unnecessary follow-up testing.
In addition, wearing the telemetry pack with its associated wires is an encumbrance for the patient.
“We want to get patients up and around,” explained Andrew Doorey, MD, a cardiologist on the telemetry redesign team. “When wrapped in wires, patients simply can’t move like they’d like. It’s very frustrating for them.”
Furthermore, being tethered to the telemetry pack can increase the risk of patient falls, especially among the elderly. And it can disrupt patient sleep. For reasons such as these, “nurses were emphatic that telemetry can be horrible for the patient experience” — an observation that cardiologists did not appreciate at first, Doorey noted.
In short: Christiana Care concluded that “more is not always better.” More monitoring and more spending do not necessarily translate into better patient outcomes. The health system needed to reconfigure its telemetry monitoring program to provide more effective, and more cost-effective, patient care.
Christiana Care formed an interdisciplinary team to examine the issue. The team — which included physicians, nurses, administrators, IT professionals, and others — established a goal of reducing the use of cardiac telemetry in non-ICU settings.
First, the team evaluated the current telemetry processes and reviewed data collected just prior to the team’s formation: Call logs from the Flexible Monitoring Center were analyzed to categorize the types of calls that were received and to estimate call volume. A time-motion study (a method for observing job tasks to improve work-process efficiency) was conducted to evaluate nursing time spent on telemetry activities. An analysis of the cost to deliver telemetry was performed, taking into account both the efforts of the Flexible Monitoring Center and the nursing time associated with telemetry activities.
Data from this evaluation showed that in this 1,100-bed system, 355 patients per day were receiving cardiac telemetry, each requiring an average of 20 minutes of nursing time to manage the administrative, equipment, and patient care needs associated with the technology. Nursing activities included reviewing telemetry strip results and orders, responding to telemetry alarms, adjusting leads, changing batteries, and accompanying some patients on transports off the patient care unit.
Significantly, the evaluation revealed that cardiac-arrhythmia-related emergencies accounted for less than 1 percent of the calls from the Flexible Monitoring Center to caregivers. The vast majority of the calls (70 percent) resulted from technical problems — specifically, lead or reception problems (60 percent) and battery-related issues (10 percent). The evaluation also estimated the cost of telemetry to be approximately $53 per 24 hours of patient monitoring.
Based on its analysis, the team developed three strategies to address factors that were identified as contributing to the overutilization:
Alignment with national guidelines for telemetry use.
Redesigning nursing processes.
Rethinking medication leveling policies.
The team at Christiana Care offered the following observations for project success:
The manner in which the nationally accepted professional society guidelines were adopted provided sufficient clinical flexibility so that physicians could order cardiac telemetry when they judged it was appropriate to do so, preserving physician autonomy and facilitating their acceptance of the change.
Obtaining buy-in was supported by the fact that the process changes enhanced nursing clinical decision making, reduced wasteful steps, and rectified clinical inconsistencies (e.g., those associated with the medication leveling policy).
“Hardwiring” a process change into an existing workflow proved to be an effective intervention for sustained change. (Education alone, by comparison, tends to be a weak intervention.)
Extensive communication with stakeholders is crucial to support change.
This article is excerpted from a digital story posted 1/4/15 on ECRI Institute’s membership website. The full article features additional background information, specific strategies for success, and details on lessons learned. Submissions are now being accepted to the 2015 Health Devices Achievement Award.
To learn more, visit www.ecri.org/Pages/Health-Devices-Award_Winners.aspx; or call (610) 825-6000; or e-mail firstname.lastname@example.org.
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