Background. Catheterization laboratory cardiologists and nurses are downsizing diagnostic catheters to enable earlier patient ambulation without compromising safety. Aims. The team sought to determine the safety and cost effectiveness of ambulation 1 hour after manual compression using 4 Fr diagnostic femoral catheters. This would enable a drastic reduction in bedrest time from our current practice. Methods. A total of 768 consecutive patients were ambulated 1 hour after a mean manual compression time of 9 minutes.
When no evidence of re-bleeding on ambulation was encountered, 455 patients were discharged 2 hours after the procedure had finished. Patients were assessed for local complications within 3 days by the catheterization laboratory nurses. Results. No related major adverse events were noted. Minor bleeding problems were rarely encountered. No pseudoaneurysms were diagnosed. No blood transfusions or surgical interventions were required. Conclusion. One-hour ambulation after 4Fr cardiac catheterization is safe and improves patient comfort. It averts the need for arterial sealing devices and requires shorter catheterization lab recovery nurse-to-patient times, thereby improving cost effectiveness. Furthermore, early ambulation will allow higher patient turnover with a possible reduction in waiting lists.
Key words: patient safety, early ambulation, cost effectiveness
Nursing has always been at the center of patient care. Professional care management and ongoing development facilitates better teamwork and focused support for patient satisfaction.
Cardiovascular disease is one of the major health problems of recent years. Cardiac catheterization for coronary artery assessment is a frequently utilized diagnostic procedure since coronary artery disease has been established as a primary cause of death in western countries. There is a great probability that in the coming years, coronary artery disease will continue to escalate.1 The disease may sometimes remain silent and thereby go unnoticed for a long time. It may then manifest itself as an acute coronary syndrome, meaning cardiologists and health care personnel have a limited time to go through the routine examination pathway.8 There is an ever-increasing number of affected people around the world, irrespective of gender, social status, economical status and geographical location2; therefore, demand for adequate diagnostic tests to help with specific therapies will increase.
Currently, there are different modalities to assess coronary artery disease, including non-invasive cardiac computed tomography (CT) angiography. However, the gold standard remains coronary angiography. Although it requires a special setup, a large number of support personnel and has a higher cost, angiography still remains the most accurate, sought after and accessible procedure, which often results in long waiting lists for the procedure. In response to increased resource and expenditure requirements, management teams seek to deliver this type of care at a more contained expense without compromising safety.
We have considered the reduction of post angiography bedrest time and possibly earlier discharge after assessing the good results reported with the use of 4 French (Fr) diagnostic angiography procedures.3-6
After obtaining the approval of the hospital management committee, one of the local interventional consultant cardiologists began to perform cardiac catheterization procedures using 4 Fr femoral artery access sheaths and related diagnostic catheters. The nursing team performed femoral artery sheath removal and manual compression in the catheterization laboratory (cath lab) recovery area.
Nurses participating in this study were all knowledgeable and experienced with femoral access site complications. This team had to provide uniform care in order to achieve safe and effective femoral artery sheath removal.
This study enrolled 768 patients who underwent 4 Fr coronary angiography procedures irrespective of test indications, gender, age, co-morbidities and body mass index. The only patients excluded from this study were those who could not have femoral artery access due to local vascular problems and those patients who required immediate percutaneous coronary intervention, thus requiring a larger French size guiding catheter. Patients on oral or intravenous anticoagulation therapy were not excluded automatically, but were assessed for possible enrollment. The entire patient study group was recruited both from the outpatient list as well as from the hospitalized patient list (Table 1).
The femoral artery vascular sheath removal was done utilizing the manual compression technique. All sheaths were removed by the cath lab nursing team in the recovery area just outside the cath lab. This resulted in a reduction in procedure time since the cath lab was vacated quicker, enabling a faster turnover, yet still maintaining easy access to the cardiologist’s support and to the cath lab should the need arise.
The patients were examined by the cath lab nursing team one hour after vascular sheath removal and on the third post procedure day. During the review, the access site and lower limb were examined and the relative data collected. This data was then assessed by the nursing team and the interventional cardiologist.
Malta covers a relatively small area, 316 square kilometers, with a local population of just over 400,000 people, ensuring that hospital access was easily available for all the patients enrolled in this study.
Seven hundred and sixty-eight (768) cardiac catheterization patients were enrolled in this study, of which 542 were males and 226 females. Maltese locals (92%) made up the vast majority of these patients, although a small mixed minority of foreigners (8%) were also included. These foreigners were either visiting the country or are permanent residents in Malta. Mean age was 59.3 years with a range spanning between 23 years and 83 years. Mean body mass index (BMI) was 29.6%.
The procedures were conducted using femoral artery access: 735 patients had a right femoral artery access, while only 8 had a left femoral artery access (Table 2). A group of 25 patients had a right femoral artery and right femoral vein access due to the cardiac study procedure. The left femoral artery access was used only on 8 patients as these had presented either with right femoral artery problems or because of recent right femoral artery interventions.
There were six patients on anticoagulant therapy who were included in the studied patient group, of whom five were on intravenous heparin therapy and one was on long-term oral warfarin sodium therapy.
Goals were chosen to enable a more cost-effective methodology by reducing cath lab bed occupancy, acute ward bed occupancy time, the use of costly vascular sealing devices and also to redirect specialized nursing personnel care time. All this saves on current hospital expenditures and allows us to more effectively deliver acute care to those patients that need it the most.
Enrolled patients perceived the new methodology positively, since it provided a drastic reduction in bedrest time of 60%. The average standard 5 Fr diagnostic angiography catheter ambulation time is around 240 minutes. The new 4 Fr methodology resulted in a related bedrest time reduction of 180 minutes.
The new methodology also resulted in fewer access site complications and minimal access site-related complaints of soreness and pain. There was also a related decrease in back pain as related to the previously longer bedrest time. All patients coming for their angiography procedure on an outpatient basis and who did not require immediate percutaneous coronary intervention or acute hospitalization were ambulated after 1 hour from the vascular sheath removal and then discharged within another hour of ambulation. As a result, there was a general reduction in the increased anxiety levels usually perceived in relation to coronary angiography procedures and ambulation, as indicated by Mueller et al.7 Quantification of this anxiety reduction in relation to 4 Fr interventional cardiology procedures would require additional study.
The majority of patients [764 (99.5%)] were ambulatory within 1 hour of the arterial sheath removal time without major complications. Four patients (0.5%) experienced minor complications. One patient had minor bleeding during the 1-hour bedrest time. This was controlled easily with manual compression. This patient was then ambulated safely one hour later, achieving a very good end result. Three had a small amount of blood oozing on ambulation that was easily controlled with manual compression. All three patients were ambulated within another hour from hemostasis.
The patients were assessed again by the nursing team on the third day after the procedure. Ninety-seven percent (97%, n = 745) were generally free from major complaints. The most common complaint within this group was minor access site pain or soreness, usually a common and acceptable effect related to femoral vascular access procedures. Mild pain relief (paracetamol) was prescribed.
Fourteen patients (2%) were found to have a small, local, soft bruise of less than 10 cm in diameter and a very small access site hematoma.* Another 6 patients (0.8%) had a slightly larger soft bruise of less than 15 cm in diameter and a very small access site hematoma. There were no patients diagnosed with major access site adverse events. None of this patient group required blood transfusion as an effect of femoral artery bleeding. No vascular repair surgery, endovascular luminal dilation or stent procedures were required. No pseudoaneurysms or arteriovenous fistula formations were diagnosed.
Another important factor of achievement is that 59% of the patients within this group (453/768), were discharged home within 2 hours from the vascular sheath removal time. While at home and until review, these patients did not encounter any access site-related problems. No bleeding or oozing episodes occurred within this period. Some of the other patients had very small site bruising at the level of the superficial skin without any notice or further complaints.
One patient developed acute pulmonary edema immediately post coronary catheterization procedure. The smaller femoral access sheath allowed for the patient to be propped up within five minutes from sheath removal without any bleeding problems.
Another patient had the vascular access done through a synthetic femoral bypass surgery artificial graft. His procedure and sheath removal went smoothly with no complications.
Image quality. The majority of these tests [n = 683 (89%)] were conducted utilizing the manual injection technique, showing no compromise to angiographic image quality and physical expenditure (see Figure 1). This method did require an increase in manual injection force. Automatic contrast injection was used in 85 (11%) procedures to confirm that there was no diagnostic difference in the resultant angiographic images.
Utilizing the 4 Fr femoral artery access for coronary angiography procedures has been indicated as a promoter for early ambulation. Our patient group (n = 768) showed no increase in related medical problems. Twenty-five percent (n = 192) had previously undergone a coronary angiography procedure with a longer bedrest time. The patients within this group felt that this new method was much easier to cope with, offering a major reduction in bedrest time and a reduced impact on the access site while allowing the physician to obtain required angiographic data for assessment.
Average manual compression time was 9 minutes, with a compression time range of 7 to 15 minutes. The smaller femoral sheath size yielded a greater reduction in the required force applied to support arterial bleeding and a greater reduction in achieving a faster access site healing time in comparison to the standard practice with 5 Fr sheaths. Keeping in mind the aspect of personnel occupational health and safety, the reduction in the required manual compression force and total compression time decreased considerably the related physical tension/expenditure and the possibility of personnel injury.
The 4 Fr data collected within this study of one-hour bedrest time was compared with the local standard 5 Fr angiography time, which is 2 hours and 30 minutes. This change achieved a safe reduction in bedrest time of 1,152 hours or 40% less. Specialized personnel time was saved, making the 4 Fr coronary catheterization procedures more cost effective as well. The early discharge group (n = 453) results show that an even greater cost reduction may be obtained, giving hospital management teams a greater indication to use this approach.
The cath lab nursing team felt that a smaller 4 Fr arterial puncture required less force for compression during vascular sheath removal and as such, was perceived as giving less physical problems to the nursing group. As an effect, there was a resultant faster patient recovery. Early ambulation, earlier transfer to the respective peripheral ward or earlier discharge may all be contributing factors in reducing the overall hospital stay. The cost reductions implied by this study could be easily adopted by hospital management, since this study showed that there is no compromise to patients and/or personnel safety. Some centers have adopted the regular use of external vascular compression devices and/or vascular sealing devices. The 4 Fr arterial access could reduce the related procedure costs, as well enable the shifting of funds to other important aspects of care.
The local cardiovascular nursing team managed and organized the patient follow-up coordination in a safe and effective manner, providing excellent, reliable results. The added benefits to the patients and to the healthcare system were the result of the responsibility, professionalism and efficiency of the whole nursing team, together with the professional responsibility of the cardiology medical team which began the use of 4 Fr diagnostic catheters.
The authors would like to thank all the patients that have participated in this study, the cath lab nursing team at Mater Dei Hospital, Malta, who have done the access sheath removal, care and regular assessments, and the director of cardiology and hospital management for their support and encouragement.
The authors can be contacted at firstname.lastname@example.org
This article received a double-blind peer review from members of the CLD editorial board.
1. Yusuf S, Reddy S, Ounpuu S et al. Global burden of cardiovascular diseases: Part 1: General considerations, the epidemiological transition, risk factors, and impact of urbanization. Circulation 2001; 104: 2746-2753.
2. The World Health Organization — The World Health Report 2002. Available at http://www.who.int/whr/2002/en/ Accessed May 29, 2009.
3. Arora P, Naik N, Bahl VK, et al. Coronary angiography using 4 French catheters with power injection: A randomized comparison with 6 French catheters. Indian Heart J 2002; 54(2): 184-188.
4. Lee C, Chow W, Kwok O, et al. Experience with four French catheters for outpatient coronary angiography. Int J Angiol 2000 Mar;9(2):122-124.
5. Koichi I, Manabu H, Etsuko T, et al. Feasibility of early ambulation three hours after transfemoral angiography using a 4 French sheath. Nippon Acta Radiologica 2002; 62: 362-365.
6. Sanmartin M, Goicolea J, Castellanos R, et al. Validation of 4 French catheters for quantitative coronary analysis: In vivo variability assessment using 6 French guiding catheters as reference scaling devices. J Invas Cardiol 2004 Mar; 16(3): 113-116.
7. Mueller PR, Biswal S, Halpern EF, et al. Interventional radiologic procedures: patient anxiety, pain perception, understanding of procedure and satisfaction with medication — A prospective study. Radiology 2000: 215(3): 684-688.
8. Committee for Practice Guidelines — European Society of Cardiology. Update of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J 2003; 24(17): 1601-1610.