Provision of an Out-reach Pacemaker Follow-Up Service in a Community Nursing Unit

Abstract

Introduction: Patients with implanted pacemakers require at least annual checks on their device, which are tyupically carried out in large hospital settings. Some patients are elderly, frail and may require ambulance transfer. In 2016, St Brendan's Community Nursing Unit (CNU) identified 11 patients who required ambulance transfer to University Hospital Galway (UHG) for this service. Description of Practice Change: UHG and the CNU collaborated to provide an Out-reach Pacemaker Follow-up Service for these patients in their nursing unit. Aim and Theory of Change: The aim was to deliver a safe follow-up service in the CNU, minimising patient upset and reducing staffing (patient escort) and transport (ambulance) costs compared to the traditional model. Targeted Population and Stakeholders: There were 11 patients, mean age 84.8yrs (64-96) with complex care needs. Stakeholders included Cardiac Physiologists, Lead Cardiologist and Manager in UHG and Nursing staff and Nursing management of the CNU. Timeline: The patients were identified in August 2016. Following collaboration between UHG and CNU staff, specifically around internet access to the UHG web-based Patient Pacing Record, environment appropriateness, safety and funding, the first Out-reach Clinic took place on December 19th 2016. Highlights: This service required 8.6 hours of a Senior Cardiac Physiologist's time. Travel costs for this clinic amounted to €56.60. If each patient was to have been followed up in the traditional model it would have involved 11 separate transfers to hospital. Patient escort time, based on a minimum of 1.8hrs per visit, would have totalled 19.8hrs. Ambulance transfer costs for these visits would have, based on minimum cost of €330 per transfer, totalled €3630. The new service showed a reduction in staffing hours of 56.5% and a reduction in transport costs of 98.4%. Comprehensive checks were carried out in a safe, appropriate environment. Sustainability: This service is highly sustainable, as all patients currently only require an annual check. Even if all patients required three monthly checks, the substantial savings in transport costs support this level of service. Internet access to allow clinical details of the follow-up checks to be entered on our web-based Patient Pacing Record, allowed all documentation to be completed at the time of the check. Transferability: This service could be equally replicated in any centre, where there a suitable number of patients to make it cost effective. Conclusions: An Out-reach Pacemaker Follow-Up Service in a Community Nursing Unit showed significant reduction in staff hours and transport costs of 98.4%. It also resulted in care being delivered in a more patient centric manner. Discussion: The initial query regarding the possiblity of this service was initiated by staff in the CNU. Support of management in both UHG and the CNU, particularly around, releasing a Cardiac Physiologist, the funding of travel costs and working space in the CNU allowed the service to start in just over three months. Lessons learned: Significant savings can be made by providing out-reach services to Community Nursing Units appropriately, as opposed to hospital based service. Collaboration between the hospital and community based service was vital.