Clinic Time Required for Remote and In-Person Management of Patients With Cardiac Devices: Time and Motion Workflow Evaluation

Abstract

Background The number of patients with cardiac implantable electronic device (CIED) is increasing, creating a substantial workload for device clinics. Objective This study aims to characterize the workflow and quantify clinic staff time requirements for managing patients with CIEDs. Methods A time and motion workflow evaluation was performed in 11 US and European CIEDs clinics. Workflow tasks were repeatedly timed during 1 business week of observation at each clinic; these observations included all device models and manufacturers. The mean cumulative staff time required to review a remote device transmission and an in-person clinic visit were calculated, including all necessary clinical and administrative tasks. The annual staff time to manage a patient with a CIED was modeled using CIED transmission volumes, clinical guidelines, and the published literature. Results A total of 276 in-person clinic visits and 2173 remote monitoring activities were observed. Mean staff time required per remote transmission ranged from 9.4 to 13.5 minutes for therapeutic devices (pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy) and from 11.3 to 12.9 minutes for diagnostic devices such as insertable cardiac monitors (ICMs). Mean staff time per in-person visit ranged from 37.8 to 51.0 and from 39.9 to 45.8 minutes for therapeutic devices and ICMs, respectively. Including all remote and in-person follow-ups, the estimated annual time to manage a patient with a CIED ranged from 1.6 to 2.4 hours for therapeutic devices and from 7.7 to 9.3 hours for ICMs. Conclusions The CIED patient management workflow is complex and requires significant staff time. Understanding process steps and time requirements informs the implementation of efficiency improvements, including remote solutions. Future research should examine heterogeneity in patient management processes to identify the most efficient workflow.

Remote Patient Monitoring: What Have We Learned and Where Are We Going?

“…The programming of RM alerts and actionable events should be tailored to the patient and the CIED type [ 57 ]. Unfortunately, there is a large variability between manufacturers on the type and number of programmable alerts which makes it challenging to develop standardized workflows.…”

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

“…Studies since 2015 have continued to show the value of RM and its potential positive effects on morbidity and mortality, cementing RM as an essential part of CIED patient care 18–23 . This has led to a deluge of patients on RM, 24 resulting in large amounts of RM data and an increase in RM‐related workload 25–28 . While the 2015 HRS Expert Consensus Statement on RM 1 provides recommendations on the benefits of RM and the importance of integrating RM into CIED patient care, it does not account for the challenges related to RM that have been realized in the intervening years.…”

“…However, staffing challenges are multifaceted, interrelated, and continue to persist ( Figure 1). The value of RM and its benefits may not be widely known or accepted, which can affect resourcing, reimbursement, and ultimately allocation of staffing for RM monitoring within an institution 28,95,114 . CIED RM work hours are incorporated into a “virtual” space; while the patient may not be physically in the clinic, the work burden related to managing CIED RM patients still exists on multiple levels 28 .…”

“…These data led to a position paper from the Italian Association of Arrhythmology and Cardiac Pacing calling for RM organizational model standardization and formally recommending the use of dedicated, trained teams to manage RM transmissions in CIED patients 102 The growth of RM and RM transmissions has been accompanied by an exponential increase in workload 3,25,28,103 . In addition to reviewing RM transmissions, other RM‐related tasks must be completed to appropriately manage CIED patients on RM 28,57,103,105,106,110,112 .…”

Remote Monitoring of CIEDs—For Both Safety, Economy and Convenience?

“…Equally as important as saving money may be the fact that RM also saves time compared to in-hospital controls [ 49 ]. This allows doctors and nurses to spend more time on tasks that require hands-on and personal attendance.…”