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Clinical survey: how much do you know about indications for permanent pacemaker insertion?

Emergency department staff knowledge of indications for permanent pacemaker insertion

Abstract

This audit was carried out at a district general hospital. In the absence of an acute cardiology service the aim was to elucidate whether cardiology patients attending the emergency department (ED) were appropriately managed. The main outcomes were to determine ED staff knowledge of indications for permanent pacemaker (PPM) insertion, and to compare this knowledge across all grades.

Using the European Society of Cardiology Guidelines1 as a gold standard, a 15-question survey was created. Each question was a clinical scenario with answer options of: A=no action required; B=non urgent referral; and C= urgent referral to cardiologist.

ED staff scored an average of 62.7% with senior house officers (SHOs) performing best. Of the 315 responses, 65% of incorrect answers were inappropriate referrals of no consequence. However, 21 % of referrals were delayed or simply not made. Following a teaching session, a subset of participants were re-tested on questions the majority had answered incorrectly. The average mark (41.2%) subsequently improved to 80%.

These findings highlight that further education is required across all grades. A teaching session improved knowledge. Extrapolating these findings, it is hoped that an electronic teaching session will help to reduce unnecessary referrals, and ensure appropriate and timely cardiological referrals.

Key messages

  • In a district general hospital, without an acute cardiology service, emergency department staff knowledge of indications for permanent pacemaker insertion was tested using a 15-question survey
  • Staff knowledge of indications for permanent pacemaker insertion was found to require improvement. This was the case across all grades of staff
  • Following a teaching session, knowledge of indications for permanent pacemaker insertion improved significantly
  • It is hoped that a teaching session will help to improve knowledge, thereby reducing unnecessary referrals and ensuring appropriate and timely cardiological referrals.

Introduction

This audit was carried out at a district general hospital that shares several acute services including cardiology, with another district general hospital based on a site several miles away. In the absence of an acute cardiology service the aim of this audit was to elucidate whether patients within the ED were receiving appropriate care and follow up with regards to their cardiological presentation. The audit focused specifically on rhythm disturbances commonly seen on ECG. The main outcomes of the audit were to determine ED staff knowledge of indications for permanent pacemaker insertion and to compare this knowledge across grades of ED staff.

Materials and methods

Using the European Society of Cardiology (ESC) Guidelines for Cardiac Pacing and Cardiac Resynchronization Therapy1 as a gold standard, a 15-question survey was created. Only indications for permanent pacemakers with Class I evidence (evidence and/or general agreement that a given intervention is useful) were included. The survey was reviewed by two cardiologists prior to circulation. ED staff included medical students, cardiac nurses, SHOs, registrars and consultants. Each question took the form of a clinical scenario with answer options of A, B or C where A = no action required, B = non urgent referral to a cardiologist (consider 24 hour tape/R test/GP referral to cardiologist), C = urgent referral to cardiologist (for consideration of permanent pacemaker/ICD). The 15 questions were:

1. A 60-year-old man presenting with syncope and sinus bradycardia, recorded during the event by paramedics at 30 bpm

2. A 30-year-old athlete presenting with asymptomatic sinus bradycardia of 36 bpm

3. A 75-year-old man presenting, on no rate-limiting medication, with asymptomatic sinus bradycardia of 55 bpm

4. A 50-year-old woman presenting with intermittent dizziness and an ECG on admission showing a beat to beat increase in the PR interval followed by an absent QRS complex

5. A 45-year-old man presenting with syncope and an ECG recorded by the paramedics at the time, showing a beat-to-beat increase in the PR interval followed by an absent QRS complex

6. A 65-year-old man presenting without symptoms but an ECG, showing alternate beat loss of the QRS complex following the P wave

7. An 85-year-old man presenting with a PR interval of 180 ms with chronic heart failure

8. A 75-year-old man presenting in asymptomatic complete heart block two weeks post anterior myocardial infarction

9. A 50-year-old woman presenting in asymptomatic complete heart block six days post-inferior myocardial infarction

10. A 55-year-old woman presenting with asymptomatic Mobitz type II heart block one week post-inferior myocardial infarction

11. A 25-year-old woman presenting with sudden cardiac arrest

12. A 14-year-old boy presenting without symptoms, noted to have a long QT interval not thought to be caused by drug therapy or an electrolyte imbalance

13. A 70-year-old man without symptoms with an ECG, showing an increased PR interval, right bundle branch block and left axis deviation

14. An 80-year-old woman without symptoms with an ECG, showing right bundle branch block and left axis deviation

15. A 45-year-old woman presenting with recurrent syncope, with a documented pause of >3 seconds following carotid sinus massage.

Results

Figure 1

Figure 1. Comparison of scores across grades

21 members of ED staff completed the survey, including two medical students, two cardiac nurses, nine SHOs, six registrars and two consultants. The average mark was 62.7%. SHOs performed best (figure 1). However, the spread of average marks ranged from 8.5–10.3 highlighting that the scores were highly clustered. Out of the total 315 responses, 65% of incorrect answers were inappropriate referrals of no consequence to the patient: 25 referred to a cardiologist unnecessarily and 63 referred to a cardiologist urgently when non-urgently indicated. However, 21% of referrals were delayed or simply not made: 12 referred to a cardiologist non-urgently when urgently indicated, 13 did not refer to a cardiologist when non-urgently indicated and three did not refer to a cardiologist at all when urgently indicated. Interestingly, errors were made across grades (tables 1 and 2).

Table 1

Table 1. Breakdown of those who did not refer to a cardiologist when non-urgently indicated

Following a teaching session, a subset of ED staff were re-tested on the six questions which 10 or more ED staff had answered incorrectly (questions 4, 7, 9, 12, 13, and 14). The results pre- and post-teaching session were directly compared. Pre-teaching session the average mark for the six questions was 41.2%. Following the teaching session the average mark increased to 80%.

Discussion

The findings from this audit highlight room for improvement in ED staff knowledge of indications for permanent pacemaker insertion and that further education is required across all grades from medical students to consultants, in order to optimise patient care. A teaching session proved a useful tool in improving ED staff knowledge in a subset of original participants. Extrapolating these findings it is hoped that an electronic version of this teaching session will help to reduce the burden on cardiology services through a reduction in unnecessary referrals and ensure patients who require referral are referred appropriately.

Table 2. Breakdown of those who did not refer to a cardiologist when urgently indicated

Table 2. Breakdown of those who did not refer to a cardiologist when urgently indicated

References

1. Vardas, PE, Auricchio, A, Blanc, J-J, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2007;28:2256–95.

Acknowledgements

Dr Kim Rajappan, Consultant Cardiologist

Dr Asim Basu, Consultant Cardiologist

Dr Hari Kishan, Cardiology Registrar

Conflict of interest

None declared

Author

Dr Joyee Basu
John Radcliffe Hospital
Headley Way
OX3 9DU

Joyee

Published on: January 25, 2013

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  • Atrial Fibrillation Association
 

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