In today’s busy world, one can be reached by phone, text, email, beeper, social media, and traditional mail. Now, our patients’ implantable cardiac devices can also reach us through remote monitoring. Industry promised us it would lighten our workloads, streamline patient care, and improve patient outcomes. Yet, practitioners have increased their workload and now have two devices to troubleshoot for each patient: their implantable cardiac device and home monitor. Although each device company offers a different monitor and standard of alerts, connectivity issues are still prominent. However, research has proven that remote monitoring has improved patient outcomes and mortality. In response to this, the Heart Rhythm Society published their expert consensus statement on remote interrogation and monitoring for cardiovascular electronic implantable devices in 2015 (hrsonline.org). Clinicians have a responsibility to navigate the information overload and medical legal implications, and to create workflows that maximize efficiency while improving patient care. We have entered unchartered territory and are witness to the birth of a new age in medicine.
Managing Alerts and Creating a Successful Workflow
Alerts were designed as an early warning system to detect lead failures, prevent inappropriate shocks, and treat new-onset atrial fibrillation (AF). Prior to remote monitoring, these events would go undetected for at least 3 months. Today, we have the ability to detect and treat within 24 hours. Countless lives have already been saved or improved because of this technology. Yet, the perception of information overload and negative medical legal implications still exist. The reality is that true alert rates are still very low. For example, in 2014, yellow alerts (atrial fibrillation) for the Pacemaker/ICD Clinic at North Shore Medical Center were 7.6% and red alerts (shocks and elective replacement) were 3.4%.
Although the numbers are small, clinics must create streamlined alert management across 5 different vendors. Alerts are fairly similar with each company, but there is some necessary fine-tuning needed to create standard alerts. Some examples of alert discrepancies: Medtronic does not consider ATP therapy an alert, yet St. Jude Medical and BIOTRONIK allow for non-sustained ventricular tachycardia as an alert. Older Boston Scientific monitors report shocks and atrial fibrillation on a weekly basis; their newer models report daily. Some alerts can only be activated within the device, some can only be activated on a website, and others have the capability of both.
In order to deal with these differences, our clinic has created standard remote monitoring alerts that are activated at the time of implant. We then tailor the alerts based on patient history and patient needs. We have also created a medical executive policy as to how and when alerts are communicated to the on-call physician. This has been especially helpful with new-onset AF. Patients are identified early for anticoagulation, cardioversion, and ablation. We also deactivate alerts that no longer provide benefit. If a patient develops persistent AF and cannot be treated, we will document that the alert has been disabled. While most alerts serve a greater purpose, there are still “nuisance” alarms such as an RV oversensing alert or an algorithm built out of necessity but that is highly sensitive to T-wave oversensing. Our staff has learned to program around the alert without sacrificing arrhythmia sensitivity. Still, alerts like this are time consuming, and at least 10 EGMs within a 24-hour period require clinician review if the device is not programmed correctly.
A successful workflow for remote management is imperative; otherwise, clinicians will feel overburdened and may suffer from alarm fatigue. Remote monitoring is a shared responsibility among industry, providers, and patients. We work closely with our device representatives to provide the best care to our patients. At implant, a device representative will enroll and pair the patient. Pairing a monitor may involve a simple serial number recognition upon enrollment or a more labor-intensive handshake between the monitor and implanted device. On the day of discharge, our clinic staff will give the patient their monitor and cellular adapter, and instruct them to plug in. At the 6-week visit, we provide a comprehensive review of remote monitoring and consent the patient to remote monitoring. We review how it works, hours of operation, and the patient’s responsibilities. This is a critical piece to workflow. The patients need to understand that this is not a 24-hour service, that they are responsible for their connections, and that the monitor is not a 911 system. The patients are also given the phone numbers to their manufacturer’s call centers to provide connectivity troubleshooting. Unfortunately, we have fielded countless connectivity phone calls from patients. Because of this, we have changed our consenting process to inform patients to utilize the call centers first. Workflows are not static; they require occasional evaluation and improvement.
Forging a new frontier into the management of patients with cardiac devices is both challenging and rewarding. Although remote monitoring has been proven time and again, we continue to struggle with information overload and workflow efficiencies. As we figure out best practices, we have the opportunity to share our knowledge, work closely with industry leaders, and fine-tune the nuances within our individual practices.
Disclosure: The author has no conflicts of interest to report regarding the content herein.