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Trim Expensive ECG Overuse with EHR Order Sets

By Christopher Cheney  
   April 02, 2019

Inappropriate electrocardiographic monitoring results in wasteful spending and decreased quality of care.

Following practice standards through an electronic order set boosts the appropriate use of electrocardiographic monitoring without increasing adverse events, recent research shows.

Earlier research demonstrated that inappropriate use of cardiac telemetry results in significant wasteful spending. Over monitoring has also been associated with quality and safety concerns such as clinician alarm fatigue.

In findings published this month in the American Journal of Critical Care, researchers conclude that ECG monitoring should only be used in situations specified under American Heart Association (AHA) guidelines.

"ECG monitoring should be restricted to patients who might benefit from it and should be discouraged in patients at low risk for arrhythmias that require treatment. ECG monitoring is often not ordered for a specific clinical concern, but instead is used as an extra patient-safety mechanism or as a substitute for frequent monitoring of vital signs," the AJCC researchers wrote.

The research was based on data collected from nearly 300 patients hospitalized in medical, surgical, neurological, oncological, and orthopedic care units. Order sets based on the AHA guidelines were placed into the hospital's electronic health record and education about appropriate use of telemetry was offered to hospitalists and medical residents.

The intervention resulted in an increase of appropriate ECG monitoring from 48.0% to 61.2%, with no significant increase in adverse patient events. Medical residents received the most education on appropriate ECG monitoring, and they showed higher adherence to practice standards compared to hospitalists, increasing their appropriate use of telemetry monitoring from 30.8% to 76.5%.

"Use of electronic order sets is an effective and safe way to enhance appropriate electrocardiographic monitoring," the researchers wrote.

The lead author of the AJCC research told HealthLeaders there are five primary considerations when implementing ECG electronic order sets.

1. Gathering the right team

"Involve end-users of the order set, including staff nurses, hospitalists, intensivists, and cardiologists. As the results of our study demonstrated, education is an important component of the practice change, so it's important to have a team member with knowledge and skill in education," said Kristin Sandau, PhD, RN, professor of nursing at Bethel University in St. Paul, Minnesota, and staff nurse, at United Hospital, Allina Health, St. Paul.

"Clinical nurse specialists are a critical part of the team as they bring not only clinical expertise in the content area but also skills and knowledge of practice changes at the nurse and system levels. The experts from our informational technology team included a nurse who is a key member of our EHR staff," she said.

2. Setting baseline metrics

"Allow adequate time to prepare and obtain baseline measures. Preparation time should include pilot-testing at a small site and revising. What are the best feasible ways for you to measure pre- and post-implementation outcomes? This can be challenging because some outcomes are very difficult to measure, such as wait times for an ICU, ED, or telemetry bed," Sandau said.

3. Embedding leadership

"Be sure to have physician and nurse champions who are ready to receive both positive and constructive feedback as the team works to make technology an asset rather than burden to busy clinicians. You should expect that adjustments and tweaks will be ongoing as you face new challenges," she said.

4. Impacting staff members

"It is critical that you consider scope of practice and direct impact on clinicians. Other sites have implemented practice standards in the EHR that require the staff nurse to answer a series of questions about a patient then make a choice to discontinue telemetry based on a set of parameters. We made a dedicated effort at our site to avoid putting the responsibility on the staff nurse," Sandau said.

Sandau's team assigned responsibility for discontinuing ECG monitoring to clinicians. "We've built prompts for nurses and prescribers to share, but we felt it was ultimately the responsibility of the prescriber to discontinue telemetry."

5. Sharing the implementation experience

"By sharing what works and what was not as helpful, we can help smooth implementation for others and shorten the time it takes for research to be integrated into day-to-day practice," she said.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Establishing telemetry monitoring practice standards in a hospital's EHR increased appropriate monitoring by 13.2 percentage points.

Educating clinicians about appropriate telemetry monitoring results in significant reductions in inappropriate monitoring.

The keys to successful implementation of electronic order sets for telemetry monitoring include gathering the right team and setting baseline measures.

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