The field of electrophysiology (EP) provides an ever-changing environment for the EP nurse. Managing the day-to-day problems that arise in a busy EP practice can be challenging at times. The EP nurses, alongside the EP physicians, feel a strong obligation to stay current with changing technologies to bring the best care to their patients. Our practice includes 4 electrophysiologists, two nurse practitioners, 4 nurses, and 5 technologists. We have 2 other nurses in our heart failure device clinic, and 4 nurses that work in our device clinic. We follow over 6000 devices. This dynamic environment affords challenges each EP nurse must assist in overcoming. In the following article, I’ve presented 5 of the common challenges encountered in the field, as well as strategies to address these challenges.
The preliminary work-up phase prior to the patient’s first office visit is crucial for a successful treatment plan. Obtaining the pertinent medical records is very important in developing the best plan for our patients. Creating a list of medicines that have been tried to treat the patient’s arrhythmia and have failed or were poorly tolerated is also necessary to help the physician make decisions about the best treatment plan. Ensuring that patients referred for devices are on guideline-directed drug therapy, if at all possible, is essential and expedites the overall process. Referrals made to the office sometimes lack the supportive documentation and proof indicating the need. Electrocardiograms with the captured arrhythmia allow for a fast track to procedure instead of waiting for the episode to appear. The use of Holter monitors in the pre-workup phase provides the tracing, and physical examination notes and records formulate the full picture of the patient’s condition. Instructing the patient to keep a journal of symptoms when wearing a Holter monitor also helps the physician to make correlations with symptoms to arrhythmias and choose the best treatment. A recent evaluation of the patient’s ejection fraction is used when assessing a patient for device implantation. A systematic approach used to develop a plan for each patient sets the stage for success.
Referrals made to the office sometimes lack the supportive documentation and proof indicating the need. Appropriate documentation and testing prior to EP consultation facilitates a more prompt treatment for the patient. As addressed in challenge #1, supportive documentation accompanying the referral should include evidence of an arrhythmia in the form of rhythm strips, device interrogations, Holter or event monitor reports, or electrocardiograms. Referring physicians sometimes do not understand the importance of this information to the EP physician in developing a treatment plan. Developing open communication with referring physician’s offices and nurses allows for the opportunity to educate as well as to expedite patient care.
The treatment of atrial fibrillation (AF) can be quite complex and often requires a detailed, multifaceted treatment plan. Selecting the appropriate medications is only the first step. Applying risk factor management and lifestyle modifications impact the long-term outcomes of these patients. Establishing an AF specialty clinic has provided us with the opportunity to assist patients in lifestyle modifications to address risk factors such as obesity, blood pressure, glycemic control, and lipid profiles. According to the ARREST-AF Cohort Study, addressing excessive body weight is vital for rhythm control.1 One of our electrophysiologists, Dr. Jay Dinerman, has also developed epTools®, an application that we use on a daily basis. Among other calculators included in this application are those to assess stroke and bleeding risk along with assessing renal function. Again, using a more encompassing approach involves the patient in the process and outcome. Empowerment of the patient becomes a part of the success.
In the innovative world of EP, application of new technologies remains one of the greatest challenges. Increased use of device monitoring technology by patients can sometimes also become a challenge when it requires remote setup with wireless adapters or other devices. To overcome this difficulty, it may be necessary for the patient’s implanted device to be paired with the Bluetooth transmitter in the office or even before implantation. Device monitoring allows for data collection and transmission regarding heart rhythm, blood pressure, thoracic impedance, and weight. The collection of this data is important because it allows the treatment plan to be modified during the periods between office visits. Once older devices undergo replacement, implantation of a wireless communicating device allows for the collection of useful biometric data on these patients as well.
When resources are not maximized, the number of cases quickly decreases. In the lab setting, appropriate resource utilization allows the greatest number of patients to be treated. Since allocated lab space is limited, scheduling ablation procedures to follow each other, utilizing the same mapping system, decreases the time lost in preparation for the next procedure. Sharing the area with multiple electrophysiologists limits time and space. Given the growing population of patients with atrial fibrillation and the use of advanced treatments such as hybrid procedures, a special focus must be placed on effective lab utilization. The lab space becomes a competitive area for EPs and cardiac surgeons. Therefore, scheduling is an important aspect for treating the most patients and maintaining the most productive day possible for the EP team.
Electrophysiology nurses face various patient care challenges in the lab and clinic, and assume a vital role by assisting in the many aspects of EP patient care. The most successful patient outcomes will be based on completing a full preliminary workup, utilizing monitoring alongside patient journaling, facilitating risk factor modification, educating the patient and the general medical community as technology emerges, and overseeing an efficient EP lab. Addressing initial issues with the referring physicians will also increase patients’ chances of long-term treatment success in the EP lab.
Jaime Caldwell can also be reached on Twitter at @jmeshortcake
- Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation: The ARREST-AF Cohort Study. J Am Coll Cardiol. 2014;64(21):2222-2231. doi:10.1016/j.jacc.2014.09.028.