Development of a Pacemaker Specific Pre-Admission Process

Overall Learning Goal

The overall learning goal of this fellowship was to acquire personal knowledge and experience implementing a Best Practice Guideline (BPG) and evidence informed practices in the pacemaker implantation program. Implementation of Person and Family-Centred Care assisted in building organizational capacity and knowledge among staff in providing care for older adults that is evidence-informed for this specialized patient population. 

During the course of this fellowship, I learned about RNAO’s BPGs and how to implement them. I was able to use the Person and Family Centred Care guideline to direct and guide the steps of this fellowship. Specifically, I used elements of the following Practice Recommendations 1.1, 1.2, 1.3, 2.0, 2.2, 3.1 and 4.1 while moving through the steps of the fellowship. I acquired knowledge in the principles of patient centred care, and how to restructure what we are doing and re-frame it in a way that patients become partners in their own health care. I learned something as simple as giving patients the choice of how and when care is provided, means the world of difference to the patient. I gained skill in designing and completing a scripted telephone interview that uses senior friendly communication strategies, that captures relevant data. I also learned how to identify when to involve caregivers to navigate the assessment process, when the patients were unable to speak for themselves due to hearing loss and/or cognitive impairment. I now have a greater understanding of the unique health care and social needs of older adults. I cultivated a greater understanding of the process behind putting a BPG into action: from selection to design and implementation to evaluation. I have gained expertise in incorporating best practices and person-centred care through learning about the Knowledge to Action framework, stakeholder engagement, program planning, and how to translate those plans into day-to-day clinical practice. 

Throughout this fellowship, I have learned about evaluation techniques and the best ways to capture the desired information. I have worked to create open-ended questions regarding this pilot initiative, in order to capture rich data about what patients and their families require from pre-operative preparation. I also gained an understanding and appreciation about knowledge dissemination techniques. Unfortunately, the current COVID-19 pandemic has limited my opportunities to present my findings more broadly throughout the organization and nursing community. I am working to simulate this as much as possible electronically and through virtual meetings with key stakeholders. I have participated in my organization’s BPSO committee meetings by providing monthly updates during virtual meetings. Additionally, I have presented a summary of this fellowship virtually to our senior management team. A slide presentation will be circulated to the frontline pacemaker staff, in lieu of a planned lunch and learn session.

Patient Outcomes:

Post intervention evaluation forms were distributed to patients (n=28) who had received a telephone interview. The forms were given out after the patient had recovered from the pacemaker implantation surgery, but prior to departure from the nursing unit. The patients handed the forms back to the bedside nurse and not the fellow, to ensure unbiased results. The response rate of the evaluation form was 36%. Outcomes for the target population (n=10) that were measured include overall satisfaction, ease of the call, length of telephone call, opportunity to ask questions and understanding of instructions provided (Figure 1). Patients were also asked if the pre-operative telephone helped to alleviate concerns and worries on the day of surgery (Figure 2). Patients who attended for a separate diagnostic testing appointment (n=5) were also asked to rate their satisfaction with the appointment and if they found it helpful in preparing for their surgery (Figure 3). The outcome questions were presented using a four-point Likert scale. The majority of patients provided positive responses, that they ‘agreed’ or ‘strongly agreed’ with the outcome points. 

The evaluation survey concluded with an open-ended question asking for their suggestions for improvement in this process. Many patients chose not to answer these questions. Some quotes include: 

“It was great”

“Very good care”

“Call was efficient. I appreciated being able to use a recent blood test for submission.

Staff Outcomes

Post intervention evaluation forms were distributed to the nursing staff caring for pacemaker patients. Nursing and clerical staff were allowed to complete the forms during the course of their shift and return them at the end of the day. Measurables included how the elements of the pre-op telephone interview helped them with patient preparation on the day of surgery. Of the returned evaluations, the majority of responses were found in the ‘strongly agree’ category (Figure 4). Two themes emerged from staff evaluations, that patients were more prepared and improved efficiency of work flow processes. Nursing staff reported a smooth admission process, with less transfers out of department for testing and better adherence to pre-operative instructions. The evaluation forms included open ended-questions about their experiences with this pilot project, and suggestions for improvement moving forward. Two themes emerged, patient preparedness and staff efficiency. Some notable quotes include:

‘patient was less stressed’

‘patient and family were more prepared’

‘chart had all necessary information, no wasted time looking up history, bloodwork, x-ray’

I was made aware of unanticipated benefits to other staff members during the evaluation of this project. The clerical support team shared that this pilot project assisted them because the patients were better prepared to follow instructions on the day of surgery, as well as being able to assist the nursing staff with comprehensive medical records. Another unexpected outcome was that the Diagnostic Imaging staff also expressed their satisfaction with the processes set up in this pilot project. The current model is for patients to have a pre-operative chest X-ray upon arrival to the hospital, on the day of surgery. This project discovered that this practice places undue stress on the Diagnostic Imaging department due to unscheduled appointments required in a set amount of time. Having the patients attend for a separate appointment where the X-ray could be completed without time constraints prior to the surgery was beneficial for this department, as well as the patients.