Email Discussion Group: IABP Removal by Registered Nurses?

Topic Under Discussion: IABP removal by registered nurses I am trying to find information about the practice of removing IABP by registered nurses. Do you have any information about this practice within the cath lab or ICU areas? Luz Kuilan, RN, MSN, CCRN Clinical Education Specialist-BG Broward General Medical Center, Fort Lauderdale, FL CCL can; but RNs, not sure In our facility, cath lab personnel are trained/certified to remove IABPs, and can do so without the presence of a MD. I am not sure if RNs can be certified to do the same, though I don't know why they wouldn't Our State Board of Nursing is particular. Probably a category skill? Our RNs are not allowed to scrub in with the MDs during a case in the cath lab because it is against the Nurse Practice Act....Go figure, right? Jackie Keith, RN Topic of interest for new lab I am also interested in this subject. Our facility is currently talking about whose responsibility it will be to pull IABP. The CCL is a new program to our hospital. Terry Ward, RN Good Shepherd Hospital, Barrington, IL tjward@sbcglobal.net Techs still called Although all of our interventional sheaths are pulled by the RNs on the cardiology floors, the techs from the cath lab still are called to pull IABPs. We have not had enough volume for the floor nurses to maintain competence. Judy Parham, Cath Lab Manager Athens Regional Medical Center, Athens, GA jparham@armc.org MDs pull, but RNs hold I have worked in critical care units and cath labs in California and Florida, and the practice has been for the MD to pull the balloon, due to the size of the insertion site and in case there were any problems with the actual removal. The RNs held after the first minute or two. Gloria Nolan, RN, Director Cath Lab RNs can do it At our facility, the RNs participated in the same training program as the CVTs and were allowed to remove IABP catheters after meeting the criteria for doing so. The education department developed a check-off list for the removal procedure, and three removals under supervision of the validator before the RN was certified for removal. Pamela Smith, RN Check with state board of nursing I would check with your state board of nursing whether they have an advisory opinion as to whether it is in the RN’s scope of practice to remove an IABP cath. It is NOT within the RN’s scope of practice to remove such a catheter in Arizona. Steve Small, RN, BSN MDs Only Our MDs remove the IABP, but the nurses hold pressure. Annie Ruppert Annie.Ruppert@sharp.com Only the physician can remove the IABP. Judy JGiovannelli@Reshealthcare.org In our institution, only a physician can remove an IABP. I personally think that this is the way it should be, due to the greater inherent risk of damaging the artery on withdrawal. Carletta Williams carletta@weirtonmedical.com We do not allow nurses to pull IABPs either. Cynthia Fielders Cynthia.Fielders@HCAHealthcare.com MDs prefer RNs do not remove IABP catheters at this institution; the physicians do. Generally, the catheters are a little larger and can damage the artery upon removal depending on the patient’s anatomy, etc. Therefore, MDs prefer to remove, ensure that hemostasis is occurring and then turn it over to the staff. Carolyn Estrada, RN Manager, CV Labs, ICU/CCU Community Memorial Hospital, Ventura, California cestrada@cmhhospital.org These RNs do remove Our Advance Practice Nurses and Registered Nurse First Assist for CABGs do remove them. JudithF@mcgh.org Only CCL staff Only cath Lab RNs and staff can remove IABP. No RN in the ICU is trained. Larry Sneed, BS, RCP, Coordinator, Cath Lab Alamance Regional Medical Center sneelarr@armc.com Most by MD In our institution, most of the IABPs are removed by the physician. A FemoStop is applied, and then the groin is maintained and monitored by the nurse. Charlene Houston RN, Winchester Medical Center charlene@shentel.net CCL staff follows manufacturer’s instructions The cath lab staff at our facility pulls all IABPs on patients who are in our CCU. If it is removed after-hours, someone from the call team comes in to remove it. We have a policy which follows the manufacturer’s instruction for the removal of the IAB. Sheila DeBastiani, RT(R) Supervisor/Educator WakeMed Invasive Cardiology SDebastiani@wakemed.org Usually CCL techs with MD available We have no specific IAB pull policy, per se. What we do is, usually the cath lab techs pull IABs, in the ICU. A cardiologist or cardiac surgeon, when applicable, must be imminently available, since this is an assist device. ICU RNs are trained to pull non-IAB sheaths. Alex Holmes alex.holmes@tenethealth.com Experience since 1974 If the nurses are formally trained through an in-service by the manufacturers such as Datascope and/or Abbott, and have their four-year certification, which should be renewed every four years; they should be able to remove intra-aortic balloons. They should be percepted by a senior nurse, who has the most experience, through five removals. One issue that has always created concern occurs when the nurses are not certified by the manufacturers’ clinical specialists; are being percepted by inexperienced peers; and are assigned by a charge nurse or a clinical manager to remove the device; because the physician has ordered it. If the ordering physician is unavailable to remove the IAB, then a qualified nurse or technologist from a cardiac cath lab should be asked to handle the task. This maneuver will reduce major complication rates. Each nurse should have thorough knowledge in the pelvic and lower extremity vascular anatomy, along with pathophysiology of the vascular bed of the two areas. One problem that is also a concern for me is the use of a FemoStop. I have seen many nurses use this device because they have other tasks to complete with other patients. The FemoStop is placed and the patient is left unattended for periods of time during the compression phase of achieving hemostasis. I was trained to manually compress the access site until hemostasis is achieved. This method reduces complications such hematomas and pseudo-aneurysms. Once hemostasis is achieved, a compression bandage should be used and left in place for 4-6 hours. Sandbags over the access site should not be used. The device only covers and obscures the area. As a cath lab professional, this respondent have been removing intra-aortic balloons from patients since 1974 and has instructed many nurses in classrooms on IAB insertions, counterpulsatile therapy, patient management, and IAB removal. Chuck Williams, RPA,RT(R)(CV)(CI),RCIS Emory University Hospital, Atlanta, GA CharlesWilliams@mail.weber.edu 3 credentials can remove Only our physicians, NPs and PAs pull out IABPs. Norman Jacinto, BSN, RN Systems Administrator Cardiac and Vascular Institute at Memorial Regional Hospital NJacinto@mhs.net Staff RNs do not do The staff nurses in our facility do not remove these. Either the surgeon or his nurse practitioner will remove them. Patti Coblentz PatriciaACoblentz@ProvenaHealth.com Only perfusionists & MDs In our hospital, only perfusionists and MDs are allowed to remove IABPs. Kevin BS, RN, RCIS ldrich3@comcast.net MDs for low complication average At this facility, it is mandated that cardiologists pull all IABP. The ICU RN assists the physician in the FemoStop placement. These are patients not requiring CABG. Post surgical cases also have MDs pull IABPs as well. Years ago, there were issues involving RN-based pulls and groin complications. Since MDs have encompassed all pulls we have had well below national average for complications. Stacey Prentis Stacey.Prentis@advocatehealth.com Rare, but staff can do In our cardiac cath lab, we rarely pull balloon pumps but if we do, RNs or RTs can pull them. They are validated by the manager of the cardiac cath lab and then they are able to pull them. The majority of the time our cardiologists hold manual pressure and then apply a FemoStop device. Thomas Gaylets t9261@epix.net Staff happy MDs/DOs do pull I’m no longer in the field, but, I can tell you that at St. Joseph Hospital in Ann Arbor, Michigan, the MD/DOs do the actual pulling of the pumps (the residents hold the pressure afterwards). Nobody in the 9.5 years I was there ever questioned doing it another way (quite frankly the staff was happy the docs did it; saved them from ‘getting behind’ with other patient care). T. Revell trev_7777@hotmail.com Fellows will pull The cardiology fellow usually will remove the IABP catheter. Our nurses are not competent to do that pull. Mary J. Maliszewski, RN, Nurse Manager Cardiology Services Stony Brook University Hospital mmaliszewski@notes.cc.sunysb.edu Change would be good Currently, only MDs can remove the IABPs, but great question. I have always wanted to see that practice change. Dina Dina_Tortorelli@chiltonmemorial.org Chart provided As far as I am aware, as long as you have a competency that is current, matching job description that is current, and a policy that states that Competent and trained RN's may do the procedure, you should be fine. You might even want to do a Performance Improvement study to document that your nurses are completing the task with no complications. JCAHO will not cite you if you are doing what your policies state. Just remember, your Scope of Care (procedures listed in policy manual) should match competencies and job descriptions. I’ve included a sample PI form (see excel chart image). You can change or redesign it, but this will give you an idea of where you need to go. Steve Gressmire RT(R)(CV) ARRT, ACCA, Cardiology Services Manager Northwest Mississippi Regional Medical Center Clarksdale, MS Steve.Gressmire@nwmrmc.hma-corp.com

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