Interventional Radiology: New Roles for Nurse Practitioners

Lynne A. Dryer, MSN, ACNP-BC, is Nurse Practitioner, Radiology and Nuclear Medicine Interventional Radiology Group, Topeka, KS. Her nursing experience of more than 20 years spans areas of practice of emergency, flight nursing, pediatrics, cardiology, and interventional radiology.

In 2000, the Radiology and Nuclear Medicine Interventional Radiology Group decided to hire a nurse practitioner to work collaboratively with the interventional radiologist. Due to the increased number and complexity of the patients, they felt they needed to improve triage of patients, evaluate the patient pre-procedure, and manage post-procedure care, education, and follow-up. Together, the nurse practitioner and interventional radiologist work collaboratively to provide better patient care and outcomes. The role of nurse practitioners and physicians’ assistants is expanding in the area of interventional radiology.

Since the publication of the National Kidney Foundation (NKF) Dialysis Outcomes Quality Initiative (DOQI) guidelines in 1997 (NKF), the value of the interventional radiologist for the treatment of both stenosis and thrombosis has been more recognized (Turmel-Rodriques, Pengloan, & Bourquelot, 2002). Interventional radiology plays an important role as part of a multidisciplinary approach, which includes nephrologists, surgeons, dialysis centers, and interventional radiology related to venous access in the patient on hemodialysis. Our team is called the Access Team. The team has been very beneficial to all of our practices.

Interventional Radiology
Interventional radiology is a medical specialty that uses image-guided, minimally invasive diagnostic and treatment techniques that are often an alternative to surgery. Interventional radiologists are highly trained in imaging, performing medical procedures and patient management. The interventional radiologist treats a variety of disease processes besides vascular access in the patient on dialysis, including treatments for peripheral vascular disease with angioplasty and stenting, aortic stent grafts, uterine fibroid embolization, chemoembolization, radiofrequency ablation, transjugular portosystemic shunt creation, percutaneous biopsy, temporary and permanent vascular access, percutaneous drainage procedures, vertebroplasty, kyphoplasty, and much more using small catheters or other devices and tools guided by radiology imaging. Procedures performed by interventional radiologists are generally less costly and are less traumatic to the patient, and involve smaller incisions, less pain, and shorter hospital stays.
Percutaneous management of hemodialysis access grafts and fistulae is a complementary treatment alternative to surgical thrombectomy and revision. The goal is to preserve vascular access (Aruny et al., 1999). Interventional radiology achieves results comparable to surgery, with minimal invasiveness and less cost (Turmel-Rodrigues et al., 2002).

A thrombosed dialysis access is defined as either a native fistula or synthetic graft that contains occlusive thrombus and has no significant blood flow. A dysfunctional dialysis access is defined as an access that has a hemodynamically significant stenosis, or a native fistula that has failed to mature during an adequate time period, or an access that cannot be successfully punctured to perform dialysis (Aruny et al., 1999).

Vascular access management. A diagnostic angiogram/venogram (fistulogram) is used to thoroughly visualize the dialysis access from the arterial anastomosis of a graft or fistula connection through the runoff veins to the superior vena cave-right atrial junction (Aruny et al., 1999). Percutaneous thrombus removal (declot) includes the removal of occlusive thrombus from within the graft or native fistula, including the out-flow veins and inflow arteries, to restore blood flow to the access. Removal of thrombus may be accomplished by any of several percutaneous catheter-directed methods, such as thrombolysis, suction thrombectomy, balloon thrombectomy, clot maceration, or mechanical thrombectomy (Aruny, et al., 1999). If the declot is unsuccessful, the interventional radiologist can place a dialysis catheter at the same time thereby saving time, reducing cost, and improving patient satisfaction. Percutaneous treatment of stenosis involves restoration to an acceptable luminal diameter and resolution of functional abnormality. Stenoses may be treated with balloon angioplasty, and in select cases, stents or atherectomy may be required to maintain patency (Aruny et al., 1999).

The goal of these management efforts is the preservation of vascular access and the prevention of re-thrombosis (Aruny et al., 1999). Acute thrombosis should be avoided and warrants surveillance programs for detection and correction of stenosis, which underlie more than eighty five percent (85%) of thromboses. Several studies have shown the outcome of grafts is significantly better after dilation or revision of stenosis on a patient access than after radiologic or surgical declotting (Turmel-Rodrigues et al., 2002).

Interventional radiology also includes image guided placement and maintenance of dialysis catheters. Some studies have demonstrated a higher rate of success and substantially lower cost than surgical placement. The difference in cost is attributable to the overhead cost associated with the operating room as well as the personnel. Interventional radiology schedules seem to be more flexible to work in patients with vascular access problems and save time. Interventional radiology has also shown better tolerance and improved patient satisfaction (Noh et al., 1999).

Nurse Practitioners

The numbers of Nurse Practitioners (NPs) and physicians’ assistants are growing in interventional radiology. NPs provide direct care to a specific population of patients, such as adults, children, women, acutely ill, and neonates. They diagnose and manage common acute and stable chronic health problems, responsibilities traditionally reserved only for physicians. NPs are master’s prepared and can take a national certification for their specialties (Stanik-Hutt & Cagle, 2002). Acute Care Nurse Practitioners (ACNPs) provide advanced nursing care across the continuum of acute care services to patients who are acutely and critically ill (American Nurses Association [ANA] & American Association of Critical Care Nurses [AACN], 1995). ACNPs are employed by hospitals as well as in specialty medical practices.

The key roles for the ACNP are to obtain health histories, conduct comprehensive physical examinations, appraise health risk profiles, perform differential diagnoses based on logical diagnostic reasoning, plan and implement advanced therapeutic interventions, and consult with and refer to other health care providers (ANA & AACN, 1995). The ACNP helps facilitate care, improves patient care, collaborates with medical, nursing, patients and significant others. The outcomes include fewer delays, earlier discharge, decrease readmission, effective, efficient, consistent care, and improved communication (Parr, 1996).

Nurse practitioners in intervention radiology. Many interventional radiology practices around the country have seen an increase in the number of patients, gaps existing in acute care delivery, limited number of work hours per week for residents, and growing emphasis on clinical care. NPs are being utilized more, and their responsibilities include histories and physicals, consultation, pre and post-procedure care, patient rounds, patient/significant other education, consent, communication with the referring physician and nursing staff, discharge, and follow-up. The goal is to allow the physicians to spend their time performing their procedures knowing the NPs are providing the other components of care that keep the practice going (Martin & Coniglio, 1996).

Many NPs in interventional radiology perform procedures such as vascular access and venography as part of their practices. Most have had an education program that provides training and experience in image-guided diagnostic vascular and interventional procedures, as well as supervised experience in the performance of image-guided diagnostic methods for treating disease (Stowe, 2003). In other practices, the NPs do not perform many procedures, but optimize the patient care, thereby allowing the physician to perform more procedures.

In my practice as an NP, I found out early that dialysis work was a major part of our practice. A wise interventional radiologist said to me, “Get to know the dialysis staff.” He was so right! I feel it is also important for the dialysis staff to understand the role of interventional radiology. Working together makes a win-win situation for the dialysis staff, interventional radiology staff and, most importantly, the patient.

When I first started, declotting procedures were common and very difficult to fit in our schedule. The cost of declotting is more than double the cost of a fistulogram. Fistulograms are scheduled ahead of time and take much less time. I found that I was speaking to many different people in the dialysis unit about the same patient and things got very confusing. I figured out that it was easier to talk to the same person all the time, so I started asking for the charge nurse. Then the vascular access coordinator (VAC) position was created and has become very instrumental to my practice.

The VAC schedules the fistulograms. Fistulograms are usually scheduled on a non-dialysis day, if possible, so that if the schedule is behind in interventional radiology it does not interfere with the dialysis schedule. I am available to triage cases that need to be added earlier. Communicating with each other facilitates a trusting relationship knowing that patients truly need to be placed ahead of others or fit into a busy schedule.

The VAC has an access referral form (see Figure 1), which is a communication tool that is faxed to the interventional radiology department, along with a medication list and an allergy list for each patient having a fistulogram. This has been extremely valuable to the interventional radiology staff, as the form communicates to all the important information such as the site of the fistula or graft, code status, special considerations for this particular patient, and names of physicians who need a copy of the report. This form is placed on the patient’s chart and is available for the hospital pre- and post-procedure staff along with the interventional radiology staff.

A pre-procedure instruction sheet (see Figure 2) was developed so the VAC can give pre-procedure instructions to the patient and a copy can be sent home with the patient. These instructions are important; if not followed, it may cause delay or cancellation of the case.

The interventional radiology report needs to go the dialysis unit, the nephrologist, and surgeon. The nephrologists usually review the reports at the dialysis unit rather than in their offices. The surgeons and their staff can better keep track of what is happening with their patients and have a record for their charts. This reporting has been a problem that has been difficult to correct and continues to be monitored. The interventional radiology NP has helped facilitate this process with the department director and hospital staff.

The VAC follows the interventional radiology reports. In the report, the interventional radiologist makes an impression explaining what was done in the procedure and delineates the plan for follow-up. The multidisciplinary group members know the VAC will track the reports, and, if follow-up is indicated, will schedule it. This allows for one consistent person following the case and ensures that the necessary follow up is getting done. The patients are reminded of the follow-up so appointments or procedures are not missed. This has really improved the surveillance and longevity of high-risk accesses and facilitated the process of new access prior to a failed access.

Communication between the VAC and the interventional radiology department provides continuity of care, including reporting important items such as lab values, weight, medications, allergies (especially to contrast), code status, follow-up, special considerations, and problem solving for difficult accesses. Lab values are important to know, especially the serum potassium levels, as this will determine whether a patient whose access needs to be declotted will require dialysis sooner or later. Obtaining prothrombin times/international normalized ratio (PTT/INR) is important, particularly if the patient is taking coumadin and needs a dialysis catheter. Blood culture results are important when dealing with infected dialysis catheter. Some lab work is done at the dialysis unit while other tests can be ordered by the NP at the hospital and preformed pre-procedure. The patient’s medication list should be provided when going for a procedure or hospitalization since many patients do not bring their pills with them or know all their medications. An allergy to intravenous (IV) contrast is important to know prior to sending the patient to interventional radiology as these patients may need pre-medication for their allergy. The patient’s current weight provides important information about a patient with a clotted access. The interventional radiology staff determine if the patient can wait until later in the day or the next day to be declotted or be triaged before a scheduled patient. The code status is another important item that needs communicated.

Many times patients who urgently need dialysis and have vascular access problems are worked into a busy interventional radiology schedule. Communication during the day helps facilitate dialysis. If the procedure is done early enough, the patient can be dialyzed that day at the dialysis unit instead of at the hospital after hours. This saves cost and overtime for staff and improves patient satisfaction. The interventional radiology NP helps facilitate scheduling for patients who require dialysis at the hospital with the hospital staff, and communicating that information back to the dialysis unit.

Conclusion
Communication between the VAC and interventional radiology NP makes both the dialysis unit and interventional radiology more efficient, with fewer delays, improved triage and better communication,  thus decreasing overtime and improving staff satisfaction both in interventional radiology and the dialysis unit. Patient care and satisfaction has also improved. There has been an increase with respect between the dialysis staff and the interventional radiology staff due to a better understanding of each other’s jobs. The Access Team has also improved everyone’s understanding of each others’ roles and how we each can benefit from the other. The key components are multidisciplinary collaboration and communication. The bottom line is better patient care.

References
American Nurses Association (ANA) & American Association of Critical Care Nurses (AACN). (1995). Standard of clinical practice and scope of practice for the acute care nurse practitioner. Washington, DC: American Nurses Publishing Company.

Aruny, J.E., Lewis, C.A., Cardella, J.F., Cole, P.E., Davis, A., Drooz, A.T., et al. (1999). Quality improvement guidelines for percutaneous management of the thrombosed or dysfunctional dialysis access. Standards of Practice Committee of the Society of Cardiovascular & Interventional Radiology. Journal of Vascular Interventional Radiology, 10(4), 491-498.

Martin, B., & Coniglio, J.U. (1996). The acute care nurse practitioner in collaborative practice. AACN Clinical Issues, 7(2), 309-314.

Noh, H.M., Kaufman, J.A., Rhea, J.T., Kim, S.Y., Geller, S.C., & Waltman, A.C. (1999). Cost comparison of radiologic versus surgical placement of long-term hemodialysis catheters. American Journal of Radiology, 172, 673-673.

National Kidney Foundation (NKF). (1997). NKF-K/DOQI clinical practice guidelines for vascular access. New York: Author.

Parr, M.B.E. (1996). The changing role of advanced nursing in a managed care environment. AACN Clinical Issues, 7(2), 300-308.

Stanik-Hutt, J., & Cagle, S.J. (2002). CNS or NP? What is a name? AACN News,19(2), 6.

Stowe, H.O. (2003). Development of an NP role in interventional radiology. Nurse Practitioner, 28(8), 57-58.

Turmel-Rodriques, L., Pengloan, J., & Bourquelot, P. (2002). Interventional radiology in hemodialysis fistulae and grafts: A multidisciplinary approach. Cardiovascular and Interventional Radiology, 25(1), 3-16.