Nurses and Patients Realize Physical and Economic Benefits of the AXERA Self-Sealing Access Procedure at Sinai Hospital of Baltimore

Can you describe the holding area at Sinai?

Rebecca Turner, NP: We have a 24-bed unit that is quite busy, with anywhere from 15 to 30 cases a day. We handle cardiac caths, stents, pacemakers, ablations, myocardial infarctions, and vascular and peripheral cases. We are staffed with three RN day shifts and two evening nurses. We also have cardiovascular technicians, and two to three nurse practitioners on during the day.

What is the typical turnaround time for your patients?

Rebecca: Anywhere from 2 to 6 hours.

Prior to the AXERA, were you primarily using manual compression?

Debbie Doll, RN: We stock hemostasis pads and use vascular closure devices, but we were doing mostly manual holds. As a result, many of us have had hand trouble and tendonitis. For example, I have trigger finger and arthritis in my left hand. Our manual compression patients, typically, are cardiac cath or stent cases. If the patient received a stent, they get heparin. Our hold times are anywhere from 10 to 20 minutes. 

Rebecca: I would say the time is more along the lines of 15-20 minutes. If patients are on eptifibatide (Integrilin), some nurses will hold longer. Our manual hold for cardiac cath patients is generally 15 minutes. 

Debbie: With the AXERA, patients require a 7-minute hold, and it is a more comfortable hold. I think the entire staff could say that. 

Your hand position is different?

Debbie: The hold is not as deep, not as hard, and it is not as long as with manual compression.

How long has your facility had the AXERA available?

Rebecca: About ten months. 

What were your initial impressions?

Debbie: The Sales and Clinical team provided a thorough presentation on the benefits of the AXERA access procedure. We were skeptical of the short hold times as we had been so deeply engrained with manual hold times ranging from 15 to sometimes 40 minutes holds, depending on heparin and eptifibatide. Our AXERA holds have been 7 minutes. 

There was a learning curve simply because we were nervous to hold for just 7 minutes. When the company suggested a little lighter pressure, we were still very skeptical. But, the AXERA has proven to be good for us. We have only had two complications that I am aware of, neither resulting in poor clinical outcomes.

How has use of the AXERA changed your work?

Rebecca: The AXERA has reduced our hold time and allowed us to be out more quickly with patients. We are seeing fewer hematomas and less bleeding than with manual compression.

Debbie: The patient can sit up sooner. We usually have them flat for an hour, but I had a patient who was short of breath, with a bad back, who couldn’t lay flat, and with use of the AXERA, we were able to put her bed 20˚ after 15 minutes. She didn’t bleed and she was comfortable. 

Rebecca: Patients can get in and out much faster; the beds don’t have to hold them for very long. Use of the AXERA sometimes saves the nurses from opening up a second unit. They can streamline their units and keep their patients in more of a central location. The nurses can supply more assistance to each other and are not as spread out on the queue half of the unit. (We are divided in the middle by a nursing center.) It does save resources. Our patients get up in two hours, and are home on the third hour. The quick turnaround for us is fabulous, because we get the bed to another patient quickly. 

Debbie: What I really like about the AXERA is that there is nothing left in the groin. There is no collagen. Nothing is left over and nothing stays in the body. I think that is really important. Many of us feel that way. 

Rebecca: We actually stopped using one particular device because we had so many complications and the treatment was very painful. If the patient had the complication at home, it required them to come back to the office. Many of our physicians do not like materials to be left in the body. 

Also, all of our peripheral patients are extremely high risk, so this is a lot nicer for peripheral patients, as well as for patients that need to go to the OR.

Debbie: As with all devices, there is a learning curve for the physicians, but we have seen more physicians adopting the AXERA access since it was first brought into the lab.

How does the holding area communicate with interventionalists and cath lab staff?

Rebecca: We have a monthly combined meeting between the CCU staff and the cath lab staff and manager. We discuss any complications or lack thereof with patients. Daily communication between holding area and cath lab staff is on more of a case-by-case basis. A report sheet is always given so the nurse knows immediately what the cath is going to be and how long it is going to take, meaning we can schedule whatever else needs to be done, other patients, lunch breaks, or discharges, etc. 

Debbie: If there is a patient with lower back pain or difficulty, who can’t lay flat for whatever reason, we will communicate this information to the cath lab. We will often recommend the AXERA in these cases, so that the patient can get up sooner and be more active.

We prep the patients in the same bed where they will recover. This point in time is where the nursing communication is essential. Any complication a patient may have, whether it is COPD (chronic obstructive pulmonary disease), perhaps the patient can’t lay completely flat or has a bad back, means we will ask for physicians to consider the AXERA device. 

How have patients reacted to the reduced hold time with AXERA?

Arthur Andrada, Jr., RN: A patient came back for a third cath via the groin and was amazed at the way I prepped his groin. He said, “Oh, that’s it? Only 5-6 minutes?” I said, “Yeah, that’s it!”

Debbie: Patients do realize that there is nothing left in the groin and that there is no pain. They have had good results and they like it. They are comfortable and there is nothing hurting them.

Rebecca: Especially those patients who have had a cath previously and perhaps had something different.

Debbie: Yes, especially those who had complications like hematomas and bleeding. It is huge for them. Also, being comfortable and then able to get up out of bed after two hours.

Any other benefits?

Debbie: The patient can sit up quickly. It is so much easier on my hands and wrists. I can’t say enough good things about the AXERA. 

Rebecca: We can use that bed quickly and there is increased patient satisfaction. Patients have said, “We were in and out. It was great!”

Arthur: We can do four cases with the AXERA in the time it takes us to do one standard manual compression patient.

Debbie: Yes, and our hands aren’t shaking and hurting. 

Arthur: For one patient, I was able to hold pressure for five minutes only. Now, I am trying to hold for four minutes. The patient is always impressed at how quickly it is done.

Any differences from manual compression in terms of the actual site?

Debbie: No, none, which is a good thing. We are holding right where the pulse is and looking at the site the entire time, so it is the same as manual compression. If the site is going to bleed, it is going to look like a regular bleed. There is no different technique, except that the AXERA requires a lighter and shorter hold. 

Have you noticed a change in your own physical response when you hold an AXERA case?

Debbie: Yes. My wrist pain has diminished. Due to my trigger finger and some swelling and arthritis, I went to see a doctor and told him about this device. He said, that is really good and that is what you should be pulling. The AXERA is so much easier on my hand. My hand is not shaking and killing me after an AXERA hold. 

We also have a couple nurses with carpal tunnel syndrome and the AXERA has been an easier hold for them. 

Arthur: I have a rotator cuff injury and I can pull with the AXERA. 

What would you tell other facilities who may be interested in this device?

Debbie: The hold time is less, the outcome is good, there are no bleeding or hematomas, and the infection rate is zero, because nothing is left in the body. There is no pain for the patient. 

Rebecca: We were very conservative and felt nervous to try this device with the out-of-bed times that were recommended. We developed our own protocol and kept track of all of our patients, doing our own research that was based on our population. It was worth it to trial the AXERA, to get our head wrapped around the theory of this device, and that it really works. If another facility is willing to trial their own patient population, the outcomes are certainly worth it.

Debbie: We initially did a trial of 30-40 patients. We monitored, kept track of hemostasis, and ambulation and discharge times. 

Rebecca: We were skeptical. We are very picky here. We want to make sure it is right for the patient, for the nurses, and for everybody. Patients first! 

Debbie: We all believe in Dr. Paul Gurbel’s goal of “do not leave anything foreign in the body.” [Dr. Gurbel is the director of the Sinai Center for Thrombosis Research]. If it was my loved one, I would not want a closure device. I would want the AXERA.