Feature

Physicians Are Turning to RT(R)s to Achieve Immediate Hemostasis in the Cardiac Cath Lab

David Joffe, MD, FACC, Medical Director, Cardiac Cath Lab, Dayton Heart Hospital, Dayton, Ohio
David Joffe, MD, FACC, Medical Director, Cardiac Cath Lab, Dayton Heart Hospital, Dayton, Ohio
Hospitals are continually trying to improve patient satisfaction levels by offering the most advanced clinical practices. Ideally, these practices are executed through creative programs that result in time saving for patients and hospital staff. They offer unique clinical benefits to meet patient needs and have the support of the hospital administration and physicians alike. At the Dayton Heart Hospital cardiac cath lab (Dayton, OH), a busy 4-lab facility performing approximately 2,300 catheterizations annually (1,720 diagnostic and 580 interventions), we have achieved this scenario by implementing a suture closure program that utilizes non-physician operators. Four technologists routinely perform over 80% of the femoral artery closures for more than 20 practicing interventional cardiologists. The physicians at the Dayton Heart Hospital cath lab utilize suture-based closure (Perclose, Abbott Vascular Devices, Redwood City, CA). Prior to leaving the cath lab, each patient who receives suture-mediated closure is asked to bend his or her leg and cough, an exercise that allows us to confirm that hemostasis has been achieved. This exercise takes less than a minute to perform and indicates that definitive closure of the access site has been obtained. The ability to perform this in-lab exercise is one of the main reasons that the closure program has been so widely accepted and supported by physicians. Physicians can be confident that every patient leaves the lab with a femoral artery verified for definitive hemostasis that will not rebleed. The success of our program is due not only to the technology we utilize, but also to the technologists who perform suture closure day in and day out. Our physicians have tasked our technologists with the responsibility of achieving hemostasis and support them fully in the process. For the techs, the result has instilled a team spirit and pride in knowing that the team at Dayton Heart is providing the best possible patient care. For the physicians, valuable time in the lab is optimized. By allowing others to handle groin management, physicians can concentrate on other patient-related responsibilities. Dayton Heart Hospital’s Experience with Tech Closure It has been our belief that tech closure with Perclose optimizes physician time in the lab while allowing patients to continue receiving the highest standard of care. It has also been our belief that there is a direct correlation between frequency of use and technical success with certain medical devices. Between January 1, 2002 and May 31, 2002, Dayton Heart prospectively tracked the rate of successful deployment with the Closer S. We compared outcomes between three certified physicians who deployed Perclose intermittently versus three certified non-physicians who deployed it on a daily basis. We also documented the time and activity-based benefits realized by physicians who employed the help of a allied health professional for achievement of access site hemostasis using Perclose. During the study period, there were 272 attempted suture closures. Fifty-four (20%) deployments were performed by physician operators versus 218 (80%) done by allied healthcare professionals (non-physician operators). Success was defined as any attempted deployment resulting in immediate hemostasis in the cath lab, without the need for additional manual or mechanical compression. There were 9 (3.3%) unsuccessful deployments reported none of which resulted in complication. In the case of an unsuccessful deployment, standard compression was used to treat the patient. As shown in Table 1, the overall success rates were 92.6% for physician operators versus 97.7% for non-physician operators. The technical outcomes of the study confirm our hypothesis that consistent and routine deployment of the Perclose device results in a high level of operator success. We attribute the difference in results to the fact that non-physician operators had the opportunity to deploy the device more regularly; conversely, if physician operators deployed the device routinely instead of the technologists, we believe the outcomes would have been reversed. Benefits of Suture-Mediated Closure by Non-Physicians The time and activity-based benefits of having a cath lab professional perform suture closure were immediately realized by the physicians. Each suture closure took from two to four minutes. While technologists managed access site hemostasis, physicians were able to do paperwork, perform dictation, talk with families and get ready for the next case. Additionally, floor nurses also expressed satisfaction. Nurses are able to spend less time pulling sheaths and holding groins, which equates to more time spent caring for patients. In our institution, the impact of tech closure with Perclose has had a contagious effect on the other interventional cardiologists in the lab. Once they saw the clinical benefits of Perclose, as well as the improved efficiencies throughout the lab and the success of the technologist operators, these cardiologists began asking the nurses and techs to manage Perclose closure for their patients. Today, all but three of our practicing physicians in the lab are utilizing non-physician operator deployment of the Perclose device. (The three physicians who do not utilize tech closure prefer using the device themselves and have great success with it.) Keys for Successful Non-Physician Suture-Mediated Closure We concluded that a successful Perclose program is dependent on consistent device use. The technologists at Dayton Heart Hospital routinely deploy Perclose, and we feel that is a primary factor in our success. Furthermore, the added responsibility of performing the suture closure fosters interest, communication and pride among the staff members. The staff teaches and supports one another in the closure program. They learn from one another, train together, and help each other become experts in access site management. Our technologists take full ownership of vascular closure and feel they are contributing to patient care in a meaningful way. The task of vascular closure is physician-driven, which gives the techs more responsibility and translates into carefully performed deployments. Further acknowledgment that techs play a primary role in this very important aspect of patient care comes from the Perclose representatives who provide continued support. In addition to the hands-on training with the device, they provided comprehensive staff education which helps promote a team-like approach for the closure program. It includes: Teaching staff members to read femoral angiograms to determine proper patient selection; Providing hands-on training with a model prior to patient deployment; Providing proctorship of 10 cases; Providing patient discharge and home care instructions; Training of floor nurses for proper post-care of patients. Each one of us has specific responsibilities in the closure program. If these responsibilities are not executed with complete excellence, the integrity of our closure program will be compromised, and the quality of patient care affected. Our program is successful because we support one another, but it is also successful because we make the most efficient use of head count, of talent and of resources. Our techs are an integral part of the process and their daily work in the lab affords us the opportunity to provide better patient care.
References
1. Baim DS, et al. Suture-mediated closure of the femoral access site after cardiac catheterization: results of the suture to ambulate aNd discharge (STAND I and STAND II) trials. Am J Cardiol 2000;85:864-869.

2. Carey D, et al. Stroobants Heart Center, Lynchburg General Hospital, Lynchburg, Virginia. Complications of femoral artery closure devices. Catheter Cardiovasc Interv 2001;52:3-7.