Discussion Group

What Do You Think?

Multiple new and ongoing questions from readers. Your responses are welcome! Answer or pose a question at cathlabdigest@aol.com Patients without Accompanying Family or Friend I work at a university-based teaching facility in the cath lab. Our elective cardiac cath patients are called before the procedure or receive written instructions about post-procedure care. Specifically, they are told to make sure that someone else will be able to drive them home after the procedure and that they should have someone stay with them the night after the procedure. This is because of the sedation administered and the arterial puncture performed. We have recently had patients arrive without a driver to take them home and/or someone to stay with them. Most of the time when the nursing staff inform the physician that the patient doesn’t have a ride home or will be home alone, the procedure will be rescheduled. But recently, we have gone ahead with the elective procedure, extended the bedrest and then sent the patient home by cab, or to a nearby hotel by cab paid for by the hospital. Our written discharge instructions clearly state that the patient should not drive for 24 hours post procedure and how to manage a bleed from the puncture site. Nursing is becoming uncomfortable, from a patient safety standpoint, when such patients are discharged from the hospital in a cab and are sent to a hotel alone. How do other institutions manage this predicament? Anonymous Email: cathlabdigest@aol.com Our patients are advised when they come in for PSTs to have a friend or family member accompany them the day of the procedure to ensure they won’t drive home. We have, on occasion, provided a taxi ride back to their home. We have not put a patient up at a hotel, however. Name withheld by request Cc: cathlabdigest@aol.com With this dilemma, if the patients are truly outpatients, they are placed in a “23-hour observation” bed for the night and then discharged. Most facilities have had the experience of sending patients home by cab or to a hotel the next day. Due to possible grave situations, I would not discharge a patient as a “same-day” patient within a few hours after an invasive procedure. No one really knows if diazepam or midazolam will recycle hours later. Several years ago, a patient was given diazepam 5 mg IV on a Friday morning at 8 am. I went to visit him on Monday afternoon. He could have gone home on Saturday morning. The problem was that the diazepam had recycled and the man remained in a hypnotic “black-out” until Monday afternoon. His cognitive levels returned to normal at 3 pm. This has happened with midazolam. If patients are sent home or to a hotel by cab, they need to be called later that day or the next morning to ensure they are okay. Tactics such as a phone call are small gestures that denote concern and enhance the continuity of patient care. Follow-up calls to the patient should then occur over the next 72 hours. Chuck Williams, RPA, RCIS, RT(R)(CV)(CI), CPFT, CCT, FSICP Cc: cathlabdigest@aol.com Career Ladder Hi, at our institution (Genesis Medical Center in Davenport, Iowa), we are attempting to institute a career ladder for RT(R)s. Can any lab provide input as to how their ladder was established and how it works? We would really appreciate the advice! Jena Moore, RT(R), CVIT, BA Email: mooreje@genesishealth.com Cc: cathlabdigest@aol.com My name is Kelly Howard, RT(R), from the Medical University of South Carolina. Several years ago I began trying to develop a career ladder for the RTs in my area (the hospital had something for nurses but no one else). It took a couple of years, but we have successfully developed a career ladder for all RT(R)s, CVTs and RNs in the cardiac cath and EP labs. We call our program the “Cardiovascular Professional Ladder”. It consist of four levels: CVP I, CVP II, CVP III and CVP IV. All new staff come on board as a CVP I (at this stage they can only function in one role in the lab). After an online educational program that we developed, as well as one year of experience and cross-training in the other roles, the new staff member moves to a CVP II level. As a CVP II, they can function in three roles within the lab (monitor, scrub and circulate). It is the expectation that all staff function at this level. After two years of experience, if they choose, they can attempt to move to a CVP III. In order to achieve this level, staff must demonstrate leadership within the lab; they are required to put together a very comprehensive packet (this includes a research project as well as many other things) to present before a board. After five years and advanced licensing credentials (CV licensing for RTs and/or RCIS, and RCIS for nurses and CVTs), they can then move on to the CVP IV level. To reach each level, they must complete the steps beforehand. We incentivised all existing staff with a bonus when we first presented our packet, to move them from a I to a II. Our lab was very role-delineated before we started this (nurses only provided traditional nursing care, CVTs only monitored, and RTs only scrubbed and circulated). The program has been very successful — we now have all staff at a level II, and two staff members are at a III (with five more to go before the board in December). If there is anything I can help you with, please let me know. Good luck! Kelly N. Howard, RT(R) Billing/Supply Coordinator Adult Heart Catheterization MUSC- Ashley River Tower Charleston, SC Email: howardk@musc.edu Cc: cathlabdigest@aol.com Monitoring Alarms I would like to know if other facilities silence the monitoring alarms in their labs. With someone constantly observing the patient and a monitor tech watching, we silence our alarms due to the constant activation of the alarm when working on the heart. I have contacted several labs in our area and found that they do the same. Is this a common practice in other cath labs? Binnie Howard, RN, BSN, Director, Regional Heart Institute Email: Binnie.Howard@st-marys.org Cc: cathlabdigest@aol.com In the past 34 years, all “beeping” alarms have beem silenced in the cath lab suites in which I have been employed. There is sufficient “noise” with all of the other equipment to annoy and eventually cause hearing loss. Monitor alarms are another noise added to this. The patients are constantly being assessed by attending physicians, scrub assistants, circulators, and monitoring staff while they are on our procedure tables. Chuck Williams, RPA, RCIS, RT(R)(CV)(CI), CPFT, CCT, FSICP Cc: cathlabdigest@aol.com I personally silence the alarms because I feel it is just another distraction; also, this allows me to be able to hear what the doctor is saying. Other members prefer the alarms on. So it depends on who is monitoring the case and what they prefer. Name withheld by request Cc: cathlabdigest@aol.com Transducers What is your standard procedure for changing transducers? Thank you! Ronald Williams Email: ronald.williams@tenethealth.com Cc: cathlabdigest@aol.com Since the late 1980s, most labs have used disposable transducers. Each tray was packaged with a transducer for the initial setup. If a second one was needed for a RHC, it was added as an extra device. Transducers should be flushed through the manifold, pressure line, and then the transducer (from table surface to table edge). If one has to be replaced due to a malfunction, the “bad” transducer is removed asceptically from the distal end of the pressure line and the “new” one is attached. The transducer is flushed and rebalanced. Chuck Williams, RPA, RCIS, RT(R)(CV)(CI), CPFT, CCT, FSICP Cc: cathlabdigest@aol.com