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8/13/12

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

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