Introduction Atrial Fibrillation (AF) is the most common arrhythmia and is associated with an increased risk of thromboembolic events. Direct Current Cardioversion (DCC) is a routine elective treatment to attempt to restore sinus rhythm in patients with atrial fibrillation/flutter. This usually requires one to two medical doctors and a cardiology nurse to assist. A delay in medical staff being able to perform the DCC due to their workloads, led to longer waiting times for patients, increasing the length of their bed stay thereby increasing pressure on cardiac beds in a busy coronary care unit (CCU). To address this problem, a nurse led DCC service was set up. The aim was to provide a safe and efficient service for patients.
Methods A nurse led cardioversion pathway was created in January 2017 in consultation with the Cardiologists and Pharmacy. All referrals originated from a Cardiologist, All patients referred by a Cardiologist who were haemodynamically stable were considered for Nurse Led DCC after eligibility criteria were met. All patients had to be taking anticoagulation for at least 4 weeks. Pre-procedural details were obtained including consent, medical history, medications, allergies, and physical examination. All patients had bloods and echocardiography performed before being included in the service. DCC was performed using the Trust conscious sedation policy using midazolam. Post procedure monitoring was done until discharge. Data including anticoagulant status, (NOAC/warfarin), referral source, sedation requirements, number of shocks, pad position, adverse reaction, anaesthetic involvement and length of stay were recorded for continuous audit purposes immediately post DCC, at discharge and at 6 week’s review. Length of stay was compared to doctor led procedures for similar time period.
Results A total of 24 Nurse led DCCs have been performed since the service began with 92% achieving sinus rhythm following DCC. Nurse led DCC length of stay was significantly less than Doctor led DCC length of stay leading to higher patient satisfaction (420 minutes vs. 240 minutes, p<0.05).
Data collected to date also suggests a trend towards lower amounts of sedation being used by the nurse led DCC service, enhancing patient outcome and higher patient satisfaction.
NOACs were the anticoagulant of choice in 24/24 (100%) cases. None of the patients were taking Warfarin avoiding the need to cancel procedures if the INR was sub-therapeutic in the weeks leading up to the day of the procedure.
Conclusion A Nurse led DCC service appears to be safe, efficient and effective way to treat AF. Such a service reduces the length of stay and increases patient satisfaction. We hope to extend this service into more complex patients that are currently excluded and will continue to audit this very worthwhile service.
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