Subacute Care and Continuous Cardiac Monitoring

Subacute Care and Continuous Cardiac MonitoringPeggy Beeley, MDJune 7th, 2010

ObjectivesUnderstand Current Availability & Utilization of Cardiac Telemetry at UHUnderstand Current Availability & Utilization of Subacute care at UHReview the literature for utility of Cardiac Telemetry in non-cardiac patientsDevelop consensus for better utilization of SAC and Telemetry resources

Reasons to Look at Utilization of SAC/Cardiac TelemetryExpensiveAffects ED throughput, ICU availabilityContinuous Cardiac Monitoring infrequently influences management decisionsMay lead to unnecessary testing and concernDecreases mobility, making VTE complications more likely

DefinitionsAcute CareIntermediate Care or Subacute CareNursing interventions at least every 2-4 hoursPost surgery or procedure requiring monitoring at least every 2-4 hoursContinuous cardiac monitoringTelemetry cardiac monitoring{Hemodynamically stable patients with extended ventilator weaning, or chronic ventilation}Intensive Care

Acute care is a level of health care in which a patient is treated for a brief but severe episode of illness, for conditions that are the result of disease or trauma and during recovery from surgery.

Subacute care is a level of care needed by a patient who does not require hospital acute care but who requires more intsive skilled nursing care than is provided to the majority of patients in a skilled nursing facility or subacute patients are medically fragile and require special services, such as inhalation therapy, trach care, TPN, complex wound management care. a less costly alternative to hospital care.4Our ResourcesTotal Adult Bed Census 29672 Adult ICU bedsIncludes MICU, TSICU, NICU136 SAC beds7S, 6S, 5S, 4E, 4W, 3S, 3E88 Med Surg5S, 5W, 5E, 4S, 3NPatients waiting for beds vary but SAC #s persistently higher than floor level care

Questions to the GroupHow 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 CareCurrently, a subjective processNo UH Protocol currently, although these were in development in the pastIndividual Floors have Unit Operational Plans that include the types of patient and services they can accommodate

Utilization ReviewUH uses a tool accepted by CMS and other organizationsPlease see your handout page 1,2Includes criteria for Intermediate CareComplicated 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 CareCommon examples Cardiac PatientsAcute MI 24 hrs, r/o MI Starting anti-arrhythmicsPost critical care, CABGNon-cardiac PatientsInsulin/Dextrose gttsSevere SepsisEtOH withdrawl requiring high Dose CAGE protocolSevere Electrolyte disturbances

Cardiac MonitoringUsually requires SAC level of CareSubset of SAC careContinuous Cardiac Monitoring (CCM)Telemetry is CCMMost CCM at UH is not telemetry

Available Types of Monitors

Centralized Cardiac MonitoringCardiac ambulatory telemetryPortable Cardiac MonitoringOxinetCapnographyFrequent Vitals, pulse oximetry

7 Capnography units in ED11UNM Continuous Cardiac Monitoring (CCM)Centralized Monitor room2 techs for ~ 100 monitors7S Monitor Tech20 rooms, including telemetryMonitoring at nurses stationsED ObsED MainICUs

Cardiac Telemetry Centralized Monitoring

1.Centralized Monitoring Room is located on 3 North2. 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 Units4West-36 beds, monitor 36, 0 tele portable monitors4 East -20 Beds, monitor 20, 2 tele portable monitors3 South-16 Beds, monitor 16, 0 teleportable monitors5 East-16 beds, monitor 8, 1 tele portable monitor5 South- 31 beds, monitor 14, 2 tele portable monitors6 South- 20 beds, monitor 20, 0 tele pacs/ 2 portable monitors3 East-10 beds, monitor 10

GuidelinesAmerican Heart AssociationAmerican College of CardiologyExpert OpinionAddresses primarily Cardiac ConditionsSee pages 3 & 4 for Classes 1-3

Class ICardiac monitoring is indicated in nearly all patientsEarly phase of ACS, including rule-out MIPostop cardiac surgeryAfter resuscitation from cardiac arrestIntensive Care patientsPoisoning w drugs/chemicals cardiac arrhythmic toxicityDuring initiation and loading of typeI or III antiarrhythmic drugsImmediate after percutaneous transluminal coronary angioplasty w complications

Class I, contCardiac monitoring is indicated in nearly all patientsHigh-risk coronary artery lesions who are candidates for urgent mechanical revascularizationTemp pacemaker or transcutaneous pacing padsPt who have undergone implantation of automatic defibrillator lead or pacemaker lead and are pacemaker dependent

Class I, contCardiac monitoring is indicated in nearly all patientsMobitz 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 MIAcute heart failure, pulmonary edema or intra-aortic balloon counterpulsionProcedures requiring conscious sedation or anesthesiaProlonged QT syndrome w associated ventricular arrhythmias or HD instability

Class IISome patients may benefit> 3 days after acute MIChest pain syndromesPt with hx of potentially lethal arrhythmia, several days after control of arrhythmiaAt risk of cardiac arrest, respiratory arrest or development of hypotensionAdjustment of drugs for rate control w chronic atrial tachycardiasSuspected or proven hemodynamically significant paroxysmal tachy or brady arrhythmias

Class II, contSome patients may benefitSubacute heart failure or in acute phase of pericarditisUnexplained syncope or TIA thigh might be due to arrhythmiasAfter uncomplicated coronary angioplasty or ablation of arrhythmiaPacer implanted w/I 48-72 hr who are not pacer dependPost cardiac surgery even if stableDNR w symptomatic arrhythmia

Class IIInot indicatedAfter low risk surgeryDuring labor and delivery (if no significant medical problems exist)Terminal illness who are not candidates for Rx of arrhythmiasChronic stable atrial fibrillationWith stable asymp PVCs or Non-sustained V tach who are not hospitalized for cardiac or HD compromiseUnderlying cardiac disease that are stable w/o arrhythmias on 3 consecutive days of monitoring.

Experiences in Improving UtilizationJackson Memorial Hospital Miami: 1,600 bed tertiary care Telemetry Utilization Review projectEvaluate whether pts currently on tele still needed itEvaluate length of time pts remained on teleImprove emergency departments throughputEvaluate the potential need for additional tele bedsSubharwal, et al

Began experiencing increased need for adult cardiac tele beds, with many waiting in ED21Most CommonlyMisusedTelemetry DiagnosesGI 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. AlSubharwal, et al

Clinical NeedDeveloped auditing tool using Guidelines by American College of CardiologyOf 651 telemetry patients reviewed54% no longer met criteria18% did meet any criteria since admissionTelemetry Authorization Form 6 month followupCharge nurses validated needMonitored bed use decreased by 60 %Subharwal, et al

Decreased use was attributed to rapid identification and discontinue of pts on tele and some due to denials.23

Similar quality improvement programsHackensack University reduced use by 34% w authorization formPortland Veterans Med Center incorporated stop times

CCM & cardiac arrest outcomesReview of 5 yrs of telemetry admissions8,932 pt were admitted to telemetry unit20 suffered cardiac arrest Two of three of survivors had significant arrhythmias detected on tele before arrestMonitor-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) 1994467 patients admitted to telemetry based on ACC guidelinesOnly 1 % of cases had ICU transfer based on tele findingsMajority of pts who deteriorated were identified clinically

Does CCM alter medical management?Estrada, et al (Henry Ford, Detroit) 1995Data collected from 2,240 pts admitted to tele for chest pain, arrhythmias, heart failure, & syncopeOutcomes ICU transfer and mortalityTelemetry 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 ElderlyLooked pts admitted for Chest Pain with low risk for a coronary event during hospitalizationExcluded pts w ACS per ECG or cardiac markersOf the 105: about half had HTN, DM, elev lipids, smoking and prior CADTelemetry did not show significant arrhythmia or lead to management changes in any ptsTele did not influence inpt mortality or 5 yr survivalSaleem, et al

Westchester Medical Center/New York Medical College.

Included patients w/o ST-segment elevation, ST segment depression, T wave inversion or new ECG changes or elevatedCK MB > 10T or Trop> 2 ng/ml, hypotension, v tach or invasive interventionObserved for 48 hrs

29Monitoring in Low Risk Acute Chest Pain Syndrome414 consecutively admitted for suspected ACSOutcomes: MI, new or rapid atrial arrhythmias, vent arrhythmias, AV nodal block and asystoleIntervention change in dose of medication, cardioversion, EP study or Txn to ICUResults: Patient w atypical chest pain, normal ECG findings are sign less likely to have arrhythmias 8%Snider, et al

North Shore University Hosptal Manhasset NYProspective observational studyExcluded if ST seg elev, revascularized on adm, admitted to surg servicew typical CP, ECG changes30ArtifactEvaluation of monomorphic or polymorphic V tachycardia in 12 patientsCardiac cath (3), Intravenous lidocaine in 7, IV NTG in 1 and SL nitro in 12 patients were given a precordial thumb that was interpreted as a successful cardioversion1 had implantable defibrillator for torsadesKnight, et al

12 patients described over 4 years of observation.Recognized as artifact by the presence of native QRS complexes at cycle of base-line rhythm31SummaryNeed for Intermediate Care should be carefully considered.More options available, such as oxynetContinuous Cardiac Monitoring should not be a reflex action for non-cardiac pts who may still need increased intensity of service.Studies suggest overuseTelemetry infrequently leads to management changesMay cause harm when misinterpreted.Increases physician phone calls for telemetry artifact or non-sustained VtachLeads to increased fall risk, VTE

RecommendationsEvaluate current use of Cardiac monitoring and intermediate care at UHDevelop guidelines for use based on other institutions protocolsEducate staff, providers, physicians on accepted uses of Cardiac monitoring and intermediate care.Encourage more thoughtful analysis of the use of these resources