Discussion Group: What Do You Think?

Left upper arm discomfort after a PCI Have any of you noticed swelling of the upper extremities on patients who have had prolonged cuff blood pressure monitoring during and after PCIs? One of our cardiologists had a patient who complained of left upper arm discomfort after a PCI. Swelling of the upper extremity was observed. I was asked about this, and mentioned that I had noticed bruising on the medial areas of the distal humoral areas on patients who had come to the cath lab after being on heparin drips and/or GP IIb/IIIas overnight. Some literature has mentioned patients with swelling and petechia from prolonged cuff blood pressure monitoring that is done frequently. Chuck Williams, RPA, RT, RCIS Atlanta, Georgia Email: rpainga@yahoo.com Cc: cathlabdigest@hotmail.com Reader response: I have frequently noticed patients who developed bruising and petechia on the upper extremity where the cuff was. I have not seen swelling from an automatic cuff, however. Maybe the patient had some type of lymph drainage issue, and with the cuff going up and down frequently, it caused swelling. Just a thought. Frequently though, patients have petechia and bruising from the automatic cuffs. Have you ever had one on? They get very tight when they inflate. The machine is supposed to (after the first inflation) not inflate as high once it learns the patient’s blood pressure, but I have had one on and it felt like my arm was going to fall off! Annie Ruppert, RN, BSN Email: Annie.Ruppert@sharp.com Cc: cathlabdigest@hotmail.com The first thing I would consider is: Is the cuff the appropriate size? When it was put on the patient, did it pinch the skin? Whenever a patient complains of cuff discomfort, I will move it to the patient’s forearm or the calf. Kevin Rich, BS,RN,RCIS Email: ldrich3@comcast.net Cc: cathlabdigest@hotmail.com Three Zones in the CCL? I am an RN from Florida, and my specialty is surgery. Currently I live in Thailand, and work in Bangkok Hospital as a nursing consultant. My primary job is to educate the staff and help them to implement international standards. My biggest project involves the cardiac catheterization lab, so I am dealing with the same problems. I am currently working on a dress code policy for a cath lab department. This is a new hospital with fairly new staff. I am an experienced O.R. nurse, and think that the dress code should not be any different than in the main O.R. due to infection control and aseptic technique issues. My question is the following: Can the cath lab department be divided into three areas (restricted, semi-restricted, nonrestricted)? Can somebody recommend some references? Yelena Barclay Email: Yelena.Ba@bgh.co.th Cc: cathlabdigest@hotmail.com Reader response: In our cath lab, most staff come to work in street clothes and change into scrubs once they arrive. As for aseptic technique and infection control, we do not practice the same standards that the O.R. does, except when we perform AICD/pacemaker implants, in which case all staff wear a mask, hat, and booties and the tray is not opened or set up until the patient is in the room. We limit traffic in and out of the room during the procedure. Once the patient is in the room, staff may not enter or leave the room. In all other cases, the scrub person wears a hat and mask, gown and booties. Circulating staff wear hat and booties, but are not required to wear a mask. In biopsy procedures, all staff wear a hat, mask and booties. No one is permitted to enter any cath lab room without a hat on. Hope this helps! Annie Ruppert, RN, BSN Email: Annie.Ruppert@sharp.com Cc: cathlabdigest@hotmail.com The cath lab is not an O.R., it is a procedure room. All of the hospitals around here wear their scrubs in from home. They clean up the spills between patients, but the rooms are not cleaned like the O.R. would be, as it's not necessary. We only treat the cath lab rooms like the O.R. if we are performing a PPM. Protective eyewear, masks, and so forth are worn to protect the employee. Larry Sneed, BS,RCP Manager, Cath Lab Alamance Regional Medical Center Email: sneelarr@armc.com Cc: cathlabdigest@hotmail.com I can understand your perspective coming from an O.R. background. I, too, have several years of O.R. experience and when I came to the lab, I was a bit uncomfortable with the way things were handled; i.e., the difference in attitude regarding infection control. In the cath lab, you do not need the different zones as you would in the O.R. As long as you maintain a good field, you should be fine. Of course, when placing a pacemaker, then you would want to use strict sterile practices. Kevin Rich, BS,RN,RCIS Email: ldrich3@comcast.net Cc: cathlabdigest@hotmail.com Bispectral index (BIS) monitoring during pacer insertion What credentials, if any, are necessary to use the BIS during a pacemaker procedure? I am a nurse new to the cath lab, and am concerned that this is getting into the anesthesia arena for which I may not be licensed. Anonymous by request Email: cathlabdigest@hotmail.com Reader response: We do not use this type of monitoring device on patients in our cath lab. If patients need to be anesthetized for a procedure, an anesthesia specialist attends the case (AICD implants, ablation procedures). Otherwise, the RNs administer conscious sedation to diagnostic and interventional patients. Annie Ruppert, RN, BSN Email: Annie.Ruppert@sharp.com cc: cathlabdigest@hotmail.com Share your door-to-balloon timing? We are evaluating our door-to-balloon time, so I wanted to see what other labs are doing. 1. What is your door-to-balloon time? 2. Do you track all AMIs? 3. Do you still have an in-house RN to handle sheath-pulling and acute patients? 4. How many are on the call team? 5. What is their expected response time? Julie Baran, RN, BSN Clinical Manager Adult and Pediatric Invasive Cardiology Memorial Hermann Hospital Email: julie_baran@mhhs.org cc: cathlabdigest@hotmail.com Reader response: 1. Our door-to-balloon time at Covenant Heart Institute averages about 50% of cases in 90 minutes or less. 2. We began tracking all AMIs just this past month. Two people from our Quality Management department handle it all. One of them is called when an AMI patient is admitted to the E.R., an AMI occurs on the floor, or an AMI patient comes by helicopter as a direct admit to the cath lab. These two individuals track all the essential elements and standards until discharge. 3. All staff in the cath lab are trained to remove sheaths [RN, LVN, CVT, RT(R), cath lab assistants]. All staff on the cardiac floors (outpatient and inpatient) are trained to pull sheaths. As a matter of policy, the inpatient floors use the FemoStop device unless the doctor orders otherwise. The cath lab uses several methods. All floors know that they can call the cath lab if they need help and we will send someone. 4. We have two call crews. The second is just a backup if we have more than one procedure taking place at a time, which is not uncommon. Each 4-man crew has an RN, RT(R), someone to scrub and someone to monitor. 5. The response time is 15 minutes; the RN has 20 minutes because he/she has to call out the other members of the crew. We do not require staff to live in Lubbock, but we tell them they must get to the cath lab in 15 minutes on the nights they are on call. Patty Freier, RN, BSN, RCIS Nurse Specialist, Cardiac Research & Education Covenant Medical Center, Lubbock, Texas Email: pfreier@covhs.org cc: cathlabdigest@hotmail.com Ergonomics and moving patients I have been a RN in the cath lab for the last three years. I worked for 20 years in the O.R. where I am CNOR-certified. I have a concern with patient safety and employee injury from the practice our facility uses for transferring patients to and from the carrier to the catheterization table. Our method involves pulling the patient over by using the carrier sheet (possibly causing skin friction and shearing injury to the patient). Anywhere from 3 to 4 people pull patients without using a roller (a transferring device I have seen used in the O.R.). We do have a long board (which is more difficult to use because of its size); I have seen it used twice during the last three years. The board is awkward to use and I had no idea how to use it until I had been in the cath lab for a year. I am trying to gather information for our department regarding employee health in terms of back injuries as a result of transferring patients from carriers to the catheterization table using this method. Barbara Forest Email: Bforest2003@wmconnect.com cc: cathlabdigest@hotmail.com Reader response: AliMed Inc. has patient shifter boards, both the regular and the Conductive Shifter. Other vendors handle them as well. I recommend the Conductive version, because when using the basic shifter in low-humidity conditions, they develop static electricity and can shock both the patient and personnel using them. We use these boards daily. Two people can transfer a patient weighing up to 150 lbs. with no problem. AliMed can be contacted at 1-888-625-4633. Item number for the Conductive Shifter is #TC9-182, cost is $300.00. Most hospitals are given a discount. Steve Gressmire, R.T.(R)(CV) ARRT, AAMA, ACP Cardiology Services Director Northwest Mississippi Regional Medical Center Clarksdale, Missouri Email: Steve.Gressmire@nwmrmc.hma-corp.com cc: cathlabdigest@hotmail.com In our cath lab, we use a board to transfer the patient from the table to the bed or gurney. It is not difficult to use; you simply have to turn the patient, put the board under the sheet, and then pull the patient to the gurney or bed. We try not to move any patient without the use of this board for employee safety as well as patient safety. Back injuries occur so frequently due to incorrect technique in moving or transferring patients. On the units and nsg areas, we have a lift team who comes and assists with patient transfers. It is standard practice to utilize this board, and our hospital has safety classes on proper body mechanics and proper transfer techniques. Just to save your own back and prevent injury, you should use the board. I hope this answers your question. Annie Ruppert, RN, BSN Email: Annie.Ruppert@sharp.com cc: cathlabdigest@hotmail.com I prefer the long board to a roller. Roll the patient as one unit (one person can do this). Slide the board under the patient, keep a sheet between the patient and the board. Move the feet first. Then slide the patient over. Two people can use this technique on most patients. If the patient is large, do the same, but have two people help pull the patient and one push. One other hint: put the patient's bed slightly lower than the lab table. Remember, gravity can be your friend. Also, with the long board, the complete patient is supported, whereas with the roller, only the hip area is supported. Kevin Rich, BS,RN,RCIS Email: ldrich3@comcast.net cc: cathlabdigest@hotmail.com I have been in critical care nursing since 1983 (ER, ICU and cath lab). Our hospital recently began using the AIRPAL system. In my opinion, it offers a superior method for transporting patients. Two people can slide a patient with ease. It does require AC power and works similar to air hockey. I would suggest you at least consider this system. I am your typical, cautiously skeptical sort of person, but am now totally sold on the concept. Dave Dahl, RN cc: cathlabdigest@hotmail.com Use of pressurized normal saline? How many cath labs use pressurized normal saline instead of heparin art line flush bags (2 USP heparin units/ML) when connecting to a sheath/IABP/Swan? Brian Crosby, RCIS, RN, BSN HealthPark Medical Center Email: brian.crosby@leememorial.org cc: cathlabdigest@hotmail.com Reader response: At Covenant Heart Institute, we consistently use the heparin art line flush bags with the sheath/IABP /Swan. Patty Freier, RN, BSN, RCIS Nurse Specialist, Cardiac Research & Education Covenant Medical Center, Lubbock, Texas Email: pfreier@covhs.org cc: cathlabdigest@hotmail.com Can you help your fellow professionals with the following questions? Technologists: Central access & closure devices? In order for our technologists to establish central access and utilize closure devices, they must be credentialed and have those items be within their scope of practice. If your technologists perform these skills, what credentialing did they obtain, and how did you reflect these skills within their scope of practice? What education and/or competency assessments were required in order to complete the training process? Anonymous by request Email: cathlabdigest@hotmail.com Nonphysician vascular closure The possibility of switching from physician-based closure (Perclose, AngioSeal) to RN or CVT closure is being explored in our lab. The idea is still in its infancy, and I would like to know what other labs that have faced the same pitfalls have done in this regard. My questions are as follows: 1. How are your cath lab’s RNs and CVTs covered for malpractice upon performing the closure? 2. Is an Operations Medical Director established, much like the field-based Emergency Medical Services provided by paramedics? 3. Do you have any hard data to support the positive aspects of nonphysician closure? 4. Are there any data to provide an example of what happens when the nonphysician closure has complications? 5. How do you make the hard sell to physicians that nonphysician closure is beneficial for both the patient and the lab? 6. In terms of physicians and cath lab personnel, what are your thoughts on nonphysician closure with respect to time management and patient care? Mica Bodenheimer, NREMTP/CVT Fax: 804-287-7527 (Tel.) 804-281-8193 Email: cathlabdigest@hotmail.com Non-RNs defibrillate/cardiovert? Do other cath lab and electrophysiology labs allow non-nurses to defibrillate/cardiovert? Historically, defibrillation and cardioversion have been the nurses’ domain, and there is resistence to the idea of allowing anyone else to do this procedure. We would like to change our policy in our cath and EP labs to allow RT(R)s, CVTs, and RCISs who are ACLS-certified to defibrillate. My guess is that this is probably the standard in the industry already. Am I right? Patty Freier, RN, BSN, RCIS Nurse Specialist Cardiac Research & Education Covenant Medical Center Lubbock, Texas Email: pfreier@covhs.org cc: cathlabdigest@hotmail.com