Subacute Care and Continuous Cardiac Monitoring

Click to edit Master subtitle style Peggy Beeley, MD June 7th, 2010

8/13/12

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 8/13/12 utilization of SAC and Telemetry

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 8/13/12

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 8/13/12

Our Resources

Total Adult Bed Census 296 72 Adult ICU beds

Includes MICU, TSICU, NICU 7S, 6S, 5S, 4E, 4W, 3S, 3E 5S, 5W, 5E, 4S, 3N

136 SAC beds

88 Med Surg

Patients waiting for beds vary but 8/13/12

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?

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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 8/13/12

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) 8/13/12

Criteria for Intermediate Care

Common examples Cardiac Patients

Acute MI 24 hrs, r/o MI Starting anti-arrhythmics Post critical care, CABG Insulin/Dextrose gtts Severe Sepsis

Non-cardiac Patients

EtOH withdrawl requiring high Dose 8/13/12 CAGE protocol

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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Available Types of Monitors

1.

Centralized Cardiac Monitoring Cardiac ambulatory telemetry Portable Cardiac Monitoring Oxinet Capnography Frequent Vitals, pulse oximetry

2.

3.

4.

5.

6.

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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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Telemetry Centraliz ed Monitorin 1.Centralized Monitoring Room is g

located on 3 North 2. Two trained monitor Techs (Basic Arrhythmia and annual Arrhythmia Competency exam)
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3. Monitor 80-90

Guidelines

American Heart Association American College of Cardiology

Expert Opinion

Addresses primarily Cardiac 8/13/12 Conditions

Cardiac monitoring is indicated in nearly all patients

Class I

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

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Cardiac monitoring is indicated in nearly all patients High-risk coronary artery lesions who are candidates for urgent mechanical revascularization

Class I, cont

Temp pacemaker or transcutaneous pacing pads Pt who have undergone implantation of automatic defibrillator lead or pacemaker lead and are pacemaker dependent
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Cardiac monitoring is indicated in nearly all patients Mobitz type II or greater atrioventricular block, adv 2nd degree AV block, complete heart block or new onset left bundle branch block in the setting of acute MI

Class I, cont

Acute heart failure, pulmonary edema or intra-aortic balloon counterpulsion Procedures requiring conscious

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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 8/13/12

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
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Post cardiac surgery even if stable

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 Nonsustained V tach who are not hospitalized for cardiac or HD 8/13/12

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 Subharwal,
et Evaluate the potential need for al

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y Misused Telemetry Diagnose s

Sabharwal, et. Al
Diagnoses at right were common. When audited: 50% of 650 patients were found to not need or no longer need telemetry.

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% Subharwal, et
al Cirrhosis/hepatitis/cholelithiasi

Audit of 753 charts at Jackon Memorial Hospital in Miami.

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

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Telemetry Authorization Form 6 month followup Subharwal,

et al

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Similar quality improvement programs

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

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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
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Monitor-signaled survival rate was

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

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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 8/13/12

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 et Saleem, 8/13/12 al changes in any pts

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 et Snider, 8/13/12 al pain, normal ECG findings are sign

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 Knight, et 1 had implantable defibrillator for
al

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Summary

Need for Intermediate Care should be carefully considered.

More options available, such as oxynet should not be a reflex action for noncardiac pts who may still need increased intensity of service. Studies suggest overuse Telemetry infrequently leads to management changes

Continuous Cardiac Monitoring

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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 8/13/12 of the use of these resources