Optimization of the clinical workflow and patient pathway in cardiac monitor implantation and follow-up
Authors: Vanhala V , Multisilta V , Lundsby Johansen M , Surakka O , Villinger J , Nicolle E , Korhonen P 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Medtronic

Background
Clinical evidence supports the use of Insertable Cardiac Monitors (ICMs) to determine the aetiology of recurrent unexplained syncope and cryptogenic stroke. ICMs continuously monitor cardiac arrhythmias, enabling appropriate diagnosis and treatment. A remote follow-up system transfers ICM data to hospital staff for analysis. This creates a significant data-burden for the staff.

Purpose
To assess the impact of efficiency optimization of the diagnostic patient pathway and clinical workflow for patients eligible for an ICM.

Methods
We collected patient-level data from all patients that received an ICM at a university hospital in 2018 and 2020 to assess the change in the clinical workflow with one year follow-up time. Pathway improvements included moving the procedure out of the catheterization lab (cath lab), switching to a nurse-led pathway as well as outsourcing part of the remote follow-up workflow to an external monitoring centre.

Results
The number of implanted ICMs doubled from 74 in 2018 to 159 in 2020. In 2018, all implantations were done by a physician while in 2020, 70 % were done by nurses. In 2018 the operation schedule was 60 min for an ICM, compared to 45 minutes in 2020. The waiting time from referral to implantation was significantly shorter in 2020 (mean=36 days) compared to 2018 (mean=49 days), p=0,008. Implantations done in the cath lab decreased significantly (19 % in 2018; 2 % in 2020). Patients receiving an ICM after syncope increased from 71 to 94 patients. Stroke and transient ischemic attack (TIA) as an implantation indication increased substantially from 2018 to 2020 (2 and 62 patients, respectively). In 2018, nurses analysed all remote transmissions. In 2020 the first line review and triaging of remote transmissions was outsourced to an external monitoring and triaging centre. This external service escalated only 11 % of the transmissions (204 out of 1817) to the clinic for revision. Under the assumption that a nurse uses 11 minutes per transmission as seen in previous studies, this saved 296 hours of nursing time in 2020. The nurse-led implantation in 2020 saved 48 hours of physicians’ time compared to what would have been used by the process in 2018. The shorter procedure scheduling freed up additional 40 hours of nursing time in 2020. Also, time in the cath lab was freed up for other procedures (27 hours per year). The complication rate did not change significantly (2,7 % in 2018 and 3,1 % in 2020, P=0,85). The 1-year diagnostic yield for syncope remained high in 2018 and 2020 with no statistically significant difference (26.8 % vs 20.2 % P=0.32). The diagnostic yield for stroke patients implanted in 2020 was 24.6 %.

Conclusions
Nurse-led care pathways and the use of an external monitoring and triaging service significantly improved the patient pathways for patients indicated for an ICM. This freed up a significant amount of staff time and resources without compromising the quality of the treatment.