Safely Decreasing Bed Rest in the EP Lab and Invasive Cardiology Pre/Post Holding Area: Experience at Penn Medicine – Lancaster General Health

Can bed rest time for the EP ablation patient population be safely decreased to two hours? In the Invasive Cardiology Department at Penn Medicine – Lancaster General Health, we recently noticed a significant difference in the ordered bed rest times after right heart catheterization versus after AV node ablation: only one hour for right heart catheterization versus four hours of bed rest for AV node ablation. Both of these procedures utilize the femoral vein, with the sheath size comparable at 8 French (Fr). Why then must the AV node ablation patient remain on bed rest for four hours, when a patient with a right heart catheterization via the femoral vein is safely discharged within one hour? In this article, I discuss the initiative to reduce bed rest time for EP ablation patients at our institution.

Getting Started

In December 2016, the Pre/Post Holding Area and Medical Outpatient Unit at Penn Medicine – Lancaster General Health merged to become one unit caring for both the cath and EP patient population. As a nurse in the Pre/Post Holding Area, I was unfamiliar with the complete post-procedural care of the EP ablation patient population related to their bed rest. It was during my orientation to this patient population in January 2017 that I noticed this difference in the ordered bed rest times between the cath and EP patient populations.

I felt further investigation into bed rest variation was important due to the possible implication on the care of the EP ablation population. If bed rest time for the AV node ablation patient could be decreased by half, it could potentially improve patient satisfaction and patient flow, decrease narcotic use for pain, and possibly decrease Pre/Post Holding Area staff overtime due to a reduced length of stay for patients post procedure. This would allow the unit to close on time each evening, and therefore, decrease the amount of overtime needed.

In February 2017, I decided to begin evaluating ways to safely decrease bed rest in the EP ablation patient population at Penn Medicine – Lancaster General Health. I began with an in-depth look at the differences between a right heart catheterization and AV node ablation. The most significant difference between the two procedures was the anticoagulation status of the patient prior to procedure. Although the pre-procedure order set for the cardiac cath patient and EP ablation patient were similar in their wording, it was always at the doctor’s discretion whether the patient could proceed with their procedure. The EP anticoagulation parameters were as follows: heparin/bivalirudin were to be stopped at 0400 the day of the procedure unless otherwise ordered by the physician, enoxaparin was to be held the PM before and AM of the procedure, rivaroxaban was to be held 24 hours prior to the procedure, apixaban was to be held for 48 hours prior to procedure, dabigatran was to be held 1-2/3-5 days based on the patient’s creatinine clearance/GFR, aspirin and clopidogrel were to be held per the physician’s order, and warfarin was not held, although there was an INR parameter. The pre-procedure cardiac catheterization order set anticoagulation parameters were as follows: heparin did not need to be stopped, enoxaparin was to be held the AM of procedure, rivaroxaban was to be held 24-72 hours depending on physician preference, apixaban was to be held 48 hours, dabigatran was to held 1-2/3-5 days depending on creatinine clearance/GFR, and warfarin was to be held 3-5 days prior to procedure with an INR parameter of less than 1.6 for femoral access.

A literature review was conducted searching for articles related to EP ablation procedures and bed rest. After extensive searches in multiple databases (CINAHL, ProQuest, and Ovid), a 2004 research study from the University of Virginia was found, in which the authors evaluated whether bed rest could be safely reduced from four hours to two hours for patients recovering from EP studies done via a femoral venous approach.¹ It was a small group study with exclusions related to sheath size (<8 Fr); however, anticoagulation status and ablation procedures were not evaluated.¹

After determining the differences related to anticoagulation status and procedures performed in our population (Figures 1 and 2), the next step was to examine the standard of care at other facilities in the area. I contacted Penn State Health ­– Hershey Medical Center (Hershey, PA), UPMC Pinnacle (Harrisburg, PA), UPMC Pinnacle Lancaster (Lancaster, PA), WellSpan Good Samaritan Hospital (Lebanon, PA), and the University of Pennsylvania (Philadelphia, PA). All facilities have EP labs that perform AV node ablations, and all utilize the same size sheath (8 Fr) and bed rest (4 hours) as Penn Medicine – Lancaster General Hospital. The only exception seen was at University of Pennsylvania, which at times utilizes a figure of eight suture that allows the patient to ambulate within one hour.

After gathering this data, I discussed the findings with the Manager of our EP Lab (Andrea Riefenstahl, MBA, BS, RN) in March 2017. We discussed how to get this information to the physicians, and she suggested presenting a one-page proposal to the Section Chief of our EP Department (Matthew A. Bernabei, MD), to see if he agreed that it warranted further investigation. During this meeting with the Section Chief, I shared my findings and proposed a 6-month trial to see if the decrease in bed rest was feasible and safe for our EP ablation patient population. The Section Chief suggested enlisting a physician champion to start a Performance Improvement (PI) project. About a week later, electrophysiologist Dr. Sandeep Bansal expressed interest and asked for additional information; shortly thereafter, he agreed to act as physician champion for this bed rest PI project. Initially, we discussed that he would decrease bed rest time from four hours to two hours for his ablation patients who were not on any anticoagulants, and we would compare those patients to his other EP patients who would still be ordered four hours of bed rest.

We monitored patients for complications over a 6-month period; this included an ultrasound of the groin to rule out AV fistula or hematoma with intervention, CT scan for evaluation of retroperitoneal bleed, and consultation with the vascular surgeon. Additionally, we monitored patient class (same-day discharge vs admission), amount of bed rest ordered, procedure performed, sheath size, number of sheaths, hemostasis time, anticoagulant status, complications, and discharge time. With the physician champion now secured, the Manager of the EP Lab and I also contacted the Institutional Review Board (IRB), and it was determined that IRB approval was not needed since the collection of data would be through chart reviews and not through direct patient interaction.

Results

By October 2017, we had compiled 6 months of data demonstrating that patients not on anticoagulation could safely decrease their bed rest to two hours. Dr. Bansal and I shared this information with the Manager and Section Chief to discuss next steps of the PI project. Dr. Bansal had 21 patients who were ordered two hours of bed rest, and 54 who were ordered four hours of bed rest. The data demonstrated that of the 75 patients, bed rest could be decreased to two hours and patients could be safely discharged after ambulation, compared to four hours of bed rest. With this data, the Section Chief, Manager, and Dr. Bansal agreed to change the bed rest times of all his patients, regardless of anticoagulation status (with the exclusion of patients with arterial access or those receiving a leadless pacemaker due to the size of the sheath).

I continued to collect the data from Dr. Bansal’s ablation patients from October 2017 to April 2018. I reviewed 69 patient charts, of which 61 patients were ordered two hours of bed rest, while the remaining eight were ordered four hours of bed rest. There were no complications during this time. I then presented this data to our EP physicians in May 2018. The data was shared so the physicians could discuss the project and disseminate the information. It was decided that data collection would continue, and I would report the findings to them in the next quarter.

From May 2018 through November 2018, I continued to collect and compile the data regarding bed rest. In October 2018, after a year and a half of data, I presented our EP physicians with a request to change our bed rest standard from the current four hours to two hours. The complication rate for two-hour bed rest was zero for Dr. Bansal’s ablation population. (Figures 3 and 4)

From October 2017 through December 2018, Dr. Bansal performed a total of 164 procedures. Of those 164 procedures, 144 were ordered two hours of bed rest. Of those 144 procedures, 124 were ordered two hours of bed rest and same-day discharge patient class. Of those 124 procedures, 101 were ordered two hours of bed rest and same-day discharge status; these patients were ambulated within two hours and safely discharged to home. Anticoagulation status was broken down to aspirin/clopidogrel (10 patients), warfarin (15 patients), novel anticoagulants (59 patients), and patients not on any anticoagulants (17 patients). Procedural breakdown was as follows: pulmonary vein isolation ablation (47 patients), SVT/WPW ablation (18 patients), atrial flutter or atrial tachycardia ablation (14 patients), VT/PVC ablation (12 patients), and AV node ablation (10 patients). Of the 101 patients, a total of 91 had an 8.5 Fr or bigger sheath in the femoral vein, and 81 patients had three or more sheaths in the femoral vein.

Conclusion

With this data collected, Dr. Bansal and I were able to successfully change the standard for bed rest from four hours to two hours. This PI project at Penn Medicine - Lancaster General Health successfully demonstrated that EP ablation patients can safely ambulate after two hours of bed rest regardless of anticoagulation status, sheath size, number of sheaths, and ablation procedure performed, and safely discharge to home. 

1. Gianakos S, Keeling AW, Haines D, Haugh K. Time in bed after electrophysiology procedure (TIBS IV): a pilot study. Am J Crit Care. 2004;13(1):56-58, 87.