A Collaborative Approach to Heart Failure Management Utilizing Remote Device Monitoring – A Community Approach

Approximately 5.8 million people in the United States have heart failure. An average of 670,000 people are diagnosed with it each year. In 2010, heart failure will cost the United States $39.2 billion. This total includes the cost of healthcare services, medications and lost productivity.¹ These are staggering statistics that affect how each of us cares for our patients. It doesn’t matter if you work in a major medical center or a small community hospital. You will come in contact with these patients on a regular basis. I was recently screening patients for an upcoming research study that involved heart failure admissions in patients with CRT-D devices. The heart failure admissions had to have occurred within one year of enrollment in the study. I began my screening with those patients currently enrolled in one of the remote monitoring systems — the Boston Scientific LATITUDE^® Patient Monitoring System. Fifty patients met the search criteria of having the specific CRT-D device required by the study. However, after reviewing the medical records of these patients, I found that only three patients met the criteria of having heart failure admissions after the implantation of their CRT-D device. All had an average of 1.5 heart failure admissions in the one to two years prior to their device implantation but had not been readmitted since. Yes, I know that these are small numbers, but I am part of a small hospital. The intent of this article is to show that good things can happen not only in the major medical centers and teaching institutions but also in the small community hospitals. LaPorte Hospital has 227 beds and is a Clarian Health Partner (Please note that Clarian recently announced that it is transitioning to Indiana University Health. LaPorte Hospital will then be known as Indiana University Health LaPorte Hospital in late January 2011). We have five dedicated staff members that are cross-trained to work in both the EP Lab and Clinic, and three nurses that work directly with inpatient/outpatient heart failure care. Both groups share in a collaborative effort to decrease readmissions from heart failure and to provide a better quality of life for our heart failure patients. We take a practical approach to the education and care of the patient. In addition, Dr. Mark Dixon, Medical Director for Cardiac Electrophysiology, believes strongly in the concept of remote monitoring and its usefulness in the care of his device patients. His encouragement to patients is vital in their acceptance of the modality. During the past year, we assessed our approach to heart failure care. There are many different facets to the program here at LaPorte. However, my staff and I were asked to focus on those patients with CRT-D devices. We were already enrolling all eligible patients in remote monitoring. The majority of our patients are implanted with Boston Scientific devices so they are enrolled in the LATITUDE^® Patient Monitoring System for arrhythmia monitoring. However, we had not enrolled patients in the heart failure monitoring component. At that time, the LATITUDE^® Patient Management System was the first heart failure management tool that was linked to remotely collect blood pressure and weight measurements. Dr. Dixon had participated in the Remote Active Monitoring in Patients with Heart Failure (RAPID-RF) trial, so we were very familiar with the concepts. As presented at Heart Rhythm in 2009, the results of the trial indicated that daily remote monitoring provides accurate data about device integrity that may lead to intervention. It was also concluded that daily remote monitoring led to more frequent patient contact and medication adjustments.² Other studies had indicated that both telemonitoring and structured telephone support appeared to reduce heart failure-related hospitalization rates and all cause-mortality.³ When telephone calls were utilized alone, researchers found no significant differences in readmission rates.⁴ All of these results were presented to the Heart Failure Care Team. It was decided that we would initiate a collaborative approach to heart failure care in those patients with Boston Scientific CRT-D devices. Patients were already utilizing LATITUDE^® for arrhythmia monitoring, so adding the heart failure monitoring component would not be a monumental task. In addition, because we would need to respond to findings from monitoring, the Heart Failure Care Team developed protocols and standing orders for treatment of patients when alerts were received from LATITUDE^®. All cardiologists in the Department of Cardiology approved these protocols for utilization. The protocols deal with titration of medication (furosemide and potassium supplements) in response to weight gain or other symptoms of an impending exacerbation such as shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, lower extremity swelling, increased abdominal girth, and nausea and vomiting after meals. In addition, there are orders for labs to be done to assess BMP/BtNP after medication changes. Special attention was also extended in securing the appropriate admitting heart failure diagnosis so that all aspects of coding were met. Patient involvement begins with the initial EP consultation. After it has been determined that a patient will receive a CRT-D device, the EP Clinic nurses start the teaching process. During pre-op teaching, important concepts of patient care are discussed with the patient and family members. Information concerning the importance of remote monitoring post-operatively is introduced during this session along with other aspects of care that the patient will receive during the implant hospitalization. The patient then undergoes the implantation of the device. Prior to discharge, the patient will again receive information concerning remote monitoring from the industry representative and the EP Clinic staff, and will be introduced to the Heart Failure Care Team. Basic information will be given concerning the advantages of remote monitoring as well as information about monitoring weight, blood pressure, the advantages of a low sodium diet and fluid restrictions. Constant reinforcement of the principles of remote monitoring during the pre-operative and post-operative periods assists in patient compliance. When the patient returns to the EP Clinic for a post-operative wound check, the entire team meets the patient. EP staff explain the arrhythmia component and obtain approval from the patient to enroll in LATITUDE^®. The patient and family then meet with the Heart Failure Care Team nurse, who reviews the heart failure program. We recognized that by coordinating our efforts in the same location, there is a greater compliance with enrollment. In addition, if a patient or family member is hesitant about enrollment, Dr. Dixon is present to lend his support and encouragement about compliance with all aspects of the program. After enrollment, the patient begins daily monitoring. EP staff monitor the arrhythmia component, while the Heart Failure Care Team nurses monitor weights and blood pressures. If alerts are received, the respective departments provide care and treatment as necessary utilizing the established protocols. Every effort is made to prevent a hospitalization. If protocol drug titrations are unsuccessful, the patient is referred on to his cardiologist for further treatment. Decisions can then be made as to if outpatient infusions or diuresis will improve the patient status without hospitalization. Although daily/weekly monitoring is done on every patient, the heart failure team prepares a formal monthly report and the EP staff prepares quarterly reports. Appropriate CPT codes are utilized to allow appropriate charging and reimbursement for these activities. The physicians bill the professional component for interpretation, while the hospital bills the technical component for services rendered by hospital staff. What does the future hold for our facility? I’m sure it will include the utilization of other remote monitoring systems when integration of arrhythmia and heart failure is available. It is also proposed that we will utilize cardiovascular nurse practitioners to assist with routine visits, drug titration, education and outpatient diuresis. As we care for more patients and clinic space becomes more valuable, remote monitoring will replace the clinic visits for stable patients. In conclusion, our results are comparable to those of the major medical centers and teaching institutions. We attribute the success of our remote heart failure monitoring program to the collaboration between the heart failure and electrophysiology teams. Our small group of physicians and nurses has worked tirelessly to make our program a success as measured by compliance with core measures and re-admission rates. Dr. Dixon’s opinion regarding the collaborative effort is simply stated. He feels that chronic CHF management requires tenacity for details that the average practitioner cannot devote enough time to because of their busy schedule. Dr. Dixon also feels that proper management is 10% inspiration and 90% perspiration! At LaPorte Hospital, specialized nursing personnel sweat the details and the remote monitoring system feeds the team endless data that makes the management of our heart failure patients run smoothly and efficiently. We are making it work!

References

1. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics – 2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2010;121;e1–e170.

2. Saxon LA, Boehmer JP, Neuman S, et al. Remote active monitoring in patients with heart failure (RAPID-RF): Design and rationale. J Cardiac Failure 2007;13:241–246.

3. Klersy C, De Silvestri A, Gabutti G, et al. A meta-analysis of remote monitoring of heart failure patients. J Am Coll Cardiol 2009;54;1683–1694.

4. Chaudhry SI, Mattera JA, Curtis JP, et al. Telemonitoring of patients in heart failure. N Engl J Med 2010 Nov 16. [Epub ahead of print]

Disclosure: The author has no conflict or financial interests to disclose.