Q J Med 2003; 96: 783-785
© 2003 Association of Physicians
Editorial |
Temporary cardiac pacing in district general hospitals—sustainable resource or training liability?
Temporary transvenous cardiac pacing is a potentially life-saving procedure for patients in whom there is an actual or a high risk of bradyarrhythmias or asystole in the emergency setting. In North America or Western Europe, provision of a temporary pacing service is normally within specialist cardiac centres, but in the UK, general physicians in District General Hospitals are typically on-call for such duties. Historically, this is the domain of the Medical Specialist Registrar. However, in the face of a fall in the number of temporary pacing procedures required, and less onerous rotas for junior doctors, critical problems with the current system now exist.The complication rates of temporary cardiac pacing remain high. The first component of temporary pacing—obtaining central venous access—may result in local trauma or pneumothorax. Failure to gain venous access itself is a recognized problem, with up to 17% of subclavian approaches and 8% of internal jugular vein approaches being unsuccessful.1 The second component—positioning of the temporary wire—may be associated with arrhythmias or cardiac perforation. However, perhaps the most feared complication is that of iatrogenic infection. In one series, 20% of patients developed microbiologically-confirmed septicaemia when the pacing wire was left in situ for > 48 h.1 This itself is a source of significant morbidity. Additionally, it often delays definitive treatment in the form of permanent pacemaker insertion when the patient is transferred to a specialist centre,2 and results in a six-fold increased risk of infection of the permanent system.3 A cycle of infected temporary wires delaying permanent pacing, requiring further interim temporary wires which again become infected, is a particularly distressing scenario.
The second problem within the system is that of training for temporary cardiac pacing procedures. Murphy et al. polled Senior House Officers and Registrars in 80 acute hospitals in England and Wales. On average, doctors reported seeing two temporary pacing procedures and performing two under supervision before being left unsupervised.4 These procedures were almost invariably taught at the bedside in the emergency setting by a fellow Senior House Officer or Registrar. The practice of learning temporary cardiac pacing at a junior level at the bedside from fellow trainees remains the norm, with Consultant involvement in less than 1/6 cases.1 The decline in the incidence of post-infarct complete heart block in the post-thrombolytic/primary angioplasty era further hinders training in temporary cardiac pacing, simply through fewer procedures needing to be performed. Combine this with the need to meet European Working Time Directive criteria, the trend towards full shift/partial shift rotas, and what appears to be the ever-shortening period post-qualification in which Membership of the Royal College of Physicians is obtained, and it is difficult to see how competency in this technique can be reasonably expected of all General Physicians, when according to the only set of guidelines available it requires a minimum of twenty-five procedures.5
Despite these issues, the recently revised Core Curriculum for General (Internal) Medicine still includes the use of a temporary pacing box and wire as a required procedural skill.6 Clinical governance dictates that these issues be addressed in a fashion that provides a safe, effective, efficient service that allows adequate training to the individual and maintains their competence.
Several measures may reduce complication rates. Collaboration with anaesthetists or intensivists may help to reduce the failure rates in gaining central venous access, and out of hours they may represent the most experienced, if stretched, staff for these procedures. Recent NICE guidelines advocate the increase in use of an ultrasound-guided approach to central venous cannulation in order to reduce complications.7 Clearly, the latter has both cost and further training implications. Training in central venous cannulation may also be performed on mannequins and a structured approach to this, including tutorials and videos, would seem sensible. Placement of pacing wires may also be learnt using simulators, although at present this system exists only for permanent pacing wires.
One prospective randomized trial has demonstrated that balloon-flotation pacing wires are easier to insert, quicker to position, and are more likely to be optimally positioned than semi-rigid electrode wires.8 This suggests that training Specialist Registrars in the use of balloon-flotation pacing wires may be a viable alternative to traditional pacing under fluoroscopic guidance, and reduce the number of procedures required to attain and maintain competency. However, it should be highlighted that in this single study, placement of pacing wires using either technique was performed fluoroscopically, since blind insertion of balloon-flotation wires may result in unstable positions, and to date no data exist on this aspect of balloon-flotation pacing. Also, positioning with a semi-rigid pacing wire under fluoroscopic guidance may still be required if the blind balloon-flotation technique fails.
Over and above complication rates and training issues, the question of where to provide this service remains. Requiring Consultants in General (Internal) Medicine to provide cover may be seen as one solution, but recent data suggests that many might not feel competent to do so.9 Centralization of the service may then be more attractive, either to large Acute Medicine units or to specialist tertiary cardiac centres. This does require better interaction between the latter and their smaller referring institutions, as well as the need to develop protocols on managing these patients in the interim. Atropine, Epinephrine infusions, oesophageal,10 or external pacing11 may all provide the means to at least stabilize a patient before transfer to the specialist centre, but distance to the centre, and hence safe transport of the patient, remains a problem that needs to be resolved in some areas.
It is important to draw attention to the indications for temporary pacing (Figure 1). In interpreting these consensus-based guidelines, if permanent pacing is expected, then the necessity for temporary pacing should be carefully considered. Where doubt exists, it is sensible to make the decision to insert a temporary pacing system in conjunction with a specialist centre. Prompt insertion of permanent pacing systems may be the best protection from complications of temporary pacing although current pressures, and prioritization of patients with ischaemia, make this challenging to achieve in practice.
|
The current practice of temporary cardiac pacing within British hospitals appears unacceptable12 and unsustainable. But how can services be improved? Some potential solutions exist, but we would contend that as a priority there should be an open discussion between all parties involved, including District General Hospital physicians, specialist referral centres, the training committees of the Royal College of Physicians, and other important protagonists such as the British Cardiac Society and The Intercollegiate Board for Training in Intensive Care Medicine, to try to resolve this vexing question.
-->
Dept of Cardiology Hammersmith Hospitals NHS Trust Charing Cross Hospital London e-mail: k.fox{at}imperial.ac.uk
References
1. Murphy JJ. Current practice and complications of temporary cardiac pacing. Br Med J 1996; 312:1134.
2. Chauhan A, Grace AA, Newell SA, Stone DL, Shapiro LM, Schofield PM, Petch MC. Early complications after dual chamber versus single chamber pacemaker implantation. Clin Electrophysiol 1994; 17:2012–15.
3. Aggarwal RK, Connelly DT, Ray SG, Ball J, Charles RG. Early complications of permanent pacemaker implantation: no difference between dual and single chamber systems. Br Heart J 1995; 73:571–5.
4. Murphy JJ, Frain JPJ, Stephenson CJ. Training and supervision of temporary transvenous pacemaker insertion. Br J Clin Pract 1995; 49:126–8.[Web of Science][Medline]
5. Francis GS, Williams SV, Achord JL, Reynolds WA, Fisch C, Friesinger GC2, Klocke FJ, Akhtar M, Ryan TJ, Schlant RC. Clinical competence in insertion of a temporary transvenous ventricular pacemaker. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology. Circulation 1994; 89:1913–16.
6. Higher Medical Training Curriculum for General (Internal) Medicine 1 January 2003 p64. London, Joint Committee on Higher Medical Training, Royal College of Physicians. [http//www.jchmt.org.uk]
7. National Institute for Clinical Excellence. NICE technology appraisal guidance No 49: guidance on the use of ultrasound locating devices for placing central venous catheters. London, NICE, 2002.
8. Ferguson JD, Banning AP, Bashir Y. Randomised trial of temporary cardiac pacing with semirigid and balloon-flotation electrode catheters. Lancet 1997; 349:1883.[CrossRef][Web of Science][Medline]
9. Murphy JJ, Carver HG, Kift HJ. Temporary cardiac pacing and the physicians of tomorrow. Clin Med 2001; 1:156.[Web of Science][Medline]
10. Santini M, Ansalone G, Cacciatore G, Turitto G. Transoesophageal pacing. Pacing Clin Electrophysiol 1990; 13:1298–323.[CrossRef][Medline]
11. Zoll PM, Zoll RH, Falk RH, Clinton JE, Eitel DR, Antman DM. External noninvasive temporary cardiac pacing. Circulation 1985; 71:937–44.
12. Murphy JJ. Problems with temporary cardiac pacing. Br Med J 2001; 323:527.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||