There Is No 'I' in Cath-Lab Quality Improvement

Cath lab assessment

Reed Miller

April 02, 2011

April 2, 2011 (New Orleans, LA) - Quality and performance data often fail to reach all the members of the cath lab team who need it to help improve the care of their percutaneous-intervention patients, those in the trenches say.

Critical-care nurse April Simon (Cardiac Data Solutions, Atlanta, GA), one of a few nonphysicians involved with the American College of Cardiology's (ACC's) interventional cardiology continuous-quality-improvement initiatives, presented on the role of nonphysician professionals in the assessment of cath labs this morning here at the American College of Cardiology 2011 Scientific Sessions . "We're not just there to hand the docs their instruments; we're there to help them through these procedures," she said. "Everybody needs to voice their concerns and participate."

Data held close are just data for data's sake.

"We've got databases, databases, and more databases" full of PCI outcomes and safety data, Simon said. But all too often hospital and private-practice leaders do not share this information with the nurses and technicians who need it to help them improve their own performance and the performance of their team. The importance of sharing performance data and collaborating on quality improvement must be consistently communicated and prioritized by the leaders of the hospital or practice. "Our frustration is usually with communication and a few people who have a lot of the information but hold it close," she told heartwire . "Data held close are just data for data's sake.

"Patients need us to watch out for them. As professionals, we're responsible for our own education and our behaviors, and we have to hold our peers accountable, and 'peers' means all of us in that team," she said during her presentation. "We're going through all this time and energy collecting and analyzing a lot of data, so we have to be willing to communicate that to the people at the bedside, the caregivers, to improve our outcomes. It always pays off to go that extra mile."

Simon cited research showing that a complication doubles the cost of a PCI and that complications with PCI cost the US healthcare system about $500 million a year.

No sweeping under the rug

In the same session, clinical nurse specialist Lisa Riggs (St Luke's Mid-America Heart Institute, Kansas City, MO) described her center's experience reducing its post-PCI bleeding rate--it was 4.7% at the end of 2007 but was down to 0.5% in the fourth quarter of 2010.

"You can't sweep that under the rug if people are going to die."

To this end, St Luke's research department analyzed data on 400 000 patients in the National Cardiovascular Data Registry (NCDR) to define the characteristics of patients most at risk for a post-PCI bleed. They found that predictors of post-PCI bleeding include age, female gender, previous heart failure, peripheral vascular disease, no previous PCI, heart-failure class, ST-elevation MI, non–ST-elevation MI, and cardiogenic shock, Riggs said.

At her center, a patients' bleeding risk is calculated and communicated to the patients and all staff that sees those patients to make sure the right bleeding-mitigation strategies are followed throughout their course of care. For example, if the patient is at high risk for bleeding, the case manager makes sure "high risk for bleeding" is written on a big white board in the cath lab during the interventional procedure. The most important practice change that has reduced bleeding rates at St Luke's has been a transition to doing most procedures with the transradial approach instead of the transfemoral approach, she said. Her center has also increased its use of bivalirudin and vascular closure devices.

Importantly, each physician gets a report of the bleeding rates in the procedures they performed in every quarter, she said. "The moral of the story is that awareness is everything," Riggs said. "We like to run and hide from that data, and we were a little bit embarrassed by a 4.7% bleeding rate, but you can't do anything about it if you don't know about it and if you don't know that you have some practices you could change as an interventionalist."

You can't do anything about it if you don't know about it and if you don't know that you have some practices you could change as an interventionalist.

Riggs and Simon both stressed that everyone on the team needs to read and understand the lab's performance data. "Everybody ought to be looking at that. If anybody won't let you see them, then call the ACC to get the report and tell them that the hospital won't share it. These are our patients. That's why we're doing this," Simon said.

Simon also emphasized that every team member must be able to voice their concerns when they see a potential safety problem or opportunity for improvement. And physicians and hospital administrators must be willing to listen to everybody.

In a recent survey of 6500 critical-care nurses by the American Association of Critical Care Nurses, 85% reported that a safety tool--such as a handoff protocol, checklist, or computerized order-entry system--had alerted them to a potential safety problem, but 58% said they could not effectively speak up and solve the problem. "We have to be willing to speak up and make sure that everybody is comfortable doing that," she said.


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