Nurse-led care, safe and sedated with a framework?

This invited commentary refers to ‘Efficacy and safety of operator-directed, nurse-administered propofol sedation in atrial fibrillation ablation’, by J. Park et al., https://doi.org/10.1093/eurjcn/zvaf252. The prevalence of atrial fibrillation (AF) has increased by ∼33% in recent years, and this global epidemic is projected to further escalate the associated economic burden.1 Recent multiple trials showed cardiac ablation to prevent AF recurrences, reduce the AF burden, and improve the quality of life in symptomatic paroxysmal or persistent patients.2-4 With this additional comparison towards pharmaceutical therapy, the recent ESC guideline recommended ablation as a first-line approach, earlier rhythm-control strategies, and emphasised the importance of multidisciplinary team management.5,6 While the role of nurse-led clinics in AF management has long been recognised, the continuous rise in ablation procedures presents both new challenges and significant opportunities for nursing practice. For instance, the growing procedural volume has created an increased demand for sedation to optimize patient comfort and lesion formation, particularly in settings with limited anaesthesiology capacity and capability.7,8 More recently, comparative studies examining conscious sedation and general anaesthesia have demonstrated that conscious sedation achieves comparable outcomes.9 These findings support the use of conscious sedation as a viable alternative during less complex lesions or for patients not classified as high-risk for AF ablation procedures.10 As part of the multidisciplinary team, nurses are involved in ablation procedure practice within cardiac catheterisation laboratories, and they are increasingly being supported to expand their skills to take responsibility for conscious sedation practices. This was, to our knowledge, first reported in 2017 by Sawhney et al.,11 and it represents a significant step in the advanced practice role of nurses in the cardiac catheterisation lab. Within the European Journal of Cardiovascular Nursing, Park et al.12 describe the results of a prospective evaluation they conducted to establish the efficacy and safety of a nurse-led, operator-directed ablation procedure in a cohort of 230 patients treated at a single centre. Patients involved represented a broad spectrum of AF types, including paroxysmal (30.9%), persistent (22.6%), and longstanding (46.5%) forms, excluding the screened 6.1% high-risk patients, with described criteria, from the provision of conscious sedation. The primary outcomes assessed were any unplanned interruption of sedation, conversion to endotracheal intubation, or the requirement for continuous vasodepressor support during the procedure.12 A detailed sedation protocol was developed and used in the study, enabling evaluation of the impact if deviation was deemed necessary by the nurse operator. The depth of sedation was monitored using the Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale13 in accordance with the established sedation protocol. The protocol’s detailed structure, combined with the defined training pathway, ensured the competency of each nurse administering conscious sedation. The competency requirements were, next to a minimum of 5 years of electrophysiology experience, the completion of annual structured didactic sessions covering sedation pharmacology, airway management, and haemodynamic support. Sedation interruption occurred in only five patients (2.2%), while two patients aged 84 years developed cardiac tamponade requiring haemodynamic intervention. Episodes of hypotension (