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EHR Order Set Helps Reduce ECG Overmonitoring

Mar 05, 2019

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Research published in American Journal of Critical Care finds an electronic order set and provider education increased appropriate ECG monitoring

ALISO VIEJO, Calif. – March 5, 2019 –A computerized order set may help reduce the persistent problem of overmonitoring hospitalized patients, according to a study published in American Journal of Critical Care (AJCC).

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 electronic health record, 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 percent before implementation to 61.2 percent 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 intensive care unit, 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 intensive care unit 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,” said co-author Kristin Sandau, PhD, RN. She is a professor of nursing, 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 said.

The largest improvement was in ordering compliance by medical residents, with an increase from 30.8 percent prior to implementation to 76.5 percent 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 healthcare 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 said.

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 post-implementation data from the third quarter of 2016. The researchers examined the electronic health record data of 150 patients from the pre-implementation period and 147 patients post-implementation. 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 AJCC, 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 after signing in, www.aacn.org/practicealerts.

To access the article and full-text PDF, visit the AJCC website at www.ajcconline.org.

About theAmerican Journal of Critical Care: The American Journal of Critical Care (AJCC), a bimonthly scientific journal published by the American Association of Critical-Care Nurses, provides leading-edge clinical research that focuses on evidence-based-practice applications. Established in 1992, the award-winning journal includes clinical and research studies, case reports, editorials and commentaries. AJCC enjoys a circulation of more than 120,000 acute and critical care nurses and can be accessed at www.ajcconline.org

About the American Association of Critical-Care Nurses: Founded in 1969 with 400 members, the American Association of Critical-Care Nurses (AACN) is now the world’s largest specialty nursing organization. In 2019, AACN celebrates 50 years of acute and critical care nursing excellence, serving more than 120,000 members and over 200 chapters in the United States. The organization remains committed to its vision of creating a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. During its 50th anniversary year, AACN continues to salute and celebrate all that nurses have accomplished over the last half century

American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656-4109; 949-362-2000; www.aacn.org; facebook.com/aacnface; twitter.com/aacnme