Manual Compression vs. Arterial Puncture Closing Devices Following Femoral Cardiac Catheterization

1. Rachel Wilkinson Brenna Johnson Stephanie Ford Michelle Giddens Manual Compression vs. Arterial Puncture Closing Devices Following Femoral Cardiac Catheterization  (introduce your name last): I have had experience dealing with this topic because I have worked in interventional cardiac services. Interventional cardiac services deals with patients pre and post cardiac catheterization. (introduce your name last): I have had experience dealing with this topic because I have worked in interventional cardiac services. Interventional cardiac services deals with patients pre and post cardiac catheterization.

2. Discussion Identify the problem Review of literature Recommended Protocol/Procedure/Intervention Suggestions for further study Today we’ll be discussing why we believe the use of APCDs should be implemented vs. the use of manual compression following cardiac catheterization. We will briefly discuss four main focus areas which include: indentifying the problem, review of literature, recommendations, and suggestions for further study. Today we’ll be discussing why we believe the use of APCDs should be implemented vs. the use of manual compression following cardiac catheterization. We will briefly discuss four main focus areas which include: indentifying the problem, review of literature, recommendations, and suggestions for further study.

3. Identifying the Problem Coronary Artery Disease is the leading cause of death in the United States (Centers for Disease Control And Prevention, 2004). Cardiac catheterization is one of the most common procedures in the United States (Harper, 2007). 1.5 million will receive a cardiac catheterization this year In 2%-10% of cases, vascular complications will occur Oklahoma is ranked 8th in the nation for being one of the “fattest” states. 65.1% of Oklahoma’s population falls in to the category of obese or overweight (Calorielab,2008). In identifying the problem we discovered that: Coronary Artery Disease is the leading cause of death in the United States. Heart disease is the leading cause of death in Oklahoma, accounting for over 30% of the state’s death. Cardiac catheterization is one of the most common procedures in the United States. In fact, 1.5 million people will receive a cardiac catheterization procedure this year. Of these 1.5 million persons, 2-10% will experience vascular complications. This number of persons receiving cardiac catheterization is expected to rise to 3 million by the year 2010. Oklahoma is ranked 8th in the nation for being one of the “fattest” states. 65.1% of Oklahoma’s population falls in to the category of obese or overweight. This is important to note because the risk for heart attack and disease increase dramatically with obesity. In identifying the problem we discovered that: Coronary Artery Disease is the leading cause of death in the United States. Heart disease is the leading cause of death in Oklahoma, accounting for over 30% of the state’s death. Cardiac catheterization is one of the most common procedures in the United States. In fact, 1.5 million people will receive a cardiac catheterization procedure this year. Of these 1.5 million persons, 2-10% will experience vascular complications. This number of persons receiving cardiac catheterization is expected to rise to 3 million by the year 2010. Oklahoma is ranked 8th in the nation for being one of the “fattest” states. 65.1% of Oklahoma’s population falls in to the category of obese or overweight. This is important to note because the risk for heart attack and disease increase dramatically with obesity.

4. PICO Question Which arterial closure method is safer, more effective, and causes less vascular complications following cardiac catheterization in adults—the use of manual compression or the use of arterial puncture closing devices (APCDs)? PICO Question: Which arterial closure method is safer, more effective, and causes less vascular complications following cardiac catheterization in adults—the use of manual compression or the use of arterial puncture closing devices (APCDs)? Arterial puncture closing devices are devices inserted during femoral cardiac catheterization by the physician in order to achieve hemostasis. A few examples of these devices include collagen plugs and suture devices. Standard manual compression refers to the pressure that the nurse applies by hand to the femoral artery to achieve hemostasis. This typically takes 15-20 minutes of pressure to the femoral site, although this can differ amongst patients depending upon the patients medical condition and the medications the patient is currently receiving. PICO Question: Which arterial closure method is safer, more effective, and causes less vascular complications following cardiac catheterization in adults—the use of manual compression or the use of arterial puncture closing devices (APCDs)? Arterial puncture closing devices are devices inserted during femoral cardiac catheterization by the physician in order to achieve hemostasis. A few examples of these devices include collagen plugs and suture devices. Standard manual compression refers to the pressure that the nurse applies by hand to the femoral artery to achieve hemostasis. This typically takes 15-20 minutes of pressure to the femoral site, although this can differ amongst patients depending upon the patients medical condition and the medications the patient is currently receiving.

5. Identifying the Problem Continued PICO Population: Adult patients18 and older receiving femoral cardiac catheterization including all genders and ethnicities Intervention: Arterial puncture closure devices (APCDs) to achieve hemostasis Comparison: Manual pressure to achieve hemostasis Outcome: Decrease vascular complications In identifying the problem we will be discussing the population, intervention, comparison and outcomes. Population: Adult patients18 and older receiving femoral cardiac catheterization including all genders and ethnicities Intervention: Arterial puncture closure devices (APCDs) to achieve hemostasis. We did not limit our intervention device to one particular APCD. Our research included all APCDs whether they be collagen plugs or suture devices. Some brand names of APCDs include: AngioSeal, VasoSeal, Mynx, etc. Comparison: Manual pressure to achieve hemostasis Outcome:The outcome of our research aimed to identify which method of closure would lead to a decrease in vascular complications. A few examples of vascular complications would be: hematomas, pseudoaneurysms, arteriovenous fistulas, limb ischemia and retroperitoneal hemorrhage. Stephanie Ford will now be discussing the review of literatureIn identifying the problem we will be discussing the population, intervention, comparison and outcomes. Population: Adult patients18 and older receiving femoral cardiac catheterization including all genders and ethnicities Intervention: Arterial puncture closure devices (APCDs) to achieve hemostasis. We did not limit our intervention device to one particular APCD. Our research included all APCDs whether they be collagen plugs or suture devices. Some brand names of APCDs include: AngioSeal, VasoSeal, Mynx, etc. Comparison: Manual pressure to achieve hemostasis Outcome:The outcome of our research aimed to identify which method of closure would lead to a decrease in vascular complications. A few examples of vascular complications would be: hematomas, pseudoaneurysms, arteriovenous fistulas, limb ischemia and retroperitoneal hemorrhage. Stephanie Ford will now be discussing the review of literature

6. Review of Literature Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis (Koreny et al., 2004). Systematic review and meta-analysis consisting of 30 randomized controlled trials Measured risk of acquiring hematomas, bleeding, developing an arteriovenous fistula, and pseudoaneurysm when using APCDs Manual compression was determined to be the best way to prevent complications following cardiac catheterization This article consisted of thirty randomized control trials. When comparing APCDs to manual compression, the articles measured the relative risk of a patient may acquire such as: a hematoma, bleeding, developing an arteriovenous fistula, and a pseudoaneurysm at the puncture site. Manual compression was determined as the best way to prevent complications following cardiac catheterization. However, there were some negative aspects of this research study. First, only two studies out of the thirty randomized controlled trials used blinded outcome assessments, intention-to-treat analysis, and allocation concealment which are all significant to increase a study’s reliability. Also, the researchers of this article identified the studies they found on this topic as having “low methodological reporting quality.” In addition, the studies used in this systematic review consisted of the earliest versions of APCDs, therefore, more effective devices may have been created from the time when this review was conducted. Overall, this article recommended the use of standard manual compression because the authors determined that patients have a higher risk of vascular complications following the use of APCDs. This article consisted of thirty randomized control trials. When comparing APCDs to manual compression, the articles measured the relative risk of a patient may acquire such as: a hematoma, bleeding, developing an arteriovenous fistula, and a pseudoaneurysm at the puncture site. Manual compression was determined as the best way to prevent complications following cardiac catheterization. However, there were some negative aspects of this research study. First, only two studies out of the thirty randomized controlled trials used blinded outcome assessments, intention-to-treat analysis, and allocation concealment which are all significant to increase a study’s reliability. Also, the researchers of this article identified the studies they found on this topic as having “low methodological reporting quality.” In addition, the studies used in this systematic review consisted of the earliest versions of APCDs, therefore, more effective devices may have been created from the time when this review was conducted. Overall, this article recommended the use of standard manual compression because the authors determined that patients have a higher risk of vascular complications following the use of APCDs.

7. Review of Literature Continued A propensity analysis of the risk of vascular complications after cardiac catheterization procedures with the use of vascular closure devices (Nipun, Matheny, & Sepke, 2006). Single study comparing manual compression to the use of APCDs and the complications associated with each after cardiac catheterization The results revealed that there was a 58% reduction in the risk of vascular complication when APCDs were used after diagnostic cardiac catheterization as opposed to using manual compression This research article compared manual compression to the use of APCDs and the complications associated with each after cardiac catheterization. This study included about 13,000 patients from a registry at Brigham and Women’s Hospital. The results revealed that there was a 58% reduction in the risk of vascular complication when APCDs were used after diagnostic cardiac catheterization as opposed to using manual compression. There was a significantly greater risk for patients to experience a hematoma or pseudoaneurysm when manual compression was used. However, as with every research article, it is important to identify its flaws. For example, this research article was conducted at one single place. Therefore, the generalizability of this article can be limited. Overall, this study recommended the use of APCDs over the use of standard manual compression. This research article compared manual compression to the use of APCDs and the complications associated with each after cardiac catheterization. This study included about 13,000 patients from a registry at Brigham and Women’s Hospital. The results revealed that there was a 58% reduction in the risk of vascular complication when APCDs were used after diagnostic cardiac catheterization as opposed to using manual compression. There was a significantly greater risk for patients to experience a hematoma or pseudoaneurysm when manual compression was used. However, as with every research article, it is important to identify its flaws. For example, this research article was conducted at one single place. Therefore, the generalizability of this article can be limited. Overall, this study recommended the use of APCDs over the use of standard manual compression.

8. Review of Literature Continued Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: A meta-analysis (Nikolsky et al., 2004). Systematic review and meta-analysis consisting of 30 studies including 37,066 patients comparing the vascular complications that result from either manual compression or the use of APCDs after cardiac catheterization This study concluded that there was no significant difference in vascular complications when an APCD was used compared to manual compression after femoral cardiac catheterization This article compared the vascular complications that result from either manual compression or the use of APCDs after cardiac catheterization. This research article was a meta-analysis consisting of 30 studies including about 37, 0000 patients. The authors of this article concluded that there was no significant difference in vascular complications when an APCD was used compared to manual compression after femoral cardiac catheterization. Most of the studies examined were made up of predominately male patients. In other words, more studies may be needed before the same results concluded in this article may be applied to women. Overall, this study recommended the use of APCDs over the use of standard manual compression. This article compared the vascular complications that result from either manual compression or the use of APCDs after cardiac catheterization. This research article was a meta-analysis consisting of 30 studies including about 37, 0000 patients. The authors of this article concluded that there was no significant difference in vascular complications when an APCD was used compared to manual compression after femoral cardiac catheterization. Most of the studies examined were made up of predominately male patients. In other words, more studies may be needed before the same results concluded in this article may be applied to women. Overall, this study recommended the use of APCDs over the use of standard manual compression.

9. Review of Literature Continued Vascular complications with newer generations of angioseal vascular closure devices (Applegate et al., 2006). A single study that compared newer generations of a particular type of APCD called Angioseal to manual compression and older generations of Angioseals after cardiac catheterization The results in this study concluded that the older and newer generations of Angioseal proved to have similar or lower vascular complications than that of manual compression This study compared older and newer generations of a particular type of APCD called Angioseal to manual compression after femoral cardiac catheterization. This single study consisted of around 4,000 patients who received manual compression and 4,000 patients who received either the older or newer generation of Angioseal. The limitations of this study include the fact that the patients all came from a single-center. Overall, this study recommended the use of APCDs over the use of standard manual compression. This study compared older and newer generations of a particular type of APCD called Angioseal to manual compression after femoral cardiac catheterization. This single study consisted of around 4,000 patients who received manual compression and 4,000 patients who received either the older or newer generation of Angioseal. The limitations of this study include the fact that the patients all came from a single-center. Overall, this study recommended the use of APCDs over the use of standard manual compression.

10. Review of Literature Continued Risk of local adverse events following cardiac catheterization by hemostasis device use and gender (Tarvis, et al., 2004). Single study that compared complications following the use of two types of hemostasis devices (sutures and collagen plugs) to manual compression Complication rates were assessed by gender Complications were less common in patients who used suture devices or collagen plugs following diagnostic cardiac catheterization than those who used manual compression Complications were more frequent in females than in males due to smaller vessel size and/or hormonal differences In this study complications following the use of two types of hemostasis devices (sutures and collagen plugs) were compared to manual compression. The rates to these complications were assessed by gender. According to the results, complications were less common in patients who used suture devices or collagen plugs following diagnostic cardiac catheterization than those who used manual compression. In addition, complications were more frequent in females than in males due to smaller vessel size and/or hormonal differences. This study concluded that the use of sutures and collagen plugs were safe and effective. Limitations to this study include: Most of the patients who underwent cardiac catheterization had severe coexisting cardiovascular problems which indicate they were at high risk for complications. Overall, this study recommended the use of APCDs over the use of standard manual compression. In the following slide, these same authors performed a follow-up study to this research article. In this study complications following the use of two types of hemostasis devices (sutures and collagen plugs) were compared to manual compression. The rates to these complications were assessed by gender. According to the results, complications were less common in patients who used suture devices or collagen plugs following diagnostic cardiac catheterization than those who used manual compression. In addition, complications were more frequent in females than in males due to smaller vessel size and/or hormonal differences. This study concluded that the use of sutures and collagen plugs were safe and effective. Limitations to this study include: Most of the patients who underwent cardiac catheterization had severe coexisting cardiovascular problems which indicate they were at high risk for complications. Overall, this study recommended the use of APCDs over the use of standard manual compression. In the following slide, these same authors performed a follow-up study to this research article.

11. Review of Literature Continued Risk of Local Adverse Events following Cardiac Catheterization by Hemostasis Device Use -- Phase II (Tavris et al., 2005). Single study that assessed the risks of vascular complications by the type of APCD used compared to manual compression The results of this article revealed that vascular complications were similar between most APCDs and manual compression after cardiac catheterization Women were at twice the risk for any vascular complication compared to men This single study assessed the risks of vascular complications by the type of APCD used to manual compression. This study included around 14,000 patients from 59 institutions. The results of this article revealed that vascular complications were similar between most APCDs and manual compression after cardiac catheterization. Gender was also assessed in this research article and found that women were at twice the risk for any vascular complication compared to men. The limitations in this research article include: The fact that the patients were nonrandomized and there was little follow up which means that most adverse events like hemorrhaging after discharge were not captured in this study. Overall, this study recommended the use of APCDs over the use of standard manual compression. This single study assessed the risks of vascular complications by the type of APCD used to manual compression. This study included around 14,000 patients from 59 institutions. The results of this article revealed that vascular complications were similar between most APCDs and manual compression after cardiac catheterization. Gender was also assessed in this research article and found that women were at twice the risk for any vascular complication compared to men. The limitations in this research article include: The fact that the patients were nonrandomized and there was little follow up which means that most adverse events like hemorrhaging after discharge were not captured in this study. Overall, this study recommended the use of APCDs over the use of standard manual compression.

12. Review of Literature Continued Predictors of Vascular Complications Post Diagnostic Cardiac Catheterization and Percutaneous Coronary Interventions (Dumont, C. J., Keeling, A. W., Bourguignon, C., Sarembock, I. J., & Turner, M.,2006). This article was a retrospective, descriptive and correlational study The population studied consisted of 11,110 patients whose records were retrieved from the Clinical Automated Office Solutions database Results of this study found that vascular complications occurred more often in patients whose age was greater than 70 years, being female, having hypertension, and renal failure - This article was a retrospective, descriptive and correlational study. - The population studied consisted of around 11,000 patients whose records were retrieved from the Clinical Automated Office Solutions database. - Results of this study found that vascular complications occurred more often in patients whose age was greater than 70 years, being female, having hypertension, and renal failure. Some limitations include the fact that this study used a retrospective analysis method. Overall, this study recommended the use of APCDs over the use of standard manual compression. Now, Michelle will discuss the Pros and Cons of manual compression and APCDs. - This article was a retrospective, descriptive and correlational study. - The population studied consisted of around 11,000 patients whose records were retrieved from the Clinical Automated Office Solutions database. - Results of this study found that vascular complications occurred more often in patients whose age was greater than 70 years, being female, having hypertension, and renal failure. Some limitations include the fact that this study used a retrospective analysis method. Overall, this study recommended the use of APCDs over the use of standard manual compression. Now, Michelle will discuss the Pros and Cons of manual compression and APCDs.

13. Review of Literature: Manual Compression Pros Easy to learn Safe and Effective No requirement for special equipment Cons Painful Prolonged mean time to achieve hemostasis (15-20 minutes) Prolonged time to ambulation (4-6 hours) Vascular complications Nurse arm and hand fatigue Longer hospital stay Pros: Some of the Pros include that it is: Easy to learn Safe and Effective No requirement for special equipment Manual compression has been the standard of care since the 1950s, therefore it has been proven to be safe and effective. Cons: Some of the Cons include that it is: Painful Prolonged mean time to achieve hemostasis (15-20 minutes) Prolonged time to ambulation (4-6 hours) Vascular complications Nurse arm and hand fatigue Longer hospital stay Longer hospital stay thus more costly for the patient. Although manual compression has been found to be safe and effective, complications may occur. Some include: DVTs, hematomas, venous stasis, and pulmonary emboli. In addition, formulation of hematomas and/or thrombuses can occur from inconsistent manual pressure due to arm and hand fatigue. Pros: Some of the Pros include that it is: Easy to learn Safe and Effective No requirement for special equipment Manual compression has been the standard of care since the 1950s, therefore it has been proven to be safe and effective. Cons: Some of the Cons include that it is: Painful Prolonged mean time to achieve hemostasis (15-20 minutes) Prolonged time to ambulation (4-6 hours) Vascular complications Nurse arm and hand fatigue Longer hospital stay Longer hospital stay thus more costly for the patient. Although manual compression has been found to be safe and effective, complications may occur. Some include: DVTs, hematomas, venous stasis, and pulmonary emboli. In addition, formulation of hematomas and/or thrombuses can occur from inconsistent manual pressure due to arm and hand fatigue.

14. Review of Literature: APCDs Pros Shorten the mean time to achieve hemostasis (1.46-8.2 minutes) Shorten the mean time to ambulation (2.2-4.5 hours) Increases patient comfort Decrease hospital stay Safe and Effective Decreases cost to patients Cons Costly ($190-$200) May take up to 20 cases for a physician to become proficient Many nurses have a knowledge deficit in regards to APCDs Vascular complications Pros: Some of the Pros include that it is: Shorten the mean time to achieve hemostasis (1.46-8.2 minutes) Shorten the mean time to ambulation (2.2-4.5 hours) Increases patient comfort Decrease hospital stay Safe and Effective Decreases cost to patients The pros of APCDs include: shorten the mean time to achieve hemostasis, shortens the mean time to ambulation, decrease hospital stay, and increases patient comfort since it decreases the time to ambulation, pain, and length of hospital stay. Because APCDs decrease the length of hospital stay, it decreases the cost to the patient. Cons: Some of the cons include that it is: Costly ($190-$200) May take up to 20 cases for a physician to become proficient Many nurses have a knowledge deficit in regards to APCDs Vascular complications APCDs can be costly if failure of the device or if vascular complications occurs. Many nurses have a knowledge deficiency in APCD care. Vascular complications that can arise from the use of APCDs include: hemotomas, psudoaneurysms, retroperitoneal hemorrhage, peripheral artery thrombosis, infections, etc. Pros: Some of the Pros include that it is: Shorten the mean time to achieve hemostasis (1.46-8.2 minutes) Shorten the mean time to ambulation (2.2-4.5 hours) Increases patient comfort Decrease hospital stay Safe and Effective Decreases cost to patients The pros of APCDs include: shorten the mean time to achieve hemostasis, shortens the mean time to ambulation, decrease hospital stay, and increases patient comfort since it decreases the time to ambulation, pain, and length of hospital stay. Because APCDs decrease the length of hospital stay, it decreases the cost to the patient. Cons: Some of the cons include that it is: Costly ($190-$200) May take up to 20 cases for a physician to become proficient Many nurses have a knowledge deficit in regards to APCDs Vascular complications APCDs can be costly if failure of the device or if vascular complications occurs. Many nurses have a knowledge deficiency in APCD care. Vascular complications that can arise from the use of APCDs include: hemotomas, psudoaneurysms, retroperitoneal hemorrhage, peripheral artery thrombosis, infections, etc.

15. Recommendation Our Recommendation: Nurses to become advocates for APCD use in non-high-risk patients Multidisciplinary approach to develop a high-risk checklist We recommend nurses to begin advocacy upon admission for patients undergoing femoral cardiac catheterization. This will begin with nurses assessing their patients by using a high risk checklist. This checklist will be developed by staff nurses, charge nurses, nursing management and physicians. Nurses will be encouraged to advocate the use of APCDs for their patients unless they are determined to be poor candidates according to the high-risk checklist. The high-risk checklist would include assessing medical conditions such as hypertension, diabetes, renal insufficiency, female gender, age, and previous femoral cardiac catheterization. Currently, in Tulsa area hospitals, no such checklist has been developed. Right now, whether a patient receives an APCD or not, is at the sole discretion of the physician performing the procedure. We recommend nurses to begin advocacy upon admission for patients undergoing femoral cardiac catheterization. This will begin with nurses assessing their patients by using a high risk checklist. This checklist will be developed by staff nurses, charge nurses, nursing management and physicians. Nurses will be encouraged to advocate the use of APCDs for their patients unless they are determined to be poor candidates according to the high-risk checklist. The high-risk checklist would include assessing medical conditions such as hypertension, diabetes, renal insufficiency, female gender, age, and previous femoral cardiac catheterization. Currently, in Tulsa area hospitals, no such checklist has been developed. Right now, whether a patient receives an APCD or not, is at the sole discretion of the physician performing the procedure.

16. Recommendations Continued Our recommendations are based on Kurt Lewin’s Change Theory (Yoder-Wise, 2007): Unfreezing Experiencing the change Refreezing We chose our recommendations based on Kurt Lewin’s change threory. The purpose of Lewin’s change theory is to implement change. Lewin believed that change had three stages: unfreezing, experiencing the change, and refreezing. We chose our recommendations based on Kurt Lewin’s change threory. The purpose of Lewin’s change theory is to implement change. Lewin believed that change had three stages: unfreezing, experiencing the change, and refreezing.

17. Recommendations Continued Unfreezing Awareness Formal Channels High-risk checklist In-services Informal Channels Talking with floor nurses/physicians First, unfreezing refers to the awareness and readiness for the need for change. As a nurse advocate for our patients, we are aware that the use of APCDs shortens the duration of bed rest, hospital stay, increases patient comfort and patient satisfaction. Therefore, our job is to persuade the people who are mostly involved with cardiac catheterization care—physicians and nurses—to implement the use of APCDs if patients are determined to be qualified candidates according to the high risk checklist. Formal: During this change we will use formal channels to construct a high risk checklist. In constructing this list a round table discussion with staff nurses, charge nurses, nursing management and physicians needs to take place. In this discussion they need to address a standard set of orders for standard manual compression and APCDs. Next, in-services need to be provided for all nursing staff on the different types of APCDs and the benefits, risk factors and complications that are likely to occur. Physicians and nurses should be made aware of the risk factors of using APCDs in high-risk patients. Nursing staff should be given the opportunity to attend in-services on the different types of APCDs, and to be given the opportunity to ask questions concerning the devices, safety and management during these times. Physicians should also be encouraged to attend the in-service to help answer nursing questions and also to receive a refresher course on the multiple new generations of APCDs. Informal: We would use informal channels such as talking with the floor nurses and doctors daily about the benefits that APCD use offers for patients undergoing cardiac catheterization. I would stress to the floor nurses the importance of advocating the use of APCDs for their patients. First, unfreezing refers to the awareness and readiness for the need for change. As a nurse advocate for our patients, we are aware that the use of APCDs shortens the duration of bed rest, hospital stay, increases patient comfort and patient satisfaction. Therefore, our job is to persuade the people who are mostly involved with cardiac catheterization care—physicians and nurses—to implement the use of APCDs if patients are determined to be qualified candidates according to the high risk checklist. Formal: During this change we will use formal channels to construct a high risk checklist. In constructing this list a round table discussion with staff nurses, charge nurses, nursing management and physicians needs to take place. In this discussion they need to address a standard set of orders for standard manual compression and APCDs. Next, in-services need to be provided for all nursing staff on the different types of APCDs and the benefits, risk factors and complications that are likely to occur. Physicians and nurses should be made aware of the risk factors of using APCDs in high-risk patients. Nursing staff should be given the opportunity to attend in-services on the different types of APCDs, and to be given the opportunity to ask questions concerning the devices, safety and management during these times. Physicians should also be encouraged to attend the in-service to help answer nursing questions and also to receive a refresher course on the multiple new generations of APCDs. Informal: We would use informal channels such as talking with the floor nurses and doctors daily about the benefits that APCD use offers for patients undergoing cardiac catheterization. I would stress to the floor nurses the importance of advocating the use of APCDs for their patients.

18. Recommendations Continued Experiencing the change Incorporating the use of APCDs Praise nursing staff Encouraging doctors Experiencing the change or solution leads to incorporation of what is new or different into work and interpersonal processes. It’s during this stage that nursing management will praise the floor nurses for utilizing their advocacy role to induce this change. Nurse management will encourage the doctors use of APCDs in patients who are eligible candidates according to the high risk checklist. Experiencing the change or solution leads to incorporation of what is new or different into work and interpersonal processes. It’s during this stage that nursing management will praise the floor nurses for utilizing their advocacy role to induce this change. Nurse management will encourage the doctors use of APCDs in patients who are eligible candidates according to the high risk checklist.

19. Recommendations Continued Refreezing Evaluation Formal Channels Informal Channels Acceptance Determined by surveys given to patients, nurses, and doctors In the refreezing stage, surveys should be conducted to evaluate the effectiveness of in-service teaching, patient, nursing, and doctor satisfaction. These surveys will allow us to determine the acceptance of the change implemented. Outcomes will be evaluated through the use of formal channels. For example, the effectiveness of the in-service teaching needs will be determined by a using an brief examination consisting of 10 questions at the end of the in-service. In 3 months, a brief follow-up examination will be given to the nursing staff to determine the information they retained from the in-service. After receiving a femoral cardiac catheterization, patients should have the opportunity to fill out a questionnaire about their experience. Questions should include: satisfaction with nursing care provided, satisfaction with explanations and treatment from physicians, time to ambulation, appropriate pain management, comfort levels experienced on a scale from one to ten, APCD or manual compression, if they have previously had this procedure done before and their overall satisfaction with their hospital stay. This questionnaire should be sent out three months post procedure and should include questions about any complications they had, if any, if they felt they had been treated in a professional manner, if all their questions had been answered during their stay in the hospital and if their discharge instructions were understandable and easy to follow. The questionnaire will be mailed back to the nurse manager for evaluation. Now, we’re going to evaluate nursing and doctor satisfaction. A survey will be given to nurses and doctors to evaluate their acceptance and implementation of the change. Questions should include asking about their satisfaction with the checklist, how they’re incorporating the change into their practice, and blank sections for providing their comments and concerns. Some informal channels to evaluate the acceptance of the change includes speaking with nurses and patients individually to determine their overall satisfaction with the change. In the refreezing stage, surveys should be conducted to evaluate the effectiveness of in-service teaching, patient, nursing, and doctor satisfaction. These surveys will allow us to determine the acceptance of the change implemented. Outcomes will be evaluated through the use of formal channels. For example, the effectiveness of the in-service teaching needs will be determined by a using an brief examination consisting of 10 questions at the end of the in-service. In 3 months, a brief follow-up examination will be given to the nursing staff to determine the information they retained from the in-service. After receiving a femoral cardiac catheterization, patients should have the opportunity to fill out a questionnaire about their experience. Questions should include: satisfaction with nursing care provided, satisfaction with explanations and treatment from physicians, time to ambulation, appropriate pain management, comfort levels experienced on a scale from one to ten, APCD or manual compression, if they have previously had this procedure done before and their overall satisfaction with their hospital stay. This questionnaire should be sent out three months post procedure and should include questions about any complications they had, if any, if they felt they had been treated in a professional manner, if all their questions had been answered during their stay in the hospital and if their discharge instructions were understandable and easy to follow. The questionnaire will be mailed back to the nurse manager for evaluation. Now, we’re going to evaluate nursing and doctor satisfaction. A survey will be given to nurses and doctors to evaluate their acceptance and implementation of the change. Questions should include asking about their satisfaction with the checklist, how they’re incorporating the change into their practice, and blank sections for providing their comments and concerns. Some informal channels to evaluate the acceptance of the change includes speaking with nurses and patients individually to determine their overall satisfaction with the change.

20. Suggestions Alternative approach to studying the problem Chart trends comparing APCDs to manual compression Another approach to studying the risk of vascular complications would include nurse managers randomly selecting 30 patients every month who have received femoral cardiac catheterization within the past 30 days. The nurse manager will conduct a retrospective chart review comparing the cost, length of stay, and vascular complications for patients receiving APCDs to those receiving standard manual compression. This information will allow the nurse manager to develop a chart showing any trends that might be correlated with the use of APCDs compared to manual compression. These trends can be translated into cost saving measures for the hospital and patients and potentially lead to an increase in patient satisfaction with femoral cardiac catheterization. Another approach to studying the risk of vascular complications would include nurse managers randomly selecting 30 patients every month who have received femoral cardiac catheterization within the past 30 days. The nurse manager will conduct a retrospective chart review comparing the cost, length of stay, and vascular complications for patients receiving APCDs to those receiving standard manual compression. This information will allow the nurse manager to develop a chart showing any trends that might be correlated with the use of APCDs compared to manual compression. These trends can be translated into cost saving measures for the hospital and patients and potentially lead to an increase in patient satisfaction with femoral cardiac catheterization.

21. Suggestions Continued Research Questions: In APCDs, are the efficacy rates the same for using a suture device compared to a collagen plug? Is standard manual compression better than mechanical compression devices such as Femostop and C-clamps? Not all APCDs function in the same way. Some questions we developed were specific to the actual devices themselves. For example, are the efficacy rates the same for using a suture device compared to a collagen plug? Another question that we formed through our research was whether standard manual compression was better than mechanical compression devices such as Femostop and C-clamps. Mechanical compression devices differ from standard manual compression in that devices are used to hold pressure rather than a nurse physically compressing the femoral artery until hemostasis has been achieved. Not all APCDs function in the same way. Some questions we developed were specific to the actual devices themselves. For example, are the efficacy rates the same for using a suture device compared to a collagen plug? Another question that we formed through our research was whether standard manual compression was better than mechanical compression devices such as Femostop and C-clamps. Mechanical compression devices differ from standard manual compression in that devices are used to hold pressure rather than a nurse physically compressing the femoral artery until hemostasis has been achieved.

22. Any Questions?

23. References Applegate, R.J., Sacrinty, M., Kutcher, M.A., Sanjay, G.K., Talal, B.T., Renato, S.M., William, L.C. (2006). Vascular complication with newer generations of angioseal vascular closure devices. Journal of Interventional Cardiology, 19(1), 67-74. Calorielab. (2008). Mississippi is the fattest state for 3rd straight year, Colorado still leanest, D.C. loses weight. Retrieved March 24, 2009, from http://calorielab.com/news/2008/07/02/fattest- states-2008/

24. References Continued Centers For Disease Control And Prevention. (2004). Division for Heart Disease and Stroke Prevention. Retrieved March 28, 2009, from Department of Health and Human Services Web site: http://www.cdc.gov/dhdsp/state_program/ok.htm Dumont, C. J., Keeling, A. W., Bourguignon, C., Sarembock, I. J., & Turner, M. (2006). Predictors of vascular complications post diagnositc cardiac catheterization and percutaneous coronary interventions. Dimensions of Critical Care Nursing, 25(3),137-142. Harper, J. P. (2007). Post-diagnostic cardiac catheterization. Journal For Nurses in Staff Development , 23(6), 271-276.

25. References Continued Koreny, M., Riedmuller, E., Nikfardjam, M., Siostrzonek, P., Mullner, M. (2004). Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: Systematic review and meta-analysis. American Medical Association, 291(3), 350-357. Nikolsky, E., Roxana, M., Amir, H., Aymong, E.D., Mintz, G.S., Lasic, Z., Negoita, M., Fahy, M., Krieger, S., Moussa, I., Moses, J.W., Stone, G.W., Leon, M.B., Pocock, S.J., Dangas, G. (2004). Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: A meta-analysis. Journal of the American College of Cardiology, 44(6), 1200-1209.

26. References Continued Nipun, A., Matheny, M.E., Sepke, C. (2006). A propensity analysis of the risk of vascular complications after cardiac catheterization procedures with the use of vascular closure devices. American Heart Journal, 153(4), 606-611. Tavris, D. R., Dey, S., Albrecht-Gallauresi, B., Brindis, R.G., Shaw, R., Weintraub, W., Mitchel, K. (2005). Risk of local adverse events following cardiac catheterization by hemostasis device use: Phase II. The Journal of Invasive Cardiology, 17(12), 644-650. Tarvis, D. R., Gallauresi, B. A., Rich, S. E., Shaw, R. E., Weintraub, W. S., Brindis, R. G., et al. (2004). Risk of local adverse events following cardiac catheterization by hemostasis device use and gender. The Journal of Invasive Cardiology , 16 (9), 459-464.

27. References Continued Yoder-Wise, P. S. (2007). Leading and managing in nursing (4th ed.). St. Louis: Mosby