The Dos and Don'ts of Telemetry Monitoring: A Telemetry Director's Top 10 Misuses, Explained

Feature |
July 6, 2017

The Dos and Don'ts of Telemetry Monitoring: A Telemetry Director's Top 10 Misuses, Explained

  1. Neil H. Winawer, MD, SFHM

Dr. Neil Winawer, NEJM Journal Watch Hospital Medicine Editor-in-Chief, describes 10 scenarios for which telemetry is inappropriate.

  1. Neil H. Winawer, MD, SFHM

The American Heart Association (AHA) guidelines, which are based on expert opinion, recommend telemetry monitoring for active cardiac conditions.1 The Choosing Wisely campaign has adopted these guidelines to optimize telemetry use outside the intensive care unit (ICU), because inappropriate use can affect patient care adversely and increases costs. However, we have little evidence to guide us about which patients actually need such monitoring or for how long. Doctors often make these decisions based on personal preferences and request telemetry for low-risk patients who do not benefit.2

In 2000, Grady Memorial Hospital — a large public teaching hospital — created the Telemetry Urgent Matters Initiative to establish criteria (in conjunction with the cardiology service) for use of telemetry beds and to empower a director (this author) to apply these criteria and streamline the transfer process. The result was a dramatic improvement in the number of patients transferred off telemetry (25 vs. 75 weekly, after applying telemetry criteria) with no adverse events reported.3,4

Cardiac monitoring is used for non-AHA guideline indications commonly. During the past 17 years, I have observed that expanding telemetry criteria to patients without active cardiac conditions increases the number of false alarms, consumes resources, and does not lead to better care.5,6 My anecdotal top 10 inappropriate telemetry indications are:

  1. End-Stage Renal Disease (ESRD): Patients with ESRD often have elevated serum potassium levels. If serum potassium is lower than 6.0 mEq/L with no electrocardiogram (ECG) changes, these patients can be managed without cardiac monitoring. Similarly, patients with hypokalemia with values higher than 2.5 mEq/L without ECG changes do not require monitoring.

  2. Sinus Tachycardia: Often patients are admitted with tachycardia related to symptomatic anemia or pain (e.g., sickle cell pain crisis, trauma). In these patients, telemetry should not be used as a proxy for closer monitoring. If the patient is hemodynamically unstable, he or she should be managed in a step-down unit or ICU.

  3. Low-Risk Chest Pain: Patients for whom myocardial infarction is ruled out by negative troponin results often remain in the hospital to undergo noninvasive cardiac stress testing. These patients do not require cardiac monitoring.

  4. Pulmonary Embolism (PE): No established recommendations exist for placing patients with pulmonary embolism (PE) on telemetry, and most do not require it. However, non-ICU patients with elevated cardiac biomarkers or echocardiographic evidence of right ventricular dysfunction (submassive PE) have excess risk for mortality and might benefit from telemetry monitoring.

  5. Chronic Heart Failure: Although acute decompensated heart failure is an AHA class I indication for cardiac monitoring, patients often present nonemergently after weeks of dyspnea and fluid overload caused by running out of cardiac medications or engaging in dietary indiscretion. If no ischemic, valvular, or arrhythmogenic precipitant is suspected, such patients can undergo diuresis without telemetry if serum electrolytes are normal.

  6. Syncope from Noncardiac Causes: Often patients are “found down” due to events such as seizure or hypoglycemia but are admitted as “syncope” patients. Such patients do not require telemetry monitoring. If the precipitant of consciousness loss is unclear but presumed benign (e.g., neurocardiogenic, micturition induced), patients can be evaluated on telemetry for 24 hours. Syncope from presumed cardiac causes should be monitored pending further evaluation.

  7. Atrial Fibrillation Without Rapid Ventricular Response: Atrial fibrillation without tachycardia or symptoms does not require telemetry monitoring.

  8. Asymptomatic Do-Not-Resuscitate (DNR) Orders: Patients who are not candidates for treating ventricular arrhythmias should not be managed on telemetry; however, telemetry is appropriate when symptom palliation is necessary (e.g., rate control in symptomatic supraventricular arrhythmias).

  9. The “Step-Down, Step Down”: Sometimes, when noncardiac patients are stable enough for transfer out of the ICU or step-down unit, clinicians order telemetry as a proxy for closer monitoring. Given the absence of a cardiac condition, no indications exist for telemetry in these patients, and no evidence shows that telemetry improves outcomes.

  10. Mild-to-Moderate Alcohol Withdrawal: Patients in alcohol withdrawal who are delirious or unstable typically go to a step-down unit or ICU for closer monitoring and administration of an alcohol withdrawal protocol. More-stable patients occasionally are admitted to observation, and telemetry monitoring is not indicated.

Editor Disclosures at Time of Publication

  • Disclosures for Neil H. Winawer, MD, SFHM at time of publication Equity Synthetic Biologics Editorial boards ACP Hospitalist (Board Member)

Citation(s):

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