Reflections on a Longstanding Career in EP as a Nurse Practitioner

In this feature interview, EP Lab Digest talks with Laura Horwood, MS, ACNP-BC, CCDS, about her long and successful career in EP at the University of Michigan in Ann Arbor, Michigan. 

What is your current role at the University of Michigan (U of M)? How long have you worked at U of M, and what made you join EP?

I began my nursing career at the University of Michigan in 1987 on a cardiology step-down unit, and 3 months in, I found myself volunteering to observe the 35th epicardial defibrillator implant performed at our institution. After presenting on this experience at our Nursing Grand Rounds, and continued interaction with the electrophysiology (EP) patient population, I found myself eager to specialize. In 1992, an outpatient EP role became available, and ever since, I have been working within the subspecialty with a primary focus on device management. At the time, pacemaker and defibrillator technology was in its infancy, and I had the good fortune to grow within the EP space as technology advanced. I realized early on the specialized nursing care these patients required and how I could make a difference. I was one of 2 device nurses in ambulatory care, and later went on to obtain my graduate degree from the University of Michigan, and board certification as an Acute Care Nurse Practitioner in 2006. Currently, I function as the clinical lead of the University of Michigan EP Device Program. 

You have worked at an academic medical center for many years, working with several fellows and trainees. How does that make your job different compared to a non-teaching environment?

Working alongside our fellows in a strong academic program provided a competitive culture that has led to my continued growth within EP, and has allowed me to operate at the forefront of new technology and research. For the past 28 years, I have had the pleasure of interacting with a magnitude of talented advanced practice providers, nurses, technicians, and fellows, many of whom have been hired on to serve as faculty at the University of Michigan. Along the way, I’ve found myself benefiting from the vast educational programs provided by our EP faculty, visiting speakers, nursing peers, and industry representatives — all of which have stemmed from working in a facility with one of the largest EP fellowship programs. Subsequently, I was afforded a role in serving as the primary resource for the clinical management of cardiac implantable electronic device (CIED) patients. As a result, I have been providing the annual EP fellow orientation as well as lectures for continued education, and spearheading our institutional guidelines and protocols that have also been adopted by outlying medical practices. 

How are you involved in research?

From my early work until present day, much of my time has been dedicated to participation in device research, and it was through these roles that I was able to exhibit a hands-on approach towards the progression of technology. Initially, I was directly responsible for the data collection of device and lead clinical trials, beginning with the introduction of the Endotak lead, which helped to revolutionize endocardial dual-coil defibrillation and served as my official introduction to research in EP. Since then, I’ve participated in the many large-scale trials that helped to progress devices away from early epicardial abdominal implants to current-day pectoral devices with tiered anti-tachycardia pacing, programmable zones, and on through to the introduction of cardiac resynchronization therapy. Devices and leads today have numerous programmable features and attributes, and it’s always exciting to see science-based medicine come to fruition, and how the results of trials you take part in help further develop the algorithms and products within our specialty. 

In addition to industry-driven investigations, I have also been very involved in our own institutional research, most recently with CIED management for patients undergoing therapeutic radiation and magnetic resonance imaging. I have collaborated with our EP and Radiology departments to publish our research results, present at the international Heart Rhythm Society (HRS) scientific sessions, and formulate several University of Michigan institutional protocols that have contributed to safe patient care and access to imaging modalities. 

How has our field changed in the past 20 years?

Technological improvements within the past 20 years have propelled the industry towards advanced mapping systems, ablation catheter development, and improvements in implantable devices and lead designs. With much development towards advanced diagnostics and automated lead and device features, genetic testing and the ability to identify high-risk patient populations have all contributed to the expansion of CIED implant indications and recognition of primary prevention cohorts. We have learned much about the progression of heart failure, the negative effects of right ventricular pacing, and defibrillation threshold testing. Today, we see continued trends and refinement with optimized resynchronization therapy, physiologic pacing utilizing both His and bundle branch recruitment, and waveform tuning techniques. 

Simultaneously, the growth in EP has been reflected in program sizes as well. As more patients became acquired, it is natural for the departments to increase their numbers in response, and the University of Michigan was no exception. What began as a team of 4 electrophysiologists, 3 nurses, 2 fellows, 1 dedicated EP lab, and 1 bay area for non-invasive procedures, has transformed into a department that encompasses 15 electrophysiologists, 7 fellows, 17 nurse practitioners, 9 device nurses, 6 EP nurse coordinators, 3 outpatient technicians, 2 research coordinators, and a facility that houses 6 dedicated interventional labs and 1 non-invasive lab. Further, our governing society has grown as allied professions play an increasingly significant role within it and in the ongoing research for our EP patient management practices. 

What will EP look like in 10 years?

In the next 10 years, the medical community and device industry will hope to further advance and address the limitations that are met with currently available products, be it with device longevity, lead integrity, or varying remote transmission concerns. With current research exploring the feasibility of solar energy and the transformation of mechanical movements of internal organs into alternate power sources, one would hope that battery longevity would far exceed the 6 to 10 years we typically see today. Wider usage of leadless pacing may become more prevalent as indications expand with the development of AV synchronous technology and anti-tachycardia pacing capabilities. We may also begin to see an expansion in our field with the use of gene therapy as a potential biological pacing option in patients with vascular access issues or problems with repeated device system infections. As industry trends toward the use of Bluetooth-enabled devices and app-based connectivity, and as remote programming becomes more of a possibility, clinic workflows will need to continue to adapt. At the University of Michigan, telemedicine has already expanded to include post-implant wound checks, initial and troubleshooting device evaluations, and antiarrhythmic medication monitoring. Remote services for patients will continue to be maximized as COVID-19 has only further heightened the need for device and arrhythmia follow-up to transition towards a virtual platform.

What devices are available for patients that were not when you started?

When I began in the early 1990s, ICDs were still being implanted abdominally. While they utilized both epicardial and transvenous lead systems, these primitive devices had very limited programmability and minimal to no diagnostic capabilities. Early sensor technology and the ability to perform rate responsive pacing was only available in single- or dual-chamber pacemakers. We frequently encountered pacemakers with minimal telemetry capabilities, unipolar pacing, and nuclear-powered pacemakers implanted predominantly in the 1970s. It was many years later that battery technology progressed enough for ICDs to reduce in size and gain the ability to also be placed in the pectoral position. Device-device interactions were a common problem, and it wasn’t until rate responsive capabilities emerged in single- and dual-chamber ICDs that the need for separate devices addressing both brady and tachy indications was eliminated. In the early 2000s, several novel devices reached the market and broadened our diagnostic and therapy options. Wearable cardioverter defibrillators were introduced and provided interim protection for patients at high risk for sudden cardiac death. Implantable loop recorders became available to aid in the diagnosis of conduction system disorders for patients with unexplained syncope, and indications have further expanded to include atrial fibrillation management and cryptogenic stroke. Cardiac resynchronization therapy was also an emerging heart failure treatment option, and has been shown to reduce morbidity, mortality, and heart failure hospitalizations. More recently, technological advancements such as the leadless pacemaker, subcutaneous ICD, His and bundle branch recruitment, left atrial appendage closure devices, and laser lead extraction tools have begun a new era of device technology — it will be exciting to see the future generations of these innovative products.

How has the adoption of remote monitoring changed the device clinic?

The ability to remotely monitor CIED populations allows providers access to closely supervise patients on a daily basis, and has been shown to improve outcomes if appropriately incorporated into clinic workflows. Due to available monitoring systems and the alert programming features, we can provide early identification of actionable device or rhythm-related events from routine downloads, alert detections, or patient-initiated transmissions. Wireless and Bluetooth connectivity have brought about improved patient compliance, while sophisticated industry websites have also contributed to the identification of patients that may be temporarily disconnected. With remote monitoring symbolizing today’s standard of care, routine in-office visits can be extended for up to 2 years, thus allowing increased availability for those who require in-person consultation in a timelier fashion. There are several hospital workflows that have also been implemented within Emergency Departments and clinic areas utilizing remote interrogations, which has led to improved patient outcomes, workflow efficiency, and cost savings. Although remote monitoring has afforded numerous benefits, there have been associated program and care concerns that cannot be ignored. Tremendous increases in workload for the outpatient staff have come about, and solutions must be considered for appropriate delivery of patient care to continue. Further, patients need to clearly understand the goals of remote monitoring to avoid unrealistic expectations from providers. With all things considered, remote monitoring has played an instrumental role in the movement towards a virtual platform and will continue to reform device patient care in the years to come. 

What is the most exciting part of your job?

What keeps me working every day is when I can affect positive change and make a difference for my patients. Throughout the years, our outpatient team has been given autonomy to innovate and create, and some of my most cherished memories are from these programs I have contributed to. The Young ICD Program was just that. Created and sustained for 20 years, this initiative addressed educational and emotional support to not only ICD recipients, but also to their family and friends. This was a collaborative effort with our pediatric and adult EP staff. Our teams donated time and resources for these individuals, and it was a life-changing experience for all that participated. Another very rewarding aspect of my job stems from years of experience and the ability to identify and optimize a device to improve a patient’s quality of life. I have been very fortunate to work at an institution that values my experience and has allowed me to be involved in the growth of our program as well as in the development of new institutional processes for improved workflows, patient safety, and access to care. 

Tell us a story about a patient or colleague who had an impact on you.

In the early years, there was no formal orientation for the “device nurse” role. Education was done in the field and on the fly, and there was an expectation to self-teach many of the complex ideas our specialty holds. I remember an early experience, about 2 months into my EP nursing role, when I was given a quick 1-hour introduction by an industry representative on the Prescriptor programmer and Ventak PRx device (Cardiac Pacemakers Inc.). That very next day, I found myself in the operating room with Adam Strickberger, one of our EP attendings at the time, to assist with the testing and programming of a newly implanted Ventak PRx ICD system. Frightened, yet motivated, it was in that moment that I realized the vital role that I could have with this patient population, and the true reality of what it means to see one, do one, and teach one. In doing so, I learned the importance of one’s initiative to self-educate, and the value in utilizing your resources, which at the time included industry representatives, physician device manuals, and a very lengthy book by Dr. Seymour Furman on how to master EP pacing concepts.

Dr. Strickberger has been a longtime friend, and has always been a tremendous support, especially in those early years. Electrophysiology at the University of Michigan began as a very small, cohesive team, and he always put forth the extra effort to mentor me and was a driving force in much of my early involvement in the field. It was through these empowering efforts he provided, and from many of my coworkers, that I began to find my own voice within our EP program. 

Have you had any family members follow your path?

I have 2 very intelligent daughters, both of whom have helped to shape my EP experience. It was from a young age that I began their exposure and involvement with decades’ worth of CIED patient support groups, and as they transitioned into their teen years, interest and initiative guided them as they began to conduct medical research of their own. Armed with a lifetime of interactions with patients and providers, and a sense of determination that belies their years, both girls have joined me in pursuing healthcare careers, and I am very proud of the trails they have blazed for themselves.

Allison, my oldest, is 25 years old and finishing her fourth year of medical school; she will be looking forward to a residency in Obstetrics and Gynecology. Alaina, my youngest, is 23 years old and is employed by one of the major CIED manufacturers. With a house full of medical minds, we find ourselves frequently discussing healthcare topics of all sorts; but with Alaina specifically, we dive deep into the past, present, and future of EP. She has joined me at numerous HRS conferences and even presented research of her own there when she was about 18. I have always pushed my girls to be their best selves, while never trying to pressure them into being people they’re not. They hold themselves to a high standard, and I believe their enthusiasm as they begin their own careers has added a layer of enjoyment to my continued journey within the field of EP.