Clinical Considerations and Challenges for the Device Clinic: Key Challenges in Managing a Device Clinic, Programming Considerations, Staffing Concerns, and Best Practice Tips

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EP LAB DIGEST. 2023;23(12):1,21-23.

Michael Silva, RN, RCES, CCDS, WellSpan Heart and Vascular, York, Pennsylvania

WellSpan Health is an integrated health system located in South Central Pennsylvania and Northern Maryland. It is headquartered in York, Pennsylvania, and has more than 20,000 employees across the region. WellSpan operates 8 hospitals, with the largest being a 593-bed community teaching hospital located in the city of York. The surrounding area has a diverse population with urban, suburban, and rural locations, and is one of the fastest growing areas in the region.

The Heart and Vascular Center (HVC) opened in May 2021 on the Apple Hill medical campus near WellSpan York Hospital. This freestanding facility was designed to offer advanced, comprehensive cardiovascular care to patients in the region. It houses multiple cardiac specialties including electrophysiology (EP), invasive, heart failure, open heart, inherited diseases, general, and structural cardiology provided by top specialists from across the country recruited by WellSpan.

The device clinic is located at the HVC and is an integral part of the services that WellSpan provides. There are over 9000 patients systemwide with various cardiac implants including pacemakers, implantable cardioverter-defibrillators (ICDs), monitors, and cardiac contractility modulation. The HVC is home to the system’s largest device clinic and manages close to 4000 patients. Additional patients are managed at several other locations around the region.

The device clinic consists of 3 rooms specifically designed for patient care delivery and device management (Figures 1 and 2). Additionally, there is an office for technicians and an office for clinic administrative duties. The staff currently consists of 2 registered nurses (RNs) (including the manager) and 5 technologists (including one lead technician and 2 administrative staff). The staff operates with an ardent team approach to patient care.

The technologists perform in-clinic device interrogations and reprogramming as well as manage scheduled remotes and alerts. Our nurses function in this role as well and will often see the newly implanted patients to provide wound care and post-implant education. Our administrative staff assist with scheduling, no-show patients, and disconnected remote monitors. The technologists normally rotate weekly with their assignments to maintain proficiency in all areas.

Patients are seen for in-clinic appointments, dual provider appointments, and walk-ins. Most of our implant patients are followed on a quarterly basis through utilization of their remote home monitors. We utilize a remote staffing model for device alerts and scheduled remotes. Alerts received from home monitors are transmitted to vendor websites and then relayed to our software platform where they are managed by staff.

Implanted cardiac devices have evolved dramatically over the past few years. The complexity and management of these devices, as well as care for these patients, have changed as a result. It can be difficult to understand what is involved in the care of device patients because there is often limited knowledge, even in the medical community. To learn more, conversations were hosted with leaders in the system, along with colleagues in other clinics, to discuss the challenges involved with managing these devices. The greatest challenge was the justification for increasing staff and resources to manage devices. Our leadership and physicians listened, and along with information from the Heart Rhythm Society (HRS) and other sources that helped to prove the need, these conversations were able to justify additional staffing and equipment with the leadership team.

Our clinics also needed updated software and equipment to manage the growing number of devices. Research was conducted on available cloud-based systems and the decision was made to opt in with advanced software to improve the way information is managed. The system adopted Murj software, which has allowed for greater collaboration between the device clinics. This has improved consistency in documentation and device care systemwide. Shared discussions were also hosted with other clinics on how to best utilize the software based upon its capabilities.

The software platform has improved how advisories and recalls are managed, which has reduced overall workload, and we continue to find ways to enhance usage for managing devices. Our electronic medical record (EMR) will be fully integrated with the software platform soon, which will further increase efficiency.

Clinical challenges are ever-increasing as devices evolve and more advanced procedures are performed. Our robust EP center performs complex procedures, including devices with left bundle branch (LBB) leads, LBB-optimized cardiac resynchronization therapy (LOT-CRT), leadless pacemakers, ablations, and research. We work closely with our EP physicians to ensure appropriate programming considerations for devices. There is also a collaborative device team who often reviews programming challenges, difficult device interrogations, best practices based upon HRS recommendations, and experience from other clinics throughout the country.

This has led to improvements in patient care, and we continue to look for new opportunities to improve our processes, workflows, and accuracy of reports and information. Our device team works closely with our advanced practice providers and registered nurses at the HVC to manage the triage of urgent device alerts, ICD shocks, and arrhythmias. Staff may escalate issues to nurses or directly to a provider in clinic. We have developed an efficient workflow and an alert protocol to manage remote alerts.

We work closely with our specialties at the HVC to coordinate multiple appointments as well. WellSpan has been performing cardiac magnetic resonance imaging (MRI) for several years. We have identified the need for additional device staff at the hospital to support the increased volume of patients with an implanted cardiac device undergoing MRI. The manufacturers’ representatives are not always available for reprogramming and the devices are not always conditional. We are starting to provide this support internally and will have staff stationed at the hospital to provide coverage on an ongoing basis. We have a cart equipped with all the various programmers for MRI. This cart will be utilized by our staff to support device care throughout the hospital soon (Figure 3).

At the HVC center, we have an additional monitoring team that resides within the same division. This team consists of 2 administrative staff and 7 cardiac technicians. Several of our technicians have certified cardiographic technician (CCT) certification/certified rhythm analysis technician (CRAT) certification or are pursuing it. Last year, we went through multiple monitor trials with our physicians to select the best vendor for our operation and one that was willing to be flexible to meet our needs. We apply 24 Holters (standard and 12-lead) which we own. These monitors are scanned and interpreted by our staff and formally read by our EP physicians. We utilize an external vendor for mobile cardiac telemetry, event, and extended Holter monitoring. Our EP physicians perform the final interpretation of these monitors as well. Last year, we applied over 6000 monitors and expect this number to increase as the practice has added more cardiology providers.

There are many challenges with outpatient monitoring, including a mass influx of data and reports because of the volume. These reports must be processed by our staff, uploaded to the EMR, and sent for interpretation and finalization by our EP physicians. Our staff spends significant time educating our patients about monitors, and we provide written education as well. Despite the education, we often receive phone calls from patients with questions and asking for assistance with their monitors.

The monitor alerts are sent to our monitor staff from the vendor’s Independent Diagnostic Testing Facility. These alerts are verified by the staff for accuracy and sent to specialized nurses that manage the alerts and triage patients. We have had situations in which a life-altering or catastrophic event was prevented for a patient due to our team’s astute and timely response. Having this team in place has allowed quicker identification of patients in need of a pacemaker or ICD, prompt treatment of patients with significant arrhythmias, and more timely referrals to EP for additional treatment. Our leadership team has been supportive in allowing these additional resources and staffing to help assist with all these tasks.

Our EP physicians provide oversight and direction for the device clinic. Our system director is Brian Schuler, MD. There are additional EP physicians in York as well: Greg Fazio, MD; Jefferson Lee, MD; Edmond Obeng-Gyimah, MD; Matthew Singleton, MD; and Anwar Chahal, MD, PhD, MRCP. These physicians perform complex ablations for various arrhythmias, device implants, and participate in research. They have been incredibly supportive of the changes made in the clinic. There are additional EP physicians that oversee the other clinics in the region as well.

We have overcome a multitude of challenges in building our program and made many changes since our move to the HVC. Our staff has more than doubled in size because of the needs of patients with implanted and wearable devices. Our philosophy is that change is inevitable, but change allows for growth and innovation.

We should always seek a better way of doing our work, when possible, to improve efficiency and provide the highest quality care. Patient care is the number one priority. We are very appreciative of the support received from both the system leadership and physicians. This has allowed us to expand and meet the continual changes and growth in the clinic. We are excited about what the future will bring to our team and ultimately for our patients. One of the common expectations of WellSpan is “Working as One,” and our team meets that expectation every day. 

Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and reports no conflicts of interest regarding the content herein.