Brief ReportElectrocardiographic monitoring in the hospitalized patient: a diagnostic intervention of uncertain clinical impact
Introduction
Many patients admitted to the hospital with cardiorespiratory and other acute syndromes are placed on electrocardiographic monitoring. Such electrocardiographic surveillance theoretically allows the clinical staff to monitor admitted patients for the development of dysrhythmia, both brady- and tachydysrhythmia—in essence, identify patient decompensation and/or clinical deterioration as it occurs rather than after the event. Electrocardiographic monitoring, also known as telemetry monitoring or cardiac monitoring, focuses on the detection of clinically significant dysrhythmia, rather than the diagnosis of acute coronary syndrome (ACS) or acute pulmonary edema.
Although electrocardiographic monitoring (ECGM) has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur. The impact of this inappropriate use increases the cost of healthcare and can delay the admission process, an unpleasant burden which the hospital and its patients must bear. In addition, the liberal use of monitoring in unnecessary situations may give the hospital staff a false sense of security and/or desensitize them to alarms [1], [2]. In many instances, electrocardiographic monitoring may not be necessary. This article will review the literature regarding inpatient telemetry and its impact; furthermore, we will suggest high-yield criteria for its application among the inpatient population.
Section snippets
Current state of practice: electrocardiographic monitoring
Currently, practitioners use electrocardiographic monitoring for patients admitted with various cardiovascular ailments as well as a range of other clinical entities, including neurologic, respiratory, traumatic, metabolic, and toxicologic syndromes. Furthermore, among these various syndromes, the degree of clinical risk varies from significant to negligible. As noted, electrocardiographic monitoring targets the patient at risk for the development of clinically significant dysrhythmia.
Limited utility of electrocardiographic monitoring for low-risk patients
Currently, the typical practice in most North American hospitals is widespread application of ECGM for patients admitted for the management of chest pain, dysrhythmia, syncope, ingestion, etc. And yet numerous studies have been performed which demonstrate the limited utility of such monitoring for these admitted patients, many of whom do not meet intermediate- or high-risk criteria. For instance, a prospective cohort study completed by Hollander et al [10] found that dysrhythmias requiring
Risk stratification and electrocardiographic monitoring patient selection
Although it is reasonably well established that electrocardiographic monitoring is not particularly useful for low-risk patients, an easily applied identification method which could be used in the ED does not yet exist. Over the past several decades, a number of chest pain risk stratification protocols have been independently developed for this purpose. In 1991, the American College of Cardiology (ACC) published a policy statement regarding recommendations for ECGM [15]. These guidelines broke
Empirically validated risk stratification protocols
Goldman et al [18] have developed the most widely studied risk stratification protocols thus far, examining more than 15 000 patients in one study alone. The Goldman criteria risk stratifies patients with chest pain suspected of ACS into high-, moderate-, low-, and very low risk categories based on 5 variables. The factors associated with an increased risk are 12-lead ECG suggestive of AMI (ST-segment elevation or Q waves), 12-lead ECG suggestive of acute ischemia (ST-segment depression or
Assessment of physician triage decisions
Several researchers have compared the admission decisions made by physicians to those of risk stratification protocols. One was a prospective cohort study completed by Selker et al [25] which analyzed 10 689 patients presenting to the ED at 10 different hospitals with symptoms suggestive of ACS, with 5951 functioning as controls while 4738 comprised the group. The model used is known as the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI), which predicted the probability
Risk stratification of the blunt chest trauma patient
In a different application of electrocardiographic monitoring for the admitted patient, Nagy et al [28] reviewed the presentations of patients with blunt trauma requiring inpatient telemetry—basically, the rule-out myocardial contusion process; patients were separated into low- and high-risk categories. High-risk patients were defined as age of 55 years, ST-segment changes, arrhythmias, hemodynamic instability, requirement for general anesthesia within 24 hours of presentation, or a past
Overcrowding
Although the “pathophysiology” of ED overcrowding is multifactorial, many authorities note a lack of inpatient bed space, especially ICU and ECGM beds, as a major contributor to the problem [29]. In a survey of 575 ED directors, “hospital bed shortage” was identified as the second most significant reason for ED overcrowding [30]. During the course of the study conducted by Durairaj et al [19], an average of 3 patients a day were denied admission to the cardiac monitoring ward owing to a lack of
Conclusion
Although electrocardiographic monitoring is undoubtedly useful for certain high-risk patients, it is also quite clear that the opposite can be stated regarding the low-risk patient. In fact, simple recognition of the low-risk patient would substantially reduce unnecessary electrocardiographic monitoring (Table 1). Certainly, the overuse of cardiac telemetry monitoring has considerable untoward consequences.
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