In this interview from Cath Lab Digest, Joel Sherwood, RN, CCRN, CV Line Educator, Chest Pain Center Coordinator; Dr. Martin Weiss, Medical Director, Cardiovascular Services; Kathleen Whelan, MHA, VP of Operations; and Terry Rives, PhD, Director of Research, JPS Health Network/John Peter Smith Hospital, Fort Worth, Texas, talk about their use of a new technique for patient relaxation in the lab. Can you describe the cath lab at John Peter Smith Hospital? Dr. Weiss: We are a 500-bed county hospital in Tarrant County, Fort Worth, Texas, mostly serving an indigent population, and county funded. We started developing cardiovascular services about six years ago, and in mid-2004, built our first cath lab. We currently have one cath lab and do about 1,500 patients a year, both diagnostic and interventional procedures. We do angioplasty without surgery on site, for acute myocardial infarction (MI) and elective cases. We take all comers, and have backup arrangements for surgery with a private hospital about two miles away. Have you been doing interventional procedures since you first opened the lab in 2004? Dr. Weiss: We started interventional procedures in 2006. We got things rolling for about a year, then developed the interventional program, which is novel to Fort Worth. Fort Worth, Texas, had no hospitals that were doing angioplasty without surgery on site, so it was a big step forward for our county. It is still unusual in most of the country. Dr. Weiss: It was really necessary for cost and care of our county indigent patients. It was an exorbitant amount of money to transport all of these patients over to the private hospital, then transport them back. The charges we were getting were quite high. Moving to interventions was cost-driven, but with the cath lab staff we put together and the physicians doing angioplasty at that time, we felt we had enough experience and there was enough literature backing us. Fortunately, we’ve only had to send two patients that crashed from angioplasty to emergent surgery, both of which survived and came out with normal ventricles. We even had one artery perforation where we were able to put a covered stent in the native left anterior descending artery (LAD) and do periocardiocentesis. We do about 400-500 interventions a year. We do have plans for a second and a third cath lab to increase our cardiovascular services, but that will probably come over the next two years, as we revamp all of our services and try to build a heart hospital within the hospital. How many physicians and staff does the cath lab currently have? Kathleen: We have four physicians in the cath lab and we have eight dedicated cath lab staff that includes RN, RT and RCIS staff members. We just hired an RN to be team leader for the three invasive labs: two special procedure labs and one cath lab. Tell us about the audio video glasses and how you decided to do the study. Joel: A few things helped to build the idea of doing a study. One is that John Peter Smith Hospital is striving to improve patient satisfaction. We recently adopted the Studer model (www.studergroup.com) just for that reason. We wanted to engage staff to a greater extent in looking at how we can improve patient satisfaction. Kathy Whelan, who is our director, charged us to come up with different ideas. The concept of using the glasses came while I was having a dental procedure. During this somewhat painful procedure, I was able to watch a movie on a flat-panel screen while wearing headphones. I thought it would be a great thing for the cath lab. However, we can’t just plaster a flat screen up on the ceiling or off to the side. With all of the different views that we take, patients would only be able to see the screen part of the time. I googled “audio video glasses,” and found this company called Myvu. For about $110, we purchased a pair of glasses. I already have an iPod movie player, and the very next day after I received the glasses, I placed them on a patient. Of course, this was after getting all the necessary approvals. After the procedure, when we asked the patient to share their experience, they said it was “awesome” and “I can’t believe you have something like this. It really helped with my anxiety. I felt much better. I was able to focus more on this than the procedure.” Next, I went to the internal review board and underwent the lengthy process of initiating this study to see if the glasses could evidence a reduction in patient anxiety and perception of pain. Study inclusion criteria are that patients are 18 and older. We’re not going to involve the vulnerable patient population of less than 18 years old. Plus, we typically don’t do younger than 18-year-old patients. Exclusion criteria are that patients can’t be prisoners (because we can’t do proper follow up). They can’t be an emergent case. Patients have to be able to put the glasses on. They can’t have eyewear or earwear for some type of visual or hearing impairment that would not let them fully participate in watching the movie. Thus far, we have done a pilot study of 30 patients. Ninety-eight percent say that they would want to have the glasses again if they needed another cardiac catheterization. We have also gotten the response from patients that they are very pleased at how the glasses are initiated immediately after they get their prep done in the holding area. During those sometimes long delays of 20-40 minutes before the patient actually goes back for a cath, they can start watching a movie. They continue watching throughout the procedure and even during the recovery. It definitely helps to reduce patient anxiety and their overall general discomfort in having to wait at various points during their stay. Kathleen: What we have heard from the patients post procedure is that they are very happy to have something to focus on while laying flat on their back and waiting to go up to the unit or to be discharged. It allows them an opportunity to take their mind off the procedure and not just look at the ceiling. We’ve seen an improvement in our patient satisfaction as a result. What do you do if you need to speak to the patient during the procedure? Dr. Weiss: Every once in a while that may happen, but as you know, the simple diagnostic cases go about 5 minutes, so that’s usually not a problem. However, we can pull the earphones right out of the patient’s ear, and even sometimes just talk around it, and they’ll nod to us. We’ll tell them, “Everything looks good, no problem,” and they’ll nod their head and say, “Thanks. Can I get back to my movie now?” It’s been interesting in that respect. If we have to go into angioplasty, we will just pull the little earphone out of their ear temporarily, explain everything to them, and get consent to move forward. Usually the patient will say, “Yes, do what you have to do, thank you, and can I get back to my movie?” The reduction in anxiety has been amazing. Patients receiving conscious sedation are still awake and still ask you questions, and the banter back and forth can get a little much. The glasses kind of put the “kibosh” on all of that. Yet it still is easy to talk to the patient. It’s easy to take the glasses off. Initially, the response from some of our nurses was uncertain. They said, “I’m up at the head of the bed and I like to watch the patient’s eyes so I can see what is going on.” However, the glasses are so small that it hasn’t even been an issue. You can clearly see the patient’s face, read facial expressions, and even see around and through the glasses to the patient’s eyes. It hasn’t really hindered that aspect of nursing during a case. Kathleen: Unless they start laughing at the movie. Interesting. What effect does that have? Dr. Weiss (smiling): It messes up our pressure waveforms! Joel: The glasses are made in such a way that the patient can participate at any level they choose. If you look above or below the glasses, then you cannot see the movie. You have to look straight ahead. So the patient can choose or not to look at the movie as it is going on during the case. Dr. Weiss: Exactly right. The glasses do not cut off peripheral vision. Do you anticipate any effects on the level of sedation? Dr. Weiss: We will be looking at the amount of sedation in the study. The more a patient needs to be sedated, the longer they need to stay in the holding area after a simple diagnostic. With our holding area being limited to four beds and doing the volume that we do, we need to get patients up and out. We use closure on almost every patient, and if we can limit our sedation, which is what we are hoping to do, we can ambulate these patients, get them up and around a lot quicker, and hopefully avoid some of those vagal types of episodes from a little too much morphine or fentanyl. The glasses hook up to an iPod movie player. Dr. Weiss: That’s exactly right. You can play music videos, TV shows, movies, whatever the patients want. The glasses are a standard device that’s out there on the market (myvu.com). It hooks up very easily. There’s no plug-in or anything else to it. Where do you rest the iPod? Joel: The iPod is in a little case and we Velcro it to the head of the bed where we have a little metal extension. We truly appreciate the folks at Myvu, because when they got word of us putting this study together, they actually gave us a second pair at their cost. They gave us a complementary pair at a $300 value, called Myvu Crystal, and the only thing that they requested in return was that if we ever published anything, that we definitely mention them by name, and of course we want to honor that. You’ve tested 30 patients so far. What are your plans for the study? Joel: The initial 30 patients were part of a pilot study in order to test out the survey. Our goal is to do 300 patients over a 12-month period. We’ll also be doing a 30-day follow up. Patients may be raving about the glasses immediately after the procedure, but we definitely want to get 30-day input from them as well. Dr. Rives: At the time Joel came to me, I was chair of the institutional review board. We looked at this as a study that was pro-patient. We went through an arduous process of getting the methodology right. For this type of study, 300 is a large amount of patients. We believe it will enable this study to withstand peer review, which is important. In the pilot study, we did find that the glasses lessened the sedation, which is a good thing. Also, the patients are more satisfied. One element which we haven’t examined yet, but that we hope to within this large study, is to see if there is a financial impact on the hospital. We are a county hospital, so any reduced cost allows us to essentially treat more patients. The thing I liked most about the study is that it is designed around patient safety and satisfaction, and the risk appeared to be little, if any. Use of this type of “distraction” is standard operating procedure for dentists these days. This study was Joel’s brainchild, and when he came to me, I was impressed that the hospital would be looking at something for patient comfort and lessening of patient anxiety. That’s not always done. Right now we have 90 open research protocols in the hospital. Some of them look at patient satisfaction. But this is the first one that looks at patient satisfaction that we think we have measured in the pilot. The survey gives the patient a chance to express whether they were less anxious or not, while the clinical personnel — the nurses and the physicians — make their observations at the same time. Dr. Weiss: So many hospitals are focused on cost and patient outcomes that we forget about just doing a nice thing for the patient and how we can help the patient out, irregardless of cost. Using the glasses seems to have so little downside and so much upside, at so little cost, that why shouldn’t we do it? It’s almost a no-brainer. If we prove our hypothesis right, that we use less sedation, that’s excellent. But if our hypothesis is wrong and we use the same amount of sedation, who really cares? If the patient feels good and likes using the glasses, at no cost or detriment to the patient, why shouldn’t we do this? Dr. Rives: Absolutely, I think that was the spirit of this study from the very beginning. Any final thoughts? Joel: Of course, all patients will be consented. Even though it seems like there is no real possibility of harm, we will go through all the real processes of the IRB to make it as official as possible and give it credibility as a study. We are excited about doing things as we usually do here at JPS Hospital, in the spirit of a desire to improve patient satisfaction and overall quality. We are hoping to get a good result from the study. Dr. Weiss: It’s been very rewarding to me as a physician. This study is yet another way we are providing excellent care to Tarrant county patients. This article was reprinted with permission from Cath Lab Digest 2009;17(11):1,28-30.