Electrophysiology Procedures & Cardiac Rhythm Management —
Training activity: 9

Details

Perform basic clinical and technical optimisation of CIEDs

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 of you when performing basic clinical and technical optimisation of CIEDs.
• Consider how the relevant learning outcomes apply, specifically concerning those related to applying specialist knowledge to programme and optimise CIEDs using evidence-based practice.
• Discuss with your training officer to gain clarity on expectations for optimisation parameters, for example, AV/VV delay optimisation in CRT patients.

What is your prior experience of this activity?

• Think about what you already know about CIED optimisation, including timing cycles and sensing capabilities.
• Consider possible challenges that might arise e.g., understanding specific algorithms like rate stabilisation or atrial anti-tachycardia pacing, assessing patient response to changes and think about 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 for complex programming decisions.
• Acknowledge how you feel about performing basic clinical and technical optimisation of CIEDs.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop related to programming strategies and assessing the clinical impact of optimisation settings.
• Identify specific insights you hope to gain regarding the interplay between device settings, patient symptoms, and device diagnostics.

What additional considerations do you need to make?

• Consult actions identified from previous experiences with device follow-up or basic programming.
• Identify any important information about the device model or patient’s clinical status you need to consider beforehand.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst implementing programming changes or testing their effectiveness?
• Are you encountering situations such as:
  • The patient responding unexpectedly (e.g., becoming symptomatic) to a programming change (e.g., rate response settings)?
  • The optimisation results being unclear or unstable after testing pacing/sensing functionality?

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 which parameters to adjust (e.g., basic timing cycles)?
• Consider the steps you are taking in the moment, such as:
  • Actively concentrating on assessing the patient’s symptomatic response or interpreting pacing/sensing tests after optimisation?
  • Seeking immediate guidance from a senior colleague or physician if the patient responds unexpectedly or if the optimisation results are unclear?
• How are you feeling in that moment? For instance, are you finding it difficult to interpret pacing/sensing tests after optimisation? Is it affecting your confidence in observing the expected device behaviour?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are the optimisation tasks you are performing 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 programming parameters affect device function and patient symptoms?

On action

What happened?

• Begin by summarising the key points of the experience of performing optimisation.
• Consider specific events, actions, or interactions which felt important, such as the specific optimisation steps you performed e.g., adjusting pacing modes, rates, AV/VV delays, sensing settings. Note the patient’s response or the impact on device function.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, reverting a setting immediately after noticing an adverse patient symptom or unclear test result. 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 CIED optimisation principles. What strengths did you demonstrate e.g., systematic application? What skills and/or knowledge gaps were evident, such as gaining new insights into how parameter changes affect patient symptoms or device behaviour?
• Identify any challenges you experienced, such as selecting the appropriate settings or managing an unexpected patient response, and how you reacted to these. How does this activity contribute to your ability to enhance patient outcomes through device programming?
• 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 with regards to your ability to optimise CIEDs.
• Identify specific optimisation strategies or device parameters (e.g., rate stabilisation or atrial anti-tachycardia pacing algorithms) that require further study or practice. How will you approach future optimisation tasks based on this experience? 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 timing cycles or sensing capabilities?

Beyond action

Have you revisited the experiences?

• Have you reviewed your actions from your previous reflections for this activity? What specific optimisation parameters e.g., ensuring adequate sensing safety margins, adjusting pacing outputs or clinical considerations e.g., patient symptoms related to pacing mode did you previously find challenging? Have you completed these previously identified actions? For example, if you planned to review pacing threshold testing techniques, how did this improve your practical skills in device optimisation?
• Engage in professional storytelling with peers, near peers, or colleagues about CIED optimisation strategies or challenging scenarios, such as managing high capture thresholds or intermittent loss of capture. Did these conversations offer new insights into balancing technical performance with clinical outcomes, influencing how you approach optimisation in future cases?

How have these experiences impacted upon current practice?

• Consider how the accumulated learning from performing or reflecting on basic CIED optimisation will support you in preparing for observed ‘in-person’ assessments for the module, such as a DOPS focused on programming devices.
• How has your confidence in adjusting device settings based on patient needs developed? For example, how does this growing competence relate to applying specialist knowledge to programme and optimise more complex CIEDs like CRTs safely?
• What transferable skills e.g., technical problem-solving or balancing electrical and clinical parameters did you develop through this activity, and how will this understanding help you evaluate and adopt new pacing algorithms in the future?

Relevant learning outcomes

#	Outcome
# 3	Outcome Apply specialist knowledge to programme and optimise CIEDs using evidence-based practice to ensure safe patient outcomes and enhance the quality of patient care.