Best Practice Standardization of Sheath Removal

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Best PracticeStandardization of Sheath Removal

• Aurora St Lukes Medical Center
• Aurora Health Care
• Milwaukee, Wisconsin

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Our Story

• Before A variety of sheath removal methods were
  used depending on the physicians request or
  because weve always done it this way
• After A standardized approach founded on
  evidence-based best practices that achieve
• Best patient care
• Staff safety
• Effective cost management

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Aurora Health Care

• Community-owned not for profit health care system
• Located in Southeast Wisconsin
• 14 hospitals within the system
• 5 hospitals in Milwaukee (Metro region)
• 3 hospital in the Metro region with
  interventional suites for coronary or peripheral
  procedures

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Aurora Facilities

• St. Lukes Medical Center
• Licensed for 938 beds
• Performs 3,400 coronary interventions annually
• Performs gt 8,000 cardiac catheterizations
  annually
• Submits data to ACC-NCDR, STS, CRUSADE, ADHERE,
  CMS, Premier
• Aurora Sinai Medical Center
• Licensed for 386 beds
• Cath volume 1300
• PCI volume 470

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Mission

• To promote health, prevent illness and provide
  state-of-the-art diagnosis and treatment,
  whenever and wherever we can best meet peoples
  individual and family needs.

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Achievements

• Magnet recognition
• Stroke center
• Chest Pain Accreditation
• 24/7 in house Cardiologist and Cath Team
• Vascular Center
• JCAHO disease specific certification applied for
  AMI, CHF, Stroke

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Information Technology

• Dedicated Cardiac Data Management department.
• Supports Core Improvement Teams for
• Cardiac Surgery-STS
• Cardiac Interventions-ACC
• Supports other data needs for Chest Pain
  Committee, CHF Team, and 24/7 Program
• Supports all requests for observational research
  from the databases

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Cardiac Core Group/SLMC

• Purpose Improve outcomes for the Cardiac
  Vascular procedure patients.
• Multidisciplinary team made up of members from
  all areas that see post-procedural patients
• Meet bi-monthly to discuss improvements in the
  care of the post-cardiac procedural patient
• Review data from ACC-NCDR including renal
  complications post PCI, hematoma rate, emergent
  CABG

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Critical Question

• Question Why are we using different methods of
  sheath removal? Could we save money? What is
  best practice?
• Ad Hoc group formed to discuss the
  standardization of sheath removal

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Ad Hoc Workgroup formed

• Invited members from areas that removed sheaths
  post procedure
• Included areas from 2 of the hospitals within our
  region
• Not all areas that pulled sheaths were able to
  participate, but requested information on the
  outcome of the workgroup
• Challenge to arrange times to meet
• Each member discussed sheath removal methods and
  rational

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Collaborative Workgroup Members of Aurora Sinai
and Aurora St Lukes

• Betty George Supervisor Cath Lab ASMC
• Stephanie Hillmann Cath Lab Educator SLMC
• Linda Lundin CNS Post Angioplasty SLMC
• Jan Nehr Cardiac Data Management
• Karin Schmehling CNS Coronary ICU SLMC
• Virginia Simerly RN Care Center ASMC
• Joanne Toetz RN PTCA Unit SLMC

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History/Current practice

• Manual, compression devices or patches used
• Staff often pick the method they are most
  comfortable with.
• We do not use a sheath removal team. Sheaths are
  pulled in dedicated areas with trained staff
• Clamp used in past was uncomfortable for the
  patient
• Closure device use was physician preference with
  utilization rate of 7.7

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What we knew

• Manual pressure was causing fatigue and injury
  which resulted in carpal tunnel for some.
• A Cath Lab study showed patients were more
  comfortable with manual or compression device
  than the clamp
• The compression device was being used on all our
  post PTCA patients
• The compression system had a cost of
  approximately 50-60 per patient compared to the
  compression device of approximately 5-6
• Patches are being used, but hold times or bedrest
  times are not being reduced

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What was our goal?

• To standardize sheath pull
• Incorporate the newest evidence related to sheath
  removal into practice
• Ensure the safety of our patients by preventing
  complications
• Prevent injury to staff
• Reduce cost with standardization

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What we did NOT know

• What the literature said about best practice
• Why some staff wanted to use the compression
  system
• Why some staff were holding manual pressure
• If any method posed concerns with the physicians

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Obstacles

• Arranging time for all members to meet
• Keeping the group on task
• Arranging for the reps from various companies to
  meet with us to review their products
• Keeping an open mind to other methods of sheath
  removal

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First Steps

• Literature review
• CNS listserve question posted
• Discuss the current process for sheath removal in
  the various departments
• Discussing the current rational for the process

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Literature review for evidenced based practice

• We divided the articles among the group members
  to review and found
• Minimal information from the lit review
• Meta analysis by Jones and McCutcheon 2002,
  concluded that mechanical compression techniques
  were the most effective for preventing hematoma
  formation. The prevalence of bleeding did not
  differ significantly for different methods of
  compression.

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CNS list serve

• Question was posted asking what sheath removal
  method is used
• Limited response from 4 individuals who all used
  different methods and had varying opinions on
  what is the best device to use

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Evaluation of devices

• We met with the representatives from several
  companies to review products
• We reviewed correct procedure for use of the
  devices
• Devices evaluated for safety and cost

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What We Learned

• Compression device comfortable for patients
• Manual pressure would be the least costly, but
  injury to staff is a concern
• Cost difference would be approximately 50 to 5
  for sheath removal equipment
• Physicians supported improvement recommendations

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Recommendation

• The recommendation of the group was to switch to
  the compression device for sheath pulls
• Manual compression could still be used
• The compression system would be used for sites
  with continued oozing or hematomas, but not
  initial pulls
• The policy and procedure for sheath removal will
  be revised

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Quality/Cost Evaluation

• Decrease use of more costly devices with
  improvement to patient comfort and maintained
  safety
• Ranges of compression devices vary
• Improved acquisition price with higher volume of
  compression device equipment
• Based on volumes of procedures, the savings could
  be approximately 20,000-40,000/year
• Improve staff satisfaction and safety by
  decreasing the volume of manual hold

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Future evaluation

• Use of the patches such as Syvek and Neptune need
  to be evaluated for the cost benefit
• Data collection or a formal study with patches to
  evaluate if hold times can be decreased or
  bedrest time can be decreased
• Continued monitoring of site complications with
  changes
• Using our ACC-NCDR data, we will identify
  patients at risk of vascular complications and
  identify strategies to improve complications post
  sheath removal

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Summary

• Standardized the sheath removal policy and
  procedure
• Shared recommendations and revisions within the
  system

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Lessons Learned

• We need to get past the we always do it this
  way and we are sure it is the best.
• We are willing to trial other methods if there is
  a big cost difference
• We were able to negotiate an even better price
  for the devices.

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Contact information

• Mia Stone MS, BSN, RN- Cardiac Program Manager
  414 649 7311
• Linda Lundin CNS,-Clinical Nurse Specialist Post
  Angioplasty Unit 414 649 5242