Pulling arterial sheaths - page 2

In our ICU, the patients usually come down from the cath lab with the sheath still in the groin, and the RNs pull them after a few hours. Until recently, we have not had too many problems with... Read More

  1. by   VU RN BSN

    OMG! That is a scary, worrisome situation you guys are in right now!

    I have worked in the past as a CCU nurse (Coronary Care Unit) and as a med/cardio telemetry floor nurse. As a night shift CCU nurse we had 2 patients. As a night shift tele floor nurse we had 5-6 patients.

    In the CCU, since it was a critical care unit, RNs were trained to pull arterial sheaths and we had to perform that quite frequently. As part of our CCU orientation, we spend an entire day in the cardiac cath lab, we spent 2 days in the cardiac recovery room (kinda like cardiac PACU) where they pulled sheaths day in and day out, and then we had to be supervised pulling several sheaths in CCU before we could be signed off on the skill. Since CCU nurses had 2 patients each, it (usually) wasn't a big deal to be stuck in your patient's room with them for 30 minutes or longer while you pulled the arterial sheath and held manual pressure and monitored them. Typically, if need be, one of your CCU co-workers could keep on eye on your second patient. Also, for those of us who were newbies and still nervous about the possible complications during sheath pulls, we could almost always get the charge nurse or another experienced nurse to stay in the room with us just incase something went wrong. They usually had 1-2 patients and their patients were usually stable, so they could be away from them for a short time without a problem.

    On the telemetry floor, RNs never ever pulled sheaths. A patient's sheath had to be pulled by a qualified nurse in the cardiac recovery room and the patient had to remain there for one full hour post sheath removal before they could be transfered to our tele floor. Thank God for that!! Working on a telemetry floor, taking care of 5-6 patients is soooo different from working in a critical care/coronary care unit, taking care of 2 patients!

    I don't mean to insult anybody, and I hope I don't get flamed for this, but I think it would be really really dangerous for floor nurses to be forced to pull arterial sheaths!!

    Heck, I can remember working with CCU nurses who had been working as critical care nurses for 20+ years who admitted to feeling a bit nervous every time they had to pull an arterial sheath, because they knew there were the risks of complications. Many of them had horror stories to tell, after all their years of experience. But, atleast in a CCU or CVICU or CTICU or CSU or a cardiac recovery room, the patient is on a monitor and the monitor is right in front of your eyes. You only have 2 patients, so it's managable to be inside one patient's room for 30+ minutes. If your second patient is really unstable, then usually the charge nurse can help you deal with that.

    On a busy telemetry floor, where the RN is responsible for 5-6 patients, that's a whole nother story! In my experience, the rooms in tele floors do not have a monitor at the bedside. Yeah, I guess you could bring in a portable monitor, but those things are never as good. But more importantly, a tele floor nurse is responsible for a lot more patients. How can a floor nurse be expected to be stuck in one patient's room for over 30 minutes, holding manual pressure on a groin, and unable to leave, when they are responsible for 4-5 other patients? Let's be honest here, we all know for a fact that many patients nowadays are admitted to telemetry floors who should technically be in the critical care unit, but since there were no remaining ICU/CCU beds, they shipped them over to tele instead, right? Many tele floor patients are just as sick as the ICU/CCU patients, but for whatever reason, they ended up on telemetry, instead of in the unit.

    Personally, I believe that you and your co-workers have a right to protect your nursing licenses. I personally believe that a Registered Nurse should never ever be forced to perform a critical patient care skill that they are not comfortable performing, especially if this is a patient care task that has the risk of death if complications arise. And, no offense to anybody, but I believe patients are much safer having delicate procedures (such as arterial sheath pulls) done in the unit by a critical care nurse than on the busy floor by an understaffed floor nurse.

    My advice would be to start a petition and have all your co-workers sign the petition. Also, you could request a special staff meeting where the nurses could discuss their concerns with your nurse managers together all in the same room. Do some research and try to find out if any studies have ever been done comparing the rate of complications from arterial sheath removal by a floor nurse versus a unit nurse.
  2. by   Virgo_RN
    Our staffing ratio is one to three days, one to four eves, and one to five nights. We have our sheath patients on bedside cardiac monitors as well as the central monitoring station. We have a vital sign protocol that includes BPs every three minutes during sheath removal until pressure on the groin site is no longer needed. Our telemetry unit has been pulling sheaths for many years, with an extremely low complication rate. Our sheath patients are very safe.

    Pulling sheaths on the floor can be done, but your management has to be willing to consider the acuity of these patients and the fact that they require frequent VS and groin checks, are one to one for at least thirty minutes during the pull, and that if anything goes wrong, they will be one to one until they are stable. You can't give one of these patients to a nurse that has a heavy patient load already, and you have to have standing orders or a protocol order set in place that the cardiologist signs off on before shipping them to you. You need adequate training not only in how to pull sheaths, but what to do in different situations. Your facility needs to do its homework and develop a policy and procedure that is evidence based, best practice. To do otherwise would be unsafe.