A Randomized Trial of Telemetry Compared With Unmonitored Floor Admissions in ED Patients With Low-Risk Chest Pain
A Randomized Trial of Telemetry Compared With Unmonitored Floor Admissions in ED Patients With Low-Risk Chest Pain
This study aims to determine, relative to telemetry admission, if admission to an unmonitored
 floor bed saves resources without an increased rate of adverse events in emergency department
 (ED) patients admitted with chest pain and low-risk features.
Many patients admitted to the hospital with concern for cardiopulmonary and other acute
 illnesses are routinely placed on electrocardiographic monitoring (telemetry). Telemetry
 surveillance theoretically allows the clinical staff to monitor admitted patients for the
 development of both brady- and tachydysrhythmias. The goal is to identify dysrhythmias
 immediately via active cardiac monitoring in the very few patients who develop them, rather
 than identifying the dysrhythmia after the patient becomes symptomatic. However, the
 overwhelming majority (greater than 99 percent) of monitored patients do not experience any
 significant arrhythmia. The liberal use of monitoring in unnecessary situations may give the
 hospital staff a false sense of security and/or desensitize them to alarms. Studies also
 suggest the liberal use of telemetry inflates costs and clogs telemetry beds with little
 potential for benefit. These findings have contributed to the American Heart Association's
 statement that telemetry is of no benefit in patients with chest pain who are clinically
 low-risk or who are awake and alert and can describe their angina. Importantly, previous
 findings provide a foundation for identifying patients that do not need to undergo
 monitoring, but no study to date has rigorously prospectively applied these criteria in a
 randomized trial to determine the impact of selective telemetry utilization on clinical care
 and resources.

 This study is a pragmatic, randomized, controlled trial of telemetry compared with
 unmonitored floor admissions in ED patients with low-risk chest pain. The primary aim is to
 determine, relative to telemetry admission, if admission to an unmonitored floor bed saves
 resources without an increased rate of adverse events in ED patients admitted with chest pain
 and low-risk features. In addition, the study will evaluate the effects of the same
 intervention in the same population on secondary outcomes including defibrillation,
 cardioversion or acute IV antiarrhythmic/vasoactive therapy. Finally, the study will
 associate reasons for telemetry exclusion, including provider discretion, with subsequent
 adverse events.
Inclusion Criteria:

 -  Adult ED patients admitted to the medical service at Vanderbilt University Medical
 Center with chest pain and low-risk clinical features.

 Exclusion Criteria:

 -  Age less than 18 years

 -  Chest pain patients admitted to the ICU

 -  Patients with sickle cell disease

 -  Chest pain patients with high-risk electrocardiogram (ECG) criteria:

 -  abnormal but non-diagnostic of myocardial ischemia (prolonged PR, QRS, QTc intervals,
 new bundle branch blocks, left ventricular hypertrophy with strain)

 -  ischemia or prior infarction

 -  suggestive of acute myocardial infarction

 -  A positive troponin at any time during the current evaluation (above the 99 percent
 reference limit, greater than 0.03 nanograms per milliliter)

 -  Patients whom the admitting team feels has another non-low-risk indication for
 telemetry (e.g. acute heart failure, syncope with features concerning for a cardiac
 etiology, other arrhythmia)