Introduction of nurse led DC cardioversion service in day surgery unit: prospective audit
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《英国医生杂志》
1 Department of Cardiology, Bromley Hospitals NHS Trust, Princess Royal University Hospital, Orpington, Kent BR6 8ND, 2 Department of Anaesthetics, Day Surgery Unit, Bromley Hospitals NHS Trust
Correspondence to: M P Currie mary.currie@bromleyhospitals.nhs.uk
Abstract
Atrial fibrillation is the most common persistent arrhythmia encountered in clinical practice. The incidence of atrial fibrillation has been shown to increase from 0.1% a year in people aged under 40 years to greater than 1.5% a year in women over 80 and greater than 2% a year in men over 80.1 Atrial fibrillation is associated with a twofold increase in mortality and considerable morbidity related to heart failure, embolic events, or poor rate control. Treatment options include attempts to restore sinus rhythm by pharmacological or electrical cardioversion.2
Outline of the problem
We established a new service comprising twice monthly dedicated theatre sessions within a day surgery unit serving a population of 300 000 in southeast London. For the first 23 months this was situated about 5 km from the acute hospital. Cardioversions were done by an appropriately trained nurse with certification as a provider of advanced life support and with training in interpretation of electrocardiograms.5 Further training included 20 cases supervised by consultant cardiologists to ensure that all aspects of the procedure had been considered, including how to manage adverse situations and adjust treatment after the procedure.
We accepted all patients needing DC cardioversion, with the following exclusions: left ventricular ejection fraction less than 35%, permanent pacemaker in situ, severe valve disease, symptoms of ischaemic heart disease, previous symptoms of bradycardia, and body mass index greater than 35. All patients had a minimum of four weeks' anticoagulation before cardioversion and an international normalised ratio of not less then 2.0 during that time. We sent patients an appointment six weeks in advance of their procedure. Patients were assessed during the week before cardioversion. The nurse consultant acted as a single point of reference for any queries.
On the day of their procedure patients arrived at 7 45 am. The nurse consultant obtained consent in accordance with guidance from the Department of Health6 and then carried out the procedure. The protocol initially consisted of monophasic shocks of 200 J, 360 J, and 360 J; from August 2003 we changed to biphasic shocks of 150 J then 200 J as needed. A senior associate specialist or consultant in anaesthetics provided general anaesthesia. After the cardioversion the nurse consultant reviewed patients with their electrocardiograms and made appropriate changes to drug treatments according to an agreed local protocol. A follow up appointment was arranged with the referring consultant for one month after the procedure to allow for review of rhythm and drugs.
Strategies for change
We monitored three key outcomes prospectively. These were waiting times, procedural success, and complication rates.
Effects of change
The re-engineering of the cardioversion service illustrates that a detailed analysis of a service and its weaknesses can identify relatively simple solutions leading to improved outcomes.
Resolving structural weaknesses
We identified structural weaknesses as non-availability of beds, theatre time, and junior doctors. We overcame these by the use of a dedicated theatre slot, dedicated anaesthetist, and dedicated nurse consultant to carry out the procedures.
Resolving process weaknesses
More subtle weaknesses related to the process. Poor coordination and communication between services involved in cardioversion led to cancellations and loss of slots. Establishment of a role for a nurse consultant to coordinate and operate the service allowed an individual member of the clinical staff to develop ownership of the service. Patients were similarly given a role in their own journey. The system previously failed to react to changing circumstances, including low international normalised ratios, changes in drug treatment, or absence of a key investigation, which led to delay and cancellation. This could be avoided in the new service by the nurse consultant liaising with the anticoagulation clinic, flexibly adjusting admission dates (placing other patients into vacated slots), and obtaining urgent investigations (for example, echocardiograms). Over time the coordinator developed relationships with the previously disparate parts of the service.
Key learning points
Logistical difficulties in many institutions lead to problems providing a prompt electrical cardioversion service, thus reducing success rates
A nurse led cardioversion service within dedicated sessions in a day surgery unit overcomes many of the logistical difficulties
This model of care is effective and can reduce waiting times and relieve pressure on acute beds and junior doctors
Conclusion
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly: the Framingham study. Arch Intern Med 1983;147: 1561-4.
Fuster V, Ryden L, Asinger RW, Cannom DS, Crijns HJ, Frye RL, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 2001;22: 1852-923.
Quinn T. Early experience of nurse led elective DC cardioversion. Nurs Crit Care 1998;3: 59-62
Jackson A. A nurse led atrial fibrillation service. Nurs Times 2002;98: 34.
Tracy CM, Akhtar M, John P, DiMarco JP, Douglas L, Packer DL. American College of Cardiology/American Heart Association clinical competence statement on invasive electrophysiology studies, catheter ablation, and cardioversion: a report of the American College of Cardiology/American Heart Association/American College of Physicians—American Society of Internal Medicine Task Force on clinical competence. J Am Coll Cardiol 2000;36: 1725-36.
Department of Health. Reference guide to consent for examination or treatment. London: Department of Health, 2001.(M P Currie, consultant nu)
Correspondence to: M P Currie mary.currie@bromleyhospitals.nhs.uk
Abstract
Atrial fibrillation is the most common persistent arrhythmia encountered in clinical practice. The incidence of atrial fibrillation has been shown to increase from 0.1% a year in people aged under 40 years to greater than 1.5% a year in women over 80 and greater than 2% a year in men over 80.1 Atrial fibrillation is associated with a twofold increase in mortality and considerable morbidity related to heart failure, embolic events, or poor rate control. Treatment options include attempts to restore sinus rhythm by pharmacological or electrical cardioversion.2
Outline of the problem
We established a new service comprising twice monthly dedicated theatre sessions within a day surgery unit serving a population of 300 000 in southeast London. For the first 23 months this was situated about 5 km from the acute hospital. Cardioversions were done by an appropriately trained nurse with certification as a provider of advanced life support and with training in interpretation of electrocardiograms.5 Further training included 20 cases supervised by consultant cardiologists to ensure that all aspects of the procedure had been considered, including how to manage adverse situations and adjust treatment after the procedure.
We accepted all patients needing DC cardioversion, with the following exclusions: left ventricular ejection fraction less than 35%, permanent pacemaker in situ, severe valve disease, symptoms of ischaemic heart disease, previous symptoms of bradycardia, and body mass index greater than 35. All patients had a minimum of four weeks' anticoagulation before cardioversion and an international normalised ratio of not less then 2.0 during that time. We sent patients an appointment six weeks in advance of their procedure. Patients were assessed during the week before cardioversion. The nurse consultant acted as a single point of reference for any queries.
On the day of their procedure patients arrived at 7 45 am. The nurse consultant obtained consent in accordance with guidance from the Department of Health6 and then carried out the procedure. The protocol initially consisted of monophasic shocks of 200 J, 360 J, and 360 J; from August 2003 we changed to biphasic shocks of 150 J then 200 J as needed. A senior associate specialist or consultant in anaesthetics provided general anaesthesia. After the cardioversion the nurse consultant reviewed patients with their electrocardiograms and made appropriate changes to drug treatments according to an agreed local protocol. A follow up appointment was arranged with the referring consultant for one month after the procedure to allow for review of rhythm and drugs.
Strategies for change
We monitored three key outcomes prospectively. These were waiting times, procedural success, and complication rates.
Effects of change
The re-engineering of the cardioversion service illustrates that a detailed analysis of a service and its weaknesses can identify relatively simple solutions leading to improved outcomes.
Resolving structural weaknesses
We identified structural weaknesses as non-availability of beds, theatre time, and junior doctors. We overcame these by the use of a dedicated theatre slot, dedicated anaesthetist, and dedicated nurse consultant to carry out the procedures.
Resolving process weaknesses
More subtle weaknesses related to the process. Poor coordination and communication between services involved in cardioversion led to cancellations and loss of slots. Establishment of a role for a nurse consultant to coordinate and operate the service allowed an individual member of the clinical staff to develop ownership of the service. Patients were similarly given a role in their own journey. The system previously failed to react to changing circumstances, including low international normalised ratios, changes in drug treatment, or absence of a key investigation, which led to delay and cancellation. This could be avoided in the new service by the nurse consultant liaising with the anticoagulation clinic, flexibly adjusting admission dates (placing other patients into vacated slots), and obtaining urgent investigations (for example, echocardiograms). Over time the coordinator developed relationships with the previously disparate parts of the service.
Key learning points
Logistical difficulties in many institutions lead to problems providing a prompt electrical cardioversion service, thus reducing success rates
A nurse led cardioversion service within dedicated sessions in a day surgery unit overcomes many of the logistical difficulties
This model of care is effective and can reduce waiting times and relieve pressure on acute beds and junior doctors
Conclusion
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly: the Framingham study. Arch Intern Med 1983;147: 1561-4.
Fuster V, Ryden L, Asinger RW, Cannom DS, Crijns HJ, Frye RL, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 2001;22: 1852-923.
Quinn T. Early experience of nurse led elective DC cardioversion. Nurs Crit Care 1998;3: 59-62
Jackson A. A nurse led atrial fibrillation service. Nurs Times 2002;98: 34.
Tracy CM, Akhtar M, John P, DiMarco JP, Douglas L, Packer DL. American College of Cardiology/American Heart Association clinical competence statement on invasive electrophysiology studies, catheter ablation, and cardioversion: a report of the American College of Cardiology/American Heart Association/American College of Physicians—American Society of Internal Medicine Task Force on clinical competence. J Am Coll Cardiol 2000;36: 1725-36.
Department of Health. Reference guide to consent for examination or treatment. London: Department of Health, 2001.(M P Currie, consultant nu)