Can Telemetry Identify Code Blue Activations in Non-ICU Units?

Background: American Heart Association (AHA) guidelines recommend telemetry monitoring for patients with active cardiac conditions. However, telemetry is often ordered inappropriately for non-cardiac reasons (e.g.... [ view full abstract ]

Background: 

American Heart Association (AHA) guidelines recommend telemetry monitoring for patients with active cardiac conditions. However, telemetry is often ordered inappropriately for non-cardiac reasons (e.g. respiratory conditions, altered mental status, GI bleed). Overuse may be driven by providers' perceptions that telemetry can identify potentially unstable patients. We studied the role of telemetry in detecting patients with cardiopulmonary arrest in non-intensive care unit (ICU) settings.

Methods: 

This IRB-approved, retrospective study was conducted at Johns Hopkins Bayview Medical Center, a 477-bed academic hospital, between April 2014 to March 2015. A Code Blue is activated for patients requiring immediate cardiopulmonary resuscitation. All Code Blue activations in non-ICU settings were reviewed, identifying the admitting diagnosis, appropriateness of telemetry indication, and whether telemetry identified the patient as unstable prior to Code Blue activation. Patients who were found to have a respiratory event only (e.g. no loss of pulse or arrhythmia) did not need immediate resuscitation and were not included.

Results: 

Telemetry monitoring detected an arrhythmia for only one patient during a cardiac catheterization procedure for myocardial infarction. Otherwise, telemetry did not detect patients at risk for cardiopulmonary arrest, since most were witnessed respiratory abnormalities or found unresponsive by medical staff. The majority of unmonitored patients presented in pulseless electrical activity(PEA), and it is unclear the role of telemetry for earlier detection since etiologies were mostly respiratory insufficiency or circulatory shock. 

Conclusion: 

Physicians may overestimate the role of telemetry, since unstable patients are identified based on clinical deterioration, rather than arrhythmias detected on telemetry. Closer clinical monitoring by medical staff may be more high yield than continuous telemetry monitoring. More sensitive monitoring devices,such as continuous pulse oximetry, capnography, or respiratory movement may better recognize these patients. We recommend further study to identify optimal monitoring systems for patients at risk of cardiopulmonary arrest.