The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 273–277, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.08.098
AAEM Clinical Practice TELEMETRY BED USAGE FOR PATIENTS WITH LOW-RISK CHEST PAIN: REVIEW OF THE LITERATURE FOR THE CLINICIAN Jack Perkins, MD,*† Michael T. McCurdy, MD,† Gary M. Vilke, MD,‡ and Adel A. Al-Marshad, MD‡ *Virginia Tech Carilion School of Medicine, Roanoke, Virginia, †University of Maryland School of Medicine, Baltimore, Maryland, and ‡Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California Reprint Address: Adel A. Al-Marshad, MD, Department of Emergency Medicine, UC San Diego Medical Center, 200 West Arbor Drive Mail Code #8676, San Diego, CA 92103
, Abstract—Background: Telemetry monitoring in patients with low-risk chest pain is highly utilized, despite the lack of quality data to support its use. Study Objectives: To review the medical literature on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians. Methods: A PubMed literature search was performed and limited to human studies written in English language articles with keywords of ‘‘telemetry’’ and ‘‘chest pain.’’ Studies identified then underwent a structured review from which results could be evaluated. Results: There were 114 paper abstracts on telemetry monitoring screened; 30 articles were considered relevant. Twelve appropriate articles were rigorously reviewed and recommendations given. Conclusions: Insufficient data exist to support telemetry use in low-risk chest pain patients. Telemetry monitoring is unlikely to benefit low-risk chest pain patients with a normal/nondiagnostic electrocardiogram, a normal first set of cardiac enzymes, and none of the following: hypotension, rales above the bases, or pain worse than baseline angina. Ó 2014 Elsevier Inc.
INTRODUCTION Every year, more than 8 million Americans present to the emergency department (ED) with chest pain, making it the second most common complaint in the ED (1). Although < 5% of low-risk chest pain patients are found to have an acute myocardial infarction (MI), many are admitted to the hospital for further evaluation (2). Telemetry monitoring in patients with low-risk chest pain is highly utilized despite the lack of quality data to support its use. In fact, it rarely detects clinically meaningful dysrhythmias, may lead to unnecessary tests and procedures, is expensive, and significantly increases ED boarding due to patients awaiting inpatient telemetry beds (3,4). The 2004 American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines for inpatient telemetry monitoring provide screening recommendations for dysrhythmias, ischemia, and QT-interval abnormalities in adults and children (5). These guidelines are based almost exclusively on expert opinion due to the dearth of pertinent clinical trials. The vague and confusing nature of these guidelines is highlighted in the Class I recommendation to keep all ‘‘rule-out MI’’ patients on telemetry until 24 h after they are pain free. However, ‘‘Chest Pain Syndromes,’’ which may include ‘‘rule-out MI’’ patients, is a separate subject in the
, Keywords—telemetry; chest pain; Goldman criteria; low-risk chest pain
This Clinical Practice paper was approved by the American Academy of Emergency Medicine Clinical Practice Committee.
RECEIVED: 4 April 2013; FINAL SUBMISSION RECEIVED: 7 August 2013; ACCEPTED: 17 August 2013 273
274
J. Perkins et al.
Table 1. The Definitions of the Grades of Evidence of the Articles Grade A
Grade B
Grade C Grade D Grade E Grade F
Randomized clinical trials or meta-analyses (multiple clinical trials) or randomized clinical trials (smaller trials), directly addressing the review issue Randomized clinical trials or meta-analyses (multiple clinical trials) or randomized clinical trials (smaller trials), indirectly addressing the review issue Prospective, controlled, nonrandomized, cohort studies Retrospective, nonrandomized, cohort or casecontrol studies Case series, animal/model scientific investigations, theoretical analyses, or case reports Rational conjecture, extrapolations, unreferenced opinion in literature, or common practice
guidelines under Class II recommendations. Such ambiguity has undoubtedly facilitated the common practice of admitting all chest pain patients to telemetry. Low-risk chest pain is defined by the ACC/AHA as those patients with a normal or ‘‘near-normal’’ electrocardiogram, (ECG; unchanged from prior or no ST or T-wave changes in contiguous leads), normal cardiac enzymes, normal cardiac rhythms, and normal hemodynamics (6). Although various risk prediction scores exist, the one most commonly utilized is the Goldman risk-scoring system, whose components include: 1) ischemic changes on ECG; 2) systolic blood pressure < 100 mm Hg; 3) bilateral pulmonary rales above the bases; and 4) pain worse than baseline angina (7). According to Goldman et al., a normal ECG and # 1 of these risk factors is categorized as ‘‘low risk,’’ meaning the patient has a # 5% chance of a major cardiac event (e.g., coronary artery bypass grafting, MI, death) at 30 days (7). For the purposes of this statement, we will utilize the above-referenced Goldman criteria to define ‘‘low risk’’ chest pain. However, based on the following data, we believe a negative first set of cardiac enzymes should be included in this definition. This work was done at the request of and published as a clinical practice statement by the American Academy of Emergency Medicine (AAEM) Clinical Practice Committee. MATERIALS AND METHODS For this structured review of the topic of chest pain and telemetry monitoring, a literature search of the National
Library of Medicine’s MEDLINE database’s PubMed system was performed and limited to articles written in the English language. A keyword search of ‘‘telemetry AND chest pain’’ was used to identify potential articles. Two reviewers independently examined all of the abstracts and selected relevant articles for full review. If either of the reviewers felt an abstract should be pulled for full review, it was selected. All of the references of the selected articles were then reviewed to determine if additional papers should be considered for review. Inclusion criteria for articles for final review were those that were randomized controlled trials, clinical trials, prospective cohort studies, and meta-analyses in human subjects. Case reports, case series, general review articles, and guideline statements were not included for the selection criteria for formal rigorous review. Studies targeting differences between specific populations, such as males vs. females, were excluded. Two emergency medicine physicians independently conducted a structured review of the identified telemetry monitoring studies, and each study was individually classified based on a Grade of Evidence Review. If there was a discrepancy between the grades by the two reviewers, a third reviewer was available to serve as a tie-breaker. The levels of the evidence were assigned grades using the definitions as noted in Table 1, and were based on reference focus, specific research design, and methodology. Each of the selected articles was also subjected to detailed review and assigned a Quality Ranking based on a critical assessment with regards to quality of the design and methodology. This includes Design Consideration (e.g., focus, model structure, presence of controls) and Methodology Consideration (actual methodology utilized). The definitions of the Quality Ranking scores are included in Table 2. Independent review of the articles, as well as discussion and joint review by the authors were undertaken to answer the clinical question. The references were sorted into three categories: supportive, neutral, and opposed. A table was constructed to assign the supportive references to the appropriate location using both the Grade of Evidence and the Quality of Evidence. Finally, based on the review of the literature, articles were assigned levels of recommendation, which are defined in Table 3.
Table 2. The Definitions of the Quality Ranking Scores of the Articles Ranking
Design Consideration Present
Methodology Consideration Present
Both Considerations Present
Outstanding Good Adequate Poor Unsatisfactory
Appropriate Appropriate Adequate with possible bias Limited or biased Questionable/none
Appropriate Appropriate Adequate Limited Questionable/none
Yes, both present No, either present No, either present No, either present No, either present
Telemetry Bed Usage for Patients with Low-risk Chest Pain
275
Table 3. Definitions for Recommendations Level of Recommendation
Criteria for Level of Recommendation
Class B 1
Acceptable Safe Useful Established/definitive Acceptable Safe Useful Not yet definitive Standard approach
Class B 2
Optional or alternative approach
Class C (Not acceptable or not appropriate)
Unacceptable Unsafe Not useful Minimal to no evidence
Class A (Recommended with outstanding evidence) Class B (Acceptable and appropriate with good evidence)
Class Indeterminate (Unknown)
RESULTS The initial literature search provided 114 citations, the abstracts of which were examined to assess relevance to study questions. From this review, 30 manuscripts were selected by the two reviewers based on their relevance to the clinical question. The reference section review did not reveal any additional articles. Of the 30 manuscripts, 12 met inclusion criteria for final review to be described in detail and are listed in Table 4. The grade of evidence and the quality of evidence for each of the reviewed articles are listed in Table 5. Several studies in the past few decades have evaluated the utility of telemetry monitoring in patients with lowrisk chest pain. Estrada et al. prospectively completed one of the first studies addressing the utility of telemetry monitoring on 2240 patients admitted to a telemetry unit (8). Of the 1225 patients admitted for chest pain, only 4 (0.3%) were transferred to the intensive care unit for dysrhythmias. A more pertinent prospective study by Hollander et al. utilized the Goldman risk score and initial cardiac enzymes (9). They reviewed 1029 cases of patients admitted to telemetry beds with negative initial cardiac enzymes and low-risk Goldman criteria. Even though 15 (1.5%) patients eventually ruled in for MI, and another 121 (11.8%) were given the diagnosis of unstable angina, none of the 1029 study patients had sustained ventricular tachycardia or ventricular fibrillation. Two of the 1029 patients died during the study, but both were due to noncardiac causes. A study by Durairaj et al. also applied the Goldman risk score algorithm to patients with and without chest pain admitted to an inpatient telemetry unit (10). There were 318 patients who had ‘‘very low-risk’’ (Goldman score of zero) chest pain, and none of these patients had
Mandatory Evidence Level A/B grade Outstanding quality Robust All positive Level A/B grade lacking Adequate to Good quality Most evidence positive No evidence of harm Higher grades of evidence Consistently positive Lower grades of evidence Generally, but not consistently, positive No positive evidence Evidence of harm Minimal to no evidence
any major complications during the first 72 h of admission. The final study reviewed for this statement was a retrospective trial by Saleem et al. involving 105 consecutive patients admitted for suspected acute coronary syndrome (ACS) (11). Although two-thirds of the patients were older than 60 years, none had any significant events on telemetry. A 2007 meta-analysis supports the data above by concluding that a subgroup of chest pain patients with normal ECGs and normal cardiac biomarkers can be safely admitted to unmonitored beds (12). DISCUSSION Telemetry bed availability is a valuable and scarce hospital resource that should be used in an efficient and appropriate fashion. Currently, most hospitals mandate that all patients being evaluated for ACS require telemetry monitoring. However, the data do not support this practice for all patients presenting with chest pain. In fact, the literature evaluating the utility of telemetry for low-risk chest pain patients suggests, and we endorse, the following recommendations: Recommendation 1: Insufficient data exist to support telemetry use in low-risk chest pain patients. Level of recommendation: Class A Recommendation 2: Patients unlikely to benefit from telemetry monitoring are those with a normal/ nondiagnostic ECG, a normal first set of cardiac enzymes, and none of the following: hypotension, rales above the bases, or pain worse than baseline angina. Level of recommendation: Class B2 The review has also identified that developing a more standardized definition of low-risk chest pain will be useful for future studies on the utility of telemetry
276
J. Perkins et al.
Table 4. Details of the 12 Reviewed Articles Ref. # 1 2 3 4 5 6 7 8 9
10
11
12
Study
Grade
Quality
Type
Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Report 2008;7:1–38. Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187–95. Henriques-Forsythe MN, Ivonye CC, Jamched U, et al. Is telemetry overused? Is it as helpful as thought? Clev Clin J Med 2009;76:368–72. Chen EH, Hollander JE. When do patients need admission to a telemetry bed? J Emerg Med 2007;33:53–9. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation 2004;110:2721–46. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain. Circulation 2010;122:756–76. Goldman L, Cook EF, Johnson PA, et al. Prediction of the need for intensive care inpatients who come to emergency departments with acute chest pain. N Engl J Med 1996;334:1498–504. Estrada CA, Rosman HS, Prasad NK, et al. Role of telemetry monitoring in the nonintensive care unit. Am J Cardiol 1995;76:960–5. Hollander JE, Sites FD, Pollack CV Jr., Shofer FS. Lack of utility of telemetry monitoring for identification of cardiac death and lifethreatening ventricular dysrhythmias in low-risk patients with chest pain. Ann Emerg Med 2004;43:71–6. Durairaj L, Reilly B, DasK, et al. Emergency department admissions to inpatient cardiac telemetry beds: a prospective cohort study of risk stratification and outcomes. Am J Med 2001; 110:7–11. Saleem MA, McClung JA, Aronow WS, et al. Inpatient telemetry does not need to be used in the management of older patients hospitalized with chest pain at low risk for in-hospital coronary events and mortality. J Gerontol 2005;60:605–6. O’Neill DR. Low-risk classified chest pain patients: do they need cardiac monitoring in the emergency department and can they be cared for in non-monitored beds? Aust Emerg Nur J 2007;10:58–63.
D
Good
Retrospective
D
Good
Review article
D
Good
Review article
D
Good
Review article
D
Adequate
Consensus guidelines
D
Good
Consensus guidelines
A
Outstanding
Multi-Center validated study
C
Good
Prospective study
C
Outstanding
Prospective study
C
Good
Prospective study
D
Adequate
Retrospective
D
Adequate
Review article
monitoring. Additionally, the subset of chest pain patients who can be safely discharged from the ED has yet to be fully identified. These are both areas of opportunity for future research.
able evidence, as well as the search parameters used for finding relevant articles for review.
Limitations
Based on our review of the literature, insufficient data exist to support telemetry use in low-risk chest pain patients. After reviewing the available literature, the ACC/ AHA guidelines, and the validated Goldman Risk scoring system, we conclude that patients unlikely to benefit from telemetry monitoring (i.e., those with a low risk for significant 30-day morbidity and mortality) are those with a normal first set of cardiac enzymes and a Goldman risk score of < 1 (i.e., a normal/nondiagnostic ECG and none of the following: hypotension, rales above the bases, or pain worse than baseline angina). Developing a more standardized definition of low-risk chest pain will be useful for future studies on the utility of telemetry monitoring. The subset of chest pain patients who can be safely discharged from the ED has yet to be fully identified.
The review of the clinical question addressed in this article is limited by the quality and quantity of the availTable 5. The Grade of Evidence and the Quality of Evidence for Each of the Reviewed Articles Supportive Evidence (Article # Referenced) Quality/Grade
A
Outstanding Good Adequate Poor Unsatisfactory
7
B
C 9 8,10
D 1–4,6 5,11,12
CONCLUSIONS
Telemetry Bed Usage for Patients with Low-risk Chest Pain
REFERENCES 1. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Rep 2008;7:1–38. 2. Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187–95. 3. Henriques-Forsythe MN, Ivonye CC, Jamched U, et al. Is telemetry overused? Is it as helpful as thought? Clev Clin J Med 2009;76: 368–72. 4. Chen EH, Hollander JE. When do patients need admission to a telemetry bed? J Emerg Med 2007;33:53–9. 5. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation 2004; 110:2721–46. 6. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain. Circulation 2010;122:756–76.
277 7. Goldman L, Cook EF, Johnson PA, et al. Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain. N Engl J Med 1996;334:1498–504. 8. Estrada CA, Rosman HS, Prasad NK, et al. Role of telemetry monitoring in the non-intensive care unit. Am J Cardiol 1995;76:960–5. 9. Hollander JE, Sites FD, Pollack CV Jr, Shofer FS. Lack of utility of telemetry monitoring for identification of cardiac death and lifethreatening ventricular dysrhythmias in low-risk patients with chest pain. Ann Emerg Med 2004;43:71–6. 10. Durairaj L, Reilly B, Das K, et al. Emergency department admissions to inpatient cardiac telemetry beds: a prospective cohort study of risk stratification and outcomes. Am J Med 2001;110:7–11. 11. Saleem MA, McClung JA, Aronow WS, et al. Inpatient telemetry does not need to be used in the management of older patients hospitalized with chest pain at low risk for in-hospital coronary events and mortality. J Gerontol 2005;60:605–6. 12. O’Neill DR. Low-risk classified chest pain patients: do they need cardiac monitoring in the emergency department and can they be cared for in non-monitored beds? Aust Emerg Nur J 2007;10:58–63.
http://dx.doi.org/10.1016/j.jemermed.2013.08.098
AAEM Clinical Practice TELEMETRY BED USAGE FOR PATIENTS WITH LOW-RISK CHEST PAIN: REVIEW OF THE LITERATURE FOR THE CLINICIAN Jack Perkins, MD,*† Michael T. McCurdy, MD,† Gary M. Vilke, MD,‡ and Adel A. Al-Marshad, MD‡ *Virginia Tech Carilion School of Medicine, Roanoke, Virginia, †University of Maryland School of Medicine, Baltimore, Maryland, and ‡Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California Reprint Address: Adel A. Al-Marshad, MD, Department of Emergency Medicine, UC San Diego Medical Center, 200 West Arbor Drive Mail Code #8676, San Diego, CA 92103
, Abstract—Background: Telemetry monitoring in patients with low-risk chest pain is highly utilized, despite the lack of quality data to support its use. Study Objectives: To review the medical literature on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians. Methods: A PubMed literature search was performed and limited to human studies written in English language articles with keywords of ‘‘telemetry’’ and ‘‘chest pain.’’ Studies identified then underwent a structured review from which results could be evaluated. Results: There were 114 paper abstracts on telemetry monitoring screened; 30 articles were considered relevant. Twelve appropriate articles were rigorously reviewed and recommendations given. Conclusions: Insufficient data exist to support telemetry use in low-risk chest pain patients. Telemetry monitoring is unlikely to benefit low-risk chest pain patients with a normal/nondiagnostic electrocardiogram, a normal first set of cardiac enzymes, and none of the following: hypotension, rales above the bases, or pain worse than baseline angina. Ó 2014 Elsevier Inc.
INTRODUCTION Every year, more than 8 million Americans present to the emergency department (ED) with chest pain, making it the second most common complaint in the ED (1). Although < 5% of low-risk chest pain patients are found to have an acute myocardial infarction (MI), many are admitted to the hospital for further evaluation (2). Telemetry monitoring in patients with low-risk chest pain is highly utilized despite the lack of quality data to support its use. In fact, it rarely detects clinically meaningful dysrhythmias, may lead to unnecessary tests and procedures, is expensive, and significantly increases ED boarding due to patients awaiting inpatient telemetry beds (3,4). The 2004 American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines for inpatient telemetry monitoring provide screening recommendations for dysrhythmias, ischemia, and QT-interval abnormalities in adults and children (5). These guidelines are based almost exclusively on expert opinion due to the dearth of pertinent clinical trials. The vague and confusing nature of these guidelines is highlighted in the Class I recommendation to keep all ‘‘rule-out MI’’ patients on telemetry until 24 h after they are pain free. However, ‘‘Chest Pain Syndromes,’’ which may include ‘‘rule-out MI’’ patients, is a separate subject in the
, Keywords—telemetry; chest pain; Goldman criteria; low-risk chest pain
This Clinical Practice paper was approved by the American Academy of Emergency Medicine Clinical Practice Committee.
RECEIVED: 4 April 2013; FINAL SUBMISSION RECEIVED: 7 August 2013; ACCEPTED: 17 August 2013 273
274
J. Perkins et al.
Table 1. The Definitions of the Grades of Evidence of the Articles Grade A
Grade B
Grade C Grade D Grade E Grade F
Randomized clinical trials or meta-analyses (multiple clinical trials) or randomized clinical trials (smaller trials), directly addressing the review issue Randomized clinical trials or meta-analyses (multiple clinical trials) or randomized clinical trials (smaller trials), indirectly addressing the review issue Prospective, controlled, nonrandomized, cohort studies Retrospective, nonrandomized, cohort or casecontrol studies Case series, animal/model scientific investigations, theoretical analyses, or case reports Rational conjecture, extrapolations, unreferenced opinion in literature, or common practice
guidelines under Class II recommendations. Such ambiguity has undoubtedly facilitated the common practice of admitting all chest pain patients to telemetry. Low-risk chest pain is defined by the ACC/AHA as those patients with a normal or ‘‘near-normal’’ electrocardiogram, (ECG; unchanged from prior or no ST or T-wave changes in contiguous leads), normal cardiac enzymes, normal cardiac rhythms, and normal hemodynamics (6). Although various risk prediction scores exist, the one most commonly utilized is the Goldman risk-scoring system, whose components include: 1) ischemic changes on ECG; 2) systolic blood pressure < 100 mm Hg; 3) bilateral pulmonary rales above the bases; and 4) pain worse than baseline angina (7). According to Goldman et al., a normal ECG and # 1 of these risk factors is categorized as ‘‘low risk,’’ meaning the patient has a # 5% chance of a major cardiac event (e.g., coronary artery bypass grafting, MI, death) at 30 days (7). For the purposes of this statement, we will utilize the above-referenced Goldman criteria to define ‘‘low risk’’ chest pain. However, based on the following data, we believe a negative first set of cardiac enzymes should be included in this definition. This work was done at the request of and published as a clinical practice statement by the American Academy of Emergency Medicine (AAEM) Clinical Practice Committee. MATERIALS AND METHODS For this structured review of the topic of chest pain and telemetry monitoring, a literature search of the National
Library of Medicine’s MEDLINE database’s PubMed system was performed and limited to articles written in the English language. A keyword search of ‘‘telemetry AND chest pain’’ was used to identify potential articles. Two reviewers independently examined all of the abstracts and selected relevant articles for full review. If either of the reviewers felt an abstract should be pulled for full review, it was selected. All of the references of the selected articles were then reviewed to determine if additional papers should be considered for review. Inclusion criteria for articles for final review were those that were randomized controlled trials, clinical trials, prospective cohort studies, and meta-analyses in human subjects. Case reports, case series, general review articles, and guideline statements were not included for the selection criteria for formal rigorous review. Studies targeting differences between specific populations, such as males vs. females, were excluded. Two emergency medicine physicians independently conducted a structured review of the identified telemetry monitoring studies, and each study was individually classified based on a Grade of Evidence Review. If there was a discrepancy between the grades by the two reviewers, a third reviewer was available to serve as a tie-breaker. The levels of the evidence were assigned grades using the definitions as noted in Table 1, and were based on reference focus, specific research design, and methodology. Each of the selected articles was also subjected to detailed review and assigned a Quality Ranking based on a critical assessment with regards to quality of the design and methodology. This includes Design Consideration (e.g., focus, model structure, presence of controls) and Methodology Consideration (actual methodology utilized). The definitions of the Quality Ranking scores are included in Table 2. Independent review of the articles, as well as discussion and joint review by the authors were undertaken to answer the clinical question. The references were sorted into three categories: supportive, neutral, and opposed. A table was constructed to assign the supportive references to the appropriate location using both the Grade of Evidence and the Quality of Evidence. Finally, based on the review of the literature, articles were assigned levels of recommendation, which are defined in Table 3.
Table 2. The Definitions of the Quality Ranking Scores of the Articles Ranking
Design Consideration Present
Methodology Consideration Present
Both Considerations Present
Outstanding Good Adequate Poor Unsatisfactory
Appropriate Appropriate Adequate with possible bias Limited or biased Questionable/none
Appropriate Appropriate Adequate Limited Questionable/none
Yes, both present No, either present No, either present No, either present No, either present
Telemetry Bed Usage for Patients with Low-risk Chest Pain
275
Table 3. Definitions for Recommendations Level of Recommendation
Criteria for Level of Recommendation
Class B 1
Acceptable Safe Useful Established/definitive Acceptable Safe Useful Not yet definitive Standard approach
Class B 2
Optional or alternative approach
Class C (Not acceptable or not appropriate)
Unacceptable Unsafe Not useful Minimal to no evidence
Class A (Recommended with outstanding evidence) Class B (Acceptable and appropriate with good evidence)
Class Indeterminate (Unknown)
RESULTS The initial literature search provided 114 citations, the abstracts of which were examined to assess relevance to study questions. From this review, 30 manuscripts were selected by the two reviewers based on their relevance to the clinical question. The reference section review did not reveal any additional articles. Of the 30 manuscripts, 12 met inclusion criteria for final review to be described in detail and are listed in Table 4. The grade of evidence and the quality of evidence for each of the reviewed articles are listed in Table 5. Several studies in the past few decades have evaluated the utility of telemetry monitoring in patients with lowrisk chest pain. Estrada et al. prospectively completed one of the first studies addressing the utility of telemetry monitoring on 2240 patients admitted to a telemetry unit (8). Of the 1225 patients admitted for chest pain, only 4 (0.3%) were transferred to the intensive care unit for dysrhythmias. A more pertinent prospective study by Hollander et al. utilized the Goldman risk score and initial cardiac enzymes (9). They reviewed 1029 cases of patients admitted to telemetry beds with negative initial cardiac enzymes and low-risk Goldman criteria. Even though 15 (1.5%) patients eventually ruled in for MI, and another 121 (11.8%) were given the diagnosis of unstable angina, none of the 1029 study patients had sustained ventricular tachycardia or ventricular fibrillation. Two of the 1029 patients died during the study, but both were due to noncardiac causes. A study by Durairaj et al. also applied the Goldman risk score algorithm to patients with and without chest pain admitted to an inpatient telemetry unit (10). There were 318 patients who had ‘‘very low-risk’’ (Goldman score of zero) chest pain, and none of these patients had
Mandatory Evidence Level A/B grade Outstanding quality Robust All positive Level A/B grade lacking Adequate to Good quality Most evidence positive No evidence of harm Higher grades of evidence Consistently positive Lower grades of evidence Generally, but not consistently, positive No positive evidence Evidence of harm Minimal to no evidence
any major complications during the first 72 h of admission. The final study reviewed for this statement was a retrospective trial by Saleem et al. involving 105 consecutive patients admitted for suspected acute coronary syndrome (ACS) (11). Although two-thirds of the patients were older than 60 years, none had any significant events on telemetry. A 2007 meta-analysis supports the data above by concluding that a subgroup of chest pain patients with normal ECGs and normal cardiac biomarkers can be safely admitted to unmonitored beds (12). DISCUSSION Telemetry bed availability is a valuable and scarce hospital resource that should be used in an efficient and appropriate fashion. Currently, most hospitals mandate that all patients being evaluated for ACS require telemetry monitoring. However, the data do not support this practice for all patients presenting with chest pain. In fact, the literature evaluating the utility of telemetry for low-risk chest pain patients suggests, and we endorse, the following recommendations: Recommendation 1: Insufficient data exist to support telemetry use in low-risk chest pain patients. Level of recommendation: Class A Recommendation 2: Patients unlikely to benefit from telemetry monitoring are those with a normal/ nondiagnostic ECG, a normal first set of cardiac enzymes, and none of the following: hypotension, rales above the bases, or pain worse than baseline angina. Level of recommendation: Class B2 The review has also identified that developing a more standardized definition of low-risk chest pain will be useful for future studies on the utility of telemetry
276
J. Perkins et al.
Table 4. Details of the 12 Reviewed Articles Ref. # 1 2 3 4 5 6 7 8 9
10
11
12
Study
Grade
Quality
Type
Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Report 2008;7:1–38. Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187–95. Henriques-Forsythe MN, Ivonye CC, Jamched U, et al. Is telemetry overused? Is it as helpful as thought? Clev Clin J Med 2009;76:368–72. Chen EH, Hollander JE. When do patients need admission to a telemetry bed? J Emerg Med 2007;33:53–9. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation 2004;110:2721–46. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain. Circulation 2010;122:756–76. Goldman L, Cook EF, Johnson PA, et al. Prediction of the need for intensive care inpatients who come to emergency departments with acute chest pain. N Engl J Med 1996;334:1498–504. Estrada CA, Rosman HS, Prasad NK, et al. Role of telemetry monitoring in the nonintensive care unit. Am J Cardiol 1995;76:960–5. Hollander JE, Sites FD, Pollack CV Jr., Shofer FS. Lack of utility of telemetry monitoring for identification of cardiac death and lifethreatening ventricular dysrhythmias in low-risk patients with chest pain. Ann Emerg Med 2004;43:71–6. Durairaj L, Reilly B, DasK, et al. Emergency department admissions to inpatient cardiac telemetry beds: a prospective cohort study of risk stratification and outcomes. Am J Med 2001; 110:7–11. Saleem MA, McClung JA, Aronow WS, et al. Inpatient telemetry does not need to be used in the management of older patients hospitalized with chest pain at low risk for in-hospital coronary events and mortality. J Gerontol 2005;60:605–6. O’Neill DR. Low-risk classified chest pain patients: do they need cardiac monitoring in the emergency department and can they be cared for in non-monitored beds? Aust Emerg Nur J 2007;10:58–63.
D
Good
Retrospective
D
Good
Review article
D
Good
Review article
D
Good
Review article
D
Adequate
Consensus guidelines
D
Good
Consensus guidelines
A
Outstanding
Multi-Center validated study
C
Good
Prospective study
C
Outstanding
Prospective study
C
Good
Prospective study
D
Adequate
Retrospective
D
Adequate
Review article
monitoring. Additionally, the subset of chest pain patients who can be safely discharged from the ED has yet to be fully identified. These are both areas of opportunity for future research.
able evidence, as well as the search parameters used for finding relevant articles for review.
Limitations
Based on our review of the literature, insufficient data exist to support telemetry use in low-risk chest pain patients. After reviewing the available literature, the ACC/ AHA guidelines, and the validated Goldman Risk scoring system, we conclude that patients unlikely to benefit from telemetry monitoring (i.e., those with a low risk for significant 30-day morbidity and mortality) are those with a normal first set of cardiac enzymes and a Goldman risk score of < 1 (i.e., a normal/nondiagnostic ECG and none of the following: hypotension, rales above the bases, or pain worse than baseline angina). Developing a more standardized definition of low-risk chest pain will be useful for future studies on the utility of telemetry monitoring. The subset of chest pain patients who can be safely discharged from the ED has yet to be fully identified.
The review of the clinical question addressed in this article is limited by the quality and quantity of the availTable 5. The Grade of Evidence and the Quality of Evidence for Each of the Reviewed Articles Supportive Evidence (Article # Referenced) Quality/Grade
A
Outstanding Good Adequate Poor Unsatisfactory
7
B
C 9 8,10
D 1–4,6 5,11,12
CONCLUSIONS
Telemetry Bed Usage for Patients with Low-risk Chest Pain
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