[Editor's Note: This article was published in the September 2001 issue of Cath Lab Digest, and is being posted under September 2010 as a reader reference only)
If we say that someone other than a cardiologist can and should perform a percutaneous stick, some people may question whether or not it is actually appropriate. The problem lies in the fact that in the cath lab world today, no universal cath lab standard exists. Does the lack of a standard mean that labs are performing at levels that are optimal or “normal” levels of operation? No.
This is quickly proven when we start to look more closely at individual cath labs.
A simple example is sheath removal. One cath lab may have only physicians removing sheaths; another only cath lab techs; another, nurses, and in yet another lab, trained Service Associates (SAs) pull sheaths. In our lab at Borgess Hospital in Kalamazoo, Michigan, no one in the cardiovascular lab (CVL) pulls sheaths, whether brachial or femoral. All the nurses in the recovery unit, the coronary unit, and critical care units pull their own sheaths, except for IABP sheaths (and even that may soon change).
Variances in cath lab standards run the spectrum, and include more serious considerations such as who gives medications, who can run the x-ray equipment, who scrubs, who sutures, who monitors and who has a right to document the procedure, who tests pacemakers, etc.
The fact that there is no universal cath lab standard has become increasingly apparent in the last five years. Living and working in Kalamazoo, Michigan, poses problems which are similar to those of many cath labs located at a distance from major metropolitan areas. Staff may have little or no exposure to fellow cath lab professionals, creating a sense of professional isolation and a feeling that their own “cath lab standard” is the norm in the industry.
Two things have altered my professional perspective. First, I discovered that the Society of Invasive Cardiovascular Professionals (SICP) has a yearly regional meeting in Chicago (and other cities around the country). Second, I acquired a computer and found websites for cath lab professionals.
I’ve gone to the Society of Invasive Cardiovascular Professional (SICP) regional meeting in Chicago for about five years. I’ve been going every year since I discovered such meetings were available in the midwest. I’ve thoroughly enjoyed the educational aspect of these meetings.
I also enjoy the chance to interact with staff from other hospitals, and until www.cathlab.com came about, (particularly the message board, “Heart to Heart”), the SICP meetings were my only means of observing the varying protocols at different labs. During lunch breaks, I purposely sat with total strangers, just to meet and see how other places do things. I’ve been surprised at the level of differences around the country.
After lunch, I especially enjoy the question asked by the SICP moderator, who asks a question guaranteed to awaken the audience and get the blood moving. Two years ago, I had a particularly interesting experience. The moderator asked an audience of between 200-300 cath lab staff:
“Who among you performs arterial access?”
I looked around the audience and saw three hands raised. There then ensued a loud discussion, with many comments against the idea of cath lab staff performing arterial access. Some people felt that this was a physician area and that it should be left as such. Someone else commented, “Why should I take on more responsibility and not get paid any more?”
At the time of this animated discussion, three things popped into my mind. The first was my personal theory of DNA, the second was Florence, and the third was myself. You see, of those three people with their hands up, I was one. The other two hands belonged to fellow staff members who were there with me that day. Performing the art of percutaneous access has long been a part of our hospital standard.
DNA and the Medical Profession
It seems fitting that I bring up my theory of DNA in at a time in history when man has mapped the human genome. My theory of DNA focuses on people in the medical field.
During the last few years at symposiums and conferences, I’ve heard things like:
1. “You can’t do that — you’re not a NURSE!”
2. “You can’t do that — you’re not a DOCTOR!”
3. (To be fair, this could also be, “You can’t do that —
you’re not a TECH.”)
I came away from these experiences feeling that certain human beings were imprinted before birth or while in school, with a specific gene that allowed them and only them to perform a specific task. When the report of the gene map was released and no mention was made of discovering these specific genes, I felt vindicated.
Let me pick on nurses (but again, this same concept can be applied to any other field) in their attitude that only they can perform certain tasks because they’ve been trained for it in school.
I’ve worked in the cath lab for twenty-five years and have met and taught student nurses for many years. Our city has the luxury of four colleges within its boundaries. Over the years, I’ve been exposed to nurses from two separate four-year programs, a two-year program, and an in-hospital program (which I actually found to result in the most highly prepared students). I have yet to meet any GN from any of these programs who is capable of going directly into a critical care area or a CVL and functioning at any level that could be considered competent.
A nurse becomes competent to work in a critical care environment with on-the-job training and lots of in-hospital classes that take up a great deal of time. Competency in critical care or the CVL also results from a very special person who’s willing to take on additional responsibility while not getting any better pay than a regular floor nurse.
Cardiac fellows learn the skill of performing percutaneous (perc) sticks while in their medical training. Perc stick skills are learned in the cath lab. Who else is there with them when they learn? Cath lab personnel. Is it too much of a stretch to think that those skills can’t be learned by cath lab staff while on-the-job in the same environment as the cardiac fellow?
A world-recognized teaching hospital set up a trial where cardiac fellows would perform diagnostic cases in one lab, while experienced cath lab scrub nurses would perform diagnostic cases in another.(1) The results of the trial showed similar diagnostic quality results; however, there were fewer complications in the cases performed by scrub nurses. The conclusion of the trial was that using experienced scrub staff to perform diagnostic procedures was a safe alternative to using up the precious resources of a diminishing physician (cardiologist) population.
Requiring specific “DNA” to perform a specific task is a myth. It’s physician and administrative support that allows staff to learn new skills. It’s staff education and patience during new learning experiences that facilitates the accomplishment of a specific task.
Are We Rejecting the Spirit of Florence Nightingale?
The audience’s attitude at the SICP conference was so negative in response to the idea of encroaching upon the duties of physicians that it reminded me of what I’ve read about a very respected person, Florence Nightingale. Up until 1860, you did not find respectable ladies involved with the medical field, especially nursing. Nursing was considered an unsuitable occupation. Nursing jobs were filled with the lower classes, especially those thrown in prison for drunkenness or who couldn’t find any other form of work.
In 1860, Florence Nightingale opened the Nightingale School and Home for Nurses at St. Thomas’ Hospital in London, changing nursing forever. She fought against the established rules that defined the nurse’s role.
From the Encarta encyclopedia: “Before she undertook her reforms, nurses were largely untrained personnel who considered their job a menial chore; through her efforts, the stature of nursing rose to a medical profession with high standards of education and responsibilities.”(2)
Recently my ten-year old daughter was writing a paper on the bubonic plague. She had several books from the children’s library, including A Doctor’s Life by Rod Storring. I looked up nursing and found the following:
“Florence (1820-1910) decided to become a nurse against the wishes of her wealthy parents. When Britain went to war against Russia in 1853, she took a small band of nurses to the Crimea. There she cared for wounded British soldiers who had been poorly looked after by untrained male orderlies in filthy conditions. Despite opposition from military doctors, Florence Nightingale and her nurses cleaned up rat-infested hospitals and saved many soldiers’ lives.”(3)
Storring also wrote, “…in those days (1865) nurses were dirty, illiterate women who often drank too much.”(3)
Notes on Nursing by Florence Nightingale states that “care of patients was not only to do with giving medicines and bandaging wounds, but also about making sure that patients were clean and well looked after.”(4)
Examples of Nightingale’s belief can be seen in other nurses of that time, like Harriet Tubman, a former slave who went the distance and helped other black slaves escape to freedom. Clara Barton worked the front lines during the Civil War rather than be safe at a hospital in back of the fighting, earning the name “Angel of the Battlefield.”
Now we have people, as evidenced by the responses that day at the SICP conference, who are afraid of taking on new roles, fear new responsibilities, or are just plain satisfied with their current established duties and want them to remain fixed and unchanged. Unfortunately, the cath lab and medicine in general remain dynamic environments. Staff who resist change are actually turning their backs on the concepts and beliefs brought about by Florence Nightingale.
The Author’s Own Fear is Overcome
I began performing the art of arterial access in 1982. It all started with our Chief of Cardiology, who, throughout the late 1970s to the early 1990s, was Dr. Enrique Leguizamon. Dr. Leguizamon was trained by Mason Sones and was a friend of Andreas Gruentzig.
Dr. Leguizamon was a great innovator and believed in pushing cardiology to the edge. He started our exercise rehab program, nuclear radiology, set up his own diagnostic lab in his office building, and also started our interventional program. Borgess did their first coronary angioplasty in 1979. I was later told we were the fifth hospital in the country to be performing angioplasty. In the 1980s, Dr. Leguizamon was doing coronary, peripheral and renal angioplasties. He even did a carotid in 1990. He was a man ahead of his time.
In 1982, he came back from a symposium and told the hospital, myself and Tom Spigelmoyer (AART, CVT) that we would be starting to perform arterial punctures. I was totally unnerved at this prospect, but also realized that no one said “no” to Dr. Leguizamon. He taught us antegrade and retrograde sticks. He taught us brachial and trans-axial approaches. Once he felt we were competent, he signed us off and gave us permission (in writing) to access any and all of his patients. Within a short time, we acquired permission from all his partners to perform sticks on their patients as well. It became apparent fairly quickly to other physician groups that Dr Leguizamon’s patients, as well as those of his partners, were moving more quickly through the cath lab and with less peripheral complications. Soon these physicians also wanted our services for their patients. They signed appropriate papers with the hospital to allow us to perform access sticks on their patients, and since then, we have been doing all patients coming into the Borgess cath lab.
Complications Result in a Productive Trial
As the years passed, more staff were acquired and training in arterial access was added into the training program. However, about seven or eight years ago, we had a staff member that had a run of bad luck and had several complications with the sticks. [Realize that at the time we had few complications, and having one or two a month is considered serious (we see over five thousand patients per year).] As a result, Borgess Hospital decided to have a trial.
For three months, no staff member would perform arterial access. Instead, physicians would perform all sticks. The resulting physician complication rate would then be evaluated against the results of complication rates for the three months prior to the trial, when only cath lab staff were performing access.
The trial was stopped after fifteen days, because the physicians had already exceeded the staff complication rate. As a result of the whole experience, we decided to set up an official protocol that would be above reproach.
Setting Up a Protocol: Not as Easy as it Looks
Setting up a protocol from the ground up and with no template to go by was certainly unnerving. I wanted it strict enough to pass the inspection of the most critical eye while fulfilling all the requirements asked of a competency. I was comfortable dealing with the clinical aspect, but I needed assistance for the educational portion. In our small department, we all wear different hats of responsibility. Mine include radiation control officer and lab troubleshooter (when a machine or a procedure doesn’t work, I get called). I turned to Mark Bergren, RN (our educational and programming person) for the educational component, and Dorothy Bennett, RN (our scheduling and competency writing person) for assistance in writing up our competencies. Following is what developed out of our collaberative efforts. It is broken down into two parts: Part A covers education and Part B is clinical.
Before a staff member can apply for the privilege of performing arterial access, they must first fulfill certain obligations:
1) Have been in our department and been scrubbing interventional procedures successfully for one year.
2) Have acquired the acceptance and respect of the physicians in the department.
3) Have proven to senior staff that they are competent. We have a career ladder for staff techs in our department where being proficient at arterial access is a requirement to go up the ladder, so observation of staff skills is an ongoing process.
Once these hurdles have been passed, the applicant then applies for perc stick privileges and begins the protocol.
Part A (education) of the protocol involves studying literature on performing arterial access and then passing a written test. The literature is bound into a small manual read by the applicant. [We relied heavily on a chapter called “Arterial and Venous Access” by Ubeydullah Deligonul, Robert Roth and Michael Flynn, from The Cardiac Catheterization Handbook by Morton Kern.(5)] Once the individual is comfortable with the material, the trainee may then test out.
Exam sample questions are as follows:
1. What step(s) are appropriate to take in the event that there is resistance felt when attempting to pass the guidewire? Please circle the correct answer(s).
a. While the wire is in the needle, advance both 1-2 cm, and attempt to advance wire again.
b. Take the wire out of the needle and withdraw the needle 1-2cm, until pulsatile flow is obtained.
c. Advance the needle slightly, obtain good flow, then lower the needle hub several mms and try to advance again.
d. Observe status of wire under fluoroscopy and remove if unable to pass freely.
2. The most common cause of retroperitoneal bleeding is:
a. Excessive anti-coagulant doses.
b. Perforation of the superficial femoral artery.
c. Arterial puncture above the inguinal ligament.
d. A-V fistula.
3. Assessment of the patient prior to arterial cannulation should include all the following except:
a. Hx. of claudication.
b. Renal insufficiency.
c. Bruits over the iliofemoral area.
d. Femoral scars.
e. Existing ecchymosis, hematoma.
Answers:
1-d.
(“a” is wrong, because you never advance anything (under fluoro) without knowing where you’re going. “b” is wrong, because the needle may be just into the artery. Withdrawing it 1-2cm may take the needle out of the artery, thereby requiring another stick. “c” is wrong because advancing the needle forward might penetrate the inferior wall, which may lead to bleeding or retroperitoneal complications.)
2-c.
3-b.
(If the patient needs a diagnostic/interventional procedure, then dialysis post procedure is normally ordered by the physician).
Part B (clinical). Once the test is passed, the applicant then moves up to the practical, which also ends with a test. The trainee attempts to cannulate arteries and veins in patients. The first twenty must be performed under the direct observation of the applicant’s proctor. The other forty perc stick attempts may be observed by physicians or senior staff.
Here is our written cannulation policy:
Those CVL staff and registered nurses given approval by their preceptor and Director/manager of the cath lab may train in femoral arterial/venous cannulation. The applicant must perform these tasks in accordance with the clinical ladder, must demonstrate competency in providing safe care for their patients by successfully completing the requirements below before they are allowed to practice their skills independently and without supervision.
The trainee must:
1. Carefully read and study the written procedure and complication literature.
2. Agree to abide by the stipulations of this training program.
3. Pass a written test on femoral arterial/venous cannulation with a score > 80%.
4. Clinical skills requirements:
a. Gain clinical perc stick experience by performing at least 60 documented sticks with preceptor (or preceptor’s designee) supervising the trainee. Supervisor/physician/preceptor must be in the room with each stick. The first 20 must be with observed by the preceptor to provide consistent instruction. A log of at least 60 successful perc stick patients must be kept by the trainee, showing patient’s cine number, date, number of attempts, comments and initials of observer.
b. Requirements for passing the clinical test:
1. 20 perc sticks performed while being observed by the trainee’s preceptor.
2. Of those 20 sticks:
• 15 must be a one stick anterior wall attempt. (One perc stick attempt is defined as a passage thru the skin and into the artery. If the applicant goes into the skin, stops, backs up and then goes forward, that is counted as two sticks. If the applicant enters the skin, goes to any depth, then pulls it out with no success at cannulation, that is to be counted as one stick. If the applicant enters the skin, stops to re-orient himself, then continues in a forward direction, then that is one stick.)
• 5 sticks may be the following:
-A maximum of 2 patients may have 3 stick attempts.
-The remaining 3 patients may only have a maximum of two sticks. (You can actually fail the test if you have 17 patients with single wall sticks and wind up with three patients with three sticks apiece.)
1. Failure to pass the clinical test will result in remediation, which will require the trainee to be re-evaluated in technique and theory by the preceptor and then to to gain experience in procedure through preceptor-supervised perc sticks. Re-testing with 20 sticks protocol will be done when it’s mutually agreed upon by the preceptor and trainee. If second clinical test is not passed, the trainee will meet with the department director and preceptor, and a further course of action will be determined.
2. At no time are trainees allowed to do perc sticks without supervision by a cardiologist, preceptor or technologist/nurse with at least two years experience in perc sticks.
3. The arterial/venous competency must be completed.
4. After the previous requirements have been met, the trainee must have a written permission to independently perform this skill in the CVL. The form (Figure 1) will be signed by the Preceptor, CVL department director, and CVL medical advisor (the chief of cardiology)
A sample sheath is given to the applicant at the end of the test.
Newer Staff Overcome Their Fear and We Tweak our Protocol
Once the protocol was in place, certain staff claimed that this criteria was impossible to meet. Terry Adlam (RCIS, RRT, CVT-4) and myself then took the test and passed with room to spare. Having seen it could be done, newer staff then went about the process of applying for privileges.
The first tech made it through, but the second tech failed. Mike (RCIS) was an excellent tech and should have passed with no problem. We did re-mediation and he attempted a second time and once again failed.
I was reminded of taking ACLS back in the early eighties. In 1981 (one of the first years for ACLS), the ACLS course was brutal. I remember seeing ER doctors failing the mega-code, and ER and critical care nurses coming out of the mega-code crying because they’d failed. I was reminded of myself, leaving the Mega-code with a great sense of relief, only to have the instructor tap me on my shoulder to tell me that the doctor observing my actions felt that I’d been a little slow in some of my responses and therefore had re-considered and failed me. The answers were right, but slow, and therefore I’d failed. I left the whole experience feeling ripped off. Now this protocol was doing the same thing to an excellent technologist (as opposed to Robert Kelly’s definition of a technician — see Figure 2).
Doing arterial access is a privilege and a responsibility in our department, and it shouldn’t be ego-busting. Arterial access should be a positive learning experience and it was turning into a negative one for both Mike and myself. I thought about it for a long time and finally realized the missing component to the learning experience. You see, the initial protocol for the test was that the trainee would do the first twenty patients that came into the lab. The test was not allowing new staff to learn assessment skills. The protocol for the test changed so that assessment became a major component. The trainee is now allowed to pick his patients and no penalty is attached for refusing an attempt.
Complete arterial/venous competency (after revision).
a. Trainee must assess his patient and determine if he/she feels comfortable in accessing the artery in one stick. If the trainee feels competent then he/she is to proceed.
b. If in the process of assessment, the trainee feels uncomfortable with the patient (groin scars, bruits, fem-fem bypasses, etc.), then the trainee may pass on the patient. The assessment and arterial access will then be performed by his proctor or physician while the trainee observes, thereby continuing with the learning process.
c. The trainee may ask for a pass on the patient but also ask for a chance at attempting a perc stick on the patient. In this situation, the trainee does not get penalized for more than one stick but also does not get credit if the trainee was able to acquire the arterial access in one stick. The purpose is to give the trainee an opportunity to develop self-confidence and awareness of his/her level capabilities.
Making this small change made the protocol very successful. In the last five years we’ve been able to successfully get staff to pass their test and become excellent “stickers.” Learning assessment skills and knowing when to back off have become part of our staff’s skills.
Figure 3 is a copy of the form used to keep a record of patients attempted during the students’ training phase. The same form is used for the test.
Toward a Universal Standard
Borgess Medical Center is not the only cath lab performing the added responsibility of perc sticks by cath lab staff; however, my experience has shown that it is not a common occurrence in the majority of cath labs.
In our lab, we have seven techs and one nurse who have privileges to perform arterial/venous cannulation. It’s not based on what career field they came from, but on criteria that states, “If you want to learn and have the necessary skills, then there’s no reason why you can’t.” This article shows how we set up our percutaneous access program and that these protocols and competency work to create cath lab professionals who are legitimate in the skills they possess.
Cath lab professionals need to discuss the differences in cath lab standards. We need to create proficiencies for skills/tasks like performing right hearts, suturing pacemaker pockets, and assessing and sedating patients independently. What about the skills needed to scrub or how much staff need to know about the patient before the case starts (i.e., how prepared should we be)?
In addition, requiring staff to work on acquiring their Registered Cardiovascular Invasive Specialist (RCIS) credential remains a good way to ensure everyone to starts on the same page. Developing competencies will help staff become proficient in all aspects of their responsibilities.
A Final Note
Invasive cardiology is currently experiencing new growth in the realm of interventional peripheral procedures (carotid, renal, peripheral), as well as in the turf wars in some hospitals. Conflict continues over who is most qualified to perform these procedures. However, the medical field is certainly no stranger to disagreements. In Florence Nightingale’s time, conflict was on the mind of many in the medical field regarding what level of responsibilities, if any, would be given to nurses.
Twenty-five years ago, cath lab staff were minimally involved in patient care. We saw the patient, watched the physician diagnose the patient, and sent them to surgery or medical management. Today, cath lab staff are involved in many different interventional procedures. Since many interventional cardiologists who also practice associated procedures have a relatively small caseload, there is no way that they can keep abreast of all the minute details of the different techniques and devices. That is where the importance of laboratory assistants comes into play most conspicuously.
Dr. Bernhard Meier, in his foreword to the recently published Invasive Cardiology: A Manual for Cath Lab Personnel, says it best. He states: “It has been shown conclusively that low-volume operators produce inferior results with interventional cardiology compared with high-volume operators. It has also been shown conclusively that this deficiency is annihilated when low-volume operators work in the realm of an experienced catheterization laboratory, i.e., with the help of experienced catheterization personnel.”(6)
The complexity of today’s cath lab has become such that it needs staff not just limited to a single field, but knowledgeable in all aspects of invasive cardiology — x-ray, cardiac anatomy/physiology, medications, etc. As the arena of knowledge continues to grow, so must our willingness to accept, incorporate, and thoughtfully advocate the changes inherent to our profession.
References
1. BD Boulton, Y Bashir, OJ Ormerod, et al. Cardiac catheterisation performed by a clinical nurse specialist. Heart 1997;78: 194-197
2. “Nightingale, Florence,” Microsoft® Encarta® Online Encyclopedia 2001 https://encarta.msn.com
3. Storring R. A doctor's life : a visual history of doctors and nurses through the ages. 1st American ed. New York: Dutton Children's Books, 1998.
4. Nightingale F. Notes on Nursing. Boston, Wm. Carter, 1860.
5. Deligonul U, Roth R, Flynn M. Arterial and Venous Access. In: The Cardiac Catheterization Handbook. Kern M, ed. Oxford, United Kingdom: Mosby-Year Book, Incorporated;1998: 51-122.
6. Meier B. Foreward. In: Watson S, ed. Invasive Cardiology: A Manual for Cath Lab Personnel. Birmingham, Mi: Physicians’ Press; 2000: ix.
Figure legends:
Figure A. Gerry Lagasse, RCIS, Level 4. This case was scheduled as a left heart cath with possible intervention. I could not feel any pulse whatsoever in either leg. The patient told me he couldn’t walk more than 100 feet. I prepped the patient for both groins and re-attempted to find a femoral pulse in either leg to no avail. I waited for the physician to enter the lab and explained the situation (the cardiologists see so many patients and get so many transfers from outside physicians that they often have not met the patient prior to entering the lab). The physician accepted my assessment and told me to go for the left brachial. I accessed the left brachial (one stick anterior wall) and we proceeded with the procedure. We fixed the patient’s LAD and also performed an abdominal angiogram, which showed complete obstruction of the aorta below the renal arteries.
Figure B. Kim Anderson (RT, Level 3) performs a stick on the left leg to acquire a femoral vein.
The patient (81y/o) had come in for a heart cath with possible intervention. He’d been told he needed something done the year before, but had refused. Now he came to us with some serious difficulties. He had documented, almost completely obstructed carotids, an abdominal aortic aneurysm, a right femoral artery aneurysm, a completely obstructed left femoral artery, an ejection fraction of 25%, a plus three mitral regurge and poor peripheral vessels in the arms.
The physician unsuccessfully attempted a left radial access. He was then successful in a right brachial access, from which we performed coronary angiograms and lv-gram.
The patient’s right coronary was found closed, his circumflex was also closed, and his left main had greater than 60% narrowing and supplying perfusion to the RCA via the LAD. We successfully stented an unprotected left main. The load of dye on the coronaries, the mitral regurge and poor pump pressure was too much for the patient and he started to go into heart failure as soon as we moved him onto the transfer cart. Back on the table he went. The physician wanted to start a dopamine drip and lidocaine drip, but the patient had only one successful IV in his right arm, through which we were giving the patient Integrilin. Furthermore, his left arm looked terrible from many failed venous attempts (from an outlying ER).
This picture shows Kim with a very intense look, attempting to access a left femoral vein which we all knew the patient needed if we were to have any chance of pulling him through. Kim and the team were successful, and the patient was transferred successfully to the critical care unit.
Figure C. Terry Adlam, RCIS, AART, Level 4. A simple Judkins approach from the right femoral artery.
