Guidelines/British Heart Rhythm Society Guidelines Contributes to CQC Regulation 12. Consulted With Post/Committee/Group Date Michelle Colton-Goff

Transcription

1 Management of Temporary Transvenous Cardiac Pacing Clinical Guideline Register No: Status: Public Developed in response to: European Society of Cardiology Guidelines/British Heart Rhythm Society Guidelines Contributes to CQC Regulation 12 Consulted With Post/Committee/Group Date Michelle Colton-Goff Principal Chief Cardiac 28/04/2017 Physiologist Daniella Bartlett Senior Sister Cardiac 28/04/2017 Angiography Suite Debbie Whitfield Lead Nurse Cardiac 28/04/2017 Onkar Dhillon Consultant Cardiologist 28/04/2017 Gerald Clesham Consultant Cardiologist 28/04/2017 Maria Richards Lead Clinical Pharmacist 28/04/2017 Resuscitation Team Resuscitation Team 28/04/2017 Professionally Approved By Clinical Effectiveness Approval Gerald Clesham Dr Kath Rowe 28/04/2017 July 2017 Version Number 1.1 Issuing Directorate Medical Ratified by: DRAG Chairmans Action Ratified on: 29 th October 2017 Executive Management Board Sign Off Date November 2017 Implementation Date 11 th November 2017 Next Review Date September 2020 Author/Contact for Information Stacey Mayes Chief Cardiac Physiologist Policy to be followed by (target staff) All Staff Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) Adult Do Not Attempt Resuscitation Trigger Response Team Op Policy Safe Conscious Sedation for Emergency Procedures in ED Document Review History Version Number Author or Reviewer Active Date 1.0 Stacey Mayes, Chief Cardiac Physiologist 30 August 2017 uploaded then removed from publication 1.1 Corrected version Stacey Mayes, Chief Cardiac Physiologist 11th November 2017

2 Contents 1.0 Purpose 2.0 Equality and Diversity 3.0 Definition/Background 4.0 Scope and Indication/Contraindications for Implantation 5.0 Staffing/Training 6.0 Infection Prevention 7.0 Clinical Procedure and Staffing 8.0 Equipment 9.0 Transfer of Patients 10.0 Return/On Going Care of Patient (GHDU/GITU Only) 11.0 Procedure for Testing of Pacing Threshold 12.0 Emergency Procedures/Troubleshooting Failure to Pace 13.0 Emergency Procedures/Troubleshooting Failure to Capture 14.0 Emergency Procedures/Troubleshooting Failure to Sense 15.0 Out of Hours Service Provision 16.0 Patient Assessment Prior to Transfer to The Essex Cardiothoracic Centre 17.0 Referral Process for Requesting Transfer to The Essex Cardiothoracic Centre 18.0 Requesting an Emergency Transfer Via Ambulance 19.0 Drug Administration for the Management of Bradycardia (In Line with the Adult Bradycardia Pathway See Appendix 6) 20.0 Breach Reporting 21.0 Audit and Monitoring 22.0 References

3 Appendix 1: Equality Impact Assessment (EIA) Appendix 2: CS Equipment Competency Appendix 3: Skill Assessment Appendix 4: Temporary Transvenous Pacing Pathway Appendix 5: Troubleshooting Guide to Medtronic 5391 External Temporary Pacing Generator Appendix 6: Adult Bradycardia Pathway

4 1.0 Purpose 1.1 To provide guidance and support to all Physicians, Cardiac Physiologists, Nurses and other relevant medical staff performing and supporting the insertion of Temporary Cardiac Transvenous Pacing in both the acute and elective setting. 1.2 To detail requirements and protocols for training within Mid Essex Hospitals NHS Trust (MEHT) to ensure all staff performing Temporary Cardiac Transvenous Pacing procedures have appropriate competencies and if not are aware of how to gain them. 2.0 Equality and Diversity 2.1 The trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. An Equality Impact Assessment is attached as Appendix Definition/Background 3.1 Temporary Cardiac Transvenous Pacing may be required in the acute setting for the management of bradyarrhythmias, and also in the management of certain tachyarrhythmias to re-establish circulatory integrity and normal haemodynamics in acute compromisation due to slow or fast heart rates/rhythms. 3.2 Temporary Cardiac Transvenous Pacing may also be required electively to support cardiac procedures, such as routine pacemaker generator changes and in provocative diagnostic procedures. 3.3 Temporary Cardiac Transvenous Pacing is a specialist cardiology procedure and should only be attempted by those appropriately trained and experienced to do so. 4.0 Scope and Indications/Contraindications for Implantation 4.1 This document is only applicable to adult patients aged 18 years and above 4.2 Temporary Cardiac Transvenous Pacing should be considered for: Bradycardia with Haemodynamic Compromise Those at increased risk of Asystole due to Slow Heart Rates/Rhythms, such as 2nd and 3rd Degree Atrioventricular Block. Ventricular Arrhythmia Suppression (Only by those experienced and trained appropriately) Termination of Tachyarrhythmia by overdrive pacing (Only by those experienced and trained appropriately) Prophylactic Use Preoperatively (Only following discussion and agreement from an appropriate cardiology consultant) 4.3 Temporary Cardiac Transvenous Pacing may be contraindicated in a patient with an active DNACPR; however the ultimate responsibility for the clinical decision to implant/withdraw temporary pacing remains with the senior clinician responsible for their care at the immediate time of the event. (In Hours (09.00am-17.00pm) discussion is to take place with a Consultant Cardiologist, Out of Hours (After 17.00pm and Prior to 09.00am) discussion is take place with a Consultant).

5 Nevertheless where reasonably possible discussion should take place with other members of the healthcare team and/or the patient/patient s relative or those representing a patient without capacity to ensure their agreement and consensus. Please refer to the Adult Do Not Attempt Cardiopulmonary Resuscitation Policy (DNACPR) Policy Number (Available via the Intranet) for further guidance. 4.4 This clinical guidance applies to all Physicians, Cardiac Physiologists, Nurses and other relevant medical professionals performing and supporting Temporary Cardiac Transvenous Pacing Procedures. 5.0 Staffing/Training 5.1 All medical staff are responsible for: Being aware and compliant with this clinical guidance Ensuring they have adequate and appropriate training and have been deemed competent before using temporary pacing equipment. (Core Competency CS Appendix 2 and Appendix 3 Skill Assessment should be completed and signed by all relevant staff prior to use of any temporary transvenous pacing equipment or management of patients with temporary transvenous pacing wires in situ). Training will be required to be refreshed every year; this will be audited through training records in line with local trust learning and development policies. 5.2 All staff involved in temporary cardiac transvenous pacing should be appropriately trained and suitably competent. 5.3 Appendix 2 Core Competency CS and Appendix 3 Skill Assessment should be completed and signed by all relevant staff prior to use of any temporary transvenous pacing equipment or management of patients with temporary transvenous pacing wires in situ. Copies of all competencies should be kept in individual staff records of Continuing Professional Development (CPD) and monitored by departmental/ward managers. 5.4 All staff involved in temporary cardiac transvenous pacing should be a minimum of Immediate Life Support (ILS) trained. 5.5 The Ward/Unit Manager (Sister, Charge Nurse or Departmental Manager) is responsible for ensuring all medical staff on their ward/unit maintain fully complete competencies and that no staff without the relevant competencies are designated to care for a patient with a temporary transvenous cardiac pacing wire in situ. 6.0 Infection Prevention 6.1 All staff will adhere to Trust guidelines on infection prevention at all times whilst performing Temporary Cardiac Transvenous Pacing, such as hand washing, the use of sterile procedures, additional infection prevention measures when required i.e.: gloves and aprons and effective decontamination of all non-disposable equipment between patients.

6 7.0 Clinical Procedure and Staffing 7.1 All medical staff are responsible for ensuring that adequate information about the procedure is relayed to the patient and/or relative and at least verbal consent is gained prior to commencement of the Temporary Cardiac Transvenous Pacing, where reasonably possible and this is clearly documented. If the patient has mental capacity and the insertion of the Temporary Cardiac Transvenous Pacing is not performed under extreme emergency circumstances written consent should be gained. 7.2 All medical staff are responsible for liaising with other members of the medical team if deemed appropriate regarding the ongoing care of the patient. 7.3 Minimum staffing requirements for Temporary Cardiac Transvenous Pacing insertion to take place are as follows 1 Cardiology Experienced Physician trained and competent in Temporary Cardiac Transvenous Pacing Wire insertion who is at least Intermediate Life Support (ILS) Trained 1 Assistant trained and competent in Temporary Cardiac Transvenous Pacing Wire insertion. Anaesthetist if appropriate and indicated Radiographer if appropriate and use of Fluoroscopy for insertion is essential and/or required 7.4 All staff involved in the patient s on-going care should be a minimum of Immediate Life Support (ILS) trained 8.0 Equipment 8.1 Minimum equipment requirements for Temporary Cardiac Transvenous Pacing insertion to take place are as follows: External Temporary Pacing Box Single Patient Use Disposable Patient Cable Cardiac Monitor Temporary Pacing Catheter (Wire) appropriate to route of use Sterile Insertion Pack 9.0 Transfer of Patients (Internal within MEHT Premises) 9.1 All patients requiring Temporary Transvenous Cardiac Pacing insertion should be transferred to and from the designated areas with an external defibrillator with pacer function. 9.2 Patients should be accompanied by a minimum of an ILS Provider. 9.3 Continuous Cardiac Monitoring should be maintained at all times, this can be achieved via the external defibrillator or separate portable cardiac monitor. 9.4 Patients with Temporary Transvenous Cardiac Pacing wires in situ should only be transferred for on-going care to the General High Dependency Unit (GHDU) or General Intensive Care Unit (GITU), following appropriate handover and acceptance by the consultant responsible for the decision to insert a temporary pacing wire.

7 10.0 Return/On Going Care of Patient (GHDU/GITU Only) 10.1 All patients with a Temporary Transvenous Pacing Wire In Situ will have a Yellow Information Sign Attached to their bed, to clearly identify presence to all staff. This should remain with the patient and be clearly visible for the duration that the Temporary Pacing Wire remains in situ. (Signs are located with Temporary Pacing Equipment in each responsible area) 10.2 Detailed full handover will be given by the staff inserting the Temporary Pacing Wire to the Critical Care Team (GHDU/GITU Staff) All Temporary Pacing Documentation (Yellow Paperwork) should have been completed by inserting staff team, and full handed over to continuing care team for on-going completion (See Appendix 4) Temporary Pacing Wire Checks will be performed by the receiving nursing team and documented on the Temporary Pacing Pathway (See Appendix 4) All patients with a Temporary Transvenous Pacing Wire In Situ should remain on continuous cardiac monitoring for the duration that the Temporary Pacing Wire remains in situ Post Implant Chest X-Ray will be arranged to document the position of the Temporary Pacing Wire, if not inserted under fluoroscopy guidance and exclude pneumothorax. This will then be reviewed by the Consultant responsible for the insertion of the Temporary Pacing Wire Patients with Femoral Temporary Transvenous Pacing Wires should be on strict bed rest and mobilisation should be kept to a minimum. Head of the Bed should be kept at a maximum of A clear Treatment Escalation Plan is to be discussed by the Senior Clinicians and clearly documented in the patient s clinical notes in case of any ongoing issue with the patient post Temporary Wire Insertion. If transferring the patient to another location, the treatment plan needs to be clearly discussed and documented prior to departure, including completion of the relevant paperwork Procedure for Testing of Pacing Threshold 11.1 The pacing rate should be set to at least 10 bpm above the patient s intrinsic rate to enforce a paced rhythm. (YELLOW light should be flashing to indicate pacing is present)

8 11.2 Decrease the Output Voltage (V) slowly and gradually until a pacing spike is seen without ventricular depolarisation (Illustrated in the Diagram Below). (YELLOW light should stop flashing to indicate loss of pacing). CAPTURE LOSS OF CAPTURE 11.3 Once Loss of Capture is seen, increase the Output Voltage (V) until consistent capture is seen with Ventricular Depolarisation occurring after every pacing spike (Illustrated in Diagram above) and the YELLOW light is flashing to indicate pacing is present. This is the Pacing Stimulation Threshold (V) 11.3 Set the Output value to a minimum of 2 to 3 Time greater than the pacing stimulation threshold to provide a 2 to 3 times safety margin. If the safety margin is greater than the agreed standard, please ensure that the responsible consultant is made aware Slowly decrease pacing rate to previous settings, or to a rate agreed with the responsible consultant Emergency Procedures/Troubleshooting Failure to Pace 12.1 Pacing Malfunction can occur for a number of reasons and are critical situations that require prompt and rapid intervention. Any patient with pacing malfunction should be connected to an external defibrillator with a pacer function. Below are some common issues and guidance on how these may be rectified Failure to pace occurs when there is no electrical output from the Temporary Transvenous Pacing Wire despite being physiologically indicated This is recognised by the absence of pacing spikes on the ECG and a heart rate less that that set via the Temporary External Pacing Generator This may reveal the patient s underlying intrinsic rhythm or lack of it, resulting in a potential bradycardic or asystolic episode.

9 12.5 Causes of Failure to Pace Lead Malfunction or Unstable Connection between the Pacing Wire and External Generator Insufficient Power from the External Temporary Pacing Generator/Battery Failure Oversensing of Inappropriate signals (For Example Large P Waves being interpreted by the device as Intrinsic QRS and Pacing being inhibited). Fracture of Pacing Electrode 12.6 Management of Failure to Pace Check Connections between Temporary Transvenous Pacing Wire and External Temporary Pacing Generator Check Battery Connection and Change Batteries if required for (1 x New 9V Battery). Increase Output Voltage (V) Switch to an Asynchronous Mode (VOO) to prevent oversensing Replace External Pacing Generator and/or Single Use Patient Disposable Cable if required If resolution cannot be reached promptly and the patient is haemodynamically compromised, sedation may be required and external transcutaneous pacing commenced Emergency Procedures/Troubleshooting - Failure to Capture 13.1 Failure to Capture occurs when there is electrical output from the tip of the temporary transvenous pacing wire (confirmed by the presence of a pacing spike on the ECG), but this does not cause ventricular depolarisation or cardiac contraction.

10 13.2 Causes of Failure to Capture Pacing Output (V) set on the External Pacing Generator is lower than the threshold of the myocardium the tip of the Temporary Transvenous Pacing Wire is in contact with Temporary Pacing Wire has displaced so that the electrode is no longer in contact with the myocardium Fibrosis or Myocardial Infarction at the site of the wire-myocardium interface Electrolyte Imbalance (e.g.: Acidosis, Hypoxia, Hypokalemia) Post Defibrillation Drugs (e.g.: Flecanide Can increase pacing threshold) 13.3 Management of Failure to Capture Check Connections between Temporary Transvenous Pacing Wire and External Temporary Pacing Generator Increase Output Voltage (V) on External Pacing Generator, if possible Treat and Correct Exacerbating Causes 14.0 Emergency Procedures/Troubleshooting - Failure to Sense 14.1 Failure to Sense occurs when the temporary transvenous pacing wire fails to detect the intrinsic activity of the heart and therefore delivers pacing regardless This may result in unnecessary and inappropriate pacing, which can also lead to life threatening arrhythmias, for example Inappropriate pacing on the T Wave, known as the R on T Phenomenon can result in the induction of Ventricular Fibrillation.

11 14.3 Causes of Failure to Sense: The External Pacing Box is configured to a fixed mode (e.g.: VOO) so is not programmed to detect the presence of intrinsic rhythm. The Sensitivity (mv) is too low (the numerical value programmed on the external generator is too high), meaning the generator is not sensitive enough to detect intrinsic signal. **Trust Standard Sensitivity 2mV** (Do not adjust this unless advised by a Cardiologist or appropriately qualified and experienced member of staff.) Temporary Pacing Wire has displaced so that the electrode is no longer in contact with the myocardium 14.4 Management of Failure to Sense Check Connections between Temporary Transvenous Pacing Wire and External Temporary Pacing Generator Increase Sensitivity (mv) external pacing generator (Decrease the numerical value, to make the device more sensitive) Out of Hours Service Provision (Outside Monday-Friday) 15.1 In the event of Temporary Transvenous Cardiac Pacing being required out of normal working hours, the out of hours service is provided by The Essex Cardiothoracic Centre where a Consultant Cardiologist specialising in Pacing will be On Call and available to discuss patients Out of Hours Service Provision will be available Monday-Friday (17.00pm-09.00am) and from 17.00pm on Friday to 09.00am on Monday For Symptomatic Bradycardia please follow the Adult Bradycardia Pathway (Appendix 6 and Section 16 for Guidance on Administration of Interim Drug Therapy) 15.4 Patients may have symptoms of presyncope, syncope or haemodynamic instability, however majority can be effectively managed without the need for emergency out of hours pacing. However if haemodynamic compromise exists or ventricular arrhythmias are present prompt access to temporary transvenous pacing can be lifesaving. Please see Table below for Indications for Temporary Transvenous Cardiac Pacing (Provided by The Essex Cardiothoracic Centre)

12 Acute Myocardial Infarction (Class I ACC/AHA) Asystole Cardiac Arrest 3 rd Degree AV Block (Complete Heart Block) Bilateral Bundle Branch Block (Alternating BBB or RBBB with alternating LAHB/LPHB) New Bifascicular Block with 1 st Degree AV Block Symptomatic Bradycardia Bradycardia not associated with Acute Myocardial Infarction Asystole Cardiac Arrest 2 nd Degree Mobitz Type II or 3 rd Degree AV Block (Complete Heart Block) with haemodynamic compromise or syncope at rest Ventricular Arrhythmias secondary to Bradycardia Transfer to Essex Cardiothoracic Centre for Primary PCI (Please Follow the PPCI Pathway) Review of Pacing Indication once revascularised Check Bloods (U&E) Correct Electrolytes Check INR Obtain Drug History Consider Transfer to The Essex Cardiothoracic Centre for TPW +/- Pacemaker Implantation (Monday-Friday prior to 09.00am and after 17.00pm) for symptomatic bradycardia, please follow the Adult Bradycardia Pathway. (See Appendix 6 for pathway and Section 15 for Guidance on Administration of Interim Drug Therapy) and contact The Essex Cardiothoracic Centre. The Essex Cardiothoracic Centre Cardiology Registrar On Call Bleep Patient Assessment Prior to Transfer to The Essex Cardiothoracic Centre 16.1 The assessment of the patient must be undertaken by an experienced clinician (On Call Medical Registrar/Cardiology Registrar or Above) to ensure that eligibility criteria has been met and that the patient is deemed appropriate and indicated for Transfer to the Essex Cardiothoracic Centre Intravenous Access should be obtained and in situ prior to transfer Referral Process for Requesting Transfer to The Essex Cardiothoracic Centre 17.1 The Referring Registrar/ Consultant should contact The Essex Cardiothoracic Centre Cardiology Registrar On Call using the below telephone number to discuss the patient:

13 The Essex Cardiothoracic Centre Cardiology Registrar On Call Bleep The Cardiology Registrar On Call at the Essex Cardiothoracic Centre (ECTC) will make the decision to accept the patient (they may discuss the patient with the on call electrophysiology devices consultant prior to a decision being made). Once accepted, The On Call Cardiology Registrar at ECTC will notify Roding Ward of the impending arrival of the patient Requesting an Emergency Transfer Via Ambulance 18.1 To transfer a patient to The Essex Cardiothoracic Centre for Emergency pacing please contact The East of England Ambulance Service and request a blue light transfer as soon as possible using the below telephone number: State that you require: East of England Ambulance Service Paramedic Crew - Blue Light Transfer to The Essex Cardiothoracic Centre for Emergency Pacing 18.2 Transfer of a patient to The Essex Cardiothoracic Centre should include staff who hold up to date Advanced Life Support (ALS) Qualification and who are competent in the management and implementation of External Transcutaneous Pacing via Defibrillation Pads It is the responsibility of the department from which the patient is to be transferred to determine the appropriate personnel required for the safe transfer of the patient according to medical needs Drug Administration for the Management of Bradycardia (In Line with the Adult Bradycardia Pathway See Appendix 6) 19.1 Atropine is the usual the first line drug used to treat Bradycardia. Use stat doses of Atropine 500microg prn (at minimum 3-5 minute intervals) for symptomatic bradycardia up to a maximum of 6 doses (3mg) 19.2 If no response/ineffective response from Atropine or maximum dose reached consider an infusion of chronotrophic drugs: Isoprenaline micrograms/min (may be unavailable*) central (preferable) or peripheral administration. *There are frequent supply problems with Isoprenaline and it therefore may not always be available. Please consider alternatives below if appropriate. Dopamine 2-10 micrograms/kg/min central (preferable) or peripheral administration. Adrenaline (Epinephrine) 2-10 micrograms/min central administration only.

14 Start the infusion at the lowest recommended dose and increase gradually if necessary according to response. **PLEASE REFER TO MEDUSA FOR FULL ADMINISTRATION GUIDELINES AVAILABLE VIA THE INTRANET OR AT Breach Reporting 20.1 In the event that this guidance is not followed and as a result the patient suffers harm, a risk event form should be completed via the Datix Reporting System Audit and Monitoring 21.1 Adherence to this guidance will be monitored by review of reported incidents and complaints via the Datix system. These will be dealt with by the relevant head of department/ward This policy will be reviewed annually and on the issuing of new guidance when required References Basildon and Thurrock University Hospitals NHS Foundation Trust (2013) Temporary Cardiac Pacing Guideline for the management of epicardial and transvenous pacing wires within the CTC British Heart Rhythm Society (BHRS) (2016) Position Statement on The Out of Hours Management of Bradyarrhythmia Emergencies Medtronic, Model 5391 Temporary Single Chamber External Pacemaker Checkout Manual Medusa (2014) Dopamine Hydrochloride. Available at: Medusa (2014) Epinephrine. Available at: Resuscitation Council (UK), David Pitcher and Jerry Nolan (2015), Peri Arrest Arrhythmias Available at: Southend University Hospital (2013) Guideline for the care of a patient undergoing permanent pacemaker procedure (including insertion/lead reposition/box change and follow up arrangements) The Essex Cardiothoracic Centre (2016) Out of Hours Emergency Pacing Service Guidelines UCL Hospital Pharmacy Department (2010) Injectable Medicines Administration Guide, 3 rd Edition

15 Appendix 1 Equality Impact Assessment (EIA) Title of document being impact-assessed: Temporary Pacing Wire Insertion Equality or human rights concern Gender Race and ethnicity Disability Does this item have any differential impact on the equality groups listed? Brief description of impact. All identified patients requiring a Temporary Transvenous Cardiac Pacing will be treated the same irrespective of their gender All identified patients requiring a Temporary Transvenous Cardiac Pacing will be treated the same irrespective of their race and ethnicity. It is acknowledged that some patients requiring Temporary Transvenous Cardiac Pacing may have/live with physical disabilities, learning disabilities, autism or other mental health issues. How is this impact being addressed? Staff communication is encouraged to support all patients and/or their relatives/carers. Staff will ensure that all patients are offered a gown to allow them to be covered regardless of gender where reasonably possible during an invasive procedure that may be performed in an emergency situation. All complaints will be fully investigated and responded to. The Trust operates within the requirements of The Race Equality Act Language may be a barrier, however if able staff should plan in advance for an interpreter to be present during the procedure or use relative/carers to assist with translation if necessary Patient information should always be accessible and up to date. All areas have disabled access such as wheelchairs, lifts and toilets. In patients with sensory impairment or sensitivities extra care will be taken to explain every step of the procedure to the patient including the use of different materials that may touch their skin to avoid distress. Religion, faith and belief Sexual orientation All identified patients requiring a Temporary Transvenous Cardiac Pacing will be treated the same irrespective of their beliefs. There is access to the multi faith chaplaincy team who offer advice and support for patients, relatives, carers and staff. All identified patients requiring All trust staff are bound to comply with

16 Age Transgender people a Temporary Transvenous Cardiac Pacing will be treated the same irrespective of their sexual orientation. This policy is specific to adults aged 18+ Years. All identified patients requiring a Temporary Transvenous Cardiac Pacing will be treated the same irrespective of their gender status. equalities legislation. Staff training is available for Equality and Diversity. All complaints are fully investigated and responded to. The trust acknowledges the differing needs of younger and older patients with regards to the need for restraint (if required), privacy, mental health issues and the related laws. A separate policy will need to be made available to address the needs of patients aged Under 18 Years. All trust staff are bound to comply with equalities legislation. Staff training is available for Equality and Diversity. All complaints are fully investigated and responded to Social class No Variance All identified patients requiring a Temporary Transvenous Cardiac Pacing will be treated the same irrespective of their social class status. Staff communication is encouraged to support patients and/or carers and relatives. Carers. Some patients requiring a Temporary Transvenous Cardiac Pacing have additional difficulties with regards to transport/financial concerns. Carer s information and advice is available regarding facilities; concessions; Carers Advocacy Services and Carers Assessment. Date of Assessment: 03/03/2017 Names of Assessor (s): Stacey Mayes

17 Appendix 2: EQUIPMENT COMPENTENCY MEDICAL DEVICE / EQUIPMENT COMPETENCY SELF ASSESSMENT STATEMENT Equipment category / name: External Temporary Pacemaker Generator - (Medtronic 5391) Areas where equipment used: Competency Statement Number: CS All areas with clinical need Staff groups using this equipment: Doctor, Cardiac Physiologist, Critical Care Scientist, Nurse, Clinical Nurse Specialist Training level: Risk Level Complex Intermediate Basic External / DCCT DCCT / Super-user Self/ Peer High The statements below are designed to assess your competence to use this device. You should self-assess your competency after you have received the relevant training. Responsibility for use of the equipment remains with you, so if you are in any doubt about your competence to use the device, you must seek additional training in liaison with your line manager / supervisor and then re-assess your competence against the statement. Sources of training support include the product operating manual and training from peers, super-users or Clinical Technicians as appropriate. Questions to ask yourself: Are you safe using this equipment? Do you know the following? Assessment Part 1 All Staff 1 How to locate Temporary Pacing Consumables for designated area? Yes / No 2 Who to contact to order replacement Temporary Pacing Consumables if required? Yes / No 3 How to activate External Transcutaneous Pacing using the External Defibrillator if needed Yes / No (Please complete competency statement CS also)? 4 Aware of how long batteries last at 100% Pacing? Yes / No 5 Aware of how and when to change the batteries? Yes / No 6 How to turn the unit on to Fixed Pacing Mode (VOO)? Yes / No 7 How to turn the unit on to Demand Pacing Mode (VVI)? Yes / No 8 How to attach patient cable to External Generator? Yes / No 9 How to attach proximal and distal ends of pacing wire to patient cable? Yes / No 10 How to safely secure patient cable to patient? Yes / No 11 Aware of standard Trust setting for sensitivity and how and when to adjust if required? Yes / No 12 How and when to check sensitivity threshold if required? Yes / No 13 How to set the Pacing base rate? Yes / No 14 How to set the output amplitude? Yes / No 15 How to check the Pacing threshold? Yes / No 16 How to identify if the Patient is pacing? Yes / No 17 How to identify if the patient is sensing intrinsic rhythm? Yes / No 18 What may be indicated when the Pace and Sense lights flash simultaneously? Yes / No 19 How to activate and set Overdrive Pacing rate? Yes / No 20 How to identify when low battery conditions are present Yes / No 21 What actions should be taken when low battery conditions are indicated by the device? Yes / No 22 How to clean and decontaminate equipment? Yes / No 23 Who to report equipment faults to? Yes / No 24 Who to report possible patient related issues to? Yes / No 25 Aware of out of hours support for Temporary Pacing and how to contact if required? Yes / No 26 Have read the Mid Essex Hospital Services NHS Trust Temporary Pacing Policy? Yes / No You must be able to answer yes to all questions relevant to your role to consider yourself competent. If you are competent, you should date and sign your Diagnostic & Therapeutic Equipment Competency Record for this equipment. If you are not competent, please identify this on your record, signing and dating the record appropriately and discuss with your manager how and when your training needs will be met. Your line manager should retain your Diagnostic & Therapeutic Equipment Competency Record. Self - assessment is undertaken on a one-off basis but will be reviewed annually at appraisal. Signature Date

18 Appendix 3: SKILL ASSESSMENT CARE OF A PATIENT WITH A TEMPORARY TRANSVENOUS CARDIAC EXTERNAL PACEMAKER IN SITU This document is designed to assess the competency of any staff member responsible for caring for patients that may have temporary transvenous cardiac pacemakers in situ and should not be completed without relevant and up to date training. The below competency assessment should be completed in line with equipment competency statement CS (Staff members should have completed both competency assessments before being allowed to care for a patient with a temporary transvenous cardiac pacemaker in situ.) Candidate Name: Designation:. Area:.. Competency Action Able to Identify the common indications for Temporary Transvenous Pacemaker Insertion Correctly and Securely able to attach the patient cable to the external generator and pacing wire to the patient cable Able to discuss the risks and complications associated with transvenous pacing Able to discuss and explain what is meant by the terms demand and fixed rate pacing Demonstrates the ability to set and alter Output Voltage (V) (Under Medical/Specialist Guidance) Able to explain the term Threshold and assist in measuring this (Under Medical/Specialist Guidance) Able to correctly identify a paced rhythm, and key features associated with this Demonstrates correct documentation of transvenous pacing wire settings and follow up care. Demonstrates how to recognise indication of low battery, and appropriate actions to be taken following this Demonstrates how to safely change the batteries in the generator Able to identify appropriate mobility levels and restrictions for patients with a temporary transvenous pacing wire in situ Demonstrated by Print Name/Sign/Date Final Assessment Print Name/Sign/Date

19 Able to identify and discuss using ECG monitoring the presence of: Failure to Pace Failure to Capture Failure to Sense and the appropriate management for each individual condition Able to correctly detach the patient cable from the external generator and pacing wire from the patient cable, and dispose of in line with trust protocol. Assessor: Completion of this documentation has deemed the above named candidate competent to care for a patient with a temporary transvenous pacing wire in situ in a safe and effective manner. Signed: Name: Designation: Date: Candidate: By signing below the above named candidate agrees that they have been demonstrated the above criteria in order to fulfil the competency actions fully and understand that they have been deemed competent as an individual to care for patients with temporary transvenous pacing wires in situ Signed:.. Name: Designation: Date:

20 Appendix 4: TEMPORARY TRANSVENOUS PACING PATHWAY Temporary Transvenous Pacing Pathway Guidance The below documentation needs to be attached to the hospital notes of every patient with a temporary transvenous pacing wire in situ throughout the duration of their hospital stay and be easily accessible for all staff. Please ensure that the attached yellow sign is placed in a location that is clearly visible to all staff at/above the patient s bedside to enable clear identification that a temporary pacing wire is in situ. The pacing threshold needs to be checked at the changeover of every shift and with every set of observations, minimum 4 hourly and recorded on the continuing care sheet below. If there are any concerns regarding the pacing wire/pacing parameters post insertion, please seek expert advice at the earliest opportunity. This may be from the person responsible for the insertion of the temporary wire or relevant medical teams such as Cardiology/Cardiac Physiologists. Cardiac Physiologists can be contacted on Extension x4185/4209 or in person in the Cardiac Centre (A210) between ( ) Cardiologists can be contacted via their individual bleeps or via switchboard. Patient Demographics Surname: Forename: Date of Birth: Hospital Number: NHS Number: Date/Time TPW Inserted: TPW Inserted by: Date/Time New Batteries Inserted: New Batteries Inserted by: Temporary Pacing Box Serial Number:

21 Temporary Pacing Measurements TPW Measurements on Insertion: Pacing Threshold Output Rate Sensitivity Mode (Fixed/Demand) Please ensure that this section is fully completed on transfer of care of the patient from place of insertion to acceptance of care in GHDU/GITU. A check of the Temporary Pacing Wire should be performed by the responsible staff member handing over from the inserting team with the responsible staff member who is to take over further care from the accepting team (GHDU/GITU) and clearly documented below. **Staff should not complete checks of Temporary Pacing Equipment/Wires without holding the relevant competencies (Appendix 2 and Appendix 3)** TPW Measurements on Acceptance of Care to GHDU/GITU: Pacing Threshold Output Rate Sensitivity Mode (Fixed/Demand) Acceptance Check Performed By: (Inserting Team) (Name and Designation) Acceptance Check Performed By: (GHDU/GITU Team) (Name and Designation) Date/Time Acceptance Check Performed:

22 Continuing Care Checklist Date Time Skin Integrity Checked (Yes/No) Connections Secure (Yes/No) Low Battery Indicator Checked (Yes/No) Threshold on Testing (V) Underlying Rhythm Present (Yes/No) If present, what is Underlying Rhythm/Rate (bpm) Rate of Temporary Pacing (bpm) Output (V) Check performed by: (Primary Staff Member) Check confirmed by: (2 nd Staff Member)

23

24 Variance Please document any variance related to the temporary pacing wire in the section below: 24

25 25

26 Appendix 5: TROUBLESHOOTING GUIDE TO MEDTRONIC 5391 EXTERNAL TEMPORARY PACING GENRATORS LOW BATTERY A Fresh 9V Battery should be used on every patient. Ideally the battery should not be replaced whilst the generator is in situ on a patient as no pacing is provided when the battery is removed. (1 Standard 9V Battery should last 38 Days at 72ppm and 8V Output) The Low Battery LED will flash RED when the device battery is getting low and the device will also beep. The Battery should be changed at the earliest opportunity as soon as the LED becomes illuminated. ERROR LED When a malfunction of the device occurs the Low Battery LED will remain constantly illuminated RED and a repeating beep will sound. If possible turn the device off and on again, if the red LED light remains illuminated remove the device from use and return to Biomedical Engineering for servicing. If once the device has been turned off and on again the LED light is no longer illuminated the device and be returned to use. SENSING INTRINSIC RHYTHM/ASYNCHORNOUS PACING (VOO) When the device is sensing the intrinsic rhythm of the patient the Sense light will Illuminate GREEN. **Trust Standard Sensitivity 2mV** (Do not adjust this unless advised by a Cardiologist or appropriately qualified and experienced member of staff.) If the device is require to pace asynchronously (not to sense intrinsic rhythm) the sensitivity dial must be set to f **(This should only be done on the advice of a Cardiologist or an appropriately qualified and experienced member of staff)** 26

27 ADULT BRADYCARDIA MANAGEMENT PATHWAY (INCLUDING OUT OF HOURS TEMPORARY TRANSVENOUS PACING) Appendix 6 Bradycardia (Heart Rate < 50 bpm) Perform 12 Lead ECG to Assess Rhythm Calculate NEWS Score Assess Patient Using ABCDE Approach Obtain IV Access Identify any Reversible Causes (e.g.: Drugs such as Betablockers, Electrolyte Abnormalities) CALL FOR URGENT SENIOR REVIEW (REGISTRAR OR CONSULTANT) YES Does the Patient meet the PPCI Inclusion Criteria? NO FOLLOW PPCI PATHWAY YES Is the Patient Symptomatic/Haemodynamically Compromised? NO Call 2222 Give Atropine 500mcg IV Attach Transcutaneous Pacing Pads Does the patient have any of the following without syncope? 3 rd Degree AV Block (CHB) 2 nd Degree AV Block Slow Atrial Fibrillation Assess for Satisfactory Response? Heart Rate Blood Pressure Urine Output (>30ml/hr) Improving Neurological Status YES Request Urgent Cardiology Review and Monitored Level One Bed (A305) NO Manage as appropriate for presentation YES NO IF PATIENT BECOMES UNSTABLE FOLLOW SYMPTOMATIC YES. Repeat Atropine 500mcg IV Every 3-5 Minutes (Maximum Dose 3mg) SEEK EXPERT HELP! Consider Interim Drug Therapy (REFER TO MEDUSA): Isoprenaline (Central or Peripheral) micrograms/min OR Dopamine (Peripheral or Central IV) 2-10 micrograms/kg/min OR Adrenaline (Central IV) 2-10 micrograms/min Does the patient have any of the following NOT associated with an Acute MI? Asystole Cardiac Arrest 3 rd Degree AV Block (CHB) or 2 nd Degree Mobitz Type II with haemodynamic compromise or syncope at rest Ventricular Arrhythmias secondary to Bradycardia **CHECK U&E s, ELECTROLYTES AND INR** ENSURE DRUG HISTORY OBTAINED IN HOURS (09.00AM-17.00PM) Contact Cardiology Registrar/Consultant 27 OUT OF HOURS (PRIOR TO 09.00AM- AFTER 17.00PM MON-FRI AND SAT/SUN) Contact The Essex Cardiothoracic Centre (ECTC) Cardiology SpR On Call (Bleep 9010) for consideration of Temporary Transvenous Pacing