New Electronic Order Set Helps Reduce ECG Overmonitoring

A computerized order set may help reduce the persistent problem of overmonitoring hospitalized patients, according to a study published in the American Journal of Critical Care.

Many hospitalized patients receive unnecessary cardiac monitoring, which contributes to patients’ inconvenience, clinicians’ alarm fatigue, and delayed hospital admissions. Appropriate monitoring remains a challenge, despite practice standards, guidelines, and recommendations that specify which patients need continuous electrocardiographic (ECG) monitoring.

According to “Implementing Practice Standards for Inpatient Electrocardiographic Monitoring,” researchers found that appropriate monitoring increased after an order set was introduced into the EHR, prompting providers to order ECG monitoring per American Heart Association (AHA) practice standards. The proportion of patients appropriately monitored on hospital admission increased from 48% before implementation to 61.2% afterward.

After implementation of the practice standards, the number of days of overmonitoring decreased, and patients had fewer days of monitoring without an indication for monitoring. Researchers found no difference in adverse outcomes, such as unexpected transfers to the ICU, death, code blue events, or calls for the rapid response team.

The study took place at Abbott Northwestern Hospital/Allina Health, a 627-bed Magnet-designated hospital in Minneapolis, where ECG monitoring of patients not in an ICU or cardiac telemetry unit is performed by staff in a dedicated space called the cardiac monitoring center.

“ECG monitoring is often ordered as an extra precaution for patient safety or as a substitute for frequent monitoring of vital signs and not for a specific clinical concern,” says coauthor Kristin Sandau, PhD, RN, a professor of nursing at Bethel University, and a staff nurse at United Hospital/Allina Health in St. Paul, Minnesota.

“Once ECG monitoring is ordered, patients may continue to be monitored even when  their condition no longer requires it. Incorporating the AHA practice standards into electronic order sets, especially with accompanying education, is an effective, safe, and feasible way to improve ECG monitoring,” she says.

The largest improvement was in ordering compliance by medical residents, with an increase from 30.8% prior to implementation to 76.5% after the intervention.

A striking difference between hospitalists and medical residents is their participation in education and correct use of the electronic order set. All 30 residents received education on the AHA practice standards and use of the order set. The 64 hospitalists received a one-slide overview but declined the formal education given to the residents. In addition, a quick-reference pocket-sized brochure with the practice standards was available to all ordering health care providers.

“Education alone does not change practice, but it may help providers understand the rationale for a practice change and better appreciate its importance to patient care,” Sandau says.

The hospital implemented the order set in February 2016, and the study compares baseline data from the fourth quarter of 2014, prior to implementation and education, and postimplementation data from the third quarter of 2016. The researchers examined the EHR data of 150 patients from the preimplementation period and 147 patients postimplementation. They examined indications for monitoring for up to six days, since a patient’s indication for ECG monitoring often changes during hospitalization.

The American Association of Critical-Care Nurses (AACN), which publishes the American Journal of Critical Care, is among the organizations that endorsed the AHA guidelines. Its library of clinical resources includes AACN Practice Alerts for managing physiological alarms, and monitoring arrhythmia and ST segments for critically ill patients. AACN Practice Alerts are available as a free download on the AACN website at www.aacn.org/practicealerts.

 — Source: American Association of Critical-Care Nurses