NR 451 Week 7 Telemetry Protocol Evaluation Plan Example

Evaluating a Nurse-Driven Telemetry Discontinuation Protocol on a Medical Step-Down Unit

Student Name

College of Nursing, Chamberlain University

NR 451: RN Capstone Course

Instructor Name

Month Day, Year

Evaluating a Nurse-Driven Telemetry Discontinuation Protocol on a Medical Step-Down Unit

The Change Being Evaluated

The capstone change is a nurse-driven protocol for discontinuing cardiac telemetry on a composite 36-bed medical step-down unit. At admission, every telemetry order will carry an indication chosen from the categories in the American Heart Association practice standards for electrocardiographic monitoring, each with a recommended duration (Sandau et al., 2017). When the duration for the indication has passed, the patient has had no qualifying arrhythmia or change in condition, and no new indication applies, the nurse may discontinue telemetry without a new order and notify the prescriber in the daily plan. A similar approach, building the guideline indications into the order itself, reduced telemetry use substantially at one hospital without an apparent increase in adverse outcomes (Dressler et al., 2014).

The unit's current practice is that telemetry, once ordered, continues until discharge unless someone remembers to stop it. The evaluation below defines how the unit will tell whether the protocol changed that practice, whether it changed the outcome it targets, and whether it caused harm.

Outcome Measure

Name: Telemetry days per 100 patient days.

Numerator: Total calendar days on which a patient on the unit had an active telemetry order for any part of the day, summed across all patients discharged from the unit during the month.

Denominator: Total patient days on the unit for the same discharged patients during the same month, multiplied by 100.

Time window: Calendar month.

Data source: Monthly report from the electronic health record order history, built by nursing informatics using the same query every month; the capstone student will validate the first report by hand-checking ten patients.

Why this measure: It counts the thing the protocol is designed to reduce, unnecessary days on the monitor, and it adjusts for census so a quiet month does not look like a success.

Baseline on the Same Definition

The baseline is the same measure, telemetry days per 100 patient days, calculated from the order history for the six months before go-live using the identical query. A preliminary run of that query for the most recent three months gave 71 telemetry days per 100 patient days, meaning that on a typical day about seven of every ten patients on the unit were on a monitor. The full six-month baseline will be reported as a monthly run chart with its median, so that the post-change months can be read against normal month-to-month variation rather than against a single average. Provost and Murray (2011) recommend at least 12 data points before a run chart is used to judge change, and the six baseline months together with at least six post-change months will provide them.

Process Measure

Name: Percentage of telemetry orders with a documented indication and duration.

Numerator: Telemetry orders placed on the unit during the month that include an indication from the protocol list.

Denominator: All telemetry orders placed on the unit during the month.

Second process measure: Among patients whose indication duration expired during the month, the percentage whose telemetry was discontinued within 12 hours of expiry or who had a documented reason to continue. Collected by the unit champion from a weekly audit of ten such patients.

Why these measures: If telemetry days fall, these tell the unit whether the protocol caused the fall. If telemetry days do not fall, they show where the process broke, at ordering or at discontinuation.

Balancing Measure

Name: Rapid response calls and unplanned transfers to intensive care for arrhythmia or cardiac deterioration per 1,000 patient days.

Numerator: Rapid response calls and unplanned intensive care transfers from the unit in which arrhythmia, syncope, chest pain or a new cardiac finding was listed as the reason, identified from the rapid response log.

Denominator: Unit patient days for the month, multiplied by 1,000.

Additional review: Every such event occurring in a patient whose telemetry had been discontinued under the protocol in the previous 48 hours will be reviewed by the unit educator and the cardiology nurse practitioner within one week.

Why this measure: The obvious harm this change could cause is a missed arrhythmia in a patient taken off the monitor. Watching for it deliberately, rather than hearing about it later, is what makes the change defensible to cardiology and to staff.

Collection Schedule and Ownership

The outcome and balancing measures will be pulled monthly by nursing informatics on the fifth business day of each month and sent to the unit nurse manager and the capstone student. The indication process measure will come from the same report. The discontinuation audit will be completed weekly by the day-shift unit champion, who will review ten patients whose indication duration expired, using a one-page tool. Results will be plotted on run charts and reviewed monthly at the unit practice council. After the capstone ends, the unit educator will own the charts, and the measures will move to the unit quality dashboard at six months.

What Would Count as Success and Failure

Success is defined in advance on three conditions together. First, telemetry days per 100 patient days fall by at least one quarter from the baseline median, to 53 or fewer, and stay there for at least three consecutive months, or a run chart signal such as six consecutive points below the median appears. Second, at least 85 of every 100 telemetry orders carry an indication, and at least 75 of every 100 expired indications lead to discontinuation or a documented reason to continue. Third, the balancing measure does not rise above its baseline range, and no case review finds that a discontinuation under the protocol contributed to harm. Requiring all three conditions at once prevents the unit from declaring success on a falling number that was bought with missed arrhythmias or produced by a quiet month.

Failure is also defined. If telemetry days do not fall after three months despite high process scores, the protocol's durations may be too long for this unit's patients and should be reviewed with cardiology. If process scores stay low, the problem is adoption, and the plan returns to education and order set design before any conclusion about the protocol is drawn. If any case review finds that a protocol discontinuation contributed to harm, the protocol will be paused for that indication pending review, whatever the other measures show. Naming these thresholds now keeps the evaluation able to reach a verdict instead of reporting numbers that cannot be judged.

References

Dressler, R., Dryer, M. M., Coletti, C., Mahoney, D., & Doorey, A. J. (2014). Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Internal Medicine, 174(11), 1852-1854. https://doi.org/10.1001/jamainternmed.2014.4491

Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.

Sandau, K. E., Funk, M., Auerbach, A., Barsness, G. W., Blum, K., Cvach, M., Lampert, R., May, J. L., McDaniel, G. M., Perez, M. V., Sendelbach, S., Sommargren, C. E., & Wang, P. J. (2017). Update to practice standards for electrocardiographic monitoring in hospital settings: A scientific statement from the American Heart Association. Circulation, 136(19), e273-e344. https://doi.org/10.1161/CIR.0000000000000527