Allied Professional Roles in the Management of Arrhythmias in the Young

Medical screening

Psychosocial screening

Anticipatory guidance

Update health history

Child/family response to planned procedure

Ask parent/guardian to identify concerns; address concerns

Identify co-morbidities

Assess family composition, support systems and coping methods

Describe procedure, post-procedure care, discharge plan, restrictions

Develop plan as needed

Consult with specialist as needed

Obtain brief family health history including anesthesia reaction, bleeding problems, allergies

Identify any current psychosocial problems needing plan or referral

Describe recovery period including return to physical activities

Identify and obtain missing medical information (documentation of arrhythmia, echocardiogram)

Identity social needs; financial, insurance, transportation, housing

Offer information to patient and child if needed

Determine other testing needed

Refer to social work as needed

Refer to child life as needed

Table 24.2

Preoperative education: device implantation

Operative detail	Device details	Restrictions
Length of procedure	ICD vs. pacemaker: purpose of device	No overhead reaching for 6 weeks for transvenous system
Incision type: axillary vs. subcutaneous	If ICD, discuss risk of inappropriate shocks	Avoid heavy lifting for 6 weeks
Length of hospital stay	Single vs. dual chamber	Return to school/work: 1 week
	Battery and lead longevity
	Device features: anti-tachycardia pacing, MRI compatibility, etc.
	Remote monitoring education

Table 24.3

Preoperative education: day of ablation

Procedure details	Restrictions
Length of procedure	Return to school: 1–2 days
Description of catheter ablation	Return to sports: 3 days or when groin sites are well healed
Cryoablation vs. radiofrequency ablation

APNs provide detailed education to patients and families prior to EP procedures tailored to their individual needs. Anticipatory education, especially important for those undergoing device implantation, emphasizes the planned follow-up care and the importance of long-term device monitoring; it decreases anxiety for the patient and family (Table 24.2). Education regarding generator replacement is dependent on the type of device selected. For example, wound care for a device generator change is similar to that of an implantation of new devices, but overhead arm movement restrictions are usually not necessary.

On the day of the procedure, APNs work closely with the EP physician, nurses, and technical staff throughout the patient’s experience. APNs perform preoperative history and physical that is reviewed by the anesthesia team and the EP physician. Throughout the procedure APNs provide continued support, education, and updates to the family. Following the procedure, APNs communicate with the recovery room nurses and physicians to ensure continuity and high quality care. APNs order and review post-procedure testing, provide pain/anti-nausea medication, and address other patient care needs.

At discharge APNs, in collaboration with attending physicians, ensure appropriately programmed pacemaker function and determine necessary clinic follow-up to monitor device safety and continued normal device function. APNs provide detailed information about the procedure outcome and follow up care to the family (Tables 24.4 and 24.5). APNs follow up with patient and families via telephone following the procedure to assess for concerns. APNs assess for complications, recurrences and other concerns and can manage these issues if they occur. Lastly, for patients who underwent device implantation, telemedicine has become increasingly useful. Wounds can be accessed via digital photo and emailed to the APN through a smart phone, making follow-up extremely convenient for the patient, especially those who live far from the implanting center.

Table 24.4

Discharge instructions for device implantation

Wound care	Activity instructions	Follow-up
When to remove initial dressing	If transvenous lead(s), avoid overhead reaching for 6 weeks	Discharge with Holter ×24 h
Cover with light dressing and protect from clothing and leave open to air as much as possible	Use sling as needed for comfort	Wound check in 1–2 weeks (via telemedicine or PCP)
Post-implant oral antibiotics often advised	With reaching restrictions, promote range of motion of that arm to prevent stiffness	In-office interrogation and appointment 2–6 weeks after implant
Avoid shower for 72 h; protect from water until that time	Return to school/work in a week	Remote monitoring education
Avoid complete submersion water (swimming/bath) until well-healed		Schedule routine remote monitoring schedule
		Encourage remote monitoring transmission with any concerning symptoms
Call immediately with signs of infection: fever, wound redness/drainage/tenderness/swelling	Return to sports/gym in 6 weeks	Discuss triage/access to medical system with concerns