What Do You Think?

Can you help your fellow professionals with the following NEW question? Nitric oxide for RH Caths Does anyone have a written procedure for right heart cath studies using nitric oxide inhalation to determine pulmonary artery reactivity for treatment for pulmonary hypertension? Debbie Herndon Email: debohern@msn.com cc: cathlabdigest@aol.com Ongoing Questions CMS Website & CAS We have a question to pose to hospitals that are CMS-certified for carotid stent placement. We have recently been told that we are not a certified hospital when we can go on the CMS website and view our hospital on the site. Is anyone else having this problem, and how is it being handled? Thank you, Jon Oliver, RN Director Cardiology Wuesthoff Health System Email: jon.oliver@wuesthoff.org cc: cathlabdigest@hotmail.com All carotid stents done on Medicare patients have to have precertifications. The diagnostic study is done one day and the interventional done the next day and/or the patient is scheduled to return if the lesions are not life-threatening. The patients have to be placed in a carotid research study, which is a government requirement. Chuck Williams, BS, RPA Atlanta, Georgia rpainga@yahoo.com Covering Trays Hi, I was wondering if there is any information out there about covering trays while awaiting procedure. We currently have a debate going on about this in our lab and would like to know what others are doing around the nation. Do you set up trays ahead of time, how long until they are torn down if not used. Do you cover them until time of use? Thanks, To-be-covered-or-not-to-be-covered Email: Cathlabdigest@hotmail.com We used to set our trays up ahead of time and then cover them. We were told by our infectious disease department that we should not do this. The ID dept. said that the tray should be set up just prior to the patient arriving and should not be covered. When we did set trays up ahead of time, if they were not used by the end of the day, we did not use them. Annie Ruppert Annie.Ruppert@sharp.com To keep the tray sterile, my practice is that it should be covered if you are not going to use it right away. If it will not be in your sight at all times, you must cover it to ensure that it in fact is not contaminated. Bhawna Oberoi, Texas bovna_rpa1@verizon.net We do set up trays before the patient arrives. We cover them with sterile plastic sheets that are part of the trays. A staff member has to be in the procedure room area to watch the tray. Anyone can contaminate it if no one is present. A tray is never left set up overnight. I have done such setups for over 30 years and have not had an infection reported. Chuck Williams, BS, RPA Atlanta, Georgia rpainga@yahoo.com We set up all our trays just prior to the case. We operate similar to surgery in that if the tray is not in view of the person setting up the tray, there is too great a chance of contamination. Patti Coblentz PatriciaACoblentz@ProvenaHealth.com I’m not sure about the JCAHO guidelines, but the AORN guidelines state that sterile fields (should be set up) as close as possible to the scheduled time of use, since the potential for contamination increases with time. At the Cleveland Clinic, we used to set up sterile trays for all (or most) scheduled cases immediately in the morning, covering them with a sterile drape which was taped down. We stopped this practice about 10 or 12 years ago at the suggestion of our infection control department. Most times, we set our tables up in the room when other team members go to get the patient, or after the patient is in the room. It really doesn’t take that long and does not slow the case down. Kenneth A. Gorski, RN, RCIS, FSICP Assistant Manager Sones Cardiac Catheterization Laboratories The Cleveland Clinic Foundation Cleveland, Ohio gorskik@ccf.org For those labs that wish to make up their trays early (we used to do that but don’t anymore), I have found that the trays can be set up quite quickly so that it is not a necessity. If you choose to make up trays ahead of time, I would cover them and make sure that they are in a secure area. From my understanding of OR procedures, if it is a dry tray it is good for 12 hours, a wet tray less than 8. Connie Gehin, RT(R), RCIS Meriter Hospital Madison, Wisconsin csgehin@yahoo.com Normally, we do not set up sterile trays far in advance of the procedure, but if we do, it must be a dry tray, covered and a staff member must be in the procedure room to monitor it. Larry Sneed, BS, RCP Manager, Cath Lab lsneed@armc.com We do prepare and cover trays; we tear them down in 4 hours if not used. Carletta Williams carletta@weirtonmedical.com At one hospital where I used to work, we would set up all the trays in the morning, but then we were told new guidelines, which were: The table was to be set up when the patient enters the room. When pressed, they said we could set up a tray and cover it if it was an emergency and we had to go to the ER to pick up the patient. This really wasn’t an issue at this lab because usually the next patient was waiting at the door when we finished the current case. At the hospital where I currently work, we set up a tray as we go to get the patient. That way it does not have to be covered. There have been, on occasion, periods of time (less than two hours) before the tray was to be used where a case has been either delayed or cancelled. As long as there are no fluids on the table, then we will still use it. Kevin Rich, BS, RN, RCIS ldrich3@comcast.net Heparinizing Arterial Sheaths Post Cath Our hospital has a policy of routinely connecting arterial lines to pressure bags with heparinized solution post cath if ACT is >210. Does anyone have information on the relevancy of this practice? Other local hospitals do not practice this procedure. Email: POdonnell@mercycare.org cc: cathlabdigest@hotmail.com Our hospital routinely uses heparinized saline on pressure bags for arterial line set up and monitoring. The only time heparin is not used for arterial line set up or IABP/swan set ups is if the patient has HIT or for some other reason should not be getting heparin at all. We do not go by the patient’s ACT level at all. All lines are set up with heparinized solution. Annie Ruppert Annie.Ruppert@sharp.com If we leave a sheath indwelling, we flush the sheath with 10“12 ml of heparinized saline (1,000 units/ml). Before this is done, we draw blood and do an ACT while the patient is still on the procedure table. If the ACT is above 210 seconds, we chart the value so the receiving nurse has a baseline, which gives her (or him) an idea when the patient's blood has returned near the preprocedural anti-coagulated state. The sheath is NOT attached to a pressurized drip system. When the nurse is ready for the sheath removal, she (or he) attaches a syringe to the side port and begins to withdraw blood from the sheath. While she is drawing the blood, she begins to withdraw the device slowly. When the tip exits the access site, a small spurt of blood is allowed, which permits any clotted debris at the arteriotomy to be forced externally. Then, firm, non-occluding manual pressure is applied for 15“20 minutes and/or longer if needed. By using a pressurized, heparinized drip system, the ACT could be kept at higher levels, which prolongs removal, increasing bed time. Chuck Williams, BS, RPA Atlanta, Georgia rpainga@yahoo.com We attach heparinized saline to pressure tubing/art line for any sheath that is not pulled on the table. Patti Coblentz PatriciaACoblentz@ ProvenaHealth.com If the sheath is to remain in place for any amount of time, it is not bad practice to connect a pressure line to the sidearm; the pressure line will keep the sheath patent and reduces any potential risk of milking/stripping clot when removing. It also allows you to connect an in-line transducer to monitor arterial pressure while the sheath is in place. Adding heparin to the flush solution offers no additional benefit, and may skew your ACT results if you do not aspirate sufficiently to totally clear any heparin from the sheath. Kenneth A. Gorski, RN, RCIS, FSICP Assistant Manager, Sones Cardiac Catheterization Laboratories The Cleveland Clinic Foundation Cleveland, Ohio gorskik@ccf.org We currently hook them up to a pressure bag of saline with no heparin in it if they are to be pulled within the next few hours. I would check with the pharmacist and see if he has any articles related to this practice. Connie Gehin, RT(R), RCIS Meriter Hospital Madison, Wisconsin csgehin@yahoo.com Our hospital does not routinely set up a heparinized pressure bag for sheaths that will be pulled in a few hours. We also transfer patients out sometimes to Duke University Medical Center and we never connect a pressure bag to those patients. This has been a practice for 10 years without any problems. Larry Sneed, BS, RCP Manager, Cath Lab lsneed@armc.com We do not put heparin in our pressure bags for our sheaths. Actually, the only pressure bags that we heparinize are those connected to the IAB central lumen. Carletta Williams carletta@weirtonmedical.com At the current hospital at which I work, we continue to use heparin in our flush bags, 2000 per liter. At another hospital I worked at, we changed to normal saline and did notice a decrease in HIT (heparin-induced thrombocytopenia). Kevin Rich, BS, RN, RCIS ldrich3@comcast.net Level Does anyone use a laser level to balance the transducers? If so, can you provide me with the company/ies that supply this item? Thanks for your help, Elizabeth Goodman, CVT Cardiac Cath Lab Children's Hospital Detroit, Michigan Email: EGoodman@dmc.org Cc: cathlabdigest@hotmail.com We do not use laser levels. We open the transducer and adjust the level of the transducer up or down until the 0 line is level on the monitor. Annie Ruppert Annie.Ruppert@sharp.com Laser levels can be purchased at any Home Depot or Lowe’s stores. Tripods are readily available too. If you need the tripod, check the size and make sure the device has adjustable legs so the laser level can be adjusted between 18“36 from the floor. Patient and staff safety is required. Eyes should not be exposed to laser beams. Chuck Williams, BS, RPA Atlanta, Georgia rpainga@yahoo.com We do not use a laser level, but we do use a bubble level on a ruler to level. Patti Coblentz PatriciaACoblentz@ ProvenaHealth.com If you go through a medical device/radiology supply company, you are going to pay through the nose. Many facilities utilize a standard carpenters level, available at any hardware store. You can get a battery-operated Craftsmen Laser Level at any Sears for under $50; if you insist on something fancier, you can easily get into hundreds of $$$$. Kenneth A. Gorski, RN, RCIS, FSICP Assistant Manager Sones Cardiac Catheterization Laboratories The Cleveland Clinic Foundation Cleveland, Ohio gorskik@ccf.org I went to Menards and purchased a laser level for $12.95. It works very well. You need to stand back slightly from the patient and let the level do its work. I got the type with the bubble in it so that I can see that I am holding it level. Connie Gehin, RT(R), RCIS Meriter Hospital Madison, Wisconsin csgehin@yahoo.com We used just a standard Lowes/Home Depot/Sears level at any hospital at which I have worked. Kevin Rich, BS, RN, RCIS ldrich3@comcast.net Role Model What facility is considered the role model for all cath labs? I currently direct a heart institute. I want to implement a total change of the organization and am well supported by administration to do so. Who should I look to as The Leader? Our facility has approximately 330 beds. Being centrally located in Florida, we are a seasonal facility, meaning that we have a huge influx of the older population in the winter. We perform about 3,500 cath procedures and about 1,500 peripheral cases (this includes carotids). Staffing is generally four per room and realistically varies with call-outs. We have a 15-bed combination pre-op and recovery area staffed by critical care nurses. We also accommodate approximately 15“17 physicians, with two large groups getting the lion’s share of the volume. The future goal for my facility is to build a heart tower with an emergency department attached. The heart tower would include all of cardiology (invasive and noninvasive). The ultimate goal is to have a Electronic Medical Record (EMR), which will be implemented over the next two years and to integrate this technology into billing, populating the ancillary department’s computers, inventory control the works. Cath lab efficiency is constantly being monitored by administration, so that plays a large role also. Any ideas? Scottie Gainey Email: WSGAINEY1@aol.com Cc: cathlabdigest@hotmail.com 1.Belk Heart Center at Presbyterian Hospital, 200 Hawthorne Lane, Charlotte, NC 28209 2.Mt Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140 3.Cleveland Clinic, Cleveland, Ohio 4.Carolina Medical Center, Charlotte, NC 5.Wake Medical Center, 3000 New Bern Road, Raleigh, NC Chuck Williams, BS, RPA Atlanta, Georgia rpainga@yahoo.com Our hospital is currently changing over to the EMR systems for medical records. We are currently piloting the system in two of our units by several physicians. Our facility has been working on this for several years. All our nursing documentation is computerized and we have computerized systems to pull up and look at dictation, x-rays, films and procedure reports, etc. We are building a new facility which should be open in 2008. Annie Ruppert Annie.Ruppert@sharp.com There are a number of facilities that you can consider leaders in the field: Cleveland Clinic, Washington Hospital Center, Lenox Hill, Columbia University/New York Presbyterian, William Beaumont, Duke, Mayo, Brigham & Women’s, among others. You may wish to go online and review the U.S. News & World Report’s list of America’s Top Hospitals (Heart and Heart Surgery list) to give you a starting point. We are constructing a new facility similar to what you describe. The Cleveland Clinic Heart and Vascular Center is under construction, due to open sometime in 2008. EPIC is being phased in as the frame for the health system EMR. We are currently using Q-Site from Owens & Minor for our inventory control in the cath and EP Labs. Q-Site is internet-based, and links with the Lawson System in our purchasing department for real-time ordering and P.O. generation. Be sure that your databases/hemodynamics meet IHE standards. Similar to DICOM imaging, IHE is an initiative by healthcare professionals and industry to improve the way computer systems communicate in healthcare and share information, enabling care providers to use information more effectively. IHE promotes coordinated use of established standards such as DICOM and HL7: http://www.ihe.net Kenneth A. Gorski, RN, RCIS, FSICP Assistant Manager Sones Cardiac Catheterization Laboratories The Cleveland Clinic Foundation Cleveland, Ohio gorskik@ccf.org Each facility’s role model I think would vary depending on the state in which you are practicing. In North Carolina, we can cross-train all staff to administer medications, monitor, scrub and operate x-ray equipment. Our techs can give moderate sedation with the physician in the procedure room. We use the Eclipsys throughout the hospital for EMR and medication, DAR notes, etc., are very easy to track for PI. Larry Sneed, BS, RCP Manager, Cath Lab lsneed@armc.com I’d like to add Western Pennsylvania Hospital (West Penn) to the list that Ken Gorski has given. Carletta Williams carletta@weirtonmedical.com Physical Issues in the CCL Reader Bob Bastile writes, My suspicion is that wearing the lead as often and for as long as we do, that the weight is causing a significant percent of our professionals lifetime damage! As a cath lab professional, do you suffer from cervical and/or lumbar disc damage? Email: rkapur@hmpcommunications.com I worked in a cath lab for 14 years. I have come out of the lab for the last three years due to lumbar disc problems. I also have cervical pain frequently, even after leaving the lab. My surgeon suggested if I wanted to stay in the lab, my only option was surgery at age 30! Personal health needs to be considered more carefully. I suffered the most damage being forced to scrub on a Bi-V pacer with a new physician for over seven hours without a break. Following this procedure, I could not get out of bed the next day. Thus, the end of my career in the lab. Anonymous by request While I have never been diagnosed with cervical and lumbar disc damage, I suffer from continuous pain in my back. I have lumbar scoliosis, for which I wore a Boston brace in high school. I was never given any instruction beyond that point. I have complained about the pain, and it was offered to me that I wear an apron lead instead of a two-piece vest and skirt. The neck collar alone triggers my shoulder muscles to spasm. Any result from your survey would be helpful in my campaign to get lighter lead. Anonymous by request I have worked full time in the cath lab since 1979. Ten years ago, I started to experience bilateral numbness, tingling and discomfort in both of my arms. I went on vacation and the symptoms subsided. Upon my return to work, when wearing my apron, the symptoms returned. An MRI revealed a posterior compression of the chord at C4-C5. I underwent surgery and returned to work without restrictions. I have since been symptom-free. My best friend, with whom I worked side-by-side, has had two cervical surgeries. She has continued to have symptoms and can no longer wear lead. She now works in the non-invasive lab. Over the years, several of our cardiologists developed cervical disc problems. Although the lead aprons we wore in the late 1970s and 1980s were significantly heavier than the ultra-light weight now available, I believe disc issues will continue to haunt cath lab personnel. Iris Metcalf-Taylor, RT