Email Discussion Group: Site Verification

(Thank you to Judy Parham, Cath Lab Manager, Athens Regional Medical Center, Athens. GA, for our current discussion group question, below). Are any cath labs using a site verification process for diagnostic or interventional access sites? Our hospital is formulating a hospital-wide site verification process to identify the surgical site for invasive procedures. It has been difficult to apply the same rules for the cath lab as they use in surgery, specifically, marking the site and team verification of procedure/site prior to beginning the case. My questions are: 1. Do you have site verification practice in your cath lab? 2. Do you have a written policy covering this practice? 3. How is site verification done and by whom? 4. Do you use site marking (or contralateral site marking)? By whom? HAVE A SUGGESTION FOR A FUTURE QUESTION? Email us at cathlabdigest@aol.com Not applicable I really don’t think site verification applies in the cath lab. There are a limited number of access sites and all or any may be used if necessary to gain access for the procedure. Charlie, ccole@carilion.com No Policy We do not have a site verification policy in our cath lab. I’m not really sure how it would apply in the lab. Richard, rjohnson@mclancaster.net Physician’s preference I don’t think it applies to the cath lab; especially since often the access site changes during a difficult procedure. It is always the physician’s preference of which site to use, according to the patient’s anatomy and history. Dina Tortorelli, dina_tortorelli@chiltonmemorial.org Discussed with JCAHO We do not have a site verification practice or policy. We are an outpatient cath lab that just went through JCAHO. It was brought up and discussed; however, since we only have 1 lab and are responsible for the admission process as well, they were satisfied with our answer. I’m not sure this exactly applies to the cath lab. It’s not like we are removing parts of the anatomy. Angela McIntosh-Petrakis Director, The Outpatient Cath Lab anpetrakis@aol.com No At present, we do not do site verification in the cath lab. carolwy@waushosp.org Verification does take place In reference to a specific site verification policy, you will need to look at your specific policy and see if any of these apply. We do not put an X on the groin. That would be stupid. But this is what we do, and what is included in the policy that would pertain to us. 1. We verify the patient’s identity (name band and verbally); 2. We verify that the consent has been signed and that the consent agrees with what the patient was scheduled for, what is in the history and physical, and what the patient says they are having. At this same time, we incorporated the skin integrity documentation. It all depends how the policy is written. These things may be covered in a separate policy. Anna, annasmith@chi-east.org Difficult to apply No. Likewise, it is very difficult to apply this verification to the cath lab, so we have not done so. carletta@weirtonmedical.com Only for OR We do not have site verification for cath lab procedures. This is only done on OR patients. KathyVaughn, Jackson-Madison County Gen Hospital, Jackson, TN kathy.vaughn@wth.org No We do not have a site verification policy and procedure, nor do we do any markings on the patient. don.sanders@bhsala.com Legal Complications? I believe that site verification applies to surgical patients that are having a specific limb on anatomical site surgically repaired. The goal is to avoid operating on the wrong extremity. In the cath lab, the site access (or verification) is not the area of concentration, it is merely a means of accessing the body to define or remodel coronary arteries (or peripheral vessels in some cath labs). Our lab determines the site to prep by the following process. After the physician assess the patient, he/she writes on a card which site and what catheters are needed. However, we always prep two sites for the situation where one artery is accessed but met with resistance on insertion of the wire. Then the physician moves to the other site that was prepped. While not an everyday occurrence, it is not unusual for this to happen. I do not know the legal ramifications if a site is designated and not used (because of blockage). Say the alternate site ends up with a complication (as sometimes happens even when everything is done correctly). Does this place you in a precarious position because you did not use the designated site? Perhaps if the physician documents why the alternate site was used you will not have a problem. Site verification is unnecessary in the cath lab and perhaps even places you in an untenable position should complications arise. James Saine RN CCRN RCIS Education Coordinator Cardiac Cath Lab Munroe Regional Medical Center JamesSaine@mrhs.org Tech verifies which side Our facility does not use site verification for cath lab procedures. As others have previously stated, it does not seem pertinent for cath patients. We do, however, check with patients before pacemaker implants to determine if they perform some type of activity that may influence which side the pacemaker is implanted on. We have had some patients who hunt or are marksmen. For these patients, and others who perform activities that require specific usage of one arm, we use the opposite side. Besides the hunters, we have had tennis players, a commercial painter and a semi-pro bowler that all requested a specific site. These requests are referred to the physician for approval. When the patient reaches the lab, the tech usually verifies which side will be used for the implant before the patient is prepped. While this is not a formal policy, implant site verification has been handled in this way by most of our techs since I have been in the lab (over 13 years). ICD implants are done according to physician specification. This is almost always on the left side. rhood@communitymedical.org Both groins may be used We do not have a site verification policy in the cath lab. We sometimes must use both groins due to vascular tortuosity, etc. The same holds true for PPM and ICD implants. Nikki, NBroady@stmarys.org No Stony Brook University Hospital does not use site verification. Mary, mmaliszewski@notes.cc.sunysb.edu Previous surgical experience Before I entered the cath lab I did work in surgery for a couple of years. This is a quick synopsis of how it worked in surgery: 1. In pre-op: the preop nurse will verify with the patient the procedure and the site with the patient. If the patient is unable to answer the questions, a family member will verify. This would be checked against the permit and if all is correct the permit would be signed and witnessed by the pre-op nurse. 2. The intra op nurse will go to pre-op and check permit. During the pre-op interview, the intra-op nurse will verify with the patient and/or family the procedure to be done. At that time, the surgical site will be marked outside of the area. Some would use an X, some would use a checkmark. We all used blue surgical markers to mark the area (meaning that the mark should not be within the incisional area). After this is completed, any pre-op narcotics that are to be given, may be given. The patient may have pepcid, valum, reglan prior to this and AFTER the permit has been signed. 3. Intra-op: once the complete team, CRNA, Circulator, First Assist., and scrub tech are in the room, the permit is again read, usually aloud. Everyone must be in agreement to the surgical site before the area is prepped. If there is a question, then the MD is called to the room for clarification. Once the physician is in the room, verbal verification with MD is done. As far as within the cath lab, we prep both groins for all of our procedures. If there is a question about whether we will be using another approach, the room captain will verify with the physician before the patient is in the room or before the prep begins to what approach will be used. As a side note, in surgery there was one ortho MD who specialized in foot and ankle that made it a part of his pre-op orders to put a name tag on the side of procedure. Another MD would sign his name to the surgical area. If you are going to use a marking for site verification, I would discourage contralateral marking, as this could be confusing and could lead to mistakes being made. Kevin Rich, RN, BS, ldrich3@comcast.net Adds costs No. It wastes time. Excellent cardiologists coupled with excellent scrub assistants palpate the access site before local anesthesia is injected. This pertains to femoral sites, axillary sites, brachial sites, and radial sites. Marking the site adds costs to the procedure by having to use a proper marking pen and by adding time to the setup time. Have seen this whole techniques used a few times over the past three decades, I’ve found it always falls by the wayside. What OR nurses do and what cath lab nurses have no parallels. charleswilliams@mail.weber.edu Conscious sedation form altered We, too, are struggling with this JCAHO Patient Safety goal. Since we implant pacemakers, we are doing site verification as to which side the pacer is going to be implanted, but have found that for the most part, the doctor has not discussed it with the patient. We verify with the doctor which side to prep before starting to prep the patient. As far as cath procedures, we verify correct patient and correct procedure both with the patient and among the staff. We modified our conscious sedation form to include a check box that patient and procedure were verified. On our pacemaker implant record, we document side implant was performed on. Sherri.DeLashmit@BMHCC.org Policy pending Presently, we don’t have a site verification policy or process in the cardiac cath lab. We do have a policy in our O.R. We recently went through a JCAHO survey (11/02). During one of the mock surveys, it was suggested that the O.R. policy be implemented hospital-wide. We haven’t heard anything further. Craig Cummings, RCIS, FSICP Cardiac Cath Lab, Erlanger Health System Chattanooga, TN CumminCG@erlanger.org Scheduling policy includes verification Our scheduling policy (below) speaks to site verification, in that the physician is to state his preference for entry site at the time of scheduling, so that the staff can adequately prepare for the procedure. The staff may use his/her preferred entry site, and the physician may be aware that the patient has an occluded right iliac artery (staff should pick up on this by pre-procedure pulse checks) and may want to use a brachial approach. It just saves time in the long run from having to page the physician just to find out the approach. It should be listed in the scheduling process (maybe even on the informed consent). Steve This policy was submitted by Email Discussion Group member Steve (his comment, at right). CARDIOVASCULAR LABORATORY POLICY AND PROCEDURE MANUAL Subject: Scheduling POLICY: A copy of the Cardiovascular Laboratory schedule will be distributed to nursing units and other departments daily. PROCEDURE: 1. Copies of the Cardiac Cath Laboratory schedule will be distributed to: Nursing Services Ambulatory Care Surgical Services Admissions 2. The schedule will include: Patient’s name Patient admit status/room numbers Time of procedure Anticipated Procedure(s) Physician’s name Anticipated Approach 3. Scheduling is done on a first-come, first-served basis. Initial cases for the day will begin at 8 am. Subsequent procedures will be scheduled as: To Follow. Physicians will be notified as to which position the procedure is in at the time of scheduling. 4. Emergent procedures must be declared Emergent and will take precedence over scheduled procedures in the event a procedure has not been started. If so, the procedure will be completed prior to the emergency. 5. Emergent procedures shall include, but not limited to: a. Acute MI b. Temporary pacemaker insertion for unrefractory bradycardia c. Limb ischemia due to vascular compromise d. Sub arachnoid hemorrhage e. Impending stroke All Emergent procedures will be reviewed monthly by peer review committee to determine validity.

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