Cardiology
Emergency medicine–trained physicians are proficient in the insertion of transvenous pacemakers

https://doi.org/10.1016/j.annemergmed.2003.09.019Get rights and content

Abstract

Study objective

The insertion and management of a temporary transvenous pacemaker can be a lifesaving procedure in the emergency department setting. We compare the success and complication rates associated with temporary transvenous pacemaker insertion between physicians trained in either emergency medicine or cardiology.

Methods

This was a retrospective medical record review of all patients with a billing code for temporary transvenous pacemaker insertion at our institution between July 1999 and December 2002. Patients were excluded if the temporary transvenous pacemaker was not supervised by an attending physician or was placed under fluoroscopy or if the indication for pacing was asystole. Cases were reviewed by 2 physicians certified in emergency medicine and categorized by the specialty training of the attending physician providing direct supervision.

Results

During the review period, 10 emergency medicine faculty and 8 cardiologists directly supervised 141 of the 158 temporary transvenous pacemaker insertions in 154 patients. Twenty-four were placed for asystole, 4 were placed under fluoroscopy, and 13 were placed without direct attending supervision, leaving a total of 117 cases (30 emergency medicine, 87 cardiology) for review. The procedure was successful 97% (95% confidence interval [CI] 90% to 100%) of the time for emergency medicine faculty and 95% (95% CI 91% to 100%) of the time for cardiology faculty. Complications were seen in 23% (95% CI 7% to 39%) of the temporary transvenous pacemakers inserted by emergency medicine attending physicians and 20% (95% CI 11% to 28%) of the temporary transvenous pacemakers inserted by cardiologists. There was no statistical difference in errors between the specialties, and no complication resulted in death or prolonged disability.

Conclusion

Physicians trained in emergency medicine perform temporary transvenous pacemaker insertions in the acute care setting with a proficiency similar to that of their counterparts in cardiology.

Introduction

Since the first report of an endocardial pacing electrode being used in the setting of complete heart block in 1958, temporary transvenous pacemakers have become invaluable in the treatment of a number of bradydysrhythmias.1 The use of a temporary transvenous pacing wire is a demanding procedure in terms of the technical skill necessary to perform the procedure and the training needed to promptly recognize the indications and associated complications. There have been few reports in the literature describing the success and complications of inserting a temporary transvenous pacemaker. The literature that is available describes temporary transvenous pacemaker use in ICU or coronary care units, where the environment can be controlled more easily than in the emergency department (ED). To our knowledge, no study to date has evaluated the use of a temporary transvenous pacemaker by emergency medicine specialty—trained physicians in the acute care setting, although a recent case series described the placement of a temporary transvenous pacemaker by emergency physicians using ultrasonographic guidance.2

This study sought to document the success and complication rates for temporary transvenous pacemaker insertions classified by the specialty training of the supervisor.

Section snippets

Study design

This study involved a retrospective chart review by 2 trained, unblinded data abstracters, involving all patients with a billing code for temporary transvenous pacemaker insertion at our institution between December 1999 and December 2003.

Setting

The record review was conducted at an urban academic ED with a 3-year residency-training program. The study period was selected 1 year after the institution of formalized training in 1998 for the appropriate use of temporary transvenous pacemaker wires. Before

Results

A total of 158 temporary transvenous pacemakers were placed in 154 patients by 10 emergency medicine core faculty and 8 cardiologists between December 1999 and December 2002. Of these temporary transvenous pacemakers, 24 were placed in the setting of new-onset asystole, 4 were placed in the cardiac catheterization/electrophysiology laboratory, and 13 were placed without direct attending supervision, leaving 117 temporary transvenous pacemaker insertions eligible for study. Thirty (26%) of the

Limitations

This study is limited by the retrospective nature of the data abstraction. Although the physicians involved received annual continuing medical education that addressed adequate and appropriate procedural documentation, the retrospective review was vulnerable to recording errors and omissions. We began our record review guided by previous literature that reported known temporary transvenous pacemaker and central venous access complications.3, 4, 5, 6, 7, 8 However, attributing remote

Discussion

Neither the success nor the complication rates associated with placing temporary transvenous pacemaker wires was observed to be statistically different between the specialties of emergency medicine and cardiology. All the emergency physicians who participated in this study were emergency medicine residency trained and participated in the initial didactic and annual temporary transvenous pacemaker skills workshops, which would suggest that the instruction received as part of the core competency

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Author contributions: All authors participated in the theoretical formulation and study design. RHB, JT, and TM took primary responsibility for data abstraction and database structure. RHB, TJG, and WMB conducted data analysis. RHB drafted the manuscript, and all authors contributed substantially to the revision and presentation of the final work. All authors take responsibility for the paper as a whole.

Presented as an abstract at the Society for Academic Emergency Medicine annual meeting, Boston, MA, May 2003.

The authors report this study did not receive any outside funding or support.

Reprints not available from the authors.

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