New Questions for December 2007

No. of Peripheral IVs
How many peripheral IVs are inserted prior to catheterization procedures? We have always placed two, but some in our lab feel it is not necessary, and others feel it is. We were hoping to get some feedback from other hospitals. Thank you!
Jena Canavan, RN, CCRN
Invasive Cardiology Educator
Email: jcanavan@notes.cc.sunysb.edu
Cc: cathlabdigest@aol.com

Normal Caths & Standard Ambulation Times
How does your institution handle the following items?
1. Do you track normal cardiac cath numbers? If so, how? If yes, what is the criteria in place that defines a normal cardiac cath (i.e., no blockages greater than 15% in any major artery greater than 2mm diameter)?
2. What are the standard ambulation times after a diagnostic cath using 5 or 6 Fr sheaths, when the patient has not received heparin. How long do you keep patients on bedrest after hemostasis is achieved? (Manual holds only, no devices used for closure.) For those responding to this question, do you know of any studies or articles/research that supports this ambulation time?
Thank you!
Annie Ruppert
Email: Annie.Ruppert@sharp.com
Cc: cathlabdigest@aol.com

Data on Pre/Post Beds per CCL
I am looking for data or research that supports the number of pre/post beds per cath lab. Are there any guidelines on recommendations ratios?
Thanks for your help.
Melissa A. Muller
Cardiovascular Service Line Administrator
Bronson Methodist Hospital
Kalamazoo, MI
Email: mullerm@bronsonhg.org
Cc: cathlabdigest@aol.com

Ambulation, T&S Questions
1. Does anyone ambulate patients to the lab (elective outpatients only)? Do they have criteria to assist with the decision to wheel or walk?
2. Do other labs require a type and screen on all patients pre-procedure? Is there a specific subset of criteria to meet for T&S requirements?
Thank you!
Terry Leonard, Unit Educator, Invasive Cardiology
Stony Brook Univer. Medical Center
Email: tleonard@notes.cc.sunysb.edu
Cc: cathlabdigest@aol.com

Medication Errors
I was wondering if anyone knows of any studies on medication errors in the cath lab and statistics involving the errors (i.e., nurses vs. techs, intervention vs. diagnostic). I was wondering who commits the most errors and during what situations the errors are committed. I feel this would help the lab where I work with calling attention to some areas where we may not always look (not that we have many errors at all). We have a lot of relatively young staff and we may be looking at cross-training techs to give medications down the road. If you have heard of any studies or know of where I may be able to find this information, I would greatly appreciate it. Thank you,
Mark Baker, MICP, RCIS
Email: cathtech99@yahoo.com
Cc: cathlabdigest@aol.com

Screening Criteria
We are a small rural hospital with one diagnostic cath lab and two cardiologists. We have been unable to locate any up-to-date screening criteria (the most recent American College of Cardiology guidelines are dated 2001). What criteria would you recommend that we follow to screen our patients (inpatients and outpatients)? We do not offer bypass or interventional procedures. The closest facility is 30 minutes away.
Thank you for your help.
Cheryl J. Harrell, RN
and Lori A. McMahon, RN
Provena United Samaritans Medical Center
Email: Cheryl.Harrell@provena.org
Cc: cathlabdigest@aol.com

Cc cathlabdigest@aol.com to have your response
published in the next issue of Cath Lab Digest.
New questions are welcome.

ACT Check Prior to Sheath Pull
Our cath lab is currently reviewing and writing policies and procedures. We are currently reviewing standards for pulling arterial sheaths when heparin has been given as a bolus prior to a diagnostic procedure or during a peripheral intervention. Currently, there is no practice in place to check an ACT unless the physician orders it. Our Policy and Procedure Committee wants to implement a policy for checking an ACT prior to pulling the sheath.
What is your department™s policy/ practice, and what level of the ACT is deemed safe for patients?
Thank you!
Mike LeGal, RN, BSN, CCRN
Cardiovascular Lab
Kaiser Sunnyside Hospital and Medical Center
Clackamas, Oregon
Email: Michael.R.Legal@kp.org
Cc: cathlabdigest@aol.com

Hi Mike,
ACC has specific guidelines on ACTs and sheath pulls, as well as the manufacturers of Integrilin, ReoPro and Angiomax. When creating a policy, you must follow manufacturer guidelines, as this goes along with FDA indications for use. ACC says don't pull unless the ACT is less than 180 seconds.
We obtain an ACT whenever heparin is given prior to sheath pull, and the result must be less than 180 seconds. AACN also has a policy on sheath removal that refers to ACTs.
Hope this helps.
Terry Leonard
Unit educator CCL
Stony Brook University Medical Center, Stony Brook, NY
Email: tleonard416@optonline.net
Cc: cathlabdigest@aol.com

Our policy and procedures contains standing orders for ACT checks for patients who receive enough heparin that they might be >200. It allows for nursing judgment and yet supports the test and a sheath pull at 200 or less. See below.

VIII. Sheath Removal
A. Prior to Sheath Removal:
1. Ensure that peripheral IV is patent and hang 500 cc 0.9% NaCl IV at KVO rate.
2. Insure patient in monitored and a baseline obtained.
3. Administer medications as needed as ordered.
4. Infiltrate the groin subcutaneously with 1% lidocaine as needed.
B. Sheath Removal Process
1. The sheath is removed by physician, physician assistant, cath lab technologist/RN, or CVCC or CRU RNs who have demonstrated competency according to the MHMH competency criteria. Circumstances under which the RN should not pull a sheath are listed in the policy/procedure. If the RN is asked to remove a sheath when a limiting factor is present and feels comfortable in doing do, a note should be written on the flow sheet. The medical back-up outlined in Part I, Section VI will be utilized if problems are incurred when RNs pull the sheaths.
2. Compression device is maintained and released by RNs according to the MHMH policy/procedure.

C. Arterial Sheath Removal Protocol
1. Do not feed patient until stable after sheath is out.
2. Check ACT q 1hr until <220 seconds, then q 30 min. until <200 seconds.
3. Pull sheath when ACT <200 seconds.

D. Venous Sheath Removal Protocol
1. Pull venous sheath after arterial sheath is pulled and patient is stable.
2. If only venous sheath in place, pull when actual (or estimated) ACT is <200 sec.

Right now, we also have to wait until the ACT is 200 to pull venous sheaths, but we are looking at that policy and will be conducting a trial of pulling at higher ACTs.
If you™d like any further information or if I can interest you in our Hypotension Protocol (which has saved lives), please let me know.
Pamela McLaren, RN, BSN
Cath Recovery Unit
Dartmouth Hitchcock Medical Hospital
Lebanon, New Hampshire
Email: Pamela.A.McLaren@
hitchcock.org
Cc: cathlabdigest@aol.com

RCIS Mandatory?
We are thinking of making it mandatory for our staff to be RCIS-certified. Are there labs that have done this? What has been your process to implement this change?
Anonymous
Email: cathlabdigest@aol.com

Approximately two years ago, we required personnel working in the cath lab (RNs and RT(R)s) to obtain the RCIS credential. We felt it was the one way to measure the knowledge levels pertinent to the cath lab. Surprisingly, it was accepted as a challenge by the staff. Our job description now includes that within one year an RN or RT(R) must obtain the credential (graduates of cardiovascular programs must obtain their credential within 3 months of hire date). Upon passing the examination, the individuals were given a 3% raise and the cost of the test was reimbursed. Some of the people took a semester class online from Wes Todd through Spokane Community College. The only people disappointed were the RCIS people because there wasn't an additional test for them! Good luck!
Debbie Herndon, Manager
Cardiac Cath Lab
Saint Alphonsus
Regional Medical Center
Email: debohern@sarmc.org
Cc: cathlabdigest@aol.com

Re: The ongoing discussion
regarding the possibility of an Advanced-Level Cardiology Physician Extender Program
I am all for the advanced training programs for cath lab professionals. However, Certified is less of an accomplishment than Registry. Extender is confusing in every aspect of the profession. I don™t want to be known as an Extender (the docs will have a ball with this one). We need to stay with specialist, technologist, etc.
We have to sustain the Cardiovascular Credentialing International (CCI) Registered Cardiovascular Invasive Specialist (RCIS) credential credibility.

AS could be:
Registered Cardiovascular Physicians Specialist.
Registered Cardiovascular Technologist.

BS could/should be something like:
Registered Invasive Cardiovascular Physician Assistant.

Respectfully,
Ron V. Boswell, CVT
(soon to be RCIS)
Salt Lake City, UT
Email: rvboswell@cvty.com
Cc: cathlabdigest@aol.com