Pulmonary Artery Catheter Guidelines for Invasive Hemodynamic Monitoring on the Cardiology Progressive Care Unit

Pulmonary artery catheters (PACs) were first introduced in the 1970s for hemodynamic monitoring, and their use has been limited to intensive care units.1 Because of the growing number of patients with heart failure2 and the limited capacity in the cardiology intensive care unit (CICU) at our institution, a need emerged to expand the use of PACs to the cardiac progressive care unit (CPCU).Guidelines were created for managing patients with a PAC in the CPCU to ensure that care for patients who require invasive hemodynamic monitoring is safe, standardized, and evidence based. Pulmonary artery catheter guidelines are important because PACs are invasive and come with risks of infection, thrombosis, arrhythmia, or rupture.3 The guidelines ensure quality of care as they promote consistency in practice and optimize resource utilization to guide decision-making in the appropriate use of PACs and proper nursing care of patients with a PAC while mitigating any risks.3The American Association of Critical-Care Nurses (AACN) guidelines for the care of patients with a PAC provided a foundation for the development of our guidelines. The AACN guidelines3 include best practices for caring for the insertion site, preparing the catheter, calibrating and zeroing, maintaining the pressure transducing system, measuring hemodynamics, ensuring accuracy, and interpreting waveforms, among others.3A subsequent article titled “Bridging the Gap Between Clinical Practice and the AACN Practice Alert on Pulmonary Artery/Central Venous Pressure Monitoring in Adults”4 addresses strategies for evaluating nursing practice for the care of patients with a PAC. These strategies validate the methods we used to evaluate competency and include proper leveling of the transducer to the phlebostatic axis and measuring with an actual level, measuring pulmonary artery pressure and central venous pressure at end-expiration, and obtaining pressure measurements by using a printed waveform strip.4 Although the AACN guidelines provide the standard for caring for patients with a PAC, we were unable to find any publications that distinguished how caring for patients with a PAC in a CPCU differs from providing care for patients with a PAC in a CICU.The PAC/hemodynamic monitoring guidelines for the CPCU (see Figure) were first developed in 2017 to ensure that patients were clinically appropriate to be cared for by nurses on the CPCU. An interprofessional team, which included the clinical nurse specialist, nursing leaders, CPCU nurses, advanced practice providers, and physicians, participated in the development of the guidelines. The interprofessional team reviewed the relevant literature and used their clinical expertise to define which patients were appropriate to be admitted to the CPCU with a PAC. A list of indications and contraindications was drafted along with monitoring guidelines that considered nursing work hours, patient ratios, scope of practice, and acuity of the patient (see Figure).The indications for admitting a patient with a PAC to the CPCU included the initiation or weaning of inotropic infusions, optimization of heart failure with oral medications and intravenous diuresis, and confirmation of the hemodynamic status required for heart transplant listing and placement of a ventricular assist device. Furthermore, the recommendations for acceptable patients admitted to the CPCU with a PAC included parameters for hemodynamics (see Figure), frequency of measurements, and indications.The guidelines also list the contraindications for patients with a PAC being admitted to the CPCU (see Figure). These provide objective measures of the types of patient acuity that require frequent intervention and more monitoring than can be safely provided in a progressive care setting given the nurse to patient ratios.The PAC position must be documented at the time of insertion and at any time thereafter if it is adjusted. Knowing where the tip of the catheter is located is critical to ensure the patient’s safety in case of catheter migration into the right ventricle, “auto-wedge” (inadvertent wedging in a branch of the pulmonary artery), or pulmonary rupture.3 A catheter insertion of more than 55 cm and/or a waveform that is a persistent wedge or auto-wedge is a contraindication for measurement of pulmonary capillary wedge pressure.3Pulmonary artery catheters require continuous monitoring with alarms set on the pulmonary artery waveform to alert if auto-wedging or migration into the right ventricle occurs. Nurses are required to obtain a complete set of hemodynamic data every 8 hours, including blood pressure, cardiac output/cardiac index, peripheral vascular resistance, pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure, and mixed venous oxygen saturation. Additionally, hemodynamic data are obtained when a patient is admitted to the CPCU. A partial set of hemodynamic data that includes blood pressure, central venous pressure, and pulmonary artery pressure must be obtained every 4 hours beginning at 10 AM (excluding 2 AM to optimize rest for the patient).Implementing PACs on the CPCU required consideration of nursing care hours because of the complexity of caring for these patients and the increased time and effort involved. To safely care for patients with a PAC in the CPCU, it was determined that the patient to nurse ratio would not exceed 3:1.A new staffing model for the CPCU was created that ensured that enough nursing staff would be present to care for patients with a PAC in a 3:1 assignment. The number of patients with a PAC that could be admitted to the CPCU at any one time is determined by the direct care hours per patient day (DCHPPD). On the CPCU, the DCHPPD allow for a maximum of 5 patients with a PAC to be safely cared for 24/7.In developing the staffing model, it was important to consider support staff (nursing assistants) and other positions that are counted in the DCHPPD. Other considerations included the number of fulltime-equivalent registered nurses (FTEs), vacancies, and nonproductive time (vacations and absences).The guidelines for PAC management specific to CPCUs are significant for several reasons: safety, standardization of care, skill enhancement, quality improvement, and resource management. Guidelines ensure a standard approach to ensure every patient gets the same level of care. Use of a standard approach reduces variability among nurses and improves safety. Determination of what makes a patient with a PAC eligible for admission to the CPCU was based on expert opinion from the interprofessional team to ensure that patients requiring CICU level care were not admitted to the CPCU. The admission criteria serve as a critical risk mitigation strategy. The criteria emphasize situations where requirements for increased monitoring or interventions would necessitate the patient’s transfer to a higher level of care.Managing PACs was a new challenge for staff in the CPCU, and although there are best practices that explain how to care for patients with a PAC from a technical standpoint, little has been published specifically about managing such patients in the CPCU. One of the pivotal aspects of these guidelines is the clear distinction between patients suitable for the CICU versus the CPCU. Establishing criteria such as the cardiac index (≥1.6), mean arterial pressure (≥55 mm Hg), and frequency of hemodynamic measurements (every 4 hours) offered the clinicians in the CPCU a framework for determining appropriate patient admission.The integration of PACs into the CPCU represents an innovative step toward optimizing patient flow without compromising quality or safety of care. The guidelines serve as a benchmark for other institutions seeking to expand their service.These guidelines have implications for improving patient outcomes and advancing nursing practice. They empower nurses with specialized skills and broaden their scope of practice while ensuring that the highest standards are upheld.Bridging the gap between critical and progressive care through thoughtful planning and collaborative efforts supports a dynamic health care model that responds to evolving patient acuity without compromising patient safety.