The prevalence of coronary artery disease (CAD) is steadily trending upward and is not predicted to decrease drastically in the near future. Currently, CAD contributes to 11.5% of overall deaths in the U.S. alone.1 Given this continued trend and the corresponding frequency of cardiac catheterization, measures to decrease patient anxiety and increase communication remain an ongoing need. Current literature indicates that 60% of adults experience increased levels of anxiety surrounding the cardiac catheterization procedure, which could potentially negatively impact their procedure outcome.2 This anxiety may be due to patient perception of the cardiac catheterization’s potential to be a life-threatening event, the uncertainty of their diagnosis, and their lack of knowledge and familiarity with the procedure process and environment.3-6 The highest level of anxiety occurs during the waiting period just prior to the procedure.6 Along with the expected high rate of anxiety comes a potential for the elevation of negative cardiac effects. The physiologic effects of anxiety affect cardiac muscle, including elevated blood pressure (BP) and heart rate (HR), and increased respiratory rate (RR), leading to a rise in oxygen consumption by the myocardium and increasing the demand on cardiac output. As a result, associated risks and angina can increase, with the potential to contribute to a negative outcome both at the time of the cardiac catheterization and during the recovery period.7 Evidence supports proper preparation of patients with information about their procedure as a way to reduce anxiety, increase post-procedure compliance, and enhance patient satisfaction.8 The potential negative outcomes of poor communication results in 10% of sentinel events and being uniformed rates highest on patient satisfaction complaints.8,9 While not all patients fully understand the pre-procedure education, when experienced personnel provide better quality information and present it in a format appropriate to the patient’s level of understanding, it results in improvements in patients’ perceived perception of communication, and reduced pain and anxiety.8,9 If improved communication results in better self-care, future medical interventions may be needed less frequently.8
In the crucial pre-procedural period, the healthcare provider has the opportunity to assess gaps in knowledge of cardiac catheterization patients. In order to reduce patient anxiety and thus potentially improve the procedure outcome, we implemented a written procedural information tool (WPIT) (Figure 1) at our hospital, provided at the time the procedure is scheduled.7 The information serves as a factual guide outlining the details of the cardiac catheterization procedure process. The WPIT should meet the needs and expectations of the patient (including sensory information such as what patients can expect to feel, see, hear, smell, and taste; and information about IV sedation, lying flat, femoral artery access site, etc.). Information should be presented in a manner suitable to the patient’s level of understanding, and easy for the healthcare providers to deliver to patients in terms of time, access, and cost.3 With the U.S. average reading level equivalent to that of children in the fifth grade, it is imperative that a written information tool not be authored above this level so that the majority of patients can effectively read and comprehend the provided information.3,10
Our hospital cardiac catheterization department performs 4800 procedures annually (400 procedures per month). Prior to implementation of the WPIT, patients within the hospital cardiac catheterization department received an outdated and incomplete standard procedure preparation sheet that insufficiently communicated and informed them on their level about the cardiac catheterization procedure process. This standard procedure preparation sheet contained an incorrect contact phone number for pre-registration and outdated hours of operation. All patients scheduled to undergo cardiac catheterization received this standard procedure preparation sheet despite its lack of accuracy, which resulted in patients’ negative perceived perceptions of communication on the patient satisfaction survey. Some of the negative comments added to surveys included “more communication between patient/nurse/front desk,” “overhaul the entire system and start communicating with patients,” “explain what to expect,” “doctor to give more information on procedure/tests,” and “if the instruction was given at the time of recommendation, this would have put me more at ease to have the heart cath procedure.”
A comprehensive pre-procedural WPIT provides patients with the information they want to know about the cardiac catheterization procedure. The cardiac catheterization procedure itself involves a level of intimacy that most patients are unaware of until the procedure begins.9 The WPIT includes the who, what, when, where, why, and how. It is presented in a manner that is easily understandable for patients and timely in its delivery. The WPIT affords adequate time for patients to review the information with their families and write down any questions they may have. The WPIT was designed to be brought with the patient on the day of the procedure, as it also contains information necessary for day-of processes. Family members can further review the WPIT while their loved ones are in the procedure, giving family members more time and information in order to ask follow-up questions.9 When the patients are contacted via telephone for pre-admission testing the day prior to their scheduled procedure, they also have the opportunity to discuss any questions with the registered nurse. The WPIT supports a personable way to enhance the patient experience, as it is impossible to separate the patient experience from the family experience.9
The information included in the WPIT was developed via a reference base of evidence-based data.9,11,12 Additional validity of the content used in the WPIT was established via a Likert-type survey completed by appropriate stakeholders. These stakeholders included the director of nursing in cardiology services, the advanced practice registered nurse (APRN) of the cardiac catheterization department, the nurse coordinator of the cardiac catheterization lab, the nurse coordinator of cardiac holding and recovery, one key cardiac holding and recovery nurse, and four intra-procedure cardiac catheterization lab nurses. The stakeholder nursing experience collectively adds up to well over 20 years in the cardiac catheterization lab.
While working on getting this project off the ground, a new cardiologist who joined the group within the hospital heard of the project’s aim and helped provide feedback from a physician prospective. He was impressed and excited about the WPITs potential to not only improve patient satisfaction but to provide momentum toward opening the door for improvements across the cardiology pre-procedure process spectrum. This included ordering the cardiac catheterization in the clinic, orders for lab testing (ie, BMP, CBC, INR, etc.), distribution of the WPIT, pre-admission testing, etc. Through collaboration with the cardiologists, cardiology nurse practitioners, and the director of cardiology, numerous rounds of edits (approximately seven) were made to finalize the WPIT to reflect the most accurate information specific to the hospital. Due to the support and involvement of the cardiology group, the marketing department of the hospital also became involved. Marketing was responsible for taking the final version of the WPIT and turning it into the company-approved template complete with color, pictures, and the Florida company logo. The official marketing version of the WPITs are slotted to permanently replace the standard procedure preparation sheet as part of the spectrum of improvements.
The WPIT has since been used as a template to develop similar WPITs for other procedures also performed by the cardiology group within the hospital (ie, transesophageal echocardiogram/cardioversion, and catheter ablation). Currently, additional WPITs are in development for implanted device (pacemaker/defibrillator) and SVT ablation procedures, which will complete the WPITs for the plethora of cardiac procedures performed in our hospital. Additionally, it has been suggested that the WPIT be implemented at the two other hospital campuses where the cardiology group practices, as well as in their seven additional outpatient cardiology clinics where patients are seen prior to their cardiac catheterization.
Patients are now being informed of their cardiac catheterization procedure process, and the final professional quality of the WPIT and enthusiastic receptiveness from the stakeholders has been astonishing. Patients are now being asked about the impact of the WPIT on their perception of communication with surveys in January 2020. We anticipate patients will benefit from this quality improvement for years to come. The future impact of the WPIT is positioned to reach well beyond the initial intended use. The significance of the passion to inform patients regarding their cardiac catheterization procedure via the WPIT has grown exponentially larger than we could have anticipated and benefits will be felt across the spectrum of cardiology care.
Laura E. Spear, DNP, APRN, FNP-BC, can be contacted at firstname.lastname@example.org.
- Centers for Disease Control and Prevention (CDC). May 2017. National Center for Health Statistics: Heart disease. Available online at https://www.cdc.gov/nchs/fastats/heart-disease.htm. Accessed December 18, 2019.
- Carroll DL, Malecki-Ketchell A, Astin F. Non-pharmacological interventions to reduce psychological distress in patients undergoing diagnostic cardiac catheterization: a rapid review. Eur J Cardiovasc Nurs. 2017 Feb; 16(2): 92-103. doi: 10.1177/1474515116670596.
- Aazami S, Jaafarpour M, Mozafari M. Exploring expectations and needs of patients undergoing angioplasty. J Vasc Nurs. 2016 Sep; 34(3): 93-99. doi: 10.1016/j.jvn.2016.04.003.
- Buzatto LL, Zanei SS. Patients’ anxiety before cardiac catheterization. Einstein (Sao Paulo). 2010 Dec; 8(4): 483-487. doi: 10.1590/S1679-45082010RW1517.
- Jamshidi N, Abbaszadeh A, Kalyani MN. Psychological problems in patients awaiting coronary angiography: a preliminary study. Anadolu Kardiyol Derg. 2013 Feb; 13(1): 84-85. doi: 10.5152/akd.2013.026.
- Moradi T, Adib-Hajbaghery M. The effect of a multi-modal preparation package on anxiety in patients undergoing coronary angiography. International Cardiovascular Research Journal. 2015; 9(1): 10-16. Available online at https://www.researchgate.net/publication/281907577_The_Effect_of_a_Multi-Modal_Preparation_Package_on_Anxiety_in_Patients_Undergoing_Coronary_Angiography. Accessed December 18, 2019.
- Ayasrah SM, Ahmad MM. Educational video intervention effects on periprocedural anxiety levels among cardiac catheterization patients: A randomized clinical trial. Res Theory Nurs Pract. 2016; 30(1): 70-84.
- Marcus C. Strategies for improving the quality of verbal patient and family education: A review of the literature and creation of the EDUCATE model. Health Psychol Behav Med. 2014 Jan 1; 2(1): 482-495.
- Knapik ML. Providing the best patient experience: Simple strategies for the cardiac catheterization laboratory. Cath Lab Digest. 2013 Sept; 21(9): 52-53. Available online at https://www.cathlabdigest.com/articles/Providing-Best-Patient-Experience-Simple-Strategies-Cardiac-Catheterization-Laboratory. Accessed December 18, 2019.
- Veneri DA, Zdanis K. Are technology-informed methods better than traditional approaches in educating patients? A meta-analysis. Health Education Journal. 2018; 77(3): 261-276. doi: 10.1177/0017896917741511
- McEnroe Ayers DM. Preparing a patient for cardiac catheterization. Nursing. 2002; 32(9): 82. Available online at https://journals.lww.com/nursing/Fulltext/2002/09000/Preparing_a_patient_for_cardiac_catheterization.57.aspx. Accessed December 18, 2019.
- Naidu SS, Aronow HD, Box LC, et al. SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory: (Endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologia intervencionista; Affirmation of value by the Canadian Association of interventional cardiology-Association canadienne de cardiologie d’intervention). Catheter Cardiovasc Interv. 2016 Sep; 88(3): 407-23. doi: 10.1002/ccd.26551.