110/The development of a cardiac physiologist and nurse-led implantable loop implant service

Introduction: Implantable loop recorder (ILR) insertion can be safely performed outside of a cardiac catheter laboratory environment but to date has typically been a procedure performed by cardiologists. In our unit, we introduced an ILR insertion service undertaken by cardiac physiologists and nurses rather than doctors. The feasibility, safety and resource implications
of this service were assessed.
Explanation of basic methods: Two Band 7 physiologists and a Band 6 nurse received dedicated training in informed consent, injectable medicines and scrub/aseptic technique, follow up information, wound aftercare and home monitoring set up. Implanters also underwent cardiology consultant and ILR manufacturer-led training in surgical technique. We formalised
agreement that nurses and cardiac physiologists could administer Lidocaine (up to 20 mls 1% w/v), with successful submissions to the Trust Pharmacy Department and the Medicines Committee. A small procedure room was passed by infection control for undertaking implants. Patients waited in the cardiac day lounge and were not fasted, cannulated or given antibiotic prophylaxis. They were discharged 30 minutes post procedure if there were no immediate complications. The clinical decision to list a patient for the procedure was still undertaken by a doctor.
Results: From October 2015 to February 2019, 385 ILR implants were performed by the service.
The number of patients receiving an ILR at Wythenshawe has doubled since service inception; in the first 6 months of the service (32 procedures were performed: mean 5/month) whereas in the most recent 6 months up to February 2019, 68 procedures were performed: mean 11/month). This has been partly achieved by more frequent weekly lists – 2/month at service inception were increased to weekly lists.
Waiting times from listing to procedure have reduced during since the service was established (16 weeks reduced to consistently less than 4 weeks). Anecdotally, there has been a reduction in the length of time patients remain in hospital peri-implant, although this has not been formally measured. Ninety-two percent of respondents to our friends and family questionnaire said they were “extremely likely” to recommend the service. Forty hours of cath lab time have been freed up per annum; which allows either 20 additional ablation procedures or a total of 10 additional CRT and 10 additional dual chamber pacemaker implants. Arrhythmias identified following ILR implant have resulted in insertion of 42 PPMs, 3 ICDs and 17 EP procedures with the associated tariffs these procedures have attracted. Complications occurred in five patients (1%); two erosions, one wound revision, one glue allergy treated conservatively and one Takusubo cardiomyopathy (which may have been related to distress peri-implant).
Conclusions and implications: An ILR implant service performed by nurses and cardiac physiologists is feasible, safe and frees up catheter laboratory resources. Since the start of the service, reductions in waiting time have been associated with increased implant numbers.