CONNECT: Coordinating Options for Neurovascular Patients Needing Electrophysiology Consults and Treatments

Abstract

Background and purpose: Though Event Monitors (EM) and Implantable Loop Recorders (ILR) are prevalent in stroke workups, complex processes to obtain placement of these device might result in delays. Our aim was to determine if the CONNECT (Coordinating Options for Neurovascular patients Needing Electrophysiology Consults and Treatments) pathway could improve Stroke-to-Electrophysiology (EP) communications, increase EM and ILR device placements prior to discharge, shorten placement time, and preserve satisfaction.

Methods: We assessed device placements when an EP consult was obtained [Pre-CONNECT (5/1/21-4/30/22), CONNECT (5/1/22-4/30/23)] for patients with stroke. In the Pre- period, consults were sent via EPIC electronic medical record (EMR), with additional direct communication when desired. In the CONNECT period, the pathway and module allowed for immediate communication between services. Outcomes included case rate, times, length of stay, and satisfaction. Hospital reports detailed Order to Activation (O-A) days. EM report review was used to obtain O-A time. Clinician satisfaction was assessed using Qualtrics survey. Patient satisfaction was assessed with Hospital Consumer Assessment of Health care Clinicians and Systems (HCAHPS) survey. Man-Whitney U test was used.

Results: 78 patients were included (30EM(38.5%), 48ILR(61.5%)). Age was 68 years (P = 0.58). For ILRs, inpatient placements prior to discharge increased (3Pre vs 51 CONNECT; P < 0.0001) as did outpatient placements (5 vs 16; P = 0.02). Order to Activation (O-A) time savings were significant for ILR overall (32 days vs 1 day; P = 0.03) and for Inpatient EM (13 days vs 3 days; P = 0.003). Time for consultant to view was 4 min and to respond was 6 min. Devices were placed at a median 6 hrs 32 min (EM: 4 hrs 19 min; ILR:7 hrs36 min). All (12/12) clinicians preferred the technique. Patient satisfaction improved on 13/19 (68%) questions.

Conclusions: There was a 1600% increase in ILR placements prior to discharge that was associated with the time period that the CONNECT process was in place. The robust improvement in ILR placements prior to discharge, high satisfaction, ease of use, closed loop communication, and respect for autonomy allowing more organic parallel discussions with patients improved clinician workflow which could potentially improve future risk reduction strategies.

Keywords: atrial fibrillation; electrophysiology; implantable loop recorders; stroke.

Figure 1.

Sample CONNECT Communication. Inter-disciplinary team communication regarding a request for Implantable Loop Recorder (ILR) implantation. The Stroke team clinician accesses the CONNECT module, enters minimal data into standard fields, and may also add-in free text information about the patient case. This results in HIPAA complaint, real-time notification of the electrophysiology (EP) team and subsequent communication pathway to streamline ILR (or event monitor) placements. This facilitates timely device implantation (7 hrs 22 min in this case) and allows for EP specialist to be able to communicate back to the requesting Stroke team, in real-time, to close the loop of communication.