Automated Predischarge Device Checks Using Remote Monitoring Technology

Cardiovascular implantable electronic devices are known as being on the forefront of telemedicine, and current devices now offer some form of remote monitoring. In the early days, transtelephonic monitoring was offered; today, remote monitoring is available for devices such as pacemakers, implantable defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. The prospective, multicenter Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) trial was the first and largest clinical trial to demonstrate the safety and efficacy of daily remote monitoring with BIOTRONIK Home Monitoring^®. Results showed that BIOTRONIK Home Monitoring reduced in-hospital evaluations by 45 percent and shortened intervention time in response to arrhythmic events from 36 days with conventional therapy to <2 days with remote monitoring.¹ Other studies have also observed a mortality benefit,² shorter hospitalization,³ shorter time to diagnosis of clinical events,⁴ fewer hospitalizations for atrial arrhythmias and stroke,⁵ and lower incidence of all ICD shock and inappropriate shocks.⁶ 

In this article, we present how Shoaib Saya, MD, FACC, FSCAI, an implanting cardiologist with Cardiology Partners in Mansfield, Texas, recently paired with company representative Ron Maxedon to deploy BIOTRONIK Home Monitoring in order to handle the predischarge device check of newly implanted pacemakers, ICDs, and CRT devices. 

Using Remote Monitoring for Predischarge Data

The goal of this collaboration was to use remote monitoring technology to streamline the patient’s hospital stay by dispensing with an in-person device check prior to discharge. BIOTRONIK Home Monitoring can be used to confirm that the implanted device is functioning properly and that threshold values fall into acceptable ranges. This step has not only demonstrated streamlined predischarge checks, but also yielded additional benefits. 

For example, it assured that the predischarge data were delivered to the physician in a timely way. In the past, the predischarge device check was performed with the support of a device company representative who traveled to the hospital in person for device interrogation and confirmation of appropriate device operation. This system required that a trained clinician use the programmer to obtain relevant threshold data and relay the information to the physician. Delays in this sequence of events could postpone a patient’s discharge. Potential delays might occur when the person checking the device was behind or had multiple predischarge checks to do on the same day. Such delays can be inconvenient to the patient and family, not to mention slowing patient throughput at the institution.
In addition, use of BIOTRONIK Home Monitoring for predischarge device checks has also lightened the clinical workload for the traveling clinicians, many of whom must follow-up with patients at multiple hospitals.

Experience Thus Far

Maxedon and Dr. Saya initiated this collaboration in 2015, by meeting with patients and providing them with BIOTRONIK Home Monitoring equipment during their hospital stay. They determined that by programming the BIOTRONIK Home Monitoring device to initiate self-testing at 5:00 a.m. daily, followed by transmission of results to the physician (usually by 7:00 a.m.), the system could become a suitable replacement for the face-to-face predischarge check. Furthermore, providing BIOTRONIK Home Monitoring equipment to patients while in the hospital meant that when patients were discharged, it was already available to them. This quickly allowed them to understand its use and setup. Previously, patients were instructed about their transmission system while in the hospital, but did not receive the actual transmission equipment until discharge from the hospital or by mail after they had returned home.

“We give the patients the BIOTRONIK Home Monitoring system while they are in the hospital, right after the implant procedures. The system is explained to them — in their presence, we plug it in and they find out they do not have to do anything complicated,” explained Dr. Saya. “They come to understand that this is part of their life as a pacemaker patient.”

The device patient has access to BIOTRONIK Home Monitoring from day one of device implantation. After an overnight stay in the hospital, device data are transmitted via the system to the physician’s smart phone as well as to a secure website for the clinic. In effect, this means the physician has all of the necessary information to discharge the device patient early in the morning, and no one has to depend on a device company representative to appear at the hospital to support an in-person device check. 

Dr. Saya has utilized this predischarge equipment distribution and explanation system dozens of times in the past few months. “Patient compliance is about 100 percent,” he remarked, noting that patient compliance with remote monitoring has been suboptimal for other types of remote monitoring systems. 

Overall noncompliance with ICD and CRT remote monitoring systems has been estimated at 21 percent.⁷ Patient education may be a factor in compliance. In some cases, patients are discharged from the hospital without learning anything about remote monitoring and receive the equipment weeks later in the mail. This may lead to the patient’s perception of the equipment as unnecessary or overly complex, especially when the monitoring does not occur automatically on a daily basis.

“We educate patients and families while the patient is in the hospital,” Dr. Saya explained.  “Once they understand BIOTRONIK Home Monitoring, they learn what it can mean for their overall health.” He recalled a patient with a new pacemaker who was concerned about taking a vacation in the mountains. The patient realized that with BIOTRONIK Home Monitoring, his pacemaker could be followed by the clinical team even though he was traveling far from home. “He said he felt very secure with Home Monitoring.”

Maria Viqar, MD, FACC, FHRS, a practicing electrophysiologist, observed that some healthcare professionals do not realize the range of capabilities of BIOTRONIK Home Monitoring. She and her team introduce BIOTRONIK Home Monitoring to patients and their families while they are at the hospital. Dr. Viqar also relies on this technology for predischarge checks.

“A big advantage of using BIOTRONIK Home Monitoring for the predischarge check is that there are no wires, no wand, and no need to put pressure or contact on the implant site,” she said. “Once patients realize the device check is done effortlessly, and with no special actions on their part, they are very accepting. Compliance is excellent.” She commented that with some remote systems, technophobic patients tend to avoid using the equipment. “This doesn’t happen with BIOTRONIK Home Monitoring when they realize all that is needed is to plug in the equipment.”

Dr. Saya noted that being able to access device data from his smart phone for his hospitalized patients facilitated prompt discharge (Figure 1). Dr. Viqar concurred, adding that, “When delays did occur with the previous method of in-person checks, it could cause a lot of inconvenience for the clinic and confusion, even distress, for the patient. Using BIOTRONIK Home Monitoring in this way also eliminates redundancy. I have the values on my phone by 7:00 in the morning, so the patient does not have to wait for anyone to arrive and use the programmer to be discharged.”

Final Thoughts

While the technological capabilities to use BIOTRONIK Home Monitoring for predischarge are nothing new, Ron Maxedon and his team have been working with physician and clinic accounts in Texas to systematically employ this method. They have found it has saved valuable clinical time and can even spare resources when patients can be discharged in a timely fashion. It also reduces the need for healthcare systems to depend on busy device representatives for certain support functions. Finally, it has boosted compliance for BIOTRONIK Home Monitoring and has the potential to reduce the need for in-clinic visits.

In addition, BIOTRONIK devices provide daily full-data transmission without any sacrifice of battery performance. Unlike some other systems, the BIOTRONIK devices utilize a cellular-based patient transmitter, which means that patients do not need to have a landline to use BIOTRONIK Home Monitoring. “The whole system is currently made available to patients while they are in the hospital, so patients come to view it as an integral part of their care,” Maxedon explained. “When clinicians consider these systems holistically, that is a very important factor.”

Hospitals can benefit from remote device checks as well. Patients who can be discharged promptly because of a remote monitoring device check may be more satisfied with their hospital experience than patients who might be delayed while waiting for a technician and programmer to evaluate their pacemaker. Prompt discharge allows for better patient throughput and may open up more beds for acute patients. In fact, for certain patients, hospitals and clinics might even be able to adopt a same-day discharge policy by taking advantage of remote monitoring predischarge checks.

Furthermore, Dr. Viqar added, “With the alert system, I know which of my patients may need prompt attention,” explaining that because of BIOTRONIK Home Monitoring, she has an up-to-date record of the patient’s device status. “For example, if my patient cannot come into the clinic for some reason or even if the patient is lost to follow-up, we can still monitor the device. We can monitor our patients 24/7.” 

“BIOTRONIK Home Monitoring allows us to get alerts from the device and may dispense with some in-clinic visits as well,” added Dr. Saya. “We have found that patients see this as reassuring. They realize that they do not have to wonder if the pacemaker is operating correctly because we are monitoring it.” He added that sometimes patients might call with a question, and BIOTRONIK Home Monitoring data available in the clinic can help answer their questions without an in-clinic visit. “For instance, a patient may call with a concern about the pacemaker, and we can reassure him that the device is functioning properly.”

As a result, remote monitoring is a win-win for all those involved: the patient, the clinician, and the healthcare system.

Disclosure: The author is with LeQ Medical, and discloses she received a fee from BIOTRONIK for writing this article.   

References

1. Varma N, Epstein A, Irimpen A, Schweikert R, Love C, Trust Investigators. Efficacy and safety of automatic remote monitoring for implantable cardioverter-defibrillator follow-up: the Lumos-T Safely Reduces Routine Office Device Follow-up (TRUST) trial. Circulation. 2010;122:325-332.
2. Saxon L, Hayes D, Gilliam F. Long-term outcome after ICD and CRT implantation and influence of remote device follow-up: the ALTITUDE survival study. Circulation. 2010;122:2359-2367.
3. Crossley G, Boyle A, Vitense H, Chang YY, Mead R, CONNECT Investigators. The CONNECT (Clinical Evluation of Remote Notification to Reduce Time to Clinical Decision) Trial: the value of wireless remote monitoring with automatic clinician alerts. J Am Coll Cardiol. 2011;57:1181-1189.
4. Crossley GH, Chen J, Choucair W, et al. Clinical benefits of remote versus transtelephonic monitoring of implanted pacemakers. J Am Coll Cardiol. 2009;54(22):2012-2019.
5. Mabo P, Victor F, Bazin P, et al. A randomized trial of long-term remote monitoring of pacemaker recipients (The COMPAS Trial). Eur Heart J. 2012;33(9):1105-1111.
6. Guedon-Moreau L, Lacroix D, Sadoul N, et al. A randomized study of remote follow-up of implantable cardioverter defibrillators: safety and efficacy report of the ECOST trial. Eur Heart J. 2013;34(8):605-614.
7. Rosenfeld LE, Patel AS, Ajmani VB, Holbrook RW, Brand TA. Compliance with remote monitoring of ICDS/CRTDS in a real-world population. Pacing Clin Electrophysiol. 2014;37(7):820-827.