Why Cardiology Nurses Should Worry about Vascular Complications and Arterial Access

The prevention of vascular complications is an issue that continues silently to crawl in the shadow of all the recent and sensational developments in the arena of coronary interventions. The solid reason behind is that vascular complications, whenever they occur, still have a significant impact on morbidity, mortality and hospital costs. In this issue of the journal, Steffenino et al. report on their policy for access-site management after cardiac catheterisation [1]. In comparison to other published series, the authors experienced a low incidence of severe vascular complications (1.2%) and isolated large (> 4 cm) hematoma (2.3%) in a real-life population. This positive result was obtained thanks to a tailored use of closure devices and manual compression. But why should vascular complications be of particular concern for the nurse of cathlab units and cardiology wards? In the study of Steffenino et al., sheath removal was performed, in the majority of patients, by the interventional cardiologist himself. On the contrary, and particularly in community hospitals, nonmedical clinicians (nurses in particular) are increasingly appointed of many duties, which were once undertaken by the medical staff [2]. This comes as an answer both to the shortage of cardiologists and to the increasing costs of hospital employees. Although someone still may argue that “cardiologists do it better”, sheath removal by experienced nurses proved to be feasible and safe. Indeed, manual compression, with or without the aid of mechanical clamps, is wearying but relatively easy to learn and practice, and, when correctly performed, it bears a low risk of complications [3]. Closure devices are, instead, more complex, they require a rigorous learning curve, they are more expensive and they do not persuasively reduce the incidence of vascular complications in comparison to “good old” manual compression. Eventually, when they are used, it is mostly by the interventionalist himself. So, the first reason why cardiology nurses should worry about vascular access-site management is because, in routine practice, their active role, from sheath removal to prevention and diagnosis of complications, is continuously expanding. In comparison to other studies, which proved that immediate sheath removal is superior to delayed hemostasis, in terms of vascular complications [4], Steffenino et al. applied a longer time of sheath dwelling to patients undergoing both urgent (up to 48 h), and elective PCI procedures without the use of a closure device (up to 7 h). According to several studies, a bed rest of 2 to 6 h after hemostasis (when allowed by the general clinical conditions) seems also sufficient, not only after closure devices deployment but also after manual compression [5]. It is evident that, no matter who takes care of sheath removal (interventional cardiologist or nurse), the earlier patients can walk and rely on themselves after the procedure, the lighter the nurse assistance during their hospital stay becomes. On the other hand, when vascular complications occur, nurse workload is dramatically enhanced due to prolonged in-hospital stay, bed confinement, increased patient needs, and additional medical procedures. So, a good balance between early mobilisation and a low incidence of vascular complications is the way to cut down nurse workload during hospitalisation for invasive coronary procedures: an equation, the solution for which should be at most of nurse's concern. As already proven by many authors [6] and as suggested by Steffenino et al., a liberal use of the radial access may be a suitable answer for this dilemma, particularly in those patients requiring aggressive anticoagulation, because it provides early mobilisation at no cost for increased vascular complications. In addition, radial access is easier to manage both by cathlab nurses (when dealing with sheath removal) and by cardiology ward nurses (when dealing with postprocedural assistance). From a nurse's point of view, radial access may well bare the disadvantages of longer procedures (during the operator's learning curve) and of novel work protocols. However, when systematically pursued, radial access proved to significantly reduce nurse workload in both environments (cathlab and ward) [7]. It is important to remember that the spectrum of individuals, with whom cardiology is dealing in developed countries, is continuously expanding both because of the aging of the population, and the increased burden of risk factors (obesity, diabetes). Beyond this, interventional cardiology foresees an enlarged availability of new technologies (drug-eluting stents) and expanded eligibility for treatment (acute MIs). It is no surprise then, that Europe has seen in less then one decade an increase from 458 to 990 PCIs per million inhabitants, and a plateau phase seems still far to be reached [8,9]. On the other hand, nurse staffing is facing the worst undersupply of the postwar age. Nurse profession is physically and psychologically demanding, requires nowadays a long and accurate training, and is not economically rewarding. As a result, the traditional candidates, who once embarked on nurse training programs, are seeking other job opportunities [10]. To employ nurses from less-developed countries, or to shift tasks from registered nurses to other caregivers is what many hospitals are doing. In a future when we will face both a shortage of (experienced) nurses and a continuing increase in invasive procedures, no aspect, including that of access-site management, should be left unexplored, in order to improve efficency, at no cost for outcomes and personnel satisfaction [11], and we acknowledge the need for a proactive role of nurses not only in delivering the best healthcare possible, but also in developing the most effective healthcare strategies.