Abstract 232: Minimizing Bleeding Complications in the Cardiac Catheterization Lab

Abstract

Background: Bleeding complications related to invasive procedures significantly increase costs, length of stay, morbidity and mortality risk. The cardiac catheterization lab [CCL] is a high risk, high volume center requiring continuous monitoring to minimize the incidence of vascular injury, hematomas/ hemorrhage, blood transfusions. Oversight extends beyond the CCL to concerns regarding post procedure access management, appropriate medication administration, ambulation, threshold for transfusion, vascular diagnostics/consultation. Based on best practices a multidisciplinary team has developed and implemented a risk stratification tool, encourages best practices, and continues to collect data to provide feedback and process improvement. Methods: The Stony Brook U Hospital CCL serves a Suffolk Co population of >1.5 million and provides 7x24 coverage for STEMI interventions over 912 square miles. Data post implementation of a bleeding risk stratification and optimal practices tool was collected from September of 2014 through September of 2015 to assess bleeding complication incidence [NCDR criteria], associations, and implementation of suggested practice improvements [radial access, bivalirudin, vascular closure). Results: A total of 1770 angioplasty procedures were performed during the monitored period [485 radial (27%), 1285 femoral (73%) approach]. In the femoral access group a total of 485 vascular closure devices (38%) were deployed. Bivalirudin [Angiomax] was used in 1,304 cases (74%); UFH was used in 466 cases (26%). Bleeding complications were identified in 69 patients during the monitored period [3.9% incidence]. Preprocedure risk screening identified 50 [72%] patients with bleeding complications as high risk and 19 [28%] patients as intermediate risk. In the patients with bleeding complications: Radial artery access was used in 16 (23%), bivalirudin in 63 (91%), vascular closure devices in 19 of appropriate femoral candidates (48%) with 12 femoral access patients (23%) receiving an Impella or IABP. Monthly case review has identified additional opportunities for improvement including: preprocedure optimization where possible, establishing transfusion thresholds, post procedure large sheathe/device management, and antithrombotic/antiplatelet medication administration. Conclusions: A bleeding complication task force developed a PCI bleeding risk assessment tool to identify patients at high risk of bleeding complications by NCDR criteria. Routine implementation accurately identifies high risk patients and encourages the use of best practices designed to reduce complications. Continued feedback, education and encouragement of practitioners and support staff in implementing best practices continues to improve implementation. Focused case review has provided additional opportunities for continued quality improvement.