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Second Opinions > Outpatient Pacemaker Placement

Outpatient Pacemaker Placement

My center is bringing on board a busy cardiologist who plans on doing outpatient pacemaker placement. Is this a good idea from the standpoint of efficiency and patient safety? Does this fall within the current community standard?

Started by: Gregory Garbin (Anesthesiologist/Nurse Anesthetist) at December 30, 2010 (6:30 pm)

Comments and Responses

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Are there any studies, statistics, opinions or recomendations supporting initial placement of pacemakers/AICDs in self standing ASC?

R. Berg (Anesthesiologist/Nurse Anesthetist) at January 31, 2013 (11:34 am)

Pacemaker generator changes and initial implants should be discussed separately, as noted in an earlier posting. We have done pacemaker generator changes in our ASC setting for over a year. All procedures are reimbursable in an ASC outpatient setting at this point. With appropriate patient selection, appropriately trained staff, etc. these run about as smooth as possible.

If you were to consider initial implantations, you would need to ensure the types of equipment, staffing, etc. can facilitate these cases. These patients would benefit from being served in a 23-hour obs setting.

ICD's initial and/or generator changes require you to report to a national registry, which costs about $4,000/year and requires a significant amount of data tracking and collection.

Lastly, these are very expensive implants and are mostly Medicare. Ensure you are reviewing your potential case costs to make certain you will cover your costs.

Ashley K. (Administrator/Director/Manager/Owner/Exec. Officer) at January 8, 2011 (12:40 pm)

While the consideration of non-dependent or temp pacer vs. PPM/AICD is a clinical consideration for acuity and procedural risk generally in this patient population, it is in fact secondary to the bigger picture of due diligence and responsibility for potential complication/outcomes in these procedures. The observation has already been made in prior commentary here that while the statistical incidence for this is small, the ensuing level of services and care required to responsibly address these instances is generally outside the ASC scope; unless the ASC was "wrapped into", in every way, a major inpatient setting, this would be ill-advised for the ASC and ill-serve the patient and the community at large. Yes, with a skilled cardiologist your probability of trouble is minimal, but things can and do happen outside of anyone's control, and placing the patient in a setting where this cannot be truly managed is never okay. Ultimately, bad idea fueled by convenience/revenue.

J. White (Administrator / Director / Manager / Owner / Executive Officer) at January 6, 2011 (9:53 am)

Would be helpful if we could separate this discussion into 1) battery changes and 2) PPM, AICD insertions. With proper patient selection, non pacemaker depedent, stable co-morbidities,minimal sedation, we would consider battery changes only. At this time, without immediate availability of surgeons, or inpatient backup we do not do ASC cardiac rhythm device insertions. Would be interested in hearing from others whether the responses would differ by 1) vs 2).

Rebecca T. (Medical Director/Chief Surgeon) at January 5, 2011 (6:19 pm)

Would be helpful if we could separate this discussion into 1) battery changes and 2) PPM, AICD insertions. With proper patient selection, non pacemaker dependent, stable co-morbidities, receiving minimal sedation, we would consider battery changes only. At this time, without immediate availability of surgeons, or inpatient backup we do not do ASC cardiac rhythm device insertions. Would be interested in hearing from others whether the responses would differ by 1) vs 2).

Rebecca T. (Medical Director/Chief Surgeon) at January 5, 2011 (6:18 pm) [last edited on January 5, 2011 (6:19 pm)]

I agree that an ASC is not the venue for such a procedure. While a facility may welcome the volume increase which would look great for the bottom line, patient safety has to win over surgeon convenience and the almighty dollar. Common sense must prevail here...keep those pacer patients in the appropriate OR suite in the hospital.

Teresa E. (Director, Surgical Services/Director of Nursing) at January 5, 2011 (4:15 pm)

Our ASC in Hawaii had no issues. We monitored the patients for a few hours. The doc was notified prior to discharge.

anthony Harkin (OR Manager/Supervisor) at January 5, 2011 (2:48 pm)

I think that everyone raises some really sound points but I would like to offer this. In a past life working in a Cath Lab/Interventional Radiology Lab all pacemaker placements and battery replacements were moved from the traditional OR setting to our Outpatient Lab. Albiet still part of a hospital, all patients were treated as outpatients and the hospital had no Open Heart program. In addition, ASC's have demonstrated levels of care and competence that have expanded the complexity of cases seen in the outpatient setting year after year. As an example we have been doing single and multi level ACDF procedures in one of our ASC's for years without an increase in our overall risk profile.

I feel that the primary factors in determining whether these cases are safe is surgeon competence and the skill and training of the support staff/anesthesia working in the ASC along side the surgeons. Patient selection is also critical in the addition of any procedure so it should be part of the discussion.

That being said I do not believe the procedure is on the approved list and would be very interested to see what the equipment reimbursement levels would be, without a 3rd party intermediary I would think the cost/benefit would rule it out in most ASC's.

Good luck in working the issue out.

William M. (Administrator/Director/Manager/Owner/Executive Officer) at January 5, 2011 (1:57 pm)

I agree. This is a bad idea, and aside from ASA class, it is unlikely that the rare pacer problem will be managed appropriately in an ASC setting. These patients are high risk, the procedure has its own set of potential complications, and although these procedures typically go off without a hitch you must be able to manage the serious complication, such as cardiac arrest, heart failure, etc. that can potentially occur. The ASC is not the scenario for this.
I am a practicing anesthesiologist and Chair/ Administrator for 20+ years.

James D. (Anesthesiologist/Nurse Anesthetist) at January 5, 2011 (1:01 pm) [last edited on January 5, 2011 (1:02 pm)]

Patient safety is a priority and we are obligated to make sound decisions regarding this. I cannot see any scenario where patient safety is not compromised by doing cardiac procedures in an ASC. If you decide to do this you have to make sure that every "what if" situation is covered and that your staff is prepared and competent to deal with it.

Cindy K. (Director, Surgical Services/Director of Nursing) at January 5, 2011 (12:28 pm)

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