Last updated: October 2, 2026
Get A Walkthrough Of The Tiered Alert Workflow
The 2023 HRS/EHRA/APHRS/LAHRS consensus statement classifies CIED alerts into red alerts that require emergency or semi-emergency response and yellow alerts that warrant early but non-urgent clinical review. BHRS guidance refines the specific criteria used to program those alerts in daily practice.
| Tier | Clinical Criteria | Response Target | Owner |
|---|---|---|---|
| Red | Per the British Heart Rhythm Society (BHRS) July 2024 position statement on programming remote monitoring alerts in cardiac implantable electronic devices (CIEDs), red-tier high-acuity criteria include sustained ventricular tachycardia >30 seconds, ventricular fibrillation, asystole, appropriate or inappropriate shocks, lead fracture or impedance out of range, and ERI/RRT battery indicators. | Same-day review and escalation target, with immediate action required (≤2 hours) and emergency or semi-emergency response. | Named primary reviewer → on-call EP |
| Yellow | Per the British Heart Rhythm Society, CIED remote monitoring alerts fall into two priority levels, red and yellow. Yellow-tier clinical alerts include AT/AF burden (continuous time in AT/AF programmable from 6 minutes to 24 hours, nominal 6 hours), non-sustained RV oversensing (SecureSense), and connectivity disruptions shown as “patient disconnected.” | 24-hour action target, with MD notification within 8 hours and MD decision within 24 hours. | Named primary reviewer |
| Green | Green-tier criteria define routine, informational-only transmissions with expected behavior, such as scheduled battery reports, successful device interrogations, programming confirmations, and medication reminders. These transmissions require same-day EMR filing and batch log entry but no MD notification. | Same-day documentation and filing target, with no MD notification required. | Device clinic coordinator |
Action: Post the tier table at every device-clinic workstation and attach it to the written protocol.
See also: Prioritizing Critical vs Non-Critical Cardiac Device Alerts
A usable protocol assigns every tier a named owner, a response window, a patient-contact step, and a documentation requirement.
The build sequence follows a defined order. Start by standardizing alert types and reference thresholds across all OEM portals, because inconsistent thresholds make cross-portal triage unreliable. With thresholds aligned, write the SOP and score sheets for each tier. Then define working-hour coverage and identify who holds each role during business hours and after hours.
Fourth, set the data-review schedule. Real-world benchmarks from high-performing remote monitoring programs set alert transmissions at one business day and non-alert transmissions at three business days. Finally, specify how findings are reported to the supervising physician.
The 2023 HRS/EHRA/APHRS/LAHRS consensus statement expects clinics to define alert-management methods in advance, including SOPs, score sheets, and reporting procedures to the supervising physician. A protocol must exist in writing, not only in staff memory.
Action: Assign a protocol owner and set a review date for the written SOP.
See also: How to Build an Efficient CIED Alert Management Workflow
See How Rhythm360 Consolidates Your Alert Workflow
Response targets define program goals and must pair with explicit patient instructions.
The 2023 HRS/EHRA/APHRS/LAHRS consensus statement recommends that high-priority alerts be reviewed and acted upon within 2 days, excluding non-consultation days. Real-world benchmarks from high-performing programs set the standard at one business day for alert transmissions and three business days for routine transmissions.
The same consensus statement states that automatic remote monitoring alerts do not replace emergency management, and patients and caregivers should hear this clearly. Patients must receive instructions to call 911 or seek emergency care for acute symptoms. This caveat belongs in every patient onboarding script and device-clinic handout, not buried in fine print.
Action: Add the emergency-instruction caveat to patient onboarding scripts and device-clinic handouts.
Every alert needs a named owner for business hours, after-hours, and shift handoff, or ownership breaks down.
The escalation ladder defines four positions. The primary reviewer receives and triages the alert. The backup reviewer accepts ownership when the primary is unavailable. The on-call electrophysiologist receives escalation for red-tier alerts that require clinical decision authority. A secondary escalation contact activates when no acceptance occurs within the target window. Routing alerts to the responsible role rather than a static contact list creates accountable ownership, because the alert follows the role as staffing and schedules change.
A shift handoff is complete only when the incoming responder explicitly accepts responsibility. Acknowledgement of an alert means a human took responsibility but does not mean the condition is fixed. An acknowledged alert that remains open must be transferred with owner, evidence, next action, checkpoint time, and escalation trigger.
The handoff checklist for unresolved alerts at shift change includes:
Action: Adopt the handoff checklist and require explicit acceptance at every shift change.
An alert label alone does not constitute a diagnosis.
That is why, before acting on any red-tier alert, the reviewing clinician examines stored electrograms, trends, battery status, lead impedance, and clinical history. The JHRS Expert Consensus Statement notes that many noise events in early stages of lead damage may be mistakenly diagnosed as arrhythmia events, which makes detailed intracardiac waveform analysis important for early detection. A five-point verification step, covering electrograms, trends, battery, lead impedance, and clinical history, applied at the top of every red-tier review, prevents reactive clinical decisions based on incomplete data.
Action: Add a five-point verification step to the top of every red-tier review.
See also: How to Configure Critical Alerts: Cardiac Remote Monitoring
Non-actionable alerts are suppressed through personalized programming, not through ignoring the queue.
The Rule of 3 provides the operational standard: if a non-emergency alert triggers three consecutive times without a clinical change, interrogate the device, adjust thresholds, or deactivate the non-actionable notification. Each threshold maps to a specific tier:
One safety exception applies. Some manufacturer systems do not allow degrading or disabling alerts directly related to serious conditions. Threshold adjustments must stay within manufacturer-permitted parameters.
Action: Audit the top ten noisiest alert types in your panel and apply the Rule of 3.
See also: How to Reduce Critical Alert Fatigue in CIED Monitoring
Documentation is what makes an alert review defensible.
Every red-tier alert requires EHR documentation of five elements: the alert itself, the clinical interpretation, the patient contact, the clinical decision, and the follow-up plan. Incomplete records can trigger claim denials or compliance exposure, and auditable documentation supports both billing integrity and defensibility in the event of a clinical review.
Documentation also determines what you can bill. Remote cardiac device monitoring CPT codes by device type and cycle:
Action: Standardize a five-field documentation template in the EHR for every red-tier alert.
Measurement is what makes a protocol defensible.
Five indicators define program performance:
Track median and tail response times rather than averages, because overdue alerts hide in the long tail of the distribution. Acknowledgement does not equal resolution. An acknowledged alert that remains open must carry an owner, evidence of what has been tried, a next checkpoint, and an escalation trigger.
Action: Build a monthly one-page dashboard using these five indicators.
Rhythm360 turns the written protocol into a single, auditable workflow across every major manufacturer.
That capacity matters at scale. At the University of Chicago Medicine, more than 73,000 reports were reviewed annually through Rhythm360 in calendar year 2025. That averages more than 18,000 reports per quarter and demonstrates the platform’s capacity to sustain high-volume monitoring at scale. As Andrew Beaser, MD, a cardiac electrophysiologist at UChicago Medicine, has emphasized, decision support, including AI-assisted decision support, will grow in importance as data volumes increase.
Practices implementing Rhythm360 have achieved up to a 300% increase in revenue capture and profitability through optimized billing documentation. Other platforms exist in the CIED monitoring space, but Rhythm360 is built to consolidate multi-OEM alerts into one auditable workflow.
See Rhythm360 In Action For Your Device Clinic
These are the questions device-clinic teams ask most often when they operationalize a tiered alert protocol.
Red alerts require emergency or semi-emergency response, and yellow alerts warrant early but non-urgent review. The full tier criteria appear in the table above. The practical difference lies in the response window: red targets same-day escalation within 2 hours, and yellow targets 24-hour action.
Non-actionable alerts decrease when you individualize device programming using the Rule of 3 described above. After three non-emergency alerts without clinical change, interrogate the device, adjust thresholds, or deactivate that notification within manufacturer limits. Rhythm360’s AI-powered triage layer further filters non-actionable noise and surfaces actionable and billable events for human review.
The same four-position ladder described above applies after hours: primary reviewer, backup reviewer, on-call electrophysiologist, and a secondary escalation contact. The key difference after hours is the need for explicit handoffs, where the incoming responder accepts ownership rather than simply receiving a message.
Every red-tier alert should follow the five-element structure outlined above: alert, interpretation, patient contact, decision, and follow-up plan. Rhythm360’s bi-directional EHR integration supports that structure at the point of care and reduces manual transcription.
Remote monitoring does not replace emergency care. As noted above, the 2023 HRS/EHRA/APHRS/LAHRS consensus statement states that remote monitoring alerts are not a substitute for emergency management. Patients must receive clear instructions to call 911 for acute symptoms.
An automatically transmitted alert does not equal a reviewed alert, and a queue without named owners does not function as a protocol. The 2023 HRS/EHRA/APHRS/LAHRS consensus statement and BHRS guidance provide the clinical foundation: tiered red, yellow, and green classifications with explicit criteria, response windows, and documentation expectations. The operational layer, including named roles, after-hours escalation ladders, shift handoff checklists, verification steps, and measurable program metrics, converts that foundation into a defensible written protocol.
Rhythm360 operationalizes that protocol across every major manufacturer in one triage dashboard, closing the documentation and after-hours ownership gaps described above.
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