Appropriate Prioritisation of EP and Device Procedures
In their October 2020 communication (https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/10/C0760-Clinical-validation-of-surgical-waiting-lists-1-2.pdf) NHSE make it clear the allocation of priorities to people on waiting lists should involve three steps:
1. A technical validation of the pre-existing waiting list.
2. A discussion with the patient (or their advocate).
3. A clinical validation with the outcomes with the options: expedite, remain on waiting list, postpone and remove from waiting list.
It is a recognition of the pressures clinicians and organisations face, rather than a criticism of any, to note that the second stage of discussion with the patient, whether by an administrative or clinical member of staff, has not always been performed to inform the final prioritisation.
BHRS supports members in making prioritisations that are clinically appropriate, the NHSE document does not require grading to reflect the practicalities of the management of the waiting list, rather the risk of harm to the patient.
If the prioritisations are not achievable in the local context the appropriate use of the validation system should be seen as a valuable tool in documenting the degree of unmet need both in absolute terms in each service and in relative terms across geographies. This should provide appropriate stimulus to give services for people with arrhythmia the investment required.
Embedded within the NHSE prioritisation is the discussion step and whilst in some cases this may be an entirely administrative competence there will be some people listed for procedures pre pandemic for whom that procedure is no longer the appropriate management due to a change in the balance of risks and benefits. BHRS support members in acknowledging the need for time and resource to be able to devote to these discussions to allow people to share in reaffirming or altering previously made management strategies.
General Guidance on Application of the Clinical Prioritisation Levels to People with Arrhythmias or Arrhythmic Risk
P1 – these procedures should be performed on the index admission or, if an OP, urgent elective within 3 days:
Diagnostic and therapeutic implantable devices and EP procedures for people at immediate risk of life-threatening arrhythmias or hospital admission. This includes:
- EPS and ablation for people with pre-excited atrial fibrillation
- EPS and ablation for people with syncope with suspected tachyarrhythmia
- Implantable devices for syncope due to suspected arrhythmia
P2 – recommend these procedures should be performed within 1 month:
Implantable devices to diagnose or prevent tachy or bradyarrhythmias or heart failure. This includes:
- Implantation of loop recorders and implantation, upgrade or renewal of PPM, CRT and ICDs
- Ablation for people with severe pre syncope with suspected tachyarrhythmia, Ablation for patients with recurrent admission to hospital despite optimal medical therapy
- Ablation or cardioversion for people with structural heart disease, heart failure or poor ventricular rate control; cardioversion in people with atrial arrhythmias considering a rhythm control strategy; diagnostic EPS to determine arrhythmic risk.
P3 – recommend procedures should be performed within 3 months of the decision to treat being made:
Diagnostic and therapeutic EP procedures for people with symptoms of or risk of symptoms of:
- Arrhythmia with low risk of hospital admission, Syncope or disease progression