Remote Patient Monitoring for Heart Failure and Beyond

Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.  

Geralyn Warfield (host): I'd like to welcome our audience to today's episode where we have the privilege of speaking with Kim Newlin. Kim, could you provide a little bit of background for yourself?  

Kim Newlin (guest): Oh, absolutely. Thank you for having me. My name's Kim Newlin. I'm a cardiology Clinical Nurse Specialist and Nurse Practitioner with Sutter Health. 

I have been working in the heart failure space for the last 13 years, and I'm actually in a new role where I'm working on process improvement and program implementation across the Sutter Health System for our cardiovascular service line.  

Geralyn Warfield (host): You've had a lot of experience with heart failure, and one of the things that happens in the trajectory of these patients is the need for monitoring. And I'm hoping you could enlighten us a little bit [00:01:00] about the options of remote cardiac monitoring devices. 

Kim Newlin (guest): Well, we are in a digital age, as we all know, and it's an exciting time for remote patient monitoring. So, we have multiple options. You're probably wearing something right now, listeners, too, that may be tracking some sort of physiological parameter, whether it's a ring or a watch or even just carrying your phone. 

But we're able to use a lot of this technology now in helping to monitor our patients to identify if they're at risk for a hospitalization or getting more congested. So, there are these devices that are wearable monitors. But we also have implantable devices which are able to give us even more insight into how the patient's doing. 

Geralyn Warfield (host): Are you finding that patients are less worried about these digital types of technologies since they are so [00:02:00] pervasive?  

Kim Newlin (guest): It depends. I think a constant discussion is around data and who's using the data, who has access to the data, and how is it being used to help, or not help me? So, you know, it depends on the patient population. 

Almost everybody has an iPhone or a smartphone at this point, so they're used to information being tracked. A lot of us have the health app, which we can look at information. So that's, I think, less intimidating.  

But how we really integrate it into our daily clinical practice continues to be something that we're exploring and trying to understand how to better work on, and provide for these patients. 

Geralyn Warfield (host): So, as we're thinking about what this really looks like in application, let's say a patient has access to that data. Do you find that those patients are bringing that data to you on a regular basis?  

Sometimes, I'm sure with these cardiac devices that are implanted, they're coming directly to the [00:03:00] office. How do you manage all that information that's coming to your office? When are your clinicians looking at that?  

Kim Newlin (guest): Yeah, that's a great question. And it depends. It depends on the program that the office or the department has set up. So, data can come in as frequently as daily, depending on the device, or every week. And then that could just be like normal transmission of data.  

But then you have alerts that are coming in. So, it's really imperative that when patients are getting these implantable devices with data, or using blood pressure cuffs, or weights, or scales that provide weights through an application on the phone and through to your office, that you have a process in place. 

So, great to have data, but you do need the people still. This doesn't replace the need for people to really have the knowledge to look at the data, understand the data, and identify when a patient may need to be triaged or brought [00:04:00] in.  

And making sure that the information gets back to the patient. I think probably one of the ways to not earn trust with patients is to tell them about this great device, place it, let them know that it's going to allow us to have regular communication with them about how they're doing, and for them to never hear anything.  

So, I think making sure they know that the data's getting to us, that we're looking at it, and then we're acting on it, in an efficient way, not weeks after that piece of data comes into our office and into our hands. 

Geralyn Warfield (host): So, in many ways it almost increases communication between the clinician and the patient. It's a different kind of communication sometimes. Is information sometimes shared with patient via text message or what kinds of things are you doing from your office setting? And I realize every office setting is a little bit different. 

How does that look in terms of getting that information back to the patient?  

Kim Newlin (guest): Yeah, I mean, it's a great question. And I think it goes back again to that shared decision making [00:05:00] conversation about how the patient wants to receive the information. 

Through my health online type apps, right, where you can access your medical record information can be shared that way. You can get text messages, you know, there's the text messaging capability through those apps. Some people still want a phone call. And so how do you work that in to make sure you can provide that? So again, kind of what the patient wishes.  

And most of us know now that usually we're getting information that's not one modality. 

I think recently I got an email, a text, hard copy letter, and a phone call as a reminder, right? Which is, is probably, maybe not the most efficient way, but a lot of it can be automated and that information can get back to the patient.  

Geralyn Warfield (host): Wonderful information about how to get information from patients and how to share information with patients, as we're continuing our discussion with Kim Newlin. 

We're going to take a quick break and we will be right back.  

 

Geralyn Warfield (host): We're back speaking with Kim Newlin. And [00:06:00] we're going to focus specifically for our heart failure patients. Could you tell us a little bit more about what's new for that remote monitoring? 

Kim Newlin (guest): Yeah. So, in the last 10 years, we have seen, just a rapid rise in options and exploration of potential options for our heart failure patients. Back in 2014, we had the first implantable device, the cardioMEMS, which is for a specific patient population who've had a heart failure hospitalization but can also tolerate being on an anticoagulant. 

So, this, this sensor can tell us when the patient's starting to develop increased congestion, earlier than weights or symptoms would allow us to identify.  

And what's exciting is that original indication, which was for kind of our Class II and III heart failure patients, is now available for patients earlier on. 

There was a study just done in [00:07:00] 2022, the GUIDE-HF trial. And that shows us that there's value in the CardioMEMS device, providing information for those Class II patients, maybe not with a prior hospitalization.  

So that's an invasive procedure. The uptake has been okay. Probably not what we all thought it would be when it first came out. I think we all thought this would be like the great answer to our issues with how to identify patients earlier and get them the treatment they wanted.  

So, there's been a lot of exploration with what other devices are out there and what information they can provide. So, a certain subset of our patients with heart failure with reduced ejection fraction qualify for a defibrillator or cardiac resynchronization therapy, which is a biventricular pacemaker.  

Those devices have some logic built into them. They have sensors, multiple sensors, that can provide us information on physiological [00:08:00] parameters such as heart rate, respiratory rate, activity levels, thoracic impedance, like how much fluid is in that chest wall.  

And, starting as early as 2017, 2018, the companies started to provide kind of heart failure risk scores based on those metrics. They even have sleep incline if sleep incline changing, right? That can be part of this risk score to tell us, you know, are these patients at risk, earlier, for possible heart failure hospitalization. 

So those are great, but again, those only really are for patients who qualify for a defibrillator or this cardiac resynchronization therapy. And it's an invasive procedure.  

So, kind of fast forward a couple of years, we now have two newer devices within the last year. One is a ZOLL patch. So, it's actually a patch that goes on the lower left, [00:09:00] kind of underneath the arm. And it's about the size of a Tic Tac box.  

And you place that onto the patch, the sensor, and it can actually measure, it uses radio frequency waves, and it can tell, again about congestion in the chest wall. And it's non-invasive. So, this can actually be used for all heart failure patients, whether they have reduced ejection fraction or preserved ejection fraction without an invasive procedure.  

So, this last year for the Zoll heart failure management system patch, there were two single-arm trials, called the BMAD trials. And they showed a 38% reduction in 90-day heart failure readmissions, as well as deaths. So, very promising. 

Don't have randomized control trials for it yet. But something that's non-invasive that can be placed at discharge on the patient's body that provides information back to our team so we can, to make decisions earlier is again, super valuable. So, excited to see more about that as [00:10:00] we see more people utilize it.  

Then just in January of 2024, we had a trial come out in JACC Heart Failure, which is looking at something called an implantable loop recorder, or an insertable cardiac monitor. So, this came from the Medtronic LINQ device, which is one of the smaller devices that can be placed just under the skin. 

Historically, we've used it to track heart rate and arrhythmias. But what this trial showed us was they were developing a heart failure risk score tool out of it. So again, it could be used for patients who have heart failure with preserved ejection fraction or reduced ejection fraction.  

Super early information, small number of patients—less than 50—but exciting to think that we'll be able to get these physiological parameters from a device that, again, meets the needs for all of our heart failure patients, and can get us information that we can act upon early.  

Geralyn Warfield (host): So, in your career working [00:11:00] with heart failure patients, you have seen a dramatic shift in what's available for diagnosis, and management, and even treatment, which we're not going to discuss in this particular episode, but it's a really exciting time for clinicians who are working with these patients. 

It's less of a, you know, just waiting for impending doom, if you will. There's a lot we can do in the interim to help with quality of life, and I suspect that's one of the things that both as a clinician and as a patient is really exciting about this particular technology.  

And so, if we think about how that looks in practice, what are some keys to making sure that this is successful, this remote monitoring?  

Kim Newlin (guest): Right. And like I alluded to earlier, you can't just place it and then not have a strategy in place to handle the data that's coming in. I think, you know, that's kind of the theme of our current lives is, how do we handle all the data coming in, in every capacity.  

But specifically, when we're talking about patients who depend on us and we're, you know, we're [00:12:00] letting them know that this data will be helpful in helping us make decisions. 

So, one is communication with the patient and expectations for how frequently they expect to hear from you. How you're going to use this data, you know. Confirmation that the data is secure and will just be used for clinical decision-making.  

So, I think that's, so kind of engagement with the patient, that shared decision-making discussion that has to happen. Including the right identification of the right device, right? So again, part of that discussion with the patient. So, what device is best for them based on kind of the buffet of options that are available, some of what we discussed. 

The second piece is a team that's available and ready to take that data. So, you have to invest in the people to handle the data. Again, it won't replace people. We need the trained individuals who have the knowledge to look at the data and provide that information back to the [00:13:00] patient.  

So, the people, the training, giving them time in their work. It can't be the thing that drops to priority number seven on the list when other things come up, right? This really needs to be a priority for that staff, which, kind of in that world of prior authorizations as well, I mean, it falls into that same space, right?  

And then the third one is our standard procedures or processes in place, right? Like, how do you consistently address the data that's coming in and make sure that the treatment protocols for whether it's, you know, stay the course. Or make an adjustment to your medication. Or come into the office today or tomorrow, right? Like you need to have those laid out, so it's a consistent process for how you're handling the patient.  

Obviously in a conversation with the patient about what's changed or what's going on, or you know, what Superbowl party did they just go to? Why did they stop their Lasix because they were traveling for five days? You know, those conversations need to happen and some of it you can, you know, kind of [00:14:00] right the course through a conversation. But sometimes you need to bring them in.  

So having those standardized protocols in place just help with efficiency, and standard of care. So, you're providing that to everybody who has those devices. 

Kim, you have given us a lot of information and a lot of hope for our patients with heart failure. Can you maybe tackle, my question, which is what's one takeaway that you would have our listeners keep as part of our conversation? 

Kim Newlin (guest): Yeah, I think probably the one thing I would recommend, and you know, even when I got ready for this podcast and presentation is make sure you’re aware of what’s out there. Really read up on the literature. And hopefully, you know, some of this information will help, but I think understanding your patient population, and which devices your population has, and what information is available, as well as what's happening right now with that information. 

Because if you don't know [00:15:00] where you are in that space, then you won't know kind of that next step to take. So that's for those who are kind of in the, “Well, what's going on with our patients?” 

And then I think the most important thing is keeping up with the newest information that's coming out. Because it's coming out so quickly and it'll just continue to provide benefit to our patients. 

Geralyn Warfield (host): And so, when you're looking at the newest information, what kind of resources would you recommend?  

Kim Newlin (guest): Well, you know, one thing I do is I get an automatic push from several organizations, including PCNA, ACC, AHA about the newest literature. And I take the time to look at those, because that's often where I'll find, you know, kind of snippets of information. 

I always go to PCNA for any patient education materials, as well as any recent educational programs that might provide me information. And then, I listen to my patients. because oftentimes they'll hear things too about newest technologies that I haven't heard of. [00:16:00]  

Geralyn Warfield (host): Kim, thank you so very much for enlightening me and enlightening our audience about the what's newest and greatest in heart failure management and remote monitoring. 

This is Geralyn Warfield, your host, and we will see you next time. 

Thank you for listening to Heart to Heart Nurses. We invite you to visit pcna.net for clinical resources, continuing education, and much more.