How do you tell who is best?
- They always supply their customers with Genesis™ recorders (does that surprise you?)
- They always use the two channel mode (there’s never a reason not to)
- They always use the automatic direct transmission mode* before sending memory (this is critically important, and those who do it deserve your business)
- They never use post-symptom recorders (because of their 90% false-negative rate)
- They provide 24/7 receiving services (a must!)
- They use highly skilled cardiac technicians or CCU nurses to do the receiving
* If a recorder’s cable must be removed from the device for transmission, automatic direct transmissions are not possible. If the patient transmits VT while in the direct mode, who cares what’s in memory? As well, a patient could have VT when calling in and hanging up, and you’d never know it without a direct transmission! Don’t go without it!
Note that all monitoring services can buy and provide their customers the Genesis recorder. Some may be reluctant because they prefer cheaper recorders, or simply don’t like dealing with the extra features like the automatic direct transmission (for greater patient safety) because it adds an extra service they can’t charge for.
However, if they balk, most services offer an “unbundled” rate so clinics and hospitals can buy their own Genesis™ recorders and receive an offsetting fee reduction. We know of no service that does not offer this, but call us if yours does not or it is insufficient.
Tricks of the trade:
After spending 25 years as a leader in the industry – and inventing and pioneering the memory loop technology in the early 1980s – we’ve learned a lot of do’s and don’ts, and we share them here. Though we are no longer in the service business, we saw many struggles by those looking for the best service, and we hope this summary helps.
On two channels:
One extra electrode is all that is required to capture the second ECG channel, and it is time well spent. It serves two purposes: First, it provides redundancy in the event one electrode fails (see below). In this example we captured a 32 beat run of VT that was total artifact in channel one, but clear VT in channel two. Secondly, in cases of wide QRS tachycardia it allows easier differentiation between VT and aberrancy. We’ve also seen flutter waves in channel two that were not apparent in channel one.
This is an important 30-day test for the proper treatment of patients, and maximizing it effectiveness with an extra electrode is clearly justified.
On post-event recorders:
With 30-day event monitoring, don’t get hung up on “patient compliance,” that is, the patient’s (un)willingness to wear electrodes. If the physician or hook-up technician describes and the patient understands the 100% capture rate when wearing electrodes, versus the 10% accuracy with post-symptom recorders, they’ll choose the memory loop recorder every time.
And the physician will be happier with the increased accuracy (though perhaps busier treating arrhythmias actually captured).
It does little good to use a higher-compliance post-event recorder if it misses 90% of the symptomatic arrhythmias. Period! You might just as well not run the test, as false information is worse than no information at all.
And when dealing with children, the parents need to be educated on the two technologies. Once they know the difference, they will make sure their child wears the electrodes.
Over the years we’ve seen salespeople, engineers, technicians, and even physicians fail to understand the importance of this very basic sequence of events. It is absolutely impossible to capture an offending arrhythmia when the electrodes are applied after the fact. Only rarely will the same arrhythmia continue long enough to be captured with a post event recorder. To us, “rarely” was not good enough.
Don’t be misled by the rare instances that the post-event recorder captures a run of tachycardia; that may or may not have been the offending rhythm prior to the button. A pre-symptom recorder would have caught not just that episode, but also all of the others missed by the non-electrode type. If memory loop recorders are 100% effective, why use anything else?
If a salesman is not well versed on the differences between pre- and post-event recorders, or downplays the differences, or doesn’t argue the benefits of memory loop recording, take care. You may be dealing with a company that likes the no-cost approach to electrodes. Not having to report an arrhythmia or dispatch 911 certainly cuts costs, but it’s not a good deal for the patient or physician.
We’ve seen some doctors criticize event monitoring in general because they had poor experiences with post-symptom devices not catching anything. Of course that will be the case, as 90% of the time they miss the arrhythmia causing the symptomatic event! Using a pre-symptom recorder a few times will win their allegiance.
On the number of days monitored:
Don’t skimp by cutting the number of days monitored; it benefits no one.
Obviously, if the patient has palpitations and transmits VT, you’ve got your answer early and the patient can be immediately treated (though keeping the patient connected during drug therapy is often valuable).
When we had our service we frequently saw patients go the entire 30 day period before transmitting their VT. Those who argue against this, or favor two-week monitoring, simply lack experience or conviction. Working in a monitoring lab for a month would soon cure that.
Don’t stop until the 30 days or a significant arrhythmia is captured, whichever comes first! In roughly 10% of the cases (where symptoms persist) an additional 30 days may be required (or if that fails, an implantable monitor).
Capturing PVCs can be misleading. We’ve seen patients complain of palpitations and we’d capture PVCs. But given enough time they’d eventually transmit VT, clearly indicating a different level of intervention.
The capture rate increases with time, and a minimum of 30 days is recommended.
On memory capacity:
Avoid using event recorders in anything shorter than a two-minute mode. We often saw patients delay pushing the button and their arrhythmia would have been missed had we not been saving two minutes or more of data. Sixty seconds is too often a wasted test, though it might make a neat, concise and inexpensive report. But why even do the test if the data is not going to be reliably documented?.
On syncopal patients, use only the eight minute mode (the longer the better). These patients sometimes take several minutes to recover and push the button, and a short amount of memory will totally miss the critical data.
On transmission speeds:
Avoid event recorders with 4X transmission (four times real time). When we first designed Genesis, 4X was our engineer’s first choice. But as we tested the available bandwidth on the public telephone system we soon learned that on sporadic bad lines we would get garbage, so we cut it to a more-reliable 3X (the theoretical maximum, and even more so with cellular technology).
Using higher speeds benefits only the company (in reduced telephone and personnel costs). There is no benefit to the patient, physician or customer.
On 24/7 services:
This is a Medicare requirement and should not be compromised. Our studies showed that 56% of the transmissions were made on second shift, third shift, Saturdays, Sundays and holidays. Saving those transmissions until the next day (or the next Tuesday if a holiday weekend) doesn’t reduce costs; it merely shifts them to another day and in the process delays some transmissions of life-threatening arrhythmias.
It can also increase the number of patients who self-admit to the E.R. at 2:00am with no arrhythmias because they didn’t have someone on the receiving end at a time of need.
This is both false economy and bad medicine.