Implementing a Nurse-Coordinated Same-Day Discharge Program for Atrial Fibrillation Ablation

Interview With Till Althoff, MD

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EP LAB DIGEST. 2024;24(10):1,10-11.

Interview by Jodie Elrod  

In this interview, EP Lab Digest talks with Till Althoff, MD, about implementation of a streamlined same-day discharge (SDD) program after atrial fibrillation (AF) ablation, including development of a standardized protocol and creation of a dedicated SDD coordinator position.¹

What drove the need to implement a nurse-coordinated SDD program for atrial fibrillation (AF) ablation at your center? 

AF ablation is a relatively complex, resource-intensive procedure. In Spain, as in many other countries, the health care system has difficulties accommodating the increasing demand for AF ablation due to limitations in health care budget and personnel as well as in structural resources (eg, hospital beds). This mismatch of supply and demand was acutely aggravated during the COVID-19 pandemic, when elective hospital admissions were prohibited or highly restricted. At that time, the only way for us to perform urgent AF ablations was through same-day discharge (SDD), which indeed proved an effective way to spare resources. 

When we started with SDD AF ablation, we already had had an SDD program for supraventricular tachycardia ablations and pacemaker implants in place for many years. However, since AF ablation is a more complex procedure with rare but potentially life-threatening complications, streamlining the peri-interventional workflow does not come without a cost.

Omitting overnight stays does not only imply reduced monitoring, but also work consolidation. Not only will there be less time available for the same tasks, there are also additional requirements specific to SDD such as teaching of patients and family members or support persons including post-discharge instructions, as well as a specific short-term follow-up. Thus, besides structural adaptations, SDD also requires more efficient in-hospital coordination and organizational efforts.

In the traditional inpatient setting, no personnel are specifically designated and budgeted for these challenges, and the responsibilities at this interface of ambulatory and in-hospital care are typically not well-defined among nurses and physicians. Thus, new SDD-specific tasks would have to be accomplished by the existing medical staff, further increasing their already dense workload. Therefore, to ensure safety and efficiency in this context, we created a specific standardized SDD protocol for AF ablation and implemented the role of a dedicated SDD coordinator.

Describe the role of the SDD coordinator in the streamlined SDD program. What responsibilities does this position entail, and how does it contribute to the overall safety and efficiency of the program?

As SDD coordinator, a specialized nurse was in charge of the full SDD protocol, including patient selection, patient flow and in-hospital logistics, patient and family education, patient discharge, and short-term follow-up with virtual visits on post-discharge days 1 and 3.

The systematic coordination of standardized workflows may well have contributed to the compelling safety outcome of our study. While in the absence of a prospective control group we cannot provide definite evidence for the impact of the SDD coordinator, the rates of unplanned medical attention or readmission within 30 days after discharge were lower than previously reported for comparable SDD cohorts, and also lower than those observed after AF ablation in an inpatient setting. This may reflect the positive impact of the standardized ambulation and discharge protocol, including a comprehensive education of patients and support persons, accompanied by close follow-up with additional smartphone visits—all provided by the SDD coordinator.

What were the components of the standardized protocol used in the study?

The standardized protocol coordinated by the dedicated nurse consisted of patient selection based on predefined eligibility criteria, teaching and post-discharge instructions provided to the patient and his or her family or support person, standardized ambulation, predischarge echocardiography and puncture site inspection, medication check, predefined discharge criteria, and virtual visits on post-discharge days 1 and 3.

Describe the key findings and take-home points of your research. 

Following a standardized protocol coordinated by a dedicated nurse, SDD was highly efficient and safe. With only few inclusion criteria (left ventricular ejection fraction ≥35%, basic support at home, and accessibility of the hospital within 60 minutes), over 90% of the eligible patients were successfully discharged the day of the ablation. Importantly, there were no primary safety events in terms of severe post-discharge complications, and 30-day rates of unplanned medical attention (6.3%) or hospital readmission after discharge (1.6%) were extremely low. 

Moreover, in our experience, the implementation of a dedicated SDD coordinator position streamlined the whole SDD protocol and patient pathway. Although we cannot provide quantitative data, it resulted in a noticeable workload reduction for physicians and nurses alike as well as significantly improved communication among all relevant parties, thus leading to a great acceptance of the SDD program. 

Finally, the feedback we received clearly indicates that the systematic interaction and patient education provided by the SDD coordinator and his/her function as a contact person considerably increased patient satisfaction. 

How did the implementation of mandatory ultrasound-guided puncture affect patient outcomes in the SDD program?

An interim analysis of the first 215 patients revealed that both post-discharge unplanned medical attention and readmissions were largely driven by femoral access site complications. Thus, compulsory ultrasound-guided femoral puncture was implemented for the remaining 205 patients, which virtually eliminated femoral access site complications triggering medical contact.

What are the potential implications of this study for future clinical practice?

It is widely acknowledged that SDD has great potential to mitigate the challenges that hospitals are facing with an ever-increasing demand for AF ablation, and the resource constraints and immense pressure on health care systems are likely to lead to fast and broad implementation of SDD. Studies like ours, which provide evidence for compelling safety and efficiency of this approach, may further accelerate this process. 

However, SDD is still an emerging concept in the context of AF ablation, and it implicates a considerable work densification and novel tasks requiring substantial adaptations and organizational efforts. We have shown that a standardized coordination of workflows and patient pathways by a dedicated nurse can overcome these challenges, ensuring a streamlined and safe SDD protocol, and at the same time, improving patient satisfaction and unburdening the existing medical staff. Against this background, it is conceivable that there will be a broad implementation of the concept of an SDD coordinator in the future. 

Finally, the fact that ultrasound-guided femoral puncture virtually eliminated relevant femoral access site complications warrants broad implementation of ultrasound guidance, particularly in SDD protocols.

For other centers interested in implementing a similar nurse-coordinated SDD program, how would you recommend approaching the development and implementation of a specialized SDD coordinator nursing role within a health care system? Specifically, what are your recommendations for ensuring the required training, standardization, and integration of these responsibilities?

Indeed, the previously undefined position of an SDD coordinator implies a novel concept of nurses specialized in ambulatory cardiac interventions. In the absence of established training programs, candidate nurses will at least require profound experience in the periprocedural care of patients undergoing invasive cardiovascular procedures. We recommend that an experienced interventional electrophysiologist in charge of the SDD program functions as a primary contact person for the SDD coordinator and provides education, initial guidance, and backup. Obviously, a standardized protocol as well as close collaboration with interventional electrophysiologists and cardiologists, respectively, will be key.

Although it is not an accredited specialization yet, ambulatory cardiac interventional nursing may be a highly attractive professional path that provides exciting perspectives to nurses in cardiovascular medicine. There is little doubt that, in the near future, there will be an immense demand for specialized nurses that have been trained accordingly, but such a concept will need structured training and education programs as well as acknowledgement by cardiac and nursing societies, and potentially even official recognition through board certification. n

Reference

1. Espinosa T, Farrus A, Venturas M, et al. Same-day discharge after atrial fibrillation ablation under a nurse-coordinated standardized protocol. EP Europace. 2024;26(4):euae083. doi:10.1093/europace/euae083