CHHS17/107

Canberra Hospital and Health ServicesClinical ProcedureTransoesophageal Echocardiogram – Nursing Management (Adults Only)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Alerts.........................................................................................................................................2

Section 1 – Transoesophageal Echocardiogram (TOE) and what is its purpose?......................2

Section 2 – Contraindications and Risks of TOE Procedure.......................................................4

Section 3 – Referrals and Booking Patients for TOE at CHHS....................................................5

Section 4 – Pre Procedure.........................................................................................................5

Section 5 – Procedure...............................................................................................................6

Section 6 – Post Procedure.......................................................................................................7

Implementation........................................................................................................................ 8

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References................................................................................................................................ 9

Definition of Terms................................................................................................................. 10

Search Terms.......................................................................................................................... 10

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Purpose

The purpose of this document is to outline the nursing care of the patient undergoing a Transoesophageal Echocardiogram (TOE) within the Canberra Hospital Health Services (CHHS).This includes the preoperative, intraoperative and postoperative care provided by nursing staff.

Scope

This document applies to all CHHS clinical staff that perform and care for patients undergoing a TOE, including: Medical staff certified to perform this procedure, such as a Cardiologist or an Advanced

Trainee Cardiologist, an Intensivist and an Anaesthetist or trainees competent in performing and managing or supervised to perform the TOE procedure

Registered nurses credentialed in Advanced Cardiac Life Support (ACLS) assisting with the procedure.

All nursing staff responsible for the pre and post care of the patient.

Alerts

Patient assessment including the suitability for sedation must be completed by the admitting Cardiologist or Advanced Trainee in Cardiology.

For intubated and/or ventilated patients in the Intensive Care Unit (ICU) or in Operating Theatres (OT), the assessment should be done by the Intensive Care Specialist or Anaesthetist.

Contraindications to TOE are infrequent, but should be checked for by the proceduralist performing the procedure (See Section 2).

It is the responsibility of the proceduralist performing the procedure and the persons assisting with the procedure to verify the sterility of the TOE probe prior to commencing the procedure. The sterilised probe will have 2 stickers indicating its certification of sterility from the gastroenterology rinse room as per the CHHS Healthcare Associated Infections clinical procedure. ( Section 7.2 )

Section 1 – Transoesophageal Echocardiogram (TOE) and what is its purpose?

Transoesophageal echocardiography (TOE) is an ultrasound of the heart done by inserting an ultrasound probe passed through the mouth, down the throat and into the oesophagus. The oesophagus is located directly behind the heart close to the upper chambers hence very clear images of the heart structures and valves can be obtained.TOE uses high frequency sound waves to make detailed pictures of the heart and the arteries supplying it. Therefore a TOE is a diagnostic procedure performed to assess the

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heart’s structure and function where greater detail is required than a standard transthoracic echocardiogram.

The most common indications for a TOE include: examination of the left atrial appendage and cardiac chambers to exclude intra-cardiac

thrombus examination of prosthetic heart valve function evaluation of possible infective endocarditis and its potential complications examination of abnormal tissue around valves (bacterial, viral and fungal) and intra-

cardiac masses assessment of valvular pathology assessment of intra-cardiac shunts. provision of information during surgery, such as heart valve repairs /replacements and

correction of congenital heart disease.

Figure 1: A diagram of a TOE performed on adult patient

(National Heart, Lung, and Blood Institute: Transoesophageal Echocardiography March 2012)

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At CHHS TOEs are conducted in various settings. These include: Outpatients are admitted to the Cardiac Catheter Laboratory Day Unit (CLD) where the

procedure is performed in a designated procedure room, located in the Sub-Acute area of the Coronary Care Unit (Level 3).

Hospital in the Home (HITH) patients are also admitted to the CLD and the procedure performed as above.

Intensive Care Unit (ICU) for ventilated/sedated patients Operating theatre Cardiac Catheter Laboratory Inpatients are transferred directly to the designated procedure room on Level 3 as

above. Coronary Care Unit On the ward at the bedside in patients that require to be isolated for infectious reasons

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Section 2 – Contraindications and Risks of TOE Procedure

Contraindications to Transoesophageal EchocardiographyAbsolute Perforated organ within the chest or abdomen Significant oesophageal pathology Acute upper GI bleeding Recent oesophagectomy/oesophagogastretomy

Relative (to be considered) Severe cervical arthritis Previous chest irradiation Symptomatic hiatus hernia Previous GI surgery Oesophagitis Thoracoabdominal aneurysm Coagulopathy

Risks of the TOE Procedure Oesophageal perforation Oesophageal burns – electrical injury from overheating of the probe Potential damage to mouth and teeth Risks related to sedation

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Section 3 – Referrals and Booking Patients for TOE at CHHS

Patients at CHHS requiring a TOE are booked as followed by the medical staff.InpatientsRequests for inpatients must be directed to the Cardiologist or Cardiology Advanced Trainee on call. They may be contacted through the switchboard or the CHHS Cardiology Department.

The patient will need to be assessed by the Advanced Trainee Cardiologist before booking the procedure. The Trans Oesophageal Echocardiogram Procedure clinical form (37545), which is available on the clinical forms register, must be completed and included in the patient file.

For patients undergoing a TOE in the operating theatre or where anaesthetic support is required, assessment by the anaesthetic team will need to occur pre-procedure.

OutpatientsOutpatients are referred to and booked through a cardiologist within the Cardiology Department of CHHS. Patients are then admitted through the Cardiac Catheter Laboratory Day Ward. (CLD)

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Section 4 – Pre Procedure

Outpatient and Ward Patient (performed in the procedure room Level 3) Medical staff should assess the patient for suitability to undergo a TOE procedure in

relation to contraindications and precautions as listed previously, including the administration of conscious sedation and document findings on appropriate forms. (Forms 37545/45360 found on the Clinical Forms Register). Please refer to CHHS Placeholder Document Procedural Sedation ANZCA PS09.

The patient is required to fast for 6 hours prior to the procedure as per CHHS Fasting Guidelines – Elective and Emergency Surgery.

Medications are to be withheld unless directed by medical staff prior to procedure. IV cannula should be inserted by a credentialed registered nurse or medical officer

(preferably in the right antecubital fossa) and checked for patency. NB This needs to be a dedicated IVC for the administration of sedation therefore an additional cannula may need to be inserted in patients such as HITH patients requiring ongoing antibiotic therapy. If unsure refer to medical staff.

Medical officer is to explain the procedure and risks to the patient and obtain written consent as per CHHS Consent and Treatment Policy.

Patient to be dressed in a hospital gown and transferred in their bed from the CCL Day Ward or from the ward to the dedicated procedure room Level 3 as previously outlined.

Partial and/or full dentures are to be removed.

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Intensive Care Patient – Ventilated Medical officer is to explain the procedure and risks to the patient/next of kin and obtain

consent as per CHHS Consent and Treatment Policy. Cease naso-gastric feeds and aspirate the gastric tube immediately before the

procedure. Increase the current sedation or administer additional sedation and adjust ventilator

settings for the procedure in consultation with the medical staff performing the procedure.

Patient on a general ward If the patient has contact precautions for infection control reasons it is usual to do the procedure on the ward. In addition to the above requirements the following should occur before the procedure Emergency equipment such as oxygen, bag and mask attached to outlet with tubing and

airway adjuncts readily available and in working order. Functioning suction equipment with yankuer attached Personal protective equipment (PPE) including gloves, protective eye wear and gowns

plus face masks if droplet precautions indicated. A clinical hand over of the patient to medical/ nursing staff performing the procedure. The staff performing the procedure will bring the equipment to perform the TOE and the

monitoring equipment to monitor the vital signs of the patient during the procedure. Medications utilised during the procedure will also be brought by the staff performing

the procedure.

The ward staff member looking after the patient should be readily available to assist the staff doing the procedure if required, for example to get extra equipment /supplies or to assist the patient as necessary.

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Section 5 – Procedure

During the Procedure: The patient is monitored throughout with ECG, pulse rate, oxygen saturations (Sa02), end

tidal CO2 (ETC02), respirations and blood pressures. Time out to be done as per CHHS Patient Identification and Procedure Matching

Procedure. Don PPE. Topical anaesthetic is to be applied to the back of the patient’s throat and the time

noted. Usually intubated/ventilated patients in the ICU or Operating Theatre are already receiving medications including pain relief and/or sedation which suppress the gag reflex. Therefore topical anaesthesia is not required.

The patient is placed in the left lateral position with a 30 degree head rise. Nasal prongs with ETCO2 monitoring are to be applied to the patient who is not

ventilated and the oxygen flow rate is documented.

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Baseline vital signs and MEWS score recorded as per CHHS Vital Signs & Early Warning Scores Clinical Procedure.

The bite block is placed in the patient’s mouth and secured ready for probe insertion. Sedation and pain relief are given as prescribed on the medication chart and signed for

as administered by the nursing and medical staff. Observations are recorded 5 minutely during the procedure or more frequently if the

patient’s condition changes or with each administration of further medication. The patient may require suctioning during the procedure if there is saliva present as they

will be unable to swallow. At the completion of the procedure, the proceduralist who performed the TOE is

responsible for ensuring the probe is taken to gastroenterology rinse room for sterilization.

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Section 6 – Post Procedure

When the probe is removed the patient should be encouraged to cough to remove any secretions left in the oropharynx or if necessary the patient may be suctioned to remove secretions.

The patient is to remain in the lateral position with oxygen continuing until fully awake. Post procedure vital signs and MEWS score are to be recorded 15minutely for ½ hour or

until the patient is awake, obeys commands and is orientated to time and place. Trans Oesophageal Procedure form (37545) to be completed including preliminary report

and time for sip test to be undertaken. Schedule 4 (S4) and Schedule 8 (S8) drugs are to be discarded and documented in the

respective S4 and S8 registers as per the CHHS Medication Handling Policy (Section 4.11). Inpatients from wards are to remain on close observation within the CLD for ½ hour post

procedure or as directed by the proceduralist. Before transfer to the ward the patient is to be awake, vital signs have returned to baseline levels and medical staff have assessed the patient post procedure. Refer to CHHS Vital Signs and Early Warning Scores (EWS) Clinical Procedure.

Patients are escorted to the ward areas with a CCL nursing staff member and clinical handover is given to the ward staff.

Post Procedure Observations and Procedures of ward patients returned to the ward area. Hand over from nursing staff involved with the procedure including observation chart,

MEWS and post-operative instructions ½ hourly observations for 2 hours post procedure including sedation level. Patient to be NBM for two hours after the throat was anaesthetised. This should be

documented on Trans Oesophageal Procedure form (37545). At 2 hours a sip test can be undertaken to assess patients swallowing and gag. If the patient tolerates this they may eat and drink normally.

If the patient has difficulty swallowing or has excessive coughing /gagging continue NBM and consult medical advice. It is normal for the patient to have a mild sore throat after the procedure.

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Post procedure observations and procedures for outpatients and HITH patients Outpatients are transferred back to the CCL Day Ward for post procedure monitoring

including vital signs and MEWS. Once they are awake and vital signs have returned to baseline levels they are then reviewed by the proceduralist who performed the TOE regarding their results. Post procedural instructions are discussed and a discharge information sheet is provided to the patient by nursing staff.

HITH patients are escorted to the HITH unit within the hospital on discharge from the CLD

The patient should remain on bed rest for 1 to 2 hours whilst the sedation wears off. The patient will undergo a sip test 2hours after the throat was sprayed. If the patient

complains of choking on foods, fluids and saliva or severe pain or bleeding from the mouth or throat the patient should remain on nil by mouth and medical advice sought.

Inform the patient it is normal to have a mild sore throat for up to 24 hours post procedure.

Post Procedure: Intensive Care patient Ventilated Patient to lie supine with head elevated 30 degree Continue hemodynamic and neurological monitoring Recommence NGT feeds as directed Return to pre-procedure ventilation settings when patient wakes as directed

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Implementation

All new staff and new graduates will receive the orientation and learning package for their designated work area and also be assigned a preceptor .

Any new changes to clinical procedures or documents will be provided and discussed at Ward meetings.

Medical staff to undergo training in the sterilisation of the TOE probe (competency certificate to be kept in CNC office).

All critical care staff should be up to date with mandatory skill requirements including ALS.

Adverse outcomes and or issues should be submitted to RISKMAN. All TOEs performed at CHHS are recorded on the cardiology data base.

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Related Policies, Procedures, Guidelines and Legislation

CHHS Healthcare Associated Infections Procedure CHHS Patient Identification and Procedure Matching Procedure CHHS Clinical Handover Clinical Procedure CHHS Vital Signs and Early Warning Scores Clinical Procedure CHHS Fasting Guidelines - Elective Surgery Patients

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Health Directorate Waste Management Procedural Sedation ANZCA PS09 Procedure

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References

1. NHMRC (2010) Australian Guidelines for the prevention and control of infection in Healthcare, Commonwealth of Australia.

2. ANZCA Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures PS09 2014

3. Leeson,P.,Raza,s.,Rayner, J., Puli, C.,Timperley, j., Mitchell, A andBecher, H. (2007) Conscious sedation for transoesophageal echocardiogram(TOE): Impact on procedure and patient of titrated low dose sedation European Journal of Echocardiogram. 8(3):33-34

4. Ashworth, A., and Roscoe, A. (2009) Anaesthesia & Intensive care Medicine. 10(9):424-429

5. Hilberath, J., Oakes, D., Shernan, S.,Bulwer, B., D’Ambra M., Eltzscig, H., (2010) Safety of transoesophageal Echocardiogram. The American Society of Echocardiogram: 1115-1127

6. Habo etal. (2013) ASE Guidelines and Standards: Guidelines for performing a comprehensive Transoesophageal echocardiogram. , Journal of American Society of Echocardiology, (26) 921-969

7. https://www.asahq.org/resources/clinical-information/asa-physical-status-classification- system

8. Mathue, S.K and Singh P. (2009) Transoesophageal Echocardiography Related Complications. Indian Journal Anaesthetics 52(5)567-574.

9. http://inhealth/acthmr/Clinical%20Record%20Forms%20NEW/Trans%20Oesophageal %20Echocardiogram%20Procedure.pdf ACT Government Health Directorate; Canberra Hospital Clinical forms register

10. http://acthealth/c/healthintranet?a=glob&object=1247699375 ACT Government Health Directorate; Canberra Hospital Clinical forms register

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Definition of Terms

Moderately sedated – or Conscious sedation is defined as a drug – induced depression of consciousness during which patients are able to respond purposefully to verbal commands or light tactile stimulation. Only exceptionally will interventions be required to maintain patent airway, spontaneous ventilation or cardiovascular function. (Guidelines on Sedation and /or Analgesia for Diagnostic and Interventional Medical, dental or Surgical Procedures – Australian and New Zealand College of Anaesthetists PS09 – 2014)

Sip test – Patients are not to eat or drink for 2 hours post local anaesthetic to the throat due to the numbing effect of the local anaesthetic. A patient is asked to take a small sip of water (20mls) to evaluate if they can eat or drink. If the water causes the patient to cough or choke the patient is to remain on nil by mouth for 1 hour and try again

MEWS – Modified Early Warning Score NBM – Nil By MouthBMI – Body Mass index S8 – Schedule 8 medicationsS4 – Schedule 4 medicationsSaO2 – Oxygen Saturation CO2 – Carbon DioxideNGT – nasogastic tube

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Search Terms

Transoesophageal Echocardiography Adult, TOEBack to Table of Contents

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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