0 subacute care and continuous cardiac monitoring
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Subacute Care andContinuous Cardiac
Monitoring
Peggy Beeley, MDJune 7th, 2010
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Objectives Understand Current Availability &
Utilization of Cardiac Telemetry at UH
Understand Current Availability &Utilization of Subacute care at UH
Review the literature for utility ofCardiac Telemetry in non-cardiacpatients
Develop consensus for betterutilization of SAC and Telemetr
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Definitions
Acute Care Intermediate Care or Subacute Care
Nursing interventions at least every 2-4
hours
Post surgery or procedure requiringmonitoring at least every 2-4 hours
Continuous cardiac monitoringTelemetry cardiac monitoring
{Hemodynamically stable patients with
extended ventilator weaning, or chronic
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Our Resources
Total Adult Bed Census 296
72 Adult ICU beds
Includes MICU, TSICU, NICU 136 SAC beds
7S, 6S, 5S, 4E, 4W, 3S, 3E
88 Med Surg
5S, 5W, 5E, 4S, 3N
Patients waiting for beds vary but
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Questions to the Group
How do you decide on SAC vs.Floor status?
How do you decide on whetheryou will use cardiac monitoring?
How often do you reassess the
need for current level of care ortelemetry?
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Subacute or Intermediate
Care Currently, a subjective process
No UH Protocol currently,although these were indevelopment in the past
Individual Floors have UnitOperational Plans that include thetypes of patient and services they
can accommodate
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Criteria for IntermediateCare
Common examples Cardiac Patients
Acute MI 24 hrs, r/o MI
Starting anti-arrhythmics Post critical care, CABG
Non-cardiac Patients
Insulin/Dextrose gtts
Severe Sepsis
EtOH withdrawl requiring high Dose
CAGE protocol
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Cardiac Monitoring
Usually requires SAC level of Care
Subset of SAC care
Continuous Cardiac Monitoring (CCM)Telemetry is CCM
Most CCM at UH is not telemetry
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va a eTypes of
Monitors1. Centralized Cardiac
Monitoring
2. Cardiac ambulatory
telemetry
3. Portable CardiacMonitoring
4. Oxinet
5. Capnography
6. Frequent Vitals, pulseoximetry
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UNM Continuous Cardiac Monitoring(CCM)
Centralized Monitor room 2 techs for ~ 100 monitors
7S Monitor Tech
20 rooms, including telemetry
Monitoring at nurses stations
ED Obs
ED Main
ICUs
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TelemetryCentraliz
edMonitorin
g
1.CentralizedMonitoring Room islocated on 3 North
2. Two trained monitorTechs (Basic
Arrhythmia and annualArrhythmiaCompetency exam)
3. Monitor 80-90
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Guidelines
American HeartAssociation
American College ofCardiology
Expert Opinion
Addresses primarily Cardiac
Conditions
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Class ICardiac monitoring is indicated in nearly all
patients
Early phase of ACS, including rule-outMI
Postop cardiac surgery
After resuscitation from cardiacarrest
Intensive Care patients Poisoning w drugs/chemicals cardiac
arrhythmic toxicity
During initiation and loading of typeI
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Class I, contCardiac monitoring is indicated in nearly
all patients High-risk coronary artery lesions whoare candidates for urgent mechanicalrevascularization
Temp pacemaker or transcutaneouspacing pads
Pt who have undergone implantationof automatic defibrillator lead orpacemaker lead and are pacemakerdependent
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Class I, contCardiac monitoring is indicated in nearly
all patients Mobitz type II or greateratrioventricular block, adv 2nddegree AV block, complete heart
block or new onset left bundlebranch block in the setting of acuteMI
Acute heart failure, pulmonaryedema or intra-aortic ballooncounterpulsion
Procedures requiring conscious
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Class IISome patients may benefit
> 3 days after acute MI
Chest pain syndromes
Pt with hx of potentially lethalarrhythmia, several days after controlof arrhythmia
At risk of cardiac arrest, respiratoryarrest or development of hypotension
Adjustment of drugs for rate control
w chronic atrial tachycardias
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Class II, contSome patients may benefit
Subacute heart failure or in acutephase of pericarditis
Unexplained syncope or TIA thighmight be due to arrhythmias
After uncomplicated coronaryangioplasty or ablation of arrhythmia
Pacer implanted w/I 48-72 hr who arenot pacer depend
Post cardiac surgery even if stable
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Class IIInot indicated
After low risk surgery
During labor and delivery (if nosignificant medical problems exist)
Terminal illness who are notcandidates for Rx of arrhythmias
Chronic stable atrial fibrillation With stable asymp PVCs or Non-
sustained V tach who are not
hospitalized for cardiac or HD
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Experiences in ImprovingUtilization
Jackson Memorial Hospital Miami:1,600 bed tertiary care
Telemetry Utilization Review project
Evaluate whether pts currently on telestill needed it
Evaluate length of time pts remained ontele
Improve emergency departmentsthroughput
Evaluate the potential need forSubharwal,
et al
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yMisused
TelemetryDiagnose
s
GI bleeding 16%
Malignancy 8%
Sepsis/Bacteremia w/o SepticShock 8%
ARF or ESRD w normal lytes8%
Sickle cell crisis 7%
DVT or PE w/o HD compromise7%
COPD/Asthma/OSA 6%
EtOH abuse or withdrawl 6%
Pneumonia 6%
Cirrhosis/hepatitis/cholelithiasi
Auditof753chartsatJackonMemorialHospitalinMiami.
Whenaudited:50%of650patientswerefoundtonotneedornolongerneedtelemetry.
Diagnosesatrightwerecommon.
Sabharwal,et.Al
Subharwal, et
al
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Clinical Need
Developed auditing tool usingGuidelines by American College ofCardiology
Of 651 telemetry patients reviewed
54% no longer met criteria
18% did meet any criteria sinceadmission
Telemetry Authorization Form 6month followup
Subharwal,
et al
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Similar quality improvement
programs
Hackensack University reduced useby 34% w authorization form
Portland Veterans Med Center incorporated stop times
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CCM & cardiac arrestoutcomes
Review of 5 yrs of telemetryadmissions
8,932 pt were admitted to telemetryunit
20 suffered cardiac arrest
Two of three of survivors hadsignificant arrhythmias detected ontele before arrest
Monitor-signaled survival rate was
Schull, etal
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Does CCM alter medicalmanagement?
Estrada, et al (Henry Ford, Detroit)1994
467 patients admitted to telemetrybased on ACC guidelines
Only 1 % of cases had ICU transferbased on tele findings
Majority of pts who deteriorated wereidentified clinically
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Does CCM alter medical
management? Estrada, et al (Henry Ford,
Detroit) 1995 Data collected from 2,240 pts
admitted to tele for chest pain,
arrhythmias, heart failure, &syncope
Outcomes ICU transfer and
mortality
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Telemetry in the Elderly
Looked pts admitted for Chest Painwith low risk for a coronary eventduring hospitalization
Excluded pts w ACS per ECG orcardiac markers
Of the 105: about half had HTN, DM,elev lipids, smoking and prior CAD
Telemetry did not show significantarrhythmia or lead to managementchan es in an ts Saleem, etal
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Monitoring in Low RiskAcute Chest Pain Syndrome
414 consecutively admitted forsuspected ACS
Outcomes: MI, new or rapid atrialarrhythmias, vent arrhythmias, AVnodal block and asystole
Intervention change in dose ofmedication, cardioversion, EP studyor Txn to ICU
Results: Patient w atypical chestain normal ECG findin s are si nSnider, etal
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Artifact
Evaluation of monomorphic orpolymorphic V tachycardia in 12patients
Cardiac cath (3), Intravenouslidocaine in 7, IV NTG in 1 and SLnitro in 1
2 patients were given a precordialthumb that was interpreted as asuccessful cardioversion
1 had im lantable defibrillator forKnight, et
al
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Summary
Need for Intermediate Care should becarefully considered.
More options available, such as oxynet
Continuous Cardiac Monitoring should not be a reflex action for non-
cardiac pts who may still need increasedintensity of service.
Studies suggest overuse
Telemetry infrequently leads tomanagement changes
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Recommendations
Evaluate current use of Cardiacmonitoring and intermediate care atUH
Develop guidelines for use based onother institutions protocols
Educate staff, providers, physicianson accepted uses of Cardiacmonitoring and intermediate care.
Encourage more thoughtful analysisf th f th