Management of the Device Patient Outside the Arrhythmia Center

Increased numbers of patients are requiring implantable cardiac devices for the treatment of rhythm disturbances. As the number of device implants increases, so does the chance that these patients will end up in the Emergency Department for conditions related to their rhythm disturbances. Other locations that could be impacted by these device patients include hospital inpatient units, heart failure clinics, the operating room, and post-anesthesia recovery areas. Caregivers impacted by our current care delivery systems are not only physicians, but also mid-level providers and allied health professionals. For example, physicians in the Emergency Department must correlate the patient’s presenting complaints with actual data before formalizing a treatment plan. An anesthesiologist may need confirmation of device function post-surgical procedure. 

The nurse practitioner in the heart failure clinic may need to confirm biventricular pacing percentages or whether atrial fibrillation has occurred in order to deliver care. The nurse at the bedside may need the information obtained during a device interrogation in order to identify causative factors of patient symptoms and coordinate medication administration and other treatments. So many aspects of care depend upon the information contained in the device.

Every center handles these situations differently. Most major health care institutions have personnel on site that can interrogate devices and provide analysis 24 hours per day. For those smaller hospitals that do not have round-the-clock coverage or those facilities in remote areas where patients have to wait for an industry representative to arrive before treatment can be provided, creativity is needed to deal with these situations in an efficient manner. As we all look to reduce costs, increase patient satisfaction, improve access to care, and deliver quality care, adjuncts to our standard operating procedures are needed.

Several device companies now offer remote monitoring services designed for use in the healthcare setting. These services are set up on the same principles as those utilized for home monitoring using some of the same technology. Services are offered at a monetary cost to the facility, or in some cases, are free of charge if no local industry representation is readily available. Design is similar among services. Most incorporate monitors that can download device information that can be transmitted to experts who will review the data and report findings to the local caregivers. It is then the responsibility of the local caregiver to develop a plan of care based on the findings of the interrogation. 

Our Experience

Indiana University Health LaPorte Hospital is a 227-bed hospital in a rural community. Although we have a strong cardiac electrophysiology program, we do not have services readily available for device interrogation 24 hours per day. We rely on industry representatives to perform device interrogations in an emergent or urgent situation. Prior to implementation of our new monitoring adjunct, if a patient in the Emergency Department required device interrogation, the industry representative would have to be paged for an in-person device interrogation. We found that based on our location and the representative’s location, response times to the Emergency Department could often reach up to or greater than 150 minutes. This delay caused issues with timely medical decision-making and increased length of stay in the Emergency Department. 

After identifying that our facility had a problem with delays in treatment, we decided a collaborative effort between the Emergency Department, Arrhythmia Center, and industry was needed. These delays were logistical and related to our location, not to any fault of industry or caregivers. It was decided that due to the high volume of patients who had received Boston Scientific devices in the Arrhythmia Center, we identified this patient population as a priority. Our local representative for Boston Scientific, Ben Mendoza, and I met to discuss possible solutions and alternatives to the identified problem. After evaluating the options, recommendations were made to the medical staff. Then, with the assistance of Dr. James Leonard, Executive Director of Emergency Services, and Dr. Mark Dixon, Medical Director of the Arrhythmia Center, an action plan was put into place. It was decided that we would implement Boston Scientific’s LATITUDE Consult System in the Emergency Department.

The LATITUDE Consult System provides access to expert technical review of a Boston Scientific implanted device. The system provides caregivers with a convenient and secure way to review data. Virtual technical support is available 24 hours per day, 7 days per week. Local caregivers are able to discuss the reviewed implanted device data live with a trained U.S.-based LATITUDE Consult Technical Services Consultant. Reports are available via fax or emailed link, and include a transmission report similar to the standard programmer or LATITUDE reports. The system is designed to be easy to use by any caregiver at the patient’s bedside. 

It was determined that although easily utilized by any provider, the ER physician would initially be responsible for performing the interrogation of the device. More colleagues would be trained in the future, but it was felt that the core group should be physician based. Boston Scientific provided education on the process to the physician group before implementation of the program. Additional costs to implement the program were minimal. The only additional equipment needed (besides the LATITUDE Consult Communicator [Figure 1], which is used to read data from a patient’s implanted device via a telemetry wand placed over the patient’s device) was a dedicated fax line that was installed in the ER Nurses’ Station and marked clearly for use with “CONSULT Only”. The workflow was identified and placed in hospital policy format for reference. Boston Scientific provided readily available educational materials. In addition, Ben Mendoza was available during the first device interrogation to assist with any issues. Routine follow-up by Boston Scientific and Arrhythmia Center personnel is done to ensure the program is functioning as planned. 

Four easy steps were identified to complete the process, once a patient need was identified. It would be determined by the ER colleagues if the patient had a Boston Scientific supported device. This would be done via interview, previous medical records, or most reliably, by checking the patient ID card and comparing it to the listing of supported devices. The LATITUDE Consult System is compatible with 92% of Boston Scientific devices.¹ The ER physician would make the decision that the implanted device data was necessary to formulate further treatment plans. The ER physician would then use the LATITUDE Consult Communicator to read the implanted device and send data to the LATITUDE Consult server.

 A call would then be made by the ER physician to LATITUDE Consult Technical Services to request a review of data. LATITUDE Consult Technical Services would review data with the ER physician and send a written report via fax to the ER. The transmission report includes a review summary and notes completed by LATITUDE Consult Technical Services. The device data in each report is current as of the time the device was read. The data can include up to 12 months of device or lead trend data as well as the most recent 72 hours of stored episode details.² The information in the report is reflected in the dictation of the ER visit as well as included in the medical record to prevent duplication of services and to provide continuity of care. 

The ER physician would then determine the needed treatment plan based on the information given. If there were questions concerning what the transmission meant to the patient condition, collaboration with the cardiac electrophysiologist or general cardiologist would be done. Although all device information can be provided through a LATITUDE Consult transmission, it is limited in the fact that changes to programmed parameters or functions or commanded lead tests cannot be done remotely. Industry representatives would be paged to the ER if programming or further diagnostic data was needed. 

After implementation of LATITUDE Consult, an analysis of the throughput times of ER patients implanted with Boston Scientific devices was undertaken in the IU Health LaPorte ER. Twenty-five patient encounters were reviewed (Table 1). The baseline time from Decision to Interrogate to Analysis was originally measured at 150 minutes. Decision to Interrogate to Analysis was a measurement of the time that began when it was determined that an interrogation was needed by the ER physician. It also includes the time it took for the Boston Scientific representative to be paged and respond for the in-person device interrogation. 

In the analysis post-implementation of LATITUDE Consult, we measured the time it took for the Interrogation to Analysis. It was felt that this was a similar measurement, as the ER physician was making the decision to interrogate the device at this time. We established a goal of less than 60 minutes from Interrogation to Analysis. Each component integral to the process was measured in minutes. Results of this analysis indicated that after the implementation of the LATITUDE Consult System, the Interrogation to Analysis time was cut to an average of 28 minutes. This consisted of an average of 21 minutes that was attributed to ER personnel performing the interrogation and transmitting to Boston Scientific, as well as additional, non-device related care to the patient. An average of 6 minutes was attributed to the confirmation call to Boston Scientific and the analysis of the interrogation. This validates comparative data noted that clinicians had access to full technical consultation in an average of 15 minutes or less.³ It should be noted that of 25 patients, 52% were discharged from the ER while 48% were admitted to the hospital for further treatment. It was determined in only one case (4%) that a representative was required for in-person programming changes after interpretation of the interrogation was complete. It was reported by Boston Scientific that 91% of patient follow-up cases were resolved via the LATITUDE Consult System rather than requiring a wait for qualified personnel with a BSC Programmer.⁴ In addition, even though 32% of the patients had noted arrhythmia within 72 hours of the ER visit, the information that was provided to caregivers allowed outpatient treatment instead of hospital admission. 

Numerous benefits were noted by reducing the time to device analysis by up to 122 minutes. After implementation of LATITUDE Consult, device interrogations were not the limiting steps in getting patients out of the ER, as had been in the past. According to Dr. Leonard, several gains were noted after use of LATITUDE Consult. “Most importantly, we have more timely medical decision-making for the patient. We act on the results noted on the LATITUDE Consult System, and expedite treatment to the patient. In addition, the LATITUDE Consult System assists the ER with throughput of patients and increases our efficiency. It has been a phenomenal success — beyond my expectations!” Dr. Leonard also explained that IU Health Laporte ER is in one of the highest deciles in the nation on the patient throughput matrix, and that “device interrogation is no longer detrimental to the process.” One of Dr. Leonard’s colleagues, Dr. Ginger Cotter, also shared similar sentiments. Dr. Cotter explained that she works a large majority of night shifts in which resources are not always so readily available. She expressed that “the biggest assist is being able to talk to a person who could analyze the data for me and explain what is happening with the patient’s device.” This allows her to provide quicker and more guided, individualized treatment to her patient. Dr. Dixon also expressed his satisfaction with the program. “The information gained from LATITUDE Consult allows the ER physician to better care for my patients. I am provided with more timely and clinically significant data when a collaborative effort is needed for a patient in the ER.” 

In addition to the report that is submitted to the ER, it was requested that a copy of the report be sent simultaneously to the Arrhythmia Center. This action also expedites continued care to the patient as the Arrhythmia Center now has an awareness that a patient had been to the ER for possible device-related causes. This allows for follow-up to be completed on an outpatient basis. 

Summary

Utilization of the LATITUDE Consult System has proven effective in the care and treatment of those patients with Boston Scientific-compatible devices at IU Health LaPorte Hospital. It is anticipated that based on the success of the program in the ER, the program will be expanded to the critical care areas and anesthesia services. Continued evaluation of the program will be utilized to identify any areas needing improvement. 

Disclosures: The author has no conflicts of interest to report regarding the content herein. Outside the submitted work, she reports paid compensation for serving on product-specific advisory committees as well as providing education for several continuing education functions sponsored by Boston Scientific. 

References

1. BSC Engineering Data, January 2015.
2. Boston Scientific Corporation, The LATITUDE Consult System, PowerPoint presentation, October, 2014.
3. LATITUDE Consult System Limited Launch Dashboard, May-December, 2014.
4. LATITUDE Consult System Limited Launch Dashboard, October-December, 2014.