In addition to clinical benefits, harms, and costs, the Task Force also considered patient and provider concerns that could influence implementation of the guideline:
Patient Concerns
Disadvantaged patients who meet criteria for pulmonary artery (PA) catheterization may lack access to hospitals with facilities and qualified personnel to perform the procedure. This is especially true for patients in minority or disadvantaged populations, who have experienced documented disparities in care, and for those with inadequate insurance coverage. Although in most cases the urgency of conditions requiring PA catheterization does not lend itself to discussions beyond the basic requirements for informed consent, patients undergoing procedures for which the use of pulmonary artery catheterization (PAC) is elective may benefit from the opportunity to review the indications for using the device and to decide, based on personal preferences, whether to proceed.
Preoperative catheterization, which as noted earlier lacks compelling evidence of benefit, may also be less desirable to patients. Insertion of the PA catheter in the operating room may be more comfortable, less anxiety provoking, and induce less physiologic stress than preoperative insertion.
Provider Competency and Training
The appropriateness of PA catheterization and the determination of whether benefits exceed risks hinge on the competence of physicians and nurses in catheter use. This competence encompasses both technical and cognitive skills, which are first acquired in residency or postresidency training. Maintenance of skills following training often requires regular catheter use, but there is disturbing evidence that skill levels are inadequate. A study in which a 31-item examination on PA catheters was completed by 496 North American physicians, found that only 67% of the answers were correct. The instrument yielded similar results in Europe. A 1996 survey of more than 1,000 critical care physicians found that, although 83% of questions were answered correctly, a third of the respondents could not correctly identify PA occlusion pressure on a clear tracing and could not identify the major components of oxygen transport.
Similar problems have been identified among critical care nurses. Exposure to the subject in nursing school is limited, and surveys of practicing nurses demonstrate knowledge deficits. A 31-item examination of critical care nurses in California found that only 57% of the responses were correct. Only 39% of respondents correctly identified a PA wedge measurement value from a waveform recording. Most of the nurses (95%) had more than 1 yr of experience in critical care, and 99% used the pulmonary artery catheterization (PAC) more than once per month. Scores were better for nurses with Certification in Critical Care Nursing (CCRN) certification, attendance at a PA catheter class, more years of critical care experience, and frequent PA catheter use.
Because PA catheterization by persons who have not maintained these skills is potentially harmful to patients and could threaten the acceptability of the procedure, it is important for the profession to periodically assess technical and cognitive performance. Recognition of the need to strengthen quality control and competency has grown in recent years. The best measure of competence is clinical outcome, but long periods of observation and careful data analysis may be necessary to obtain meaningful information. Surrogate measures such as the frequency of catheter use or the results of proficiency examinations may be the best alternative, but they are imperfect measures of competence.
Reimbursement
Reimbursement policies play a role in the ability of providers to offer PAC. In addition to other factors, the evidence that PAC is only appropriate for certain indications and should therefore not be used as a matter of routine in the perioperative setting makes it inappropriate to assume that PAC is part of the surgical procedure or for payers to bundle it in reimbursement.
Utilization Review and Medicolegal Liability
Because of limitations in scientific evidence about the limits of appropriateness for PA catheterization, guidelines based on expert opinion should not be used as standards of care or to define cases of unnecessary catheterization.