EP Lab Digest - January 2008 - (Page 32) EMAIL DISCUSSION GROUP JANUARY Email Discussion Group: January 2008 ur January discussion group is bursting with activity! Work schedules, pocket closure, and antibiotics are all hot topics this month. In addition, we’ve brought back our discussion group moderator; Dr. Martin Burke from the University of Chicago helps answer one reader’s question (see inset). If you would like to join in on the discussion, please email us at eplabdigest@hotmail.com or visit www.eplabdigest.com (click on the Email Discussion Group link). Remember, when posting or responding to the discussion group, please let us know if you would like your name, location, and/or email address listed. Discussion Group Guest Moderator: Antibiotics Our electrophysiologist wants to know the standard practice for antibiotics post PM and ICD implants. He currently gives a second dose of IV antibiotics, and no oral antibiotic is given at home. Is it common to send patients home on oral antibiotics? — Janice Christian, RN, CCRN (To reply to this question, please type “Antibiotics” in your subject line.) O We look forward to hearing from you! Under Discussion: EP Lab Work Schedule Our EP lab will be going to 8-hour shifts, 5 days a week in a couple of months. This is a decision that is widely unpopular with our nurses and techs. I am wondering if any other EP labs work 8-hour shifts (all 7–3:30) 5 days a week, and if so, what has been your experience with this scheduling format? Any pros, cons, suggestions? — Lee Henry, RN (To reply to this question, please type “Work Schedule” in your subject line.) to a 10-hour shift. This type of shift also caused procedures to be put off until the next day, which we all know doesn't work anymore because of length of stay issues. I think that depending on the volume, 8-hour shifts don't belong in a procedural area. We need to be able to accommodate the patients who need these procedures 10–14 hours a day, not only 8 hours. — name withheld by request I am not sure what you are asking/what the real issue is here (the hours the lab is open or the scheduling of the staff), but the hours for our lab have always been 0700–1530 (although we are frequently here later than that) 5 days a week. We have seven EP physicians who do cases in our lab, and all cases are scheduled on a first come, We consider ourselves 8-hour shifts Monday first served basis. Our lab does an average of through Friday, but we cannot leave until all cases 13–15 cases per day, so there is no way we could are completed for each day. Rarely is our day only get everything done otherwise. Most of our techs 8 hours, hence, overtime every day. We have no and nurses work the 0700–1530 shift, but we do second shift, nor any replacements, so it is the have some who work 10-hour shifts (0700–1530) same four staff members (two RNs, two techs) and only work 4 days a week. The flexible schedthat complete each day, no matter how long it uling allows our staff to take classes, arrange takes. Having someone call us "8-hour shifts" child care, etc. just makes us laugh. We have a "call" team that stays until cases — anonymous are done for the day; there are three teams, and each takes call for a week. If someone normally Our cath lab likes the 10-hour shifts for sched- works 10-hour days, they work 8-hour days duruling. Our EP lab does 8-hour shifts because there ing their call week. Our staff members do not are not enough trained people in EP to be able to carry beepers once they leave the lab. The EP lab do 10-hour shifts and allow someone time off for is not open weekends or holidays. doctor appointments, vacations, birthdays, or I am not sure if this answers your question or whatever. EP has to borrow from the cath lab for not, but hope it was helpful. personnel. EP has more desire for time off than a — Sue Deck, BS, RN, RCES, EP Educational 10-hour schedule. Coordinator, Lancaster General Hospital — Dana St. John, RN Our EP staff works 5 days a week. This allows We work 10-hour shifts because of the busy for EP procedures to be done all week. No EP caseload here. About two or three nurses work wants to work past 4 pm in the lab. 6:30–4:30, two nurses work 7:00–5:00, one — name withheld by request nurse works 7:30–5:30, and two work 8:00–Late (whenever). We typically schedule 6 to 8 nurses Pocket Closure a day. We used to work 8-hour shifts (6:30–2:30) I am a registered nurse in a fairly and the Late nurses working 8:00–Late. This new EP lab. The only procedures schedule caused enough overtime to cause we currently do are EP studies and administration to finally listen to us and change AICD/Bi-V AICDs. We have one It is not common, nor is it standard of care, to send patients home with antibiotics after routine permanent pacemaker or internal cardioverter defibrillator implantation. The critical component of antibiotic prophylaxis is to maintain adequate tissue levels prior to skin incision and throughout the procedure. Extending prophylactic antibiotic administration past 24 hours in cardiac device implantation is not supported by the literature. The initial dose should be delivered at least 30 minutes prior to the procedure and no more than 2 hours prior to incision. Intra-operative re-dosing of the prescribed antibiotic should be performed during long cases that encroach on the known half-life of the antibiotic. The Centers for Medicare and Medicaid is benchmarking the timing of antibiotic prophylaxis administration as a quality measure. The choice of antibiotic should be tailored to the patient’s clinical background. We are seeing more skin flora populated with resistant organisms especially in frequently hospitalized patients and changes in current practice are imminent. Our laboratory’s standard is to administer cefazolin 2 grams for typical cases with two repeat doses in recovery. In the case of allergy to cephalosporin and/or penicillin, we administer a single dose of vancomycin with a second dose has been reserved for higher risk patients (diabetes, immunosuppressed). — Martin C. Burke, DO, Associate Professor of Medicine, University of Chicago electrophysiologist on staff. He requested that myself, an RN, and another staff member (an RCIS) learn how to close the pocket. He personally taught each of us how to suture the pocket closed. After approximately 10 months, hospital administration told us we were no longer allowed to perform this task, so we quit. Now, two months later, the RN is being formally reprimanded for working out of her "scope" of practice. Do rules about this vary from state to state, institution to institution, or is it just plain wrong for anyone besides the MD to close the pocket? — anonymous (To reply to this question, please type “Pocket Closure” in your subject line.) allowed. Having the EP doc show you is not training or education or demonstration of competency. The RN is being reprimanded because of her level of education and a license that can be threatened. I feel sorry for her. — name withheld by request In response to your question regarding pocket closure by non-physician personnel, it is truly unfortunate that your RN is being reprimanded since he or she had physician support to perform device pocket closure, but hospitals may require certain procedures be listed in your particular scope of practice. As an RCIS, I often refer my physicians and administrators to the SICP scope of practice, which appears to have been written specifically for the practicing RCIS. It clearly states that the credential RCIS is the recognized cardiac cath lab credential of choice by the American College of Cardiology (ACC) and the Society of Cardiac Angiographers and Laws vary. We cannot suture. There is a cre- Interventionalists (SCA&I). It does recommend dentialing to be able to do so, but this is not per- that additional education and training be committed for techs or RNs. Our 12 EP doctors and pleted before assuming responsibilities for which many cardiologists ALL suture their own pockets. you have not received previous formal training. If — D.L. Hart, RCIS, Valley Hospital, Las you look at that scope of practice, you will find Vegas, NV those skills that the SICP believes are applicable for the practicing professional. I believe in the It is out of the scope of practice for any of you advanced practice of Allied Health Care to close the pocket of devices. If you are an Professionals in the cath lab, specifically those extensively trained surgical RN to close wounds who have been certified as an RCIS and have the and are kept current, then closure of wounds is necessary experience to perform these advanced http://www.eplabdigest.com http://www.eplabdigest.com
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