Questions Under Discussion:

Question 1: Hemostasis after radial cases
I have a question for labs that do radial cases. What do you do for hemostasis after the case? Do you hold manual pressure? Do use a pressure device such as the HemoBand*? We are currently trying to research products to use in our lab to assist with radial artery hemostasis.

Thanks,

Liz, RN, BSN
University of Wisconsin Hospital and Clinics
ea.levi@hosp.wisc.edu

Question 2: Cross-training
There is some controversy over the role(s) available in the cath lab for different credentialsš and just to what extent they can and should be cross-trained. What do you feel are the proper role(s) or responsibilities for RNs, RCISs, and RT(R)s in the cath lab? What about other credentials like physician assistants (PAs)?

Group Members™ Responses to Question 1: Hemostasis after radial cases

Minor percentage radial
We always use manual pressure, but still do the vast majority of our cases femoral.

Mike Martin, cardiacguy@san.rr.com

Many options available
We currently pull the radial sheath as we immediately place the Comfort Band by TZ Medical, Portland, OR. We have wonderful success.
Vascular Solutions has a band called D-Stat Radial with a thrombin-laced pad that looks wonderful and we will trial it later this year. We have switched to the Vascular Solutions D-Stat pad with good success. Our success with the radial band is with both diagnostic and interventional.

Patti Coblentz, PatriciaACoblentz@ProvenaHealth.com

HemoBand best
Currently, for our radial cases we hold 10 minutes of manual pressure and then apply a HemoBand afterwards. The HemoBand usually stays on for 30 or 60 minutes. We also have researched various types of pressure devices and found this to be the best.

Thomas Gaylets, t9261@epix.net

Manual pressure
At the hospital I work at, we use manual pressure.

Kevin BS, RN, RCIS, ldrich3@comcast.net

Manual, then device
While I™m now in a nurse anesthesia program, when we did radial cases, we always achieved hemostasis manually, then used the HemoBand (although a cotton gauze pledgette and a tight wrap worked as well for one of our docs).

Jcathlabrn@cs.com

Radial hemostasis step by step
We use the HemoBand. The band is placed into position. One person draws blood from the sheath during removal so any clot debris is removed from the tip of the sheath. As the sheath exits the site, the artery is permitted to spurt slightly. Digital pressure is applied above and below the site.

A sterile, folded 4 x 4 is placed over the site so pressure is applied over the skin entry site and the actual arteriotomy site. If the radial artery is not compressed this way, retrograde flow from the ulnar artery will occur. The band is tightened until bleeding is stopped. The ulnar pulse has to be intact so the distal wrist and the hand continued to be perfused. The band is released two clicks q 15-20 minutes over the next 2 hours. Pulses are often checked throughout the procedure. The patient is placed in his (her) bed with the arm draped across a pillow on their upper abdominal area.

Chuck Williams, RPA, RT(R)(CV)(CI), RCIS, Emory University Hospital, Atlanta, GA,
CharlesWilliams@mail.weber.edu

Step by step
Bon Secours St. Mary™s Hospital, Richmond, VA, accessed radial arteries in the mid-1990s. Physicians were not pleased with this technique (patient discomfort, complications). Since then, if access from the groin is not possible, they simply perc the brachial artery (as oppose to a cut down) and hand hold later. I™ve used a blood pressure cuff/wick (4x4) technique and I prefer to hand-hold the artery.

Chris Reoch RCIS, reochris2000@comcast.net

Always manual pressure
As far as radial cases go, we do a very low percentage, but we always use manual pressure after a radial case, then fold a 4x4 and apply a pressure bandage. The majority of our cases are femoral.

Larry Sneed BS, RCP, Coordinator, Cath Lab

Group Members™ Responses to Question 2: Cross-training

There is some controversy over the role(s) available in the cath lab for different credentialsš and just to what extent they can and should be cross-trained. What do you feel are the proper role(s) or responsibilities for RNs, RCISs, and RT(R)s in the cath lab? What about other credentials like physician assistants (PAs)?

Alamance Regional Medical Center, sneelarr@armc.com

Everyone plays a role
I believe all three disciplines are needed in the cath lab. The RTs are needed more than ever with the advent of peripherals in the lab. The RNs for the conscious sedation and the CVTs for their monitoring skill. I also believe they should all be cross-trained except for conscious sedation and exposing and setting up peripheral. Most importantly, everyone should be paid the same, with experience being the determination of rate of pay.

Georgann Bruski, RT(R), CRT, ARRT, Cath Lab Digest Editorial Board Member, Manager Invasive Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
gbruski@bidmc.harvard.edu

Limitations = boredom
I started in the cath lab in 1988 as an RT(R) and was trained with 2 paramedics. All of us were trained to med circulate, scrub and monitor all cases that came through the lab. If there were questions, there was always a resource on the team. I have since became an RCIS and have worked at places where the roles are limited. After a while, it really becomes boring compared to the places where you can rotate your roles from case to case.

Anonymous by request

Any mix can do well
This seems to vary from state to state, but in general, I think cases can be done well in a setting where there is any mixture of credentials, including all one type (i.e., all CVTs, all RTs or all RNs).

Mike Martin, cardiacguy@san.rr.com

RNs and RTs
We only have RNs and RTs. There is a very fine line between these two professionals in the area of medications. The RTs give sublingual NTG and heparinize our pour bottle solutions. Otherwise everybody scrubs and monitors.

Patti Coblentz, PatriciaACoblentz@ProvenaHealth.com

No conflict with Nurse Practice Act
Our lab is cross-trained. We have two CVTs who do not circulate. RCIS- and RT(R)-credentialed people give drugs under the direction of a physician. In Tennessee, this doesn™t conflict with the nurse practice act and in other states it might. Some hospitals in our area don™t permit this because of their own policies.

Presumably, other credentialed people could give drugs in the cath lab with in-house education covering how to administer drugs and education regarding the drugs used in the cath lab setting. This would be governed by hospital policy. I would think a PA would be completely cross-trained in our cath lab.

Marcia Todkill, BSN RN, Cath Lab, Methodist Medical Center, Oak Ridge, TN, Todkill@worldnet.att.net

All give meds
We are all cross-trained. I have 2 RNs, 1 radiologic tech, 2 respiratory therapists (RCP) and 4 RNs in RR. All cath lab staff is trained equally to give meds, covered by our Medical Director. In the state of North Carolina, the law is the extended hand of the physician. Several hospitals in the area do the same thing.

Larry Sneed, BS,RCP, Coordinator, Cath Lab, Alamance Regional Medical Center, sneelarr@armc.com

Looking ahead
Credentials have no bearing what the responsibilities are in the cath lab system at Emory, because everyone is cross-trained. Within the next decade, I do envision a movement of nurse practitioners, physician assistants, and radiology practitioner assistants into the labs. The reasons are because they can: (1) fully assess patients in pre-procedure states; (2) obtain consents if mandated by the credentialing committees; (3) perform diagnostic procedures especially in private cath lab systems; (4) administer medications, and (5) fully assess patients after the procedure has been completed.

These advanced hospital credentialed professionals will also complete all history and physicals, do the procedure reports for the physicians, do the discharge summaries on the patients, and most importantly, free the physician-in-charge to care for more patients. In essence, productivity is greatly increased.

In addition, these advanced trained allied health professionals will all have master level degrees, which is going to become the precedent for the very advanced invasive and interventional cardiac care systems.

Chuck Williams, RPA, RT(R)(CV)(CI), RCIS, Emory University Hospital, Atlanta, GA, CharlesWilliams@mail.weber.edu

In-fighting counterproductive
I™ve worked in several labs, in various states, and am very much in favor of cross-training as much as local laws and BoN will allow. As long as specific areas are not prohibited by law, general cross-training can make for a much closer working relationship between the groups that may be found in a CCL. That way, any available individual can take care of a problem, rather than hunting for the nurse, or the rad tech, or the respiratory therapist, or the cath tech (the RCVTs in our lab.) After spending over fifteen years in various labs (including radiology special procedures rooms), I feel that there is no room for in-fighting over ownership of specific areas. Intelligent, well-educated, carefully trained people of any field are capable of doing much more than they are given credit for. Different fields bring variety, and new ways of doing things, to the table that is the cardiac cath lab.

Cross-training can bring the opportunity for large scale process improvement. HOWEVER, this supposes that there is a carefully thought-out plan and schedule for educating your staff in the cross-training process. Standards must be identified for each role or task, and documentation of how and when those standards are met must be maintained.

Jcathlabrn@cs.com

Patient care suffers
We don™t have any PA™s at either hospital I work at. Personally, I think that everyone should be one field...everyone should be cross-trained, because of: 1) morale; 2) diversity; 3) staffing; 4) available resources. I have seen where labs have lost GREAT staff members because they have gone away from cross-training. One of the great things about being in the lab is the different positions and responsibilities...if everyone gets stuck in one role, burnout rises and I think patient care suffers.

Kevin BS, RN, RCIS, ldrich3@comcast.net

Ideal to have; realities difficult
In our lab, the RTs and the CVTs do the scrubbing. The CVTs do the monitoring and we do have some RTs that monitor also. The RNs don™t scrub on cases but circulate and we do have some RNs cross-trained to monitor. There has to be a RT and RN in each procedure.

I think ideally, everyone should be cross-trained because it gives you an appreciation of the roles other have in the lab and what their job responsibilities include. I think people tend to be less critical of others when everyone is cross-trained. I believe it also makes you more diversified and you have a better overall understanding of cath lab procedures; it broadens your own knowledge base. We have not trained RNs to scrub mainly because we have not had enough RNs in the lab to have two in the rooms. I also think that to really become proficient in scrubbing, you have to do it on a regular basis, so once trained, if you only scrub once every couple weeks you never get to a point where you feel confident in your abilities. I think it is ideal to have everyone cross- trained. The realities of that, however, are more difficult to obtain.

Annie.Ruppert@sharp.com

20 years & says ˜yes™ to cross-training
I™ve been a RCVT since 1984, CCVT before that, and now an RCIS since the conversion. I've seen many changes over the years. I've worked at Norfolk General Hospital in the late 1970s; Geisinger Medical Center in the 1980s and St. Mary™s Hospital since 1983. I personally believe in a skilled staff cross-trained to perform all tasks. An RCIS is able to perform all roles except administering medication (I was able to administer meds until 1995 and I am trained to do so). Now when there are two nurses and myself on a team, the nurse monitoring will assist me when I™m circulating. There are no PAs in our lab. RTs perform all tasks (except meds). We utilize paramedics in our lab (3 presently) who are excellent techs.This is a RN-based lab.
Hope this helps.

Chris Reoch RCIS, reochris2000@comcast.net