Prevention of radial artery occlusion after transradial angiography and intervention: a best practice implementation project

ABSTRACT

Introduction:

Among the complications associated with transradial artery access, radial artery occlusion (RAO) is the most frequent and serious, limiting the reuse of the same radial artery for subsequent procedures and as a graft for coronary artery bypass grafting.

Objective:

The objective of this project was to implement best practices to reduce the incidence of RAO, thereby enhancing the quality of patient care after transradial coronary angiography or intervention.

Methods:

The project was conducted in cardiology department of the Huadong Hospital, Shanghai, China. The seven-phase JBI Evidence Implementation Framework was used to guide the project. Eight audit criteria were developed and a baseline audit was conducted to compare current practice with best practices for RAO prevention. Following the implementation of improvement strategies, a follow-up audit was conducted to evaluate the success of the strategies.

Results:

The implementation of best practices led to significant improvements in reducing the sheath/catheter size and systematically assessing radial artery patency before discharge, with both criteria reaching 100% compliance. The use of prophylactic ulnar compression increased from 0% to 90%, and the adoption of a minimal pressure strategy improved from 0% to 70%. The use of pre-puncture and post-procedural pre-hemostasis nitrates also increased from 23% to 93%. Barriers to implementation included the lack of dedicated devices for prophylactic ulnar artery compression, the possibility of bleeding after removal of the compression device, absence of an evidence-based care workflow, and absence of nursing assessment record forms for RAO prevention.

Conclusions:

This project promoted evidence-based practices among nurses for the care of RAO patients following transradial angiography and intervention. Efforts should be made to sustain the best practices in the future.

Spanish abstract:

http://links.lww.com/IJEBH/A261

What is known about the topic?

• Radial artery occlusion (RAO) is a common and problematic complication. Even when the patient is asymptomatic, RAO can be a significant problem, as it may limit future access routes for coronary catheters.

• The prevention and management of RAO poses challenges for health care professionals following cardiovascular interventions, particularly those involving transradial access.

• To identify and screen high-risk patients for RAO early on, it is necessary to implement optimal prevention strategies.

What does this paper add?

• Multidisciplinary teamwork is a key factor in reducing the incidence of RAO.

• Standardized preventive management strategies are effective in reducing the incidence of RAO.

• Joint health care training may increase the health care team's focus on RAO and improve theoretical and practical knowledge of RAO.

INTRODUCTION

Compared with the femoral approach, the percutaneous radial approach offers advantages, such as reduced trauma, faster recovery, and fewer complications. First, there is no need for bed rest. After the radial artery approach is completed, the patient is usually allowed to move around after the procedure without having to stay in bed for a long period of time. Thus, compared with femoral artery puncture, patients avoid the discomfort of prolonged bed rest. Moreover, the complications that may result from prolonged bed rest are also reduced. Second, it is a relatively simple operation. The radial artery is superficial and fixed, making it easy to locate, thus simplifying the puncture operation. In addition, since radial artery puncture does not require skin incision, it reduces surgical trauma and post-operative recovery time. Third, there is greater patient comfort. After radial artery puncture, the patient's upper limbs can be placed in a natural position without the need to maintain external rotation for a long period of time, thus improving patient comfort. In addition, due to the absence of wrist compression, the bruising and swelling of the palms is also significantly reduced, further increasing the comfort of patients. Moreover, the effect of compression hemostasis is better: as the radial artery is superficial, the compression time is shorter after removal of the sheath. In addition, the compression hemostasis bandage is simple, reducing the patient's pain and nursing difficulty. Above all, there are fewer complications. Compared with femoral artery puncture, radial artery puncture reduces the risk of complications such as bleeding, infection, and arteriovenous fistula.

Andò and Capodanno¹ demonstrate that the percutaneous radial approach has 27% lower post-operative mortality, 14% lower adverse cardiovascular events, 63% lower puncture site bleeding, and 40% lower major bleeding complications than the femoral approach. In addition, the 2018 European guidelines on myocardial revascularization recommend the transradial route as the standard approach for coronary angiography and percutaneous coronary intervention.² Consequently, the radial approach has become widely utilized in clinical practice because of its advantages.

However, although the radial artery route offers many advantages for coronary interventions, it is smaller than the femoral artery route, making successful puncture more challenging. The radial artery vessel wall contains a high distribution of α-adrenergic receptors, which makes it susceptible to spasms induced by catheter expansion and stimulation. In addition, the small diameter of the radial artery increases the risk of vessel wall damage; intimal thickening; and local thrombosis during puncture, sheath placement, and catheter manipulation. Radial artery occlusion (RAO) is one of the most common vascular complications associated with transradial access and transradial intervention.

The standard access site for the radial artery is typically located distal to the anterior aspect of the forearm, approximately 2 cm lateral to the transverse wrist flexure, between the skin and radius. This positioning facilitates sheath access and post-operative compression for hemostasis.³ The right radial artery is generally preferred because the left radial artery increases the operator's difficulty and reduces intra-operative comfort and patient cooperation. Although the transradial route has a low probability of RAO, vascular complications, such as radial artery spasm and thrombotic occlusion (1%–10%), still occur. Although RAO does not cause severe blood supply deficiency to the hand, it hinders the use of the radial artery for subsequent coronary angiography procedures and increases the likelihood of femoral artery puncture.⁴

Furthermore, the radial artery cannot be utilized as a graft in coronary artery bypass surgery, and the affected side of the radial artery becomes unsuitable for arteriovenous fistula procedures in patients undergoing hemodialysis. Therefore, reducing the occurrence of RAO is an important topic in clinical research.⁵ However, even in experienced radial artery centers, the real-world incidence of RAO remains high. A meta-analysis conducted by Rashid et al.⁶ involving 66 studies and 31,345 patients, reported a peri-operative RAO rate of 7.7% for transradial access. Hahalis et al.⁷ studied 3,102 patients and found a peri-operative RAO rate of 5.6% for transradial access. Dahal et al.'s⁸ meta-analysis, which included 2,239 patients with transradial access from six randomized controlled studies, reported peri-operative RAO rates of 4.2% and 10.7% in the high-dose and low-dose heparin groups, respectively. These findings indicate that transradial intervention can lead to long-term injury or RAO.

Despite the prevalence of RAO and its associated adverse outcomes, RAO often goes unrecognized or is misdiagnosed during routine radial interventions, resulting in inadequate assessment, prevention, and care. Shroff et al.⁹ reported that only 70% of patients underwent routine testing for radial artery patency prior to discharge, with radial artery pulsation assessed by simple touch in 50% of cases. However, clinical palpation of the radial artery is not recommended, because it can grossly underestimate the presence of RAO.

Rashid et al.⁶ investigated the effect of sheath size on RAO incidence and found that larger sheath sizes were correlated with higher RAO rates. The incidence of RAO was 0% with a 4F sheath, 2% with a 5F sheath, 11% with a 6F sheath, and 19.5% with a 7F sheath. Therefore, the lack of pre-operative selection of sheath size based on ultrasound findings of the radial artery diameter is another important factor contributing to RAO occurrence. Studies have shown that the probability of early RAO can reach a maximum of 10.6% when low-dose heparin is used, suggesting that RAO may occur in 10% of patients without proper anticoagulation during coronary surgery via the transradial route.¹⁰

Consequently, health care professionals often react to the occurrence of RAO rather than taking anticipatory and preventive measures, resulting in deficient care and a lack of systematic radial artery assessment. Identifying and managing RAO poses a significant challenge for health care professionals, with barriers to early detection at both the individual and organizational levels. Individual-level barriers include lack of education and awareness regarding RAO and insufficient multidisciplinary team support and involvement. Organizational-level barriers include the failure to translate knowledge on RAO into workflows or systems; the absence of formal screening, assessment, and diagnostic tools; the lack of preventive measures for RAO; low priority given to pre-operative and post-operative radial artery management; and insufficient leadership support. In November 2019, the Journal of the American College of Cardiology published an international consensus paper entitled “Best practices for the prevention of radial artery occlusion after transradial diagnostic angiography and intervention.”¹¹ The paper provides guidance for radial artery operators, aiming to increase the adoption of effective and simple prevention strategies to achieve an early RAO rate of less than 5%.

The quality improvement activities in this evidence implementation project were based on the aforementioned consensus paper, in response to the incidence of RAO after transradial interventions. The project was conducted at Huadong Hospital of Fudan University, a municipal tertiary care hospital with 160 cardiology beds. The methodology used to guide the project was the JBI Evidence Implementation Framework,¹² a seven-phase process model for translating evidence into practice. The central tenets of JBI's approach to implementing evidence into practice include the use of evidence-based audit and feedback, identification of the context in which the evidence is being implemented, facilitation of any change, and an evaluation process.^12,13 The overall goal of the project was to facilitate the implementation of best practices for RAO care and optimize the prognosis of inpatients with radial artery involvement in cardiovascular medicine.

OBJECTIVES

The objectives of this evidence implementation project were to:

• 1.reduce the incidence of RAO;
• 2.enhance the quality of care after transradial coronary angiography or intervention by implementing best practice recommendations;
• 3.enhance the knowledge and skills of nursing staff in preventing RAO.

METHODS

This project was guided by the seven-phase JBI Evidence Implementation Framework,¹² which is grounded in an audit and feedback approach. These seven phases of the framework are described below.

Phase 1: Identification of practice area for change

In 2021, the Huadong Hospital recorded 36 cases of post-procedure RAO in 363 patients who had undergone transradial coronary angiography within 1 month, representing an incidence of 10.1%. By way of comparison, Rashid et al.'s⁶ meta-analysis involving 31,345 patients from 66 studies conducted between 1996 and 2015 reported RAO incidences ranging from 1% to 33%. The overall RAO incidence in the early phase (within 24 hours) was 7.7%, which decreased to 5.5% in the 1-week follow-up (30% reduction). In a sub-group analysis of 5,258 patients from 12 randomized trials, the early phase RAO rate remained at 7.7%, indicating that the rate at Huadong Hospital was higher. Moreover, the hospital identified several issues affecting RAO care, including a general lack of knowledge and management strategies; the absence of standardized screening and assessment tools; and the need for hospital policies, workflow, assessment, and prevention systems. These issues prompted the hospital's nursing department to initiate a quality improvement project across all cardiovascular medicine units.

Phase 2: Engaging change agents

After identifying the practice area for change, the project leader established a research team. The core team consisted of a professor specializing in evidence-based methodology, who was responsible for guiding the evidence translation methodology. A nurse with a master's degree in nursing, extensive experience in cardiology, and the title of supervising nurse practitioner played a crucial role in project implementation, team training, evidence implementation process control, and data management. Additionally, three nursing managers with bachelor's degrees or higher and over 10 years’ experience were responsible for coordination, communication, resource mobilization, and allocation in the cardiac catheterization laboratory, cardiology, and ultrasound departments. Furthermore, six nurses with bachelor's degrees and at least 8 years’ experience in cardiology were responsible for the implementation of evidence. Monthly meetings led by the project leader were held for progress reporting and collaborative discussions on the factors influencing implementation and any barriers.

Phase 3: Assessment of context and readiness to change

The project leader organized roundtable discussions involving all team members to perform a situational analysis. The discussions covered various aspects, such as leadership support, availability of resources, interdisciplinary relationships, team culture, and the knowledge and skills of health care professionals specializing in the field. This process aimed to identify enabling factors and collectively prepare for a comprehensive approach to the project goals. Thus, the project commenced with strong nursing leadership support, positive engagement from the cardiology medical team, and the involvement of a multidisciplinary team, including members from the catheterization and ultrasound departments.

Phase 4: Review of practice (baseline audit) against evidence-based criteria

Before conducting the baseline audit, best practice recommendations and expert consensus on the prevention of RAO were synthesized and refined to form audit criteria to guide the audit. Eight evidence-based pieces of information on reducing RAO following transradial coronary angiography were extracted and documented^{10–11,14–19} (see Table 1).

Table 1.

Audit criteria, sample size, and methods to measure compliance with best practices

Audit criteria	Sample	Methods to measure compliance with best practices
1. Health care professionals must demonstrate competence in detecting and managing complications associated with a transradial approach for percutaneous coronary procedures.	Baseline: 16 nurses Follow-up: 16 nurses	Review of staff attendance in cardiovascular nurse training of Shanghai Nursing Association.
2. Health care professionals must possess the necessary skills to promptly identify and manage complications related to a transradial approach for percutaneous coronary procedures.	Baseline: 16 nurses Follow-up: 16 nurses	Check electronic nursing records.
3. Implementing a patent hemostasis protocol, with or without prophylactic ulnar compression, is a crucial preventive measure against radial artery occlusion and should be employed whenever feasible.	Baseline: 30 patients Follow-up: 30 patients	On-site observation Check electronic nursing records.
4. To achieve optimal results, compression should be administered using a dedicated compression device, employing a minimal pressure strategy in conjunction with a short hemostasis time.	Baseline: 30 patients Follow-up: 30 patients	Check electronic nursing records.
5. The smallest possible sheath/catheter size should be used to complete the procedure.	Baseline: 30 patients Follow-up: 30 patients	Check operation records.
6. Appropriate procedural anticoagulation is advised for cases involving transradial access.	Baseline: 30 patients Follow-up: 30 patients	Check operation records.
7. The administration of pre-puncture subcutaneous nitrates and post-procedural pre-hemostasis intra-arterial nitrates is encouraged, whenever applicable.	Baseline: 30 patients Follow-up: 30 patients	Check operation records.
8. Patients who undergo transradial procedures should undergo a systematic assessment of radial artery patency before being discharged.	Baseline: 30 patients Follow-up: 30 patients	Check electronic nursing records.

For the baseline audit, data were collected from 30 inpatients in the cardiovascular department between June 1 and 30, 2022. In addition, 16 nurses completed a survey. Each audit criterion was used to gather baseline data before the implementation of evidence-based interventions. This approach ensured that the data were standardized, uniform, and reliable. Table 1 summarizes the audit criteria, the sample, and the method used to measure compliance with each criterion.

Phase 5: Implementation of changes to practice

A multidisciplinary practice group was established to organize joint medical and nursing training. Expert consultants from the cardiology department conducted lectures on the basics of radial artery knowledge, the gold standard for diagnosis of RAO, as well as preventive and nursing care measures to improve health outcomes for patients. A health education video on post-transradial artery coronary intervention care was produced, using evidence-based recommendations. Several measures were implemented, such as grouping nursing teams into competitions; rewarding the winning team with the lowest incidence of RAO; providing performance incentives, certificates, and recognition; and allowing the leader of the winning team to share experiences to guide other team members. Designing, developing, and applying for patents on ulnar artery compressors and developing an emergency response plan for radial artery hemorrhage were also conducted.

Phase 6: Re-assessment of practice using a follow-up audit

As shown in Figure 1, the results of the follow-up audit demonstrated a 100% compliance rate for audit criteria 1, 2, and 7. The compliance rates for audit criteria 5 and 6 increased from 60% to 37% and 100%, respectively. Following the implementation, there was an increase in RAO knowledge and prevention among health care staff; pre-operative and post-operative radial artery assessment; execution of prophylactic ulnar artery compression; shortening of hemostatic compression duration; correct selection of sheath size; and application of nitrates at the puncture site. Most importantly, the incidence of RAO decreased from 10% at baseline to 3.33% at follow-up, meeting the quality control target of less than 5%.

Figure 1.

Compliance with best practice audit criteria: comparison of baseline and follow-up audits.

Phase 7: Consideration of the sustainability of practice changes

Evidence-based prevention of RAO was incorporated into the nursing routine for coronary interventions, and nurses’ duties were revised for each shift to integrate evidence into their daily work. This included procedures such as ultrasound assessment of the radial artery for patients undergoing coronary angiography, pre-operative and post-operative radial artery assessment using the developed coronary angiography nursing assessment record sheet, selecting the appropriate sheath type based on radial artery assessment, implementing prophylactic ulnar artery compression nursing measures with a designed dual radial/ulnar artery compression device, using minimal compression force and duration for hemostasis, and establishing a contingency plan for bleeding at the radial artery puncture site.

RESULTS

Baseline audit

In the baseline audit, Criterion 1 was evaluated by reviewing nurses’ cardiovascular nursing training certificates. Criteria 2, 3, 4, and 8 were evaluated by reviewing nursing assessment sheets in the electronic medical record and by conducting on-site reviews. Criteria 5, 6, and 7 were evaluated through a review of intra-operative records. In the baseline review, Criteria 3 and 4 were at 0% and Criteria 5, 7, and 8 were below 50%. However, criteria 1, 2, and 6 were all at 100%.

Getting Research into Practice (GRiP) strategies

Following the baseline audit, the project leader met with the 25 health care professionals involved in the research team to analyze and identify potential barriers hindering the implementation of best practices. JBI's Getting Research into Practice (GRiP) approach was used for this purpose, and weaknesses below 50% were prioritized. The participants in this process included cardiologists, coronary interventional surgeons, cardiology nurses, cardiac catheterization unit nurses, ultrasound unit physicians, the chief of cardiology, and the director of nursing.

The identified barriers encompassed the organizational, individual, and equipment levels. At the organizational level, the barriers consisted of a lack of standardized tools for screening, assessing, preventing, and managing RAO, as well as the absence of evidence-based nursing workflows to prevent RAO. At the individual level, challenges included limited access to nursing information resources on RAO; insufficient theoretical and practical knowledge among nurses; and inadequate communication with interventionalists, ultrasound room physicians, catheterization lab nurses, and other multidisciplinary teams. At the equipment level, barriers included the absence of specialized devices for prophylactic ulnar artery compression.

The project team then explored strategies that could be implemented in the cardiology wards and catheterization units to improve the quality of care by working as a cohesive multidisciplinary team. Table 2 outlines the strategies developed to address the barriers.

Table 2.

Getting Research into Practice (GRiP) analysis

Barriers	Strategies	Sources	Outcomes
Organizational level
• Lack of screening and assessment for peri-operative radial artery occlusion (RAO).	• Implementation of radial artery ultrasound screening and assessment for all pre- and post-coronary intervention patients.	• Developed the checklist. • Trained the nurses in its use. • Monitored the implementation.	• The checklist (assessment form) was developed and used by all nurses to assess patients. • All patients underwent pre- and post-radial artery ultrasounds.
• Lack of evidence-based care workflow for RAO prevention.	• Development of a nursing workflow for RAO prevention based on best practices.	• Consulted literature to identify best practices. • Developed nursing workflow based on the best practices. • Organized training for nurses. • Supervised nurses following the standard workflow.	• All nurses were taught evidence-based preventive radial artery ultrasound nursing routines, which were followed by nurses and implemented into their daily nursing routines.
Individual level
• Nurses lack access to information related to RAO and lack appropriate theoretical and practical knowledge.	• Establishment of training courses on RAO and other surgical limb complications, to be taught by physicians.	• Selected the first, second, and third place nurses on theoretical study. • Set financial incentives. • Performance appraisal of outstanding results. • Continuous improvement and enhancement of theoretical knowledge.	• All nurses acquired theoretical and practical knowledge of RAO.
• Lack of support and collaboration with multidisciplinary teams, including interventionalists, ultrasound room physicians, and catheterization room nurses.	• Monthly nursing team competitions to evaluate the team with the lowest incidence of RAO. • Coordination and organization of multi-departmental collaboration by nursing leadership.	• Selected the winning team with the lowest incidence of RAO. • Head nurse with strong leadership skills organized and coordinated the multidisciplinary collaboration.	• A multidisciplinary team for the prevention of RAO was established, with team members supporting each other and working closely together.
Equipment level
• Lack of dedicated devices to prevent ulnar artery compression.	• Designed, developed, and patented ulnar artery compression device.	• Manuscript. • Sketch. • Design mindset. • Sample.	• An application for this utility model patent has been filed and the results of the selection are awaited.
• Increased likelihood of bleeding after shorter duration of compression and the removal of the radial artery compression device.	• Added emergency kits for bleeding • Developed an emergency plan for bleeding.	• Emergency kits for bleeding back-up. • Developed an evidence-based emergency plan form. • All nurses were taught to use the emergency kit. • Emergency drill.	• Checked items in emergency kits daily. • Nurses were aware of the emergency plan. • Patients’ radial artery bleeding was treated promptly • Nurses responded quickly to the emergency plan.

All strategies aimed to enhance the health care team's knowledge and proficiency in screening, assessing, and preventing RAO, as well as improve nurses’ ability to identify patients at risk of this complication. The following strategies were implemented.

Joint training of the medical and nursing teams. A training course focusing on RAO was developed by the project leader. The topics included the gold standard for diagnosing RAO, protection of the radial artery during interventions, preventive measures, ulnar artery compression techniques, selection of the radial artery auscultation site, differentiation between normal sounds and murmurs, and the observation of complications. Expert cardiologists conducted 1-hour collective and standardized lectures. Throughout the 12-week study period, three training sessions were held for the research team and implementers. Knowledge assessments were conducted before and after the training using the same set of questions to evaluate the effectiveness of the intervention.

Improvement in the nursing process. The post-operative care routine and process for transradial coronary interventions were revised based on the best available evidence. Additionally, the nurse in the catheterization laboratory recorded the name and dose of anticoagulants and the dose of locally administered nitroglycerin at the puncture site. These details were added to existing pre-operative and post-operative evaluation sheets for transradial coronary interventions. This standardization aimed to facilitate pre-operative, post-operative, and pre-discharge assessment of the radial artery on the operative side in patients undergoing transradial coronary interventions, thereby supporting collaborative efforts to reduce the incidence of RAO.

Improvement in system resources. A health education video on post-operative care for transradial coronary interventions was produced, incorporating evidence-based recommendations on limb immobilization, duration of balloon compression, frequency of balloon relaxation, and preventive ulnar artery compression techniques. The video, which was approximately 10 minutes in length, was broadcast on the ward's electronic screen. Additionally, 500 copies of an educational booklet were printed and distributed to post-coronary intervention patients, containing information on the procedure, key points of post-operative care, and limb rehabilitation exercises. Posters for the prevention of limb complications were also displayed in the cardiology ward. Electronic educational content was sent to the cell phones of patients undergoing transradial coronary interventions through a structured electronic medical record system and follow-up system, allowing patients to access information anytime and anywhere. Furthermore, a transradial coronary intervention patient exchange group was established and a post-discharge follow-up plan was developed using a cloud follow-up platform to provide ongoing support after patients were discharged.

Nursing team competition. The cardiology nursing team was divided into three groups consisting of six nurses each. Using evidence-based nursing practice, the number of patients with RAO occurring within each group in a given month was recorded. The group with the lowest incidence of RAO was recognized as the winner. The leader of the winning group shared their experiences and provided guidance to the other group members. The competition took place over 3 months, and monthly assessments were conducted three times. The best nursing team for preventing RAO and the nursing team leader with the most wins were selected and linked to performance bonuses, year-end assessments, promotions, and merit evaluations.

Design, development, and patent application of ulnar artery compressors. Studies have indicated that peri-operative ulnar artery compression helps prevent RAO after coronary angiography. Currently, dedicated ulnar artery compressors are lacking, and the commonly used radial artery compressors can only be temporarily applied for ulnar artery compression. To address this limitation, the medical and nursing team designed and applied a new type of radial and ulnar artery duplex compression device. This device aims to overcome issues such as inaccurate compression and insufficient compression strength, as well as potential bleeding at the radial artery puncture site during ulnar artery compression.

Follow-up audits

Through the implementation of evidence-based practice, the project achieved significant progress in the prevention of RAO. The incorporation of evidence-based strategies into nursing routines, the establishment of bleeding contingency plans, and the implementation of preventive measures reduced the incidence of RAO from 10% to 3.33%.

Following the implementation, three of the eight audit criteria (1, 2, and 6) maintained a 100% compliance rate. Two criteria (5 and 8) achieved 100% compliance, two criteria (3 and 7) showed some improvement, and one criterion (4) continued to pose challenges. (see Figure 1).

Criteria 5 and 8 focused on reducing the sheath and catheter size and conducting radial artery assessment. This involved ultrasound assessment of the radial artery for each patient and the use of the results to guide the selection of the appropriate sheath size. Appropriate sheath selection plays a crucial role in minimizing radial artery injury and effectively reducing the incidence of post-operative RAO.

Criteria 3 and 7, which involved prophylactic ulnar artery compression and post-operative nitroglycerin injection, required continuous improvement. These measures were not fully implemented, and further efforts are required to integrate the new workflow into daily practice. The next research direction will be the development of a dual radial/ulnar artery compression device to facilitate effective ulnar artery compression.

Criterion 4, which focused on the duration of balloon compression, continued to pose challenges owing to variations in patients’ anticoagulant regimens and coagulation status. It is difficult to guarantee that all patients can have their balloon compression time minimized without bleeding upon removal of the radial artery compression device. Therefore, achieving compliance with Criterion 4 is challenging.

DISCUSSION

The goal of this quality improvement project was to decrease the risk of RAO in patients following transradial coronary angiography and intervention. Standardized tools for radial artery screening, assessment, prevention, and management were implemented at the hospital, and the hospital's standard workbook, systems, and processes for radial artery care were updated. This resource was key to reducing the screening and assessment of patients at risk of RAO, which prompted the health care team to take appropriate preventive measures after transradial coronary angiography and interventions.

Critical to the success of the project were multidisciplinary team collaboration, expertise sharing, teaching, assessment, and consensus-based decision-making. One of the vital ingredients for the successful implementation of evidence into practice is facilitation, which also involves cooperation.

For this quality improvement initiative, the team with the lowest incidence of RAO was selected as the winner. The team was rewarded, awarded, and recognized for its performance. This recognition motivated the winning team members to drive practice change and establish themselves as exemplary leaders within the department. Simultaneously, the project team was engaged in various activities, namely, educating the health care team about the radial artery, conducting a baseline audit of current nursing practices in the unit, and evaluating practice changes and support of the multidisciplinary team. Additionally, nursing managers and the chief of cardiology provided education on evidence implementation and offered technical research support to ensure the smooth running of the project. These activities align with the findings of prior studies on facilitation, which emphasize that successful facilitation efforts in health care organizations involve both internal and external facilitation.²⁰ As highlighted in the literature, internal facilitation is crucial for sustainable implementation, while external facilitation provides support to internal facilitators.²⁰ This strategic partnership promotes an integrated approach to evidence-based practice, which is considered ideal for achieving sustainable practice change.²⁰

This quality improvement project relied on several key enablers to reduce the incidence of RAO. These included constructive discussions, sharing of experiences and knowledge by the winning team, joint problem-solving by the multidisciplinary team, the design and application of practice tools (i.e., ulnar artery compressors), and a collective effort to integrate resources. Essential strategies included pre-operative and post-operative radial artery screening and assessment, intra-operative prophylactic measures, and post-operative care interventions. The team collaboratively developed and validated workflows that were well received by frontline clinicians and nursing professionals. Full participation from all stakeholders in the study demonstrated a sense of ownership and strong commitment to improving RAO practices. These findings align with a recent study, which suggests that effective delirium care necessitates a “choreographed dance” of teamwork and integration across services.²¹ Psychological and organizational research also confirms that enhancing teamwork is important for improving care coordination and optimizing health care outcomes.²²

This quality improvement project emphasizes the crucial role of education in facilitating changes to clinical practice. Feedback from clinical nurses revealed that, prior to the start of this project, RAO was not regarded as a priority. Only a few clinicians were aware of the associated risk factors. The assessment of RAO was unfamiliar to many clinical nurses, and routine screening and assessment of the radial artery were never performed before coronary angiography, despite it being an important component of prevention and diagnostic pathways. Discussions regarding the risk and prevention of RAO were largely absent from medical and nursing handovers. Informal diagnosis was made when the surgeon identified a RAO through palpation prior to radial puncture. Moreover, it has been reported in the literature (Shroff et al.⁹) that 50% of surgeons assess radial artery pulsation through simple palpation. However, clinical palpation of the radial artery is not recommended, as it can lead to a significant underestimation of RAO. Studies have demonstrated that ultrasonography is superior to clinical assessment in terms of detection rate of RAO. Ultrasonography allows visualization of radial artery blood flow and provides relevant anatomical information.²³

Moreover, the clinical approach (i.e., arterial palpation) is limited by factors such as hypotension, local hematoma, residual tissue compression after surgery, and false-negative findings resulting from retrograde perfusion of the ulnar artery. Ultrasonography has shown palpable radial artery pulsation in 20%–33% of patients with RAO,²⁴ making it a reliable test for detecting RAO.

In this project, education was a key strategy for enhancing current practices regarding RAO. The study confirms that training for nurses improves compliance for recognizing, assessing, and preventing RAO. Therefore, an effective educational approach should encompass a multifaceted strategy that extends beyond knowledge dissemination, but includes training, implementation, assessment of relevant knowledge, and comprehensive inter-provider handoffs.

Patient-centered care is the cornerstone of high-quality clinical practice. Lizarondo et al.²⁵ used five evidence implementation projects to demonstrate that facilitation involves various components, such as education and capacity-building, collaboration, action planning, problem-solving, and evaluation. Implementing prophylactic measures against RAO presents an opportunity for nurses to gather pertinent information about a patient's radial artery, enabling the delivery of personalized care. This may involve providing health education brochures, educational videos, and timely preventive interventions.

Although positive changes have been observed in the prevention of RAO, there are still areas in medical and nursing practice in which the implementation of measures may not be as effective as desired. One such area is the implementation of measures to minimize the duration of compression, which may not be feasible for all patients owing to variations in their anticoagulant regimens and coagulation status. Additionally, the occurrence of wound bleeding after the release of the radial artery compression device within 2–4 hours is a concern. Prior to project implementation, the radial artery compression balloon was deflated by 2 ml every 2 hours, and the compression device was completely released after 8 hours. During the project, our team made efforts to release the radial artery compression device as early as possible, aiming for release after 6 hours. However, we encountered cases of bleeding from the radial artery wound after device removal. Consequently, the research team developed emergency hemostatic measures and corresponding workflows to address bleeding from radial artery wounds and ensure patient safety. Addressing the challenges associated with reducing the duration of compression is crucial and warrants further review. This measure should be aligned with current preventive strategies to mitigate RAO resulting from prolonged compression, maintain radial artery blood flow patency, and safeguard the radial artery from the outset. These efforts have had a positive impact on reducing the incidence of post-operative RAO. Therefore, this measure is a crucial step in our efforts for improvement.

Furthermore, the implementation of two measures—post-operative local nitroglycerin injection and prophylactic ulnar artery compression—faced challenges due to several reasons. First, the vasodilator effect of nitroglycerin injection effectively reduces friction between the radial artery and the sheath and catheter, thus aiding in the prevention of RAO.²⁶ However, the practice of recording post-operative local nitroglycerin injections in the patient's surgical record was not mandatory, leading physicians to overlook its administration during implementation. Second, despite the education and training provided to the medical and nursing staff of the project team, the high turnover of trainee physicians within the department and the inclusion of newly hired employees who had not attended the training posed challenges. Third, the implementation of prophylactic ulnar artery compression requires dedicated time. However, owing to the need for emergency surgeries in some cases, for which physicians expedited the process, it became impractical to apply this intervention to every patient within the given time constraints. These challenges highlight the complexities encountered during project implementation.

In summary, this quality improvement project experienced certain limitations. First, the project had a relatively short implementation period of 2 months and used a small sample of 60 patients. Consequently, the findings may not be fully representative of all patients with RAOs. Future studies should increase the sample size to enhance feasibility. Additionally, the 6-month duration allocated for implementing all preventive measures may not provide sufficient time for each health care provider to carry out the interventions consistently and comprehensively. Addressing this challenge requires collaborative efforts between investigators and administrators. For instance, using the incidence of RAO as a specialty-sensitive indicator could allow for the continuous monitoring and sustainability of this quality improvement project.

CONCLUSION

In this study, a seven-phase evidence-based continuous quality improvement model was employed to implement the best evidence for reducing RAO in patients undergoing transradial coronary interventions. The project standardized various aspects of nursing care, including pre-operative and post-operative assessment of the radial artery, peri-operative care, preventive measures, ulnar artery compression, control of the radial artery balloon compression duration for hemostasis, and sheath selection. It also enhanced nurses’ knowledge of RAO and improved the nursing process and health education content related to managing complications in the surgical extremities of patients after transradial coronary intervention. The project resulted in the development of an evidence-based health education manual for patients aimed at reducing complications in the operated limb and ensuring normal blood supply, function, and safety of the radial artery. However, further investigation and study is required to determine the safety and effectiveness of prophylactic ulnar artery compression. Future audits should be conducted to explore these areas and assess the sustainability of practice improvements.

ACKNOWLEDGMENTS

We would like to acknowledge Yang Chen from the Cardiovascular Department, who played a crucial role in the development of the educational resources.

ETHICS

Ethical approval was obtained from the Ethics Committee of Huadong Hospital, affiliated with Fudan University (No. 20220115).

FUNDING

This study was supported by grants from the JBI Clinical Fellowship Program of Fudan University (No. FNSF202204).