Taking Emergency Preparedness to “Heart”

By Kelly Bemis

With the migration of cardiology cases into the ambulatory surgery center (ASC) setting, there are many things for center administrators to consider if they are thinking about adding these cases, the most critical of which is emergency preparedness.

The first thing you will want to do is take every possible step to avoid having an emergency in the first place. Emergency preparedness starts with establishing a clear set of guidelines for patient admission criteria. Cardiovascular patients often have multiple comorbidities and may be more vulnerable than your average ASC patient.

Prior to the procedure, the patient should undergo stringent pre-procedure testing, lab work and medical clearance. On the day of the procedure, it is critical to reassess the patient to confirm that they are an appropriate candidate for an outpatient procedure on that particular day and to allow the team to recognize even subtle changes in the patient’s condition that may arise during or after the procedure.

While complications in an ASC are infrequent, when they do occur, it could be catastrophic if you are not prepared. The most common complications for outpatient cardiovascular patients are hematomas. While most will be minor and resolve on their own, others can be life-threatening if not caught and treated early.

Other key considerations for emergency preparedness when performing cardiovascular procedures include having a highly trained and skilled staff, the appropriate emergency equipment and a dedicated crash cart.

Here are three more areas to focus on for cardiovascular emergency preparedness:

1. You will need an experienced cardiologist, cath lab-trained nursing staff and a cath lab-trained radiologic technologist or registered cardiovascular invasive specialist inside the procedure room. One of the essential ways to reduce the risk of groin hematomas is to use precautionary measures, such as the use of a micropuncture needle or ultrasound for vascular access which can help you lower your risk for these types of complications. In addition, having someone trained in sheath removal, manual compression and access-site assessment can be key in managing groin site complications.

2. At a minimum, there are three key pieces of emergency equipment you will want to have on hand—equipment not normally kept in a traditional ASC. These items are not used frequently, but, believe me, when they are needed, you will be glad that you have them and that your staff is trained to use them.

  • An intra-aortic balloon pump (IABP) is a therapeutic device used to reduce the workload of the heart. For instance, if there is a critical blockage, the heart is working very hard to pump blood, and so the IABP can be used to pump blood and allow blood to flow into the coronary arteries.
  • Covered stents are sometimes used when there is an arterial dissection or perforation. While there may be times when a balloon can treat the dissection, a covered stent is used to treat major complications that require an immediate bail out. The size of the vessel and the location of the damage can determine your need for a covered stent, non-covered stent or a simple balloon angioplasty.
  • Pericardiocentesis kits are used to treat symptomatic pericardial effusion or cardiac tamponade by aspirating fluid from the pericardial space. This can happen in the cath lab during coronary procedures when a perforation causes an accumulation of blood in the pericardial sac, thus putting pressure on the heart and causing irregularity. It can also occur during pacemaker or defibrillator implants with incidental lead perforation, typically through the right ventricle of the heart.

3. While you no doubt have a crash cart in your center, you will need to invest in a second crash cart that is fully stocked and dedicated to these cardiovascular cases. This cart should always be kept in the interventional suite.

As you can see, adding a cardiology service line to an existing ASC is both challenging and complicated. If you are thinking about adding cardiology cases to your existing ASC, the smartest thing you could do is proceed cautiously and ensure you have the cardiovascular expertise required to properly address the specialty’s unique quality and safety issues.

Kelly Bemis is the chief clinical officer for National Cardiovascular Partners in Edina, Minnesota. Write her at kbemis@ncplp.com.

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