Pain Assessment in the Cath Lab

[toomuchbaloney]

This week the cath lab sent a patient to the telemetry unit post stent placement who was confused, agitated, and complaining of back pain 9-10/10 and a body temp of 97.1 F.

The cath lab nurse addressed his pain in this manner. "He got as much fentanyl and midazolam as we could give him but he wouldn't lay still." Post procedure orders included ONLY po Vicodin. The nurse was in a hurry to get to the next case in a very busy schedule.

The painful patient reported that he had told the team, when they put him on the table, that the padding under his hips had moved and he was not comfortable. He told them that he had an old lumbar fracture with arthritis and they needed to reposition his hips because he was in increasing pain.

The team responded by saying "you're going to be sleeping anyway" while giving him an IV dose of midazolam. No one repositioned him for comfort, they ignored his request. This patient is a retired RN.

It took the telemetry/ICU team almost 5 hours to obtain a single order for MS 2m IVP which finally provided the poor guy some relief. Not before his poor spouse struggled that entire time to keep her crying, diaphoretic, hypertensive, and painful husband still enough to keep him safe.

Because of his painful agitation the pressure dressings could not be reduced on schedule. 48hour bruising involved all of his anterior lower abdomen, down his inner thigh to just above his knee, his scrotum collected blood, and the floor of his perineum was fully involved.

In my view, this is horrible nursing care and I believe that this patient should complain to the Joint Commission. What do you all think?

[MunoRN, RN]

That's certainly not typical of any cath lab or cath recovery that I've worked in, analgesia is typically needed to be given liberally in the recovery period in a patient with a bad back. There is no option for the Docs which allows them not to order post-procedure fentanyl or similar IV analgesia.

If this was a planned elective procedure then ideally they should have been a radial approach, which would have avoided many of the issues with their back. The ability to reposition during the procedure with a groin approach is pretty minimal, particularly once he sterile drape is on and the groin is accessed, and BP can limit the amount of analgesia that can be used.

It sounds like the patient for some reason went to a care area that normally doesn't do the initial cath lab recovery (sheath pulls, groin management, etc)?

[toomuchbaloney]

It was an add on case secondary to ED visit with chest pain and elevated labs.

They tried a radial approach but the fellow has a congenital cardiac defect which causes tortuous thoracic vasculature. The cath team was told this information by the patient and his spouse but the team told them they would try radially anyway.

So the guy was restless and painful with 2 arterial wounds.

In this hospital he went to the ICU/telemetry unit where they recover ALL interventional patients. Low BP was not an issue as he was hypertensive with the pain of 10/10 (+ diaphoretic and nauseous) at arrival to unit. They simply kept repeating fentanyl and versed trying to get him to lay still during the procedure and then brought him to the unit.

During that 4-5 hours post procedure one other ICUpatient coded and one of the earlier cath patients started bleeding...the ICU nursing staff was overwhelmed.

[MunoRN, RN]

I should point out the most concerning thing is the description of how the site was managed. I sort of hope that by "pressure dressing" you're referring to something like a femostop, which is a device used to help achieve hemostasis of the vessel. But it sounds like you are referring to a regular pressure dressing to keep blood from exiting the puncture site, which is very bad practice.

The goal in pulling a sheath is not to prevent blood from exiting the puncture at the surface of the skin, it's to stop the vessel itself from bleeding. The tract left by the sheath isn't where the vessel bleeds out of, it's just a window to help assess the bleeding of the vessel. I have seen where some nurses don't understand this and think that if they can just get hemostasis at the puncture, often using some form of pressure dressing, that will mean they've stopped the bleeding, when really all that means is that the patient is now bleeding internally rather than both internally and externally.

As far as the pain control goes, there's nothing really specific to the cath lab or cath recovery in terms of pain management skills, it's the all the same basic concept which all acute care nurses should understand. Some patients are fairly resistant to fentanyl, so if repeated doses aren't having any apparent effect then another type of opiate should be used. The downside to that is that other opiates are longer acting, which shouldn't have been a problem for the cath lab nurse. When the patient is in the cath lab, they are still going to require acute pain control that continues well beyond the case, usually for at least for the few hours the patient will need to remain flat and largely immobile.

While I get the idea behind using an ICU as a post-cath recovery in my experience it's a bad idea. I would guess Anchorage has a relatively low case volume for heart caths, which makes having a specialized recovery staff all the more important. Having low case volumes and using an ICU to recover patients only worsens the low volume problems.

[toomuchbaloney]

I appreciate your replies.

The care was not delivered in Anchorage but rather in Fairbanks. They have been practicing this level of care there for a couple of years now.

This fellow has had 5 heart caths now. His last was in 2011. He has NEVER had back pain secondary to positioning previously. Apparently they were using femostop type devices on both his wrist and groin.

I have never worked in the cath lab, but this situation seems really really unacceptable to me. How can they ignore a pain level of that magnitude and then hand the patient off to the telemetry/ICU staff with nothing but oral vicoden ordered? Isn't that pain assessment and resolution a huge issue for JC?

[michlynn, BSN, RN]

Generally if they use a closure device like starclose, angioseal, perclose, etc. then the use of a fem stop isn't needed and a pressure dressing would be the norm- which is also why we are assessing the site for bleeding and hematomas constantly. But anyways, it doesn't matter how "busy" the cath lab is, they need to address the pt's pain accordingly or a doc should have given some orders for the floor nurse. If that was my pt the doc would have been called until the pt's pain was at least tolerable. I would probably bring it up to someone...

[dianah, ASN]

I would first initiate an internal examination of the events r/t pain control and how it was handled -- an "incident report" or "Patient Event Report," whatever it is called in your facility.

Use facts. Not vindictiveness.

The goal is for something like this to NOT happen again, for patients' pain to be controlled, for a necessary study to be completed so the plan of care may proceed in the patient's best interest (adjust care according to study findings), for hemostasis to be maintained.

Not knowing what went on during the study, I cannot speak to how the patient positioning or pain control was handled.

Perhaps the patient was unstable at times, or the catheter position was tenuous.

Perhaps concern for the patient r/t the study itself (it was a technically difficult study) was high enough that patient comfort took a back seat to patient safety.

Neither you nor I can second-guess what happened during the exam.

You, however, can address what happened after, when the patient was in your care.

You can question why the original order was basically too little, too late, and that it took 5 hr to achieve adequate pain control.

Remain objective and keep the focus on patient care, with the goal of improving "how we do things."

Let us know how things progress, and kudos to you for pursuing better patient care!

[toomuchbaloney]

Actually, the patient was not in my care. I heard about it from his son, my colleague.

[MunoRN, RN]

The JC provides accreditation services for a regulatory agency (CMS) but isn't a regulatory agency itself, so outside of a survey process I doubt they will do much. The state Dept of Health might be more likely to weigh in, although that's certainly not automatic since bad care isn't necessarily illegal, unfortunately. What you might have more success with is someone within the hospital who has both the power to do something about it, and would care enough to something about it. A CNO, nurse manager, or clinical experience person might be good places to start.

[MendedHeart]

Follow the chain of command. Manager, Director, ethics committee, corporate compliance line if available. Joint commission and cms take pain management seriously but don't jump the gun.

[toomuchbaloney]

Follow the chain of command. Manager, Director, ethics committee, corporate compliance line if available. Joint commission and cms take pain management seriously but don't jump the gun.

The family, including the MSW family member complained to the unit, to the patient relations liaison, and to the cardiologist.

What is jumping the gun about reporting to JC early?

[toomuchbaloney]

The JC provides accreditation services for a regulatory agency (CMS) but isn't a regulatory agency itself, so outside of a survey process I doubt they will do much. The state Dept of Health might be more likely to weigh in, although that's certainly not automatic since bad care isn't necessarily illegal, unfortunately. What you might have more success with is someone within the hospital who has both the power to do something about it, and would care enough to something about it. A CNO, nurse manager, or clinical experience person might be good places to start.

I did a little review and discovered that the JC accredidation of the hospital in Fairbanks, where this happened, is currently at risk secondary to their recent JC review. The Director of Nursing was just asked to resign, and they are trying to gear up to regain status.

Seems like maybe the JC might like to hear about stuff like this as they prepare to revisit the interior of AK.