Vascular Access and Vascular Closure Programs for Nurses and Technologists at INOVA Heart and Vascular Institute, Fairfax Hospit

The admission and recovery areas house 39 beds and are divided into three Team Centers. Each center is responsible for a specific area of patient care: Team Center A - admissions and pediatrics Team Center B - outpatient recovery, electrophysiology and patient transfer Team Center C -patients admitted for 24 hours or less Prior to the move, INOVA Fairfax Hospital had a total of five labs that handled approximately 7,200 adult/ pediatric diagnostic and interventional procedures with two electrophysiology labs doing approximately 2,200 procedures. Presently the new labs are staffed by 102 physicians, 32 cardiovascular technologists and 16 registered nurses with projected staff growth in 2005. How were the nurse and technologist access and closure program started at INOVA Fairfax Hospital? The initial access program was started 20 years ago with several physicians and a small staff. At that time the program had no formal structure. Physicians would work with individual cardiac technologists instructing them and guiding them through the vascular access procedures. As the staff grew and more cardiac technologists showed interest in training, a greater need for the documentation of individual competency was required and a formal program was developed. In October of 2000, the CCL instituted an educational and evaluation program with physician involvement for cardiac technologists/nurses seeking privileges in arterial and venous access. Closure procedures that were traditionally performed by the cardiac technologists/nurses required 15 to 20 minutes of manual or clamp pressure and five to six hours of patient bed rest. In 1988 we conducted and published a study on 1,026 patients comparing the rate of complication when Vasoseal® VHD (Datascope Corporation, Mahwah, NJ) was deployed by physicians versus the cardiac technologists/nurses.¹ The results of the study showed no change in the rate of complications, thus further supporting the technologist/nurse program. As technology advances and more closure devices have become available, there is an increase in the need for comprehensive training of the cardiac technologists/nurses to minimize the chances of any procedural complications and to increase patient satisfaction. How was the program received by physicians and hospital administration? At first the hospital administrators and attending physicians didn't feel it was necessary because the staff involved was so small. As the hospital grew and there was an increase in the number of staff members and physicians in the CCL it became apparent that a more formal program was needed. Once drafted and the benefits explained the program was well received and approved by both the hospital administrators and the attending physicians. What are the steps to the training program? The guidelines for the Cardiac Catheterization Vascular Access Program require the cardiac catheterization administrative staff to provide a written list of candidates eligible for the application of privileges to the Cardiac Catheterization Lab Medical Director and preceptor physicians for approval. The individual eligible for the application of privileges into the program must be a Registered Cardiovascular Invasive Specialist (RCIS) or a Registered Nurse (RN). The technologist or nurse must be in good standing and proficient with routine catheterization lab diagnostic and interventional skills. They must have completed two years in the IHVI, CCL or have two years of interventional cardiac catheterization experience in another facility with an additional six months of training in the IHVI, Fairfax Hospital, CCL. Once accepted, the candidate must complete a didactic course prior to training. Within four months, a minimum of 15 arterial and five venous accesses with sheath insertions must be completed under the guidance of a preceptor physician prior to being considered for program completion. Each candidate must be evaluated by at least three preceptors and it will be the final decision of the CCL Medical Director, preceptor physician committee and the CCL Administrator to determine the amount of training each candidate needs. The technologists/nurses are only permitted to attempt access while in the presence of an attending physician who is also an approved preceptor. They are responsible for recording specific information about the cases on which they work. The information will include the patient's name, medical number, type of sheath inserted, and number of attempts to attain access. Each case will be evaluated by the attending preceptor. This will include written commentary of the candidate technique, review of any complications due to the access process and finally, the preceptor’s signature on the evaluation form. The technologist/nurse must demonstrate knowledge in cardiac and femoral anatomy and complications related to obtaining access. Knowledge of femoral artery access includes: Location of femoral pulse by palpation and auscultation Location of inguinal ligament Location of entry site of artery and/or vein landmarks Knowledge of local anesthesia Training for the Cardiac Catheterization Vascular Closure Program using the Perclose® device (Abbott Vascular Devices, Redwood City, CA) is similar to the Vascular Access Program. Candidates must initially be recommended into the program by the same medical committee. The program for use of the Perclose device includes a four-hour didactic course that covers anatomy, possible procedural complications, the program requirements and expectations, training using the various Perclose devices with a manufacturers’ simulator, and reviewing tips and tricks for successful closure using the various devices. All physicians and staff are mentored on use of the devices by the manufacturers’ clinical representatives. Certification for use of the various Perclose devices requires a minimum of 15 closures with Perclose AT and 10 closures with ProGlide. In addition, each candidate will receive training with the Closure S devices. Once the program is successfully completed and all requirements are met, certification is awarded and filed with Abbott Vascular, with follow up to the FDA. What have been the keys to success with the nurse/tech program? To have a successful program, you must have the support of the physicians and their willingness to instruct and mentor the technologists/nurses through the certification requirements. How has a nurse and tech program affected physician and lab efficiency? Since physician’s time is at a premium, the program has helped to concentrate their time in the lab and enables them to work on other complex issues. How are nurses and techs trained and competency measured on new devices? Devices are evaluated by the product review committee, the CCL Medical Director and invasive supervisors for complexity and potential usage problems. Training is done by the manufacturers’ representative and clinical training staff in conjunction with the physicians. Protocols for competency are established by the administrative staff. Do you have any advice for how another facility could begin a nurse/tech closure program or propose it to administration? First, get physicians to buy into and support a program. Next, make them an integral part of the program development, educational process and certification guidelines. Develop a program that meets your hospital's needs and start with a small group of select candidates. Set stringent guidelines for applicants, training programs, data collection, patient selection, and most importantly, proceed cautiously. Complications in the early stages of the program can have lasting and devastating effects both to the program future and above all to patient satisfaction. What has your experience been with Perclose? Although mastery of the Perclose device takes time and practice, the results have been excellent. The physicians, technologists and nurses who use the Perclose devices develop their skills and comfort level through extensive training and guided practice. The device itself offers positive closure of the vessel with patients ambulated earlier and discharged faster. Are there certain patient subsets that benefit more from suture closure? Yes, there are several groups who especially benefit from suture closure. Patients undergoing diagnostic and interventional procedures benefit because the time to hemostasis, ambulation and discharge is reduced. Patients undergoing procedures requiring large sheath placement (>9F) also benefit when the Perclose device is used at the beginning of the procedure, prior to the placement of the large sheath in the vessel (known as Preclose). In this case the sheath is removed at the end of the procedure and the site suture is closed. Overall the significant benefit is positive closure of the vessel and patient comfort. What types of patients will not get closure devices? Each case is evaluated separately in conjunction with the device guidelines and the physician’s recommendation. Patients requiring greater attention would have the following: multiple attempts at access, double wall punctures, vessels smaller than 5mm, access of the bifurcation of the profunda and iliac artery, femoral artery stenosis greater than 50 percent, visible fluoroscopic calcifications, hematoma, pseudo-aneurysm or aterio-venous fistula present prior to sheath removal, vascular grafts, anti-grade punctures, bleeding diathesis and coagulopathy, or pregnant and/or lactating patients. Do you challenge hemostasis (stress the groin) on the table? How does that impact confidence in closure/early ambulation? Yes. We have patients cough and bend their knees. We check for feeling in the leg and the ability to apply firm pressure with the foot to the technologist/nurse’s hand to ensure that the leg is weight bearing. The site is observed for oozing or major bleeds and for any reaction to the lidocaine. If clear, we have a high degree of confidence that early ambulation is possible. When a closure device is used, how soon will diagnostic/intervention patients ambulate? If the site is challenged and dry, diagnostic patients can ambulate immediately to within one hour after the procedure is completed. These patients are in a program called Fast Track. Of course ambulation is based on the individual patient and takes into consideration the sedation used and condition of the closure site. For interventional patients, ambulation can occur anywhere from two to four hours after the procedure is completed. One example involves a cardiologist who had undergone a left heart catheterization in which a Perclose device was used to close the artery. Immediately after the procedure, the site was stressed and challenged, and he was able to walk off the table into a cardiac chair. After being observed for an hour, the cardiologist was discharged and he returned to his daily patient rounds. Although we do not recommend patients return to this level of activity so aggressively, this case demonstrates that with a positive closure patients can quickly return to their normal lifestyle. What has been the patient response? Positive. Most patients entering the CCL have a preconceived idea that they will be immobile for an extended period of time after their procedure. They marvel at the idea of being up and moving so quickly. Patients who have had procedures prior to the use of closure devices and have been required to recover flat on their backs for the six to eight hours with a high level of discomfort are totally amazed at the reduction in their recovery time and ability to ambulate so quickly. What are the most common types issues seen? Site oozing composes the most of the issues seen. This is common to all closure devices that do not address disruption of the tissue track. Utilization of fibrinolytics, enoxaparin, GP IIb/IIIa inhibitors, clopidgrel, and other clotting pathway inhibitors create this minor side effect which is tolerated in most clinical instances. Other complications include major hematomas greater than 10 cm diameter, bleeding causing a drop in hemoglobin > 3.0 gm/dl and rarely, infections. At our institution, the total vascular complications rate was 0.2% from January 1, 2003 to September 30, 2004, using the American College Of Cardiology guidelines on 11,687 patients. How are these types of complications handled at Fairfax Hospital? Most oozing and minor bleeding are handled by applying additional manual pressure for 10-15 minutes to the site. If bleeding is still not resolved possible use of a Femostop® (Radi Medical Systems, Inc., Wilmington, MA) may be necessary. How are hematomas treated? The CCL has a standard protocol for treating all hematomas. Initial treatment with manual compression of a hematoma is started by the attending nurse and checked by a member of the cardiovascular staff. If bleeding continues, a Femostop® is placed for the next several hours, all blood lab work is repeated, and the attending physician is notified. Patients on the unit are also treated in a similar manner, with notification of the medical resident prior to consulting with the cardiologist. If further attention is needed, there will be a consultation with the cardiologist and a vascular surgeon. How will the new Heart Center impact the heart program at Fairfax Hospital? With the additional space and advanced technology, we expect growth in all areas of cardiac care. INOVA Fairfax has been rated one of the Top 100 Hospitals in Cardiology by U.S. News and World Report. The Heart and Vascular institute demonstrates the commitment to excellence the INOVA system has made in treating heart and vascular disease. How many patients do you expect to treat at the new center? During 2005, the CCL expects to increase volume to treat 35-40 cardiac patients, with EP cases increasing to 10-15 patients daily. Author Russell D'Sa can be contacted at russell.d'sa@inova.com. He has nothing to disclose.

1. D’Sa R, et al. A Change in Practice: Femoral Closure Using VasoSeal® VHD. TCT Abstract no. 326. Am J Cardiol Suppl 1988 (Oct):116S.