Improving the quality of patient care: A nurse’s perspective

Jennifer Freeman RN CCRN

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Overview

• Over the last year we have been working on improving the pre and post cath care throughout UCI.

• Focusing on two areas:– Education to the nursing staff – Improving communication between cath lab and

the units.

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Why?

• Trend of RNs questioning pre procedure medications.

• Questions regarding access site care including radial band management

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Is there a problem?

• To assess if there was a true need for education, surveys were sent to nurses throughout UCI that care for our patients ….

• Opportunity validated

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Pre Education Survey Results

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National Cardiology Database Registry: NCDR Data

• UCIs Hematoma Rate is above the 50th Percentile • Many factors contribute:

– Access techniques during the procedure– Reporting- ? Accuracy of reporting to the registry– Early identification and treatment- (Nursing care

directly affects)

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NCDR vascular access site injury

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To Qualify for hematoma must be associated with any of the following:1.Hemoglobin drop of >=3g/dL2.Transfusion of whole blood or packed cells3.Procedural intervention/surgery at the bleeding site to reverse/stop or correct

Implementation• In servicing to all nursing units• Communication• Computer based training module (CBT)

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Implementation- In-Service

In servicing to all nursing units– Vascular access site care-

Radial and Femoral– TR band protocol– Hematoma identification and

treatment (proper manual pressure technique)

– Retroperitoneal Bleed identification and interventions

– Medication Overview

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Implementation- Communication

• Improved communication among procedural team– Difficult access/closure– Anything unusual

• Improved communication on handoff – Anticoagulation – Higher risk of bleeding complication– Difficult or Trauma during access

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Implementaion- CBT

• Still to come

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Handout Used for Education

What Medications do I Give and or Hold Prior to cath?• GIVE: All scheduled oral

medications including:– Antiplatelets: Aspirin, Plavix, Effient

• Rational: the effects of ASA & Plavix will not negatively affect our efforts of anticoagulation and/or hemostasis in the cath lab.

– Antihypertensives: ACE, beta blockers, Ca Channel blockers, etc.

• Rational: the blood pressure needs to be controlled adequately during cath lab procedures to decrease stress on the heart and increase coronary blood flow.

• Check with MD: – Low molecular weight

heparin/antithrombin: Lovenox• Rational: we anticoagulate in the lab

with heparin and other agents that affect the ACT (coagulation time). If lovenox is given, there is no direct reversal agent and will affect our true ACT (clotting) levels. The lab needs to know if and when it was last given

– Metformin: usually hold 24 hours pre procedure and 48 hours post procedure or until BUN/CR return to base line• Rational: Metformin can lead to

decreased kidney function in conjunction with contrast dye. Monitor I/O post procedure.

– If pt is on Coumadin,Pradaxa ect., please check with MD for hold parameters.

DO NOT HOLD ANY MEDICATIONS WITHOUT A MD ORDER!!!!!!!

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Evaluation• Vascular access site management responses

improved

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Evaluation

• Medication Management remains an issue– Self-paced CBT learning module will be sent to

all nurses caring for this patient population

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Evaluation

• Hematoma rates improved according to NCDR database

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Summary

• Collaboration is key • Communication and Sharing knowledge is

vital • There is always an opportunity to improve the

quality of care

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QUESTIONS & DISCUSSION

THANK YOU

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