Laura Schiff, MSN, RN-BC, can be contacted at email@example.com.
At Enloe Medical Center in Chico, California, we are a ST-elevation myocardial infarction (STEMI) receiving center and perform approximately 110 STEMIs per year. Our call crew consists of a registered nurse (RN) circulator, a radiologic technologist/invasive cardiovascular technologist (RT/CVT) scrub tech, and a RT/CVT in the control room. For almost all of these cases, we have found a three-person call crew to be adequate. If we have a very critical patient during the day, we are able to find extra staff to assist with the procedure from our other room. However, during the middle of the night and on weekends, we have very critical patients who don’t quite require a full code team, but who would benefit from another cath lab RN.
We briefly considered having a second RN on the call team. However, we estimated that we would need a second RN during call hours once every few weeks, and it didn’t make sense to have a second RN only for these cases. Plus, with only 5 total RNs on staff in the cath lab, we would either have to hire additional staff or have the existing nurses take substantially more call. Neither of these would be cost-effective options.
We then looked to our rapid response team, which has been in place since 2010. Our rapid response team consists of a rapid response nurse, a respiratory therapist, and a pharmacist. We found the entire rapid response team was too many people: we really just wanted the nurse. Plus, we felt that we were spending most of our time showing them where the lead, gloves, and masks were, rather than having them give medications or assist with monitoring the patient.
Our next idea was to have the rapid response nurses come down individually for a brief tour and to see a case. While this would have been effective at orienting the day shift nurses, it would be far more difficult to orient the night shift rapid response nurses without incurring overtime. Additionally, it was the night shift nurses that we wanted to focus on, since we needed the most help on night shift.
When we realized we weren’t going to be able to do one-on-one orientations, one of our RNs suggested a video tour. We modified the idea to having a PowerPoint presentation with plenty of photos. This idea met all of our objectives: It would be cost-effective, it would give a focused orientation, and we could discuss how we wanted them to assist during a procedure. With the help of the ICU educator and ICU nurse manager, we decided to present this to the rapid response nurses during their quarterly meeting.
First, we needed to decide what we wanted the rapid response nurses to do, and how they could be utilized most effectively. During a series of informal meetings with the RNs and the RT/CVTs in our department, we decided we wanted them to focus on administering medications and patient monitoring. These two things were chosen because the rapid response nurse would already be competent in administering medications and patient monitoring, and it could be done with only a brief orientation. This would allow our nurses to focus on nursing duties that required a more intimate understanding of the cath lab, such as mixing medications, setting up the balloon pump, and handing off supplies.
The final PowerPoint presentation included a visual tour of the cath lab, a discussion of the rapid response nurse role, and some tips. We explained that they needed to wear a disposable cover coat, a disposable hat, and a mask while in the room, and showed them where these items are located. We showed them where the lead is located and had a brief segment on radiation safety, explaining what steps to take to minimize their exposure to radiation. We showed them where our emergency equipment is located, like the temporary pacing equipment and the oxygen.
The final presentation included our request that the rapid response nurse focus on administering medications and monitoring the patient. We also explained that our current system does not have audible alarms, since we realized they were accustomed to listening for alarms. For medications, we explained that virtually every patient receives an anticoagulant. Since the rapid response nurses were already familiar with eptifibatide and heparin, we gave a brief explanation of bivalirudin. We have a few doctors who order neosynephrine boluses, so we explained those and the usual doses ordered.
During the presentation, one of the rapid response nurses suggested adding the rapid response nurse to the group page. Now, the rapid response nurses are involved with the STEMI activations by going to the emergency department (ED) and assisting the ED staff. They are able to help with stabilization, giving medications, preparing the patient for the procedure, and even transporting the patient to the cath lab.
The response from this initiative has been positive, both from the cath lab RNs and the rapid response nurses. The cath lab RNs like it, because we know we have a backup set of hands, and we know exactly what we are going to ask them to do when they get to the cath lab. They are also able to find and put on the appropriate attire and protection before going into the rooms. Tessa Niswonger, a Rapid Response Clinical Resource Nurse, reports, “The rapid response nurses truly love going to the cath lab, and enjoy learning and seeing many new things.”