Email Discussion Group: October 2008

Take a look at this month’s discussion questions and let us know if you can provide any input. Our most frequently asked topic certainly has been about the RCES exam — we’ve had several readers ask about it! 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: EP Fellowship I would like to know what types of paid fellowships are available. I have done my post doctoral in cardiology and followed it up with an interventional cardiology fellowship. Therefore, my total duration of cardiology training is five years’ certification and licensure from India. — Dr. Joy Sanyal (To reply to this question, please type “EP Fellowship” in your subject line.) RCES Exam I am planning on taking the RCES exam and have two questions: 1) Do you know of any review seminars for this exam or review materials? 2) If you have taken the exam, what (if any) compensation did you receive from your place of employment (i.e., increase in pay, step/level increase)? — Janeen Jones, RCIS (To reply to this question, please type “RCES Exam” in your subject line.) Under Discussion: Hair Removal Does your facility shave the patient prior to an EP procedure in the procedure room or in the pre-op area? — Martine Kinman (To reply to this question, please type “Hair Removal” in your subject line.) At Columbia, we generally shave the patient in the procedure room as it provides the most privacy and lends itself to the order of preparing the patient for the procedure. We also sedate the patient at the same time to reduce procedural anxiety; logically it makes sense because this is the time for Foley insertion as well (if warranted). Our pre-op area tends to resemble Grand Central Station during rush hour, so the procedure room is the best setting. — Edmund Donovan, Clinical Nurse II, New York Presbyterian Hospital At our facility, we do not shave hair. Shaving abrades and nicks the skin, leaving a portal for infection. Instead, we use electric clippers. They are used for both groin preps and chest preps. All preps are done outside of the procedure room — either in our pre/post procedure area or in the patient's room. After the preps are completed, the patient gets a clean gown and fresh bed linens so that hair is not carried into the procedure room. — Sue Deck, BS, RN, RCES Our Infection Control Department and the CDC recommends clippers for hair removal on the grounds that shaving can cause nicks that defeat skin integrity (CDC1999). Evidence shows that infection can form in small cuts made by a razor. We prefer to clip before entering the procedure room, but this is our preference rather than firm policy. — John Fisher, MD, Director, Electrophysiology Lab, and Mariane O'Shea, CCRN Mgr., Cardiac Cath and EP Lab, Montefiore Medical Center 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.) 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.) 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.) Hats & Masks Inside the Lab 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 “Inside the EP Lab” 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. — Jill, RN (To reply to this question, please type “Conscious Sedation” in your subject line.)