Placement of cardiac implantable electronic devices (CIEDs) including pacemakers, implantable cardioverter defibrillators (ICDs), and loop recorders, has risen rapidly over the past several years.1,2 Management of these devices is supported by established guidelines for remote home monitoring.3 While patients are instructed how to use remote monitoring equipment, they often need device interrogations in the hospital to assess device settings, evaluate stored events, or determine the cause of syncope or defibrillator discharge. The current workflow is to wait for a trained personnel or manufacturer’s representative with a programmer to interrogate the device.
Manufacturers have developed technology for remote interrogation of CIEDs for hospital use. This standalone equipment can interrogate a patient’s CIED via a wand placed over the device. The systems can only read data, they cannot reprogram or change any functions. Like the patient’s home monitoring system, the CIED can be interrogated by anyone, without specific training in devices or electrophysiology. Data is securely transmitted to the specific manufacturer’s representative for interpretation. Findings are reported to local care providers via a phone call, fax, and/or secure email. The final report is also available to enrolled patients on the home remote monitoring website. Research has shown that hospital remote interrogations provide a safe, efficient, and cost-effective alternative to traditional CIED interrogation.4-9 Time to interpretation of the interrogation has been reported to be as low as 15 minutes.4-7,9 Patients needing further in-person programming has been reported to be <5%.4,8-9 Despite these positive outcomes, this innovative technology has been slow to be adopted.
In this article, we describe a nurse-managed remote CIED interrogation program for hospital patients. In 2017, we began using this remote technology at Edward Hospital, and have now performed over 300 interrogations. We have trained approximately 20 charge nurses on the new technology. The following discussion includes personnel training, the logistics of a new workflow, and reporting of results for Medtronic, Boston Scientific, and Abbott CIEDs.
Personnel and Training
Remote interrogations do not require device training, knowledge of specialized electrophysiology, or the use a device programmer. Personnel who are willing and able to learn the simple technology can perform this skill. Performing a remote interrogation is similar to the patient’s at-home interrogation process; there is no possibility of programming changes. The remote interrogation equipment is available at no cost from the manufacturer. The simple equipment can be kept in a locked area accessible to the trained users. Medtronic, Boston Scientific, and Abbott all require a specific fax number to be linked to their equipment, so a secure report can be automatically faxed to the hospital. Future plans focus on a remote transmission report directly exported into the electronic medical record.
We recommend enlisting a champion to start up this new workflow as well as an administrative leader who supports the new technology and workflow. In addition, it is necessary to identify clinical personnel to implement the program. At our institution, this effort was led by a cardiology nurse practitioner and cardiac telemetry nurse clinical leader. The director of our inpatient telemetry units identified a core group of telemetry unit charge nurses to be trained. Those that were interested were trained by the representative from each manufacturer and the clinical leaders. Cardiology nurse practitioners were also trained on how to perform remote interrogations in our outpatient heart failure and left ventricular assist device (LVAD) clinics. We initially planned to train a core group from the emergency department, but the charge nurse team chose to travel to all units.
The clinical leaders made “tip cards” to supplement specific manufacturer instruction cards and created a resource folder on their computer-based education website. Once the core group of nurses were trained on use and logistics, we started with remote interrogations and made weekly process improvement changes.
Performing an interrogation is a relatively straightforward process. When there is a request for a device interrogation from the physician or nurse practitioner, the charge nurse is notified of patient name, room number, and device manufacturer. The remote interrogation is done by the nurse, and takes 5-10 minutes. The manufacturer’s representative is then notified of the patient’s name, reason for the interrogation, and the contact number for the requesting provider. The nurse doing the transmission documents in the electronic medical record that the transmission is complete.
Reporting of Results
Reporting of remote interrogation results is the important final step. Ensuring that the final interpretation is relayed to the appropriate provider is a protocol that should be established from the start. At our hospital, the remote interrogation is reviewed by the local manufacturer’s representative, and then the findings are called to the provider. One of the important changes that we made after the initial startup was ensuring that the physician or nurse practitioner requesting the interrogation receive the phone call from the manufacturer. We specifically did not want the representative to call the charge nurse with the interpretation, but rather, the provider requesting the information. For example, the battery, sensing, and pacing functions may be “normal”, but there may be stored events or possibly an increased atrial fibrillation burden that needs to be relayed to the provider. This level of detail is likely beyond the expertise of the staff nurse.
Hospitals have the option on how to receive the final report, including:
- A phone call to the provider with final interpretation;
- A final report to a secure dedicated fax number;
- A final report to the secure manufacturer’s website if patient is enrolled in home remote monitoring;
- A final report to the electronic medical record.
Remote interrogation of CIEDs can improve efficiencies in care, as the device interrogation can be done immediately rather than waiting for trained personnel or a manufacturer’s representative with a programmer to interrogate the device. The systems can only read data, they cannot reprogram or change any functions. This new workflow is outlined in Figure 1. Starting a successful hospital remote interrogation program can be done with nurses, although other institutions have also successfully used ECG technicians or respiratory therapists as well.
We see potential uses for remote interrogation to improve efficiencies throughout the hospital. Use in the ED or telemetry units for evaluation of shocks, syncope, or atrial fibrillation burden can be evaluated by remote interrogation. Diagnostics from the device can also be remotely evaluated for heart failure patients. Workflow improvement with remote interrogations should be considered in perioperative or radiation therapy areas where device interrogations are often requested. There is also a potential for use of this technology with routine post-implant checks as well. A change in workflow may not always be easy in hospitals, but once implemented, you’ll wonder why you hadn’t started sooner!
Disclosures: Ms. Gifford has received honoraria from Medtronic and Boston Scientific for Allied Professional Advisory Boards, as well as received research grants from Medtronic. Ms. Szymanek has nothing to disclose. Dr. Larimer has received consultancy fees from PhysIQ, Inc.
- Hammill SK, Kremers MS, Stevenson LW, et al. Review of the registry's fourth year, incorporating lead data and pediatric ICD procedures, and use of a national performance measure. Heart Rhythm. 2010;7(9):1340-1345.
- Mond G, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009— a World Society of Arrhythmia’s project. Pacing Clin Electrophysiol. 2011;34(8):1013-1027.
- Slotwiner D, Varma N, Akar J, et al. HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Heart Rhythm. 2015;12(7):E69-100.
- Atherton C. Management of the device patient outside the arrhythmia center. EP Lab Digest. 2015;15(8):1,6-9.
- Ahmed I, Patel AS, Balgaard TJ, Rosenfeld LE. Technician-supported remote interrogation of CIEDs: initial use in US emergency departments and perioperative areas. Pacing Clin Electrophysiol. 2016;39(3):275-281.
- Mittal S, Younge K, King-Ellison K, Hammill E, Stein K. Performance of a remote interrogation system for the in-hospital evaluation of cardiac implantable electronic devices. J Interv Card Electrophysiol. 2016;46(2):121-128.
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- Neuenschwander JF, Peacock WF, Le P, et al. 102: Pacemaker and defibrillator interrogations in the emergency department and hospital rarely lead to device reprogramming (abstract). Ann Emerg Med. 2017;70(4):S41.
- Kloosterman E, Rosman J, Rosenbaum M. Hospital in-patient remote interrogation of cardiac devices is effective and significantly decreases the need for bed-side specialist interaction (abstract). Heart Rhythm. May 2018.