Femoral Access Site Management: A Critical Skill

With the advances in technology for PCI procedures, most operators have transitioned to trans-radial access as the primary access modality over femoral access. From a post-procedure care perspective, we are faced with the challenge of maintaining the competency to manage femoral access via manual compression due to it being a high-risk, low-volume procedure. Learning and retaining femoral access management skills are still critically important, so how do we keep our post-procedural nurses competent to manage femoral access post-PCI?

The NCDR Risk Adjusted Bleeding metric is a system-wide quality metric tracked at my organization. As we evaluated the factors impacting this metric, we wanted to address femoral access site management. Due to the low volume of femoral access procedures at four of the five campuses, this was an area the team felt deserved attention. We considered placing a Cath Lab team member on call to pull any femoral sheath post PCI however, we decided against that option because the post-procedure nurse needs to be able to manage the patient and know the potential complications to look for after hemostasis is obtained. We ultimately concluded the post-procedural nurse would be responsible for femoral sheath removal and access site management post-PCI. Using evidence-based practice, our teams came to a consensus to support five femoral sheath pulls to obtain initial competency and three femoral sheath pulls for ongoing annual competency. The Cath Lab and inpatient leadership met to define how we would meet this objective. 

We needed a process to implement across the system with the least impact on our staffing challenges. We decided to keep the group small for training and identified the ICU leaders (Supervisors and Charge RNs) as the group tasked to hold this competency. We used several options to achieve this objective: have the ICU nurses go to our facility where more femoral procedures are performed to do training.

Additionally, someone from the ICU leadership is identified each day, so if there is a femoral sheath during the day, they will come to the Cath Lab to get checked off. Finally, our organization invested in a femoral line mannequin to obtain and maintain manual compression competency. A nurse can schedule a maximum of 2 check-offs using the mannequin for initial and ongoing competency of this skill. This process is working well for us, and we have increased the number of ICU nurses who are competent in manual compression. We continue to monitor our opportunities for improvement related to bleeding, and over the last four months, we have not had any events related to access site management.