Remote Monitoring of Respiratory Pattern in an ICD Patient With COVID-19 Pneumonia

Cardiac implantable device interrogation in left ventricular systolic dysfunction reveals physiologic abnormalities prior to symptom onset in COVID-19: a case series

Background

COVID-19 has affected individuals across the globe, and those with cardiac implantable electronic devices (CIEDs) likely represent a high-risk group. These devices can be interrogated to reveal information about the patient activity, heart rate parameters, and respiratory rate.

Case summary

Four patients with CIEDs and left ventricular dysfunction were admitted to a single institution for COVID-19 infection. Each patient survived hospitalization, and none required intensive care. Retrospectively, CIED interrogation revealed each patient had decreased activity level prior to their reporting COVID-19 symptoms. Similarly, respiratory rate increased before symptom onset for three of the patients, while one did not have these data available. Of the three patients with heart rate variability (HRV) available, two had decreased HRV before they developed symptoms. After hospital discharge, these parameters returned to their baseline.

Discussion

This case series suggests physiologic changes identifiable through interrogation of CIEDs may occur prior to the reported onset of COVID-19 symptoms. These data may provide objective evidence on which to base more sensitive assessments of infectious risk when performing contact tracing in communities.

Deployment of Tele-ICU Respiratory Therapy and the Creation of an eRT Service Line

Penn Medicine launched a 24-7 telemedicine respiratory therapist (eRT) service as part of its tele–critical care medicine (tele-CCM) service serving seven hospitals and more than 320 critical care beds. Service line interventions were focused on protocolized evidence-based practices, safety, documentation compliance, and urgent emergent ad hoc clinical needs. Concomitantly, the eRTs were available to respond to urgent and emergent interventions on the basis of the clinical bedside situation. Their activity was triggered by Penn E-lert staff (serving the tele-ICUs), bedside staff, algorithmic trigger software, or the eRT’s own review of a patient’s clinical condition. A standardized data collection was deployed to gather information about the interventions. The value of the eRT service was defined in terms of estimated lives saved by implementing the standards of care earlier than the bedside staff would or acute respiratory distress syndrome (ARDS) algorithmic trigger and by intervening during emergent and urgent clinical request, improving care delivery, and complying with best clinical practices, and by the time freed for onsite staff to perform other duties. Between May 2020 and August 2021, eRTs registered 31,609 activities; 97.8% of interventions were related to the routine established workflows, while 1.9% were urgent and 0.3% emergent. In 51.2% of all eRT accomplished activities, no communication with other staff was needed. When communication did take place, eRTs connected with the bedside respiratory therapist in 36.7% of interactions, followed by house staff (7.2%), advanced practice providers (5.2%), and registered nurses (1.6%). The eRTs communicated via phone (81.4%), asynchronous text platform (16%), or tele-CCM software (1.4%). While prompted by staffing, safety, and logistics challenges during a Covid-19 surge, the resulting eRT service line has been well received and has become a part of the standard of care. Overall efficiency of respiratory care service delivery was increased as Penn retained staff and increased the flexibility of bedside therapists. Furthermore, the eRT service detected unfavorable practice patterns in ARDS treatment and intervened before the ARDS algorithmic trigger was activated or acted upon. Some of the tasks can be accomplished by the eRT in a shorter amount of time than it would take bedside staff. In addition, the remote staffing reduced personal protective equipment utilization. All of these gains translated into postpandemic time savings. Penn’s experience shows that the eRT care model can be transformed into a system-valued proposition and retained with sustained benefit beyond the pandemic surge.