Electrophysiology Procedures & Cardiac Rhythm Management —
Training activity: 16

Details

Identify, respond and escalate the following significant clinical findings during a device check

• Device lead malfunction
• Recurrent syncope
• New atrial fibrillation
• Worsening heart failure /symptoms
• Ventricular arrythmias

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected when identifying, responding to, and escalating these specific significant clinical findings during a device check.
• Consider how the relevant learning outcomes apply, specifically regarding identifying changes in patient conditions requiring escalation and regarding interpreting complex CIED follow up data.
• Discuss with your training officer to gain clarity on expectations for identifying these pathologies and the appropriate urgency of escalation.

What is your prior experience of this activity?

• Think about what you already know about recognising these clinical findings and potential device correlations, for example, device parameters that may indicate a lead malfunction.
• Consider possible challenges that might arise (e.g., differentiating device issues from clinical progression, or deciding the urgency of escalation for new atrial fibrillation) and how you might handle them.
• Recognise the scope of your own practice for this activity, i.e., know when/from whom you will need to seek advice or help when encountering complex arrhythmias or needing urgent management decisions.
• Acknowledge how you feel about responding to and escalating the significant clinical findings identified.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop related to pattern recognition of clinical/device findings, critical thinking, and effective escalation.
• Identify specific insights you hope to gain regarding the presentation and management pathways for these significant findings.

What additional considerations do you need to make?

• Consult actions identified from previous experiences with device follow-up or reviewing complex patient cases.
• Identify any important information about the patient’s medical history, baseline status, or current symptoms you need to consider beforehand. Identify any important information, such as guidelines for managing new atrial fibrillation or assessment protocols for recurrent syncope, you need to consider.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst reviewing symptoms and device data?
• Are you encountering situations such as:
  • Ambiguous device data complicating the assessment of a lead malfunction or the severity of worsening HF symptoms?
  • Sudden recognition of a high-risk finding, such as sustained Ventricular Arrhythmias or acute Recurrent Syncope, requiring immediate attention and escalation?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you deciding when a clinical finding warrants immediate attention and escalation?
• Consider the steps you are taking in the moment, such as:
  • Actively concentrating on assessing the severity of symptoms or differentiating between causes of syncope or worsening HF?
  • Immediately seeking guidance from a senior colleague or physician upon identification of these significant findings, as they require actions beyond your current scope of independent practice?
• How are you feeling in that moment? For instance, are you finding it difficult to interpret ambiguous device data under pressure? Is it affecting your confidence in effectively communicating concerns to the clinical team?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are the identification, initial response, and escalation tasks appropriate for your level of training and supervision?
• What are you learning as a result of the unexpected development? For example, are you gaining a better understanding of how device issues or clinical changes present during a check?

On action

What happened?

• Begin by summarising the key points of the experience where you identified one of these significant findings.
• Consider specific events, actions, or interactions which felt important, such as the specific evidence from device data, patient history, or symptoms and your initial response or actions taken.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately communicating the presence of sustained Ventricular Arrhythmias or unexpected lead data to the senior physician. How did you feel during this experience?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding recognising serious clinical issues. What strengths did you demonstrate e.g., critical thinking? What skills and/or knowledge gaps were evident, such as difficulties in deciding when and how to escalate new atrial fibrillation or worsening heart failure symptoms?
• Identify any challenges you experienced, such as deciding when and how to escalate, and how you reacted to these. How does this activity contribute to your critical thinking and patient safety skills?
• Acknowledge any changes in your own feelings now you are looking back on the experience.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take, including incorporating any feedback received about your ability to respond appropriately to the clinical findings listed.
• Identify specific findings or scenarios where you need to enhance your recognition or escalation skills. How will you prepare to identify and respond to these critical issues in future? Has anything changed in terms of what you would do if you were faced with a similar situation again?
• Do you need to practise any aspect of the activity further, such as reviewing assessment protocols for recurrent syncope or device lead malfunction?

Beyond action

Have you revisited the experiences?

• Have you reviewed your actions from your previous reflections for this activity? What specific clinical scenarios or types of findings e.g., recognising a subtle lead fracture, differentiating complex arrhythmias did you previously find most challenging to recognise or react to effectively? Have you completed these previously identified actions? For example, if you planned to review emergency protocols for managing ventricular arrhythmias detected during follow-up, how did this improve your response skills?
• Engage in professional storytelling with peers, near peers, or colleagues about managing these specific critical clinical scenarios, or discussed real cases with senior clinicians regarding appropriate escalation protocols. Did these opportunities provide new insights into recognising warning signs, understanding underlying pathophysiology, or coordinating care, shaping your approach to future critical patient encounters?

How have these experiences impacted upon current practice?

• Consider how the accumulated learning from performing or reflecting on managing significant clinical findings will support you in preparing for observed ‘in-person’ assessments for the module, such as a Case-Based Discussion requiring analysis of complex device findings and recommendations for patient management.
• How have your skills in vigilance, assessment, and escalation pathways enhanced over time? For example, do you feel more adept at recognising subtle signs of deterioration e.g., worsening heart failure indicators on the device and knowing when and how to escalate concerns to ensure timely patient management?
• What transferable skills e.g., diagnostic triage under pressure or clinical critical reasoning did you develop through this activity, and how does this skill contribute to identifying changes in patient conditions requiring escalation across all your cardiac science duties?

Relevant learning outcomes

#	Outcome
# 4	Outcome Identify changes in patient conditions requiring escalation of findings to the relevant responsible person(s) and with reference to the patient pathways.