Decrease in Inpatient Telemetry Utilization Through a System-Wide Electronic Health Record Change and a Multifaceted Hospitalist Intervention
BACKGROUND: Unnecessary telemetry monitoring contributes to healthcare waste.
OBJECTIVE: To evaluate the impact of 2 interventions to reduce telemetry utilization.
DESIGN, SETTING, AND PATIENTS: A 2-group retrospective, observational pre- to postintervention study of 35,871 nonintensive care unit (ICU) patients admitted to 1 academic medical center.
INTERVENTION: On the hospitalist service, we implemented a telemetry reduction intervention including education, process change, routine feedback, and a financial incentive between January 2015 and June 2015. In July 2015, a system-wide change to the telemetry ordering process was introduced.
MEASUREMENTS: The primary outcome was telemetry utilization, measured as the percentage of daily room charges for telemetry. Secondary outcomes were mortality, escalation of care, code event rate, and appropriateness of telemetry utilization. Generalized linear models were used to evaluate changes in outcomes while adjusting for patient factors.
RESULTS: Among hospitalist service patients, telemetry utilization was reduced by 69% (95% confidence interval [CI], −72% to −64%; P < .001), whereas on other services the reduction was a less marked 22% (95% CI, −27% to −16%; P < .001). There were no significant increases in mortality, code event rates, or care escalation, and there was a trend toward improved utilization appropriateness.
CONCLUSION: Although electronic telemetry ordering changes can produce decreases in hospital-wide telemetry monitoring, a multifaceted intervention may lead to an even larger decline in utilization rates. Whether these changes are durable cannot be ascertained from our study.
© 2018 Society of Hospital Medicine
Wasteful care may account for between 21% and 34% of the United States’ $3.2 trillion in annual healthcare expenditures, making it a prime target for cost-saving initiatives.1,2 Telemetry is a target for value improvement strategies because telemetry is overutilized, rarely leads to a change in management, and has associated guidelines on appropriate use.3-10 Telemetry use has been a focus of the Joint Commission’s National Patient Safety Goals since 2014, and it is also a focus of the Society of Hospital Medicine’s Choosing Wisely® campaign.11-13
Previous initiatives have evaluated how changes to telemetry orders or education and feedback affect telemetry use. Few studies have compared a system-wide electronic health record (EHR) approach to a multifaceted intervention. In seeking to address this gap, we adapted published guidelines from the American Heart Association (AHA) and incorporated them into our EHR ordering process.3 Simultaneously, we implemented a multifaceted quality improvement initiative and compared this combined program’s effectiveness to that of the EHR approach alone.
METHODS
Study Design, Setting, and Population
We performed a 2-group observational pre- to postintervention study at University of Utah Health. Hospital encounters of patients 18 years and older who had at least 1 inpatient acute care, nonintensive care unit (ICU) room charge and an admission date between January 1, 2014, and July 31, 2016, were included. Patient encounters with missing encounter-level covariates, such as case mix index (CMI) or attending provider identification, were excluded. The Institutional Review Board classified this project as quality improvement and did not require review and oversight.
Intervention
On July 6, 2015, our Epic (Epic Systems Corporation, Madison, WI) EHR telemetry order was modified to discourage unnecessary telemetry monitoring. The new order required providers ordering telemetry to choose a clinical indication and select a duration for monitoring, after which the order would expire and require physician renewal or discontinuation. These were the only changes that occurred for nonhospitalist providers. The nonhospitalist group included all admitting providers who were not hospitalists. This group included neurology (6.98%); cardiology (8.13%); other medical specialties such as pulmonology, hematology, and oncology (21.30%); cardiothoracic surgery (3.72%); orthopedic surgery (14.84%); general surgery (11.11%); neurosurgery (11.07%); and other surgical specialties, including urology, transplant, vascular surgery, and plastics (16.68%).
Between January 2015 and June 2015, we implemented a multicomponent program among our hospitalist service. The hospitalist service is composed of 4 teams with internal medicine residents and 2 teams with advanced practice providers, all staffed by academic hospitalists. Our program was composed of 5 elements, all of which were made before the hospital-wide changes to electronic telemetry orders and maintained throughout the study period, as follows: (1) a single provider education session reviewing available evidence (eg, AHA guidelines, Choosing Wisely® campaign), (2) removal of the telemetry order from hospitalist admission order set on March 23, 2015, (3) inclusion of telemetry discussion in the hospitalist group’s daily “Rounding Checklist,”14 (4) monthly feedback provided as part of hospitalist group meetings, and (5) a financial incentive, awarded to the division (no individual provider payment) if performance targets were met. See supplementary Appendix (“Implementation Manual”) for further details.
Data Source
We obtained data on patient age, gender, Medicare Severity-Diagnosis Related Group, Charlson comorbidity index (CCI), CMI, admitting unit, attending physician, admission and discharge dates, length of stay (LOS), 30-day readmission, bed charge (telemetry or nontelemetry), ICU stay, and inpatient mortality from the enterprise data warehouse. Telemetry days were determined through room billing charges, which are assigned based on the presence or absence of an active telemetry order at midnight. Code events came from a log kept by the hospital telephone operator, who is responsible for sending out all calls to the code team. Code event data were available starting July 19, 2014.
