Cath Lab Digest - March 2008 - (Page 68)

CATH LAB KNOWLEDGE & SKILLS MARCH Precious Minutes Gerard Lagasse, RCIS Borgess Medical Center Kalamazoo, Michigan Introduction: Who is this article for? And why? This article is directed toward new staff. I’m talking about the time the staff member has spent in the cath lab. Even for a person with years of cardiac patient care, critical care or emergency room care can find those first few months in the lab to be totally mindnumbing. The first real cardiac emergency can be a shock. Suddenly, you become all thumbs, and don’t know where to stand or what to do. Scheduled cases that are done on a daily basis are planned events. In an emergency there is no knowing. There is no knowing what to plan for ‘till you’ve hooked your patient to your monitoring devices and started to assess the patient now lying on your cath lab table. This past year I went to the Cath Lab Basics Course in Chicago, presented by NACCME (North American Center for Continuing Medical Education). The main speaker was Dr. Morton Kern. His talk and slides were the same that he uses to teach cardiology fellows preparing to pass their boards. It was a wonderful conference. Interestingly, he started his talk by asking the same question asked at previous Society of Invasive Cardiovascular (SICP) conferences I had also attended in Chicago. He asked for members of the audience to stand who had one year or less in the cath lab. He then asked for those with two years. He stopped at three years, by which time over half of the attendees had stood up. In my own lab, we have four staff with two years or less in the cath lab. One new staff member has less than a month (she’s still in overload mode). This article is directed toward you, the new staff member, and preparing yourself for your first emergency patient. Education is a funny thing. Education for an experienced cath lab staff member may mean reading an article on the longterm effects and incidence of sudden closure of one drug-eluting stent versus another or against a bare-metal stent. For a new member of the cath lab, education is vastly different. Education is learning where the drugs are located and which ones to use. Education is learning where to get procedural supplies. Education is learning which catheters are for the right coronary artery (RCA) and which ones are used for the left coronary artery (LCA). Education is learning the angiographic views of the heart and which coronary artery is which. Education for a new staff member is learning to use a physiologic monitor, how to chart into the cath lab data system and how to charge the patient for the procedure. Education is doing these things over and over again, until the new staff member (and their proctor) feel comfortable that he or she can perform appropriately for normal scheduled procedures. All too often, however, staff education is a rushed affair, with a back seat given to teaching the how, the why and what to expect when an emergency appears. Scheduled cases are the meat of a cath lab. As a new staff member, you’re shown the schedule for the day, and you are assigned a lab. When the patient arrives, you look at the schedule and set up the lab for the assigned procedure. You look over the patient’s chart, read the H&P, look at the labs, check the consent form, introduce yourself to the patient and ask the patient if they understand the procedure along with questions of height, weight, allergies and any other relevant questions that may help in making the procedure a success. The physician arrives and goes over the plans for the procedure with the staff. Pertinent data about the patient is discussed among the team and any necessary changes are made before the procedure begins. The Emergency Patient and the Cath Lab Team An emergency patient is totally different from the scheduled patient and procedures described above. This patient is unscheduled and the cath lab usually is unable to plan. There may not be an H&P or labs available. The patient may arrive responsive or unresponsive. The patient may arrive with a rhythm, none or attached to an external pacemaker. The patient may arrive in pain or pain-free (and both may be an acute situation). The patient may arrive from an outlying hospital, home, an accident, your emergency department (ED), postsurgery or even from your own waiting room. The physician may arrive knowing all about the patient or as clueless as a new cath lab staff member. Remember the first rule of patient care in the acute setting — door-toballoon time. I prefer to look at it as time = muscle. The longer the vessel is closed, the more muscle tissue is lost. With this in mind, the sooner a staff member prepares for the arrival of the emergency patient, the greater the likelihood of success. Once the cath lab has been notified of an incoming emergency, three steps of patient care come into action. These are pre-preparation, assessment and preparation of the emergency patient for a cath lab procedure. Knowing what to do in those first few minutes of the patient’s arrival may save their life. How prepared the team is for the emergency is broken down into specific tasks that need to be done. These tasks are team-driven. Think of this as a race. When a racecar pulls into the pit at an Indy race, everyone has a specific task. One person fills the gas tank while others are changing tires and someone is cleaning the windshield. They work as a team. They each know their assigned task and winning the race may very well be determined by how well the Pit Team performs their job. An emergency patient arriving in the cath lab is similar to the racecar arriving in the pit. There are specific tasks that need to be done to get the patient from the transport cart to the cath lab table, and ready for the procedure. You can’t have three people on one side of the patient attempting to shave the groin at the same time. A welltrained team will know who is going to scrub, who will be on the monitor and who will circulate before the patient even arrives in the lab. A well-trained staff will understand what responsibilities or tasks automatically are assigned to that particular position, and upon the patient’s arrival, will start to perform those tasks just like a pit crew at the racetrack. Pre-Preparation There are two possible scenarios when dealing with an emergency. One is during shift hours (on hours) and the other is off shift hours (off hours). If the emergency occurs during on hours, the room has already been checked. Doublechecking that all emergency devices are available and setting up a tray may be all that’s necessary. The secretary will be in contact with admitting, the cardiac physician and Path (your emergency HQ). She’ll get the paperwork made up and get the physician there on time. Start the process of getting a patient bed. If it’s in the middle of the night, then things are a little more complicated. The room you’re using for the emergency may not have been re-stocked by the staff that last used the room. I can’t count the number of times I’ve arrived in our predetermined emergency lab to find the room still set up for a pacemaker (from the left side), temporary wires or pacer missing or no balloon pump. When you arrive, don’t take it for granted that the lab is ‘good to go.’ Check it out, and replace or restock any necessary supplies. You have no secretary making up paperwork for the patient and some piece of equipment may not come on as expected, so check the room and get the paperwork ready. Once the room is ready, tray is set up and paperwork available, then it’s time to think about the patient. Saving an emergency patient’s life begins before the patient arrives in the lab. An important thing you can do is check hospital records. If you have the patient’s name available, then check the cath lab records for possible previous cine films. If something curious was seen on a previous cine, then looking up the old cath data report can give you information that the cath lab video can’t answer. The cath data report will have information on the patient’s height and weight (necessary for proper weight-base medical care), allergies, catheters used and medications given to the patient during the last visit. It will give you information the type, size, length and number of previous stents and also the pressure used at deployment time. This may be very useful to know if the patient arrives unresponsive, intubated or in such great pain that he is unable to respond to the simplest of questions. We have saved many, many, many precious moments over the years by simply having this information available before the patient arrived in the lab. The physician is better prepared for the patient and it also means that the staff and physician can all start on the same page for the planned procedure — as a team. By being prepared as a team, we can deal with potential problems before they become a problem. In other words, we save time (time = muscle) by not trying to reinvent the wheel.

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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