EVIDENCE BASED PRACTICE STEP BY

STEPTammy Chandler RN MSN ACNS,

BCJune 8, 2015

Step by Step Knowledge Focused Triggers 1. New Research 2 National Agencies Is it a poritity? Yes, it a priority to the cath lab because

we have a lot of problem with beds within the hospital.

Terumo Band(TR) New Director of the Cardiac

Catheterization lab Planning session New protocol Gathering a team Researching the literature

Searching the literature for advantages to radial

RADIAL Dual blood supply which

limits the potential for limb threatening ischemia

• Advantageous for patients with severe occlusive aortoiliac disease

Advantageous for patients with difficulty laying/lot (back pain, obesity, CHF)

• The vessel is easily compressible

• Less chance for local nerve injury

• Less chance for local nerve injury

• Radial approach allows earlier patient ambulation and likely will cost less (closure devices are not necessary)

• Vascular complications are less frequent (1, 8-10)

• Randomized trials to date suggest patients prefer the radial approach

Searching the literature to the advantages of the groin

Long history of use • Technically easy • Facilitates the use of larger

catheters/equipment

Phrasing the question In patients undergoing cardiac

catheterizations would radial access be advantageous to patients or would the groin be appropriate ?

Category 1 We look at the strength of evidence conclusions of the study are valid and strongly supported by the study designs analysis is the risk.

Allen’s Test The Allen Test should be documented on

every patient when preparing to obtain radial access.

To perform the Allen’s test occluding of the radial and ulner arteries should be performed then the ulner artery is released.

Abnormal Allen test noted is when the coloring doesn’t return within 8 seconds.

Research supports the allen’s test.

Patient Received Less Than 5,000 units of

Heparin

Patient Received Greater Than 5,000 units of Heparin or

Angiomax__ cc inflated @ ___________ __ cc inflated @ ___________

30 min: 3 cc down @ _____________ 1 Hour: 3 cc down @ ____________

5 min: 3 cc down @ ______________ 30 Min: 3 cc down @ _____________

5 min: 3 cc down @ ______________ 5 min: 3 cc down @ ______________

5 min: 3 cc down @ ______________ 5 min: 3 cc down @ ______________

5 min: 3 cc down @ ______________ 5 min: 3 cc down @ ______________

Total deflated @ ___________ Total deflated @ ___________

Test pilots of change initially in the post

anesthesia care unit (PACU) and then as we

progressed we utilized theCICU.

Revisions Time Interval Procedure End (Time: )

15 min vital signs ( Time: )

15 min vital signs (Time: )

5 min (Time: )

5 min (Time: )

5 min (Time: )

Patient Received Less Than 5,000 units of Heparin

__ cc inflated @ ___________ HR:______ Blood Press____

HR:______ Blood Press____ 30 min: 3total compression: 3 cc

down @ _____________ 5 min: 3 cc down @ ______________ 35

min total compression:

5 min: 3 cc down @ ______________ 40 min total compression 5 min: 3 cc down @ ______________ 45 min total compression Repeat the cycle until completed

without any bleeding Total deflated @ ___________

CompetencyTASK Met Not Met Method of Verification

1. Verbalizes the Policy and Procedure for TR Band Care      

2. Verbalizes the procedure to the patient      

3. Identifies the necessary equipment for care      

4. Verbalizes the proper air removal process      

5. Can perform the re-inflation procedure      

6. Identifies the maximal air inflation amount      

7. Can identify signs of hemostasis prior to TR Band removal

     

8. Can state three signs relating to decreased perfusion to the distal extremity

     

TASK Met Not Met Method of Verification

9. Verbalizes patient education points with follow-up care

     

10.Verbalizes the need to evaluate the access site and distal extremity while the TR Band is in place

     

11. Recognizes the need for immobilization of the wrist.      

12. Notes any adverse response to treatment      

13. Documents the procedure in patient’s record.      

14. Can perform a reverse modified Barbeau test      

Post Procedure Care Check for capillary refill, sensitivity, temperature, and pulse

oximetry tracing of affected site If site oozes, inflate the TR Band with 1-2 cc of air or more to

prevent oozing When TR Band is deflated and no bleeding is noted, remove TR

Band and apply a Tegaderm occlusive dressing. Additionally an Ace Wrap/wrist support device at the site may be utilized.

Instruct patient not to bare weight on procedure site for 72 hours.

Blood pressure or blood drawn to affected arm for 24 hours. Do not submerge hand for 5 days (no tub bath, no swimming,

no dish washing) Instruct the patient to watch for signs of infection, redress,

swelling, fever

Conclusions Is the change appropriate for adoption

into practice monitor and analyze strategies and potential outcomes.

Policy will have to be made to reflect this practice change.

Leading to same day post coronary interventions.