THE CHALLENGES OF THE ARRHYTHMIA NURSE PRACTITIONER ROLE

1. THE CHALLENGES OF THE ARRHYTHMIA NURSE PRACTITIONER ROLE Andréa Grieger and Eleanor Cusack Arrhythmia Nurse Practitioners (Supported by the British Heart Foundation)

2. ADVANCED NURSE PRACTITIONER ROLE Royal College of Nursing (2008) definition A registered nurse who has undertaken a specific course of study of at least first degree (Honours) level and who: - makes professionally autonomous decisions, for which he or she is accountable - receives patients with undifferentiated and undiagnosed problems and makes an assessment based on highly developed nursing knowledge and skills, including skills such as physical examination - makes differential diagnosis using decision-making and problem solving skills - orders necessary investigations, and provides treatment and care both individually, as part of a team, and through referral to other agencies

3. ARRHYTHMIA NURSE PRACTITIONER British Heart Foundation supported Degree level essential Working towards or has obtained a Masters degree Arrhythmia M Level module Nurse prescribing?

4. Assess new patients with palpitations, syncope or abnormal ECG Run nurse-led DC cardioversion service pre- EP procedure advice – telephone/ clinic visit Counsel patients who are referred for permanent pacemaker (PPM)/ implantable cardioverter defibrillator (ICD)/ cardiac resynchronisation therapy (CRT) Inherited Cardiac Conditions Service – coordinate clinic/ investigations, fam hx SCD, HCM, DCM, ARVD, Long QT, Brugada. Assess new patients with palpitations, syncope or abnormal ECG Run nurse-led DC cardioversion service pre- EP procedure advice – telephone/ clinic visit Counsel patients who are referred for permanent pacemaker (PPM)/ implantable cardioverter defibrillator (ICD)/ cardiac resynchronisation therapy (CRT) Inherited Cardiac Conditions Service – coordinate clinic/ investigations, fam hx SCD, HCM, DCM, ARVD, Long QT, Brugada.

5. AF SERVICE

6. CHALLENGES – ARRHYTHMIA CLINICS Triaging referrals Documented evidence on ECG Timely access to diagnostics Managing patient expectation and anxiety levels Time to definitive diagnosis Phone call support - Not always clear if the referral is routine or not or holter monitoring- Not always clear if the referral is routine or not or holter monitoring

7. CHALLENGES - TREATING AF NICE guidance in the treatment of AF (2006) Local protocols and care pathways Choice of drug treatment – pharmacological cardioversion Increasing awareness of EP interventions - when, how and who to refer Initiating treatment through GP Nurse prescribing essential to arrhythmia nurse role, importance of personal development. Dr and patient preference Nurse prescribing essential to arrhythmia nurse role, importance of personal development. Dr and patient preference

8. CHALLENGES – AF FOLLOW UP Clinic support Patient population Coordinating tests locally (ECG, holter monitor) Outreach clinics Post AF ablation 3 months/ 6 months/ 1 year then annually Educating patients on what to expect post procedure Ref: HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow up (2007) Patient population – age, geographical location, distance to travel, tests performed locally Outreach clinics- local protocols, obtaining results Patient population – age, geographical location, distance to travel, tests performed locally Outreach clinics- local protocols, obtaining results

9. CHALLENGES – DC CARDIOVERSION DC cardioversion service – nurse led since mid 2009 Competencies – consent Nurse sedation - training Location/ access to Cardiology support Managing waiting list Consenting process Interpreting rhythm in between shocks When to call for Cardiology support Waiting list – time consuming need for admin support/ healthcare assistant Consenting process Interpreting rhythm in between shocks When to call for Cardiology support Waiting list – time consuming need for admin support/ healthcare assistant

10. CHALLENGES - ANTICOAGULATION Patient compliance with Warfarin Educating patients Relationship with anticoagulation services (hospital and GP) CHADS2 score Referral and waiting times Weekly INR inconvenient for some and older patients, hard to keep records Weekly INR inconvenient for some and older patients, hard to keep records

11. FUTURE CHALLENGES Expansion of the service Developing the arrhythmia nurse practitioner’s role Outreach clinics Arrhythmia clinics in primary care Specific AF clinics Nurse prescribing/ Patient Group Directions Expansion – which direction with the current population group AF clinics – previous GPsI, now nurses Working within own sphere of knowledge and skills Coordinating referrals and investigations between primary care and secondary care Research opportunities Administrative assistance/ health care assistan tLink with anticoagulation services Expansion – which direction with the current population group AF clinics – previous GPsI, now nurses Working within own sphere of knowledge and skills Coordinating referrals and investigations between primary care and secondary care Research opportunities Administrative assistance/ health care assistan tLink with anticoagulation services