Best clinical practice
When Do Patients Need Admission to a Telemetry Bed?

https://doi.org/10.1016/j.jemermed.2007.01.017Get rights and content

Abstract

Non-intensive telemetry units are utilized for monitoring patients at risk for life-threatening dysrhythmias and sudden death. Physicians often use monitored beds for patients who might only require frequent nursing care. When 70% of the top 10 diseases admitted through the emergency department (ED) are clinically indicated for telemetry, hospitals with limited resources will be overwhelmed and admitted patients will be forced to wait in the ED. We examine the evidence behind admitting patients to telemetry. There is evidence for monitoring in patients admitted for implantable cardioverter-defibrillator firing, type II and complete atrio-ventricular block, prolonged QT interval with ventricular arrhythmia, decompensated heart failure, acute cerebrovascular event, acute coronary syndrome, and massive blood transfusion. Monitoring is beneficial for selected patients with syncope, gastrointestinal hemorrhage, atrial tachyarrhythmias, and uncorrected electrolyte abnormalities. Finally, telemetry is not indicated for patients requiring minor blood transfusion, low risk chest pain patients with normal electrocardiography, and stable patients receiving anticoagulation for pulmonary embolism.

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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