International Journal of Nursing Practice 1998; 4: 261–266

✠ C L I N I C A L R E P O R T ✠

Performance indicators and standards of care forcoronary angioplasty procedures:

A quality initiative

Monica Higgins RN BA (Nsg) Dip Critical Care*Registered Nurse and Student MA (Nsg), The Prince Charles Hospital, Rode Road, Chermside, Queensland, Australia

Accepted for publication April 1998

Higgins M. International Journal of Nursing Practice 1998; 4: 261–266Performance indicators and standards of care for coronary angioplasty procedures: A quality initiative

The growth of coronary angioplasty procedures in Australia has provided opportunities for role development innursing practice. In response to changes in health care demands, the angioplasty nurse specialist role was developed.This paper discusses a quality activity with two goals. First, to facilitate a change in culture within the angioplastyservice from the existing fragmented system to a cohesive system based on a quality approach. Second, to develop aprocess improvement strategy involving a data collection tool that would facilitate the monitoring of performanceindicators and patient outcomes.

Key words: coronary angioplasty, performance indicators, patient outcomes, quality care.

INTRODUCTION femoral arterial sheath removal. The activity was conduc-Procedures that were once considered rare and risky, ted over a period from June 1995 to May 1996.such as coronary angioplasty and stent placement, have The quality activity was conducted in accordance withbecome widely practiced routines at many hospitals. organisational guidelines for quality improvement activi-The very nature of the procedures provides many ties. This was a seven step process that included (i)challenges arising from short hospital stays, high patient reason for improvement, (ii) current situation, (iii)turnover rates, the commitment to quality care and analysing for root causes, (iv) potential solutions, (v)education, to name a few. testing and results, (vi) standardisation and (vii) continu-

In response, The Prince Charles Hospital introduced ous improvement.1

the Clinical Nurse Specialist—Angioplasty Services pos-ition in 1993. The purpose of this paper is to discuss a

THE ANGIOPLASTY NURSEquality improvement activity within the service. TheSPECIALIST ROLEactivity had two aims. The first aim was to institute a

The Angioplasty nurse specialist role functions fromchange in culture (the way things were) towards aboth an educational and a clinical perspective. The Nursequality improvement philosophy. The second was toSpecialist provides individualised educational pro-implement a strategy to enable the evaluation of perform-grammes for patients and significant others of thoseance indicators and patient outcomes in the area ofundergoing angioplasty procedures. The introduction ofsuch a service meant that for the first time a dedicatedCorrespondence: M. Higgins, 29 Tillapai Grove, Karana

Downs, Queensland 4306, Australia. Fax: +07 32012680; role was allocated to the education of angioplasty

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patients. Continued care and support is provided after has not been described or evaluated in the Australianliterature. This lack of published research makes itdischarge, by a telephone follow-up advisory service.

The clinical aspects of the role are intravenous can- difficult to ascertain whether this role is common practicefor nurses, and also, what the patient outcomes are. Innulation and femoral arterial sheath removal. The clinical

aspects supplemented and supported the care delivered the United States, a survey of current practice patternsfor coronary angioplasty care was conducted across 70by ward and coronary care nurses. The introduction of

the role also meant that, for the first time, registered hospitals and represents care practices for #80 000patients annually.7 Juran et al.7 report that the majoritynurses at this hospital performed intravenous cannulation

and femoral artery sheath removal for these patients. of sheaths were removed by registered nurses. In Canada,a survey was sent to all 35 hospitals that performSenior medical officers previously undertook thiscoronary angioplasty.6 In contrast to the Americanclinical role.study,7 the Canadian survey reported that nurses onlyremoved 13.3% of sheaths, whilst the physicians

LITERATURE REVIEW removed 76.7%.6 These two studies reflect varyingCoronary angioplasty has grown rapidly in Australia. In nursing practice in femoral sheath removal. This situation1981, six units performed 45 procedures. Due to the indicates the need to establish safe nursing practice thatincreasing number of units, the number of coronary is based on formal standards of practice, performanceangioplasty procedures performed in 1993 was 39 843.2

indicators and patient outcomes.This rapid expansion of services has provided new The patient outcomes of sheath removal includeopportunities for registered nurses to care for people vascular complications, such as haemorrhage, haema-undergoing these procedures. toma, retroperitoneal bleed, pseudoaneurysm and

Coronary angioplasty and coronary stent placement arteriovenous fistula formation.8 These complicationsare common treatment modalities offered to people with may require surgical repair under general anaestheticcoronary artery disease. These treatments offer an and resuscitation with blood transfusion, and result inalternative to open heart surgery and medical therapy. prolonged hospital stays.9

As coronary artery disease progresses, the coronary A gap in the literature exists between publishedarteries become narrowed, due to a build-up of athero- nursing and medical research into the incidence ofsclerotic plaque.3 This narrowing restricts the flow of femoral vascular complications. Medical research is wellblood to the heart muscle and can result in ischaemia represented; however, there is little research to dem-that is manifested as angina pectoris or acute myocardial onstrate the safety and efficacy of registered nursesinfarction.3 With coronary angioplasty, a small inflatable performing sheath removal.6,7

balloon on the end of a catheter is fed into the narrowed In the only nursing study found Schnickel et al.10

section of the artery. The balloon is inflated and the report a change in practice initiative that facilitatedplaque is remodelled into the wall of the artery.4 A sheath removal by registered nurses. An educationcoronary stent is a wire scaffolding device, implanted programme was implemented and the resulting study ofinto the wall of the artery to provide support and to 200 patients found a 4% incidence of haematomahelp keep the artery open.5 formation.10 Medical studies also report a low incidence

The procedure is performed under local anaesthetic of complications. Popma et al.11 in a study of 1413and the person usually goes home within 1 to 2 days. patients reports the incidence of haematoma as 2.8%,All equipment enters the body through a tube called a pseudoaneurysm 2.1% and arteriovenous fistula 0.4%.sheath, which is inserted into the femoral artery.3 The Similarly, Moscucci et al.12 report haematoma 3.2%,sheath is removed about 4–6 h post procedure.6 Very pseudoaneurysm 11.1%, arteriovenous fistula 2.9% in afirm pressure is applied so that a blood clot can form study population of 688. Whereas, Johnson et al.13

and seal the hole in the artery. The pressure can be report haematoma 1.27% and pseudoaneurysm 0.38%applied by hand or by the use of a mechanical pressure in a study of 1579 patients. The work of Schnickeldevice. et al.10 reflects a desire to provide structured education

Sheath removal was a traditional medical role at this for sheath removal which is recognised as crucial forextended practice. Not only is a sound knowledge basehospital. The nursing practice of femoral sheath removal

Coronary angioplasty procedures 263

required, nurses must also evaluate the outcomes ofnew care initiatives.

The review of the literature has identified that coron-ary angioplasty procedures are growing in number. Inthe United States and Canada registered nurses areremoving femoral sheaths. It is not known if the practiceof nurse-initiated sheath removal is widespread inAustralia. Limited information is available on the patientoutcomes of nurse initiated sheath removal. The lack ofdata in the nursing literature confirmed the belief thatthere was a need to improve the system of monitoringand tracking performance indicators and outcomes withinour Angioplasty Service.

REASON FOR IMPROVEMENTTwo problems with our service were identified. Thefirst problem related to inadequate numbers of nursesto perform the work. It was identified that there wereinadequate numbers of nurses to cover the allocatedshifts. At the time the quality activity was initiated, thenurse specialist’s role was basically one of an independent

Figure 1. Original work process flowchart.practitioner, with two registered nurses from CardiacCath Lab and Coronary Care working one late shift eachper week to remove femoral artery sheaths. It was patient care delivery and the recording of care on the

card and personal register as a flow diagram. Thisacknowledged that if an expanded team was developed,its guiding structure should be based on a quality information was also recorded in the patient notes.approach.

The second problem related to evaluation of the work ANALYSING FOR ROOT CAUSESAn analysis of the two methods of data collection wasprocess. Because this was new nursing practice, there

was no formal context in which to evaluate or monitor conducted. A cause and effect diagram was utilised todetail the possible causes for the current situation. Thesethe work. The existing system did not enable the

collection of objective data to determine patient out- included inconsistent recording of information that wasof a poor standard, double documentation and variationscomes. There was no framework for evaluating perform-

ance indicators for femoral arterial sheath removal. in verbal communication. This led to an inability toconduct follow-up calls, inability to assess performanceSubsequently, a quality team was formed to address the

problems. indicators and confusion over care provided. As a resultof team discussion and the analysis of root causes, twogoals were established for the quality activity.CURRENT SITUATION

The work process data was collected and recorded intwo ways prior to the commencement of the quality GOALS OF THE QUALITY ACTIVITY

1 To facilitate a change in culture within the Angioplastyactivity. The first of these was via the card system,which was a small sheet of cardboard used to record Service, resulting in a movement from the existing

fragmented system to a comprehensive and sustainablerelevant patient history; the procedure performed noteson sheath removal and details of information given to system based on a quality approach.

2 To develop a process improvement strategy involvingthe patient. The second way was via the personalregister, consisting of exercise books that the individual a data collection tool that would facilitate: i) the

monitoring of performance indicators, and ii) the moni-nurses used to record details of sheath removal and notehaematoma formation. Figure 1 details the sequence of toring of patient outcomes.

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POTENTIAL SOLUTIONS diagram the team continually asked two questions: i)what information is required to perform the work?, and,Goal 1: A cultural change

It was identified that more nurses were required to ii) how can the work process be monitored withobjective data? The answers to these questions generatedcover the shifts. This afforded the opportunity to provide

education on the organisation’s quality philosophy. The the Record of Care form (Table 2).vision of this goal involved directing energy into humanresource development by creating an awareness of the TESTING AND RESULTS

Goal 1: A cultural changequality philosophy; putting systems in place that wouldfacilitate team building and nurture continued develop- The written evaluation provided by the nurses on the

orientation programme was positive, and some com-ment. It was felt that education and team building werethe keys to actively involving the nurses in the change mented that they felt the standard of education provided

was more than they expected. The responses about theprocess.learning contracts were also positive. The nurses com-municated that they liked having the learning programmeImplementation

First, an orientation programme (Table 1) was devel- planned out and liked the flexibility to learn at theirown pace.oped. It entailed an eight-hour theoretical programme,

which acknowledged the input of a variety of nursing Second, although the Angioplasty Nurses AdvancedEducation Program was instituted in early May 1995, itand medical professionals. A 40-hour practical pro-

gramme was provided for each nurse individually. The has not been able to run since June 1995 due toresourcing issues. Two angioplasty nurses undertooknurses had control and responsibility for their own

learning by utilising beginner, intermediate and advanced their own research project; one involves the CordisStent@ Protocol. The other project involves improve-learning contracts. The contracts were based on perform-

ance indicators and provided the means by which the ment of patient education in the area of medications.nurses could evaluate their progress.

Second, motivation for continued change and develop- Goal 2: The process improvementstrategyment was provided by The Angioplasty Nurses Advanced

Education Program. Each nurse was also encouraged to The Record of Care form was tested for a period of3 months.undertake her own research project, the aim being to

recognise and reward individual achievement.Monitoring of performance indicators

The Record of Care form has generated baseline per-Goal 2: The process improvementstrategy formance indicators. The preliminary data of 127 patients

records the incidence of pseudoaneurysm as 0.8%,The work process had been detailed as a flow diagram.The next step was to critically analyse the work process vasovagal syncope 0.8%, and nil retroperitoneal bleed

or arteriovenous fistula formation. Haematoma forma-as a means of generating solutions. In analysing the flowtion was monitored by measuring the width of thehaematoma before and after sheath removal. The strategyTable 1. Quality care education: Orientation programmewas to determine the number of new haematomasformed as a result of digital pressure applied by theTheoretical componentangioplasty nurses. Results are presented in Table 3.The incidence of new haematoma in the <3 cm groupThe Angioplasty Service 30 minwas 5.5%. The incidence of new haematoma in theQuality improvement 30 min4–7 cm group was zero, as the application of digitalCoronary artery disease 60 minpressure caused neither an increase or decrease inCoronary artery anatomy 60 minhaematoma size. The incidence of new haematoma inCoronary angioplasty 45 minthe 8–20 cm group was zero, as the application of digitalAnatomy, femoral sheath removal 90 minpressure reduced the size of the pre-existing haema-Patient education 30 mintomas. As this is a quality activity and not a formal

Coronary angioplasty procedures 265

Table 2. Summary of the Record of Care form, including work process information

Record of Care form

Page 1 Patient profile/procedural outcomes

$ demographic information

$ nursing and medical history

$ cardiac risk profile and knowledge assessment

$ pre procedure consult and intravenous cannulation

$ procedure performed and procedural outcomes

Page 2 Sheath removal/performance indicators

$ records the sheath removal process

$ details current practice e.g. mechanical/manual pressure

$ records femoral vascular complications, e.g. haematoma

$ details of post procedure education programme

$ monitoring of femoral vascular complications until discharge

Page 3 Follow-up advisory service/patient outcomes

Records patient outcomes at one month post discharge, defined as:

$ return of angina pain

$ femoral vascular complications

$ readmissions to hospital and patient outcomes

$ actions taken to modify lifestyle—exercise, low fat eating, stress management

Self-report on quality of life and lifestyle modification collated as a precursor to formal research

Page 4 Acute admission to TPCH

Records acute admission to TPCH within the one-month period after discharge

Table 3. Haematoma formation Monitoring of short- and longer-termpatient outcomes

Haematoma Pre Post The Record of Care form has enabled the angioplastynurse, for the first time, to actually monitor patientwidth sheath sheath New

n=127 removal removal haematoma % outcomes in the area of femoral vascular complications.It could be assumed that the low incidence of vascular

<3 cm 2 9 7 5.5 complications has benefits to the patient.The one-month post discharge follow-up calls have4–7 cm 8 8 0 0

8–20 cm 3 0 0 0 enabled the tracking of longer-term outcomes. Fromthe experiences shared by the patients and the concernsthey expressed, certain themes have emerged. Theseinclude feelings of fatigue, lack of energy, return ofresearch project, no direct comparisons can be made to

research discussed in the literature review. However, chest pain, medication use, return to normal activitiesand healing at the femoral puncture site. These themesthese results do provide this team of practising nurses

with an indication of the baseline quality of care correlate somewhat to the findings of Chien Yun Wu,14

who conducted a quantitative study on the post dischargedelivered. Evaluation processes have resulted in furtherimprovements to tighten up the data collected. This concerns of coronary artery bypass patients. She reports

concerns that include wound healing, sternum problems,quality activity has highlighted the need to conductprospective randomised control trials into the femoral pain, activities of daily living, fatigue/weakness, spouse

coping and diet. The initial findings of the quality activityvascular complications of nurse-initiated sheath removalwith digital versus mechanical pressure devices. highlight the need for qualitative research into patient

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perceptions of their experiences and needs in the care. The quality process provides the tool for ensuringpatient-focused care with demonstrated patient outcomes.immediate post discharge recovery period following

coronary angioplasty.ACKNOWLEDGEMENTS

I gratefully acknowledge Mrs M Lowe, Mrs M Dahl, DrSTANDARDISATIONP McEniery, Mrs Vickerstaff, Mr L Stapledon, Miss TGoal 1Chorley, Mrs S Cleary, Mrs C Mason, Miss GIt was identified that resources were insufficient toCarrington, Miss A McCann, Mr L Hindom, The Princeprogress, which led to a focus on goal 2.Charles Hospital.

Goal 2 REFERENCESMonthly reports on the number of procedures per-

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