Cath Lab Digest - March 2008 - (Page 54)

54 WHAT WE LEARNED MARCH 2008 Groin Bleeds and Other Hemorrhagic Complications of Cardiac Catheterization: A list of relevant issues Jackson Thatcher, MD, FACC, Director of Inpatient Cardiology The Park Nicollet Heart Center at Methodist Hospital St. Louis Park, Minnesota prompt intervention are the key to optimal catheterization patient management. This represents a substantial opportunity for systematic care improvement. 8. Groin bleeds are not just addressed at the time of sheath removal or when a hematoma forms; they must be anticipated and steps taken to avoid them at each step of the catheterization procedure. The early signs of hemorrhage may be subtle and misinterpreted as a reaction to a nitrate or an unexpected vagal reaction during a case. Early recognition of a groin bleed requires attention to these often subtle, but common, clues. 9. Nurses must be trained to distinguish nuisance skin wound bleeding (very common in patients pretreated with clopidogrel, glycoprotein IIbIIIa receptor inhibitors and low molecular weight heparins) from significant femoral vein or arterial bleeding and retroperitoneal hemorrhage. Standardized protocols for the management of nuisance bleeding, and evaluation and initial management of hematomas, including obtaining an ultrasound for possible pseudoaneurysm and providing an initial fluid bolus for a sustained, unexpected drop in blood pressure, will expedite staff response should serious bleeding become evident even while the physician is being contacted. 10. Systematic review of groin bleeds and retroperitoneal hemorrhage — the “Groin Group” a. Members from Cath Lab, CCRN, CCU staff nurse, outpatient unit nurse, and step-down unit nurse b. Selected input from interventional radiology and vascular surgery c. Goal: 0% surgical groin bleeds. In aiming for that improvement transfusion, length of stay costs and mortality from bleeding complications will be reduced. 11. Systematic review can reduce major bleeding events by half. a. Lessons learned become lessons lost if the review of complication is not timely, within 1-2 weeks b. Every serious bleed should be reviewed in cath conference or otherwise disseminated among staff and physicians. 12. With such an approach, our lab has reduced groin bleeds by 60%. Our goal is 90%. When we started this process, we were ‘average,’ according to the American College of Cardiology database comparisons. We hope to eventually set the database standard. 13. Steps for prevention and early recognition of groin bleeds in all patients: a. Identify the femoral head landmark for safe puncture attempt on fluoroscopy with a Kelly Clamp or other metal device. b. Cine a right anterior oblique (RAO) and/or left anterior oblique (LAO) shot of the femoral arterial sheath in situ with 6-8 cc contrast whether or not a closure device is to be used (especially if there were any entry difficulties) — it is essentially standard practice for interventional radiologists to look at the arterial puncture. In a cardiac program wishing to reduce groin bleeds, filming that look might identify the problem upfront and leaves a record that can be reviewed if something unexpected happens. Interventional radiology physicians have virtually no bleeds, so there is a lot we can learn from them — it is rather cavalier for interventional cardiologists whose patients are routinely treated with heparin, clopidogrel, and glycoprotein receptor inhibitors to think they can get by with less attention to cannulation and decannulation, and not have their patients suffer the consequences. No matter how experienced an individual physician may be, standardizing the preprocedure assessment of each groin will further reduce bleeds. Indeed, the problem is usually identifiable, and hence earlier recognition and management of the bleed may be facilitated by systematic review of these ‘boring’ little cine runs. We must train ourselves to systematically review the entire groin study, not just the sheath entry site or sheath relation to the common femoral-profunda bifurcation, inferior hypogastric artery or femoral head. Leaks tracking up along the femoral bundle can be subtle. H emorrhagic complications of cardiac catheterization remain one of the most common adverse outcomes of the procedure. Along with cerebrovascular events and contrast-induced nephropathy, bleeding complications far outweigh the cardiovascular complications of the procedure. Efforts at error-proofing health care have focused on patient and procedure identification/ confirmation to eliminate wrong-patient and wrong-site surgery, and medication reconciliations to eliminate medication errors. Such systematic review, coupled with improvement effort, has met with much success. Whenever clinicians accept a complication (error) as part of the cost of providing care, an opportunity to improve care is missed. Such is the case with groin bleeds, retroperitoneal hemorrhage, and cardiac tamponade complicating heart catheterization and percutaneous coronary intervention. These complications create substantial patient risk and increase the mortality of catheterization procedures in an ever-aging and infirm patient population. Methodist Hospital is a 426-bed community and teaching hospital in St. Louis Park, Minnesota, a western suburb of Minneapolis, where more than 2000 catheterizations and 1000 interventional procedures are performed each year. The interventional cardiology department had noted a groin complication rate that, although average for the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR), was consistently at the trailing edge of that bar. Given the morbidity, mortality, costs and disruption associated with groin bleeds, a 2-year effort was undertaken on top of earlier initiatives to reduce these adverse events. The subsequent improvement brought Methodist Hospital to the leading edge of the average bar, a 60% reduction in bleeds. In the effort, earlier recognition and treatment of bleeds was also seen. The institution hopes to ultimately reduce bleeds by more than 90%. The list that follows annotates a number of issues, opportunities and requirements identified. 1. Groin bleeds are a major cause of morbidity and mortality associated with cardiac catheterization procedures and percutaneous coronary interventions. 2. Cardiologists and staff receive essentially no formal training on reducing groin bleeds and cardiologist and staff skills vary widely in techniques for preventing, recognizing, and managing groin bleeds. 3. Unless each cardiologist and staff member takes a zero tolerance attitude towards groin bleeds, preventable groin bleeds will continue to occur. 4. New care guidelines will eliminate CMS reimbursement for faulty care. Groin bleeds undoubtedly will make that list. 5. Groin bleeds and retroperitoneal hemorrhage can no longer be viewed as a rare, but necessary evil. 6. In almost every bleeding incident, a potentially preventable root cause as well as a missed opportunity for earlier recognition of bleeding and therapeutic intervention can be identified. 7. Reducing the incidence of groin bleeds as much as possible, plus improving their early recognition and

Table of Contents Feed for the Digital Edition of Cath Lab Digest - March 2008

Cath Lab Digest - March 2008 Are You Being Paid Fair Market Value in 2008? A Cardiac Cath Lab Professionals Survey by Cath Lab Digest and the Society of Invasive Cardiovascular Professionals Saint Joseph’s Hospital Invasive Imaging Tools for Optimizing Coronary Stent Deployment Contents Clinical Editor’s Corner A Workflow Revolution in Cath Lab Reporting Advantages of a New Digital Lab at Baystate Medical Center Cardiac Computed Tomography: What Does it Mean for the Cath Lab? The Latest in Cardiac Magnetic Resonance Imaging (MRI) Cellular Cardiomyoplasty and Cardiac Regeneration Intravascular Ultrasound in the Cath Lab: A Powerful — and Underutilized — Tool to Improve Patient Outcomes The Stentplus™ Patient Success Program Cardiac Cath Lab Clutter — or, Spring into Action! Groin Bleeds and Other Hemorrhagic Complications of Cardiac Catheterization: A List of Relevant Issues Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab What Do You Think? Experience with a New Guidewire: The Terumo Runthrough NS The Ostial Pro™ Stent Positioning System: Perfecting Aorto-Ostial Stent Placement Precious Minutes The Ten-Minute Interview with…Mark Bowles, BSN, CCRN Vascular Care in the Cath Lab: Planning a Smooth Transition Cath Laughs CMS 2008 OPPS Final Rule Review An Extensive Set of Review Courses for the CCI Basic Science, Non-Invasive Echocardiography and Vascular, and ARDMS Ultrasound Exams Meetings Calendar CEU Education Center Clinical & Industry News STEMI Interventions Classifieds Advertisers Index

Cath Lab Digest - March 2008

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