Clinical and Operational Benefits of an Electronic Medical Record Alert for Patients With Cardiac Implantable Electronic Device Infection

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EP LAB DIGEST. 2023;23(12):7-8.

In this feature interview, EP Lab Digest talks with Mark Metzl, MD, and Cheryl Wong, MSN, BSN, RN, Cardiovascular Service Line Director, from NorthShore University Health System, an integrated health care delivery system serving patients throughout the Chicago metropolitan area, about implementation of electronic medical record (EMR) alerts for identification of patients with an infected cardiovascular implantable electronic device (CIED).

Tell us about your health system, number of electrophysiologists (EPs), device patient volume, lead management program, and how the EP program is looking at growth.

Mark Metzl, MD: NorthShore University Health System is a 9-hospital system. We are part of NorthShore Legacy, which is comprised of 4 hospitals. There are 6 EPs, and we follow over 5000 device patients. Our lead management program was started in 2016, when cardiothoracic (CT) surgeon Dr Hyde Russell and I were recruited. We have been averaging between 40 and 50 lead extractions per year. We certainly see a lot more patients for lead management than those who are evaluated for extraction. Lead management has been growing, as well as ablation and cardiac rhythm management volume.

Cheryl Wong: Across the NorthShore University Health System, there are 10 EPs, and we are annualized to do 338 pacemaker insertions and 177 pacemaker replacements in 2023. Our heart rhythm program has recovered significantly from the start of the pandemic. As far as EP program development, we are opening a cardiovascular institute (CVI) at Glenbrook in April 2024.

Metzl: At Glenbrook Hospital, we are building 4 brand-new labs with state-of-the-art facilities and equipment. We have tried to future-proof the technology for years to come. The concept of the Glenbrook CVI is to accommodate growth and subspecialize care to allow for more efficient staffing as well as a better patient and family experience. We have done a lot of planning and are excited to move into our new home.

Could you describe how your extractions are scheduled and how surgical backup works?

Metzl: I think extractions across the country have some common pain points in terms of scheduling. We have adopted what I call a “cavalry in the room” approach to extraction. Extractions are currently performed in a hybrid operating room (OR) at Evanston Hospital with CT surgery, perfusion, and a cardiac anesthesiologist in the room. All our patients are prepped and ready in case we need to convert to an open procedure, despite the overall low risk of extraction procedures.

At NorthShore, we have been successful at overcoming the perceived risk of extraction procedures. However, having all those resources scheduled together can be difficult. We have tried to solve some of those issues by dedicating days for extraction in our hybrid lab. Currently, we schedule elective cases one day per month. We may find out about extraction cases weeks or even months ahead of time, and we are able to group those, so our resources are a little easier to schedule. It can be more difficult when we have a case that needs to be done more urgently. A lot of times, those more urgent cases are infections. When we schedule a case where a patient has an active infection, quickly getting those resources together can be a challenge.

It has been a year since your article on the importance of EMR alerts to better identify infection patients was published in the Journal of Interventional Cardiac Electrophysiology.¹ Can you elaborate on the specific care gap or workflow challenge that an EMR alert was able to address? Have you seen an improvement in timeliness of infection identification?

Metzl: The gap in care and workflow challenge for extraction programs is trying to mobilize resources quickly for patients with active infections. We often find out about patients who need extraction for an infected device at inopportune times. There is data that early source control for patients with infected devices leads to improved outcomes, including mortality benefit.² Oftentimes, patients are brought to an extractor’s attention late in their hospitalization, but sometimes, not at all. The difficulty is that we would find out about these cases after they have been in the hospital for quite a few days, and we would scramble to get their device extracted in an urgent manner.

Finding out about these cases earlier can alleviate some of those pain points that we had and that are shared among extraction programs around the country. One of the more common scenarios is being sent a picture of a vegetation on a lead on a Thursday afternoon, trying to mobilize resources on a Friday, and having to do the case on a Friday afternoon. Being alerted about these potential cases in real time can alleviate some of that pressure. We can help facilitate the workup of these patients, start forward-thinking of how we would plan to mobilize our resources, and perform that lead extraction in a timely manner.

Wong: By having the EMR alert and workflow, a dedicated EP staff, and specializing our teams between EP and structural heart, we are now able to provide better care to patients more quickly, which has decreased patient mortality. This approach has a quality benefit to our patients and helps improve outcomes.

Can you give us an update on the EMR alert and what your process for reviewing alerts looks like today? Have you made any changes to your EMR alert?

Metzl: We started the EMR alert at our institution in March 2018. We found out about it at a poster presentation at the Heart Rhythm Society’s annual scientific sessions, and it resonated with us because of the quality and workflow challenges that we were facing. When we started to put it in place, the concern that we had was that alert volume could be potentially overwhelming. We had no idea how many alerts we would be seeing daily. When we started the alert, we modeled it for a year, in retrospect. We realized in 2017 that we would have seen between 70-80 alerts. Over a 50-week period, that was not so onerous.

Nonetheless, when we first started with it, I was worried about annoying my colleagues if I asked them to monitor or be added as alert recipients. As the only EP extractor, I did not want my colleagues to be bothered. One of the administrative champions and I were the only people receiving those alerts. The downside of that is sometimes I am out of town and the service is covered by someone else. After the first year, we realized that those numbers were very much in line with the modeling that we had done.

The biggest change that we made over time was to broaden the amount of people who could be responsible for looking at potential CIED infections. This increased awareness among all EPs about infection of CIEDs. That awareness has spread among our service line as well as to the cardiology section and the infectious disease team.

We are now seeing these alerts in real time, and oftentimes, before our infectious disease colleagues. Occasionally, when a patient presents with bacteremia but does not meet the criteria for the alert because it requires us to have entered in that they have a device, the infectious disease doctor will say, “Did you catch this one? This came from outside the system.” The awareness about CIED infection that this has created in our hospital has been beneficial for our program.

Were any operational or clinical workflow changes made following implementation of the EMR alert?

Wong: These alerts have helped us strategically navigate the care of these patients in an ideal time, ensuring we are performing these procedures at a time that is more readily available for the hybrid OR, CV surgery team, perfusion, and personnel, instead of after-hours or in the middle of the night.

What operational benefits have you seen following the EMR alerts on CIED infection? Could you elaborate on how these benefits have supported OR/hybrid scheduling? Could you elaborate a bit more on the presurgical case benefits?

Metzl: Because we are having these conversations earlier in the patient’s care, we have seen a lot of operational benefits in our hospital system. We had infectious disease doctors who were not even aware that we could remove CIEDs or that we had a program for extraction at our hospital. We had a program for several years that was already quite successful. This awareness has spread because of the EMR alert. That has been extremely beneficial for improving the quality of care delivered to NorthShore patients.

There are a few benefits that came as a result of the EMR alert. One of the biggest is that we are involved in the case very early. When an alert comes through, we can help facilitate earlier workup of that patient, including transesophageal echocardiography and infectious disease consults. The workup of that patient is facilitated much quicker because of the alert. From an operation standpoint, our hybrid lab is shared with vascular surgery and structural heart, so when we get an alert that we think may be actionable, we must think about where we can do this extraction in a reasonable timeframe.

Wong: There have been many benefits and wins with this EMR alert, including decreased cost of hospitalization, decreased mortality, improved care for our patients, and improved outcomes. The scheduling component has also been huge. No one really wants to do procedures after hours—it is better to do them when the team is rested and there are people in the OR who can support us during regular business hours. The EMR alerts have helped us with this.

Have you continued to see improvements in the bacteremia care pathway?

Metzl: We have learned a lot over the last 5 years of monitoring EMR alerts mostly due to increased CIED infection awareness. We have an improved partnership with our infectious disease colleagues, hospitalist team, and noninvasive cardiac imagers. Because of these ongoing conversations, we have a more in tune and receptive team.

Can you speak to how you engaged administration and operations through the alert implementation and bacteremia care pathway changes? Who was your biggest ally during the approval or implementation process?

Metzl: To implement an EMR alert, you need a physician champion, resources from administration, and an information technology (IT) resource. When we discussed this possibility, we talked about this as being a quality program. This improves overall care and timeliness of care for our patients, which as a result, improves outcomes. It also improves cost by potentially decreasing length of stay and improving resource efficiency. It is a multi-level win because it improves both the quality and cost of care. Our administration readily understood the impact that this pathway would provide.

Wong: Dr Metzl was a clear champion, and both he and Dr Russell saw the value-add of this program. The chief of cardiology was very supportive of the alert implementation as well. We should also highlight the clinical leadership of the operational folks, Dana Melgar and Sheri Umansky, who really deserve a lot of credit for taking ownership, accountability, and an interest.

Do you have any tips or tricks to manage the increased infection volume while maintaining efficiency and safety?

Metzl: The alert helps manage increased infection volume because we know about these cases ahead of time. If every one of these cases was urgent, it would potentially be overwhelming. This alert offers a solution. We now know about these cases as they come in, before their workup, so we can start planning how to do these cases in an efficient and safe manner during working hours.

What recommendations would you provide to your peers as they talk to operations or administration about implementing EMR alerts for identification of CIED infection patients?

Wong: The first thing to do is share with operations and administration that this will financially benefit the organization or hospital. It is a quality improvement initiative that will also really improve operational workflow. We are trying to schedule patients efficiently and during ideal hours, so that teams can be available for these cases. This reduces cost and improves quality. Those are the key buzzwords with administration and health care organizations: quality and cost. You will need a physician champion and an administrative champion, but you will also need to partner with IT, because building the alerts is critical to the success of being able to run reports. That really helps maximize the program. Lastly, the one thing that was critical in planning and designing the new EP space in the CVI is that Dr Metzl and I made the EP labs hybrid, so that we could do lead extraction procedures in a surgical EP hybrid OR setting and not be competing in the space with vascular surgery. It is a critical point to highlight. It is still the same team and the same setting, but we are not necessarily competing for space. That is very beneficial for our patients.

Metzl: The EMR alert is a clear win for the patients and for the hospital. It alleviates a lot of pressure for the EPs and lead extractors. It is also not that difficult to implement. I agree with Cheryl on her recommendations about what to tell administrators. Sometimes, the biggest hurdle is just the decision to do something about it. This is a clear win for everybody. Everyone should be really excited about implementing this pathway in their system. 

References

1. Paz Rios LH, Minga I, Gaznabi S, et al. The impact of an electronic medical alert system for patients with cardiac implantable electronic devices and bacteremia. J Interv Card Electrophysiol. 2023;66(3):525-529. doi:10.1007/s10840-022-01423-6

2. Pokorney SD, Zepel L, Greiner MA, et al. Lead extraction and mortality among patients with cardiac implanted electronic device infection. JAMA Cardiol. 2023 Oct 18:e233379. doi:10.1001/jamacardio.2023.3379

This article was published with support from Philips.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They report no conflicts of interest regarding the content herein.