Countess of Chester

OPERATIONAL POLICY

PROTOCOLS & GUIDELINES

FOR THE

CARDIAC CATHETERISATION SUITE

CONTENTS

Section 1 Operational Policy

Section 2 Pre admission clerking

2.1 Fasting Guidelines for cardiac angiography

Section 3Admission for procedure

3.1 Patient care; Pre procedure

Section 4 Variances

4.1 Patients taking oral metformin/glucophage

4.2 Patients with Renal Failure

Section 5 Catheterisation Laboratory

5.1 Nursing

5.1.1 Checking patients into the lab

5.1.2 Procedure for checking swabs and instruments

5.1.3 The role of the circulating nurse in the laboratory

5.1.4 The role of the scrub nurse

5.1.5 Sedation administration and observation

5.2 Cardiac Physiology

5.2.1 Setting up procedures

5.2.2 Catheter recording protocol

5.2.3 Non invasive monitoring in the laboratory

5.2.4 Dealing with emergencies

Section 6 Infection control

6.1 Universal precautions and infection control

Skin prep pre procedure

6.3 Clearing and cleaning of trolleys

6.4 Donning gown and gloves for a sterile procedure

6.2 Latex Policy

6.3 Protective theatre wear and lead protection

6.4 Patients with MRSA

6.5 Post procedure cleaning of the lab

Section 7 Emergencies

7.1 Cardiac/Respiratory arrest

7.2 Care of patient receiving IABP therapy

7.3 Ambulance transfer policy

7.4 External pacing

Section 8 Line removal/wound care

8.1 Femoral arterial and venous line removal and early mobilisation post angiography

8.2 Care of a patient post angioseal device insertion

8.3 Femostop use and placement when lines are in situ

8.4 Femostop use and placement for a bleeding artery

8.5 TR band placement and use.

Section 9Post op and discharge

9.1 Patient care post procedure

9.2 Routine transfer of patients to and from Wards/CCU

9.3 Safe discharge protocol

Section 10 Visitors to the unit

10.1Company Representatives visiting the department

10.2 Visitors non essential to patient care

Section 11 Environmental

11.1 Policy for Checking Defibrillator

11.2 Environmental/Safety Checks

11.3 Reporting faults/malfunctioning equipment

11.2 Manual handling

11.3 Risk assessment

Section 12Staff management

12.1 Annual Leave

12.2 Conducting a Staff Meeting

12.3 Sickness and absence procedure

SECTION 1

OPERATIONAL POLICY

1.1 Introduction

1.2 Nursing

1.3 Medical

1.4 Cardiac Physiologist

1.5 Radiology

1.6 Administration & Clerical

1.7 Stock Control

1.8 Hotel Services

1.9 Waiting Lists, Booking of Patients & Medical Records

1.1Introduction

The Cardiac Catheter Suite is situated on the first floor of the CARE building, adjacent to outpatients three, Countess of Chester NHS Foundation Trust Hospital.

The main functions of the Cardiac Catheterisation Laboratory and Catheter Day Suite are:

Cardiac Catheterisation.

Timetable

Cardiac Catheter Laboratory

The Cardiac Catheter Laboratory will run for an average of 6 sessions each week of diagnostic cardiac catheterisation .The lists will run from 09:00 hours until 12:45 hours each morning and 13:30 hours to 16:45 hours each afternoon. The timing of the lists will be flexible to accommodate difficult or urgent cases.

Catheter Day Suite

The day area consists of 10 Stryker trolleys, two located in side rooms, each with a patient locker and curtains to provide dignity and privacy. As male and female patients will be admitted, it is essential that privacy and dignity is taken into account when patients are admitted.

Hours of Opening

Routine Day Cases

Patients booked for the morning session will be asked to arrive at 08:00 hours. Patients on the afternoon list will be invited to arrive at 12:30 hours.

Unless there are difficult or complex cases which take longer than anticipated the final case of the day should be on the table before 16:00 hours.

Patients Requiring Overnight Stay

Occasionally some patients will be unsuitable for a day case procedure due to social or medical reasons. Patients in this category can be booked into a Cardiology Ward the day of the procedure and stay overnight post procedure. It is important to inform the Clinical Co-ordinator as early as possible. These patients should be identified at pre-operative assessment. This will be the responsibility of the Consultant or Registrar delegated to the organisation and overseeing of the pre-assessment clinic.

In-Patients

Some patients on the wards or CCU after being seen by a Consultant Cardiologist may require to have inpatient catheter studies.

Only patients fulfilling the strict criteria for in-patients will be listed and studied. The Inclusion/Exclusion criteria MUST to be checked by the Catheter Lab Manager or Deputy and Consultant BEFORE any such patients are listed.

These patients will be booked via Consultant to Consultant referral depending who is doing the list.

Pre-Operative Assessment

Elective patients from COCH will be screened approximately 3 days prior to the procedure. The pre-operative assessment date will be given to the patient when they are booked for the procedure. Initially, the consultant or registrar will undertake the pre-operative assessment using the pre-assessment care pathway developed for this purpose.

1.2Roles and Responsibilities

The Nursing Team

The nursing team consists of the Clinical Leader, two Nursing Sisters/Charge Nurse and three Staff Nurses. There is a Health Care Catheter Lab Assistant, who works under the direct supervision of the registered nurses.

A named nurse will be responsible for the running of the list on a day to day basis. Although this may not always be a senior nurse, any junior staff will be supported in this aspect of their development.

Staffing levels

Catheter Laboratory

This will be staffed by two nurses, one of whom will be ALS certificated.

Cardiac Day Suite

This area will be staffed by at least two nurses, one of whom will be ALS certificated. Due to the nature of the work, the staffing levels will rise during the day to care for the patients immediately post, procedure, and then fall, as patients are ready to discharge.

All staff must undergo competency-based training and will be assigned a mentor. Continuous peer evaluation and feedback will ensure high standards of care are maintained.

Responsibilities

Pre-Clerking

The Cardiologist or Registrar will oversee clinics.

Patients from Wrexham will be clerked by their medical teams at the start of the morning/afternoon session who will ensure written consent has been obtained.

Admission and pre procedure

It is a nursing responsibility to ensure that patients are appropriately prepared for their procedure. This will include the collection of personal information, accurate completion of the care pathway, obtaining and interpreting physical observations, cannulation and phlebotomy, and the reduction of any patient anxiety through good communication and information giving. The Nurse will check that a consent form has been completed as per protocol 5.1.1.

The circulating nurse will be responsible for patient comfort and the provision of explanation when necessary. He/she will provide equipment for the scrub team and ensure that documentation is accurate. He/she will also be proactive, observing the patient, anticipating any problems and ensuring that the laboratory is organised and prepared for emergencies.

The scrub nurse will assist the doctor directly. It is their responsibility to ensure that equipment is prepared correctly, that the sterile field is maintained, and that the environment is safe from, for example, sharps. This nurse will also work in a proactive manner, anticipating the needs of the operator, and being prepared in the event of an emergency.

The laboratory nurses will be responsible for the safe delivery and hand over of the patient back to the day case area.

Post procedure

Nurses will ensure that the patients' arterial and venous lines are removed safely, and that the patients' recovery is closely monitored for complication. Medical advice will be requested as appropriate. Patients will receive post operative and discharge advice, with supporting literature, and will have the opportunity to ask questions regarding their future treatment. They will only be discharged when they meet the criteria set down in protocol 9.3 and have been seen by their consultant. The nurse must liaise with the Medical Team in the case of any problems.

Patient Transfer to other wards

Registered nurses are required to collect patients from the unit, in cases of routine inpatients or overnight stay. This will usually be to a Cardiology ward or CCU.

Patient Transfer to CTC

Once a CTC bed has been identified, and a consultant to consultant handover has taken place, an ambulance will be requested for transfer as per the unit protocol. The consultant attending the case will decide which personnel will transfer the patient, according to clinical need.

Dress code

All members of the multidisciplinary team will be dressed in theatre scrubs. This will allow staff to move between the day case area and the laboratory should an emergency require them to do so.

Within the laboratory, all staff will wear hats, and hair should be tied back. Jewellery etc will be as per hospital policy.

No scrubs or theatre shoes to be worn outside the suite, unless an emergency dictates this.

Annual Leave and Study Allowance

Only two members of staff, one sister and one staff nurse, may be on annual leave at once. The manager will consider all other annual leave and study leave requests, if the unit is fully covered.

1.3 Medical Responsibilities

The Consultant will be responsible for the appropriate conduct and safety of the procedure. Under no circumstances should a trainee start a case without the express wish of the supervising consultant and then only when the Consultant is present in the catheter laboratory. All operators are expected to have seen the patient before handover and be familiar with the patient.

Sessions

There are start and finish times for the laboratory sessions and all staff are asked to adhere to these so as to ensure an efficient running of the service. Only operators and trainees approved by the Clinical Director will be allowed to be involved in the procedure.

Consent for Inpatients/Outpatients

All patients will be required to sign an informed consent form. The consent should be obtained by a consultant responsible for the case or by the catheter lab trainee assisting with the procedure at the Consultant's discretion.

Appropriate pre-medication may be required by patients and prescribed by the Medical staff.

Contrast Allergies

Patients with contrast allergies should receive non-ionic, low osmolar contrast should be premeditated with steroids (see existing protocol for guidance). Patients with renal insufficiency should be adequately hydrated before and after the procedure (see protocol 4.2). Special management should apply in patients on Warfarin or diabetes particularly if on Metformin (see guidelines).

Puncture Site Management

The Consultant Cardiologist will supervise the management of the puncture site. Catheter Lab nursing staff competent in sheath removal will assist with the majority of sheath removals. Trainees will also be given the opportunity to do this under supervision of the consultant or an experienced catheter lab nurse. Femoral closure devices, Femostop and Angioseal, will be used in selected cases only. The haematoma and pseudo aneurysm rate will be monitored for different groin closure methods and devices.

Discharge

All patients will be seen by the Consultant operator prior to discharge and have a treatment plan and their results explained and any questions answered.

Data Collection

The pre-procedure demographic and risk factor information will be entered onto the Tomcat Database System at the time of pre-admission. The operator will be responsible for entering the procedural details and results.

Overnight Stay

If a patient is required to stay overnight, the patient's own team will hand over care to the on call Consultant Cardiologist. The nurses will liaise with the duty bed manager to find a suitable bed (usually on a cardiology ward or CCU). In the event of a requirement to emergency transfer a patient to the Cardiothoracic Centre, medical case handover will be arranged between the operating consultant and the accepting consultant at CTC.

Inpatients

Requests for inpatient cases should be discussed with the nurse in charge and consultant operator responsible for the list.

Cover of Lists

Consultants not able to perform a list due to planned leave will have informed the waiting list co-ordinator as soon as leave was planned. Lists will therefore not have been booked. In situations of unexpected short notice all efforts will be made to cover the list internally, otherwise the list will be cancelled.

Procedure for Emergency Transfer to CTC

If emergency transfer to the CTC is necessary the consultant must refer the patient to the consultant on-call. Only when a bed has been identified will the senior nurse ensure that emergency transfer takes place according to protocol 7.3 "Emergency Transfer" and protocol 7.2 "Care of Patient Receiving Intra-aortic Balloon Pump Therapy". The consultant in charge will decide which staff are to accompany the patient.

Operational Issues/Incidents

The Operational Manager of the Cardiac Catheter Laboratory will inform the Clinical Services Manager and Clinical Director of any operational issues and clinical incidents. Incident forms are found on the intranet.

1.4Cardiac Technicians

Technical aspects of the Catheterisation Procedure will be provided by appropriately trained & ILS certified technician, approved by the Principal Technician. Technicians in training must be supervised directly by an appropriately trained senior technician.

The Cardiac Physiologist's Role

• To monitor the patient's haemodynamics during cardiac catheterisation, i.e. ECG, NIBP, Sp02, invasive cardiac pressures, cardiac outputs, etc.
• To communicate any abnormalities to the operator in an effective manner.
• Initiate cardiac arrest procedures and act accordingly to policy, i.e. to defibrillate patients in VF/pulse less VT, or externally pace patients in asystole.
• Check and maintain equipment, which the physiologist may use or be responsible for i.e. Physicon, HP defibrillator, Blood Gas analyser, Balloon Pump, Dash monitor, Temporary pacing box, etc.
• To liase with Biomedical engineering to report faults on equipment and if necessary take corrective action.
• To ensure adequate stock control for all appropriate supplies i.e. electrodes, transducers, transducer sets, heparinised saline, defibrillator paper, etc. To liaise with supplies department.
• Ensure that all equipment and working environment is kept clean, in accordance with Trust's Health and Safety Policy.
• Ensure that animate and inanimate leads are moved safely in accordance with Trust's Manual Handling Policy.
• To participate in training other members of staff, whether that be more junior physiology, nursing, medical or administrative staff.
• To ensure continuous professional development in invasive procedures and promote good practice initiatives within the Cardiology Directorate.

• The Physiologists will be expected to begin at 08:45 am, to enable them to set up all the equipment needed for the session.

Procedure for Haemodynamic Monitoring/Recording

Switch on Fysicon and defib, (see defib checking policy, appendix 1).

• Check blood gas analyser and put through a QC.
• Set up monitoring transducers (setting up procedure policy 5.2.1).
• Welcome patients, check details, attach ECG and Sp02 if necessary.
• Attach monitoring lines and record pressures (see haemodynamic recording and monitoring protocol 5.2.2).
• Physiologist must remain vigilant throughout the whole procedure. He/she must communicate any changes in haemodynamic state IMMEDIATELY and act accordingly (see protocol 5.2.4).
• Print out any haemodynamic calculations and blood gas analysis reports and ensure that it is entered into patient's case notes.
• Physiologist will record pressures from fysicon system in control area of the Catheter Lab.
• Disconnect patient and participate in safe transfer to Day Ward.

Breakdown Policy

In the event of Witt Failure

Nursing Staff

Ensure patient safety – use alternative ECG monitoring facilities – M3 monitor. Scrub or circulate nurse to:

• Switch on M3 monitor
• Attach M3 monitor ECG leads to patient using electrodes
• Observe patient status

If need to observe patients invasive blood pressure, i.e. that a cardiac catheter is inserted into the patient then:

• Disconnect Witt electronic pressure lead from logical transducer
• Attach electronic pressure lead from M3 monitor to the logical transducer
• Observe patient status

Contact Operational Manager or Deputy

Technical staff

Contact Fysicon- using #6 581 or 00800 00653333

Request G5 reset

Fysicon will require an access code to dial into the system.

This is obtained by given using the remote access card kept in the top drawer of unit

How to use remote access key card

• Press on
• This will ask for code No:
• Enter code 5114
• Remote access ID number displayed – relay this to Fysicon Technician
• Press on to switch card off
• Follow instructions from Fysicon technician

In the event of card failure use the telephone,

• Dial 5114 and press option 2

• If the technician answers tell them you are calling from the Cath lab and the Witt system has failed.
• They will follow procedure and let you know what is happening
• If this goes to voice mail hang up

Then use bleep system to

• Bleep 2370
• How to use bleep system Dial 82 then bleep no 2370 and extension number from which you are dialling

So dial

• 82 2370 6238(cath Lab)

This will be answered almost immediately

• Tell them you are calling from the Cath lab and the Witt system has failed.
• They will follow procedure and let you know what is happening

Witt System Reboot is successful

Consultant and technician will decide if procedure will continue.