Transitioning Implantable Cardiac Monitor Implants to Advanced Practice Providers

In this interview, we speak with Eugene Fu, MD, and Beth Loessin, MSN, APRN, FNP-C, about their initiative to transition to a 100% advanced practice provider (APP)-implanting Implantable Cardiac Monitor (ICM) program, as well as out of the cardiac electrophysiology (EP) lab to the inpatient bedside, at OhioHealth Riverside Methodist Hospital in Columbus, Ohio.

Can you provide an overview of OhioHealth’s ICM program?

Eugene Fu, MD: Our hospital serves as a quaternary referral center within our health system, so we get a lot of complex patients. We do a high volume of invasive and noninvasive procedures. We have 4 dedicated invasive labs and 2 noninvasive labs. There are currently 6 board-certified electrophysiologists on staff and 8 APPs.

Beth spearheaded the ICM program, along with several of the other APPs at our institution. The ICM program came about through an effort to maintain efficient throughput in our lab. We found we had a fairly large volume of ICM patients being referred to us, principally for cryptogenic stroke. So we embarked on a program with our APPs to develop a program in which the electrophysiologists were not the principal operators for these devices. We learned about similar nurse-led ICM implant programs in Europe that were very successful, so that is how we got the idea to start, and it has been going very well.

Tell us about the protocol review of the ICM program and how this initiative came about.

Fu: When we started, we wanted to see how it would mimic what we were already doing, but we realized that if we were going to get any kind of maximum efficiency in the lab, it would eventually involve taking ICM implants out of our EP lab. In the 6-9 months that the program has been fully implemented, the APPs have already performed over 200 of these implants. When starting the program, we engaged representatives from our administrative leadership, EP lab leadership, electrophysiologists, and APPs. We developed a team to evaluate how best to develop a safe and efficient way for patients to receive indicated cardiac monitoring implants at the bedside, outside of the EP lab. The team devised a strategy for developing a credentialing pathway, which was later cleared by the hospital credentialing committee. Interestingly enough, from the vendor side, there was not an existing certification process for doing these kinds of implants. So, we developed a pathway that we believed was reasonable. Once the protocol was built and approval from the hospital was received, we established a credentialing pathway in which the individual vendors that we were using would do a basic introduction to how their monitoring system and implants worked. This would be followed by a period of observation, 5 proctored cases, and then the APPs would be free to do independent implants based on their comfort level.

What can you tell us about the transition to a 100% APP-implanting program?

Beth Loessin, MSN, APRN, FNP-C: It was a pretty smooth transition. From the time of credentialing to developing the training process was the biggest challenge. Once that was in place, everything went pretty quickly. Because of the high volume of ICMs that we have, we were able to quickly get each person their proctor cases. We started our first proctored cases in January 2021 and were fully, independently implanting 100% of the ICMs by June 2021. It was a smooth process for the most part. We kept in close communication with the EP lab and neurology staff as well, since most of our referrals were coming from them. Updating them with the change in workflow was helpful for everyone involved.

What details can you share about the new workflow?

Loessin: Most of our ICMs are done as inpatients, so I’ll speak to that workflow. Initially, the consult is placed by the requesting service, such as neurology or cardiology. As APPs, we complete the consult independently. We visit the patient to review the procedure and go over all the information, providing education preprocedure and postprocedure. If appropriate, we put them on the schedule and are in contact with the lab to let us know when they have lab staff available.

Currently there is 1 EP lab staff member and 1 device representative who come to the bedside and help with the procedure. We work around their availability as to when that lab staff person is available. We established a mobile ICM cart that has all the supplies needed in the event of an emergency. This cart is brought to the bedside and the implant is performed. The device representative is also available for education following the procedure. Patients are usually able to be discharged the same day.

Fu: From an EP provider standpoint, we as a group have been so incredibly proud of what the APPs have accomplished. It was mostly the APPs doing the heavy lift on all of this, and the impact has been tremendous. When these procedures were done in the EP lab, there was a 30-minute minimum turnaround. While the actual implant procedure only takes a minute or so, additional time was spent getting the patient ready, having the family there, and providing education afterward. If you add up each of those 30-minute procedures from the 200 implants they have done so far, that has saved us 100 hours of work time and lab staff availability. That is not an insignificant amount of time that has been given back to the EP lab to allow us to do other things. It has clearly made us more efficient.

In looking over what has been accomplished, I want to make 2 main points. First, the credentialing pathway has certainly led to a level of confidence from the APP standpoint, which has in turn led to successful implants. In addition, we didn’t realize up front that by taking this to the bedside, it would involve needing to create a mobile implant cart with the appropriate types of equipment on it to handle all types of different clinical scenarios. Details such as getting the patient set up for the procedure and charting within the electronic medical record are some of the things that the APPs and the rest of the team worked through to make this a clean and efficient process. Being able to take a procedure to the bedside is certainly better than having the patient be wheeled around the hospital. It’s much more comfortable for them and better accepted by the patient and their family.

What feedback have you received from APPs regarding job satisfaction as a result of the transition?

Loessin: For the most part, everyone is very excited about it. We’re happy to be able to help get the patients through the lab. We’ve always been very focused on getting the patients to the lab and providing them access to procedures, but now we can help get those patients through there and not only improve lab efficiency, but also the patient experience through continuity of care from the consult to the implant. Having a familiar face is also comforting when the person who does the initial consult is the same person who will be doing the implant. In addition, having the procedure performed at the bedside is more convenient for patients. The ability to have the implant completed before they leave the hospital saves them an extra trip back as an outpatient. Patients already have a lot on their plate just being hospitalized. Finally, it’s exciting for us as APPs to be able to learn new skills. In this role, we don’t always have the opportunity to do clinical tasks.

Tell us about the importance of APPs in EP.

Loessin: This is an extension of our service. With the growth of EP in general, it’s important to have access to more patients and extend our reach. So, by having us in the hospital seeing these patients, we’re getting more people the procedures and treatment that they need.

Fu: I’ve been practicing EP for a long time now, and early on in my career, we were somewhat limited by the types of technology available—there were only so many things that we could do within the scope of treating arrhythmias. But now, technology has advanced to a point where both, on the diagnostic side to the therapeutic side, the range of options that we can offer to treat arrhythmias is advancing quickly. It’s a tremendously exciting field to be in, but it has also put a burden on us in trying to deliver timely care to patients. Therefore, seeing our group grow and incorporate APPs has been essential to being able to deliver best practice care. They are an integral part of what we consider a care team approach rather than having a patient assigned only to the physician. It’s a much better model for delivery of patient care. It has been very important to have APPs involved in the care of both inpatients and outpatients, including having APPs involved in doing procedures. It is also more rewarding to be able to complete that circle of care for patients. It is something that we always strive for, but can sometimes be difficult to achieve in a traditional care model in which patients are seen on the floor and brought down to the lab where the procedure is performed by someone else. For the patient, it’s nice to be able to see a consistent face through the whole process. Having APPs has been one of the ways we have been able to achieve that for these kinds of situations.

What do you consider to be the keys to a successful implementation of this initiative?

Loessin: The support from the physicians, administration, and our heart and vascular team in general was instrumental in allowing us to get this initiative up and running. There was a lot of work that had to be done in the beginning to get us to where we are in allowing APPs to help in this way. Getting that framework for the training was most of the battle. Getting the privileges added for us was also important. In addition, we received cooperation from the EP lab when making adjustments to workflows as we moved from the lab to the floor. Overall, the support we received from the physicians, administration, and the lab was invaluable. They helped us overcome challenges, including helping us come up with a strategy for supplies at the bedside such as a mobile ICM cart. Having cooperation from device reps was also helpful, as they have been a great resource for us with advice and guidance.

Fu: It may seem like this was a simple, automated process, but there were a lot of components involved to make this a simple bedside procedure. The APPs made it happen and we are very proud of them. 

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