Email Discussion Group: August 2008

There are several interesting new questions this month, including one about whether or not to discharge patients post procedure when there is no caregiver there to drive them home. If you can provide any input on any of the discussion questions, please email us at eplabdigest@hotmail.com or visit us online at www.eplabdigest.com (and click on the email discussion group link). Remember, when responding to the discussion group, don’t forget to let us know if you would like your name and/or location listed. We look forward to hearing from you! New Questions: Procedure Scheduling I am looking for references pertaining to block scheduling of procedures in EP labs. Does anyone use this method and what are the rules? — LeeAnne Hockey, RCIS, Sentara Heart Hospital, Norfolk, VA (To reply to this question, please type “Procedure Scheduling” in your subject line.) Electrocautery Cut/Coag Settings We are interested in collecting information on electrocautery cut/coag settings used by other facilities during pocket formation for devices. What settings are you using in your lab? Do you find that patients tolerate procedures better with fewer complaints of discomfort using lower settings? Can you keep sedation lighter by decreasing the discomfort from electrocautery? — anonymous (To reply to this question, please type “Electrocautery” in your subject line.) Discharging Patients After Sedation & Arterial Puncture Without Caregiver to Drive Them Home I work in a teaching hospital that has separate staff for the EP lab, Cath lab and Prep & Recovery areas. We have had patients arrive for their procedure without someone to drive them home or remain with them for the 24 hours post procedure. The patients either receive written instructions and/or a phone discussion about the pre and post procedure expectations, including information about having someone to drive them home and to stay with them for 24 hours after procedure because of the sedation they receive and the bleeding precautions. Other precautions, such as avoiding legal decisions for 24 hours, limiting activity for 7 days if arterial puncture, site infection prevention and assessment, and medicine changes, are again given to the patient and ‘caregiver’ both verbally and in writing, in which the ‘caregiver’ signs prior to discharge. We have had patients arrive without assistance, and staff notifies the MD as soon as possible. Some of these patients are ‘regulars’ here for device testing or transplant follow-up, and in the past, they were allowed to drive home. Sometimes the procedure is rescheduled, but sometimes the procedure is performed anyway and the patient is recovered ‘a little longer’ or even sent by cab to a nearby hotel. I am becoming more uncomfortable discharging these patients knowing that they are not following our written best practice plan. How do others handle this situation — do they always reschedule the procedure? Add a waiver for the patient and MD to sign? Or add a clause to the consent form if the patient insists on having the elective procedure? — anonymous (To reply to this question, please type “Discharging Patients” in your subject line.) Device Clinic Orientation Plans I would like to develop a comprehensive training program for technicians and midlevels in a busy ambulatory device clinic setting. Does anyone know of any online training manuals or competency-based orientation programs that I could reference? — D. Lavin, RN, MSN (To reply to this question, please type “Device Clinic Plans” in your subject line.) Hats and Masks In the March 2008 issue there was discussion about wearing hats and masks. We have been having the same major discussion. What are the standards, policies and procedures in other facilities? Are the physicians compliant, if not, how do you address this issue? — Karen Langston (To reply to this question, please type “Hats and Masks” in your subject line.) Under Discussion: Protocol for Tilt Table Study I recently encountered a superior manager who halted all tilt studies unless the physician was at the bedside. Prior to this we were performing these exams while the MD was in the lab, within close proximity, and not directly watching the patient. We are only tilting the patient on a table and if they do not respond to an 80-degree tilt in 15 minutes, we spray nitro under the tongue. The worst that has happened is they have gone asystole [during which time] we place them at zero degrees, give fluids, or at the worst-case scenario, give atropine. They immediately respond. Are there any rules which state that the physician must be directly at the patient’s bedside? Are the nurses not qualified to do this if the physician is not within arm’s length? — name withheld by request (To reply to this question, please type “Protocol for Tilt Table Study” in your subject line.) Operators Do other EP labs have both nurses and RTs operate the EnSite ablation computers and the diagnosis EKG computers (like Bard), or are these usually operated by just the RTs? — name withheld by request (To reply to this question, please type “Operators” in your subject line.) I am presently working in a dedicated EP lab staffed by 4 RNs, 3 RCIS's, 1 CVT and 2 RTRs. Complex ablations require a certain level of EP knowledge and skill. Once a person is able to operate the CardioLab and Micropace (our lab’s monitoring and pacing systems), then training with the St. Jude Medical EnSite mapping system is initiated. Presently I am teaching an RN to operate the CardioLab, and she will progress to the mapping system. There are two other RNs, 1 RCIS and 2 RTRs who I am teaching EP to and who have expressed an interest in learning the recording system. The Clinical Coordinator (an RCIS) and myself are the two seasoned EP personnel in our lab who are able to do it all. I have taken on the Clinical Education for EP and continue to learn every day. The staff who are willing to learn, commit their time to further their education, and maintain a level of professionalism in EP should be given the chance to learn the mapping and recording systems. Those who do not meet the educator's expectation in a given time frame will be the ones who scrub, monitor implants, do TEEs, CV and tilt table studies, and operate the burn box during ablations. Retention of EP personnel in the labs requires active participation from all of your staff; equipment and training should not be limited to certain personnel based on their credentialing. — Christine J. Reoch RCIS EP Schools I was wondering if someone can let me know if there are any EP schools other than the Carnegie Institute in Troy, Michigan? I live in upstate New York. — Ross Scardino (To reply to this question, please type “EP Schools” in your subject line.) We are an academic institution that is seeking RNs with CC experience who want to be trained in EP. Otherwise what we've found out is most EPs are trained in-house. — Rick Carlson, HR, University of Pennsylvania Health System, Philadelphia, PA Mobile EP Labs I was wondering if anyone is aware of any functioning mobile EP labs? I have found little information on mobile electrophysiology laboratories. I am specifically wondering how one is set up, the cost to run a mobile lab, funding for the lab, and how staffing works for this type of facility. — name withheld by request (To reply to this question, please type “Mobile EP Labs” in your subject line.) Conscious Sedation The discussion of “moderate sedation” or conscious sedation has been the subject of a lot of discussion in our lab. We are supposed to be sedating moderately, but we often find the physicians pushing for deeper sedation for DFTs. Currently we do not use CRNAs or anesthesia for this purpose; the RNs in the lab maintain adequate sedation levels. I've recently been researching “procedural sedation” to see if that would better describe what we do as opposed to moderate sedation. I continuously am searching for standards of practice for sedation in EP labs, particularly for long cases and DFTs. Any discussion would be helpful. — Jill, RN (To reply to this question, please type “Conscious Sedation” in your subject line.)