British Journal of Radiology 74 (2001),648-650 © 2001 The British Institute of Radiology
Diagnostic angiography performed by nurses
R Morgan, MRCP, FRCR,
L Wallis, SRN and
A-M Belli, MRCP, FRCR
Department of Radiology, St George's Hospital, Blackshaw Road, London SW17 0QT, UK
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Abstract
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The aim of this study was to assess the feasibility of a nurse performing diagnostic angiography. After a theoretical and practical training course on the techniques of arterial catheterization, the nurse performed diagnostic angiography under supervision on 68 patients. Patients with impalpable femoral pulses or scarred groins as well as obese patients were excluded. Successful arterial catheterization was achieved in 58 (85%) patients. Complications were limited to a severe haematoma requiring surgery in one patient and seven minor self-limiting haematomas. On this evidence, it is feasible and safe for appropriately trained nurses to perform angiography in radiology departments that have limited radiology staffing levels and no non-invasive alternations to catheter-based angiography.
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Introduction
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There is increasing use of skill mix in medicine, with nurses, radiographers and technicians being trained to perform tasks previously the preserve of doctors. Radiographers have been trained toundertake ultrasound examinations, report casualty radiographs and perform barium enemas [1–3]. Recently, we performed a prospective study to assess the feasibility of a nurse performing diagnostic angiography. Our experience is presented in this report.
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Materials and methods
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A nursing sister with 23 years experience working in the angiography department was trained to perform diagnostic angiography. Approval to perform this prospective study was obtained from the local ethics committee, the hospital Trust, the medical director and the chief nursing officer.
The nurse was trained for the procedure by a vascular radiologist. The training course was aimed specifically at teaching relevant vascular anatomy, radiation exposure and radiographic technique.
Patients
Patients were considered suitable for inclusion in the study if they were referred for diagnostic angiography of the legs, renal arteries or abdominal aorta. Patients were excluded if they were obese or had poorly palpable femoral pulses, if there was a surgical scar in the groin, if coagulation was not completely normal or if the patient was considered unsuitable by either the nurse or the radiologist. Consent was obtained from the patient by the nurse and the supervising radiologist. All procedures were supervised bya radiologist experienced in angiographic procedures.
Angiography was performed by a nurse in 68 patients. The indications for angiography were the assessment for lower extremity occlusive vascular disease in 31 patients, assessment for renal artery stenosis in 29 patients and aortography in 8 patients with abdominal aortic aneurysms.
Procedure
Single-wall puncture of the femoral artery wasroutinely performed, similar to the method taughtto our specialist radiology registrars. Catheterization of the common femoral artery was followed by insertion of a 4 F pigtail catheter into the upper abdominal aorta for flush angiography. All fluoroscopy was performed by the radiologist, in accordance with local radiation protection rules.
The projections for angiography were directed according to departmental protocols. At the end of the procedure, the nurse removed the catheter from the femoral artery over a guidewire and achieved haemostasis by manual compression of the groin. Mechanical compression devices were not used.
Record keeping
A log book was kept of all nurse-performed procedures and this was audited after the first 20 procedures. The interim results were assessed by two consultant radiologists (RM and A-MB); satisfactory results for the first 20 procedures enabled continuation of the study.
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Results
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Technical results
68 patients have undergone angiography performed by a nurse. All patients gave consent for the nurse to perform angiography. Successful angiography (without radiologist intervention) was achieved by the nurse in 58 (85%) of 68 patients. The radiologist was required for part of the procedure in 10 patients. Failure to puncture the artery with the needle occurred in four patients, and failure to pass the guidewire through the needle into the artery was experienced in six patients. Figure 1
shows the success rate with time for femoral catheterization followed by passage of the catheter and guidewire into the aorta by the nurse. After an initial improvement, there was a slight decrease in success from 85% for the first 20 patients to 70% for the second 20 patients. The technical success rate for the final 28 patients increased to 96%, which compares favourably with our trainee radiologists with a similar level of experience.
After arterial cannulation, the nurse successfully manipulated a catheter and guidewire into the aorta and performed angiography in all 68 patients.
Complications
There were complications in eight patients. Seven patients had a minor self-limiting groin haematoma, which did not delay discharge from hospital. One patient developed a severe groin haematoma 6 h after the procedure. Surgical exploration in this case showed a large haematoma in the thigh and a bleeding point in the mid common femoral artery, which was oversewn. The patient was extremely thin and the overlying skin became necrotic, requiring plastic surgery. Six of the patients with haematomas had elevated blood pressure, and the common femoral artery was severely diseased and calcified in two patients.
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Discussion
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As with radiology trainees, there was clear evidence of a learning curve during this series. The success rate was 77.5% for the first 40 patients and 96.4% for the final 28 patients. The success rate for the final 28 patients compared favourably with success rates for femoral artery catheterization by standard radiology trainees.
The severe complication rate for this series of 1.47%, consisting of a large haematoma requiring surgery in one case, was well within the recommended standards for complications of diagnostic vascular procedures published by the Royal College of Radiologists [4]. In that document, which lists standards of performance for consultant radiologists performing vascular interventional procedures, the recommended upper limit of severe haematoma requiring surgery, transfusion or delayed discharge was 3%.
This study demonstrates that nurses can be trained safely to perform invasive diagnostic procedures such as angiography. This may be useful in radiology departments with limited staffing resources and may enable busy consultant radiologists to perform other more complex tasks while the nurse performs the basic angiographic procedure.
This may be deemed less valuable with the advent of non-invasive vascular imaging. However, understaffing and limited equipment mean that diagnostic angiography is still performed in many hospitals. The catheter skills acquired by nurses may be put to other uses, for example the placement of central venous catheters or even therapeutic vascular procedures such as angioplasty. However, an experienced vascular radiologist should always be available because of the potential complications of invasive angiography such as vessel damage, haematoma formation and distal embolisation.
We believe that the role of nurses performing diagnostic angiography is to help improve the efficiency of imaging departments, particularly in non-training centres where there is a lack of junior staff.
Received for publication November 20, 2000.
Revision received March 27, 2001.
Accepted for publication April 19, 2001.
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References
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Board of the Faculty of Clinical Radiology, The Royal College of Radiologists. Skills mix in clinical radiology. London: Royal College of Radiologists, 1999.
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Board of the Faculty of Clinical Radiology, The Royal College of Radiologists. Guidance for the training in ultrasound of medical non-radiologists. London: Royal College of Radiologists, 1997.
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Law RL, Longstaff AJ, Slack N. A retrospective 5-year study on the accuracy of the barium enema examination performed by radiographers. Clin Radiol 1999;54:80–3.[Medline]
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Board of the Faculty of Clinical Radiology, The Royal College of Radiologists. Good practice guide for clinical radiologists. London: Royal College of Radiologists, 1999.
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Abstract
Introduction
