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Error Management inInterventional Cardiology
. Fig. 5.3 Endovascular
simulator, example:
Mentice VIST-Lab
149
5
mistakes that they would not have been
expected to make. The soft skills were lacking.
The quality of the technical skills is often in
great contrast to the soft skills/non-technical
skills. Ultimately, however, only both skills
contribute to optimal patient care and only
together guarantee a high level of patient
safety, especially in complex procedures or in
emergency situations. Even if interventional
cardiologists are not directly comparable with
the pilots mentioned above, there are commonalities in the requirements prole for both
occupational groups as well as similar behavioral expectations despite different training
courses.
Similarities in the Requirement Prole
Between Cardiologists and Pilots
5 Acting in a complex working environment
5 The perception of the situation and its
changes
5 The fullment of high communication
requirements
5 Cooperation with others
5 Making decisions
5 The consistent use of standards
5 Managing resources
While pilots have been training in (full-ight)
simulators for decades, neither basic skills
training nor emergency management for
interventional cardiologists is part of their
training, licensure or even licensing. This is all
the more astonishing as non-technical skills
training in interventional cardiology using
endovascular VR simulators and full-scale
patient simulators is very effective and efcient. There is a high level of self-commitment
among physicians in cardiology training,
which makes it clear that the need for
simulator- based training in interventional
cardiology continues to grow steadily with the
complexity of procedures possible today.
There is now more than 20 years of experience in conducting non-technical skills training with cardiologists in the virtual cardiac
catheterization laboratory (. Fig. 5.4). And
during this long time, the training physicians
and teams have shown repetitive behavioral
patterns that have often stood in the way of
successful, error-free patient care.
150
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E. Kaiser
5
. Fig. 5.4 Virtual cardiac catheter laboratory in the Cardioskills Simulation Center Frankfurt am Main with
endovascular simulator and fullscale patient simulator
video debrieng systems in semi-open debrief-
Behavioural Patterns of Cardiological
Teams Leading to Errors in Nontechnical Skills Training
5 Not a good brieng before the proce-
dure
5 No clear division of tasks
5 No clear responsibilities
5 Self-underestimation
5 Lack of perception of facts
5 Lack of questioning of circumstances
5 No good decision making in the deci-
sion making process
5 Hierarchy problems
5 No support of the other
5 Imprecise communication
5 No constructive error management in
the team
5 No debriengs
These behavioral patterns are immediately
apparent to the trainer observing the training
scenario, but can be used through the use of
ings to engage in constructive error management with the participating physicians (Hoff
and Adamowski 1998). The combination of
endovascular VR simulation and fullscale
patient simulation offers the possibility to
train all common emergency situations and
potentially complication-prone situations
with the physicians.
Topics That Are Trained in a Standardized Manner Within the Framework
of Emergency Management Simulation
Training in the VR Cath Lab
5 Acute coronary syndrome
5 NSTEMI
5 STEMI
5 Cardiogenic shock
5 Rhythm problems
5 Anaphylactic reaction
5 Sedation issues
5 Cardiopulmonary resuscitation
5 Acute pulmonary artery embolism
Error Management inInterventional Cardiology
latent errors at
management level
psychological
antecedents
unsafe acts
local triggers internal
defects atypical
conditions
internal defenses
151
Path of an accident
opportunity
5
. Fig. 5.5 Swiss cheese model. (From St. Pierre etal. 2005)
5 Neurological complications
5 And much more
It is also important to understand that, even
in the cardiac catheterization laboratory, it is
always a chain of unfavorable circumstances
that leads to a major error or even a loss in the
end. Sometimes protective mechanisms, which
should always be incorporated into a work
process, also fail to take effect. The so-called
Swiss Cheese model by James Reason
(. Fig. 5.5) illustrates this relationship very
vividly using the example of a Swiss cheese
with holes in it (Reason etal. 2000). Only if
safety checks, perhaps also supported by
checklists, are established and effective can
undesirable treatment outcomes be actively
prevented in the best possible way.
Thus, it must also be the task of a cardiology education and training specication to
support the learning physician and the teams
in the best possible way through appropriate
training recommendations. The proximity of
interventional cardiology to aviation is also
evident in the concrete situation of a decisionmaking problem in the cardiac catheterization
laboratory. Especially for younger and inexperienced operators, the problem arises of making the right decision in highly complex
situations. In addition to delegating parts of
the activity in the specic situation, it has
proven helpful to use decision-making models
in the team in order to make the right decision
despite opaque circumstances. Medicine
today can also learn from reghting, for
example. . Tables 5.1 and 5.2 list decisionmaking models for this purpose (Benner 1975;
Hörmann 1994, 1995).
Both decision-making models support the
operator in the cardiac catheterization laboratory, but also the entire team in decisionmaking. The collection of facts always takes
place jointly, but the decision is then the
responsibility of the team leader, i.e. as a rule
the operator as the hierarchically highestplaced personality. A steep hierarchy helps to
work faster and more effectively in critical
situations, while a very at hierarchy should
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E. Kaiser
. Table 5.1 DECIDE model
D etect Perception that the current course
deviates from the norm
E sti-
mate
C hoose The coming decision will be taken
5
I den-
tify
D o Concrete planning and execution
E valu-
ate
. Table 5.2 FORDEC model
Does the change have any
signicance for the course of
events?
from the point of view of safety
Option with the best prospects of
success and lowest risks is chosen
Framing of alternatives
of the measure
Checking the result. Does it t the
plan?
go back to the beginning of the algorithm and
perform a new evaluation.
Training
Team training of emergency situations in
the cardiac catheterization laboratory now
plays a central role in the quality management of an interventional cardiology
department. In the virtual cardiac catheterization laboratory, all relevant emergency situations can be trained in a safe
training environment using full-scale
patient simulations, and team performance
can be measurably improved, among other
things by applying decision-making models (7 www.cardioskills.com).
Cardiology training and continuing education
can be given a completely new impetus if inu-
F acts What is the situation? Is there a
need for action?
O ptions What are the options for
action?
R isks and
benets
D ecision Option with the best prospects
E xecution Concrete planning and
C heck Checking the result. Does it t
Assessment of risks and uncertainty factors
of success and lowest risks is
chosen
Framing of alternatives
execution of the measure
the plan?
ences from outside the eld are transferred
into cardiology and the realism of the training
is adapted. For example, non- technical skills
such as communication, situational awareness,
stress management and teamwork can be
trained specically and effectively in the
Boeing 737 style cockpit simulator (. Fig.5.6)
(7 www.cardioskills.com).
Here, the parallelisms (. Table5.3) between
a Boeing 737 style cockpit and a cardiac catheterization laboratory are used to train physicians and then to transfer what they have
learned back to their actual working environment, the cardiac catheterization laboratory.
In the course of three standardized training runs, this training method can be used to
measurably optimize the non-technical skills
be chosen as the basic working model to create a team-friendly working atmosphere characterized by mutual respect. In both
decision-making models, the nal review of
the action, i.e. the “C”, is of crucial importance. If the result of the executed action does
not match the initial plan, it may be that the
wrong facts were assumed or that circumstances have changed in the meantime. So the
whole team has to mentally and collectively
of teams in the cardiac catheterization laboratory. A similar approach from Stanford also
showed good results in the eld of laparoscopic surgery. Here, surgeons were allowed to
warm up with video games before performing
laparoscopic surgery on a simulator
(Plerhoples et al. 2011). Warming up with
video games before laparoscopic surgical procedures on the simulator signicantly reduced
procedural errors and tissue injuries.
Error Management inInterventional Cardiology
153
5
. Fig. 5.6 Boeing-737 style cockpit simulator in the CardioSkills Simulation Center Frankfurt am Main
. Table 5.3 Parallelisms between a cardiac
catheterization laboratory and a Boeing-737
cockpit
Boeing 737 cockpit Cardiac cath lab
Watch ight displays Monitor patient
vital signs
Communication with PNF
(Pilot Non Flying)
Work off checklist Standardized work
FORDEC in case of
emergency
Communication
with assistance
FORDEC in case
of emergency
5.3 Outlook
ErhardKaiser
From the above it must be concluded that
standardized simulation training in basic technical skills and non-technical skills should be
further and consistently integrated into cardiology education and training. Various efforts
in this direction have already been made and
will be continued. For example, the working
group “Simulation and Virtual Reality”
(founded by the editor in 2004) of the German
Society of Cardiology (DGK) in cooperation
154
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E. Kaiser
Working Group
Interventional cardiology
OF THE GERMAN SOCIETY FOR CARDIOLOGY - HEART
AND CIRCULAR RESEARCH e.V.
Home Autumn meeting 2011 Spring meeting 2011
5
Please click here to download the criteria
Copyright: © German Society of Cardiology - Heart and Circulation Research e.V.
. Fig. 5.7 Quality criteria simulation courses DGK
AGIK Publication Award
Quality criteria and content (QI) for DGK simulation courses in interventional cardiology
The QI for simulation courses were created by the Simulation Working Group of the
AGIK (Interventional Cardiology Working Group) on behalf of the DGK and serve as a
basis for the certication of simulation courses by the DGK.
The paper describes the basic requirements (models and simulators, teacher-student
ratio, theory-practice ratio) that should be met in DGK certied simulation courses and
denes the content and formal requirements for four course levels:
1. Basic course coronary diagnostics
2. Basic course PCI
3. Advanced course PCI
4. Emergency management in HKL
Simulation left
Imprint
with the working group “Interventional
Cardiology” of the DGK was able to publish
training recommendations and quality criteria
for simulator-based training in interventional
cardiology and to comment on the require-
punitive reporting systems should be
implemented in every interventional cardi-
ology department to contribute to error
prevention and patient safety.
ments for simulation devices to be used
(7 www.agikintervention.de/Simulation).
These quality criteria (. Fig. 5.7) form
the basis for DGK-certied training using
simulations.
Conclusion
Cardiology must continue to learn from the
lessons learned in aviation. Pilot training
and error management and the use of simulators in regular training of standards and
complex situations helps to minimize errors
and losses. It must be recognized that training must keep pace with the current very
rapid development of endovascular therapeutic options, and it must take advantage
of the fact that state-of-the-art training
models can help improve patient safety and
training. In addition, it must be the goal of
all societies, boards, and individuals
involved to create a shift away from a blaming culture toward a culture of error. Non-
References
Benner L (1975) L.D.E.C.I.D.E. in hazardous materials
emergencies. Fire J 69:13–18
Chaer RA, DeRubertis BG, Lin SC et al (2006)
Simulation improves resident performance in
catheter- based intervention: results of a random-
ized, controlled study. Ann Surg 244:343–352
Gallagher AG, Renkin J, Buyl H, Lambert H, Marco J
(2006) Development and construct validation of
performance metrics for multivessel coronary inter-
ventions on the VIST virtual reality simulator at
PCR2005. EuroIntervention 2:101–106
Hoff LA, Adamowski K (1998) Creating excellence in
crisis care: a guide to effective training and program
designs. Jossey-Bass, San Francisco
Hörmann H-J (1994) Urteilsverhalten und
Entscheidungsndung. In: Eißfeldt H, Goeters K-M,
Hörmann H-J, Maschke P, Schiewe A (eds) Effektives
Arbeiten im team: crew resource management-
training für Piloten und Fluglotsen. Deutsches
Zentrum für Luft-und Raumfahrt, Hamburg
Hörmann H-J (1995) FOR-DEC: a prescriptive model
for aeronautical decision making. In: Fuller R,
Error Management inInterventional Cardiology
155
5
Johnston N, McDonald N (eds) Human factors in
aviation operations. Avebury, Aldershot
Hsu JH, Younan D, Pandalai S etal (2004) Use of com-
puter simulation for determining endovascular skill
levels in a carotid stenting model. J Vasc Surg
40:1118–1125
Patel AD, Gallagher AG, Nicholson WJ, Cates CU
(2006) Learning curves and reliability measures for
virtual reality simulation in the performance assessment of carotid angiography. J Am Coll Cardiol
47:1796–1802
Plerhoples TA, Zak Y, Hernandez-Boussard T, Lau J
(2011) Another use of the mobile device: warm-up
for laparoscopic surgery. J Surg Res 170(2):185–188
Reason J etal (2000) Human error: models and manage-
ment. BMJ 320(7237):768–770
St. Pierre M, Honger G, Buerschaper C (2005)
Notfallmanagement. Springer, Berlin
Further Reading
www. cardioskills. com. Retrieved 07.09.2012
www. vasa- ffm. com. Retrieved 07.09.2012
www. agikintervention. de/Simulation. Retrieved 07.09.2012
www. cardiovascular- complications. com (under con-
struction)
www. failureculture. com (under construction)
After the Cardiac
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Catheterization
Laboratory
Contents
Chapter 6 Patient Follow-Up – 159
Torsten Konrad and Erhard Kaiser
157
III
159
Patient Follow-Up
TorstenKonrad andErhardKaiser
Contents
6.1 Removing theIntra-arterial Sheath andClosing/
Pressing thePuncture Site – 160
6.1.1 Access via theGroin, Puncture oftheCommon Femoral
Artery – 160
6.1.2 Access via theArm, Puncture oftheRadial Artery – 163
6.2 Monitoring After Coronary Angiography
andCoronary Intervention – 163
6.3 Outpatient Follow-Up Examinations After Cardiac
Catheterisations – 164
6
6.4 Conclusion – 164
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
E. Kaiser (ed.), Complication Management In The Cardiac Catheter Laboratory,
https://doi.org/10.1007/978-3-662-66093-5_6
160
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T. Konrad and E. Kaiser
Patient follow-up after diagnostic or therapeutic cardiac catheter examinations is always
standardized and is characterized by the
aspects inherent to the procedure. During the
patient follow-up, clinical and laboratory
results are obtained and, if necessary, additional tests are performed (e.g. color-coded
duplex sonography, see 7 Sect. 2.1.1). In
addition, the therapy started in the cardiac
catheter laboratory is of course continued.
This concerns both the medication, such as
dual platelet aggregation inhibition, or circu-
6
lation stabilizing drugs up to further intensive
medical therapy.
However, even after an uncomplicated
intervention or purely diagnostic procedure,
follow-up measures are necessary, which
ultimately also involve the general practitioners who continue to treat the patient. This
poses a particular challenge to all involved
practitioners, and it has been shown time
and again that only through optimal communication with each other can adequate
therapy adherence be guaranteed for
patients.
6.1 Removing theIntra-arterial
Sheath andClosing/Pressing
thePuncture Site
TorstenKonrad and ErhardKaiser
6.1.1 Access via theGroin,
Puncture oftheCommon
Femoral Artery
The intra-arterial sheath should be withdrawn
as soon as possible, depending on the anticoagulation chosen (. Fig.6.1). In purely diagnostic cardiac catheterizations without
standard heparin administration, the intraarterial sheath can therefore be pulled directly
in the cardiac catheterization laboratory. For
organizational reasons, however, there is no
reason why trained personnel should not pull
the intra-arterial sheath in the normal ward.
In patients anticoagulated with heparin,
the intra-arterial sheath is ideally pulled under
ACT control. Clinically, it is common to pull
. Fig. 6.1 Pulling the sheath after puncturing the femoral artery. (Thanks to R.Schräder)
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