A Hematoma Process Improvement Team

Professional Research Consultants (PRC, Omaha, NE) data assists Carolinas Healthcare System (CHS) in the maintenance of our elite status, and allows our organization to evaluate all areas of business and execute departmental plans to achieve service excellence. Overall quality of care drives vitality in healthcare, and service excellence is the driving force. The cardiac catheterization lab at Carolinas Medical Center in Charlotte, NC, has consistently scored at or above the 90th percentile in overall quality of care. In the pursuit of excellence, patient satisfaction in all realms of care is our key driver. Key drivers, we feel, will contribute directly to our continued growth, success, and overall quality of care. In the cath lab, the key drivers consist of: most involved staff member’s quality of care, staff member’s courtesy and friendliness, overall quality of care and likelihood of recommending to friends/relatives. During fiscal year 2004, the cardiac cath lab experienced what was considered to be an interrelated decrease in the indicator likelihood to recommend (August 2004, 88th percentile) and most involved staff member’s quality of care (August 2004, 45th percentile), both of which were below the expected 90th percentile. Management began to analyze what could be done to improve our patients’ experience and thus the success of the cath lab. While in a staff meeting, this information was shared with our team of nurses and specialists. Through effective collaboration, we were determined to identify the issues driving this decline in performance and implement strategies to correct the issues and increase our scores. One factor the collective staff and management team attributed to the decline was the rise in vasovagal response due to the lack of consistent access/groin management. This often resulted in a costly extended stay that required further care (i.e., blood transfusion, thrombin injection or vascular surgery). A hematoma process improvement (HPI) team was developed to further investigate the appropriate measures necessary to ensure that we were, and still are, doing all we can to provide the best treatment and care to our patients. At that time in 2004, the standing orders were to leave the method of sheath removal up to the specialists and nurses’ discretion. The common practice was for the cardiac invasive specialists to place a C-clamp on the groin post sheath removal in the holding area, where a nurse would assume care. After thirty minutes, the clamp would be removed. The process seemed simple enough, but on assessment it was realized that because of staff constraints and overall lab volume, the C-clamp was often times ineffective for true access/groin management. The HPI team began to contact regional medical center cath labs to see what policies were in place to decrease access complications. After several calls, it became evident that clinical data supported the “gold standard” of manual pressure, which seemed to be the most common and appropriate method practiced. With this information, the HPI team developed a manual compression protocol to obtain hemostasis. Hemostatic pads replaced the C-clamp to decrease manual compression times. Access/groin management became more cost effective and time efficient for the staff and more importantly, for patient comfort. The HPI team also began collecting hematoma incidence data to follow the possible correlation with patient satisfaction scores, and the American College of Cardiology (ACC) hematoma guidelines were adopted for consistent data collection. As anticipated, when compared to our 2004 scores, there has been a consistent rise in the key driver scores of most involved staff member’s quality of care and likelihood of recommending to friends/relatives. Since the inception of the HPI team, the cath lab has seen the number of costly hematomas drop below the national average, based on ACC data. We attribute our success to the “3 M’s” approach: All access/groin complications are Marked and Measured to reduce subjectivity of the actual size, and the patient is then Monitored frequently to determine any changes in depth or breadth of the site. The cath lab’s overall goal is to prevent any complication, most importantly those that are the most costly, i.e. surgical intervention, thrombin injections or blood transfusions. Achieving this goal ensures patient satisfaction by increasing comfort, reducing length of bed rest, decreasing patient cost, as well as standardizing care throughout the division. Since the HPI team was developed, the lab has seen a dramatic increase in performance of the 2 focused key drivers (most involved staff member’s quality of care and likelihood of recommending to friends/relatives). The cath lab has also seen a decrease in incidence of costly ACC-category hematomas. Prior to the HPI team, the PRC scores were 54% excellent (45th percentile) in the third quarter (2004) for most involved staff member’s quality of care and 63.3% excellent (85th percentile) in the 3rd quarter for likelihood of recommending to friends/relatives. By the end of the first quarter of 2005, there was an increase to 62.5% excellent (80th percentile) and 75.5% excellent (100th percentile) in most involved staff member’s quality of care and likelihood of recommending to friends/relatives, respectively. Currently, the cath lab is in the 90th percentile in both categories when compared to national PRC data. In addition to the PRC data improvements, after adopting the ACC guidelines to define a hematoma, Carolinas Medical Center displayed a reduction in the incidence of ACC-qualified hematomas over this period. The current American Heart Association incidence rate of hematomas is roughly 2-5%. In 2004, considering the lack of data collected and an inconsistent hematoma protocol, there was roughly a 15% hematoma incidence rate. After the HPI team was formed, in 2005 there was a 1.02% incidence, in 2006, a 1.07% incidence, and in 2007, a 1.3% incidence. Therefore, after initiating a HPI team, adopting ACC guidelines and utilizing a practical application of the new hand pressure with hemostatic pad guidelines, we feel this unique team had a direct effect on reducing bed rest and duration of stay, increasing staff resources and improving patient-perceived quality of care. Skilled clinicians now have a more direct line of care with patients in preventing and controlling hematomas, thus improving communication and patients’ perceived level of staff care and friendliness. Before the development of the HPI team, we had no precise protocol for access/groin management and measurement of complications. Since its inception, the HPI team has provided the cardiac division at Carolinas Medical Center with appropriate education on proper technique of hand pressure and access/groin management. A hematoma monitoring tool, filled out at the time of the occurrence, was developed to assist with the more efficient tracking of cath lab-related hematomas. Furthermore, a hematoma/ bleeding algorithm was introduced to successfully manage, define, and treat cath lab-related access site complications. In turn, all these initiatives led the cath lab and cardiac division into a more fluid and efficient system. Communication has increased between holding area and procedure rooms, and from the cath lab to the outlying post procedure units, ranging from cardiac ICU to ‘sheath bed’ units. As a result of the HPI and other initiatives, the Carolinas Medical Center cardiac cath lab team has been the proud recipients of the 5 Star Customer Service Excellence Award for 3 consecutive years. In a healthcare setting, the primary goal should always be efficacy and care for the patients. The cath lab at Carolinas Medical Center as a whole is unique. Our lab is comprised of cardiovascular invasive specialists in the procedure rooms, and nurses in the pre/post holding areas working collaboratively to ensure the best patient care. As a result of the Hematoma Process Improvement team, the cath lab increased solidarity. The demand of constant communication and teamwork forces all members to rely on each other as an extension of themselves. Specialists are an extension for the nurses and vice versa. Hematoma process improvement started as a Clinical Staff Nurse II project to establish hand pressure guidelines for the unit. As further issues arose, management realized the need to establish a process improvement team. A collaborative effort incorporated nurses, specialists, management and physicians to directly facilitate an appropriate change for improved patient care. The standardization of care has alleviated ambiguity of staff roles in their treatment of hematomas. Our drive to be ranked among the “who’s who” of interventional cardiac care continues to push the Carolinas Medical Center cardiac cath lab team to exponential growth in patient care among the nation’s best facilities. The authors can be contacted at david.reich@carolinashealthcare.org

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