Email Discussion Group: December Round-Up

New Questions: Placing Sheaths What about placement of femoral venous and/or arterial sheaths for EP catheters? Also, if non-MDs are placing sheaths, what are their qualifications, and are there protocols for credentialing, etc.? Esther Weiss, RN, MSN, Manager, Cardiac Arrhythmia Center (Readers, to reply to this question, please type Placing Sheaths in your subject line.) Billing for Failed CRT Implant Does anyone know if CRT (DRG 535 or 536) covers the hospital s costs if the patient is a non-responder and must go to the OR for epicardial lead placement? name withheld by request (Readers, to reply to this question, please type Failed CRT Implant in your subject line.) Anticoagulation During AF Ablations Do any EP labs use a continuous heparin infusion during atrial fibrillation (AF) ablations? If so, what is the concentration and rate of the infusion? What other anticoagulants are being used during AF ablations? Michelle Meyer, RN, BSN, Kansas City, MO (Readers, to reply to this question, please type Anticoagulation for AF Ablations in your subject line.) Under Discussion: Licensed Personnel Double-checking Certain Medications During Procedures I work in a university-based hospital electrophysiology lab. We have a policy that requires two licensed persons to check certain medications prior to administration (e.g., heparin, insulin, chemotherapeutics, etc.) The policy arbitrarily states that these licensed practitioners may be an RN, MD, or resp. therapist. We would like to add the rad tech [RT(R)] as well. Frequently, during a late case, there may only be 1 RN, 1 MD, 1 rad tech and 1 CVT in the procedure room, and the MD would be scrubbed. It seems unreasonable to expect the MD to break scrub to sign off on a bolus of heparin during an atrial fibrillation ablation. We are planning to check scope of practice for RT(R) in our state and the hospital job description. Also would provide an annual medication competency. Any thoughts? Name withheld by request Historically, the cardiac cath labs here in lovely hurricane country, Florida, have the RCIS, RRT and RT(R) included in policy and procedure statements as an appropriate second for all vasoactive drugs, anticoagulants, and insulin. All this was cleared with the Legal/Risk Management. The only exception is that blood and blood products administration require two individuals: one has to be an RN with another RN or an RN and an LPN. I should mention that a clinical competency test on medications is given yearly to all cath lab personnel as a requirement to give the above mentioned medications. All medication on the scrub table has to be labeled; it is a Joint Commission requirement. Also, here is one area that could help you with your atrial fibrillation ablations. One hospital JFK in Avalon, Florida, where Dr. Fishel performs his atrial fibrillation (AF) ablations all the medications pertaining to AF ablations like heparin, Diprivan, lidocaine for local anesthesia, are labeled accordingly and given by the physician. It is hard to believe, but Dr. Fishel administers these drugs. Sedation such as Valium, Versed, Demerol, Fentanyl are given by the RNs. This impacts JFK s staffing in EP cases, only requiring two EP trained individuals per case. For AF ablations, general anesthesia is given, so a CRNA is present. Regarding documentation during a procedure, we do not document or state that two specific individuals witnessed or checked a medication prior to administration. This is hospital/system-wide. Blood products come with their own documentation clipped to the infusion bag. Dana St. John, RN, Fort Myers, FL Every state and every hospital is different. If this is a state regulation, you may be stuck. It sounds more like a hospital regulation, and while JCAHO mandates a single standard within an institution, they acknowledge that procedural areas may have a different standard than nursing units. You may want to make sure this is a hospital policy, then approach administration with the issue. Check with areas like the OR, L&D, Interventional Radiology, and GI Lab first. They may have the same issue, which would give your argument more force, or they may have come up with an innovative solution that you could apply as well. In another center I worked in, regulations required the physician to give the first sedative dose, and nurses could give supplemental doses a similar problem to yours. While we worked to change the policy, we convinced the physicians to give 0.5 mg of Versed before they scrubbed for the case, then we gave whatever else was needed after they returned from scrubbing. We were able to comply with the rules and care for the patient at the same time. Sometimes, you just need to be creative. Howard Mattingly, RN, Team Leader, EP Lab, Methodist Hospital, Indianapolis, IN Staffing Guidelines Are there any set staffing guidelines for the EP lab? I realize some states require an RT to be in the room, but what about the number of RNs in the lab? Steven Fultz, RN, CAMC, Charleston, WV We mandate that one of the personnel in all EP/implant cases be an RN. Our director is an RN. We also require this is loaned out for TEEs and cardioversions. Our director is a registered nurse, and she made this change to all procedures: cardiac cath. PTCA, IABP, and temporary pacers performed in association with the cardiac cath lab. EPS/ablation: Three individuals [RN and two of the following: RCIS, RRT, RT(R)]. Implants/pacer/ICDs: Three individuals [RN and two of the following: RCIS, RRT, RT(R)]. Also and this is important the EP/implant staff are not cross-trained to the cardiac cath lab. Conversely, the cardiac cath lab personnel floated to the EP/implant side are cross-trained to perform all roles on pacer and ICD implants only. Only EP-trained personnel are allowed to work in the EP lab. EP lab personnel are trained for venous sheath insertion for EP/ablation procedures via a policy and procedure that is supported by our Cardiology Department and EP medical director. Dana St. John, RN, Fort Myers, FL NASPE (now HRS) has published minimum standards. That is a good place to start, but they are minimum standards. You need to look at how you practice, how sick your patients are, do you have dedicated staff or floats, and what kind of procedures you are doing. If your staff are responsible for giving sedation (especially deep sedation), one nurse should be committed to sedation, documentation and patient monitoring only! If you provide a scrub for all implants who stays sterile for the entire procedure, that person cannot be counted as anything else. If you perform mostly device implants and can break for lunch, you do not need to have someone available for lunch relief like you might if you do a lot of AF ablations, which can take six or more hours. Do you have someone to pull into the lab if the BiV patient suddenly gets unstable and you need extra hands? In general, if you have sicker patients and/or longer procedures especially if your staff are responsible for giving the sedation you probably need two nurses in the room. If anesthesia sedates your more complex patients, or you are in a smaller center that doesn t do many complex cases (long or unstable ablations, lead extractions, or unstable BiV implants for example), one nurse may be enough. Just know who you can call in an emergency. As for an RT, some states require that they be in the room during the procedure, while others require that they be available in the department and oversee equipment operation (you ll need to check that out in your state s regulations). I can say that I ve worked with some phenomenal RTs, so if you have ones that are interested in EP, they can be great assets. Howard Mattingly, RN, Team Leader, EP Lab, Methodist Hospital, Indianapolis, IN Staff Placing Catheters for Diagnostic EP Studies I have been trained by our EP doctor to place catheters in the CS, HRA, RVA, RVOT, etc. for the purpose of diagnostic testing during EP studies. The hospital in which I work now feels that this is not the standard of care; therefore, they will not allow this anymore. The doctor that trained me states that this is being done across the country. What are the standards of care regarding this matter? What policies are in effect at other facilities across the country? V. Maestas, ARRT RT (R) (T) (CV) In regard to placement of EP catheters, in our lab we are able to both gain access and place catheters. Under our lab s policies, if you have been formally trained and signed off by the medical director of the EP/cath labs, you may do this. The physician needs to first enter the room and do an official "Time Out" per JCAHO guidelines and hospital policy, and then go to another room and work while access is gained and catheters are placed. John Makal, T.G.H. Hospital, Tampa, FL Yes, I have heard and seen several places that have their scrub person placing catheters. They do so only after being trained by their EP physician. In other places, the administration has felt that this is the physician s realm and have declined to have the staff trained for this function. Laurie Potter, RN, Saginaw, MI We are not at the present time, in our dedicated EP lab in a community hospital in the Midwest. We have a very limited number of EP docs, so it might be a possibility, if we could get it approved by the hospital. Esther Weiss, RN, MSN, Manager, Cardiac Arrhythmia Center