Q: Should cardiac monitoring be routinely ordered for non-ICU in-patients with concern for clinical deterioration to provide early indication of worsening status?
The Bottom Line: Cardiac monitoring is indicated for specific patient populations at high risk for life-threatening arrhythmias and should not be used in place of or as an adjunct to close clinical observation.
Context: Telemetry is often used on patients who do not fit criteria for appropriate use. Limited telemetry beds contribute to increased ED boarding times for admitted patients1. Telemetry monitoring has high false positive rates that result in unnecessary downstream tests and a high incidence of medical staff alarm fatigue2. Monitors also limit patient movement, cause patients and families to focus on the monitor and create significant hospital costs when patients leave with them.
The Data: A retrospective analysis was performed of 562 patients admitted to a telemetry unit. A total of 1932 monitoring days were evaluated. Using institutionally derived guidelines in part based on ACC/AHA consensus criteria, patients were divided into: “telemetry indicated” and “telemetry not indicated.” In the “telemetry indicated” group, 34% had a total of 336 arrhythmic events. In contrast, in the “telemetry not indicated” group, only 11% had a total of 53 events (P < 0.001). None of the patients in “telemetry not indicated” group had a clinically significant arrhythmia (P < 0.05)3.
Another prospective study was performed of 2,240 patients admitted to a telemetry unit over 7 months. Telemetry led to direct modifications in management in 156 patients (7%; 95% confidence interval [CI] 5.9% to 8%). Telemetry was perceived as useful but did not alter management for 127 patients (5.7%; 95% CI 4.7% to 6.6%). There were 20 deaths in the telemetry unit (0.9%; 95% CI 0.5% to 1.3%): 4 of the 20 deaths (i.e 20%) occurred while patients were being monitored. This study suggests the role of telemetry may be overestimated by physicians4.
In a separate study, the cost of telemetry monitoring in a non-ICU setting averaged at $41, 690 for 379 telemetry days5. More recent estimates have put this cost at $1400 per patient per 24 hours of telemetry6.
Conclusion: Telemetry monitoring is useful in patients with clear indications and who have a high risk of arrhythmia. It is often overused due to inappropriate initiation in low risk patients and continuation of monitoring beyond recommended duration of benefit. This monitoring is costly, can lead to unnecessary testing and can affect the patient experience.
The ACC/AHA practice standards based on expert consensus (not randomized control trials) recommends cardiac monitoring for ischemia, QT interval, Class I, and some Class II patients8. It is not indicated in Class III patients:
- Class I: at risk of an immediate, life-threatening arrhythmia—typically ICU appropriate patients (i.e. patients in the first 48 hours of ACS or with high grade lesions awaiting intervention, acute heart failure, 2nd and 3rd degree AV block, temporary pacing, long QT syndrome, WPW with rapid anterograde conduction, IABP, post cardiac arrest, post cardiac surgery, post-PCI or ablation with complication, post pacemaker placement with pacemaker dependence and conscious sedation.
- Class II: individuals presenting with chest pain syndromes, syncope, known arrhythmia with active arrhythmia medication titration, heart failure, post-PCI, post-ablation or post-pacemaker placement without complications.
- Class III: includes rate-controlled atrial fibrillation, chronic PVCs, ESRD on HD and low risk post-surgical patients.
- J Emerg Med 2007; 33(1): 53–60. PMID: 17630076
- Am J Emerg Med. 2006 Jan;24(1):62-7 PMID: 16338512
- J Cardiol Res 2012;3(1):16-22 doi:10.4021/cr129w
- Am J Cardiol 1995;76:960-965 PMID: 7484840
- Clin. Cardiol. 1998; 21, 503-505 PMID: 9669059
- CCJM 2009 6;76(6):368-372 PMID: 19487558
- Circulation 2004; 110:2721–2746. PMID: 15505110
Written by Sabra Lewsy, MD for the: High Value Care Committee