Access site management

When a Clinician Becomes the Patient, What Matters? The Importance of Good Access.

Gerald Lagasse, RCIS, Borgess Medical Center, Kalamazoo, Michigan
Gerald Lagasse, RCIS, Borgess Medical Center, Kalamazoo, Michigan

My son was coming of age to drive a car. He had older siblings that drove, had been with my wife and I and seen us drive, was a proficient driver on his Xbox games and had recently graduated from his classroom driver’s education course with high marks. It was time to get behind the seat of our 1999 Windstar. The mirrors, seat and steering wheel were properly adjusted, seat belt secured, key in the ignition, and everything was ready to go. Then my son looked down at the floorboard, stopped what he was doing and said, “Dad, what’s the second pedal for?”

Many times people think that because they understand the concept of something, they are equipped with the ability to perform the action.  

I’m here to tell you, that isn’t always the case.  And for those interested, thanks to some practice, I can say my son is the best driver of all seven of my kids.

With the rapidly paced environment of the cardiac cath lab, the things that seem the most routine and mundane to us (like the initial stick of the access site) can be the one thing the patient remembers from the entire procedure. In our lab atBorgess Medical Center, in Kalamazoo, Michigan, we have several types of operators that have privilege to gain access: the attending physicians, the fellows, and qualified scrub staff.

With thirty-one years of practical experience in arterial access (38 years total in the lab), I have learned that developing the skills of proper access and being a diagnostician can be as important as the interventional cardiac catheterization itself. I have learned not to think too fast, instead choosing to simply slow down and focus on what is taking place in that moment of the procedure.  When the attending physician, the fellow or the scrub staff are in a rush or not thinking about proper access, complications will arise. At Borgess, some of the access site best practices include marking the femoral head, limiting the number of sticks one person may perform per patient, and performing a sheath-o-gram to start the procedure.

Taking proper care of the access site is critical to ensuring that all parts of the intervention have a successful outcome. As members of the cath lab environment, we know just how busy it can get. Once the procedure is completed, the patient is taken to the recovery unit, critical care unit or cardiac floor. We turn over rooms and prepare for the next patient. We know little of what happens to the patient when they leave our care. But I happen to know exactly what happens — times 5.

The day I became the cardiac cath patient

2003: Emergency intervention to my left anterior descending artery (LAD) and right coronary artery (RCA) (my dominant vessel).

A pseudoaneurysm on my femoral artery post procedure requiring that I go to vascular repair via thrombin injection using duplex ultrasound. 

2006: Diagnostic exam for checkup. Good results, coronaries doing fine.

2007: Sudden closure of the RCA (dominant coronary) and emergency intervention. Honestly, I have to say that this one was scary.

2012: Got a call from my cardiologist (Wednesday, December 5th) saying that staff were worried about me. I seemed to be breathing harder and maybe it was time for a checkup. Seeing as how it had been five years since my last procedure, on December 7th, I went into the cath lab again. I was woken by the cardiologist and told that I had a critical proximal lesion in the ostium to the LAD and another tight lesion in the circumflex at the bifurcation to the obtuse marginal. He had called the surgeon and I’d be going straight to surgery. We talked it over, and I chose to receive a stent in the ostium to my LAD.  

2013: January 8th, I had an intervention to my circumflex artery.

In my first three catheterizations, manual compression was performed post procedure each time.  When asked to describe what that was like, I can sum it up this way: “TOTALLY MISERABLE!” In an age where healthcare is being measured not only on successful clinical outcomes, but also on patient satisfaction scores, it is important to provide the best patient experience. I hope my story sheds some light on the process after the procedure, as I have walked a mile in our patients’ shoes.   

The real world 

Have you ever been in a cast and had an itch you couldn’t reach?

Have you ever laid down for a nuclear scan and been told not to move, and after 15 minutes, moved a half-inch and was told you have to start all over again and NOT MOVE!?

What about the cardiac cath patient?  Post intervention, the sheath gets pulled once the activated clotting time (ACT) has reached hospital protocol. Sometimes it can take 2 hours. Once the ACT is within normal levels, it is another 20 minutes or more to gain hemostasis through manual compression. This is followed by strict bed rest for 4 hours. (Of course, this is only if you have a 1:1 patient caregiver ratio.  It could be longer if the caregiver has multiple patients.)  

You are told to lie in bed for hours on end without moving your leg. Sounds easy enough. Maybe for the first hour it is, but then it becomes totally, unbelievably miserable. You try your best to lie still, but the clock keeps ticking and family, friends, and even television don’t take your mind off of the fact you are forbidden to move that leg. Even after being allowed to sit up at an angle, there is the anxiety of having to keep the leg still and the ongoing back discomfort that begins to feel like a spike: 2 hours in, and 4 hours to go. So you end up wiggling just slightly to gain some sort of comfort, but before you know it, the sheets and blankets are wrapped all around you, like bandages on a mummy. Even the hospital gown is no longer an article of clothing, but part of the tourniquet of sheets. Frustration and misery set in.

Change for the better

My first three post-procedure cath experiences were just as described above. My last two experiences were different. We had brought a new method of access into our lab, a shallow-angle access that allows for rapid time to hemostasis, rapid sit-up times, and rapid ambulation.  

As a qualified scrub registered cardiovascular invasive specialist (RCIS), I had performed this access using the Axera access device (Arstasis, Inc.). I can’t say I wasn’t nervous about sticking the patient twice for one access, but with care and close observation toward following proper procedure, I had no complications.  We saw good success with our patients. I was comfortable with the procedure and the benefits it brought. I was impressed by the reports coming to us from our recovery unit. During lunch breaks, I kept hearing praise and joy from the recovery nurses as to speed of hemostasis times with the Arstasis device.  I kept hearing about the surprise and happiness of patients (who had previous cardiac procedures) with significant decrease in bed restraint time.  Happiness in being able to go home earlier.  Happiness in getting out of bed and being able to sit in a chair within an hour of getting back into the room. That was my tipping point, as to why I chose Axera access for my last two cardiac procedures. Remembering the agony and misery of my first three post cath experiences, in December 2012, I requested Axera access as my access method of choice. One of my peers, a trained RCIS with 28 years of experience, performed the arterial stick for both procedures (he was also the assigned scrub tech for both procedures). 

In my December 2012 procedure with the Axera, the physician opted to use 10,000 units of heparin and eptifibatide. I already had aspirin and clopidogrel on board. The sheath was pulled within thirty minutes post procedure.  The nurse held for five minutes.  I was oozing a little, so he held for another 5 minutes, after which hemostasis was achieved. Forty-five minutes later, I was sitting up at 45 degrees and 15 minutes later, ambulated.

In my January 2013 procedure, I was given heparin, clopidogrel, and aspirin.  Again, sheath removal was performed within 30 minutes of the end of the procedure; hemostasis time was 5 minutes, with 45 minutes to ambulation.

My post-procedure experience was remarkably improved with Axera access versus my first three procedures.

Although I experienced a small hematoma on the 2012 procedure, it did not require any intervention and I attribute this minor complication to the amount of anticoagulation on board and not the access procedure or manual compression post procedure. (Note: Even 6 hours post procedure, I was still experiencing blood and clots in my urine.)

The procedure in 2013 had no complications and I was able to leave my bed within one hour post procedure.

Moving forward

When a technology provides a safe and effective means to better the patient’s experience, it is worthy of sharing. Not only have our patients benefitted from the Axera access procedure, but our staff has as well. The recovery unit nurses that once had to go on medical leave due to hand, wrist and shoulder injuries related to prolonged manual compression are happy when they are told the patient had an Axera access procedure. (With Axera access, time to hemostasis is, on average, 5 minutes in our hospital.)  

Our administration recognizes that the costs associated with disability to staff can be significant and one of the benefits of having to hold pressure for less time is the alleviation of some of those costs.

With future government regulations and oversight to patient care, we as staff need to consider new ways of caring for the patient and getting them out of the hospital on the same day, while doing it safely. Axera can do this.

Even some of our most conservative and cost-conscious physicians have found the Axera access procedure to be successful and beneficial.

We have happy staff, happy administrators, and most importantly, happy patients.  

Access may not be the first thing one thinks of when it comes to taking care of the heart in the cardiac cath lab, but it brings lasting memories for the patient. We should all look to getting back to fundamentals when it comes to groin access. We have undergone a transition in how we view femoral access complications in cardiology. The insertion has to be treated with the same care and interest a person would apply during an intervention. Do it slowly, with attention on following the protocols given by the manufacturer. Every step of the procedure is important. Starting smart has lasting implications. 

On a personal note,  I have received no financial benefit from this article. No extra CEUs, no free pen or T-shirt. No “percs” of any kind. Over the years, I have seen many different closure devices brought into our lab.  Some have worked well and some disappeared as quickly as politician promises. All devices experience some complication in their use. I have even seen a few with Axera. Nothing is perfect. With care and proper deployment I have seen this device perform beautifully. I feel comfortable and confident enough about this product that I have had it used on me not once, but twice, with great results. So think about it next time you are looking for a way to shorten a patient’s stay and make them happy, happy, happy about having a cardiac procedure.

Gerald Lagasse, RCIS, can be contacted at glagasse@borgess.com