What Do You Think?

Reader question: 

“Re: TJC (The Joint Commission) staffing guidelines. How do other labs meet the requirement for recovering from conscious sedation? Is the circulating RN’s role also monitoring for conscious sedation and opening supplies?”

Lisa Yes to admin, monitor and opening supplies in the UK. They recover patients to maintaining their own observations satisfactorily, i.e., sats. Otherwise patient can sleep it off.

Kelly Yes to monitoring patient and opening supplies. In Atlanta, GA.

Simon Dedicated nurse administering conscious sedation, hands over to recovery nurse who continues to monitor patient (theatre recovery model anaesthetist to rec nurse).

Mark Two nurses per room now. One to monitor conscious sedation only and the other to circulate. In CA.

Rachael Yes, we require a RN in the room for all sedations, as they are only ones who can administer both fentanyl and midazolam, which we give for the sedations (or sometimes morphine and midazolam as per physician preference). Cath lab located in Australia.

Rochelle No anesthesia here.

Ashley Great info...does anyone have anesthesia sedate pacemakers and EP ablations? If so, do you still have to put an RN in the room? We currently are, but it feels like we are wasting a nurse.

Rochelle Circulating nurse does meds, monitors patient, and drops supplies, then patient recovers on tele floor primarily....Colorado.

Ginny Circulating nurse does sedation, meds, and opening. Hands off to ICU RN for recovery. Small cath lab in WA. 

Gail Circulating nurse, also gathers supplies, then hands off patient to recovery room nurse. In PA.

Reader question regarding Dr. Kern’s February 2014 “Code Blue” column: 

“I would like to know what roles the circulator and monitor take during a code blue. At our hospital, the code team arrives and mass chaos follows. Since the procedure needs to continue, the circulator needs to get back to getting needed supplies and the monitor needs to chart the events occurring. They are the first responders, so usually they are bagging and medicating when the code team arrives (with the scrub doing chest compressions). They are also the only ones who know where the supplies are that will be needed for the procedure. How do other cath labs control the chaos? Our hospital also requires a code blue sheet to be filled out (separate from any other charting).”

Dawn We do not call a code in the middle of the day, because there are too many people in the way. If we are fully staffed, we handle it ourselves. But at night we have to. And pretty much it’s exactly what you described.

Cassidy We also do not call a code, usually. If we need more hands, we call the rapid response nurse, an intensivist to intubate, and respiratory. If we do call a code, we stand at the door and make everyone leave, keeping just the necessary folks.

Connie In our lab, we run our own codes. If the patient needs intubation, we call anesthesia.

Amanda We don’t call a full code in our lab due to the number of people that arrive and all the chaos like you mentioned. We have rapid response teams and we page them, so we have just a few extra pairs of hands and it isn’t too crazy, since the procedure does need to continue in most cases.

Sarah The radiographer puts call out, the runner nurse does airway, physiologist compressions/shock, the doctor and scrub nurse continue case. Crash team arrives and takes over airway and drugs, while running nurse can continue with role, Lucas machine put under patient, freeing physiologist from compressions.

Roberta We run our own codes. If intubation is needed, we call surgery.

CA reader question: 

“I work at a facility in California. Radiologic technologists who work in the cardiac cath lab are usually cross-trained to do everything except administer medications. What is the position of the cath lab as far as the scrub person (rad tech) drawing up meds for the physician to administer during a procedure? This would include lidocaine, verapamil, cardene, and NTG. An RN would be holding the med, while the RT draws up the meds and double-checks with the RN as to correct dose and properly labels the med before handing to the MD.”

Doyle Worked in 4 labs. One person pours or delivers the medication to the scrub, and the scrub verifies it. Doesn’t matter if you are an RCIS, RN, or RT, as long as the hospital protocol is detailed properly. Ultimately, the physician is responsible for everything in the lab, but this stuff usually comes with a trust factor. And as hard as it is to accept for some people, the MD or DO is solely responsible for that care given in the CCL.

Christopher In my work history, the labs had total cross-training. All meds, all routes, and all degrees of acuity by all staff, regardless of formal training. The only caveat is that everyone must be RCIS-credentialed. The lab does 5000+ procedures per year.

Cheryl The RN actually draws up the correct amount and then pushes it into a sterile cup on the table. This is still double checked when the RT retrieves it from the med cup and gives it to the MD.

Bobby I’ve been a scrub tech for 13 yrs in the cath lab adult/peds. The RN gives the drugs to the scrub, and the scrub tech gives the dose to the Dr. We were trained, and checked off, per hospital protocol, and to my knowledge, there has never been a mis-dose. However, some techs are not trusted, even though the drugs are labeled according to protocol, date, dose concentration, and amount.

Raymond Our rad techs sometimes scrub, depending on the physician, because they are cross-trained to do so. Cocktails such as NTG, verapamil, heparin, and Actilyse are drawn/mixed by us nurses and given on the table through aseptic technique; however, all IV medication and infusions are carried out by the circulating nurse.

Nixy The RNs mix the meds and drop it in our sterile cups where we, the scrub techs, draw it up and hand it to the MD. Or in the case of NTG, we can administer it. All meds are double checked with the RN as they drop it on the table and confirm dose w/scrub. Some MDs will administer their own meds, but it is the RN’s responsibility for mixing it all (etc). Like Cheryl mentioned. At the 2 cath labs that I worked at, in Kansas & Wisconsin, it’s the RN that handles the meds. Draws and administers. No MD involvement.

Reader question: 

“We currently staff cath and EP procedures with one physician and 3 non-physician team members (RT, RN, and a scrub [scrub could be an RN, RT, or scrub tech]). We are exploring adding a fourth team member, preferably an RN, as standard protocol, but are having a difficult time finding evidence-based literature or best practice data to quantify the benefit/quality versus the added labor cost. Does anyone have any best practice data or evidence-based support for this? I am curious to hear if other cath labs staff with a 4 person non-physician team and how they justify it.”

Amanda In our lab, we have 4 non-physician team members. 1 scrub, 1 monitor, 1 circulate and 1 fluoro. Our hospital allows us to cross train in all positions, which works out great and with a fourth person on fluoro, you technically have a “back up” circulator, which is very helpful in STEMIs or other critical cases.

Christopher Three RCIS, regardless of formal training. All are cross-trained to scrub, monitor or circulate and work in a very busy lab in a major city in NC.

Gail Christopher, who gives moderate sedation in your lab?

Ginny Gail, that’s what I was wondering, too. We do 1 scrub RT and 2 RNs — one to monitor and the other to circulate. For STEMI, we add another RN.

David If you’re putting the patient first, then how can 4 people be bad? Are you talking about justifying patient care or dollars???

Doyle The credentials of the team members don’t matter, their competency and experience in the lab is the only thing that matters. I don’t think you’ll find literature... just customs on a per-lab basis.

Jamie In the UK, the team consists of 1 doctor, 1 cardiac phys, 1 radiographer, and 2 nurses (1 scrub, 1 circulating).

Dawn One RN, two RCIS. All cross-trained. Would be nice to have another set of hands for on call.

Gail For elective procedures or call cases? We do 3 for CATH cases, both elective, and call. EP lab has 4-5 staff for ablations, specifically cryo PVIs.

Donna We would only have one RN and maybe a RCIS, or RT, scrub tech. So three for all cases.

Greg 4 non-MD team members, a mix of RCIS/RN, all cross-trained, all paid same rate for call. Suburbs of DC.

Mark In Calif., CMS says we have to have a nurse do conscious sedation only. We need another to circulate so we now have two techs and two RNs on call.

Debbie We have 2 nurses and 2 techs always. In GA.

Raymond In procedures like TAVI and EP, we need 4 non-physician staff, otherwise 3 are enough for routine angiogram, angioplasty, and pacemaker implantation. Staff are cross-trained to function accordingly. Two nurses (scrub & circulating), 1 rad tech, 1 physio/cardiac tech.

Cathy More and more, we are getting more cardiogenic shock or post cardiac arrest patients to my lab. I was wondering what other labs did, because we only have 3 members, plus the interventionalist. I’m finding it harder and harder with only 2 RN and 1 tech scrubbed, to do everything we need to do, especially since patients spend little time in the ED because of door-to-balloon time goals. Things that used to be done in ED are even left for the cath lab. 

Anh In the navy cath labs, we have 3 techs that are all trained to scrub, monitor, circ, and pass meds/do sedation. Our supplies are all kept in the room as well, so we rarely have to run out of the room to get anything. Works pretty well.

Bobby I’m curious as to whether the amount of on-call would change. What is the general on-call for cath labs?

Titus We have 3 and an ICU nurse responds to code STEMIs for extra hands.

Syeda Only for STEMI with cardiogenic shock do we need 4 people. 1 scrub, 1 pressure RN, 2 circulatory. In other condition, we need just 3. All staff is cross-trained.