Efficient Clinical Operating System: Workflow Improvement to Meet Needs of Expanding Cardiac Implantable Electronic Device Population

How Regional Cardiac Arrhythmia Optimized Their Workflow to Address Workload and Staffing Challenges

EP LAB DIGEST. 2023;23(6):18-20.

Regional Cardiac Arrhythmia (RCA) is an independent electrophysiology practice covering 7 clinics in Pennsylvania, Ohio, and West Virginia. Through absorbing new clinics and increasing cardiac implantable electronic device (CIED) implants, RCA has rapidly doubled their CIED population from 4300 patients in January 2020 to over 9100 in November 2022.

To meet the growing CIED patient needs amid resource constraints, RCA developed the Efficient Clinical Operating System (ECOS), an effective workflow that can be easily scaled and replicated in new clinics.

In this article, we describe the ECOS workflow and the value impact to RCA staff and patients.

ECOS Workflows

CIED Implant Workflow

Several focus areas pertaining to the CIED implant workflow were identified as critical to drive efficiency and increase remote monitoring (RM) compliance: patient education, same-day discharge, and RM setup (Figure).   

Patient education: Patients receive pre-operative education to set expectations for the procedure and post-procedure follow-up, including RM and clinic visits. They are also referred to the CareLink Network Get Connected service (Medtronic), an industry-provided service supporting proper RM setup.

Streamlined discharge: The peri-operative workflow is designed with the goal of mitigating delays to patient discharge, often leading to discharge on the same day as the implant when clinically appropriate. Streamlined discharge is enabled through use of a tablet-based device interrogator, the CareLink Express Mobile (CLEM) system (Medtronic), which is used by operating room staff to interrogate the device after the pocket is sewn and transmit initial device readings to the CareLink network. Following transfer of the patient to post-operative recovery, hospital staff conduct another CLEM-enabled interrogation and subsequent CareLink data transfer. The implanting physician is then able to review the device data in the CareLink network and confirm that the patient is ready for discharge—either on the day of implant or the following morning—without having to wait for a programmer evaluation.

RM setup: The final step prior to hospital discharge is to ensure a connection has been made between patients and the Get Connected service, which guides patients through RM education, selection, and setup, including smartphone app-based monitors such as the MyCareLink Heart mobile application, which have been shown to significantly improve the scheduled transmission success rate,¹ improving patient care and reducing the burden on clinics to call and request manual transmissions from patients. Further, utilization of the Get Connected service has been estimated to save hospital staff 1.2 hours per patient by completing patient education, RM setup, and troubleshooting.²

Clinic Follow-up Workflow

Remote/in-clinic management paradigm: RCA prioritized RM adoption while simultaneously reducing the frequency of in-person routine visits for the RM population to one annual visit in alignment with Heart Rhythm Society guidelines and evidence.^3-5

Streamlined clinic visit workflow: Upon patient check-in, RCA administrative assistants use tablet-based CLEM to download device data while the patient is still in the waiting room. The data is transmitted for remote interpretation and review so that findings are available in CareLink by the time the physician sees the patient, reducing wait times for both the patient and clinician.

Electronic medical record (EMR) interoperability: Finally, enhanced EMR interoperability was achieved through use of vendor-neutral patient management (PM) software to improve the workflow for both in-person visits and RM. All data and interpretation are automatically transferred to the PM software by the time a physician sees the patient, allowing for a timely and efficient visit for both the clinician and the patient. Further, integration with PM software streamlines the EMR documentation and visit billing process.   

ECOS Value Impact

After implementing the ECOS workflow in January 2020, RCA observed several improvements with respect to clinic efficiency and economics, improved patient care, and clinician satisfaction.

Operational Efficiency: Doubled CIED Patient Population and Grew Implant Volume With Only 30% Staffing Growth

Prior to ECOS, RCA managed 230 patients and performed 81 implant procedures for each member. The 4 RM-dedicated staff monitored approximately 3500 patients with CIEDs, or 875 patients managed per one staff member (Table).

By November 2022, RCA’s CIED population grew by 200% but staffing increased only modestly from 19 to 25 (20 clinical, 5 administrative), with 5.5 being dedicated to RM. This translates to a 58% increase in patient-to-staffing ratio while maintaining a similar or slightly improved procedure volume per staff. Moreover, the 5.5 RM-dedicated staff were following 8653 patients, representing a substantial (80%) increase in the number of patients remotely monitored per staff: 1573 patients vs 875 pre-ECOS.

Improved Patient Care: 30% Growth in RM Compliance Amid Doubled RM Population

With the implementation of ECOS, RCA’s RM adoption outpaced their CIED population growth—the number of patients not remotely monitored decreased by 48% while adding 5153 new patients to the total volume of patients managed. The Get Connected service also optimizes the effectiveness of RM by helping patients set up Bluetooth-enabled RM apps, which have been demonstrated to maintain higher RM compliance.¹ Taken together, impact of the optimization of follow-up and monitor use is demonstrated with a 30% increase in RM compliance post-ECOS.

Satisfaction: High Staff Satisfaction Despite Increased Patient-to-Staffing Ratios

A survey was deployed to all non-EP clinic staff (n = 20) to examine their experience with the workflow. Of the 12 (60%) staff who responded to the survey, 12 (100%) said they “agreed” or “totally agreed” that their “clinic is efficient in its workflow and management of patients.” Most importantly, despite the expanded patient-to-staffing ratios, when asked whether they can complete their scheduled workday at a predictable and reasonable time, 12 (100%) reported that they “agreed” or “totally agreed.” Overall, 12 (100%) of clinic staff “agreed” or “totally agreed” that they are satisfied with the ECOS workflow.

Conclusion and Next Steps

The ECOS workflow developed by RCA resulted in meaningful improvements in clinic efficiency, patient care, and staff satisfaction. The key drivers of these improvements were: (1) growth in RM; (2) decrease in routine in-person visits; (3) leverage of tablet-based device interrogators to optimize the efficiency of CIED implant procedures and in-clinic follow-up visits; and (4) use of vendor-neutral software for seamless EMR documentation with in-clinic follow-up visits and RM.

RCA continues to refine their workflow, looking for opportunities for further improvement. The transition from 2 to 1 annual routine clinic visits for RM patients has significantly reduced the clinic workload. However, growing evidence suggests that routine clinic visits are not clinically actionable,^6,7 and patients with only remote follow-up have comparable outcomes to patients followed with routine clinic visits.⁸ Therefore, RCA will continue to reassess its workflow to optimize patient outcomes and maximize clinic efficiency as the evidence base grows and guidelines update. 

This article was published with support from Medtronic.

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They have no conflicts of interest to report regarding the content herein. Mr Lanctin reports receiving salary compensation and stock or stock options from Medtronic.

References

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