(Thank you to JCha602066@aol.com for the current discussion group question, below).

Is there anyone out there that can give me some idea as to how many techs (RNs, etc.) insert sheaths in the cath lab these days? How do policies cover this?

Group Members’ Responses to "Inserting Sheaths"

Only physicians

At our hospital, only the physician can administer local Xylocaine and obtain arterial access and insert the sheath.

Tracijo Capua, CCL Coordinator
Flagler Hospital, St. Augustine, Florida
cathlab@flaglerhospital.org

No techs and RNs insert

The techs and nurses do not insert sheaths in our lab.

Annie Ruppert RN, Annie.Ruppert@sharp.com

Possible contacts

Physicians insert all sheaths. I have inserted sheaths when asked. I had the opportunity to work with the physician who invented the first sheath in the middle 1970s. He was also the person who taught to use all of the preformed catheters.

Check with the directors at the Belk Heart Center, Presbyterian Hospital, Charlotte, NC. Their support staff, which consists entirely of RCISs by job description, has inserted sheaths for years. This center is always a forerunner in advanced staff participation in patient care.

Also, check with the Arkansas Heart Institute, Little Rock, AR. Their technical staff perform procedures at advanced levels.

Chuck Williams RPA, RT(R)(CV)(CI), RCIS
Emory University Hospital, Atlanta, GA
codyrpa@yahoo.com

Physicians only

Physicians only insert sheaths in our lab. The solution is actually the same as the premixed bags of heparinized solution we use to maintain our arterial lines.

Charlie, ccole@carilion.com

Yes, RCISs and MDs

We’re Kootoenai Medical Center in Coeur D’Alene, Idaho. RCISs and doctors put in sheaths here. The policy is being written to better define this. Not all the techs are trained yet, but in time, all will be. While training, each tech will perform approximately 20 sheath accesses, then will work individually provided there were no adverse situations which would require more one-on-one training.

Randy Nilsson, RCIS, Kootenai Medical Center
Coeur D’Alene, Idaho
Nelsongo24@aol.com

Not common, but done

I don’t have numbers, but I suspect that it is not common. I have inserted both femoral arterial and venous sheaths as both RCVT and RN at different hospitals. Both times, discussion with the medical direction established a training policy: two physcians gave direction, and together we developed an SOP and written policy for each technique. Once both training doctors were satisfied, we all signed off and it was placed in my permanent training folder. My skills were demonstrated for each physician that I worked with and each also signed off. Out of ten techs and RNs, only two of us ended up placing sheaths on a regular basis. Consistency, tracking complications and retraining, if needed, all need to be addressed in the SOP and policies. Placing sheaths occured only with direction of the cardiologist, though they didn’t need to present. Risk management was consulted in view of the inreased risk and responsibility incurred by both the physician and myself. In spite of the care needed and concern for risks, the ability to place sheaths, particularly in an emergency, is invaluable. Even in routine cases there can be a significant time savings when doctors are multi-tasking a call to the lab and they know that everything will be ready to place the catheter or the guide.

Jcathlabrn@cs.com

Not enough data

We do not have a policy at this time for tech (RN, etc,) to insert arterial or venous sheaths. The possibilities have been looked at, but there is not enough data to support outcomes. However, I do know of one hospital in the Phoenix area that does allow its cath lab staff to insert sheaths.

Our cath lab consists of RNs and Techs and there is no policy for the RNs or Techs to insert sheaths. This is for the physicians only.

Charlene Houston,
Winchester Medical Center
charlene@shentel.net

Ask further questions

This is a very good question and although the variety of answers address the specific question, there are several other questions that need to be answered.

1). Does your state law allow people other than physicians to inject an anesthetic?

2). Does your state law allow people other than physicians to insert a sheath?

3). Does your medical consent forms explain clearly to the patient that someone ‘other’ than a physician may be inserting his/her sheath?

4). Does your personal or instititional malpractice insurance cover you for inserting sheaths or administering lidocaine?

5). What does JCAHO say with regard to this topic?

While it is certainly convenient for the physician to walk into a room and have the sheath ready and waiting for him/her to perform the procedure, one might want to ponder these questions and even discuss them with your personal attorney. Consider the impact to ˜your’ assets if a patient were to litigate for any reason. Will the physician and hospital stand behind your both legally and economically?

Robert J. Basile, Sr., RT(R)
Lead CardioVascular Radiologic Technologist
bobstero@ptd.net

No interest or support

That is one thing that has never found physician support here. There is also not a driving interest from the techs.

Anna, annasmith@chi-east.org

Could disrupt relationships

I know that busy cath lab staff would have opportunity to become proficient because of the number of cases done and regular use of skills. But, the MD will ultimately be responsible for the patient; good technique and bad. This could leave room for poor MD-staff relationships. I don't believe procedure time reduction is a trade off for poor patient outcomes anddisruption of lab relationships.

Carla Lenart, RT-R CV, Banner Thunder bird Medical Center, Glendale, Arizona
cvgal5000@yahoo.com

Inserting under radar

I, as an RCIS, have been inserting sheaths for years. This is done under the MDs’ licenses, and is not charted as such. We also have a scrub X-ray tech, and a scrub nurse, both of whom have been trained, and insert sheaths, also. Once again, this is done under radar, so to speak.

Name and Hospital withheld by request

Only MDs

Only MDs insert sheaths in our lab.

Natalie D. Beiler
Assistant Director of Cardiology
Rockingham Memorial Hospital
nbeiler@rhcc.com

Respiratory Therapists covered

In my lab, I have 2 Respiratory therapists and they are covered to insert sheaths. No RNs are covered or Rad techs.

Larry Sneed, BS, RCP Coordinator,
Cath Lab
lsneed@armc.com

No insurance

Our physicians recently asked us to start this. We did some research and found very little support for the practice. In the end, our insurance would not cover the liability.

Michele Pierski, RTR, Cath Lab Leader
Baxter Regional Medical Center
Mountain Home, Arkansas
mpierski@baxterregional.org

Not allowed

In our cath lab in northeastern PA. Our techs or nurses are not allowed to insert sheaths.

t9261@epix.net

Under investigation

Currently, only physicians insert sheaths and administer local at Erlanger Health System in Chattanooga. I am investigating the possibility of Cardiovascular Specialists performing some of these procedures, though.

The questions Bob posed (at left) are good ones to be thinking about, and will help to set the stage for getting permission. The answers thus far are intriguing but with the questions that Bob posed, it should give us all a flag of caution to be sure that we check all avenues first. Sometimes it’s hard to be forgiven when we’re a little careless in getting the permission.

Craig Cummings, RCIS, FSICP,
Cardiac Cath Lab\EP Lab Director,
Erlanger Health System, Chattanooga, TN
cummincg@erlanger.org

Ugliest complications

No one here has ever inserted sheaths except the cathing physician. There has been some discussion of it in the past mainly from cardiologists who want someone else to do everything for them! but the majority of our physicians and our medical director oppose for scope of practice reasons. Although they are rare, some of the ugliest complications come from the arterial stick and sheath insertion. I will be interested in hearing from others.

jparham@armc.org

RNs insert PICC lines only

Currently, we do not have anyone other than MDs inserting sheaths anywhere in the hospital. RNs insert PICC lines, but that is the limit at this time.

I’m not sure the Board of Registered Nursing in California allows this practice, but will check.

Carolyn Estrada, RN, CMH Hospital, Ventura, California
cestrada@cmhhospital.org

Policy and procedures provided

Below is our policy/procedures for sheath insertion. We have been doing this for years and years.

Scott Fylling, Manager of Cardiac Cath / Special Procedures
Scott.Fylling@bhsnet.org