Pulling Sheaths on a Cardiac Stepdown

[ItalianRN, BSN, RN]

We were recently informed that we are going to start pulling sheaths, post PTCA's, on my floor. We get 5 pts during the day (up to 6), & normally 6 pts at night (up to 7 at times). None of us, except our Manager, feels this would be safe to do. The training that only a select few are being offered, is 4 hours in ARU.

I was told that my hospital tried this a while back, but stopped it because someone died. I guess it was so long ago that the powers that be have forgotten about it. I do not want to put my license on the line for this. Neither do my co-workers.

We spoke to some of our CCU nurses & they think this is insane. They told us that they don't even like pulling sheaths. We'll have to do this with at least 2 nurses because the pt. usually vagals out & has to receive Atropine immediately. I think this whole idea is insane!! Any thoughts of what we can do to protect our jobs & our license in this upcoming situation??? Even some of the docs are against it, but most of them don't care either way. Nice, huh??

Thank you for your responses in advance.

[WalkieTalkie, RN]

Our CPCU nurses pull sheaths all the time on days when their staffing ratio is about 1 nurse to every 3-4 patients. At nights, the patients come up to the ICU since the staffing ratio is lower. We routinely pull sheaths and it's really not that big of a deal, but it does require close monitoring, and with your staffing ratio, it doesn't seem like a a good idea since the patient is at risk for bleeding, hematoma, etc.

[ItalianRN, BSN, RN]

Thank you. That's exactly what we have been saying, but it seems to be falling on deaf ears.

[CrazyPremed, MSN, RN, NP]

On the tele floor where I work we routinely have 5 pts (true tele patients), and we pull sheaths. It drives me crazy, but it really is doable. The only thing that worries me is the situation in which the patient died. I would check with risk management and get the true story. Otherwise, it isn't too bad.

CrazyPremed

[Virgo_RN, BSN, RN]

We typically have 4 patients and we pull sheaths. It is totally doable. Any more than 4 patients and I start to feel unsafe.

[perkizme]

If you tend to have a lot of patients vagal down during sheath pulls, your RNs should check their technique. They're hitting the nerve right near the artery and not pinning down the artery specifically. I've been in on many a sheath pull and we always have atropine bedside but never have pts vagal on us. We rarely have hematomas either unless it was a pt that endured multiple sticks. Make sure RNs are using fingers, not fists, in technique and 2cm/fingerbreadth above site. We always have 2 RNs bedside or an RN and resident if no other RNs avail. (we're a teaching hosp). One to circulate, document vitals and check distal pulse while the other holds pressure. Though this is in a CCU with a 1:2 ratio and our cardiac stepdown with a 1:3 ratio. Sounds like this could be a poss. problem in your unit depending on the acuity of the other pts. We also check VS and site q15 x4, q30 x4, the q1 x4 after the pull. Is there a charge RN or RN manager who can assist with pulls? Addtional cath lab staff that can come up and help? Otherwise they need to give the nurses who will have pulls the easier assingments... Just my

[cvicugirl, BSN, RN]

:yeahthat:I'd also recommend training everyone on sheath pulls, not just a few. Training should include basic A & P review, technique, and troubleshooting (what to do when things go badly.) Ideally, the RN should have several pulls under his/her belt, with a variety of patient body types before going independent. If you still feel strongly against pulling sheaths in your environment, check your unit's Scope of Service (your Manager should have one.) This will delineate what types of patients are admitted to your unit, typical acuity, frequency of assessment and VS, and admission/discharge criteria. You might be able to argue these admissions if the frequency of vital signs and assessment exceeds your unit's scope of service, just a thought.

[UM Review RN, ASN, RN]

My info packet also included a couple of teachings on potential for injuries to the nurse doing the procedure.

https://allnurses.com/ccu-nursing-forum/ez-hold-use-171149.html

[SEOBowhntr]

If you tend to have a lot of patients vagal down during sheath pulls, your RNs should check their technique. They're hitting the nerve right near the artery and not pinning down the artery specifically. I've been in on many a sheath pull and we always have atropine bedside but never have pts vagal on us. We rarely have hematomas either unless it was a pt that endured multiple sticks. Make sure RNs are using fingers, not fists, in technique and 2cm/fingerbreadth above site. We always have 2 RNs bedside or an RN and resident if no other RNs avail. (we're a teaching hosp). One to circulate, document vitals and check distal pulse while the other holds pressure. Though this is in a CCU with a 1:2 ratio and our cardiac stepdown with a 1:3 ratio. Sounds like this could be a poss. problem in your unit depending on the acuity of the other pts. We also check VS and site q15 x4, q30 x4, the q1 x4 after the pull. Is there a charge RN or RN manager who can assist with pulls? Addtional cath lab staff that can come up and help? Otherwise they need to give the nurses who will have pulls the easier assingments... Just my

Good Post, pretty much sums up my thoughts. Having been pulling sheaths for just over 13yrs, I've seen quite a few go very easy, and I've seen quite a few go terribly wrong. If you're staffed 5-6 pt's to 1 nurse, then I'm not really sure that pulling sheaths would be a very good idea, 3-4pts. per nurse is quite manageable though.

[jaimeeann]

our cardiac stepdown unit ratio is 4/1 and we pull sheaths quite often. in my limited experience - 1 1/2 years - i have seen MANY that go well and have no problems. A few that have minor problems, and only 2-5 that had major problems and no one died the worst thing that happened was ICU nurses had to come up and help out - mainly because the patient was non-compliant about staying flat.

I would agree with the poster who said they need to be checking their technique. I've only seen atropine given once. It shouldn't be a usual thing.

[ghmccart]

it sounds like you are at one of those crossroads in life where you will be making a choice which will take you down two different paths. If you take the ethical stance in the sake of pt safety and safe practice for you it could mean your job at worst. If you just submit and go with the flow of an unsafe environment you will probably find yourself in a situation that you did not want to be in, pulling a sheath with unexperienced staff, with complications can go from bad to worse in seconds. You always have to choose how you will practice. If my leaders ears were that deff I would be looking for a new job. good luck, i applaud your energy

[MatthewRN]

I work in a CCU and we get every post-cath patient who a stent placement. Depending on acuity at the time, even pulling with a 2:1 or occasional 3:1 load can be a pain in the ass. I tip my hat to anyone who is doing it with a 4:1 load because I just don't see how you do it.