BACKGROUND
: The Insertable Cardiac Monitor (ICM) clinical pathway in Tampere Heart Hospital, Finland, did not correspond to the diagnostic needs of the population due to a lack of resources for insertion and follow-up. There has been growing evidence of delegating the insertion from cardiologists to specially trained nurses and outsourcing the remote follow-up. However, it is unclear if the change in the clinical pathway is safe and improves efficiency.
OBJECTIVE
To describe and assess the efficiency of the change in the clinical pathway for patients eligible for an ICM.
METHODS
Clinical pathway improvements included initiating nurse-performed insertions, relocating the procedure from the catheterization laboratory to a procedure room, and outsourcing part of the remote follow-up to manage ICM workload. Data was collected from EHR concerning all patients who received an ICM in the Tampere Heart Hospital in 2018 and 2020. Follow-up data was collected 12, 24, and 36 months after insertion for both groups.
RESULTS
The number of inserted ICMs doubled from 74 in 2018 to 159 in 2020. In 2018, cardiologists completed all insertions, while in 2020, 70.4% were completed by nurses. The waiting time from referral to procedure was significantly shorter in 2020 (mean=36 days) compared with 2018 (mean=49 days), P=.02. The scheduled ICM procedure time decreased from 60 minutes in 2018 to 45 minutes in 2020. Insertions performed in the catheterization laboratory decreased significantly (18.9% in 2018; 1.9% in 2020, P=<.001). Patients receiving an ICM after syncope increased from 71 to 94 patients. Stroke and transient ischemic attack (TIA) as an indication increased substantially from 2018 to 2020 (2 and 62 patients, respectively). In 2018, nurses analyzed all remote transmissions. In 2020, the external monitoring service escalated only 11.2% of the transmissions (204 out of 1817) to the clinic for revision. This saved 296 hours of nursing time in 2020. Having nurses insert ICM in 2020 saved 48 hours of physicians’ time and the shorter procedure additional 40 hours of nursing time compared with the process in 2018. Also, the catheterization laboratory was released for other procedures (27 hours per year). The complication rate did not change significantly (2.7% in 2018 and 3.1% in 2020, P=.85). The 36-month diagnostic yield for syncope remained high in 2018 and 2020 (45.1% and 38.3%, P<.005). The diagnostic yield for stroke patients with a procedure in 2020 was 43.5%.
CONCLUSIONS
The efficiency of the clinical pathway for patients indicated for an ICM can be increased significantly by changing to nurse-insertions in procedure rooms and to the use of an external monitoring and triaging service. Thereby, patient access to an ICM is increased while a significant amount of staff time and resources are saved without any compromise to treatment quality.
