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

1. Improving the quality of patient care: A nurse’s perspective Jennifer Freeman RN CCRN

2. 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.

3. Why? • Trend of RNs questioning pre procedure medications. • Questions regarding access site care including radial band management

4. 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

5. Pre Education Survey Results

6. 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)

7. NCDR vascular access site injury • To Qualify for hematoma must be associated with any of the following: • Hemoglobin drop of >=3g/dL • Transfusion of whole blood or packed cells • Procedural intervention/surgery at the bleeding site to reverse/stop or correct

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

9. 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

10. 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

11. Implementaion- CBT • Still to come

12. Handout Used for Education What Medications do I Give and or Hold Prior to cath? 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. • 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. DO NOT HOLD ANY MEDICATIONS WITHOUT A MD ORDER!!!!!!!

13. Evaluation • Vascular access site management responses improved

14. Evaluation • Medication Management remains an issue • Self-paced CBT learning module will be sent to all nurses caring for this patient population

15. Evaluation • Hematoma rates improved according to NCDR database

16. Summary • Collaboration is key • Communication and Sharing knowledge is vital • There is always an opportunity to improve the quality of care

17. THANK YOU Questions & Discussion