Tips for Running a Busy Lead Extraction Program

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EP LAB DIGEST. 2024;24(2):1,19,22.

Cardiovascular implantable electronic device (CIED) extractions typically come with challenges to operators and cardiovascular care delivery institutions. Often urgent and lifesaving, these procedures are also resource-intense, risky, and poorly reimbursed. With an expanding number of CIED implants, the demand for their removals is growing. Many areas lack trained operators or programs that perform CIED extractions, which limits patient access. For these reasons, building lead management and extraction programs creates opportunities for professional growth within cardiac electrophysiology (EP) departments and provides a needed service to patients in the community. Lead management programs consist of highly functioning teams that foster institutional collaboration and a sense of purpose. Also, being aware of the difficulties with lead extraction leads to more thoughtful and skilled device implanters. In the past year, we led the development of a lead management program at the University of Wisconsin Hospitals. Although efforts are still ongoing, we present our experience here.

In August 2022, shortly after joining the university faculty, immediate efforts centered around addressing the case backlog that developed due to staffing departures and the pandemic. Initial procedures were performed for patients needing device upgrades or revisions for those with deteriorating leads. Procedures were performed in the cardiovascular hybrid room as “add-on” cases. This early experience was formative as well as a time of rapid adjustment and growth. First, we realized the magnitude of effort going into planning and carrying out extractions. Coordination was required between the outpatient clinic, schedulers, hybrid room, inpatient teams, hospital transfer coordinators, anesthesiologists, perfusionists, cardiothoracic (CT) surgeons, equipment and manufacturer clinical support, and referring providers, etc. This could overwhelm the extraction provider and impact the stability of the entire program. In general, excessive nonclinical demands placed on operators performing complex procedures increase the probability of errors. Poor outcomes follow, reducing the longevity for many programs. For these reasons, we concluded that a successful extraction program must be firmly rooted in the “Heart Team” model. Additionally, we discovered that performing extractions late in the day (whether due to availability of the hybrid suite, anesthesia, or CT surgeons), resulted in staff dissatisfaction and burnout, which ultimately compromised patient safety. We saw an opportunity for improvement.

The next step was to contact Pierce Vatterott, MD, a leader in the field and an experienced extractionist, about guidance on program development. He detailed 3 priorities that are nonnegotiable components of a lead management program:

1. Importance of having a dedicated nurse coordinator

2. Hybrid room block time (mid-week is preferable to accommodate outside transfers)

3. Scheduled CT surgery coverage

We developed a more detailed list and approached our administration, beginning the process to create the program. Our first “win” was obtaining a hybrid room block time with cardiac anesthesia coverage. Transesophageal echocardiogram (TEE) capability is an important component of monitoring complications for higher risk extractions and would now be provided by the cardiac anesthesia team. This enabled scheduling of outpatients with morning start times as well as a predictable opportunity for lab technologists, nurses, and mid-level providers to develop extraction skills. We created an inventory of tools and equipment (extraction cart, Figure 1) and performed an extraction drill with an emphasis on complication management. Team member roles were defined and a preoperative checklist was created.

Next, we sought dedicated CT surgeon coverage for extraction block times. This is an essential, but often rate-limiting step for many programs. Fortunately, our CT surgery leadership agreed to designate a lead surgeon to cover most extraction cases, with others filling in as needed. Forming a partnership with a lead CT surgeon is highly beneficial, and in general, consultation and communication with CT surgeons fortifies patient care and improves the handling of complications. Additionally, other procedural specialties such as interventional cardiology, interventional radiology, and vascular surgery may assist in completing complicated extractions. Additional stakeholders include the infections disease service, hospital medicine, wound care service, and imaging cardiologists. Forging relationships with these groups increases the likelihood of program success.

Our third step was securing approval for the lead management coordinator position. This was a must. Previous iterations of our extraction program relied on clinic nursing staff to informally fill this role. Opening new support positions can be a tough sell for hospital administrators, and heading into these discussions with a clear vision of how this program was going to aid the institutional mission was important. Drawing on existing institutional experience with other heart teams (transcatheter aortic valve replacement and left atrial appendage closure) was helpful, as these programs often depend on nurse coordinators to provide scheduling coordination, communicate with referring providers and patients, maintain records and registries, and provide follow-up care. Our institution assigned an outstanding supervisor-level nurse to temporarily serve in the coordinator role during the transitional period, and we are deeply thankful for this important step. Staffing our initial coordinator position with an experienced leader enabled us to advance rapidly. In a short period of time, we had a formal extraction patient list, electronic medical record folders of pending and completed cases, and a planned monthly team meeting to discuss and prioritize upcoming cases.

With this third step, our outlook dramatically changed. Case volumes increased, lab efficiency improved, and we received interest from our staff members and trainees in extraction case participation. Collective anxiety about extractions dissipated and extractions became a routine part of the week.

We now have a formal working extraction program with significant accomplishments. We are still early into our journey and our formula is evolving. Our next focus will be on increasing case volumes and adding operators. Additional consideration will be on creating a dedicated lead management clinic, improving risk stratification models, and expanding clinical research efforts.

We hope our experience is instructive for others in the contemplative or preliminary stages of building an extraction program. Our experience thus far has been both challenging and rewarding. We recommend setting high goals and continuing with professional improvement for the benefit of the patient and community. 

Disclosure: Dr Igic has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and reports no conflicts of interest regarding the content herein. He reports stock in Medtronic.