Application of the Plan-Do-Check-Action Cycle in Reducing the Incidence of Forearm Hematoma in Patients After Transradial Artery Percutaneous Coronary Interventions

Introduction

The American Heart Association (AHA) predicts that by 2035, approximately 130 million people will have cardiovascular disease, with coronary heart disease (CHD) being the leading cause of death in patients with CHD and a high rate of recurrence.¹ Cardiovascular Health and Disease Report 2020 states that 11.39 million people have CHD in China.² Radial artery access is currently indicated for all percutaneous procedures, but local vascular complications still occur and can lead to serious adverse events such as bleeding, combined forearm hematoma syndrome, and, if hemostatic care is inadequate, radial artery occlusion.^3–6 Therefore, from this perspective, a standardized radial artery hemostasis protocol care may improve prognosis.

In 1954, scholar Deming created the Plan-Do-Check-Act (PDCA) cycle management model. It is a scientific idea for solving problems arising from work and has been widely recognized. The main feature of the PDCA cycle management model is to carry out quality management according to the sequence of Plan (P), Perform (D), Check (C), and Act (A) so that the management objectives can be developed step by step in order to achieve the final goal.⁷ By applying the PDCA cycle to reduce the incidence of forearm hematoma in patients after transradial PCI training and quality management, we summarized and identified the main causes of forearm hematoma and proposed appropriate corrective measures for each cause. The study is summarized and reported as follows.

Methods

Design

Study Subjects

This study was conducted on 260 patients with acute myocardial infarction admitted to our hospital between January 2022 and June 2022 who underwent coronary intervention. The subjects were divided into control-group (n=130) and observation-group (n=130) in accordance with their admission time. The control-group received routine nursing care; and the observation-group, was applied with PDCA nursing management in addition to conventional treatment (Table 1).

Table 1 The Characteristic of Respondents in Control Group and Intervention Group in Transradial Artery Percutaneous Coronary Interventions From 2022 (n=260)

Planning

A brainstorming discussion was conducted to analyze the factors influencing the occurrence of forearm hematoma through investigation and certification; forearm hematoma cases were studied. Causes of formation are plotted as fishbone diagrams (Figure 1). The argumentation by Platonic analysis identified main causes, namely: irregular postoperative nurse balloon deflation and irregular postoperative patient limb movement (Figure 2).

Figure 1 Fishbone diagram of cause.

Figure 2 Proportions of causes.

Do

Check

The nurse manager and quality control staff ensure that quality of care checks and care for each patient are adequately implemented. Patient care is able to be fully implemented.

Act

Several recommendations for improvement were made in response to the problems, and the nurse manager and members of the quality team followed up on the issues identified and took steps to ensure the effectiveness of patient care and staff training.

Inclusion Criteria and Exclusion Criteria

Inclusion criteria: age ≥18 years; NYHA cardiac function classification in class I–II, Patients with cardiac function class III–IV who can tolerate the procedure. Exclusion criteria: Combination of serious arrhythmia, heart valve disease, and so on.

Statistical Methods

All data were incorporated into the SPSS Statistics 22.0 software for statistical analysis. The χ2 test was used to analyze the relationship between control-group and observation-group. The enumeration data were expressed as a percentage (%), P < 0.05 indicated a statistically significant difference.

Ethical Considerations

The study was approved by the Institutional Review Board of the author’s institution, specifically the Jinhu Hospital Health System, through a full-board review conducted in January 2022 (No. 3–2022-0123). Informed consent was obtained from all participants in the study.

Results

Mean of control-group age was 56.47±3.25, male was 67 (51.54%), female 63 (48.46%), history of smoking 85 (65.38%), history of hypertension 96 (65.38%), history of diabetes mellitus 45 (34.61%), history of Hyperlipidemia was 38 (29.23%), Intravenous and oral antiplatelet and anticoagulant drugs 15 (11.54%), Repeated punctures was 8(6.15%). Mean of observation-group age was 56.36±3.43, male was 56(43.8%), female 74 (56.92%), history of smoking 78(60%), history of hypertension 88 (67.69%), history of diabetes mellitus 40 (30.77%), history of Hyperlipidemia was 47 (36.15%), Intravenous and oral antiplatelet and anticoagulant drugs was 23 (15.33%), Repeated punctures was 6(4.61%). From January 2022 to March 2022, there were 130 patients after transradial PCI, of which 32 patients with forearm hematoma occurred, with an incidence of 24.62%. During the implementation of PDCA, from May 2022 to June 2022, the condition of 130 patients after transradial artery puncture was investigated and forearm hematoma occurred in 11 patients, whose incidence was 8.46% (P < 0.05) (Table 2).

Table 2 Comparison Table of Data Before and After Improvement

Discussion

With the continuous progress of society and the continuous improvement of living standards, the traditional nursing model can no longer meet the patient’s care needs, and can not effectively improve the patient’s quality of life or reduce the incidence of complications, and prolong the disease course. The Plan-Do-Check-Act (PDCA) management method was first applied in the United States to improve the quality of management. In recent years, with the continuous development and progress of nursing discipline, PDCA management system has been applied more and more in nursing work, which can help nurses accumulate practical and effective nursing experience, avoid nursing errors and gradually improve the quality of nursing management.⁸ As a circular management method, PDCA mainly includes four aspects of plan, do, check and act in accordance with the principles of “large ring nests the small ring, while the small ring props up the large ring”.⁹ Therefore, the application of the PDCA cycle method to the nursing care of reducing the incidence of forearm haematoma in patients after transradial artery PCI is of great significance in providing quality nursing care for patients and improving clinical outcomes.

With the continuous improvement of coronary artery disease interventional diagnosis and treatment technology, the feasibility of transradial coronary artery intervention in clinical application has been widely recognised, which has the advantages of small trauma, fast postoperative recovery, and reduction of patients’ postoperative bedtime.¹⁰ However, it is worth noting that the majority of patients undergoing coronary intervention are elderly, mostly with hypertension and diabetes. Elderly patients’ reduced physical function greatly increases the possibility of forearm haematoma after the operation, therefore, it is crucial to give the necessary nursing management to alleviate patients’ pain and improve patient satisfaction.

At present, coronary intervention via the radial artery route has become a routine route for coronary intervention in our department. The distal radius approach is currently the most recommended surgical approach for PCI because of less bleeding and ease of maneuvering, but it is prone to forearm hematomas.¹¹ In order to reduce the incidence of forearm haematoma in the radial artery puncture route, to reduce the pain of the patients, and to increase the satisfaction of the patients, the PDCA management model was used in our hospital with a view to improving the incidence of forearm haematoma after transradial artery intervention. Some studies have reported an incidence varying from 0.04% to 14.4%.^12,13 Our forearm hematoma incidence was 24.2%, which is much higher than that reported in the literature. The results of this study showed that the occurrence of forearm haematoma in the PDCA group was 8.46%, which was significantly lower than that in the control group, which was 24.62%, and the difference was statistically significant (P < 0.05). It was confirmed that the incidence of forearm haematoma could be significantly reduced by applying the PDCA cycle management model and strengthening the professional training of nurses, so that both the nursing level of nurses and the pain of patients could be reduced and the satisfaction of patients could be improved. The current situation and causes were analysed through discussion, and the causes of postoperative forearm haematomas were listed and classified, and finally identified as 2 aspects, namely, irregular deflation of the nurse’s airbag and irregular limb movement of the patient in the postoperative period. In this regard, all nursing staff in the cardiovascular department were trained during the implementation stage, and the key points of nursing learning were emphasised through PPTs and dynamic diagrams; the department formulated a mechanism for nurses’ training and assessment, and carried out training on haematoma-related knowledge, and so on. For patients’ failure to comply with medical advice, two nurses were specially arranged to serve as health education, actively communicate with patients and their families, and actively provide feedback to physicians when patients have a sense of abnormality or when their families find abnormalities in the skin around the puncture, so as to facilitate early detection of haematoma. There are some major limitations of this study, mainly due to the small number of participants and the need for future studies with larger sample sizes to support the findings.

Conclusion

In conclusion, the application of PDCA cycle management model can significantly reduce the incidence of forearm haematoma after transradial artery puncture intervention, improve the quality of medical services, enable patients to better cooperate with the treatment, alleviate the pain of the patients, improve the satisfaction of the patients and enable them to be discharged from the hospital successfully. Therefore, the PDCA management model is worth popularizing and applying in clinic.