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When transplant cardiologists at the Debakey Heart and Vascular Center at Houston Methodist Hospital, began to use percutaneously placed axillary intra-aortic balloon pumps (PAxIABPs) in 2007, there was one problem. Not with the procedure, which would act as a bridge to heart transplants. But rather, with the nursing care that would take place after. When CICU nurses searched for literature on the subject, there was one problem.

There wasn’t any.

The procedure was so new, so no patient care protocols existed. So they developed them. And now an article about the problems and solutions developed by the nurses is out.

Frederick R. Macapagal, BSN, RN, CCRN, RN, Cardiac Intensive Care Unit, Houston Methodist Hospital, was a part of that team and is a lead researcher on the article. What follows is an edited version of our interview with him

Q: Were you on the original team that discovered that no nursing literature existed on PAxIABPs in 2007?

I was part of the team at Houston Methodist Hospital that searched the literature in 2007 and did not find any nursing articles about caring for patients with PAxIABPs. Medical journals had a few articles about similar procedures, but they focused on the surgical intervention with nothing about nursing care.

Since this was a relatively new procedure, the lack of nursing articles was not surprising. Our protocols were developed over time, using evidence-based nursing care and lots of “learning by doing.” After about 10 years of developing, reevaluating, and taking care of more than 100 patients with PAxIABPs who are awaiting heart transplant, our staff has become more competent and comfortable taking care of these patients.

Q: Explain how the nursing and medical teams collaborated to develop these protocols. Did you work together to determine what to try and what not to? Please explain.

The cardiologists informed us about the new procedure and what the change meant for the patients. They gave us parameters and guidelines on what to do and not to do to take care of the balloon pump and the insertion site. Overall, the doctors trusted the nursing staff to figure out how to walk these patients safely and provide the care needed at the bedside. The multidisciplinary team of nurses, doctors, physical therapists, and ancillary staff collaborated to devise interventions to mitigate the problems that arose and incorporate them into the standard of practice.  

Q: How did you decide how to develop and implement clinical practice guidelines if there was no previous literature with evidence-based practice backing it?

We did not have a choice. Our patients with intra-aortic balloon pumps needed us to find a way to get them moving. Our patients needed to walk to keep up their strength while waiting for a transplant, and we had to develop our own nursing care protocols based on existing evidence-based practices in order to safely incorporate walking and mobilizing into their care.

Q: What are the resulting clinical practice guidelines that reflect nursing care practice and patient treatment?

The mobility guidelines we developed address issues such as where patients walk within the cardiac care unit, for how far, and how long. We defined the number of staff who need to walk with the patient, based on each one’s individual strength. The guidelines also cover how often laboratory tests and x-rays need to be completed. For example, laboratory tests such as complete blood count and basic metabolic panel are obtained every other day to minimize blood loss and the need for blood transfusions. On the other hand, chest radiographs are obtained every day to determine the PAxIABP position.

Our nursing team also developed a PAxIABP repositioning kit so that transplant cardiologists can perform simple repositioning of the PAxIABP at the bedside as needed.  This kit contains sterile gloves, masks, surgical cap, stabilization device adhesive, CHG scrub stick, and a prepackaged central catheter dressing kit. The kit, stored in a clear plastic bag, is hung on a pole attached to the IABP console for easy access.

Q: The article lists some really interesting morale boosters used. Why are these so important to patients in these situations?

Our pre-heart transplant patients with IABPs wait anywhere from a few days to months for a donor heart. Anyone would get depressed with waiting for so long under such stress. So the nursing staff came up with different ways of helping our patients cope.

We consider these patients part of the CCU family and treat them as such. We call them by their first names, chat with them about anything and everything whenever we pass by their rooms, and get to know their family and other visitors. We celebrate birthdays, anniversaries, holidays, and other special occasions. We’ve found ways for patients to enjoy the occasional home-cooked meal, have their pets come for a visit, and more, in an effort to keep their spirits lifted.  

Our patients from 10 years ago regularly come to our unit when they are in town, chat with us, and offer to visit with current patients who might need a pep talk and some cheering up. Patients appreciate the extra effort we put into making their stay with us enjoyable.

Q: What else is important about the nursing protocols for patients with PAxIABPs?

We started with existing evidence-based practice, but our journey didn’t end there. Whenever a challenge arose, we found solutions to address the situation. We documented each lesson learned and worked through the unique challenges encountered with our patients. We gained confidence throughout this process in our ability to innovate and improve the care we provide to all of our patients. We hope that this article helps other nurses who are caring for patients with PAxIABPs or who may do so in the future. In addition, we hope it inspires nurses to trust in their abilities to be innovative and courageous as they strive to provide the best care for their patients.

To learn more about the protocols, visit https://www.aacn.org/newsroom/nurses-develop-protocols-for-patients-with-paxiabps.

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Michele Wojciechowski

Michele Wojciechowski is an award-winning writer and author of the humor book Next Time I Move, They’ll Carry Me Out in a Box.

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