Background: Nurse-led sedation protocols are common for many procedures, yet cardiac disease represents an additional risk factor (Sneyd, 2013). Subsequently, nurse-led procedural sedation and analgesia (NLPSA) during cardiac ablation is rarely practiced or studied (Conway et al., 2014). Such a protocol has potential benefits in resource management (Gaitan et al., 2011), without requiring the operator to also act as sedationist, which is considered inappropriate (Furniss and Sneyd, 2015). To gain these benefits, NLPSA must be both safe, and effective in controlling the patient’s pain and anxiety.
Method: An NLPSA protocol for cardiac ablation was studied, using a mixed methods design consisting of a survey followed by case studies. A questionnaire was completed by 64 patients undergoing pulmonary vein isolation (PVI); case data from clinical records was then added by the researcher. Safety was studied using Fisher’s Exact Test to compare rates of complications to previous studies. Hierarchical Cluster Analysis (HCA) and Fuzzy Set Qualitative Comparative Analysis (FsQCA) were used to construct a model of sufficient conditions for a positive patient experience.
Results: Results rejected the hypothesis that NLPSA was less safe than other sedation methods for such cases. No deaths, reversals of sedation, or need for anaesthetic support occurred during the study. Cardiac tamponade occurred in two cases, but this was not significant when compared to rates of tamponade in cases performed under alternative sedation methods (Fisher Exact Test 0.0925; insignificant at p<0.05).
HCA revealed three clusters describing patient experience: positive (n=17), mostly positive (n=37) and negative (n=8). These were based on patients’ report of pain, anxiety and satisfaction during cases via the questionnaire. FsQCA constructed an equifinal model of pathways resulting in a positive experience which included combinations of intravenous medication (fentanyl, midazolam and paracetamol), patient body mass index, and age. This model had a high consistency value
(0.858674) but moderate coverage (0.613544).
Conclusion: Moderate solution coverage indicated that a causal factor had been omitted. Some individual sedationists facilitated consistently positive experiences without their cases matching the model’s solution terms. In the case study phase, their practice will be studied, both to explain their success, and to comment on the transferability of the protocol’s results to other cardiac catheter laboratories. The case studies also aim to validate the FsQCA model by considering whether factors
such as midazolam dose and age genuinely contribute to a positive experience, or only to positive report of experience through mechanisms such as amnesia or stoicism respectively.
References
- 1. Furniss SS, Sneyd JR. Safe sedation in modern cardiological practice. Heart. 2015;101:1526–30.
- 2. Gaitan BD, Trentman TL, Fassett et al. Sedation and analgesia in the cardiac electrophysiology laboratory: A national survey of electrophysiologists investigating the who, how, and why? J Cardiothorac Vasc Anesth. 2011;25(4), 647–59.
- 3. Sneyd JR. Safe sedation practice for healthcare procedures—standards and guidance. 2013. Available at: http://www.aomrc.org.uk/publications/reports-guidance/safe-sedation-practice-1213/ (accessed 11 April 2019).
