What Is Going On With Cath Lab Flow?

Ashley Remillard, BSN, RN

Picture This

You are a telemetry nurse a few hours into your twelve-hour day shift. You have four cardiac patients assigned for the day, and you are trying to organize your plan of care for your shift. Two patients are pending discharge, one has an MRI scheduled, and the other—let’s call him Mr. Ganz—is scheduled for a cardiac cath. You’ve finished your morning medication pass and are beginning the process of discharging your two stable patients. Suddenly, the cath lab charge nurse calls you.

“Good morning. Are you the nurse taking care of Mr. Ganz?”

“Yes, I am.”

“Great, we are ready for him. Please have him prepped and downstairs as soon as possible. Thanks!” —click—

I know what you must be thinking—This is going to completely throw off my plan for this morning. I need to get these patients discharged; admissions are waiting in the ER. My other patients need me right now. Why couldn’t the cath lab give me a heads up?

I want to preface by saying not all facilities run this way. If you work in a facility with top-notch cath lab flow, cheers to you! However, in my experience as a traveling cath lab nurse, many cath labs operate with a choppy flow system. But this isn’t necessarily due to poor organization or lack of management—it’s the nature of the beast. To help you understand, I’d like to explain what a cath lab does and how it operates.

What Happens in the Cath Lab?

Cardiac catheterization is performed by injecting contrast media into the coronary arteries and capturing live pictures via X-ray imaging. Images are taken from multiple different angles to visualize any blockages in the arteries. Taking these images is the diagnostic portion of a cardiac catheterization and typically takes 45 minutes to complete. If there are no significant blockages, the procedure is over, and the patient can return to their room. If the physician finds blockages that are treatable with stents, these will typically be taken care of immediately during the same procedure. Depending on the complexity, coronary interventions can add anywhere from 30 minutes to a couple of hours to a procedure.

The Cath Lab Is Not an OR

Operating rooms work on a strict schedule, blocking out designated start times and procedure lengths for each patient’s surgery. Because the patient has undergone all of the necessary diagnostic testing before their surgery, the surgeon knows exactly which procedure needs to be done and how long it will take to complete. There is typically minimal deviation from the schedule unless there is an unforeseen emergency or complication.

In the cath lab, it is impossible to know what each procedure entails until we capture our initial images during the diagnostic portion of the case. Until then, there is no way to determine how long each procedure will take, making scheduling and flow incredibly challenging.

The Schedule Changes. A Lot.

In addition to the unpredictable nature of each procedure, there is the added difficulty of accommodating urgent and emergent cases in the daily schedule. It’s impossible to know when an acute MI will roll into the emergency room, and if an inpatient suddenly starts having unstable chest pain, they will take priority over a stable patient.

The schedule of a cath lab on any given day is incredibly fluid and changes often. A day that starts with a handful of simple outpatient procedures can quickly turn into a hectic day filled with emergencies and a lot of grumpy patients that need to be rescheduled. I assure you that cath lab nurses are doing their best to keep the schedule moving as smoothly as possible. Sometimes that means pushing cases to later in the day, rescheduling cases, or trying to get patients downstairs as quickly as possible.

Working Together for Our Patients

Patient care is always a collaborative effort, which means we should all be sensitive to each other’s workflow. Communication is critical, so if there is something important you must tend to before bringing your patient to the cath lab, just let the team know. I guarantee the charge nurse appreciates it.

I encourage cath lab nurses to exercise the same respect. Unit nurses are extremely busy juggling multiple patients with time-sensitive needs, so it is unrealistic to expect them to be at the cath lab’s beck and call. If you are a cath lab nurse, be respectful of your peers by giving them a fair amount of time to safely finish what they are doing before bringing the patient to the cath lab.

Five Tips for Prepping Your Patient for the Cath Lab

Now that you have a better understanding of the goings-on in the cath lab, I want to share a few tips that will improve patient care and make the day run smoothly for everyone.

Check your orders. If you were told in report that your patient is scheduled for a cardiac cath, double-check the orders to ensure the physician has entered the procedure. If the procedure isn’t ordered, it is unlikely that the patient is on the cath lab’s schedule. Be sure to communicate with the appropriate people in charge to ensure nothing is missed.
Aspirin. Fluids. Antiplatelets. This step depends entirely on your facility’s protocol, but many cardiologists want their patients to receive a full-strength aspirin and prehydration before their cardiac cath. Check your orders and facility policy first. If your patient is taking an antiplatelet medication (Plavix, Brilinta, Effient), check with the cardiologist before holding this medication. It is often okay for the patient to take this before the procedure.
No Breakfast. Sips of water with their morning medications are perfectly acceptable, but please make sure your patient doesn’t eat breakfast. Not following NPO orders will significantly delay the procedure, often till the next day. Make sure any family members are aware of this as well to avoid any delays in care.
Have Your Patient Ready Early. Because it’s difficult to predict when the cath lab will be available for your patient, it is best to have them ready early in the day. You will be able to check this off your to-do list and continue the rest of your tasks. When the cath lab is ready, you’ll feel relaxed knowing the patient is all ready to go.
Communication is Key. Patient care consists of many moving parts, so make sure you are communicating with your team as often as necessary. Don’t be afraid to call the cath lab charge nurse if you have questions, concerns, or if you want a general idea of when they might be ready for your patient. Even if the charge nurse can only tell you, “we probably can’t get to that patient until late afternoon,” you will at least be able to update your patient and plan out the rest of your day.