Introduction
Congestive heart failure (CHF) continues to be a major cause of morbidity and mortality in the United States & around the globe. CHF is responsible for 1.1 million hospitalizations per year with an average 30-day readmission rate of 25%. It is estimated that spending for HF will reach 100 billion dollars in 2030.
Many patients with reduced ejection fraction heart failure are implanted with ICD’s/BiV ICDs. These devices are able to be monitored remotely from home utilizing a remote transmitter that sends device data over a secure connection to a server. That data can then be reviewed to assess device function. These transmissions occur automatically every 91 days or so and only require the patient to make sure the transmitter is connected at the bedside. Remote monitoring is considered the standard of care per the Heart Rhythm Society.
In addition to routine quarterly remote interrogations, most ICDs and BIV ICDs collect and trend physiologic parameters such as thoracic impedance, respiratory rate, nighttime heart rate, activity level, and heart rate variability that can be followed monthly. Heart failure events that require a trip to the Emergency Department or admission are often preceded by changes in one or more of the parameters. These changes occur well before the patient becomes symptomatic. Some devices now have an algorithm that attempts to alert clinicians via a remote website when a patient is at higher risk of a heart failure event.
Traditionally, HF specialists and EP physicians have had little reason to collaborate. EPs implanted and followed the device, and HF specialists managed HF. Technology is now blurring those lines, so we need to rethink the way we manage HF data. Who is going to “own” this data? EP’s may not wish to manage HF, and HF specialists may not have the expertise to manage devices.
Our Practices
The Heart Center uses a collaborative approach to bridge that gap. Our device clinic has a team of 2 RNs and 1 data technician dedicated to remote monitoring of HF diagnostic data. We review remote interrogations on a monthly basis and pay close attention to changes in physiologic parameters as well as increase in atrial fibrillation burden and/or ventricular arrhythmia that could indicate a change in the patients condition. We have a protocol in place to triage the patient, if a change is noted. Our protocol allows for temporary up titration of diuretics for 3 days if patient has normal serum creatinine resulted in the previous six months.
Next, the patient is sent for basic lab work and scheduled to see an advanced practice provider or cardiologist within 7 days. If the patient is enrolled in the outpatient CHF clinic, the data is reported to the HF clinic and they follow up with the patient. Findings from the device are copied into our EMR and are available for all team members following the patient.
If a patient is admitted to any facility within our health system with a diagnosis of CHF, the nursing admission assessment includes asking the patient if they have a PPM or ICD. If the answer is yes, a text message is automatically sent to the CHF device clinic (CHFD) nurse phone. We enroll that patient in CHFD if they have a device with ICM monitoring capability. The outpatient CHF clinic is also notified. Both monitor the patient on a weekly basis after discharge until stable. This aggressive approach has allowed for reduction in HF hospitalizations to be realized across our practice. Data regarding diagnostic data from the device is reported to the HF clinician the day prior to the patient’s appointment, thus the CRNP will have the data in hand at the time of the appointment.
Our Collaborative Approach
We work very closely with our organization’s heart failure management team, the outpatient CHF Clinic, and our general cardiologists to provide the best patient care possible. This collaboration allows for device optimization and arrhythmia management by the EP service. On top of that, we focus on reducing ED visits, hospitalizations, and readmissions by our CHF clinic. Our organization has seen tremendous success with this collaborative approach. Additionally, our 30-day readmission rate of 17% is well below the national average!
Insurance companies and Medicare realize the value of remote monitoring of HF diagnostics. They reimburse for monthly remote monitoring, in addition to the routine quarterly remote follow up schedule. This reimbursement has made it possible for our practice to provide this very valuable service to our community.
Conclusion
CV Remote Solutions offers best-in-class monthly monitoring for Heart Failure diagnostics to device clinics and/or Heart Failure clinics who would like to take their HF program to the next level. Let the dedicated professionals at CV Remote show you what a device-based heart failure management program can do for your practice!
Regina R. McGee, RN is the senior device nurse at The Heart Center in Huntsville, Al. She has over 14 years of experience with CRDM. She has developed protocols for and implemented a Congestive Heart Failure Device Clinic that now follows over 1300 patients. She developed a close working relationship with the Heart Failure Management Team at Huntsville Hospital and has built a successful remote monitoring program that is recognized worldwide. Regina serves as a CV Remote Solutions consultant to help develop successful remote monitoring programs.