Continuity of Care during pacemaker checks

Hello everyone,

I recently had a pacemaker check, which I will do a separate post on. May I ask, do you usually see the same pacemaker technician, once you have found one that you can work with?  

My recent pacemaker check started me thinking about what I should expect at a follow up.  Although published some years ago, I found the attached link well worth a read:- 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1769065/

Like most medical interventions, pacemaker follow up has to be tailored to suit the individual.  One important principle of pacemaker follow up mentioned in the link was to provide patient support and education, see Table 1. 

In my hospital, my device follow up is performed by a different technician each time, although all are experienced, fully qualified cardiac physiologists.  Even though the device follow-up still remains the responsibility of my consultant EP, the pacemaker technician seems to be more than qualified to make changes to my settings without any input from my EP and certainly does.

May I ask, do you feel you are being fully supported when you see your pacemaker technician, or do you struggle to be heard or to get advice on your settings?   What has been your experience during your pacemaker checks and are there any improvements/changes you would you like to see happen during a routine follow up?   

Personally I would like to see more  “continuity of care”, to be able to see the same technician at each visit. This would help to build trust and provide reassurance that I am being followed up by a clinician who knows me best.

I will be discussing this with my consultant EP when I see him, but would like to get some feedback from you all.  Many thanks


22 Comments

I rarely see the same EP-tech for my yearly in-person checks

by crustyg - 2022-10-12 13:32:49

It's a large team at my local teaching hospital.  I recognise some of the names on the occasions when I call in about something.

Last year the trainee (with supervising trainer) completely messed up the session, clearly hadn't been taught how to approach patients and the need to explain why something might be required and then went on to miss a vital change in my PM.  Happily I saw an EP-tech I recognised at my urgent session under a week later (where I managed to get the EP-tech's name right (not common for me) and set the session off on the right foot) and all was resolved.

I have once got the EP-techs to make an adjustment (lower rate limit back up from 45=>50BPM the day after a change from 50=>45), but in general I know *not* to ask them to change anything as I know that they will decline.  Anything I want changed has to go through my EP doc first.  I suspect that has more to do with the relationship between me and my EP-doc.

pacemaker checks

by new to pace.... - 2022-10-12 14:52:13

thanks Gemita for posting this question.  I am in the US and have my yearly pacemaker check done in the heart doctor's office.  I do see the same Medtronic tech so far since 2019.  As she goes to various offices during the month. So far no changes have been done to my pacemaker.  Did notice that the EP signs the copy electronictly.  Have always wondered if he really reads these.  the summary states  most of the same information that the quarterly remote transmission says.

new to pace

Continuity of Care

by Gemita - 2022-10-12 15:00:39

Thank you crustyg.  Hope all well your end.  That is interesting.  I thought you had more influence over your technicians during exercise testing and the like and worked with a device rep to get your settings fine tuned for you but no doubt this is with your EP's blessing.  

I think the problem I have is getting to see a cardiologist/EP at the moment.  The waiting times are horrendous in London and my EP has now retired, so waiting to see a new consultant.  

I have to admit I have managed to get my settings changed without EP approval on two occasions and also those of my husband’s after describing his symptoms to the cardiac technician.  On one occasion, she increased his Right Ventricle Voltage Threshold Output to give a better safety margin and more certainty of consistently capturing the heart.  On another occasion after describing his symptoms and asking about his lower rate limit, they increased it from 50 bpm to 60 bpm. 

My husband attends another London hospital.  They did both changes without initially going through his cardiologist/EP.  Perhaps these adjustments were not regarded as critical. 

I know there is another UK member who also manages to get the changes he needs by asking, but I can see this is not the norm and probably shouldn’t be for obvious reasons.  

Technicians

by doublehorn48 - 2022-10-12 15:02:43

Yes, I see the same one. In 30+ years I've had 3 techs that were a lot better than the rest. When I make an appointment I ask for a certain technician and I will schedule my appointment based on their schedule. When you find a technician you like request that person. I will now climb down from my soapbox.

New to Pace

by Gemita - 2022-10-12 15:23:14

I am sorry about your difficulties posting earlier and thank you for doing so again.  It is reassuring that you have had continuity of care since 2019 and with a Medtronic rep which sounds even better.  He should know so much more about your device than a hospital technician.  My hospital technicians often have to seek advice from a Medtronic rep in identifying an arrhythmia which has been recorded.

Yes I often wonder how much an EP is really involved in our routine care? Not much I suspect unless he sees evidence of a serious event. This is why I like to engage with Cardiac Physiologists whenever I see them, since they always give valuable feedback which I can then discuss with my EP.  But perhaps I shouldn't be asking them to make any changes.  That might be a step too far

Some adjustments don't need EP-doc approval

by crustyg - 2022-10-12 15:39:15

To the surprise of the experienced EP-tech I met nearly 2yr ago, my PM cannot be set to auto adjust capture threshold in the current mode (AAIR).  So if the capture threshold test that they do annually were to show an inadequate safety margin I'm sure that they would fix that then and there, no EP-doc reference required.  The MV-vector change that had to be fixed last year - no EP-doc involved, AFAIK.  The changes that I ask for are related to tuning - these need approval.

I haven't seen my EP-doc since implantation and have only seen a cardiologist (of any type) once since implantation (due to my own stupidity - but we laughed about it).  In some ways I'm an easy case - my EP-doc is waiting for the process that destroyed my SA-node to wreck my AV-node, and I'm betting (hoping?) that it won't - this is why my in-person checks are annual and not biennial. But apart from that I'm blessed with a healthy heart so a light touch is all that's required.  Others are not so lucky.

doublehorn48 and crustyg

by Gemita - 2022-10-12 17:52:42

crustyg, that is useful info on auto adjust capture threshold in the mode AAIR.  Would this also apply to AAI mode without rate response and to other pacemaker manufacturers, like Medtronic?  I know you have a different pacemaker.  Yes you do seem to have a well behaved heart.  It must be the cycling and your healthy lifestyle.  Long may it last.

doublehorn48, as an arrhythmia sufferer, I think continuity of care is very important.  I had a very helpful technician check my pacemaker 3 months ago and I wish I had been able to see her again last week.  I agree, I will try to ask next time whether it will be possible to see the same technician.  I don't see why not

Pacemaker checks

by Lavender - 2022-10-12 18:56:22

The article you posted is very informative!

I asked my pacemaker tech about auto-calibration but she said it's not done in my pacemaker. Auto-capture is not done either.  
 

My Boston Scientific CRT-P pacemaker checks (interrogations) are done every three months. Alternatively they are done in the cardiologist office by a pacemaker tech. I've seen three men and one woman. The woman is the only one who I saw two times in a row. It's a roll of the dice as to who's on duty. The techs tell me more and are much more patient than my cardiologist. They answer questions and clearly explain things. 
 

No changes are made without cardiologist approval. I only saw my EP the day of surgery. I'm not on any meds. 

Pacemaker Checks

by Marybird - 2022-10-12 20:44:15

I've been followed by my interventional cardiologist for a bit over two years now ( since the EPs in the practice left) and since then have seen the pacemaker technician employed by the practice. I see her routinely once a year for an in-office device check, and she has made a couple changes in the settings each time. Last year if I recall those changes were to turn off an auto-test mode that I felt as palpitations- I thought those were from me- but she said I didn't need that check, and she adjusted a setting ( don't know what it was) that would increase the sensitivity to A-fib episodes. During the last check she adjusted a setting ( possibly shortened or turned off the ventricular intrinsic preference (VIP) mode that allows a longer pause after atrial pacing to give the ventricles a chance to initiate their own contraction- as she said my pacing reports showed a significant number of pauses she thought indicated a possible heart block. She said the ventricle would be paced, possibly at 100% following that adjustment. I'm guessing this means my sinus node dysfunction has begun to spread to my AV node, but I guess that is the nature of things, and I'm grateful for those adjustments.

In this office patients with implanted cardiac devices have their remote reports sent to a cardiac monitoring company (Cardionet, I think) that reads and interprets the data, and sends a completed report to the office, this same technician gets those reports. As she explained to me when I asked, she reviews the reports, makes note of abnormalities and alerts, takes the initial step of seeing if the abnormality or alert is actionable ( ex, a patient showing A-fib is already on an anticoagulant), and sends the reports to the cardiologists' PA, who will triage the patients further as needed and notifies the cardiologist. This pacemaker technician also directly receives pacemaker report alerts from the company, via text message, and passes the information along.

This technician is excellent at explaining things and answering questions for patients. She has a direct phone line and encourages patients to call her with concerns ( with the pacemakers or settings, not their general health) or questions.

Like New To Pace, we're in the middle of the Hurricane Ian aftermath and recovery. Many areas ( including ours) have had power and other services restored in what I'd call a record time, but our internet services have, for the most part, not been yet restored, or if they have, they're spotty or intermittent. This may be what NTP was referring to with difficulties in posting. We are connecting our computers to our mobile phone AT&T wireless internet services ( using the phone service as a "hot spot" and "tethering" the device to that, if I got the explanation right) and that's been working pretty well, though it's a bit slower.

Gemita, thanks for this thread and for the linked article, I've saved it to my favorites to read it later.

Continuity of care

by AgentX86 - 2022-10-12 22:17:12

I see the same device tech each time, unless I have to see my EP (in the hospital).  I have no scheduled appointments with him anymore so I have no reason to use thier device techs.  Obviously, it's not the same person in the hospital as I normally do.

Interesting that you bring this up today, though.  I just went to see my device tech today.  I was in a car accident on Sunday (same intersection, same stop sign, I was turning left both times but from a different direction). We're fine, as is the other driver. It's a good thing she was wearing her shoulder harness and the airbags were working.  She swerved at (almost) the last second.  She just clipped the rear of my truck but lost control and rolled it down an embankment. I and passerby had to get her out of the vehicle (lying on the passenger side).

Anyway, Monday I noticed I had some scratches right where the leads exit the can and again where they go under the clavicle.  It was kinda sore there, too.  Evidently, the shoulder harness scraped across my PM. 

I sent them a remote transmission this morning but the device tech and a nurse wanted to check it out (device and injury) in person. The device tech did some tests that I haven't had done before.  She had me do some isometric exercises to put strain on the chest, then she looked for noise.  She also checked for thresholds and all that.  It took a lot longer than a normal interrogation.

Anyway, all is good.

Pacemaker checks and continuity of care

by BionicSenior - 2022-10-12 22:40:01

Thank you for the link I will look up.  I have felt the same way. Patient support and education is so important and to be able to hear comments in a way I can understand as a patient.   

Device f/u

by Rch - 2022-10-12 23:41:10

AgentX86, sorry about the MVA. I'm glad both you and the other driver are well and the pm and the leads are intact. I always worry about any falls or accidents being on the antithrombotics!!! 

Excellent topic of discussion Gemita! You must be a patient advocate!!🙏  As we all know healthcare professionals are extremely busy. Even though the appointments are generally 15-20 min long and the providers seemingly do not spend more than 5 mins with the patient, they do spend a significant amount of time power-reviewing records and electronic charting which takes up a lion share of the time! As to my PM f/u, I have had only 2 in-office interrogations since the implant 2 months ago. I trust my device tech's knowledge on the programming more than that of my interventional Cardiologist's who is great with cardiac catheterizations, angioplasties, pm implantation etc etc but device programming and interpreting intra cardiac electrograms etc are beyond his scope. Generally, if I have any questions, I directly consult the Boston Scientic representative. I'm not pm-dependent nor have CI, so far. My intrinsic HR is the 50s on beta blockers. But my basal rate is left at 60 out of the box, and since I feel fine, my device tech said she would just let the sleeping dog lay there! The only reprogramming done so far has been to extend the duration of PVARP for PMTs and that seemed to have solved the issue although the process resulted in reconfiguration of a few other parameters like the MTR. The auto ventricular capture threshold search every 21 hrs is really a nuisance but we decided to leave it as such at least for a year post-implant. I always request an after-visit summary for my own records, and I encourage everyone to do so. I learn a lot from this site. I enjoyed reading your reference on Osteoporosis management on another post! I hope more people would participate and ask questions so we can all learn from each other!!
Thanks

 

Thank you all for your contributions

by Gemita - 2022-10-13 07:03:19

Bionic Senior, It is important for me too to understand what is going on with my device and electrical disturbances.  My husband and I both required pacemakers in 2018.  It is not easy with time constraints during routine appointments to come away feeling totally reassured, fully supported and better equipped to cope with whatever lies ahead.  On our part, we need to be patient.  Pacing and pacemakers is a vast technical area that cannot be understood overnight.  It will be a journey for each one of us, but it is all about finding a caring professional to work with and this can be the challenge.  I wish you well

Rch, thank you for your valuable comments and for all your support on this forum. I agree the device technician looks after our settings very well indeed, allowing the EP/cardiologist to concentrate on treating the patient’s condition and symptoms.  I am always aware of the time constraints my device team are under which is why I try not to ask too many questions at one appointment.  Yes my experience too has been that the manufacturer rep is a mine of information and will know his own device best.  My hospital technician often consults the Medtronic rep for assistance in interpreting my intra cardiac electrograms to arrive at an accurate arrhythmia diagnosis.  I agree, getting a summary report of our pacemaker interrogation is always helpful.  In the UK I sometimes still have to apply “formally” for this information, but access is getting easier now after being told that if I need assistance, not to hesitate to contact my pacing clinic.

AgentX86, it is interesting to see how many of you see the same technician each time.  Makes complete sense to me although I accept my hospital sometimes gets in agency staff to help out our busy pacing departments.  I am glad all is well with your pacemaker following your accident and hope this will continue.  It does sound as though you received a very thorough check to reassure you and your team.  Will they want to see you earlier for your next check, or have they given you the all clear?  No doubt you will watch for any new symptoms and get advice if you need to.  Please take care and I hope you will recover completely.

Marybird, it was good to hear from you and I hope you are slowly recovering from Hurricane Ian. I am grateful you have found the time to respond to my post in such detail.  You are getting a lot of feedback from your clinic.  I was particularly interested in the settings changes you mentioned.  I am trying to establish whether my current pacemaker is up to the job in helping to “smooth out” pausing after premature atrial beats which frequently trigger Atrial Fibrillation (like atrial rate stabilisation), but this will be the subject of another post.  I did try asking the technician on 5th October but he unkindly hinted my pacemaker was of pensionable age, so I took that to mean it didn’t have such a function but I will continue to ask questions which he encouraged me to do.  I am beginning to realise they haven’t perhaps chosen the best pacing system to suit my personal needs, but I will make the most of this device until I am due an upgrade. 

Lavender I agree my technicians are so helpful too, usually have more time than my cardiologist/EP and are clearly more able to explain something in simple terms.  They are often surprised when I start asking questions about my settings, pacemaker and heart condition and seem to enjoy engaging.  I have a long way to go but I have started my journey and that is what counts.  I know some members would rather not know and that is fine too and in any event, not all members will have complex health conditions to manage but for those of us who do, understanding our pacing systems and condition can help relieve stress and get us the best possible care.

Pacemaker Checks

by Flo - 2022-10-13 07:10:02

Thanks for the informative  link Gemita.  I have a different Medtronic Tech every six months that I have a pacemaker check in the Cardiologist office.  A couple have been informative but mostly not.  I have gotten a lot of information and answers from searching this pacemaker club site.  

Hit and Miss

by MinimeJer05 - 2022-10-13 16:45:26

For a while, I was seeing the same PM tech (both in-person and on the phone), he seemed to take an active approach to trying to adjust settings to make me feel better and to help keep an eye on things.

But recently, I have been doing the 6 month "bed check" where they pull data when I am asleep and just send me a message saying "no signficant change". I like the ease of this, but I feel like I am completely in the dark on what this means.

I would prefer to have someone that is more actively engaged and not just "plugging you in, looking at numbers and sending you on your way".

But I guess if everything "looks okay", then they should be spending their time with the ones that aren't so lucky?

Jer

MinimeJer05 and Flo

by Gemita - 2022-10-14 02:21:40

MinimeJer05/Flo, thank you both for your contributions.  Yes it is a massive task to monitor each patient which is why the EP sets up our pacemakers to only report events which meet a certain criteria for their recording and storage.  These program parameters are set up by your EP based on your condition and symptoms.  Any rhythm disturbances that don’t meet the criteria set up for their recording will obviously not be stored.  Remember there just wouldn’t be enough space to keep every brief, irregular heart beat that we can all experience.  

When we attend clinic for our pacemaker check up, it is important therefore to let the technician know about any symptoms we may have had during the period monitored, like breathlessness, chest pain, tachycardia.  I keep diary notes of time, duration, date of any significant symptoms, so my technician can quickly locate the problem (if stored).

When the pacemaker technician checks my downloads they may be able to match my symptoms to a particular event and then either report this to my EP for additional treatment or see whether any settings need adjusting.  If nothing is recorded/stored, it usually rules out an important event.  But unless we report our symptoms, ideally backed up with a time, date, duration, they may not see the problem or be aware of our continuing symptoms.  My doctors only treat my arrhythmias when I am symptomatic, when I need to seek help, otherwise they may leave well alone.   

it varies widely and cant be regulated

by dwelch - 2022-10-14 03:07:32

It varies widely.  Some practices use techs from the device company, and that might improve or mitght not improve seeing the same person.  

this is really on par with wanting to go to the drive through one time a year and expecting or demanding the same person to be working the window when you come through.  

Techs and nurses, etc are free to change jobs at will.  Doctors offices are free to fire and rehire folks.  The pacer companies reps are free to come and go as they please as well.  And further all of these folks have work schedules that may or may not be every week day every week of the year, no vacations.

Because of insurance and me moving through the last 34 years with pacers, I have seen a number of pacer docs and nurses/techs.   Each practice does it a little different, one even put livingroom recliners in for us to sit in during the pacer check (I wonder if they had some one pass out and fall during a test).  When i started in the 1990s, my doc was a one man show, he wired up the ekg he ran the interrogation, he did the surgeries, other than the receptionist and some nurses during surguries, it was all him.  After him though it would vary.  The current place, in part due to how health care is now, a nurse brings me in, does the what meds are you on (even though we paid hundreds of milliions of dollars into infrastructure to make it so they knew, yet they dont) and such.  And she wires you up.  then the tech comes in, does the test, then takes the wires off, then the doc comes in after reading the report,  but I have been at this practice/doc for 15 years.  One tech was there for many years, but moved on, came back one time, but moved on.  had various techs.  The last one I loved, will see if he is there next time. 

But I have zero expectaiton to see the same one more than once.  They are just following their training to push the buttons and record the data, and keep an eye on you-ish as they do it.  If I saw a different doc every time i would move to another practice, but techs and nurses with a year between visits, no expectations.  And unless I hired them myself, no way that I could influence who is there.  I have already retired docs and will continue to. I am expecting any year now that my doc will retire, that does worry me...

For the many years that I did the old fashoined phone checks, with the big magnet, etc..That happened to be the same person for all of those years, but again, she didnt quit or get fired and I assume that she was the only one, if they had more than one then I would expect to not have had the same person.   Likewise I do not think my doc has more than one nurse or tech working at the same time, might have more than one during the week but would expect not. 

Now my dentist does have multiple techs and except when she is out for some reason they do schedule me with the same person.  she so far has not quit or been fired.  but is not always there when I am there.

so anyway.   There is no reason to expect the same person to be working there year after year.  Just like the same person may not be the manager at the grocery store for many years running.  Folks are free to pursue their own lives.  If you happen to be somewhere that they have multiple techs working and they can manage to schedule a specific tech, then sure that office might do that for you.

Based on a comment above.  I dont get anything useful out of techs, they are quite limited legally as to what they can say relative to the doc.  Maybe they can talk about the test they are running but that would be it, otherwise that practice could be in big trouble.  My experience is the techs silently do their job, often to the point that they surprise you with the speed up and slow down tests.  Seem annoyed that you ask them for a printout, etc.  Then the doc comes in and we have a wonderful conversation.  Get my questions answered if any, etc.  (at multiple practicies in different cities with different insurance companies).  Outside the operating room, the only time a pacer rep was there to run the interrogation was when I had an issue and they had them fix it. otherwise it has been trained staff.  but from this site I understand that some pratctices for I assume various reasons use a rep from the pacer company and not staff from the practice or hospital.

For me continuity of care is the doc not the nurses.  I expect the nurses/techs to come and go, but I have gone to various lengths over the years to keep/select my doc.  At this office (not my experience from prior docs).  I see the EP, same doc for the long run manging the device.  They have more than one surgeon and I have had both of them at least once, the EP in this case is not the surgeon.  If I had a non-pacer, no-EP issue then I would be seeing a different doc in the practice for that, but that is just how this office chooses to do things.  The nurses and techs come and go at this office, is what it is. IMO find a doc you trust, and trust the doc you find.   the doc can be great at medicine but not at conversation or conversation with you, so if the communiation is not good and does not seem like it can get better.  find a new doc.  The techs/nurses, legally, cannot provide you with much, they can lose their license the doc can as well the whole practice can be shut down.  At best ask for your printout and ask for them to tell you when they are running the tests.

 

Dwelch

by Gemita - 2022-10-14 04:44:10

Dwelch, thank you for your valuable contribution.  I see you have had years of experience dealing with monitoring staff, so I am very grateful to receive your opinion.  I don’t agree with your analogy that “expecting to see the same technician is on a par with wanting to go to the drive through one time a year and expecting or demanding the same person to be working the window when you come through”.  However I take your point that we cannot expect the same continuity of care with a device technician as we might currently enjoy with our EP or general doctor, although the latter isn’t always guaranteed either.  In the UK cardiac technicians/physiologists/scientists, in my experience, are highly skilled, highly qualified members of any cardiac team and are indeed able to talk to patients about their symptoms and their pacemaker settings and are able to make setting changes without consulting the EP.  Mine certainly do.  (The same with my husband's monitoring team).  I am sure specialist technicians/physiologists will have a much bigger role to play in the future, leaving our overworked EPs/cardiologists to focus more on patients with serious heart conditions.

Tech

by Lavender - 2022-10-14 09:07:31

My pacemaker tech this last two times told me that it's the hardest job she's ever had in terms of learning it. She also said it's the most rewarding given that she can help others. 

Pacemaker checks

by Aberdeen - 2022-10-14 14:22:37

I have seen the same pacemaker technician a couple of times.He answered quite a few questions I had.It is quite reassuring to see someone who remembers you. He had also seen me when I was in for my 3rd pacemaker operation in 2 years 3 months.

 

Pacemaker checks

by Daedalus - 2022-10-15 00:53:38


Gemita.....

Got my PM on Feb. 1 of this year.  The Biotronik tech was in the OR for the procedure and saw me later that day in my hospital room.   I saw him again a week later at my cardiologist's for my 1st follow up.  Then in mid March I had some questions and met him at the cardiologist office where he checked my device again and answered my questions.   I've seen him twice since for regular checks (most recently on Oct. 3), and will again in January.  He's been very forthcoming with info and spends all the time I need with him.   Glad to have him as the tech. 👍🏽

Lavender, Aberdeen, Daedalus

by Gemita - 2022-10-15 05:18:12

Lavender, Aberdeen, Daedalus, thank you all for your help.  Clearly from comments I have received both privately and on this thread, seeing the same technician has been reassuring and can have many clear benefits.  

I certainly don’t believe a check up only entails looking for events, confirming battery and lead status, checking those numbers and then reporting the findings to our EP or Cardiologist.  Most “good” technicians will engage with us and will want to know of any symptoms we may be having, so they can optimise our settings or make recommendations to our doctors for such changes to be made.  

I hope as more of us start getting involved in our own care, start asking more questions about pacing and our devices, our care providers will understand the important role the device technician has to play.  They are sometimes our only point of contact over many years once our heart condition has been successfully treated with a pacemaker, so it is important that we can feel safe in their hands

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