Remote Monitoring of Cardiac Implantable Electrical Devices (CIEDs) Changing the face of enhanced self-management and improved coordinated healthcare K Fan, CKC Tsui, KL Au, RTC Ng, CYS Chung, KW Lai, KW Sit, MH Jim, G Yip Cardiac Medical Unit Grantham Hospital
Remote Monitoring of CIEDs Background 葛 量 洪 醫 院
2009 SURVEY CARDIAC PACEMAKERS AND ICDS (Number of devices implanted worldwide) 1200000 1000000 800000 600000 400000 PM ICD 200000 0 1997 2001 2005 2009 Source: The 11th World Survey of Cardiac Pacing and Implantable Cardioverter-Defibrillators: Calendar Year 2009-A World Society of Arrhythmia s Project
Continuous increases in services demand and expertise
Remote Monitoring of CIEDs CIEDs with Remote Monitoring capability Remote Monitoring transmitter Remote Monitoring system website Devices send information via wireless radio frequency at scheduled time Encrypted information upload through household telephone lines Treatment, detection & record Encrypt the Received information Authorized personnel access the information by logging into the system with PIN codes
Patient convenience Clinic efficiency Better device surveillance Remote Follow-up Improved monitoring of arrhythmia and heart failure Proactive approach and improved disease management Remote Monitoring
Features of Remote Monitoring Longevity Lead integrity Types of arrhythmia, duration and frequency Severity of pulmonary edema Pre-set Urgent alerts can be detected by the Remote Monitoring System, and then faxed to the healthcare staff Information confidentiality: information is kept in accordance to Information Security Standard ISO/IEC27001:1995
Routine OPD arrangement for CIEDs Specialist Out-patient Clinic Self-monitoring Self-monitoring Self-monitoring Self-monitoring Self-monitoring In-clinic follow up 1 In-clinic follow-up 2 In-clinic follow-up 3 In-clinic follow-up 4 In-clinic follow-up 5 In clinic follow-up 6 Patient Visit the OPD/ A&Es when there are symptoms of heart disease 葛 量 洪 醫 院
OPD FU with remote monitoring for CIEDs Remote Monitoring Service Remote Monitoring Remote Monitoring Remote Monitoring In-clinic follow up 1 In-clinic follow up 2 / Remote follow up In-clinic follow up 3 In-clinic follow up 4 / Remote follow up Health care professionals : Once any abnormal condition is reported, proactively contact patients for further check-ups Patients : send messages to the system if symptomatic/ device problems 葛 量 洪 醫 院
Application of Remote Monitoring International Guidelines HRS/EHRA experts advice for follow-up consultation of CIEDs* Pacemaker ICD CRT-P CRT-D Types of visit In-clinic Follow up 72 hours after implantation 2-14 weeks after discharge Remote Follow up Every 3-12 months Every 3-6 months In-clinic or Remote Follow up 1-3 months after alert for battery depletion of device Until the battery depletion, once per year Implantable Cardiac Monitoring Depends on patients symptom and condition every 1-6 month(s) Types of visit In-clinic or Remote Follow up * HRS/EHRA Expert Consensus on the Monitoring of Cardiovascular Implantable Electronic Devices (CIEDs): Description of Techniques, Indications, Personnel, Frequency and Ethical Considerations
Study Objectives To study feasibility and efficacy of remote monitoring and remote follow-up in transmitting in a HA specialist cardiac unit To assess clinical outcomes of transmitted events To assess the effect on out-patients clinic waiting time
Prospective analysis of remote CIED monitoring (Pilot Study) Patients chose the CIEDs with Remote Monitoring compatibility Physician explain the details of the Remote Monitoring program Disagree Patient s choice Agree Household assessment by Nurses or Technicians Patient signed an Agreement & Consent Routine clinic Follow up Remote Monitoring
Prospective analysis of remote CIED monitoring (Pilot Study) 1 4 7 * 2 3 5 6 8 9 0 #
Patient s demographics Age Sex Education Level Living Condition CIEDs 9-40 41-65 65 or above 13% 57% 30% Male Female 13 17 Primary Secondary Tertiary or above 27% 46% 27% Alone With 1-2 family member(s) With 3 or more family member(s) 10% 67% 23% Pacemakers ICDs CRT-Ps CRT-Ds 6 5 3 16 (Total :30 participants)
Data Collection Remote Monitoring Period (November 2010 to January 2012)
Results of the Pilot Study of Remote Monitoring Program 30 pts implanted with CIEDs with Remote Monitoring system (CRT-D = 16; ICD = 5 ; CRT-P=3; PM = 6) Total number of transmissions = 571 (period of Remote Monitoring 11 / 2010 1 / 2012) Scheduled Transmissions N = 293 (51.3%) Unscheduled Transmissions N = 196 (34.3%) Registration, System Testing, Enquiries N=82 (14.4%) Specific actions required N=1 (0.3%) No significant findings nor actions required N=292 (99.7%) Alert Triggered N=134 (68.4%) Self-initiated N=31 (15.8%) Technical Issues (e.g. Transmission failure, Loss of pt contact) N = 31 (15.8%) Specific actions required N = 21 (11%) No significant findings nor actions required N = 113 (57.7%)
Remote Monitoring Follow-up Service Example of Arrhythmia Detection During the Remote Monitoring period, ventricular tachycardia assessments were carried out Stable condition participants do not need check-ups in the hospital Detection of Ventricular Tachycardia with successful ATP delivered
Remote Monitoring Follow-up Service Progress Monitoring and Drug Titration Here are any new episodes I ve received for XXXX (ID: ABCDEFGH(K)) as of XX-XX-XXXX. Which would you like to see? Alert Summary Show: Episodes and EGMs >=3 VT/VF episodes in 24 hours Intensive monitoring of patient progress Date/Time Zone/Type CL (ms) Therapy Duration EGM Alerts Select 08-20-2011 09:50 下 午 VF 270 Aborted Defib 30 J (771 V) 0:08 Non-sustained episode, >=3 VT/VF episodes in 24 hours 08-20-2011 09:36 下 午 VF 270 Aborted Defib 30 J (771 V) 0:08 Non-sustained episode, >=3 VT/VF episodes in 24 hours 08-20-2011 09:32 下 午 VF 265 Defib 30J (771 V) 0:10 >=3 VT/VF episodes in 24 hours 08-20-2011 09:28 下 午 VF 270 Aborted Defib 30 J (771 V) 0:08 Non-sustained episode, >=3 VT/VF episodes in 24 hours 08-20-2011 09:21 下 午 VF 270 Aborted Defib 30 J (771 V) 0:08 Non-sustained episode, >=3 VT/VF episodes in 24 hours 08-20-2011 06:50 下 午 VF 275 Aborted Defib 30 J (771 V) 0:08 Non-sustained episode, >=3 VT/VF episodes in 24 hours 08-20-2011 06:47 下 午 VF 275 Aborted Defib 30 J (771 V) 0:08 Non-sustained episode, >=3 VT/VF episodes in 24 hours
Remote Monitoring Follow-up Service Detection of new onset AF Earlier discovery of symptoms and treatment Antiarrhythmic agents Anticoagulations as stroke prevention Detection of Atrial Arrhythmia
Remote Monitoring Follow-up Service Early detection of fluid overload Pulmonary edema deterioration will receive treatment in timely manner Reduce heart failure hospitalizations Pulmonary Edema deterioration
Results of the Pilot Study of Remote Monitoring Program *p <0.01
Remote Monitoring Follow-Up Service Summary Transmissions were successful in all patient enrolled Overall time spent on follow-up consultations reduced by 25% Frequency of follow-up consultations reduced from four times a year to twice a year Unnecessary follow-up consultations and hospitalization can be avoided Earlier discovery of symptoms and treatment
Achievements of Remote Monitoring More effective and updated assessment of the condition Earlier identification of change of conditions Provides appropriate medical follow-up actions Reliefs patients burden Reduces follow-up consultations frequency Reduces workload of Out-patient Department
Future Development Strengthen healthcare staff training in Remote Monitoring Expand the coverage of Remote Monitoring Remote Monitoring Transmitter with Cellular Adaptor - compared with the conventional information transmission via household landline, it is more suitable for patients without access to household landline or frequent travelers
Remote monitoring of Cardiac Implantable Electrical Devices (CIEDs) Changing the face of enhanced self-management and improved coordinated healthcare 葛 量 洪 醫 院 葛 量 洪 醫 院
Testing of Wireless phone line extender system
Utilisation of Wireless phone line extender system Phone line extender (EMITTER) Phone line extender (RECEIVER)