IMPLEMENTATION OF

NURSE –LED

CARDIOVERSION

Presented by Ceri Mealing

Introduction

• Atrial fibrillation Atrial fibrillation Atrial fibrillation Atrial fibrillation – A disturbance of the normal rhythm of the heart.A disturbance of the normal rhythm of the heart.A disturbance of the normal rhythm of the heart.A disturbance of the normal rhythm of the heart.

– The most common persistant arrhythmia in adults and The most common persistant arrhythmia in adults and The most common persistant arrhythmia in adults and The most common persistant arrhythmia in adults and carries an increased risk of thromboembolism and carries an increased risk of thromboembolism and carries an increased risk of thromboembolism and carries an increased risk of thromboembolism and stroke. stroke. stroke. stroke.

• Direct current cardioversion Direct current cardioversion Direct current cardioversion Direct current cardioversion remains the most remains the most remains the most remains the most effective method for restoring sinus rhythm In effective method for restoring sinus rhythm In effective method for restoring sinus rhythm In effective method for restoring sinus rhythm In patients with persistent atrial fibrillation.patients with persistent atrial fibrillation.patients with persistent atrial fibrillation.patients with persistent atrial fibrillation.

Electrical (DC) cardioversion

• The delivery of an electric current synchronised The delivery of an electric current synchronised The delivery of an electric current synchronised The delivery of an electric current synchronised to the activity of the heart using a defibrillator.to the activity of the heart using a defibrillator.to the activity of the heart using a defibrillator.to the activity of the heart using a defibrillator.

• Electrical (DC) cardioversion Electrical (DC) cardioversion Electrical (DC) cardioversion Electrical (DC) cardioversion – should be attempted within 3 months of onset of should be attempted within 3 months of onset of should be attempted within 3 months of onset of should be attempted within 3 months of onset of

persistent AF persistent AF persistent AF persistent AF – with concurrent anticoagulation therapy.with concurrent anticoagulation therapy.with concurrent anticoagulation therapy.with concurrent anticoagulation therapy.

• If successful health benefits to patients If successful health benefits to patients If successful health benefits to patients If successful health benefits to patients – improvement in well being improvement in well being improvement in well being improvement in well being – improved exercise capacity.improved exercise capacity.improved exercise capacity.improved exercise capacity.– EraducateEraducateEraducateEraducate the need for long term anticoagulation the need for long term anticoagulation the need for long term anticoagulation the need for long term anticoagulation

therapytherapytherapytherapy

The past –a need for change• Inadequate resources Inadequate resources Inadequate resources Inadequate resources

• Safety issuesSafety issuesSafety issuesSafety issues

• Patient issuesPatient issuesPatient issuesPatient issues

• Resulting in the cardioversion being Resulting in the cardioversion being Resulting in the cardioversion being Resulting in the cardioversion being stopped as an elective procedure.stopped as an elective procedure.stopped as an elective procedure.stopped as an elective procedure.

Service development

• A group was set up that incorporated key A group was set up that incorporated key A group was set up that incorporated key A group was set up that incorporated key stakeholders.stakeholders.stakeholders.stakeholders.

• An integrated care pathway (ICP) was An integrated care pathway (ICP) was An integrated care pathway (ICP) was An integrated care pathway (ICP) was developed.developed.developed.developed.

• Trust procedure developed.Trust procedure developed.Trust procedure developed.Trust procedure developed.• NurseNurseNurseNurse----led cardioversion service setup.led cardioversion service setup.led cardioversion service setup.led cardioversion service setup.

Service development

Referral from Cardiologist

Patient contacted 4 weeks prior to ECV

Pre-assessment 48 hours before procedure

ECV performed in day surgery

Day case ECV waiting list

Discharge and appointment follow-up arranged

Nurse –led pre-assessment clinic• As an integral part of the cardioversion As an integral part of the cardioversion As an integral part of the cardioversion As an integral part of the cardioversion

process the patients attend a preprocess the patients attend a preprocess the patients attend a preprocess the patients attend a pre----assessment assessment assessment assessment clinic 48 hours before the day of the clinic 48 hours before the day of the clinic 48 hours before the day of the clinic 48 hours before the day of the procedure.procedure.procedure.procedure.

– Full history of patient obtainedFull history of patient obtainedFull history of patient obtainedFull history of patient obtained– Series of bloods takenSeries of bloods takenSeries of bloods takenSeries of bloods taken– Observations recordedObservations recordedObservations recordedObservations recorded– Procedure explained to patientProcedure explained to patientProcedure explained to patientProcedure explained to patient

Aims of the preAims of the preAims of the preAims of the pre----assessment assessment assessment assessment sessionsessionsessionsession

•To ensure the ECV is neededTo ensure the ECV is neededTo ensure the ECV is neededTo ensure the ECV is needed•To ensure the patient is fully informedTo ensure the patient is fully informedTo ensure the patient is fully informedTo ensure the patient is fully informed

•To exclude patients from the procedureTo exclude patients from the procedureTo exclude patients from the procedureTo exclude patients from the procedure•To reinforce administrative details To reinforce administrative details To reinforce administrative details To reinforce administrative details

•Informed written consent is obtainedInformed written consent is obtainedInformed written consent is obtainedInformed written consent is obtained

Exclusion Criteria

• Atrial fibrillation or flutter not evident on ECGAtrial fibrillation or flutter not evident on ECGAtrial fibrillation or flutter not evident on ECGAtrial fibrillation or flutter not evident on ECG• INR <2 or >3INR <2 or >3INR <2 or >3INR <2 or >3• Serum potassium outside rangeSerum potassium outside rangeSerum potassium outside rangeSerum potassium outside range• Urea and creatinine outside rangeUrea and creatinine outside rangeUrea and creatinine outside rangeUrea and creatinine outside range• Hyper or hypotensiveHyper or hypotensiveHyper or hypotensiveHyper or hypotensive• Recent illness or infectionRecent illness or infectionRecent illness or infectionRecent illness or infection• Poor EF as assessed by cardiologistPoor EF as assessed by cardiologistPoor EF as assessed by cardiologistPoor EF as assessed by cardiologist• Documented valvular dysfunctionDocumented valvular dysfunctionDocumented valvular dysfunctionDocumented valvular dysfunction• HR <55bpmHR <55bpmHR <55bpmHR <55bpm

Day of procedure• Patients attend CCUPatients attend CCUPatients attend CCUPatients attend CCU• ECG is recorded prior to transfer to day theatreECG is recorded prior to transfer to day theatreECG is recorded prior to transfer to day theatreECG is recorded prior to transfer to day theatre• ECV performed ECV performed ECV performed ECV performed

– In safe controlled environment In safe controlled environment In safe controlled environment In safe controlled environment – in presence of anaesthetistsin presence of anaesthetistsin presence of anaesthetistsin presence of anaesthetists– CCU nurse according to trust policy (maximum 3 CCU nurse according to trust policy (maximum 3 CCU nurse according to trust policy (maximum 3 CCU nurse according to trust policy (maximum 3 shocks given)shocks given)shocks given)shocks given)

• Patients monitored for recovery Patients monitored for recovery Patients monitored for recovery Patients monitored for recovery • Patient taken back to CCUPatient taken back to CCUPatient taken back to CCUPatient taken back to CCU• Patient reviewed by nurse and Doctor post Patient reviewed by nurse and Doctor post Patient reviewed by nurse and Doctor post Patient reviewed by nurse and Doctor post procedure.procedure.procedure.procedure.• Future management discussed with the patient.Future management discussed with the patient.Future management discussed with the patient.Future management discussed with the patient.

– Advice given and OPD appointment arrangedAdvice given and OPD appointment arrangedAdvice given and OPD appointment arrangedAdvice given and OPD appointment arranged

Today’s picture• Total patients Total patients Total patients Total patients cardiovertedcardiovertedcardiovertedcardioverted 72 since October 72 since October 72 since October 72 since October

2005 to present date.2005 to present date.2005 to present date.2005 to present date.

• 9 patients on waiting list at present.9 patients on waiting list at present.9 patients on waiting list at present.9 patients on waiting list at present.

• Approx waiting time 16 weeks currentlyApprox waiting time 16 weeks currentlyApprox waiting time 16 weeks currentlyApprox waiting time 16 weeks currently

• Recent audit conducted patients undergone Recent audit conducted patients undergone Recent audit conducted patients undergone Recent audit conducted patients undergone elective cardioversion from august 2006 to elective cardioversion from august 2006 to elective cardioversion from august 2006 to elective cardioversion from august 2006 to august 2007 total patients.august 2007 total patients.august 2007 total patients.august 2007 total patients.

RESULTS SUCESSFUL

CARDIOVERSION

0

5

10

15

20

25

1

Successful

79 %[23]

Failed/immediate

recurrence 21%[6]

Future Development• Extend the role of nurseExtend the role of nurseExtend the role of nurseExtend the role of nurse----led serviceled serviceled serviceled service

• Closer liaison with the anticoagulation serviceCloser liaison with the anticoagulation serviceCloser liaison with the anticoagulation serviceCloser liaison with the anticoagulation service

• Two monthly theatre slotsTwo monthly theatre slotsTwo monthly theatre slotsTwo monthly theatre slots

• Atrial fibrillation nurse statusAtrial fibrillation nurse statusAtrial fibrillation nurse statusAtrial fibrillation nurse status

• NurseNurseNurseNurse----led follow up clinicled follow up clinicled follow up clinicled follow up clinic

Nice Guidelines• One year post cardioversion One year post cardioversion One year post cardioversion One year post cardioversion

– 50% of patients are back to AF 50% of patients are back to AF 50% of patients are back to AF 50% of patients are back to AF • Complete shock failure Complete shock failure Complete shock failure Complete shock failure

– 25% of patients25% of patients25% of patients25% of patients• In In In In comparisoncomparisoncomparisoncomparison with nice guidelines number of with nice guidelines number of with nice guidelines number of with nice guidelines number of

patients in AF patients in AF patients in AF patients in AF – >4/52 53%>4/52 53%>4/52 53%>4/52 53%

Conclusion

• Nurse-led cardioversion offers a practical and safe solution.

• An ECV service can be safely operated by an appropriately trained nurse .

• This model of care is effective– reducing waiting times.

– reducing pressure on acute beds and junior doctors.

The Nurse-led service

• Has utilised resources efficiently.

• improved communication with other disciplines.

• most importantly.

Improved patient care

Any Questions?