Reduced Time-To-Ambulation in the Diagnostic Catheterization Patient at Florida Cath Lab

Marcie Gruchevsky, RN, Claudio Manubens, MD, Patti Lawrence, ARRT, Laurence Hearn, Stephanie Hardy, RN, Jorge Molina, RCIS, Frances Farmer, RN, Teresa Toering, MA
Marcie Gruchevsky, RN, Claudio Manubens, MD, Patti Lawrence, ARRT, Laurence Hearn, Stephanie Hardy, RN, Jorge Molina, RCIS, Frances Farmer, RN, Teresa Toering, MA
Our facility is no exception. Florida Cath Lab is a small outpatient cardiovascular catheterization facility located in Orlando, Florida. The facility is a freestanding lab with a small staff that includes one ARRT, one RCIS, three RNs, and a registration secretary who keeps us all together. Structurally, we have a single diagnostic catheterization lab with a six-bed pre- and post-catheterization area. Seven physicians utilize the facility, performing diagnostic cardiac and peripheral vascular procedures. Overall, our facility is fairly young. We became operational in May of 2002. Since that time, we estimate that approximately 3600 procedures in 1200 patients have been performed annually. As a smaller facility, one of our continual quests is to maximize the efficiencies of our facility through the enhancement of patient care, without compromising patient safety. One mechanism is shortening post-procedure stays (i.e., a swifter time to discharge), with the obvious rule that patients not be placed at an increased safety risk. To impact early ambulation of patients when 4 and 5 French arterial sheaths are placed in the femoral arteries, Florida Cath Lab has been utilizing the D-Stat Dry Hemostatic Bandage (Vascular Solutions, Inc., Minneapolis, MN). The D-Stat Dry Bandage is composed of a lyophilized (freeze-dried) pad containing thrombin, sodium carboxylmethylcellulose (CMC), and calcium chloride in a non-woven gauze. It has an accompanying adhesive bandage (Figure I). The D-Stat Dry Bandage is designed as an adjunct to manual compression to reduce the time to hemostasis and is indicated for the control of surface bleeding from vascular access sites and percutaneous catheters or tubes. Currently, to be considered for D-Stat use at Florida Cath Lab, a patient must present to the Cath Recovery Area: Post cardiac or peripheral angiography, during which a 4 or 5 French sheath was utilized in the femoral artery; With a post catheterization, non-invasive systolic blood pressure equal to or less than 150 mm of mercury; Without significant evidence of hematoma or bleeding at the access site. Patients that meet the above criteria are treated with D-Stat Dry following removal of the femoral arterial sheaths. They are scheduled for early ambulation to be accomplished at ninety minutes following sheath removal, complete a patient survey to assess their level of satisfaction, and are evaluated for complications or adverse events the day after discharge (via teleconference) and by their treating physician at one to two weeks post procedure (in office examination). Prior to the implementation of D-Stat Dry, standard protocol at our facility for patients undergoing diagnostic cardiac catheterization or peripheral angiographic procedures dictated the application of digital compression typically for fifteen to twenty minutes in order to achieve hemostasis. This was followed by a minimum of 2 hours of bed rest (1 hour completely supine; 1 hour with head of bed at 90 degree incline). Subsequent ambulation was then accomplished, providing there were no confounding events such as blood pressure abnormalities, hematomas, or other difficulties. If a patient ambulated successfully without issue, they were then discharged. Generally, overall time spent in the Cath Recovery Area was approximately 2.5 hours. As you might imagine, holding pressure even for 15 or 20 minutes has a strong impact on availability of staff members to accomplish other patient care-related tasks. In a smaller facility like ours, every hand counts. Therefore, after a successful initial in-house evaluation, we began utilizing the D-Stat Dry with manual digital compression of 5 minutes in patients following catheterization when size 4 or 5 French sheaths were inserted. Our protocol includes application of the D-Stat Dry Bandage, employing 5 minutes of manual digital pressure to achieve hemostasis, and immediately elevating the head of the bed to 30 degrees. We then raise the head of the bed to 90 degrees for the reminder of the first hour. Thirty minutes later, or ninety minutes total from the time of sheath removal, patients are ambulated and subsequently placed in a reclining chair for an additional thirty minutes of observation. Our reasoning for this supplemental observation is two-fold. It provides us with a sufficient level of comfort while also ensuring continued patient safety. Beyond this cumulative 2-hour period, we then ambulate the patients again, and providing there are no issues, they are discharged from our facility. Based on our current experience, it is our belief that in time, with a sustained observation of the continued positive trending that we have seen to date for the D-Stat Dry patients, we will be able to discontinue the thirty-minute observation time point and be able to discharge patients approximately ninety minutes post sheath removal. Our patients are extremely satisfied with the decrease in time that is required to remain in the supine position (remember the head of the bed is elevated to 30 degrees immediately post sheath removal, and shortly thereafter increased to a 90 degree angle, as compared to lying completely supine for the first hour). Patient levels of satisfaction remain high when they are permitted to ambulate at 90 minutes. As they all stated, they needed to urinate post catheterization, so this reduction in bed rest helped to allay their anxiety regarding elimination. To evaluate the overall effectiveness of the new bandage when utilized at our clinic, and to attain a reasonable level of comfort and assurance within the clinic staff prior to general implementation, we initially evaluated 110 consecutive patients that met the previously specified criteria for treatment with the D-Stat Dry. All 110 patients agreed to treatment. Ninety-eight percent (98%: 108/110) of patients receiving the new bandage achieved hemostasis in