Telemetry Overuse and the Effect of Educational and Electronic Health Record-Based Interventions on an Academic Internal Medicine Ward.

OBJECTIVES: Guidelines for appropriate use of telemetry recommend monitoring for specific patient populations; however, many hospitalized patients receive telemetry monitoring without an indication. Clinical data and outcomes associated with nonindicated monitoring are not well studied. The objectives of our study were to evaluate the impact of an education and an order entry intervention on telemetry overuse and to identify the diagnoses and telemetry-related outcomes of patients who receive telemetry monitoring without guidelines indication. METHODS: A retrospective cohort study of hospitalized patients on internal medicine (IM) wards between 2015 and 2018 examining the effects of educational and order entry interventions at an academic urban medical center. A baseline cohort examining telemetry use was established. This was followed by the delivery of IM resident educational sessions regarding telemetry guidelines. In a subsequent intervention, the telemetry order entry system was modified with a constraint to require American Heart Association guidelines justification. RESULTS: Across all of the cohorts, 51% (n = 141) of patients lacked a guidelines-specified indication. These patients had variable diagnoses. The educational intervention alone did not result in significant differences in telemetry use by IM residents. The order entry intervention resulted in a significant increase in the proportion of guidelines-indicated patients and a decrease in nonindicated patients on telemetry. No safety events were noted in any group. CONCLUSIONS: A telemetry order entry system modification implemented following an educational intervention is more likely to reduce telemetry use than an educational intervention alone in IM resident practice. A variety of patients are monitored without evidence of need; therefore, the clinical impact of telemetry reduction is unlikely to be harmful.

Validity of a Novel Research-Grade Physical Activity and Sleep Monitor for Continuous Remote Patient Monitoring.

In the midst of the COVID-19 pandemic, Remote Patient Monitoring technologies are highly important for clinicians and researchers. These connected-health technologies enable monitoring of patients and facilitate remote clinical trial research while reducing the potential for the spread of the novel coronavirus. There is a growing requirement for monitoring of the full 24 h spectrum of behaviours with a single research-grade sensor. This research describes a free-living and supervised protocol comparison study of the Verisense inertial measurement unit to assess physical activity and sleep parameters and compares it with the Actiwatch 2 actigraph. Fifteen adults (11 males, 23.4 ± 3.4 years and 4 females, 29 ± 12.6 years) wore both monitors for 2 consecutive days and nights in the free-living study while twelve adults (11 males, 23.4 ± 3.4 years and 1 female, 22 ± 0 years) wore both monitors for the duration of a gym-based supervised protocol study. Agreement of physical activity epoch-by-epoch data with activity classification of sedentary, light and moderate-to-vigorous activity and sleep metrics were evaluated using Spearman's rank-order correlation coefficients and Bland-Altman plots. For all activity, Verisense showed high agreement for both free-living and supervised protocol of r = 0.85 and r = 0.78, respectively. For physical activity classification, Verisense showed high agreement of sedentary activity of r = 0.72 for free-living but low agreement of r = 0.36 for supervised protocol; low agreement of light activity of r = 0.42 for free-living and negligible agreement of r = -0.04 for supervised protocol; and moderate agreement of moderate-to-vigorous activity of r = 0.52 for free-living with low agreement of r = 0.49 for supervised protocol. For sleep metrics, Verisense showed moderate agreement for sleep time and total sleep time of r = 0.66 and 0.54, respectively, but demonstrated high agreement for determination of wake time of r = 0.83. Overall, our results showed moderate-high agreement of Verisense with Actiwatch 2 for assessing epoch-by-epoch physical activity and sleep, but a lack of agreement for activity classifications. Future validation work of Verisense for activity cut-point potentially holds promise for 24 h continuous remote patient monitoring.

Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study.

OBJECTIVES: Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods. MATERIALS AND METHODS: Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after 3 and 9 months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed. RESULTS: Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg. CONCLUSION: ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.

Cardiovascular nurses' adherence to practice standards in in-hospital telemetry monitoring.

BACKGROUND: Correct electrode placement and proper skin preparation for cardiac telemetry monitoring of patients at risk for arrhythmias increase the quality of the arrhythmic surveillance. Inconsistent arrhythmia surveillance can compromise patient safety and care outcomes. An inspection of international literature demonstrates that nurses generally do not adhere to cardiac monitoring standards. AIM: The aims of this study were to determine cardiovascular nurses' knowledge of and adherence to practice standards for cardiac surveillance and whether their knowledge and practice improves over time. STUDY DESIGN: A comparative study design was applied, and data were obtained by survey methodology. METHODS: Nurse delegates at the Annual National Congress on Cardiovascular Nursing in Norway completed surveys in 2011 and 2017 (delegates from 44 and 38 hospitals, respectively). RESULTS: In total, 363 cardiac nurses (70%) responded to the questionnaires. Of these, 95% were female, with a mean age of 41 years. In 2011, 97% of participants were unaware of international practice standards. However, by 2017 unawareness decreased to 78% (P < .001). Despite their lack of knowledge of practice standards, 94% of participants often or always prepared patients' skin for telemetry; this improved from 2011 to 2017 (P = .001). Overall, 73% of nurses never or seldom scrubbed or washed the patients' skin before electrode placement, and 38% of the electrodes were misplaced. In 2011, 49% of nurses used protective telemetry covers; this increased to 80% in 2017 (P < .001). Overall, 64% always informed patients of the purpose of cardiac monitoring. CONCLUSION: A significant percentage of nurses fail to adhere to recommendations for electrode placement, skin preparation and providing patients with telemetry information. In order to raise the quality of arrhythmic surveillance, investment in educational programmes in cardiac telemetry monitoring is required. RELEVANCE TO CLINICAL PRACTICE: Improved in-hospital telemetry practice is required to ensure patient safety and better care outcomes.

Wireless measurement of rectal temperature during exercise: Comparing an ingestible thermometric telemetric pill used as a suppository against a conventional rectal probe.

Wireless measurement of rectal temperature during exercise may circumvent some limitations associated with the use of a conventional wired probe. We determined, for the first time, whether temperatures provided in vivo by wireless ingestible thermometric telemetric pills and a rectal probe compare favorably under conditions producing slow and rapid increases and decreases in rectal temperature. While wearing a rectal probe linked to a wireless ingestible thermometric telemetric pill, 13 participants completed the following phases: 1) 30 min sitting; 2) 45 min passive heat exposure (40-42 °C); 3) 45 min sitting while ingesting 7.5 g of ice slurry · kg body mass-1; 4) running exercise (38 °C) at 68% V˙O2max until a 39.5 °C increase in rectal probe temperature and; 5) cold-water (10 °C) immersion until a 1.5 °C decrease in rectal probe temperature. Acceptable differences between devices were taken as ≤ 0.3 °C. Mean differences within phases were all < 0.3 °C, whereas 95% limits of agreement ranged from ±0.2 °C to ±0.4 °C, coefficient of variations from ±0.3% to ±0.6% and typical error of measurements from ±0.1 °C to ±0.2°. Of the 14881 rectal temperature values measured over the experiment with the wireless ingestible thermometric telemetric pills and rectal probe, 91% of the differences between devices were found to be ≤ 0.3 °C. Results suggest that rectal temperatures provided by a wireless ingestible thermometric telemetric pill used as a suppository agree with those of a conventional wired probe. Hence, rectal temperature can reliably be measured using a wireless ingestible thermometric telemetric pill as a suppository.

Appropriate utilisation of cardiac telemetry monitoring: a quality improvement project.

For hospitals located in the United States, appropriate use of cardiac telemetry monitoring can be achieved resulting in cost savings to healthcare systems. Our institution has a limited number of telemetry beds, increasing the need for appropriate use of telemetry monitoring to minimise delays in patient care, reduce alarm fatigue, and decrease interruptions in patient care. This quality improvement project was conducted in a single academic medical centre in Kansas City, Kansas. The aim of the project was to reduce inappropriate cardiac telemetry monitoring on intermediate care units. Using the 2004 American Heart Association guidelines to guide appropriate telemetry utilisation, this project team sought to investigate the effects of two distinct interventions to reduce inappropriate telemetry monitoring, huddle intervention and mandatory order entry. Telemetry utilisation was followed prospectively for 2 years. During our initial intervention, we achieved a sharp decline in the number of patients on telemetry monitoring. However, over time the efficacy of the huddle intervention subsided, resulting in a need for a more sustained approach. By requiring physicians to input indication for telemetry monitoring, the second intervention increased adherence to practice guidelines and sustained reductions in inappropriate telemetry use.

Patients' experiences of remote communication after pacemaker implant: The NORDLAND study.

BACKGROUND: The concept of 'patient experience' has become central to how to improve healthcare. Remote communication with patients is today a frequent practice in healthcare services, showing similar outcomes to standard outpatient care while enabling cost reduction in both formal and informal care. The purpose of this study was to analyse the experiences of people with telemonitoring pacemakers. METHODS: Patients were randomly allocated to either the telemonitoring or hospital monitoring follow-ups. Using the 'Generic Short Patient Experiences Questionnaire' (GS-PEQ), as well as an ad-hoc survey from the 'telehealth patient satisfaction survey' and 'costs survey', patients' experiences were measured six months after the pacemaker implant in a cohort of 50 consecutive patients. The mean age was 74.8 (± 11.75) years and 26 (52%) patients were male of which 1 was lost in follow-up. Finally, 24 patients were followed up with standard hospital monitoring, while 25 used the telemonitoring system. Differences in baseline characteristics between groups were not found. RESULTS: Findings showed overall positive and similar experiences in patients living with telemonitoring and hospital monitoring pacemakers. Significant differences were found in GS-PEQ concerning how telemonitoring patients received less information about their diagnosis/afflictions (p = 0.046). We did not find significant differences in other items such as 'confidence in the clinicians' professional skills', 'treatment perception adapted to their situation', 'involvement in decisions regarding the treatment', 'perception of hospital organisation', 'waiting before admission', 'satisfaction of help and treatment received', 'benefit received', and 'incorrect treatment'. CONCLUSIONS: The remote communication of pacemakers was met with positive levels of patients' experiences similarly to patients in the hospital monitoring follow-up. However, telemonitoring patients received less information. Thus, improving the quality and timing of information is required in telemonitoring patients in the planning and organisation of future remote communication healthcare services for people living with a pacemaker implant.

ReStore: A wireless peripheral nerve stimulation system.

BACKGROUND: The growing use of neuromodulation techniques to treat neurological disorders has motivated efforts to improve on the safety and reliability of implantable nerve stimulators. NEW METHOD: The present study describes the ReStore system, a miniature, implantable wireless nerve stimulator system that has no battery or leads and is constructed using commercial components and processes. The implant can be programmed wirelessly to deliver charge-balanced, biphasic current pulses of varying amplitudes, pulse widths, frequencies, and train durations. Here, we describe bench and in vivo testing to evaluate the operational performance and efficacy of nerve recruitment. Additionally, we also provide results from a large-animal chronic active stimulation study assessing the long-term biocompatibility of the device. RESULTS: The results show that the system can reliably deliver accurate stimulation pulses through a range of different loads. Tests of nerve recruitment demonstrate that the implant can effectively activate peripheral nerves, even after accelerated aging and post-chronic implantation. Biocompatibility and hermeticity tests provide an initial indication that the implant will be safe for use in humans. COMPARISON WITH EXISTING METHOD(S): Most commercially available nerve stimulators include a battery and wire leads which often require subsequent surgeries to address failures in these components. Though miniaturized battery-less stimulators have been prototyped in academic labs, they are often constructed using custom components and processes that hinder clinical translation. CONCLUSIONS: The results from testing the performance and safety of the ReStore system establish its potential to advance the field of peripheral neuromodulation.

Evaluation of Telemetry Utilization on Medical-Surgical Units.

Alarm fatigue is the most common contributing factor in alarm-related sentinel events. Researchers have demonstrated a 35% overuse of telemetry, a key factor in alarm fatigue. This project evaluates practice patterns for the ordering and discontinuation of telemetry on medical-surgical units. Practice patterns were reviewed to determine if they aligned with the American Heart Association evidence-based practice guidelines for telemetry monitoring and whether the order indication was congruent with the patient's clinical status. Nurse's attitudes and practices related to alarm safety were evaluated.

Reliability of Tidal Volume in Average Volume Assured Pressure Support Mode.

BACKGROUND: Remote monitoring is increasingly used in patients who receive home mechanical ventilation. The average volume assured pressure support mode is a target volume pressure preset mode that delivers a given tidal volume (VT) within a range of controlled inspiratory pressures. In a mode such as this, it is important to verify that the VT value retrieved from the ventilator SD card is accurate. METHODS: A lung model was set with C (Compliance) 0.075 L/cm H2O and RI (Inspiratory resistance)-RE (Expiratory resistance) 15-25 cm H2O/L/s (model 1) or with C 0.050 L/cm H2O and RI 6 cm H2O/L/s (model 2) and 6 cm H2O effort. Three home-care ventilators (A40, PrismaST30, and Vivo40) were set to average volume assured pressure support mode with 0.3 and 0.6 L VT each at PEEP 5 and 10 cm H2O, and were connected to the lung model with and without nonintentional leak. The reference airway pressure and flow were measured by a data logger. VT was expressed in body temperature and pressure saturated. We assessed the difference in VT between the ventilator SD card and a data logger relative to set VT and factors associated with its magnitude. RESULTS: For A40, PrismaST30, and Vivo40, the adjusted mean VT differences between the ventilator SD card and the data logger were -0.053 L (95% CI -0.067 to -0.039 L) (P < .001), -0.002 L (95%CI -0.022 to 0.019 L) (P = .86), and -0.067 L (95% CI -0.007 to 0.127 L) (P = .03), respectively. The partial Spearman correlation coefficients between the ventilator SD card and a data logger were 0.89 (P < .001), 0.59 (P < .001), and 0.78 (P < .001), respectively to the ventilators. The relative variations in measured VT from the set VT were 16.0, -12.0, and 6.7% for the ventilator SD card, and were -2.5, -7.5, and -27.2% for the data logger, respectively. The discrepancy in ventilator between SD card and data logger were influenced by PEEP for the PrismaST30 ventilator, nonintentional leak for the Vivo40 ventilator and PEEP, nonintentional leak, and underlying disease, the effect of each depending on the levels of the other factors, for the A40 ventilator. CONCLUSIONS: In the 3 home-care ventilators, the ventilator SD card underestimated VT. Factors involved in this difference differed among the ventilators.

Mayo Registry for Telemetry Efficacy in Arrest Study: An Assessment of the Utility of Telemetry in Predicting Clinical Decompensation.

INTRODUCTION: Our study assesses the utility of telemetry in identifying decompensation in patients with documented cardiopulmonary arrest. METHODS: A retrospective review of inpatients who experienced a cardiopulmonary arrest from May 1, 2008, until June 30, 2014, was performed. Telemetry records 24 hours prior to and immediately preceding cardiopulmonary arrest were reviewed. Patient subanalyses based on clinical demographics were made as well as analyses of survival comparing patients with identifiable rhythm changes in telemetry to those without. RESULTS: Of 242 patients included in the study, 75 (31.0%) and 110 (45.5%) experienced telemetry changes at the 24-hour and immediately preceding time periods, respectively. Of the telemetry changes, the majority were classified as nonmalignant (n = 50, 66.7% and n = 66, 55.5% at 24 hours prior and immediately preceding, respectively). There was no difference in telemetry changes between intensive care unit (ICU) and non-ICU patients and among patients stratified according to the American Heart Association telemetry indications. There was no difference in survival when comparing patients with telemetry changes immediately preceding and at 24 hours prior to an event (n = 30, 27.3% and n = 15, 20.0%) to those without telemetry changes during the same periods (n = 27, 20.5% and n = 42, 25.2%; P = .22 and .39). CONCLUSION: Telemetry has limited utility in predicting clinical decompensation in the inpatient setting.

Long-term Outcomes of the Effects of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Among Adults With Uncontrolled Hypertension: Follow-up of a Cluster Randomized Clinical Trial.

Importance: Hypertension is a leading cause of cardiovascular disease. The results were previously reported of a trial of home blood pressure (BP) telemonitoring and pharmacist management intervention in which the interventions stopped after 12 months. There were significantly greater reductions in systolic BP (SBP) in the intervention group than in the usual care group at 6, 12, and 18 months (-10.7, -9.7, and -6.6 mm Hg, respectively). Objectives: To examine the durability of the intervention effect on BP through 54 months of follow-up and to compare BP measurements performed in the research clinic and in routine clinical care. Design, Setting, and Participants: Follow-up of a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension in a large health system from March 2009 to November 2015. Interventions: A home BP telemonitoring intervention with pharmacist management or usual care. Main Outcomes and Measures: Change from baseline to 54 months in SBP and diastolic BP (DBP) measured as the mean of 3 measurements obtained at each research clinic visit. Results: Among 450 patients, 228 (mean [SD] age, 62.0 [11.7] years; 54.8% male) were randomized to the telemonitoring intervention and 222 (mean [SD] age, 60.2 [12.2] years; 55.9% male) to usual care. Research clinic BP measurements were obtained from 326 of 450 (72.4%) study patients at the 54-month follow-up visit, including 162 (mean [SD] age, 62.0 [11.1] years; 54.9% male) randomized to the telemonitoring intervention and 164 (mean [SD] age, 60.0 [11.2] years; 57.3% male) to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was -2.5 mm Hg (95% CI, -6.3 to 1.2 mm Hg; P = .18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of -1.0 mm Hg (95% CI, -3.2 to 1.2 mm Hg; P = .37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months. Conclusions and Relevance: This intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases. Trial Registration: ClinicalTrials.gov Identifier: NCT00781365.

An Integrated Approach Using Chaotic Map & Sample Value Difference Method for Electrocardiogram Steganography and OFDM Based Secured Patient Information Transmission.

This paper presents a patient's confidential data hiding scheme in electrocardiogram (ECG) signal and its subsequent wireless transmission. Patient's confidential data is embedded in ECG (called stego-ECG) using chaotic map and the sample value difference approach. The sample value difference approach effectually hides the patient's confidential data in ECG sample pairs at the predefined locations. The chaotic map generates these predefined locations through the use of selective control parameters. Subsequently, the wireless transmission of the stego-ECG is analyzed using the Orthogonal Frequency Division Multiplexing (OFDM) system in a Rayleigh fading scenario for telemedicine applications. Evaluation of proposed method on all 48 records of MIT-BIH arrhythmia ECG database demonstrates that the embedding does not alter the diagnostic features of cover ECG. The secret data imperceptibility in stego-ECG is evident through the statistical and clinical performance measures. Statistical measures comprise of Percentage Root-mean-square Difference (PRD), Peak Signal to Noise Ratio (PSNR), and Kulback-Leibler Divergence (KL-Div), etc. while clinical metrics includes wavelet Energy Based Diagnostic Distortion (WEDD) and Wavelet based Weighted PRD (WWPRD). The various channel Signal-to-Noise Ratio scenarios are simulated for wireless communication of stego-ECG in OFDM system. The proposed method over all the 48 records of MIT-BIH arrhythmia database resulted in average, PRD = 0.26, PSNR = 55.49, KL-Div = 3.34 × 10-6, WEDD = 0.02, and WWPRD = 0.10 with secret data size of 21Kb. Further, a comparative analysis of proposed method and recent existing works was also performed. The results clearly, demonstrated the superiority of proposed method.

[The telemedical service centre as an essential element of the conceptual approach for telemonitoring of cardiac patients : Requirements on the service, quality, and technical realization of telemonitoring]. / Das Telemedizinische Zentrum als essenzieller Baustein konzeptioneller Ansätze zum Telemonitoring kardialer Patienten : Anforderungen an Leistungen, Qualität und technische Umsetzung von Telemonitoring.

Telemonitoring as part of a treatment strategy supports and facilitates the monitoring, disease management and education of patients with heart failure and cardiac arrhythmias. Therefore, telemonitoring affects quality and success of the therapy. Thus, meeting the needs of the patients and of the involved health care professionals is important for the success of the telemonitoring service. Moreover, a high quality of the service has to be ensured. The following article describes several configuration options for telemonitoring services considering technical as well as quality- and service-related aspects.

The haemtrack home therapy reporting system: Design, implementation, strengths and weaknesses: A report from UK Haemophilia Centre Doctors Organisation.

INTRODUCTION: Haemtrack is an electronic home treatment diary for patients with inherited bleeding disorders, introduced in 2008. It aimed to improve the timeliness and completeness of patient-reported treatment records, to facilitate analysis of treatment and outcome trends. The system is easy to use, responsive and accessible. METHODS: The software uses Microsoft technologies with a SQL Server database and an ASP.net website front-end, running on personal computers, android and I-phones. Haemtrack interfaces with the UK Haemophilia Centre Information System and the National Haemophilia Database (NHD). Data are validated locally by Haemophilia Centres and centrally by NHD. Data collected include as follows: treatment brand, dose and batch number, time/date of bleed onset and drug administration, reasons for treatment (prophylaxis, bleed, follow-up), bleed site, severity, pain-score and outcome. RESULTS: Haemtrack was used by 90% of haemophilia treatment centres (HTCs) in 2015, registering 2683 patients using home therapy of whom 1923 used Haemtrack, entering >17 000 treatments per month. This included 68% of all UK patients with severe haemophilia A. Reporting compliance varied and 55% of patients reported ≥75% of potential usage. Centres had a median 78% compliance overall. A strategy for progressively improving compliance is in place. Age distribution and treatment intensity were similar in Haemtrack users/non-users with severe haemophilia treated prophylactically. CONCLUSION: The Haemtrack system is a valuable tool that may improve treatment compliance and optimize treatment regimen. Analysis of national treatment trends and large-scale longitudinal, within-patient analysis of changes in regimen and/or product will provide valuable insights that will guide future clinical practice.