A newly published consensus statement outlines how cardiac catheterization laboratories can best operate to ensure quality patient care and safety. The document, written by an expert committee of the Society for Cardiovascular Angiography and Interventions (SCAI), appeared online March 20, 2012, ahead of print in Catheterization and Cardiovascular Interventions.

“This paper will provide a benchmark for cath labs,” SCAI president Christopher J. White, MD, of the Ochsner Heart and Vascular Institute (New Orleans, LA), said in a prepared statement.

While more technically oriented materials on cath lab equipment and operation exist, “we wanted to put together a kind of handbook that is very practical and user friendly, and really puts the patient first,” lead author Srihari S. Naidu, MD, of Winthrop University Hospital (Mineola, NY), told TCTMD in a telephone interview. Accordingly, the paper’s recommendations are organized around a typical patient’s movement through the lab, with practices divided into those applicable before, during, and after the procedure.

Before: Checklist of Essentials

As a baseline, cath lab physicians and all staff including nurses, technologists, and physician assistants should maintain proper credentialing and have adequate experience. Procedural outcomes including success rates and hospital complications should be documented.

A checklist is recommended to ensure that no preprocedural reviews or evaluations have been overlooked. This includes:

• Planned procedure

• Patient history and updated physical
• Issues regarding sedation and analgesia
• Patient’s medications and ability to adhere to required regimen
• Necessary lab work and baseline ECG
• Assessment of bleeding risk and drug allergies
• Informed consent

In particular, informed consent should cover what the procedure entails, its risks and benefits, potential complications, and the alternatives, all presented in lay language and if possible in the presence of a third party. Any treatments that may flow from a diagnostic procedure should be discussed.

During: Time-out for Review

The physician performing the procedure should manage sedation, and appropriate staff must monitor medication administration and any side effects as well as the patient’s hemodynamic and respiratory stability. Careful attention should be paid to minimizing radiation exposure, with fluoroscopy times and patient total radiation dose recorded.

Just before catheterization, a ‘time-out’ is recommended to brief all team members on the:

• Patient’s name and medical record number
• Procedure to be performed
• Access route to be used
• Availability of the equipment needed including the intended stent type for PCI patients
• Patient’s allergies and premedication
• Special lab or medical conditions (eg, elevated international normalized ratio [INR] or chronic kidney disease)

After: Patient Discussion and Hand-off

The attending physician should discuss the results of the procedure as well as any complications or unexpected findings or events with the patient and family. This information must also be documented and passed along to all the patient’s healthcare providers. The management plan and any medication instructions such as for dual antiplatelet therapy should also be set out and the importance of adherence explained. In addition, any discrepancies between hospital and home medications should be reconciled. Arrangements should be made for follow-up evaluation with the interventional cardiologist or primary care provider 2 to 4 weeks after discharge.

According to Dr. Naidu, the SCAI document incorporates many of the practices that regulatory agencies such as the Joint Commission have been asking hospitals to implement, such as checklists, time outs, and hand-offs to the recovery room or referring physicians.

Although cath labs have intuitively gravitated toward many of these practices, he observed, they have not had a comprehensive written statement detailing them. “Now they can look at this and say, ‘Well, we’re doing 80% of these, but here are things that are missing and that make good sense from a patient care standpoint.’”

One area in which some labs may currently fall short is preprocedural preparation, Dr. Naidu suggested.

“Not all labs have a robust system to make sure that all the appropriate information is documented in the history and physical and in the charts,” he said. “Because that is becoming one of the most important parts of the procedure, we decided that would be a great place for a checklist, to make sure that you have addressed everything that could potentially be a problem.” In particular, that includes making sure that a patient who may receive a stent is a candidate for dual antiplatelet therapy, ie, is not facing upcoming surgery or at high bleeding risk.

More Reiteration Than Innovation

Although he welcomed the paper, Morton J. Kern, MD, of the University of California, Irvine (Irvine, CA), told TCTMD in a telephone interview that it is “pretty much a reiteration of standard textbook material.” For most cath lab personnel, it will “reemphasize what they already know and probably what they already do,” he said.

Noting a reference to physician trainees, Dr. Kern said the document “appears to be written with training programs in mind.” He praised inclusion of a preprocedure checklist and emphasis on evaluating eligibility for dual antiplatelet therapy, both of which guidelines sometimes overlook. On the other hand, failure to mention radial access for patients with a high INR indicating bleeding risk is a “minor omission,” he commented.

Dr. Kern acknowledged that the document highlights a number of practices not included in most cath lab handbooks, such as medication reconciliation, physician hand-off, and follow-up evaluation. However, he added, that is because these aspects are part of hospital-dictated standard medical practice rather than specific to the cath lab.

Overall, Dr. Kern found use of the term ‘best practices’ to be a stretch in characterizing the SCAI recommendations. “They may be the current practices and appear to be the best,” he said. “But to be ‘the best’ you have to have outcomes.” In fact the authors call for further research into cath lab processes and quality improvement.

Nonetheless, Dr. Kern concluded, leaders in interventional cardiology “will be happy to know that the codification of cath lab activity is now well established and people should comply in order to reduce errors that cause injury.”

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