Prospective Single-Centre Experience of a Nurse-Led Chair-Based Pathway for Implantable Loop Recorder Explantation

Prospective Single-Centre Experience of a Nurse-Led Chair-Based Pathway for Implantable Loop Recorder Explantation | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 2 September 2025 V1 Latest version Share on Prospective Single-Centre Experience of a Nurse-Led Chair-Based Pathway for Implantable Loop Recorder Explantation Authors : Abdul Hanan Hamid , Ayman Helal 0000-0001-5321-4377 [email protected] , Bino Job , and Rachana Prasad Authors Info & Affiliations https://doi.org/10.22541/au.175679661.15002761/v1 Published Pacing and Clinical Electrophysiology Version of record Peer review timeline 153 views 94 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background- Implantable loop recorder (ILR) explantation has traditionally been performed in catheterization (cath) labs, with bed-based recovery lasting 30–60 minutes. This conventional model can strain cath lab resources, delay urgent interventional procedures, and inconvenience patients. Currently, there are no standardized guidelines for streamlined ambulatory pathways for ILR removal. Aim- To evaluate the feasibility, safety, and efficiency of a nurse-led, chair-based ambulatory pathway for ILR explantation. Method and results- A prospective, single-centre quality improvement project was conducted over a 4-month period. Patients were admitted via reception and transferred to a side room or procedure room, bypassing the cath lab. Explant procedures were performed by trained nurses and physiologists, with consultant oversight available. Post-procedure, patients recovered in a chair for 10–15 minutes before discharge. Standard wound care and safety instructions were provided. Safety monitoring, efficiency metrics, and patient satisfaction questionnaires were collected. A 182 patients were enrolled in this study. We compared 82 patients who underwent ILR explant through the ambulatory chair-based pathway to 100 patients who underwent consultant-led cath lab- based traditional pathway. In the new nurse-led chair-based pathway, there were no infections, bleeding, or major complications occurred. One case required consultant intervention due to a deep implant. Patient satisfaction was uniformly high, with no complaints reported. Compared to the traditional model, the new pathway reduced cath lab occupancy and bed utilization. Notably, no cancellations occurred during the study period, whereas in the cath lab era, cases were often delayed or cancelled due to scheduling conflicts with urgent procedures or using cath lab beds as escalltion plan. Conclusion- A nurse-led, chair-based ILR explant pathway is safe, efficient, and highly acceptable to patients. It reduces reliance on cath lab infrastructure, eliminates procedure cancellations, optimizes resource utilization and has significant implications for reducing waiting list backlogs. This model is reproducible and may inform best practice protocols in other centres. Prospective Single-Centre Experience of a Nurse-Led Chair-Based Pathway for Implantable Loop Recorder Explantation Abdul Hanan Hamid 1* , Ayman Helal 1,2# , Bino Job 1 , Rachana Prasad 1 1 Department of Cardiology, Kettering General Hospital, University hospitals of Northamptonshire, Kettering, Northamptonshire, United Kingdom. 2 Department of Cardiology, Derriford Hospital, University hospitals Plymouth, Plymouth, Devon, United Kingdom. * # First authors and corresponding authors: Both Dr Abdul Hanan Hamid and Dr Ayman Helal are considered first authors and corresponding authors with equal contributions, * Corresponding author: Dr Abdul Hanan Hamid, Department of Cardiology, Kettering General Hospital, University hospitals of Northamptonshire, Kettering, Northamptonshire, United Kingdom. Email: [email protected] , Phone: +4407585044792 # Corresponding author: Dr Ayman Helal, Department of Cardiology, Kettering General Hospital, University hospitals of Northamptonshire, Kettering, Northamptonshire, United Kingdom. Email: [email protected] , Phone: +447376863806 Both Dr Abdul Hanan Hamid and Ayman Helal are both considered as 1 st author for this manuscript with equal contribution. Data availability statement: Data available on request from the authors Funding statement: None Conflict of interest disclosure: None Ethics approval statement: NA Patient consent statement: Obtained Permission to reproduce material from other sources: No materials from other sources Clinical trial registration: NA Prospective, Single-Centre Experience of a Nurse-Led, Chair-Based Pathway for Implantable Loop Recorder Explantation Abstract Background- Implantable loop recorder (ILR) explantation has traditionally been performed in catheterization (cath) labs, with bed-based recovery lasting 30–60 minutes. This conventional model can strain cath lab resources, delay urgent interventional procedures, and inconvenience patients. Currently, there are no standardized guidelines for streamlined ambulatory pathways for ILR removal. Aim- To evaluate the feasibility, safety, and efficiency of a nurse-led, chair-based ambulatory pathway for ILR explantation. Method and results- A prospective, single-centre quality improvement project was conducted over a 4-month period. Patients were admitted via reception and transferred to a side room or procedure room, bypassing the cath lab. Explant procedures were performed by trained nurses and physiologists, with consultant oversight available. Post-procedure, patients recovered in a chair for 10–15 minutes before discharge. Standard wound care and safety instructions were provided. Safety monitoring, efficiency metrics, and patient satisfaction questionnaires were collected. A 182 patients were enrolled in this study. We compared 82 patients who underwent ILR explant through the ambulatory chair-based pathway to 100 patients who underwent consultant-led cath lab- based traditional pathway. In the new nurse-led chair-based pathway, there were no infections, bleeding, or major complications occurred. One case required consultant intervention due to a deep implant. Patient satisfaction was uniformly high, with no complaints reported. Compared to the traditional model, the new pathway reduced cath lab occupancy and bed utilization. Notably, no cancellations occurred during the study period, whereas in the cath lab era, cases were often delayed or cancelled due to scheduling conflicts with urgent procedures or using cath lab beds as escalltion plan. Conclusion- A nurse-led, chair-based ILR explant pathway is safe, efficient, and highly acceptable to patients. It reduces reliance on cath lab infrastructure, eliminates procedure cancellations, optimizes resource utilization and has significant implications for reducing waiting list backlogs. This model is reproducible and may inform best practice protocols in other centres. Keywords: Nurse-Led; Chair-Based Pathway; Implantable Loop Recorder Explantation Introduction: Implantable loop recorders (ILRs) are invaluable tools for diagnosing infrequent arrhythmias such as syncope or palpitations, allowing extended cardiac monitoring far beyond the capabilities of external devices. [1] Traditionally, ILR explantation is conducted in catheterization labs with bed-based recovery lasting 30 to 60 minutes—a workflow that consumes substantial specialized resources and can result in scheduling delays and case cancellations. Despite the relatively simple and minimally invasive nature of ILR removal, there is no widely accepted ambulatory model for performing such procedures. To address this gap, we implemented a nurse-led, chair-based ambulatory pathway for ILR explantation at our centre and prospectively evaluated its feasibility, safety, efficiency, and patient acceptance over a four-month period. Methods Place - This prospective, single-centre quality improvement project was conducted at Kettering General Hospital, United Kingdom, over a four-month period. The project was designed in accordance with institutional QI governance standards and was reviewed and registered as a service evaluation rather than a formal interventional trial. Patient Selection and Sample Size - All consecutive patients scheduled for ILR explantation during the study period were considered eligible. There were no exclusion criteria beyond inability to provide informed consent or medical contraindications to ambulatory recovery (such as inability to ambulate independently or concurrent acute illness). A sample size was calculated as 80 patients, based on projected procedural volume and comparison with the prior year’s cath lab–based explant activity (100 cases) with confidence Level of 95% and Margin of Error of 5% and population proportion of 50%. This size was considered sufficient to detect clinically meaningful differences in workflow efficiency and safety outcomes. Patient Pathway and Procedure Protocol - On the day of the procedure, patients were admitted directly via the hospital’s reception area and sit in the waiting area. They were called to the designated side room for the procedure, thereby bypassing the catheterization laboratory. Explant procedures were performed by an experienced cardiac specialist nurse who have undergone supervised training in ILR removal, including recognition and management of potential complications. A named consultant cardiologist was on-site and available for immediate review if escalation was required. The procedure was performed under local anaesthesia with a small incision made to extract the device. Hemostasis was achieved with gentle compression, and the wound was closed with tissue adhesive (skin glue) to avoid the need for sutures or dressing changes. This method facilitated early showering and faster return to normal activity. Following device removal, patients were assisted to ambulate to a designated recovery chair in the waiting area. Patients were observed for approximately 10–15 minutes. If they remained clinically stable and comfortable, they were discharged the same day. Patients unable to ambulate independently were excluded from this pathway and managed through the conventional bed-based recovery protocol. Discharge Instructions - Patients received both verbal and written discharge instructions. These included advice on wound care, permission to shower the following day, recommendations for the use of simple analgesics such as paracetamol or ibuprofen if required, and reassurance that anticoagulation therapy could be continued uninterrupted. Patients were advised to monitor for red-flag symptoms such as persistent bleeding, swelling, discharge, or signs of infection, and to contact the pacing team if concerns arose. No routine follow-up appointments were scheduled unless clinically indicated, aligning with existing institutional post-explant guidelines. Patient Feedback and Outcome Measures - Before discharge, all patients were asked to complete a short safety and satisfaction questionnaire assessing comfort during the procedure, confidence in wound care instructions, readiness for discharge, and overall satisfaction with the new pathway. The primary outcomes measured were safety (procedural complications, infection, bleeding, or need for consultant intervention) and efficiency (cath lab utilization, requirement for bed recovery, and cancellation rates). Secondary outcomes included patient satisfaction scores and comparison against the prior year’s 100 ILR explants conducted under the cath lab model. Results: Study population: A total of 182 patients were enrolled in this study. A total of 82 patients underwent ILR explantation via the new chair-based ambulatory pathway during the four-month study period were compared to those of the previous year’s 100-patient managed under the traditional cath lab model. Safety Outcomes: No major complications were observed in the ambulatory cohort. Specifically, there were no cases of infection, bleeding, wound dehiscence, or device fragmentation requiring secondary intervention. Only one case required escalation to consultant review due to a deeply embedded ILR, which was managed successfully without adverse sequelae. Importantly, no patients required conversion to cath lab support, and no readmissions related to the procedure were recorded within 30 days. By comparison, the historical cath lab cohort also had low complication rates, but the current project demonstrated that streamlined monitoring and recovery did not compromise patient safety. Efficiency and Cath Lab Utilisation: The shift from bed-based to chair-based recovery generated marked efficiency gains. In the historical model, patients underwent 30–60 minutes of bed rest following explant, with at least two sets of post-procedure observations. In contrast, under the new pathway, patients were discharged after approximately 10–15 minutes of chair recovery, with only a single pre-procedure set of observations recorded. No patients required prolonged observation or inpatient admission. Crucially, no cancellations occurred in the ambulatory group during the study period. This contrasts with the previous year, where ILR explants were occasionally cancelled or delayed due to cath lab pressures, particularly when emergency PCI or cath lab beds were used as escalation beds. Furthermore, procedural throughput improved substantially. The project achieved 82 explants in four months, a pace that, if maintained, would exceed the previous year’s total of 100 explants performed over 12 months. This indicates a potential to more than double annual capacity, which has significant implications for reducing waiting list backlogs and improving timely access to care. Patient Satisfaction: Patient-reported outcomes were uniformly positive. All patients completed a short satisfaction questionnaire prior to discharge. All of them reported feeling comfortable during chair-based recovery, confident about discharge instructions, and ready to resume normal activities. There were no formal complaints received during the study. Qualitative comments highlighted appreciation for the shorter visit duration and the avoidance of unnecessary hospital bed stays. This represents a clear enhancement in the patient journey compared with the prior cath lab–based pathway. Overall Impact: These results demonstrate that the nurse-led, chair-based pathway delivered equivalent safety, greater efficiency, and higher patient satisfaction compared with the cath lab model. By freeing cath lab slots for more complex interventions, avoiding cancellations, and enabling a higher annual throughput of explants. Importantly, the expected ability to exceed the previous year’s volume also suggests that the new model can contribute meaningfully to reducing waiting list pressures, which remain a critical challenge in contemporary NHS practice. Discussion An Implantable Loop Recorder (ILR) is a long-term monitoring device used to record the heart rate and rhythm in patients with unexplained palpitation or syncope. The ILR is implanted under the skin, typically in the chest area, during a minimally invasive procedure. Once implanted, it continuously records heart rhythms, providing valuable data for diagnosing intermittent cardiac events. Explantation of the ILR involves a simple outpatient procedure to remove the device once its monitoring period is complete or if it’s no longer needed. Both implantation and explantation of ILRs are typically performed in specialized settings, often by trained healthcare professionals [2]. The implementation of a nurse-led strategy has been gaining increasing recognition for its potential to improve patient outcomes, particularly in the management of cardiovascular diseases. This approach has shown positive results in ensuring timely interventions. Given its benefits, the integration of nurse-led interventions into clinical practice for the management of cardiovascular patients should be actively pursued. Such a strategy empowers nurses to play a more prominent role in patient care while easing the burden on other healthcare professionals, ultimately fostering a more efficient and patient-centered healthcare system [3]. In this prospective, single-centre quality improvement initiative at UK centre, our nurse-led, chair-based ambulatory ILR explant pathway demonstrated compelling improvements across safety, efficiency, and patient-centred outcomes. This pathway offered significant efficiency benefits as this service eliminated the delays and cancellations that were frequent in the traditional model. Furthermore, the new model not only streamlines care but also expands overall capacity. This increase directly impacts waiting lists, providing a pragmatic solution to backlogs that challenge most cardiac device services. Patient satisfaction was uniformly positive, with patients expressing confidence in discharge instructions and comfort with the rapid ambulatory recovery process. The British Heart Rhythm Society has outlined comprehensive standards for the insertion, follow-up, and explantation of implantable loop recorders (ILRs). While an increasing number of centers across the UK have developed services for the implantation of ILRs by non-medical staff, there remains a notable lack of published data on the practice of ILR explantation conducted by non-medical professionals. [4] Our study is unique in that it specifically addresses a nurse-led chair-based pathway for implantable loop recorder (ILR) explantation, an area that has not previously been reported in the literature. While there are several publications exploring nurse- or physiologist-led ILR implantation services, and even few data of explantation, evidence focusing on nurse-led, chair-based explant pathways is lacking. This makes our work, to the best of our knowledge, the first to evaluate and report on a dedicated nurse-led, chair-based explant model. Although physiologist-led implantation has been described, there was no published data discussing nurse-led combined with chair-based explantation. Our work therefore represents both a novel contribution and a practical, reproducible solution to the dual challenges of cath lab strain and growing procedural demand. The only comparable work published by Lamprou et al., who reported a physiologist-led service. While their model demonstrated safety and feasibility, it retained several conventional elements such as use of sutures, procedure room set-up, and triaged patient exclusions, with throughput averaging around five cases per month. In contrast, our pathway bypassed the cath lab entirely, relied on skin glue closure alone, minimised monitoring and recovery, and included anticoagulated patients, allowing us to perform 82 cases in just four months—on course to exceed the annual volume of the traditional consultant-led model [5]. The implications of this model are significant. It demonstrates that ILR explantation does not require the infrastructure or resources of a cath lab, freeing both physical space and consultant cardiologist time for more complex interventions. In summary, our study demonstrates that a nurse-led, chair-based ambulatory pathway for ILR explantation is safe, efficient, and patient-centred. It eliminates delays and cancellations, increases throughput to a level exceeding prior annual volumes, and offers an innovative model of care not previously described in the literature. This pathway represents a pragmatic strategy to improve both service delivery and patient experience in cardiac device management. Conclusion A nurse-led, chair-based ambulatory pathway for ILR explantation is safe, efficient, and highly acceptable to patients. This model eliminates reliance on cath lab resources, reduces procedure cancellations, and substantially increases throughput, with projected annual volumes exceeding those of the traditional consultant-led approach. With negligible complications and high patient satisfaction, this pathway represents a novel and practical strategy for streamlining ILR explant services, addressing waiting list pressures, and optimizing healthcare resource utilization. References 1. Pistelli L, Di Cori A, Parollo M, Torre M, Fiorentini F, Barletta V, Giannotti Santoro M, Grifoni G, Canu A, Segreti L, De Lucia R, Viani S, Zucchelli G. The Diagnostic Yield of Implantable Loop Recorders Stratified by Indication: A ”Real-World” Single-Center Experience. J Clin Med. 2025 Feb 7;14(4):1052. doi: 10.3390/jcm14041052. PMID: 40004583; PMCID: PMC11856419. 2. Bisignani A, De Bonis S, Mancuso L, Ceravolo G, Bisignani G. Implantable loop recorder in clinical practice. J Arrhythm. 2018 Nov 20;35(1):25-32. doi: 10.1002/joa3.12142. PMID: 30805041; PMCID: PMC6373656. 3. Qiu X. Nurse-led intervention in the management of patients with cardiovascular diseases: a brief literature review. BMC Nurs. 2024 Jan 2;23(1):6. doi: 10.1186/s12912-023-01422-6. PMID: 38163878; PMCID: PMC10759353. 4. Foley P, Thomas H, Dayer M, Robinson S, Ezzatt V, Swift M, Johal N, Roberts E. British Heart Rhythm Society Standards for Implantation and Follow-up of Cardiac Rhythm Management Devices in Adults: January 2024 Update. Arrhythm Electrophysiol Rev. 2024 Jul 1;13:e10. doi: 10.15420/aer.2024.01. PMID: 39082056; PMCID: PMC11287656. 5. Lamprou V, Ahmed F, Hogan K, et al78 Implantable loop recorders: a cardiac physiologist led explant serviceHeart 2023;109:A87-A88. Information & Authors Information Version history V1 Version 1 02 September 2025 Peer review timeline Published Pacing and Clinical Electrophysiology Version of Record 7 Jan 2026 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keyword clinical: non-invasive techniques – holter/event recorders Authors Affiliations Abdul Hanan Hamid Kettering General Hospital NHS Foundation Trust View all articles by this author Ayman Helal 0000-0001-5321-4377 [email protected] Kettering General Hospital NHS Foundation Trust View all articles by this author Bino Job Kettering General Hospital NHS Foundation Trust View all articles by this author Rachana Prasad Kettering General Hospital NHS Foundation Trust View all articles by this author Metrics & Citations Metrics Article Usage 153 views 94 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Abdul Hanan Hamid, Ayman Helal, Bino Job, et al. 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