Increasing Patient Satisfaction and Throughput at Memorial Hospital: Self-Sealing Vascular Access with the AXERA Access Device

Can you tell us about the cath lab at Memorial Hospital?

Mike Bull, Manager, Cath Lab: We have three labs, and between prep and recovery and the cath lab, we have 32 staff. Eight cardiologists are part of our team and work in the labs, 4 who do diagnostic-only cases and 4 interventional cardiologists. We perform about 110 cases/week or 20-25/day, both cardiac and peripheral diagnostic and interventional procedures. We also perform pacemaker and implantable cardioverter-defibrillator (ICD) implants. 

Olivia Jones, RN, Supervisor Prep & Recovery Area: We have a 12-bed recovery unit and a 5-bed prep area. We recover all the cases from the cath lab, including inpatients, and we also perform transesophageal echos (TEEs) and cardioversions in this area.

How long has your facility been using the Axera device?

Olivia: Since February 2012.

Mike: Dr. Le, our medical director of the cath lab and an interventional cardiologist, was at a meeting and saw the Axera device. He brought back information and asked us to pursue bringing it on site. We brought in the representative, learned more about the product, and then primed for an implementation and a trial period.

What goals did you hope to achieve with the Axera device?

Mike: Over the three-week trial period, our three main goals were to continue to provide a safe environment for our patients, reduce time to ambulation and deliver high success rates. We have a safe practice right now and did not want to have more complications, so we were looking for safety. We also hoped to reduce our time to  ambulation or bedrest times in recovery. Finally, we wanted to make sure the device had a high success rate from the physician standpoint.

How did you achieve hemostasis and ambulate patients prior to using the Axera device?

Olivia: We used a variety of closure devices, but before the Axera was brought on board, we were seeing more and more manual compression patients. We seemed to be undergoing a period where the doctors were not using closure devices as frequently.

For our diagnostic patients, if a closure device was used, patients had to be on bedrest for 2 hours, but, as I noted, we were seeing more manual compression patients. In these cases, patients had to be on bedrest anywhere from 3 to 6 hours, with the average being 4 hours for a diagnostic. For interventional patients, the timeframe was 6 hours post sheath pull, and as you know, sometimes it would be 2 or 3 hours before the sheath could be removed. 

At 20-25 cases/day, and 12 beds in your holding area…

Olivia: It could pile up very quickly. Between the two areas, I would be juggling staffing and trying to find space to keep patients.

Whether it was a diagnostic or interventional patient, manual pressure required that we hold 20 minutes at a minimum, and sometimes longer. With the Axera device, we only hold 5 minutes for our diagnostic and 10 minutes for our patients who cross over to intervention. The shorter hold times alone speed up the process.

Were there any other challenges?

Olivia: With some of our closure devices, sometimes patients had what we call “the oozing groin.” We would fight it the whole time. We would inject epi-lidocaine around the site to help. Often we would have to hold pressure longer, meaning patients experienced a longer bed rest time, and would have to change out the dressing multiple times. With the Axera device, once hemostasis is obtained, the groin is dry.

What kind of complications are you seeing with the Axera device?

Olivia: Really, none. There may be an occasional hematoma, but nothing big, nothing that we wouldn’t have seen if the groin was accessed with the previous technique. 

How did physicians react?

Mike: They actually became used to the Arstaotomy technique very quickly. The company clinical specialist was available to answer questions during our validation period.  The physicians picked it up quickly and had no issues adjusting. There is a very high procedural success rate. We did not experience any issues with Axera implementation, and now the physicians are on board. Some physicians tried the device right away, and then other physicians got on board as they saw the success of their colleagues.

How has Axera use changed your lab?

Mike: We are using the Axera on most cases. We have always had high patient satisfaction, but the Axera has helped to increase it. Patients are much happier having reduced bed rest times — much happier. The device has also helped with efficiency and throughput in the holding area. On the days when we do 25+ cases, we run out of room very quickly. Getting those diagnostic patients up at 60 minutes after the procedure and on their way home safely has helped tremendously. Patient satisfaction, along with efficiency and throughput in our holding area, are the two biggest wins for us.

Olivia: Holding 5 minutes versus 20 minutes on a diagnostic patient and holding 10 minutes versus 20-25 minutes on an intervention or an anti-coagulated patient is easier not only on the nurse, but the patient as well, because they don’t have to endure that strong pressure on their groin.

The big thing is that I can keep the lab moving without delays due to space issues. I also know that even though my patients may be moving quickly through the post cath process, they are doing so in a safe manner.

Memorial Hospital also has a stat ST-elevation myocardial infarction (STEMI) program. On some days, we might see several STEMI patients come in that can push back our scheduled cases. While the patient may have waited a little bit longer in the prep area, they can still get their case done and go home at a reasonable hour, and as a result, we have found patient satisfaction can still be high. For example, we may start a late case at 6 pm and instead of the patient not being able to go home until 2 or 3 o’clock in the morning (or, because they don’t want to drive that late, spending the night when normally the case does not require it), the patient can be up in one hour, and out the door a half an hour after ambulating. Even if their case was delayed, patients are more understanding when they can ambulate quickly. Being able to send our late patients home in the evening also means we do not have to get extra staffing for the night (we do keep our interventional patients overnight).

Is your facility doing radial caths?

Mike: Occasionally, but not a high volume.

Can you talk more about how patients are recovered and ambulated?

Olivia: The sheath pull is sometimes done in the lab. Often, on diagnostic patients, because it is such a quick procedure, the sheath will be pulled in the lab. However, if we are trying to do a quick turnover, the sheath pull happens in the holding area. With the Axera device, basically it is the same as a normal sheath pull, but without having to hold pressure as long, because of how the sheath enters into the artery. Once we obtain hemostasis, a dressing is applied. We keep the patient flat for 30 minutes, then raise the head of the bed up 45 degrees. If it is a diagnostic case, the patient is up out of bed 30 minutes later, for a total of 60 minutes. We ambulate them in the area at that point, usually to the bathroom. The patient comes back and then sits in a chair for about a half hour to 45 minutes, just depending on the patient. During that time we bring the patient some food to eat, go over their discharge instructions, and they go home. If the diagnostic does cross over to an intervention, the process is the same, except the patient lies down for 2 hours post sheath pull. The head of the bed can still go up to 45 degrees after 30 minutes, and the patient gets up after 2 hours, but interventional patients stay the night and go home the next morning. The patients that are staying overnight are happier, because they are up out of bed and more self-sufficient. We are still taking care of them in the same manner, checking vital signs and administering medications, but the patients can move around however they would like to help maintain their comfort. 

Mike: If we do pull the sheath in the cath lab, the reduced hold time also helps room turnaround. There are some cases where we pull in the lab and some cases where we pull in the holding area. Holding 5 minutes of pressure for a diagnostic case versus 20 minutes obviously means a quicker room turnaround time. Staff has gotten used to using the device and everything has been fine.

Olivia: The physicians are happy mostly because they are hearing how happy their patients are, and cases are not being delayed because the holding and recovery area gets full. We can keep moving.

Mike: For our diagnostic caths, our average bed rest time was about 4 hours and now it is down to an hour. For interventions, it was 6 hours, and now it is down to 2 hours. That has been a huge advantage, both from the patient perspective and a throughput perspective.

Really, the Axera access is similar to traditional groin access; it just adds in an extra step that creates a different angle. Physicians have bought in and are using this technique successfully for both cardiac and peripheral work.

Olivia Jones can be contacted at olivia.jones@sih.net.

Mike Bull can be contacted at michael.bull@sih.net.