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Spotlight: Tallahassee Memorial HealthCare

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Author(s): 

Thomas Noel, MD, FACC, Interventional Cardiologist, 
Tallahassee Memorial HealthCare, Tallahassee, Florida

About Tallahassee Memorial HealthCare:

Founded in 1948, Tallahassee Memorial HealthCare (TMH) is a private, not-for-profit community healthcare system committed to transforming care, advancing health, and improving lives, with an ultimate vision of leading the community to be the healthiest in the nation. Serving a 17-county region in North Florida and South Georgia, TMH is comprised of a 772-bed acute care hospital, a psychiatric hospital, multiple specialty care centers, three residency programs, 31 affiliated physician practices and partnerships with Doctors’ Memorial Hospital, Florida State University College of Medicine, University of Florida Health, Weems Memorial Hospital and Wolfson Children’s Hospital.

About the Tallahassee Memorial Heart & Vascular Center:

The Tallahassee Memorial Heart & Vascular Center is a leader in the Southeast for advanced heart care and research. We are the first hospital in Florida to offer the Absorb BVS (Abbott Vascular). Our Heart & Vascular Center is as home to an accredited chest pain center with percutaneous coronary intervention (PCI) and the area’s only certified atrial fibrillation program. 

With an expert team of cardiologists and surgeons, we provide exceptional heart and vascular care for our patients. In fact, our physicians perform more clinical research and advanced procedures than any other program in the North Florida and South Georgia region.

What is the size of your cath lab facility and number of staff members? 

We currently have one cath lab, two hybrid cardiac/vascular suites, and a biplane neurovascular suite. There are currently 22 positions with 13 registered nurses (RNs), 7 radiologic technologists (RTs), and 2 cardiovascular technologists (CVTs) with an average “in residence” time of 10 years. 

What procedures are performed in your cath lab? 

We provide comprehensive cardiac diagnostic and interventional services, performing 2,500 diagnostic caths and 800 cardiac interventions annually. We have a robust structural heart program that includes transcatheter aortic valve replacement (TAVR), MitraClip (Abbott Vascular), and Watchman (Boston Scientific) devices. Our team performs a variety of complex peripheral endovascular procedures and aortic endografts. We have a full arsenal of circulatory support technology, including intra-aortic balloon pumps (IABPs), Impella (Abiomed), and CardioHelp (Maquet). We provide urgent intervention for pulmonary embolism using the EkoSonic Endovascular System (EKOS Corporation, a BTG International group company). TMH is a Comprehensive Stroke Center, providing acute intervention in our neurovascular suite, and the cath lab program supports a growing volume of elective and urgent endovascular neurosurgery procedures, including angiography, coiling, stenting, and clot retrieval. In addition to our tertiary-level services, the Heart & Vascular Center partners with Tallahassee Research Institute (TRI) in bringing advanced clinical research trials, with the cardiac cath lab service supporting many of those studies. 

If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 

TMH has a comprehensive, multidisciplinary structural heart program. The service began in 2012 and has grown into a regional referral center for tertiary-level services. Our two hybrid labs support transcatheter aortic and mitral valve procedures, with 1-2 days per week primarily devoted to structural heart procedures. As many of our structural heart cases have transitioned to percutaneous access with conscious sedation, we have improved efficiency by “flipping” rooms, and recovering these patients on our pre/post-procedural care unit. A majority of our structural heart patients do not require intensive care unit (ICU) admission, reducing length of stay and improving patient satisfaction. 

Do any of your physicians regularly gain access via the radial artery?

Between 60-65% of our diagnostic and interventional procedures are via radial access. 

Who manages your cath lab? 

Our cath lab manager is a licensed RT who has been with our lab for over 30 years. 

Do you have cross-training? Who scrubs, who circulates and who monitors? 

We cross train for all positions, scrub, circulator, and monitoring/recording. RNs administer medications.

Who documents medication administration during the case?

The colleague at the recorder position repeats back, then documents medication administration in the case record, at the direction of the nurse administering the medication.

What percentage of your diagnostic caths are normal?

We are at the 50th percentile of the National Cardiovascular Data Registry (NCDR) CathPCI registry in this outcome.

Which personnel can operate the x-ray equipment (position the image intensifier [II], pan the table, change angles, step on the fluoro pedal) in your cath lab? 

Physicians and RTs may step on fluoro; however, any of the colleagues may pan the table. The physician primarily positions the II during the procedure.

How does your cath lab handle radiation protection for the physicians and staff?

Colleagues receive annual education regarding radiation safety. Monthly monitoring of film badges keeps us mindful of physician and colleague exposure. We have recently updated some of our equipment with radiation reduction software, which allows for quality images at reduced radiation doses.

What are some of the new equipment, devices and products recently introduced at your lab? 

At TMH, participating in clinical research with our physician partners lays the foundation for early adoption of new technology. Most recently, our program was the first commercial site in the state of Florida, second in the Southeast and sixth in the country to implant the Absorb BVS. Our program was the third in the nation and first in the Southeast to offer the Watchman device commercially.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We have 5 clinical co-management councils that meet monthly, and are led by cardiologist-administrator dyads. We hold monthly meetings with our colleagues. Our manager, our clinical educator, and our performance improvement (PI) advisor work as a team to facilitate communication to keep colleagues involved in and abreast of change.

How is coding and coding education handled in your lab? 

We have a reimbursement/charge capture analyst who tracks documentation, coding, and reimbursement for our Heart & Vascular Center. We have a contractual partnership with a specialty service to provide coding education and assist us with assuring the accuracy of our coding and billing; we have recently expanded that agreement to include specialty coding for high dollar, new technology accounts. 

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

The majority of the sheaths are pulled by nurses in the post-procedure care area. We have a formal preceptor training process for sheath pull and access site management.

Where are patients prepped and recovered (post sheath removal)? 

Patients are prepped and recovered in our procedural care area. Due to the broad range and complexity of our services, hemostasis is highly individualized, and we utilize both manual compression and closure devices.

How is inventory managed at your cath lab? 

Inventory management is handled by our cath lab manager. Purchasing of equipment and supplies is reviewed through a value analysis agenda in our co-management meetings. Our materials management team reviews all requests and provides details to the councils so informed decisions can be made.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Our biplane neurovascular suite will move to a new surgical/intensive care tower when it opens, and that lab space will be repurposed as a third structural heart/vascular suite. We plan to open a third EP lab in the next 1-2 years.

Can you tell us more about your involvement in clinical research?

Tallahassee Memorial HealthCare, Southern Medical Group, and Tallahassee Research Institute collaborate regularly to bring new clinical cardiovascular research to our area, with as many as 20 open research studies at any given time. Through this relationship, our labs have been included in many research trials, such as ABSORB, which allowed us to be one of the first programs in the country to offer the technology to our patients.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? 

Our average D2B time is under 60 minutes. We are accredited by the Society for Cardiovascular Patient Care as a Chest Pain Center with PCI, and we are seeking accreditation as a Chest Pain Center with PCI and Resuscitation in the Cycle V accreditation process. Our Chest Pain Center coordinator tracks ST-elevation myocardial infarction (STEMI) times in real time and provides immediate feedback to EMS, our emergency centers, the STEMI team, and our physicians. We hold a monthly multi-disciplinary meeting to review all STEMI cases, discuss strategies to continually reduce time, and also to celebrate successes. 

Who transports the STEMI patient to the cath lab during regular and off hours?

Cath lab colleagues escort the STEMI patient to the lab in all cases.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the emergency department (ED)?

STEMI call, stroke call, vascular call, and acute pulmonary embolism (PE) call all fall within the cardiac cath lab service, and we provide response times within 30 minutes. As services have expanded, we have built redundancies into our call team strategies to accommodate the potential for multiple case demand — it takes a dedicated team and flexibility. There are 6 labs in the Heart & Vascular Center, all capable of accommodating a STEMI case, and our team works hard to ensure we can get our emergency cases on a table without delay. In the very rare circumstance that we could not accommodate a STEMI patient, our emergency centers are prepared to provide thrombolytic therapy.

What measures has your cath lab implemented in order to cut or contain costs?

Our co-management program and value analysis process are highly effective in managing costs, and our lab colleagues are very engaged in charge capture accuracy and in helping the organization manage costs.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

We participate in the ACC-NCDR CathPCI registry, Society of Thoracic Surgeons (STS)/ACC TVT (Transcatheter Valve Therapy) registry, Watchman registry, and ICD (Implantable Cardioverter Defibrillator) registry. These data are used in assessing and improving our outcomes.

How are new employees oriented and trained at your facility? 

Hospital and clinical orientation is 5 days. We have developed a formal cardiac cath lab orientation program with a 90-day competency plan, and a 6- to 9-month competency plan, which is tailored to the new colleague’s clinical experience prior to joining our team. Our clinical educator coordinates and oversees the orientation plan with the cath lab manager and preceptors within the service. The cardiologists have partnered in colleague education and competency, which has increased cath lab staff and physician satisfaction. 

How do you handle vendor visits to your lab? 

Vendors coordinate their visit to the lab with the cath lab manager and are required to check in through the VendorMate system in materials management prior to reporting to the lab.

How is staff competency evaluated? 

After orientation is successfully completed, we evaluate ongoing competencies through assessing annual case volumes at all positions, the use of a colleague skills self-assessment, and feedback from peers and from cardiologists.

How does your lab handle call time for staff members? 

We have a mix of 2 nurses and 2 technologists, and we have additional competency requirements related to acute stroke call.

Within what time period are call team members expected to arrive to the lab after being paged? 

Colleagues are required to arrive within 30 minutes.

Do you have flextime or multiple shifts? 

We have staggered shifts starting at 7:00 am, with the last shift arriving at 10:00 am.

Do you have any recommendations or advice for labs about to undergo a national accrediting agency inspection?

Remain ready at all times. We do monthly patient tracers and weekly environment of care rounds within the department. Leadership rounds are performed on a monthly basis.

Where is your cath lab located in relation to the OR and ED? 

The OR is located directly below us and we have a dedicated elevator between our 2 floors. The ER is located in an adjacent building with a crosswalk.

What trends have you seen in your procedures and/or patient population? 

Over the past five years, we have experienced a rapid, dynamic increase in technology and in the complexity of patient population. Our team has been very engaged and progressive in adapting to these changes and we are actively seeking colleagues who want to be a part of our exciting growth!

What is unique or innovative about your cath lab and staff?    

Our physicians and cath lab staff are innovative in trying to improve the patient experience from the moment of admission to the time of discharge. This patient-centered approach has required significant change in practice by both physicians and the cath lab, but has improved patient outcomes and satisfaction.  

How does your facility handle the challenges of operating a cath lab that inevitably crop up on a regular basis?

Our clinical co-management program, which started in 2013, has evolved into a very effective structure for managing challenges within the program.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?

Tallahassee is one of the most educated cities in the country and is Florida’s capital, placing us in the spotlight for new programs, research, and policies. With three major higher education institutes, Tallahassee is retaining a growing population of young professionals. Pair the city’s cultural boom with the beautiful parks, excellent schools, and mild year-round weather, we find that more and more people are eager to move to our capital city. Our cath lab team is a reflection of our dynamic city, creating a culture dedicated to advancing research and technology, and providing to excellent care for the entire region.

The Society of Invasive Cardiovascular Professionals (SICP) has added a question to our spotlight:

Does staff receive an incentive bonus or raise upon passing the registered cardiovascular invasive specialist (RCIS) exam?

We do offer additional compensation for registry.

A question from the American College of Cardiology’s National Cardiovascular Data Registry:       

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We have developed executive snapshot reports for all registries that are reviewed with each quarter release. The registry outcomes are an important source for monitoring and improving performance and outcomes in the CathPCI, ICD, transcatheter valve, and Watchman patient populations.


Spotlight: Sentara Norfolk General Hospital

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Author(s): 

Kevin Akers, BSHA, RCIS, Team Coordinator Cath Lab, 
Anne Kiernan BS, Senior RCIS, Norfolk, Virginia

Sentara Norfolk General Hospital, the region’s first Magnet Hospital, is a 525-bed tertiary care facility and home to the area’s only Level I Trauma Center and burn trauma unit. In 2015-16, Sentara Norfolk General Hospital was ranked for the 15th time in the U.S. News & World Report’s “America’s Best Hospitals” edition for its heart program. Sentara remains the only nationally ranked heart program in our region, and only one of two hospitals in Virginia to be ranked by U.S. News & World Report.

Tell us about your cath lab.

We have 5 dedicated cath labs, 1 hybrid operating room (OR), and a minor procedure room. Currently we have 23 staff members, with 20 registered cardiovascular invasive specialists (RCISs) who perform all cardiac, peripheral and hybrid cases. Our three registered nurses (RNs) staff the minor procedure room where cardioversions, and transesophageal echocardiograms (TEEs) are performed. We also perform dental extractions in our minor procedure lab, for those patients who are awaiting cardiac OR procedures but have an infection in their teeth. This is a unique function of our department, but has aided in improving efficiencies in our cardiac OR.

What procedures are performed in your cath lab? 

Our cath lab performs a variety of diagnostic and interventional procedures that include: 

  • Left heart caths
  • Right heart caths
  • Myocardial biopsies
  • Angioplasty (percutaneous transluminal coronary angioplasty [PTCA])
  • Percutaneous coronary intervention (PCI)
  • Intravascular ultrasound (IVUS)
  • Optical coherence tomography (OCT)
  • Fractional flow reserve (FFR)/Instant wave-free ratio (iFR)
  • Chronic total occlusions (CTOs) 
  • Intra-aortic balloon pumps (IABPs)
  • Percutaneous ventricular assist devices (Impella [Abiomed])
  • Rotoblators (Boston Scientific)
  • Diamondback (CSI)
  • Structural heart procedures 
    • Patent foramen ovale (PFO)/atrial septal defect (ASD) closures
    • Valvuloplasty (aortic [AO], mixed venous [MV], and pulmonary vein [PV])
  • Permanent pacemakers (PPM)
  • Diagnostic and interventional peripheral angiograms (renal, runoffs, PTA, and stenting)
  • Transcatheter aortic valve replacement (TAVR)
  • MitraClip (Abbott Vascular)
  • Watchman (Boston Scientific)
  • Parachute procedures (Cardiokinetix)
  • Minor room procedures include:
    • Cardioversions
    • TEEs
    • Loop recorders
    • Dental extractions

Can you share your lab’s experience with TAVR?

We are proud of our TAVR program. We celebrated our 500th TAVR procedure in March 2016. The experience of launching and maintaining a busy TAVR program has been rewarding. We started the program 5 years ago. Everything was new, including the hybrid OR. Over the last 5 years, we have developed our technical expertise side by side with the cardiologists, surgeons, and OR staff.  There are three cath lab technologists in every TAVR procedure. We monitor, circulate, and scrub to prep the valves. When we started the program, we trained a core team of four and now we have seven on our team. We typically do three TAVRs two days a week, and anticipate adding one or two more days as our volume increases. Our success with TAVR has caused our structural heart program to blossom. Our MitraClip and Watchman procedure volume has picked up, and we anticipate both will increase in the next few years. Our structural heart program also includes ASD, PFO, ventricular septal defect (VSD), and perivalvular leak closure cases.

Does your cath lab perform primary angioplasty without surgical backup on site?

No, we have a busy cardiac surgery suite that operates one floor above us in the Sentara Heart Hospital. The surgical team is on call after hours and has a 30-minute response time.

Do any of your physicians regularly gain access via the radial artery?

Our 2015 volumes show a 50% radial access use by our physicians. We have increased our radial access by 10-12% over the last 3 years. 

Who manages your cath lab?

Jocelyn Dawes, RN, BSN, manages the invasive cardiology department, which includes interventional cardiology and electrophysiology. Kevin Akers, BSHA, RCIS, is the team coordinator for the cath lab. He runs the lab’s daily operations. 

Do you have cross-training? Who scrubs, who circulates and who monitors?

All of our technologists are RCIS-credentialed and cross-trained to scrub, circulate, and monitor our large variety of cath lab procedures. We have special teams designated for the less frequent, high acuity procedures like CTOs, TAVRs, and MitraClips. This allows a core group of techs to master the procedure, and then share the skill set with other staff members.  

Are there licensure laws in your state for fluoroscopy?

Virginia licensure laws require that fluoroscopy practice be performed under the direct supervision of a physician.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

The RCIS Scope of Practice allows RCISs to activate fluoroscopic imaging and manipulate imaging equipment, as well as select magnification. The Registered Cardiovascular Invasive Specialist program at the Sentara College of Health Professionals is a very rigorous program. In the program, the instructors teach digital subtraction and analysis, as well as image annotation.

How does your cath lab handle radiation protection for the physicians and staff?

Every member of the cath lab team is custom-fitted, and issued a lead apron and lead glasses. Lead pieces are cleaned monthly and inspected annually for defects. Sentara will replace an employee’s lead piece as necessary for damage or after 10 years. We have recently partnered with Bar-Ray, a personal radiation protection company and adopted their SmartID, a web-based inspection and inventory asset management system. This management system tracks each piece of lead and other radiation accessories by serial number to ensure timely inspections and replacement. Each employee is issued a radiation badge at the start of employment that is switched out quarterly.  A report is generated that indicates amount of exposure for that quarter, as well as cumulatively. 

Currently two of the five labs have Philips DoseAware, an instant radiation detection system where a special badge is worn. While wearing the badge, a screen above the monitor boom indicates the amount of radiation exposure for the individual. This empowers the staff to manage their radiation exposure in real time.

How are you recording fluoroscopy times and dosages? 

Fluoroscopy time and dose are recorded in the electronic medical record (EMR), Radiant, and Xper monitoring system. By recording the fluoro dose in the EMR, we help keep track of the patient’s lifetime dose.  The physicians are given regular reports of their average fluoroscopy times.

What are some of the new equipment, devices and products recently introduced at your lab?

We have been using the Impella CP for a few years, and recently acquired the Impella RP. In the past 6 months, we have acquired a new Diamondback system, the Boston Scientific Comet wire, and CardioMEMS equipment (St. Jude Medical). Our staff has had training on the new Portico valve (St. Jude Medical), we have now completed two Portico procedures. Our newest stents on the shelves are the Boston Scientific Synergy as well as the Abbott Vascular Absorb.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

There are a lot of moving parts to our cath lab at Sentara Heart Hospital, and it takes commitment to keep everyone informed. There are several committees that meet monthly to keep physicians up to date on changes to staffing and equipment in the labs. We have a Cardiac Value Analysis Committee (CVAC) that is primarily responsible for reviewing and approving all new products and/or replacement products used in the cardiac surgical and invasive areas of Sentara Heart Hospital. The Invasive Committee oversees systems and processes to ensure quality and efficiency in the cath lab. Finally, the Acute Myocardial Infarction Committee (AMI) establishes standard treatment protocols, collects and reviews data regarding AMI management, identifies areas of improvement, and facilitates timely treatment and reperfusion benchmarks. 

To get the information to staff, we have daily huddles at the beginning of our shift. Staff meetings are also held monthly to get out information and give staff the opportunity to ask questions about anything that could have changed. Our team coordinator also emails a weekly huddle update on Fridays to recap information discussed in huddles that staff may have missed.

How is coding information handled in your department?

In December of each year, the cardiac service line leadership meets to discuss the changes in coding. We then determine what coding will be deactivated and what will take its place. Once we have determined the changes, this information is given to our cardiovascular IT team and they deactivate the old codes and enter the new codes in our Philips Xper monitoring system. Our Xper system processes the billing when our procedure is complete, so it is important that our staff know the coding. There is a cheat sheet that is created for the deactivated vs new codes for staff, but communicating this in our daily huddles is the most effective method of disseminating the information. 

Who pulls the sheaths in post procedure, both post intervention and diagnostic? 

The Cardiac Assessment Recovery and Evaluation unit (CARE unit), our 36-bed pre/post nursing unit, pulls the sheaths after diagnostic or interventional catheterization. However, all the cath lab technologists are trained to pull sheaths. Our educators organize an annual sheath pull competency to keep that skill set current. The competency includes a study packet on vascular complications, an online test, and two sheath pulls under direct observation of an experienced nurse.

Can you tell us more about the CARE unit?  

The CARE Unit functions as a pre/post procedure area and an overflow unit for cardiac inpatients and transfer patients.  All of our patients are prepped in the CARE unit. The CARE unit nurses provide pre/post care for patients undergoing cath lab, electrophysiology (EP) lab and cardiac OR procedures.  Our CARE unit nurses pull sheaths and care for patients with vascular closure devices as well.

Patients are also recovered in the CARE unit by RNs. Patients usually receive their caths by radial or femoral access, so when returning to the CARE unit, they may have a D-Stat (Vascular Solutions), TR Band (Terumo), Angio-Seal (St. Jude Medical), Perclose (Abbott Vascular), or sheaths in place. It is the direct responsibility of the nurse to either pull the sheath or remove the radial bands, but the cath lab technologists are required at times for access site management. It is for that reason that both the RNs and cath lab technologists are required to complete annual competencies on vascular complications and groin management.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

We have a full-time inventory coordinator, Timothy Henry, who manages the inventory and purchasing of supplies and equipment.

Has your cath lab recently expanded in size or patient volume, or will it be in the near future?

Our PCI volumes have increased. The Sentara Healthcare system has moved to a centralization of care. In the past, the community hospitals would perform elective PCI, but now those patients are routinely transferred to Sentara Heart Hospital. Our TAVR volume has really expanded in the past year. This has led to reciprocal volume increases in the cath lab. All of the TAVR patients require a left- and right-heart/TAVR workup catheterization. The increase in volume has warranted more staffing and the ability to run 5 labs daily.  A year ago, we reallocated an old cath lab as a minor procedure room to accommodate the increase of TEEs due to TAVR workups.  

Is your lab involved in clinical research?

Yes, we have a long history with coronary trials. Currently we are involved with:

  • The REDUAL-PCI trial (evaluation of dual therapy with dabigatran vs triple therapy with warfarin in patients with atrial fibrillation that undergo a PCI with stenting);
  • ARTEMIS trial (affordability and real-world antiplatelet treatment effectiveness after myocardial infarction study). 

We are soon to be enrolling in the EVOLVE Short DAPT trial (assessing the safety of 3-month DAPT in subjects at high risk for bleeding undergoing PCI with a Boston Scientific Synergy stent). 

We are still following patients in:

  • The ABSORB III trial (Absorb bioresorbable vascular scaffold [Abbott Vascular]);
  • EXCEL trial (safety and efficacy of the Xience Prime/Xience V everolimus-eluting stent [Abbott Vascular] compared to coronary artery bypass graft surgery in select patients with unprotected left main coronary artery disease); and 
  • BIONICS trial (study of the BioNIR drug-eluting stent [Medinol] in coronary stenosis).

We are involved in many TAVR/structural heart studies, including:

  • Edwards Lifesciences PARTNER TAVR studies;
  • Medtronic CoreValve trials;
  • Portico TAVR trial; 
  • Watchman left atrial appendage (LAA) trials; and
  • SENTINEL and REFLECT trials (cerebral protection devices used during TAVR procedures).

Sentara Heart has a busy transplant service and we participate in many heart failure studies as well, including:

  • The PARACHUTE trial (Parachute Implant System, CardioKinetix);
  • INTERMACS registry (The Interagency Registry for Mechanically Assisted Circulatory Support); and 
  • A trial looking at the effects of cardiac resynchronization therapy (CRT) and left ventricular assist device (LVAD) therapy.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep DTB times under the mandated 90 minutes? 

We are registered with American Heart Association’s Mission: Lifeline and American College of Cardiology (ACC)’s D2B Alliance. We recently formed an initiative with the emergency department (ED) and CARE unit to lower our D2B times. We found that cath lab transport times were high because of the relatively long distance from the cath lab to the ED. The ED staff agreed to transport ST-elevation myocardial infarction (STEMI) patients to the cath lab to cut down on transport time. The CARE unit staff helps to expedite the STEMI process by turning on our x-ray and other equipment as soon as the STEMI is called. This allows the cath lab technologists to focus on arriving safely and quickly to set up the lab.  These changes have significantly decreased our D2B times. For 2015, our median D2B time, excluding transfer patients, was 56 minutes.

Who transports the STEMI patient to the cath lab during regular and off hours?

During regular hours, the cath lab staff transports the patient from the ED. Transfer STEMIs from other facilities or the field are transported straight to the lab by emergency medical services (EMS). During off-hours, an RN and a technologist from ED transfer the patient to the cath lab. 

Where is your cath lab located in relation is the OR and ED?

Sentara Heart Hospital was built in 2006 as an addition to Sentara Norfolk General Hospital. The cath lab, CARE unit and CICU are located on the second floor of the Sentara Heart Hospital. The OR is directly above us on the third floor. The ED is in a separate but connected building. By having the ED staff transport during call cases, we have been able to significantly reduce our D2B times.

How does your lab handle call time for staff members? 

Our call team consists of three RCISs. The cath lab is considered part of the cardiac suite, along with the CARE unit and cardiovascular intensive care unit (CICU). These units have nurses available 24 hours a day, if a call team were to need some additional help in a case. Our staff covers call at Sentara Heart Hospital and another Sentara community hospital. The community team serves as a backup team in the event of multiple emergencies. Our staff averages a total of 9 scheduled days of call a month.

Within what time period are call team members expected to arrive to the lab after being paged?

Team members are expected to arrive to the lab 30 minutes after being paged.

Do you have flextime or multiple shifts?

We currently only have one part-time staff member and one flex staff position posted. The way our schedule currently works is that staff rotates shifts: one week they do 5 eight-hour days and the next week they work 4 ten-hour days. This gives staff members at least two days off a month. Our call team is our late team and finishes out the day for cases. We typically run two rooms until we get down to one doctor doing cases.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

If the call team is in a procedure, a decision is made by the charge technologist and the physician to determine what is safest for both patients. If it is a safe stopping point and the procedure can be postponed, the current patient will be removed from the table and the STEMI patient has their intervention. Our staff covers call at a nearby community hospital, and in the case of two concurrent STEMIs, that community team serves as backup. They will be paged to Sentara Heart Hospital to do the STEMI.

What measures has your cath lab implemented in order to cut or contain costs?

Staff education on differing vendor pricing is one measure. We keep a bulletin board in our inventory area that lists the vendor for stents and balloons as red, yellow, or green in terms of pricing. Staff and physicians are always encouraged to use the product that is best for the patient, but when the brand of stent isn’t necessarily important, staff is encouraged to pull the most affordable option. We also use Stryker to reprocess certain equipment. Finally, we maintain a practice of not opening equipment to the sterile field before the physician asks for it.

What quality control measures are practiced in your cath lab?

We have daily, weekly, and monthly quality assurance tasks for the staff. Our daily measures include testing the x-ray systems, Avoximeter (Accriva Diagnostics) controls, and defibrillator operation. Each month, special teams perform hand-washing audits, moderate sedation chart audits, and code cart inspections. In addition to the staff’s effort, the pharmacy department performs a monthly medication inspection. The point-of-care testing (POCT) laboratory carries out six-month and annual inspections and calibrations on i-STAT machines (Abbott Labs). Lastly, our clinical engineers perform calibration of x-ray and digital imaging equipment in addition to the inspections and certification by Virginia Health Department.

Who documents medication administration during the case?

The monitor technologist documents all medication given in the Xper monitoring system during the case to serve as our legal document. The circulating technologist administers and documents medications given in the EMR for post care staff to review. Our EMR system has the safety feature that requires a barcode scan of the patient’s armband and of the medication to be administered. All medications are given by the RCIS staff under the direction of the physician.

Are your physicians dictating their cath procedure reports?

We have recently implemented the Dragon Voice Recognition Program.  Our EMR program (EPIC) allows for a variety of data entry options via personal templates physicians have created, and we still have some physicians that utilize transcription services.

Do you use the ACC’s National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we do use the ACC-NCDR, as well as the Society of Thoracic Surgeons (STS)/ACC’s Transcatheter Valve Therapy (TVT) registry.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

As the region’s first Magnet hospital, Sentara Norfolk General Hospital, a 525-bed tertiary care facility, is home to the areas only Level I Trauma Center, burn trauma unit, and nationally ranked heart program at Sentara Heart Hospital. In addition to a first-rate heart program, the hospital is home to Nightingale Regional Air Ambulance. We have formed alliances with many outlying community hospitals that do have the option to transfer patients to other facilities.

How are new employees oriented and trained at your facility?

The majority of our technologists are graduates of the Cardiovascular Invasive program at Sentara College of Health Sciences and completed most of their clinical hours at our hospital. This process gives our technologists an introduction to our lab before they are even hired. Once our employees are hired, they are required to go through a ninety-day hospital-based orientation period. The orientation includes EMR classes, patient safety concepts, and point-of-care testing, e.g. i-STAT machines and Avoximeters. Our department-specific orientation pairs the new employee with a preceptor for ninety days. The new employee must complete a series of competency check-offs to demonstrate proficiency in all three roles (monitor, float, and scrub) in the common diagnostic and interventional procedures. The cath lab-specialized competencies are maintained by our two staff educators, Anne Kiernan and Steve Mattke, and renewed on an annual basis.

What continuing education opportunities are provided to staff members?

Sentara Healthcare is accredited by the Medical Society of Virginia to provide continuing medical education for physicians. Every Tuesday morning, our cath lab staff is invited to join our physicians for an hour-long lecture and CME opportunity on a contemporary cardiology topic. Staff has another CME opportunity at one of the annual conferences hosted by the regional cardiology groups. Additionally, we have recently reinstated a process for our staff to attend the Transcatheter Cardiovascular Therapeutics (TCT) conference. We rotate this privilege among the interested staff members. 

How do you handle vendor visits to your lab? 

All vendors are required to complete an annual departmental orientation package and are also required to be Reptrax-approved. Reptrax is company we use to track and manage our vendor credentials, activity, and behavior before they can enter our area. Each vendor is assigned a specific day of the week that they are allowed to be in the lab. On the days that vendors are here, they are required to sign in through Reptrax, which prints a badge for them, and vendors must sign in to the lab. All vendors have an area specified for all of their educational material on the days that they are in the lab.  Vendors can speak to any physician outside of the lab, but they have to be invited into the lab. It is also a requirement that vendors change into the appropriate departmental scrubs and wear color-coded vendor hair covers. There are two Reptrax kiosks in the building that issue temporary badges to the vendors.

How is staff competency evaluated?

Staff competency is very important to our lab. As the largest and busiest cath lab in the area, we strive to be the “gold standard” in our abilities. Our staff is required to complete 12 annual skills lab competencies on high-acuity machines, such as the Rotablator (Boston Scientific) and Impella. We have annual exams on medications, moderate sedation, and vascular complications. We schedule one education day a month to complete a skills lab. At the end of the year, we have “Skills Week”, during which the staff is given an opportunity to review or make up any missed skills labs.

Does your lab have a clinical ladder?

In our lab there are three clinical levels: Junior, Senior, and Expert. Each person is hired into the Junior technologist position and upon completion of a leadership course and precepting a student, they will have the opportunity to rise to next level, Senior. In order to reach the Expert level, a technologist has to excel as a senior as well as be knowledgeable about every piece of equipment that we have. The Expert position is usually held by our educators.

Has your lab recently undergone a national accrediting agency inspection? 

DNV GL performs annual inspections in our lab. Mock surveys are useful exercises to find opportunities for improvement. They are also a good chance for the staff to practice speaking to the safety and quality measures they take every day.

What trends have you seen in your procedures and/or patient population?

We have a large heart failure population in the Hampton Roads region. We have seen a marked increase in our ventricular assist device (VAD) population in the past few years. We see the left VAD patients routinely for right heart caths. The indications for TAVRs have started to include a lower-risk patient profile. We have gone from doing 1 TAVR a week to doing 4 or 5 each week. The TAVR patients often have more than one procedure in the lab in preparation for the TAVR procedure (diagnostic cath, balloon aortic valvuloplasty [BAV], and/or staged PCI). In general, we are seeing more structural heart cases. Our lab has a steady volume of MitraClip, Watchman, and closure procedures.

What is unique or innovative about your cath lab and staff?

Our staff has a lot of pride in being part of the cath lab at Sentara Heart Hospital and there are a few key things that make us unique:

  • Our cath lab is entirely RCIS-certified. We have a few wonderful nurses that staff the minor procedure room, but the rest of the staff is RCIS. Sentara has a College of Health Professions, and their RCIS students complete their clinical requirements in our lab. The RCIS staff floats cases, gives medications, and runs the x-ray systems. Our school was actually founded by some of our cardiologists, and we have their full support in the way that we function as independent, highly trained healthcare providers.
  • Our hospital is consistently ranked by U.S. News & World Report as having one of the top 50 cardiology and cardiac surgery programs in the nation. 
  • Sentara Heart Hospital has a concierge service for staff and patients. The idea was proposed by one of our own staff members, and Sentara put it into action. Some of the highlighted activities the concierge department has coordinated include a hospital wedding for one of our inpatients and wrapped Christmas presents for the busy staff.

Is there a problem or challenge your lab your lab has faced?  

The biggest issue our lab has faced has been establishing a good balance between work and quality of life. Limited staffing made it challenging to accomplish anything outside of work, so we decided to switch to rotating shifts. Each staff member works a week of eight-hour shifts, followed by a week of ten-hour shifts. This schedule allows the staff to have day off every other week. Since the inception of this schedule, morale has improved. Now we have been able to make it to more teeth cleanings, hair appointments, and dance recitals for our children!

What is special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your “cath lab culture”?

Norfolk is part of the Hampton Roads, which is a very diverse regional area. We are located in a hub for the U.S. Armed Forces, resort towns, and rural communities. Sentara Heart Hospital services Virginia Beach and the Outer Banks of North Carolina, both popular vacation destinations. During the summer months, we often treat patients that are visiting from distant places. This situation creates challenges for the staff and the patients. Having an emergent procedure performed when on vacation definitely adds anxiety to an already stressful event. It is not uncommon for us to receive a STEMI from the field, straight from the beach. The other aspect of treating vacationers in the middle of the night is that it is hard to get medical records from another state if the patient has a standing cardiac history.

There are over 10 military installations in the Hampton Roads region and their influence is pervasive. We have two staff members who are veterans. Our turnover is affected when staff members with military spouses leave the area with new orders. 

Kevin Akers, BSHA, RCIS, can be contacted at kxakers@sentara.com. Anne Kiernan BS, Senior RCIS, can be contacted at arkiern1@sentara.com.

Spotlight: Harris Health System Ben Taub Hospital – Cath Lab

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Author(s): 

Jaromir Bobek, CVT, RCIS, Ana Davis, MSN, RN, CCRN, FNP-C

Houston, Texas 

Tell us about your cath lab.

Ben Taub Hospital is the flagship hospital for Harris Health System and is located in the heart of the Texas Medical Center. Harris Health is a safety net dedicated to providing high quality, cost-effective, compassionate healthcare to all residents of Harris County. Ben Taub Hospital is a 487-bed academic facility staffed by physician partners from Baylor College of Medicine. Services that support cardiovascular care include an eight-bed coronary care unit (CCU), twelve-bed post cardiac cath unit, two cardiovascular operating rooms, and a 30-bed post-anesthesia care unit (PACU). 

How many rooms are in your cath lab?

The cath lab consists of two rooms with a layout that is ideal for patient flow, and for utilizing the two labs as a swing lab between different procedures and doctors.

What is the mix of credentials at your lab, and how long have staff members been “in residence?” 

Staff members include six full-time registered nurses (RNs), one cardiovascular technologist (CVT), one registered cardiovascular invasive specialist (RCIS), one radiologic technologist (RT), and a procedure scheduler. The experience of staff ranges from 2 to 11 years.

What procedures are performed in your cath lab?  

We perform a variety of procedures, including: 

  • Coronary angiography
  • Percutaneous coronary intervention (PCI)
  • PCI of chronic total occlusions (CTOs)
  • Stenting
  • Coronary thrombectomy
  • Left heart catheterization
  • Right heart catheterization 
  • Myocardial biopsy 
  • Aortic valvulosplasty
  • Alcohol septal ablation
  • Foreign body retrieval
  • Intracardiac ultrasound
  • Atrial septal defect (ASD), patent foramen ovale (PFO) and patent ductus arteriosus (PDA) closure devices
  • Peripheral angiography with interventions (lower extremities, renals, subclavian)
  • Right and left ventricular angiography
  • Intra-aortic balloon pump (IABP) 
  • Implantable cardioverter-defibrillator (ICD) insertion
  • Permanent and temporary pacemaker placement 
  • Bi-ventricular implantable cardiac defibrillator & pacemaker placement 
  • Electrophysiology studies (EPS) and radiofrequency ablation
  • Cardioversion 
  • Fractional flow reserve (FFR)

Approximately how many procedures are performed each week?

The cath lab is staffed 24 hours daily for cardiac emergencies. An average of 40 diagnostic procedures and 16 PCIs are performed each week. Three of the procedures are typically for primary PCI related to ST-segment elevation myocardial infarctions (STEMI). In 2014, our lab performed 1675 diagnostic catheterizations, 850 PCIs, and 300 EP/cardiac rhythm management (CRM) procedures. 

Is your cath lab performing transcatheter aortic valve replacement (TAVR)? 

Transcatheter aortic valve replacement is not planned for the near future at our facility.  

Does your cath lab perform primary angioplasty without surgical backup on site?

No, the cath lab has an operating room (OR) for surgical backup within the hospital.

What percentage of your diagnostic caths is normal?

On average, 40% of diagnostic caths are found to be non-obstructive disease. 

Do any of your physicians regularly gain access via the radial artery?

Between the two full-time interventional cardiologists, about 50% of the cardiac cath cases are radial approach.

Who manages your cath lab?

The Ben Taub cath lab is managed by an interprofessional collaborative team consisting of the physician medical director, Nasser Lakkis, MD, Cath Lab Nursing Director Ana Davis, MSN, RN, CCRN, FNP-C, and a charge nurse.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Emails, texting, meetings, and morning huddle are the major methods of communicating information. Staff meetings are held on a regular basis; physicians have monthly meetings to update faculty and staff members. The cath lab nurses have a very strong shared governance council or Community of Practice (CoP) that meets monthly, and is where nursing practice and or any other issues are discussed. 

Do you have cross-training? Who scrubs, who circulates and who monitors?

All the nurses and cardiovascular technologists can scrub, circulate, and monitor. Medications and documentation are done only by the nurses. The radiologic technologist can scrub and circulate, and is responsible for operating the imaging equipment.

Are there licensure laws in your state for fluoroscopy?

Texas law provides guidelines on who can operate radiation-emitting equipment. The physicians are certified through the radiation safety officer. The radiologic technologists are the only ones allowed to use fluoroscopy without the presence of a doctor. Cardiovascular technologists can use fluoroscopy with a physician present. 

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

All cath lab staff has been trained in appropriate use of x-ray equipment, radiation protection and safety. The x-ray equipment can be operated by the staff with the presence of a physician or radiology technologist, but stepping on the fluoroscopy pedal is only done by the physician or fellow.

How does your cath lab handle radiation protection for the physicians and staff?

Radiation safety training is undergone yearly by all physicians and staff. The staff also has quarterly checks of their lead aprons and radiation badges. Individual, personalized lead aprons are provided to all staff members and there are additional shields in each cath lab to reduce the amount of scattered radiation.

What are some of the new equipment, devices and products introduced at your lab lately?

The cath lab recently installed the new Philips Xper Hemodynamic System and St. Jude Medical 3D Mapping. Another big change is the utilization of the Transradial (TR) Band (Terumo) this past year. 

Who pulls the sheaths post procedure?

The fellows or faculty physicians pull the sheaths immediately after the procedure in the cath lab for both diagnostic and interventional cases. Attending physicians train the fellows on closure devices and monitor their closure technique until they feel the fellow physician can utilize closure devices independently.    

Where are patients prepped and recovered (post sheath removal)? 

The patients are prepped in the cath lab holding area and if discharged, they are recovered in the PACU. If patients are admitted, they go straight to the admitting unit, CCU, or post cardiac cath unit. Patients receive closure devices if applicable in groin cases, and if radial access is obtained, then TR Bands are placed. Groin closure options include Angio-Seal (St. Jude Medical), Mynx (Cardinal Health), and manual pressure. Manual pressure is done by the primary fellow who was involved in the procedure. The receiving nurses in the recovery units are responsible for managing TR Bands until removed per protocol.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

Inventory is managed by our cardiovascular invasive specialist, who utilizes a Pyxis (CareFusion) for general supplies and high-dollar items. Larger purchases or new equipment must go through the system’s Medical Capital Committee, which conducts a value analysis. 

How is coding and coding education handled in your lab?

The monitoring RN selects and records in Xper for each procedure performed during each case. Xper extracts all charges entered by the staff, which also includes the supplies used during the procedure. The main procedure is ordered by the physician in the electronic medical record (EMR) via Epic, which is linked to the report. Once the procedure report is archived, it generates the charges in the patient’s accounts. The charges are reviewed by the office manager for accuracy in collaboration with the coding department. 

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

The cath lab volume has been stable during past two years, and there is no anticipated expansion in size or volume in the near future.

Is your lab involved in clinical research?

Not at this time.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  

Ben Taub has exemplary D2B times, despite having mostly walk-in patients in the emergency center (EC). The EC is one of two level-one trauma centers in the city and is considered one of the busiest in the Houston area. Through collaboration between the EC, cardiology, and Houston Fire Department Emergency Medical Services, our D2B times have consistently been below 60 minutes. We are also 100% compliant in meeting the 90-minute D2B time over the last several years. Also, 80% of STEMI patients transferred to our facility in 2015 have a door-to-device time of <120 minutes. Ben Taub has been awarded the American Heart Association Mission Lifeline: STEMI Receiving Center Gold Plus Award and the NCDR-Action Registry Platinum Performance Achievement Award in both 2015 and 2016. 

Who transports the STEMI patient to the cath lab during regular and off hours?

The transfer of patients from EC to the cath lab is the result of collaboration between the EC nursing staff and cath lab fellows, while the cath lab staff prepares the cath lab for the patient’s arrival. 

What do you do when the call team is already busy doing a procedure and a STEMI comes into the emergency center?

The CCU nursing staff will assist in getting the patient ready and the cath lab staff will take over once the other case is finished. This practice and collaboration has shed minutes from our door-to-balloon time and improved quality of care. 

What measures has your cath lab implemented in order to cut or contain costs?

We have negotiated pricing on drug-eluting stents, ICDs, and cardiac resynchronization therapy (CRT) implants. We have limited the number of vendors used for all supplies and we review the cost of CRT implants on a monthly basis. Additionally, every new product used in the cath lab is reviewed by the value analysis committee. 

What quality control measures are practiced in your cath lab? 

Quality control is ensured through a quarterly review of all procedures by the cardiology quality review committee. All cases with adverse outcomes are reviewed immediately. All STEMI cases are concurrently reviewed by the chest pain coordinator, who shares a STEMI log with all the stakeholders on critical time elements. Additionally, these data logs are discussed during the chest pain steering committee.  

Are you recording fluoroscopy times/dosages? 

Fluoroscopy time and total radiation dose (mGy) is recorded from the Innova image system (GE Healthcare) into the Xper monitoring system for each case. 

Who documents medication administration during the case?

The circulating nurse documents all the medications in the EMR and the recording nurse will keep real-time recording of the administration in the hemodynamic system. The medication record is reconciled by both nurses during or after the case.

Are your physicians dictating their cath procedure reports or do they use a structured reporting tool?

The physicians use ProSolv reporting software that has built-in templates for complete documentation of the procedure. ProSolv reports are interfaced to the EMR (Epic) system.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry? 

Currently, Cedaron is installed, in order to interface with the new Philips Xper hemodynamic recording system and transfer the cath lab data to the NCDR-ACTION registry. We also participate in the NCDR-ICD registry to meet the

CMS requirement and we include all ICD patients, regardless of payer or indication.  

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

Ben Taub is the only facility that provides invasive cardiology services within Harris Health System. Harris Health System is a large healthcare system that includes over 20 ambulatory clinics and a sister hospital that refers outpatient, inpatient, urgent, and emergent cases.  

How do you handle vendor visits to your lab? 

All vendors check in using our electronic vendor sign-in. The computer will print them a badge that lists the area and the person that they will be visiting for that day. They are allowed in the cath lab to visualize procedures.  

How are new employees oriented and trained at your facility?

The cath lab only hires nurses with a minimum of two years of critical care experience. Each new RN hired to work in the cath lab will receive the Performance-Based Development System (PBDS) exam. The exam is used as a tool to determine the nurse’s assessment and critical thinking skills. Based on each new RN’s PBDS clinical assessment summary, a plan of action is created to formulate a competency-based orientation plan. Each nurse will receive a competency-based orientation form to complete prior to orientation. The newly hired RN will use a daily documentation form to engage in critical thinking exercises.  

Each employee is given a competency-based performance tool to document their self-assessment needs. The competency-based performance tool self-assessment, PBDS clinical assessment summary, job description, and plan of action will be employed by the preceptor to the guide the nurse’s practice and assess for clinical competency. The preceptor provides 1:1 feedback daily during the unit-based orientation process. The nursing director, clinical resource nurse, preceptor, and new RN meet to review the new RN’s progress. They work collaboratively to revise the action plan when needed and outline specific desired outcomes to assist the new RN in meeting the required objective within a precise timeline. 

What continuing education opportunities are provided to staff members?

Staff members are informed of and encouraged to attend the numerous local or national conferences to continue their education by nursing leadership. The hospital has partnered with vendors to provide educational opportunities on new and upcoming equipment. The cardiology service has a bi-annual nursing educational symposium that focuses on any trends or updates in cardiology.

How is staff competency evaluated?

There is a comprehensive process in place to assess staff competency within the cardiovascular work environment. After completion of the orientation-based competency assessment, each staff receives an annual evaluation to assess competency via exams, staff feedback, and day-to-day performance observation. Prior to the annual evaluation process, there is a continuous evaluation of staff competency based on daily assignments, monthly meetings with nursing director, and impromptu meetings when needed. 

Competency evaluation is a continuous assessment. Staff competency evaluation is an inclusive assessment that involves a written exam, staff self-assessment, and preceptor assessment (for new RNs). 

Does your lab have a clinical ladder?

There is a hospital-wide nurse clinical ladder for clinicians. The clinical advancement programs are recognized within the nursing profession as an indication of a highly developed professional environment. The American Association of Critical Care Nurses (AACN) cited clinical advancement programs as one of the eight hallmarks of a professional environment. The Harris Health System Nursing Practice and Professional Model (NPPM) includes a Clinical Advancement Program (CAP) component that differentiates practice levels based upon education, credentials, and demonstrated clinical ability. 

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?

Call time is evenly distributed among nursing and technologist staff. With every STEMI on call, there is at least one nurse who meets annual credentials to manage temporary pacemaker, IABP, advanced cardiovascular life support (ACLS), and moderate sedation monitoring.

Within what time period are call team members expected to arrive to the lab after being paged?

The call team is expected to arrive within 30 minutes; however, the CCU teams are next to the cath lab and also get paged when the cath lab gets activated. The CCU nurse will open the cath lab, receive the patient, and start the case until the cath lab staff members arrive. They assist with bed management and other activities as needed. This is a collaborative effort to ensure patients receive timely, safe care.

Do you have flextime or multiple shifts?

All shifts are staggered, with first nurse starting at 0600 and the last nurse finished at 1800. We have 12-hour day shift coverage and 12-hour on-call coverage, Monday through Friday, and 24-hour on-call weekends and holidays.

Has your lab recently undergone a national accrediting agency inspection? 

Yes, yearly national accreditation by the Det Norske Veritas (DNV) is required. We recommend having the hospital’s infection control and safety officers involved in surveying relevant areas, with advice supplied regarding anything that does not meet specific safety standards. 

Additionally, two years ago, Ben Taub received Chest Pain Accreditation from the Society of Chest Pain Centers. Having a strong collaborative relationship with all departments involved in the accreditation process is paramount to a successful accreditation visit.

Where is your cath lab located in relation to the operating room (OR) and EC? 

The cath lab is on the sixth floor and the OR is on the fourth floor. The EC has straight access to the cath lab and OR through a set of emergency elevators. 

What trends have you seen in your procedures and/or patient population? 

A major trend we have seen recently is the percutaneous treatment of patients with complex lesions. Our patient population is becoming more ethnically diverse as the Houston area grows, and therefore, the evolution of disease processes varies in terms of presentation. Shifting to radial approach procedures has increased patient comfort and lessened ambulation time.  

What is unique or innovative about your cath lab and staff?

Collaboration with the CCU has helped in expediting STEMI care during cath lab off hours. The cath lab is unique in that all patients are set up for success during the patient’s pre-procedure cardiology clinic appointment for elective cases and while in the hospital for inpatients. All cath lab outpatients are scheduled through the cardiology clinic, which is across the hallway from the cath lab. The proximity and access to all the services provides an environment that is conducive to continuity and increases access to cardiology care. In addition, the electronic health record at Ben Taub is shared with the clinic and all information is available for all providers. The patients’ entire medical record is seen as “one” in the Epic electronic health record, which makes it easy for follow-up for all patients post cardiac catheterization. We believe Ben Taub Hospital has one of the strongest cardiology programs in the nation, with the outcomes to show it, and this is possible due to the commitment and team spirit of the staff. There is a collaborative team approach with common goals among the staff, helping to get things done quickly and effectively. 

Is there a problem or challenge your lab has faced? 

One challenge we have faced is a long transfer time between hospitals. The sister hospital to Ben Taub does not have a cath lab. A systematic process was put into place that was developed in order to decrease transfer time of cardiac patients requiring specialized care in a timely fashion. 

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture?”

Houston houses the world’s largest medical center and is populated by diverse cultures. Ben Taub Hospital is in the Texas Medical Center and patients come from all over the world to be treated here. Ben Taub is the only safety net hospital with PCI capabilities, so there is a large collaboration with EMS and the Houston Fire Department to provide timely care. The hospital sits a couple of miles from downtown Houston and about 2 miles from the NRG stadium, home to the Houston Texans. The staff in the cath lab is diverse in culture and age; they come from a variety of places throughout the world. 

A question from the American College of Cardiology’s National Cardiovascular Data Registry:       
How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility??
The NCDR Outcome Reports are shared with all stakeholders via the hospital quality review committee, which evaluates any opportunity in areas that may need improvement. Based upon the outcome results, initiatives are developed to focus on and improve patient care and processes.   

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

Only the invasive cardiovascular technologists are required to take the exam for the RCIS credential. Nurses are encouraged to take the RCIS exam.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

We have several nurses and technologists that are involved in the SICP and Alliance for Cardiovascular Professionals (ACVP). 

The authors can be contacted via Jaromir Bobek, CVT, RCIS, at jaromir.bobek@harrishealth.org.

Spotlight: Northwell Health – Lenox Hill Hospital

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Author(s): 

Pansy Currie, RN, John Coletti, RN, New York, New York

 

Tell us about your cath lab.

Lenox Hill Heart and Vascular is part of the Northwell Health cardiac service line.

What is the size of your cath lab facility and number of staff members? 

We have 6 angio suites and a 12-bed pre/post area, including a multi-specialty interventional lab and a stroke encephalo-volumetry (EVM) center where we also treat pulmonary embolism and structural heart disease. Our lab employs 41 registered nurses (RNs), 6 nursing technologists, 8 angioplasty specialists, 4 scheduling staff (for authorization), and 2 nurse coordinators. Over 25% of the staff has been here 15 years or more, 20% have been here 10 years or more, and 10% has been here 5 years or more. Approximately 40% of our staff has been here less than 5 years.

What procedures are performed in your cath lab? 

We perform many different procedures, including: 

  • Cardiac catheterization with angioplasty
  • Peripheral angiography/angioplasty
  • Cerebral angiography
  • Electrophysiology (EP) studies
  • Structural heart procedures 
  • Pulmonary embolectomy
  • Carotids 
  • Embolization
  • Cerebral stenting 
  • Coiling
  • Use of Penumbra
  • Endovascular aneurysm repair (EVAR), transcatheter aortic valve replacement (TAVR), thoracic endovascular aortic repair (TEVAR)

We perform between 100 and 125 procedures per week. 

Can you share your experience with structural heart repair? 

Our lab is performing TAVR, EVAR, and TEVAR. Cases use an integrated team approach with the operating room (OR), 2 surgeons, anesthesia, and perfusion as needed. We perform approximately 150 TAVRs/year and will open a brand new hybrid OR suite in a few months.

What is your percentage of normal diagnostic caths? 

Between 20-25% of our diagnostic caths are normal.

Do any of your physicians regularly gain access via the radial artery?

Yes, over 50% of our physicians use radial access. 

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Yes, for advanced critical limb ischemia (CLI) cases, Dr. Mitchwell Weinberg, director of endovascular therapies, performs pedal access.

Who manages your cath lab? 

Sinead Merrick, BSN, is the cath lab nurse manager. She has been at Lenox Hill for the last 3 years, although a cath lab nurse manager for the past 10 years. She will be graduating from an MBA program in May 2017. Sinead comments, “I love being the manager of a multi-discipline interventional unit. I am privileged to be a part of a truly dynamic, passionate team that provides outstanding patient care with superior patient outcomes.”

Do you have cross-training? Who scrubs, who circulates and who monitors? 

Yes. RNs monitor and circulate as well as staff the pre and post area. Angioplasty specialists scrub during cases.

What are some of the new equipment, devices, and products recently introduced at your lab? 

  • CSI’s Diamondback orbital atherectomy system, Impella (Abiomed), laser
  • Drug-eluting balloons for percutaneous transluminal angioplasty (PTA)
  • Synergy stents (Boston Scientific)
  • Coiling, fractional flow reserve (FFR), ultrasound, optical coherence tomography (OCT), and intravascular ultrasound (IVUS)

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We use a variety of methods, including emailing, weekly education meetings, staff huddles, online I Learn courses, and a notice board.

How is coding and coding education handled in your lab? 

Coding is performed by the billing department.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

Sheaths are pulled by angioplasty specialists, physician assistants, and physicians, and RNs perform radial band removal.

Where are patients prepped and recovered (post sheath removal)? 

Patients are prepped and recovered in the holding area. We use Angio-Seal (St. Jude Medical) and Perclose (Abbott Vascular), as well as radial compression bands.  

How is inventory managed at your cath lab? 

The lab has 2 dedicated supply chain managers who order, stock, and maintain equipment. Purchasing of equipment is discussed with the director of the lab, who provides par levels to the supply managers. Supply managers monitor par levels to gauge usage, and increase or decrease equipment as necessary.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?  

Yes, the lab has expanded over the years to support neuro intervention, arteriovenous malformation (AVM), and peripheral vascular and structural heart interventions, as well as EP. The case mix and overall volume has increased, but not the actual footprint of the lab.

Is your lab involved in clinical research? 

Yes. We are national leaders in enrollment for many and varied cardiovascular trials.

Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance? 

Yes, we were recognized with a Silver level of recognition award by Mission: Lifeline.

Who transports the ST-elevation myocardial infaction (STEMI) patient to the cath lab during regular and off hours?

Emergency department staff and physicians.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED? 

We have 2 call teams to support cases.

How does your lab handle on-call time for staff members? 

Our lab has 2 call teams: Team 1 and Team 2. Team 1 is the traditional STEMI team that also covers any emergencies coming to the lab after hours, neurovascular, endovascular, and structural heart. Examples include cerebrovascular accidents (CVAs), pulmonary emboli, abdominal bleeds, and high risk, valve-related emergencies. Team 2 handles late cases and any patients remaining in the holding area after hours. Additionally, Team 2 covers elective cases on weekends and can cover when a second emergency comes in.

Each call team is comprised of 2 nurses, 1 registered cardiovascular invasive specialist (RCIS), 1 fellow, and 1 attending.

Within what time period are call team members expected to arrive to the lab after being paged? 

For Team 1, we are required to be here within 30 minutes of being called for an emergency. Team 2 has greater leniency, as for non-emergent calls, and is usually given about an hour to arrive. 

Do you have flextime or multiple shifts? How do you handle slow periods?

We currently have three 11.5-hour shifts (0630, 0730, 0900) with some ability to come in earlier or later than needed. During slow periods, we are given the opportunity to complete continuing education hours, staff development classes and unit-based lectures. 

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? 

We are located on the 11th floor of the main hospital. The cardiac ORs are one floor below us and the ED is on ground level.

What quality assurance measures are practiced in your cath lab?

There are 3 quality assurance measures currently being measured:

  • Aseptic technique (quarterly topic) 
  • Time out procedure (quarterly topic)
  • STEMI door-to-device time (ongoing)

Are you recording fluoroscopy times/dosages? 

Yes. We currently record fluoroscopy times and dosages. We record it within the electronic medical record (EMR). 

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

We inform the physician at 3,000 cumulative air kerma during the procedure.

Who documents medication administration during the case?

The monitoring nurse documents medications administered during the case.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool (if so, which tool)?

It is the physicians’ choice. A few physicians dictate their cath procedure reports. Most complete a written report on the XIM system (Philips).

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we participate in the ACC-NCDR. We have a large, dedicated quality analysis team that captures NCDR data for every percutaneous coronary intervention patient.

How are you populating the registry data records? Who is inputting the data, and is any of it accomplished through in-lab systems?

The ACC-NCDR data is collected during the case via the XIM system. 

How are new employees oriented and trained at your facility? 

We have two orientation and training programs for new employees. New employees with intensive care unit (ICU) experience go through orientation for 12 weeks. New employees without ICU experience go through fellowship program for one year. New employees are trained with assigned preceptors for their entire orientation and training.

What continuing education opportunities are provided to staff members?

Staff is encouraged to attend monthly journal meetings, and we have morbidity and mortality (M&M) conferences on Wednesdays.

How do you handle vendor visits to your lab? 

Vendors are allowed in our cath lab. They are only allowed into rooms when requested by the physician and the patient signs a vendor consent form. A badge and proper attire are mandatory prior to entering the cath lab procedure areas.

How is staff competency evaluated? 

Nursing leadership performs annual testing.

Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?

We have a small joint holding/recovery area that is not always able to handle the inflow of new and post procedure patients. On busy days, we stagger the arrival times of patients to allow for adequate throughput. Additionally, on busy days we have a Surge Room on our progressive care unit (PCU). The Surge Room has a single dedicated Surge Nurse, who cares for up to 4 diagnostic radial patients at once. The activation of the Surge Room allows us to free up 4 beds in our holding area.

What trends have you seen in your procedures and/or patient population? 

Patients in the lab are generally older with more comorbidities compared to a decade ago.

What is unique or innovative about your cath lab and staff?    

We are a versatile lab where interventional cardiologists, cardiac surgeons, vascular surgeons, interventional radiology, and neurosurgeons all work together. Our staff is truly able to handle any vascular procedure in the entire body.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?

New York City is incredibly diverse and our staff is similarly so. We have a very “inclusive” staff culture. 

The authors can be contacted via Margarita Oksenkrug at moksenkrug@northwell.edu.

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?  

Yes, we do require staff to take the RCIS exam, and staff does receive money upon passing the exam.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

Not yet, but it is being discussed.

Spotlight: Palmetto General Hospital

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Author(s): 

Dayami Rodriguez, ARNP-BC, Director, Cardiac Cath Lab; 
Mike Diaz, MD, FACC, FSCAI,
Director, Interventional Cardiology Fellowship Program,
Palmetto General Hospital, Hialeah, Florida

Tell us about your cath lab. Is it part of a cardiovascular service line?

Yes, our cath lab is part of the Heart Institute at Palmetto General Hospital (PGH). We also partner with several regional Tenet hospitals, including Delray Medical Center, in order to offer our patients a complete range of percutaneous and minimally invasive complex procedures. We have a heart team, spearheaded by our structural heart clinic, to help identify, evaluate, and treat complex cardiovascular patients in a multi-specialty approach. 

What is the size of your cath lab facility and number of staff members? 

We have 3 cath labs, one with subtraction angiography for peripheral procedures, a 6-bed pre/post procedure area, and we use the hybrid room for complex structural heart procedures. Our lab employs 1 director, 1 assistant nurse manager (ANM), 12 registered nurses (RNs), 2 registered cardiovascular invasive specialists (RCISs), 4 cardiovascular technologists (CVTs), 2 radiologic technologists (RTs), 1 RCIS-inventory coordinator, and 2 transporters. Over 35% of the staff has been working with us at least 10 years; nearly half of the staff has been here more than 5 years. We’ve also added some employees in the last few years to meet the demands of our growing program.

What procedures are performed in your cath lab?  

We perform all types of coronary procedures, including high risk percutaneous coronary intervention (PCI) using left ventricular (LV) support, atherectomy, balloon aortic valvuloplasty, atrial septal defect (ASD) and patent foramen ovale (PFO) closures, peripheral angiograms and interventions, carotid angiograms, electrophysiology (EP) studies, ablations, device implants, loop recorders, tilt table tests, transesophageal echocardiogram (TEE), and cardioversion. The total number of weekly procedures is approximately 60 to 80.

If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 

We opened our state-of-the-art hybrid suite 18 months ago and began our TAVR program a few months later. We developed a multidisciplinary heart team for TAVR, a cohesive group including interventional cardiologists, cardiothoracic surgeons, clinical cardiologists, anesthesiologists, and a cross-trained structural heart team consisting of dedicated members from both the cath lab and the cardiac surgery services. We are averaging 25 TAVRS per year with plans to expand the program, which is coordinated by Jackie Wheatley, ARNP.

Does your cath lab perform primary angioplasty without surgical backup on site? 

We have a busy ST-elevation myocardial infarction (STEMI) program that offers primary PCI 24 hours per day with surgical backup on site during the day and available on call during off hours.

What is your percentage of normal diagnostic caths?

Between 20-25% of our diagnostic angiograms are normal.

Do any of your physicians regularly gain access via the radial artery?

Yes, some of our operators use the transradial approach for almost 100% of their cases and over 90% of our total cases are transradial. 

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

No pedal artery access is used at this time.

Who manages your cath lab?

Dayami Rodriguez, ARNP-BC, is the cath lab director. She has been in the cath lab at PGH for the last 11 years, and part of the management team for the last seven. She commented “The cath lab is not my work place; it is my passion. I am privileged to be part of a truly committed and enthusiastic team that provides outstanding patient care with excellent patient outcomes.”

Do you have cross-training? Who scrubs, who circulates and who monitors? 

We plan to cross-train our nurses to scrub cases in the future. But now we have a team of 3-4 staff members by procedures according to the need and complexity, where usually 2 nurses circulate, and the technologists scrub and record data on the monitor. 

Are there licensure laws in your state for fluoroscopy?

We follow the guidelines, protocol, and practices of the hospital radiology committee, which are based on Florida regulations. 

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab?

Our physicians position the tube, change angles and step on the fluoro pedal.

How does your cath lab handle radiation protection for the physicians and staff? 

Our cath lab director is in communication with the hospital radiology safety committee regarding radiation protection and dose readings. The dosimeters are changed out on a monthly basis, and high readings are flagged and reported. We evaluate the quality of all lead protection equipment on a regular basis and appropriate eye protection with leaded glasses is strongly encouraged. We rotate the staff involved in complex procedures like chronic total occlusions (CTOs) and peripherals. We also monitor radiation exposure during each procedure, keeping track of increased exposure cases.

What are some of the new equipment, devices and products recently introduced at your lab? 

We were traditionally a high-volume Rotablator (Boston Scientific) cath lab, but have been using orbital atherectomy (CSI) regularly for the last year. We are also getting ready to launch the SHIELD 2 trial. This trial will give us the opportunity to use the Thoratec HeartMate PHP device in comparison to Impella (Abiomed), which we have been using for several years. We recently started our percutaneous mitral valve repair program using the MitraClip device (Abbott Vascular) and we have an active CTO program that is always eager to try out new equipment in this rapidly evolving field. Other new products include the Supera peripheral stent from Abbott, near-infrared spectroscopy (NIRS) (Infraredx), used for a recent trial, and the Dye Vert system (Osprey Medical) for minimizing contrast exposure.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We use different methods, including email, weekly education meetings, staff huddles, online “I Learn” courses, and a monthly Cardiovascular Lab Committee meeting.

How is coding and coding education handled in your lab? 

The coding and charges are performed by an RCIS in the cath lab who works very closely with our finance and coding departments. She does a great job of educating our nurses and technologists regarding accurate coding. 

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull a sheath?

The sheaths are pulled by our cardiovascular technologists, RCISs, and interventional cardiology fellows. They need to have appropriate competencies and at least 5 lines pulled without complications.

Where are patients prepped and recovered (post sheath removal)?

Our patients receive pre/post care in the holding area. We use radial compression bands, ProGlide (Abbott Vascular), and Angio-Seal (Abbott) for hemostasis. A small percentage of our patients still receive manual compression for hemostasis.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

We have 2 staff members dedicated to inventory and orders in the lab. The cath lab director oversees new equipment orders and par levels.  

Has your cath lab recently expanded in size and patient volume?

We added a third cath lab in December 2015 and have increased our non-coronary volume by 30% in the last year. We plan to continue increasing our volume through high risk PCI, structural heart cases, CTO procedures, and EPS/mapping studies.

Is your lab involved in clinical research?

Yes. In the last year, we have participated in the Lipid-Rich Plaque (LRP) study testing NIRS infrared technology. We are also an enrolling site for the COMPLETE trial (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Primary PCI for STEMI) and will soon start to enroll in the SHIELD 2 trial testing the Thoratec Heart Mate PHP device vs Impella for high risk PCI patients.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  

During the last 3 quarters of 2016, our average D2B time was 57 minutes. We maintain a standard below 60 minutes. We have a protocol for each department involved with STEMIs and our goal is to have the patient on the table and ready for vascular access within 40 minutes of hospital arrival.

Who transports the STEMI patient to the cath lab during regular and off hours?

During regular hours, the emergency department (ED) staff transports STEMI patients. During off hours, the cath lab staff transports STEMI patients.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

Our primary responsibility is always to complete the procedure on the table safely or at least reach a point where the procedure can be staged without danger to the patient. Having three cath labs has made our cath lab much more flexible when it comes to dealing with STEMI patients without having to disrupt our daily schedule. 

What measures has your cath lab implemented in order to cut or contain costs?

We evaluate cost vs volume monthly, we evaluate new options in the market in an effort to reduce costs, and we have a strict policy for the use of contracted products whenever possible.

What quality control measures are practiced in your cath lab?

We work very closely with the quality department and we have some performance improvement (PI) mandatory markers like pain assessment, hand washing, and moderate sedation. We also have some specific markers for the department like D2B time, PCI appropriate use criteria (AUC), cardiac cath AUC, and noninvasive tests prior to cardiac cath. 

How are you recording fluoroscopy times/dosages? 

We use 2 different systems, Mac-Lab (GE Healthcare) and Sensis (Siemens Healthineers). 

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

We notify the physician when any higher than usual amount of radiation is used. As part of our CTO program, we plan to develop specific protocols for patient education and follow-up recommendations when excessive radiation dose is reached for a given case.

Who documents medication administration during the case?

The monitoring nurse documents medications administered during the case.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

We use a dictation system mostly, with some physicians using templates in the electronic medical record (EMR) to document their findings.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we report to the NCDR database and we meet quarterly to review it. 

How are you populating the registry data records? 

This is the responsibility of the Quality Department. 

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

We keep a close relationship with the clinical cardiologists in the area who have always supported our cath lab. We also have a busy marketing department that is always working on different campaigns to highlight our cath lab services in order to attract both patients and new referring physicians. Our strongest asset for attracting referrals is our experienced and dedicated staff. We are currently working closely with other regional Tenet hospitals to develop and expand our cardiovascular service line.   

How are new employees oriented and trained at your facility? 

All new employees at PGH must attend a general orientation for 2 weeks and a department orientation. They work with a preceptor for the first 3-4 weeks according to their previous professional experience.

What continuing education opportunities are provided to staff members?

Staff is encouraged to attend monthly education meetings, quarterly hospital educational fairs, and we schedule monthly in-service sessions related to the new products, procedures, and equipment introduced to the cath lab.

How do you handle vendor visits to your lab? 

Vendors are allowed in our cath lab with previous appointment and are only allowed in the treatment rooms when specifically requested by the physician. A vendor badge and proper attire is mandatory prior to entering the cath lab and procedure areas.

How is staff competency evaluated? 

General staff competencies are evaluated annually by the nursing leadership and with the introduction of every new system or product.

Does your lab have any physical layout bottlenecks or limitations? How do you work around the resulting challenges?

We have a small holding/recovery area (6 beds) that is not always able to handle the inflow of new and post procedure patients. This is our most frequent challenge. We try to navigate the situation by using some beds in PACU (surgical recovery area) when necessary. This year, we are working to create a post radial access unit closer to the lab. 

Is there a particular mix of credentials needed for each call team? Are staff permitted to leave early or start later after a night of on-call?

We have a call team consisting of 1 interventional cardiologist, 1 interventional fellow, 2 nurses and 2 cardiovascular technologists (RCIS/CVT). They are allowed to start later the day after a busy call night, according to staff needs. 

Within what time period are call team members expected to arrive to the lab after being paged? 

They must be in the lab within 30 minutes.

Do you have flextime or multiple shifts? How do you handle slow periods?

We have 4/10 and 3/12 shifts. During slower periods, we schedule in-service sessions for the staff or they work on their mandatory education units. Also, we flex volunteers without affecting patient care. 

Has your lab recently undergone a national accrediting agency inspection? Do you have any recommendations or advice?

We have Joint Commission inspections every 18 months. Avoiding shortcuts and doing things the same way every day makes it easier to prepare for an inspection.

Where is your cath lab located in relation to the operating room (OR) and ED? 

The cath lab is located on the second floor with a direct access elevator to the OR. The ED is on the ground floor. 

What trends have you seen in your procedures and/or patient population?

Coronary disease and structural heart disease is growing more complex each year. Procedures are more challenging than ever before, but fortunately, technology is keeping pace with these developments and allowing us to deliver complex percutaneous treatment to patients previously considered too risky for the cath lab. 

What is unique or innovative about your cath lab and staff?    

Our cath lab is a multicultural team working together in a very challenging environment. They combine significant clinical experience with impressive academic credentials, and are always willing to learn and take on new challenges, and develop new programs. The educational level for our nurses has increased tremendously during the last 4 years. Seventy-five percent of our nurses have BSN or masters degrees in nursing. 

Is there a problem or challenge your lab has faced? 

We faced some significant scheduling challenges in 2014 and 2015 as our cath lab volume continued to expand. Fortunately, we were able to add a third cath lab that helped improve our efficiency and patient satisfaction.

What’s special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your “cath lab culture”?

We have a very high number of non-English-speaking patients in our community, as well as recent immigrants. As a result, we have a very high incidence of advanced, untreated vascular disease that often presents for the first time under emergency situations. This often places a burden on our team to deliver good outcomes under difficult circumstances. The positive result has been a cath lab team highly trained and experienced in treating complex patients with severe vascular disease. This has provided an opportunity for the staff to more easily transition and pivot toward complex structural heart procedures quickly and without apprehension. 

The authors can be contacted via Patty Vila at patricia.vila@tenethealth.com.

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?  

This not a requirement for our staff at this time, but we are strongly encouraging them to take the RCIS test. We pay for the test and they receive a salary raise once they pass the exam. 

2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

We work with the American Heart Association and the Hispanic Chamber of Commerce to create some initiatives for the community. 

A question from the American College of Cardiology’s National Cardiovascular Data Registry:      

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We have a very strict screening tool to increase some of the metrics related to the NCDR data and we present the results monthly in our Cardiovascular Lab Committee meeting. 

Spotlight: Invasive Cardiology Unit, UHS Wilson Medical Center

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Author(s): 

Mary Farley, RN, BSN, Nurse Manager Invasive Cardiology
Alon Yarkoni, MD, FACC, Director, Structural Heart Program 
Johnson City, New York

Tell us about your cath lab. 

Our cath/electrophysiology (EP) labs are part of the UHS Heart and Vascular Institute, which is an all-encompassing cardiovascular service line. We have 2 cath labs, 1 EP lab, and a coronary ambulatory care unit. We currently employ 32 staff members, including 21 registered nurses (RNs) and 6 radiologic technologists (RTs). We have a mix of new staff members, staff that have been here from 3 to 7 years, and long-term staff that have worked in invasive cardiology for more than 15 years.

What procedures are performed in your cath lab?   

Cath lab procedures include right and left heart catheterizations, percutaneous coronary intervention (PCI)/stenting, intra-aortic balloon pump (IABP), Impella (Abiomed), intravascular ultrasound (IVUS), balloon aortic valvuloplasty (BAV), transcatheter aortic valve replacement (TAVR), alcohol septal ablations, and patent foramen ovale (PFO) closures. We average approximately 40-45 procedures per week. 

Can you share your experience with TAVR?

Dr. Yarkoni joined our team in July 2014, after completing a structural heart fellowship at Henry Ford in Detroit. Under his guidance, we spent 6 months building a TAVR program, including acquiring the necessary equipment, training physicians and staff, creating policies, and, most importantly, evolving a collaborative team between the operating room (OR) and cath lab staff. Our first TAVR cases were performed on December 9, 2014, and we have successfully performed over 100 to date. It has been inspiring to see the cath lab and surgical teams come together for this phenomenal procedural process. [Editor’s note: CLD interviewed Dr. Yarkoni about the UHS TAVR program in the June 2016 issue. Read more at http://www.cathlabdigest.com/article/TAVR-UHS-Structural-Heart-Valve-Cen...

What is your percentage of normal diagnostic caths?

We have averaged between 24-25% normal diagnostic caths in the last two years, with normal defined as <50% lesions, patent grafts, and no significant valvular disease. This is slightly higher than the state average. We are currently working on a quality improvement process to address this and believe that proper documentation of case indication and findings is primarily responsible.

Do any of your physicians regularly gain access via the radial artery?

Yes, three of our six full-time interventional cardiologists routinely perform radial access. We also perform right heart catheterizations utilizing the brachial vein. Together, these two methods of access have drastically reduced our patient recovery times and increased patient satisfaction. We have seen, as have other sites across the country, a reduction in the use of vascular closure devices and vascular complications as a result. 

Are you performing peripheral vascular procedures? Do any operators utilize pedal artery access when appropriate?

We do not perform peripheral vascular procedures on a regular basis, but with the recent opening of our hybrid room, we hope to perform more in the future. We recently had a very challenging case of chronic total superficial femoral artery (SFA) occlusion that could not be cannulated antegrade due to a large collateral. The team utilized ultrasound-guided pedal access, successfully crossed the lesion, and snared the wire with an excellent result. We were very proud to see how the team approached the case using the most advanced techniques and devices.

Who manages your cath lab? 

The cath lab is managed by the nurse manager, along with the medical and the service line directors.

Do you have cross-training? Who scrubs, who circulates and who monitors? 

We currently cross-train our RNs with our CACU (coronary ambulatory care unit). RNs circulate and monitor, and RTs scrub.

Who documents medication administration during the case?

The monitoring and/or circulating RNs.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

Our physicians and RTs are credentialed to perform all of the above functions.

What are some of the new equipment, devices and products recently introduced at your lab? 

We recently renovated and expanded one cath and EP lab. The cath lab was built for use as a hybrid interventional lab, and in both rooms, we installed state-of-the-art equipment. We recently upgraded our fractional flow reserve (FFR), IVUS, and vascular ultrasound equipment with the newest technology. We also introduced Impella when we started the TAVR process two years ago and have expanded its use to high-risk PCI cases.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We communicate through various methods, including service line meetings, staff meetings, staff “Weekly Wrap” emails, etc.

How is coding and coding education handled in your lab? 

Coding is handled by assigned coders within the UHS HIM/coding department. 

Who pulls the sheaths post procedure, both post intervention and diagnostic?

Most of our access sites are sealed with closure devices. If, however, a sheath needs to be pulled, it will be done by either trained staff or a physician.

What kind of training is mandated before someone can pull a sheath?

A minimum of 10 arterial sheaths must be pulled with direct observation to be considered competent.

Where are patients prepped and recovered (post sheath removal)? 

Outpatients are prepped and recovered in our coronary ambulatory care unit by the CACU RNs. Inpatients are prepped and recovered on our telemetry or the cardiac intensive care floors.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

We have an inventory technologist that is responsible for most of our inventory. This individual orders, stocks, and manages outdates. To ensure best pricing, new product must be approved by our value analysis team prior to purchase. Capital purchases are handled by our service line director and the nurse manager.

Is your lab involved in clinical research?

There are no people currently enrolled in ongoing trials. We have done a number of IVUS arms of drug trials over the past ten years.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?

Our average 2016 D2B time was 61 minutes. We have evolved a multidisciplinary approach, including our system-wide clinical staff and providers, Emergency Medical Services (EMS), and our regional healthcare partners in the ST-elevation myocardial infarction (STEMI) process to assure the most efficient approach to D2B time.

Who transports the STEMI patient to the cath lab during regular and off hours?

A combination of cath lab RN and emergency department (ED) RNs transport STEMI patients during both on and off hours.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

The on-call cardiologist, interventionalist, and ED physician agree on a plan of action, which may include triaging patients or considering the use of thrombolytic therapy.

What measures has your cath lab implemented in order to cut or contain costs?

We are part of a system-wide value analysis team that looks at the best pricing opportunities for all products.

What quality assurance (QA) measures are practiced in your cath lab?

We are involved with the New York State (NYS) Percutaneous Coronary Interventions Reporting System (PCIRS) reporting process. We hold a weekly cath conference and monthly CVPI (CardioVascular Process Improvement) meetings that involve case review and NYS/Centers for Medicare & Medicaid (CMS) data review. Each cardiologist also performs blinded case reviews that are part of our QA process.

How does your cath lab handle radiation protection for the physicians and staff?

We perform annual, mandatory radiation safety education. We have a very active radiation safety committee that oversees and performs quality checks on the equipment and lead, as well as monitoring radiation exposure to patients/staff.                    

How are you recording fluoroscopy times/dosages? 

We document fluoro time and dose area product (DAP) for each case in our electronic medical record (EMR). Our organization recently installed DoseWatch (GE Healthcare), which captures all exposures for each patient and keeps a lifetime exposure record.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

Our process with high exposure cases involves sending a letter, within 48 hours of the case, to the patient’s provider, alerting them of the exposure and possible effects. The letter also includes a contact number should the provider/patient have questions. A copy of this letter is also sent to our radiation safety department and the information is placed into a database for tracking. Any trends or issues are shared with the department at the quarterly radiation safety meeting.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Our physicians are currently dictating all cath reports.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

In our area, there is very little competition from nearby institutions. There are two main hospital systems in this area, UHS and Lourdes Catholic Health System. We are the only hospital in the area with cath lab capability. We have a good working relationship with the cardiology services at Lourdes Hospital and facilitate cath lab transfers on a regular basis.

How are new employees oriented and trained at your facility?  

New employees are oriented through our corporate training first and then spend approximately six months undergoing on-unit training.

What continuing education opportunities are provided to staff members?

We arrange clinical vendor educational sessions throughout the year. We also attend a yearly cardiac teaching day each fall.

How do you handle vendor visits to your lab? 

We allow vendors in the lab on a prescheduled appointment day. They must have badged in prior to entering the lab and are required to wear hospital scrubs if they enter a procedural area. All procedural product must be inspected, opened and handed off by hospital staff members only.

How is staff competency evaluated? 

We have an annual credentialing process that includes direct observation and formal educational sessions throughout the year.

Does your lab have a clinical ladder? 

Yes. RNs have a clinical ladder that is based on education, national credentialing, and organizational involvement.

How does your lab handle call time for staff members? 

Our call teams consist of two RNs and one RT. Minimum call expectation is currently 1-2 nights a week and every 4th weekend. To ensure staff and patient safety, we allow call personnel who have worked the night before to come in later or leave early.

Within what time period are call team members expected to arrive to the lab after being paged? 

Thirty minutes.

Do you have flextime or multiple shifts? How do you handle slow periods?

We staff with rotating, staggered start times and we try to use slow periods to provide the time for learning and credentialing opportunities for staff. We also occasionally place staff on call during these slow periods. 

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? 

Our cath lab is located on the second floor down the hall from the OR and just above the first floor ED. This convenient location helps shorten our patient transport times in emergent cases.

What trends have you seen in your procedures and/or patient population? 

In the last few years, we have seen approximately a 5% drop in STEMI cases. Likewise, we have seen a decrease in the number of elective outpatient PCIs. However, the number of inpatient non-STEMI and valve cases has increased. This correlates with the national trends.    

Is there a problem or challenge your lab has faced? 

While our EP and hybrid labs were under construction, we were down to one functioning cath lab from March 2016 to September 2016. During this period, we employed an early and a late shift for staff. We also retrofitted two OR rooms and an interventional radiology room to use for EP device implants. Our physicians had to change their schedules to allow for procedures to start at 7am and as late as 10pm. We performed outpatients and urgent cases first, followed by non-urgent inpatients. While this posed some inconveniences to our patients and staff, we were able to maintain the same case volume and quality outcomes as before.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  

Binghamton, New York is located in the southern tier of upstate New York. We are a three-hour drive from New York City, a two-hour drive from Albany, and one hour from Syracuse. This area is best known for being the birthplace of the IBM corporation (Endicott, New York) and the home of Binghamton University. Our patients vary from small-town farmers to university professors and retired executives. Our physicians are very dedicated to the community, some having practiced here for more than thirty years. We try to always do what is right for the patient and stay within our comfort zone. We are fortunate to be in close driving distance to some of the nation’s most highly respected healthcare organizations. When we are not able to provide a service locally, we refer that patient to a more capable facility. 

The authors can be contacted via Mary Farley, RN, BSN, Nurse Manager Invasive Cardiology, at mary_farley@uhs.org.

Spotlight: Beaumont Trenton Cath Lab/Interventional Radiology

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Author(s): 

Katie Sturgill, RN, BSN, Clinical Manager, Trenton, Michigan

 

Tell us about your cath lab. 

We have two labs at Beaumont Trenton. They are state of the art and provide services for both cardiac and interventional radiology procedures. Beaumont Trenton gained approval and accreditation to perform elective percutaneous coronary intervention (PCI) on March 30, 2016. Beaumont Trenton was the second in the state of Michigan to perform elective PCI without surgical backup. Our first elective PCI was performed on April 18, 2016 by Dr. Abedlrahim Asfour. Since then, we have performed 200 elective PCI interventions.  

What is the size of your cath lab facility and number of staff members?  

We have two labs. Our medical director is Dr. Abedlrahim Asfour. Lisa M. Landry, MBA, is director, imaging and cardiology. Our clinical manager is Katie Sturgill, RN. We have 6 full-time registered nurses (RNs), 1 part-time RN, 1 contingent RN that takes on-call only, 4 registered radiologic technologists [RT(R)s], 1 business office assistant, and 1 office manager. We have staff who have been with us for more than 15 years, as well as new staff. Our total years of experience for RNs and technologists equals 65+ years. 

What procedures are performed in your cath lab?

Cardiac procedures include left heart catheterization with possible intervention, peripheral angiogram with intervention, Ocelot (Avinger), EKOS/thrombolysis (both for pulmonary embolism and deep vein thrombosis), permanent pacemakers, implantable cardioverter defibrillators (ICDs), transesophageal echocardiogram (TEE), direct current cardioversion, and loop recorder insertion. Interventional procedures also performed in the labs include nephro tube placement, myelogram, lumbar puncture, kyphoplasty, drain placement, Quinton (Covidien), permacath, inferior vena cava (IVC) filter, mediport placement, coils, and thrombectomy.

Do any of your physicians regularly gain access via the radial artery? 

Yes. Physicians gain radial access approximately 83% of the time.

Do any operators utilize pedal artery access for peripheral vascular procedures when appropriate?

Yes. Most of the time, pedal access is ultrasound-guided. We have the ViperWire Advance (CSI) and Ocelot (for chronic total occlusions) that can be advanced through a 4 French (F)/5F sheath.

Do you have cross-training? Who scrubs, who circulates and who monitors? 

Our interventional radiology (IR) technologists are cross-trained to monitor and scrub. RNs circulate procedures and rotate into the cath lab holding area to care for patients pre and post procedure.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

The IR technologist and cardiologist can perform all of the above.

How does your cath lab handle radiation protection for the physicians and staff?

The use of protection devices, including lead aprons, vests, thyroid shields and glasses, are mandatory for all staff when in procedures utilizing ionizing radiation. All staff and physicians are provided with dose oximetry badges monthly. Badges are sent out for analysis and a monthly report is posted in the department highlighting individual exposure. Leads are checked and logged every 6 months by the cath lab IR technologist and replacement leads are ordered accordingly. There is a protective shield at the head of the table and an extra protective leaded skirt hanging from the side of the table.

What are some of the new equipment, devices and products recently introduced at your lab? 

We have intravascular ultrasound (IVUS)/fractional flow reserve (FFR), Ocelot, Pantheris (Avinger), EKOS for pulmonary embolism and deep vein thrombosis, the Indigo venous thrombectomy device (Penumbra), Impella (Abiomed), and a capital request complete for Avox (Accriva Diagnostics).

How does your lab communicate information to staff and physicians to stay organized and on top of change?

For physicians:

  • Cardiology Process Improvement business meeting monthly
  • Quarterly Interventional Cardiology Process Improvement
    • Meetings include cardiovascular surgeons from Beaumont Dearborn (tertiary site), intensive care unit (ICU), cardiac rehab, quality specialist, data extractor for the American College of Cardiology’s National Cardiovascular Data Registry (NCDR)/ The Blue

Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

  • Changes/updates regarding scheduling, protocols, and new equipment are sent to each physician via memos and emails on a regular basis.

For cath lab staff:

  • Daily morning huddles
  • Communication board
  • Monthly staff meeting held by clinical manager
  • Monthly staff meeting held by our director with imaging and cardiology
  • Designated staff RN attends the clinical practice council monthly
  • Department unit council 

How is coding and coding education handled in your lab? 

A group known as McGladry visits annually in our department to audit charts and give the latest updates and upcoming changes with coding and billing in compliance with Michigan regulations. The clinical manager and lead IR tech receive important changes and reminders via e-mail.

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull a sheath?

All IR techs pull sheaths and intra-aortic balloon pumps (IABPs). They are initially trained by a competent senior staff member and complete an annual competency.

Where are patients prepped and recovered (post sheath removal)? 

We have an 11-bay holding area for both pre and post patients. We use Angio-Seal (Terumo), Mynx (Cardinal Health), and TR Bands (Terumo) for closure. All sheaths are removed in the holding area by an IR tech, with the exception of the ICU patients. Those patients can go to the ICU with a sheath, but the IR tech is responsible to pull the sheath when appropriate. All patients who have received coronary intervention go to 3ICU/3IMC. Any diagnostic or same-day discharge post intervention is managed and discharged from our holding area. 

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

The lead IR tech is responsible for inventory and ordering product. A few hours each morning is dedicated to be sure that this is done. The staff as a whole does continuous monitoring of supplies so that a real-time inventory is kept. Staff communicates to the lead IR tech when a specific supply needs replacement.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

On September 1, 2015, we expanded from 1 to 2 labs, and from 5 bays to an 11-bay holding area. This includes a medication room, staff lounge and locker room, physician consultation room, and comfortable lounge area for patient family members. On April 18, 2016, we performed our first elective PCI and year-to-date, our heart catheterization volume is up 150%!

Is your lab involved in clinical research?

No, not at this time.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  

We are 100% D2B <90 minutes. We are 100% cath lab team arrival <30 minutes.

Many of our physicians that take STEMI call do not live within 30 minutes of the facility. As a result, we began to provide in-house accommodations for physicians to stay overnight beginning in September 2016. Since the institution of the on-call room, our physician arrival time is 94% <30 minutes.

Who transports the STEMI patient to the cath lab during regular and off hours?

An RN and/or a resident or physician from the emergency department (ED).

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

We finish as quickly and efficiently as we can. Because we have 2 labs, we move into the second lab for the STEMI. We have a diversion guideline, but it is a last resort.

What measures has your cath lab implemented in order to cut or contain costs?

We stagger shifts, work to decrease casual overtime, and send staff home on days that are not busy. Beaumont Health also has a value analysis team that looks at cost savings through high-volume supply purchases. Through this initiative, the lab has been able to reduce the cost of supplies.

What quality control measures are practiced in your cath lab?

We have daily checks of x-ray equipment, temperature and humidity in rooms, and crash cart and defibrillator functionality. ACT and glucometer are tested for accuracy.

How are you recording fluoroscopy times/dosages? 

We record fluoro time and dosage on every case in our hemodynamic monitoring system. The time and dosage are reported in the patient’s procedural report.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? How is the patient notified and what follow-up do they receive?

There is a policy in existence for this. We educate the patient at discharge. All patients receive a follow-up phone call by a cath lab staff member where we would ask for signs/symptoms of a radiation burn.

Who documents medication administration during the case?

The RN documents all medications given in EPIC on the sedation narrator.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

The physician dictates post procedure in EPIC. No structured reporting tool is utilized.

How are you populating the registry data records? 

Amber Thompson is our quality consultant who extracts data for PCI. She uses a program known as Armus that requires manual entry. We do not have a system that communicates directly with our hemodynamic monitoring system (Xper [Philips]) at this time.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

In our geographic area, Beaumont Hospital, Trenton is well known as a patient-centered community facility that provides compassionate, exceptional care every day. We also offer seminars on peripheral vascular disease to the public. We offered tours and information sessions with the opening of new cath labs. We have an excellent rapport with referring physicians and specialists, and also work with the media (Trenton’s local newspaper, The News-Herald) for marketing purposes.

How are new employees oriented and trained at your facility? 

The orientation period can last anywhere from 6-12 weeks, depending on prior experience. Each new staff member is paired with an experienced mentor who provides education and training. We have an orientation manual for each new employee with policies, guidelines, important information for reference, and checklists that are completed by their preceptor.  The lab manager sits down with each new employee and their preceptor weekly in order to get an update on their progress and how they are feeling about the orientation. Progress is documented weekly and a final evaluation is completed at the end of the orientation period to document competency in all areas. 

What continuing education opportunities are provided to staff members?

Certified education units (CEUs) are provided with many in-services in the department and off-site with new equipment, products and techniques. We offer annual renewal of basic life support (BLS) and advanced cardiac life support (ACLS). Seminars and conference opportunities also are provided annually.

How do you handle vendor visits to your lab? 

Vendormate is the program used for vendor sign in. They must have a badge printed for the day. We ask that each vendor notify the lab for approval before planning to come. Product specialists required intra-procedure are permitted to enter the lab, but visiting vendors are not allowed in the procedural areas.

How is staff competency evaluated? 

Competency is verified annually for groin management, point-of-care testing (activated clotting time [ACT], Accu-Check [Roche], hCG), IABP setup and monitoring, and understanding of IVUS/FFR through either online modules, or via demonstration of knowledge and skill to a senior staff member.

Does your lab have a clinical ladder? 

Not at this time. This is a goal for the Beaumont health system for 2017.

How does your lab handle call time for staff members? 

On call is self-scheduled. We have a 4-person call team with 2 RNs and 2 technologists. A member from perfusion is also on call for STEMI cases to assist with IABP setup.  Depending on the caseload for the day, staff is permitted to leave early or start later after working through the night. In many cases, we offer staff the day off, if possible.

Within what time period are call team members expected to arrive to the lab after being paged? 

All staff members are required to arrive within 30 minutes of being paged.

Do you have flextime or multiple shifts? How do you handle slow periods?

The staff may choose to use CTO (combined time off) for pay or VTO (voluntary time off) without pay during slow periods. 

Has your lab recently undergone a national accrediting agency inspection? Do you have any recommendations or advice?

Yes. Corazon made 2 visits initially for final accreditation for elective PCI. They have been back to evaluate at 3 months and 6 months after accreditation was granted. We are anticipating them in May 2017 for our 12-month evaluation then biannually thereafter.  
We passed all three visits with accolades. Some statements from our last Corazon visit include:

  • “State-of-the-art cath labs”
  • “Quality performance is outstanding”
  • “Performance improvement follow-up is quick and responsive”
  • “Excellent radiation exposure monitoring and infection control”

Our advice would be to keep an open mind when an accrediting body makes suggestions and make changes where you feel there is an opportunity for improvement. Upon return visits, they have appreciated the fact that we identify an opportunity and work to solve it.

Where is your cath lab located in relation to the operating room (OR) and ED? 

The cath lab is on floor 2R. The ED is just below the cath lab on the first floor and the OR is ½ floor above us on floor 2. 

What trends have you seen in your procedures and/or patient population? 

Patients are getting younger. Patients are waiting longer to come to the hospital and arriving sicker; most of the time, this is for lack of insurance.  

What is unique or innovative about your cath lab and staff?    

The staff has come from all different types of backgrounds with a wealth of knowledge to offer the team. We all live within the community, and take pride in the care and services that we deliver.

Is there a problem or challenge your lab has faced? 

Our cardiologist arrival time for STEMI was over 30 minutes due to the fact that all physicians live >30 minutes from the facility. We proposed the idea of an on-call room to be available each night for physicians. Since the beginning of September 2016, we have offered accommodations on site for the physicians to stay the night. Since the institution of the on-call room, our physician arrival time is 94% <30 minutes. 

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?  

We do not have RCIS in the cath lab here at Beaumont Trenton.  

2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

Not at this time.

A question from the American College of Cardiology’s National Cardiovascular Data Registry: 

How do you use the NCDR Outcome Reports to drive quality improvement (QI) initiatives at your facility?

With the information reported quarterly at the performance improvement plans (PIPs) meeting, we are able to track and trend performance. For example, are we hydrating our patients prior to a cath? If this measure is low, we can put an action plan in place and monitor quarter to quarter to see if we are improving. This is where the glomerular filtration rate (GFR) ratio below 3 goal came from, pre/post medication administration came from, and so on. All of these initiatives are to create better outcomes for our patients and follow best practice. 

Katie Sturgill, RN, BSN, Clinical Manager, can be contacted at katie.sturgill@beaumont.org

Spotlight: Albert Einstein Medical Center

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Author(s): 

Roslyn Scriber, MSN, RN, Trish Townsend, RCIS, RCS, Kendra Velonis, MS, BSN, RN, D. Lynn Morris, MD, Sean Janzer, MD, Jon C. George, MD, Philadelphia, Pennsylvania

Tell us about your institution and cath lab. 

Einstein Medical Center (EMC) has a 150-year history of serving the Philadelphia community and is one of the largest, most comprehensive healthcare providers in the region. The cath lab is part of the Einstein Heart and Vascular Institute, which is a complete multi-disciplinary cardiovascular service line including cardiology, cardiothoracic surgery, endovascular medicine, and vascular surgery. Our cath facility consists of four labs: one coronary single-plane lab, one single-plane endovascular lab, and two state-of-the-art hybrid labs. 

What is the size of your cath lab facility and number of staff members? 

We have 18 full-time staff members serving the holding area and four cath labs. They comprise an experienced clinical team of 10.0 FTE registered nurses (RN) and 8.0 FTE cardiovascular technologists (CVT) holding additional certifications (RCIS). Our clinical team’s experience ranges from 1 to 25+ years and we continue to train RN and CVT students with observerships and clinical rotations. The interventional cardiology physician team includes 5 board-certified interventional cardiologists that are fellowship-trained in coronary, structural, and endovascular medicine.

What procedures are performed in your cath lab?  

We perform the entire spectrum of diagnostic and interventional coronary, structural, and peripheral procedures via radial, brachial, jugular, femoral, and tibial access. Procedures include right and left heart catheterization; coronary angiography, balloon angioplasty and stenting; coronary chronic total occlusion (CTO) interventions; rotational, orbital, and laser coronary atherectomy; cutting and scoring balloon angioplasty; rheolytic and mechanical thrombectomy; intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve (FFR); intra-aortic balloon pump (IABP) and percutaneous left and right ventricular assist device (VAD); pericardiocentesis and endomyocardial biopsy; percutaneous closure of atrial septal defect (ASD), patent foramen ovale (PFO), patent ductus arteriosus (PDA), and ventricular septal defect (VSD); alcohol septal ablation; aortic and mitral balloon valvuloplasty; transcatheter aortic valve replacement (TAVR); left atrial appendage (LAA) exclusion; peripheral arterial atherectomy, angioplasty, and stenting; angioplasty and stenting of carotid, upper extremity, aortic, renal, mesenteric, and lower extremity vascular beds; endovascular thoracic and abdominal aortic aneurysm (AAA) repair; superficial venous radiofrequency ablation; deep venous stenting; inferior vena cava (IVC) filter placement and retrieval; and thrombectomy for deep venous thrombosis (DVT) and pulmonary embolism (PE). We perform in the range of 70-80 procedures each week.

Can you share your experience with TAVR thus far? 

We perform TAVR weekly in our hybrid cath lab. It is a team approach between interventional cardiology, cardiothoracic surgery, echocardiography, anesthesia, and cath lab and surgical staff. We have performed 70+ TAVRs at our facility and over 100 between our facility and other campuses.

What is your percentage of normal diagnostic caths?

Less than 50% of our coronary angiograms are normal diagnostic caths.

Do any of your physicians regularly gain access via the radial artery?

Access is determined primarily on an individual case basis, specifically catering to the patient’s needs, requests, and best outcome. About 50% of our coronary cases are performed via transradial access.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Our endovascular physicians are highly experienced in pedal and tibial artery access, utilizing them routinely for complex and limb salvage cases. Furthermore, they host training courses for pedal access and complex peripheral interventions for other physicians. 

Who manages your cath lab? 

Our cath lab is managed by a physician medical director and a nurse administrative manager. The medical director works closely with the nurse manager to handle the administrative duties for the cath lab. The clinical manager for the lab works closely with the staff to handle all the day-to-day issues and concerns for efficient running of the lab. 

Do you have cross-training? Who scrubs, who circulates and who monitors? 

Some of our RNs are cross-trained to scrub and monitor. The remaining RNs are in the process of being cross-trained. Our CVTs are all trained to scrub and monitor. The RNs circulate and administer medications. We also have interventional and general cardiology fellows who scrub into cases, which frees up the CVTs to perform additional supportive duties.

Are there licensure laws in your state for fluoroscopy?

Pennsylvania does not have fluoroscopy licensure laws.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

The physicians and fellows generally control fluoroscopy, occupy the assisting position, change imaging angles, and pan the table. The scrub CVT is also available to assist with these duties when the fellow is not available.

How does your cath lab handle radiation protection for the physicians and staff?

Radiation protection for the cath lab personnel includes annual radiation safety training, radiation badges that are monitored monthly, and posting radiation exposure every month. All operators are provided customized lead aprons, thyroid collars, and lead glasses as needed. Each room has an adjustable lead shield on a boom, and a portable lead skirt for use under the table. Furthermore, portable lead shields are also available for use by the circulating RN.

What are some of the new equipment, devices and products recently introduced at your lab? 

Einstein has maintained its position at the forefront of cutting-edge technology with two state-of-the-art hybrid cath labs, and integrated IVUS, OCT, and FFR assessment capabilities. We recently became one of the few sites in the region to purchase the CorPath robotic percutaneous coronary and peripheral intervention system (Corindus) to improve accuracy and minimize radiation exposure. Our array of novel endovascular devices includes OCT-guided chronic total occlusion crossing and atherectomy devices to further minimize contrast and radiation exposure. 

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Technology is everchanging with emerging new data from new clinical trials. A weekly staff educational conference with cath lab fundamentals, daily huddles with the cath lab team at the beginning of the day, communication boards with notification of novel technology, and monthly unit-based council meetings are some of the ways of keeping everyone apprised of change.

How is coding and coding education handled in your lab? 

The physicians and staff are trained to code the procedures performed during each case for accurate documentation. However, final coding for procedures is handled by a separate institutional billing department.  

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

Hemostasis is typically attained using closure devices after most diagnostic and interventional cases. We currently use Angio-Seal (Abbott), Perclose (Abbott Vascular), Starclose (Abbott Vascular), and Mynx (Cardinal Health) for femoral access, and VascBand (CHS Interventional) or TR Band (Terumo) for radial access. Occasional sheaths post-procedure are pulled by fellows, although some staff are trained for sheath removal and radial band removal.

What kind of training is mandated before someone can pull a sheath?

Current protocol for sheath removal includes observation, proficiency with proctored removal, quota for independent removal, and checklist with policy and procedure.

Where are patients prepped and recovered (post sheath removal)? 

Our cath lab has a 14-bay holding area. Most outpatient sheaths and radial compression devices are removed within this holding area and the patient is discharged directly from the bay. 

How does your lab handle hemostasis?

Hemostasis is primarily achieved using closure devices, as mentioned above. Outpatients are discharged directly from the holding area, while inpatients are monitored in the cardiac interventional care unit on telemetry post procedure.

How is inventory managed at your cath lab?  

We have a dedicated inventory manager and a full-time inventory assistant staff member.

Who handles the purchasing of equipment and supplies?

Our purchasing department for the hospital handles all contracts and pricing. Ordering is performed by our inventory manager for re-orders of existing supplies and by the purchasing department for new equipment.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

We just recently opened our 4th state-of-the-art hybrid cath lab in January 2017, and completed renovation and expansion of our holding area and inventory storage.  

Is your lab involved in clinical research?

Einstein Medical Center continues to be at the cutting edge of research and science for patient care by participating in a variety of clinical trials. We are currently involved in a total of 14 trials within the interventional cardiology department with the help of three full-time, experienced research coordinators.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? 

Our cath lab has an average D2B time of 70 minutes. We maintain the standard of 90 minutes or less by having a strong partnership with the emergency department (ED), facilitating education for local EMS teams and by reviewing the ACTION registry Executive Summary for quality outcomes. We are registered with the American Heart Association: Mission Lifeline and receive the quarterly Mission Lifeline report.

Who transports the ST-elevation myocardial infarction (STEMI) patient to the cath lab during regular and off hours?

The ED team brings the STEMI patient to the lab. If the patient is an inpatient, the cath lab staff assists in the transport of the patient to the lab.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

Our current priority is to safely complete the case on hand, while stabilizing the STEMI patient in the ED. The STEMI patient is then transported to the first available lab.  

What measures has your cath lab implemented in order to cut or contain costs?

Our lab is one of the few to implement a perpetual inventory system utilizing a bi-directional interface between our centralized enterprise resource planning (ERP) system (Lawson), and our clinical hemodynamics system (GE Centricity, GE Healthcare). This systematic interface helps us to manage the labs within our ERP system, and provides an abundance of data to help improve demand forecasting, utilization trends, cost per case, automated reorder points, intra-departmental logistics, and much more. At any point, we can develop and review advanced reports that give us visibility for where we can focus our efforts for improvements related to containing, and often cutting, costs. We also have a hybrid team comprised of system developers, CVIT professionals, supply chain administrators, and department representatives to work towards improving our current technology, and adding new features to our interface in order to push our data collection and analysis capabilities a step further. 

Every month, we also have our value-analysis committee meeting, and discuss new products and areas for inventory improvement with cardiology administration, physicians, and purchasing and contract management representatives. With all of the data readily available, we are able to have productive discussions on inventory that has accumulated over time and not getting used due to emerging technologies, products, and clinical techniques that evolve over time.

What quality assurance measures are practiced in your cath lab?

Recent changes in the cath lab and quality/compliance leadership created an opportunity for a great partnership. This collaboration allowed the cath lab team to maintain quality assurance measures that were already in place, such as meeting the <90-minute door-to-balloon time. It also presented the opportunity to create new measures such as monitoring and reducing peri-procedural vascular complications.

Are you recording fluoroscopy times/dosages? 

Our cath lab records both fluoroscopy times and radiation dosages for every case. We record mGy as well as DAP for fluoroscopy. It is recorded and documented in the GE case report.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? How is the patient notified and what follow-up do they receive?

After 30 minutes of fluoro or 5 Gy exposure, the physician is notified. We document every 15 minutes thereafter in the chart. The patient is also notified and educated by the physician. The dose is noted in the patient chart, as well as the GE report. High exposures result in the patient being brought back for follow-up and close evaluation.

Who documents medication administration during the case?

The RNs document medications administered during the case.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Our physicians currently use dictations for their reports, but we are in the process of moving towards structured physician case reporting.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

We use the ACC-NCDR to capture our cardiac cases, including LAAO, ACTION, and TAVR registries. We also use Lumedx to capture the CATH/PCI registry due to its analytic capabilities, which we have found to be of great value.

How are you populating the registry data records? Who inputs the data, and is any of it accomplished through in-lab systems?

The data for all the registries is collected and populated manually. There is no ADT feed that provides any transfer of data. The clinical data analyst team is comprised of 5 RNs (2 of the RNs are full time, and 2 are per diem, in addition to the manager, who abstracts approximately 20% of the time). 

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

The cath lab has a referral base by which patients enter into our system via referrals from primary care physicians, referring cardiologists, and our interventionalists who see patients in the office. 

How are new employees oriented and trained at your facility?

New staff members attend hospital orientation, followed by one-on-one training and orientation with a preceptor. They traditionally have a 12-week orientation period, but it is modified as needed, based on performance during that period. 

What continuing education opportunities are provided to staff members?

We have weekly educational conferences for the cath lab staff by our attending physicians and fellows. There are many other opportunities for education, both within our facility as well as through sponsored medical conferences. 

How do you handle vendor visits to your lab? 

Vendors are scheduled through a vendor calendar. We prefer only a single representative per area visit per day (for example, 1 peripheral, 1 cardiac, 1 electrophysiology). They must be credentialed and verified through VendorMate upon arrival. Additional vendors are allowed on a daily basis per physician request for support of cases.

How is staff competency evaluated? 

Staff competency is assessed utilizing annual evaluation by managers. We have a plan to move toward peer review.

Does your lab have a clinical ladder?

At this time, the lab does not have a clinical ladder in place. There are opportunities for RNs and CVTs to receive monetary compensation for obtaining specialty certifications.

Does your lab have any physical (layout) bottlenecks or limitations? 

With continued growth, we could use a larger holding area. Patient volumes on busy days overwhelm our holding area bays. Same-day patients and discharges also hold up bays. Furthermore, bed availability in the hospital can also delay turnover of bays.

How does your lab handle call time for staff members? 

Call time is currently from 6 pm to 7 am. We use at least 1 RN and 1 CVT, and the third staff person on call can be either an RN or CVT. We are flexible with our staff with late night and early morning call-ins. We often offer the opportunity to leave early, go home, or come in late after a call in the late night and early morning call-ins on weekdays.

Within what time period are call team members expected to arrive to the lab after being paged? 

We have a mandatory 30-minute response time.

Do you have flextime or multiple shifts? How do you handle slow periods?

We have recently transitioned to 7:30 am to 6 am for our scheduled staff in our procedural area. Our holding area has 2 shifts: 6:30 am-5:00 pm and 7:30 am-8:00 pm.  This facilitates early arrival of patients to the holding area to prepare for the procedure, and covers late discharges and any issues waiting for beds for patients. During slow periods, staff is expected to organize equipment and rooms, check expiration dates and ensure product is stocked and properly rotated, coordinate education and training, and they also have the option to use paid time off (PTO) and go home.

Has your lab recently undergone a national accrediting agency inspection? 

We successfully passed the Joint Commission inspection with the rest of the institution.  We follow majority of the operating room standards of care.

Where is your cath lab located in relation to the operating room (OR) and ED? 

We are located on the second floor of the Heart and Vascular Center. The OR is located in the adjoining building on the fourth floor. The ED is located on the ground floor in another adjacent building. All of these buildings are internally connected for efficient patient transport. 

What trends have you seen in your procedures and/or patient population? 

Trends of increasing cardiovascular disease around the country are replicated within our community. Furthermore, being located in an under-served inner city community, Einstein Medical Center has seen trends of increasingly complex and advanced cardiovascular disease.

What is unique or innovative about your cath lab and staff?    

The cath lab staff at Einstein Medical Center is comprised of highly technically skilled personnel. They are very motivated and work well with the physicians as a team to take care of some of the most complex patients in the hospital.  

Is there a problem or challenge your lab has faced? 

Due to our geographic location and the demographics of the community, we are challenged with hiring consistent adequate staff that is able to respond within the 30-minute response time for emergent cases. We, therefore, also rely on highly skilled contracted staff and a local staffing solution partner to keep adequate staffing numbers to meet the demands of the lab.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?

We serve a population of people that includes multi-cultural and economically diverse subsets. We also serve an underprivileged community that often has limited access to primary care. These factors keep us acutely aware of the importance of creating a culture of acceptance, understanding, teaching, and patient advocacy. 

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?  

An RCIS credential is currently a requirement to maintain position as cath lab staff. If a new hire is not RCIS certified, they have 1 year to obtain certification. There is a certification bonus of $500 given annually to staff who are RCIS certified. 

2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

Our managerial team members are encouraged to be involved with interventional societies such as American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Invasive Cardiovascular Professionals (SICP) at the local, regional, and national levels.  

A question from the American College of Cardiology’s National Cardiovascular Data Registry: 

How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility?

Quality and process improvement initiatives within our service line are formed from the quarterly outcome reports that we receive. The quarterly reports are reviewed in depth by way of set monthly meetings. These meetings include the division chair, attending physicians, the cath lab manager, the service line administrator and the quality & compliance manager. By identifying the metrics that fall below the U.S. 50th percentile, it gives our team an opportunity to prioritize the outliers, put a process in place for improvement, and set a timeline for reassessment.

The authors can be contacted via Jon C. George, MD, at jcgeorgemd@gmail.com.


Spotlight: Mercy Medical Center Cardiovascular Lab

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Author(s): 

Richard Joens, RN, BSN, Cardiac Cath and EP Lab Manager, Becky Quijano, RT(R)(CV), IR, Quality & Safety Specialist, 
Ryan Hollenbeck, MD, FACC, Cardiac Cath Lab Medical Director, Cedar Rapids, Iowa

Tell us about your cath lab. 

Mercy Medical Center’s cardiovascular lab in Cedar Rapids, Iowa, provides services for cardiac revascularization, cardiac electrophysiology, peripheral revascularization, and interventional radiology. We also have a ten-bed patient care area to monitor patients pre and post procedure. Mercy was recently approved for cardiothoracic surgery and our lab is part of a rapidly growing cardiology service line. Earlier this year, we hired an additional interventional cardiologist and a cardiothoracic surgeon; this is a very exciting time for our department and hospital. 

What is the size of your cath lab facility and number of staff members?  

Our lab consists of four procedure rooms equipped with Siemens x-ray equipment and has a pre/post area including ten patient care areas. Our staff consists of seven procedure room nurses, eight cardiovascular radiologic technologists, four recovery bay nurses, one scheduling coordinator, one patient care tech, one administrative assistant, one quality and safety specialist, and one cath/electrophysiology (EP) lab manager. A majority of staff has been within our department less than five years. 

What procedures are performed in your cath lab?

Procedures include right and left heart catheterization, percutaneous coronary intervention (PCI), coronary thrombectomy, coronary atherectomy, intra-aortic balloon pump (IABP), Impella (Abiomed), intravascular ultrasound (IVUS), fractional flow reserve (FFR) assessment, peripheral angiograms and intervention, endovascular aortic aneurysm repair (with OR staff), cardioversion, permanent pacemaker implant, implantable cardiac defibrillator, loop recorder implants, EP studies and ablation, along with interventional radiology procedures.

Does your cath lab perform primary angioplasty without surgical backup on site? 

Our lab does perform percutaneous coronary interventions without surgical backup on site. Currently, we have options to transfer to three hospitals within a 30-minute radius. When our cardiothoracic surgeon starts this summer, we will have on-site surgical backup. We are excited to add this new service line so patients can stay within Mercy, their preferred hospital.  

Is your lab planning to start performing transcatheter aortic valve replacement (TAVR)?

We are making plans to start a TAVR program. Two of our interventional cardiologists have experience performing TAVR. We are anxious to start a TAVR program after our surgical valve program is up and running with sufficient numbers. 

What is your percentage of normal diagnostic caths?

Approximately one-third of our cases are considered normal.

Do any of your physicians regularly gain access via the radial artery?

Yes, we have four interventional cardiologists and all of them perform radial access. We currently do 82 percent of our cases with radial access, including ST-elevation myocardial infarction (STEMI).

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

We do not routinely perform pedal artery access in our lab; however, we have performed this access when appropriate.  

Who manages your cath lab? 

Our cath lab is managed by a nurse manager who works with the medical director in making decisions for the lab and its future. The manager reports directly to the vice president of outpatient services for the hospital.      

Do you have cross training? Who scrubs, who circulates and who monitors? 

We cross train all of our staff. A nurse will start in the nursing role of the room, which includes patient assessments and sedation monitoring. We then cross train our nurses into a scrub role and eventually into the monitor role. Our nurses are also trained to work in the pre/post area, if needed. Radiologic technologists start in the circulating role, which includes pulling appropriate equipment and positioning the x-ray equipment. They set up angles and pan for the physician as they inject the contrast agent. We cross train our radiologic techs into the scrub role and eventually into the monitor role as well. 

Who documents medication administration during the case?

The RN in the room has a workstation on wheels that documents patient assessments along with medications given during the procedure. 

Are there licensure laws in your state for fluoroscopy?

Yes.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

The radiologic technologists and cardiologists perform the actions listed. 

How does your cath lab handle radiation protection for the physicians and staff?

Radiation safety is extremely important to us at this institution. We use protection devices including shields that hang from the ceiling, lead aprons, vests, thyroid collars, and lead-lined sterile drapes (i.e., RadPads [Worldwide Innovations & Technologies, Inc.]). The physicians also use radiation protection safety caps and radiation protection glasses. Every staff member and physician involved in radiation cases is given dosimetry badges and monitored monthly. This report is reviewed bi-monthly and presented at a quarterly radiation safety meeting. The lead aprons, vests, and thyroid collars are checked annually and upgraded as needed. In addition, the manager tracks monthly fluoroscopy times and doses, and presents this information at a cath quality meeting held monthly. The cardiologists are always conscious of staff in relation to the x-ray tube. 

How are you recording fluoroscopy times/dosages? 

Our staff enters the radiation time in our electronic medical record within the procedure log. Dose and fluoroscopy times are also captured within the Siemens equipment and reported to the manager at the end of the month to present at the cath quality meeting.  

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

The hospital has an established protocol for tracking cases with more than 60 minutes of fluoro time. The patient’s physician is notified, and reports any clinical concerns.  

What are some of the new equipment, devices and products recently introduced at your lab? 

In the past year, we have added the Impella device. We have used this device primarily for staged complex PCI; however, all staff are trained in case it is needed for an emergent situation. We recently upgraded our FFR equipment to incorporate iFR technology from Philips Volcano. This has been a useful tool and patient satisfier. We have also upgraded our activated clotting time (ACT) monitoring device to the Accriva Hemochron (Accriva Diagnostics). Our previous device would take five to ten minutes to receive a result, but the new device provides a result in less than three minutes. This has been a physician satisfier, especially in PCI cases and EP procedures. It has also allowed us to cut costs by increasing our heparin usage. 

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Staff members are updated with monthly meetings, email, face-to-face, or small group huddles, as necessary. The cardiologists have a monthly medical director meeting and a bi-weekly cardiology clinic meeting to talk about changes and updates on projects. 

How is coding and coding education handled in your lab? 

Our radiologic techs put in the procedure codes for the procedure performed. Our quality and safety specialist then reviews for accuracy. A coder assigned to our area reviews this information. The coder emails daily edits they make, and educates occasionally at staff meetings on recurring mistakes. 

Where are patients prepped and recovered (post sheath removal)?

Outpatients are prepped in our pre/post recovery bay area. This area has ten bays that can provide patient care. Cardiologists prefer to have inpatients come down to our pre area before their scheduled cases, so our staff can get them ready and verify meds have been given appropriately; however, the nursing floors have a checklist they follow that details what needs to be done before patients are taken down for a procedure, if taken directly to the procedure room. 

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

We do more than 80 percent of our cases via radial access, and hemostasis is achieved using a compression device that is applied in the room upon completion of the procedure. The other 20 percent of cases are managed using a closure device or by manual pressure. Our manual holds occur in our recovery bay, the nursing floor, or in the procedure room. The procedure room is not a preferred choice, since we want our room to be open for emergent cases. Because of our high radial usage, femoral sheaths are not as common in the hospital as they use to be, and it has been difficult to keep nursing staff on the wards competent in removal and groin management. Currently, the cath lab staff members are the “experts” in the hospital for sheath removal. We are working with nursing units to develop sheath removal teams on their floor so the cath lab staff does not need to be present. The cath lab staff has a checklist in their orientation packet that requires at least three sheath pulls with a preceptor before being independent. 

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

We have a designated staff member that helps order stock items and a designated staff member that orders non-stock items. We use a Kanban system for reordering products. Staff members also check for product expirations at the beginning of each month and look ahead for future expirations. To ensure best pricing, all products are reviewed with the manager and our purchasing department. 

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

We recently renovated a state-of-the-art EP procedure room with biplane x-ray equipment. This room is treated as an OR suite with strict infection control measures and can function as a hybrid OR. We have added a new interventional cardiologist; this has increased our procedure volume. Our cardiologists enjoy the option of running two cath rooms at the same time, with the option to flip into the next room if it is available. We have begun talking about space available to create additional procedure rooms and adding to our pre/post area. 

Is your lab involved in clinical research?

No, we do not currently participate in any clinical research. 

Can you share your lab’s average door-to-balloon (D2B) times?

Our facility averages a monthly D2B time of less than 60 minutes. Having a response time of 20 minutes has helped with our amazing D2B times. We have also worked on processes between local emergency medical services (EMS), emergency department (ED) physicians, and cardiologists to streamline the emergent patient quickly into the cath lab. 

Who transports the STEMI patient to the cath lab during regular and off hours?

Our staff sets up the room and once this is complete or near complete, the RN and another staff member will get the patient from his or her location.       

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

During daytime hours, we have four rooms that can handle STEMI patients. If all rooms are occupied, we triage the patients in those rooms, and decide who can finish quickly, or who is at a stopping point and can be taken off the table. 

During off hours, we have a protocol in place to triage the status of the lab and available options to assist. Our staff is known to go above and beyond, and off-call staff, including cardiologists, have assisted in dual STEMIs in the middle of night. This type of passion and commitment shows the dedication our staff members have to to our patients and their health.  

What measures has your cath lab implemented in order to cut or contain costs?

We use a value analysis team to help coordinate the best prices on the market with the products we use. We also communicate savings opportunities to the staff and cardiologists at cath lab quality meetings and steering committees. 

What quality control measures are practiced in your cath lab?

The manager monitors trends in radiation, sheath access, medications used, closure devices, complications, and patient volumes. This information is presented at the monthly cath quality committee meeting. We also have a clinical specialist that works with our clinical improvement and accreditation department. This person helps us facilitate care and current standards of practice.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

We are currently using Siemens’ SyngoDynamics for our structured reporting system, but this process will be changing. We anticipate using EPIC to document all of our case information in the near future. 

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

We are registered to use the ACC-NCDR CathPCI registry and ICD registry. Our staff is capturing data during the case and then a second person double-checks their work after the case. We make corrections in our documentation system, if needed, and have a staff member in the quality and accreditation department submit the data. 

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

This information is reviewed to monitor trends in the nation. We look at how we compare to the national averages and strive to exceed those. 

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

There are two PCI-capable hospitals in our area. Our cath lab currently does not compete for patients, per se. We have not formed alliances. Some of our providers do hold outreach clinics in surrounding communities. Local EMS is excellent at taking patients to the hospital of their preference. 

How are new employees oriented and trained at your facility? 

New employees come in with a variety of previous work experiences, so we tailor our orientation to the person. We have an orientation manual that is given to the new employee, which outlines a plan for their first 16 weeks. We try to implement a one-preceptor model of learning in order to facilitate education. The manager keeps an open-education model in the department, meaning we are all continuously learning and asking questions.

What continuing education opportunities are provided to staff members?

We take advantage of educational opportunities provided by vendors. We also try to do monthly lectures on topics submitted by staff for furthering education. The manager has required all new hires to complete the “Back to Basics” education program sponsored by Medtronic within their first year. This program has a lot of good information for both new and experienced staff. 

Are clinical staff members required to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

We do not require staff to take the RCIS exam. We do not have an incentive program currently for passing the exam; however, management is working on creating an incentive level program including certification.

How do you handle vendor visits to your lab? 

We do not allow vendors to come into the lab to wait for cases to arrive, but if we know of a case that will require vendor support, we reach out to them and let them come in for the case. They sign into Reptrax before they are allowed into the department, and we also try to coordinate education as well since they will be in our lab. 

How is staff competency evaluated? 

The hospital uses modules in our intranet that keep us competent on hospital and state competencies. We also have a simulation lab where we do annual competency testing to keep us up to date with sedation. The manager also does performance evaluations annually and is active in the lab to view work performance issues. 

Does your lab have a clinical ladder? 

Our hospital has a clinical ladder program in which all clinical staff can participate. The levels have pay incentives for the employee if they provide the proper paperwork. This can be a rewarding program to keep employees engaged and compensated for their excellent work performance. 

Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?

Our pre and post area is limited to ten patient care areas and our department is growing rapidly. The supervisor and manager look ahead to form a game plan on where to place patients, how long it will take to recover, and who can sit in recliner versus a flat cart. Procedure results can be hard to predict, and sometimes the patients go directly to the cardiac telemetry floor to be observed overnight. Backup plans have consisted of utilizing other recovery areas in the hospital if needed. 

How does your lab handle call time for staff members?

If staff members are called in the middle of the night, they are still expected to report for the morning shift if they were scheduled to do so. The manager looks at the schedule that day and works with the supervisors to decide if the call team can be relieved and sent home early. We currently have three call teams in our department. The teams consist of four people that can scrub, circulate, nurse, or monitor. Not everyone is able to function in certain roles, so we pair call teams to make them as strong as possible. Currently, staff members take call two nights per week and every third weekend. Our future goal, once staffing is in place, is to make four call teams to reduce the workload for staff. 

Within what time period are call team members expected to arrive to the lab after being paged? 

We require a 20-minute response time. 

Do you have flextime or multiple shifts? How do you handle slow periods?

We do flexed scheduling in our area. If procedures do not start until later in the morning, we will keep the staff assigned in that room at home and have them be on call. If an emergent or add-on case occurs, we call them in. During slow periods in the day, we clean rooms, put away supplies, check for expiration dates, and work on education materials. 

Where is your cath lab located in relation to the OR and ED? 

Our cath lab is located within close proximity to the ED. The OR is directly above the cath lab. There is a large elevator next to the cath lab for transport, and the intensive care unit is next to the OR as well. 

What trends have you seen in your procedures and/or patient population? 

Procedure volumes have increased in all areas (cath, EP, and interventional radiology). We have noticed an increase in complex PCI cases this past year, which may reflect a small change in our patient population. With the recent renovation of our EP lab, we have also seen a significant increase in ablations, as we expected. 

What is unique or innovative about your cath lab and staff?    

Our cath lab staff is very team-oriented and works well with one another. This helps with morale and patient interaction. There are times when the job can be stressful and busy, but it can be amazing to watch a team of people work so hard and well with each other, and accomplish the same goal at the end of the day. The physician and staff interaction has been collaborative and positive in nature. The cardiologists are always willing to educate and are very involved with staff satisfaction. This brings the department together and provides better care overall to our patients.

Is there a problem or challenge your lab has faced? 

One challenge we have faced has been maintaining competency in femoral sheath management, given the shrinking number of femoral cases we do. We are working towards developing a core team of “femoral champions” on the floors who maintain competency and can train other nurses to pull femoral lines. The other issue we face is training our relatively young and inexperienced staff during a period of rapid growth. It can be hard to properly staff multiple rooms with new staff and more experienced staff learning new roles. One way we continue to progress is by blocking one room for emergency cases in order to promote a safe and effective learning environment in the other cath room. 

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?

Cedar Rapids has a population of about 125,000. Eastern Iowa is a rural area, and so we care for a rural population covering a very large area. We try to promote same-day discharge after PCI when possible; however, serving a rural population presents challenges with same-day planning. We try to accommodate our patients with the benefits of same-day discharge when possible, but our primary focus is always safety. 

The authors can be contacted via Richard Joens, RN, BSN, Cardiac Cath and EP Lab Manager, at rjoens@mercycare.org.

Spotlight: North Mississippi Medical Center

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Author(s): 

Carla Durham, RN, Tupelo, Mississippi

 

Tell us about your cath lab. Is it part of a cardiovascular service line? 

The North Mississippi Medical Center (NMMC) cath lab is encompassed within the North Mississippi Medical Center Heart and Vascular Institute, which contains the electrophysiology, cardiology, and vascular service lines. 

What is the size of your cath lab facility and number of staff members?   

There are twenty full-time employees (FTEs) supporting the cath labs and hybrid room, and another eight FTEs supporting electrophysiology (EP). 

The cath lab area is comprised of four labs to support cardiac and endovascular procedures, as well as a hybrid OR for lead extraction, transcatheter aortic valve replacement (TAVR), and complex vascular procedures. In addition, there are two bi-plane rooms dedicated to EP, which is separate from the cath lab.

Half of the cath lab FTEs are nurses, and the other half are radiologic technologists (RTs). The average tenure of the present cath lab FTEs is 10 years. 

There is another team of 25 FTEs that staff a cardiac observation unit for elective patients, managing admissions and post-procedure recovery.

What procedures are performed in your cath lab? 

Cardiovascular: diagnostic cath, angioplasty, stent implantation (including bioresorbable scaffolds), coronary atherectomy, atrial septal defect/patent foramen ovale (ASD/PFO) closure, septal alcohol ablation for hypertrophic cardiomyopathy (HCM), coronary intravascular ultrasound (IVUS) and optical coherence tomography (OCT), pericardiocentesis, pulmonary embolus mechanical thrombolysis, intracardiac echo, carotid stenting, subclavian stenting, renal stenting, iliac stenting, peripheral atherectomy using TurboHawk (CSI) and laser, peripheral angioplasty and stenting, alternative access peripheral intervention including pedal access (three of our operators use the pedal approach), and peripheral vascular mechanical thrombolysis. 

Hybrid procedures include laser lead extraction (performed by EP), TAVR (combo cases with cath lab staff and OR staff), and endovascular aneurysm repair (EVAR) for thoracic aortic aneurysms (TAA), abdominal aortic aneurysms (AAA), and dissection (performed by OR staff).

Our EP lab performs pacemaker implants, transvenous and subcutaneous implantable cardioverter defibrillator (ICD) implants, diagnostic EP studies, atrioventricular (AV) node ablation, atrial flutter ablation, afib ablation, ventricular tachycardia (VT) ablation, accessory pathway ablation, and left atrial appendage (LAA) closure. 

Approximately 100 procedures are performed weekly. 

Can you share your experience with TAVR?

We were the seventh commercial start hospital performing TAVR. We have performed 115 TAVR procedures. In those with no surgical options, the one-year survival is >85% (exceeding the PARTNER trial data).

What is your percentage of normal diagnostic caths?

20%.

Do any of your physicians regularly gain access via the radial artery?

Yes, presently 70% of all diagnostic caths and interventions are done using the radial approach.

Who manages your cath lab?

Carla Durham, RN.

Do you have cross-training? Who scrubs, who circulates and who monitors?

Yes, there is cross-training. Nurses and RTs rotate on who might scrub, circulate, and monitor. A nurse always is in the room to administer meds and monitor conscious sedation. 

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

Most of the time, the doctors operate the table. When they do not, an RT operates the table for the case.

How does your cath lab handle radiation protection for the physicians and staff?

We have a dedicated radiation safety officer. Staff and physicians are monitored with monthly radiation badges. As Low As Reasonably Achievable (ALARA) is strongly encouraged and education is provided.

What are some of the new equipment, devices and products recently introduced at your lab?

We have recently implemented:

  • Toshiba dual-plane room for cardiovascular 
  • OCT imaging 
  • Vascular ultrasound 
  • Absorb (Abbott Vascular) bioresorbable scaffold implantation 
  • Impella LV and RP (Abiomed)
  • Cardioform ASD closure (Gore)
  • Watchman LAA closure (Boston Scientific)
  • Philips bi-plane room for EP 

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We huddle daily with staff for updates and we meet with the doctors monthly. 

Service line meetings and door-to-balloon time meetings are held quarterly. 

The cardiology section meets on a quarterly basis.

How is coding and coding education handled in your lab?

Education updates are held annually, and in conjunction with the hospital and physician office staff.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

We have adopted a philosophy of closure first for femoral access cases. Our doctors perform the closure device placement. When femoral closure is not possible, specially trained nurses pull the sheaths. There are differing protocols for post-diagnostic and post-intervention cases. All trained nurses go through an educational didactic training followed by supervised, proctored sheath removals.

Where are patients prepped and recovered (post sheath removal)?

Outpatients are prepped in their pre-procedure room. Inpatients are prepped in their hospital room or in the procedure room itself. Outpatients are recovered in their observation room. 

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

Utilizing the McKesson Inventory system, our inventory is maintained at par levels pre-set by the management team. Many supplies are bought in bulk and held in our logistics center for use. The cath lab management team, which includes physicians, determines needed purchases of equipment and supplies. Diane McNeil is charged with maintaining supply levels. Mike Switzer, as VP of Purchasing, assists with equipment acquisitions.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Yes, the addition of three new vascular surgeons has increased percutaneous vascular procedures; therefore, this has increased the need to add additional staff.

Is your lab involved in clinical research?

Yes.

Can you share your lab’s average door-to-balloon (D2B) times?

At present, 63 minutes. There is a multi-disciplinary committee that meets quarterly to review procedures and protocols. We are part of the American Heart Association: Mission Lifeline.

Who transports the STEMI patient to the cath lab during regular and off hours?

Cath lab personnel.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

There is a second team on call.

What measures has your cath lab implemented in order to cut or contain costs?

We have a co-management agreement with the physicians. This agreement, in part, rewards the physicians for high quality care, but also for cost containment. This agreement passed Office of Inspector General (OIG) scrutiny and serves as the national model.

What quality assurance measures are practiced in your cath lab?

We participate in several registries (American College of Cardiology-National Cardiovascular Data Registry [ACC-NCDR]) that allow comparison to national averages. Also, we rotate assessment of quality metrics selected by the management team every six months for additional review.

Are you recording fluoroscopy times/dosages? 

Yes, we record fluoroscopy times on all cases in all rooms. Recently, we updated rooms to provide radiation doses given to patients.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

As we now have the technology described above, we are presently developing those policies and procedures with our radiation safety officer.

Who documents medication administration during the case?

 A nurse assigned to medication administration and conscious sedation.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Our physicians use structured reporting via McKesson Cardiology. NMMC is actually one of the national McKesson Cardiology Demonstration sites.

How are you populating registry data records? 

Most of the registry data is pre-populated through the McKesson Cardiology system. There are required fields to assure adequate data collection. Any remaining needed data is added by one of two registry coordinators devoted to the cardiovascular service line.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

NMHS consists of five spoke hospitals and three other aligned hospitals for referrals. Additionally, we compete through promoting our outcomes.

How are new employees oriented and trained at your facility?

New employees go through a pre-set hospital orientation, and then a more specific, six-month cath lab training.

What continuing education opportunities are provided to staff members?

Staff members are provided access to regional CME programs and attend national programs on a rotating basis.

How do you handle vendor visits to your lab? 

Vendors have pre-arranged cath lab dates. All representatives are tracked through RepTrax. Representatives are not allowed into the cath lab space or control rooms unless requested by the physician.

How is staff competency evaluated?

Staff undergoes an annual review that includes core competency assessments and anonymous peer review.

How does your lab handle call time for staff members? 

Call is assigned on a rotating basis. Each call team consists of two nurses and two radiologic technologists. Staff members post-call are allowed to leave early.

Within what time period are call team members expected to arrive to the lab after being paged?

Within 30 minutes.

Do you have flextime or multiple shifts? How do you handle slow periods?

No. Staffs are asked to leave early during slow times.

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)?

The cath lab is across the hall from the OR, and two floors directly above the ED with ready elevator limited access.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

No.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line?

Yes, the outcomes team for the facility follows the SICP [now merged with the Alliance of Cardiovascular Professionals (ACVP)].

What trends have you seen in your procedures and/or patient population? 

We have seen an increase in outpatient procedures and vascular procedures.

What is unique or innovative about your cath lab and staff?

Given the rural nature of north Mississippi, we believe it is unique to support a high number of increasingly complex cardiovascular procedures at such a high level of competency. We face all issues with a multi-disciplinary team to discuss challenges and find solutions.

What’s special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your “cath lab culture”?

NMMC-Tupelo is the largest non-metropolitan hospital in America. NMMC is a 2006 recipient of the National Malcolm Baldrige award and is affiliated with North Mississippi Health Services, a 2012 Malcolm Baldrige award recipient. Our reputation, not just regionally, but also nationally, drives a strong commitment to quality care. 

A question from the American College of Cardiology’s National Cardiovascular Data Registry:  

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We have used our outcomes report to changes processes and order sets to improve outcomes. We have tried to hardwire things like medications and cardiology rehab orders.

Carla Durham, RN, can be contacted at cdurham@nmhs.net.

Spotlight: Bon Secours St. Francis Health System

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Author(s): 

James E. Conner, RT(R), Greenville, South Carolina

Tell us about your institution and cath lab. 

Our department contains three cardiac cath labs (diagnostic and interventional), one electrophysiology (EP) lab, a non-invasive area, a dedicated cardiac prep and recovery unit (CPRU), a hybrid OR for structural heart procedures (transcatheter aortic valve replacement [TAVR] and WATCHMAN left atrial appendage procedures [Boston Scientific]), cardiac surgery, and a coronary care unit (CCU). In addition to diagnostic and interventional heart catheterizations, we perform peripheral diagnostic and interventional procedures, pacemaker, and generator implant procedures. We began performing TAVRs in July 2016, and recently performed our 50th TAVR case. We will perform our first WATCHMAN procedures this July. 

We built a specific hybrid room, OR 12, for TAVR. Interventional radiology also uses that room. In addition, two of the three cath rooms in our department are brand new Siemens labs. Bon Secours St. Francis Health System has invested a lot of capital into our cardiac services in the last 12-15 months, which we are very excited about.

Our facility is located in downtown Greenville. Recently Greenville, South Carolina, was listed as the fourth largest growing city in the United States. Our city has a tremendous amount to offer individuals and families moving into the area. 

As a healthcare provider, we have responded to that growth in our market accordingly, and our cardiac department has specifically benefited from that growth. Our catheterization volume is growing at 4-6% annually. The use of lean processes has made our service line very safe and efficient, allowing us to offer our services to more patients in the region.

Can you tell us about the physicians and staff at your lab?

Upstate Cardiology is a phenomenal group of cardiologists and physicians with 18 interventionalists working in our lab. We have approximately 26 staff members assigned and dedicated to the cath lab, with 9 prep and recovery RNs and 5 EP staff. Among the cath staff, we have 5 dedicated call teams. In addition to RNs, we have registered radiologic technologists (RT[R]s), and 3 registered cardiovascular invasive specialist (RCIS) credentialed staff currently in our department. The average length of stay in our department is more than 7 years, with some staff members that have more than 11 years. If you look at the industry standard, that far exceeds the stay expectancy at most departments. We “hire to retire”. Our retention is a result of the culture at St. Francis, a culture that starts with our CEO and works its way throughout the organization. It is a culture upheld by our director, DeAna Simpson, BSN. Our department offers a very family-oriented environment and we are a close-knit group. Our physicians value and respect what we do as staff to support their services as cardiologists. 

Can you tell us more about the management team at your lab?

Ron Spencer is the administration director, and is in charge of both invasive and non-invasive cardiology. Our invasive cardiology director is DeAna Simpson, BSN, and the cath lab charge nurse is Barney Wasson, RN. 

Do you have cross-training? Who scrubs, who circulates and who monitors? 

Cross-training is one of the core expectations of the department. We are blessed to have a talented group of professionals that have a desire to learn all aspects of our department and within our organization.

What is the percentage of radial procedures at your lab?

Our cardiology group performs more than 85% of cases via the radial approach. The radial program is one of the jewels in the Bon Secours St. Francis Health System crown. The entire lab is oriented towards radial access and our same-day discharge program. We are one of the few labs in upstate South Carolina that offer a dedicated radial lounge approach with an emphasis on same-day discharge. As a matter of fact, the majority of our ST-elevation myocardial infarction (STEMI) procedures are done via the radial approach, whether left or right radial.

When I arrived at the Bon Secours St. Francis cath lab in May 2010, less than 10% of cases were done radially. Dr. Mathew Nessmith is an Upstate Cardiology interventionalist who was formally trained in Georgia as a radialist. Dr. Nessmith and some of his fellow interventionalists wanted us to do more radial cases. At Dr. Nessmith’s request, and with his and Barney Wasson’s support, I worked to create a radial board called the Cardio-TRAP (Cardiovascular Trans-Radial Access Platform) (Trans-Radial Solutions LLC), which helped usher in our ability to provide a same-day discharge program and a radial lounge atmosphere. We actively market that atmosphere to our patients. Patients are far more educated now than they were 7-8 years ago, and come in asking for radial access for their procedures.

Can you share more of the story behind the creation of the Cardio-TRAP?

Prior to the board’s creation, about 10% of our cases were being done radially and neither the physicians nor the staff felt comfortable in being able to set the patient up properly for the procedure. We lacked a proper access platform. Knowing my entrepreneurial side, Dr. Nessmith asked me if I could develop a radial access platform. I spent four to five weeks looking at some potential constructs and configurations, and I developed the first radial board in the fall of 2010. That device went through four generational changes to what we currently use in the lab today, the Cardio-TRAP. Dr. Nessmith requested that we find a more efficient, safe way to perform radial access, and part of the culture at St. Francis that I enjoy, and I think our staff also enjoys, is that the hospital encourages us to think outside the box. When we see a problem or opportunity, they want us to bring ideas and concepts forward. It brings value to the organization and value to our patients. 

So the administration was aware of the work you were doing?

Yes. The hospital promotes this kind of innovation and it is a theme that runs all the way through our organization, whether ideas come from somebody in the cath lab, the OR, or in transportation. Our organization promotes innovative thinking.

What has been the impact of the Cardio-TRAP?

It affects the entire department. We use the platform on every radial case. Because we have a very competent radial access platform, we are able to offer same-day discharge. It allows us to turn the rooms over much quicker. Prior to the board, if the patient had bypass surgery, we would have to convert the room to a left room setup, which was time consuming. Use of the board has made the department more efficient and increased our ability to treat more patients. It provides us with the ability to perform more radial cases. The Cardio-TRAP has become an important part of our same-day discharge program. Same-day discharge is important to the patient. To come in and have a diagnostic heart cath, or even have a stent placed, and meet certain qualifications to be able to go home the same day is of enormous value to our patients. It is also of enormous competitive value when competitors in the same market don’t offer those benefits. 

What were some of the challenges you faced in designing the Cardio-TRAP?

The platform had to be utilized in the cath lab, so it had to be radiolucent, and it had to be a material that would not absorb body fluids and create a contamination or sterility issues. That was the easy part. The hard part was in developing the overall design as to how staff would articulate the device. In terms of mechanics, what I think is easy someone else may not. There is a wide, diverse group of individuals that work with the platform. When any new device comes into the cath lab, companies recognize the value in staff being very comfortable with their device in order for that product to be successful. So we were fortunate in being able to get the staff involvement in the evolution of the Cardio-TRAP. It was important to get their buy in, as they are the ones using and working with the device. It has to be comfortable, and it has to be quick and efficient to install and take away after the procedure. It took about 18 months of changes and modifications until we got to where the final product is now. 

However, the Cardio-TRAP is a small part of all that is required to put together a same-day discharge program and a radial lounge environment, although it definitely assisted in that process. It is always a goal of St. Francis to provide value to our patient and have a competitive edge in the market. We saw the trend of same-day discharge and a radial lounge atmosphere in other facilities, especially in the northeast, where you may have six or seven operators in a four-square-mile radius. We felt our staff could work toward same-day discharge and a radial lounge environment, and the organization was committed in working toward that goal. The radial platform was simply another device, similar to the wires and catheters we use, that came together to allow us to provide that capability to our patients.

It sounds like individuals can take on a high level of responsibility at your facility.

Exactly. We believe in “to whom much is given, much is expected.” We as staff feel empowered, that this is our department and not just the Bon Secours St. Francis cath lab. Our leadership gives us that freedom and flexibility. You never know where a solution is coming from and you never know where that next great idea is coming from. Bon Secours St. Francis Health System recognizes the value and importance of their employees, and that is what makes it a special place. It is not uncommon to walk through the hospital and see the CEO in the hall, and have him come in and talk with us. All senior level administrators hold that attitude of empowering their employees. 

Are there licensure laws in your state for fluoroscopy?

Yes. From the South Carolina Department of Health and Environmental Control (DHEC): 4.2.2.1 No person other than a licensed practitioner or a radiologic technologist possessing a current, valid certificate from the South Carolina Radiation Quality Standards Association (SCRQSA) shall use equipment emitting ionizing radiation on humans for diagnostic purposes.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

Scrub staff is composed of RT(R)s, RCISs, and RNs. All can pan and drive the table. As per DHEC, only SCRQSA-certified RT(R) and RCIS staff can step on the floor pedal.

How does your cath lab handle radiation protection for the physicians and staff?

We have dedicated RT(R)s that monitor our radiation numbers and scan our lead on a regular basis, and handle the quality control checks for our lead and other radiation control devices. When there is a need in the department, director DeAna Simpson will alert our team, and very often, somebody from within the department will rise to the occasion and take ownership. Fluoro limits are reported in the Mac-Lab, and RT(R) Scott Pinion spends his personal time transferring that data into a separate excel spreadsheet so we can provide daily, weekly, and monthly reports to our health physicist department that show staff and cardiologists’ individual dose limits and radiation numbers. It is something that Scott takes ownership of, because he is interested in doing so. This is just one example of the sense of empowerment and ownership that the hospital creates and that brings value to the department. The Cardio-TRAP offers a radiation protection component as part of the device that also reduces radiation exposure to physicians and cath lab staff.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? How is the patient notified and what follow-up do they receive?

We use Quantros, a web-based software to report safety events and unsafe conditions. Patients receiving more than one hour of floor time are logged into our exposure log. A Quantros report is filled out, and a Mac-Lab report is attached with all dosing and angle information. This information is given to the physicist for further calculations to determine if the dose exceeds the threshold (3 Gy) for radiation-induced skin injury. Follow-up, depending on the outcome, is done by the cardiologist per physicist recommendations. 

What are some of the new equipment, devices and products recently introduced at your lab? 

In addition to our two new Siemens labs, Bon Secours St. Francis Health System recently incorporated the ACIST dedicated contrast injection system.

Are your physicians dictating their cath procedure reports or do they use a structured reporting tool?

Our cath lab physicians dictate their reports and our EP physicians use structured reporting in ConnectCare (Kodak Alaris)
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How does your lab communicate information to staff and physicians to stay organized and on top of change?

Our department conducts a morning huddle prior to the start of procedures and has a regular department meeting the second Wednesday of each month. Every staff member is active with organizational email. 

Who pulls sheaths post procedure?

All staff is regularly trained and tested on sheath and groin management.  We require new staff to watch six sheath pulls, then, under supervision, the staff member will pull an additional six sheaths. The high radial count of our procedures creates an environment in which we deal with very few sheath pulls.

Where are patients prepped and recovered (post sheath removal)? 

Our outpatients’ journey starts with our prep department. After the procedure, our recovery department provides patient care. Most of our caseload is performed via the radial approach and we use a TR Band (Terumo) for our radial patients. The few cases that require a femoral approach are closed with Mynx (Cardinal Health), Angio-Seal (Terumo) or Perclose (Abbott Vascular). Our cardiologists make every attempt to access via radial; in the event of femoral access, an emphasis on a closure device is common practice. In the event of a sheath pulls, we have many experienced staff available to pull the sheath.

How do you promote staff education?

Our department educator is Leah Hall. Education is ongoing throughout the year. In-services are provided formally every second Wednesday of the month with CEUs often provided. New products or changes to existing produces are discussed during morning safety huddle in-services. All new procedures require in-servicing and quarterly education is done for high-risk equipment. Training, credentialing, and personal growth are emphasized and are an important part of the culture at Bon Secours St. Francis.

How is inventory managed at your cath lab? 

We utilize a web-based inventory system that is managed by a dedicated staff member.

How are your five call teams organized and scheduled?

We use an internet-based software application to notify the call team. Once the notice goes out, staff has 30 minutes to be in the room, ready to perform the procedure. Patients may already be in our ED when we arrive, but often they will come straight from the EMS truck directly into the cath lab. We will send cath lab staff over to meet the EMS or ED staff with the patient. Our door-to-balloon times average 33 minutes. 
Our call teams consist of three staff members, with one RN required. In South Carolina, only RNs are allowed to push drugs. All of our RNs are BSNs. There is a program hospital-wide within the hospital to get all non-BSNs credentialed to BSN over a certain timeline. RT(R)s and/or RCISs are the second and third members of the team. During a call weekend, staff can be called upon to do a pacemaker, a heart cath, or an emergent peripheral case. 

Barney Wasson is the cath lab charge nurse, and he manages our schedules in eight-week block intervals. We know our days off eight weeks out. We work four days during the week with one day off. The particular day may vary. In an eight-week period, we may get two Fridays off, for example. We are on call one night a week, late stay one night a week, and are assigned weekend call every fifth weekend. It is variable as a result of paid time off, department fluctuations, vacations, sicknesses, and so on. One thing that really makes our department special is how we all support each other if someone needs to change a call weekend, or has a family crisis or a sick child. If I need somebody to pull my call for the night, it is not uncommon to have two or three people volunteer. We are that close as a family. Many times we will pull call two or three nights in a row, if that is what it takes for a fellow co-worker. When we are on call, we are there until the last case is done. On the weekends, call starts on Friday evening from the last case until Monday morning at 7am. Typically, staff will be off after being on call, but this obviously changes as the staff and work volume dictates. We typically park in the emergency department (ED) parking lot, which is right outside the ED. Parking is never an issue.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

Our department has a call team and a late team, Monday through Friday. Typically, the late team will be on site if we have more than one cardiologist actively performing cases.  The late team is required to remain on site up to or after 7pm to ensure that the call team can handle the current caseload. There have been times when more than one team has been required on the weekend or after hours, and many times staff volunteers will respond to handle the additional STEMI event.

What quality control measures are practiced in your cath lab?

Many of the quality controls in the lab are completed by staff. The rooms are checked every day, lead aprons are scanned regularly, and we do systematic and regular scanning for out-of-date products. We employ a system of date checking for cardiac supplies. RNs regularly validate ACT quality control functions. Mac-Lab reports are checked by two separate individuals prior to going to medical records. We take great pride in our quality control process.

How does your cath lab compete for patients? 

Bon Secours St. Francis Health System competes against a much larger facility within the Greenville market space. We provide a strong emphasis on patient care in an atmosphere that places a high priority on the patient as a person of value. This hometown, personal touch fosters an atmosphere in which our patients can feel our compassion and interest in their care and recovery.  

How are new employees oriented and trained at your facility? 

The orientation process is competency based and goal oriented. New employees are assigned a preceptor, but all staff participates in the orientation process. Performance is evaluated and discussed with the new employee, preceptor, educator, and director. Individual competencies and comfort are evaluated weekly. Each new employee begins in the position for which they were hired and then is cross-trained into other responsibilities as their skills advance. Depending on initial skills, the new hire spends twelve weeks orienting to the hired position. New hires take “buddy call” as a fourth person until they are competent to be a third with another technologist or nurse as appropriate.

How is staff competency evaluated? 

Staff competency is evaluated and verified on a yearly basis. We currently use the Donna Wright method. The goal of competency assessment is to evaluate individual performance, group performance, meet standards set by regulatory agencies, address problematic or high-risk procedures and equipment, and encourage professional development.

Does your lab have a clinical ladder? 

The hospital has a nursing clinical ladder. The cath lab does not have a clinical ladder for technologists at this time. The institution is currently revising the preceptor program to include all staff and align itself with the nursing model, rewarding knowledge, accomplishments, and education.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we participate in the CathPCI registries, ACTION, ICD, TVT, and upcoming will be the LAAO registry. We have three full-time data extractors who also navigate patients through the health care system. Registry data entry is mostly done manually. Limited data is populated in from GE Mac-Lab reports. 

Has your lab recently undergone a national accrediting agency inspection? 

Our hospital participates in the Joint Commission inspection. We are due again as early as December. 

What are some of the trends you have seen in your patient population?

We are seeing and treating a younger patient population. Greater than 50% of the patients treated last year were less than 64 years old. We are seeing a trend in growth in our structural heart program, from TAVR to WATCHMAN procedures. We have seen an increase in our peripheral volume. Three of our physicians perform peripheral procedures. On average, we are probably doing anywhere from eight to twelve peripheral procedures/month in the cath lab. We are spending more capital to increase our abilities in our same-day discharge program and radial lounge. 

You will be working under construction for a while.

Yes, and we have already put in two new rooms. When you are doing nearly 400 cases/month, patient volume doesn’t slow down. We brought in a portable lab to allow us to treat our patients during construction. 

Not enough can be said about Ron Spencer and DeAna Simpson’s leadership through that process. As you can imagine, it was an enormous undertaking to change a room out while keeping procedures flowing, but it impacted our department as minimally as possible. We still did the same volume during this period. The first room was done in ten weeks and the second room was completed in a little under nine weeks. There was a great deal of work on the front end to make sure all the details were in place. It is wonderful now to have two new Siemens rooms, which offer us new capabilities and technology. The display screens are amazing. We went from an 18 x 20 monitor to 80 x 60. The doctors are really excited about it and the technology that Siemens brings to the table is just phenomenal.

Can you share more about the culture behind the success of Bon Secours St. Francis Health System?

The story of Bon Secours St. Francis is the culture our organization creates. What we hope will come out of this story is that it is okay to be innovative. Maybe others will see what we have achieved and allow for that atmosphere of innovation to take place in their facilities. When an employee has the ability to think out of the box, and bring forward answers and solutions to problems, it adds enormous value to the department, and it presents enormous value to the patients and organization. The success of our department is the people — the staff and the management. It is the Bon Secours St. Francis family. 

To create our same-day discharge program, our director DeAna Simpson gathered eight volunteers from our team and said: Okay, it’s your department. How do you want the same-day discharge program to look? The eight of us looked at related protocols, policies, and procedures, and what other departments in other hospitals were doing. We visited four different facilities in the southeast. Our same-day discharge program was not something that the management created and expected the staff to adhere to. Like many aspects of how our department is governed, our same-day discharge program and radial lounge were put into place by our staff. Our hospital encourages us, as staff, to take ownership of the overall daily functions of the department. You see that in the length of stay of our staff. You see it in what we are able to accomplish. And you see it not just in our department, but throughout the hospital. If we see a problem, we feel very much empowered to not just deal with the problem, but to bring a solution to bear to eliminate that problem. Our staff are known for their resilience and willingness to rise to a challenge and promote the department, not one’s self. We have experienced much change and growth in the last three years. We are proud of our department and coworkers for meeting these goals and challenges while maintaining our family environment. 

The author can be contacted via Ashley Taylor at ashley_taylor@bshsi.org.

Spotlight: Yuma Regional Medical Center

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Author(s): 

Soo Jung VanWinkle, BS, RT(R)(CI)(VI), RCIS, Cristina Espinoza, RT(R)(CI), Claudia Gallardo, BSRS, RT(R)(CV), RCIS, Greg Titensor, Cath Lab Director, MSN, RN, Yuma, Arizona

Tell us about your facility and cath lab. 

Yuma Regional Medical Center is a 406-bed acute care hospital. Our cath lab has 3 angiography suites, a hybrid suite and an electrophysiology (EP) suite. Our prep/recovery area has recently expanded from 14 to 29 beds to accommodate our growing program.  We currently have 7 full-time registered nurses (RNs) and 10 full-time radiologic technologists (RT[R]s) in the procedure area. According to the American Registry of Radiologic Technologists (ARRT) census, Arizona has 40 RT(R)s credentialed in Cardiac Interventional Radiography (CI), and 8 of them are in our lab. In addition, one of our techs has her Cardiovascular Interventional Radiography (CV) credential, one has her Vascular Interventional Radiography (VI) credential, and both are registered cardiovascular invasive specialists (RCISs), with much of our staff scheduled to obtain further credentials. We take great pride in this accomplishment. In the prep/recovery area, we have 11 full-time RNs. Our staff experience ranges from 1 to 18 years in the cath lab setting. We average 7.5 years amongst all of us. 

What procedures are performed in your cath lab?  

We routinely perform right and left heart catheterizations, percutaneous coronary interventions (PCIs), diagnostic and interventional peripheral procedures to include carotid stenting, CRM device implantation (pacemaker, implantable cardioverter defibrillators [ICDs], BiV, Sub Q ICD, loop recorder), inferior vena cava (IVC) filter placement, pericardiocentesis, temporary pacemaker insertion, biopsies, valvuloplasy, device implantation (pacemaker, implantable cardioverter defibrillators [ICDs], BiV, Sub Q ICD, loop recorder), inferior vena cava (IVC) filter placement, pericardiocentesis, temporary pacemaker insertion, biopsies, valvuloplasy, endovascular aneurysm repair (EVAR), thoracic endovascular aneurysm repair (TEVAR), transcatheter aortic valve replacement (TAVR), EP studies and ablations, cardioversions, transesophageal echocardiogram (TEE), and tilt tables. For coronary interventions, we utilize intravascular ultrasound (IVUS) OptiCross (Boston Scientific), Rotablator (Boston Scientific), AngioJet (Boston Scientific), and the pressure wires Aeris (St. Jude Medical) and Comet (Boston Scientific). For cardiac support, we use Arrow balloon pumps (Teleflex), and the Abiomed Impella. For our peripheral vascular cases, we use the Peripheral Rotablator (Boston Scientific), the Pathway/Jetstream (Boston Scientific), IVUS, Outback (Cordis), Frontrunner (Cordis), and orbital atherectomy (CSI). We perform approximately 150 of procedures/week. 

If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 
 
We have been performing TAVRs for over two years and have implanted over 150 valves. We implant both the Sapien 3 (Edwards Lifesciences) and the Evolut R/ Pro (Medtronic) valves. The experience has been great. We have a dedicated TAVR team that is present for every case so that we are consistent in our care. We felt that this was an important step in starting and maintaining a successful structural heart program. 
 
Do any of your physicians regularly gain access via the radial artery?
 
Yes, several of our physicians do gain access via the radial artery. About 60-70% of our cases are done via this approach.
 
Who manages your cath lab? 
 
Our cath lab manager is Greg Titensor, MSN, RN. Greg has been an RN for over 17 years. He worked in the ICU for 2 years, and then came to the cath lab, where he worked as an RN for 7 years. Greg has served as director for over 8 years.  
 
Do you have cross-training?  
 
Yes, we do cross-train in scrubbing, circulating, and monitoring. RNs administer medications and RT(R)s control the x-ray equipment. 
 
Are there licensure laws in your state for fluoroscopy? 
 
Per Arizona state laws, a radiologic technologist must be in the room and in control of the x-ray equipment, along with the physician, at all times. 
 
How does your cath lab handle radiation protection for the physicians and staff?
 
We provide lead aprons, lead glasses and lead-lined scrub caps for all employees. We also provide monthly monitoring of radiation dosage with film badges that are reviewed by the hospital radiation safety officer. We utilize all lead shields available and practice “As low as reasonably achievable” (ALARA), as well as basic radiation safety precautions.
 
What are some of the new equipment, devices and products recently introduced at your lab? 
 
The newest equipment introduced to the lab includes the Sapien 3 and the Evolut Pro valves. In the peripheral world, we have recently acquired the Tigris and balloon-mounted stents (Gore). All of our EP equipment is new in our EP suite, to include the Carto 3 mapping system (Biosense Webster), Stockert RF generator, and Soundstar ICE catheter (Biosense Webster), as well as Biosense Webster diagnostic and ablation catheters. 
 
How does your lab communicate information to staff and physicians to stay organized and on top of change?
 
We have monthly staff meetings to keep everyone up to date on our growing heart program. We also utilize email and our resource coordinators to help keep us informed of pertinent information between meetings. During the summer, which is our slow season, we schedule in-services with vendors to keep up with any changes to our products. 
 
How is coding and coding education handled in your lab? 
 
Our department has a designated coder who handles our coding in the lab. She has over 10 years of experience in cardiovascular coding and has her CVC and CIRCC credentials. In addition, she currently in pursuit of her CCC and CCVTC credentials. 
 
Who pulls the sheaths post procedure, both post intervention and diagnostic? 
 
All RT(R)s and RNs are trained to pull sheaths. They must perform 10 supervised successful sheath pulls to be deemed competent. Sheaths are pulled in the lab or in the recovery area depending on anticoagulation and scheduling. 
 
Where are patients prepped and recovered (post sheath removal)? 
 
Patients are prepped and recovered in our prep/recovery area. We currently use Angio-Seal (Terumo), and Perclose (Abbott) for femoral closures. For radial approaches, we use the TR Band (Terumo) and Vasc Band (Vascular Solutions). We hold manual pressure in the lab or recovery whenever closure devices are contraindicated. All staff is trained for sheath pulls and groin management. 
 
How is inventory managed at your cath lab? 
 
Our lab has an inventory specialist who keeps track of supply levels and orders equipment as needed. 
 
Has your cath lab recently expanded in size and patient volume?
 
Within the past four years, we have built a hybrid OR suite and an EP suite. We have also expanded our prep/recovery area from 13 to 29 beds. The expansion is due to the growing need for these technologies in Yuma.
 
Is your lab involved in clinical research?
 
Yes. We are currently involved (enrolling/follow-up) in the ILLUMENATE Pivotal trial, FSS OPEN, CROSS X4, ISCHEMIA, IMPERIAL, TOBA II, and TOBA II BTK trials.
 
Can you share your lab’s average door-to-balloon (D2B) times and ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  
 
Our average door-to-balloon time is 63 minutes. We have worked closely with our emergency department (ED) to facilitate the movement of the patient to the lab, which has resulted in lower D2B times than previous years. Recently, we have integrated new equipment into the local EMS that sends in-field EKGs to the hospital and the cardiologist on call. This will allow for earlier activation of the on-call STEMI team. We are registered with the American College of Cardiology’s D2B Alliance.
 
Who transports the STEMI patient to the cath lab during regular and off hours?
 
During regular and off hours, the ED RN transports the STEMI patient to the lab.
 
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
 
If a STEMI comes in and the call team is busy, we will do our best to quickly and safely complete the current procedure and get the current patient off of the table. 
 
What measures has your cath lab implemented in order to cut or contain costs?
 
We utilize LEAN processing, which has led to a significant drop in costs to the lab. We also adjust par levels based on utilization of supplies. Our inventory staff is very efficient at keeping any of our close-to-expiration equipment marked so that we can use them first before they do expire. Staying up to date with vendor contracts is also another way we have reduced costs to the lab.
 
What quality control/quality assurance measures are practiced in your cath lab? 
 
We use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) reports to help improve on any areas that are below national standards. Our physicians also have peer meetings to discuss any complications that they may have. After our patients are discharged, some are randomly selected to participate in a follow-up survey about their experience and care with us. We use that data to help drive our quality of care for our patients.  
 
Are you recording fluoroscopy times/dosages? 
 
We are recording both fluoroscopy times and dosages in our hemodynamics charting system (Xper, Philips) as well as in the imaging system. Our cath reports that are charted on Xper then get archived into the patient’s medical record.
 
Who documents medication administration during the case?
 
The charter/monitor documents medication administration during the case. 
 
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
 
Our physicians are dictating their cath reports into the EMR via the Dragon software (Nuance Communications).
 
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
 
Yes, we have recently started using the ACC-NCDR for our heart cath/PCI data.
 
How many of your diagnostic caths are normal?
 
About 23% of our diagnostic caths are normal.
 
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
 
Yuma Regional Medical Center is the only hospital in the area; therefore, we have no need to compete for patients. With our growing facility and procedure list, we are also able to keep our patients in town instead of referring them to out-of-town facilities. 
 
How are new employees oriented and trained at your facility? 
 
 All new employees go through new employee orientation through the hospital. After that is completed, they are paired with a seasoned cath lab employee to precept them throughout their training period, which ends when they begin STEMI call on their own. 
 
What continuing education opportunities are provided to staff members?
 
Throughout the year, we are afforded many opportunities for continuing education. We are sent to conferences, off-campus training on equipment, and vendors come in for in-services. Most of the opportunities come in the summer when we are slower.
 
Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 
 
We do not require staff members to take the RCIS exam, but we highly encourage it. There is a raise upon passing the exam, following the hospital protocol and job descriptions. 
 
How do you handle vendor visits to your lab? 
 
Vendors are allowed into the lab when we schedule an in-service for new equipment, or per physician request. In order for them to be in the facility, they must check in at the front desk and obtain a vendor pass. 
 
How is staff competency evaluated?
 
Our staff undergoes yearly competency evaluation. Competency evaluation may be required from the lab as well as the hospital. Most are due in the summer, as this is our slow season. We take that opportunity to fulfill competencies as well as get updated on equipment and procedures through in-services and other educational opportunities.  
 
How does your lab handle call time for staff members? 
 
Our call team consists of three members. One RN, one RT(R) and the third can be of either credential. We generally have one call night a week, and one weekend a month. 
 
Within what time period are call team members expected to arrive to the lab after being paged? 
 
The call team must be in the lab within 20 minutes of being called in. 
 
Do you have flextime or multiple shifts? 
 
We do have flextime shifts. Our morning cases start in 30-minute increments and the teams are flex scheduled accordingly. We work four 10-hour shifts.
 
Has your lab recently undergone a national accrediting agency inspection? 
 
In the fall of 2016, our facility underwent inspection by Healthcare Facilities Accreditation Program (HFAP) and did very well. 
 
Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)?  
 
The OR and ED are both on the first floors of the hospital and we are on the ground floor (one floor below).
 
What trends have you seen in your procedures and/or patient population? 
 
Due to the gentle winter climate in the desert southwest, we see a large influx of winter residents every year. This in turn increases our patient load.
 
What is unique or innovative about your cath lab and staff?
 
We are a “young lab” with the median age being 37.5 years old. Most of our cath lab staff is bilingual in Spanish and English, because of our close proximity to the Mexico border. We are able to provide excellent care to our patients by comforting them without a language barrier present. 
 
Is there a problem or challenge your lab has faced? 
 
In the past 5 years, the growth of our city has increased our volume in procedures, and need for new technologies. To accommodate that growing need, we have expanded our lab from 3 to 5 rooms, and our prep/recovery from 13 to 29 beds. We have also started our EVAR, TAVR, and EP programs in an effort to keep all of our patients’ care here in Yuma. They have appreciated not having to travel out of town to have procedures done. 
 
What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?
 
Yuma, Arizona borders California and Mexico, so we have very large Hispanic population. In the lab, being bilingual is an asset to provide excellent patient care, since a lot of our patients are Spanish-speaking only. Our winters are beautifully mild as well, so our population booms with “snowbirds” from the northern states and Canada. This also causes an influx of patients to the lab. 
 
A question from the American College of Cardiology’s National Cardiovascular Data Registry:  

How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility?

Our facility receives the reports and we find the areas where we are below the national average. We then create an initiative to improve in those areas.

 
The authors can be contacted via Soo Jung VanWinkle at skimvanwinkle@yumaregional.com.
 

Spotlight: Miami Cardiac & Vascular Institute at Baptist Health South Florida

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Author(s): 

Barry T. Katzen, MD, Founder and Chief Medical Executive, Miami Cardiac & Vascular Institute; Dan Krauthamer, MD, Medical Director of Interventional Cardiology, Miami Cardiac & Vascular Institute – South Miami Hospital; Marcus St. John, MD, Medical Director of Cardiac Catheterization Lab, Miami Cardiac & Vascular Institute – Baptist Hospital; Jane Kiah, MSN, RN, Director of Invasive Services, Miami Cardiac & Vascular Institute – Baptist Hospital;  Brenda John, MSN, MS-HSA, RN, Director of Nursing, Interventional Services & Heart Rhythm Center, Miami Cardiac & Vascular Institute – South Miami Hospital, Miami, Florida

Tell us about your cath lab. Is it part of a cardiovascular service line? 

Dr. Katzen: One of the things that is unique about Miami Cardiac & Vascular Institute is that we are responsible for the entire service line of cardiac and vascular care at Baptist Health South Florida. Starting 30 years ago, the Institute became the model for integrating all technology, equipment and medical disciplines that relate to cardiac and vascular disease, both organizationally and architecturally. This also helps us to achieve economic benefits by eliminating redundancy in disposable inventory and imaging equipment. Miami Cardiac & Vascular Institute is the largest and most comprehensive cardiovascular facility in the South Florida region. The Institute is responsible for all cardiology, vascular and electrophysiology services. Our team of multilingual, multidisciplinary specialists are pioneers in the development of minimally invasive techniques used to treat occlusive arterial disease throughout the body, aneurysms wherever they occur, and structural heart disease. 

The benefits to patient care are that all physicians involved in invasive therapy are working side-by-side. Literally. We don’t have barriers. If there is a problem with a patient, we have incredible human professional resources here to help solve the problem. Our physicians benefit from the satisfaction of working in a super sophisticated environment with all the technology in one place.
 
Two hospitals house our cath lab facilities, where physicians are credentialed to schedule and perform procedures.
 
What is the size of your cath lab facility and number of staff members? 
 
Dr. Katzen: The Miami Cardiac & Vascular Institute cath labs are located at Baptist Hospital of Miami and South Miami Hospital. Both settings have what we call interventional suites, where cath labs are interspersed among interventional radiology and endovascular labs to foster the model of collaboration and integration of the specialties. These types of environments don’t exist in general operating rooms at Baptist Health.
 
At Baptist Hospital, there are 15 interventional suites for procedures and diagnostics:
  • 3 cardiac cath labs including one lab with robotics for coronary intervention;
  • 2 electrophysiology (EP) labs;
  • 2 interventional neurovascular labs;
  • 4 interventional radiology and vascular labs;
  • 2 advanced endovascular suites for structural heart and endovascular procedure suites that are fully hybrid, which allows us to bring physicians from different disciplines together to perform both catheter-based procedures and surgical approaches to provide the best solution for the patient;
  • 2 cardiovascular imaging environments, one for MR and one CT scanner dedicated to image-guided interventional work.
At the Baptist Hospital cath lab, our staff consists of: 
  • 9 RNs and 9 cardiovascular technologists (CVTs) or radiologic technologists (RTs) in the cath labs;
  • 2 RNs and 5 CVTs in the EP labs.
The Baptist Hospital endovascular and interventional radiology lab staff consists of 11 RNs and 15 RTs.
 
The Baptist Hospital CT/MR staff consists of 4 RTs (CT)(MR).
 
The Baptist Hospital Cardiovascular Care Unit (CVCU) staff is 32 RNs, 4 ARNPs, and 15 ancillary and support staff.
 
Several members of the team have more than 15 years of service. Others range from one to 15 years, including those who left and came back to rejoin the team.
 
The South Miami Hospital facility has 6 interventional suites:
  • 3 cardiac cath labs: two rooms for cardiac diagnostic and interventional procedures; one for EP procedures;
  • 3 rooms are for vascular, endovascular and interventional radiology cath labs.
The South Miami Hospital staff consists of 8 RNs and eight CVTs for the 3 cardiac cath labs.
 
Half of our South Miami Hospital staff members have been “in residence” for an average of 20 years, while the other half for an average of six years.
 
What procedures are performed?  
 
Dr. Katzen: Comprehensive coronary intervention, structural heart, and vascular and non-vascular procedures are performed at both Baptist Hospital of Miami and South Miami Hospital. The average weekly volume for cath and EP labs at Baptist Hospital is 70 to 80 cases.  The average weekly volume for the South Miami Hospital labs is 30 to 40 cases. At this time, transcatheter aortic valve replacement (TAVR) procedures are done at the Baptist Hospital facility.  
 
Can you share more about your experience with TAVR?
 
Dr. Katzen: We were early adopters of TAVR and the first in South Florida to perform TAVR outside of a research trial. Because our fundamental infrastructure involves multidisciplinary collaboration, we were sitting with the heart teams and valve teams in place when TAVR was approved. Our TAVR program has grown consistently, and now we are doing about 100 a year. Two additional interventional cardiologists recently were approved to become part of the TAVR team as a result of volume growth. We have a process in place to increase the number of TAVR-credentialed interventional cardiologists, based on both credentialing criteria and an onboarding process to make sure they become part of the team as opposed to independent operators. 
 
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
 
Dr. Katzen: Yes, we recently completed a $120 million expansion and renovation that nearly doubled the Institute’s size in anticipation of an increase in volume for both cardiac and vascular patients and procedures. 
 
Is your lab involved in clinical research?
 
Dr. Katzen: We participate in clinical research across the board that includes vascular, neuro, and cardiac trials. Our clinical research and outcomes infrastructure includes a dedicated research director who is a clinical cardiologist by training. I provide physician leadership and oversight, and a significant number of incredible research coordinators and regulatory people round out the coordination. 
 
Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  
 
Dr. Katzen: Many hospital personnel and departments are involved in expediting ST-elevation myocardial infarction (STEMI) care, from emergency services, the transfer center and registration to the operators and the security department. Physicians and staff are activated and arrive within 30 minutes. Some team members go to the cath lab to set up and some go to the emergency department (ED) to meet the patient. The collaborative team effort is the key to our great D2B times, currently averaging 57 and 58 minutes. 
 
If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?
 
Dr. Katzen: Yes, the interventional radiologists and vascular surgeons go a good amount of pedal artery access. 
 
Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance?
 
Dr. Katzen: Both Baptist Hospital and South Miami Hospital are accredited by the Accreditation for Cardiovascular Excellence (ACP) organization for our Cath/PCI programs. 
 
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
 
Dr. Katzen: We compete for patients on several grounds. One is by establishing clinical and patient service excellence, and raising awareness within the general public and physician peers. 
 
Second, we compete by having innovative solutions for patients who previously were told that surgery is the only solution, which relates specifically to our complex chronic total occlusion (CTO) program. On the vascular side, by participating in innovation, we attract patients who, again, had been denied less invasive therapy for aneurysms and other areas that are part of our standards of excellence. Third, our demographic practice base is increasing. Miami Cardiac & Vascular Institute delivers cardiovascular care at 7 hospitals and 25 outpatient centers within our rapidly expanding Baptist Health system, which has become a regional enterprise extending from Palm Beach to the Florida Keys, a large geographic area. 
 
In addition, we support other aligned organizations and are actively involved in the American Heart Association in the community, leading the annual Heart Walk and Heart Ball in the region.
 
What’s special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your “cath lab culture”?
 
Dr. Katzen: South Florida is a melting pot, and often you will have patients who feel more comfortable being cared for by people who are from their own culture. This includes different Hispanic cultures from Central and South America. Other cultures originate from the Caribbean and Europe. Many patients come from Brazil and Asia. So, you can see we live in a unique environment. The majority of patients in South Florida have a Hispanic background, which means that Spanish language is important. We meld all of this into how we take care of patients. At Miami Cardiac & Vascular Institute, we are a multi-cultural organization that appreciates and incorporates diversity into how we deliver care. We need to make patients, regardless of their culture and language, feel comfortable in their time of illness. It doesn’t mean that everybody who works here has to be bilingual, but we have that as a resource as an integral part of our teamwork. It layers with our everyday employee culture of caring for one another, making eye contact when speaking to others, smiling, making sure you are concerned for the other person, and if you see a problem, you own it. 
 
Do you require your clinical staff members to take the registry exam for the registered cardiovascular invasive specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?
 
Dr. Katzen: Our CVTs and RTs must be RCIS- or registered cardiac electrophysiology specialist (RCES)-eligible upon hire, and achieve certification within one year of employment. The exam is reimbursed upon passing. Those certified are eligible to advance to a higher level in the career advancement program, which offers a pay increase for advancing to the senior (advanced) and specialist (expert) levels.
 
Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP) or regional organizations?
 
Dr. Katzen: Various team members belong to the ACVP. Staff participates as educators as well as registrants in a number of meetings such as the International Symposium on Endovascular Therapy (ISET), Society for Cardiovascular Angiography and Interventions (SCAI), Cardiovascular Research Technologies (CRT), and the American College of Cardiology (ACC).
 
How do you use the ACC’s National Cardiovascular Data Registry (NCDR) outcome reports to drive quality improvement initiatives at your facility?
 
Dr. Katzen: We are part of several of the registries, and we use them to fill out our metrics of performance and dashboards. Established within our management company model here at Miami Cardiac & Vascular Institute, which is 50 percent owned by physicians and 50 percent owned by Baptist Health, are financial incentives associated with quality metrics required from a number of registries, including the NCDR. Therefore, a monetary incentive is built in to achieving high quality standards. 
 
Do you regularly gain access via the radial artery?
 
Dr. Krauthamer: More than 50 percent of the cardiac catheterization cases are performed through the radial artery at Miami Cardiac & Vascular Institute. We were one of the first centers to use the procedure when it was introduced in the United States. I will use the transradial approach for certain indications, such as when a patient is morbidly obese or has peripheral vascular disease. But I prefer to use transfemoral catheterization for about 80 percent of my cases. Almost all of them end with a closure device, and the patient will be ambulatory within two or three hours. Perhaps it is a comfort level after more than 30 years of experience with femoral access. Both access points have their advantages and risks, depending on the condition of the patient.
 
Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 
 
Dr. Krauthamer: Usually the doctor performing the procedure in our catheterization labs operates all the x-ray equipment. There are some doctors who have a CVT perform the panning, but the great majority of us do it ourselves. Some doctors compensate by using lower magnification so they will not have to do any panning. The advanced x-ray equipment in our labs allows us to process the images later and to magnify if needed. For me, I do everything myself, and I magnify. In the vascular and IR labs, this is done by the physician.
 
How is coding and coding education handled in your lab? 
 
Dr. Krauthamer: In our lab, we have a registered nurse whose only job is to perform the coding. She captures the list of devices and supplies used during a procedure by reviewing a physician’s dictation and the records kept by the CVT.  
 
What measures has your cath lab implemented in order to cut or contain costs?
 
Dr. Krauthamer: There are many ways to cut costs. Our committees for cost containment and interventional cardiology meet frequently to review pricing. Final decisions are made by the Interventional Cardiology Committee. We meet with cath lab administrators to go over supplies that could be substituted to contain costs. We work closely with the purchasing department, which negotiates supply contracts on our behalf. In one instance, we limited the number of stents we use to two brands in order to get a better price. On another occasion, we found a company that sold its J-wire for $10 less than we had been paying. For us, a wire is a wire. We gave it a trial period for a month, it worked fine, and we switched. Yet there are some items we can’t compromise on, and when we can’t compromise, we try to save by buying volume. 
 
Who documents medication administration during the case?
 
Dr. Krauthamer: A cath lab nurse is in the room for every procedure, and that’s the person who documents the medications in the computer. 
 
What trends have you seen in your procedures and/or patient population? 
 
Dr. Krauthamer: The overall population in Miami-Dade County has doubled in the past 20 years, yet the number of coronary intervention procedures we do has remained steady. The reason? People are healthier now. They take better care of themselves. They exercise. They take medications that are more effective in controlling cholesterol. Therefore, the way we grow is by doing more complex cases that previously were treated with open-heart surgery or were too high risk for coronary intervention altogether. Technological advancements have given us the ability to perform more percutaneously complex procedures. For example, we are able to treat patients with multiple coronary artery obstructions with drug-eluting stents that minimize renstenosis. We can treat patients with diffuse and calcific coronary artery disease and chronic total occlusions, because we have better wires and devices. We do more high-risk coronary interventions in place of bypass surgery. Whereas 20 years ago coronary procedures dominated, you are seeing electrophysiology and structural heart procedures being done today.
 
Does your cath lab perform primary angioplasty without surgical backup on site? 
 
Dr. St. John: No. We are a tertiary facility with a very well established and robust cardiac surgery program where surgical backup is always available. 
 
Do you have cross-training? Who scrubs, who circulates and who monitors? 
 
Dr. St. John: We have cross-training, but with certain limits. The typical team for a catheterization case is two RNs, and two either CVRTs or RTs. The nurses administer medications and act as circulators to help set up the table and be an extra set of hands. The technologists monitor and document in real-time everything we do. They also circulate and scrub the case with the interventional cardiologist.
 
How does your cath lab handle radiation protection for the physicians and staff?
 
Dr. St. John: Radiation safety has undergone a resurgence of interest because of increased risk to interventional radiologists and cardiologists for certain types of malignancies. It is something we all think about and take quite seriously. Our physicians and staff remind one another to be protected during each procedure. Everyone has custom-fit lead aprons and lead glasses. We have also started using lightweight lead aprons that I think will help reduce orthopedic problems. Imaging systems in our cath labs have radiation reduction software that cuts exposure by up to 70 percent. In addition, a variety of aerial and rolling shields screen the staff and physicians. We use the Philips DoseAware System that alerts the person wearing it to know when they have entered a high radiation zone. It is effective in training the staff and physicians to find the best place to stand. We are evolving in our use of robotic percutaneous coronary intervention, which lets the operator be completely shielded. At least once a year, we receive radiation safety education updates. We currently have a Miami Cardiac & Vascular system-wide radiation reduction committee, which is looking at standardizing reporting from various machines and deploying uniform radiation protection protocols, as well as optimizing performance of the technology. 
 
What are some of the new equipment, devices and products recently introduced at your lab? 
 
Dr. St. John: We have most of the up-to-date tools that any modern cath lab should have. We have recently updated the fractional flow reserve (FFR) that incorporates instantaneous wave-free ratio (iFR) technology. We have optical coherence tomography (OCT) intravascular ultrasound devices. We have several image applications, such as Philips’ StentBoost that lets you see the stents more clearly when you deploy them and a program that allows you to overlay CT images with coronary angiograms in real time to help with both the planning and performance of complex interventions. There also are behind-the-scenes software applications that improve the image quality and, in some cases, can help guide decision making and appropriateness. In addition to the latest imaging technology, we constantly evaluate new products that can improve patient care. We are developing a protocol for a product called DyeVert (Osprey Medical) that reduces contrast utilization in patients who are at particularly high risk for contrast-induced nephropathy. 
 
Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull a sheath?
 
Dr. St. John: In the interventional cardiology labs, the technologists and the nurses are both trained to pull the sheaths both post intervention and diagnostic. The nurses and technologists learn the skill in a competency-based program that requires them to do 10 sheath pulls under direct supervision before they do the procedure on their own. We have recurrent inservices on sheath pulling and groin management to make sure everyone is doing it properly. In the vascular and IR suites, generally physician fellows pull the lines with completion by the technologists.
 
Where are patients prepped and recovered (post sheath removal)? 
 
Dr. St. John: The Cardiovascular Care Unit (CVCU) is our dedicated recovery area. We do a lot of radial approaches that usually require just a short period of manual compression, or more commonly a HemoBand that is applied to the wrist. For a femoral approach, many of us use closure devices. Cases that require manual compression are done by a properly trained nurse or technologist. We encourage a minimum hold time of 20 minutes. If the procedure is diagnostic without anticoagulation, the sheaths are pulled immediately in the procedure room. Otherwise, the sheath pulling and compression are done in the CVCU.
 
Who transports the STEMI patient to the cath lab during regular and off hours?
 
Dr. St. John: During regular and off hours, a catheterization team goes down to the ED to meet the patient. The team that wheels the stretcher back upstairs includes the interventional cardiologist, the room nurse, and generally speaking, a nurse or technologist from the emergency department. The circulators are in the room getting the table ready. When we have STEMI alerts, the security department also is notified. Their role is to make sure all doors and hallways are clear, and the elevator is waiting for us. Those little things help ease the transfer of the patient from the ED to the cath lab and shave off a few minutes from our door-to-balloon time.
 
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
 
Dr. St. John: During regular hours, there are enough teams and enough rooms that even if the call team is tied up doing a case, another team and another doctor will jump in and manage the patient. Sometimes during off hours, it can happen that two cases arrive in close proximity. Depending on the timing, the patient might need to be stabilized in the ED while the team finishes the case on the table. We would prefer the new patient receives primary angioplasty rather than go with thrombolytics, because even a complex case underway will usually be done within an hour or two — a window of time in which primary angioplasty usually still offers more benefits than thrombolysis. It is a stressful scenario that fortunately does not happen very often. 
 
What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? How is the patient notified and what follow-up do they receive?
 
Dr. St. John: As the complexity of the cases increase, and therefore the length of the procedures, we are acutely aware of radiation exposure to patients. The threshold for when we monitor patients for radiation damage post procedure is 5 gray (Gy). Thankfully, it is not a protocol that we have to use very often. Should we reach that threshold, however, I would have a conversation with the patient, or a family member, right after the case. It is important for patients to be made aware should a lot of radiation occur for their procedure and for them to take proper care should they see changes to their skin. We also inform the follow-up cardiologist if they aren’t part of the team. If a patient did develop a radiation injury or burn, it would be important for them to be seen by a dermatologist who understands what they are looking at and not treat it as something else. Frankly, I can’t remember the last time we had such a case. 
 
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
 
Dr. St. John: Our new structured reporting tool is in development in conjunction with the Philips XPER and Xcelera systems. At this point, we follow a dictation template to ensure we are including all the required elements.
 
Where is your cath lab located in relation to the operating room (OR) and ED? 
 
Dr. St. John: Our cath labs at the Baptist Hospital campus are located on the third floor and the general OR is on the first floor. The ED is in a different building altogether on the first floor. The cath labs have 2 advanced endovascular suites — or hybrid rooms — which can serve as operating rooms, especially when we do very advanced endovascular procedures or structural heart procedures. So technically, we do have two operating rooms in the cath lab. 
 
What is unique or innovative about your cath lab and staff?
 
Dr. St. John: The unique thing about Miami Cardiac & Vascular Institute, which was founded in 1987, is that from the very beginning, it was committed to less invasive therapy and focused on collaborative, multidisciplinary care in an environment of transparency. I think one of the things you would see when you walk into our cath lab is that transparency is not just a metaphor; it is a way of life. The whole place is made of glass so that from the center of the cath lab, which is shaped like a horseshoe, you can see what is going on in each of the surrounding rooms. Indeed, there are seats outside the Advanced Endovascular Suite to allow viewing of live cases. This transparency has many benefits. It fosters a great deal of collaboration, but also encourages you to practice at your best. When complications happen, and they will, specialists from all across the spectrum are there to jump in to help. Say there is a vascular access complication — the interventional radiologist can lend support. Conversely, if there are cardiac issues or arrhythmias that develop in an IVR procedure, there will be a cardiologist who can jump in and offer advice. Vascular surgeons, cardiac surgeons, interventional radiologists, and cardiologists are all working in tandem for the best care of the patient. That is what sets us apart and is one of our main advantages. 
 
What is your percentage of normal diagnostic caths? 
 
Kiah and John: We are at 22 percent, which is consistent with the national rate of normal diagnostic catheterizations.  
 
Who manages your cath lab? 
 
Kiah: The leadership and management structure includes medical directors of Interventional Cardiology, Structural Heart Therapy, Electrophysiology, Interventional Radiology, and Neuroradiology.  There is a team of Registered Nurse and Technologist Supervisors, an Operations Manager, and Director of Invasive Services. The executive team includes Founder and Chief Medical Executive of the Institute, Barry T. Katzen, MD, Chief Operating Officer, Carol Melvin, and Vice Presidents Harold Girado at Baptist Hospital and Carol Biggs at South Miami Hospital.   
 
How does your lab communicate information to staff and physicians to stay organized and on top of change?
 
Kiah and John: One of the core philosophies of the Institute is multidisciplinary, multispecialty collaboration. Staff and physicians participate together in meetings and work groups for collaborative improvement efforts and shared decision making. We also communicate at meetings, group huddles, and through emails.  
 
How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?
 
Kiah and John: Inventory is managed by a team of inventory technicians and a manager, who order and receive stock into a general location. They manage items to maintain the integrity of the packaging, review utilization for increases or decreases, and rotate stock to avoid expiration. Lab staff stocks the rooms to set par levels, and scans supplies when used for billing and reordering.  
 
What quality control measures are practiced in your cath lab?
 
Kiah and John: We maintain Association of periOperative Registered Nurses (AORN) standards, including mandatory surgical attire. Time out procedures, equipment checks, and room readiness are audited for effectiveness and compliance. Radiation and fluoro time are monitored, and physicians are alerted at increasing levels. “Not-to-exceed” safe contrast doses are calculated for each patient based on individual risk factors. These are just some of the many measures we take for high quality and safety.   
 
How are you recording fluoroscopy times/dosages? 
 
Kiah and John: Fluoro times and radiation dosages are documented in the patient’s medical record and on the procedure record, and images stored in the PACS image archiving system. 
 
How are you populating registry data records? 
 
Kiah and John: We participate in the ACC-NCDR’s Cath/PCI and PVI NCDR registries. We enter some of the data into the Philips XPER electronic medical record, which integrates with a third-party vendor for NCDR data collection. A dedicated research and outcome team of abstractors collect and enter remaining elements, review the integrity and completeness, and submit the data for reporting and benchmarking. 
 
How are new employees oriented and trained at your facility? 
 
Kiah and John: We have a Versant Nursing Residency program for new and transitioning nurses.  Lab training is facilitated by clinical educators and staff preceptors guided by a comprehensive, competency-based orientation checklist that has to be completed successfully. A new model will be adding a physician preceptor to the mix.  
 
What continuing education opportunities are provided to staff members? 
 
Kiah and John: Staff is encouraged to attend the monthly Cath Lab Conference, Grand Round lectures, and special guest lectures. Physicians conduct monthly “Know-on-the-Go” sessions for focused topic training. Clinical educators, peers and vendors provide education and training sessions on pertinent topics or devices and equipment. Education conferences sponsored by Baptist Health South Florida are available at no charge to all employees and learning modules are available on the hospital intranet, Baptist Health University. Staff is also encouraged to attend the annual International Symposium for Endovascular Therapy (ISET), a world-renowned educational conference for medical and allied health, which is directed by Miami Cardiac & Vascular Institute medical staff and sponsored by the Institute. The team also participates in live case presentations to international conferences throughout the year.  
 
How is staff competency evaluated? 
 
Kiah and John: Evaluations are based on competency checklists, and clinical educators and preceptors teach and observe return demonstrations. Physicians also evaluate competency and provide feedback.  
 
Does your lab have a clinical ladder? 
 
Kiah and John: Yes, we have a Clinical Advancement Program for both nurses and technologists that is based on Pat Benner and the Dreyfus model of skill acquisition and competency. There are four levels: novice, proficient, advanced, and expert.  
 
How does your lab handle call time for staff members? 
 
Kiah and John: Two RNs and two technologists are on call for off hours. The teams are permitted up to seven hours from the end of a call case after a night or weekend on call to return to a scheduled shift.  
 
Within what time period are call team members expected to arrive to the lab after being paged? 
 
Kiah and John: The team must arrive in 30 minutes or less for a call case.
 
Do you have flextime or multiple shifts? How do you handle slow periods?  
 
Kiah and John: Staff works four 10-hour shifts a week. Flextime is managed on an individual basis. Team members are reassigned to other specialties such as EP, IR, the prep and recovery area, or assigned to special projects when the need exists. At times, they are relieved from duty when volume is low. 
 
The authors can be contacted via the Marketing & Communications Department: Email Georgi M. Pipkin at georgip@baptisthealth.net or Sahyli C. Hartney at sahylih@baptisthealth.net.

Spotlight: Mercy Health Springfield

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Author(s): 

Daniel S. Price BS, RRT, EMTP, Manager of Cardiology, Electrophysiology, Interventional Radiology, Springfield, Ohio

Tell us about your cath lab. Is it part of a cardiovascular service line?

We are part of the cardiovascular service line that consists of the cath lab, electrophysiology (EP), cardiovascular operating room (CVOR), cardiovascular intensive care unit (CVICU), heart center (stress testing, electrocardiogram [EKG], echo, cardiac computed tomography [CT], tilt table testing, enhanced external counter pulsation [EECP]), and cardiopulmonary wellness. 

What is the size of your cath lab facility? 

We have four labs, two of which are hybrid labs, and one of which is a dedicated EP lab. We have a 19-bed holding area for pre and post procedures. Staffing consists of 19 registered nurses (RNs), two radiologic technologists, one respiratory therapist, one nursing assistant, one cardiovascular analyst, and one secretary. We have nine cardiologists, of which a total of six perform interventions and one is an electrophysiologist. We have three cardiovascular surgeons. Depending on the case, our staffing mix is 2 to 3 RNs with one radiologic technologist or respiratory therapist. Experience ranges from 1 to 20 years. 

What procedures are performed in your cath lab?  

  • Diagnostic heart catheterizations: 170/month
  • Percutaneous coronary interventions (PCI): 70/month
  • Peripheral vascular angiograms: 35/month
  • Peripheral vascular interventions: 25/month
  • ST-elevation myocardial infarction (STEMIs): 6-10/month
  • Impella (Abiomed), intra-aortic balloon pump (IABP), atrial fibrillation and SVT ablations: 25/month
  • Temporary pacemaker, implants (pacemaker, implantable cardioverter defibrillator [ICD], bi-v pacemaker, bi-v ICD): 15-20/month 
  • Peripheral abdominal aortic aneurysm (AAA) stenting, carotid angiograms: 4-8/month 

We are not doing transcatheter aortic valve replacement (TAVR), but plan to start in the near future. AAA repair is performed in the hybrid lab. We also do fistulagrams and fistulagram declotting.

What is your percentage of normal diagnostic caths?

Our rate of normal diagnostic caths is approximately 28 percent.

Do any of your physicians regularly gain access via the radial artery?

They all utilize femoral and radial access, but we have three physicians that primarily do radial procedures.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Yes.

Who manages your cath lab?

Lori Blanton RN, MSN, is the Cardiovascular Service Line Director and Dan Price BS, RRT, EMTP, is Manager of Cardiology.

Do you have cross-training? Who scrubs, who circulates and who monitors?

Everyone is cross-trained to do all three roles, although only RNs pass meds. Everyone is also cross-trained in the pre and post holding area. 

Which personnel can operate the x-ray equipment (position the image intensifier [II], pan the table, change angles, step on the fluoro pedal) in your cath lab? 

All can position the II, pan the table, and change angles. Only radiologic technologists and physicians can step on the fluoro pedal.

How does your cath lab handle radiation protection for the physicians and staff?

All staff is fitted for their lead. There are lead barriers on the table, an adjustable one from the ceiling that protects from the II, and we also have a mobile barrier. 

How does your lab communicate information to staff and physicians to stay organized and on top of change? 

We have a dedicated phone that the assigned charge nurse carries. All calls go through her. We have a large scheduling whiteboard in the center core.

How is coding and coding education handled in your lab?

We have a dedicated coder in the cath lab and we also use IRCoder.com.

Who pulls the sheaths post procedure, both post intervention and diagnostic?

All cath lab staff pulls sheaths post intervention (if held in post-op holding) and diagnostic and post intervention patients are admitted to the cardiac step-down unit, where their sheaths are removed by the unit nurse. Everyone that pulls sheaths goes through the cath lab for training.

Where are patients prepped and recovered (post sheath removal)? 

Outpatients are prepped and recovered in our pre/post holding area. If they are PCI patients, they will go to the cardiac step-down unit. Inpatients are prepped in their room and recovered in their room. We still do a lot of manual holds, but will use Angio-Seal (Terumo). We use the TR Band (Terumo) for radial procedures.

How is inventory managed at your cath lab? 

The cardiology manager and supply clerk manage inventory, plus we have Pyxis (BD) in the labs. The cardiology manager and cardiovascular service line director handle the purchasing. Routine daily supplies are ordered by supply clerk. We also have a value analysis committee where we review possible new equipment and supplies. 

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

We are expanding our peripheral vascular program and planning on adding TAVR, so patient volume will increase.  

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  

Our D2B time averages 57-59 minutes. We use Lifenet so medics can transmit an EKG and ask for a cardiac alert. At that time, STEMI is paged out. When the cath lab team is on site, patients coming from the field bypass the emergency department and go directly to the cath lab. 

Who transports the STEMI patient to the cath lab during regular and off hours?

Squad personnel and ED staff.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

A second page goes out and a member of the call team or house nursing supervisor will call other cath lab staff to come in. Staff is very good at helping each other out — the patient always comes first. 

What measures has your cath lab implemented in order to cut or contain costs?

Our core value analysis team meets on a monthly basis to look at new requests, consignment opportunities, corporate contracts, and phase out unutilized inventory and equipment. 

What quality control measures are practiced in your cath lab?

We review National Cardiovascular Data Registry (NCDR) data with physicians, administration, and staff. Staff participates in monthly performance improvement projects and quality control projects. 

How do you determine contrast dose delivered to the patient during an angiographic procedure?

This is physician driven. 

Are you tracking the incidence of contrast-induced acute kidney injury in patients? 

We track this through our data collection. Post procedure BUN and creatinine are performed on all PCI patients. 

How are you recording fluoroscopy times/dosages?

We record in McKesson, which transfers to the patient chart as well. 

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

Full disclosure is given to the patient. The radiation safety officer is notified. Follow-up is per physician order.

Who documents medication administration during the case?

The person monitoring the case does all documentation, which is then reviewed by the administering RN at the end of the case.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

We are using McKesson structured reporting. 

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we use the PCI, ICD, and PVI registries, and also report to ODH (Ohio Department of Health).

How are you populating the registry data records? 

We utilize Cedaron for assistance with data input. We have a CV analyst inputting the data. 

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

We have no alliance with other facilities at this time. We do advertise on billboards, in the newspaper, on social media, and occasionally on TV, and via word of mouth.

How are new employees oriented and trained at your lab?

We usually start out training in circulating, then scrubbing a straight heart cath with a mentor scrubbed in, then PCI with a mentor, and lastly, they learn the monitoring. This takes place over a minimum of 6 months. After they become proficient in the heart, we will train in peripheral cases.   

What continuing education opportunities are provided to staff members?

We have assigned computer iLearns, and will review 1-2 items per month such as orbital atherectomy, nstantaneous wave-free ratio (iFR)/fractional flow reserve (FFR), Impella, etc. Vendors give training as well and staff can also attend seminars.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP [now including the Society of Cardiovascular Professionals, SICP]) or regional organizations?

Yes, we are involved with the ACVP.

How do you handle vendor visits to your lab? 

Vendors sign in with VendorMate. They must have a badge to get into the cath lab or anywhere, for that matter. Representatives must sign in at the front desk in the cath lab holding area. For their first visit to our lab, they must sign a contract that explains the rules. Vendors are only allowed at a desk in the center core where if physicians can speak to them if they wish. Vendors are only allowed in the monitor room or cath lab if a physician asks for their assistance or they are there for particular case. If they are in the lab on physician request, they are not permitted to sell or push for new supplies or equipment.

How is staff competency evaluated?

Evaluations are based on competency checklists, written tests, and direct supervision for teach and observe return demonstrations. 

Does your lab have a clinical ladder? 

Not at this time, but we are looking into it.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

We encourage them to take it but it is not required at this time. There is no raise or bonus for passing.

Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?

We have a good layout and are just down the hall from the OR. The ICU and CVICU are on the same floor and just as close. The only drawback is majority of our patients go the cardiac step-down unit and that’s on another floor.

How does your lab handle call time for staff members? 

Call is every fourth weeknight and every fourth weekend. Call starts at 4:30pm and ends at 6:00am Monday through Friday. Weekend call starts at 6:00am Saturday and ends 6:00am Monday. If staff is called in during the night and staffing permits, we send them home early. We have four staff on call, and must always have at least two RNs (usually it ends up as three RNs and one technologist).

Within what time period are call team members expected to arrive to the lab after being paged? 

Staff must arrive within 30 minutes, with no exceptions. It is the same for physicians.

Do you have flextime or multiple shifts? How do you handle slow periods?

Cath pre/post has two shifts. Start times are 5am and 7am. The two that come in at 7am stay until the last patient is discharged. All staff is rotated through. During slow periods, we offer the option to take time off with or without pay. Some staff has chosen to cross train to other areas within cardiology as well. 

Has your lab recently undergone a national accrediting agency inspection? 

We were surveyed this year by ODH (Ohio Department of Health) and the Joint Commission. We had no recommendations.

What trends have you seen in your procedures and/or patient population?

We are seeing much younger STEMI patients and younger patients in general. We have moved to radial cases more often. 

What is unique or innovative about your cath lab and staff?

Staff is very involved in helping to make the lab a high-quality environment for patients and their families. They coordinate multiple team-building activities such as potlucks for birthdays and holidays. The team is very dependable and always willing to come in on days off or for second call team if needed. They work with the physicians to continue to learn and grow in their roles. Staff also plays an active role in education of other nurses throughout the facility on cath lab procedures and sheath pulls. 

Is there a problem or challenge your lab has faced? 

We have trouble hiring. These days, it seems no one wants to take call. We continue try to recruit. Also, we do not hire to just fill the open position, we hire for the right person with the right attitude: the right fit.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?

We are the only community hospital within a 25-mile radius and are located directly between two larger cities, Dayton and Columbus. Most of the primary market share, approximately 80%, is maintained for cardiology at this facility. Our cath lab is very busy. We have state-of-the-art labs and equipment, as well as nationally known cardiologists and CV surgeons working in our lab. 

Daniel S. Price can be contacted at dsprice@mercy.com

Spotlight: Florida Medical Center

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Author(s): 

Cinthia Rodrigues, RN, Director Cath Lab
Fort Lauderdale, Florida

Tell us about your cath lab. Is it part of a cardiovascular service line?

The cardiovascular cath lab at Florida Medical Center is one part of a comprehensive endovascular service line inclusive of cardiac intervention, peripheral intervention, neuro intervention, and electrophysiology (EP) procedures. We work collaboratively with cardio-thoracic surgery, neurosurgery, and vascular surgery to provide a comprehensive endovascular-cardiac program to satisfy our patient needs.

What is the size of your cath lab facility and number of staff members? 

Our team is comprised of 7 registered cardiovascular invasive specialists (RCISs), 1 cardiovascular technologist (CVT), and 5 registered nurses (RNs). We also have 1 assistant nurse manager and a nursing director. The two most senior of the staff have been in the cath lab for 16 years and the newest member is the nursing director, who started in August 2017. We have a total of 5 procedure rooms, including 2 cath lab suites, one bi-plane where we perform our neuro interventions, one EP suite, and one hybrid operating room (OR). Three of our rooms have multi-endovascular capability to perform interventional and cardiac procedures. 

The hybrid OR has the capability of integration of imaging with multiple modalities (i.e., computed tomography [CT], magnetic resonance imaging [MRI]), and we can perform 3-D imaging, 3-D roadmapping, Xper CT (Philips), and multi-modality matching. 

What procedures are performed in your cath lab?

Because we are a comprehensive endovascular and non-vascular lab, our procedures include the following: left and right diagnostic catheterizations, cardiac intervention with percutaneous transluminal coronary angioplasty (PTCA), balloon pump, left ventricular (LV) support, fractional flow reserve (FFR), intravascular ultrasound (IVUS), and patent formen ovale (PFO) closure. We are a comprehensive stroke center and perform neuro interventions with diagnostic cerebral angiograms, and intervention, including thrombus retrieval devices and cerebral embolization. We perform a variety of peripheral arterial and venous system cases. The team also performs various elective interventional radiologic procedures, both vascular and non-vascular. Our EP program performs diagnostic EP studies and ablations, including cryo atrial fibrillation procedures, supraventricular tachycardia (SVT) and ventricular tachycardia (VT) ablations. We collaborate with the cardiac surgeons to perform epicardial VT ablations, and convergent a-fib surgery. We also use this suite to do our implant procedures inclusive of pacemakers, implantable cardioverter defibrillators (ICDs) and bi-ventricular devices, and loop recorders. We perform approximately 35 procedures per week. 

If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 

We are looking to grow our hybrid program to include a TAVR program. 

Does your cath lab perform primary angioplasty without surgical backup on site?

Florida Medical Center has a cardiothoracic surgical program on site for emergency back-up. We have a busy ST-elevation myocardial infarction (STEMI) program that offers primary percutaneous coronary intervention (PCI) 24 hours per day with surgical backup on site during the day and available on call during off hours.

What is your percentage of normal diagnostic caths?

Currently, about 50% of our diagnostic catheterizations are negative.  

Do any of your physicians regularly gain access via the radial artery?

Yes, some operators do use the transradial approach and 90% of our total cases are transradial.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access?

Many of our physicians will use pedal artery access when appropriate.

Who manages your cath lab?

We currently have an assistant nurse manager, Dawne Garcia, RN, who works in the rooms and takes call. Our Nursing Director, Cinthia Rodrigues, RN, recently joined our lab in August, and our Lead Tech, Gilberto Benitiz, RCIS, has been in the lab for over 16 years.

Do you have cross-training? Who scrubs, who circulates and who monitors?

We do cross train the technologists to do multiple job functions and cross-train for all modalities. This allows us greater flexibility with our staffing. 

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

Our physicians position the tube, change angles and step on the fluoro pedal.

How does your cath lab handle radiation protection for the physicians and staff?  

Our cath lab director is in communication with the hospital radiology safety committee regarding radiation protection and dose readings. The dosimeters are changed out on a monthly basis, and high readings are flagged and reported. We evaluate the quality of all lead protection equipment on a regular basis and appropriate eye protection with leaded glasses is strongly encouraged. We rotate the staff involved in complex procedures like chronic total occlusions (CTOs) and peripherals. We also monitor radiation exposure during each procedure, keeping track of increased exposure cases.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We have excellent open lines of communication with our physicians. Routine information is usually passed along via email and staff meetings, and we have monthly Cardiovascular Care Committee meetings. Neuro intervention has weekly meetings to go over cases and programs.  We also have regional director meetings that take place quarterly. The director’s office is strategically placed within the workings of the lab, so staff and administration are involved in the day-to-day of the department.  

How is coding and coding education handled in your lab?

The coding and charges are performed by an RCIS in the cath lab who works very closely with our finance and coding departments. She does a great job of educating our nurses and technologists regarding accurate coding. 

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

The sheaths are pulled by our cardiovascular technologists, RCISs, and RNs. They must have appropriate competencies and at least 5 lines pulled without complications. 

Where are patients are prepped and recovered (post sheath removal)?

We have a 5-bay holding area where patients are routinely prepped for their procedures and can be recovered or held if needed. Patients who receive monitored anesthesia care (MAC) or general anesthesia recover in the post-anesthesia care unit (PACU). Sheath pulls, when performed in the lab, are done by both technologists and nursing, but most of our patients are either sealed, or if done transradially, have a TR Band (Terumo) placed.

Has your cath lab recently expanded?

We have not increased in size, but recently upgraded an existing lab.  

Is your lab involved in clinical research?

At the current time, we do not participate in any research studies in the lab, but we are looking to develop the research infrastructure at our facility.

Can you share some of the ways employees at your facility have worked together to keep door-to-balloon (D2B) times under the mandated 90 minutes?  

According to our National Cardiovascular Data Registry (NCDR) statistics, D2B times in 2016 averaged 53 minutes and to date, our D2B time in 2017 averages 64 minutes. We have a protocol for each department involved with STEMIs, and our goal is to have the patient on the table and ready for vascular access within 40 minutes of hospital arrival. 

Who transports the STEMI patient to the cath lab during regular and off hours?

STEMI patients are always transported by nursing and helped by technologists if necessary.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the emergency department (ED)?

We have a second call team on backup for patient readiness so the physician can follow if the case is activated after hours.

What measures has your cath lab implemented in order to cut or contain costs?

Cost savings are implemented through regional purchasing initiatives and discounting contracted by our parent company, and tracking of compliance is tracked at our regional quarterly meetings.

What quality control measures are practiced in your cath lab?

We work very closely with the quality department and we have some performance improvement (PI) mandatory markers like pain assessment, hand washing, and moderate sedation. We also have some specific markers for the department like D2B time, PCI appropriate use criteria (AUC), cardiac cath AUC, and noninvasive tests prior to cardiac cath.

How do you determine contrast dose delivered to the patient during an angiographic procedure?

Contrast dose is based on contrast directly delivered to the patients, based on 100 cc bottles used, less any known waste and unused volume.

Are you tracking the incidence of contrast-induced acute kidney injury (AKI) in patients? 

Yes, we are tracking AKI using National Cardiovascular Data Registry (NCDR) benchmarks and creating action plans based on this metric.

How are you recording fluoroscopy times/dosages?

Fluoroscopy dosing is directly recorded by our Philips and McKesson PACS system.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?

We notify the performing physician when dosing over the nominal amount of radiation is used. The physicist is also notified. This is also communicated to the nurse caring for the patient on the floor, so that patient education can take place.

Who documents medication administration during the case?

The monitoring nurse documents medications administered during the case.

Are your physicians dictating their cath procedure reports or are they using a structured reporting tool?

Some physicians still use the dictation line, while others do their reports on the McKesson Physician reporting system, and our interventional radiologists use PowerScribe.

Do you use the American College of Cardiology (ACC) NCDR or any other outside data collection registry? 

Yes, we report to the NCDR database and we meet quarterly to review this information. For neuro intervention, we report to Get With the Guidelines®-Stroke.

How are you populating the registry data records?

We have two chest pain nurses that do our data gathering and reporting for ACC-NCDR and a neuro nurse navigator who reports to Get With the Guidelines®-Stroke.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

We keep a close relationship with the clinical cardiologists in the area, who have always supported our cath lab. We also have a busy marketing department that is always working on different campaigns to highlight our cath lab services in order to attract both patients and new referring physicians. Our strongest asset is our experienced and dedicated staff, and high standards for quality. We are currently working closely with other regional Tenet hospitals to develop and expand our cardiovascular service line.   

How are new employees oriented and trained at your facility?  

All new employees at Florida Medical Center must attend a general orientation for 2 weeks and a department orientation. They work with a preceptor for the first 3-4 weeks, according to their previous professional experience.

What continuing education opportunities are provided to staff members? 

Staff is encouraged to attend monthly education meetings, quarterly hospital educational fairs, and we schedule monthly in-service sessions related to the new products, procedures, and equipment introduced to the cath lab.

How do you handle vendor visits to your lab?  

Vendors are allowed in our cath lab with a previous appointment and are only allowed in the treatment rooms when specifically requested by the physician. A vendor badge (Reptrax) and proper attire is mandatory prior to entering the cath lab and procedure areas.

How is staff competency evaluated?  

General staff competencies are evaluated annually by the nursing leadership and with the introduction of every new system or product.

Do you require your clinical staff to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

We are proud that 6 of our technologists are RCIS-credentialed and our CVT is sitting for the exam in November.  The staff does receive a raise upon passing the exam.

Within what time period are call team members expected to arrive to the lab after being paged?

Call teams are expected to respond to the call of activation within 30 minutes. They are responsible for reporting that they are on their way within 5 minutes of the activation and if they do not, a secondary communication is sent out.

Do you have flextime or multiple shifts? How do you handle slow periods?

We do have flextime. But with multiple disciplines being serviced in our lab, we very rarely flex our staff.

Has your lab recently undergone a national accrediting agency inspection? 

We have Joint Commission inspections every 18 months. Doing things the right way creates good habits, so you are always prepared for an inspection.

Where is your cath lab located in relation to the operating room (OR) and ED?

We are on the same floor and next door to the OR, and down the hall from the ED and our CT machine for our stroke alerts. Our hybrid room opens between the cath lab and the OR.

What trends have you seen in your procedures and/or patient population?

We are seeing much sicker patients with an extensive disease process. Procedures and technology are continually changing in allowing us to deliver the best care for our patients.

What is unique about your cath lab and staff?

We are unique because we perform cardiovascular, endovascular, interventional, electrophysiology, and neuro interventional procedures in one lab, with a cross-trained staffing model.

What’s special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your “cath lab culture”?

The Fort Lauderdale area sees a large number of tourists per year both from within the United States and internationally. Fourteen million visitors a year visit the area for our beaches and our rich cultural diversity; this also brings a large number of patients to our hospital that we treat and facilitate their safe return home. 

Cinthia Rodrigues, RN, can be contacted via Patricia Vila at patricia.vila@tenethealth.com.


Spotlight: Boulder Community Health

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Author(s): 

Julie Jenkins, BSN, RN, Cath Lab/EP Lab/CVC/Echo Manager, Boulder, Colorado

 

Tell us about your cath lab. Is it part of a cardiovascular service line?  

Yes, we are part of a cardiovascular service line that includes Interventional Cardiology, Electrophysiology, Echo, Structural Heart, Open Heart Surgery, Heart Failure, Cardiac Rehab, and a cardiology physician practice that includes all of the physicians for the above programs. 

What is the size of your cath lab facility and number of staff members?  

We are a community-owned regional health system with a 2 cath labs (one of which is a hybrid room), and an electrophysiology (EP) lab. Cath lab staff credentials include a mix of critical care registered nurses (CCRN), RNs, registered cardiovascular invasive specialists (RCIS), and radiologic technologists (RT[R]) registered with the American Registry of Radiologic Technologists (ARRT). EP staff credentials are a mix of RN, RCIS, RT(R), and certified electrophysiology specialists (CEPS). Our staffing longevity is well balanced. We have some team members who have worked in our lab for 15 years, others who have only been here a year, and the rest cover the span between.

What procedures are performed in your cath lab? 

Left and right heart catheterizations, endocardial biopsies, fractional flow reserve (FFR), intravascular ultrasound (IVUS), transcatheter aortic valve replacement (TAVR), balloon valvuloplasties, intra-aortic balloon pump (IABP), Impella (Abiomed), peripheral diagnostics and interventions, permanent pacemaker implant (PPM), implantable cardiovascular defibrillator (ICD), biventricular ICD, EP studies and ablations, including cryogenic ablation for atrial fibrillation (afib), radiofrequency ablation for afib, supraventricular tachycardia (SVT), AV nodal reentrant tachycardia (AVNRT), atrial flutter, and ventricular tachycardia (VT). We will have the WATCHMAN left atrial appendage closure device (Boston Scientific) and MitraClip (Abbott) at the beginning of 2018. 

Can you share more about your center’s structural heart program? 

The structural heart program started in October 2017 with TAVRs and balloon aortic valvuloplasties. We were fortunate to bring in a highly experienced structural heart medical director, Dr. Sirinivas Iyengar, to start the program, so the program’s implementation has been relatively smooth and our first case was well ahead of target. The cardiovascular surgeon is part of our physician group and was actually one of the key drivers behind the creation of a structural heart program at Boulder Community Health. Having a unified front between the surgeon and the structural heart director has really made for a smooth implementation. The cath lab already had a well-established and supportive relationship with anesthesia, the OR staff, and the cardiovascular surgeon, so we were able to avoid the OR/cath lab rivalry that some facilities face.

What is your percentage of normal diagnostic caths?   

As part of our quality control measures, the team reviews the indications and documentation prior to the procedure. Involving the staff in the appropriate use criteria (AUC) review helps ensure compliance, as well as gives the whole team a better understanding of the patient. This focus keeps our number of diagnostic caths low.

Do any of your physicians regularly gain access via the radial artery?  

Yes. One of our physicians has been primarily radial for over 15 years. This has helped us to move forward and we are at about 75% radial.

Who manages your cath lab?  

We have an RN manager that manages cath, EP, echo, and the Cardiovascular Center, which is our pre/post area.

Do you have cross-training? Who scrubs, who circulates and who monitors?   

We always have one RN circulating, one RCIS/RT(R)/RN at the table and the monitor person can be either. We currently have two RNs who also scrub.  

Are there licensure laws in your state for fluoroscopy?  

No.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

The RCIS/RT(R)/RN at the table can do all of these.

How does your cath lab handle radiation protection for the physicians and staff?  

We have an in-house physicist who oversees all radiation protection and education for staff, physicians, and patients.  

What are some of the new equipment, devices and products recently introduced at your lab?  

We have been focusing on the new equipment needed to build our structural heart program.

How is coding and coding education handled in your lab?  

We have a coding department and semi-annual coding reviews.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

Closure devices are deployed in the labs. Manual pulls are performed by the staff. The majority are pulled in our Cardiovascular Center by the RNs there and the intensive care unit (ICU) RNs will pull the sheaths for their patients. 

What kind of training is mandated before someone can pull a sheath?   

We have a mix of observation, skill labs, and didactic training. Once training is complete, the new staff must meet the required supervised sheath removals before being signed off as competent to pull on their own.

Where are patients prepped and recovered (post sheath removal)? 

We have a very dynamic and skilled Cardiovascular Center. This area preps and recovers our patients, including post anesthesia EP patients, as well as performs cardioversions, transesophageal echocardiograms, and other similar cardiac procedures. They also manage patients with sheaths and sheath removal. We do use closure devices unless restricted by anatomy or if we need to keep the vessel free for upcoming large-bore access (such as TAVR).

How is inventory managed at your cath lab? 

We manually manage the inventory with the assistance of our cardiovascular information system (CVIS) reports. Materials management places the orders with the vendors.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?  

An expansion of our services to include structural heart is expected to grow the program.

Is your lab involved in clinical research? 

Not at this time.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? 

We have worked with emergency medical services (EMS) and they are able to directly alert the emergency department for suspected ST-elevation myocardial infarctions (STEMIs). The ED can call the cardiac alert prior to the patient’s arrival. After hours, the interventional cardiologist and cath lab team are paged. 

Who transports the STEMI patient to the cath lab during regular and off hours? 

This is performed by the cath lab team.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?  

This happens very infrequently. We do have an Administrative Resource Nurse on staff who helps us problem-solve in these situations and we have also called in our own staff that we knew were available. One of the benefits of a tight, close-knit team is knowing who is available.

What measures has your cath lab implemented in order to cut or contain costs?  

We work closely with our vendors to optimize our pricing. We also work to consign as much as possible and adjust our par levels of items whenever possible. We are also part of a national buying group, which can help us keep our costs down.

What quality control measures are practiced in your cath lab?  

Physicians hold cath conferences weekly, and morbidity and mortality (M&M) meetings monthly. Physicians use these as a forum to present complex cases for peer input on plan of care as well as for review of all M&M cases. Anyone can refer a case for review. We also audit and track all patients for complications, and present any trends that need to be addressed.  

How are you recording fluoroscopy times/dosages?  

We have dose mapping and dose tracking on all of our systems. Our physicist is automatically notified of any cases that exceed thresholds.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

The physicist reviews the case, and both the physician and patient receive a letter documenting this occurrence.

Who documents medication administration during the case? 

The circulating RN.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?  

They use a mix of dictation and templated notes in our emergency medical record.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)? 

Yes. Currently, the registry data is input manually, but we are moving toward some auto population of records.

What continuing education opportunities are provided to staff members? 

Vendors provide education, as do our physicians, and as our budget allows, staff attend conferences, including the Transcatheter Cardiovascular Therapeutics (TCT) conference.

How do you handle vendor visits to your lab? 

All vendor visits must be scheduled with the manager. Those representatives that support cases are allowed in the lab and the rest are only allowed in our meeting room. We do have restrictions on the number and frequency of these visits. Vendors are only allowed if we currently carry their products, unless we have requested information on a new product.  

How is staff competency evaluated? 

We use competency-based occupational standards (CBOS) and annual competencies.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

No. All staff must be licensed, but it can be as an RN, RCIS, or RT(R).

How does your lab handle call time for staff members? 

We always have an RN, an RCIS/RT(R), and the third can be either. The staff is welcome to adjust their hours as long as staffing allows. We recognize the importance of work/life balance. We can’t control when the pager goes off or how long the days will be, but we can allow people to come in later, leave earlier, or take the day off, as long as the cases are covered.  

Within what time period are call team members expected to arrive to the lab after being paged?  

Our policy is 30 minutes, but most staff prefer to arrive within 20 minutes.

Do you have flextime or multiple shifts? 

We are primarily a 10-hour day lab. 

How do you handle slow periods?   

We have a team that loves to work, but also loves to get out and do things. We always have people willing to leave when it is slow.

Where is your cath lab located in relation to the OR and ED?  

We were fortunate to be involved in the design of this facility. We are in close proximity to the OR, ICU, and progressive care unit (PCU). The OR room designated for open heart surgery is just across the sterile hallway and the ED is directly below us. 

What trends have you seen in your procedures and/or patient population?  

We have the honor of serving a highly educated and very active population, so much so that our vision statement emphasizes that we are “Partnering to create and care for the healthiest community in the nation”. Most of our patients do their research prior to their procedures and are highly involved in their care. The active, healthy lifestyle here in Boulder does impact the disease processes we see; for example, we see more “athletic hearts” than peripheral disease.  

Is there a problem or challenge your lab has faced? 

There is no shortage of cath labs in the Denver metro region. This, coupled with the increasing cost of living in the area, has made it a bit more challenging for us hire in certain departments, like our cath and EP labs. Fortunately, over the past two years, our organization has prioritized offering more competitive recruitment and compensation packages, which has enabled us to fill these open positions with great employees.

What is unique or innovative about your cath lab and staff?

The staff are really what makes us unique and sets us apart. We have been able to be highly selective in our hiring process to ensure everyone we hire really adds to the team.  We have a very intelligent and invested group of professionals who take pride in their work and care about their patients. But just as important, they truly care about each other.  We love what we do and this is reflected in the care our patients receive.  

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?  

Boulder definitely has a strong culture and those that live here really want to be here.  This directly impacts the culture of the lab. We enjoy our time at work as well as outside of work. We all appreciate the outdoors and what life here has to offer, and work hard to support each other’s endeavors to do so. We moved to 10-hour shifts to allow everyone a day off during the week and to increase the number of people covering call. We allow the team to do their own scheduling, including call and vacations, and everyone is very supportive if someone needs to make a change. You can also see the Boulder culture reflected in our physician relationships. We work closely together, and value each other’s opinions and insight. This creates a very interactive and open environment for learning.  As a community hospital, we also have the opportunity to know and work with the management team, all the way up to the CEO. 

Cath Lab Spotlight: Methodist University Hospital

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Author(s): 

Derrick Bowen, BSN, RN, Team Lead; Roxanne Gardner, RCES, Lead  Invasive Cardio Tech, Angela Knox, MSN, Jason Weatherly, BSN, CCRN

Rami Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI, Program Director, Interventional Cardiology Fellowship, Vice Chair of Medicine, Associate Chief of Cardiology, Associate Program Director, Cardiology Fellowship; Associate Professor, University of Tennessee Health Science Center; Medical Director, Cardiac Cath Lab, Methodist University Hospital; President, Unified Medical Staff, Methodist Le Bonheur Healthcare, Memphis, Tennessee

[Editor's Note: Angela Knox, MSN, and Jason Weatherly, BSN, CCRN, were accidentally left off the author byline for this article. Their names have been added in the online version for readers.]

Tell us about your cath lab. 

Methodist University Cath Lab is part of the Cardiovascular Service Line at Methodist University Hospital (MUH). MUH is a faith-based organization located in the medical district of Memphis, Tennessee, providing high-quality, cost-effective patient- and family-centered care to diverse socioeconomic populations across West Tennessee, North Mississippi, and East Arkansas. MUH is the most comprehensive and largest hospital in the Methodist LeBonheur Healthcare System, with 617 beds. MUH is partnered with the University of Tennessee Health Science, and acts as the major academic campus and principal teaching hospital. MUH is a Joint Commission and DNV-GL Healthcare accredited tertiary referral center with highly specialized healthcare providers.

As a teaching facility, Methodist University Cath Lab serves as a model for the organization in integrating new technology. We place a strong emphasis on service excellence, as well as our values of quality, integrity, teamwork, and innovation. We continually strive to seek out best practices and take ownership for applying them as we focus on comprehensive regional cardiac care.

What is the size of your cath lab facility and number of staff members? 

Our department consists of 6 procedural rooms: two cardiac cath labs (diagnostic and interventional, coronary and peripheral) labs, two electrophysiology labs (EP), one neurovascular lab (diagnostic and interventional), and one hybrid suite, and a dedicated pre and post recovery unit. Diagnostic and interventional cath procedures are performed in the two EP rooms or hybrid suite, as needed.

We have a total of 40 associates working in the cath lab. Twelve associates are assigned and dedicated to cardiac cath and vascular procedures, 7 EP associates, 6 registered nurses (RNs) for pre and post recovery, one certified nursing assistant (CNA), and 10 neurovascular associates. The associates in the cath lab have been in residence anywhere from 3 months to 30 years.

There are two dedicated call teams, one for ST-elevation myocardial infarction (STEMI) and one for stroke. In 2017, we averaged a total of 500 cases per month.

The cardiovascular service line volume is growing in the region. Our cath lab has benefited from that growth, with a 10-12% increase in cases annually. We are very excited that the Methodist LeBonheur Healthcare System has invested capital into our cardiac services. We have 2 new GE rooms and a new Philips room, and we are possibly adding another room in the near future. 

What procedures are performed in your cath lab? 

We have an extensive cardiac, electrophysiology, neurovascular, and vascular program. 

Our lab does comprehensive coronary and vascular diagnostic and intervention procedures. Moreover, we do structural heart procedures, valvuloplasties, pacemakers, defibrillators, endovascular stent grafts, abdominal aortic aneurysm (AAA) repairs, and atrial fibrillation/flutter ablations. We place left ventricle (LV) and right ventricle (RV) supportive devices (Impella, Abiomed). Our neurovascular procedures include complex embolizations (arteriovenous malformation [AVM], arteriovenous fistula, tumor, aneurysms). Neurovascular also does spinal arteriograms, kyphoplasty, venous sinus pressure monitoring, and sclerotherapy procedures. 

Can you share more about your transcatheter aortic valve replacement (TAVR) experience? 

Our lab was performing TAVR from 2013 until March 2017. The program has since moved to our sister facility, Methodist Germantown. We are planning to restart performing these procedures at MUH in the near future.

Does your cath lab perform primary angioplasty without surgical backup on site?

Our lab performs primary complex angioplasties. We have surgical backup on site. MUH has a total of 21 OR suites.

What is your percentage of normal diagnostic caths?

Out of 222 total cardiac cath cases in November 2017, 36.4% of cases required angioplasty. This equates to 81 patients. Of our patients, 63.6% do not require any intervention. 

Do any of your physicians regularly gain access via the radial artery?

Our cardiology group performs procedures via radial and femoral access. There are two cardiologists that primarily use the radial approach to obtain access, including our cath lab medical director, Dr. Rami Khouzam, who is reinforcing the importance of this safe approach and practice. We have used radial access to perform elective cardiac catheterizations, as well as acute coronary syndromes, both non-ST elevation myocardial infarction and some STEMI procedures. The entire cath lab staff has been educated on the radial program. The number of procedures via radial approach is expected to increase in the upcoming months as this approach is being adopted by more interventionalists. 

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Cardiologists and vascular surgeons obtain ultrasound-guided pedal access on complex vascular cases when appropriate.

Who manages your cath lab?

Angela Knox, MSN, RN, is Director, Cardiovascular Services. Rami Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI is the medical director of the cath lab. He is also the program director for interventional cardiology fellowship training at the University of Tennessee Health Science Center.

Do you have cross-training? Who scrubs, who circulates and who monitors?

We have a wide range of experience in our lab. RNs and scrub techologists can circulate, monitor, and scrub. 

Are there licensure laws in your state for fluoroscopy?

On April 20th, 2016, the State of Tennessee passed Senate bill 899 that amended Title 63 Chapter 6 Part 224 in regards to the use of fluoroscopy. It established the baseline credentials needed for licensed personnel to operate radiologic imaging and radiation therapy equipment. It also mandates that each certified individual must also biennially complete twenty hours of continuing education to maintain certification.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

The scrub tech can operate the x-ray equipment (position the II, pan the table, change angles). This includes the RNs, registered cardiovascular invasive specialists (RCISs), and registered radiologic technologists (RT[R]s). RT(R)s and RCISs can step on the fluoro pedal. The physicians can operate the x-ray equipment as well.

How does your cath lab handle radiation protection for the physicians and staff? 

Lead RT(R) Terence Gaither monitors the radiation numbers and performs quality control inspections of the lead aprons yearly. Physicians and staff are custom-fitted for lead aprons. Eyewear and lead caps are also provided.

What are some of the new equipment, devices and products recently introduced at your lab?

  • CSI orbital atherectomy for coronary arteries: we were the first lab in West Tennessee to utilize this technology for the coronary arteries in 2013.
  • Instantaneous wave-free ratio (iFR), Opsens fractional flow reserve (FFR), and new intravascular ultrasound (IVUS) devices have been recently purchased.
  • Newest Resolute Onyx stents (Medtronic).
  • New high-resolution ultrasound systems for facilitating pedal access.
  • Optical coherence tomography (OCT) technology for peripheral procedures.
  • We are introducing the WATCHMAN left atrial appendage occlusion device (Boston Scientific) as well.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Most of the communication is done through the holding room RN. She keeps the flow of the procedures going by letting the room lead know what is going on. She also communicates any add-on cases to the schedule. The cases are also written on the board in our main hallway, along with room assignments for that day. 

Every morning, our director conducts a daily safety huddle. We have weekly meetings with cath lab staff and management to review policies/procedures, set unit goals, and to stay up-to-date on future unit endeavors. 

How is coding and coding education handled in your lab?

Whitnie Anderson, RCIS, is responsible for cath lab coding and charges. Whitnie does an excellent job ensuring that documentation follows all department, hospital, and regulatory protocols.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

The techs, nurses, or fellows in training pull the sheaths for both post intervention and diagnostic procedures. There is mandated, regular training to keep our team familiar and competent with manual hemostasis and closure devices, as well as the TR Band (Terumo) for post radial access procedures.

Everyone in the cath lab is trained to pull sheaths, along with groin and wrist management. The patients are transported to our AngioRecovery unit post procedure. If a closure device is not used, the RNs in our angioplasty recovery area will pull the sheaths post procedure for both interventional and diagnostic procedures. 

Before a staff member is able to pull sheaths, they must go through an in-depth training from experienced nurses. Each member must complete a pre-education regarding sheaths. They will then observe multiple sheath removals by an experienced staff member. After all observations have taken place, the staff member will pull 10 sheaths under supervision. Upon completion of supervision, the staff member is able to pull sheaths by themselves. 

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

Inventory specialist David Van Netta’s sole responsibility is to manage our large inventory. It is a daunting task with our plethora of necessary supplies. He is constantly doing inventory and will purchase the required equipment under supervision of our director.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Since we are the tertiary care center and hub for West Tennessee, North Mississippi, and East Arkansas, we receive and perform the highest volume of STEMIs in the area. A new cath lab is under construction, with the potential addition of another lab to accommodate the expanding and increasing numbers of procedures.

Is your lab involved in clinical research?

  • Our lab has completed the ARTEMIS trial: Affordability and Real- World AntiPlatelet Treatment Effectiveness After Myocardial Infarction Study. A Prospective, Cluster-Randomized Clinical Trial that Will Evaluate Whether  Patient Copayment Elimination Significantly Influences Antiplatelet Therapy Selection and Long-term Adherence, as well as Patient Outcomes and Overall Cost of Care after Acute Myocardial infarction, where Dr. Khouzam as the principal investigator and a number of fellows in training as sub-investigators.
  • We are currently participating in the UPSTREAM registry: Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Acute Coronary Syndrome (UPSTREAM): An ED-Based Clinical Registry. This is a collaborative, prospective registry with the Hospital Quality Foundation under a grant from Astra Zeneca. It is a Phase IV, post-approval, multicenter, prospective, non-interventional, observational registry of consecutive patients with a working diagnosis of NSTEMI and treatment with an oral antiplatelet agent (ticagrelor, clopidogrel, or prasugrel) 4 to 72 hours upstream of diagnostic angiography. The primary objective of the UPSTREAM registry is to address in detail the data gap regarding the course of NSTEMI between emergency department (ED) arrival and diagnostic angiography, by characterizing and following the ED and peri-ED use of oral antiplatelet agents. Dr. Khouzam is the principal investigator and a number of fellows in training are sub-investigators.
  • We also recently started the Detroit Cardiogenic Shock Initiative, led by Raza Askari, MD. 

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? 

Our average D2B time is 56 minutes. To keep our D2B times <90 minutes, we have implemented a STEMI Task Force, cross-trained our Chest Pain Neuro Staff in the ED, and patients from the helipad are transported directly to the cath lab if certain criteria are met. We have also implemented a four-person call team. Our lab is registered with the American Heart Association’s Mission: Lifeline and the American College of Cardiology’s D2B Alliance.

Who transports the STEMI patient to the cath lab during regular and off hours?

During regular and after hours, STEMI patients are transported to the cath lab by the Chest Pain Neuro staff.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

We have a four-person call team. If the physician is finishing the case, one of the call team members prepares another room. The Chest Pain Neuro staff assist the second patient until the cardiovascular intensive care unit (CVICU) staff or medical response team arrives. The CVICU staff and/or the medical response team transport the first patient to the unit. If the second patient meets the criteria to undergo tPA (tissue plasminogen activator), it could be an option to allow time for the previous case to finish. Patient safety is always our priority and we will do whatever is necessary to provide the utmost care for our patients.    

What measures has your cath lab implemented in order to cut or contain costs?

We have started only using Omnipaque dye (GE Healthcare) for all procedure vs using Visipaque (GE Healthcare). We also use the ACIST power injector for all of our procedures.  This is very cost efficient in that we are not wasting a lot of contrast.

Also, following recent guidelines, most of our interventionalists have started replacing bivalirudin with heparin during percutaneous coronary and peripheral interventions.

What quality control measures are practiced in your cath lab?

We incorporate Appropriate Use Criteria (AUC). We also use a hydration protocol and calculate the maximum radiographic contrast dose (MRCD) prior to each case.

How do you determine contrast dose delivered to the patient during an angiographic procedure? 

The ACIST power injector allows us to have an exact measurement of the amount of contrast delivered to the patient.

Are you tracking the incidence of contrast-induced acute kidney injury in patients? 

Yes. However, we have implemented a pre and post cath hydration protocol to reduce the incidence of contrast-induced acute kidney injury. Establishing a baseline protocol for proper patient hydration before and after a cardiac catheterization is crucial to avoiding a contrast-induced kidney injury.

How are you recording fluoroscopy times/dosages?

Fluoroscopy times and dosages are documented in the GE Mac-Lab/ CardioLab system. 

We record the fluoro times using equipment from Philips, GE, and Siemens Healthineers.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

Our policy is to inform the physician when they are getting close to reaching 5 gray (Gy)/60 minutes of fluoro time, and again at 7Gy. If the physician goes over 7Gy, then the physician must provide consultation with the patient before discharge. Also the patient will be given a “Fluoroscopy Exposure Information Sheet” which provides radiation follow-up instructions.

Who documents medication administration during the case?

The monitor tech documents medication administration in the GE Mac-Lab hemodynamics monitoring system during the case. However, the RN documents medication administration in Cerner.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

The cardiologists dictate their cath procedure report. They also chart an immediate post procedure note in Cerner.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we participate in the CathPCI registries. Registry data records are populated using the GE Mac-Lab system. We have two full-time data abstractors (Clinical Quality Analysts).

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

MUH cath lab competes with two other hospitals in the greater Memphis metropolitan area. We participate in monthly outreach programs with outlying hospitals.

How are new employees oriented and trained at your facility?

We assign all new employees to a preceptor and depending on their experience in the cath lab, the orientation period can last anywhere from six weeks to six months. 

What continuing education opportunities are provided to staff members?

A great deal of the continuing education comes from vendors. They offer education on their websites where staff can receive continuing education units (CEUs). Vendors can also come in and do training that allows for CEUs. 

How is staff competency evaluated?

A cath lab skills fair is held yearly to evaluate staff competency. The evaluations are based on checklists, direct observation, and written tests. Several vendors are in attendance to assist with evaluating staff. Computer-based learning is also available through Cornerstone.

How do you handle vendor visits to your lab?

Vendors are required to schedule time in advance to visit the lab. They must meet the Reptrax requirements and have a badge on at all times. The vendors are allowed to sit in the staff breakroom unless requested by a physician. They are limited to one visit per week.

Do you require your clinical staff members to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

All cardiovascular technologists are required to take the registry exam for the RCIS within 2 years of their hire date. A raise is received upon passing the exam. 

What do you like about your department’s physical space? 

All the rooms are very spacious and well organized. The layouts are very staff-friendly and make the complex cases easier due to the size of the rooms. 

How does your lab handle call time for staff members? 

We have a cardiac call team and a neuro call team. Both call teams consists of two nurses and two techs, or one nurse and three techs. There must be at least one nurse on call at all times. 

Within what time period are call team members expected to arrive to the lab after being paged?

The cardiac call team has thirty minutes to arrive after being paged.

Do staff members have any little or big particular perks that you might like to share? 

The associates are permitted to leave early or start later after a night of on-call. Our staff enjoy the fact that they are guaranteed to get their 40 hours a week without having to use their PTO hours. There is also free parking within a covered garage.

Do you have flextime or multiple shifts? How do you handle slow periods?

The teams work four ten-hour shifts. Staffing levels are driven by volume. During low census, staff are offered time off or assigned other duties.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP)?

Yes.

Has your lab recently undergone a national accrediting agency inspection? 

Yes, we were recently inspected by DNV-GL Healthcare. Our recommendation would be to treat each day as if you were being inspected at that moment. Make sure you are doing everything the right way every day.

What trends have you seen in your procedures and/or patient population?

We have seen a trend in our patients requiring cardiac services being younger and with several comorbidities. We have also seen an increase in patients requesting radial access for their procedures. Many patients really like this approach because the bedrest is not as long as for procedures with femoral artery access.

Is there a problem or challenge your lab has faced? 

While undergoing renovation, it was necessary to use only one room for cardiology. Our staff and physicians worked very well together to rotate their schedules so that every patient was accounted for in a timely manner. The volume increased 18% during this time.

What is unique or innovative about your cath lab and staff?

Our cath lab team is a very diverse, with ages ranging from early 20s to late 50s. The background of the team consists of individuals who have worked as first responders, CVICU, ED and telemetry nurses, respiratory therapists, radiologic technologists, and surgical technologists. Our administrative director formerly worked as a police officer for the Memphis Police Department.

What’s special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your “cath lab culture”?

Memphis is located in the southwest portion of Tennessee. We are bordered by eight other states: Kentucky, Virginia, North Carolina, Mississippi, Alabama, Georgia, Arkansas, and Missouri. We can have patients flown to our facility from any of these states. Memphis is known nationally for our barbecue, with the World Championship Barbecue Cooking Contest held every year in May. Our city also hosts the St. Jude Memphis Marathon with thousands of runners yearly. We are home to Elvis Presley’s Graceland, and receive visitors from around the world to see Elvis’ residence. With so much to do in our city, our staff members are well versed in giving out restaurant and entertainment recommendations to our patients and families.  

The authors can be contacted via:

Derrick Bowen, BSN, RN, Team Lead, at derrick.bowen@mlh.org

Roxanne Gardner, RCES, Lead Invasive Cardio Tech, at roxanne.gardner@mlh.org

Spotlight: East Cooper Medical Center Cardiac Cath Lab

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Author(s): 

Patrick Beaver, Chief Nursing Officer – 

East Cooper Medical Center

Mount Pleasant, South Carolina

Tell us about your cath lab. Is it part of a cardiovascular service line?  

Yes. Our new cardiac catheterization lab is part of our cardiovascular service line.  Cardiology is a service line that East Cooper is focused on expanding to better serve the needs of our community. Our new lab officially opened in February 2018. The cath lab is physically located in our department of radiology, located within our main hospital building.

What is the size of your cath lab facility and number of staff members?  

Our cath lab also serves as an interventional suite for radiology and we are fortunate to have a total of four highly skilled, dedicated staff for this area. Currently, three staff members are trained in both cardiac cath and interventional radiology procedures. At the time of the cath lab opening, we hired two staff members specific to the cath lab. As the program develops, all cath lab staff members will be trained to do both cardiac cath and interventional radiology. Both our nurses and our technologists are experienced and motivated to help us further grow and develop our service offerings.  

What procedures are performed in your cath lab?  

We offer diagnostic cardiac caths and pacemakers. We also offer procedures for vascular stenting including aortic stents and renal stents; basically, we are able to offer most non-cardiac-related vascular procedures in our lab. It is important to note that our new lab is the only cath lab in the city of Mount Pleasant. This is key for patients and physicians who previously had to travel into Charleston, South Carolina for this service, and who can now respectively receive and provide this care closer to their homes. This also saves valuable treatment time. As a brand-new lab, we don’t yet have statistics to share from a historical perspective, but our experienced cardiologists and interventionalists from within our community have expressed that our ability to provide this service fills a major community need for our population, and we are already considering opportunities for future expansion.   

Do any of your physicians regularly gain access via the radial artery?  

Yes, our physicians primarily gain access through the radial artery.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?  

Our vascular team is qualified to utilize pedal artery access when appropriate and they are skilled for any kind of radial access.

Who manages your cath lab? 

Our cath lab has a director who reports through our department of radiology, and then ultimately to Patrick Beaver, our Chief Nursing Officer.    

Do you have cross-training? Who scrubs, who circulates and who monitors?   

The cath lab team is truly a cohesive group of nurses and technologists who offer care up to the scope of their licenses. A nurse will monitor the patient, but a tech will manage the control panel during a procedure.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

In South Carolina, the laws are very clear. Only trained radiology professionals and/ or physicians can operate the equipment.

How does your cath lab handle radiation protection for the physicians and staff?  

The health and wellness of our staff is a top priority and we take their safety very seriously. We require all of the standard protocols including vests and collars, and all staff in this department use radiation exposure badges.

What are some of the new equipment, devices and products recently introduced at your lab?  

Some of our newest equipment at East Cooper includes balloon pumps and an upgraded physiological monitoring system.   

How does your lab communicate information to staff and physicians to stay organized and on top of change? 

Communication is key in our organization. It is the culture of our leadership to keep staff informed and to receive valuable feedback for improvements. We do daily safety huddles, host regularly scheduled staff meetings, and also provide written communications of key changes and updates. We also have a cardiac cath lab committee that meets weekly for this particular service. It consists of our medical director, Dr. Eric Powers, nursing, business development, quality and education.

How is coding and coding education handled in your lab?  

Our team has been trained as part of ICD-10 implementation and the topic of coding is a regular agenda item at the cardiac cath lab committee.  

Who pulls the sheaths post procedure, both post intervention and diagnostic?  

Nurses in the intensive care unit (ICU) and cath lab can both pull sheaths for our cath lab patients. They have been trained by the vascular device representatives and undergo annual competencies. 

Where are patients prepped and recovered (post sheath removal)? 

Once the sheath is removed, patients stay in the cath lab recovery area. Should they require a more prolonged observation, they are moved to the ICU.  

How does your lab handle hemostasis?

Our lab handles hemostasis manually and patients either stay in the cath lab or get transported to the ICU.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?  

The director of the cath lab and the staff are all responsible for inventory and supply management. We do have some items that are stocked on consignment.  

Do you have any plans for expansion?  

We are pretty new, so we have plenty of room to expand at this point. Our medical staff is very excited as we have plenty of openings to offer care to patients from a time perspective. We know that those slots will all begin to fill up as our program matures, so we are looking now at what we want our budding program to grow into. Our plan is for our diagnostic cath lab to lay the foundation to lead into chest pain accreditation in the next year. Future plans beyond that would include becoming an interventional cath lab.  

Who transports patients to the cath lab during regular and off hours?  

We are not receiving ST-elevation myocardial infarction patients at this time, but cardiac cath patients will be transported by a private advanced cardiovascular life support (ACLS) ambulance company and a nurse.

What measures has your cath lab implemented in order to cut or contain costs? 

Our cath lab is new, so we developed all of our processes with cost containment in mind.  One of the biggest things we are doing is stocking high-ticket items on our shelves by consignment, especially items with an expiration date. As part of a larger organization, Tenet Healthcare, we benefit from the buying power of the system.

What quality control measures are practiced in your cath lab?  

We are reviewing 100% of all of our cases using best practice algorithms, considering medical necessity, and doing follow-ups. While our lab is new, our community physicians and staff are highly experienced, and East Cooper is able to benefit from clinical expertise around the country, and benchmark against other facilities as part of Tenet Healthcare’s network. Our goal is to ensure 100% of our cases undergo quality review. 

How do you determine contrast dose delivered to the patient during an angiographic procedure?  

Contrast dose is determined by the physician in our cath lab.

Are you tracking the incidence of contrast-induced acute kidney injury in patients? 

The physician makes acute kidney injury determinations, but we also monitor and review kidney function pre and post procedure.

How are you recording fluoroscopy times/dosages? 

Our system and equipment allows us to automatically calculate fluoroscopy times/dosage. 

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

If there was to be a patient with higher than normal radiation exposure, it would be recorded by the physician in the post-op record and then transparently discussed with the patient, including any follow-up required.

Who documents medication administration during the case?  

One of our cath team members records during the cath as the monitor tech; another team member documents medication administration during our cath lab cases.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?  

Our physicians use the PowerScribe 360 Recording System (Nuance), which allows for templates that can be filled in by the cardiologist. It is part of a comprehensive cath lab workflow infrastructure designed to help with efficiency and productivity, and offers the ability to care for patients more effectively. From imaging to recording to IT, everything works as one. The system captures key information that becomes part of the patient’s medical record. It also gives data to the interventionalist for their procedural note.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?  

We plan to going forward. Data input will be the responsibility of our quality department.      

Can you tell us more about the advantages of having a cath lab available to citizens of Mount Pleasant?  

A cardiac cath lab within Mount Pleasant was a major need of our community. Our cardiologists and interventionalists in our neighborhood were having to travel outside of the city to care for their patients into downtown Charleston, where traffic and parking are major issues. Treatment time is more optimal when patients don’t have to travel for care, and we know our population will greatly benefit from us offering this service closer to their homes.      

How are new employees oriented and trained at your facility?

One of our best assets is our people, and we want to start off their employment experience on the right foot. There is hospital-wide orientation for all employees and then a clinical pathway for certain departments. We offer a combination of didactic or classroom-based instruction that is combined with hands-on training.

What continuing education opportunities are provided to staff members?  

We want our staff to be as up-to-date as possible on all of the latest and greatest in their fields. They have outside educational opportunities afforded to them, as well as assessments by internal staff and providers. We also believe that our goal of 100% review of all cath lab cases will provide direction for educational needs moving forward, and we meet all regulatory requirements.

How do you handle vendor visits to your lab? 

All vendors must go through our materials management department. Our cath lab is a restricted badge access area, but vendors may come in when needed.  

How is staff competency evaluated? 

Our staff competency is evaluated in a variety of ways including from the trainer perspective. Major interventional competencies are determined by the medical director, the chief nursing officer (CNO), or the cath lab director.

Does your lab have a clinical ladder?  

A clinical ladder is coming soon to East Cooper! We plan to start with nursing.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?  

We have one technologist who is a certified RCIS, and we are looking at all staff members becoming certified. They would get an economic incentive as part of the clinical ladder for achieving this important certification.

What do you like about the physical space you work in? 

Simply put, our hospital is gorgeous! We offer free on-site parking and our location is incredibly convenient. Our cath lab is new, but so is our hospital! Our physical plant was built in 2010, so it has many amenities and modern conveniences not generally found in hospitals. The space we work in is important, but our success is due to our people that fill it. Our organization is dedicated to a high level of customer service, and those who enter our doorways are greeted with southern hospitality!

How does your lab handle call time for staff members? 

We have 24/7 call coverage and our expectation is that staff have sufficient downtime for rest and travel. They do need to be able to arrive at the lab within 30 minutes.  

Do staff members have any little or big perks that you might like to share? 

Parking is free at East Cooper, and staff education is provided and individualized. We offer many employee incentive programs and we are dedicated to investing in our people, first and foremost, as part of our organizational culture. 

Has your lab recently undergone a national accrediting agency inspection? 

We will undergo accreditation when we formalize our chest pain program.

What trends have you seen in your procedures and/or patient population?  

As a new lab, we know there is a need in our community as patients and physicians are having to travel out of the area for this service. Our community is unique in that it is a very young, highly educated population. The average age is 47, so with such a young population, the ability to save time and offer quicker access to care could be very beneficial for them in the long-term.  

What is unique or innovative about your cath lab and staff?    

Our actual lab may be new, but our experience comes from our medical staff and employees who share a combined skill and knowledge level that rivals others in the area. Patients in Mount Pleasant will see their same cardiologist or interventionalist that they currently see, but now, they don’t have to travel out of the city for cath lab services.  

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?  

Our cath lab culture transcends any one department.  We are committed to excellence and we invest in our people and our community to keep healthcare moving forward.  We are a unique community in terms of demographics — young, highly educated, health conscious — but what truly sets us apart is offering high-quality healthcare with the southern hospitality the area is known for. 

Patrick Beaver can be contacted at patrick.beaver@tenethealth.com.

Spotlight: Appalachian Cardiovascular Associates

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Author(s): 

Shari Hill, RN, Cardiovascular Suite Manager, 

Fort Payne, Alabama

Tell us about your facility and cath lab.  

Appalachian Cardiovascular Invasive Suite is located in Fort Payne, Alabama. Our facility consists of a 5-bay pre and post area, and a one-room interventional suite. We are one of 5 outpatient vascular labs in Alabama, and the only outpatient lab currently performing coronary angiograms. Our lab consists of a ceiling-mounted Artis zee system (Siemens) with Mac-Lab hemodynamics (GE Healthcare) integrated with the Medrad Mark 7 Arterion Injector (Bayer).

What is the size of your cath lab facility and number of staff members?   

Our facility is approximately 6000 square feet. We currently have one lab, but have room for expansion. We have a variety of credentials in our lab ranging from nurse practitioner (NP), registered nurse (RN), certified vein access technologist (cVAT), and certified medical assistant (CMA). Staff years of experience ranges from 1-20.

What procedures are performed in your cath lab?  

  • Left heart cath
  • Left ventriculogram
  • Right heart cath
  • Abdominal aortography with and without runoff
  • Temporary pacemaker
  • Peripheral atherectomy
  • Peripheral angioplasty with and without stent placement
  • Intravascular ultrasound (IVUS)
  • Renal angiography selective (unilateral or bilateral)
  • External pacing
  • Venogram with or without iliocaval stent placement

Currently, we perform 8 to 10 procedures per week.

What is your percentage of normal diagnostic caths?

Approximately 20%.

Do any of your physicians regularly gain access via the radial artery?

We currently offer radial and femoral artery access. Our lab has adopted a “radial first” philosophy, allowing our patients a safer procedure, and more comfortable and shorter recovery.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Yes, our physician has utilized ultrasound-guided pedal artery access when over the horn or antegrade access was unavailable.

Who manages your cath lab? 

Shari Hill, RN.    

Do you have cross-training? Who scrubs, who circulates and who monitors? 

We do have cross-training. Our goal is for everyone to scrub, circulate, and monitor within their scope of practice. Currently our technologists monitor, and our RNs scrub and circulate.    

Are there licensure laws in your state for fluoroscopy?

No. We voluntarily perform radiation physics testing and report to the state Bureau of Radiation Control.

Which personnel can operate the x-ray equipment in your cath lab? 

  • Position the II – physician or scrub
  • Pan the table – physician or scrub
  • Change angles – physician or scrub
  • Step on fluoro – physician

How does your cath lab handle radiation protection for the physicians and staff?

Each staff member is required to wear a dosimetry badge to monitor radiation dosage. All staff wear lead aprons and thyroid collars to aid in shielding. We also use RadPad products (Worldwide Innovations & Technologies, Inc.) to reduce radiation scatter to staff. All staff are required to take an occupational radiation test annually.

What are some of the new equipment, devices and products recently introduced at your lab? 

We have recently adopted the radial-first philosophy, and so have acquired a Rad Board (Merit Medical) and have started using the PreludeSYNC radial compression device (Merit Medical) for hemostasis.    

How is coding and coding education handled in your lab? 

We utilize off-site coding. The physician takes coding classes, and we are part of an accountable care organization (ACO) that helps us keep on top of changes to codes and coding rules. 

Who pulls the sheaths post procedure? What kind of training is mandated before someone can pull a sheath?

All staff members are trained to pull sheaths. The training process includes: observation of seasoned staff members, performing sheath pulls with direct supervision and then demonstrating competency to allow for solo sheath pulls.

Where are patients prepped and recovered (post sheath removal)? 

We have a 5-bay pre and post area. We use a combination of vascular closure devices and manual pressure post procedure. One RN and one medical assistant remain with the patient at all times.

How is inventory managed at your cath lab? 

Charity Nute, RN, and Shari Hill, RN and manager, currently handle inventory. They are involved in all of our procedures, so they know which products are used, and can reorder within 24 hours. Our plan is to move to a software system for inventory control.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Our lab opened in late 2016 and has had a steady increase in volume. We expect that trend to continue and we have room for expansion as we continue to grow.

Is your lab involved in clinical research?

Not at this time; however, this is something we are interested in for the future.    

What measures has your cath lab implemented in order to cut or contain costs?

Most of the products we use are on consignment. Products that are not consigned are monitored closely. We only stock what we intend to use within a 30-day period. We also work closely with our vendors to rotate products in order to prevent expiration issues.

What quality control measures are practiced in your cath lab?

We currently monitor fluoro and contrast dosages, patient complications, patient satisfaction, and patients transferred for intervention. We also perform daily checks on equipment as part of our quality assurance process. Each of our patients receive a follow-up call 24 hours post procedure to evaluate outcomes and answer any questions the patient may have.

How do you determine contrast dose delivered to the patient during an angiographic procedure?

The ACIST system reports total contrast delivered per case. We calculate creatinine clearance (CrCL) and obtain a glomerular filtration rate (GFR) prior to every case to plan maximum dosage. We utilize a renal insufficiency protocol. We have not had any incidence of contrast-induced nephropathy (CIN) due to rigid adherence to the renal insufficiency protocol (Figure 6).

How are you recording fluoroscopy times/dosages? 

The x-ray system reports radiation exposure per case. We currently use our Mac-Lab system to document the amount of fluoro used during each procedure.

Who documents medication administration during the case?

The RN verbalizes the medication and dosage given. The monitor technologist then documents this information in the Mac-Lab report.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Currently, procedure reports are documented using an original template designed by Dr. Sanjeev Saxena. We are in the process of switching to a fully integrated scheduler, electronic medical record, and PACS software system. With the new system, data is populated in the procedure report during the case. When the procedure is complete, the software automatically generates a “plain English” report with images that can be emailed to the referring physician. 

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Not at this time.

How does your cath lab compete for patients? 

We use multiple advertising techniques and reach out to referring physicians.    

How are new employees oriented and trained at your facility? 

Each new employee is assigned a “starting position”, either scrub technologist, monitor technologist, or circulator. They will be trained until competent at that position before cross-training to the next position. There are initial and annual competencies that must be completed, and basic life support (BLS) and advanced cardiac life support (ACLS) are expected within 6 months of hire.   

What continuing education opportunities are provided to staff members?

We are currently working with vendors to help provide CEUs for our different disciplines.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP) or regional organizations?

Our manager, Shari Hill, is a current member of the ACVP.

How do you handle vendor visits to your lab?

Vendors make appointments prior to their visit. They must also check with the physician prior to entering the lab.

How is staff competency evaluated? 

The orientee will observe and perform the designated task multiple times with a trained staff member. After demonstrating competency, the orientee can then perform the task unsupervised.

Does your lab have a clinical ladder?

We currently do not have this in place. With one shift, and one crew, we have sufficient staff to perform cases, and we hire personnel with appropriate skills and training. 

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

While we do not require staff to obtain RCIS certification, all team members are compensated according to their credentials and experience levels.

What do you like about your facility’s physical space? 

We have a very large procedure room with state-of-the-art equipment, which is well lit with LED lighting, an ionic air purification system, and emergency backup generator. The facility itself is decorated in muted rust and mustard colors, with an Asian art theme throughout.  

Do you have flextime or multiple shifts? How do you handle slow periods?

We currently have one shift for cath procedure days. All staff are cross-trained to assist with patients and other procedures in our practice. On slow procedure days, they help wherever there is a need.

Do staff members have any little or big particular perks that you might like to share? 

Free lunch on procedure days and sponsored travel to a yearly conference are a few of our perks.

What trends have you seen in your procedures and/or patient population? 

We have been performing an increased number of venous cases for non-thrombotic iliac vein compression syndrome. This syndrome has long been undiagnosed in many individuals. We are seeing great success with this treatment. 

What is unique or innovative about your cath lab and staff?    

  • Our lab is one of five outpatient vascular labs in Alabama.
  • Our lab is the only outpatient facility in Alabama performing coronary angiograms. This is because we have a fixed ceiling mount system, not just a mobile C-arm.
  • Our staff members offer multiple levels of experience. All are motivated, and willing to learn.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?

Fort Payne is located in a beautiful mountain valley in northeastern Alabama. The home of famed country music group “Alabama”, Fort Payne is the location of the band’s fan club and museum. Alabama and Mississippi rank 49th and 50th in education and 1st and 2nd in diabetes and obesity in the U.S. Our staff makes a concerted effort to provide patient teaching regarding healthy cooking and lifestyles. 

Shari Hill, RN, can be contacted at sharihill1309@gmail.com.

Spotlight: West Hills Hospital & Medical Center

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Author(s): 

Michael Aquino, MBA, BSBM, RT(R)(CI), Director Cardiac Cath Lab/Cardiac Services, West Hills, California

Tell us about your facility and cath lab. Is it part of a cardiovascular service line? 

West Hills Hospital is nestled deep in the San Fernando Valley, offering evidence-based medicine close to home for our patients. Our cath lab is part of our division’s cardiovascular service line strategy. We align our services with our sister hospital in the market, and share best practice and learning across eight hospitals in the HCA system. It is a great model because of the multiple resources readily available.

What is the size of your lab and number of staff members?    

We currently have 2 labs, with a third planned for construction in the near future. We have 5 full-time registered nurses (RNs), one part-time RN, 2 PRN RNs, 3 full-time technologist, and one PRN technologist. The techs are all cardiac interventional (CI) radiography licensed, and 2 of the nurses are critical care (CCRN) certified. One of our nurses has been with the HCA system for over 30 years. Our longest in-resident nurse has been in the cath lab for 17 years.  

What procedures are performed in your cath lab?  

We perform both coronary and peripheral angiograms and interventions, including percutaneous transluminal coronary angioplasty and stenting. Available technologies include intravascular ultrasound (IVUS), fractional flow reserve (FFR), rotational atherectomy, intra-aortic balloon pump (IABP), and Impella (Abiomed). We also do implants of cardiac rhythm management (CRM) devices and loop recorders, electrophysiology studies and ablations, and tilt tests.

Can you share your level of normal diagnostic caths?

R4Q ending 2Q2017, only 88/209 of our elective patients were diagnostic.

Do any of your physicians regularly gain access via the radial artery?

Yes. All of our cases are planned via radial access unless they have a limiting factor   (R4Q ending 2Q2017, 475/937 = 50.67%).

Who manages your cath lab? 

Michael Aquino is Cardiovascular Service Line Leader and Zandra Miller is the Charge Nurse for Cardiac Services. 

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

Radiologic technologists (RTs) and physicians can perform these duties.

How does your cath lab handle radiation protection for the physicians and staff? 

We have lead shielding, lead aprons, and internal radiation protection initiatives.

What are some of the new equipment, devices and products recently introduced at your lab?   

  • Tryton Bifucation Stent (Cardinal Health);
  • Jetstream Atherectomy System (Boston Scientific);
  • Micra Transcatheter Pacing System (Medtronic).    

How does your lab communicate information to staff and physicians to stay organized and on top of change?  

We have daily huddles, staff meetings, and cath conferences with staff and physicians.  We also have a Cardiovascular Operations Improvement Committee (CVOIC).

How is coding and coding education handled in your lab? 

Coding is performed by our health information management (HIM) department. The lab reconciles all charges and recommends coding modifications.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

RTs pull the great majority of the sheaths; however, nurses are trained and competent as well, both in the cath lab and in our post cath departments. We have annual skills labs and competencies that cover sheath removals.

Where are patients prepped and recovered (post sheath removal)? How does your lab handle hemostasis?

Patients are prepped prior to arriving to the cath lab by their admitting nurse on the floor (either same-day surgery or in patient room). Radial patients are managed with radial bands applied by the RTs prior to patient leaving the cath lab. Femoral access is usually Angio-Seal (Abbott Vascular) placed by the RT or we occasionally use Perclose (Abbott Vascular). Manual pressure is also used as needed by the RTs and/or the nurse on the floor. Our post-op patients go to the recovery room, and ST-elevation myocardial infarction (STEMI) patients go to the intensive care unit (ICU). After the recovery room, patients go to either outpatient for discharge or the step down unit for management and care.

How is inventory managed at your cath lab?   

We do our own inventory management and stocking of all of our supplies and equipment.     

Has your cath lab recently expanded in size and patient volume, or will it be in the near future? 

Plans are underway to expand our capacity and also include more advanced procedures.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?   

We rock! Our average D2B is 42 minutes (2Q2017). For a period of time last year, we were the number-one STEMI receiving center for D2B in all of Los Angeles county. We also became the number-one hospital in the HCA system for consistently having our D2B time under 90 minutes. Our team is dedicated to working together with emergency medical services (EMS), the emergency department (ED), cardiology, quality, and physicians to achieve the best outcomes for our patients. We have multidisciplinary weekly case reviews for our STEMI patients.

Who transports the STEMI patient to the cath lab during regular and off hours?

The ED team usually bring the patients up to the cath lab.  The cath lab team will help as needed.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED? 

The STEMI doctor, ED doctor, and the cath lab team triage patients if a second room, team, and doctor are not available. If necessary, the patient on the table will be moved and held in the recovery room temporarily until their case can be completed.

What measures has your cath lab implemented in order to cut or contain costs?  

Bulk purchases for supplies and consignment. Our staff is cross-trained and handles multiple responsibilities including stocking, purchasing, transporting, and billing.    

What quality control measures are practiced in your cath lab?  

We perform STEMI reviews, use DoseWatch (GE Healthcare) for radiation monitoring, and monitor achievement of the hospital’s core measures. We also follow-up with our patients post-op by rounding while they are at the facility and with a phone call after discharge.

How do you determine contrast dose delivered to the patient during an angiographic procedure?    

We use the maximum allowable contrast dose (MACD) equation to prevent acute kidney injury (AKI): patient weight in kilograms x 5, divided by creatine.

Are you tracking the incidence of contrast-induced AKI in patients? 

Yes, through the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR). The information is shared with our physicians and staff, and is also tracked internally.

How are you recording fluoroscopy times/dosages? 

In our Mac-Lab reports (GE Healthcare), our department log book, and DoseWatch.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?  

An incident report is filed. The radiation safety officer reviews the case. Follow-up is completed by the cardiac cath lab team.  

Who documents medication administration during the case?    

Medications are documented in both the patient’s electronic medical record by the administering RN and in the Mac-Lab report, which is done by either an RN or RT.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?  

Doctors dictate in addition to the detailed cath lab report that is in the patient’s chart.

How are you populating registry data records? 

Our cath lab staff enter some information in the Mac-Lab report. Other information is entered by our quality department as abstracted from the patient’s medical record.    

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?   

We have arrangements with local hospitals to care for their STEMI patients and our hospital is a participant in the county-wide EMS STEMI receiving program.    

How are new employees oriented and trained at your facility?   

We use an on-the-job “buddy system” to orient new employees. They are proctored with experienced staff until they display the competencies required.     

What continuing education opportunities are provided to staff members?   

We provide in-services and vendor-sponsored/provided training opportunities and classes, along with regular cath conferences.  

How do you handle vendor visits to your lab? 

Vendors are managed through an internal process called DHP. They must be preapproved and badged every time they visit the facility. They can only visit the department they have been cleared/badged for.      

How is staff competency evaluated?  

Competency is evaluated annually using vendors/representatives, in-house education, and a skills lab.

Do you require your clinical staff members to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam? 

No, it is not required. There is no bonus/raise.

Does your lab have any physical (layout) bottlenecks or limitations?  

We are experiencing growing pains. Inventory and storage are dynamic challenges.

What do you like about your physical workspace? 

What we like most about our space is the people in it. It takes an amazing, dedicated team to perform consistently at our level and this dedication is infectious. I am privileged to be part of such an amazing group of staff and physicians.     

How does your lab handle call time for staff members?   

All team members take call, and each team has 2 RNs and one RT at all times. We have language in our nursing contract to allow staff to leave early or call off if they feel they aren’t safe to work after callbacks. 

How does your lab schedule team members for call?

We do self-scheduling for call. We have 2 RNs and 1 RT on call. Call is divided up equally amongst the staff. We use a rotating schedule of who gets first choice in their call days.

Within what time period are call team members expected to arrive to the lab after being paged?   

The team has a 30-minute response time. In light of the Los Angeles traffic and our current D2B performance, it is a testament to our team’s commitment.

Do you have flextime or multiple shifts? How do you handle slow periods?  

We have one shift from 6:30am to 3pm, Monday to Friday. We use the slow times to catch up on education, stocking, inventory, patient rounding and follow-up. Staff also get cancelled and flexed as needed by the department.

Has your lab recently undergone a national accrediting agency inspection? 

We currently have our Society of Cardiovascular Patient Care (SCPC) certification and we are preparing for The Joint Commission accreditation for chest pain.    

What trends have you seen in your procedures and/or patient population?   

Radial access allows for quicker recovery and discharge of patients.  

What is unique or innovative about your cath lab and staff?        

We are a small team committed to patient outcomes, cross-trained and fully functional to handle multiple responsibilities in our lab.

Is there a problem or challenge your lab has faced? 

Problems and challenges are faced in many ways, depending on what it is. Policy, practice, and quality issues are handled through the CVOIC (Cardiovascular Operations Improvement Committee). We take challenges on as a team and grow together. 

A question from the American College of Cardiology’s National Cardiovascular Data Registry:

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We use the NCDR CathPCI reg- istry to help drive quality initiatives, which in turn helps improve patient care. We look closely at our door- to-balloon times, mortality, AKI, and bleeding, to name a few. For exam- ple, D2B in 2Q2017 = 42 min and 3Q2017 = 46 min. We have been in the top 90th percentile for 2 quarters in a row! Immediate percutaneous coro- nary intervention within 90 min = all of 2015,2016,and the first 3 quarters in 2017 = 11 straight quarters!

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