Outcomes for Cardioversion Performed by an Advanced Practice Provider
What are the quality outcomes for electrical cardioversion for atrial fibrillation when the procedure is performed autonomously by an advanced practice provider?
After extensive training and hospital credentialing, a licensed advanced practice provider following guideline-directed protocol performed 415 cardioversions autonomously in a noninvasive procedure room with an attending electrophysiology (EP) physician immediately available in an adjacent EP laboratory or office. The anesthesia service administered sedation. Rates of successful conversion to normal sinus rhythm, complication rates, and patient satisfaction scores were compared with those for 387 cardioversions performed by a medical doctor (cardiology fellow).
After performing 227 cardioversions under the supervision of an attending EP physician, an advanced practice nurse was granted hospital privileges to autonomously perform elective cardioversions. A guideline-directed protocol including pre-procedural, procedural, and post-procedural checklists was developed and utilized for each patient. All inpatient and outpatient cardioversions were subsequently performed autonomously on days when the advanced practice provider was available. On days when advanced practice provider was not available, all cardioversions were performed by a medical doctor (cardiology fellow). The advanced practice provider performed the pre-procedure assessment, reviewed findings with the supervising EP physician, obtained informed consent for the procedure, and performed all technical aspects of the cardioversion. Patients were observed post-cardioversion for at least 90 minutes in a cardiac recovery and observation unit. The advanced practice provider managed the discharge process and coordinated follow-up care. If indicated, transesophageal echocardiogram was performed immediately prior to cardioversion by a cardiologist. Device interrogation was completed for all patients with implanted pacemaker or defibrillator prior to and following the cardioversion procedure. In 98% of cases, the anesthesia team administered sedation; in the remaining 2%, sedation was administered by a cardiac nurse under the direct supervision of the attending anesthesiologist.
Data was prospectively collected; charts were also retrospectively reviewed. Baseline data collection included patient age, sex, left ventricular ejection fraction, left atrial diameter by recent transthoracic echo, CHA2DS2-VASC score, presenting rhythm, novel oral anticoagulant anticoagulation, presence of implanted device, and antiarrhythmic drugs. Patient satisfaction scores were based on Press Ganey questionnaire responses.
Baseline characteristics of the two groups did not significantly differ. Fewer patients with cardioversion by advanced practice provider required transesophageal echocardiogram prior to cardioversion (40 vs. 55%). Initial conversion to normal sinus rhythm was higher for an advanced practice provider (90 vs. 84%). However, after development of recurrent arrhythmias, subsequent shocks, or possible Ibutilide administration, the percentage of patients discharged in normal sinus rhythm was similar (95% for advanced practice providers vs. 96% for medical doctors). Following advanced practice provider cardioversion, four complications occurred: one transient ischemic attack (TIA) and three bradycardia events requiring atropine. (The patient who developed TIA had been on uninterrupted novel oral anticoagulant with CHA2DS2-VASC 4. The TIA occurred 2 days post-cardioversion, but the patient recovered completely). Following medical doctor cardioversion, one complication occurred: hypotension requiring vasopressor therapy. Patient satisfaction scores following implementation of autonomous advanced practice provider cardioversion were not statistically different from those in the prior year.
Elective cardioversion can be safely and autonomously performed by an advanced practice provider who has received additional training and utilizes a guideline-directed protocol with procedural checklists and deep sedation administered by an attending anesthesiologist. Supervision by an attending EP cardiologist is still needed, but physical presence in the procedure room is not needed. By utilizing the services of an autonomous advanced practice provider for elective cardioversions, overall clinical efficiencies were created for the EP physicians, fellows, and anesthesia service.
Following appropriate training, an advanced practice provider can perform cardioversions safely and autonomously, achieving excellent clinical outcomes and high patient satisfaction. Additional studies utilizing multiple advanced practice providers could further validate outcome results for cardioversions by advanced practice providers.
Keywords: Electric Countershock, Anti-Arrhythmia Agents, Atrial Fibrillation, Bradycardia, Ischemic Attack, Transient, Electrophysiology, Anesthesia
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