COUNTESS OF CHESTER - WhatDoTheyKnow
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OPERATIONAL POLICY
PROTOCOLS & GUIDELINES
FOR THE
CARDIAC CATHETERISATION SUITE
CONTENTS
Section 1 Operational Policy
Section 2 Pre admission clerking
2.1 Fasting Guidelines for cardiac angiography
Section 3 Admission for procedure
3.1 Patient care; Pre procedure
Section 4 Variances
4.1 Patients taking oral metformin/glucophage
4.2 Patients with Renal Failure
Section 5 Catheterisation Laboratory
5.1 Nursing
5.1.1 Checking patients into the lab
5.1.2 Procedure for checking swabs and instruments
5.1.3 The role of the circulating nurse in the laboratory
5.1.4 The role of the scrub nurse
5.1.5 Sedation administration and observation
5.2 Cardiac Physiology
5.2.1 Setting up procedures
5.2.2 Catheter recording protocol
5.2.3 Non invasive monitoring in the laboratory
5.2.4 Dealing with emergencies
Section 6 Infection control
6.1 Universal precautions and infection control
Skin prep pre procedure
6.3 Clearing and cleaning of trolleys
6.4 Donning gown and gloves for a sterile procedure
2. Latex Policy
3. Protective theatre wear and lead protection
4. Patients with MRSA
5. Post procedure cleaning of the lab
Section 7 Emergencies
7.1 Cardiac/Respiratory arrest
7.2 Care of patient receiving IABP therapy
7.3 Ambulance transfer policy
7.4 External pacing
Section 8 Line removal/wound care
1. Femoral arterial and venous line removal and early mobilisation post angiography
2. Care of a patient post angioseal device insertion
3. Femostop use and placement when lines are in situ
4. Femostop use and placement for a bleeding artery
5. TR band placement and use.
Section 9 Post op and discharge
9.1 Patient care post procedure
9.2 Routine transfer of patients to and from Wards/CCU
9.3 Safe discharge protocol
Section 10 Visitors to the unit
10.1Company Representatives visiting the department
10.2 Visitors non essential to patient care
Section 11 Environmental
11.1 Policy for Checking Defibrillator
11.2 Environmental/Safety Checks
11.3 Reporting faults/malfunctioning equipment
11.2 Manual handling
11.3 Risk assessment
Section 12 Staff management
12.1 Annual Leave
12.2 Conducting a Staff Meeting
12.3 Sickness and absence procedure
SECTION 1
OPERATIONAL POLICY
1. Introduction
2. Nursing
3. Medical
4. Cardiac Physiologist
5. Radiology
6. Administration & Clerical
7. Stock Control
8. Hotel Services
9. Waiting Lists, Booking of Patients & Medical Records
1.1 Introduction
The Cardiac Catheter Suite is situated on the first floor of the CARE building, adjacent to outpatients three, Countess of Chester NHS Foundation Trust Hospital.
The main functions of the Cardiac Catheterisation Laboratory and Catheter Day Suite are:
Cardiac Catheterisation.
Timetable
Cardiac Catheter Laboratory
The Cardiac Catheter Laboratory will run for an average of 6 sessions each week of diagnostic cardiac catheterisation .The lists will run from 09:00 hours until 12:45 hours each morning and 13:30 hours to 16:45 hours each afternoon. The timing of the lists will be flexible to accommodate difficult or urgent cases.
Catheter Day Suite
The day area consists of 10 Stryker trolleys, two located in side rooms, each with a patient locker and curtains to provide dignity and privacy. As male and female patients will be admitted, it is essential that privacy and dignity is taken into account when patients are admitted.
Hours of Opening
|Laboratory |09:00 to 16:45 hrs |Tuesday |
| |13:30 to 16:45 hrs |Wednesday |
| |09:00 to 16:45 hrs |Thursday |
| |09:00 to 12:45 hrs |Friday |
| | | |
| | | |
|Catheter Day Ward |08:00 to 20:30 hrs (approximately) |Tuesday |
| |12:30 to 20:30 hrs(approximately) |Wednesday |
| |08:00 to 20:30 hrs (approximately |Thursday |
| |08:00 to 16:00 hrs (approximately) |Friday |
| | | |
|Bank Holiday no elective lists will take place |
Routine Day Cases
Patients booked for the morning session will be asked to arrive at 08:00 hours. Patients on the afternoon list will be invited to arrive at 12:30 hours.
Unless there are difficult or complex cases which take longer than anticipated the final case of the day should be on the table before 16:00 hours.
Patients Requiring Overnight Stay
Occasionally some patients will be unsuitable for a day case procedure due to social or medical reasons. Patients in this category can be booked into a Cardiology Ward the day of the procedure and stay overnight post procedure. It is important to inform the Clinical Co-ordinator as early as possible. These patients should be identified at pre-operative assessment. This will be the responsibility of the Consultant or Registrar delegated to the organisation and overseeing of the pre-assessment clinic.
In-Patients
Some patients on the wards or CCU after being seen by a Consultant Cardiologist may require to have inpatient catheter studies.
Only patients fulfilling the strict criteria for in-patients will be listed and studied. The Inclusion/Exclusion criteria MUST to be checked by the Catheter Lab Manager or Deputy and Consultant BEFORE any such patients are listed.
These patients will be booked via Consultant to Consultant referral depending who is doing the list.
Pre-Operative Assessment
Elective patients from COCH will be screened approximately 3 days prior to the procedure. The pre-operative assessment date will be given to the patient when they are booked for the procedure. Initially, the consultant or registrar will undertake the pre-operative assessment using the pre-assessment care pathway developed for this purpose.
1.2 Roles and Responsibilities
The Nursing Team
The nursing team consists of the Clinical Leader, two Nursing Sisters/Charge Nurse and three Staff Nurses. There is a Health Care Catheter Lab Assistant, who works under the direct supervision of the registered nurses.
A named nurse will be responsible for the running of the list on a day to day basis. Although this may not always be a senior nurse, any junior staff will be supported in this aspect of their development.
Staffing levels
Catheter Laboratory
This will be staffed by two nurses, one of whom will be ALS certificated.
Cardiac Day Suite
This area will be staffed by at least two nurses, one of whom will be ALS certificated. Due to the nature of the work, the staffing levels will rise during the day to care for the patients immediately post, procedure, and then fall, as patients are ready to discharge.
All staff must undergo competency-based training and will be assigned a mentor. Continuous peer evaluation and feedback will ensure high standards of care are maintained.
Responsibilities
Pre-Clerking
The Cardiologist or Registrar will oversee clinics.
Patients from Wrexham will be clerked by their medical teams at the start of the morning/afternoon session who will ensure written consent has been obtained.
Admission and pre procedure
It is a nursing responsibility to ensure that patients are appropriately prepared for their procedure. This will include the collection of personal information, accurate completion of the care pathway, obtaining and interpreting physical observations, cannulation and phlebotomy, and the reduction of any patient anxiety through good communication and information giving. The Nurse will check that a consent form has been completed as per protocol 5.1.1.
The circulating nurse will be responsible for patient comfort and the provision of explanation when necessary. He/she will provide equipment for the scrub team and ensure that documentation is accurate. He/she will also be proactive, observing the patient, anticipating any problems and ensuring that the laboratory is organised and prepared for emergencies.
The scrub nurse will assist the doctor directly. It is their responsibility to ensure that equipment is prepared correctly, that the sterile field is maintained, and that the environment is safe from, for example, sharps. This nurse will also work in a proactive manner, anticipating the needs of the operator, and being prepared in the event of an emergency.
The laboratory nurses will be responsible for the safe delivery and hand over of the patient back to the day case area.
Post procedure
Nurses will ensure that the patients' arterial and venous lines are removed safely, and that the patients' recovery is closely monitored for complication. Medical advice will be requested as appropriate. Patients will receive post operative and discharge advice, with supporting literature, and will have the opportunity to ask questions regarding their future treatment. They will only be discharged when they meet the criteria set down in protocol 9.3 and have been seen by their consultant. The nurse must liaise with the Medical Team in the case of any problems.
Patient Transfer to other wards
Registered nurses are required to collect patients from the unit, in cases of routine inpatients or overnight stay. This will usually be to a Cardiology ward or CCU.
Patient Transfer to CTC
Once a CTC bed has been identified, and a consultant to consultant handover has taken place, an ambulance will be requested for transfer as per the unit protocol. The consultant attending the case will decide which personnel will transfer the patient, according to clinical need.
Dress code
All members of the multidisciplinary team will be dressed in theatre scrubs. This will allow staff to move between the day case area and the laboratory should an emergency require them to do so.
Within the laboratory, all staff will wear hats, and hair should be tied back. Jewellery etc will be as per hospital policy.
No scrubs or theatre shoes to be worn outside the suite, unless an emergency dictates this.
Annual Leave and Study Allowance
Only two members of staff, one sister and one staff nurse, may be on annual leave at once. The manager will consider all other annual leave and study leave requests, if the unit is fully covered.
1.3 Medical Responsibilities
The Consultant will be responsible for the appropriate conduct and safety of the procedure. Under no circumstances should a trainee start a case without the express wish of the supervising consultant and then only when the Consultant is present in the catheter laboratory. All operators are expected to have seen the patient before handover and be familiar with the patient.
Sessions
There are start and finish times for the laboratory sessions and all staff are asked to adhere to these so as to ensure an efficient running of the service. Only operators and trainees approved by the Clinical Director will be allowed to be involved in the procedure.
Consent for Inpatients/Outpatients
All patients will be required to sign an informed consent form. The consent should be obtained by a consultant responsible for the case or by the catheter lab trainee assisting with the procedure at the Consultant's discretion.
Appropriate pre-medication may be required by patients and prescribed by the Medical staff.
Contrast Allergies
Patients with contrast allergies should receive non-ionic, low osmolar contrast should be premeditated with steroids (see existing protocol for guidance). Patients with renal insufficiency should be adequately hydrated before and after the procedure (see protocol 4.2). Special management should apply in patients on Warfarin or diabetes particularly if on Metformin (see guidelines).
Puncture Site Management
The Consultant Cardiologist will supervise the management of the puncture site. Catheter Lab nursing staff competent in sheath removal will assist with the majority of sheath removals. Trainees will also be given the opportunity to do this under supervision of the consultant or an experienced catheter lab nurse. Femoral closure devices, Femostop and Angioseal, will be used in selected cases only. The haematoma and pseudo aneurysm rate will be monitored for different groin closure methods and devices.
Discharge
All patients will be seen by the Consultant operator prior to discharge and have a treatment plan and their results explained and any questions answered.
Data Collection
The pre-procedure demographic and risk factor information will be entered onto the Tomcat Database System at the time of pre-admission. The operator will be responsible for entering the procedural details and results.
Overnight Stay
If a patient is required to stay overnight, the patient's own team will hand over care to the on call Consultant Cardiologist. The nurses will liaise with the duty bed manager to find a suitable bed (usually on a cardiology ward or CCU). In the event of a requirement to emergency transfer a patient to the Cardiothoracic Centre, medical case handover will be arranged between the operating consultant and the accepting consultant at CTC.
Inpatients
Requests for inpatient cases should be discussed with the nurse in charge and consultant operator responsible for the list.
Cover of Lists
Consultants not able to perform a list due to planned leave will have informed the waiting list co-ordinator as soon as leave was planned. Lists will therefore not have been booked. In situations of unexpected short notice all efforts will be made to cover the list internally, otherwise the list will be cancelled.
Procedure for Emergency Transfer to CTC
If emergency transfer to the CTC is necessary the consultant must refer the patient to the consultant on-call. Only when a bed has been identified will the senior nurse ensure that emergency transfer takes place according to protocol 7.3 "Emergency Transfer" and protocol 7.2 "Care of Patient Receiving Intra-aortic Balloon Pump Therapy". The consultant in charge will decide which staff are to accompany the patient.
Operational Issues/Incidents
The Operational Manager of the Cardiac Catheter Laboratory will inform the Clinical Services Manager and Clinical Director of any operational issues and clinical incidents. Incident forms are found on the intranet.
1.4 Cardiac Technicians
Technical aspects of the Catheterisation Procedure will be provided by appropriately trained & ILS certified technician, approved by the Principal Technician. Technicians in training must be supervised directly by an appropriately trained senior technician.
The Cardiac Physiologist's Role
• To monitor the patient's haemodynamics during cardiac catheterisation, i.e. ECG, NIBP, Sp02, invasive cardiac pressures, cardiac outputs, etc.
• To communicate any abnormalities to the operator in an effective manner.
• Initiate cardiac arrest procedures and act accordingly to policy, i.e. to defibrillate patients in VF/pulse less VT, or externally pace patients in asystole.
• Check and maintain equipment, which the physiologist may use or be responsible for i.e. Physicon, HP defibrillator, Blood Gas analyser, Balloon Pump, Dash monitor, Temporary pacing box, etc.
• To liase with Biomedical engineering to report faults on equipment and if necessary take corrective action.
• To ensure adequate stock control for all appropriate supplies i.e. electrodes, transducers, transducer sets, heparinised saline, defibrillator paper, etc. To liaise with supplies department.
• Ensure that all equipment and working environment is kept clean, in accordance with Trust's Health and Safety Policy.
• Ensure that animate and inanimate leads are moved safely in accordance with Trust's Manual Handling Policy.
• To participate in training other members of staff, whether that be more junior physiology, nursing, medical or administrative staff.
• To ensure continuous professional development in invasive procedures and promote good practice initiatives within the Cardiology Directorate.
• The Physiologists will be expected to begin at 08:45 am, to enable them to set up all the equipment needed for the session.
Procedure for Haemodynamic Monitoring/Recording
Switch on Fysicon and defib, (see defib checking policy, appendix 1).
• Check blood gas analyser and put through a QC.
• Set up monitoring transducers (setting up procedure policy 5.2.1).
• Welcome patients, check details, attach ECG and Sp02 if necessary.
• Attach monitoring lines and record pressures (see haemodynamic recording and monitoring protocol 5.2.2).
• Physiologist must remain vigilant throughout the whole procedure. He/she must communicate any changes in haemodynamic state IMMEDIATELY and act accordingly (see protocol 5.2.4).
• Print out any haemodynamic calculations and blood gas analysis reports and ensure that it is entered into patient's case notes.
• Physiologist will record pressures from fysicon system in control area of the Catheter Lab.
• Disconnect patient and participate in safe transfer to Day Ward.
Breakdown Policy
In the event of Witt Failure
Nursing Staff
Ensure patient safety – use alternative ECG monitoring facilities – M3 monitor. Scrub or circulate nurse to:
• Switch on M3 monitor
• Attach M3 monitor ECG leads to patient using electrodes
• Observe patient status
If need to observe patients invasive blood pressure, i.e. that a cardiac catheter is inserted into the patient then:
• Disconnect Witt electronic pressure lead from logical transducer
• Attach electronic pressure lead from M3 monitor to the logical transducer
• Observe patient status
Contact Operational Manager or Deputy
Technical staff
Contact Fysicon- using #6 581 or 00800 00653333
Request G5 reset
Fysicon will require an access code to dial into the system.
This is obtained by given using the remote access card kept in the top drawer of unit
How to use remote access key card
• Press on
• This will ask for code No:
• Enter code 5114
• Remote access ID number displayed – relay this to Fysicon Technician
• Press on to switch card off
• Follow instructions from Fysicon technician
In the event of card failure use the telephone,
• Dial 5114 and press option 2
• If the technician answers tell them you are calling from the Cath lab and the Witt system has failed.
• They will follow procedure and let you know what is happening
• If this goes to voice mail hang up
Then use bleep system to
• Bleep 2370
• How to use bleep system Dial 82 then bleep no 2370 and extension number from which you are dialling
So dial
• 82 2370 6238(cath Lab)
This will be answered almost immediately
• Tell them you are calling from the Cath lab and the Witt system has failed.
• They will follow procedure and let you know what is happening
Witt System Reboot is successful
Consultant and technician will decide if procedure will continue.
Once procedure has ended clinical incident form to be completed and Risk management informed.
Decision to proceed with list will be made by the Consultant.
If decision is not to proceed contact Senior Management.
DGM Elaine Kelly Xtn 5392 or Deputy Sian Williams Xtn 5117 or bleep 2608
If both unavailable Contact Cardiology Matron Karen Rees bleep 2698
Contact EBME
Witt System Reboot is unsuccessful or Consultant decision to not proceed with list.
Patient is returned to the day suite for recovery.
Senior management informed.
DCG Elaine Kelly Xtn 5392 or Deputy Sian Williams Xtn 5117 or bleep 2608
If both unavailable Contact Cardiology Matron Karen Rees bleep 2698
Lab to be closed
Clinical incident form to be completed and Risk management informed.
Contact EBME
1.5 Radiology
Quality management system
All works carried out by staff employed by the Radiology Directorate is done so following procedures under the Quality Award ISO 9001:2000. All procedures referred to in this policy can be found within Level 3 documentation.
Environment
Comprises of the Cardiac Catheter Laboratory, all associated equipment capable of emitting ionising radiation and Med Rad pressure Contrast Injector.
Radiographic staffing
The laboratory will be staffed by qualified radiographers, appropriately trained in the use of the installed equipment and associated radiographic techniques employed within the catheter laboratory.
Tuesday 1 radiographer (all day)
Wednesday 1 radiographer (pm)
Thursday 1 radiographer (all day)
Friday 1 radiographer (am)
Cover for annual leave and sickness absence is provided from within the group of trained Radiographers.
Radiographic staffing will generally be provided between the hours of 08:45 and 17:00, however these times are flexible, where start of session is required before 08:45 this can be pre-arranged. Radiographic staff will be available for 7hrs 15 mins hours during this period (45 minute lunch break).
Generally, Radiographic staffing will not be available after 17:00, unless pre-arranged in normal circumstances cases should therefore not be started after 16:00 hours to ensure examinations are complete within the staffing period.
In the absence of the rostered radiographer, staffing issues should be directed to the Assistant General Manager for Radiography Sue Griffiths extension 5638.
Equipment / service / breakdown / quality assurance
All equipment within the Laboratory, under the control of radiographic staff, will be operated in line with Radiology Directorate procedures.
All equipment will be serviced in line with Radiology Directorate policy at scheduled times as per service contract. Service will be scheduled on an agreed mutually convenient date, in a timely manner to allow organisation or workload.
In the event of an equipment breakdown, the Radiographer working in the Laboratory will contact the company contracted for service and repair immediately, in line with Trust and Radiology Directorate procedures.
All equipment capable of emitting ionising radiation will undergo regular Quality Assurance Testing in line with the manufacturer's recommendations, Radiology Directorate Procedures and current legislation.
Generator / power failure
In the event of a power failure the imaging equipment will cease to work (except for UPS on Archive system).
See contingency plan for completion of investigation.
Radiation protection
To ensure the safety of patients, staff and the general public a set of Local Rules for the use of ionising radiation has been drawn up. These are displayed within the working environment at all times. Staff working in the area should familiarise themselves with their contents.
Staff monitoring, for received radiation dose, will be carried out at all times. Staff working in the Catheter Laboratory must wear protective clothing and monitoring badges whenever ionising radiation is being used.
A Radiation Protection Supervisor (RPS) has been employed by the Trust to ensure the safety of all persons within the Cardiac Catheter Laboratory this is Polly Haslam. In her absence issues relating to radiation protection should be addressed to the Radiology Directorate Lead RPS Bernie Jenner extension 5287.
Appropriately trained staff, approved by the Trust can only operate equipment, capable of emitting ionising radiation. A list of approved Operators will be maintained and displayed within the Catheter Laboratory.
Justification for the use of ionising radiation
All examinations carried out within the Cardiac Catheter Laboratory (angiography, insertion of temporary pacing wire) will be done using ionising radiation. The examinations will be authorised by the radiographer working in the area providing the request meets the established referral criteria.
A request for the use of ionising radiation will be completed by the radiographer and logged on the Tomcat database and Meditech the electronic patient’s case sheet.
A record of exposure factors used for the examination must be made in line with Radiology Directorate procedures.
Contrast agents
The type of agent, quantity and injection rate will be decided by the operating clinician on a case by case basis following guidelines within ISO 9001:2000 documentation.
A record of administered dose must be kept, as must a record of all reactions occurring.
Archiving of images
The radiographer will carry out archiving immediately following the completion of a patient's examination.
All CDs, 1 per patient, must be clearly identified with the patients full demographics and identifying study number.
All CDs will be stored in a locked, metal cabinet within the Cardiac Catheter Laboratory for security. An appropriately trained member of staff will carry out copying of discs. Original discs must not be removed from the Cardiac Catheter Laboratory.
1.6 Administrative and Clerical Staff
The administrative and clerical staff consists of
1 Waiting List Co-ordinator
1 Medical Secretary
1 Admin/Clerical Assistant
The waiting list co-ordinator will be responsible for the booking of patients and the management of waiting lists.
The Medical Secretary will be responsible for all typing for the Cardiac Catheter Laboratory and discharge letters for all Consultants.
The Medical Secretary will cover the waiting list co-ordinator when on leave.
The administrative and clerical assistant will cover the waiting list co-ordinator when on leave as well as being responsible for all ward clerk duties within the laboratory.
Annual Leave - Only 1 member of the admin team may be on annual leave at any one time.
Hours - The reception will be staffed from 08:30 hours until 17:00 hours, Tuesday and Thursday, 08:00 hours until 16:30 hours, Friday. The admin team must liase between themselves in advance to agree hours. The reception must be continuously staffed during opening hours.
1.7 Stock Control
Catheter lab staff, via procurement will order stock. The Clinical Leader for the lab will sanction routine orders, with special orders overseen by the Clinical Director.
1.8 Hotel Services
Security
The Cardiology Laboratory has the pinpoint security system linked to the hospital main security system.
Keys will be left with the Security Officer, Main Desk, Hospital Foyer, after the laboratory closes each evening. It is the responsible of the most Senior Nurse on duty to ensure the keys are handed over each evening and signed over.
It is also the responsibility of the most Senior Nurse on duty to hand over the CD keys to the CCU Nurse in charge and kept in the CD cupboard on CCU. A record must be kept of the handover of the CD keys to CCU each evening.
Portering
The hospital portering service will provide a service for transferring patients to other departments.
Catering
A snack service will be available for patients as and when required. Daily orders will be given to the Catering Department and kept in the patient's fridge.
Cleaning
The laboratory will be cleaned each evening with a check twice during the day to empty waste bins etc.
Linen Service
Arrangements have been made with linen service to ensure adequate linen and staff scrubs are available at all times.
If inadequate supplies are distributed contact Linen Services immediately on Ext 5350
1.9 Active Waiting Lists
The active waiting list will consist of patients who have elected to undergo investigation and who are available for admission.
Non-Active (Suspended Waiting Lists)
Patients who have elected to undergo investigation but who are unavailable or unsuitable for admission for clinical, social or other reasons will be placed upon the day case waiting list as appropriate but will be suspended until they are available or suitable for admission. Whilst patients in this category will remain on the waiting list the period of suspension will not be included in the waiting time for statistical purposes. It is essential that suspension periods are accurately recorded and the status of the patient regularly reviewed.
Planned Waiting Lists
Patients who are undergoing a course of treatment, surgical intervention or investigation will remain on the waiting list for recall purposes. However, patients in this category will not be included in waiting lists for statistical purposes from the date of the initial treatment, investigation.
Maintenance of the Waiting Lists
The management of the waiting lists particularly in the context of selecting patients for admission is the responsibility of the relevant Consultants. Consultants will select patients to go onto the Waiting List and indicate the priority.
The maintenance of waiting lists is the responsibility of the Waiting List Co-ordinator. The Waiting List Co-ordinator will receive information-identifying patients to be added or removed from the list. This information must be acted upon promptly in accordance with the patient administration system procedures, i.e. Tomcat.
The Patient Administration System
All waiting lists will be maintained on the patient administration system. All staff concerned with the management or maintenance or waiting lists must follow the Medway procedures and the waiting list policy to ensure accurate lists are maintained and patients called for admission in chronological order or subject to instructions of the consultant.
Confirmation of Listing
All patients will receive communication confirming that they have been added to the waiting list and in addition the General Practitioner will be notified.
Booked Admissions
Full Booking - the patient is given the choice of when to attend and this is negotiated within 1 working day of the decision to refer or investigate.
Partial Booking - the patient is informed of the current length of wait for their procedure when they are referred or listed. The patient will have the opportunity to negotiate their admission date 4-6 weeks with the exception of the 14-day rule and other urgent cases before they are due to attend.
Process for Full Booking Angiograms - Routine
The patient is seen in the Cardiology outpatient clinic at COCH or Ellsemere Port Hospital.
The Consultant Cardiologist informs the patient that an angiogram is required and provides them with the information leaflet to contact the Waiting List co-ordinator within 24 hours to arrange a date.
The Consultant Cardiologist or middle grade doctor completes a referral form but form must be signed by the Consultant.
If the referral is from out with the COCH, i.e. outlying clinics or visiting consultants, then a referral has to be faxed to the waiting list co-ordinator.
The waiting list co-ordinator or deputy will collect from the consultants’ secretary on the morning after the clinic all angiogram referrals.
If the decision is made at a clinic appointment the patient will be given a confirmation letter before leaving.
The patient is then added to the waiting list with a date.
The patient is then sent an acknowledgement letter and the GP notified.
Process for Full Booking Angiograms - Urgent
• The patient is seen in the Cardiology outpatient clinic at COCH or Ellesmere Port Hospital
• They patient is informed by the Consultant Cardiologist that an urgent angiogram is required.
• The Consultant Cardiologist will have urgent slots available as part his/her template.
• The Consultant Cardiologist completes a referral form and contacts the waiting list co-ordinator or deputy.
• The catheter lab waiting list co-ordinator or deputy will agree a date with the patient before the patient leaves the clinic.
The patient is then added to the waiting list with a date.
The patient is then sent an acknowledgement letter and the GP notified.
If a decision is made after 5pm the patient is given a contact card to contact the Waiting List co-ordinator within 24 hours to arrange a date.
Process for Partial Booking Angiograms - Routine Patients Only (If the Waiting List is more than 6 months)
The patient is seen in clinic and informed that an angiogram is required.
The patient will be informed of the approximate length of their wait and that they will be contacted 6 weeks before the anticipated date.
The Consultant Cardiologist or middle grade doctor completes a referral form but form must be signed by the Consultant.
The patient will then be added to the list using the partial booking code.
Approximately 6 to 8 weeks before admission the patient is written to asking him/her to contact the waiting list co-ordinator in the catheter lab.
The patient agrees and picks a suitable date.
The patient is then added to the waiting list on the system and an acknowledgement letter is sent with a copy to the GP.
Visiting Consultants - Booking of Patients onto Waiting List
The visiting Consultants will use the same booking process used at the Countess of Chester Hospital except for pre-assessment, which will take place at the Consultants place of work. Consent of their patients will take place prior to the procedure by the Visiting Consultants. Clerking of patients will be done on the day. Secretarial cover will be provided by COCH for all consultants, COCH and Wrexham.
SECTION 2
PRE ADMISSION CLERKING
FASTING GUIDELINES FOR CARDIAC ANGIOGRAPHY
2.1 FASTING GUIDELINES FOR CARDIAC ANGIOGRAPHY PATIENTS
Aim
To ensure patients are fasted correctly pre-cardiac catheterisation.
Scope
Ward nurses, all Catheter Laboratory Staff
Method
Patients on the morning list will follow the early fasting guidelines it. Patients on the afternoon list will follow late fasting guidelines.
• Morning patients are to fast from 12 midnight & allowed to drink water until 7am
Afternoon patients are allowed a light early breakfast of tea & toast before 9.00am & allowed to drink water until 11am
References
Maltby, J.R. (1993) New Guidelines for pre-operative fasting.
Canadian Journal of Anaesthesia 40 (5): 113-117
Philip et al (1993) Preoperative Drinking does not affect Gastric Contents
British Journal of Anaesthesia 70:6-9
Splinter, W. (1990) Unlimited clear fluid ingestion two hours before surgery in children does not affect volume or pH of stomach content.
Anaesthesia & Intensive Care 18 (4):522-526
SECTION 3
ADMISSION PROCEDURE
1. PATIENT CARE: PRE PROCEDURE
3.1 CARE OF PATIENT PRE-PROCEDURE
Aim
To welcome patients to unit and ensure nursing assessment and documentation completed accurately.
Scope
All nursing staff, including RN, HCA (supervised by RN)
Method
Named nurse or HCA will welcome patient, introduces self and orientates patient to the unit
Named nurse/HCA (supervised) will complete Care Pathway which will include:
➢ Nursing assessment, vital signs
➢ Pre-operative checklist: ID bracelet present and correct with “A” form in case notes, fasting status, consent completed, skin preparation completed, allergy status documented, pre medication ordered and given (if relevant) routine medications given (or with-held as ordered), presence of dentures, caps, crowns, contact lenses, hearing aids and any prosthesis is documented.
➢ Ensure all documentation present, such as patient’s notes, X-rays, ECG and consent form.
• Insert IV Cannula.
• Patients fasting status will be determined.
• Groin site shave will be examined.
• Pre procedure pedal pulses will be examined and documented.(as per guidelines)
• Any relevant bloods are obtained: e.g.: INR, Renal profile, FBC and Glucose. If blood samples have been obtained previously, obtain results from notes or computer system.(Medline)
• Named nurse will ensure consent completed, as per unit policy.
• Patient will be asked to dress in theatre gown.
• Patient will be accompanied into lab, by named nurse.
References:
Care pathway for Cardiac Catheter lab
Directorate of Radiology: Fasting Guidelines:
Countess of Chester Hospital NHS Foundation Trust: Venepuncture Policy: IV Cannulation policy
SECTION 4
VARIANCES
4.1 PATIENTS TAKING ORAL METFORMIN/GLUCOPHAGE
4.2 CONTRAST GUIDELINES
4.2.1 USE IN PATIENTS WITH OR AT RISK OF RENAL FAILURE
4.2.2 generalised contrast media reactions in adults
4.1 PATIENTS TAKING ORAL METFORMIN/GLUCOPHAGE
Aim
To eliminate any risk of adverse events, namely renal failure and lactic acidosis occurring to patients who are taking oral Metformin/Glucophage who are to receive intravascular contrast.
Scope
Named Nurses, Radiographer, Cardiologist and members of the cardiology medical team.
Method
At pre-clerking
Identify if the patient is a diabetic taking Metformin/Glucophage, if so adhere to the following
• Document findings on the Integrated Care Pathway
• Provide information regarding the cessation of medication as per the physicians’ guidelines (see over).
• Check renal function
On the day of the procedure
Identify if the patient is a diabetic taking Metformin/Glucophage
• If so check that it has been documented on the Integrated Care Pathway at pre-clerking
• Check when the patient took their last dose of medication
• Check U & E, if normal proceed with routine preparation
• If abnormal refer to Consultant Cardiologist and await further orders
• Document accordingly
References
Please read attached information taken form the
“Guidelines with Regard to Metformin-Induced Lactic Acidosis and X-ray Contrast Medium Agents”, Professor Jamie Weir Vice-President and Dean Faculty of Clinical Radiology, Royal College of Radiologists.
Following previous advice issued by the Royal College of Radiologists, BFCR(96)8, and the subsequent statement BFCR(98)2, considerable concern has been expressed by Members and Fellows of the College regarding the administrative difficulties that the advice has caused. The following statement is therefore issued after discussion with the British Diabetic Association and the Medicines Control Agency. The previous statements from the Royal College of Radiologists are withdrawn.
Statement
The Metformin (glucophage) product information has been updated and now contains the following warning:-
"Intravascular contrast studies with iodinated materials can lead to acute alteration of renal function and have been associated with lactic acidosis in patients receiving Metformin. Therefore, in patients in whom any such studies are planned, Metformin should be discontinued at the time of, or prior to, the procedure and withheld for 48 hours subsequent to the procedure and re-instituted only after renal function has been re-evaluated and found to be normal."
Based on the above statement, the following are the Royal College of Radiologists recommendations for patients with Diabetes Mellitus who are receiving Metformin and who are referred for a radiological investigation using intravascular contrast media.
The referring clinician should take responsibility for assessing the patients' renal function, either by checking the serum creatinine or accepting a normal level within the past year. The Radiology Department should inform the referring clinician of the timing of the investigation to enable this to occur.
In patients with normal renal function, although there are as yet no reports of Metformin-induced lactic acidosis in the United Kingdom after intravenous contrast agents, there is a remote theoretical risk of interaction. Metformin should therefore be discontinued at the time of the investigation and withheld for the subsequent 48 hours.
For those patients with abnormal renal function, Metformin should similarly be discontinued at the time of the investigation and the subsequent 48 hours, and only reinstated when renal function has been re-evaluated and found to be normal.
As the British Diabetic Association states that Metformin is contra-indicated in the presence of abnormal renal function, it is suggested that such patients who require intravascular contrast examinations should have their drug history reviewed by the appropriate physician to ensure suitability of the drug regime.
4.2 CONTRAST GUIDELINES
4.2.1 Guidelines to Avoid Contrast Induced Nephrotoxicity
Definition
• Contrast medium nephrotoxicity is a condition in which impairment in renal function (an increase in serum creatinine by more than 25% or 44mmol/l) occurs within 3 days following the intravascular administration of a contrast medium (CM) in the absence of an alternative etiology.
Risk Factors
Look for
• S-creatinine levels, particularly secondary to diabetic nephropathy.
• Dehydration
• Congestive heart failure
• Age over 70 years old
• Concurrent admission of neprotoxic drugs, e.g. non-steroid anti inflammatory drugs.
In patients With Risk Factor(s)
DO
Make sure that the patients is well hydrated (give at least 100 ml intravenous (normal saline) depending on the clinical situation) per hour starting 4 hours before 1and about 4 hours after contrast. Use low-or iso-osmolar contrast media (VISIPAQUE)
Stop administration of neprotoxic drugs for at least 24 hours if possible.
Consider alternate imaging techniques, which do not require thee administration of iodinated contrast media.
Minimise contrast volume e.g. in cardiac catheterisation procedures consider omitting thee ventriculogram.
DO NOT
Give high osmolar contrast media
Administer large doses of contrast media
Administer mannitol and diuretics, particularly loop diuretics
Perform multiple studies with contrast media within a short period of time.
4.2.2 Guidelines for the prevention of generalised contrast media reactions in adults
Risk factors for reactions
• Previous generalised contrast medium reaction, either
Moderate (e.g. urticaria, bronchospasm, moderate hypotension) or severe (e.g. convulsions, severe bronchospasm, pulmonary oedema, cardiovascular collapse).
• Asthma
• Allergy requiring medical treatment.
To reduce the risk of generalised contrast medium reactions
• Use non-ionic low or ISO osmolar contrast e.g. Visipaque
Premedication is recommended in high risk patients (defined in A)
• But, when non-ionic agents are used, opinion is divided about the value of Premedication.
Recommended Premedication
• Corticosteroids: orally 12 and 2 hours before contrast medium. Corticosteroids are not effective if given less than 6 hours before contrast medium.
• Antihistamine may be used in addition to Corticosteroids, but opinion is divided.
Remember for all patients
• Have a trolley with resuscitation drugs in thee examination room.
• Observe patients for 20 to 30 minutes after contrast medium injection.
Extravascular administration
• When absorption or leakage into the circulation is possible, take the same precautions as for intravascular administration.
Source: S.K Morcos, H.S. Thomsen, J. A.W. Webb FRCR and members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Prevention of generalised reactions to contrast media: A consensus report and guidelines. Eur Radiol 2001; 11: 1720-1728
(Modified from The European Society of Urogenital Radiology (ESUR) guidelines on contract use)
()
SECTION 5
CATHETERISATION LABORATORY
SECTION 5.1
NURSING
5.1.1 CHECKING PATIENTS INTO THE CATHETER LABORATORY
5.1.2 THE ROLE OF THE CIRCULATING NURSE IN THE LABORATORY
5.1.3 THE ROLE OF THE SCRUB NURSE
5.1.4 SEDATION ADMINISTRATION AND OBSERVATION
5.1.1 CHECKING PATIENTS IN TO CATHETER LABORATORIES
Aim
To ensure the correct patient is admitted to the lab, eliminate errors, and ensure patient documentation is completed, accurate and available.
Scope
All staff
N.B. Any documentation must be counter signed by a registered nurse.
Method
• Ward nurse to remain with the patient until checks are completed
• An appropriately trained person should identify the patient in the procedure room by checking;
• Full name
• Date of birth
• Hospital number
• Identity band
• Each check must be ticked & the document signed.
• Check case notes, X-ray (if requested), ECG and all accompanying documentation corresponds with patients name, case sheet number and date of birth.
• Any history of allergic reactions to be reported to the Cardiologist.
• Well fitting dentures may be left in for procedures requiring local anaesthetic.
• False teeth to be removed for general anaesthetic
Check consent forms for:
• Patients details
• Name & signature of person consenting patient
• Patient identity band
• Name of proposed procedure
• Check that patient has signed, dated & printed their name
• Check with patient that it is their signature
• If the patient is unable to sign, check witness signature & confirmation of consent from the health professional who admitted the patient for the procedure
• If Jehovah’s Witness, check for separate consent.
NB Questioning a premedicated patient is unreliable
References
NATN 1998 Safeguards for invasive procedures: The management of risks. NATN Harrogate NATN Publications
2. THE ROLE OF THE CIRCULATING NURSE IN THE CATHETER
LABORATORY
Aim
To assist both the operator and scrub nurse during the procedure, whilst ensuring that patients are comfortable and aware of treatment decisions made.
Scope
Nursing staff that have had a period of supervision in this discipline and have been assessed to be competent.
Method
• Ensure the lab is checked at the beginning of each shift following the safe environment protocol
• Introduce self to the patient, taking handover from the day case nurse
• Ask the patient to state their name, date of birth and address as confirmation of identity
• Check the ID wrist band with the hospital number and notes
• Check the consent form (signed by the doctor and patient with the correct procedure details & date) with the patient. Sign the confirmation of consent* on the back of the form.
*Confirmation of consent:
This is only to confirm that this is the patient’s consent form and signature, and that they are happy to undergo the procedure. Under NO circumstances should the nurse enter into discussion with the patient regarding the risks and benefits of the procedure. If the patient wishes to go through the risks and benefits again, the operator should be informed.
• Check that there is a recent ECG in the patients notes
• Check the patient’s height and weight are documented on the drug chart or observation chart
• Check for a recently documented blood pressure, heart rate and temperature
• If the patient takes warfarin, an INR will be required
• Ensure that the patient has a venflon in place
• Dentures may be left in if they are tight fitting
• Note if or when
o an oral premed has been given on the ward
o I/V infusions have been commenced/discontinued
o patient has a history of
• diabetes mellitus (recent blood sugar)
• asthma (inhalers present)
• any allergies
• other relevant history
• Patient should have been fasted as per the Nil by Mouth protocol
• Report to radiography staff if patient is a radiation worker
• If the patients is female and of childbearing age, check for details of the patient’s last menstrual period (a 28-day rule form should be completed by the patient and radiographer if it has not already been checked during pre-clerking). Inform the radiographer if a 28-day rule form needs to be completed.
Assist the patient onto the table and ensure that they are safe, comfortable and warm. The patient’s dignity should be maintained at all times.
• Advise the patient of what is expected of them, and provide reassurance
Hand over relevant information to the scrub nurse
• Assess the patient for the need for sedation. Prepare and give medications when prescribed
• Prepare the groin/arm for the application of antiseptic solution; shave the groin if necessary
• Observe the patient’s general condition during the case
• Provide the scrub nurse with equipment as soon as possible
• Document the procedure in the database
• Send for the next patient and collecting nurse when appropriate
The circulating nurse should ensure that they are available to deal with any requests from the scrub nurse or doctor and to deal with any complications/adverse events
References:
Safe Environment protocol
Nil by Mouth Protocol
Local rules on radiation
Mallett J & Dougherty L (2000) Peri-operative care ch 30
Mallet J & Dougherty L (2000) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 5th ed Blackwell Science, Oxford
Fortunato, NH (2000) Berry & Kohn’s Operating Room Technique Mosby, Boston, USA.
5.1.3 THE ROLE OF THE SCRUB NURSE IN THE CATHETER LABORATORY
Aim
To assist the operator with invasive procedures whilst ensuring that the environment is safe and sterile, and that equipment used is accounted for.
Scope
Nursing staff who have had a period of supervision in this discipline and have been assessed to be competent.
Method
• Ensure that the environment is safe and that mandatory equipment checks have been carried out
• Scrub as soon as the previous patient is out of the room to maximise lab time
• Introduce self to the patient and emphasise that the patient should inform staff of any chest pain or concerns
• Receive hand over of patient details from the circulating nurse
• Maintain aseptic technique throughout the procedure, paying particular attention to the initial preparation of the groin
• Ensure ECG electrodes are in place before the drapes are applied to promote asepsis
• Prepare the equipment in an organised fashion, in accordance with the manufacturer’s instructions.
• Ensure sharps are kept safe in the sharps pad and that syringes are clearly labelled.
• Evaluate the equipment throughout the case
• Reassure the patient whilst being aware of their vital signs
• Check the puncture site during the procedure for signs of bleeding or haematoma and advise the operator
• Observe contrast levels throughout the case – check the label and date of contrast with the radiographer
• Anticipate requirements of the operator to facilitate a smooth and time efficient case
• Be prepared for adverse events and think ahead
• Act as advocate for the patient
• At the end of the procedure, clear away the equipment
• Ensure a computer printout is placed in the notes and signed by the operator and the nurse who administered the drugs
• Give a thorough hand over of procedural events and any follow-up care to the patient’s nurse
References
Mallett J & Dougherty L (2000) Aseptic Technique ch 3
The Royal Marsden Hospital Manual of Clinical Nursing
Procedures 5th edn Blackwell Science, Oxford
Mallett J & Dougherty L (2000) Peri-operative care ch 30
The Royal Marsden Hospital Manual of Clinical Nursing
Procedures 5th edn Blackwell Science, Oxford
Phippen, ML & Wells, MP (2000) Patient Care During Operative and Invasive Procedures WB Saunders Co, USA.
Fortunato, NH (2000) Berry & Kohn’s Opereating Room Technique Mosby, Boston, USA.
5.1.4 SEDATION OF PATIENTS IN THE CATHETER LABORATORY
Aim
To ensure that an appropriate practitioner administers sedation and that observation of patient and correct intervention is administered when required following accepted guidelines.
Scope
Appropriately trained practitioners.
Method
Sedation may be administered either orally (pre procedure) or intravenously, where it is required to reduce anxiety, in line with a prescription by a doctor, who will take in to account patients medical history i.e. airway disease, hepatic impairment. Conscious sedation is defined as a minimally depressed level of consciousness that retains the protective reflexes, a patent airway and continuous independent vital signs.
Before administration the following issues should be addressed:
Do I know the patient’s baseline saturation prior to administration?
Is oxygen readily available?
Do I have access to a saturation reading and is the patient appropriately monitored?
Do I have access to the appropriate antidote?
Does the patient trolley tip head down?
Is intravenous access available and patent?
Patient monitoring
A suitably trained individual must be present throughout the procedure and must take responsibility for recording these observations:
Level of consciousness, patient should follow verbal commands
Respiratory rate
Heart rate
Pulse oximitery
Action to take if respiratory rate is less than 8 per minute & sedation score is 2, an increase in the depth of inspiration / expiration or if verbal responsiveness is lost;
Inform physician
Attempt to waken patient
Give 40% oxygen via mask (seek physicians advice)
Maintain airway
|Patients Sedation |Level |
|Asleep |A |
|Fully awake and alert |1 |
|Rousable to be verbal command |2 |
|Rousable to be physical stimuli |3 |
|Rousable to be painful stimuli |4 |
| |5 |
Reference
Implementing and ensuring Safe Sedation and Practice for healthcare procedures in adults, U.K. Academy of Medical Colleges and their faculties.
SECTION 5.2
CARDIAC PHYSIOLOGY
5.2.1 POLICY FOR CHECKING DEFIBRILLATOR
5.2.2 SETTING UP PROCEDURES
5.2.3 CATHETER RECORDING PROTOCOL
5.2.4 NON INVASIVE MONITORING IN THE LABORATORY
5.2.5 DEALING WITH EMERGENCIES
5.2.1 POLICY FOR CHECKING DEFIBRILLATOR
Introduction.
The aim of this policy is to ensure the defibrillators throughout the Cardiology Directorate are at all times safe and ready for immediate use. A senior member of staff from each Ward / Department should be nominated to be responsible for: -
• Organising maintenance and checking of defibrillator
• Accurate records of maintenance and daily checks
• Cascade teaching to other staff on correct checking and maintenance
Please note the Manufacturer’s Manual for individual defibrillators should be consulted and instructions followed in order to maintain validity of warranty.
Procedure for testing Defibrillator
Defibrillators should be checked each shift and after each use.
A signed record of this check should be kept.
The defibrillator should be clean and free of fluid spills – nothing should be stored on the defibrillator. There must at all times be 2 packs of defibrillator pads available – check expiry dates. Cables should be checked for breaks
1. Turn on the defibrillator. Allow time for self-test.
2. Turn defibrillator dial to TEST position
3. Press CHARGE button and wait for ready tone.
4. Hold defibrillator paddles and depresses orange button with your thumb to deliver charge. Ensure no part of hand contacts paddle plate – this will result in receiving a shock.
5. Chart will begin to print.
6. Check the print out shows – date and time
7. Test ok
8. Joules del = 30J
• Correct technique for checking the defibrillator should be incorporated into Statutory CPR Training.
• Biomedical Engineering should routinely check and clean the defibrillator as necessary or every 12 months.
• Ensure when not in use the defibrillator is plugged in and charging.
5.2.2 SETTING UP PROCEDURES FOR CARDIAC PHYSIOLOGISTS
This is the setting up procedure for physiologists working in the cardiac catheter laboratory recording diagnostic angiograms.
Daily Procedures
• Switch on recording system, ensure no fault errors occur
• Two transducers need to be plugged into the correct module beneath the bed; the transducer heads must be slotted into the transducer stand attached to the side of the bed.
• The transducer sets need to be connected to a 500ml bag of heparinised saline in a sterile manner. Connectors should be covered until manometer line is connected to the patient. The saline needs to be placed in a pressure bag that is pumped up to 300mmHg; this needs to be checked at the beginning of each case. If the pressure drops below the patient’s arterial systolic pressure, then blood will leak back through the manometer line.
• The dome should be placed onto the transducer head and then flushed through ensuring no air bubbles remain in the line. Any air could potentially be flushed through to the patient during a procedure, and it will also cause the pressures to be damped.
• Two transducers should be set up for the first case of the day; the majority of catheters will be left heart and will only require one monitoring line. The second line is set up in case there are problems with the transducer during a case and then the lines can easily be swapped. Sometimes, a patient may be mistakenly listed for a left heart when he/she is in fact a left and right, if this happens, there should be no delays if a second line is already available. If the second line has not been used during the day, then it could be used for the last case to ensure it is not wasted.
• Enough transducer sets should be set up at 8:30am to cover all patients listed for the whole day. This will ensure physiologists have enough time in between cases to flush through and calibrate properly. Sets can then be left on wall hooks in the catheter lab and be available when needed.
• ECG cable should be plugged into the correct module and checked.
• SpO2 and NIBP should be available if needed, they will not be necessary for routine cases, in fact, they would be in the way of patient’s lifting their arms when imaging coronary arteries. If the patient becomes haemodynamically unstable, then it may be appropriate to measure SpO2 or NIBP, they should always be checked each morning and be readily available.
• Defibrillator must be switched on at all times. It should be switched on and checked (see defib checking procedure) first thing in the morning and then not switched off until the last patient has left the Lab. It must be plugged in at all times to ensure that the battery will always be at capacity in case it is needed for transfers. The check must be signed,
• Check blood gas machine is operating properly
• Switch on Dash monitor and ensure each Tram block is connected and working properly. It may be needed for transfers in an emergency.
5.2.3 CARDIAC PHYSIOLOGIST CATHETER RECORDING PROTOCOL
Setting Up
• Patient arrives; details are checked and logged. ECG electrodes must be placed on the patient’s left and right shoulder, on the back, and 2 electrodes on the left hip. The site for electrode placement should be prepped with abrasive tape to ensure a good contact. Limb leads should be applied ensuring that they run under the patient’s neck and shoulder. The lead connection junction should be placed under the mattress at the patient’s left hip. No wires should be left “dangling” because they can become entangled with the X-ray equipment during angiography. Leads are radio-translucent and should not interfere with angiography pictures.
• When ECG leads are applied and patient has groin uncovered and is lying relaxed on the bed, level for transducers can be measured. The transducer needs to be zero in relation to the internal body measurements; this should be taken at mid-axillary line-V6 position. When the patient is lying flat, a long spirit level can be placed at the mid-axilla to check the level of the port that will be open when the transducer is zeroed.
• Once the level has been established, the transducers are opened to air and zeroed.
• A small button in the front of the transducer allows the pre calibration to be checked. When this button is pressed, 100mmHg should register on the monitor. Medex advise that 2mmHg is acceptable either way i.e. 98-102 mmHg. If the calibration is not 100mmHg, the first step is to remove the dome and clean the surface of the transducer. Replace the dome, re-zero and then try the calibration again. For left heart catheters, 2mmHg is acceptable, but for right heart pressures it is essential that both transducers have the same calibration factor. In this case a difference in the calibration factor of the transducers of more than 2mmHg is unacceptable and one or both of the transducers should be changed.
• The patient details, staff details and catheter number should be entered into the system.
• Once the Cardiologist has punctured the groin, the scrub nurse will be ready to flush through the manometer lines; they will be connected to the manifold system. The operator will pass the sterile tubing to the physiologist who will ensure that it is connected to the appropriate port on the transducer dome. This needs to be done without desterilising the connection site. When the Cardiologist is ready, and then the line can be flushed through using the flushing device on the transducer set.
Left Heart Catheter Haemodynamic Recording (Coronary Angoigram recorded first)
• Baseline ECG should be recorded for reference
• Baseline Aortic pressure should be recorded, usually on range 200. If the patient’s BP is higher than 200mmHg the range may be changed to 400 but the Cardiologist should be informed. It is essential that the Cardiologist be informed of the systolic pressure before the case proceeds any further.
Coronary Angiograms
• Angiography of the left coronary artery is usually undertaken first. This will entail the Cardiologist flushing x-ray contrast down the catheter into the left coronary artery. This obviously causes momentary de-oxygenation down the coronary; the ECG may show ischaemic changes that should resolve very quickly. If they do not, the Cardiologist must be informed. It is not possible to monitor pressure at the same time, but it is monitored immediately before and after each shot. IT IS CRUCIAL FOR THE PHYSIOLOGIST TO REMAIN VIGILANT DURING EACH ANGIO, IT IS ESSENTIAL TO COMMUNICATE ANY CHANGES IN ECG OR PRESSURE AND TAKE ACTION IF NECESSARY (see cardiac arrest protocol)
• Angioiography of the right coronary usually follow, this means that the catheters will be changed and the physiologist may be required to flush the manometer line through
• Again, the physiologist may remain vigilant during the right coronary artery angiography, the right coronary supplies the conducting system, and it is not uncommon for rhythm disturbances to be seen during the right coronary shots. AGAIN IT IS CRUCIAL TO COMMUNICATE ANY CHANGES IN ECG OR PRESSURE TO THE CARDIOLOGIST AND ACT ACCORDINGLY.
Recording LV Pressures
The Cardiologist will change the catheter to a pigtail for the LV angiogram.
• The physiologist will be required to flush the manometer line through at the change of catheter.
• The LV pressure is measured on range 200, at speed 25mm/sec to record the systolic phase.
• The range is changed to 50, speed 50mm/sec to look at the diastolic phase more closely and measure an end diastolic pressure (EDP). The EDP is the pressure in the ventricle immediately preceding ventricular contraction, and is called preload. Preload is a measure of the presystolic muscle fibre stretch, it is proportional to ventricular end diastolic volume and directly determines the force of cardiac contraction. The higher the EDP, the greater the load imposed on the ventricular pumping action. Measurement of the EDP before the LV angiogram is essential. The patient should be asked to hold their breath to ensure that the LV tracing does not have respiratory swing and then the measurement can be taken.
• The system will automatically measure an EDP at 0.05 seconds after the Q wave on the ECG. This can be changed manually, but as it is a standard measurement, it should be accepted to ensure continuity. The normal range for EDP is 5 – 20mmHg. The Cardiologist may want to be informed of the EDP before proceeding with the LV angiogram.
• The ECG should be monitored throughout the LV gram.
• Following the LV gram, the Cardiologist will reconnect the monitoring line, and may require the physiologist to flush it through
• The physiologist will indicate that he/she is ready to pull the catheter back into the aorta. The pullback button should be pressed on 200 range, speed 25mm/sec; when the trace changes from LV to aorta, it can be entered. The system will automatically measure an aortic valve gradient from the point that is indicated as crossing the valve. This is usually unreliable because the pressure trace can “bounce” quite a bit as it crosses the valve. The physiologist should make an assessment of any difference in systolic pressure.
Ending the case
• Final report should be generated including procedure log, aortic pressure tracing, LVEDP pressure tracing and LV systolic pressure tracing.
• Report should be filed safely in patient’s case sheet; the procedure should be saved to the Witt Biomedical Series III database.
• ECG leads can be disconnected; leads must be placed on or above the end of the bed so that they are not damaged when the patient is moved.
• Transducer set can be disposed of and a new set attached for the next patient.
Left Heart Haemodynamic recording (LV angiogram first)
• ECG should be recorded for reference
• Left heart pressures recorded (see above)
• LV gram
• LV to aorta pull back (see above)
• Left and right coronary angiograms recorded (see above)
• Ending the case (see above)
Recording a Right Heart Catheter
• Setting up procedure is the same as above, it is essential to ensure that the transducers are calibrated to within 2mmHg (see above)
• Attach ECG and enter details (as above)
• Two manometer lines should be attached and flushed through
• RA pressure is recorded on 50 range at 25mm/sec; the mean should also be recorded. Normal pressure range is 4 – 6 mmHg.
• RV pressure should be recorded on 40 range at 25mm/sec, mean off; normal range for RV systolic pressure is 25 – 35 mmHg.
• PA pressure should be recorded on 40 range at 25mm/sec, mean on. Normal pressure range for PA is 25 – 35mmHg
• Pulmonary artery capillary wedge (PCW) pressure is taken by advancing the right heart catheter as far as possible until the catheter tip wedges firmly at the arterioles, effectively plugging flow and recording an indirect pressure from the left atrium. The V wave of a true LA pressure will overlie the upstroke of the ventricular trace; a pulmonary wedge pressure will have a slight delay.
• The Cardiologist may want to then record a right heart pullback. This can be done on 50 range at 25mm/sec. The multiple pullback key will record each pressure when identified by pressing the space bar key as the pressures change.
Simultaneous Pressures
Patients with valve disease will have changes in their pressure tracings; patients with a valve stenosis will require simultaneous pressures to calculate gradients across the valve.
• Aortic Stenosis causes pressure differences between the left ventricle and the aorta. This can be evaluated by a LV pullback, or by simultaneous recordings of LV and aorta. A peak to peak gradient can be calculated by working out the difference in the peak systolic values. The systems computer will also calculate a mean pressure gradient from the area between the two pressure curves.
• Pulmonary Stenosis causes pressure differences between the right ventricle and the pulmonary artery and is calculated in the same way as aortic stenosis.
• Mitral stenosis, to accurately assess the mitral valve simultaneous pressures should be recorded from the left atrium and the left ventricle. The left atrium is inaccessible unless a trans-septal needle is used. The diastolic phase of the LV trace should be recorded with the PCW (pulmonary capillary wedge). This will mirror the LA pressure, but have a slight time delay. The system will calculate the pressure difference between the area bounded by both pressures to give a mitral valve gradient.
• Tricuspid Stenosis is uncommon, but is routinely checked with a right heart pullback. The system can calculate a gradient from the pullback
• Mitral Regurgitation can be more easily quantified from angiography or echocardiography but a tall V wave on the PCW trace can indicate MR
• Aortic Regurgitation again is quantified elsewhere, but a reduced diastolic pressure on the aortic trace indicates AR.
Patients with HOCM
A multiple pullback can be recorded from the LV cavity through the LV outflow tract and into the aorta. The gradient of the obstruction can be calculated by a difference in systolic pressure through the LVOT. In some cases patients may be asked to exercise by lifting saline bags as this can often increase the pressure gradient.
Oxygen Saturations
Blood samples taken during a cardiac catheter are used to measure the flow of blood across a shunt, such as an ASD or VSD. They can also be used to assess cardiac output and stenotic valve area. Normal values are as follows:
Left Heart
• LA, LV, Aorta, Femoral artery = 97%
Right Heart
• SVC, IVC = 65%
• RA, RV = 65%
• PA = 65%
• PCW should have an arterial value of 95%
Blood Gas Run
Oxygen saturations are used to detect and quantify abnormal blood flow within the heart. The major use is to determine a cardiac shunt. Obviously, most shunts flow from left to right due to the differences in pressure. Right to left shunts do occur and are seen mostly in certain congenital abnormalities which result in higher right-sided pressures and also in the presence of pulmonary hypertension.
To accurately assess intracardiac blood oxygen content, samples are taken via a catheter from various sites. This is referred to as the diagnostic blood run. Commonly samples are taken in this sequence:
Left and right pulmonary artery
Main pulmonary artery
Right ventricular outflow tract
Right ventricular apex
Right ventricular inflow tract
Low right atrium
Mid right atrium
High right atrium
Low superior vena cava
High superior vena cava (inominate vein)
Low inferior vena cava
High inferior vena cava
Quantification of Intracardiac Shunts
A step up in oxygen saturations of more than 10% indicates the presence and position of an intra cardiac shunt. A left to right shunt can be calculated by obtaining oxygen saturations. Those saturations needed for quantification of the shunt are:
• Mixed venous (average of SVC and IVC)
• Arterial
• Pulmonary artery
• Pulmonary venous (assume 98% if not available)
Left to right shunt = Qs = systemic blood flow
Qp = pulmonary blood flow
Hence:
Qp = (Art O2 – MV O2)
Qs = (PV O2 – PA O2)
Where:
Art O2 = systemic arterial saturation
MVO2 = mixed venous oxygen saturation (which is 3xSVC + IVC)
4
PVO2 = pulmonary venous oxygen saturation
PAO2 = pulmonary arterial oxygen saturation
|A small left to right shunt gives a ratio of |2.5:1 |
Cardiac Output
The Fick Method
For calculating the cardiac output the Fick method is the simplest. It works on the principle that; the total uptake or release of a substance (oxygen) by an organ (the heart) is the product of the blood flow through that organ and the arteriovenous difference of that substance. More simply, the rate at which oxygen is consumed is divided by the quantity of oxygen removed from the blood by the body. The result is the quantity of blood in which the oxygen was contained.
Cardiac Output (CO) = Oxygen consumption
Arterial-venous oxygen difference
The system will estimate the average patient’s resting oxygen consumption at 3.5ml/kg/min, rather than measuring the patient’s actual oxygen consumption.
Although this is not a direct measurement, it does provide useful information. It is also more accurate than thermodilution CO measurements in patients with tricuspid or pulmonary regurgitation. However the Fick method is invalid in patients with an intracardiac shunt.
Thermodilution Method
The Cardiologist will position a Swan-Ganz catheter into the right heart. The CO cable should be plugged into the correct module on the Mac-Lab tram. There will be a thermistor connector which is plugged into the catheter, and the injectate probe connector which is screwed into the appropriate port. The cooling coil is filled with injectate and submerged into a bowl of ice. The patient’s height and weight must be entered and also the size of the catheter/type of catheter so that the computer constant can be calculated to ensure an accurate measurement.
A specific quantity (which must also be entered into the Mac-Lab) of known indicator solution, is withdrawn from the cooling coil and injected into the injectate port of the thermodilution catheter. The cold injectate solution is introduced rapidly and smoothly as a bolus into the right atrial chamber. The bolus passes into the right ventricle and is then ejected into the pulmonary artery. The patient’s blood temperature is established and recorded by the Mac-Lab before the injection. During the test, the temperature of the mixed blood (a combination of the cold indicator solution and blood) is recorded farther downstream in the pulmonary artery by a thermistor bead located near the tip of the pulmonary artery catheter.
The CO is plotted as the difference in blood temperatures on a time/temp curve. Time is plotted on the horizontal axis and blood temperature differential on the vertical axis. A normal CO curve is smooth, with a rapid rise to a peak and a slow return to baseline. The top of the curve represents the lowest temperature or greatest temperature differential between baseline blood and the injectate/blood mixture as it is sensed by the thermistor.
The curve drops back to baseline as the cold solution washes out of the pulmonary artery and blood temperature returns to normal.
The volume of CO is inversely proportional to the area observed under the curve. A high CO has a small area under the curve. In patients with a low CO, the upstroke of the curve may be slurred, and the area under the curve is large because washout of the cold indicator is prolonged.
The CO curve should be inspected for deviations from the expected normal shape; the Mac-Lab read out should never be accepted without question. The Mac-Lab will retain 5 curves in total and average the CO; the curves used should be within 10% of each other.
5.2.4 CARDIAC PHYSIOLOGIST'S PROTOCOL FOR NON INVASIVE MONITORING IN THE CATHETER LABORATORY
Introduction
During cardiac catheterisation ECG and invasive pressures are monitored as a routine. There may be occasions when non-invasive monitoring is also indicated.
Patients who have had pre-op sedation, or sedation during the procedure
Patients with an underlying condition e.g. COPD, heart failure, etc. who may require oxygen while lying supine
Haemodynamically unstable patients, e.g. Patients who may have a vasodilatory response to femoral access, or during applied pressure to the femoral artery
Cardiologist may request non-invasive monitoring
Role of the Cardiac Physiologist
The Physiologist has the responsibility of being aware of the patient’s haemodynamic state from the moment the patient enters the Laboratory until the patient is transferred to the day ward area. Patients who are transferred should be haemodynamically stable. Patients who are unstable will be transferred to the Coronary Care Unit using a portable DASH monitor.
The Physiologist must remain vigilant at all times throughout the whole procedure. Patients with a vasovagal response will drop their blood pressure and heart rate very rapidly. This can occur at any time, even before the monitoring equipment has been attached.
Non-Invasive Monitoring Equipment
In the Catheter Laboratory – located on the tram System
Non-invasive tram module or automatic/manual BP system
SpO2 finger oximetry probe
ECG
non-invasive blood pressure cuff, 3 sizes, small, medium and large
Mobile – DASH monitor for transfer of patient’s
• As above, all monitoring equipment is compatible and interchangeable throughout Cardiology e.g. wards 42, 43 and CCU
Non-Invasive Monitoring Procedure for all patients entering the Laboratory
• Limb ECG electrodes should be applied to the patient’s left and right shoulder and on the patients left side; to ensure they do not obscure X-ray pictures. The leads themselves are translucent to X-ray, so they should not obscure the angograph pictures. The site for each electrode should be prepped with abrasive tape. The right arm lead should be placed under the patient’s neck. The other leads are attached and placed under the mattress at the patient’s left side. Any leads left dangling should be taped to the mattress to ensure they do not become damaged by entanglement with the X-ray equipment, or being stepped on, etc.
• SpO2 probe should be placed on the patient’s toe, ensuring a good contact and stable recording. The infrared light requires a large capillary bed to monitor arterial blood oxygen saturation. The probe can also be placed on the finger, but this may impede the X-ray equipment during the cine run. Again, any cables dangling on the floor should be taped to the mattress to ensure they do not become damaged.
Patients with an SpO2 of less than 90% should be administered 60 – 100% oxygen at the appropriate flow rate. The Cardiologist must be informed.
Non-Invasive Monitoring under special circumstances
NIBP should be applied to patient’s left arm and can be inflated when necessary. For routine angiography, the NIBP cuff should not be necessary because once arterial access is gained, invasive pressures are available. The NIBP is indicated in the following cases:
• Catheter patients who have had sedation before or during the procedure
• Routine patients who become grey, sweaty, heart rate may be slow and vasodilatatory response is suspected, and invasive pressures are not available
• Patients with a tachyarrythmia, e.g. VT, SVT, etc and are haemodynamically compromised
• Patients with prolonged chest pain following the procedure, invasive pressure lines may have been removed
• Cardiologist requests NIBP/Nursing staff
• The Physiologist feels that NIBP is required
The cuff should be the correct size, and the time intervals for measurement of BP can be set. A manual recording can be taken at any time.
Vasovagal event may occur outside the Lab, in the day ward area. The Day Ward staff should be able to deal with this. In the event that they require assistance, the Physiologist should be available to attach all the non-invasive monitoring described above on the DASH monitor.
• The Cardiologist must be informed if the systolic pressure is less than 100mmHg.
5.2.5 DEALING WITH EMERGENCIES - PROTOCOL FOR CARDIAC PHYSIOLOGISTS
Cardiac Physiologists are responsible for monitoring patients undergoing invasive cardiac procedures, i.e. diagnostic angiography. This protocol is an outline to the physiologist’s role when the patient becomes haemodynamically compromised, and a guide to the subsequent action that must be taken when such incidents occur.
What common emergencies occur?
During invasive procedures, a patient’s haemodynamic stability can change very quickly. Injecting contrast media into the coronary arteries during diagnostic angiography can result in a VF arrest, even in normal patients. Patient’s can become vagal and have a sudden drop in blood pressure and heart rate, patient’s in high grade AV block may have ventricular standstill.
The Physiologist must remain vigilant and be prepared for any of these events.
Ventricular Fibrillation and Pulseless VT
The onset will be very sudden and may follow an injection down the coronary arteries, pacing on a T wave, it may occur for no apparent reason. The Physiologist should recognise this immediately:
• The Cardiologist Must be informed at once
• The defib must be pulled across to the patient’s bedside
• Check the patient, make sure the ECG leads have not fallen off, ensure that the patient is unconscious
• A pre-cordial thump should be administered, if unsuccessful
• Open defib pads and place onto chest in correct positions
• Place paddles onto the chest wall
• Under direction from the Cardiologist, charge the defib to 120J, ensure all staff are aware and have moved away from the patient and any piped oxygen has been removed. Defib when it is safe to do so.
• Wait and check ECG. If normal rhythm has occurred return paddles to defib. If not under direction from the Cardiologist shock again and follow Resusitation pathway for VF arrest.
• If the patient is not being monitored invasively, then a stat NIBP measurement should be recorded when normal rhythm has been resumed. SpO2 should be checked and appropriate level of oxygen administered.
Ventricular Standstill
This is common in patients with high grade AV block, but it can occur at any time during invasive procedures, or if the patient becomes vasovagal.
• The ECG shows no evidence of ventricular activity, there may be atrial activity (P waves) which are of no consequence
The Physiologist should recognise this immediately and inform the Cardiologist
• The defib should be pulled to the patient’s bedside
• External pacing electrodes should be placed in the appropriate place, usually the easiest is red in patient’s right pectoral region and black on patient’s left axilla
• Defib ECG electrodes must be placed on patient’s left and right shoulder and right hip.
• Pacer can be switched on, it will default to 60bpm with 0MA. The amplitude should be gradually increased until ventricular capture is obtained.
• The threshold should be obtained, the patient should be paced at 10MA above the perceived threshold. It is inappropriate in these circumstances to repeat thresholds to be more accurate. Just be aware that for the patient, this will be a very painful procedure, the higher the MA, the more painful it will be.
• If invasive pressures are not being monitored then a stat NIBP must be recorded and SpO2 noted and correct oxygen flow administered.
• Once the patient has become stable, they should be weaned off the pacemaker if possible by gradually decreasing the rate. This should be on the direction of the Cardiologist.
• Pads should be left on the patients chest for the remainder of the procedure, they are radio-translucent and so should not impede the Cardiologist during X-ray screening
Vasovagal Episode
• Patient’s heart rate will begin to fall rapidly; if invasive pressures are available BP starts to drop.
The Cardiologist must be informed at once
• If NIBP is being monitored, a stat recording should be taken as soon as the Physiologist notices a change in heart rate, and SpO2 noted.
The Cardiologist should be informed at once.
• The Cardiologist will advise of any action to be taken. The Physiologist should only proceed further without direction if the patient degenerates to ventricular standstill or VF arrest.
Transfer of Haemodynamically Unstable Patients
The selection criteria for cardiac catheterisation at COCH states that only patients with stable angina or stabilised acute coronary syndrome will be catheterised.
There will be occasions however when a patient may become unstable during the case, e.g following VF arrest, vasovagal episode, etc. These patients will be transferred to CCU or even the Cardiothoracic Centre. The patient will then require portable monitoring, i.e. the DASH monitor.
• For ECG, invasive pressures, NIBP and SpO2 can be transferred individually into the DASH monitor. Invasive pressures should be recalibrated before the patient is transferred. The Cath Lab defib may also be used to transfer the patient.
• Once the patient has arrived at CCU, the monitor can be plugged straight into the CCU sytem. Invasive pressure lines will need to be recalibrated once the patient is settled. The Defib, monitor and another M3 must be brought back to the Lab.
• Patients to be transferred to CTC will also require the DASH monitor and Defib. When the Paramedics are informed of the transfer, a request should be made for a defib to be provided for the journey. The DASH monitor, and transducers will be swapped at CTC. This equipment needs to be brought back by the transferring nurse/physiologist.
• Patients transferred to CTC on a balloon pump, refer to balloon pump protocol.
SECTION 6
INFECTION CONTROL
6.1 UNIVERSAL PRECAUTIONS AND INFECTION CONTROL
6.2 SKIN CLEANING PRE PROCEDURE
6.3 CLEARING AND CLEANING OF TROLLEYS
6.4 DONNING GOWN AND GLOVES FOR A STERILE
6.5 LATEX POLICY
6.6 PROTECTIVE THEATRE WEAR AND LEAD PROTECTION
6.7 PATIENTS WITH MRSA
6.8 POST PROCEDURE CLEANING OF THE LAB
UNIVERSAL PRECAUTIONS & INFECTION CONTROL POLICY FOR CARDIAC CATHETER LABORATORY
Aim
To provide guidance for all persons in the department on good practice relating to the prevention & control of infection. Universal precautions eliminate the risk of random, inappropriate practice &permits staff to deliver high standards of care.
Scope
All staff & persons who enter the clinical area
Method
Universal Precautions
• Cover all cuts or skin abrasions with waterproof dressing
• Avoid contact with blood / body fluids if compromised by a hand or arm skin disorder
• Always use effective hand washing techniques
• The use of gloves does not preclude the need for hand washing before & after contact with the patient
• High quality gloves should always be worn when contact with blood / body fluids is anticipated
• Assess the risk of splash & wear mask & goggles or full face visor
• Avoid hand to mouth/eye contact
• If contact with blood / body fluid is anticipated wear water repellent clothing
• Circulating staff should wear gloves, plastic aprons & eye protection whenever there is a risk of possible contamination
• Adhere to local policy for sharps disposal
• Use an appropriate instrument for careful application & removal of
• surgical blade to a handle
• Careful, correct disposal of sharps at the end of the procedure
• Needles should never be re-sheathed
• Use appropriate solution for dealing with spillage’s
• All staff should know & follow the hospital policy for sharps injury
• All clinical refuse must be placed in appropriate sacks & sealed prior to incineration
• Soiled & used linen is to be bagged as per hospital policy
Scrub Technique
Aim
To prevent cross infection by removing the transient &resident micro-organisms on the hands & arms
• Clean, appropriate theatre clothing is to be worn
• Hair is completely covered
• Mask is worn correctly
• Jewellery is removed
• Finger nails are short
• Sleeves are above the elbow
• Temperature of water is comfortable
• Water flow is such to prevent clothing getting wet
• Hands are held higher than elbows at all times
• Vigorous shaking of hands & arms is unacceptable
• Open disposable nail brush at beginning of the procedure
• Hands & arms are washed up to the elbow using a skin antiseptic for one minute. Rinsing in every instance from fingertips to elbow using water flow not hands
• Apply antiseptic brush to nails (not hands) & scrub for 2 minutes, discard brush
• Wash hands for 2 further minutes, washing to above the wrist only, rinse. This makes a total of 5 minutes preparation time
• The hands are dried first, then working from fingertips to elbows blot the arm dry. Avoid touching the arm with fingers. Discard the towel immediately. With a second clean towel the process is repeated with the other arm
• Don gown & gloves correctly maintaining sterility
Subsequent hand preparation through out the day requires a 3 minute wash with antiseptic solution (omit scrubbing nails)
References
Advisory Committee on Dangerous Pathogens (1995) Protection against bloodbourne infections in the workplace – HIV & Hepatitis. London HMSO
NATN (1997) Universal Precautions NATN Publications Harrogate
Norman A. (1995) A comparison of face masks & visors for the scrub team. British Journal of Theatre Nursing 5 (2) 10-13
Royal College of Nursing (1997) Universal Precautions. RCN London
6.2 SKIN PREP PRE PROCEDURE
Aim
Ensure proper use of solutions to maximise their effectiveness for skin preparation pre-procedure.
Scope
All staff involved in preparing the patient
Method
• Solutions should be prepared following manufacturing guidelines and pharmaceutical advice
• Aqueous based solutions are recommended for skin preparation pre-procedure
• Only a sufficient amount of antiseptic solution should be applied. Great care should be taken to avoid pooling of fluids
• Cleansing should begin at the incision site & continued outward. It is recommended that the swab should not be brought back to the incision site, this returns micro-organisms to the area
References
Guide to Good Pharmaceutical Practice (1983)
Jespen O Bruttomesso K A (1993) The effectiveness of Perioperative Skin Preparations AORN Journal 58 (3) 477-48
6.3 CLEARING & CLEANING OF TROLLEYS
Aim
To prevent cross infection
Scope
All Staff
Method
• All trolleys stored in the Catheter Lab with necessary CSSD & consumables available for the relevant procedure
• After use, dispose of all sharps as per hospital policy
• Dispose of clinical waste in yellow bags
• Clean trolley with alcohol preparation
Follow hospital infection control policies
References
Line S (2003) Decontamination & Infection control in theatre. British Journal of Perioperative Nursing 13 (2) 70-75
NATN (1997) Universal Precautions & Infection Control in the Perioperative Setting. Harrogate NATN Publications
University Hospital Aintree Infection Control Guide Lines
6.4 DONNING GOWN & GLOVES FOR A STERILE PROCEDURE
Aim
To make certain that all personnel maintain an aseptic technique to prevent infection or contamination
Scope
All staff who scrub for procedures
Method
Gowns
• All gowns should be in a good state of repair and any found not to have been processed to a high standard should be discarded
The practitioner must make certain that they touch the inside of the gown only
• The circulator should assist by securing the back of the gown with the ties
Gloving
• Alternative gloves should be made available to personnel sensitive to latex
• All glove packs should be checked prior to opening to ensure sterility
• Closed glove technique will be employed.
Post scrub
The practitioner understands the area of sterility is from:
• Fingers to elbows
• Below nipple line to waist
• Hands to be kept above waist level at all times
• Scrub person must stay within the sterile field at all times
• At the end of the procedure, gown should be removed before gloves
References
ACORN (1998) Surgical Scrubbing, Gowning & Gloving. Standards, guidelines & policy statements Australia ACORN Ltd
Fay M (1996) Latex Sensitisation. South African Theatre Sisters Journal 21 (1) 27-34
5. LATEX POLICY
Authorising Manager:
Issue Date:
Review Date:
Review Responsibility:
Job Title:
Issuing Dept/Directorate:
Cancellation Date:
Revision Status:
Purpose
This policy provides for the management of latex sensitisation.
Scope
The policy applies to all employees of the Trust.
Definitions
In this policy definitions used are mainly those referred to in the policy and by the documents mentioned.
Allergy - can be defined as any immunological reaction to a foreign substance that produces detrimental consequences to the body.
Hypersensitivity - can be defined as a type of inappropriate or excessive r response of the immune system.
Sensitisation - can be defined as the process of the body producing specific
antibodies in response to repeated exposure to a specific antigen.
"The Trust" – COCH Foundation Trust
INTRODUCTION
The Trust has a statutory duty to ensure a safe working environment for employees and patients. The Medical Devices Agency of the Department of Health stated in their bulletin, published in April 1996 that, "the risk of latex allergy is exacerbated by the use of powdered gloves, which increases exposure to latex allergens, not only to the user but also to other sensitised individuals in the vicinity".
It also states "that most powdered gloves have higher extractable protein levels than the powder free gloves and that the use of powdered latex gloves increases the likelihood of sensitisation to both health professionals and patients, as well as adding to the risk of procedural complications".
Whilst the MDA document does not specify any definitive guidance on safe protein levels it does recommend that latex gloves should contain the lowest level of extractable proteins practicable.
Modified starch is used in some gloves as a form of lubrication, making them easier to put on, or assist manufacture. Although the starch powder is not an allergen in itself, the protein residue in the latex readily attaches to the starch which then acts as a carrier, allowing surface or airborne transmission. Absorption of latex proteins via the respiratory tract may cause respiratory allergic reactions.
At the time of writing there are no gloves containing starch powder available throughout the Trust sterile or non-sterile, and all gloves that are available have protein levels below 100 micrograms.
AIMS
Stage One
Gloves used throughout the Trust (excluding Surgical Gloves) should be natural rubber latex free as far as is reasonably practicable, this should be achieved by 30/06/03.
Stage Two
Surgical gloves used throughout the Trust should be natural rubber latex free as far as is reasonable practicable, this should be achieved by the end of 2003.
GENERAL INFORMATION - Types of Sensitivity
The two types of Natural Rubber Latex (NRL) Allergy most frequently referred to are Type I and Type IV - see Appendix 1 for more information re signs & symptoms.
MANAGEMENT OF SENSITISED EMPLOYEES
Responsibilities of the Occupational Health Department
Prospective employees should be advised at the pre-employment stage with regard to signs and symptoms of latex sensitisation and the reporting procedure.
• Prospective employees should be advised at the pre-employment stage with regard to existing medical conditions which could be related to latex.
• In cases where this may prove to be a serious risk to their health, the individual will be referred to the Occupational Health Physician for advice regarding fitness to work in that area.
• Provide advice for any employees who develop skin related problems and advise managers where relevant.
• Provide advice relating to re-deployment and ill health retirement where cases of dermatitis or sensitisation are causing more serious health problems.
• To review on an annual basis those individuals identified as having being sensitised.
• Ensure cases of latex sensitivity are reported to HSE under RIDDOR 1995.
Responsibilities of Infection Control
• Liaise with Occupational Health Department and Supplies Dept for the
purchasing of gloves.
• Educate employees about basic hand hygiene.
Responsibility of Supplies
• To liaise with Infection Control and Occupational Health regarding the supply of gloves to the Trust.
Responsibility of Managers
• To ensure during local induction that training and information is given with regard to latex sensitisation and that such training and information is appropriation to the employees’ role and responsibilities.
• To ensure records to illustrate that local induction has been carried out are held within the dept/ward/directorate.
• To carry out Risk Assessment of tasks to ascertain type of glove required for task.
• To ensure that all staff who need to wear NRL gloves are aware of the risk of sensitisation to latex proteins.
• To refer to Occupational Health any member of staff who reports a skin reaction related to the use of NRL gloves.
• To ensure that there are sufficient supplies of an alternative type of glove.
• To evaluate the risk to all staff who need to wear NRL gloves on a regular basis.
Responsibility of Employee
• To wear the correct glove for the task being carried out as per risk assessment.
• To report to their manager or to Occupational Health should they develop any untoward skin conditions which may be due to NRL gloves.
• To adhere to any advice given by Occupational Health concerning the management of their condition.
Appendix 1
GENERAL INFORMATION - Types of Sensitivity
The two types of Natural Rubber Latex (NRL) Allergy most frequently referred to are Type I and Type IV.
Type I
Allergen Extractable Latex Proteins
Timing Immediate - 2-3 minutes after exposure
(once sensitised)
Symptoms Localised or systemic wheal & skin flare reaction
Asthma, rhinitis, conjunctivitis, anaphylaxis
Type I allergies may be localised but have the potential to become systemic at any time. Sensitisation to any latex protein demands avoidance of all latex proteins. The consequences of Type I allergies are therefore more serious than for Type IV:
Type I reactions may result in serious anaphylactic reactions which can be fatal.
Type I sensitisation precludes contact with any latex products, in both work and home environment.
Type I reactions may require a change in practice by colleagues of the sensitised individual.
Type IV
Allergen Residual Accelerators
Timing Delayed - 6-8 hours after exposure
(Once sensitised)
Symptoms Localised reddening of skin and itching
Type IV allergies are localised and there is no risk of systemic reactions. However:
• The localised skin reaction can be serious and can be aggravated by factors such as frequent hand washing or by irritant materials.
• A Type IV sensitised individuals must avoid contact with the accelerator to
which they are sensitised.
6.6 PROTECTIVE THEATRE WEAR AND LEAD PROTECTION IN THE
CATHETERISATION LABORATORY
Aim
This protocol has been drawn up in response to a recent literature review, and with reference to the Trust’s Infection Control Theatre Guidelines and Local Rules relating to diagnostic radiology.
Scope
All personnel entering the lab environment
Method
All staff taking part in clinical investigations must wear the protective equipment provided, as detailed below:
• All staff taking part in clinical investigations must wear theatre scrubs.
• All members of staff entering the cardiac catheter lab must wear a surgical hat. (Long hair should be tied back to reduce shedding of loose hairs). These must be changed at the end of each session, or when visibly soiled.
• Footwear should be cleaned daily or when visibly soiled.
Scrub team
“The value of masks in reducing the number of post op infections is inconclusive. Masks do, however, act as a deflector for droplets that are released when the wearer speaks. More importantly, masks protect the wearer’s mouth from inadvertent exposures (splashes etc).”
ORH Infection Control Guidelines for Operating Theatres 2001
• Members of the ‘scrub team’ must wear surgical masks during all sterile procedures. This includes primary and secondary operators, radiographers, scrub nurses, and any other member of the multidisciplinary team who is close to the table. These must be changed at the end of each case.
• Eye protection must be worn by the operator, scrub nurse, radiographer and /or assisting doctors.
Running team
It is not necessary for the ‘running team’ to wear masks and/or eye protection, as they are not in the immediate vicinity of the theatre table and the risk from splashing is minimal.
Lead protection
• Any person in a controlled area must wear a lead coat, unless the Radiation Protection Advisor has assessed that it is unnecessary.
• Protective lead glasses and a thyroid shield must be worn by operator and any other person who must remain near the x-ray source during radiation exposures
• Thyroid shields are recommended for anyone entering a controlled area.
N.B. The practice of staff leaving the unit and walking around the hospital in theatre scrubs is to be actively discouraged and will be closely monitored.
References
- Bashmore TM et al (2001) American College of Cardiology/Society for Cardiac Angiography and Interventions clinical expert consensus document on cardiac catheter laboratory standards Journal of the American College of Cardiology, Vol 37, No 8.
- Bernath, V (1999) Does the wearing of face masks by the non scrub team operating theatre staff affect surgical wound infection rates? Centre for clinical effectiveness, Monash Institute of Public Health C, Health Services, USA.
-Cardella, JF et al(1994) AHA Intercouncil report on peripheral and
visceral angiographic and interventional laboratories, American Heart Association.
-Sjol, A & Kalbaek, H (2002) Is the use of surgical caps and masks
obsolete during percutaneous heart catheterisation? Ugeskrift for Lauger
16 (12) 1673-5.
-ORH (2001) Local Rules Relating to Diagnostic Radiology at the John
Radcliffe Hospital
-ORH (2001) Infection Control Guidelines for Operating Theatres
-"The Personal Protective Equipment at Work Regulations” (1992) Regulation 10
-"Health & Safety at Work Act” (1974) Sections 7 & 8
-"Management of Health & Safety at Work Regulations” (1999) Regulation 14.
-Aintree Hospitals NHS Trust Theatre Services Directorate (1998) Mask wearing policy AH/TS/P+P/008/98
6.7 PATIENTS WITH MRSA
Aim
To ensure that patients with MRSA are studied efficiently and effectively, minimising the risk of infections to the patient, staff and others following guidelines for dealing with such occurrences.
Scope
All staff, Nurses, Radiographers, HCA’s etc.
Method
• When possible the patient should be studied at the end of the daily list.
• All staff to wear gloves and plastic disposable aprons over lead aprons.
• Minimise the patient contact i.e. one primary nurse to administer care.
• Standard cleaning of all equipment having been in contact with the patient using the recommended hard surface disinfectant solution.
• Linen to be placed inside RED disposable bag inside white linen bag.
• All waste to be disposed of as clinical waste.
References
NATN (1997) Universal Precautions & Infection Control in the Perioperative Setting. NATN Harrogate, NATN Publications
Infection control policy folder, Countess of Chester Hospital.
6.8 POST PROCEDURE CLEANING OF CARDIAC CATH LAB
Aim
To maintain a safe and clean environment in which to perform cardiac catheterisation and facilitate efficient change over of patients, therefore preventing delay.
Scope
All staff
Method
Roles and responsibilities to be discussed
• Scrub nurse will accompany patient out of lab to day case area
• Circulating nurse/team member will change sheet on table
• Bins will be changed at the end of every case
• Blood/body fluids to be spot cleaned with a hard surface disinfectant spray
• Floor to be mopped if blood/body fluids have been spilled
• Clean procedure trolley with a hard surface disinfectant spray in preparation for the next case
References
AORN (1996) Recommended practices for Environmental cleaning in the surgical practice setting. AORN Journal 64 (4) 611-5, 813-6 (5) 817-21
NATN (1993) Principles of Safe Practice in the Operating Theatre. Harrogate NATN Publications
SECTION 7
EMERGENCIES
7.1 CARDIAC/RESPIRATORY ARREST
7.2 CARE OF PATIENT RECEIVING IABP THERAPY
7.3 AMBULANCE TRANSFER POLICY
EXTERNAL PACING
7.1 CARDIAC ARREST PROTOCOL
Aim
To effectively manage cardiac arrest situations, ensure patient and staff safety
Scope
All staff
Method
It is the individuals responsibility to ensure that they;
• Read and follow the Countess of Chester Hospital Policy on Resuscitation.
• Attend mandatory basic life support training on a yearly basis.
• Follow protocol for daily checking of resuscitation equipment.
• Know your equipment and where to find it.
• Senior staff are to be trained in Advanced Life Support and should attend retraining every three years.
• Life support should be carried out in accordance with the current European Resuscitation Council (ERC) protocols.
Should a cardiac arrest occur:
To call the arrest team ring 2222
State clearly cardiac arrest and location
On hearing the cardiac arrest alarm, the senior nurse in the day ward area is responsible for directing the arrest team to the catheter lab, they must not go through the ward.
• All staff must ensure their own safety at all times.
• The radiographer should move the table to allow access to the patient, put out the arrest call and document events.
• Nurses are primarily responsible for maintaining the patients airway as directed by resuscitation protocol and training.
• The cardiac physiologists are best placed to perform defibrillation, should it be required. A nurse trained in this procedure may also undertake this duty.
• Rhythms that respond to defibrillation may take up to 3 shocks and the arrest team may not be required.
• Non - shockable arrests (PEA, Systole) should have the arrest team called at the outset.
To call Anaesthetist only ring 2222
State clearly location and ask for anaesthetist only
Call for the full team for any cardiac arrests on the Day Ward.
Post arrest
• Monitoring bed may be required and should be organised by the nurse in charge.
• Audit forms should be completed and sent to the resuscitation department.
• Documentation for in lab complications should be completed.
• Following arrest, personnel involved should be debriefed.
• All supplies must be replaced and equipment checked before continuing the list.
• Should a death occur, follow the protocol for care of the deceased patient.
References
Advanced Life Support Manual 4th Edition Resuscitation Council (UK) 2002
7.2 CARE OF PATIENT RECEIVING INTRA AORTIC BALLOON PUMP THERAPY IN THE LABORATORY
Aim
To provide skilled personnel & the equipment necessary to deliver the specialised care needed to safely transfer a patient on the Intra Aortic Balloon Pump.
Scope
Nurses, Technicians, Specialist Medical Staff. Care of IABP to be delivered by health care professionals who have undergone specific training and who can adequately provide care.
Method
Prior to transfer ensure that;
• ECG leads are firmly connected
• Helium connection is secure
• Balloon catheter is sutured & sterile dressing has been applied to insertion area
• ECG trace is monitored on IABP
• That timing is checked & correct there by maximising diastolic augmentation
• That patients observations are stable, including radial & pedal pulses
• Consider urinary catheter before transfer of patient
• Place IABP at foot of bed trolley
• Allocate one person to co-ordinate patient transfer to bed / trolley
• Switch from AC power to battery immediately prior to transfer
Prior to transfer to referral centre;
• Record observations on IABP sheet
• Team for transfer of patient; ALS trained, trained & competent in the use of IABP
• Arrange ambulance (as per Emergency Ambulance protocol)
• Ring referral centre to give time of arrival
• Ensure IABP console is secured in ambulance
• Switch IABP to emergency vehicle inverter
References
Transport for patients on an Intra-Aortic Balloon Pump, Datascope 2003.
7.3 AMBULANCE TRANSFER PROCEDURE
Aim
To ensure a safe, organised ambulance transfer in the event of an emergency, non-emergency (urgent), or same day transfer to the Cardio Thoracic Centre (CTC).
Scope
Multidisciplinary Team
Method
The consultants referring a patient to CTC will liaise with the consultant accepting the patient. Once transfer has been agreed and a bed has been identified:
The consultant will inform the nurse in charge of the acuity of the transfer:
➢ Emergency - life threatening. Requires transfer within the hour.
➢ Non emergency (same day) - Dr will give specified time frame for transfer i.e. within 2 hours.
➢ Same day (non-urgent/routine) - no time frame required.
Nurse will then:
➢ Call 0151 264 6902: Priority one (for emergency/1hour transfer) stating the following:
IF AN IABP IS TO BE TRANSPORTED, A WILKER OR MERCEDES AMBULANCE MUST BE REQUESTED.
➢ Patients airway status; do we need a portable ventilator or just oxygen?
➢ Circulatory status; cardiac monitoring required?
➢ Destination at CTC (direct to cardiac catheter lab/coronary care/operating theatres)?
➢ Number of staff accompanying patient.
Call 0151 264 6904: Urgent or same day transfer. Provide operator with a time frame during which transfer would be acceptable.
References
Ray Lunt
Operational Services Manager
Merseyside Regional Ambulance Service
7.4 EXERNAL PACING
This protocol has been developed in response to the withdrawal of isoprenaline from the marketplace. External pacing is a treatment option for patients who develop severe bradycardia and haemodynamic instability during procedures.
• Place the external pads on the patient’s chest as prescribed in the ALS guidelines for hands free defibrillation (the lateral electrode in the mid-axillary line, lateral to the nipple – V6 position, the anterior electrode below the right clavicle). Connect the pads to the external lead on the defibrillator.
• Ensure that monitoring leads are placed on patient so that the defibrillator can detect the patient’s underlying cardiac rhythm. (Once recognised the QRS will be highlighted, as in sync shock mode.)
• Once the equipment is in place, turn the external pacer on (the machine will automatically default to a demand mode, 70bpm, at 30mA).
• Press start to begin delivery of electricity, increasing the current until capture is achieved (press current increase button). A pacing spike will appear on the screen.
• Ensure that myocardial capture is occurring by checking the patient’s femoral pulse as well as observing the screen for electrical capture (a wide QRS complex after the pacing spike), as the patient’s chest wall may capture without myocardial contraction occurring.
• A manual blood pressure reading may be more accurate then a dynamap, if arterial monitoring is not available. Increase pacing rate if necessary.
• The patient will find external pacing uncomfortable and will require sedation and analgesia.
• If a DC shock is required whilst external pads are in place, turning the dial from monitor to 120j will override the pacing function and the shock will be delivered through the external pads. ALS guidelines must be followed. If pacing is required again, the pacing mode will need to be reactivated.
If it is expected that a patient will require external pacing during a procedure, then place the pads and monitoring leads before the patient is gowned for that procedure, in consultation with the medical staff.
Reference
Resuscitation Council (UK) Advanced Life Support Manual (4th Ed) 2001
SECTION 8
LINE REMOVAL/WOUND CARE
1. FEMORAL ARTERIAL AND VENOUS LINE REMOVAL AND EARLY MOBILISATION POST ANGIOGRAPHY
2. CARE OF A PATIENT POST ANGIOSEAL DEVICE INSERTION
3. FEMOSTOP USE AND PLACEMENT WHEN LINES ARE IN SITU
4. FEMOSTOP USE AND PLACEMENT FOR A BLEEDING ARTERY
8.1 FEMORAL ARTERIAL AND VENOUS LINE REMOVAL AND EARLY MOBILISATION POST ANGIOGRAPHY
Aim
To provide a guideline for the safe removal of femoral arterial and venous lines post-diagnostic coronary angiography. To enable mobilisation to commence earlier, reducing potential complications associated with prolonged bed-rest, increasing patient satisfaction and achieving earlier discharge.
Phase 1
Scope
All appropriately trained staff, staff undergoing sheath removal training, Medical Staff, HCA’s.
Method
Named nurse receiving patient into unit will receive a full handover from the scrub nurse containing:
• Vital signs
• Medications administered during procedure
• Procedure findings
• Complications
• Introducer size
• Contrast usage
Confirm with consultant if introducer/femoral lines are to be removed.
If so, gather all relevant equipment
Non-sterile gloves
Gauze swabs
Clock/watch to time procedure
Small clear occlusive dressing
BP monitoring equipment
Sandbag (optional)
Have access to a call bell and inform staff on the unit that arterial line removal is about to take place. Do not become isolated.
Have access to
Atropine
Infusion/giving sets
IV fluids/Volume expanders
Oxygen
Check
• Patients anticoagulation status
• Palpate pedal pulses, if absent notify Consultant.
• Blood Pressure >150/90 notify Consultant prior to sheath removal
• Blood Pressure 6french (arterial)
Obesity BMI>35
Observations to be performed
BP, Pulse every 15mins for first hour, every 30mins for second hour and hourly thereafter and prior to discharge
Wound and peripheral pulses every 15mins for first hour, every 30mins for second hour and hourly thereafter and prior to discharge
Document colour, movement, sensation, warmth of the feet and pedal pulses document any abnormalities.
On return to ward
• Perform observations as listed above
• Observe femoral puncture site for sign of bleeding or haematoma formation
• Palpate peripheral pulses and record accordingly
If observations are satisfactory on return to ward patient care is as follows
• Sit the patient up to a maximum angle of 45degrees
• During the two hours patient can be gradually sat upright
• Observations to be recorded accurately
• Encourage the patient to keep the limb as straight as possible
Upon completion of two hours bed-rest mobilisation may commence unless any of the following has occurred
• Swelling or bleeding from the femoral puncture site
• If the patient has experienced any procedural related side effects ie. Vaso-vagal, contrast allergy
• Loss of pedal pulses
• Any pain, cold or change in colour, perfusion of the limb
• Any other post procedural complications
Prior to mobilisation check the following
• BP, pulse
• Femoral site for haematoma formation
• Pedal pulses and document accurately
Patients are then to be encouraged to mobilise in the ward area. After a minimum of one hour’s mobilisation the patient may be discharged home as per protocol.
For patients who are on four hours bed rest, nursing care is as above.
Mobilising after 4 hours and then encouraged to mobilise for a minimum of 1 hour and then discharged as per protocol.
References
Cragg AH, Nakagawa N, Smith TP, Berbaum KS. haematoma formation after diagnostic angiography: effect of catheter size Journal of Vascular & Interventional Radiology, May 1991
Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet. 1999. 354. 1229-1233
Miiward SF, Marsh JI, Peterson RA. Outpatient transfemoral angiography with a two hour observation period, Cardiovascular and Interventional Radiology October 1989.
CTC, Liverpool NHS, Day Ward 2hour Mobilisation protocol. January 2002.
8.2 CARE OF A PATIENT POST ANGIO-SEAL STS PLATFORM DEVICE
INSERTION
Aim
Angioseal is a 60-90 day bio-reabsorbable plug for earlier mobilisation post femoral artery puncture
This protocol is aimed to guide the named nurse responsible through the care of a patient who has had an Angio-Seal device deployed.
Scope
RN, HCA’s (under supervision), who have been trained to care for patients post Angioseal insertion.
Method
Possible Indications
Obesity
• Chronic hypertension
• High INR (between 1:1.5) The procedure will not take place if INR>1.5
• Bleeding disorder
• Inability to lie flat due to breathlessness or severe back pain
• Osteoarthritis
• Valvular disease
• Operators discretion
NB: Angio-Seal is not for general use. The use of an Angio-Seal Device is indicated when early ambulation, early discharge, increased patient comfort, consistent and predictable haemostasis are all desired outcomes.
Contra-indications
• Patients who have an allergy to bovine collagen products
• Uncontrolled hypertension
• History of Peripheral Vascular Disease
• Groin area infection
• Autoimmune disease
• Pregnancy / lactation
• High/Low Arterial Puncture (ie not a common femoral artery puncture)
Post procedure Assessment
• Femoral Arterial Site Checks; palpate the site assessing bruising haematoma swelling and bleeding.
• Pedal pulses; Assess presence and quality as compared to pre procedure status (see pulse assessment guidelines).
• Assess lower extremity for colour, temperature, sensation and movement.
• Vital signs.(q 15minutes x1hr ,q 30minutes x1hr , q1hrly x2hrs)
• Keep puncture site clean and dry using aseptic technique
Patient activity
• Head of bed may be elevated to maximum 45 degrees.
• Patient may turn side to side.
• Patient must support puncture site when coughing straining or sneezing.
Care of the patient with an Angioseal
• Document the time and date of placement of the device
• Baseline observation of pulse, blood pressure, puncture site and distal pulses
• The patient should remain flat for 30 minutes. Bed rest should continue for 2 hours (if bleeding or bruising occurs patient may need longer bed rest)
• The patient can mobilise gently with supervision after bed rest
If bleeding occurs
Oozing- Sheath has created a tract to the artery and it may fill with blood and saturate the dressing.
Nursing interventions
• Apply a light digital pressure to puncture site for 2-3minutes. In this time assessment of source and intensity can take place along with condition of the site.
• Once haemostasis is attained apply sterile dressing with a clear occlusive dressing over the site. A pressure dressing may be applied if soft tissue (capillary) ooze persists.
• Inform Physician prior to discharge
Brisk bleeding- exhibited by pulsetile flow or growing haematoma
Nursing intervention
Inform Attending Cardiologist immediately
• Apply manual pressure above puncture site to control bleeding and follow protocol for arterial line removal.
• Lower head of bed..
• Consider Femstop usage.
• Once haemostasis has been attained apply a sterile dressing and cover with a clear occlusive dressing.
Discharge instructions
• Review the patient care instructions with the patient.
• Following guidelines are recommended.
• Dressing may be removed the following day and the site cleaned with mild soapy water. A Band-Aid dressing should be applied and changed daily until the skin heals.
• It is normal to feel a pea sized lump and or mild tenderness in the groin. Advise the patient that this will disappear after 3 months once the collagen has dissolved
• Modify activity for 48-72 hours avoid driving day of discharge, no heavy lifting.
• Provide Angio-seal Patient Guide and Information Card to patient or family.
• Instruct the patient to carry the information card for 90 days . Time required for full absorption of Angio-seal and its components.
• Instruct the patient to contact his/her cardiologist if the following symptoms occur.
• Fever
• Bleeding
• Persistent swelling or tenderness
• Redness or warm to the touch
• Numbness or pain in the affected limb on mobilisation
• Wound drainage
• Rash
References
Nursing care and Patient Instructions,
Angio-Seal, St Jude Medical 2002.
Arterial line removal protocol- Document 8.1
Femostop Care protocol – Document 8.4
8.3 FEMOSTOP USE AND PLACEMENT
Femostop device will only be used:
• After a period of manual compression, when haemostasis has not been achieved.
• In the event of Angioseal device failing to achieve haemostasis
Aim
To ensure the correct use and placement of the Femstop Device, decreasing complications due to haematoma formation or excessive blood loss from the femoral veins and arteries.
Scope
Named Nurses, RN, HCA’s, Medical Staff, and all persons trained in the usage of the Femostop Device.
Method
Prior to Femostop use and placement
examine puncture sites
examine and identify existing haematoma for size (if present consider the following points)
Is it pulsetile?
Hard or soft in nature?
Mark for future reference
Establish the patients current blood pressure
When positioning the femostop device
• ask the patient to bend their unaffected leg and raise their hips off the bed
• pass the belt under the patients hips directly inline with the puncture site(s)
• Ensure that dome is firmly locked in place on Femostop arch keep protective peel-back lid insitu
• Remove protective peel-back lid maintaining sterility of the dome area
• Position the centre of the dome slightly superior (1-2 finger spaces) and medial to the puncture site(s)
• Thread the belt through the arch by fully releasing the side arm locks
• Adjust belt so arch fits snugly
• The arch should be parallel and horizontal
• Attached sphygmomanometer to the dome and secure it
• Inflate the dome 20-30mmHg. Remove the venous sheath if present.
• Continue to increase the pressure to 60-80mmHg while simultaneously removing the arterial sheath
• Increase the dome pressure 10-20mmHg above the patient systolic blood pressure or until haemostasis is achieved
• Once bleeding is controlled slowly release the pressure in the dome until a pedal pulse can be palpated
• Hold compression for routine time frame (10minutes) observing for bleeding at all times
• Gradually reduce pressure in increments of 10-20mmHg every 2-3 minutes until haemostasis is completed
• Once completed dress the site as per routine
References
Femostop II, Directions for use, RADI Medical Systems, Norway
1 FEMOSTOP USE AND PLACEMENT FOR A BLEEDING ARTERY
Aim
To ensure the correct use and placement of the Femostop Device, decreasing complications due to haematoma formation or excessive blood loss from the femoral veins and arteries.
Scope
Nursing Staff , HCA’s, Medical Staff, and all persons trained in the usage of the Femostop Device.
Method
Prior to Femostop use and placement
While continuing to press on the femoral artery ask a colleague to place the nylon belt under and around the patients hips in line with the skin and arterial puncture sites
establish the patients current blood pressure
When positioning the femostop device
• Ensure that dome is firmly locked in place on Femostop arch keep protective peel-back lid insitu
• Remove protective peel-back lid maintaining sterility of the dome area
• Position the centre of the dome slightly superior (1-2 finger spaces) and medial to the puncture site(s)
• Thread the belt through the arch by fully releasing the side arm locks
• Adjust belt so arch fits snugly
• The arch should be parallel and horizontal
• Attached sphygmomanometer to the dome and secure it
• Note the patients blood pressure at this time
• Remove the fingers as the dome is inflated 10-20mmHg above systolic pressure or until haemostasis is achieved
• Once bleeding is controlled slowly release the pressure in the dome until a pedal pulse can be palpated
• Hold compression for routine time frame (10minutes) observing for bleeding at all times
• Gradually reduce pressure in increments of 10-20mmHg every 2-3 minutes until haemostasis is completed
• If bleeding reoccurs then increase the pressure in the dome
• If no bleeding reoccurs then completely deflate the dome but leave insitu for 10minutes
• Once completed dress the site as per routine
References
Femstop II, Directions for use, RADI Medical Systems, Norway
SECTION 9
POST OP AND DISCHARGE
9.1 PATIENT CARE POST PROCEDURE
9.2 ROUTINE TRANSFER OF PATIENTS TO AND FROM CCU/WD 42/43
9.3 SAFE DISCHARGE PROTOCOL
9.1 POST PROCEDURE ROLE OF THE NAMED NURSE
Aim
To highlight the role and responsibility of the named nurse post procedure.
Scope
Named Nurse, HCA (under supervision).
Method
The named nurse will receive handover from the catheter lab scrub nurse, which will include;
• Vital signs
• Medications administered intraoperatively, including contrast dose
• Procedure findings
• Complications
• Sheath size
The named nurse will discuss arterial line removal with the patient.
• The arterial line will then be removed according to arterial line removal protocol and the care pathway.
• Following successful arterial line removal and haemostasis, the patients head may be elevated 30-40degrees.
• The named nurse will perform haemodynamic, circulation, sensation, and movement observations according to arterial line removal guidelines and the care pathway
• The named nurse/HCA will encourage oral fluids. Reasonable amounts of food will be offered.
• The named nurse will ensure the patient has passed urine prior to discharge.
• The named nurse will ensure that all discharge criteria has been met.
• The patient will not be discharges until seen by the Consultant.
• The named nurse will ensure the patient and family are well informed about current condition, and appropriate literature is distributed to the patient.
• The named nurse will relay any follow up appointment information to the patient prior to discharge.
References
NMC (2002) Cope of Professional Conduct. Publications Department, Nursing & Midwifery Council. Portland Place, London
Integrated care pathway for Cardiac Catheterisation Arterial line removal protocol
2. ROUTINE TRANSFER OF PATIENTS TO AND FROM CCU/WARD 42/43
Aim
To ensure the safe transfer of patients from the Cardiac Catheter Lab, to either CCU or wd 42/43 and vice versa.
Scope
Registered Nurses
Method
• Cath lab staff to call CCU/Ward 9 staff when the patient has met the discharge requirements for transfer back to their respective area and is ready for collection
• Cath lab staff to call for a porter when CCU/Ward 9 staff have been informed and request relevant mode of transport
• Hand over to include
• Integrated care pathway and all post care information
• Documentation applicable to the patient
• Case notes & X-rays
• Post procedure orders
• Procedure/finding results
• Vitals signs
• Haemostasis status
• Peripheral pulses
• Any complications or adverse events if they have occurred
References
NATN (1998) Safeguards for Invasive Procedures: The Management of Risks. NATN Publications, Harrogate
NMC (2002) Code of Professional Conduct. Publications Department, Nursing & Midwifery Council, Portland Place, London
9.3 DISCHARGE CRITERIA
Aim
To ensure safe discharge of patients post angiography.
Scope
Registered Nurses
Method
Prior to discharge, consider the following;
• Dr has stated in notes that patient can be discharged today.
• Patient states readiness to be discharged.
• Responsible adult accompanying patient.
• Have any drugs used affected the patient, are they alert /orientated and are not experiencing any nausea.
• Check vital signs are stable and within normal limits for that patient
• Verify that patient has passed urine.
• The patient should be free from chest pain.
• Confirm that the patient is mobile, without experiencing any dizziness or feeling faint.
• Remove any venflons and dress area.
• Check peripheral pulses, circulation, sensation and movement of limb.
• Immediately before discharge check the wound site for any signs of bleeding, haematoma or pain.
• Explain medication changes and document in discharge booklet.
• Return any valuables.
• Provide a discharge booklet and a verbal explanation of after care instructions
• Allow time for patients or relatives to discuss any issues or anxieties.
• Accurately record discharge in care pathway.
Failure to meet discharge criteria
Any problems at discharge you must inform the patients consultant or if not available, the on call consultant.
References
Bradshaw EG & Davenport HT. Day Care Surgery, Anaesthesia & Management. Edward Arnold. London 1989
Stephenson ME. Discharge criteria in day surgery. Journal of Advanced Nursing 5. 601-613
SECTION 10
VISITORS TO THE UNIT
10.1 COMPANY REPRESENTATIVES VISITNG THE DEPARTMENT
10.2 VISITORS NON-ESSENTIAL TO PATIENT CARE
10.1 VISITORS NON-ESSENTIAL TO PATIENT CARE
Aim
To maintain privacy and dignity for patients, by ensuring only essential staff are present during procedures
Scope
Medical, nursing, health care assistant, support workers, visitors
Method
Overall responsibility for implementation of this policy resides with the Clinical Lead or his/her deputy. Day to day the policy will be enforced by the senior nurse on duty.
• Prior to visit, visitors are required to book a time in the unit diary, following discussion with the Clinical Lead.
• Ideally, there should be no more than one visitor at any time.
• Visitors are required to sign in and out of the visitors’ book.
• Theatre wear should be worn at all times for infection control purposes.
• All visitors are to wear identification, which should be visible at all times.
• Patient details are confidential. Only those with direct care responsibilities for the patient are to have access to patient notes.
• All visitors must bide by the ionising radiation regulations and are not allowed beyond lead screens when radiation is in use.
• The teaching and education of visitors is actively encouraged, but will be carried out at the discretion of the nurse in charge.
References
ACORN (1998) Visitors to Operating Suite. Guidelines & Policy Statement. ACORN Australia Ltd
Radiation Protection HSE 1985
Ionising Radiation Regulations. SI (1985) No 1333 London
10.2 COMPANY REPRESENTATIVES VISTING THE DEPARTMENT
Aim
The aim of this policy is to put the relationship between the staff at the University Hospital Aintree and its current and potential suppliers on a sound and professional footing.
Scope
All company representatives
Method
• All company representatives wishing to visit the department must discuss this with the unit manager. In addition, discussion with the attending consultant is required for attendance of laboratory procedures.
• If the consultant agrees to the representative visiting the department, they should book a session into the unit via the secretarial staff on 01244 365285
• For new devices/equipment for possible use/trial in the catheter lab should be discussed with the Lead Consultant, Attending Consultant, and Unit Manager prior to visit and confirmed (requested and approved) in writing
• There should ideally be no more than 1 visitor to the unit at any one time
• Visitors identification must be worn at all times
• Company representatives must sign in & out of the visitors book & fill in all relevant information
• Visitors may be asked to leave the unit at any time, by any member of staff where patient care may be compromised or their presence impinges on the work environment
• All patient information verbal or written is strictly confidential. Company representatives are not permitted access to patients notes / files
• Consent for visitors to be present during procedures is covered in the information leaflet at the time of consent. Any objections are to be raised by the patient prior to the commencement of their case
• Company Representatives may arrange product and information sessions outside of the patient environment after discussion with the Unit Manager.
References
ACORN (1998) Visitors to Operating Suite Guidelines & policy statement
ACON Australia Ltd
Radiation Protection HSE 1985
Ionising Radiation Regulations SI (1985) No 1333 London
SECTION 11
ENVIRONMENTAL
11.1 POLICY FOR CHECKING DEFIBRILLATOR
11.2 ENVIRONMENTAL SAFETY CHECKS
11.3 REPORTING FAULTS/MALFUNCTIONING EQUIPMENT
11.4 MANUAL HANDLING
11.5 RISK ASSESSMENT
SAFE KEEPING OF CONTROLLED DRUG CUPBOARD KEYS
11.1 POLICY FOR CHECKING DEFIBRILLATOR
Introduction.
The aim of this policy is to ensure the defibrillators throughout the Cardiology Directorate are at all times safe and ready for immediate use. A senior member of staff from each Ward / Department should be nominated to be responsible for: -
• Organising maintenance and checking of defibrillator
• Accurate records of maintenance and daily checks
• Cascade teaching to other staff on correct checking and maintenance
Please note the Manufacturer’s Manual for individual defibrillators should be consulted and instructions followed in order to maintain validity of warranty.
Procedure for testing Defibrillator.
1. Defibrillators should be checked each shift and after each use. A signed record of this check should be kept.
2. The defibrillator should be clean and free of fluid spills – nothing should be stored on the defibrillator. There must at all times be 2 packs of defibrillator pads available – check expiry dates. Cables should be checked for breaks.
3. Biomedical Engineering must be informed if the test is failed or impedance is > 5 ( Tel No 3498 ).
4. Correct technique for checking the defibrillator should be incorporated into Statutory CPR Training.
5. Biomedical Engineering should routinely check and clean the defibrillator as necessary or every 12 months.
6. Ensure when not in use the defibrillator is plugged in and charging.
11.2 ENVIRONMENTAL/SAFETY CHECKS
Aim
To ensure all staff contribute to the maintenance and promotion of a safe and efficient working atmosphere.
Scope
All staff
Method
• Locate and familiarise self with all Trust Policies, such as Health and Safety at Work, Infection Control policies, Incident Reporting, Fire and Safety policies, Sharps Disposal Policy, Manual Handling and Risk Assessment/Management.
• Familiarise self with equipment e.g. arrest trolley and defibrillator, medical gases cylinders, suction equipment, IABP, glucometer.
• Meet minimal mandatory training requirements.
• Promptly report faulty equipment.
• Perform daily safety checks and complete the appropriate documentation
o Fire
o Crash Trolley/Emergency drugs
o Medical Gases
o Suction
o IABP
o Drugs
o Glucometer
o Stock fluids
Avoid any action that may be in any way detrimental to the health and safety of any person entering the Cardiac Cath Lab.
References:
Health and Safety at work Act:1974{s3, s7}
Countess of Chester Hospital:
Health and Safety:
• COSHH guidelines
• Sharps Disposal Policy
• Manual Handling Loads policy
• Fire Safety Policy
• Risk Assessment Guidelines
• Risk Management Policy
Incident reporting Policy
Fire Precautions Policy
11.3 REPORTING FAULTS/MALFUNCTIONING EQUIPMENT
Aim
To ensure all staff are able to identify and report faults, contributing to the
maintenance of the lab, and prevention of injury to members of staff or patients.
Scope
All staff working in the Cardiac Catheterisation Laboratory
Method
• In the event of a fault occurring or equipment failing, the equipment will be withdrawn from use immediately and placed in a safe area.
• If unable to move equipment to safe area, staff will apply a” DO NOT USE FAULTY” label on the equipment, so as to warn other staff or patients of potential danger.
• The details of the fault/malfunctioning will be recorded in the “Fault “ register, which will be provided.
• Maintenance Requisition/ Biomedical engineering slip will be completed and relevant dept informed of the nature of the fault, and the urgency status of the repair.
• The staff member completing the record will inform a senior member of the nursing staff of the fault/malfunction, and of any action taken.
• Senior member of staff will follow up the request and ensure appropriate action taken to minimise risk to either staff or patients.
References
Health and safety at work Act: 1974{s3,s7}
Countess of Chester:
Risk Assessment Guidelines
Health and Safety Polices
Reporting Equipment Policy
5 MANUAL HANDLING OF LOADS
Aim
To ensure the safe handling of loads, and the correct procedures are followed, reducing/eliminating the risk of injury to staff.
Definition : ”Manual Handling means any transporting or supporting of a load by hand or bodily force. This includes tasks that involve pushing pulling carrying, holding or lifting loads.”
Scope
Registered nurses, technicians, medical staff, clerical staff.
Method
• Avoid manual handling if there is a risk of injury.
• Carry out a formal risk assessment if manual handling cannot be avoided.
• Introduce control measures to reduce the risk of injury
• Provide information on the load.
• Review the assessment, check the improvements have worked.
Staff will have regular Manual Handling Updates via the Manual Handling Cascader.
Staff are to be familiar with The Manual Handling Operations Regulations 1992 guidelines as outlined in the UHA Manual Handling of Loads Policy document.
References
Countess of Chester:
Manual Handling Policy
Manual Handling Operations Regulations 1992
11.5 RISK ASSESSMENT
Aim
To maintain a safe environment, whilst identifying all potential risks to patients, staff and visitors.
Scope
All staff
Method
Identification of potential risks to the laboratory, patients, staff and visitors will be undertaken through a systemic approach to;
• Risk assessment
• Evaluation of risk
• Elimination of risk
• Reduction in risk
➢ The Clinical Leader for the Cardiac Catheterisation laboratory will perform an annual unit risk assessment.
➢ Staff are to be encouraged that it is essential to report faulty equipment that may affect/be harmful to the operation of the cardiac catheterisation laboratory, the patients, staff and visitors.
➢ Staff are to be encouraged to ensure that faults that have been reported are followed up and essential repairs have been carried out to prior to the equipment being used again.
➢ A system that is pro-active and positive in nature for the reporting of errors, near misses and incidents so that learning and improvement is the outcome will be in place.
References
Countess of Chester Hospital:
Risk Management Policy
Manual Handling Policy
..uk/doh/rm5.nsf/AdminDocs/CAStandards
11.6 SAFE KEEPING OF CONTROLLED DRUG CUPBOARD KEYS
Aim
To ensure the safe keeping of controlled drugs keys at all times
Scope
All qualified nursing staff
Method
• The CD keys for the cath lab and the day case area will be held by a registered nurse in those areas. These keys will be kept separate from keys to non controlled drug cupboards.
• When the lab and day case area close for the day, both sets of keys will be taken to CCU, where a record book will be kept.
• Two nurses (1 lab nurse & 1 CCU nurse) will sign & date book when keys have been locked in controlled drug cupboard.
• The same procedure will be followed the next morning for the collection of both sets of keys from CCU.
References
Medicines Section 2a Edge Hill School of Health Studies
Guidelines and Principles to Practice
Administration of Drugs andGuidelines for the Safe and Secure Handling of Medicines: Report to the Secretary of State for Social Services:Chaired :Professor R B Duthie(1988)
SECTION 12
STAFF MANAGEMENT
12.1 ANNUAL LEAVE
12.2 CONDUCTING A STAFF MEETING
12.3 SICKNESS AND ABSENCE PROCEDURE
12.1 ANNUAL LEAVE PROTOCOL
Aim
Ensure suitable staffing of department
Scope
All nursing staff
Method
• No more than one person of each grade should be on annual leave at the same time.
• Only two people to be on annual leave at the same time.
• Annual leave to be booked at least two weeks in advance.
• Requests should be written in the diary.
• Any annual leave over two weeks will need to be put in writing, and discussed with the manager.
Annual leave at short notice will be at the discretion of the manager and depend on workload and staffing levels.
• Any requests not covered by the above will be considered, depending on the circumstances.
• Any leave to be carried over to following year must be discussed with manager and be in line with Trust policy
References
Countess of Chester Hospital
Human Resource Policies
Leave
12.2 CONDUCTING A STAFF MEETING
Aim
To aid effective communication within the multidisciplinary team.
Scope
All Cardiac catheter Suite staff.
Method:
A nominated chairperson will schedule regular, planned meetings:
• These meetings will have a set agenda.
• They will be organised and planned, with advance notice given to staff.
• They will be an open forum, promoting two way communication.
• They will be available to all staff.
• Terms of Reference for any forum will be distributed to members.
• Minutes will be drawn up and will be distributed by designated secretary.
References
Westwood F. (2002) Making meetings effective. British Journal of Perioperative Nursing. 12 (1) 39-42
12.3 SICKNESS AND ABSENCE PROCEDURE
Aim
To ensure the Catheter Lab is covered in the event of sickness or absence
Scope
Nurses, Health Care Assistants, Clerical staff
Method
• You will phone the department at 8am to inform of absence
• Speak only to the clinical lead, if available. Otherwise speak to the senior nurse on duty.
• Inform the person in charge the reason & approximate length of absence (this will be kept confidential).
• Do not leave messages with junior staff or switchboard.
• You must ring the department before resuming duty or you will be marked absent & paid accordingly.
• On resuming duty you will have a return to work interview with the person in charge.
• Self-certification and/or GP letters will be sought as per Trust policy.
References
Countess of Chester Hospital
Human Resource Policies
Attendance Management Flow chart
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