Page 156 - Simplicity is Key in CRT

156
3. Step-wise implementation of the “Operational pathway” in MUMC
To introduce the “Operational pathway”, a step-wise implementation design was used. This encompasses an introduction of the new processes in each subsequent step in the process; (1) Referral and Pre-assessment clinic, (2) Implantation Procedure and (3) Follow-up management as shown in figure 3. Depending on medical content, contributors to the process and anticipated time needed to introduce and implement the process, the process steps were implemented into current practice. As such the ‘Implantation Procedure’ step was the first to be implemented; as a ‘stand-alone’ process, not depending on implementations of the other two, this could more easily be implemented without interfering with care processes in the other steps. Subsequently, the ‘Referral and Pre-assessment clinic’ and the ‘Follow-up Management’ steps were introduced.
Referral and Pre-assessment clinic
From January 2014 to July 2014 the new referral and pre-assessment pathway was implemented into practice. Contributors to this part of the pathway were HF cardiologists and electrophysiologists, specialised nurses and administration/planning office.
Major changes in pre-assessment were the introduction of a multidisciplinary (HF cardiologists and electrophysiologists) evaluation of the referred patient; identifying possible caveats in the work-up, discussing the need for additional tests and if possible deciding on whether CRT is indicated. A referral review checklist (see Chapter 8) was introduced to reassure consideration of every possible confounder in delivery of CRT.
In order to reduce patient and recourse burden, single-day visits were introduced. The planning office invites the patient for a standardized series of consultations with the implanting cardiologist and subsequently the specialised nurse. No specific training was involved in implementing this evaluation. During these consultations general medical and pre-implantation assessment are conducted. Also a thorough discharge planning is prepared. Informed consent is obtained in this pre-assessment phase. Planning of the pre-assessment visit and the date of implantation happens simultaneously as a standardised sequence of events. A specifically designed patient invitation package includes a letter detailing the pre-assessment visit, patient educational materials (booklet on implantation procedure, complications and therapy goals, follow-up and remote monitoring), the implantation procedure day details and contact information in case of questions or required change in bookings. Implementation into the planning system took 4 consultant day and 2 hours of additional training of contributors.
Implantation procedure
From September 2013 to December 2013 the use of a specific pre-assessment checklist (see Chapter 8), as well as a pre-discharge checklist (see Chapter 8) guiding patient pre- and post- implantation assessment by a specialised nurse was implemented, within the single-day admission protocol. The implementation of the checklist did not involve any additional training of the contributors.