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Dorothy Cupich is a staff nurse in the cardiac intermediate care unit at the Hospital of the University of Pennsylvania.
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Although the time the sheaths remained in place after PCI changed, nursing practice remained the same. Connecting a transducer to the arterial sheath requires additional nursing time to set up the heparinized and pressurized flush device. In sharing information with nurses from other institutions and with nurses who had joined our staff, we found that using a transducer and monitoring the arterial sheath are not universal nursing practices.
Little clinical research has been done on management of the vascular access sites after PCI. Juran et al1 studied patterns of nursing practice in the postoperative care of patients undergoing routine PCI. Use of heparin, time of sheath removal, and nursing care related to positioning and mobility of patients and frequency of assessment after PCI were examined. The study did not determine whether the arterial sheaths were monitored before they were removed. Craney et al2 compared 2 methods for maintaining patency of invasive sheaths. In one method, a registered nurse set up an arterial transducer and connected the sheath to a heparinized (500 IU of heparin in 500 mL of isotonic sodium chloride solution) and pressurized flush device. In the other method, the sheath was flushed with a heparin (500 IU) solution, capped, and covered with a sterile occlusive dressing. In both methods, the sheaths were left in place for 24 hours. Patients treated with the 2 methods had no significant differences in bleeding complications, infection, or hematoma formation.
PURPOSE
The purpose of this study was to evaluate whether capping the arterial sheath after PCI increased the occurrence of complications such as bleeding, hematoma, and clot formation. We used evidence-based practice as our model for change. Our goal was to determine if the use of a transducer was necessary to prevent these complications. Could we change our nursing practice without compromising patients’ care?
Rosenberg and Donald3 define evidence-based medicine as the process of "systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions." Health-care providers who use this process ask questions, evaluate the relevant data, and apply the information to change in clinical practice. In evidence-based practice, a clinical question is asked about a specific area of practice.3,4 We posed the following question: Must the arterial sheath be connected to a transducer with a heparinized and pressurized flush device to prevent bleeding, hematoma, clot formation, or other adverse events?
METHODS
We searched the literature for relevant clinical articles, and considered the results of Craney et al,2 who found that use of a heparinized and pressurized flush device was as effective as use of a capped sheath with a sterile occlusive dressing. We also obtained anecdotal information on current practice standards for care of patients after PCIs from 4 hospitals in the Pennsylvania region, via the Internet and list-servers. Some institutions continued to monitor the arterial sheath as we did, and some capped the arterial sheath. All the information was critically appraised for its validity and usefulness. We decided to implement a practice change in our monitoring of arterial sheaths after PCIs. We then evaluated whether our change in practice produced the expected outcomes: no bleeding complications, no hematomas, and no clot formation.
A meeting was held with physicians and nurses who worked in the cardiac catheterization laboratory, the cardiac care unit, and the cardiac intermediate care unit. A practice change was proposed: patients’ arterial sheaths would no longer be connected to a transducer with a heparinized and pressurized flush device during the 2 to 4 hours after PCIs before sheath removal. Instead, the sheaths would be fast flushed for 3 to 5 seconds with 500 IU of heparin in a pressurized 500-mL bag of isotonic sodium chloride solution and then capped.
As shown in Table 1
, the arterial sheaths would be capped in patients who were in stable condition without complications after PCI, primarily patients who were hospitalized with myocardial infarction or because they had unstable angina. The patients would have frequent monitoring of vital signs by a noninvasive blood pressure monitor. Patients in unstable condition, operationally defined as those who required placement of an intra-aortic balloon pump or inotropic infusions or were in cardiogenic shock, would have the arterial sheath connected to a transducer for blood pressure monitoring. The variance tool was revised to monitor the practice change. We used the tool to evaluate the effectiveness of this change in practice and to monitor for any adverse events associated with the new practice. Because this change in practice was evidence based, consent from the patients who were involved was not obtained. Table 2 shows the revised outcome measures for patients who had PCI.
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From July 1, 1999, through December 31, 1999, a total of 352 patients underwent PCI. Variance forms were completed for 254 of the 352 patients. However, our updated variance form was used for only 147 patients. Among those 147 patients, 120 had the arterial sheaths capped, 6 had the arterial sheaths connected to a transducer, and 21 had missing data (Figure). Of the 147 patients with updated variance forms, 109 (74%) had no reported complications. Nurses reported difficulty withdrawing blood from the arterial sheath in 3 patients (2%). Once the individual catheters were pulled back a couple of centimeters, blood was withdrawn, establishing patency. Issues not outlined on our data collection form were involved in the care of 6 patients (4%). Evaluation forms of the remaining 29 patients (20%) had missing data.
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Staff satisfaction was assessed via a questionnaire distributed to 54 nurses in the cardiac and cardiac intermediate care units. Questionnaires were returned from 27 nurses, a 50% return rate. Of those who responded, 100% reported satisfaction with the new practice. The major reason for satisfaction was time saved in not setting up the heparinized pressure bag and transducer. Other reasons cited were less equipment to manage and savings in unit supply costs. The cost of each transducer is approximately $10.
When asked what they liked least, 4 nurses responded that they missed having a continuous blood pressure reading on the monitor. Two nurses responded that they missed not being able to have immediate knowledge of unstable arterial blood pressure, an indication of possible internal bleeding. Concerns listed once by nurses included thrombus formation, no audible alarm for disconnection of the catheter, and no obvious indication on the monitor that a patient has a sheath in place when a nurse or support staff personnel might be responding to the patient’s call light.
In addition to the savings in nursing time, we found a savings in unit supply costs, specifically, the costs for pressure tubing, transducers, vials of heparin solution, syringes, and half-liter bags of isotonic sodium chloride solution. We estimated that the reduction in costs was approximately $6000 to $7000 per year, based on the 700 PCIs performed at our hospital annually.
DISCUSSION
As a result of our evidence-based change in practice, vascular access sheaths are no longer connected to a transducer in patients in stable condition without complications after PCI. The change in practice has resulted in more efficient use of nursing time and a decrease in supply costs, with no increase in complications.
The results of this change have been integrated into the care pathway and nursing practice for these patients. Any patient whose condition is unstable (patients who require placement of an aortic balloon pump, use of inotropic infusions, or invasive blood pressure monitoring or who are in cardiogenic shock) is maintained on arterial monitoring according to the physician’s orders. If the condition of a patient with a capped arterial sheath should become unstable and require invasive blood pressure monitoring, the arterial sheath will be connected to a transducer for monitoring.
Some nurses were concerned about not having a visible blood pressure tracing and audible blood pressure alarm. Care of patients after PCIs continued to include frequent monitoring of vital signs and of the sheath for bleeding complications. In addition, any complications were indicated on the variance form. No major problems related to not having a visible blood pressure tracing and audible blood pressure alarm occurred.
Three steps were key in researching and instituting the ultimately successful practice change. First was the use of an evidence-based practice model and queries of other institutions before the change was introduced. A literature review provided a research article that supported the change; the authors2 of the article found no occurrence of adverse effects in patients when arterial sheaths were capped. Through the Internet and list-servers, other hospitals were queried about their practice. The second key was multidisciplinary collaboration; we had involvement and communication among physicians and nursing staff. The potential change in practice was presented to the nurses as a way to decrease workload while saving on supply costs. Finally, using our revised variance tool to evaluate the change in practice provided information that would alert us to any possible complications associated with the capping of arterial sheaths.
CONCLUSION
Nurses play a vital role in the management of patients after PCIs. Care and removal of the arterial sheath and monitoring of patients’ anticoagulation status are becoming acceptable practices in most inpatient cardiac settings. With the increasing use of potent platelet-inhibiting medications and the associated risk of bleeding complications, time-efficient nursing care becomes even more important in patients’ optimum outcome. As pharmaceutical therapy and invasive technology evolve in the treatment of cardiovascular disease, nurses cannot practice on the basis of assumptions. Nurses must continually evaluate and revise clinical practice on the basis of the results of clinical research. By instituting evidence-based changes in practice, such as capping the arterial sheaths, nurses will be able to provide the best possible care in a rapidly evolving clinical environment.
References
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