Citing a need for more clear process explanation for cardiovascular catheterization labs, leaders from prominent cardiology departments across the country have united to develop a consensus statement on best practices for the cath lab, published in this month’s Catheterization and Cardiovascular Interventions. The groups recommendations span the full scope of the process, from credentialing and team composition, to most effectively managing pre-,peri-, and post-operative procedures.
The group, including cardiology department leaders from 9 hospitals such as Duke, Geisinger, and Mayo Clinic, developed best practice recommendations for 18 subjects across four principle categories: provider qualifications and care team composition, preoperative processes, perioperative processes, and post-postoperative processes. The statement generally reflects best demonstrated practices across each of these terrains, with a particular focus on clinical indications and patient safety. We have summarized their findings below.
Provider Qualifications and Team Composition
Provider competence and documentation
All physicians performing catheterizations within the hospital should be properly credentialed, compliant with continuing education standards, and undergo regular evaluation around procedural outcomes, complication rates, and success rates. Participation in national quality registries such as the CathPCI registry is also recommended. Technicians should be RCIS certified, and nurses should have 1 year of experience in critical care.
Optimal cath lab team
In addition to the credentialed attending physician, the group recommends a multidisciplinary care of at least two other individuals (comprised of nurses, technicians, training physicians or physician assistants), trained on all crucial cath lab equipment. An anesthesiologist or CRNA should also be present for cases where moderate to deep sedation may be necessary.
Preprocedure Best Practices
Documentation of Procedure, History and Physical
All patients should have an up-to-date history and physician prior to the procedure, with the caveat that an emergent patient may necessitate a more limited examination. The history and physical should be performed within 30 days for outpatient procedures (with a focused updated within 24 hours), and within 24 hours of admission for those on the inpatient side. In addition to the history of the illness in question, the group suggests that providers also screen for comorbidities and review all systems which can be negatively impacted by the procedure, including cardiovascular, renal, gastrointestinal, peripheral vascular and pulmonary. Providers must also screen for any history of contrast reaction, or any indications which would conflict with the long-term use of oral anticoagulants. With respect to the physical, providers are instructed to focus on the heart and vascular system, including the peripheral vascular system.
Informed consent process and documentation
The group recommends that all hospitals have a written policy on informed consent, including the process used to obtain consent and documentation of consent and any related surrogacy issues. Consent must be obtained in the patient’s native language, using language comprehensible to a lay person, and include both what the procedure entails as well as anticipated outcomes/benefits, potential complications, and alternative to the procedure. The group also suggests that best practice would be for consent to be witnessed by a third party, such as a patient family member or hospital staff member working outside the cath lab.
Sedation, anesthesia, and analgesia evaluation
Hospitals should follow the established guidelines for training of physicians and cath lab personnel in proper sedation techniques, including sedation pharmacology, airway management and patient monitoring. While nurses, NPs and Pas may administer sedation and assist in patient monitoring, this must be done under the supervision of the attending physician.
One of the most extensive recommendations in the consensus statement, the group recommends that hospitals develop a detailed preprocedure checklist to ensure all safety precautions appropriate for the cath lab have been taken. This suggested checklist includes the following:
- Review of patient medications, in particular anti-platelet therapies or others which may impact renal function
- Evaluation of any upcoming potential or required surgeries
- Bleeding risk assessment
- Review of history for intolerance to anti-platelet or antithrombotic agents
- CBC, serum electrolyte panel, and renal function assessment (within 30 days)
- Confirmation previous anemias have been addressed
- PT/INR for patients with chronic warfarin therapy
- Baseline EKG
- Beta-HCG evaluation for women of childbearing age
- Review of past procedure notes for patients with previous catheterizations or bypass surgeries
- Documentation of common allergies, especially to latex or contrast
- Confirmation patient has remained NPO for at least 3 hours prior to the procedure, 8 hours if conscious sedation is anticipated
Intraprocedure Best Practices
Patient preparation in the procedure room
At least one cath lab provider should carefully review the patient’s medical record, confirm their NPO status, and assess any potential access site concerns, allergy issues or other key risk factors.
Sedation, anesthesia, and analgesia administration and documentation
The physician performing the procedure should manage the sedation process. A nurse or other credentialed provider should be present during the administration of anesthesia to monitor for side effects or deterioration in the patient’s condition. All administered medications must be recorded in the patient record for review by the physicians taking responsibility for the patient following the procedure.
Though not a common problem for the cath lab, the group does recommend a few best practices in preventing infections, including clipping over the access site, use of chlorine-based preparations, and drapes the adhere tightly to the skin around the access site and do not loosen during the course of the procedure. As to hand hygiene, the group recommends that physicians complete a surgical hand scrub before the first case of the day, then use self-drying solutions before subsequent cases.
Environmental issues (radiation safety)
The group recommends that cath lab team members take particular note of the fact that ionizing radiation is used within the lab, and suggests that staff don protective equipment such as lead aprons, thyroid shields, and even leaded glasses for those operating near the radiation source. Patient radiation dose should be carefully tracked, and those patients receiving doses above key thresholds should be educated about radiation burns and seen within two weeks of the procedure to assess any radiation damage.
Universal protocol and time out procedures
Before the start of each procedure, each team members should be fully briefed on the details on the case and associated protocol. Each team member should independently confirm the patient’s identity and the planned procedure. If a team member rotates out in the course of a procedure, the substituting team member should introduce themselves and announce their role. Based on universal infection protocols, the group recommends that all solutions be labeled in real time, with preprinted labels for common mediations as well as blank labels and markers readily available. Finally, all verbal physician orders in the course of the procedure must be documented.
Postprocedure Best Practices
Physician to patient communication
The group recommends that the attending physician directly discuss the results of the procedure with the patient and his/her family, as well as complications or pertinent findings. Management plans for the patient and additional instructions should also be communicated at this time.
Access site management
A host of clinical recommendations currently exist for assessing and selecting closure devices and techniques. In addition to adherence to these existing guidelines, the group suggests that ambulation be restricted for 1-4 hours post-procedure, contingent on groin site hemostasis and peripheral pulse. Patients for whom radial access was used have no ambulatory restrictions, but the group recommends the arm be kept immobile for 2-4 hours following sheath removal.
Appropriate monitoring and length of stay
Patients should be monitored on telemetry, with vital signs checked every 15 minutes for 2 hours postprocedure, with telemetry continued throughout the stay unless otherwise indicated. Length of stay for a diagnostic cath ranges from 2-6 hours depending on access site, but is considerably more variable for PCI.
Discharge instructions and patient information
Providers caring for the patient at time of discharge must carefully review all discharge instructions, including limitations in physical activity and other follow up instructions. Patients with particular increased risk for renal complications should have creatinine checked within 5-7 days post-discharge. Patients should receive contact information for their physician and the post-PCI unit, as well as any information on a stent if one was implanted.
While medication reconciliation procedures should be in place broadly across the hospital, the group recommends specific care be placed on following up with referring physicians to indicate new medications, discontinued medications, and any changes in dosage for the patient that occurred during their stay in the hospital. Dual anti-platelet therapy is recommended one year for patients receiving drug eluting stents and 1-12 months for those receiving bare metal stents.
Appropriate attending to referring physician handoff
The group notes that handoffs from interventional cardiologists to other team members are exceedingly common following cath procedures. These handoffs must include appropriate documentation of the procedure, any complications, and the postprocedure plan for the patient. While these transitions can be done verbally, best practice indicates that formal annotation also occur to ensure the transfer of information.
Appropriate follow-up evaluation
Patients should see a provider within two to four weeks following discharge to ensure medication compliance, medication reconciliation, and reinforce long term plans for the patient including lifestyle recommendation or other changes. These exams should also confirm appropriate healing of the access site. Patients with renal challenges should have this exam much sooner, within one week following discharge.
Peer review, quality assurance and morbidity/mortality conferences
The group recommends that each cath lab have a procedure in place to conduct random peer review of procedures and cases, in addition to regular organized review of cases with significant morbidity and mortality.
More from the Roundtable
While the guidelines proposed in the piece discussed here cover a wide range of best practices within the cath lab, they nevertheless represent only a fragment of the learning our industry has done on providing safe, effective, and efficient catheterization procedures. Over the past few years, the Roundtable has written at length on a variety of best practices for securing not only safety in the cath lab, but also efficient operations. To learn more, roundtable members may access our publication on Cath Lab Performance, as well as The Outmigration of Cardiovascular Services, which addresses both PCI strategy and practices for streamlining cath lab throughput. Those members interested in benchmarks for staffing, length of stay and other productivity questions should see the 2011 Cardiovascular Productivity Benchmarking Report.