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To the Right: A Right Heart Cath (RHC) Education Project at the Louis Stokes Cleveland VA Medical Center
“It’s JUST a right heart catheterization (RHC).”
Sounds easy, right? Insert a Swan, obtain a few pressures, run a few saturations, and you are done.
...Well, not really. To the experienced cardiac team member, the right heart catheterization seems to be just another routine task. To the nurse or technologist that is new to the cardiac catheterization laboratory, the RHC can be completely overwhelming. Saturations, shunting, pulmonary vascular resistance (PVR), systemic vascular resistance (SVR), and valve area, just to name a few terms, can cause great anxiety for anyone who is new to cardiology. The RHC gives a wealth of information about the general health of a patient. Understanding the meaning of each measurement and applying that information to patient care is imperative for any staff member in any cath lab.
Important aspects of monitoring RHC procedures include reviewing the background history on the patient, knowing the supplies needed during the procedure, recording an accurate pressure within each chamber, recognizing acceptable and unacceptable wave forms, and performing accurate oxygen saturations. It goes without saying that the patient must be continuously monitored during the procedure for any changes in their hemodynamic status. One of the more challenging areas of understanding the RHC is correlating the pressures within the heart to the waveform on the screen (Figure 1). In order to do so, we need to know where the physician has positioned the catheter within the heart chamber/venous system, and where they are planning to move to next. The physician advances the catheter in approximate centimeters in relation from one area to the next; however a nurse is not able to see the centimeter advancement and must rely on the knowledge base of recognizing wave formations, catheter images, and output numbers on the monitor. Right-sided heart pressures provide the physician significant information to confirm a patient diagnosis and future treatment modalities. It is essential to identify proper waveforms from the recorded data and calculations without totally relying on a computerized system. Acknowledging abnormalities in measurements seen by the physician during the procedure reassures the validity of documentation and is just as critical in obtaining appropriate results.
An Education Project
At the time of our RHC education project, our team consisted of several members (registered nurses and technologists alike) who had never worked in the cardiac cath lab environment, and our team decided to formulate a right heart catheterization improvement project. The goal was to formulate learning sessions that would augment the staff’s current knowledge during a RHC procedure. Cath lab staff and the interventional cardiologists were resourceful advisors in this project. Our subject matter was divided and groups were formulated to enhance our educational aptitude while incorporating a simplistic level of understanding communicated by experienced staff. Areas undergoing research covered information that was more complicated, and many times, on a cellular level. Designated groups created presentations of their assigned topic, providing research and information to the other groups. Each group was given the opportunity to choose their presentation method, tools, and resources, utilizing pre/post staff assessment. Groups were encouraged to promote different ideas to test knowledge and understanding of their education platform.
Determining a Baseline: Pre and Post Testing
Our acting interventional cardiologist agreed to administer testing before and after our presentations, so that we could record objective improvements. The initial average results of testing were less than 70%. The entire group was composed of the cardiologist, five nurses, and two technologists. The pre-test consisted of eight questions involving the heart that evaluated the baseline knowledge of the team. The testing method for administration of the test was multiple choice, and asked questions regarding anatomy and physiology, as well as identifying pressures related to various chambers of the heart. Our method was testing over time, with a pre and post test. The pre-testing allowed us, as a team, to determine what parts of the RHC procedure required more thorough teaching and additional research in order to build our knowledge base. Our second test was administered after all teaching and research had been presented (one person from each created team was assigned to review all the information that was to be presented). Staff showed an improvement in scores and answered more questions in advanced areas of the RHC procedure. (Examples of the test questions are in the sidebar.)
Education Tools
A significant amount of teaching was involved with this project. Evidence-based practice articles, scholarly medical journals, and textbooks were utilized to obtain the information necessary to formulate our teaching plans. We utilized staff meetings and case studies to increase communication about the RHC. We reviewed the patient’s history and physical note and labs — for example, diagnosis and hemoglobin, respectively, related to procedural consult by the physician. We also discussed competency and physiological implications supporting the recommendations to complete the RHC. We applied practical steps, like repetitious monitoring, that developed our confidence level during the RHC procedure. Figure 2 is a worksheet that was an additional tool utilized during our learning process. Educational in-services were also offered by vendors and other cath lab/hospital programs were provided for our development.
Our education was structured using the “Read, Teach, and Test” method, and this process was repeated until the team felt confident in the terminology, was able to acknowledge appropriate measurements, and was capable of scoring a >80% on the post test (which was both written and verbal) given by the cardiologist.
Teach One, Show One
Teaching each other using different presentation techniques opened the door to becoming more competent and increased our knowledge base regarding the RHC procedure. It allowed us to improve and provide evidence-based, researched care for each patient — before, during, and after the RHC procedure. Working together as a group and embracing each other’s skillset has promoted teamwork and increased communication.
The physicians in our cardiology department understand the importance of developing a highly functional team. All the physicians within our department were supportive and willing to provide insight towards our goal markers for our project. This was especially true of the interventional physicians who perform RHC procedures on a regular basis. Our primary support person was the director of the cardiac catheterization lab, who was instrumental in preparing the test as well as administering it.
Creating a highly functional cardiac team is a priority that we continue to strive towards within our cardiology department. Physicians depend on the experience, skills, and expertise that our cardiac nurses offer during the procedure while managing the care of the patient. It is important that the nurse can anticipate the needs of not only the patient, but the physician, before and during the procedure. We offer and maintain an “Evidence-Based Practice Environment” that has been commended and rated among VA medical centers nationally for providing excellent cardiovascular service and high-quality care.
Reaching Our Goals
With this learning endeavor, we identified those areas that required modification in our allied health professionals during the time of monitoring. We designed a template/worksheet to organize measured data that is provided to the physician at the close of the procedure (Figure 2). This information has been instrumental in reviewing the waveforms, measurements, and documented blood gases. This information is also a pre-operative intra-departmental resource provided to our cardiothoracic team, which has helped to engage and provide pertinent results to the surgeons. We are contributing to the balance of decisions that is necessary for developing a plan of care on behalf of the patient. If a patient is receiving a RHC procedure, we become, as some say, “a second set of eyes and ears” for our physicians.
The goals of our cardiac catheterization lab staff were to achieve a higher level of educational competency during a right heart catheterization. Our overall gains in the process were remarkable, because the post-test percentage margin elevated to greater than 80%. The educational techniques that we used promoted team collaboration, research, and supported clinical competency. Collaboration is the foundation to a successful cardiac cath lab team and research is the core foundation. We achieved significant improvement within our team as we integrated basic review and staff experience. Each individual teaching technique provided multiple avenues for learning and process improvement. The outcome of our team collaboration provided us with an objective measurement of performance improvement. Being accountable for our own education and comfort level in assessing the patient’s chart, waveform recognition, and collecting appropriate measurements has contributed to decreasing the myth of complexity surrounding right heart catheterization procedures.
Special thanks to Dr. Joseph Jozic, former Director of the Cardiac Catheterization Laboratory, Louis Stokes Cleveland VA Medical Center.
Bibliography
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- Kelly CR, Rabbani LE. Videos in clinical medicine. Pulmonary-artery catheterization. N Engl J Med. 2013 Dec 19; 369(25): e35. doi: 10.1056/NEJMvcm1212416.
- Kern M. The Cardiac Catheterization Handbook. 4th ed. St. Louis, MO: Mosby; 2003.
- Eckel RH, Jakicic JM, Ard JD, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jul 1; 63(25 Pt B): 2960-2984. doi: 10.1016/j.jacc.2013.11.003.
- Rosenkranz S, Preston IR. Right heart catheterisation: best practice and pitfalls in pulmonary hypertension. Eur Respir Rev. 2015 Dec; 24(138): 642-652.
- Wei K, Main ML, Lang RM, et al. The effect of Definity on systemic and pulmonary hemodynamics in patients. J Am Soc Echocardiogr. 2012 May; 25(5):584-588. doi: 10.1016/j.echo.2012.01.019.
The authors can be contacted via Tammy Chandler, RN, MSN, ACNS, at tammy.chandler@va.gov.
