Responsibilities in the Catheterization Laboratory

RESPONSIBILITIES IN THE CARDIAC CATHETERIZATION LABORATORY

Everyone in the cardiac catheterization laboratory has the responsibility to enhance patient care and advance the missions of the laboratory. As a fellow in the laboratory, you are the key to good patient care and an important link in the chain of education.

Pre-Catheterization Evaluations

Pre-catheterization evaluations are the responsibility of the fellows assigned to the cardiac catheterization laboratory. You are expected to perform a thorough evaluation of each patient, insure that a patient meets the criteria for catheterization, and assess concurrent medical problems.

After evaluating a patient, you must contact the cardiac catheterization laboratory faculty member assigned to the case (day or night). It is not appropriate to present elective patients in the minutes before the procedure. After a discussion of the approach, write a "pre-catheterization note" in the patient's chart. This note should contain:

• A brief history, with an outline of concurrent medical illnesses and allergies (including contrast);

• A physical examination with peripheral-pulse desription;

• Pertinent laboratory data, including serum potassium and creatinine concentrations, and an ECG interpretation;

• A statement of preliminary diagnosis, rationale for catheterization, expected findings, and informed consent.

In the cath lab, write the necessary equipment and approach on the scheduling board. Make sure that:

• Appropriate laboratory data has been obtained, usually including:

--Complete blood count

--Serum potassium, creatinine, and BUN concentrations

--INR (if applicable)

--Recent electrocardiogram

• You have asked about prior contrast reactions or other allergic reactions.

• Reduced serum potassium or elevated creatinine concentrations have been treated appropriately.

Prior to anigiography, Mucomyst should be given to patients whose serum-creatinine concentrations are > 1.5 mg/dl (diabetic) or > 1.7 mg/dl (non-diabetic).

• Anticoagulants have been adjusted appropriately.

• Prior cineangiograms (from the University of Minnesota Medical Center and/or an outside facility) and cardiac operative reports are available.

Inpatients

All patients in the hospital the day before catheterization must be seen the day before catheterization. On Sundays, one member of the catheterization team should see inpatients scheduled for procedures on Mondays.

Outpatients

Outpatients can be seen on the outpatient cardiology procedure unit (2A) on the morning of the procedure. Expeditious, timely consultation is very important. Failure to see patients early on the morning of procedure markedly reduces catheterization laboratory efficiency. As with inpatients, speak with the catheterization laboratory staff member assigned to the case after examining the patient. Write the necessary equipment and approach on the scheduling board in the cath lab.

Informed Consent

It is important that all patients (or their legal proxies) understand the purposes of their procedures, what will be done, likely outcomes, and risks involved. The easiest format is a frank discussion with the patient (or family, if the patient is incompetent) before administration of sedative drugs.

Research procedures require separate consent, even when the research will be performed during a clinically-indicated procedure. The consent for the research portion of the study should be signed on a special "research consent" form (hospital forms are not valid). In most cases, the principal investigator or research nurse will secure consent for research studies. You should not secure consent for research studies with which you are not familiar, or without speaking to the principal investigator. You should, however, be alert for patients who meet the criteria for specific studies, and discuss eligibility with the faculty member responsible for the patient's clinical care.

Patient Care After Catheterization

After routine catheterizations, patients with arteriotomies should have their arterial catheters removed in the cath lab. After adequate hemostasis is achieved, patients should be transported to unit 2A (or to their inpatient beds). Outpatients without arteriotomies can be observed in the cath lab and released.

On return to 2A (or inpatient beds), be careful to hold the arteriotomy site during bed transfers. A standard "post-catheterization" order sheet can be used, with appropriate changes made as needed. After cineangiogram review, a follow-up "post-cath" note should be written in the patient's chart. Final angiographic interpretations and recommendations should be outlined.

For outpatients, final discharge notes should be written and patients should be given instructions for follow-up (e.g. clinic visit, admission for surgery), medication changes, and activity restrictions. Generally, patients with arteriotomies should avoid heavy lifting and extreme exertion for one week. When a patient is discharged on the day of procedure, the discharge note and "post-cath" note can be combined into one.

Outpatients can and should be observed overnight if they have significant complications or bleeding from arteriotomy sites. If outpatients need to stay overnight for any reason, they must move from unit 2A to an inpatient area (e.g. 6C/D). They do not have to be admitted to an inpatient housestaff service unless they are at risk or require care lasting more than overnight. When admitted outpatients stay overnight, you will be the responsible physician. In the morning, admitted outpatients should be seen, and their discharge notes should be written.

Angioplasty patients must return to 6C/D or to an ICU (usually 4C/E). A separate "post-angioplasty" order sheet is available to cover care for the first 24 hours after procedure. Another standard order sheet is available for patient care after arterial-cannula removal.

When a patient is on an inpatient service, remember to call housestaff and communicate procedural findings and recommendations.

Scheduling

To facilitate patient safety and minimize patient waiting, scheduling rules for the catheterization laboratory have been developed (Appendix A). The schedule for the following day should be arranged by 5:00 p.m. on the previous day by the senior fellow in the catheterization laboratory and the faculty member assigned to the catheterization laboratory. If you change a scheduled procedure time, be sure to tell the cath-lab secretary so the patient can be notified.

When patients are scheduled at least one day prior to procedure, previous University of Minnesota cineangiograms are pulled automatically.

On-Call Catheterizations

If you are on call and need to bring a patient to the catheterization laboratory, call the page operator and ask him/her to call the interventional cardiology on-call team (job code 0209). It is helpful if you can give the operator the patient's name, location (or an estimated time of patient arrival), level of urgency, and the procedure needed (in one or two words). Be sure to keep housestaff informed.

Receiving Referral Calls

When you receive a phone call, the person calling is asking for help. We are in the business of helping people. The first phone call should be the last for physicians trying to schedule or transfer patients. If additional calls are required, you should make them and re-contact the referring physician.

Inside Referral Calls

Patients on an inpatient cardiology service and those seen by the cardiology consultation service should be added to the cath-lab schedule and seen prior to catheterization (see above). Patients on other services should be seen in consultation if the referring service specifically asks for pre-catheterization consultation. If general consultation is needed, you should contact the general cardiology consult service (the "one call does all" rule for referrals).

Our function is to assist the housestaff. If you are called about a patient, see the patient; don't rely only on the information you receive over the phone. Please also remember that our housestaff are referring physicians. Treat them appropriately and keep them informed.

Outside Referral Calls

We encourage physicians to call us for advice or patient referral. If you receive a call from an outside physician, BE HELPFUL. The first phone call should be the last for physicians trying to schedule or transfer patients. If additional calls are required, you should make them and re-contact the referring physician.

If you need help answering an outside physician's questions, call the appropriate staff. An interventionalist can always be reached on pager. If a referring physician requests transfer, accept the patient, obtain the referring physician's telephone number, and make the following calls:

Transportation of Patients

Patients can be transported to the University of Minnesota Medical Center by private car, ambulance, helicopter, or fixed-wing aircraft. Patients at low risk should be transported by private car (e.g. outpatients or patients ready to leave another hospital) or ambulance (e.g. patients with unstable rest angina, patients receiving intravenous infusions). Acutely-ill patients from a long distance (e.g. acute infarction, shock, dissection) should be transported by air.

Ground-ambulance transport can be arranged through the referring hospital or LifeLink; air transport can also can be arranged through LifeLink. If LifeLink is unavailable to transport, North Air or Mayo Air may be available.

If a patient is to go directly to the catheterization laboratory, be sure the laboratory is ready and that the nursing staff has the patient's estimated time of arrival.

Quality Assurance

Improving the quality of care delivered in the catheterization laboratory is everyone's responsibility. The catheterization laboratory has an extensive surveillance system for complications of catheterization. If you have a complication as the result of a procedure, you must report the complication to Pat Maurine, R.N., who heads the QA team.

Every significant complication is reviewed at a morbidity and mortality conference, which is held every other month on a Wednesday morning at 7:20 a.m. Attendance is mandatory and supersedes all other responsibilities.

The catheterization laboratory has a number of mandatory policies regarding patient care and paperwork.

The paperwork time rule:

All catheterization laboratory preliminary reports are due by the time the patient leaves the laboratory. Reports not completed within two working days will lead to automatic withdrawal of laboratory privileges until incomplete reports are completed.

Radiation and Biological Hazards Protection

All persons working in the catheterization laboratory must observe appropriate measures to reduce the possibility of radiation and biological hazard exposure (e.g. blood-borne agents such as HIV and hepatitis viruses). You must wear a lead apron and lead thyroid shield if you enter a room using radiation. Additionally, if you are near a patient or blood specimens, you must wear gloves and an eyesplash shield. A gown, hat, and mask are required if you handle catheters or are near an arteriotomy site.

You will be issued a radiation-exposure monitoring badge every month (whether you are scheduled in the laboratory or not). One badge goes on the collar (outside the lead apron protection) and one goes under the lead apron (deep-dose detector). You should wear the badges when you enter a room where radiation is used. Be careful not to leave your badges in a procedure room (e.g. attached to your lead apron) when you are not present. At the end of each month, radiation badges will be collected. Monthly exposure data from each university-affiliated site is calculated at a university laboratory. If your dose exceeds federal guidelines, you will be asked to attend a meeting with radiation safety officers.

Educational Programs

You are here to learn the science and art of cardiac catheterization. A course in catheterization has been designed for you.

Your syllabus constitutes the “core” material for the course. It is supplemented by a year-long series of didactic sessions highlighting important aspects of catheterization. Remember that cardiac catheterization consists of both technical and interpretive skills.

CONFERENCE SCHEDULE

CATH RULES (“LITE” VERSION)

Scheduling Patients

Call the cath-lab secretary (leave information on the voicemail if it is after hours) and provide the following information:

• Procedure(s) requested (be specific: e.g. CORS; grafts)

• Date desired (please be flexible if a requested date is already full)

• Name, medical-record number, date of birth, location (e.g. 6C/D), and ordering staff physician

• If the patient has:

--Prior coronary PTCA, stenting, and/or CABG, or is a transplant patient

--Diabetes (scheduling priority; if type 2, possible research candidate)

--Renal failure (hydration and N-acetylcysteine)

--Contrast reaction (steroid or other pre-treatment)

Pre-Catheterization Evaluation

Pre-cath evaluation should include:

• A brief history, an outline of concurrent medical illnesses, CV risk factors, and allergies (including contrast)

• A physical examination (with peripheral-pulse description)

• Pertinent laboratory data:

--CBC with platelets; basic metabolic panel (K+, creatinine, BUN, and glucose)

--INR (if indicated: prior warfarin use; liver disease coagulopathy)

--Recent electrocardiogram

• A statement of preliminary diagnosis, the rationale for catheterization, expected findings, and informed consent.

Be sure that you:

• Treat low K+ (see protocol)

• Give N-acetylcysteine and hydration to patients with renal insufficiency (see protocol)

• Adjust diabetes drugs (see protocol)

• Adjust anticoagulants (INR < 1.6 for elective cases)

• Pretreat patients with a history of contrast reaction (see protocol)

• Obtain signed informed consent

• Request/obtain outside films/CDs and (if s/p CABG) prior op reports

Post-Cath

• Fill out order forms (post-cath outpatient; post-cath inpatient; post-angioplasty)

• Generate a cath report before the patient leaves the lab, including:

--A summary of findings

--Recommendations

• Readjust anticoagulation:

--Restart warfarin (where needed)

--Write for 2B3A continuation (where needed)

--Add clopidogrel 75 mg/day for stents (3-6 months) and brachytherapy (6-12 months)

• Ensure adequate preventive therapy before discharge and send the patient home with scripts

--Unless contraindicated, all CAD patients should be discharged on ASA, an ACE inhibitor (or ARB), and a statin

• Arrange outpatient follow-up (if a patient is being referred for CABG, ask CV surgery to see the patient prior to d/c)

• After angiogaphy/intervention, see inpatients in the evening and leave notes.