- Hello, everybody. Welcome. Welcome to this new episode. I am Angelo Auricchio. Really a great pleasure to be here today with Dr. Archie Rao. She's an outstanding specialist in device management, and I'm very, very glad that she has time today to be with us and to discuss with all of you of what we should do better immediately, and then in long term. So last episode, we heard the story of two patients who experienced major consequences due to delayed treatment of a infection. And we understand that this is not a seldom issue. I mean, unfortunately they are not the only two patients. There are many, many more. And today, most of the experts, they do really agree that we have to improve the care pathway, because we all believe that delay in extraction, and we have evidence that delay in extraction may lead to major consequence, and because of that, we need to do better and earlier. So, and with that, I'd really like to start with Dr. Rao Archie, if I may. Thank you very much to be with us. And probably could you please tell us, or tell me what is about the way, or issue about related to awareness or unawareness of physicians and patients about the delay in the extraction or in thinking of device infection? And the other thing says, "What should we do differently?"

- Thank you, Angelo. A topic very close to both our hearts, and we just talked about in the previous few episodes, about how very different types of patients present with CIED infection, and of course, the consequences of delayed treatment. We also talked about the fact that the delayed treatment is primarily, because patients don't reach the right people at the right time. So although they present to various people at different times, the first point of contact often doesn't make that connection between the infection and the fact that this needs is related to the device and that device needs to be extracted. And it's making that connection as bridging those time gaps, and also allowing the patient to make that connection themselves so they can aid in the process. You asked me about what can we do differently, I think there are many things we can do differently, but to a large extent, I think we first of all need to ensure that there's knowledge out there to understand that device infections can present in two different types of ways. We talked about pocket infections, where the pocket itself was distorted, but also the fact that they can have a systemic infection where they're generally unwell, and it's a blood stream infection that's affecting the device. And depending on the type of infection, the patient presents differently. So there are, I think many stages, many phases in which this pathway needs to be smoothened. And in the very short term, I think education is key. It's really important that the first point of contact that the patient makes is making that association between infection and the cardiac device, and furthermore, the risk of not treating that infection. So there's a sense of urgency when they see that patient.

- Archie, sorry to interrupt you. When you talk about awareness to the patient, so you should communicate first to the patients, I mean, in your current practice, it is the device nurse, is yourself, is any one of your young fellow, because I doubt that most of the general practitioners eventually are really asking the patients, or informing the patients about potential consequence of what they should look at.

- You're absolutely right, Angelo. And I think this is where the challenge is for the problem, the challenge is that patients present to different people at different stages in their journey. And often the first point of contact could be the accidents and emergency doctors, because patients have found that their device is not working, or it looks very swollen or is painful, so they're present to accidents and emergency. So it may be the accidents and emergency doctor. On other occasions they might go to their device nurse, or they might give her a call and say, "Look, I'm not really happy, I haven't been too good, haven't felt well." So it's that sort of thing. So it could be the device nurse or the cardiac physiologist in the UK who deal with the pacemaker clinic itself, or indeed, it could be the primary care physician, because the patient's unsure as to what's going on, they're non-specifically unwell or have had an infection. So it is this divergence in the presentation of this heterogeneous group of patients that makes it challenging. And so educating each is quite important as the patient themselves.

- Well, actually I also ask you eventually whether you find or you think important to talk to local patients organisation or which might be their role in creating more awareness on one side, and also one of the experience, at least I have, with my own patients is the fact that you may talk to the patients once a day, eventually to the family. But frequently, this is the kind of information where over time is lost. So is there any way to at least provide any material or any access where to information for an example, on your website, in the hospital or eventually scientific societies?

- I think you're absolutely right, Angelo. It's a very important point that education has to be ongoing and accessible, both. And I think when we say accessible, this has to be delivered locally for patients via patient groups that they're comfortable accessing, or perhaps via the hospital's own website where the device data is, where the device details are, the device clinic website. So there are no, there's no one right way, and this will vary depending on the healthcare system, but you're absolutely right, and in the medium to longer term, we're looking at involving bigger patient groups, national and international patient groups, so that there is a general awareness that every time a cardiac device goes in, the patient also has responsibility to look out for the device and to highlight the fact that they have a device when things are not going to plan. And this is a medium to longer term effort, but I would sort of go back to the short term, would be to really contact everybody, all the stakeholders who might interact with these patients and for medical practitioners like ourselves perhaps weekly grand rounds, monthly grand rounds to interact with our infectious diseases colleagues, with our internal medicine colleagues, with our A&E department colleagues, so that patients with devices, when they're present to these colleagues, the colleagues are thinking that, "Is this a cardiac device infection and are the consequences of missing it going to be detrimental to the patient care really?"

- This is quite interesting, Archie. The other thing says about the, I mean, thinking of a need that we need to reinforce the message to bring the message back. I'm also wondering, and this is probably, we are not very good in that, I'm also wondering whether there are some specific patients categories who you may consider at very high risk in which, and I'm thinking of dialysis patients, I'm thinking of very fragile patients, because one is local pocket infection but other things is about systemic infection, which is significantly more challenging to be captured, if you like. So the question is how we can eventually iterate or reiterate, and how we can reach again multiple specialties, who are treating the patients for different diseases the same.

- You're absolutely right and I think there are categories of patients who are far more vulnerable to infection, and as you said, frailty scores, immunosuppression, renal dialysis patients, these are patients who are much more vulnerable in general to infection, particularly cardiac implant or device infections. And one of the ideas that has been talked about is electronic patient or medical record alerts. Is there a way of reaching out to clinicians from various subspecialties at one time, and if a patient with a CIED in situ comes in with bacteremia or has recurring courses of intravenous antibiotics, is there a best practice alert that can go out? It has been sort of, it's currently being piloted in a few countries, and I think this is of great interest to us to leverage what innovation and digital technology allow us to do to improve patient care. So I think a best practice alerts which sort of marry up the presence of a device with an ongoing infection, and if these alerts were to be highlighted to the cardiologist, perhaps the EP doctor, the extractor, the infectious diseases, then I think there's a good chance that these subspecialties are interacting with each other.

- Well, I think the electronic management recording system would be a great opportunity indeed, but at least, we don't have in our hospital, or the integration between home doctor, general cardiologist and hospital to use a single platform where we can really share some of the key information. I don't know what is the practice in your hospital, or in UK in general. But I see this one as a really long term goal, at least for us in our centre but also in Switzerland, it is a very, say, nice to have, must to have, but probably very challenging to have.

- Absolutely. And the electronic patient records, or electronic medical records are similarly a very challenging theme across the United Kingdom, and I suspect across the wider world in general. However, it's these things that we can leverage where possible. But I think beyond that is building those cross-specialty bridges to say that we all are stakeholders in the problem, we need to be talking to each other, we need to be discussing these patients together. The idea of something like a heart team where, which has been recommended for the management of infective endocarditis anyway, where there's a multi-specialty team that discusses the patient, that puts the patient first at the centre of all intervention. And I think that sort of approach is more doable in the medium term where these cross-specialties can work together when there's a patient at risk with an infection and a CIED in situ.

- Well, Archie, thank you for that. Now, going back to one of a point that you were alluding before is about the role of, and I believe it's a central role at national level for working groups in general. So I believe that have, it is their duties but it's also a great opportunity for scientific societies to be more involved, and to be more vocal eventually about the problem of device infection or appropriate, and timely recognition of a device infection.

- I couldn't agree more. I think the longer term strategy should be that this is out there on the agenda for scientific societies and thereby on local working groups to try and make this a priority for every device group to be aware of and highlighted as a, as almost a quality standard that we can be held accountable to.

- Excellent. So I think we have to close, and it is very unfortunate. I could really spend hours talking to you and to talk about the topic. This has been very, very nice, Archie. Thank you so much for defining so nicely the pathway or how we can improve the pathway of better informing the patients, but also on how we should really do better in terms of, say, short-term activities, and also the long-term ambition, if you like. Important is, as you said, is also the continuous interaction with the patients, but probably to get also the family, or the caregivers more involved, and really making them aware that the moment that you have a device, and it is certainly a life saving devices, but it can also be something that you have to care of it. And of course, in more, probably long term, I wish very much and you wished also very much to have better electronic medical recording system, which really may automatize all the way what that can really follow the patients. And of course, the role, central role I would say, of scientific society and national working groups, and probably local patients organisation, they do really play, I believe, a really great, great role in that. With that, thank you very much, Archie, for being with me. I leave to you whether you have any final word that you can give to our audience.

- Only to say that awareness is key, and we all have to work together, because it's really important. CIED infection is an important problem, but we have to work together to kind of try, and get to the solution.

- Well, thank you so much again, Archie. And in the next episode, other colleagues of ours will certainly present to you, and will discuss the importance of prevention. I think that is really all about this prevention, of course. And thank you very much to all of you for being with us.