Elective Cardioversion at Leeds General Infirmary 2013-2015Andrew Hogarth, Craig Russell, Saagar Mahida, Reza RasoolAlexandra Pike

What we did What we changed How it has improved service

DCCV at LGI pre Sept 2013

Elective list most weeks

Consultant Cardiac Anaesthetist present

Cardioversions carried out by SpR covering SJUH. ◦ Different operator each week

◦ Different methods (voltages, K+ criteria etc)◦ Different documentation – no standard place to document – except in notes◦ List delayed by SpR◦ Cardiobase not used. ◦ Inconsistent.

Aims: To provide a better quality service:

◦ Specialist nurse led◦ Consistency◦ Improved documentation/audit trail◦ Free up SJUH SpR time

Step 1:

AUDIT of procedure to date

Audit (Early 2013)Looked at:

Rate of successful restoration of sinus rhythm

Number of shocks delivered

Any documented complications from procedure

….in a series of 100 consecutive elective cardioversions done from Jan 2012. (Cardiobase data system entries examined)

Possible Complications Thromboembolism (1-2%) – higher if inadequate anticoagulation

Brady or Tachyarrhythmia◦ Increased if K+ low◦ Increased if shock not correctly ‘R’ synchronised◦ Increased if digitalis toxicity

Skin Burns

Failure of procedure

Anaesthetic complications

Results 100 cases

◦ 48 cases – 1 shock◦ 22 cases – 2 shocks◦ 4 cases – 3 shocks◦ 2 cases – 4 shocks◦ 24 cases – no documentation of number of shocks.

◦ 78 successful◦ 19 unsuccessful◦ 3 already in sinus before DCCV

◦ NO MAJOR COMPLICATIONS DOCUMENTED

Conclusions, Sept 2013 A safe procedure – no major complications

Acutely successful in approximately 80%

No major complications◦ ? necessary to have cardiac anaesthetist and cardiology SpR present

Large number of senior cardiologists in neighbouring rooms.

Observation of poor documentation in notes and on Cardiobase system◦ Poor discharge plan communication◦ Inconsistent approach◦ Not always a procedure report◦ ?INR/K+ checked (causes of infrequent but potentially serious complication)

Recommendations, 2013

Potential to improve quality by introducing uniform protocol delivered by Nurse specialist

Safe procedure to be carried out by appropriately trained Nurse Specialist

Design a protocol

Bespoke proforma to be added to Cardiobase to improve documentation

Re –audit to prove non inferiority and markers of service quality improvement after 100 nurse led cardioversions.

STEP 2:

Negotiation

Training

Protocol

STEP 3: Re-audit (2014)

1 year on Protocol introduced

◦ Based on current guidelines

Arrhythmia nurse main operator in all 109 cases

Cardiobase module for ‘Elective DCR’

Results of re-audit 109 cases

◦ 78 cases – 1 shock◦ 21 cases – 2 shocks◦ 9 cases – 3 shocks◦ 1 cases – 4 shocks

104 successful

4 unsuccessful

1 already in sinus before DCCV

Results Complications recorded

◦ 2 transient bradycardias – one settled spontaneously, one required atropine due to haemodynamic instability

◦ 1 documented burn to chest wall – a recognised complications that is consented for◦ 1 increased in ventricular pacing threshold – a recognised complication when

cardioverting in the presence of a pacemaker.

No major adverse events

Events similar to those above may have occurred before but there was no space to document them.

Data now on Cardiobase. Easier to view for follow up and audit purposes.

Documentation of pre op assessment (INR and K+ levels)

Training of SHOs

Conclusions 2014 Completion of the audit cycle shows that changes implemented have not led to any major adverse events

Documentation has been significantly improved.

The new service has released more SpR time.

Procedure carried out according to guidelines.

Increased rate of successful cardioversions.

More training of CMTs/SHOs

It’s safe and effective

STEP 4: Is it valued by patients and staff?

Nurse led DC cardioversion patient satisfaction survey

Surveys given to patients attending for elective outpatient cardioversion

Jubilee Wing LGI Cath lab

Survey based on a validated patient satisfaction survey

Autumn 2014

Results 32 responses

Surveys fully completed except 4 which were partially completed.

All included in results

Completely satisfi

ed

Somewhat satisfi

ed

Neutral

Somewhat diss

atisfied

Completely dissatisfi

ed0

5

10

15

20

25

30

35

Preparing for the procedure

Informed consent/explanation of your procedure Opportunity to meet the operator

Completely satisfi

ed

Somewhat satisfi

ed

Neutral

Somewhat diss

atisfied

Completely dissatisfi

ed0

5

10

15

20

25

30

35

During the procedure

Explanation while preparing you for cardioversion Level of attention you received

Level of professionalism of the nurses Level of safety checks

Level of professionalism of the anaesthetists

Completely sa

tisfied

Somewhat s

atisfied

Neutral

Somewhat d

issatisfi

ed

Completely diss

atisfied

not answ

ered/m

issing

0

5

10

15

20

25

30

35

After the procedure

Explanation of results of the procedure Staff response to your questions

Courtesy and respect you were given Explanation of follow up or other options to treatment

Discharge information Overall satisfaction of procedure from start to finish

Yes No not answered/missing0

5

10

15

20

25

30

Patient recommendations

Would you recommend the nursing staff to other patients?

Would you recommend the anaesthetists to other patients?

Would you recomment this Cath Lab to other patients?

Patient free comments

“My complete satisfaction with everything is not the result of the anaesthetic, it is a sincere reflection of my appreciation of my treatment in the Jubilee Wing. Without exception the nursing and other staff are so cheerful and pleasant to deal with” MB 17/11/14

Conclusions Excellent feedback from patients regarding their DC cardioversion experience before, during and after the procedure.

Patients like it

Nurse led DC cardioversion serviceStaff satisfaction survey resultsDECEMBER 2014

Completely satisfied Somewhat satisfied Neutral Somewhat dissatisfied Completely dissatisfied0

1

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10

Nurse delivered cardioversion is safe

Nurses HCA Doctor Anaesthtist Admin staff Unknown/other

Completely satisfied Somewhat satisfied Neutral Somewhat dissatisfied Completely dissatisfied0

1

2

3

4

5

6

7

8

9

10Nurse delivered cardioversion has improved patient expe-

rience

Nurses HCA Doctor Anaesthtist Admin staff Unknown/other

Completely satisfied Somewhat satisfied Neutral Somewhat dissatisfied Completely dissatisfied0

1

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Nurse delivered cardioversion has improved staff experience on L14

Nurses HCA Doctor Anaesthtist Admin staff Unknown/other

Completely satisfied Somewhat satisfied Neutral Somewhat dissatisfied Completely dissatisfied0

1

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10

Nurse delivered cardioversion has improved anaesthetist's experience

Nurses HCA Doctor Anaesthtist Admin staff Unknown/other

Completely satisfied Somewhat satisfied Neutral Somewhat dissatisfied Completely dissatisfied0

1

2

3

4

5

6

7

8

9

10

Nurse delivered cardioversion has enhanced continuity of care of these patients

Nurses HCA Doctor Anaesthtist Admin staff Unknown/other

Nurse led DCCV at LGI (2015)• Safe• Efficient• Effective•High Quality

◦ Valued by patients ◦ Valued by Staff◦ Valued by trainees

Challenges ANS support

Anaesthetic availability

2015 waiting time 8-12 weeks