Outsourcing the Remote Management of Cardiac Implantable Electronic Devices: Medical Care Quality Improvement Project

Abstract

Background: Remote management is partially replacing routine follow-up in patients implanted with cardiac implantable electronic devices (CIEDs). Although it reduces clinical staff time compared with standard in-office follow-up, a new definition of roles and responsibilities may be needed to review remote transmissions in an effective, efficient, and timely manner. Whether remote triage may be outsourced to an external remote monitoring center (ERMC) is still unclear.

Objective: The aim of this health care quality improvement project was to evaluate the feasibility of outsourcing remote triage to an ERMC to improve patient care and health care resource utilization.

Methods: Patients (N=153) with implanted CIEDs were followed up for 8 months. An ERMC composed of nurses and physicians reviewed remote transmissions daily following a specific remote monitoring (RM) protocol. A 6-month benchmarking phase where patients' transmissions were managed directly by hospital staff was evaluated as a term of comparison.

Results: A total of 654 transmissions were recorded in the RM system and managed by the ERMC team within 2 working days, showing a significant time reduction compared with standard RM management (100% vs 11%, respectively, within 2 days; P<.001). A total of 84.3% (551/654) of the transmissions did not include a prioritized event and did not require escalation to the hospital clinician. High priority was assigned to 2.3% (15/654) of transmissions, which were communicated to the hospital team by email within 1 working day. Nonurgent device status events occurred in 88 cases and were communicated to the hospital within 2 working days. Of these, 11% (10/88) were followed by a hospitalization.

Conclusions: The outsourcing of RM management to an ERMC safely provides efficacy and efficiency gains in patients' care compared with a standard in-hospital management. Moreover, the externalization of RM management could be a key tool for saving dedicated staff and facility time with possible positive economic impact.

Trial registration: ClinicalTrials.gov NCT01007474; http://clinicaltrials.gov/ct2/show/NCT01007474.

Keywords: cardiac implantable electronic devices; follow-up; implantable cardioverter defibrillator; implantable defibrillators; pacemaker; remote monitoring; telemonitoring; triage outsourcing.

Figure 1

Remote management flowchart. Green events are all transmissions not reporting device detections listed as low or high priority. In case of missed scheduled transmissions or disconnected monitors, the external remote monitoring center (ERMC) inform the technical team responsible for contacting the patient. RRT: recommended replacement time; TAO: oral anticoagulation therapy; AT/AF: atrial tachyarrhythmia/atrial fibrillation; CRT: cardiac resynchronization therapy; SVC: superior vena cava. DOO, VOO, and AOO are programming modes.

Figure 2

(A) Distribution of transmission by priority; (B) low-priority detected events; and (C) high-priority detected events. CRT-D: cardiac resynchronization therapy defibrillator, ICD: single- or dual-chamber implantable cardioverter defibrillator, IPG: single- or dual-chamber pacemaker, CRT-P: cardiac resynchronization therapy pacemaker.

Figure 3

Time from transmission to communication with the hospital.

Figure 4

(A) Distribution of time from transmission to review, benchmarking phase versus external remote monitoring center (ERMC) phase; and (B) Percentage of reviewed transmissions, benchmarking phase versus ERMC phase. RM: remote monitoring.