ICD (Integrated Cardiac Device) Care through PACED (Patient-centred And Cardiac Nursing Engaged Device) Services in a Regional Hospital in Hong Kong

Abstract

Introduction: Cardiac implantable electronic devices (CIED) are effective treatment to patients with bradycardia and life-threatening arrhythmia. However, without appropriate CIED settings and adaptation to life, patient may restrict activities for years. Furthermore, population of newly-implanted CIED patient has doubled in last decade. It challenged our service greatly, since cardiologist needs to follow up CIED patient *indefinitely in HK*. United Christian Hospital is a regional hospital serving a million populations. PACED services and ICD care were established here to provide intensive care during patient most needed period; and seamless integrated care along patient’s journey. “We are retaining not only heart rhythm, but helping patient’s life being PACED again” - That’s our motto. Methodology (CIED Patient Journey): Pre-operative: Patient is interviewed by cardiac nurse and ambulatory care nurse for pre-operative counselling and risk assessment. Implantation: Day admission and early discharge are facilitated with prior assessment. Acute phase: Patient will attend cardiology nurse clinic 1-2 weeks post-discharged for wound care; counselling & empowerment on living with device are delivered to both patient and family/caregiver; CIED functions are monitored under electro-diagnostic unit nurse assist. Between home and clinic, community nurse will visit patient and report for abnormality detected. Early phase: Intensive follow-up by cardiologist and cardiac nurse intermittently in first year. CIED functions are optimized based on unique patient’s physiological needs, e.g. life style, exercise capacity and age, etc. Retaining PACE of life: After condition stabilized, self-care ability and knowledge will be reassessed and reinforced in nurse clinic. Patient and family will join an integrated workshop collaborated by physiotherapist (PT), occupation-therapist (OT), social worker of health resource centre and cardiac nurse to meet with peer patients; and to retain confidence to live with device. Long term care: Protocol-driven regular device check-up intermittent with cardiac clinic to make sure safely function of CIED. Results: Data in 2015 were collected and analyzed. 1) Clinical: 180 patients were managed in nurse clinic. No adverse effect is noticed. Complications are now managed earlier e.g. wound problem; unstable lead parameter, etc. 30% patients with over-avoidance in daily-activity have showed improvement, some even retained job. 3.75% cases referred to cardiologist for e.g. symptomatic arrhythmia for treatment; lead-repositioning. 2) Client: Care ability and knowledge of patient / caregiver have improved from 52.6% to 96.3% and sustained at 87.2% in two-month evaluation. Patient surveys have shown high overall satisfaction at 98%; and have self-rated at 92% in retaining confidence to live with device. 3) Service utilization: Length of hospital stay is shortened; ~150 bed days are saved per year with pre-operative service. Over 600 nurse clinic attendances, cardiac clinic workload in early phase are thus alleviated by ~50%. New case waiting time is shortened in a consequence. Multidisciplinary referrals (~2%) were made e.g. OT for hypertrophic scar; PT for frozen shoulder, etc. Conclusion: ICD care and PACED services have demonstrated seamless collaboration among multidisciplinary for better patient outcomes. Delivering CIED services with cardiac nurse engagement is one of the pioneers among HK, and has achieved Hospital Authority nurse clinic accreditation in 2013.