Advanced Outpatient Cardiac Monitoring: Impact on Outcomes and Workflow

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EP LAB DIGEST. 2023;23(12):24,26.

In this feature interview, EP Lab Digest speaks with Taylor C Bazemore, MD, FACC, and Heather Dowgos, CRAT Certified, about their use of Philips MCOT (Mobile Cardiac Telemetry) at Novant Health – Heart and Vascular Institute in Wilmington, North Carolina.

How long have you been at this practice? How many electrophysiologists (EPs) and cardiologists are there? What is the size of the hospital and how many patients are seen?

Taylor C Bazemore, MD, FACC: I joined the team at Novant Health Heart and Vascular Institute in August 2022. Our Wilmington practice includes 32 cardiologists, 7 of which are EPs, as well as 24 advanced practice providers (nurse practitioners and physician assistants) and 3 clinical pharmacists. Novant Health New Hanover Regional Medical Center is an 800-bed hospital. Our clinic has 1200 new referrals per month and 25,000 patient encounters per year.

How do you use outpatient cardiac monitoring (MCOT) as a diagnostic tool? How does it play a role in assisting with intervention and treatment?

Bazemore: Ambulatory ECG monitoring is one of the most important diagnostic tools utilized for clinical care in our patient population. At every clinic visit, we perform an electrocardiogram (ECG) on each patient. While they are a fundamental component of our patient assessment, these ECGs only provide 10 seconds of heart rhythm analysis, which results in the need for further investigation in many patients. For patients in whom we have concern for paroxysmal arrhythmias, intermittent bradycardia, or other symptoms suspected to be rate or rhythm related, ambulatory ECG monitoring is extremely valuable. In addition to allowing for the diagnosis of electrical disturbances (arrhythmias, conduction disease, and bradycardia) that may not be recognized during a clinic visit, these monitors also allow patients to correlate their symptoms with these clinical events.

Our device clinic utilizes ambulatory ECG monitors both with and without mobile cardiac telemetry monitoring. The decision to use these different types of monitors (MCOT, event, Holter) depends on the clinical suspicion of the ordering provider. A unique benefit to the Philips monitoring system is the ability to provide telemetry monitoring to any patient if needed. Whereas other monitoring systems are limited in their ability to offer mobile cardiac telemetry monitoring to some patients (often due to insurance or cost restrictions), Philips offers telemetry monitoring to any patient for whom there is concern for possible malignant arrhythmias. As a result, our clinical team can provide earlier diagnosis and expedited clinical care to patients with life-threatening cardiac arrhythmias and conduction disease.

What is your typical duration of monitoring for an MCOT prescription? Why this duration? How do you determine the duration of monitoring for any given patient?

Bazemore: Our standard Holter monitors are generally performed for 24 to 72 hours, while extended Holter monitors, event monitors, and MCOT are prescribed for periods of one week to one month. The prescribed duration of ambulatory monitoring is determined on a case-by-case basis, based on the ordering providers’ clinical judgment. A shorter duration of monitoring is generally appropriate to determine ectopy burden in patients with frequent PVCs or to characterize heart rate trends in patients with suspected chronotropic incompetence. In patients who experience infrequent syncope or are being evaluated for cryptogenic stroke, a longer duration of monitoring is often needed.

Can you share any stories of how telemetry with MCOT’s near real-time arrhythmia analysis with built-in SmartDetectAI has helped facilitate patient care?

Bazemore: On an almost daily basis, our device clinic receives critical telemetry alerts that allow for actionable and expedited clinical care. We have countless examples for which MCOT has resulted in early diagnosis of atrioventricular block and conduction pauses. For example, a monitor was recently placed on a patient with symptoms of suspected bradycardia, and the next day, our clinic received an alert for a 9.3-second pause. Using our clinic protocol, the patient was contacted to arrange for expedited hospitalization, and he underwent pacemaker implantation that same day.

MCOT also allows for earlier diagnosis and treatment of atrial and ventricular arrhythmias. With the use of mobile cardiac telemetry monitoring, many patients have been started on oral anticoagulation on the day they were diagnosed with atrial fibrillation. Likewise, our clinic has diagnosed sustained ventricular arrhythmias in many other patients whom we have been able to coordinate emergent hospitalization for expedited workup and treatment.

While it is difficult to quantify the benefit that our clinic’s expanded telemetry capabilities have provided to our patient population, we are confident that lives have been saved and strokes have been prevented.

How do Holters, including extended Holter, fit into your practice?

Bazemore: We offer standard Holter monitoring up to 72 hours and extended Holter monitoring for up to 14 days. These monitors are used for patients in whom there is low suspicion for malignant arrhythmia or serious conduction disease. Our providers have the flexibility to order whatever type monitor they feel is appropriate for their patient. However, based on the examples above of the frequent (and sometimes unexpected) abnormalities diagnosed in our patients with telemetry monitoring, I have a low threshold to order MCOT for my patients.

Given the challenges many large EP practices face, what value do you see in accessing reports with clinically actionable data sooner?

Bazemore: One of the greatest challenges is the need to offer timely cardiac care to our large patient population, as our clinic provides 25,000 patient encounters per year. With such a sizeable patient population, we also face the challenge of appropriately triaging clinical acuity to provide expedited interventions to the patients who need it. Mobile cardiac telemetry monitoring is incredibly useful in allowing for this real-time decision making and targeted interventions. For example, these monitors have allowed for same-day pacemaker implantation in patients who are diagnosed with complete heart block. Other patients for whom MCOT reveals previously undiagnosed AF may ultimately benefit from routine AF ablation, but their most immediate need is the initiation of oral anticoagulation. It is our priority to provide outstanding care to all our patients, but the type and urgency of this care is not the same for each patient. Our device clinic has developed our ambulatory monitoring system to effectively provide the appropriate, individualized care to each patient in the way that it is needed.

How did you go about setting the ordering guidelines/recommendations for your team when it comes to outpatient cardiac monitoring? How do you think this has helped your patients?

Bazemore: As above, each provider is able to order the type of monitor that they feel is most appropriate for their patients. Although our providers are cost-conscious in their use of our clinical resources, we are fortunate to have ability to offer mobile cardiac telemetry to any patient without concern for cost or insurance limitations.

To create an efficient workflow, how has your staff and practice managed the overall process to create a satisfactory experience from the time of enrollment and hookup of a patient, to finalizing the report?

Bazemore: Our device clinic has developed an effective workflow for ambulatory monitoring in our patients. An order is placed by a provider during a clinic visit with a patient. These monitors are generally mailed to the patient, although they can be placed on the patient that day if appropriate. Before these patients leave their clinic visit, our medical assistants and nurses provide education on wearing their monitor and transmitting their symptom episodes. As discussed above, our clinic receives daily alerts for our patients undergoing mobile cardiac telemetry monitoring. Once the monitoring period is complete, we can finalize a report within days.

How did you establish the workflow to manage the data from MCOT monitoring?

Heather Dowgos, CRAT Certified: When I first came on board here 11 years ago, it was a very small practice, so we placed all the monitors in the office. As we grew, I transitioned this process to having all monitors shipped to patients, with the exception of a few in-office applications for those patients who the physician did not want to leave unmonitored.

In today’s health care environment, there is a focus on doing more with fewer resources. As such, how do you manage the volume of 400+ patients per month? Specifically, how does your team manage the alerts/notifications that result from urgent and emergent events? Did you implement any changes or a process to minimize after-hours phone calls?

Dowgos: The first thing that I do each morning is filter through all the reports and triage the most urgent to the physician or physician’s nurse. Next, I triage all the daily reports, because sometimes those need to be sent to the physician as well. I then constantly triage throughout the day. The filters for after-hours notification criteria for our physicians are set relatively high since I triage all those reports first thing in the morning, so they do not need to be unnecessarily contacted for something if it does not need immediate action.

How do you use the data from MCOT to manage patients while they are still in service?

Dowgos: The physician may do medication titration or start new medication. If it is new-onset AF, the patient may need to be anticoagulated or need rate or rhythm control medication. We then continue to monitor the patient while that titration is in place.

When monitoring your patients for existing or potential arrhythmias, do you ever use the data to titrate medications? If so, can you provide a use-case scenario?

Bazemore: Telemetry monitoring has proven to be very useful for individualized medication management. Because we can quickly characterize the effect of medications on patients’ heart rate and rhythm, we are able to actively titrate a medication dose several times over a single period of monitoring. Conversely, in patients without telemetry monitoring, mediation titration is performed over multiple clinic visits in order to determine the appropriate dose of a medication.

Dowgos: We had a patient wearing a monitor for AF detection and later discovered the antiarrhythmic medication was causing bradycardia. The physician titrated the medication to a half dose and continued to monitor. However, the patient was still experiencing bradycardia, so we stopped the medication and continued to monitor. The patient continued to experience bradycardia and was later placed with a pacemaker.

How has MCOT helped you manage your cardiac monitoring patients? How has it impacted outcomes?

Dowgos: Medication titration is one example. We are also able to continue to monitor patient status after interventional procedures such as an ablation or cardioversion to monitor for effectiveness.

For example, I had a patient who was wearing a monitor for syncope, and on day 2, they began experiencing multiple pauses greater than 6.2 seconds. On day 3, they had a pacemaker implanted. Another patient presented with cerebrovascular accident (CVA) with no prior diagnosis of AF. They were anticoagulated and cardioverted that day, with a diagnosis of complete heart block. We saw multiple pauses on day 1, so the patient had a pacemaker implanted. We see these kinds of examples multiple times during the week.

How does your workflow differ when managing data and reports from MCOT compared to extended wear Holter devices?

Dowgos: For an MCOT, we may have multiple reports attached to one order if we have abnormal findings along the way before end of service. With a Holter, we only have one final report, since those are never longer than 72 hours.

What are the advantages of working with Philips to manage MCOT and Holter monitoring services?

Dowgos: We have a wonderful partnership with Philips. For example, when the pandemic started in March 2020, we could no longer have our patients come into clinic for in-office Holter applications. We monitor over 400 patients with mobile cardiac telemetry monitors and approximately 200 Holters per month. So, we paired with Philips to switch all our monitoring to 7-day MCOTs that were mailed to patients. That all happened within one day, allowing us to keep seeing those patients without having an in-office clinic and continue to assess burden for PVC, heart rate, and AF with those monitors. We were also doing telehealth. So, during the pandemic, we did not slow down.

At the time, we were working with 2 monitor companies, and Philips said they would absolutely do this for us. We are currently working on an interface with Philips so that all our end of services will automatically go into the patient’s chart. That is a mindless uploading task that does not need to be triaged, but we calculated that 7 and a half weeks per year are spent uploading these end-of-service reports. So, they are soon going to automatically upload to the chart, which will tremendously help our workflows, since our department currently consists of only myself and a part-time person. By removing the task of uploading reports, it allows me to clinically review and triage those daily and abnormals so that Dr Bazemore is only getting what he needs right away. Because of this unique workflow and expertise, it allows us to intervene sooner with patients versus waiting until the final report is available.

Have there been any memorable patient outcomes since utilizing MCOT?

Dowgos: Yes, I have a whole booklet full of them! We can more quickly provide treatment to prevent stroke in patients with a cerebrovascular accident or new-onset AF. We can also implant pacemakers or implantable cardioverter-defibrillators in patients with ventricular tachycardia. We see these examples daily because of our high volume.

How do you feel monitoring with near real-time arrhythmia analysis has impacted your patients wearing monitors?

Dowgos: It has been significant for our patients since we are able to detect arrhythmias and urgent situations that need to be quickly acted on.

Results from customer experiences are not predictive of results in other cases. Results in other experiences may vary.

This article was published with support from Philips.

Disclosure: Dr Bazemore and Ms Dowgos have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They report no conflicts of interest regarding the content herein.