Cardiac Rhythm Management (CRM) - UCL · Rhythm Management database. ... You can double-click on a...

CCAD Training Manual

CardiacRhythmManagement(CRM)

Version 1.0 A D Cunningham 19/3/2008

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IntroductionThis manual is intended to assist users of the Notes Client version of the CCAD CardiacRhythm Management database. It is not intended to address issues relating to theweb-based version of CRM. For further information on the web-based application,please contact CCAD at [email protected] or 0846 300 6016 option 2.

ContentsIntroduction.....................................................................................................................................1Contents......................................................................................................................................... 1Getting Started ...............................................................................................................................2

The Opening Splash Screen............................................................................................................. 2The Main CRM Screen...................................................................................................................... 2

Adding a New Patient ...........................................................................................................................3Accessing Existing Patient Data.................................................................................................... 3

Devices: Pacemaker, ICD and CRT ................................................................................................4Adding a new procedure.................................................................................................................. 4

Patient Details ........................................................................................................................................5Procedure Details ...................................................................................................................................6Indications for Implant .................................................................................................................... 9

CRT and ICD Devices....................................................................................................................... 9

Implant Procedure......................................................................................................................... 11Generator Details........................................................................................................................... 12

Other Generator Fields for CRT and ICD Devices....................................................................14

Lead Details .........................................................................................................................................16In Hospital ...........................................................................................................................................17

Editing procedure data ...................................................................................................................... 18

Device Follow-Up..........................................................................................................................19Device or Lead Explant ...................................................................................................................... 21

File Closure / Death...................................................................................................................................22

Reports and Letters......................................................................................................................23Available device reports ............................................................................................................23

Available device letters .............................................................................................................24EPS/Ablation Procedures .................................................................................................................. 27

Patient Details ......................................................................................................................................27

Procedure Details .................................................................................................................................27

Indication for Intervention ........................................................................................................29Procedure.................................................................................................................................29Outcome (in hospital) .................................................................................................................... 30Outcome (late) .....................................................................................................................................30

System Reports.............................................................................................................................31PM/ICD Procedure Reports ............................................................................................................ 31EPS/Ablation Reports..................................................................................................................... 34

Getting StartedTheOpeningSplashScreenThis is important – PLEASE READ IT !

You MUST NOT disclose your password/PIN to any other users. If you do so, CCADmay suspend your access to the database without further warning!

TheMainCRMScreen

When you havelogged in andcleared the splashscreen, you will seepatients in the rightwindow, and amenu in the leftwindow.

Training ManualCardiac Rhythm Management (CRM)

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Adding a New PatientIn the main CRM view, click on _________ . A blank patient document will appear,and you can enter the patient details.

Some fields are mandatory, e.g. Hospital Number. Some fields are desirable, and aprompt will ask you to try to enter this field. Please make every effort to get thedata, but it is recognised that some data cannot be found, e.g. NHS Numbers andPostcodes1 for Overseas patients. You will still be able to save the recordwithout these fields.

Accessing Existing Patient Data

You can double-click on a patient to reveal their demographic data:

Click on the task bar (Edit Document) above the document if you want to edit thedetails:

1 The NHS provides pseudo-postcodes (beginning with ZZ99) for all overseas patients – if you donot know the correct one for the native country of the patient, use ZZ99 9ZZ as a generalindicator that the patient is of overseas origin.



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Devices: Pacemaker, ICD and CRT

AddinganewprocedureSelect a patient record. Then click on and this menu will appear:

Select Pacemaker/ICD if you want to enter a device record. This screen willappear:

This screen has 3 sections:

1. Patient Details (top left section)

2. Procedure Details (top right section)

3. Procedure specific data (lower section, which has 3 tabbed sections)

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PatientDetails

The top left section, Patient Details, is completed automatically from theDemographics form, with the exception of two fields.

Patient Status

This field has possible values:

'Amenity' means a patient being treated in a private hospital but paid for by the NHS.The other options are self-explanatory.

Consultant Responsible

This field should be completed with the Consultant looking after the patient on thisadmission.

This can be typed in free text or selected from a list of local staff members which ismaintained in the Local Staff Database.



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ProcedureDetails

The next (top right) section contains Procedure Details.

Date

The procedure date defaults to today's date, but it can be altered either by typingthe date in or selecting from the Date Picker by clicking on the icon then selectingthe date you require.

Implanted at

This field will automatically take the value of the hospital registering the implant. Ifthe implant was carried out elsewhere, please enter that different hospital's name inthis field.

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Intervention

The intervention type is usuallyeither a new system (GN+LD)or a box change (GN). Pleaseselect the intervention beingcarried out from the dropdownlist.

Pacing mode

Pacing mode is selected fromthe dropdown list.

NB: Please record the final(intended or actual)programmed mode atdischarge, not any temporarymode at the end of the procedure, which can sometimes be different.

Operator 1

Like the Consultant field, this can be typed in or selected from the dropdown list.

Operator 2

Like the Consultant field, this can be typed in or selected from the dropdown list.

ICD Option

PLEASE DO NOT LEAVE THIS FIELD BLANK!

Biventricular pacing option

If the device can deliver cardiac resynchronisation therapy (CRT), click onotherwise click on

PLEASE DO NOT LEAVE THIS FIELD BLANK!


If the device has high voltage defibrillation capability, click on otherwise clickon


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The lower section of the form contains three tabbed sheets called:

1. Indications for Implant

2. Implant Procedure (detailed information on the implant)

3. In hospital (complications and discharge)

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IndicationsforImplantYou will be asked to fill in the following four fields:

Date of first implant

The Date of First Implant is very important – it tells us whether this is a new systemor not. Please enter this field carefully.

Symptom, ECG and Aetiology

Please select the required value from the dropdown list.

CRTandICDDevices

If you select BiV pacing = Yes, then you must be registering either a CRT-P orCRT-D device. A further three fields will appear if you select this option:


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Baseline QRS duration

Please enter the QRS duration in milliseconds.

LV Function

NYHA Score

The New York HeartAssociation dyspnoea score isa measure of how badly thepatient is disabled by heartfailure; the correct optionmust, if possible, beascertained and entered.

Indication for ICD

If ICD Function = Yes, a further field will appear. Thisfield is designed to record whether the implant followsNICE guidelines for Primary or Secondary prevention ofsudden cardiac death, or is implanted for anotherindication.

Please select from these options:


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ImplantProcedureThe Implant Procedure form opens at the generator page.

It is also possible to enter details of up to four leads – two atrial2 leads and twoventricular3 leads.

2 Bi-atrial pacing is occasionally used to control atrial fibrillation.

3 Bi-ventricular pacing is frequently used to improve ventricular synchronization, often for

patients in heart failure. The LV lead is not actually located in the left ventricle, it is placed inthe distal coronary sinus and the electric stimulation field effectively paces the left ventricle.


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GeneratorDetailsFor a pacemaker4, the generator form looks like this:

Manufacturer

CCAD provides a list of current generator manufacturers. Select from this dropdownlist.

Model

CCAD maintains a library of generator models, but it is impossible to keep thiscompletely up to date. If the model you need is not in the list, you can enter itmanually. The list only shows you devices for your chosen manufacturer and yourselection of ICD and BiVoptions – so if you selectMedtronic and you haveselected a CRT-D device, thelist will look like this:

4 If a CRT or ICD device is selected, further generator options will appear – see later pages.


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Serial Number

For many models a standard serial number format is stored. If you enter a serialnumber with a different format you will be prompted to check that your data entry iscorrect.

‘A’ stands for ‘alphanumeric’, i.e. a letter. ‘N’ stands for a number.

Site

Bradycardia Pacing On?

Usually bradycardia pacing will be switched on at the end of the procedure.

Pacing Mode

This field records the INTENDEDpacing mode at discharge, not any temporary modeat the end of the procedure.

Low Rate

The fallback pacing rate (in beats per minute [bpm]) for the device.

Antitachycardia pacing On?

If the device has antitachycardia (ATP) capability, record here whether it is switchedon.


The generator site will usuallybe Pectoral Subcutaneous.

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Lead Extraction Performed?

Usually this will not be the case.

Procedure Comments

Free text comments. These will appear in the Procedure Report (see below).

OtherGeneratorFieldsforCRTandICDDevices

If ICD and/or BiV functionality is selected, more fields will appear:

VT shock on?

Will the device deliver a cardioverting shock when VT is sensed?

Defib therapy on?

Will the device deliver a defibrillating shock?

Biventricular pacing on?

Is resynchronization pacing enabled?

AV delay (sensed)

Delay between a sensed atrial event and a ventricular pacing stimulus.


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AV delay (paced)

Delay between an atrial pacing stimulus and a ventricular pacing stimulus.

Which ventricle paced first?

Left, right or simultaneous?

V-V delay

If not simultaneous, what is the delay between the ventricles being paced?


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LeadDetails

The four lead detail forms are functionally identical. The RV lead form looks like this:

Ventricular Lead Manufacturer

Again select from the list of current manufacturers.

Ventricular Lead Model

Models for that manufacturer can be selected from the list.

Ventricular Lead Serial Number

Lead serial number will be compared to a known format if available, to assist inentering the serial number in the correct format.

Ventricular Lead Site/Access

Ventricular Threshold

Enter the ventricular pacing threshold (in Volts) and the pulse width (in ms) at whichit was measured.

This fieldspecifiesthe vascular access and theendocardial or epicardial locationof the lead tip.


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R Wave

Enter the R-wave amplitude (P-wave for atrial leads) in milli-Volts.

Impedance

Enter the lead impedance in Ohms.

InHospitalThe post-procedure complications form looks like this:

ProcedureComplications

Multiple in-hospital complications can be recorded by clicking the appropriate option.

Additional Comments

Additional comments can be entered as free text.


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Editing procedure dataIn the main CRM view, click on the icon (to the left of a patient record). Theassociated procedure records will appear:

In the example above, patient # 1088447 has two procedures – a first implant in1998 and a generator replacement in 2005.

Double-click on a procedure record to view the procedure. The record will open inlockdown (read-only) mode. Ifyouareauthorisedtodoso, you can click on thebutton and you can then edit the details.


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Device Follow-UpSelect and open an implant record. Click on Follow Up:

This screen will open:

Previous follow-up records are shown in a list:

Actions available are:


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Enter New Follow-Up

The follow-up form appears, and the date defaults to today’s date – but can bechanged if you wish.

Enter as much information as you wish in this form then click OK to save.

Edit Last Follow-Up

The most recent follow=up record will be displayed, and you can edit it and saveyour changes.

Remove Last Follow-Up

Click on this and you will be prompted toconfirm that you wish to delete the mostrecent follow-up record. This cannot beundone so please ensure you really want todelete the record.


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Device or Lead ExplantSelect and open an implant record. Click on Explant:

Select which component you want to record as explanted (usually the generator),and enter the Date and Reason for Explant.

Finally, save the record.

In future CCAD will implement automatic prompting of explants when a new implantis registered; this facility is not yet ready.


This screen will appear:

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File Closure / DeathThe patient’s file is closed for one of three reasons:

Death

Transfer to another hospital

Lost to follow-up

To record a file closure, select and open a patient record.Date

Enter the date of file closure (the date of the event, such as the date the patentdied, not the date you were informed of the event).

Reason

This drop down list allows you tospecify whether the patient died,was transferred or was lost tofollow-up.

CAUTION: the entry B2. Deathrelated to pacemaker implies thata device or lead malfunction directly contributed to the patient’s death. Only use thiscode if you are CERTAINthis is the case, as it may trigger an enquiry.

Click on . This screen will open:

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Reports and LettersThe device database has a number of Reports and Letters available.

When viewing an implant record, at the top of the record is a menu bar:

Availabledevicereports

PM - Patient Passport

This report creates the traditional format of registration document that the patientshould carry with them at all times.

PM – Patient Passport Credit Card (etc...)

A new format of much smaller registration card which can be folded (where the reddotted line is shown) and inserted into a miniature self-laminating pouch 5. This is avery convenient size for patients.

5 Suitable self-laminating pouches (credit card size: 86x54mm) can be ordered from a number of

suppliers, including bindingbazaar.com (product code 15C30010, 100 for £6.95 + VAT). If youwish to try some out, contact NPDB on 01505 612829 and we can send you a few samples.


The Reports menu looks like this:

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PM Manufacturer Warranty

This version of the report suppresses patient identifiers and is suitable for sending tothe manufacturer(s) for warranty purposes.

Availabledeviceletters

The device letter menu shows two options:

Letter Defaults

These default values will determine what is printed on the letterhead.



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Pacing Implant Letter

A dialog box will open to allow you to specify to whom the letter will be sent andfrom whom it will be written:

ReferrerSelect GP or Consultant. A drop down listwill appear from which you can select avalue, or you can type in a ReferrerName.

Signatory

Select from the dropdown list or type in a value.


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The finished letter looks something like this, but can be customised/edited as it is anembedded Word document.


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EPS/Ablation ProceduresThe CRM database can also store procedure information on ElectrophysiologyStudies6 (EPS) and Ablation Procedures7.

PatientDetails

These are entered in the same way as for device implant patients (see page 3).

ProcedureDetails

Select a patient record. Then click on and this menu will appear:

6 Electrophysiology Studies (EPS) investigate the underlying cause of a patient’s heart rhythm

disturbance – usually (but not always) a rapid heart rhythm (tachycardia).

7 If a patent’s rhythm abnormality is amenable to catheter-delivered therapy, then Catheter

Ablation may be performed.


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Select EPS Ablation. This screen will appear:

Follow the instructions on page 5 to complete the Admin Status and ConsultantResponsible field. The remaining sections relate to the specific procedure. Theyare:

Indication for Intervention

Procedure

Outcome (in hospital)

Outcome (late)

There is also a facility to define and use User Defined Fields. Please contact theCCAD Helpdesk for more assistance with this feature.


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IndicationforIntervention

All fields are completed from drop down lists, apart from Baseline QRS duration,which should be entered in milliseconds.

Indication for Intervention is a mandatory field.

Procedure

The procedure form contains the key detail for an ablation procedure.

Crucial fields include Ablation Procedure(s) and Ablation Energy Source(s).

The second part of the procedure form is shown below.


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Ablation Procedure Success must be entered for every procedure.

Outcome(inhospital)Early complications are entered in this form:

Outcome(late)Late events are entered here, if known:


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System ReportsPM/ICDProcedureReportsIn the left window are the standard reports. For PM/ICD

these are shown to the right.

The intention of these reports is self-explanatory.

The Report section is open to user input. If any reportscan be improved, or new reports could be added, pleasecontact the CCAD Helpdesk.

Some of the reports are described below.

Data Completeness

This view shows how good your hospital is at completing the most important datafields.

UCL’s 2007 data shows generally good data completeness, but poor for BiV function(0% vs. 94% nationally) and Presenting ECG (69% vs. 93% nationally).


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Indications

Indications for pacing can be viewed by Aetiology, Presenting ECG or PresentingSymptom. The Aetiology view is shown here.

There if, of course, a huge difference in the aetiology of pacing (ICD=No) and ICDpatients. ICD patients have predominantly ischaemic or myopathic aetiologies.

For pacemaker patients the most common aetiology remains Conduction TissueFibrosis

Procedure Types

This view shows a breakdown of the type of procedures performed nationally byyear.

Pacing Mode

The declining use of VVI mode and the increase of dual chamber pacing can beclearly seen.


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Outcomes

These views are still under development.


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EPS/AblationReports

Data Completeness

This view shows how good your hospital is at completing the most important datafields.

The upper section shows the national data. The lower section shows the data foryour hospital. In this case UCL have data for 2007 and 2008. The national datacovers 2002-2008.

You can see, for instance, that UCL is better than average at recording NHS Numberand Complications, but not as good at recording the patient’s arrhythmia or theprocedure type.


Reports can be selected from the menu:

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Indications

This view shows the national pattern of indications for EPS/ablation. Below is shownthe 2007 aetiology for patients who were ablated. Most patients had apparentlynormal hearts.

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Procedures by year (all)

This view shows all procedures - their type, duration and success rate by year.

For 2007, the most common procedure was AV nodal slow pathway ablation,with 92% success rate and average procedure time 81 minutes.

Atrial flutter ablation had a 90% success rate and procedure time 107minutes.

Atrial fibrillation ablation has a lower success rate and a longer proceduretime.


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