Email Discussion Group: Ongoing Discussions

New Question: Billing for Failed CRT Implant Does anyone know if CRT (DRG 535 or 536) covers the hospital's costs if the patient is a non-responder and must go to the OR for epicardial lead placement? name withheld by request (Readers, to reply to this question, please type Failed CRT Implant in your subject line.) Under Discussion: Placing Sheaths What about placement of femoral venous and/or arterial sheaths for EP catheters? Also, if non-MDs are placing sheaths, what are their qualifications, and are there protocols for credentialing, etc.? Esther Weiss, RN, MSN, Manager, Cardiac Arrhythmia Center The trainee is either an RCIS or RN, and must successfully place venous sheaths in 20 patients. The EP medical director proctors sheath insertion performed by the candidate for the first 5 -10 patients. The patients and the sheaths are documented. Once the candidate has successfully completed the 20 patients or amount specifically designated by the medical director, the medical director signs off on a form stating that the designated professional has successfully completed "number of venous sheath insertions successfully and is credentialed to insert venous sheaths in the EP lab on the medical director's patients. The physician must be present in the hospital during the venous sheath insertions. The Cardiology Committee is the governing body that approved the whole process. I should tell you that not all of the EP doctors permit sheath insertion on their patients. Dana St. John, RN, Fort Myers, FL When I've looked into having lab staff place sheaths in the past, I contacted the state Dept. of Health and the Nursing Board. Their answer was that the person would be held to the same standard as the practitioner that usually performs this task (the physician). Nurses would be working outside their scope of practice (so would the techs), so their malpractice insurance might not cover them if a case went to court. Rules may vary from state to state, so you would need to check. If you decide to proceed, make sure you have policies and procedures in place and that they clearly describe what the person can and cannot do. Policies signed by hospital administration that delineate responsibility (and accept liability) can help protect the staff. Just make sure your administration knows what you find out and agrees. Howard Mattingly, RN, Team Leader, EP Lab, Methodist Hospital, Indianapolis, IN Credentialing and Education for EPs Do you think there should be a credentialing exam for electrophysiology technologists, analogous to the RCIS examination? Also, in your opinion, is there a need for formal education programs for electrophysiology? Letitia P. Esbenshade-Smith, Staff Educator, Cardiac Electrophysiology Regarding credentialing and education for EPs, Carnegie Institute, located in Troy, Michigan, offers a 15-month Cardiac Electrophysiology Technologist Program. Our Invasive Cardiovascular Technologist and Non-Invasive Cardiovascular Technologist programs are accredited through JRC-CVT and CAAHEP. The Cardiac EP Technologist program grew from  our Invasive CVT Program as hospitals demanded trained specialists  to keep up with developments in diagnostic and interventional technology. Linda Ingraham, Chief Operating Officer, Carnegie Institute, Troy, MI I've noted some people feel that HRS should be considered for credentialing for EP. However, the guidelines state that the NASPExAM is merely a test. It's not meant to be any form of credentialing. So  it may be difficult for any institution to make passing it mandatory. My  facility simply encourages it on the staff member's own accord. Anonymous Anticoagulation During AF Ablations Do any EP labs use a continuous heparin infusion during atrial fibrillation (AF) ablations? If so, what is the concentration and rate of the infusion? What other anticoagulants are being used during AF ablations? Michelle Meyer, RN, BSN, Kansas City, MO We do not use continuous heparin gtt for anticoagulation purposes during AF ablations. If we go transeptal in any ablation, a weight-based loading dose of heparin is given IV and ACTs are then followed q 15 - 30 minutes throughout the procedure. Heparin boluses are given intravenously to maintain the ACT > 250. Protamine Sulfate IV is given at the end of the procedure, after catheters have been removed to reverse the anticoagulation effects of the heparin prior to sheath removal. Karen Wright, BSN, BS, El. Eng., Charleston, SC In our lab, a community hospital without medical students, once we have finished the transeptal punctures, we give a heparin bolus right away. This is usually 4000 - 5000 units of heparin. Then we start a heparin infusion to keep the ACT about 275 - 300 seconds. Our heparin infusion concentration is heparin 25,000 units in 250 ml of saline (100 units per ml). We then do ACTs every 30 - 45 minutes, and adjust the heparin infusion rate accordingly to maintain the desired ACT.  Once the catheters and sheaths are withdrawn from the left side of the heart, we stop the heparin infusion.  When the procedure is finished, we check the ACT, and if it is < 200 seconds, we pull the sheaths. If the ACT is quite a bit higher than 200 seconds, we often give Protamine IV to reverse the heparin so we can pull the lines.  Esther Weiss, RN, MSN, Manager, Cardiac Arrhythmia Center We use a heparin infusion for all procedures performed on the left side of the heart. It's a standard concentration (25,000 units/250 ml NSS), and we typically start at 1,000 units/hour and have it infuse through one of the femoral venous sheaths. We also give a heparin bolus when we start the infusion (usually 4000 - 5000 units). During the case we check ACTs every 15 minutes until we reach the desired level of anticoagulation (depending on the physician, anywhere from 220 to 300 seconds). We report the ACT, and the physician orders changes in the infusion and/or additional boluses as he desires.  After three consecutive ACTs are within the desired range, we check ACTs every 30 minutes. If we need to adjust the heparin again, we go back to ACTs every 15 minutes. Howard Mattingly, RN, Team Leader, EP Lab, Methodist Hospital, Indianapolis, IN I have seen the anticoagulation two ways. One method by heparin bolus, and the other by continuous infusion of heparin. Heparin amounts and drip rates are regulated according to ACT results performed every 30 minutes. Dana St. John, RN, Fort Myers,  FL