Subacute Care and Continuous Cardiac Monitoring Peggy Beeley,
MD June 7th, 2010
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Objectives Understand Current Availability & Utilization of
Cardiac Telemetry at UH Understand Current Availability &
Utilization of Subacute care at UH Review the literature for
utility of Cardiac Telemetry in non-cardiac patients Develop
consensus for better utilization of SAC and Telemetry
resources
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Reasons to Look at Utilization of SAC/Cardiac Telemetry
Expensive Affects ED throughput, ICU availability Continuous
Cardiac Monitoring infrequently influences management decisions May
lead to unnecessary testing and concern Decreases mobility, making
VTE complications more likely
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Definitions Acute Care Intermediate Care or Subacute Care
Nursing interventions at least every 2-4 hours Post surgery or
procedure requiring monitoring at least every 2-4 hours Continuous
cardiac monitoring Telemetry cardiac monitoring {Hemodynamically
stable patients with extended ventilator weaning, or chronic
ventilation} Intensive Care
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Our Resources Total Adult Bed Census 296 72 Adult ICU beds
Includes MICU, TSICU, NICU 136 SAC beds 7S, 6S, 5S, 4E, 4W, 3S, 3E
88 Med Surg 5S, 5W, 5E, 4S, 3N Patients waiting for beds vary but
SAC #s persistently higher than floor level care
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Questions to the Group How do you decide on SAC vs. Floor
status? How do you decide on whether you will use cardiac
monitoring? How often do you reassess the need for current level of
care or telemetry?
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Subacute or Intermediate Care Currently, a subjective process
No UH Protocol currently, although these were in development in the
past Individual Floors have Unit Operational Plans that include the
types of patient and services they can accommodate
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Utilization Review UH uses a tool accepted by CMS and other
organizations Please see your handout page 1,2 Includes criteria
for Intermediate Care Complicated list: Severity of illness (at
least one) Intensity of Service (major criteria or 3 minor
criteria) If patient doesnt meet criteria, then should be changed
to a lower level of care
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Criteria for Intermediate Care Common examples Cardiac Patients
Acute MI 24 hrs, r/o MI Starting anti-arrhythmics Post critical
care, CABG Non-cardiac Patients Insulin/Dextrose gtts Severe Sepsis
EtOH withdrawl requiring high Dose CAGE protocol Severe Electrolyte
disturbances
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Cardiac Monitoring Usually requires SAC level of Care Subset of
SAC care Continuous Cardiac Monitoring (CCM) Telemetry is CCM Most
CCM at UH is not telemetry
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Available Types of Monitors 1.Centralized Cardiac Monitoring
2.Cardiac ambulatory telemetry 3.Portable Cardiac Monitoring
4.Oxinet 5.Capnography 6.Frequent Vitals, pulse oximetry
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UNM Continuous Cardiac Monitoring (CCM) Centralized Monitor
room 2 techs for ~ 100 monitors 7S Monitor Tech 20 rooms, including
telemetry Monitoring at nurses stations ED Obs ED Main ICUs
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Cardiac Telemetry Centralized Monitoring 1.Centralized
Monitoring Room is located on 3 North 2. Two trained monitor Techs
(Basic Arrhythmia and annual Arrhythmia Competency exam) 3. Monitor
80-90 patients at all times. 4. Max # is 90, we are at capacity
most of the time. 126 adult SAC beds are monitor beds. Individual
Units 4West- 36 beds, monitor 36, 0 tele portable monitors 4 East -
20 Beds, monitor 20, 2 tele portable monitors 3 South-16 Beds,
monitor 16, 0 tele portable monitors 5 East-16 beds, monitor 8, 1
tele portable monitor 5 South- 31 beds, monitor 14, 2 tele portable
monitors 6 South- 20 beds, monitor 20, 0 tele pacs/ 2 portable
monitors 3 East- 10 beds, monitor 10
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Guidelines American Heart Association American College of
Cardiology Expert Opinion Addresses primarily Cardiac Conditions
See pages 3 & 4 for Classes 1-3
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Class I Cardiac monitoring is indicated in nearly all patients
Early phase of ACS, including rule-out MI Postop cardiac surgery
After resuscitation from cardiac arrest Intensive Care patients
Poisoning w drugs/chemicals cardiac arrhythmic toxicity During
initiation and loading of typeI or III antiarrhythmic drugs
Immediate after percutaneous transluminal coronary angioplasty w
complications
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Class I, cont Cardiac monitoring is indicated in nearly all
patients High-risk coronary artery lesions who are candidates for
urgent mechanical revascularization Temp pacemaker or
transcutaneous pacing pads Pt who have undergone implantation of
automatic defibrillator lead or pacemaker lead and are pacemaker
dependent
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Class I, cont Cardiac monitoring is indicated in nearly all
patients Mobitz type II or greater atrioventricular block, adv 2 nd
degree AV block, complete heart block or new onset left bundle
branch block in the setting of acute MI Acute heart failure,
pulmonary edema or intra- aortic balloon counterpulsion Procedures
requiring conscious sedation or anesthesia Prolonged QT syndrome w
associated ventricular arrhythmias or HD instability
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Class II Some patients may benefit > 3 days after acute MI
Chest pain syndromes Pt with hx of potentially lethal arrhythmia,
several days after control of arrhythmia At risk of cardiac arrest,
respiratory arrest or development of hypotension Adjustment of
drugs for rate control w chronic atrial tachycardias Suspected or
proven hemodynamically significant paroxysmal tachy or brady
arrhythmias
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Class II, cont Some patients may benefit Subacute heart failure
or in acute phase of pericarditis Unexplained syncope or TIA thigh
might be due to arrhythmias After uncomplicated coronary
angioplasty or ablation of arrhythmia Pacer implanted w/I 48-72 hr
who are not pacer depend Post cardiac surgery even if stable DNR w
symptomatic arrhythmia
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Class III not indicated After low risk surgery During labor and
delivery (if no significant medical problems exist) Terminal
illness who are not candidates for Rx of arrhythmias Chronic stable
atrial fibrillation With stable asymp PVCs or Non-sustained V tach
who are not hospitalized for cardiac or HD compromise Underlying
cardiac disease that are stable w/o arrhythmias on 3 consecutive
days of monitoring.
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Experiences in Improving Utilization Jackson Memorial Hospital
Miami: 1,600 bed tertiary care Telemetry Utilization Review project
Evaluate whether pts currently on tele still needed it Evaluate
length of time pts remained on tele Improve emergency departments
throughput Evaluate the potential need for additional tele beds
Subharwal, et al
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Most Commonly Misused Telemetry Diagnoses GI bleeding 16%
Malignancy 8% Sepsis/Bacteremia w/o Septic Shock 8% ARF or ESRD w
normal lytes 8% Sickle cell crisis 7% DVT or PE w/o HD compromise
7% COPD/Asthma/OSA 6% EtOH abuse or withdrawl 6% Pneumonia 6%
Cirrhosis/hepatitis/cholelithiasis 6% AMS, uncontrolled DM, UTI, Fx
or wound infection, Pancreatitis, dehydration comprised the other
25% Audit of 753 charts at Jackon Memorial Hospital in Miami. When
audited: 50% of 650 patients were found to not need or no longer
need telemetry. Diagnoses at right were common. Sabharwal, et. Al
Subharwal, et al
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Clinical Need Developed auditing tool using Guidelines by
American College of Cardiology Of 651 telemetry patients reviewed
54% no longer met criteria 18% did meet any criteria since
admission Telemetry Authorization Form 6 month followup Charge
nurses validated need Monitored bed use decreased by 60 %
Subharwal, et al
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Similar quality improvement programs Hackensack University
reduced use by 34% w authorization form Portland Veterans Med
Center incorporated stop times
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CCM & cardiac arrest outcomes Review of 5 yrs of telemetry
admissions 8,932 pt were admitted to telemetry unit 20 suffered
cardiac arrest Two of three of survivors had significant
arrhythmias detected on tele before arrest Monitor-signaled
survival rate was 0.02% Conclusion: Routine telemetry offers little
cardiac arrest survival benefit Schull, et al
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Does CCM alter medical management? Estrada, et al (Henry Ford,
Detroit) 1994 467 patients admitted to telemetry based on ACC
guidelines Only 1 % of cases had ICU transfer based on tele
findings Majority of pts who deteriorated were identified
clinically
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Does CCM alter medical management? Estrada, et al (Henry Ford,
Detroit) 1995 Data collected from 2,240 pts admitted to tele for
chest pain, arrhythmias, heart failure, & syncope Outcomes ICU
transfer and mortality Telemetry was helpful in modifications of
management in only 7% 0.8% of all admission to tele were
transferred to ICU because of telemetry findings
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Telemetry in the Elderly Looked pts admitted for Chest Pain
with low risk for a coronary event during hospitalization Excluded
pts w ACS per ECG or cardiac markers Of the 105: about half had
HTN, DM, elev lipids, smoking and prior CAD Telemetry did not show
significant arrhythmia or lead to management changes in any pts
Tele did not influence inpt mortality or 5 yr survival Saleem, et
al
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Monitoring in Low Risk Acute Chest Pain Syndrome 414
consecutively admitted for suspected ACS Outcomes: MI, new or rapid
atrial arrhythmias, vent arrhythmias, AV nodal block and asystole
Intervention change in dose of medication, cardioversion, EP study
or Txn to ICU Results: Patient w atypical chest pain, normal ECG
findings are sign less likely to have arrhythmias 8% Snider, et
al
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Artifact Evaluation of monomorphic or polymorphic V tachycardia
in 12 patients Cardiac cath (3), Intravenous lidocaine in 7, IV NTG
in 1 and SL nitro in 1 2 patients were given a precordial thumb
that was interpreted as a successful cardioversion 1 had
implantable defibrillator for torsades Knight, et al
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Summary Need for Intermediate Care should be carefully
considered. More options available, such as oxynet Continuous
Cardiac Monitoring should not be a reflex action for non-cardiac
pts who may still need increased intensity of service. Studies
suggest overuse Telemetry infrequently leads to management changes
May cause harm when misinterpreted. Increases physician phone calls
for telemetry artifact or non-sustained Vtach Leads to increased
fall risk, VTE
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Recommendations Evaluate current use of Cardiac monitoring and
intermediate care at UH Develop guidelines for use based on other
institutions protocols Educate staff, providers, physicians on
accepted uses of Cardiac monitoring and intermediate care.
Encourage more thoughtful analysis of the use of these
resources