Device programming protocols for procedures or MRI will be brought by the clinic charge nurse to the staff MD assigned to Device Clinic that day. On the day of, the patient will generally be brought to Device Clinic preoperatively to have their device reprogrammed as per the protocol, and then will return afterwards to have it reprogrammed back to prior settings. Occasionally, the Device Clinic nurses will come to you if they have questions at the time of programming. For the most part, this all happens without input from the fellows, with the exception being after hours cases, in which case we are responsible for reprogramming.
For MRIs we are required to have the patients provide verbal consent for reprogramming (must be documented on chart otherwise MRI techs will not do the procedure). For patients with ICDs you may need to accompany the device clinic nurse to the MRI suite at the Civic in order to obtain consent there (patient needs to be on cardiac monitor while tachytherapies are off).
We quote a very low risk of complication as a result of undergoing MRI with a cardiac device. As the device is checked postoperatively, any immediate issues would be identified and can be addressed then.
There is now a satellite Device Clinic on Baffin Island which only sees patients intermittently through the year. If a patient from up North requires closer follow up, they should be scheduled to be seen at the UOHI Device Clinic instead. Issues or concerns regarding the Baffin Island Device Clinic patients should be directed to Dr. Birnie.
1) Select Orders --> Orders for Ambulatory Care/Visit
If outpatient, select 'Place Amb Orders'
2) Enter 'Ambulatory referral to Cardiology'
3) Choose 'UOHI', then 'Electrophysiology', then 'Device Settings Assessment', then the appropriate option
4) Complete remaining clinical information
5) Select date
Select Orders --> Orders for Ambulatory Care/Visit
If outpatient, select 'Place Amb Orders'
Enter 'Ambulatory referral to Cardiology'
Choose 'UOHI', then 'Electrophysiology', then 'Device Settings Assessment', then the appropriate option
Complete remaining clinical information
Select date
Nurses will enter comments in the Paceart note which will automatically be transferred to EPIC as a 'Cardiac Device Check' exam under the 'Cardiology' tab. The Paceart note itself can also be found under 'Media'. If a Paceart note is not transferred over, let the device clinic nurses know and they will fix it.
Fellows should add comments when appropriate using the 'Reading Work List,' which is accessed from the top toolbar. Double click the patient name, click the 'Summary' tab, and enter notes in 'Interpretation Summary.'
An alternative is to write a 'Progress Note' associated with the encounter. These have the advantage of being more easily found by other physicians.
Make sure you are associated with the current Device Clinic 'Encounter'
If you want to write a 'Progress Note' for a phone call related to a device clinic patient (ie there is no current encounter):
Make sure you are not currently in an 'encounter' (may need to close patient tab and open via 'Patient Lookup').
Select 'Write Note' from left.
For Department, select 'UOHI CARD DEVICE CLN.'
You can enter orders using 'ADD ORDER' button in bottom left, and send letters using 'Communication' button on left toolbar.
Ensure you are in the right context (this may affect where it prints)
Under 'Orders', select 'Orders for Ambulatory Care/Visit' tab
Place your order. If it is not printing, the most common reason is because you are in the incorrect context, or because you haven't logged off Citrix from a different computer.
For UOHI Inpatients:
Order 'Cardiac Device Check'
For patient to be seen at bedside, speak to the Device Clinic charge nurse
For Outpatients:
On the 'Orders for Ambulatory Care/Visit' tab, order 'Cardiac Device Check' (make sure it is a 'Future' order)
For TOH Inpatients (including Civic) and Inpatients at other hospitals:
Order as if they are an outpatient
Minimize opportunity for errors. Where possible, go with the simplest approach: ask that a magnet be taped over the device and removed postoperatively. This prevents the opportunity to miss reprogramming postoperatively. However, this simple approach is not always possible (ex ICD in a pacer-dependant patient)
Operative table positioning: if positioned prone (ex many neurosurgery cases) it may not be possible to tape the magnet over the device in a reliable position. In these situations, the device will need to be programming.
Operative field: if the field is near the device, it may not be possible to have a magnet over it without encroaching on the surgical field.
Intraop/postop heart rate: anesthesia may request a particular rate for maintenance of hemodynamics.
Use templates in EPIC for letters regarding reinstatement or suspension of drivers licenses.
Remember that we are sending the letter to the Ministry at the patient's request, and to provide the minimum necessary information in the letters. Always check with staff if you are uncertain about wording.