Nasir, Ayan

Background: Owing to reduced bleeding risks, radial is favored over femoral for access site selection in patients referred for coronary angiography, with specific benefits in patients presenting with acute coronary syndrome. However, studies were often limited to patients without coronary artery bypass grafts (CABG), given the technical challenges of the radial approach in these patients. Methods: We evaluated patients with prior CABG undergoing coronary angiography with or without percutaneous coronary intervention (PCI) from 2015-2020 at our institution. We reviewed access site and bleeding outcomes as defined in the NCDR CathPCI registry. Additional outcomes included procedural duration, fluoroscopy time, contrast volume, and clinical events. Results: Of the 1,546 patients studied, 280 (18%) patients had radial access while 1,266 (82%) patients had femoral access. Over the study time period, frequency of radial access for post CABG catheterization procedures increased from 0% in 2015 to 45% in 2020. There were no statistically significant differences in comorbidities, bleeding events, complications, or mortality between radial vs femoral (Table). Fluoroscopy time was higher for radial vs femoral (14.9 mins vs 13.3 mins, p=0.04). Conclusion: Over time, radial access choice in post CABG patients increased, without significant differences with respect to bleeding events or complications as compared to femoral, though at increased fluoroscopy times.

Hyponatraemia on hospital admission is associated with increased length of stay, healthcare expenditures and mortality. Urine studies collected before fluid or diuretic administration are essential to diagnose the underlying cause of hyponatraemia, thereby empowering admitting teams to employ the appropriate treatment. A multidisciplinary quality improvement (QI) team led by internal medicine residents performed a QI project from July 2020 through June 2021 to increase the rate of urine studies collected before fluid or diuretic administration in the emergency department (ED) in patients admitted with moderate to severe hyponatraemia. We implemented two plan-do-study-act (PDSA) cycles to address this goal. In PDSA Cycle #1, we displayed an educational poster in employee areas of the ED and met with nursing staff at their monthly meetings to communicate the project and answer questions. We also obtained agreement from ED attending physicians and nursing leaders to support the project. In PDSA Cycle #2, we implemented a structural change in the nursing triage process to issue every patient who qualified for bloodwork with a urine specimen container labelled with a medical record number on registration so that the patient could provide a sample at any point, including while in the waiting area. After PDSA Cycle #1, urine specimen collection increased from 34.5% to 57.5%. After PDSA Cycle #2, this increased further to 59%. We conclude that a combination of educational and structural changes led to a significant increase in urine specimen collection before fluid or diuretic administration among patients presenting with moderate-to-severe hyponatraemia in the ED.