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UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Cardiovascular and Infusion

Temporary Pacing: Transvenous, Transcutaneous, Epicardial, and Semi-Permanent (Adult) (1.37A)

Temporary Pacing: Transvenous, Transcutaneous, Epicardial, and Semi-Permanent (Adult) (1.37A) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.37A

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
November 30, 2016


Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.37A

Original
Revision

Page
1
of 10

Title: Temporary Pacing: Transvenous,
Transcutaneous, Epicardial, and Semi-
Permanent (Adult)

I. PURPOSE

To facilitate electrical stimulation of the heart via a temporary pacemaker in the setting of
symptomatic bradycardias, conduction abnormalities, or ventricular standstill.

II. POLICY

A. Use of temporary pacemakers is limited as follows:
1. Transvenous/transvenous:
a. Definition: Use of a temporary pacemaker wire through an introducer :
b. Location: cardiothoracic surgery intensive care, cardiac medical
intensive care, the trauma and life support center, Heart and Vascular
Lab, operating room, post anesthesia care unit (PACU), and
emergency department.
c. Level of care: intensive care
2. Epicardial wires:
a. Definition: cardiac pacing via wires which are brought through the
chest wall and are connected to the epicardium after cardiac surgery
b. Location: cardiothoracic surgery unit
c. Level of Care:
i. Adult ICU: All fresh post-ops and as ordered by provider.
ii. Adult IMC: Patients requiring 100% pacing with epicardial
pacing wires and who have minimal underlying rhythm should
be intermediate care (IMC) status and require a nurse to
accompany the patient off the unit.
iii. Adult General Care: Patients with epicardial pacing and a
stable underlying rhythm may be general care on the
cardiothoracic surgery unit. Provider order determines need
for nurse to accompany patient off unit for tests.
3. Semi-permanent:
a. Definition: Temporary pacemaker lead that screws into the
endocardium which attaches externally to a permanent pacemaker
generator. This device can be in place for several weeks or months.
Because this pacemaker lead screws into the endocardium it is a more
stable pacemaker than a temporary device.
b. Location: cardiothoracic surgery, cardiac medical intensive care, the
trauma and life support center, cardiac catheterization lab, operating
room, PACU, heart vascular progressive care and medical cardiology
unit.

Page 2 of 10

c. Level of Care: general, intermediate or intensive care
B. To safely facilitate the insertion of a temporary transvenous pacemaker by the
cardiology fellow or attending physician for symptomatic bradycardia, the patient
will be in an ICU/ED/cardiac catheterization lab settings or other appropriate
environment with the appropriate medical personnel.
C. The initiation of any transcutaneous pacing requires a provider order on any unit even
in emergency situations. Transfer to another unit will be determined by the primary
team and patient condition.
D. All temporary pacemaker settings and changes to settings will be ordered by the
provider.
E. When starting any type of pacing (except transcutaneous or semi-permanent), make
sure a new battery is put in the pacemaker box prior to hooking up to the patient.

III. COMPONENT PROCEDURES

A. Procedure for Transvenous Pacing
B. Procedure for Pacing through a Pulmonary Artery Catheter
C. Procedure for Epicardial Pacing
D. Procedure for Troubleshooting: Transvenous and Epicardial
E. Procedure for Transcutaneous Pacing
F. Procedure for Semi-permanent Pacing

IV. PROCEDURE FOR TRANSVENOUS PACING

A. Transvenous pacing primarily provides ventricular pacing only.
B. Equipment
1. Insertion
d. Sterile towels, gowns and gloves, cap and large drape with access hole
e. Masks
f. Fluoro required: fluoroscopy bed, fluoroscopy cove, lead aprons
g. Local anesthetic, syringe and needle
h. Catheter contamination shield (Central Services [CS] Item Number
2200256)
i. Suture material: sterile scissors, sterile needle driver and 3-0 or 4-0
suture
j. Introducer kit (6 Fr introducer preferred [CS Item Number 2200133])
k. Pacing electrode (5 Fr balloon-tipped pacing catheter [CS Item
Number 2200014])
2. Pacing
a. Pacing cable
b. Pulse generator
c. New battery for generator
3. Site care
a. For: transvenous pacemakers:
i. Sterile central line dressing kit but use the antimicrobial disc
and transparent dressing. CHG impregnated dressings should
not be used for pacing wires.
ii. Transparent occlusive dressing x 2 (cover entire wire)


Page 3 of 10

C. Insertion
1. Health Unit Coordinator should alert Radiology to have fluoroscopy on call if
needed. Provider may choose to have fluoroscopy present during the
procedure. Place patient on fluoro bed. If fluoroscopy is used, all staff in room
must wear lead aprons and consideration given to the shielding of the patient
as appropriate.
2. Confirm that consent has been obtained unless it is an emergency. Refer to
UWHC Hospital Administrative Policy 4.17, Informed Consent. Universal
protocol must be completed prior to the beginning of the procedure according
to UWHC Hospital Administrative Policy 8.48, Operative, Invasive & Other
Procedures.
3. Ensure cardiac monitoring can be done continuously at the bedside during,
prior to, during and after insertion of the temporary pacing wire. Ventricular
arrhythmias may occur during insertion.
4. Emergency equipment and medications should be immediately available (not
limited to transcutaneous pacing equipment).
5. The transvenous approach may include use of the jugular, subclavian or
femoral veins.
6. The provider will prep the selected site and sterilely drape the site. Inserter
and assistants should wear mask, caps, sterile gown and gloves. All persons in
the immediate area should be masked and capped.
7. If patient will be sedated for procedure, follow UWHC Hospital
Administrative Policy 8.38, Adult Sedation.
8. The provider places the introducer/sheath. Provider covers the temporary
pacing wire with a contamination shield prior to inserting the pacing wire.
Provider inflates the balloon on the temporary pacing wire and floats the wire
into the right ventricle. Fluoroscopy is frequently used to guide catheter
placement. Once the pacing wire is in a good position the balloon on the
pacing wire will be deflated.
9. Connect leads to pacing cable. Make sure connections are secure. Insert cable
into pulse generator. All connections should be negative-to-negative and
positive-to-positive.
10. Insert new battery and turn on pulse generator.
11. Provider determines the mode of pacing desired. Ventricular demand is most
commonly used.
12. Set the initial pacemaker rate (commonly 80-100 beats/minute). All temporary
pacemaker settings and changes to settings will be ordered by the provider.
13. Set the initial output at five (5) milliamps (mA). Set the sensitivity dial at the
fully clockwise position (demand mode). Increase the mA until capture is
achieved (patient’s pulse matches rate of pacemaker).
14. Stimulation and sensitivity threshold testing should be done by provider. .
15. Tape the electrode wire securely to the introducer/sheath and to the patient.
Limit mobility of the affected extremity. Use knee immobilizer for femoral
sites. The provider will usually suture the introducer and pacing wire at the
insertion site. This prevents dislodgement of the wire.
16. Perform site care. A thoroughly dry dressing provides a measure of safety
against micro shocks.

Page 4 of 10

a. Using sterile technique, cleanse site with 2% chlorhexidine solution,
place

Biopatch
®
around insertion site and cover with transparent,
occlusive dressing.
b. Label dressing with "pacing wire" and date.
17. Obtain chest x-ray to verify pacemaker electrode placement and to rule out
pneumothorax and myocardial perforation.
18. After the insertion, document the pacemaker settings (rate, mA, and
sensitivity), percent paced, peripheral pulses (femoral inserted catheters),
heart rate, and central line insertion including site condition and dressing.
D. Maintenance
1. Patient’s cardiac rhythm will be continuously monitored for appropriate pacer
function (correct sensing, correct firing).
2. Patient’s response to pacing will be monitored at a minimum of every four (4)
hours and as needed.
3. Pacer wires and cable should be taped securely near the wire insertion site.
Place the pacemaker generator in a location (such as on the IV pole) where it
will not be pulled or dropped.
4. Ensure back up pacer box, appropriate cable and batteries are on the unit or
can be obtained quickly.
5. It is not recommended to flush or infuse fluids or medications through the
introducer, port with the transvenous pacing wire or side port as these actions
may cause the pacemaker wire to move.
6. When the patient travels off of the unit, the RN should take an extra battery
along (consider taping the extra battery to the generator).
E. Documentation
1. Document every four (4) hours and as ordered: heart rate, percent paced, mA,
pacing mode, pacemaker rate and sensitivity.
2. Document as needed: any changes made to pacer (mA, mode, rate, and
sensitivity), changes in pacing percentage, inappropriate pacing or problems
with pacer, if battery was changed, and provider notified of changes.
F. Discontinuation
1. The pacing wire is removed by the provider after the patient has a stable heart
rhythm or permanent pacemaker has been implanted.
2. Complete flowsheet documentation.
3. Separate orders will be given for removal of the introducer or pulmonary
artery catheter (PAC). Follow Nursing and Patient Care Policy 1.56 AP,
Central Vascular Access Device Use, Maintenance and Removal (Adult &
Pediatric) and 1.14AP, Invasive and Non-invasive Hemodynamic Monitoring
(Adult & Pediatric).
4. Provider needs to discontinue the temporary pacing wire. Nursing staff may
maintain or discontinue the introducer according to UWHC Nursing and
Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric).

V. PROCEDURE FOR PACING THROUGH A PULMONARY ARTERY CATHETER

A. The only option for pacing is an atrial and ventricular pacing swan. D200F7
B. Insertion is same as described in Nursing and Patient Care Policy 1.14AP, Invasive
and Non-invasive Hemodynamic Monitoring.

Page 5 of 10

C. Fluoroscopy should be used for the insertion to validate placement of the pacing
electrode.
D. Maintenance
1. No blood draws or infusions greater than 10 mL/hr are allowed through the
pacing catheter in the RV port of the PAC. These two things can cause
migration of the pacing catheter leading to failure to capture.
2. If no maintenance infusion is going through this port, flushing every eight (8)
hours is recommended to prevent the port from clotting off with normal
saline.
3. Patient’s cardiac rhythm will be continuously assessed for appropriate pacer
function (correct sensing, correct firing).
4. Patient’s response to pacing will be monitored minimum every four (4) hours
and as needed.
5. Pacer wires and cable are taped securely near the wire insertion site. Place the
pacemaker generator in a location (such as on the IV pole) where it will not be
pulled or dropped.
6. Ensure back up pacer box, appropriate cable and batteries are on the unit or
can be obtained quickly.
7. Documentation
a. Document, at minimum, every four (4) hours and as ordered: heart
rate, percent paced, mA, pacing mode, pacemaker rate and sensitivity.
b. Document as needed: any changes made to pacer (mA, mode, rate,
sensitivity), changes in pacing percentage, inappropriate pacing or
problems with pacer, if battery was changed, and provider notified of
changes
E. Discontinuation is as stated above under transvenous pacing, section IV.E.

VI. PROCEDURE FOR EPICARDIAL PACING

A. Set up of the pacemaker to epicardial wires
1. Obtain provider order for the following: mode (DDD, AAI, or VVI), rate, mA
and sensitivity. Asynchronous pacing is not allowed unless approved by
attending surgeon.
2. Obtain temporary pacemaker box, cables (atrial/ventricular or both depending
on need) and 9-volt battery.
3. Insert a new battery before turning on pacemaker.
4. Connect atrial/ventricular leads or both to the cables. Ensure “positive to
positive” and “negative to negative” connections on pulse generator. Make
sure the wires are in the connection tight and double check after securing with
tightening screws. The cables are interchangeable but are coded with the
temporary pacemaker box if DDD pacing is necessary.
5. Hook up cables to the correct port on the temporary pacemaker.
6. Turn the pacemaker on. Set the initial pacemaker rate (commonly 80-100
bpm). All temporary pacemaker settings and changes to settings will be
ordered by the provider. Pacing and sensitivity thresholds testing will be
conducted by the provider.
7. After settings are entered, reassess the appropriateness of pacing and notify
the provider if changes are needed. If changes are ordered, make the changes
and reassess again.

Page 6 of 10

8. Secure the cables to the patient’s abdomen to prevent from accidental
disconnect.
9. Epicardial exit site should be covered with gauze.
B. Documentation
1. Document, at minimum, every eight (8) hours or as ordered: percent paced,
mA, mode, rate and sensitivity.
2. Document as needed: any changes made to pacer (mA, mode, rate,
sensitivity), changes in pacing percentage, inappropriate pacing or problems
with pacer, if battery was changed, and provider notified of changes.
C. Assessment
1. Patient should have continuous ECG monitoring to assess for arrhythmias.
2. Patient’s rhythm will be continuously assessed for appropriate pacer function
(correct sensing, correct firing).
3. Patient’s response to pacing will be monitored at a minimum of every four (4)
hours and as needed. Assess blood pressure, level of consciousness, cardiac
rhythm and other hemodynamic measurements.
4. Pacer wires and cable secured correctly with tape to the patient’s abdomen.
5. Make sure back up pacer box and appropriate cable and batteries are on the
unit.
6. Check to see if the battery needs to be changed.
D. Dressing/Site Care
1. While pacing wires are in use:
a. The 4x4 dressing covering the stitch site where the wires exit the chest
are changed every day. Assess for signs of infection.
b. Pacer wires and cable(s) secured with tape to the patient’s abdomen.
c. Pacer wires visible and easily accessible through tape.
2. While pacing wires are NOT in use:
a. Pacer wires are capped appropriately. Do not tape wires together. Cap
wires with filter needle caps.
b. Ensure pacing wires are visible and easily accessible.
c. Stitch site where wires exit chest is covered with gauze and dressing
changed every day.
E. Epicardial wire removal
1. Epicardial wires are removed by the provider for cardiothoracic surgery.
Patient is to remain in bed for determined amount of time by provider.
2. The following should be used as a guide for patients requiring epicardial wire
removal unless otherwise ordered by the provider.
a. If INR less than 2.5, pacemaker wires can be pulled and patient needs
to be on telemetry for two (2) hours post-removal.
b. If INR greater than 2.5, pacemaker wires should be clipped and
telemetry can be discontinued.
F. Nurses will not check the underlying rhythm unless ordered to do so by provider.
G. Second temporary pacemaker box/cable(s) will be accessible.

VII. PROCEDURE FOR TROUBLESHOOTING: TRANSVENOUS AND EPICARDIAL

NOTE: Check patient for stability prior to troubleshooting in all situations.
A. Failure to Pace (VVI/DDD: absence of pacemaker spike and subsequent QRS
complex; AAI: absence of pacemaker spike and subsequent P wave complex)

Page 7 of 10

1. Check battery; replace if needed.
2. Check security of connections from the patient to the pulse generator.
3. Verify mA (output) is as prescribed and above stimulation threshold.
4. Check pulse generator; replace if needed.
5. If failure to pace continues, notify provider of failure to pace and interventions
performed thus far. Prepare to transcutaneous pace if necessary. The provider
may order chest x-ray to visualize pacemaker wire integrity and tip location
(transvenous/RV pacing in the PA catheter).
B. Failure to Capture (VVI/DDD: absence of pacemaker spike and subsequent QRS
complex; AAI: absence of pacemaker spike and subsequent P wave complex)
1. Check battery; replace if needed.
2. Check security of connections from the patient to the pulse generator.
3. Verify mA (output) is as prescribed and above stimulation threshold.
4. Increase mA to achieve capture. If this intervention resolves the problem,
chart the change in mA and notify the provider of the change and need for the
change.
5. Check pulse generator; replace as needed.
6. If failure to capture continues, notify provider of failure to capture and
interventions performed thus far. Prepare to transcutaneous pace if necessary.
The provider may order chest x-ray to visualize pacemaker wire integrity and
tip location (transvenous/RV pacing in the PA catheter).
C. Failure to Sense (temporary pacemaker is competing with intrinsic rhythm;
pacemaker spikes landing in inappropriate places on the ECG)
1. If the pacemaker senses P or T-waves instead of QRSs, the sensitivity may
need to be decreased.
2. Pacemaker spikes landing on T waves ("R on T" pacing) may require
sensitivity to be increased. It should also be reported to a provider
immediately, as life-threatening arrhythmias may ensue.
3. Check battery; replace if needed.
4. Check security of connections from the patient to the pulse generator.
5. Verify sensitivity is as prescribed and above sensing threshold.
6. Decrease sensitivity (turn dial toward "demand" or "most").
7. Check pulse generator; replace as needed.
8. If failure to sense continues, notify provider of failure to sense and
interventions performed thus far. Prepare to turn down rate of temporary
pacemaker if R-on-T or arrhythmias occur. The provider may order chest x-
ray to visualize pacemaker wire integrity and tip location.

VIII. PROCEDURE FOR TRANSCUTANEOUS PACING

A. Provider order is required to initiate transcutaneous pacing.
B. Provider may order sedation based on pt’s condition.
C. Indications: hemodynamically significant (symptomatic) bradyarrhythmias,
bradycardia with escape rhythms, over-drive pacing of tachycardias refractory to drug
therapy or electrical cardioversion, and standby pacing.
D. Contraindicated in severe hypothermia; not recommended for asystole.
E. Equipment
1. ECG electrodes (one package of 5 electrodes)
2. Self-adhesive electrode pads CS # 4013256 (anterior and posterior) or

Page 8 of 10

CS # 4015943 (anterior and anterior)
3. External defibrillator with transcutaneous pacing capabilities and cable
F. Transcutaneous Pad Placement
1. Skin preparation: improves signal quality, patch adherence and decreases
resistance
a. Clip excessive chest hair.
b. Wipe any moisture off of skin.
c. Wash with soap and water (if time allows) and dry well.
d. Do not place pads over medication patches or internal pacemakers or
defibrillators. Placement of patches over the nipple, diaphragm, or
bony prominences should be avoided.
e. Anterior-posterior placement (preferred): Follow the diagram on the
pad package. One patch should be placed on the left anterior aspect of
the chest, halfway between the xiphoid process and below the left
nipple at the apex of the heart (V2-V3 ECG position). The second
patch should be on the left posterior aspect of the back beneath the
scapula and lateral to the spine at the heart level.
f. Anterior-lateral placement: Follow the diagram on the pad package.
One patch is positioned over the left anterior aspect of the chest lateral
to the left nipple 4
th
intercostals space midclavicular line. The anterior
patch is positioned in the right subclavicular position lateral to the
sternum.
g. Change pacing pads at least every 24 hours or whenever pads are not
sticking to the patient.
G. Initiating Transcutaneous Pacing
1. Connect cable from pads to cable from defibrillator.
2. Place pacing pads on patient’s chest.
3. Place defibrillator ECG electrodes on patient in addition to standard EKG
monitoring electrodes.
4. Adjust ECG sizer and lead to find maximal R wave.
5. Turn on defibrillator.
6. Ensure pacemaker is set for demand pacing (instead of asynchronous).
7. Push pacer button or turn dial to pacing mode.
8. Set the rate and current according to provider order.
a. Slowly increase mA until capture is present.
b. Set mA slightly higher than capture threshold (increase by two [2]
mA).
c. Check for appropriate response to pacemaker firing. Ventricular pace
should have a wide QRS and T wave in opposite deflection of QRS.
9. Assess the patient’s peripheral pulses (should be equal to pacemaker set rate),
vital signs, cardiac rhythm, patient’s response, and patient’s level of
consciousness.
10. Document set pacemaker rate, sensitivity and mA.
H. Maintaining Transcutaneous Pacing
1. This is a short-term pacing method until a transvenous wire can be placed.
2. Patient must have continuous ECG monitoring.
3. When patient is conscious and stable, obtain orders for sedation and pain
control as appropriate.

Page 9 of 10

4. Assess and document patient’s cardiac rhythm, response to pacing, pacemaker
settings and pacemaker connections every two to four (2-4) hours or as
ordered by the provider. Do not use the carotid pulse to assess response to
pacing as muscular jerking may mimic the carotid pulse.
5. Document pacemaker settings (rate and mA), heart rate, cardiac rhythm, any
arrhythmias, resolution of condition requiring pacemaker and peripheral
pulses every two (2) hours and as needed.
6. Assess pacemaker function (sensing and capturing) with any change in vital
signs or change in patient condition.
I. Discontinuing Transcutaneous Pacing
Provider’s order is required to discontinue transcutaneous pacing. This is usually
done when pacing is no longer necessary or a transvenous line has been placed.
J. Troubleshooting Transcutaneous Pacing
1. Ensure pacing pads are adhering to the skin. Replace if not. Ensure the skin is
dry and chest hair is clipped. Wash and dry skin if necessary.
2. Ensure pacing cable and wire are connected to the defibrillator and are intact.
3. Ensure defibrillator is plugged into red outlet or battery power is sufficient.
4. Verify pacemaker settings are correct.
5. Obtain provider order to increase mA.
6. Change defibrillator and cable if necessary.

IX. PROCEDURE FOR SEMI-PERMANENT PACING

A. Maintenance:
1. Vital signs and site assessment as ordered post procedure. Activity as ordered
(usually ordered as bedrest for first 72 hours after semi-permanent pacemaker
placement and up ad lib if able thereafter). Assess for cardiac tamponade and
pneumothorax after placement.
2. Verify monitoring order for continuous versus intermittent cardiac rhythm
monitoring if the patient is to go off of the unit..
3. This pacemaker is typically placed in right internal jugular vein and
pacemaker mode is VVI or AAI.
4. Dressing: Do NOT change the dressing. Pacing wire exiting the body is
covered with transparent dressing; pacemaker generator is covered with
another transparent dressing. Ensure dressings over pacemaker and wire
remain intact; reinforce dressing only.
5. Assess site at the same frequency as vital signs for signs of bleeding,
pacemaker box or lead movement (displacement) and infection at site.
6. Remind patient not to move head/neck quickly and notify RN of any pulling
of tape or trauma to site. Limit arm movements above the shoulder.
7. No showering while semi-permanent pacemaker is in place.
8. Troubleshooting pacemaker rhythm issues is the same as a permanent
pacemaker.
9. Emergent patient care: Discuss with pacemaker nurse, cardiology or
electrophysiology fellow to have settings changed.
10. Emergency procedure (CPR, defibrillation): Treat the semi-permanent
pacemaker the same as a permanent pacemaker.



Page 10 of 10

X. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 4.17, Informed Consent
B. Hospital Administrative Policy 8.38, UWHC Adult Sedation Policy
C. Hospital Administrative Policy 8.48, Operative, Invasive & Other Procedures
D. Nursing Patient Care Policy 1.14AP, Invasive and Non-invasive Hemodynamic
Monitoring (Adult & Pediatric)
E. Nursing and Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric).

XI. REFERENCES

A. Field, J. M., Gonzales, L., & Hazinski, M. F. (2006). Advanced cardiovascular life
support: provider manual. American Heart Association.
B. Moser, D. K., & Riegel, B. (2008). Cardiac nursing: a companion to the braunwald’s
heart disease. St. Louis, MO: Saunders Elsevier.
C. Timothy, P. R., & Rodeman, B. J. (2004). Temporary pacemakers in critically ill
patients. AACN Clinical Issues, 15(3), 305-325.
D. Spotts, V. (2011). Temporary transcutaneous (external) pacing. In: Wiegand, D. J.
AACN Procedure Manual for Critical Care (6
th
Ed.). Philadelphia, PA: WB
Saunders.
E. Spotts, V. (2011). Temporary transvenous and epicardial pacing. In: Wiegand, D. J.
AACN Procedure Manual for Critical Care (6
th
Ed.). Philadelphia, PA: WB
Saunders.
F. Pecha, S., Aydin, M. A., Yildirim, Y., Sill, B., Wilke, I., Reichenspurner, H., &
Treede, H. (2013). Transcutaneous lead implantation connected to an externalized
pacemaker in patients with implantable cardiac defibrillator/pacemaker infection and
pacemaker dependency. Europace, 15(8).
G. Kawata, H. et al. (2013). Utility and safety of temporary pacing using active fixation
leads and externalized re-usable permanent pacemakers after lead extraction.
Europace, 15: 1287-1291.
H. http://www.zoll.com/medical-products/product-manuals/?pid=982
I. http://www.physio-control.com/ProductDetails.aspx?id=2147484980

XII. REVIEWED BY

Clinical Nurse Specialist, Cardiology
Clinical Nurse Specialist, Cardiac Surgery, Cardiopulmonary Transplant and Mechanical
Circulatory Device Programs
Nursing Patient Care Policy and Procedure Committee, November 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer