John Mandrola, MD

Disclosures

August 30, 2016

Ghazala Yasin is professional cardiology caregiver in Buckinghamshire, near London.

She cares for patients. She performs coronary angiography.

She delivered a confident             talk during a young investigators competition at the    European Society of Cardiology (ESC) 2016 Congress[1].

Ms Yasin is a nurse—an advanced practice nurse, and now, a skilled nurse angiographer.

Her study aimed to show that nurses can be taught to perform coronary angiography with the same safety, efficiency, and quality as doctors in training.

Dr Piers Clifford, one of her physician mentors, told me that "we did not train Ms Yasin to do angiography because we needed another person to do     procedures; we trained her to keep her in our department." Clifford said she had been a cath-lab nurse for 5 years and had advanced to the highest level in     clinical nursing. Going further in nursing meant moving into administration, away from the bedside.

Yasin wanted to stay in clinical care, and Clifford did not want to lose a talented and motivated caregiver. "Frankly, if someone has manual dexterity,     compassion, training, and common sense, they don't need to be a doctor to perform an angiogram; once you have seen 5000 angiograms [as she had], you know     which views to take, which catheters to switch to if intubation is difficult," Clifford said.

Her abstract presentation was a case study describing her path to mastery of one of cardiology's gold-standard tests.

The components of her training process included the normal things: supervision in informed consent, arterial access, intubating coronaries, achieving     hemostasis, dosing of X ray and contrast. She did a retrospective review of all her cases looking for vascular, cerebrovascular, or renal     complications.

She met with all patients before the procedure to give informed consent and tell them she was a nurse. Only a handful of patients requested another     operator.

Another hurdle was gaining approval. This was no easy task. It meant getting the okay from cardiologists, nursing boards, hospital committees, human     resources, and trade unions. Not surprisingly, training doctors voiced the loudest opposition, Yasin said.

During a yearlong training process, she performed 250 coronary angiography procedures, the number required for competence for doctors in training. Each of     these cases were audited, as were 143 procedures after training. The review revealed no quality issues.

For the study, she compared her results with those of first-year training cardiologists.

Repetition paid off. Success rate for radial and femoral access increased from 76% during training to 91% in the posttraining phase.

Compared with first-year cardiology trainees, Yasin's angiograms averaged less contrast use (72 vs 95 mL) and shorter X-ray time (2.42 vs 5.7 min).

Cost comparisons also favored nurse angiography. One 6-hour session per week carried out by the nurse angiographer saved €18.52, which added to €20,800     annually. "These savings," she said, "did not affect quality, safety, or efficiency."

In the discussion section of her talk, Yasin cited other published studies in which advanced nurse practitioners can develop skills once considered the     realm of doctors. The point being, her case study is a not an outlier.

She showed a slide listing many of the benefits of nurse angiography. One made me grin: now she can help train first-year doctors. Clifford confirmed this:     "When the trainees can't get access, she goes in to help."

Comments

This compelling case study is one of the reasons I love international meetings like ESC. A nurse—no matter how talented—doing coronary angiograms is     completely foreign to US physicians. "Cath" is our signature procedure.

Herein lies one of cardiology's problems. We love procedures—perhaps too much. Procedures are one part of our work. These techniques, these     physical maneuvers, require technical skills that medical training has little influence on.

But Clifford is right; being a skilled proceduralist requires dexterity, persistence, common sense, and compassion. Doctors own no monopoly on these     traits. If you work in a cath or electrophysiology lab, you know this is true. You also know A students in the classroom don't always achieve that grade in     a procedure room.

Another notable part of this story is the role of the healthcare system in allowing it to happen. In the UK, a cardiologist's salary is not tied to the     number of procedures he or she does. Outside of a small private practice, Clifford told me he makes the same daily wage whether he does one or 10     procedures. How can this not be a better system for medical decision making?

I'll close with a note for the doubters. I go to a lot of talks at a lot of medical meetings. Yasin's presentation is among the most polished I have heard.     Public speaking is hard, much harder than writing. There are no cut/paste options when you speak.

I asked Clifford how Yasin became so skilled at lectures.

He said it was her first public lecture! "She read a book on techniques for giving good talks. And she practiced a lot."

I rest my case.

JMM

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