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Renewing clinical faith: reducing telemetry overuse by improving med-surg monitoring

By Michael Maylahn

Forget hospitals for a minute. Instead imagine two bookshops, their teetering shelves lined with dog-eared paperbacks. The first shop is neatly divided by genre and categorized by author. Bookshop Two operates on more lenient guidelines, encouraging staff to place books wherever feels right. Soon Macbeth is in the Children’s section, Nancy Drew has been missing for a week, and no one is quite sure who to blame.

Today's hospital bears an uncanny resemblance to Bookshop Two. Rather than using diagnoses to assign patients to wards, physicians place them in the unit that feels right. The trouble with this model is that it results in extensive patient misfiling, which reduces quality of care, while raising costs.
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Current estimates suggest that nearly 37 percent of telemetry patients actually belong in med-surg. This misclassification is largely a product of the fact that physicians, trained to prefer catch-all care, believe telemetry offers better treatment. Though their patients might not actually qualify for continuous monitoring, clinicians choose to send them to telemetry. However, rather than improving patient outcomes, this misclassification aggravates operational inefficiencies and reduces profit margins.

Triaging protocols, such as the AHA's “ECG Practice Standard,” often take the fall for patient-misfiling. However, studies have proven these guidelines are capable of reducing telemetry overuse by 70 percent – suggesting that misfiling has a different root cause. To trace this source, it’s helpful to examine the differences between telemetry and med-surg. Telemetry has a higher nurse to patient ratio, and a central monitoring station where patients receive continuous monitoring and constant care. Conversely, nurses in med-surg collect vitals, on average once every four to six hours. This operational difference causes physicians to reflexively avoid sending their patients to med-surg. In short, ward mistrust translates to patient misclassification.

This mistrust theory is supported by surveys. Only 22 percent of physicians cite arrhythmia monitoring as their primary reason for sending patients to telemetry. In contrast, over 50 percent choose telemetry because they want to “detect deterioration early.” This implies that physicians send their patients to telemetry because they think they’ll receive better care, rather than because they need continuous monitoring.

So why all this mistrust of med-surg? It boils down to the quality of patient monitoring. Med-surg’s spot-check monitors fail to provide a complete picture of a patient’s health, causing clinicians to miss signs of an impending patient crash.
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