Ambulatory electrocardiogram (AECG) monitoring is a common cardiovascular investigation. Traditionally, this requires a face-to-face appointment. In order to reduce contact during the COVID-19 pandemic, we investigated whether drive-by collection and self-fitting of the device by the patient represents an acceptable alternative.
A prospective, observational study of consecutive patients requiring AECG monitoring over a period of one month at three hospitals was performed. Half underwent standard (face-to-face) fitting, and half attended a drive-by service to collect their monitor, fitting their device at home. Outcome measures were quality of the recordings (determined as good, acceptable or poor), and patient satisfaction.
A total of 375 patients were included (192 face-to-face, 183 drive-by). Mean patient age was similar between the two groups. The quality of the AECG recordings was similar in both groups (52.6% good in face-to-face vs. 53.0% in drive-by; 34.9% acceptable in face-to-face vs. 32.2% in drive-by; 12.5% poor in face-to-face vs. 14.8% in drive-by; Chi-square statistic 0.55, p=0.76). Patient satisfaction rates were high, with all patients in both groups satisfied with the care they received.
In conclusion, drive-by collection and self-fitting of AECG monitoring yields similar AECG quality to conventional face-to-face fitting, with high levels of patient satisfaction.
Background
Ambulatory electrocardiogram (AECG) monitoring is a common investigation performed as part of the assessment of patients with known or suspected cardiac arrhythmias. This normally requires the patient to attend a face-to-face hospital appointment. The role of patient-led collection and self-fitting of AECG within the National Health Service (NHS) has not previously been investigated. In order to reduce patient contact during the COVID-19 pandemic, and in order to maintain AECG services while other non-urgent diagnostics were suspended, we sought to assess the feasibility, reliability, and patient acceptability of a drive-by collection and self-fitting AECG service.
Method
This was a prospective, observational study of patients scheduled for AECG within our trust (Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust), comprised of three separate hospitals (Doncaster Royal Infirmary [DRI], Bassetlaw District General Hospital [BDGH], and Montagu Hospital [MH]). All patients attending between 1 and 30 November 2020 were included. There were no exclusion criteria. All AECG appointments at DRI were defaulted to drive-by, unless the patient requested a face-to-face appointment or was an inpatient at the time of fitting; all services at BDGH and MH were maintained as face-to-face, with this cohort acting as a control group. The project was registered internally as a quality improvement project within the trust; we sought ethical approval from our ethics committee, who deemed that this was not required.
Face-to-face fittings were performed as per usual clinical practice. Patients attending for drive-by appointments parked in a designated area outside the hospital entrance close to the cardiology department and a cardio-respiratory assistant delivered a monitor pack to the patient (including laminated instructions, alcohol wipe, skin preparation pad, electrodes, monitor, and patient diary). Patients were asked to fit the monitor as soon as possible and return to a drop-off box by reception after the designated monitoring period.
The primary outcomes were the quality of the AECG recording, and patient satisfaction rates. The AECG recordings were analysed by associate practitioners and cardiac physiologists, and categorised as good, acceptable, or poor. Recordings were classed as good if the electrocardiogram (ECG) recording was easily analysed without having to make any significant adaptations in order to provide sufficient data/information; acceptable, if the ECG could be analysed, but required significant adaptations and/or took markedly more time than expected, although the referral question could still be effectively answered; poor, if the referral indication/question could not be answered due to insufficient analysable ECG data.
Satisfaction rates were assessed through a custom-designed questionnaire, consisting of the following five questions, with yes or no answers.
- If you attended the drive-by service, was it easy to park?
- Are you happy with the care you received?
- Given the COVID pandemic, did you feel safe attending?
- Were the instructions for the equipment clear?
- Would you recommend the department to friends and family?
Data are presented as mean ± standard deviation (SD), or number (percentage) as appropriate. For the comparison of ECG quality between the two groups, a two by three Chi-squared test of independence was performed. A p<0.05 was deemed statistically significant. All analyses were performed using IBM SPSS version 26.
Results
In total, 375 patients were included: 183 in the drive-by and self-fitting group, and 192 in the face-to-face fitting group. Baseline demographics are summarised in table 1. In the drive-by group 51.3% of patients were female, and 51.6% in the face-to-face group. The mean patient age was similar in both groups (61.6 ± 19.2 years in the drive-by group, 63.9 ± 21.0 years in the face-to-face group, p=0.29). The indications for referral for AECG are summarised in table 1, and were similar in the two groups. The most common indications for referral were: assessment of ventricular rate in the context of known atrial arrhythmia; symptoms of palpitations, dyspnoea, or chest pain; symptoms of syncope or pre-syncope; recent stroke or transient ischaemic attack.
Table 1. Patient demographics and indication for ambulatory electrocardiogram (AECG)
| Drive-by and self-fitting group | Face-to-face fitting group | |
|---|---|---|
| Total number, n | 183 | 192 |
| Mean age, years ± SD | 61.6 ± 19.2 | 63.9 ± 21.0 |
| Female, n (%) | 94 (51.3%) | 99 (51.6%) |
| Indication for AECG, n (%) | ||
| Assessment of ventricular rate in context of known atrial arrhythmia | 44 (24.0%) | 54 (28.1%) |
| Symptoms of palpitations, dyspnoea, or chest pain | 44 (24.0%) | 35 (18.2%) |
| Symptoms of pre-syncope or syncope | 33 (18.0%) | 37 (19.3%) |
| Recent stroke or transient ischaemic attack | 26 (14.2%) | 30 (15.6%) |
| Suspected bradyarrhythmia | 10 (5.5%) | 12 (6.3%) |
| Monitoring in the context of structural heart disease | 10 (5.5%) | 6 (3.1%) |
| Suspected ventricular arrhythmia or bundle branch block | 5 (2.7%) | 9 (4.7%) |
| Other | 3 (1.6%) | 3 (1.6%) |
| Not known | 8 (4.4%) | 6 (3.1%) |
| Key: SD = standard deviation | ||
No significant differences were observed in the quality of the AECG recordings between the two groups: 52.6% were deemed of good quality in the face-to-face group, compared with 53.0% in the drive-by group; 34.9% acceptable in the face-to-face group compared with 32.2% in the drive-by group; 12.5% poor in the face-to-face compared with 14.8% in the drive-by group (Chi-squared statistic 0.55, p=0.76). The reasons for poor quality recordings were: artefactual baseline (drive-by n=6; face-to-face n=11), loss of channels (drive-by n=3; face-to-face n=6), and no ECG data recorded (drive-by n=8; face-to-face n=0). Twelve patients within the drive-by group were re-booked for a face-to-face fitting and repeat recording due to poor quality.
All of the patients in both groups indicated that they were ‘happy’ with the care that they received (table 2). In the drive-by group, 99.2% (128/129) felt safe attending their appointment, and 99.2% (128/129) felt the instructions provided for the equipment were clear (table 2).
Table 2. Responses to patient satisfaction questionnaire
| Drive-by and self-fitting group | Face-to-face fitting group | |||
|---|---|---|---|---|
| Yes n (%) |
No n (%) |
Yes n (%) |
No n (%) |
|
| If drive-by, was it easy to park? | 123 (95.3%) | 4 (3.1%) NR: 2 (1.6%) |
N/A | N/A |
| Are you happy with the care you received? | 129 (100%) | 0 (0%) | 75 (100%) | 0 (0%) |
| Given the COVID pandemic, did you feel safe attending? | 128 (99.2%) | 0 (0%) NR: 1 (0.8%) |
74 (98.7%) | 1 (1.3%) |
| Were the instructions for the equipment clear? | 128 (99.2%) | 0 (0%) NR: 1 (0.8%) |
74 (98.7%) | 0 (0%) NR: 1 (1.3%) |
| Would you recommend the department to friends and family? | 129 (100%) | 0 (0%) | 75 (100%) | 0 (0%) |
| Key: N/A = not applicable; NR = no response | ||||
Discussion
This is the first study to compare drive-by collection and self-fitting of AECG monitoring with traditional face-to-face fitting. In a cohort of nearly 400 unselected cardiology outpatients, we have demonstrated that the quality of recording using this novel method is similar to the traditional method, while maintaining patient satisfaction levels.
We observed a number of advantages to a drive-by and self-fitting AECG service, compared with a traditional face-to-face fitting service. First, the drive-by method was, in our experience, time-efficient. In our trust, face-to-face appointments are typically allocated 20 minutes for fitting and configuration of the monitor, with additional time between slots during the COVID-19 pandemic in order to prevent over-crowding. The drive-by issuing of all AECG monitors in our study hospital was possible in half a day; in contrast, an entire day was usually required to issue the same number of monitors via a face-to-face service prior to the pandemic. This enabled us to reconfigure our departmental staffing in order to transition to a seven-day service, with all available monitors issued on Saturday and Sunday mornings, keeping waiting times from referral-to-investigation to a minimum. A second benefit of a drive-by AECG service is its high satisfaction rate among patients, during a time when patient apprehension towards face-to-face consultations was high. Indeed, as many services transitioned to virtual appointments, our drive-by AECG service enabled patients, who may not have otherwise opted to attend the hospital, to undergo investigation within a timely manner. Third, we believe that a drive-by AECG service has the potential for integration within wider community services. Indeed, the British Cardiovascular Society’s recent report, The Future of Cardiology, recommends a move towards more diagnostic hubs in the community.1 Further development of a drive-by AECG service like ours, which does not necessitate co-location in a hospital setting, could facilitate such hubs.
We recognise the limitations of our study, and of a drive-by AECG service more generally. First, the study was undertaken in a single trust, and was not randomised or blinded. Second, we did not formally assess staff feedback and satisfaction regarding this new way of working. Finally, not all patients will be suitable for a drive-by AECG service. Specifically, in patients who cannot drive, or in those who are older, frailer, or who have a physical or cognitive disability, a face-to-face fitting may remain preferable.
Conclusion
Drive-by collection and self-fitting of 24-hour ambulatory ECG monitoring represents a feasible and reliable alternative to face-to-face 24-hour ambulatory ECG fitting. In the context of the COVID-19 pandemic, this method can be adopted to minimise face-to-face patient contact.
Key messages
- Ambulatory electrocardiography (AECG) is a common investigation, usually requiring a face-to-face appointment for fitting. The COVID-19 pandemic has impacted the delivery of regular clinical services
- We examined whether drive-by collection and self-fitting of AECG monitoring represents a suitable alternative to face-to-face fitting in terms of ECG quality and patient satisfaction
- We found that the quality of ECG data was similar in the drive-by fitting group compared with the face-to-face fitting group, with only 15% of patients having poor quality traces in the drive-by group, and 12.5% in the face-to-face group. Patient satisfaction levels were high among both groups
Conflicts of interest
None declared.
Funding
None.
Study approval
The project was registered internally as a quality improvement project within the trust; we sought ethical approval from our ethics committee, who deemed that this was not required.
Acknowledgement
The authors would like to thank and acknowledge the contributions of all colleagues from the Cardio-Respiratory Department at DBTH involved in this project.
Reference
1. British Cardiovascular Society. The future of cardiology. A paper produced by the British Cardiovascular Society Working Group on The Future of Cardiology. London: BCS, August 2020. Available from: www.britishcardiovascularsociety.org/__data/assets/pdf_file/0010/21142/BCS-Future-of-Cardiology-17-Aug-2020.pdf [accessed 15 May 2021].
