Intended for healthcare professionals

  1. Education
  2. Decreasing unnecessary...
  3. Decreasing unnecessary use of continuous cardiac monitoring (telemetry) in hospitalised patients
Practice Change

Decreasing unnecessary use of continuous cardiac monitoring (telemetry) in hospitalised patients

BMJ 2024; 386 doi: https://doi.org/10.1136/bmj-2023-077499 (Published 29 July 2024) Cite this as: BMJ 2024;386:e077499
  1. William K Silverstein, assistant professor, staff physician, associate scientist, lead in choosing Wisely Canada14,
  2. Irene Y Chang, medical student45,
  3. Shiva Sreenivasan, consultant in acute and general internal medicine67,
  4. Sanket S Dhruva, assistant professor810
  1. 1Department of Medicine, University of Toronto, Toronto ON, Canada
  2. 2Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto ON, Canada
  3. 3Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto ON, Canada
  4. 4Choosing Wisely Canada, Toronto ON, Canada
  5. 5Temerty Faculty of Medicine, University of Toronto, Toronto ON, Canada
  6. 6South West Acute Hospital, Western Health and Social Care Trust, Enniskillen, UK
  7. 7Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
  8. 8University of California, San Francisco School of Medicine, San Francisco CA, USA
  9. 9Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco CA, USA
  10. 10Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco CA, USA
  1. Correspondence: W K Silverstein William.Silverstein{at}mail.utoronto.ca

What you need to know

  • In-hospital continuous electrocardiographic monitoring (telemetry) in patients without a clear clinical indication is associated with negative patient outcomes (such as delirium, risk of invasive procedures as a result of artefact, reduced mobility) and drives unnecessary healthcare waste

  • Successful strategies to reduce telemetry in patients without a clear clinical indication include improving ordering practices to avoid unnecessary monitoring altogether and discontinuing telemetry after the appropriately indicated duration has passed

  • Targeted initiatives safely reduce incidence and duration of unnecessary monitoring without increasing incidence of life-threatening medical emergencies, mortality, or critical care outreach team activation

Since its development in 1949, in-hospital continuous electrocardiographic monitoring (hereinafter “telemetry”) has become increasingly important for clinical care of hospitalised patients.1 Telemetry is used for a variety of applications, including diagnosis and monitoring of arrhythmias, detection of myocardial ischaemia, and monitoring of ST segments and QT intervals. Specialist societies around the world have published practice standards to inform clinicians when telemetry should be used.234 Appropriate clinical indications are listed in box 1 and include patients with suspected or confirmed acute coronary syndromes, acute decompensated heart failure, high grade arrhythmias, post-cardiac arrest, severe electrolyte derangements, use of certain medications, and ingestion of pro-arrhythmic agents.234

Box 1

Indications for appropriate continuous electrocardiographic monitoring recommended by international specialist societies

Agency for Clinical Innovation’s Clinical Practice Guide (Australia)2

  • Acute coronary syndrome (confirmed or suspected)

  • Critical illness—Includes but not limited to cardiogenic shock, haemodynamic compromise, or respiratory compromise requiring support with inotropic agents or intra-aortic balloon pump

  • Electrolyte abnormalities—Serum potassium <3 mmol/L or >6 mmol/L, serum magnesium <0.6 mmol/L or >2 mmol/L, serum calcium <1.8 mmol/L or >3 mmol/L

  • High grade arrhythmias—Ventricular tachycardia, ventricular fibrillation, supraventricular tachycardia with aberrancy, narrow complex tachyarrhythmias causing haemodynamic instability, second or third degree atrioventricular block, symptomatic bradycardia, atrial fibrillation with rapid ventricular response

  • Medications—Intravenous inotropic agents, vasoactive drugs, anti-arrhythmics, fibrinolytics

  • Pending insertion of implantable cardiac devices—Implantable cardioverter defibrillator, permanent pacemaker

  • Preoperative cardiac surgery—Critical left main coronary artery …

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