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The purpose of this study was to determine if rates of telemetry events differ between patients whose monitoring is appropriately “indicated” versus “not indicated” by systematically applying rigorous criteria for appropriateness of electrocardiogram (ECG) telemetry usage. We performed a retrospective cohort study on 1097 telemetry admissions between January 1, 2000 and March 31, 2000. A convenience sample of 218 patients generated 236 telemetry admissions. One-hundred-sixty-two arrhythmic events were detected during 400 “indicated” telemetry days. Nine arrhythmic events were detected during 345 “not indicated” telemetry days. The relative rate for arrhythmic events was significantly different, at P < 0.0001, with the incidence rate ratio of 15 indicating a very large effect size. Consequently, current use of ECG telemetry may not be optimal, and a prospective analysis of the application of rigorous indications for ECG telemetry needs to be undertaken.