Sheath Insertion Procedures and Protocols for Cath Lab Staff

Almost 10 years ago, Cath Lab Digest’s September 2001 issue included the article, “The Process of Developing Competencies for Cath Lab Skills: “To perc, or not to perc; that is the question…” by Gerald Lagasse, available online at https://tinyurl.com/PercStick. After being asked for an update by a reader, Gerry shares current-day access policies at Borgess Medical Center. —————————————————— In this article, we discuss the procedures and protocols accepted by Borgess Medical Center in Kalamazoo, Michigan, for staff to perform sheath insertion. For a staff member to become eligible, he/she must do the following:

1) Staff member has to pass a written test with questions derived from Grossman's Cardiac Catheterization, Angiography, and Intervention (D. Baim, ed., published by Lippincott Williams & Wilkins), Invasive Cardiology: Manual for Cath Lab Personnel (S. Watson, K. Gorski, published by Jones and Bartlett Learning), or other reliable sources. 2) Staff member, after passing the test, then performs sixty (60) arterial accesses under the supervision of a proctor. (This number was determined by the director, chief of cardiology and senior staff personnel). 3) Staff member then takes the “perc stick” test. The test is as follows: Staff member must have a minimum of 15 arterial acquisitions on the first pass. Maximum of three (3) attempts on one patient is all that is permissible. Three (3) patients with three (3) attempts means the staff member fails the test. A person can have 15 single acquisitions and 5 double acquisitions, and pass. A person can have 15 single, three double, and two triple acquisitions, and pass. The purpose of the test is to show a staff member’s ability to safely access an artery and also know when not to attempt access. The staff member is permitted to determine on which patients he/she will attempt to test. In the beginning, when we first set the test up, we would have the first twenty patients in the room as the twenty patients for the test. The staff failed miserably and said it couldn't be done. I took the next senior staff member and myself, and we showed them that it could be done. But I realized that I had years of experience and they had none. I then decided to let the staff decide which patients would be included on their tests. They then ask the patient pertinent questions (“What's that scar down here?,” “Do you have problems walking? Which leg?” and so on) and palpate the pulse. They become comfortable with the artery. Staff then turns to the tester and state if the patient is a candidate for the test. If the patient is not a candidate, they can still make an attempt (if the patient is appropriate), but had to stop at three. This is a good way for the testee to develop greater confidence in their clinical abilities and possibly in their access skills.

The femoral head has become an important indicator for complication rates. For the last few years, we have also required that all access attempts be made after determining the location of the femoral head. Access of the artery over the femoral head greatly improves the success of hemostasis after the procedure. Here is how we do it: Turn on fluoro and position a hemostat directly over the femoral head. The position of the tip of the hemostat becomes your bull’s eye area. Reposition patient away from II tube, remove hemostat and give local anesthetic to the area. Gently massaging the area after the anesthetic has been given allows for greater absorption into the area, diminishes volume size over the artery, and allows for easier palpation of the pulse. Allow sufficient time for the local to make the area pain-free and then perform the access. Once the sheath is in place, rotate the C-arm 30 degrees LAO and RAO, and fluoro record an injection of dye, visualizing the femoral head, femoral artery and access point of the sheath into the artery. Results are marked on a femoral access sheath in the back of the lab, along with the number of attempts in the cath data record. The femoral sheath has the patient name, person performing access, and location of access (high, low and optimum). Not only does this allow important information to be passed on to the floor nurse who will be removing the sheath, but it is also used for tracking complications. Complications from the cath lab can include retroperitoneal bleed due to access above the femoral head or hematoma due to access below the femoral head. If complications do occur, and records show minimal perc stick attempts and appropriate sheath placement, then other sources of potential problems can be followed and resolved. Recording sheath site access can also be used to determine if a closure device is appropriate for the patient. ———————————————————— Gerald Lagasse can be contacted at gerrylagasse@live.com

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