Page 157 - Simplicity is Key in CRT

Follow-up management
The improvements to the continuous follow-up post-implantation process were introduced from August 2014 to January 2015. Implementation involved training of both device technician as well as specialised (HF) nurses to use a standardized way of interdisciplinary transfer of contributing information (device HF diagnostics, arrhythmias and biventricular pacing percentage) and the use of a CRT optimization checklist (see Chapter 8) to be used at every patient contact to ensure optimal benefit from CRT. In addition, systematic enrolment on remote device monitoring was introduced to reduce patient and resource burden. The implementation of this part of the pathway was facilitated through designing standardized templates of reports and providing training for the interpretation of findings by the specialized nurses. This took 6 hours (3 times 2 hours) of dedicated training of HF nurses by an implanting cardiologist. To ascertain optimal follow-up care and improve implementation, specialized nurses outpatient clinic consultations were supervised by an electrophysiologist (1 part-time day every week) during the implementation period.
Discussion
In this paper, we describe the development and implementation of a protocol-based, structured clinical CRT care- pathway. The objective of this care pathway is to provide standardized care for all HF patients treated with CRT by providing protocolled care by using forms and algorithms, while allowing for adjustments to local practices and resources.
As demonstrated during the baseline assessment of current practice care in the referral hospital in this report, one of the major issues in CRT is uncoordinated care. This results in diminished quality of patient selection, reduced benefit of therapy, more complications and unnecessary resource utilisation. Studies and registries have shown this to be a general issue in CRT care [24-27]. Although guidelines and extensive practice documents are available to guide clinical CRT care [3, 7, 13], adherence to recommendations is heterogeneous [11, 28-30]. As shown in HF care in general, treatment of this disease requires structured, multi-disciplinary care. Structured multidisciplinary HF care is currently widely recommended [3], but has yet to be implemented in many practices. This is even more important when patients are indicated and treated with CRT. Often consultations for these patients focus on the electrical part of the treatment, rather than the underlying condition and general HF treatment. Whereas further optimization of HF treatment seems mandatory to obtain maximal benefit from CRT [31, 32]. On the other hand, when patients are on the scope for their HF, these frail patients are requested to visit the outpatient clinic for many consultations and additional investigations which often are redundant when care would be structured and coordinated.
A few studies have focused on this problem, introducing a structured, multidisciplinary approach to optimize outcomes in HF, and more specifically CRT care. Single and multicentre, randomised trials have focused on the introduction of (in hospital) care pathways in the treatment of HF. Overall the outcomes of these trials show positive results on mortality and length of stay during admission [33, 34]. Mullens et al. were the first to show that an algorithm with standard equipment and testing, reproducible in any outpatient cardiology clinic, could identify suboptimal HF and CRT care. If adjusted accordingly, this could improve response to CRT [35]. Furthermore, improvement in response to CRT appeared to be driven not only by appropriate device and arrhythmia management but also by improved HF care, by HF education and optimization of HF medication [31]. More recently, a larger multidisciplinary CRT care program was evaluated and compared to a retrospective conventional care group of patients. This study confirmed that a multidisciplinary approach in CRT was associated with improved outcomes [36].
157