UH Case Medical Center Adult Inpatient Telemetry Admission, Transfer and Discharge Guidelines STATEMENT OF PURPOSE: To facilitate appropriate geo-location placement of patients who require telemetry monitoring for abnormal or adverse cardiac or pulmonary events. This guideline will serve as the criterion for admission, discharge, and transfer to the defined level of telemetry monitoring. The nurses collaborate with the interdisciplinary team to assess the need for telemetry and continuation of telemetry monitoring. General Telemetry Admission and Continued Stay Guidelines 1. Telemetry admission will be determined by utilizing the telemetry criteria listed below and based on the practice standards set forth by the American Heart Association. 2. Telemetry guidelines are utilized in conjunction with the UH Case Medical Center Adult IV medication guidelines and M-223. 3. A telemetry order is required for all telemetry admission specifying level of telemetry. 4. A Cardiology and/or Pulmonary consult should be considered for all level II patients requiring monitoring >24 hours. 5. A Cardiology consult will be initiated for all patients with new onset atrial fibrillation and increased troponins. 6. Telemetry admission/ continued stay is not indicated for Do Not Attempt Rescuscitation (DNAR)/Comfort Care measures only. 7. Those patients who do not meet the continued stay criteria and no longer requiring rhythm monitoring will be identified and removed from telemetry monitoring. 8. An order will be placed to discontinue telemetry monitoring. 9. Patients admitted for Aldesleukin/IL-2 treatments will be monitored on Seidman Cancer Center 3 only (see addendum guidelines). 10. Patients requiring high risk pulmonary hypertension medications i.e., Epoprostenol or Treprostinil will be admitted to Lerner Tower 5, CICU, and MICU. 11. Patients admitted to Lerner Tower 9 post-operative kidney transplant may receive Labetalol per order in compliance with UH Case Medical Center Adult IV guidelines. 12. Patients who require continuous pulse oximetry for sleep apnea and or post orthopedic procedure may not require cardiac telemetry. 13. The following criteria will assist in establishing eligibility for admission, and appropriate level of or continued telemetry monitoring. Telemetry Discontinuation Guidelines Telemetry II 1. Chest pain work up complete 2. 24 hour hemodynamic stability 3. 24 hour without 4. Electrolyte imbalances corrected, no for 24 hours
Location Population Critical Care Cardiac/ Progressive Care Telemetry Telemetry I Telemetry II NON Telemetry ED All CICU Intensive cardiac care MICU Medical populations NSU Neuro populations SICU Post-Surgical MAC 2 L&D Lerner Tower 3 Post cardiothoracic Medical Step Down Unit Lerner Tower 4 Neurological Lerner Tower 5 Advanced Heart Failure Lerner Tower 7 Heart Failure and Medical Lerner Tower 8 Infectious Diseases and Medical NIU Neuro-intermediate unit (15 bed spaces) Seidman 5 Post procedure ENT Seidman 3 Bone Marrow Transplant Seidman 4 Hemoncology Seidman 6 General and surgical oncology Tower 9 Transplant and Bariatric populations Lakeside 50 Medical / renal telemetry Lakeside 20 Medical populations Lakeside 55 Medical GI Lakeside 60 Geriatric/ Trauma EMU Epilepsy specialty Lerner Tower 6 Orthopedic surgery Mac House 3,4,5 Women s Health
SCC3, SCC4, SCC6, LT9, LK50 LT7, LT8, NIU, SCC5 LT3/SDU, LT5 ED, CICU, MICU, NSU, SICU, MAC 2, L&D Chest Pain (cardiac origin) If patient has significant CAD risk factor (prior MI, CAD, DM), ideally admit patient to cardiac unit LT3 or LT5 ECG: normal or nondiagnostic, or w/ nonspecific T wave changes Cardiac serum markers normal or borderline (troponin < 0.2) Hemodynamically & electrically stable angina without ECG changes Chest pain with risk factors and non-specific ECG abnormalities Accompanying condition(s) requiring inpatient workup and/or therapy (e.g., heart failure, dialysis pt. with electrolyte imbalance/fluid overload, HTN urgency, accompanying syncope) Chest pain with risk factors and non-specific ECG abnormalities History consistent with ACS (STEMI, NSTEMI or Unstable Angina) ECG abnormalities Requiring IV antithrombotic/anti-ischemic therapy (exception: heparin/enoxaparin) Hemodynamically and/or electrically unstable Syncope Not attributable to lifethreatening cardiac disease Low probability of TIA, CVA Cardiac etiology is not being pursued/possible cardiac etiology Cardiac etiology is being pursued/possible cardiac etiology With life-threatening (VT or highdegree AV block) Palpitations Recommend cardiac monitoring for 24 hours Cardiac etiology is not being pursued/possible cardiac etiology Cardiac etiology is being pursued Malignant s Atrial Fibrillation/ Flutter Atrial fibrillation, controlled ventricular response NOT requiring IV drips or drug loading except diltiazem Known chronic atrial fibrillation rate controlled first 24 hour post-op flutter requiring rate control, drug loading to convert, or new onset flutter with rapid ventricular response (heart rate > 120 bpm) (see UH CMC IV drug Guidelines) flutter requiring rate control, drug loading to convert, or new onset flutter with rapid ventricular response (heart rate > 120 bpm) (see UH CMC IV drug Guidelines) Hemodynamically unstable supraventricular tachycardia: unable to control ventricular response, hypotensive
SCC 3, SCC4, SCC6, LT9,, LK50, LT 7, LT8, NIU, SCC5 LT3/SDU, LT5 ED, CICU, MICU, NSU, SICU, MAC 2, L&D Bradycardia workup & treatment Non-life threatening rate without significant pauses and NOT requiring external/temporary transvenous pacing Non-life threatening rate without significant pauses and NOT requiring external/ temporary transvenous pacing Non-life threatening rate with significant pauses and requiring external/temporary transvenous pacing Life-threatening AV block or sinus arrest with hypotension and/or requiring external or temporary transvenous pacing Ventricular Arrhythmias/ Tachycardia (VT) tachycardia controlled by initial therapy or not requiring continuous IV therapy (discontinue telemetry after 24 hours) Hemo-dynamically stable/non-sustained ventricular tachycardia (no acute ischemia requiring workup and/or treatment) New onset ventricular tachycardia controlled by initial therapy and/or requiring continuous IV therapy Hemo-dynamically stable/non-sustained ventricular tachycardia (no acute ischemia requiring workup &/or treatment) New onset ventricular tachycardia not controlled by initial therapy Requiring drip titration (see UH CMC IV guidelines) Heart blocks tachycardia with hemodynamic changes. Antiarrhythmic Drug Therapy loading/ changing dose (see UH Case Medical Center Pharmacy website) No IV infusions or drug loading except diltiazem Transfer to Cardiac Telemetry Drugs requiring hospitalization for initiation IV infusions requiring monitoring but not for hemodynamic titration Drugs requiring hospitalization for initiation IV infusions requiring monitoring and hemodynamic titration See UH CMC IV medication guidelines for LT3 infusions IV infusions requiring titration
SCC 3, SCC4, SCC6, LT9, LK50, LT 7, LT8, NIU, SCC5 LT3/SDU, LT5 ED, CICU, MICU, NSU, SICU, MAC 2, L&D Cardiac Procedure No elective cardioversion Pre-procedure high risk patient requiring less than 24 hours telemetry Elective inpatient or outpatient cardioversion Hemo-dynamically stable post-procedure Pacemaker / AICD: insertion, infection, malfunction (LT7) Cardiac cath Pre-procedure high risk patients requiring >24 hours telemetry Pacemaker / AICD: insertion, infection, malfunction Post Op cardiothoracic procedures (LT3) Post op Thoracic (LT3) MICU SDU (LT3) Post thoracic vascular procedure Surgical Cardioversion Unstable patient (hypotensive or decreased hemoglobin) Acute Decompensated Heart Failure Hemo-dynamically stable patient requiring IV diuretic therapy Symptomatic hypertension Magnesium < or equal to 1.2 Hypoxia with PO 2 <90% on room air patient with heart failure Arrhythmia patient with heart failure Requiring IV therapy Newly diagnosed Heart Failure ( risk) Hemodynamically unstable and/or requiring PA line In pulmonary edema/ requiring greater than 50% FiO 2 Electrolyte Imbalance without ECG changes and abnormal ECG and abnormal ECG with ECG changes
SCC 3, SCC4, SCC6, LT9, LK50 LT 7, LT8, NIU,SCC5 LT3/ SDU, LT5 ED, CICU, MICU, NSU, SICU, MAC 2, L&D Drug Overdose Low probability for lifethreatening Without respiratory depression Consider telemetry for 24 hours and reevaluate Low probability for lifethreatening Potential for Low probability for lifethreatening Potential for High probability for lifethreatening or respiratory depression Other Rule out pulmonary embolism (troponin <0.5 ng/ml) Continuous pulse oximetry post procedure Pulmonary embolism stable troponin Pulmonary embolism stable troponin Pulmonary embolism with hemodynamic instability Trauma Low probability of cardiac /pulmonary contusion (no creatinine measurements needed) References: http://bhf.org.uk//factfiles - Click on Medication then Anti-Cancer Drugs and the Heart http://circ.ahajournals.org/content/110/17/2721.full.pdf http://circ.ahajournals.org/content/109/25/3122.long