Clear Advantages of Radial-First Catheterization, Including Improved Recovery Experience
“We’re a unified group of interventional cardiologists with similar practice patterns,” says Vincent Pompili, MD, Director, Interventional Cardiovascular Medicine and Cardiac Catheterization Laboratories. “We reviewed data from across the country and our own institution, agreed this change was best for patients, then committed to the new direction, with transradial catheterization as our first choice for patients having cardiac catheterization or intervention at Ohio State’s Heart and Vascular Center.”
The data is related primarily to bleeding rates and access site complications. Since introducing transradial catheterization, the practice has recorded a steady decrease in bleeding rates and access-site complications from catheterization. Today, with approximately 60 percent of the practice’s catheterization patients undergoing a transradial approach, these complications are significantly lower than the national average.
“Patient safety is a key driver of practice modification,” says Pompili. “The first quarter after the switch to a radial-first practice, bleeding complications and access-site complications decreased by 60 percent.”
Another important aspect of the data relates to cardiac outcomes. According to Quinn Capers IV, MD, Director of Peripheral Vascular Interventions, patients who have major bleeding from the femoral artery and require transfusion after catheterization are at increased risk for adverse cardiac events, including death for up to 12 months afterward.
“Transradial catheterization has reduced complications (access site and bleeding) at our institution, so it was an obvious and unanimous decision to change the practice,” says Capers.
While some patients are not candidates for transradial catheterization due to their anatomy, the practice anticipates the percentage of patients catheterized transradially could reach 75 percent.
“We look at all options for patients, consider their unique situations and identify any reasons to exclude transradial,” says interventional cardiologist Charlie Bush, MD, associate medical director of the Ross Heart Hospital. “The advantages are that significant. Pompili anticipates transradial catheterization will be gradually adopted as the norm around the country.
“We do not take advantage of all of the benefits of transradial catheterization if we do not also modify the recovery process,” says Pompili.
Patients undergoing transradial catheterization present a unique opportunity to optimize the recovery experience. Toward that end, The Ohio State University Wexner Medical Center opened a new Radial Lounge in September 2012.
Previously at Ohio State, all catheterization patients recovered in the same 23-bed invasive prep and recovery unit. Now, during catheterization procedures, the charge nurse is alerted when patients do not need stenting and are good candidates for recovery in the Radial Lounge.
These patients are transported via wheelchair to the Radial Lounge, where their IVs are removed. They can change into their clothes and spend the next two hours recovering comfortably in a recliner. The lounge has seven recliners for patients, couches for family members, and iPads. Patients wear an inflatable wristband that applies light pressure to the area of access and are monitored with wireless telemetry, allowing them freedom to walk around, eat and visit. Dedicated nurses, experienced in the care and recovery of post-transradial catheterization/PCI population, observe patients until they are ready to go home.
The Radial Lounge was designed with an adjacent consultation room for patients and their family members to discuss the procedure and view images with the physicians.
“Patients get one-on-one time with the cardiologist in a comfortable, private setting, which helps to increase the personalized feeling,” says Amanda Parkinson, Amanda Parkinson, RN, BSN, Nurse Manager of Invasive Prep and Recovery. “This wasn’t possible for transradial patients in our invasive prep and recovery unit because they have to lie down and are connected to monitoring equipment. The set-up in the Radial Lounge promotes mobility and supports positive changes in post-procedure protocols.”
“A significant benefit of transradial catheterization is faster, more comfortable recovery,” says Ernest Mazzaferri Jr, MD, interventional cardiologist and medical director of Ohio State’s Richard M. Ross Heart Hospital. He says the Radial Lounge improves the patient experience, eases the transition to discharge and provides the appropriate level of care to each patient.
Not having to lie down for hours after catheterization is especially good news for patients who have chronic pain, such as degenerative disk disease; who have had back or knee surgery; or who have a respiratory complication, such as congestive heart failure, COPD or emphysema.
“Patients who can sit up without compromising their safety during recovery need not be made uncomfortable by lying still for four to six hours,” says Marti Taylor, executive director, Ohio State’s Richard M. Ross Heart Hospital. “In addition to decreased complications and increased patient satisfaction, we consider efficiency of care. Clearly, moving patients who are ambulatory away from traditional recovery areas and toward discharge more quickly is a good thing. And hospital beds are freed up for patients who truly need them. By modifying our post-procedural care and pulling out these patients from the traditional recovery space, we have altered the way we’ve done something for two or three decades. It’s exciting to be a part of this progress.”
“Patients have great interest in advances such as this. Those who have had both types of catheterization like being able to get up and use the bathroom and have a snack. They much prefer the more active recovery to lying flat for hours with pressure on their groin.”
Parkinson emphasizes the emotional benefits of transradial catheterization and the new approach to recovery at The Ohio State University Wexner Medical Center.
“Patients may heal faster when they are comfortable and feel a sense of control over their situation,” says Parkinson. “With transfemoral catheterization, some patients are stressed by having their modesty compromised regularly while they lie still, without any options. Their stress is compounded when they need to use the bathroom during that time. We must consider the entire patient experience,⎯not just the physical, but also the emotional. In the new Radial Lounge, patients can have two to four family members with them, which helps everyone involved feel like part of the recovery process.”
“It’s no longer one-size-fits-all recovery. All eyes are on the Radial Lounge as other areas in the hospital consider the benefits from nontraditional recovery areas. As health care evolves, we focus increasingly on improving the patient experience.”
This focus includes training the next generation of cardiologists.
“We’re training and retraining our physicians and fellows in transradial catheterization because we think it’s the future of cardiac catheterization, with significant benefits for patients and hospitals alike,” says Mazzaferri.
An anatomy lab in The Ohio State University College of Medicine has become a simulation center for in-depth radial artery and wrist anatomy education.
“Approximately 95 percent of percutaneous coronary interventions (PCIs) in the United States are done via transfemoral approach because of physician inertia,” says Capers. “Cardiologists learned how to perform the procedure through the groin and do it very quickly. Switching to the radial artery requires additional effort, initially makes procedures longer and, therefore, can be frustrating. It’s common for cardiologists to try transradial once, determine that it is an unnecessary hassle and resume transfemoral. We have taken a strong intgerest in transradial training so that future cardiologists graduating from OSU will be experts in this approach.”
The interventional cardiology team at The Ohio State University Wexner Medical Center is parlaying this change into other aspects of its practice, including allowing low-risk PCI patients who live locally to have same-day discharge. “We’ve discharged 15 patients on the same day as their transradial PCI. The results have been excellent with no complications and no readmissions,” says Capers. “There are significant cost-savings to the hospital and to the patient.”
Preliminary data will be presented later this year at the American Heart Association meeting, demonstrating that the total cost to the hospital and the patient is reduced by approximately 40 percent when PCI patients are discharged on the same day of the procedure.
“The primary reason these patients had to spend the night was to monitor for risk of bleeding from the femoral artery,” says Pompili. “When we reduce the risk of bleeding and access-site complications with a transradial approach, PCI patients recover in the Radial Lounge, return home the same day and return the next day for a checkup. Nationwide, fewer than 1 percent of PCI patients are discharged home the same day. Across the board, health care is driving toward less invasive procedures that increase patient safety.” Now, the practice is leveraging its proficiency in elective transradial catheterization cases with emergency cases.
“We are researching using transradial catheterization and PCI in critically ill, STEMI patients,” says Capers. “Currently, only about 30-40 percent of STEMI cases at Ohio State are performed via the transradial approach. The benefits to this patient population could be significant because they are at such high risk for bleeding. Because the transradial approach can take a little longer, many physicians say it should not be used with heart attack patients. But we are using a special protocol to keep down the time in the cath lab and we are seeing exciting results. Of course, we will continue using transradial with stable elective patients. Time will tell if it becomes the future direction for unstable sicker patients. The potential benefits make it well worth exploring.”
As other interventional cardiology practices consider adopting transradial catheterization to improve patient safety and satisfaction, Pompili cautions that a learning curve exists. But, he emphasizes, transradial may not take longer to perform once physicians develop proficiency and have 50 to 100 cases under their belt.
“Your practice behavior can increase the level of safety for patients,” says Pompili. “The drop in bleeding complications can be drastic, making adapting to change well worthwhile.”
The team at Ohio State’s Medical Center has logged about 2,000 transradial cases to date, with some of the cases related to the SAFE-PCI trial, sponsored by Duke University. The trial aims to compare the efficacy and feasibility of the transradial approach to percutaneous coronary intervention (PCI) in women compared with the transfemoral approach. The Ohio State University Wexner Medical Center is one of the top enrollers of patients in the trial, which commenced in August 2011 and involves approximately 35 centers in the United States.
The authors can be contacted via Toni Hare at Toni.Hare2@osumc.edu.