Disclosure: Dr. Kern reports he is a consultant and speaker for St. Jude Medical
and Volcano Therapeutics, and a consultant for Opsens, ACIST Medical, Heartflow, and Merit Medical.
Many cardiac interventional programs have a team of dedicated personal to assist the physicians with sheath removal and hemostasis, and assist in the diagnosis and management of post sheath bleeding or other complications. The composition and scope of practice of the sheath management team is of concern to Dr. David Rizik, who asked our expert colleagues in the cath lab about sheath management in their hospitals. Many labs have developed competencies for cardiovascular techs and others to be specifically trained to perform this important aspect of interventional cardiology care.
As with our prior “Conversations in Cardiology”, I thank my colleagues for making this important discussion relevant to our readership, and sharing their wisdom and experience with us.
Dr. Rizik asks, “For more than 20 years, our hospital has utilized cardiovascular (CV) technologists to manage the arteriotomy site post cath. They are not registered nurses (RNs) nor respiratory technicians. Over time, our CV techs have evolved into a discipline directly overseeing: 1) simple sheath pulls post PCI [percutaneous coronary intervention]; 2) radial artery line placement pre-operatively for CV surgery; 3) Impella [Abiomed], IABP [intra-aortic balloon pump], and large-bore sheath management and removal; and 4) sheath management post TAVR [transcatheter aortic valve replacement] and TMVR [transcatheter mitral valve repair]. They have been an integral part of our CV department. We have tracked numbers over the years and our observed-to-expected number ratio of bleeding/groin complications has been exceedingly low, comparing favorably regionally and nationally.
“These individuals have no particular certification, because when we initiated this program there wasn’t a formal certification process. Rather, we have developed a robust internal training and certification process which has worked well. Some of these techs have been doing this for 40 years with an excellent track record. Some of them started off in the cath lab and others started directly in this CV tech position.
“Here’s the problem. Recently, our administrators have stated their intention to sunset this program. The rationale which they cite is as follows:
- Groin management with these CV techs is out of step with national and state standards.
- In the future, this practice will be ‘out of compliance’ with state and national guidelines.
- The job (post PCI sheath management) is regionally and nationally being shifted to the respiratory therapists, as they are increasingly becoming ‘cardio-pulmonary specialists’ and sheath management falls within their domain of practice.
- What are other institutions doing?
- Is this really evolving into respiratory therapists’ scope of practice?
- Are there other institutions who continue to practice as we have?
- Are the financial pressures of the new world order mandating a change in these types of practices?
“This issue is important to us. Anyone who has practiced in the cath lab understands that quality prevention of bleeding complications is the best way to decrease morbidity, mortality, and hospital length of stay.”
Mort Kern, Long Beach, California: Since I am always the first to get the question, I will be the first to answer. In our system, fellows with attending physicians pull sheaths, so issue of scope of practice of CV techs is not really applicable to us. However, I believe sheath pulling is beyond the normal scope of practice for respiratory therapists. They could be trained and develop competencies to do the job, but this requires a curriculum and apprenticeship in the cath lab environment.
To your last question, the goal of a merged hospital system redesign is always directed at strong financial restructuring. The new scope of practice for respiratory therapists (or anyone) should not sacrifice good outcomes, and should not overreach to individuals not competent or interested in doing the work.
Bonnie Weiner, Worchester, Massachusetts: [At our place], when closure devices are not used, fellows, mid-levels, or nurses hold the groin. With the increase in radial cases, this has been less of an issue, but there is still a need to have people that are well trained not only in how to do it, but in what to look for when things don’t go well. We have seen respiratory therapists trained to work as cath lab techs, although it always concerns me that they don’t have the background to do it, but may just be the only people interested in the job. Yes, I think they can be trained to do this, but agree that safety and good outcomes need to be the goal. There may also be local hospital and/or state regulations that determine who can do what.
Lloyd Klein, Chicago, Illinois: We have had this issue at one of the hospitals I cath at. Fortunately, the fellows pull many sheaths, but with collagen devices, even that training is disappearing. My advice is that in a world where one has to pick and choose ones battles with administration, this isn’t one to fall on your sword over. Still it does reflect changing times, and not in a beneficial way.
Gus Pichard, Washington, D.C.: In Washington, our CV tech group takes care of all sheath pulling (femoral and radial). They do it in the cath lab or the floors. This includes balloon pumps, but not TAVRs. They have done it for decades, very successfully. We keep data on results and outcomes. Because of experience, they are much better at it than fellows or physicians (who never do it). The CV techs are certified as registered cardiovascular invasive specialists (RCISs), and the certification includes sheath management.
John W. Hirshfeld, Jr., Philadelphia, Pennsylvania: We have been relatively modest radial adopters, principally because we have a highly effective femoral sheath management system that has kept our groin complication rates well below that of most published series. Thus, in our hands, we do not see an important difference between radial and femoral in terms of access site complications. We use access site closure devices sparingly. Different operators in our group have differing levels of radial experience and proficiency, and we generally select the access site that we feel will provide the best quality study, given the particular patient’s characteristics and the experience level of the particular operator. The important aspect of success in sheath management is the program. Our recovery unit is staffed by nurses who care for cath and EP patients pre and post procedure. They are all highly proficient in femoral access management and take pride in the quality of their work. They are so much better than inpatient unit staff that we hold all our inpatient intervention patients in the CRU until sheath removal and demonstrated access site stability. Different nurses prefer either manual groin hold or the CompressAR clamp [Advanced Vascular Dynamics]. They believe in the Syvek patch [Marine Polymer Technologies] and use it. Our arterial access is almost all 6 French and typical hemostasis times are 15 minutes with ambulation in two hours after hemostasis is achieved. For anticoagulated patients, we pull sheaths when ACT [activated clotting time] <200 sec.
The end product of this is that our fellows have had very little experience in access site management — probably not a good thing. We tried training our cardiac intermediate care unit nurses in sheath removal, but abandoned it. None of those nurses ever acquired sufficient experience to be proficient, we had a lot of problems, and the nurses themselves actively disliked the responsibility. Having our recovery unit nurses highly proficient and taking pride in their proficiency has proved to be the key to success.
James Tcheng, Durham, North Carolina: We have a balanced approach to choice of access, with several operators strongly favoring radial while others continue to primarily use the femoral approach. A partial reason for us to continue to emphasize the femoral approach (and to continue the use of a manifold, and to have our fellows pan the table, etc.) is the desire to give our fellows the maximal “hands-on” experience from all perspectives. Consistent with Dr. Hirshfeld’s experience, our femoral access bleeding complication rate is well below rates observed at the national level (e.g., NCDR [American College of Cardiology-National Cardiovascular Data Registry]) and in published series. And this is accomplished in an environment where fellows are attaining access over 90% of the time. Our rates are sufficiently low that we review every major bleeding complication at our monthly morbidity and mortality meeting — and we do go months without needing to review a case.
I believe there are several contributors to the success of the Duke cath lab. First, a lecture is provided to the fellows (after about 2 weeks of experience) teaching the correct approach to attaining femoral arterial access. I need to specifically acknowledge Zoltan Turi for assembling a phenomenal presentation that articulates the specifics — it should be a standard part of every cath rotation curriculum.
We have largely converted to micro puncture technique — much more comfortable for our patients, and fewer issues related to missed passes. We rarely use vascular closure devices. Absolutely critical is our approach to sheath removal hemostasis. Sheaths are pulled and manual compression applied by our cath lab techs and nurses. When a patient needs to have a sheath pulled on the floor, we send one of our cath lab techs/nurses to do it. When a fellow pulls the sheath, they are supervised (usually by staff) to make sure they do it correctly. As with UPenn, our cath lab staff are all highly proficient in femoral access management and take pride in the quality of their work. This is a specific proficiency that is included in their competency training and annual review. Virtually all of the pulls are manual — we do have the CompressAR clamp, but in general, our staff prefers manual compression.
Sheath management is not within the scope of practice of respiratory care. They know little about vascular access and vascular hemostasis.
Claudia Echeverry, Chief of the Angioplasty Specialists at Columbia Presbyterian Cardiac Cath Lab, New York City, New York: Dr. Ajay Kirtane (Chief of the Cath Lab at Columbia University Hospital) asked me to give you some information about groin management practice in our institution. Hemostasis and groin management is mostly a responsibility of 3 different clinicians in our lab: general cardiology and cardiac interventional fellows, physician assistants taking care of post-procedure patients, and angioplasty specialists in the lab. My angioplasty specialists are certified by CCI (Cardiovascular Credentialing International) as RCIS (registered cardiovascular invasive specialist), a credential renewed every 3 years and requiring 36 CEUs to remain active. One requirement for the credential is to have at least an associate degree from an accredited cardiovascular training program, which is usually a 2-year program to obtain the cardiovascular technologist title.
The scope of practice for the RCIS from the Society of Invasive Cardiovascular Professionals1 includes post-procedure recovery: access management and hemostasis skills (Section III-F). I required my team to have this registration, because we scrub on all cardiac and endovascular procedures, get access, and deploy closure devices. I want them to have not only several years of experience, but also full knowledge of groin assessment, management, and possible complications treatment and care.
I definitely think is very important to have well-experienced people taking care of sheath pulling and hemostasis, but it is also a good idea to have the cardiovascular technologist group credentialed to comply with hospital policy and procedures, including a well-defined job description and qualifications in your department and human resources. I know every state is different. Some utilize RNs and radiologic technologists (RTs), like Illinois. Florida and New Jersey hire RCIS and CVT in all the labs. California has RN, RT, and RCIS. RNs and RTs are also part of my group, with the same requirements for the RCIS to become part of the Angioplasty Specialist team. I have been doing this job for 25 years in different parts of the country and I haven’t heard of respiratory therapists performing this task. I think they have a totally different job description.
The bottom line
The sheath management team is usually from experience in the cath lab, with some institutions requiring RCIS credentialing. Local hospital policies and competencies must be adhered to and maintained. None of the labs above have noted an appropriate role for respiratory therapists unless they meet the requirements of education, training, and experience of their local sheath management team. Finally, administration’s attention to the appropriate scope of practice should never sacrifice a good track record of care for expediency.
David, I hope this addresses your concerns. I believe we all learned more about sheath management teams in the cath lab from this conversation.
- Society of Invasive Cardiovascular Professionals. RCIS Scope of Practice Rev 2010. Scope of Practice for the Registered Cardiovascular Invasive Specialist (RCIS). Available online at http://www.sicp.com/Scopeofpractice. Accessed September 23, 2015.