Best clinical practiceWhen Do Patients Need Admission to a Telemetry Bed?
Introduction
Historically, inpatient electrocardiographic (ECG) monitoring was simply used to track patient heart rate and underlying rhythm. More recently, telemetry has evolved into technological marvels that can detect complex dysrhythmias, myocardial ischemia, and prolonged QT intervals (1). However, because ischemia monitoring is absent or underutilized in many hospitals and evidence for QT interval monitoring is inconsistent, monitored, non-intensive care units are most often utilized for detecting life-threatening dysrhythmias and sudden death (1). Moreover, they are used for patients who might require frequent nursing care and monitoring, such as the demented elderly patient admitted for pneumonia or the patient requiring transfusion for gastrointestinal bleeding (Table 1) (2). When physicians do not systematically apply rigorous criteria for inpatient telemetry admissions, monitored beds quickly become unavailable and admitted patients are forced to wait in the Emergency Department (ED), contributing to ED overcrowding.
To establish some consistent criteria for telemetry admissions, the American Heart Association (AHA) published its comprehensive practice guidelines for ECG monitoring (1). These guidelines make specific recommendations for monitoring patients in telemetry units, based on available evidence or expert consensus opinion, and are especially useful when requests for telemetry beds overwhelm a hospital’s monitoring capacity (e.g., the number of available ECG monitors, skilled medical personnel to interpret the ECG data). When 70% of the top 10 diseases admitted through the ED (Table 2) are clinically indicated for inpatient telemetry, hospitals with limited resources may easily be overwhelmed (3).
This article, therefore, examines the evidence behind admitting patients with common diagnoses to non-intensive care telemetry units. Although the AHA guidelines are comprehensive, they do not address several non-cardiac conditions that clinicians might often monitor on telemetry. Our discussion focuses on issues facing the practicing emergency physician from a very simple perspective: can this patient safely walk around the shopping mall without being monitored? If a patient’s admission diagnosis and treatment plan do not increase his/her dysrhythmia risk above the general population (i.e., people walking around the mall), then he/she should not require telemetry monitoring simply because he/she is now in the hospital. For example, a patient with an implantable defibrillator who is admitted for cellulitis is not at a higher risk of a dysrhythmia than they were while they were shopping last week. Therefore, the mere presence of the defibrillator should not result in mandatory use of an unnecessary resource (telemetry). The placement of a patient in an available telemetry bed today might mean that another patient that may truly need a monitored bed tomorrow will be forced to spend an additional night in the ED. Telemetry beds should be used when indicated and not simply because they are available.
Section snippets
Patients whose Automatic Defibrillator has Fired
Implantable cardioverter-defibrillators (ICDs)/permanent pacemakers are often placed in patients with structural heart disease or ventricular arrhythmias to prevent sudden cardiac death (4). Early complications are typically procedure related, whereas generator (6%) or lead (12%) complications and inappropriate shocks (12–16%) may develop at any time (5, 6). The most common reasons for hospital re-admission are ventricular arrhythmias (61%) and progressive heart failure (13%) (6). Patients
Patients Evaluated for Syncope
Syncope patients with underlying cardiovascular disease, particularly congestive heart failure, have a poorer prognosis than patients without underlying cardiac disease or patients with unexplained syncope (31). One risk stratification study determined that the risk factors associated with clinically significant cardiac arrhythmias or death within 1 year include age over 45 years, abnormal ECG, history of heart failure, and history of ventricular arrhythmias. The incidence of arrhythmias is
Patients Requiring Blood Transfusion
Stable patients with acute or chronic anemia requiring blood transfusion do not benefit from cardiac monitoring. Life-threatening arrhythmias have been reported in patients who are transfused their entire blood volume from citrate toxicity, causing significant electrolyte abnormalities, particularly hypocalcemia (29, 30). For most patients, the most common reaction—a febrile non-hemolytic transfusion reaction (1–5%), often manifested by fever, chills, and urticaria—is not detected by cardiac
Conclusion
Consensus guidelines have established criteria for a subset of patients who require inpatient continuous electrocardiographic monitoring, based on evidence and expert opinion. When physicians do not systematically apply these criteria for telemetry admissions, those resources can be easily overwhelmed. Based on the available literature, we categorized several common medical conditions based on their proarrhythmic risk to determine the benefit of inpatient monitoring.
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Cited by (41)
Telemetry Bed Usage for Patients with Low-Risk Chest Pain: An Updated Review of the Literature for the Clinician
2021, Journal of Emergency MedicineLessons Learned from Efforts to Reduce Overuse of Cardiac Telemetry Monitoring
2020, Joint Commission Journal on Quality and Patient SafetyTelemetry Monitoring: Indications and Strategies to Reduce Overuse
2017, Hospital Medicine ClinicsCitation Excerpt :Gastrointestinal bleed: not indicated, except in cirrhotic patients with variceal hemorrhage who may benefit from telemetry, especially in the context of electrolyte abnormalities19 Blood transfusion: unnecessary, unless expecting to transfuse more than 10 units of blood in a 24-period19 Seizures: the subject has never been studied in such patients.
Life-threatening ventricular tachyarrhythmias in the cardiology department: Implications for appropriate prescription of telemetry monitoring
2016, ResuscitationCitation Excerpt :Ventricular arrhythmias used to be the most common causes of in-hospital death in patients admitted for acute myocardial infarction until the introduction of cardiac telemetry monitoring, which is now routinely utilized in all patients with acute coronary syndrome.3 However, there are several other categories of cardiovascular patients that may be at risk of LT-VA during hospitalization and continuous ECG monitoring is prescribed in a variety of clinical scenarios other than acute coronary syndromes.1,4 Although it can be life-saving,5,6 the cost/benefit of telemetry monitoring outside the intensive care unit setting is a matter of debate.7–9
Non-critical care telemetry and in-hospital cardiac arrest outcomes
2015, Journal of ElectrocardiologyCitation Excerpt :Cardiac monitoring was first introduced for critically ill patients, but today it is increasingly used to monitor patients, often remotely via telemetry, in the general inpatient setting. The AHA and ACC/ECCC have both published guidelines listing diagnostic indications for when cardiac monitoring is appropriate and indicated [1,2], but these guidelines are generally ignored [3,4], and do not reflect the current trends of increased telemetry monitoring in non-critical patients [5]. The impact of telemetry in non-critical patients is controversial.
Telemetry bed usage for patients with low-risk chest pain: Review of the literature for the clinician
2014, Journal of Emergency MedicineCitation Excerpt :Telemetry monitoring in patients with low-risk chest pain is highly utilized despite the lack of quality data to support its use. In fact, it rarely detects clinically meaningful dysrhythmias, may lead to unnecessary tests and procedures, is expensive, and significantly increases ED boarding due to patients awaiting inpatient telemetry beds (3,4). The 2004 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for inpatient telemetry monitoring provide screening recommendations for dysrhythmias, ischemia, and QT-interval abnormalities in adults and children (5).