Email Discussion Group II: Group "Housekeeping" Questions

Minimizing nephrotoxic effects What is your protocol for minimizing nephrotoxic effects of radiocontrast media in angiography patients? We use Mucomyst and adequate pre-hydration. What about iodixanol (Visipaque)? Do you have a stated protocol for using iso-osmolar dimeric nonionic contrast in high risk patients? Is it defined by serum creatinine? Monica C. Simpson, RN, MSN, CCRN Cardiovascular Clinical Nurse Specialist, The Heart Center of Excellence, Broward General Medical Center, Fort Lauderdale, FL mcsimpson@nbhd.org In addition to Mucomyst, we use Corlopam(fenoldopam). Increases in renal blood flow is demonstrated in hypertensive and normal patients when treated with Corlopam. The drug is infused 2 hours prior to the radiocontrast-requiring procedure. Start the infusion at 0.1mcg/kg/min, titrate every 20 minutes by 0.1mcg/kg/min, as long as SBP remains greater than 100mm Hg and diastolic blood pressure remains within 20mm Hg of baseline. Blood pressure and heart rate are to be measured every 15-20 min following every dose adjustment. Maximum dosage is 0.5mcg/kg/min. Continue infusion 4 hours post-procedure. We are investigating iodixanol now as part of a study, due to the expense we do not use it, yet. Hope this helps Roberta.Sparks@advocatehealth.com Heparinizing contrast Our cath lab currently heparinizes our contrast. Is this an institution-based concept or do other facilities do this as well? We originally started heparinizing the contrast when we stopped giving the patient routine heparin at the start of a diagnostic procedure. Currently we put 2,000 units per 200 cc bag of contrast. Connie, Meriter Hospital, WI csgehin@yahoo.com We do not heparinize our contrast. Annie.Ruppert@sharp.com I’ve never heard of doing this before. My first comment is that contrast material has it’s own anticoagulant properties. My second is, I wonder what the drug interaction in the contrast bag would be? Personally, I think it’s unnecessary. Mike Martin, Cardiac Services Manager Sharp Chula Vista Medical Center Mike.Martin@sharp.com I have been in a couple of places where Omnipaque was heparinized because the non-ionic contrast media has a tendency to be thrombogenic. The other agents have an anticoagulation agent in them. Chuck Williams, RPA(G), RT(R)(CV), RCIS, CPFT,CCT, Emory University Hospital, Atlanta, GA We heparinize our saline flush, not the contrast. In the lab we utilize 1000u/100cc saline (which is twice the standard for our nursing units). It is not enough to cause patient heparinization, but highly successful in keeping clots from forming during procedures. All equipment is flushed with this mix prior to use as well as while indwelling. Pam_Ragland@bshsi.com We have never heparinized contrast. annasmith@chi-east.org H&Ps on Inpatients How are you handling having H&Ps on the charts of inpatients prior to their procedure? My issues are with the patients who are direct admits in the evening, and then are scheduled for a 0530, 0630, 0730, 0830 or 0930 cath. Are you refusing to allow patients who do not have an H&P on their chart to have their procedure? carletta@weirtonmedical.com Hospital-wide policy requires a H&P on chart prior, otherwise the procedure is delayed. IF H&P not up to date, i.e., > 24 hrs prior, chart has to have procedure note by MD verifying is correct. If 7 days. Addendum must be dictated and typed. If > 30 days, must be performed, dictated and on chart prior to procedure. The hospital did a facility-wide education of MDs, and we also discussed with cardiologists as well as their office managers. Additionally, for OP (all), we have worked with MD office staff so that info is faxed as soon as procedure is posted or no later than 24 hours prior. Holding area staff review, put chart together, call for any missing info, etc. on the day prior. If labs are missing or values out of range, we have standing protocol that they are automatically performed on patient arrival by HA staff, who then notify MD of problem & any possible delay. We also utilize Point-of-Care Testing (all staff trained) so that labs can be repeated very quickly w/minimum delay. pam_ragland@bshsi.com It is our policy that the pt has a H&P on the chart when the pt comes to the cath lab. Our policy is that the pt is not done if there is no H&P. We do have a short H&P form that MDs can complete for the outpt population. Annie.Ruppert@sharp.com Patients need to have an H&P. Also, it must be a current H&P. If it is old then the physician needs to write an interval note in the progress notes to bring it up to date. We have a mini H&P that the physician can complete prior to the procedure that satisfies minimal requirements but it is not the standard. annasmith@chi-east.org Histories and physicals have to be completed on all patients prior to any procedure. We use an approved form at Emory that is handwritten and serves as the H&P. If we are in an emergent situation, the physician can complete a short form until the long form is completed. Chuck Williams, Emory University Hospital Atlanta, GA H&Ps are a JCAHO requirement. They should be on the chart prior to the procedure. Does not specify that it has to be transcribed and typed on the chart. At our facility we use an Outpatient procedure form which lists the elements of the History and Physical where the MD can hand-write this information. You might want to also check to see if your facility approves the Handwritten version or a note in the progress notes that H&P dictated at ?:00 o’clock; dictated but not typed, or a recent H&P faxed from the MD’s office if seen. Recently. I have had physicians who saw their patients up to one week prior to cath, fax the H&P to admissions or to the cath lab. Maybe you could institute a Users Group made up of cathing docs meet monthly to help with a consensus. We also have a policy that states Emergent procedures shall be evaluated by the members (peer review) to deter the practice of declaring an Emergent case just to get it on the table. Steve Gressmire, Cardiology Services Manager Northwest Mississippi Regional Medical Center, Clarksdale, MS Steve.Gressmire@nwmrmc.hma-corp.com H&Ps on the chart of inpatients or outpatients is a JCAHO standard. If it isn’t, there they could give you a type one citation. No H&P means no procedure in our lab. We do have a short form H&P that the cardiologist can use to hand-write one. Mike Martin, Cardiac Services Manager Sharp Chula Vista Medical Center Mike.Martin@sharp.com

NULL