In this month’s article, we welcome members of the nursing and medical staff at McLaren Bay Region Cath Lab to talk about what many might consider a controversial topic…non-physician vascular access. However, this facility now has over ten years of experience and a proven track record that suggests this is not only feasible, but contributes greatly to the procedural flow of the cath lab. McLaren Bay Region has leveraged their extensive experience with radial access to achieve a robust same-day discharge rate.
— Gary Clifton, Vice President, Terumo Business Edge
McLaren Bay Region (McLaren Health Care) cath lab is located in Bay City, Michigan. Our cath lab consists of three coronary labs and two electrophysiology (EP) labs. The cath lab is staffed with 13 staff members. The cath lab is supported by a 28-bed prep and recovery area. Our Bay Region cath lab team and physicians have done some unique training that greatly improves throughput, efficiency, and learning opportunities for the staff.
The technologists and nurses at McLaren Bay Region have always been integrated into the procedure flow to obtain access. Our lab was previously recognized by Cath Lab Digest in February 2008 for providing this training and opportunity to the staff. Not only was the uniqueness of the nurse or tech access role acknowledged, but our low site complication rate was presented as well.
This approach has evolved into obtaining radial access. Staff will attempt radial access in 100% of all appropriate patients. If unable to obtain access after three attempts, access will be deferred to the physician. A radial access training competency is in place that requires ten successful attempts in front of a physician prior to independent practice. Since allowing staff to participate, engagement has increased, as staff feel a part of the process and included in patient care. Our 2018 data shows that techs and nurses obtain 88% of radial access in our program.
Radial access is a major component to the success of our cardiac program. Seventy percent of all cases performed are done so by radial access. It saves time for the physician, allowing for faster turnover and increased cases per room. Physicians who were hesitant to proceed with radial cases quickly became comfortable with the procedure relying on experienced staff for guidance. This strategy has been extremely effective in acute myocardial infarctions, allowing staff to obtain access before the physician even arrives and shortening the door-to-balloon time. Our current door-to-balloon time averages between 47-54 minutes. Considering our program covers a large geographic area and has additional challenges of winter weather, this approach shaves off critical minutes for the patients we serve. We have three outlying facilities that perform diagnostic angiograms only and transfer PCI cases to our facility. Radial approach provides a more comfortable and safe transport for the patient when compared to a femoral sheath management.
Our 2018 data puts our same-day discharge (SDD) rate at 40%. We believe our ability to outperform the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) average of 28% is due largely to our commitment to radial access and the inclusion of staff in the access work. Our radial access physician champion achieves over 90% SDD for elective PCI patients. Initially, we identified candidates for SDD as younger patients, minimal comorbidities, adequate family support, and in close proximity. Our patients often live over two hours from our program. Providing radial access is an integral part of our SDD success. Our goal is to safely discharge our scheduled elective patients who receive a stent 2-3 hours post procedure.
The biggest emphasis is that our patients obtain proper prescriptions for dual platelet therapy prior to leaving the hospital. Our outpatient pharmacy fills and delivers the medication to the patient’s bedside prior to discharge. We have arranged for a free thirty days of ticagelor on discharge for appropriate patients. This is so important to our program because our early experience showed that patients would not pick up their prescriptions, for a variety of reasons. This process assures us of a safe discharge with uninterrupted dual antiplatelet therapy (DAPT) for 30 days, a message emphasized by the physician and re-emphasized by the nursing staff prior to discharge. We stress the importance of repeating the message and also including the caregiver in that message, as many patients may not be coherent during the initial physician counseling due to sedation. At the time of discharge, physicians and nurses collaborate to ensure core measure are met and key therapies, including statin therapy and cardiac rehab referrals, are in place. An additional safety net is that patients are sent home with a red bracelet that includes a hotline number for any urgent issues. The patient receives a phone call the day following discharge and an office visit within one week.
As our SDD program proliferated, we aborted any algorithm as to who qualifies for SDD. We are aware many programs follow guidelines such as early cases, age limits, and proximity to the hospital as requirements to consider SDD. We have not witnessed any specific rule that benefits or defines safe SDD. Late in the day cases can have the same success as early morning cases. It is the review of the physician, outcome of the case, and response of the patient that drives the SDD criteria.
Our SDD numbers have increased gradually over time, with significant focus on the subject. Finding ways for patient and physician comfort is key. Starting out conservatively will help boost confidence and allow the facility to validate the SDD program is producing a safe patient outcome and positive patient experience. Our program focuses on making sure the patient has everything they need for a healthy recovery.
If your program is considering staff-led access or growing your SDD program, a driven physician champion must be dedicated to the cause. Radial access must be a priority and success with quality, financial, and patient experience should be shared within and outside the organization. Patients will spread the word about radial access and SDD, and they will request it. Today patients can find more information than ever related to physician and hospital quality numbers, and soon to come, cost. Providers should be aware of the competition from those successfully performing radial access and providing SDD. It takes a program with a culture of respect for physicians to learn techniques from each other and teach their team. Our program is a blend of integrated and independent physicians, yet both side work together to create best practice guidelines and standardize care when able. It all comes down to improving clinical practice and developing best standards of care. So much literature and research has been presented on radial and SDD, much like hypertension and hyperlipidemia. The gold standard of radial access and SDD should be provided to every eligible patient.