CCAD Training Manual
Cardiac
Rhythm
Management
(CRM)
Version 1.0
A D Cunningham
19/3/2008
Introduction
This manual is intended to assist users of the Notes Client version of the CCAD Cardiac
Rhythm Management database. It is not intended to address issues relating to the
web-based version of CRM. For further information on the web-based application,
please contact CCAD at helpdesk@ccad.org.uk or 0846 300 6016 option 2.
Contents
Introduction..................................................................................................................................... 1
Contents......................................................................................................................................... 1
Getting Started ............................................................................................................................... 2
The Opening Splash Screen ............................................................................................................. 2
The Main CRM Screen...................................................................................................................... 2
Adding a New Patient ...........................................................................................................................3
Accessing Existing Patient Data.................................................................................................... 3
Devices: Pacemaker, ICD and CRT ................................................................................................ 4
Adding a new procedure.................................................................................................................. 4
Patient Details ........................................................................................................................................5
Procedure Details ...................................................................................................................................6
Indications for Implant .................................................................................................................... 9
CRT and ICD Devices....................................................................................................................... 9
Implant Procedure......................................................................................................................... 11
Generator Details........................................................................................................................... 12
Other Generator Fields for CRT and ICD Devices....................................................................14
Lead Details .........................................................................................................................................16
In Hospital ...........................................................................................................................................17
Editing procedure data ...................................................................................................................... 18
Device Follow-Up..........................................................................................................................19
Device or Lead Explant ...................................................................................................................... 21
File Closure / Death...................................................................................................................................22
Reports and Letters......................................................................................................................23
Available device reports ............................................................................................................23
Available device letters .............................................................................................................24
EPS/Ablation Procedures .................................................................................................................. 27
Patient Details ......................................................................................................................................27
Procedure Details .................................................................................................................................27
Indication for Intervention ........................................................................................................29
Procedure.................................................................................................................................29
Outcome (in hospital) .................................................................................................................... 30
Outcome (late) .....................................................................................................................................30
System Reports.............................................................................................................................31
PM/ICD Procedure Reports ............................................................................................................ 31
EPS/Ablation Reports..................................................................................................................... 34
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Training Manual
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Getting Started
TheOpeningSplashScreen
This is important – PLEASE READ IT !
You MUST NOT disclose your password/PIN to any other users. If you do so, CCAD
may suspend your access to the database without further warning!
TheMainCRMScreen
When you have
logged in and
cleared the splash
screen, you will see
patients in the right
window, and a
menu in the left
window.
Training Manual
Cardiac Rhythm Management (CRM)
Adding a New Patient
In the main CRM view, click on _________ . A blank patient document will appear,
and you can enter the patient details.
Some fields are mandatory, e.g. Hospital Number. Some fields are desirable, and a
prompt will ask you to try to enter this field. Please make every effort to get the
data, but it is recognised that some data cannot be found, e.g. NHS Numbers and
Postcodes1 for Overseas patients. You will still be able to save the record
without these fields.
Accessing Existing Patient Data
You can double-click on a patient to reveal their demographic data:
Click on the task bar (Edit Document) above the document if you want to edit the
details:
1 The
NHS provides pseudo-postcodes (beginning with ZZ99) for all overseas patients – if you do
not know the correct one for the native country of the patient, use ZZ99 9ZZ as a general
indicator that the patient is of overseas origin.
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Devices: Pacemaker, ICD and CRT
Addinganewprocedure
Select a patient record. Then click on
and this menu will appear:
Select Pacemaker/ICD if you want to enter a device record. This screen will
appear:
This screen has 3 sections:
1. Patient Details (top left section)
2. Procedure Details (top right section)
3. Procedure specific data (lower section, which has 3 tabbed sections)
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PatientDetails
The top left section, Patient Details, is completed automatically from the
Demographics form, with the exception of two fields.
Patient Status
This field has possible values:
'Amenity' means a patient being treated in a private hospital but paid for by the NHS.
The other options are self-explanatory.
Consultant Responsible
This field should be completed with the Consultant looking after the patient on this
admission.
This can be typed in free text or selected from a list of local staff members which is
maintained in the Local Staff Database.
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ProcedureDetails
The next (top right) section contains Procedure Details.
Date
The procedure date defaults to today's date, but it can be altered either by typing
the date in or selecting from the Date Picker by clicking on the
icon then selecting
the date you require.
Implanted at
This field will automatically take the value of the hospital registering the implant. If
the implant was carried out elsewhere, please enter that different hospital's name in
this field.
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Intervention
The intervention type is usually
either a new system (GN+LD)
or a box change (GN). Please
select the intervention being
carried out from the dropdown
list.
Pacing mode
Pacing mode is selected from
the dropdown list.
NB: Please record the final
(intended or actual)
programmed mode at
discharge, not any temporary
mode at the end of the procedure, which can sometimes be different.
Operator 1
Like the Consultant field, this can be typed in or selected from the dropdown list.
Operator 2
Like the Consultant field, this can be typed in or selected from the dropdown list.
ICD Option
If the device has high voltage defibrillation capability, click on
on
PLEASE DO NOT LEAVE THIS FIELD BLANK!
Biventricular pacing option
If the device can deliver cardiac resynchronisation therapy (CRT), click on
otherwise click on
PLEASE DO NOT LEAVE THIS FIELD BLANK!
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Training ManualCardiac Rhythm Management (CRM)
The lower section of the form contains three tabbed sheets called:
1. Indications for Implant
2. Implant Procedure (detailed information on the implant)
3. In hospital (complications and discharge)
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IndicationsforImplant
You will be asked to fill in the following four fields:
Date of first implant
The Date of First Implant is very important – it tells us whether this is a new system
or not. Please enter this field carefully.
Symptom, ECG and Aetiology
Please select the required value from the dropdown list.
CRTandICDDevices
If you select BiV pacing = Yes, then you must be registering either a CRT-P or
CRT-D device. A further three fields will appear if you select this option:
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Baseline QRS duration
Please enter the QRS duration in milliseconds.
LV Function
Please select from these options:
NYHA Score
The New York Heart
Association dyspnoea score is
a measure of how badly the
patient is disabled by heart
failure; the correct option
must, if possible, be
ascertained and entered.
Indication for ICD
If ICD Function = Yes, a further field will appear. This
field is designed to record whether the implant follows
NICE guidelines for Primary or Secondary prevention of
sudden cardiac death, or is implanted for another
indication.
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ImplantProcedure
The Implant Procedure form opens at the generator page.
It is also possible to enter details of up to four leads – two atrial2 leads and two
ventricular3 leads.
2
3
Bi-atrial pacing is occasionally used to control atrial fibrillation.
Bi-ventricular pacing is frequently used to improve ventricular synchronization, often for
patients in heart failure. The LV lead is not actually located in the left ventricle, it is placed in
the distal coronary sinus and the electric stimulation field effectively paces the left ventricle.
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GeneratorDetails
For a pacemaker4, the generator form looks like this:
Manufacturer
CCAD provides a list of current generator manufacturers. Select from this dropdown
list.
Model
CCAD maintains a library of generator models, but it is impossible to keep this
completely up to date. If the model you need is not in the list, you can enter it
manually. The list only shows you devices for your chosen manufacturer and your
selection of ICD and BiV
options – so if you select
Medtronic and you have
selected a CRT-D device, the
list will look like this:
4
If a CRT or ICD device is selected, further generator options will appear – see later pages.
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Serial Number
For many models a standard serial number format is stored. If you enter a serial
number with a different format you will be prompted to check that your data entry is
correct.
‘A’ stands for ‘alphanumeric’, i.e. a letter. ‘N’ stands for a number.
Site
The generator site will usually
be Pectoral Subcutaneous.
Bradycardia Pacing On?
Usually bradycardia pacing will be switched on at the end of the procedure.
Pacing Mode
This field records the INTENDED pacing mode at discharge, not any temporary mode
at the end of the procedure.
Low Rate
The fallback pacing rate (in beats per minute [bpm]) for the device.
Antitachycardia pacing On?
If the device has antitachycardia (ATP) capability, record here whether it is switched
on.
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Lead Extraction Performed?
Usually this will not be the case.
Procedure Comments
Free text comments. These will appear in the Procedure Report (see below).
OtherGeneratorFieldsforCRTandICDDevices
If ICD and/or BiV functionality is selected, more fields will appear:
VT shock on?
Will the device deliver a cardioverting shock when VT is sensed?
Defib therapy on?
Will the device deliver a defibrillating shock?
Biventricular pacing on?
Is resynchronization pacing enabled?
AV delay (sensed)
Delay between a sensed atrial event and a ventricular pacing stimulus.
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AV delay (paced)
Delay between an atrial pacing stimulus and a ventricular pacing stimulus.
Which ventricle paced first?
Left, right or simultaneous?
V-V delay
If not simultaneous, what is the delay between the ventricles being paced?
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LeadDetails
The four lead detail forms are functionally identical. The RV lead form looks like this:
Ventricular Lead Manufacturer
Again select from the list of current manufacturers.
Ventricular Lead Model
Models for that manufacturer can be selected from the list.
Ventricular Lead Serial Number
Lead serial number will be compared to a known format if available, to assist in
entering the serial number in the correct format.
Ventricular Lead Site/Access
This field
specifies
the vascular access and the
endocardial or epicardial location
of the lead tip.
Ventricular Threshold
Enter the ventricular pacing threshold (in Volts) and the pulse width (in ms) at which
it was measured.
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R Wave
Enter the R-wave amplitude (P-wave for atrial leads) in milli-Volts.
Impedance
Enter the lead impedance in Ohms.
InHospital
The post-procedure complications form looks like this:
Procedure
Complications
Multiple in-hospital complications can be recorded by clicking the appropriate option.
Additional Comments
Additional comments can be entered as free text.
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Editing procedure data
In the main CRM view, click on the icon (to the left of a patient record). The
associated procedure records will appear:
In the example above, patient # 1088447 has two procedures – a first implant in
1998 and a generator replacement in 2005.
Double-click on a procedure record to view the procedure. The record will open in
lockdown (read-only) mode. Ifyouareauthorisedtodoso, you can click on the
button and you can then edit the details.
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Device Follow-Up
Select and open an implant record. Click on Follow Up:
This screen will open:
Previous follow-up records are shown in a list:
Actions available are:
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Enter New Follow-Up
The follow-up form appears, and the date defaults to today’s date – but can be
changed if you wish.
Enter as much information as you wish in this form then click OK to save.
Edit Last Follow-Up
The most recent follow=up record will be displayed, and you can edit it and save
your changes.
Remove Last Follow-Up
Click on this and you will be prompted to
confirm that you wish to delete the most
recent follow-up record. This cannot be
undone so please ensure you really want to
delete the record.
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Device or Lead Explant
Select and open an implant record. Click on Explant:
This screen will appear:
Select which component you want to record as explanted (usually the generator),
and enter the Date and Reason for Explant.
Finally, save the record.
In future CCAD will implement automatic prompting of explants when a new implant
is registered; this facility is not yet ready.
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File Closure / Death
The patient’s file is closed for one of three reasons:

Death

Transfer to another hospital

Lost to follow-up
To record a file closure, select and open a patient record.
Date
Click on
. This screen will open:
Enter the date of file closure (the date of the event, such as the date the patent
died, not the date you were informed of the event).
Reason
This drop down list allows you to
specify whether the patient died,
was transferred or was lost to
follow-up.
CAUTION: the entry B2. Death
related to pacemaker implies that
a device or lead malfunction directly contributed to the patient’s death. Only use this
code if you are CERTAINthis is the case, as it may trigger an enquiry.
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Reports and Letters
The device database has a number of Reports and Letters available.
When viewing an implant record, at the top of the record is a menu bar:
Availabledevicereports
The Reports menu looks like this:
PM - Patient Passport
This report creates the traditional format of registration document that the patient
should carry with them at all times.
PM – Patient Passport Credit Card (etc...)
A new format of much smaller registration card which can be folded (where the red
dotted line is shown) and inserted into a miniature self-laminating pouch 5. This is a
very convenient size for patients.
5
Suitable self-laminating pouches (credit card size: 86x54mm) can be ordered from a number of
suppliers, including bindingbazaar.com (product code 15C30010, 100 for £6.95 + VAT). If you
wish to try some out, contact NPDB on 01505 612829 and we can send you a few samples.
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PM Manufacturer Warranty
This version of the report suppresses patient identifiers and is suitable for sending to
the manufacturer(s) for warranty purposes.
Availabledeviceletters
The device letter menu shows two options:
Letter Defaults
These default values will determine what is printed on the letterhead.
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Pacing Implant Letter
A dialog box will open to allow you to specify to whom the letter will be sent and
from whom it will be written:
Referrer
Select GP or Consultant. A drop down list
will appear from which you can select a
value, or you can type in a Referrer
Name.
Signatory
Select from the dropdown list or type in a value.
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The finished letter looks something like this, but can be customised/edited as it is an
embedded Word document.
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EPS/Ablation Procedures
The CRM database can also store procedure information on Electrophysiology
Studies6 (EPS) and Ablation Procedures 7.
PatientDetails
These are entered in the same way as for device implant patients (see page 3).
ProcedureDetails
Select a patient record. Then click on
6
7
and this menu will appear:
Electrophysiology Studies (EPS) investigate the underlying cause of a patient’s heart rhythm
disturbance – usually (but not always) a rapid heart rhythm (tachycardia).
If a patent’s rhythm abnormality is amenable to catheter-delivered therapy, then Catheter
Ablation may be performed.
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Select EPS Ablation. This screen will appear:
Follow the instructions on page 5 to complete the Admin Status and Consultant
Responsible field. The remaining sections relate to the specific procedure. They
are:
 Indication for Intervention
 Procedure
 Outcome (in hospital)
 Outcome (late)
There is also a facility to define and use User Defined Fields. Please contact the
CCAD Helpdesk for more assistance with this feature.
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IndicationforIntervention
All fields are completed from drop down lists, apart from Baseline QRS duration,
which should be entered in milliseconds.
Indication for Intervention is a mandatory field.
Procedure
The procedure form contains the key detail for an ablation procedure.
Crucial fields include Ablation Procedure(s) and Ablation Energy Source(s).
The second part of the procedure form is shown below.
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Ablation Procedure Success must be entered for every procedure.
Outcome(inhospital)
Early complications are entered in this form:
Outcome(late)
Late events are entered here, if known:
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System Reports
PM/ICDProcedureReports
In the left window are the standard reports. For PM/ICD
these are shown to the right.
The intention of these reports is self-explanatory.
The Report section is open to user input. If any reports
can be improved, or new reports could be added, please
contact the CCAD Helpdesk.
Some of the reports are described below.
Data Completeness
This view shows how good your hospital is at completing the most important data
fields.
UCL’s 2007 data shows generally good data completeness, but poor for BiV function
(0% vs. 94% nationally) and Presenting ECG (69% vs. 93% nationally).
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Indications
Indications for pacing can be viewed by Aetiology, Presenting ECG or Presenting
Symptom. The Aetiology view is shown here.
There if, of course, a huge difference in the aetiology of pacing (ICD=No) and ICD
patients. ICD patients have predominantly ischaemic or myopathic aetiologies.
For pacemaker patients the most common aetiology remains Conduction Tissue
Fibrosis
Procedure Types
This view shows a breakdown of the type of procedures performed nationally by
year.
Pacing Mode
The declining use of VVI mode and the increase of dual chamber pacing can be
clearly seen.
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Outcomes
These views are still under development.
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EPS/AblationReports
Reports can be selected from the menu:
Data Completeness
This view shows how good your hospital is at completing the most important data
fields.
The upper section shows the national data. The lower section shows the data for
your hospital. In this case UCL have data for 2007 and 2008. The national data
covers 2002-2008.
You can see, for instance, that UCL is better than average at recording NHS Number
and Complications, but not as good at recording the patient’s arrhythmia or the
procedure type.
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Indications
This view shows the national pattern of indications for EPS/ablation. Below is shown
the 2007 aetiology for patients who were ablated. Most patients had apparently
normal hearts.
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Procedures by year (all)
This view shows all procedures - their type, duration and success rate by year.

For 2007, the most common procedure was AV nodal slow pathway ablation,
with 92% success rate and average procedure time 81 minutes.

Atrial flutter ablation had a 90% success rate and procedure time 107
minutes.

Atrial fibrillation ablation has a lower success rate and a longer procedure
time.
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