Where: Grady Memorial Hospital, a 774-bed academic medical center affiliated with the Emory University and Morehouse schools of medicine in Atlanta.
The issue: Standardizing admission and transfer criteria for the hospital's 41-bed telemetry unit to address overcrowding in the unit that spilled over into emergency department (ED) backups.
In 2002, Grady received a grant from the Robert Wood Johnson Foundation's Urgent Matters Initiative to study the problem of ED overcrowding. Research revealed that one factor contributing to overcrowding was inefficient use of the telemetry unit, a resource-intensive critical care area. Patients admitted for chest pain were often housed in the ED for 24 hours or more while waiting for a telemetry bed to open up.
To address the problem, the hospital formed a Telemetry Urgent Matters Initiative (TUMI) task force, headed by Neil Winawer, ACP Member, director of Grady's hospital medicine unit. The group determined that many telemetry unit beds were being used inappropriately because physicians were admitting low-risk patients who did not need continuous monitoring and only the patients' primary care team physicians could authorize transfers out of the unit. Without official standardized criteria, physicians were slow to order transfers based on their own judgment. On top of that, transfers required filling out several pages of forms.
“A lot of times doctors in training feel that by putting a patient on a telemetry monitor, they have another set of eyes watching the heart rate,” said Dr. Winawer. “But the service is clearly overutilized.”
The task force concluded that many low-risk patients could be safely moved to less resource-intensive areas of the hospital or considered for discharge. They aimed to smooth the flow of patients in and out of the unit by establishing standard criteria for admission and transfer, amending policies about who could authorize transfers, and reducing paperwork.
How it works
The task force looked at the American College of Cardiology guidelines and sought input from the hospital's senior cardiologists in order to develop up-to-date criteria for telemetry unit admission. The best evidence was used when available and consensus recommendations were made when evidence was lacking. They identified two main hurdles preventing efficient flow of patients on and off the unit: Unit directors were not authorized to initiate transfers, and excessive paperwork was bogging down the transfer process.
Initially, the hospital tried posting the criteria in the ED and telemetry unit in order to encourage physicians to transfer low-risk patients. This strategy ultimately failed as physicians still balked at filling out lengthy transfer forms.
The hospital subsequently gave the two physician directors of the telemetry unit authority to transfer patients off the unit based on the standard criteria. The directors would page the primary medical team and inform them about impending transfers rather than wait for the teams to make a decision during regular rounds.
The new process facilitated easier identification and transfer of low-risk patients and quicker diagnosis and treatment for those at high risk.
The task force also streamlined the process by consolidating information needed for transfer onto a one-page form, instead of the five-page document used in the past. Reducing the paperwork made it easier for primary care teams to move forward immediately with appropriate transfers.
“The doctors despised the five-page transfer form and would do everything in their power to avoid filling it out, and I couldn't blame them,” said Dr. Winawer. “Who would want to spend 20 minutes filling out new orders on a downgraded patient who would probably be going home the following day? Once primary teams realized how easy it now was to transfer patients they soon began to do so.”
The results were dramatic: Within one week of implementing the changes, the number of patients moved off the unit tripled.
Grady compared transfer statistics from the week before the changes went into effect with the week after and found that transfers off the unit went from 25 to 75. With more telemetry beds freed up, patients waiting in the ED no longer experienced long waits to be admitted to the unit.
The biggest ongoing challenge is educating ED personnel and medical residents how to get it right the first time, said Dr. Winawer. There are several disease processes that generally do not require remote monitoring yet get admitted to the telemetry unit, such as symptomatic anemia, renal failure without hyperkalemia and nonischemic heart failure. If these types of patients were never placed on telemetry, there would be even more beds available.
When he rounds on the telemetry unit today, Dr. Winawer sees patients falling into three categories: those who need to be there, those who needed to be there initially but now do not (for example, someone with chest pain who is ruled out for a heart attack but stays in the hospital for a stress test), and those who never should have been placed on a heart monitor in the first place.
- In order for the initiative to work and gain widespread acceptance, the telemetry directors should be physicians with significant experience working with telemetry patients. Also, allowing only physicians to authorize transfers (as opposed to nurses or others on the care team) provides more credibility and leads to greater acceptance of the program.
- Having standardized criteria is essential to avoid the perception that transfers are based on individual physician preference. If questioned, directors should emphasize that their decisions are based on the accepted criteria.
- “I try to be very conservative in my approach and if I'm 50-50 about transferring patients, I always give them the benefit of further monitoring,” said Dr. Winawer. “We haven't had to change the criteria since its inception and, knock on wood, most importantly, I have never in the seven-plus years I've been doing this had a resident come and tell me that I moved a patient off telemetry and they later had a bad outcome.”
How patients benefit
Fewer unnecessary admissions to the telemetry unit increases patient satisfaction because patients who do not need to be there do not have to go through the process of a bed transfer.
Dr. Winawer and his colleagues are now expanding the initiative onto other floors, including surgery and neurology beds.
Words of wisdom
Don't be afraid to change the culture. “Many doctors trained during a time of limitless resources which fostered overutilization of telemetry,” said Dr. Winawer. “In an era of evidence-based medicine and cost control, doctors need to learn to follow the guidelines.”
There is no one-size-fits-all solution. In a centralized telemetry unit like Grady's, it's easy for telemetry directors to round on patients but patients must be physically transferred off the unit. Some hospitals may use satellite telemetry throughout the hospital. Whatever approach you use, advised Dr. Winawer, teamwork is essential because you need buy-in from multiple stakeholders, including housestaff, nursing, cardiology and administration.