subacute care and continuous cardiac monitoring peggy beeley, md june 7th, 2010

Subacute Care and Continuous Cardiac Monitoring Peggy Beeley, MD June 7th, 2010

Objectives Understand Current Availability & Utilization of Cardiac Telemetry at UH Understand Current Availability & Utilization of Subacute care at UH Review the literature for utility of Cardiac Telemetry in non-cardiac patients Develop consensus for better utilization of SAC and Telemetry resources

Reasons to Look at Utilization of SAC/Cardiac Telemetry Expensive Affects ED throughput, ICU availability Continuous Cardiac Monitoring infrequently influences management decisions May lead to unnecessary testing and concern Decreases mobility, making VTE complications more likely

Definitions Acute Care Intermediate Care or Subacute Care Nursing interventions at least every 2-4 hours Post surgery or procedure requiring monitoring at least every 2-4 hours Continuous cardiac monitoring Telemetry cardiac monitoring {Hemodynamically stable patients with extended ventilator weaning, or chronic ventilation} Intensive Care

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 SAC #s persistently higher than floor level care

Questions to the Group How do you decide on SAC vs. Floor status? How do you decide on whether you will use cardiac monitoring? How often do you reassess the need for current level of care or telemetry?

Subacute or Intermediate Care Currently, a subjective process No UH Protocol currently, although these were in development in the past Individual Floors have Unit Operational Plans that include the types of patient and services they can accommodate

Utilization Review UH uses a tool accepted by CMS and other organizations Please see your handout page 1,2 Includes criteria for Intermediate Care Complicated list: Severity of illness (at least one) Intensity of Service (major criteria or 3 minor criteria) If patient doesnt meet criteria, then should be changed to a lower level of care

Criteria for Intermediate Care 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 Severe Electrolyte disturbances

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

Available Types of Monitors 1.Centralized Cardiac Monitoring 2.Cardiac ambulatory telemetry 3.Portable Cardiac Monitoring 4.Oxinet 5.Capnography 6.Frequent Vitals, pulse oximetry

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

Cardiac Telemetry Centralized Monitoring 1.Centralized Monitoring Room is located on 3 North 2. Two trained monitor Techs (Basic Arrhythmia and annual Arrhythmia Competency exam) 3. Monitor 80-90 patients at all times. 4. Max # is 90, we are at capacity most of the time. 126 adult SAC beds are monitor beds. Individual Units 4West- 36 beds, monitor 36, 0 tele portable monitors 4 East - 20 Beds, monitor 20, 2 tele portable monitors 3 South-16 Beds, monitor 16, 0 tele portable monitors 5 East-16 beds, monitor 8, 1 tele portable monitor 5 South- 31 beds, monitor 14, 2 tele portable monitors 6 South- 20 beds, monitor 20, 0 tele pacs/ 2 portable monitors 3 East- 10 beds, monitor 10

Guidelines American Heart Association American College of Cardiology Expert Opinion Addresses primarily Cardiac Conditions See pages 3 & 4 for Classes 1-3

Class I Cardiac monitoring is indicated in nearly all patients Early phase of ACS, including rule-out MI Postop cardiac surgery After resuscitation from cardiac arrest Intensive Care patients Poisoning w drugs/chemicals cardiac arrhythmic toxicity During initiation and loading of typeI or III antiarrhythmic drugs Immediate after percutaneous transluminal coronary angioplasty w complications

Class I, cont Cardiac monitoring is indicated in nearly all patients High-risk coronary artery lesions who are candidates for urgent mechanical revascularization Temp pacemaker or transcutaneous pacing pads Pt who have undergone implantation of automatic defibrillator lead or pacemaker lead and are pacemaker dependent

Class I, cont Cardiac monitoring is indicated in nearly all patients Mobitz type II or greater atrioventricular block, adv 2 nd degree AV block, complete heart block or new onset left bundle branch block in the setting of acute MI Acute heart failure, pulmonary edema or intra- aortic balloon counterpulsion Procedures requiring conscious sedation or anesthesia Prolonged QT syndrome w associated ventricular arrhythmias or HD instability

Class II Some patients may benefit > 3 days after acute MI Chest pain syndromes Pt with hx of potentially lethal arrhythmia, several days after control of arrhythmia At risk of cardiac arrest, respiratory arrest or development of hypotension Adjustment of drugs for rate control w chronic atrial tachycardias Suspected or proven hemodynamically significant paroxysmal tachy or brady arrhythmias

Class II, cont Some patients may benefit Subacute heart failure or in acute phase of pericarditis Unexplained syncope or TIA thigh might be due to arrhythmias After uncomplicated coronary angioplasty or ablation of arrhythmia Pacer implanted w/I 48-72 hr who are not pacer depend Post cardiac surgery even if stable DNR w symptomatic arrhythmia

Class III not indicated After low risk surgery During labor and delivery (if no significant medical problems exist) Terminal illness who are not candidates 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 compromise Underlying cardiac disease that are stable w/o arrhythmias on 3 consecutive days of monitoring.

Experiences in Improving Utilization Jackson Memorial Hospital Miami: 1,600 bed tertiary care Telemetry Utilization Review project Evaluate whether pts currently on tele still needed it Evaluate length of time pts remained on tele Improve emergency departments throughput Evaluate the potential need for additional tele beds Subharwal, et al

Most Commonly Misused Telemetry Diagnoses GI bleeding 16% Malignancy 8% Sepsis/Bacteremia w/o Septic Shock 8% ARF or ESRD w normal lytes 8% Sickle cell crisis 7% DVT or PE w/o HD compromise 7% COPD/Asthma/OSA 6% EtOH abuse or withdrawl 6% Pneumonia 6% Cirrhosis/hepatitis/cholelithiasis 6% AMS, uncontrolled DM, UTI, Fx or wound infection, Pancreatitis, dehydration comprised the other 25% Audit of 753 charts at Jackon Memorial Hospital in Miami. When audited: 50% of 650 patients were found to not need or no longer need telemetry. Diagnoses at right were common. Sabharwal, et. Al Subharwal, et al

Clinical Need Developed auditing tool using Guidelines by American College of Cardiology Of 651 telemetry patients reviewed 54% no longer met criteria 18% did meet any criteria since admission Telemetry Authorization Form 6 month followup Charge nurses validated need Monitored bed use decreased by 60 % Subharwal, et al

Similar quality improvement programs Hackensack University reduced use by 34% w authorization form Portland Veterans Med Center incorporated stop times

CCM & cardiac arrest outcomes Review of 5 yrs of telemetry admissions 8,932 pt were admitted to telemetry unit 20 suffered cardiac arrest Two of three of survivors had significant arrhythmias detected on tele before arrest Monitor-signaled survival rate was 0.02% Conclusion: Routine telemetry offers little cardiac arrest survival benefit Schull, et al

Does CCM alter medical management? Estrada, et al (Henry Ford, Detroit) 1994 467 patients admitted to telemetry based on ACC guidelines Only 1 % of cases had ICU transfer based on tele findings Majority of pts who deteriorated were identified clinically

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 Telemetry was helpful in modifications of management in only 7% 0.8% of all admission to tele were transferred to ICU because of telemetry findings

Telemetry in the Elderly Looked pts admitted for Chest Pain with low risk for a coronary event during hospitalization Excluded pts w ACS per ECG or cardiac markers Of the 105: about half had HTN, DM, elev lipids, smoking and prior CAD Telemetry did not show significant arrhythmia or lead to management changes in any pts Tele did not influence inpt mortality or 5 yr survival Saleem, et al

Monitoring in Low Risk Acute Chest Pain Syndrome 414 consecutively admitted for suspected ACS Outcomes: MI, new or rapid atrial arrhythmias, vent arrhythmias, AV nodal block and asystole Intervention change in dose of medication, cardioversion, EP study or Txn to ICU Results: Patient w atypical chest pain, normal ECG findings are sign less likely to have arrhythmias 8% Snider, et al

Artifact Evaluation of monomorphic or polymorphic V tachycardia in 12 patients Cardiac cath (3), Intravenous lidocaine in 7, IV NTG in 1 and SL nitro in 1 2 patients were given a precordial thumb that was interpreted as a successful cardioversion 1 had implantable defibrillator for torsades Knight, et al

Summary Need for Intermediate Care should be carefully considered. More options available, such as oxynet Continuous Cardiac Monitoring should not be a reflex action for non-cardiac pts who may still need increased intensity of service. Studies suggest overuse Telemetry infrequently leads to management changes May cause harm when misinterpreted. Increases physician phone calls for telemetry artifact or non-sustained Vtach Leads to increased fall risk, VTE

Recommendations Evaluate current use of Cardiac monitoring and intermediate care at UH Develop guidelines for use based on other institutions protocols Educate staff, providers, physicians on accepted uses of Cardiac monitoring and intermediate care. Encourage more thoughtful analysis of the use of these resources

subacute care and continuous cardiac monitoring peggy beeley, md june 7th, 2010

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