Improving the quality of patient care:
A nurse’s perspective
Jennifer Freeman RN CCRN
1
Overview
• Over the last year we have been working on
improving the pre and post cath care throughout
UCI.
• Focusing on two areas:
– Education to the nursing staff
– Improving communication between cath lab and
the units.
2
Why?
• Trend of RNs questioning
pre procedure
medications.
• Questions regarding
access site care including
radial band management
3
Is there a problem?
• To assess if there was a true need for
education, surveys were sent to nurses
throughout UCI that care for our patients ….
• Opportunity validated
4
Pre Education Survey Results
5
National Cardiology Database Registry:
NCDR Data
• UCIs Hematoma Rate is above the 50th Percentile
• Many factors contribute:
– Access techniques during the procedure
– Reporting- ? Accuracy of reporting to the registry
– Early identification and treatment- (Nursing care
directly affects)
6
NCDR vascular access site injury
To Qualify for hematoma must be
associated with any of the
following:
1. Hemoglobin drop of >=3g/dL
2. Transfusion of whole blood or
packed cells
3. Procedural
intervention/surgery at the
bleeding site to reverse/stop or
correct
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Implementation
• In servicing to all nursing units
• Communication
• Computer based training module (CBT)
8
Implementation-
In-Service
In servicing to all nursing units
– Vascular access site careRadial and Femoral
– TR band protocol
– Hematoma identification and
treatment (proper manual
pressure technique)
– Retroperitoneal Bleed
identification and interventions
– Medication Overview
9
Implementation- Communication
• Improved communication among procedural team
– Difficult access/closure
– Anything unusual
• Improved communication on handoff
– Anticoagulation
– Higher risk of bleeding complication
– Difficult or Trauma during access
10
Implementaion- CBT
• Still to come
11
Handout Used for Education
What Medications do I Give and or Hold Prior to cath?
• GIVE: All scheduled oral
medications including:
–
–
Antiplatelets: Aspirin, Plavix, Effient
• Rational: the effects of ASA
& Plavix will not negatively
affect our efforts of
anticoagulation and/or
hemostasis in the cath lab.
–
• Check with MD:
Antihypertensives: ACE, beta
blockers, Ca Channel blockers, etc.
• Rational: the blood pressure
needs to be controlled adequately
during cath lab procedures to
decrease stress on the heart and
increase coronary blood flow.
Low molecular weight
heparin/antithrombin: Lovenox
• Rational: we anticoagulate in the lab
with heparin and other agents that affect
the ACT (coagulation time). If lovenox is
given, there is no direct reversal agent
and will affect our true ACT (clotting)
levels. The lab needs to know if and when
it was last given
–
Metformin: usually hold 24 hours pre
procedure and 48 hours post procedure or
until BUN/CR return to base line
• Rational: Metformin can lead to
decreased kidney function in conjunction
with contrast dye. Monitor I/O post
procedure.
–
If pt is on Coumadin,Pradaxa ect., please
check with MD for hold parameters.
DO NOT HOLD ANY MEDICATIONS WITHOUT A MD ORDER!!!!!!!
12
Evaluation
• Vascular access site management responses
improved
13
Evaluation
• Medication Management remains an issue
– Self-paced CBT learning module will be sent to
all nurses caring for this patient population
14
Evaluation
• Hematoma rates improved according to NCDR
database
15
Summary
• Collaboration is key
• Communication and Sharing knowledge is
vital
• There is always an opportunity to improve the
quality of care
16
THANK YOU
QUESTIONS & DISCUSSION
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