Implementation of radial arterial access for cardiac interventions: a strong case for quality assurance protocols by the nursing staff.

BACKGROUND: Radial arterial access is becoming increasingly popular for coronary angiography and angioplasty. The technique is, however, more demanding than femoral arterial access, and hemostasis is not care-free. A quality assurance program was run by our nursing staff, with patient follow-up, to monitor radial arterial access implementation in our laboratory. METHOD: In 973 consecutive patients, both a hydrophilic sheath and an inflatable bandage for hemostasis were used. Bandage inflation volume and time were both reduced through subsequent data audit and protocol changes (A = 175 patients; B = 297; C = 501). RESULTS: An increase was achieved in the percentage of patients with neither loss of radial pulse nor hematoma of any size (A = 81.3%, B = 90.9%, C = 92.2%, P < 0.001), and no discomfort at all (A = 44.2%, B = 75.1%, C = 89.3%, P < 0.001). Follow-up was available for 965 patients (99%), and in 956, the access site could be re-inspected at least once. There were no vascular complications. Overall, the radial artery pulse was absent at latest follow-up in 0.6% of cases (95% confidence interval 0.21-1.05%). In 460 consecutive patients with complete assessment in protocol C, a palpable arterial pulse was absent in 5% of cases at about 20 h after hemostasis. Barbeau's test was positive in 26.5% of patients (95% confidence interval 22.5-30.6%). They had a significantly lower body weight, a lower systolic blood pressure at hemostasis, and a higher bandage inflation volume; a hematoma of any size and the report of any discomfort were also more frequent. Barbeau's test returned to normal in 30% of them 3-60 days later. CONCLUSION: Our nurse-led quality assurance program helped us in reducing minor vascular sequelae and improving patient comfort after radial access. Early occlusion of the radial artery as detected by pulse oxymeter is frequent, often reversible, and may be mostly related to trauma/occlusion of the artery during hemostasis.

Vascular access complications after cardiac catheterisation: a nurse-led quality assurance program.

BACKGROUND: Vascular access complications may be a cause of discomfort, prolonged hospital stay, and impaired outcomes in patients undergoing cardiac catheterisation. AIMS: To assess vascular access complication in our patients with/without the use of closure devices as a first local benchmark for subsequent quality improvement. METHODS: A nurse-led single-centre prospective survey of all vascular access complications in consecutive patients submitted to cardiac catheterisation during 4 months. RESULTS: The radial and femoral access were used in 78 (14%) and 470 (83%), respectively, of 564 procedures, and a closure device was used in 136 of the latter. A haematoma (any size) was isolated and uneventful in 9.6% of cases. More severe complications (haemoglobin loss >2 g, need for blood transfusion or vascular repair) occurred in 1.2% of cases, namely: in none of the procedures with radial access, and in 0.4% and 2.4% of femoral diagnostic and interventional coronary procedures, respectively. During complicated (n=40) vs uncomplicated (n=172) transfemoral interventions, the activated coagulation time was 309+/-83 vs 271+/-71 s (p=0.004), but the use of closure devices was similar. CONCLUSION: Severe vascular access complications in our patients were fewer than in most reports, and virtually absent in radial procedures. Vigorous anticoagulation was associated with increased complications in our patients, but closure devices were not. A new policy including both the use of the radial access whenever possible, and a less aggressive anticoagulation regimen during transfemoral interventions will be tested.

[How informed is patient consent to interventional cardiology procedures. A quality assurance survey by the nurses]. / Quanto è informato il consenso dei pazienti alle procedure di emodinamica? Una survey di quality assurance degli infermieri.

BACKGROUND: A new patient consent form has recently been adopted in our Institution, with a uniformly written text to be used for all medical procedures and interventions. It is accompanied by a separate information sheet, explaining both the details and the risk/benefit profile for each specific procedure/intervention. It should be given to the patient as early as possible after the procedure/intervention is planned. Testing the effectiveness of this new information policy has been included into the quality assurance goals by our nursing staff. METHODS: From mid April to mid June 2004 a questionnaire was administered to all patients who had undergone an elective cardiac interventional procedure. The timing, manner and perceived completeness of the information received by patients was investigated by 14 yes/no or multiple choice questions. A goal of <5% deviation from a 100% standard was set for all indicators. RESULTS: Two hundred and thirty-eight valid questionnaires were obtained out of 308 consecutive procedures. Seven patients (3%) refused the questionnaire. The response rate was >90% for each question. Seventy-eight patients (33%) had a history of cardiac interventional procedures. The information sheet had been received before the procedure in 93% of cases, and this had happened in the ward in 58% of cases; the procedure had been performed at least 1 hour after receipt of the information sheet in 83% of cases. Twenty-seven patients (13%) stated they had not read the information sheet, in most cases (92%) because they felt they already knew enough. Among patients who had read the information sheet, 99% deemed it could be easily understood. Difficulties in asking questions were reported by 6% of patients. When questions had been asked, the nursing staff was addressed in 42% of cases, and the answers were rated as clear in 98% of cases. The consent form was not read at all by 13% of patients, due to alleged lack of time, and was not read completely by another 15%; 98% of those who had read it, however, found it was fairly understandable. CONCLUSIONS: The effectiveness of our new patient information policy seems to approach our quality goals, and is liable to further improvement. The nursing staff of the cardiac catheterization unit is involved in the patient information process, and has full competence to study this issue.