The physicians and staff of the Johns Hopkins Heart and Vascular Institute (HVI) work diligently around the clock to provide the highest quality of comprehensive care for their patients. Our department—the Cardiovascular Interventional Laboratory (CVIL)—is one of the teams that comprises the HVI. CVIL is home to the cardiac catheterization and electrophysiology (EP) laboratories. It consists of 12 procedural suites—five dedicated catheterization suites, five dedicated EP suites, one cardiac magnetic resonance imaging (MRI) suite and one cardiac computed tomography (CT) suite. Both the EP and catheterization service lines have hybrid procedure suites. These hybrid labs provide a mutually conducive environment for complex procedures that require the partnership of the interventional and surgical teams. 

In April 2012, the HVI moved into a new location in the Sheikh Zayed Tower. The move was the culmination of years of forethought and planning. Our lab needed “all hands on deck” for the actual move day to ensure a successful transition into our new home.

Prior to the move, HVI services — cardiology, cardiac surgery, vascular surgery and imaging — were located on different floors and buildings of our historic hospital building. The Sheikh Zayed Tower was designed to centralize care by placing all of these specialties on the same floor. This allows our patients and their loved ones convenient and complete access to the cardiac services needed. 

What is the goal of your lab?

The goal of our lab is aligned with the mission of Johns Hopkins Medicine:   

“To improve the health of the community, and the world, by setting the standard of excellence in medical education, research and clinical care. Diverse and inclusive, Johns Hopkins Medicine educates medical students, scientists, health care professionals and the public; conducts biomedical research; and provides patient-centered medicine to prevent, diagnose and treat human illness.”

Tell us about your cath lab.

Our lab consists of five dedicated cath suites. Two suites were constructed as hybrid rooms. These rooms can perform procedures that range from minimally invasive to full surgical operations. Throughout the department, we have the imaging capabilities to perform cardiac and vascular procedures for our adult and pediatric patients. We share our department with EP; however, EP has its own separate procedure rooms and staff. Our department also houses both an MRI unit and a CT scanner. 

We currently employ 18 radiologic technologists (RTs) and 13 registered nurses (RNs) for cath. Both teams of healthcare professionals are licensed by the state of Maryland. A majority of the technologists have advanced certifications, such as cardiac-interventional radiography (CI), cardiovascular-interventional radiography (CV), and registered cardiovascular invasive specialist (RCIS). Many RNs have earned their cardiovascular and critical care certifications as well. All staff members are advanced cardiac life support (ACLS) certified. 

Is the cath lab separate from the EP lab? Are employees cross-trained?

Due to the size of our lab and case complexity, the cath and EP RTs operate as two separate teams. However, all staff members are encouraged to learn and grow together within their respective teams. There are EP technologists who are cross-trained to cover cath cases when staffing and volumes are favorable. The nursing team has several “hybrid” RNs who are cross-trained to cover cath and EP procedures. This provides flexibility for high volumes, acuity, vacations and sick calls. CVIL also partners with the department of anesthesiology on multiple cases per week.

Who manages your cath lab?

We have a robust leadership team that oversees the staff, operations, and clinical development in the cardiac catheterization lab:

• Jon Resar, Director of the Adult Cardiac Catheterization Laboratory, Director of Interventional Cardiology and Associate Professor of Medicine/Cardiology;
• Kevin Hsu, Administrative Director of Cardiac Services;
• Lauren Johnson, RT Manager;
• Kim Sweitzer, RN Manager;
• Kelly Hagin, Inventory Manager;
• Carol Tunin, Financial Manager.

What procedures do you perform in your cath lab?

The cath lab represents five service lines: adult cardiac catheterization, pediatric catheterization, cardiomyopathy/heart failure, structural interventions, and peripheral vascular imaging and intervention.  

• Some common procedures performed in our labs include:
• Diagnostic and interventional cardiac catheterization
• Peripheral vascular procedures
• Chronic total occlusions (CTOs)
• Pediatric interventional procedures
• Right heart catheterization
• Right ventricular biopsy
• Adult congenital procedures, including atrial septal defect (ASD) and patent foramen ovale (PFO) closure, patent ductus arteriosus (PDA) closure, aortic coarctation treatment and ventricular septal defect (VSD) closure 
• Balloon valvuloplasty (aortic, mitral, pulmonary)
• Mitral clip treatment
• Transcatheter aortic valve replacement (TAVR) 
• Coronary imaging and pressure differential (intravascular ultrasound [IVUS], fractional flow reserve [FFR], and optical coherence tomography [OCT])
• Cardiac support device insertion (intra-aortic balloon pump, Impella [Abiomed], TandemHeart [CardiacAssist])
• Research protocols, including stem cell therapy

Note: We have a separate EP workforce that handles ablations, devices, and lead extractions.

Ancillary equipment

We have a complete spectrum of ancillary equipment on hand for patient needs, including:

• IABP
• Impella
• TandemHeart
• FFR
• IVUS
• OCT
• Rotoblator (Boston Scientific)
• AngioJet (Boston Scientific)
• Laser
• Intracardiac echo (ICE)
• ACIST CVi contrast injection

Have you recently upgraded your imaging technology?

In preparation for the expansion and move to our new clinical building, we purchased three brand-new Philips rooms, two single-plane units and one biplane system. Additionally, our pediatric interventional team had a new Toshiba biplane system installed. This room can be utilized for pediatric and adult cardiac and vascular cases. Our fifth room is a Toshiba dual plane system equipped with a separate cardiac and vascular tube. This unit was relocated from our previous location.  

Our first hybrid room functions as a cardiac/vascular lab that can expand into an operating suite if needed. We most often utilize this hybrid room for our TAVR procedures or peripheral vascular cases that that may require surgical intervention.

The second hybrid suite functions primarily as the pediatric room. The hybrid design allows the pediatric team to implant Melody transcatheter pulmonary valves (Medtronic), and facilitate joint interventional and surgical procedures.

There are integrated Volcano IVUS/FFR units in four of our procedure rooms. ACIST CVi consoles are utilized in three of our procedure rooms. The other two rooms utilize a standardized 3-port manifold for selective imaging and Medrad auto-injectors for large-contrast injections.  

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

Yes! We perform radial access coronary procedures in approximately 80 percent of our patients. That number will continue to increase with the development of more radial-specific tools and protocols.  

How are ST-segment elevation myocardial infarction (STEMI) cases handled at your lab?

In 2012, we achieved door-to-balloon (D2B) times of less than 90 minutes in 96 percent of our core measure cases. Our median D2B was 66 minutes. It is important to note that 100 percent of our field-activated cases met a D2B time of less than 90 minutes. Our heart attack team conducts a multidisciplinary meeting each month to review all STEMI case events. Representatives from the emergency department, cath lab, quality improvement, and transport team examine each element from activation to completion to look for areas of improvement. We are very proud of our success, especially in light of the challenges involved in opening a new clinical building. This hard work has not gone unrecognized. In 2013, Johns Hopkins was the recipient of the Delmarva Foundation’s Excellence Award for Quality Improvement in Hospitals. The Joint Commission also recognized The Johns Hopkins Hospital as a Top Performer on Key Quality Measures. 

How does your lab handle call time for staff members? 

STEMI call is covered by a five-member team — one interventional attending, one interventional fellow, two RTs, and one RN. Each week, one RN and one RT participate in the call model. That team does not come in to work during normal business hours. They are expected to cover all cases after 5:30pm on weeknights and any emergent case over the weekend. The second on-call RT rotates daily and is filled on a voluntary basis.

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

After a page is sent out, one fellow, one nurse, and one radiologic technologist are expected to arrive to the cath lab within 30 minutes. A second radiologic technologist will arrive within 45 minutes.  

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

Johns Hopkins Medicine sends daily news updates to staff members via email, publications, and electronic message boards throughout the institution. CVIL leadership highlights key institutional messages to staff via email and during staff meetings. There is a monthly management meeting that includes stakeholders from the RT, RN, inventory, case management, quality improvement, scheduling, administration, and medical teams. The division of cardiology hosts grand rounds each week to discuss various cardiac topics, image interpretations, and research updates. Physicians and staff meet weekly during a morbidity & mortality conference to discuss cases and procedural techniques. The department hosts a monthly comprehensive unit-based safety program (CUSP) meeting for all staff members to address safety concerns and develop action plans. Departmental information, policies, schedules, photos, and updates are housed on our unit’s SharePoint site.

How is staff competency evaluated?

Various skills are evaluated for competency on a yearly basis. Competencies may be mandated by the state, the hospital, or by our department. Our primary focus for competencies is on high-acuity, low-incidence scenarios. One unique opportunity offered by our department is a full ACLS/basic life support (BLS) course taught by members of our own unit. We feel that practicing critical scenarios as a team helps us to perform more proficiently in times of duress.  

Additionally, every RT is expected to provide a minimum of one educational in-service per year for their co-workers. This practice helps to facilitate and promote an environment that endorses continuous education and growth.

RN staff members are currently implementing the Donna Wright Competency Model to streamline competency-based assessments.

What continuing education opportunities are provided to staff members?

Weekly in-services pertaining to a variety of clinical applications are provided for the team. We offer a minimum of 12 CEUs per year for our staff. New procedures, devices and equipment are accompanied by a launch period and in-servicing to assist all team members in becoming comfortable with that technology.  

Do you participate in any registries?

We participate in several American College of Cardiology National Cardiovascular Registry (ACC-NCDR) Registries: ACTION, CathPCI, and IMPACT. We participate in the Society of Thoracic Surgeons (STS)/ACC TVT registry for transcatheter valve replacement procedures.

How do you use the NCDR outcome reports to drive quality improvement initiatives?

NCDR outcomes are reviewed with the leadership team on a quarterly basis. Action plans are created to address any areas of opportunity or to build on positive clinical momentum. Key elements from the registries are included in our annual Key Performance Indicator (KPI) dashboard. This dashboard is reviewed and revised by the leadership team. KPI success is aligned to annual performance review ratings for managers. Outcomes are highlighted for all staff during the annual “State of the Union” address given by administration and leadership teams.

Can you tell us about your TAVR program?

We instituted our TAVR program in 2011. Since its inception, we have steadily built our case volume. We have performed over 250 TAVR procedures with both iliofemoral and non-iliofemoral access, including subclavian, direct aortic, and apical alternative access. We currently implant the Medtronic CoreValve under both research and commercial programs.   We also implant the commercially available Edwards Sapien XT valve and the new CoreValve Evolut R valve by Medtronic.

We have four dedicated TAVR days per month and frequently perform additional cases each week as needed. We average two cases per day. We anticipate continued growth and success in the structural heart field over the next few years and will be participating in the pivotal clinical trials of several new TAVR devices.

We partner with anesthesia, cardiac surgery, and perfusion for all cases as part of our multidisciplinary approach. The TAVR team meets weekly to discuss the program, upcoming patients, and best practices.

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

Kelly Hagin is our inventory manager. She has a team of dedicated cath inventory specialists who meet the various demands of our department. Inventory specialists oversee supply usage of assigned procedure rooms and storerooms, perform visual inspection of supplies for proper rotation of inventory (first in, first out), perform supply cycle counts to eliminate discrepancies, and collaborate with clinical staff on a daily basis to address supply needs.  

Capital equipment is purchased through a collaborative effort between clinical leadership, physician leadership, and materials management. Disposable supplies are purchased through the SAP program. All supplies are set up in SAP with minimal par levels and maximum stock needed. At the time of scanning of the manufacturer bar code, the supply is automatically decremented from inventory and reordered if it meets the minimal stocking criteria.

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

Our physicians actively participate with hospital administration and corporate purchasing on cost reduction initiatives. The team has been focused on formulating new contract negotiation strategies, developing actionable performance and supply benchmarking data, and aligning the product selection process across the Johns Hopkins Health System. The catheterization lab was able to achieve more than $1.5 million in savings over the past three years on supplies.

Management actively monitors staff schedules and case volumes to minimize overtime. The department strives to achieve on-time starts for 70 percent of its first cases. Starting our first cases on time greatly increases our room utilization, decreases our overtime, and creates provider and staff satisfaction.

How does your lab handle vendors/visitors?

The Johns Hopkins Health System Corporation, in response to The Joint Commission recommendations, has engaged the services of  Vendormate to credential and assist in monitoring vendor representatives that provide services to The Johns Hopkins Health System. Vendormate is a web-based system that enables Johns Hopkins to upload new or revised policies, medical or educational requirements, and any other notifications to vendors via a Vendormate e-blast. This system requires vendors to read and acknowledge notification within a two-week window.  

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

At the department level, we have a senior radiologic technologist who is deemed the Radiation Safety Officer. This person implements policies and procedures set forth by the institutional Radiation Safety Officer, and is responsible for educating staff on radiation safety on a regular basis. As part of orientation, new physicians and staff members attend a course with the radiation physicist, and are expected to complete an annual radiation safety refresher course. The radiation physicist is also available to consult on special projects, i.e., a new product entering the lab or a potential research study, to guide lab staff on the recommended safety precautions.

How are coding and coding education handled in your lab?

Coding is handled by certified coders who are part of the medical records group for the institution. However, cardiology has a departmental documentation application that will suggest coding based on the procedure notes entered.  Internal medical coders provide education and updates to physicians and fellows on a yearly basis, and free online training through vendors and reimbursement specialists can be used to supplement. Profee billing is handled through certified medical coders in the physician practice association.

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is required?

All femoral sheaths are pulled by the post anesthesia care unit (PACU) nurses, as long as the patient meets the criteria outlined in the nurse sheath-pulling policy. If the patient does not meet the nurse sheath-pulling criteria, then the cardiology fellow will pull the sheath. Nurses must complete a written exam and perform ten observed sheath pulls before they can remove sheaths independently. 

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

Outpatients are undressed and prepped with an IV for their procedure in the pre-PAC area, whereas inpatients come directly to the procedure room. Post procedure patients will either return to the PACU or to the inpatient unit, depending on the level of care they will require post procedure. 

How does your lab handle hemostasis? 

Radial access is our preferred method to achieve vascular access. For our radial patients, we use either the Vasc Band or D-Stat Band (both from Vascular Solutions). For femoral access we utilize manual pressure, Angio-Seal (St. Jude Medical), Perclose (Abbott Vascular), or Boomerang (Cardiva Medical). The physician will remove the radial sheath and apply the Vasc Band or D-Stat Band, or remove the femoral sheath and deploy any percutaneous closure device while the patient is in the procedure room. For patients requiring manual pressure, sheath removal will be done in the PACU or on the inpatient unit. 

The PACU and our designated inpatient units are prepared to care for post cardiac catheterization patients. This includes vascular closure devices and post manual pressure removal in accordance with post cardiac catheterization protocols and guidelines. 

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

Our physicians do not dictate their reports.  We currently utilize a computer-based reporting system where physicians enter text case notes and a report is generated into the EMR. This report is automatically sent to the selected referring physician. We are moving to the EPIC electronic health record system, which will contain our reports in the near future. 

The authors can be contacted via Jessica Moore, MHA, at jmoor101@jhmi.edu.

A question 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?

The RCIS is not a requirement for clinical staff members. We strongly encourage the Cardiac Interventional Boards to obtain the ARRT credential. Staff members are incentivized to work towards this certification, as it places them on a leadership track and makes them eligible for a Senior RT position. The hospital will reimburse the individual for exam fees if a passing score is achieved.

The authors can be contacted via Dr. Sunil Rao at sunil.rao@duke.edu.

Tell us about your cath lab.

We currently have two procedure rooms, one of which is dedicated to electrophysiology (EP) procedures. Our staff is cross-trained to work both cath and EP procedures. Our lab is staffed with 8 registered nurses (RNs) and 3 cardiovascular technologists. Five RNs hold certifications as CCRN and 1 technologist holds both the registered cardiovascular invasive specialist (RCIS) and registered cardiac electrophysiology specialist (RCES) credentials. Staff longevity ranges from 8 months to over 10 years.

Tell us about the procedures performed at your lab. 

The average number of procedures performed each week is 30 (we have only one cath procedure room). This number includes 

diagnostic cardiac catheterization and complex coronary intervention. We have the full array of diagnostic and interventional equipment including fractional flow reserve (FFR) (both wire and catheter-based systems), intravascular ultrasound (IVUS), rotational and orbital atherectomy, and hemodynamic support. In addition, we perform diagnostic and interventional EP procedures, including ablations of atrial and ventricular arrhythmias, atrial fibrillation, pacemakers, and internal cardiac defibrillators. 

Our cath lab is undergoing significant renovation in the next few months. We are currently not performing transcatheter aortic valve replacement (TAVR), but we are in the process of building a hybrid operating room. This will allow us to bring structural heart disease procedures to our veterans.

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

This has been a program in evolution. Our hospital is across the street from Duke University Medical Center and all of our physicians also work at Duke. Duke has a very high annual ST-elevation myocardial infarction (STEMI) volume and some of the best outcomes in the country. Since our physicians also cover the Duke cath lab and take call, many STEMIs go directly to Duke, bypassing the VA hospital. We do, however, perform coronary artery bypass graft surgery (CABG) at the VA and our surgeons are Duke surgeons who, like our interventional cardiologists, work at both hospitals.

What percentage of your diagnostic caths is normal?

Approximately 10-15% of our angiograms are completely normal, with an additional 5-7% having insignificant disease.

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

Our lab is “radial first.” All of our operators perform transradial procedures. Over 95% of our procedures are transradial and we have the highest radial volume in the VA system nationwide.

Who manages your cath lab? 

Nicki Fryar, RN, MBA, MHA is the Cardiovascular Lab manager. Dr. Sunil Rao is the Cardiology Services and CV Lab Director.

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

All staff is cross-trained to scrub, monitor and circulate caths and EP procedures. Only RN staff is trained in the administration of medications. This allows us flexibility in those cases of unplanned absences, planned absences, and emergencies, etc.    

Are there licensure laws in North Carolina for fluoroscopy?

Not currently.

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? 

We have a very active fellowship training program at Duke, and both diagnostic and interventional fellows rotate through the cath lab. Our goal is to train them to be the best, so they are expected to set up the shots, inject the coronaries, and pan the table. Our staff is also trained to do this, so they often support the fellows who are early in their training.

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

We are very meticulous about radiation protection and adhere to Society of Cardiovascular Angiography and Interventions (SCAI) recommendations.  Aside from the usual “ALARA” principles of appropriate personal protection, wearing radiation badges, minimizing source-to-image distance (SID), and effective use of shields, we have established a practice in which the monitor staff person notifies the physician operator if the air kerma reaches 3Gy and again if it reaches 5Gy. At 5Gy, serious consideration is given to stopping the procedure, as long as it is safe for the patient.

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

We have been very proactive at keeping current with our equipment. We were the first VA cath lab in the country to have orbital coronary atherectomy. We have also recently brought in the ACIST Navvus FFR, which is a catheter-based FFR system that allows you to use any workhorse 0.014-inch wire. This is a nice addition to our ACIST contrast injection system, which has allowed us to reduce our contrast use per case by a third. In 2015, we are looking forward to renovating both of our procedure rooms with the latest imaging equipment, including an EP “cockpit.”    

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

We have a relatively small physician staff of 5 interventional cardiologists.  Communication of new equipment, protocols, or important issues is generally done through email. When important new data that may influence practice are published or presented, we get together either in person or virtually to discuss whether our current practice should change. We also have regular cath lab staff meetings to discuss new policies and procedures, as well as review any issues that have come up.

How is coding and coding education handled in your lab? 

We are a VA hospital and traditionally, coding was not a focus of our efforts. However, recent changes have forced us to be very attentive to coding. Every provider in the VA system now has their workload measured, and for physicians, this includes Relative Value Units (RVUs). The VA also aggressively bills private insurance when the veteran has it. This has been a steep learning curve for many VA physicians, but we are now very thorough in our documentation and completion of encounter forms. We rely on a variety of sources for information on coding and are trying to stay current.

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

The overwhelming majority of procedures we do are transradial, so there is no issue with sheath removal. For the rare transfemoral case, either our nurse/technologist staff pulls the sheath or the fellow pulls it. We have a specific competency for sheath removal and new nurses, technologists, and fellows are trained in it. Staff observes the removal of one sheath and are proctored for several sheath pulls until it is determined that the trainee has mastered the skill.  

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

Patients start their prep in our Interventional Recovery Unit (IRU), which also serves as a post-procedure recovery area. Initial screening of vital signs and general physical assessment is completed, as well as insertion of IV lines and marking the site of access. After the procedure, the patient returns to the IRU with the radial hemostasis device in place. Once the recovery period is completed, the patient is either discharged home or admitted as an inpatient. Our same-day discharge program includes selective PCI cases. 

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

This is a complex process in the VA system, but it does work well. Regularly used equipment like catheters are purchased through materials management. Like other labs, we have par levels and orders are placed daily. Implantable devices, including coronary stents, are ordered through the Prosthetics department, and again, orders are placed daily. If there is a capital purchase that we would like to make, we apply to an acquisitions committee for approval. The VA has been very good in allowing us to bring new technology to better serve our veterans.    

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

Our volumes have been relatively stable over time and daily volume tends to be cyclical, with certain times of the year being much busier than others.

Is your lab involved in clinical research?

We are very involved in clinical research and participate in industry-funded, NIH-funded, and VA-funded studies. We currently are enrolling in two protocols that are VA-funded trials. We tend to enroll very well in studies because we are selective about which trials we will participate in. 

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

Costs are a huge issue in the VA system because all of the resources we use are funded by taxpayer dollars. We are very attuned to being efficient with the resources we have. Some of what we have done to curtail costs in the VA includes reducing wait times for cath by restructuring our scheduling. We can offer same-day or next-day service for veterans. We also started a same-day discharge program to free up inpatient bed availability. We use automated contrast injection to reduce our contrast usage and costs.  We also reprocess many different EP cables and have instituted bulk purchasing options as another way to save cost. In addition, as we mentioned, our lab is radial first, with >90% of our procedures performed via radial access. This has significantly reduced our complications, thus saving money. 

What quality assurance measures are practiced in your cath lab?

We have an ongoing program for quality improvement (QI) that is headed up by our staff. We also participate in case reviews on a regular basis. This program is integrated into the overall QI program within the VA system. All caths and PCIs performed in the VA are required to be entered into CART-CL, the national VA cath lab database, headed by Dr. John Rumsfeld. All VA cath labs must enter data into CART-CL. This is similar to the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) and provides regular feedback reports on outcomes and processes of care. CART-CL provides 100% capture of all procedures being performed in the VA system, including diagnostic cath data as well as PCIs.

Are you recording fluoroscopy times/dosages?

The CART-CL database has a field to record both fluoroscopy time and DAP, and these fields are regularly filled out by our providers. In addition, cardiovascular lab staff record fluoroscopy time and dose in each procedural record.

Who documents medication administration during the case?

Every case has a nurse who records and documents medications into the procedure record, which ultimately gets recorded in the electronic medical record.

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

As a VA lab, we do not compete for patients in the traditional sense. There are so many veterans that need cardiovascular care in our network (VISN 6), that our volumes remain quite stable. We are, however, very keen on getting veterans care within the VA and try our best to transfer any veteran who is hospitalized in the private sector to the Durham VA. We are often limited by bed availability, but are actively working to find creative solutions.

How are new employees oriented and trained at your facility? 

New employee orientations are specific to the prior experiences of the new hire. As well, the new employee completes a self-assessment that assists in determining priorities for training and education. Each employee is assigned a preceptor that works with the new employee for the entire orientation. Nurse educators and the RN managers monitor the progress of each new employee. Competencies are completed and signed off by the assigned preceptor, educator, and RN manager. Orientation is generally completed in 3 months.    

What continuing education opportunities are provided to staff members?

We have provided yearly opportunities for staff members to attend off-site educational programs that provide CEU credits. We utilize our vendors to provide in-servicing on equipment, current trends, and updates. Our physicians provide education through cardiac cath conferences offered throughout the year.   

How do you handle vendor visits to your lab?

We utilize RepTrax vendor credentialing. Vendors check in at a designated area and receive an ID badge for that visit. Each vendor is required to make an appointment prior to arrival.      

How is staff competency evaluated? 

Staff receives a performance review annually. A competency-based tool outlines specific criteria for individual staff members to complete on an annual basis and it is reviewed by the nurse manager at completion. Staff can meet these competencies by performance of procedures, use of equipment, and/or self-learning packets/videos, with completion of a post test. As well, our vendors provide a review of low-use, high-risk equipment and procedures. Advanced cardiac life support (ACLS) is required of all RNs and CVTs in our labs.

Does your lab have a clinical ladder? 

We do not use a clinical ladder process, but we have instituted a Clinical Expert Recognition program for our nurses. It requires certification in their area of expertise or a master’s degree. A monetary reward is presented upon completion.

How does your lab handle call time for staff members? 

We are not a 24-hour cath lab, because our physicians also work at Duke, which is across the street. All STEMIs go directly to Duke, so our physicians take primary PCI call at Duke.

Do you have flextime or multiple shifts? 

No.

Has your lab recently undergone a national accrediting agency inspection? 

We have not undergone any private sector national accreditation process, because the VA has its own requirements for PCI programs. We do participate in Joint Commission inspections, as well as inspections by the Office of Inspector General.    

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

Our cath lab is on the 3rd floor of the VA hospital, which is where the majority of the cardiology services are located, with the exception of electrocardiogram (EKG). The ED is on the first floor, and the OR is on the 4th floor.

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

We have noted a significant increase in the complexity of coronary disease that we are seeing. Despite this, we have maintained our “radial first” approach. We have also noted an increase in the number of patients with congestive heart failure with or without valve disease.   

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

Our lab is unique in that our pre-procedure assessment process allows us to reduce the number of unnecessary or inappropriate procedures. All patients referred for cath are seen in a pre-cath clinic where they are evaluated for the appropriate tests, one of which may be a cardiac catheterization. During this visit, we also assess their suitability for prolonged dual antiplatelet therapy. All of this is documented in the medical record. Many of the patients seen in pre-cath clinic are also consented for their procedure, which allows our lab to function very efficiently. Our cath lab staff is unique because they do both cath and EP procedures. They are very efficient at patient turnover and it is routine for us to perform 5-8 procedures in one room on a daily basis between 8am and 6pm.   

Is there a problem or challenge your lab has faced? 

We have had many challenges, given the surge in the veteran population over the past decade. Our most pressing problem a few years ago was scheduling. Our previous system was very inefficient, resulting in long wait times and paradoxically, some very low volume days. By using a “lean” process, we were able to eliminate many redundant steps in the process, significantly increase cath lab availability, reduce wait times, and save the VA money.     

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 biggest influence has been the close relationship with an academic center like Duke University Medical Center. As mentioned, all of our operators have academic appointments at Duke and work there as well. This allows for sharing of “best practices” at both institutions and increases the opportunities to offer veterans the latest in cutting-edge cardiovascular care. 

Editor's Note: The online version of this article has been corrected from the print version regarding the correct number of CICUs (13) and telemetry beds (29) at Memorial Hermann Heart & Vascular Institute-Southwest. Cath Lab Digest apologies for the error.

Terrence Devine, RN III, can be contacted at terrence.devine@memorialhermann.org.

Tell us about your cath lab.

Memorial Hermann Heart & Vascular Institute-Southwest is part of the 12-hospital Memorial Hermann Health System, known for world-class clinical expertise, patient-centered care, leading edge technology, and innovation. With its exceptional medical staff and more than 22,000 employees, the system serves to advance health in Southeast Texas and the Greater Houston community. 

Located on the Campus of Memorial Hermann Southwest Hospital, the Memorial Hermann Heart & Vascular Institute-Southwest opened in 2006 as Houston’s first freestanding heart hospital. Dedicated, specialized programming distinguishes the Institute from other similar facilities. The Institute’s Heart Valve Clinic, for example, offers patients innovative care delivered by a multidisciplinary team of affiliated specialists who work together to diagnose and treat heart murmurs.

The Institute offers five cardiac catheterization labs, two of which are also electrophysiology labs, a 15-bed pre/post-operative area, five cardiovascular operating rooms, a 13-bed cardiovascular intensive care unit, and 29 telemetry beds. The catheterization lab staff includes six registered nurses, three registered technologists, two cardiovascular technologists, and one registered cardiovascular invasive specialist. Recently, medical experts from the Institute began treating patients and training staff at nearby Memorial Hermann Sugar Land Hospital.

Selected from more than 1,000 U.S. hospitals, Memorial Hermann Heart & Vascular Institute-Southwest is among Truven Health’s 50 Top Cardiovascular Hospitals. The hospital recently received the American College of Cardiology’s 2014 NCDR ACTION Registry–GWTG Platinum Performance Achievement Award and was awarded the Society of Thoracic Surgeons’ highest rating of three stars for quality related to heart bypass surgery.

What procedures are performed in your catheterization lab?  

With hundreds of cases a month, we perform a wide variety of diagnostic and interventional procedures, both elective and emergent ST-elevation myocardial infarctions (STEMIs), angioplasty, and stenting, including chronic total occlusion (CTO) interventions. In addition, we utilize intravascular ultrasound (IVUS), PressureWire Aeris (St. Jude Medical) for fractional flow reserve (FFR), optical coherence tomography (OCT), rotational atherectomy, and AngioJet ultra thrombectomy (Boston Scientific). We offer Maquet Cardiac Assist intra-aortic balloon pumps (IABPs) and Abiomed Impella 2.5 left ventricular assist devices for cardiac support. For peripheral vascular cases, we offer Crosser catheters (Bard), the Diamondback 360˚ Coronary Orbital Atherectomy System (CSI), and IVUS catheter systems (Volcano). We also perform temporary pacing wire insertions, permanent pacemaker implants, and carotid stenting. 

For electrophysiology studies, we offer the new MediGuide Visualization and Navigation System (St. Jude Medical), and both the EnSite Velocity Cardiac Mapping System (St. Jude Medical) and Carto 3 System (Biosense Webster) mapping platform for ablation procedures. We work with advanced systems for cardiac ablation and perform cryoablation. Our electrophysiologist implants automatic implantable cardioverter defibrillators (ICDs), biventricular ICDs, and just recently began performing subcutaneous ICDs.

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

The Heart Valve Clinic program at Memorial Hermann Heart & Vascular Institute-Southwest began in January 2012 and we have performed about 70 TAVR cases in the last three years. The Institute is one of the few facilities in Houston outside of the Texas Medical Center approved to perform TAVR cases.

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

This approach has been used at Memorial Hermann Heart & Vascular Institute-Southwest for a number of years. We have five affiliated physicians who regularly use the radial approach, usually through the left radial artery. We have found that inserting the catheter through the radial artery in the wrist, rather than through the groin, markedly reduces major vascular complications. However, as with every procedure, we evaluate each patient’s case carefully to determine the best type of procedure to perform.

Who manages your catheterization lab?

Mario Herrera, RN, BSN, CVRN-BC, is the director of the catheterization lab at Memorial Hermann Heart & Vascular Institute-Southwest, while Charles Brooks, RN, is the program manager.

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

Cross-training is an integral part of our catheterization lab. This helps the schedule flow on a busy day and builds teamwork among the staff. While all the technologists are versatile and scrub, circulate, and monitor, the RNs circulate and monitor, with many capable of operating the table and scrubbing. For electrophysiology, new staff members are oriented after they master the catheterization lab.

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

All appropriately trained catheterization staff can operate the x-ray equipment with physician supervision.

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

Along with appropriate radiation protection training, all physicians and staff are fitted with their own lead aprons. Additional protection includes clear shields and a lead skirt that hang from the operating table. Radiation badges are assigned to each employee and monitored regularly. 

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

Memorial Hermann Heart & Vascular Institute-Southwest completely upgraded its monitoring software and hardware to Mac-Lab/CardioLab from GE Healthcare. We recently began using the latest percutaneous, catheter-based Impella device and updated to Biosense Webster’s Carto 3 System in order to to use the new SmartTouch ablation catheter.  

The Institute now offers a new treatment for minimally invasive heart procedures that reduces radiation exposure for the patient, physician, and associated medical staff. The hospital is the first in Texas, and the only one in Houston, to employ St. Jude Medical’s MediGuide Technology, a device that uses GPS-like technology to guide heart catheters during the surgical treatment of arrhythmia. MediGuide Technology is a 3-D visualization system that uses electromagnetic signals to evaluate a patient’s vascular and cardiac anatomy, and track its therapeutic and diagnostic devices in real time on pre-recorded fluoroscopy images. Automatic adjustments are made to the previously recorded images to compensate for cardiac motion, respiratory changes, and patient movement. This is different from the standard practice, where physicians view devices in the heart using fluoroscopy. The 3-D visualization is outstanding, but the real advantage of MediGuide is that it helps us perform safer procedures by reducing radiation exposure for all involved. We recently performed a right atrium flutter ablation using only 40 seconds of fluoroscopy.          

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

Staff meetings are held on a regular basis, along with daily emails to keep everyone up to date and brief huddles to discuss urgent information. The physicians hold monthly cardiology and interventional section meetings. To lighten things up, we make poster boards focusing on a wide range of interesting topics, from the history of cardiac catheterizations to electrophysiology studies. 

How is coding and coding education handled in your lab?  

We have a trained, dedicated catheterization lab RN who reviews procedure charge sheets and compares them to the procedure reports. Any discrepancies are brought to the team’s attention and immediately addressed.

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

All staff members are trained to pull sheaths; however, it is usually performed by the pre/post catheterization lab staff. For patients going directly to the intensive care unit, ICU nurses are also trained. Training is done by a thorough review of material, demonstrations, return demonstrations, and evaluations by the catheterization lab manager until the employee is proficient.

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

For hemostasis, Memorial Hermann Heart & Vascular Institute-Southwest has a 15-bed pre/post-operative area with seven RNs, a patient-care assistant, and an office secretary. Along with prepping and recovering patients for the catheterization lab, blood transfusions are given on an outpatient basis. This area is also used for cardioversion, tilt table studies, and transesophageal echocardiography (TEE). Staff from the noninvasive cardiology department assist with these procedures.  

How is inventory managed at your catheterization lab? 

Two trained staff members handle supplies, one specifically for the catheterization lab and one for electrophysiology. Each employee has a designated backup. To track inventory and ordering, we use a Mac-Lab program to scan all items. We use Crystal Reports by SAP SE to make inquiries into the Mac-Lab database. We use a sticker sheet system for interventional procedure supplies. By peeling off the package’s sticker for such items as guide catheters, balloons, and stents, it is a quick way to double-check items used.

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

In 2013, Memorial Hermann Heart & Vascular Institute-Southwest completely renovated one of our catheterization labs especially for procedures with the Siemens MediGuide Navigation and Artis zee Angiography System. Navigation with the St. Jude Medical MediGuide Technology uses a special electromagnetic tracking procedure to determine the position of medical devices during minimally invasive interventions. During the intervention, a miniaturized sensor integrated into the catheter can be located by receiving electromagnetic positioning signals from the MediGuide transmitters, which are incorporated into the detector housing of the Artis zee system. The MediGuide Technology then calculates the respective position and orientation of the catheter and displays it in real time on fluoroscopic images of the patient that were recorded earlier. To display the catheter’s position precisely, the technology also compensates for patient movement caused by respiration and heart motion.

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 door-to-balloon time is 65 minutes. We work closely with our emergency department and area emergency medical services to activate and coordinate responses to an ST-elevation myocardial infarction (STEMI). Electrocardiograms can be transmitted directly to the interventional cardiologist and once confirmed, the hospital operator announces ‘Code Heart’ over the intercom system. In addition, a group page is sent out for the on-call team. We are registered with American Heart Association’s Mission: Lifeline and the American College of Cardiology’s D2B Alliance.

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

Emergency department staff transports STEMI patients during regular hours, after-hours, and on weekends. The patient is accompanied by a resident, an emergency department RN, an administrator officer, and a security officer.

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

After consultation with the physicians and STEMI team, off-duty catheterization lab staff is called in, thrombolytics are considered, or the patient is transported within minutes to another Memorial Hermann hospital by Memorial Hermann Life Flight^® helicopter. 

Is your lab involved in clinical research?

No.

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

To cut and contain costs, we have reduced our inventory levels, order items as needed, and work closely with physicians to eliminate unnecessary supplies. We also are very aware of expiration dates, use items with closer expiration dates, and verify with physicians before opening supplies. Our administration staff continuously works with vendors to review supply contracts. Staffing is another area we have looked at to cut costs. We work 9.5 hours and have four-day work weeks. We float to other departments and even to other Memorial Hermann hospitals when not needed in the catheterization lab.  

What quality control/quality assurance measures are practiced in your catheterization lab?

We use a patient survey from Press Ganey and receive monthly performance reports. Physician performance is also measured using a monthly peer review of selected procedures. We created an American College of Cardiology (ACC)-approved audit tool form to ensure core measures, such as updated patient history and physical examination, hydration protocol, and angiographic (TIMI grade) blood flow, are tracked. We have a concise checklist for automatic ICD implants to comply with the ICD registry.

Are you recording fluoroscopy times/dosages? 

Yes. We document the time and dosages of radiation on the patient’s medical record, and record this information on logbook for easy reference. Any excessive radiation exposure is immediately reported to the Radiation Safety Committee.

Who documents medication administration during the case?

Prior to the start of a case, either a technologist or an RN is assigned the task of documenting medication administration. After the case, a medication sheet is printed, and both the physician and RN sign off on it.

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

Currently, physicians dictate their reports. We are moving toward using a structured reporting tool. 

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

We use the ACC-NCDR database, the ACTION registry for acute coronary syndrome patients, the Cath PCI registry for STEMIs, and the ACC-NCDR ICD registry for defibrillator implant patients. We use the Vascular Quality Initiative (VQI) registry for carotid stents.

How does your catheterization lab compete for patients? 

The world-famous Memorial Hermann Life Flight is one element that makes patient care at Memorial Hermann unique. Life Flight is a critical care air medical transport service that serves the community within a 150-mile radius of the Texas Medical Center with helicopters and worldwide using fixed-wing transport. Founded in 1976 by James “Red” Duke, MD, who still is medical director, the service operates around the clock – weather permitting – 24 hours a day, 365 days a year. Since its inaugural flight, Memorial Hermann Life Flight has flown more than 140,000 missions. Through Life Flight and solid relationships with many local emergency clinics, Memorial Hermann Heart & Vascular Institute-Southwest regularly receives patients from outlying areas. We have the ability and reputation to care for high-risk patients with multiple comorbidities.

How are new employees oriented and trained at your facility? 

After a general hospital orientation, each new staff member is assigned a preceptor for specific department orientation. Using a skill checklist, new employees are required to keep a daily log of their progress. For someone completely new to the Memorial Hermann catheterization lab environment, orientation could be as long as four months before they reach an acceptable proficiency level to take a call.

What continuing education opportunities are provided to staff members?

Memorial Hermann Heart & Vascular Institute-Southwest offers free, online continuing education classes. Additionally, employees are provided in-depth training on all new procedures and regular reviews of existing produces. Educational opportunities are often presented by various vendors and partner organizations. Advanced Cardiovascular Life Support (ACLS) classes are provided by the hospital and employees receive reimbursement for the cost of accreditation exams.

According to the International Board of Heart Rhythm Examiners (IBHRE), Memorial Hermann Heart & Vascular Institute-Southwest is one of the few hospitals in Houston to elevate its cardiology program with the addition of a certified cardiac electrophysiology nurse. Catheterization laboratory nurse Mary Abanto, RN, BSN, received her competency certification in cardiac electrophysiology for allied professionals from the IBHRE. Recipients of this designation are recognized for professional competence, are highly respected by peers and other medical professionals, can demonstrate advanced skills in clinical practices, and represent a standard of excellence in the arrhythmia community.

How do you handle vendor visits to your lab? 

Vendors are allowed in the catheterization lab procedure room, but only when assisting with a procedure or providing training. They must go through the hospital badging process, and wear a disposable white jacket and red surgical cap to identify them as non-hospital employees. 

How is staff competency evaluated? 

We undergo yearly competency testing with 40 percent based on skills and 60 percent on customer service.

Does your lab have a clinical ladder? 

We have a Clinical Ladder program for both RNs and technologists.

How does your lab handle call time for staff members? 

We have a team comprised of two RNs and two technologists for call. Weekend call is Friday through Sunday, every two to three weeks.

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

Team members are expected to arrive within 30 minutes.

Do you have flextime or multiple shifts? 

Employees work four 9.5-hour shifts.  

Has your lab recently undergone a national accrediting agency inspection? 

Memorial Hermann Heart & Vascular Institute-Southwest recently received the American College of Cardiology’s NCDR ACTION Registry–GWTG Platinum Performance Achievement Award for 2014. The Institute is also an accredited Chest Pain Center as designated by the Society of Chest Pain Centers (SCPC). 

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

The cardiovascular OR is on the same floor, next to the catheterization lab. The ED is on the 1st floor in the next building.

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

In Texas, the Houston-Sugar Land-Baytown region has the largest Asian population — more than 300,000 people. According to the U.S. Census, Asians accounted for 3.5 percent of the Texas population in 2008, but nearly 15 percent of Fort Bend County’s population and 6 percent of Harris County residents. Memorial Hermann Heart & Vascular Institute-Southwest, on U.S. 59 near the Fort Bend-Harris county border, is located in the middle of this thriving community.

An Asian component is the latest development in a robust initiative to cater to the unique needs of the population surrounding the hospital. Memorial Hermann Southwest offers Chinese and Vietnamese interpreters throughout the hospital, bilingual nursing and clinical staff, Asian TV programming available in all patient rooms, and a guest policy allowing overnight stays in patients’ rooms.

As for procedures, we have seen an increase number of radial and pre-TAVR catheterizations.

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

Memorial Hermann Heart & Vascular Institute-Southwest offers the latest technology, state-of-the-art equipment, and high quality medical care, but our people are what make us special, beginning with the front desk, where our office secretary, Fabiola Guzman, makes patients and family members feel at ease. Our administrative staff provides the tools and supplies we need when we need them. This support, from people like Greg Blunt, our clinical support analyst who is a technical genius, is invaluable. Our catheterization lab physicians and staff, with their special, welcoming mix of backgrounds and personalities, bring a tremendous amount of talent, experience, and skill to care for each patient. The work brings us together and it brings out our best: commitment, positive attitude, and determination. It is not without a great sense of pride that we say, “I work in the Cath Lab at Memorial Hermann Heart & Vascular Institute-Southwest.”

Is there a problem or challenge your lab has faced? 

Scheduling is always a concern. One day brings challenging case after challenging case with long hours, while the next day can be slow with time to reflect. During busy times, our strong teamwork comes into play with both the manager and director jumping in to assist in the pre/post area, start IVs, pull sheaths, and even transport patients. On occasion, staff from sister Memorial Hermann hospitals float to assist us with patient care. 

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

Houston is home to the Texas Medical Center (TMC), the world’s largest medical complex. Since opening in 1945, TMC has been pioneering patient care, research, education, and prevention. Today, TMC includes 21 renowned hospitals, 13 support organizations, eight academic and research institutions, six nursing programs, three public health organizations, three medical schools, two universities, two pharmacy schools, and a dental school. Houston, thus, is a very competitive market for catheterization lab services and patients have many choices.

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?

Memorial Hermann Heart & Vascular Institute-Southwest participates in the NCDR and a multidisciplinary group from our hospital attended the 2014 meeting in Washington, D.C. Two of the best NCDR practices we have incorporated are the hydration protocol and blood transfusion reduction effort.

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?    

No. RCIS is not required; however, two staff members do have this credential. There is no incentive bonus, but the exam is paid for by Memorial Hermann Heart & Vascular Institute-Southwest.

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?  

Several staff members belong to the SICP.

Tell us about your cath lab.

Our lab is approximately 3200 square feet and employs 30 staff members. In June 2015, we will be beginning an expansion project that will increase our size to approximately 4400 square feet. We have 4 rooms, including 1 electrophysiology (EP) lab and 2 catheterization labs utilizing GE Innova imaging, and 1 hybrid lab utilizing Philips imaging. Our lab has a mix of credentials. Our staff includes registered nurses (RNs), registered radiologic technologists (RT[R]s), registered cardiovascular invasive specialists (RCIS), and registered cardiac electrophysiology specialists (RCES), some of whom hold more than one licensure and/or credential. Our staff rotates through the roles of monitor, circulator and scrub.

What procedures are performed in your cath lab?  

Our lab performs a variety of cases, including but not limited to left heart cath, percutaneous coronary intervention (PCI),

Rotablator (Boston Scientific), coronary orbital atherectomy (CSI), Impella insertion (Abiomed), intra-aortic balloon pump (IABP) insertion, carotid angiography, peripheral angiography and intervention, cryo and radiofrequency ablation with and without transseptal puncture, device implants, and valvuloplasty, and assists with thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR); additionally, when the interventional radiology (IR) lab schedule is full, IR procedures can also be accommodated in the cath lab. We have three RNs and three technologists that are cross-trained to do IR procedures; however, when a complex case is completed in the cath lab, for the physician comfort, we bring up one of our IR teams.

We average approximately 110-115 cases per week.

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

We have a fully functioning hybrid room and Osceola Regional Medical Center is preparing for our first TAVR, planned for May. 

What percentage of your diagnostic caths are normal? 

42.6% of our diagnostic catheterizations are normal.

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

Our lab has a strong radial program, with 28% of our cases completed via the radial artery, including ST-elevation myocardial infarction (STEMI) patients.

Who manages your cath lab? 

Our lab has a dynamic leadership team, with two coordinators as the first level of leadership (one RN and one RCIS), followed by the cardiac cath lab/EP/staging/IR manager and directors.

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

We do have cross training; however, our RCISs and RT(R)s are only able to monitor and scrub, as our facility prefers that only RNs give medications. Our RNs can monitor, circulate, and some can scrub. We are currently in the process of training all of our RNs to scrub.

Which personnel can operate the x-ray equipment in your cath lab? 

All of our staff can position the II, pan table, inject and handle the manifold, and only the physician or RT(R) can step on the pedal. In our state (Florida), the laws regarding fluoroscopy state that only a registered radiologic technologist or physician can step on the fluoro pedal.

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

Our facility has a radiation safety officer (RSO) for the hospital and each radiology area has a RSO delegate. We have a delegate for our labs and this person is responsible for monitoring all aspects of radiation protection and exposure. 

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

The Osceola Regional Medical Center Cardiac Cath Lab was the first lab in all of Central Florida to place the new LINQ device (Medtronic), a loop recorder that is the size of a matchstick. We were also the first lab in the area to place the new Boston Scientific subcutaneous implantable cardioverter defibrillator (S-ICD), and are currently one of the few facilities implanting the CardioMEMS heart failure monitor system (St. Jude Medical).

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

We have monthly staff meetings, weekly huddles, and frequent emails to keep our staff up to date on all changes and new information.  

How is coding and coding education handled in your lab? 

Coding is handled by the two coordinators and by the manager. All coding education presented by our division is completed by this team.

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

Everyone in all of our labs and staging area has been trained on proper sheath pulling technique. All staff is required to have 10 pulls with the preceptor present prior to doing a sheath pull without supervision.

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

We have a 6-bay staging area and are beginning an expansion project in June. 

How does your lab handle hemostasis? 

Patients post procedure my have vascular closure device such as an Angio-Seal (St. Jude Medical) or Mynx (AccessClosure) placed by our physicians in the lab at the end of their procedure or the physician may order a manual pull for hemostasis. 

Our program boasts a cardiovascular tower that manages all our cardiac patients. All of our patients requiring 23-hour observation or who are inpatient status post cardiac cath are sent to our cardiovascular unit on the 5th floor of our tower. This floor is able to care for patients post diagnostic or interventional cath. Patients may be brought to this floor post intervention with their sheath intact for monitoring until their activated clotting time (ACT) reaches our policy set level. Our diagnostic patients that have not received a closure device will have their sheath pulled immediately post procedure in our staging area, prior to transfer to the unit.

How is inventory managed at your cath lab? 

Currently our two coordinators are responsible for inventory management. Our coordinators and manager handle the purchasing of all equipment and supplies in unity with our supply chain.

Can you share more about the reason and expectations for your planned June 2015 expansion? 

Our cath lab averages about 4,000 cases a year and as mentioned previously, will be expanding our staging area to accommodate further expansion of our cardiovascular service line offerings. We anticipate further growth of our EP and cath lab service lines, as well as our interventional radiology program. We have many new services on the horizon that we hope to be able to offer to our community in the near future.

What are your plans for working through the construction?

We will be adjusting our staffing to be able to accommodate performing procedures later in the evening. Some construction will be completed at night; however, most will be completed during the day. This will require the construction team to complete the work in phases. Each phase will require shut down and enclosure of the area where work will be completed.

Is your lab involved in clinical research? 

Yes, we are currently involved in several trials. One example is INOVATE-HF (INcrease Of VAgal TonE in Heart Failure), which is comparing the safety and effectiveness of the CardioFit system (BioControl Medical) plus optimal medical therapy to optimal medical therapy alone for the treatment of heart failure.

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 corporation holds us to a higher standard in regards to door-to-balloon time. Our current threshold for D2B must be under 60 minutes. We have used a collaborative approach with our emergency department (ED), emergency medical services (EMS) teams, cath lab teams, and physicians to ensure our patients that come through the ED are treated urgently and prepped immediately for cath while our cath teams are en route. Our mean D2B time for the last quarter was 57 minutes. If the patient is brought in by EMS, our EMS teams are fabulous in identifying ST elevation, and can alert our ED and cath teams to a STEMI patient prior to arrival at the ED, allowing for the early initiation of further time-saving measures. 

We are registered with the American Heart Association’s Mission: Lifeline, and Osceola Regional Medical Center has Level 3 Chest Pain Center accreditation. We recently submitted for Level 4 accreditation.

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

Our STEMI team transports all of our STEMI patients to the cath lab 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? 

In the rare incidence during off hours that our call team is already in a STEMI case, we have several staff members and a cath lab manager who are willing to come in despite not being on call. Thrombolytics are also reviewed with the physician as a viable option. During all other hours, a team is always available.

Who documents medication administration during the case? 

We use our Mac-Lab (GE Healthcare) system to document everything occurring during the case; additionally, the RN documents the medications in the patient’s chart via Meditech.

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

The physicians utilize our dictation line to dictate their reports.

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

We report to the NCDR for our ACTION (STEMI and non-STEMI) cases, as well as CathPCI for all interventional cases. We use the Society of Thoracic Surgeons (STS) database for our open-heart program and will be beginning participation in the STS/ACC TAVR registry.

Are you recording fluoroscopy times/dosages? 

We monitor fluoro times and dose area product (DAP), and report these to the NCDR. 

How does your cath lab compete for patients? 

Our lab advertises, like most facilities; however, we also have physicians that prefer to send their patients to our facility to receive a higher standard of care.

How are new employees oriented and trained at your facility? 

All new employees are put through our standard facility orientation and then are provided a comprehensive training period with an experienced preceptor. 

What continuing education opportunities are provided to staff members? 

Our facility is constantly providing in-house educational opportunities from outside vendors, as well as assisting in the coverage of educational expenses for training completed outside of the facility. Each year, Osceola Regional Medical Center holds a stroke symposium and cardiovascular symposium. These learning opportunities provide up to eight hours of CEUs/CNEs. 

How do you handle vendor visits to your lab? 

All vendors are now required to be verified through our parent companies’ verification system. Once they have passed the verification process, vendors are required to wear a printed badge from our facility. They must check in with our coordinator and have limited access to the facility. 

How is staff competency evaluated? 

Our staff is constantly assessing the skills of their team members. Each member’s competency is re-evaluated by leadership each year. We utilize a standard set of competencies and the RN or technologist must be watched to ensure they are fully competent. In cases where a specific competency cannot be visually verified (i.e. watching a specific procedure performed) the staff member must verbalize each step in a mock scenario.

Does your lab have a clinical ladder? 

We have a clinical ladder in that there is always the availability to move up into a leadership role and then up through the leadership ladder. The current director and manager both started as nurses in the cath lab. 

Is there a particular mix of credentials needed for each call team? 

Our call team consists of two RNs and 2 RCISs. Our facility requires our technologists to have either ARRT or RCIS credentialing.

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

Our team is required to arrive at the facility within 30 minutes of call.

Do you have flextime or multiple shifts? 

We allow our teams to self-schedule and have no flex-time requirements. Our teams utilize a hospital-wide scheduling program where they schedule themselves for the days they prefer. This allows the flexibility for our staff to go to school or take care of personal concerns. The schedule is posted two weeks before the start of the schedule and is closed a week prior to allow the leadership to adjust the staffing to meet the needs of the unit.

Has your lab recently undergone a national accrediting agency inspection? 

We recently underwent our tri-annual survey by The Joint Commission. We would encourage hospitals to reach out to each other and exchange learning opportunities between their facilities. Ensure proper hanging storage of your lead, as this was something they ensured we did properly. 

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 directly above the ED and is situated between the CVOR and the CVICU to allow for smooth transition of the patient based on their needs. 

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

Based on the new appropriate use criteria (AUC) guidelines, we have seen a small decrease in our procedural numbers as we hold our physicians to tight standards in regards to AUC. Despite that, we continue to have a high number of diagnostic cases as well as EP cases as in our region. We have a high number of patients visiting our area.   

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

We have a very low turnover rate. Some staff has been with our lab for almost 20 years. We have a very close-knit team. We are constantly seeking new challenges and are excited to be gearing up for TAVR.

Is there a problem or challenge your lab has faced? 

The largest challenge we have faced is the high patient population and limited staging area. We begin construction on an updated area in June. 

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 facility is located in the heart of the tourist capitol of the world, Orlando, Florida — specifically Kissimmee, Florida — the home of Mickey Mouse. We are within a 40-mile radius of 3 theme park destinations, accounting for 10 amusement parks, as well as multiple large entertainment areas. Guests come from around the world to visit our area, and sometimes end up in our lab. This unique conglomerate of patients allows us the uncommon opportunity to interact with cultures from around world.

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? 

We do require our team members to be (or become) RCIS credentialed or to have their ARRT. Our facility will cover the cost of the exam and the team member receives additional compensation once they receive their certification. 

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

Our team members are involved with the SICP, ACC, and Heart Rhythm Society (HRS). 

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?

We present the data to our physicians and utilizing this data, as well as the NCDR Physicians dashboard, we assist them in adjusting their practices to meet appropriate use criteria. We utilize nationally reported percentiles to set goals for our physicians, staff, and lab.

The authors can be contacted via Shane Melder, RT(R), Cath Lab Radiology Supervisor, at rmelder@stph.org.

Tell us about your cath lab.

St. Tammany Parish Hospital cath lab has 4 catheterization suites: 2 dedicated cardiac, 1 cardiac/vascular, and 1 electrophysiology (EP) room. We have 21 staff in the cath lab, 

including 5 radiologic technologists (RT[R]s), 

8 registered nurses (RNs), 1 surgical technologist, 

2 assistants, 1 scheduler/clerical, 

1 radiology/technical supervisor, 

1 nurse supervisor, 1 PACS/cardiovascular information systems (CVIS) administrator, and 1 American College of Cardiology (ACC) database abstractor. There are also 7 RNs in our cardiovascular outpatient unit.

What procedures are performed in your cath lab?  

We perform diagnostic coronary catheterizations, percutaneous coronary intervention (PCI), including stents, percutaneous transluminal coronary angioplasty (PTCA), atherectomy,  EP procedures and ablations including afib ablations, bi-ventricular ICD implantations, peripheral vascular diagnostic and intervention, including management of acute and critical leg ischemia, acute and chronic deep vein thrombosis (DVT) interventions, abdominal aortic aneurysm (AAA) repairs, acute and chronic mesenteric ischemia interventions, and carotid stenting. From a structural heart disease standpoint, we perform balloon valvuloplasties and percutaneous atrial septal defect (ASD)/patent foramen ovale (PFO) repair, and mitral balloon valvuloplasty. We perform approximately 50-60 cases per week.

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

At this time, we are at more than 80% radial artery access for coronary catheterization. Improved patient comfort and lower morbidity rates are significant advantages to transradial cardiac catheterization. Even with vascular closure devices, transfemoral cardiac catheterization requires that the patient maintain a supine position for an extended period post procedure when compared to radial access cases. This can be especially uncomfortable in patients with chronic back problems. Transradial catheterization removes the need for postprocedural flat time, and most patients are able to ambulate immediately following the procedure. Transradial catheterization also has the potential to reduce procedural costs. Fewer bleeding complications equate to shorter hospital stays.

Who manages your cath lab? 

We have a department head responsible for all of cardiovascular services, a radiology/technical supervisor, and a nursing supervisor for the cath lab. 

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

Our employees are all cross-trained to accomplish multiple tasks in the cath lab. This helps with room assignments and in continuity of the lab throughout the day. All the technologists are trained to scrub, circulate, and monitor/record. All nurses are trained to circulate, administer conscious sedation and all needed medications, assess the patients before, during, and after the procedure, and monitor/record.

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 Louisiana, only the radiologic technologists and physicians are able to use fluoroscopy. Our radiologic technologists perform all of those tasks, with the physician usually operating the exposure switch/pedal.

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

Along with appropriate radiation protection training, all physicians and staff are equipped with lead aprons and thyroid shields. We also have lead hanging shields in all of the rooms for extra table side protection. We are evaluating the Zero-Gravity system (CFI Medical) to help with radiation protection as well as taking the weight of the lead off of the physicians. Every employee is assigned a radiation badge and is monitored monthly.

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

We have recently begun using the Diamondback 360 coronary orbital atherectomy system (CSI) and the CryoConsole cardiac cryoablation system (Medtronic).

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

We have departmental meetings as well as a cardiovascular committee meeting every other month. We use our email system to communicate important information to all employees. For things on a lighter note, we use our bulletin board to post hospital-wide information as well as information on a wide array of topics.

How is coding handled in your lab? 

Our PACS/CVIS administrator is responsible for setting up and monitoring all of the charges and billing for the cath lab.

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

The radiologic technologist scrubbing in the case will pull sheaths post diagnostic cases. Post intervention, the sheath is pulled in our cardiovascular outpatient unit area by one of the RNs. Training is done during the three-month orientation process through a review of training, demonstrations, and oversight by the senior technologists and nurses.

How is inventory managed at your cath lab? 

We have an inventory management system along with Pyxis supply stations (CareFusion) that help with the inventory process. Our charge tech handles all of the ordering of supplies with communication through the materials management department.

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

Compared to previous years, we have noticed an increase in patient volume over the past 12 months, resulting from physician alignment, patient population, and the formation of strategic partnerships.  

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? 

For the St. Tammany Parish Hospital year-to-date 2015 acute myocardial infarction (AMI) D2B times, 67% are less than 60 minutes. Our mean time is 56 minutes with a median of 49 minutes. All cath lab staff and cardiologists, along with emergency physicians and staff, are engaged in AMI and D2B quality outcomes.  

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

The cath lab team always meets the cardiologist performing the PCI in the emergency department (ED) and transports the patient to the cath lab.

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

We try to limit any elective cases done after hours or on the weekend to alleviate this problem. If procedures are going on in the lab during normal hours and there isn’t an available room, the charge tech makes the decision as to which procedure is stopped to make a room available. If a STEMI arrives after hours while the call team is doing another procedure, then the decision is made to bring in another team to assist.

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

All of our employees are very conscious of the reality that cost is a major concern and do everything in their power to keep that a priority. We keep the correct amount of inventory on hand without having to worry about items expiring by using the JIT (just-in-time) ordering system. It enables us to keep less inventory on hand and resupply as needed. Most of our high-dollar items are consigned, removing the burden of being responsible financially for those items going out of date. We continuously work with vendors to get the best pricing possible through various contracting structures.

What quality control/quality assurance measures are practiced in your cath lab?

We use ACC National Cardiovascular Data Registry outcome reports to drive quality. Additionally, we perform patient rounds on post cath patients to discover any potential quality indicators. All complications are also peer reviewed for quality. The hospital’s decision support and process improvement department also monitors several metrics through several benchmarking organizations.  

Are you recording fluoroscopy times/dosages? 

This is automatically recorded and documented in the procedure record via an interface between the x-ray system and the hemodynamic system.

Who documents medication administration during the case?

Medications are recorded in the hemodynamic system (GE Mac-Lab) and Pyxis system by the circulating nurse in the case.

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

The majority of the report is documented throughout the case on the hemodynamic system. At case end, the data is exported to a structured reporting tool (GE Centricity cardiology data management system) in the physician reading room. The physicians will then log in and dictate the indication, findings, recommendations, and conclusions. The report is then electronically signed by the physician and sent to our EMR.

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

Last year, the hospital employed a cardiology practice. We also formed a partnership with Ochsner Health System that is contributing to the growth of our cath volume.    

How are new employees oriented and trained at your facility? 

All new employees have a three-month orientation and training regimen in our facility. After a general hospital orientation, each new staff member is assigned a preceptor for department orientation. Using a skill checklist, new employees are checked off once they are deemed competent for that certain skill. For someone completely new to the cardiac cath lab, orientation can be extended until the employee is competent to take call. 

How do you handle vendor visits to your lab?

We only allow one representative per day. They have to be in good standing with our Reptrax system.    

How is staff competency evaluated? 

Hospital-wide nurse competency requirements are coordinated through the education department. Department-specific competency is evaluated by management, senior personnel, and physician input.

How does your lab handle call time for staff members? 

We have a three-person team that takes call one night a week and one weekend a month. 

What kind of relief is offered to staff after a busy night of call? 

We try to be reasonable in these situations. If the schedule allows, we will definitely send those team members home early if they would like. They do have to use their paid time off for those hours missed.

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

The staff is expected to be here within 30 minutes.

Do you have flextime or multiple shifts? 

All of our shifts are 10 hours (6:30am–5pm).

Has your lab recently undergone a national accrediting agency inspection? 

The hospital recently completed the reaccreditation process with the Society of Cardiovascular Patient Care and was again recognized and accredited as a Chest Pain Center with Primary PCI.  

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

The OR is one the same floor and directly down the hall. Our ED is one floor down in the same building. 

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

We see more and more patients each year coming to the lab with heart disease at a young age, some in their upper 20s and quite a few in their 30s. We are also seeing an increased number of AMIs each year.

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

Our cath lab staff is highly experienced and engaged in their profession. Each holds the others to very high expectations and levels of performance. It is truly a multidisciplinary team that works together for optimal performance and quality outcomes.    

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

As a suburb of New Orleans, the culture of our area is very strong and often diverse. We see patients from varying socioeconomic status levels and our staff is able to respond to each in a professional and caring way. Our work culture is one of dedication and high performance, and one that also likes to have fun both away and at work. We have strong teamwork and trust. 

Learn more about St. Tammany Parish Hospital at stph.org.

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? 

Not at this time.

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. 

Tell us about your cath lab.

We currently have four cath labs staffed with registered nurses (RNs), technologists, and technical associates. Staff longevity ranges from two months to 27 years, with an average of about 12 years. We have several advanced-level certified team members: an RN and registered cardiovascular invasive specialist (RCIS), two certified emergency nurses (CENs), three critical care registered nurses (CCRNs), an American Association of Moderate Sedation Nurse (AAMSN) and one registered radiologic technologist (RT[R]). We have two Philips and two Siemens rooms. We added a biplane system about 2 years ago that is used for both neuro and peripheral procedures. Every staff member has certification with the National Institutes of Health Stroke Scale (NIHSS) to support our neuro interventional and BAT (Brain Attack Team) team role.

We proudly celebrated the completion of our 100,000th procedure this past winter. The first coronary angioplasty at Baystate was performed in 1981 by Dr. Marc Schweiger. Our primary PCI program includes 12 interventional cardiologists who belong to three distinct groups. They share the interventional call responsibilities equally and work in a collaborative manner. Baystate received the American Heart Association’s Mission:Lifeline Silver Plus award this year for quality outcomes in ST-elevation myocardial infarction (STEMI) patients.

What procedures are done in your cath lab?

Procedures done in the lab include:

• Left and right diagnostic catheterization;
• Percutaneous coronary intervention (PCI), which may include the use of intravascular ultrasound (IVUS), fractional flow reserve (FFR), iFR (instant wave-free ratio), AngioJet (Boston Scientific) and Rotoblator (Boston Scientific);
• Device implants, intra-aortic balloon pump (IABP), Impella (Abiomed);
• Peripheral diagnostic and interventional cases (interventional cases may include use of the Diamondback 360 orbital atherectomy device [CSI]);
• Aortic angiography, carotid angiography and stenting;
• Visceral angiography and interventions;
• Structural heart procedures such as patent foramen ovale (PFO)/atrial septal defect (ASD) closure, and valvuloplasty;
• Kyphoplasty and vertebroplasty;
• Neurovascular angiography and interventions (coiling, stenting, and embolization [arteriovenous malformation (AVM)]).

We have 24-hour, seven days/week call for both the cardiac STEMI team and neuro BAT team. We perform 295 cases/month, averaging about 75 cases per week. Of these cases, 250 monthly are cardiac catheterizations. Each quarter, we perform anywhere from 280-325 PCIs. Our neuro interventions are rapidly increasing with the recent studies in favor of endovascular treatment for stroke.

Do you perform transcatheter aortic valve replacement (TAVR)?

We have been performing TAVR for approximately two years. TAVRs are conducted in our Heart & Vascular endovascular suites, designed specifically for hybrid procedures. Our team consists of cardiac surgeons, interventional cardiologists, and cath lab and OR staff. We have completed over 80 cases to date.

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

More than half our physicians perform radial procedures. About 20% of our caths are performed via radial access. 

Who manages your cath lab? 

The manager of our cath lab is Corey McKinstry, cardiovascular technologist (CVT). She is a retired Air Force veteran of 21 years. Corey worked in the lab as a cardiovascular technologist for 10 years and became the manager in 2012. The cath lab medical director is Dr. Greg Giugliano, who has been at Baystate since 2003 and is a practicing interventionalist. They work together and collaborate across the Heart & Vascular Center with the HVOR, cardiothoracic surgeons, vascular surgeons, and interventional radiologists, to manage inventory and achieve a common set of goals.    

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

Our lab always maintains a team approach. All the members of this team train and are competent in all roles. Everyone monitors, circulates and scrubs for the cases. Only the RN administers medications, conducts patient assessment, and provides moderate sedation. This provides flexibility for staffing and schedule changes. 

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

According to the Massachusetts state law, only radiologic technologists, physicians, and physician assistants with training are permitted to operate the x-ray equipment. Our physicians manage the pedal and maneuver the table.

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

Our department supplies all staff and physicians with lead vests and skirts or aprons, which are inspected annually by our radiation safety department. Our department also supplies each employee with his/her own pair of radiation protective glasses, as well as lead scrub caps for the physicians. In addition to the protective equipment, we wear dosimeters that are collected monthly and analyzed to monitor exposure. Each procedure room has lead aprons mounted to the bottom of the procedure table to protect the lower section of the body and lead shields to protect the upper section of the body. We have a daily radiation reporting system to monitor patients who receive a high fluoroscopy doses. In those particular patients who have received a dose above our radiation threshold, the medical director notifies the performing physician, radiation safety department, and the patient by formal letter. The clinical follow-up is subsequently arranged to identify both early and late sequelae.

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

We recently updated to a new IVUS/FFR/iFR system from Volcano. We have upgraded to the Impella CP system for left ventricular assistance, as well as the Pipeline embolization device (Covidien) and Solitaire thrombectomy device (Covidien) for our neuro service line. We also have peripheral drug-eluting balloons and stents.

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

We have staff meetings monthly, educational inservices, and email frequently. We have a Facebook page and also use an internal social media website.

How is coding and coding education handled in your lab? 

We use the Horizon Cardiology Charge manager (McKesson). Procedures are chosen and procedure codes are attached. Supplies are scanned. We have a comment area in the charge worksheet online to which the coders have access. The staff can leave notes if they are unsure what to choose, or want to explain complexity or special events such as aborting a procedure. The coders review all cases and ensure proper coding before charges are submitted. We also developed a post-procedure checklist that is completed in the recovery room. High interest areas are addressed to avoid errors and rework. 

Can you describe the path to hemostasis for both interventional and diagnostic procedures? 

Whether an interventional or diagnostic procedure, our physicians may utilize a closure device. If a closure device is not used, sheaths are removed in the recovery room. Hemostasis is achieved by manual pressure if the activated clotting time (ACT) is <180 seconds. If sheaths are sutured in place, patients are returned to their nursing unit after recovering for a minimum of 30 minutes. Sheaths are pulled by cath lab staff, certified floor staff or cardiology fellows two hours after an interventional procedure. 

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

During orientation, staff is instructed in proper sheath removal and hemostasis. Each orientee must successfully remove 12 sheaths and achieve hemostasis in preparation to perform this task. Upon completion of orientation, staff members are required to remove 10 sheaths per year with successful hemostasis in order to maintain competency.    

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

Patients arrive to the lab with groin or radial sites clipped. Patients are then placed on the procedure table, and access sites are prepped, scrubbed, and draped by an RN or CVT assigned as scrub staff per case. Post procedure, patients are recovered in our four-bed recovery area. If no closure device is used, the sheaths are pulled by recovery area staff. If a closure device is used, the sheath is pulled by the fellow or attending physician prior to closure device deployment.

How is inventory managed at your cath lab? 

Our inventory technician works for the manager of the lab. He uses Vuemed/Lawson to order and keep track of stock levels. A Heart & Vascular Value Analysis team reviews and evaluates requests for new equipment. An e-requisition application was recently implemented to allow for electronic approval with set approval levels.    

Is your lab involved in clinical research? 

Baystate Medical Center Heart & Vascular has an active research department. We have been involved in many clinical research trials, including investigational pharmaceuticals and device trials. Recently we completed enrollment in the worldwide EXCEL study that randomized patients with left main disease to coronary artery bypass graft surgery (CABG) or PCI. Currently, we are participating in the Multi-center Prospective Study to Evaluate Outcomes of the Moderate to Severely Calcified Coronary Lesions (MACE trial). This is a CSI-sponsored, real-world study to determine if increasing severity of calcification within coronary arteries can be correlated with outcomes.

Who handles relevant data and its entry into the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)?

Our physicians enter the pre-procedural information into our McKesson hemodynamic reporting system. This information is double-checked by the cath lab staff both before and after the procedure. We have a dedicated Heart & Vascular Quality Outcomes Department that is then responsible for data collection and reporting outcomes for cath/PCI.

Can you tell us about your STEMI program?  

Baystate Medical Center is involved with the American Heart Association’s Mission:Lifeline, a program designed to enhance national STEMI care, and American College of Cardiology’s D2B Alliance. Mission:Lifeline has over 900 hospitals that perform emergency coronary angioplasty. Baystate Medical Center is the 6th highest volume program across the nation. Our average door-to-balloon time is 57 minutes. During regular hours of 7:00am to 7:30pm, our average door-to-balloon time is 50 minutes. During off hours of 7:30pm to 7:00am, our average door-to-balloon time is 60 minutes. We have the highest volume of STEMI patients within the Commonwealth of Massachusetts. All of our referring hospitals, emergency medical services (EMS), and hospital staff contribute to the positive outcomes and receive feedback from the regional STEMI coordinator. 

When do you start the “clock” for door-to-balloon times?

We use the earliest documented time in patient’s medical record to determine the start time. This may be the triage time or the time of the first electrocardiogram (ECG).

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

Due to our unique geographic regions, we are challenged with time and distance when caring for a critical STEMI patient. All STEMI patients at non-PCI hospitals with anticipated long transfer delays will receive fibrinolytic therapy (if not contraindicated) and then be transferred to Baystate Medical Center for a cardiac catheterization. When a STEMI patient is admitted directly to Baystate Medical Center Emergency Department (ED) transported via EMS, the 12-lead ECG is transmitted to the ED staff and the cath lab from the field. The ED communicates with the cath lab and the patient is evaluated by the cardiology fellow and/or the interventional cardiologist in the ED on regular hours. The patient is then transported to the cath lab with the nurse, nursing support, and the cardiology fellow. If the cath lab team is ready and waiting both during regular and off hours, EMS will transport the STEMI patient directly to the cath lab if there is no reason to be evaluated in the ED. If the cath team is not readily available when the patient arrives from a referring hospital, the patient is assessed in the ED and then transported by the ED staff caring for the patient.

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

When a STEMI arises during the hours of 7:00am to 5:30pm, we assess the progress of all four rooms and the first room that has the best opportunity for starting or stopping takes the case. The flow coordinator collaborates with the on-call physician to identify who will perform the case. During off hours, if an emergency patient is undergoing a cardiac cath and another STEMI presents to the ED, an available cardiology fellow/physician assistant (PA) will evaluate the patient. Depending on the progress of the STEMI patient on the table, we will either call for the patient as soon as possible or the patient will be treated with lytic therapy. The patient will either be monitored in the ED or Heart & Vascular Critical Care (HVCC). Under rare circumstances, we will ask the HVCC nurse to transport the completed STEMI case, so that the cath lab team can turn the room over and proceed with the next emergent case.

What quality control/quality assurance measures are practiced in your cath lab? 

We have many quality improvement committees and programs. The staff participates in collecting the data and it is reviewed during Heart & Vascular Performance Improvement committee meetings. We also have a quality program for our point of care. This is managed by the hospital reference lab and maintained by a CVT in the cath lab.

Who documents medication administration during the case? 

Horizon Cardiology is our documentation and reporting system. The monitor role documents all events during the case, including medication administration. A procedural report is printed at the end of the case and transported to the floor with the patient. This tool is used for handover and then scanned in the electronic medical record (EMR).

How do you handle vendor visits to your lab?

Vendors use a program called Reptrax. They must have an appointment to be in the lab and cannot go into a procedure unless they have been asked to support a specific case.  Our vendors must wear red scrub hats in the clinical area.

How are new employees oriented and trained at your facility? 

New employees start with a hospital orientation to review hospital-wide applications and programs. Upon arrival to the cardiac cath lab, they are assigned a preceptor and are guided by an extensive checklist. At the end of their training, they begin “buddy call” to familiarize themselves with the nuances of STEMI call after hours.      

What continuing education opportunities are provided to staff members?

Twice a week, we have 1 hour of in-service. Classes are arranged to provide education on new equipment and procedures, required re-occurring training, and special areas of interest. Staff, physicians and manufacturers’ clinical specialists present the information.  Also, we have hospital symposiums. Specialty associations provide CEU (continuing education unit) opportunities. On occasion, staff is chosen to attend regional conferences.  

How is staff competency evaluated? 

Once a year we have a mandatory skills night. We have stations for equipment, where information and procedures are reviewed. Staff has hands-on practice and the ability to ask questions. A checklist must be completed. Food is provided and it is a rare opportunity for the entire staff to be together without the pressure of workload requirements.

Does your lab have a clinical ladder? 

Career development is an important facet of our cath lab. Personal and professional growth is encouraged. RNs participate in the Hospital Nursing Clinical Recognition Program, or “clinical ladder”. This ladder consists of four levels of professional expertise based on Patricia Benner’s work, From Novice to Expert. We have adapted this to provide a clinical ladder for our cardiovascular technologists.

Each level is awarded a wage increase and requires an increase in responsibility and building of leadership behaviors. Annual performance evaluations include a revalidation of each individual’s maintenance of the standards required for their clinical level.

Initial and maintenance documentation include a resume, a detailed self-assessment, clinical narratives, and peer and manager evaluations.

Movement on the clinical ladder is based on clinical competence, pertinent knowledge base, education, professional development, participation in institutional programs and initiatives, and specialty certifications. A one-time bonus is awarded when the first specialty certification is achieved. Currently, RCIS certification is required for CVTs to advance to Level IV.

Maintenance of higher levels results from consideration of: participation in cath lab projects, quality assurance, precepting new employees, providing in-service education, maintaining unit-based competencies, and completing required hospital-wide, web-based training. Becoming a super-user, project champion, lead trainer, room lead, and patient flow coordinator are also considerations.

The clinical ladder encourages individuals to consistently evaluate their clinical practice and professional growth. It also fosters an attitude that keeps us flexible and ready to take on new procedures and challenges.    

How does your lab handle call time for staff members? 

The call teams are developed at the beginning of the year and the calendar is posted independently from the daily schedule. A STEMI team is comprised of 3 people. At a minimum, one must be a nurse. Our BAT team is a hybrid team, which has minimum of an RN, one CVT/RN and one RT(R).    

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

We have a 30-minute response time for both teams.   

Do you have flextime or multiple shifts? 

We have multiple shifts to adjust to fluctuations in volume: 12-, 10-, and 8-hour shifts keep the lab open from 7am until 7:30pm.    

Has your lab recently undergone an accrediting agency inspection? 

We had 3 visits in one year from The Joint Commission, Massachusetts Department of Public Health (DPH) and DPH for Radiation Safety. Contrast and warmers, tracking lead inspections, and labeling trays were some of the items that were highlighted. 

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

The Emergency Department is located on the ground floor of the Davis Family Heart & Vascular Center. The Heart & Vascular endovascular suites that specialize in cardiac and vascular surgical procedures (HVOR) are located on the second floor. It takes under 3.5 minutes to get to the HVOR and from the ED to the cath lab. Our future home in the Davis Family Heart & Vascular Center was designed to have direct elevator access to the helicopter pad, HVOR, and ED. 

Is there a current challenge faced by your lab?

The most challenging problem is being fiscally responsible while responding to the unpredictable volume. We have sampled different work schedules and work flows to best meet the needs of the patient while still striving to be efficient. Dedicated staff has been the key to our success.

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”? 

Baystate is the only PCI receiving center in Western Massachusetts. We have 10 referring non-PCI hospitals as part of our regional STEMI program. We have a very diverse patient population that may live in rural towns over 2 hours away or come from the inner city of Springfield. We have the busiest emergency room in the state of Massachusetts and treat more patients with STEMI than any other hospital in the state. We serve a large minority population in Springfield that is primarily Hispanic. Our staff adjusts their approach to patient care to provide an individual experience to suit the patient’s needs. 

A question 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? 

To receive a Level 4 as a Heart & Vascular Tech, you must have your RCIS. The RCIS is credential is one of several options for the Clinical Level 4 RNs. We have partnered with the Hoffman Heart Institute and are a clinical site for their RCIS program. A study program was conducted during our weekly in-services and there are several staff currently scheduled to take the RCIS certification exam. Upon successful certification, all staff is reimbursed for the test and receives a monetary bonus. 

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 report to the national ACC-NCDR registry in addition to the Massachusetts PCI registry. The interventional cardiologists review outcomes data collected by our cardiovascular outcomes department to verify the information on a quarterly basis prior to submission to these groups. We evaluate how we compare to the rest of the country to identify areas for improvement. For example, about a decade ago, we used this data to identify an area for improvement with regard to vascular complication rates and initiated multiple changes that resulted in a dramatic reduction in vascular bleeding.  

Mike Colgate, RCIS, MPH, Lead Cardiovascular Technologist, can be contacted at mike.colgate@samc.com. Katherine McCardell, RN, Heart and Vascular Services Director, can be contacted at katherine.mccardell@samc.com.

Tell us about your cath lab.

Saint Agnes Medical Center is a 436-bed acute care hospital with a comprehensive heart and vascular service line. We are a ST-elevation myocardial infarction (STEMI) receiving center, with a combined cath lab/interventional radiology (IR) department. Housed within the department are three dedicated Philips cardiac cath suites and two IR suites. The cath lab and IR employ separate staffing, utilizing teams of registered nurses (RNs), registered cardiovascular invasive specialists (RCISs) and registered radiologic technologists (CVRTs). The cath lab operates with 9 RNs, 5 RCISs, 4 CVRTs, and 4 supporting staff members who each have between 5 and 25 years of experience.

What procedures are performed in your cath lab? 

The following procedures are performed in our cardiac cath lab: diagnostic and interventional angiography, cardiac rhythm management (CRM), electrophysiology studies (EPS)/ablations, 

peripheral revascularization, abdominal aortic aneurysm (AAA) repair, and structural heart procedures. We serve 40 cardiologists that include diagnosticians, interventionalists, and electrophysiologists. Approximately 80 to 90 procedures are performed each week.

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

In April 2014, Saint Agnes became the first area hospital to offer the TAVR procedure, and has since performed 28 cases utilizing the Philips Allura FD20. Multiple disciplines from both the cardiac cath lab and cardiovascular operating room (CVOR) are involved in the procedure. The synergy created by this collaboration is the driving force of our success. 

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

Our cath lab operates with informal surgical back up. Formal back up is available upon request for high-risk percutaneous coronary intervention (PCI).

What percentage of your diagnostic caths are normal?

Approximately 10 percent of our diagnostic caths are normal.

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

Approximately 35 to 40 percent of our interventional cardiologists utilize radial access for diagnostic and interventional procedures.

Who manages your cath lab? 

Practice coordinators George Nan, RN, and Bryan Weiss, RN, along with RCIS lead Mike Colgate, manage the cath lab’s daily operations. These positions are governed by a nurse manager under the supervision of the Heart & Vascular Services Director, Katherine McCardell, RN, and Cardiac Cath Lab Medical Director, Rimvydas Plenys, MD. 

Who scrubs, who circulates and who monitors? 

The scrub role is shared by all 3 disciplines. The circulating role, however, is only assigned to RNs. The monitor role is shared by both RCIS and CVRT staff.Are there licensure laws in your state for fluoroscopy?  

Yes. The staff operates under the direct supervision of the performing physician who holds a fluoroscopy license in the state of California. In addition, all CVRTs are licensed by the state of California for the use of fluoroscopy. Performing physicians and licensed CVRTs are the only individuals authorized to position the tube, pan the table, change angles and step on the fluoro pedal.

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

We have a designated CVRT who is given the role of radiation safety officer. He/she reports to the radiology department. All physicians and staff utilize lead aprons, lead glasses, and dosimetry badges. These badges are reviewed and renewed on a monthly basis.

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

Our three cardiac suites recently underwent comprehensive upgrades. We utilize Philips Healthcare Systems: 2 Allura FD 10s and 1 Allura FD 20. All three suites feature FlexVision to integrate multiple IS modalities onto the 56-inch flat-panel display monitor. Stentboost, along with the latest software and hardware release, allow staff to easily navigate from suites. We have also incorporated Volcano’s CORE and St. Jude Medical’s ILUMIEN systems for intravascular ultrasound (IVUS), fractional flow reserve (FFR), and optical coherence tomography (OCT) at tableside.

We use St. Jude Medical’s WorkMate for recording of all EP studies/ablations. All 3-D mapping and ablation procedures are navigated by Biosense Webster Carto 3 and St. Jude Medical’s NavX Velocity.

Our TAVR program employs both Edwards Sapien and Medtronic Core Valve for optimum patient outcomes.    

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

Our lab has monthly staff meetings, as well as daily morning huddles. In addition, our cath lab leadership team attends the monthly cardiology meetings to discuss operational and policy issues.

How is coding and coding education handled in your lab? 

All coding is performed by a dedicated clinical revenue specialist, Cynthia Martinez. Coding education is administered through corporate and vendor webinars.

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

Routinely, femoral sheaths are pulled in our post-procedure recovery area by RNs. At the physician’s request, clinical cath lab staff may be called upon to pull sheaths in the procedure room or in the post-procedure recovery area. All radial sheaths are pulled in the procedure room immediately after procedure, utilizing the Terumo TR Band.

All staff must be validated for sheath pulls. This requires five successful sheath pulls.

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

All patients are prepped and recovered in our 35-bed Cardiovascular Recovery Area (CVRA). This area is staffed by RNs, a licensed vocational nurse (LVN), and clinical assistants, who perform all preop prep and postop sheath pulls and recovery care.

Hemostasis is achieved by both manual compression and vascular closure devices. We utilize Abbott Vascular’s Starclose and Proglide, St. Jude Medical’s Angio-Seal and FemoStop, and AccessClosure’s MynxGrip. Vascular Solutions’ D-Stat Dry Patch can be used with manual compression.

How is inventory managed at your cath lab? 

The cath lab utilizes Omnicell for inventory management and patient equipment charges.  The RCIS lead and the supply chain system administrator work in conjunction to purchase equipment and manage inventory par levels.

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

The cath lab recently underwent a two-and-a-half year renovation of all procedural rooms. Construction began July 2015 on a fourth suite, which will be a hybrid suite specializing in TAVR, peripheral, and EP procedures.

The Saint Agnes cath lab is on track to increase our volume by 10 percent. Our success is a direct result of our commitment to offer a service-oriented, high-quality experience, for our patients and physicians. Our workflow, as it pertains to throughput of pre- and post-areas, electronic medical record (EMR) and information systems (IS) interfaces, aids us in achieving this goal, which ultimately has an impact on growing our volume.

Is your lab involved in clinical research?

Not at this time. However, we are actively looking to participate in future trials.

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?  

Based on data from the last 12 months, we are currently averaging D2B times of 59 minutes — well below the national standard of 90 minutes. The STEMI team is comprised of four clinical staff members and has a required 20-minute response time. All suites are fully equipped to emergently perform acute myocardial infarction (AMI) procedures. The hospital maintains an integrative AMI committee comprised of the emergency department (ED), quality department, cath lab, cardiovascular (CV) diagnostics, and clinical cardiology, in conjunction with administration. This committee meets monthly for case review, enhancement of protocols for early activation, and to streamline patient throughput. There is same-day review of STEMI cases with delayed door-to-electrocardiogram (EKG) times. Emergency medical services (EMS) maintains protocols to active the STEMI team from the field in order to decrease door-to-balloon times. 

We are not currently registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance.

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

All STEMI patients are transported to the cath lab by two clinical cath lab staff members.

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

In the event a STEMI comes to the ED when the call staff is in the middle of a non-emergent procedure, communication takes place between both physicians. An arterial line is secured and the patient is transported to CVRA for observation.

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

We have implemented a Unit Based Council comprised of cath lab and CVRA staff. This Council meets monthly to evaluate workflow, patient throughput, and policy and procedures in order to streamline and reduce duplication of efforts. Our Value Analysis Team (VAT) meets monthly to review all equipment and product trends to promote standardization of equipment and reduce costs.

What quality control/quality assurance measures are practiced in your cath lab?

The cath lab quality assurance and control measures include, but are not limited to, the following: universal protocol or “time out,” radiation safety and reduction, appropriate and consistent hand hygiene, correct sponge accountability, accurate “point of care” testing, and minimizing contrast utilization.

Are you recording fluoroscopy times/dosages? 

Fluoroscopy times/dosages are manually entered into the Philips Xper procedural log.  We are currently evaluating the use of Philips’ Modality Performed Procedure Step (MPPS) to electronically transmit all numeric fluoroscopy data.

Who documents medication administration during the case?

The RN circulator records and documents all medication administration and conscious sedation.

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

Physicians are currently dictating their cath reports. However, structured reporting is currently being evaluated for efficacy and workflow.

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

Yes. We currently participate in the CathPCI and Implantable Cardioverter Defibrillator (ICD) Registries.  

How does your cath lab compete for patients? 

In April 2015, Saint Agnes Medical Center and Dignity Health signed a definitive agreement that will expand health care resources for patients and physicians from Stockton to Bakersfield.  

How are new employees oriented and trained at your facility? 

New employees are placed on a 6-month probationary period. They are assigned a preceptor who is responsible for their orientation and training. Weekly evaluations are conducted to monitor progress. Physician and peer input is solicited to determine whether or not the individual is retained or the probation period extended. 

What continuing education opportunities are provided to staff members?

Continuing education opportunities are provided by approved American Society of Radiologic Technologists (ASRT)/Board of Registered Nursing (BRN) vendor in-services and webinars, the Heart & Vascular clinical educator, and hospital-based educational conferences.

How do you handle vendor visits to your lab?

The hospital utilizes RepTrax for the management of outside vendors and representatives who visit the cath lab. All must wear a RepTrax identification badge and adhere to policies and guidelines that direct their role in the cath lab. Vendors/representatives must obtain prior approval to obtain access to the cath lab. There are guidelines to ensure competing vendors are not present on the same day. At the request of a physician, vendors/representatives are allowed in the procedure rooms to assist with procedures.

How is staff competency evaluated? 

Annual comprehensive evaluations are conducted for merit-based compensation and retention. The evaluations are conducted with a physician and peer. Computer-based competencies are performed to maintain hospital policies and procedures.  

Does your lab have a clinical ladder? 

All clinical disciplines have merit-driven ladders based on licensure/registry, years of experience, and hospital committee and project involvement.  

How does your lab handle call time for staff members? 

Staff members average 8-10 call shifts per month, including weekends. Call teams require four staff members that include two RNs and two RCISs or CVRTs for all cardiac cases. The cath lab maintains a required 20-minute response time from activation

Do you have flextime or multiple shifts? 

Flextime and multiple shifts are not a common practice. All clinical staff members work 12-hour shifts.

Has your lab recently undergone a national accrediting agency inspection? 

The hospital underwent successful Joint Commission accreditation in July 2014. We recommend paying careful attention to the following: ensure pre-procedure history and physicals (H&Ps) are complete and accurate, and ensure proper charting in EMR as it relates to plan of care and medication administration.

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

The three cath lab suites and four cardiothoracic (CT) operating rooms are adjacent and are located two floors above the emergency department. 

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

Utilization of radial access has increased for both diagnostic and interventional procedures. TAVRs and high-risk PCIs with mechanical support (Impella, Abiomed) have modestly increased in volumes. In addition, EP/afib ablation procedures continue to grow at a steady pace. Unfortunately, co-morbid conditions and varied advanced diseases are seen in a majority of patient populations.

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

The cardiac cath lab maintains a dynamic partnership with numerous vendors, which integrates forward thinking and state-of-the-art technology to benefit our patients and physicians.

The staff has invested a tremendous amount of time evaluating workflow and case navigation from start to finish. The goal has always been to reduce time and expedite physician throughput by streamlining workflow.

Is there a problem or challenge your lab has faced? How was it addressed?

Case turnover time has markedly improved with metric-based solutions. Utilizing Philips Xper Information Management System and charting, we have improved patient case flow, increased efficiency, and exceeded physician satisfaction. These metric-based solutions have decreased our average case turnover time to less than 10 minutes.

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 city of Fresno is located in the heart of California, in the fertile San Joaquin Valley — what many describe as the agricultural capital of the world. Unique to Fresno is its cultural diversity, representing more than 80 different nationalities. With such diversity comes language and cultural differences that Saint Agnes must be careful to address in its delivery of care. To that end, we offer audio and visual interpreter services to assist in integrating the patient and family in the cardiovascular plan of care. In addition to audio and video interpreter services, educational materials are also printed in multiple languages.

Read more about Saint Agnes Medical Center and their technological and systems expertise! 

Don’t miss Cath Lab Digest’s April 2015 interview:

“Saint Agnes Medical Center Improves Cardiovascular Workflow with the Philips Xper Flex Cardio with Xper IM”, online at: http://www.cathlabdigest.com

U Mass Memorial Health Care (UMMHC) is a dominant health care system in central Massachusetts. UMMHC is a non-profit organization integrated with the University of Massachusetts Medical School. It consists of four hospitals with 1125 beds throughout the system. Our department is called the Heart and Vascular Interventional Laboratory (HVIL), and is located on the University Campus of the flagship UMass Memorial Medical Center, the only hospital in the UMMHC system with a full-service catheterization laboratory. We provide primary to quaternary health care for the integrated UMMHC system and serve as a regional myocardial infarction center for central Massachusetts, as well as parts of Connecticut and New Hampshire. We provide the most advanced technologies in electrophysiology (EP), interventional cardiology, and interventional vascular procedures. 

What is the size of your lab?

The HVIL consists of a suite of 7 contiguous procedure rooms, plus a hybrid operating room located within the general OR. Of the seven main procedure rooms, two are primarily dedicated to cardiac procedures, two to EP procedures, and one to peripheral procedures. A third cardiac room is peripheral-capable and a seventh serves as a multifunctional “swing” room that can be used for a wide array of procedures. The hybrid operating room is used for transcatheter aortic valve replacements (TAVR), endovascular graft implantations, and repairs of ruptured abdominal aortic aneurysms. It is staffed by both HVIL and general OR personnel. 

Whatis the mix in your lab?

The HVIL was formed from an integration of cardiac, electrophysiology and vascular staff, in a move to improve overall operating efficiency and patient flow, and consolidate costs. The staffing mix is flexible and based on patient acuity. Typical staffing for cardiac and EP cases consists of 1-2 registered nurses (RN) and one radiologic technologist (RT). Vascular cases are frequently staffed with 1 RN and 2 RTs. In addition to our clinical staff, there are 2 clinical quality managers, a supply coordinator, 2 patient care associates, and 4 ambulatory service representatives. We also have 2 dedicated IT specialists, 1 database coordinator, and 1 coding specialist. Our staff longevity ranges from one year to forty years with an average of 17 years experience.  

What procedures are performed in your lab?

We perform a wide array of diagnostic and interventional vascular, EP, and cardiac procedures.  In addition to standard vascular peripheral and carotid procedures, our vascular surgeons perform dialysis fistula repair, tunnel catheter insertion, and placement of inferior vena cava (IVC) filters, as well as endovenous laser treatment. Our electrophysiologists perform insertions of implantable cardioverter defibrillators (ICDs) and single and dual-chamber pacemakers, along with complex ablations for ventricular and atrial arrhythmias, including atrial fibrillation using cryoballoon, and hybrid percutaneous and surgical ablations. Our interventional cardiologists perform complex percutaneous coronary intervention (PCI) using rotational, orbital, and laser atherectomy supported by imaging modalities such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), and if necessary, percutaneous left ventricular (LV) support using a balloon pump, Impella (Abiomed), or even extra-corporal membrane oxygenation. In addition to TAVR, our interventional cardiologists also perform structural heart interventions such as aortic, mitral and tricuspid valvuloplasty, and atrial-septal defect (ASD) and patent foramen ovale (PFO) closures.

How many procedures are performed per week?

We are prepared 24/7 for any and all cardiac or peripheral emergencies. In 2014, we averaged 57 cardiac diagnostic cases per week and 26 PCIs per week, of which 5 were primary PCI for ST segment elevation myocardial infarctions (STEMIs). In addition to 2974 diagnostic cardiac catheterizations and 1369 PCIs, we also performed 866 peripheral diagnostic cases, 931 peripheral interventional cases, and 2199 EP cases, for a total of 8,339 procedures performed in 2014. Unlike most catheterization laboratories with a high percentage of elective cases, only 22% of our cases are elective (compared to 35% nationally), with 52% being urgent and 26% being emergent (compared to 46% and 19% nationally, respectively).

Can you tell us about your TAVR program?

We began the TAVR program in 2013. From January to July 2015, we have performed more than 40 TAVR procedures in the OR/hybrid room. The TAVR team is an organized collaboration between OR and HVIL staff. After establishing a core TAVR group, we are now educating additional personnel to increase the number of TAVR-ready staff. 

What percentage of your diagnostic caths is normal?

The incidence of non-obstructive disease found on elective diagnostic catheterizations averages around 40%, which is slightly lower than the 43% median for other American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) participants. However, elective cases constitute only 22% of our cardiac volume, with urgent or emergent cases having a much lower incidence of non-obstructive disease.

Do your physicians utilize radial access?

Approximately 90% of all our cases are radial access (ACC-NCDR PCI Registry). The rate of radial access for STEMI is 95%. Because of the high rate and improved safety of radial access, we are one of the few hospitals in New England to routinely discharge patients home on the same day of their PCI. Instituted two years ago, approximately 60% of elective PCIs are suitable for same-day discharge. We have recently expanded early discharge for stable acute coronary syndrome patients in whom revascularization is the final element of their care. 

Who manages the cath lab?

The HVIL is managed with a collaborative model consisting of a physician medical director, Jeffrey J. Rade, MD, FACC, a senior director, Kathleen Korenda, MSN, ACNP, MBA, and a nurse manager, Mary Hodgerney, MSN, CNML, ACNP.

Are there licensure laws in your state for fluoroscopy?

Massachusetts state law allows only licensed radiologic technologists, physicians, credentialed nurse practitioners, and physician assistants to operate the fluoroscopic equipment. All staff is required to complete yearly competencies in radiation safety. Staff members directly involved in patient care are provided lead protection, leaded glasses, thyroid protection, and an exposure badge. We have incorporated radiation badge checks as part of our safety time out.

Regulations dictate that radiation technologists operate the x-ray equipment, and nurses administer medication and monitor conscious sedation. All staff members retrieve and set up equipment. Both RNs and RTs can scrub and set up the table. Generally, each room has 2 RNs and 1 x-ray technologist. Monitoring patient status and case recording is assigned to one of the RNs observing in the control room, while the other helps with medication administration and equipment retrieval.   

What are some of the equipment or devices recently introduced in your lab?

Newer/updated technologies include OCT, a new approach to chronic total occlusions (CTOs), coronary orbital atherectomy (CSI), an updated version of the Impella, cryoablation, and a peripheral drug-coated balloon (DCB).

How does your lab handle communication?

We hold regular staff meetings, and utilize newsletters, emails, information/communication boards, and information disseminated through the resource/charge nurse on a daily basis.

How is coding handled in your lab?

We have a coding specialist that handles all coding for EP, cardiac, and vascular procedures. She attends coding seminars and is recertified on a yearly basis. The monitoring RN chooses and posts each procedure performed in the case. RFID technology (WaveMark) and bar coding ensures accurate charging and replenishment of equipment for each patient encounter.

Describe the path of hemostasis for diagnostic and interventional procedures.  

As most of our access is radial, we use the Vasc Band (Vascular Solutions) or Neptune band (TZ Medical) for hemostasis. Before the patient is taken off the table, we assess for patent hemostasis. After application post procedure, these devices are managed by the nursing staff in the designated recovery area. Groin closure includes Perclose (Abbott Vascular), Angio-Seal (St. Jude Medical) and manual pressure. Manual pressure is addressed by the fellow, physician assistant (PA), or nurse practitioner (NP) directly involved in the procedure. Because of predominant use of radial access, our bleeding event rates are low: 0.1% for diagnostic catheterizations (vs 0.4% nationally) and 1.5% for PCI (vs 2.2% nationally). 

Where are patients prepped and recovered?

Over eighty percent of patients are prepared in our short stay recovery area. This area is utilized to ensure all information, intravenous (IV) access, skin prep, premedication, and consent are completed prior to entry to the procedure room. Upon completion of the procedure, the patient is returned and recovered in the same short stay area. This ensures continuity of care, since the admitting RN cares for the patient following the procedure. 

How is inventory handled in your cath lab and who handles supplies?

We have a dedicated supply coordinator that utilizes the Wavemark inventory system. A McKesson supply chain management e-procurement system is used for hospital-wide ordering.

Is your lab involved in clinical research?

Yes, currently we are involved in:

• ABSORB (ABSORB Everolimus Eluting Bioresorbable Vascular Scaffold System – Abbott Vascular);

• SIELLO (safety and effectiveness of the Siello S pacing lead – Biotronik);

• EMANATE (Eliquis evaluated in acute cardioversion coMpared to usuAl treatmeNts for AnTicoagulation in subjEcts with NVAF – Bristol-Myers Squibb, Pfizer);

• ALLSTAR (ALLogeneic Heart STem Cells to Achieve Myocardial Regeneration – Capricor Therapeutics); 

• Sodium Nitrite in Acute Myocardial Infarction (whether the intravenous infusion of sodium nitrite safely prevents ischemia-reperfusion injury in subjects with acute myocardial infarction resulting in improved left ventricular function – Johns Hopkins University and Hope Pharmaceuticals); 

• CARIN (CMX-2043 to prevent contrast-induced acute kidney injury in acute coronary syndrome patients undergoing coronary angiography – Ischemix, LLC); 

• ARTEMIS (Affordability and Real-world Antiplatelet Treatment Effectiveness After Myocardial Infarction Study – AstraZeneca); and

• PROTEGO (to confirm the long-term safety and reliability of the Protego DF4 right ventricular lead – Biotronik).

We are also involved in investigator-initiated and National Institutes of Health (NIH)-sponsored research studies, such as TRIP-PCI (a Phase II, multicenter, randomized, placebo-controlled study to evaluate the safety and efficacy of PZ-128 [pepducin] in patients undergoing non-emergent PCI).

Can you tell us about your lab’s door-to-balloon times and STEMI program?

Our median door-to-balloon time for June 2015 (D2B) was 62 minutes. There are several measures we utilize to help maintain the shortest D2B times in the region. We developed a regional STEMI program to ensure patients presenting to the 11 referring sites receive the same safe standard of care as those that present directly to our emergency department (ED). This includes standardized medication recommendations and no IV drips. We provide outreach education to local and regional emergency medical services (EMS) using a structured feedback process, including time, to individuals directly involved in each STEMI. We have developed a STEMI time study sheet to assist us in maintaining our excellent D2B times. The data from those sheets are reviewed daily, directing immediate change where necessary. 

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

Transport depends on several factors. If a room is available, the ground/air ambulance team will deliver the patient directly to the waiting STEMI team in the procedure room. If a patient requires evaluation, if a room is not immediately available, or the staff has not yet arrived during off hours, the patient will be held in one of the trauma bays (designated as a STEMI room) in the ED. For the latter, transport would then be performed by the ED RN and the in-house transport structure. Inpatient STEMIs are transported to the catheterization laboratory by the patient’s RN and the interventional cardiology fellow. The transport teams do not change for off-shift hours. 

What do you do if the call team is already busy doing a procedure and a STEMI comes in? 

Multiple activations require a triage and prioritization process. During normal operating hours, we have enough built-in flexibility to typically accommodate simultaneous activations with minimal delays. Having multiple rooms offers the advantage of eliminating “turnaround” time in urgent situations. If necessary and safe to do so, an active procedure can be halted or a scheduled patient can be potentially “bumped” to follow an emergent case. While multiple off-hour STEMI activations occur frequently, simultaneous activations are more challenging, but fortunately, relatively rare. In the setting of simultaneous STEMIs, the most urgent or the in-process case would go forward and the next case would follow in another room. As one case is winding up, one or two of the staff can break off to prepare a second room. 

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

Over the last few years, physician and staff schedules were reviewed and adjusted to maximize room utilization. The lab hours of operation were changed to decrease down time. A late-stay team was added to the schedule, in addition to the call team, to finish cases running past normal hours.

RN and RT staff began orienting to basic shared competencies in both areas. This increases productivity by providing the ability to utilize all staff where needed.

Supplies and equipment have been scrutinized and consolidated where possible to maximize savings through contracts and bulk pricing.

What quality control/quality assurance measures are practiced in your cath lab?

Within the last few years, we have developed a standardized nursing handoff sheet. This is to address National Patient Safety Goal (NPSG) #2, safe handoff. Addressing this issue can help to reduce up to 85% of errors caused by lack of full information transfer. 

One of our communication boards displays the D2B times and other issues in the lab on a monthly basis. We have an idea board for any and all thoughts addressing improving efficiency, decreasing waste, or something as simple as improving our trash recycling efforts.  

Are you recording fluoroscopy times/dosages?

Every case involving fluoroscopy or cine time is recorded in the case record by the RN. At completion, the x-ray is terminated and the doses are recorded in the report section for radiation dosage. Doses are closely monitored by our IT staff and in-house radiation safety officer. The HVIL medical director receives notification from the radiation safety officer of every case that exceeds standard limits. 

Who documents medication administration during the case?

The RN who gives the medication documents the administration. This is the nurse inside the lab who also helps with equipment retrieval and patient needs. The nurse in the control room documents case events and is a backup to ensure all medication administration is documented. 

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

The cardiac physicians use the Centricity DMS reporting system (GE Healthcare). The peripheral physicians dictate their reports. 

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

We have formed alliances with 11 hospitals, primarily serving central Massachusetts, northern Connecticut and southern New Hampshire, but will also receive patients from Rhode Island and eastern New York State via our Life Flight or Boston Med Flight. There is only one other hospital in central Massachusetts with an active cardiac catheterization laboratory. We provide ongoing and timely feedback to referring physicians and hospitals regarding patient outcomes and door-to-balloon times. 

How are new employees oriented and trained at your facility?

New staff members without prior catheterization laboratory experience are oriented over a three-month period. New staff members with prior experience are assessed by several experienced staff members and an appropriate, adjusted orientation is agreed upon. We start with basic procedures and educate up to the more complex. 

What continuing education opportunities are provided to staff members?

We have frequent in-services on equipment we stock, but may not use routinely. The weekly staff meeting can provide continuing education credits if applied for. Dedicated time is available on a weekly basis for learning needs identified by staff requests. Staff has the ongoing opportunity to attend the weekly interventional cardiology and HVIL clinical conferences.

How do you handle vendor visits to your lab?

All vendors to the hospital must register every day and display a badge for that day. The HVIL restricts vendors from using the break room and from walking into cases unless specifically invited by the attending physician for that case.

How is staff competencies evaluated?

The individual is responsible for completing online and face-to-face competency tests on a yearly basis. These include electrocardiogram (EKG) interpretation, intra-aortic balloon pump counter pulsation therapy, wound care, IV insertion, policy updates, moderate sedation protocol, and medication administration testing. Every x-ray technologist and RN is basic life support (BLS) and advanced cardiac life support (ACLS) certified.

Is there a particular mix of credentials needed for each call team?

Each call team consists of one attending physician (cardiac or peripheral), one fellow (cardiac or peripheral), two RNs, and one RT. We perform both peripheral and cardiac procedures on a daily basis, so there are no additional credentials required to take call.  

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

We have a 30-minute response time. Staff members live at varying distances from the hospital; earlier arrivals will begin the information gathering and room set up before the rest of the team arrives, so we can accept the patient to the lab as soon as possible.       

Do you have flextime or multiple shifts?

We have a modified fixed schedule. We start our days at 7:00am and run until 5:30pm, except for Wednesday, when we start at 7:30am and run until 6:00pm, in order to accommodate physician and staff meetings. Each workday has a late-stay team responsible for completing cases not quite completed by shift end. The late-stay team consists of 2 RNs and an RT.

Has your lab recently undergone a national accrediting agency inspection? 

Our Joint Commission visit was in 2014. The best advice is to continuously seek improvement. Be consistent in your approach to every case, practice effective communication, and stay focused on the needs of the patient.  

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

The operating rooms are on the same floor and on the other side of a dividing corridor. The ED is located one floor down on the other side of the dividing corridor. Transport from/to either is very easy.

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

The shift to radial approach has essentially eliminated groin complications. This has also improved patient satisfaction related to immediate mobility and prompt discharge times. The use of wrist hemostasis devices has freed up fellows immediately post procedure. 

The patient population demographics have remained consistent, with 67% being male and 33% female.

What is unique or innovative about your cath lab staff?

The HVIL staff is quite unique and extremely innovative. Because nearly 80% of the cardiac cases are urgent or emergent, we have had to maximize flexibility within our system to accommodate the tremendous hour-to-hour unpredictability in case mix and volume. Integrating EP and cardiac/vascular staff and developing shared competencies has allowed us to better adapt to this ever-present unpredictability. 

The high percentage of radial cases (89% vs 26% of other reporting NCDR institutions) has allowed us to institute a same-day PCI program that makes us a stand out for both safety and patient satisfaction.

We are unique in that the average number of years of cardiac cath lab experience for our staff is roughly 17. Our recognition-primed decision-making prevents errors rather than reacting to them. Our skill level and ability improves patient safety, lab efficiency, and has allowed the opportunity to continue growth into new competencies and technologies.

Our lab is unique in that it performs procedures such as TAVR and convergent a-fibs in a hybrid OR. Staff are actively involved in developing workflows and macros to accommodate the shared procedures, and have learned to provide skilled care in the OR environment. We routinely accommodate procedures from standard diagnostics to highly specialized endovascular, EP, and cardiac procedures. Education and learning is ongoing as we frequently trial and evaluate new equipment and technology.  

We continuously explore opportunities for new types and numbers of procedures we perform. This has allowed us to expand our skills and our repertoire of procedures. All of these innovations maintain profitability and improve our marketing abilities.  

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 service a very diverse population in central Massachusetts. There is only one other cardiac catheterization laboratory in the area. We have nurtured connections with 11 area hospitals to mutually benefit all involved, while improving service to the communities we serve. 

The authors can be contacted via Scott Hantz, BSN, RN, EMT-P, Nurse Manager, at hantzs@ccf.org

Tell us about your cath lab.

The Cleveland Clinic Cath/EP Labs have a total of 16 rooms plus 2 hybrid operating rooms (ORs). In the cath lab, we have 8 cath lab rooms plus 2 hybrid ORs that we utilize on Monday, Tuesday, and Wednesday of each week. The cath lab staff consists of 27 registered nurses (RNs), 7 x-ray technologists/registered cardiovascular invasive specialists (RCISs), 4 patient care techs, 2 patient schedulers, 1 inventory specialist, 2 IT specialists, 2 assistant nurse managers, and 1 nurse manager. The cath lab is staffed 24/7/365 with at least 2 staff members in-house to support our busy ST-elevation myocardial infarction (STEMI) program. We have staff that has been with the lab for more than thirty years as well as some who have been with us for as little as a couple of months. The staff work well together and use each other’s strengths to give each patient world-class care.

What procedures are performed in your cath lab? 

Per our outcomes book, on an annual basis:

• Diagnostic cardiac catheterizations: 7000-8000
• Interventional cardiac procedures: 1500-1700
• Percutaneous aortic valvuloplasties: 150-250
• Percutaneous mitral valvuloplasties: 10-20
• Percutaneous atrial septal defect and patent foramen ovale closures: 40-70

Can you tell us about your transcatheter aortic valve replacement (TAVR) program?

We started a TAVR program in May 2006, one of the first three centers in the United States as part of the early feasibility trial (REVIVAL). We have been leaders in several TAVR trials and continue to be passionately involved in the field. We published our intital experience of all transfemoral cases performed in the catheterization laboratory, showing only 0.4% 30-day mortality¹, almost 10 times lower compared to other studies at that time. We have now built another biplane hybrid OR, staffed by cath lab and OR personnel, where we do all transfemoral cases. Other alternative access cases are done in a different hybrid OR. We are typically performing 6-8 cases per week.     

What percentage of your diagnostic caths is normal?

About 15%, although this number is difficult to interpret due to preoperative surgical catheterizations that can be normal and due to our highly complex cases.

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

Yes, at this time, we are 60% radial and we only see that number rising. 

Who manages your cath lab? 

Scott Hantz, BSN, RN, EMT-P, Nurse Manager, and Samir Kapadia, MD, Medical Director, Section Head.    

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

In the lab, we use the team approach. Each staff member is assigned a daily room assignment with other team members, usually consisting of 3-4 staff members with a mix of at least 2 RNs and 1 cardiovascular technologist. Each room is assigned a room charge who is the leader of the team in the room. Besides taking a leadership role in the lab they are assigned, the room charges are also responsible for effectively communicating to the charge issues that affect patient care in the room, such as patient flow or delays.

Each team member is assigned a role for a case. Typically one team member scrubs, another is assigned as the circulator, and the other RN team member will monitor during the case and administer conscious sedation. The team rotates assignments after each case so that each team member participates in each role throughout the day. This allows the staff to stay proficient and competent in each role so that they can easily assume multiple roles if the situation dictates.  

Fellows and staff physicians also are also an integral part of our team. Fellows and attending cardiologists also help in turning the room around and scrubbing when needed.  

Are there licensure laws in your state for fluoroscopy?

Yes, there are specific laws that pertain to the use of fluoroscopy in Ohio. We have a radiation safety department that is in place to make sure that all departments using fluoroscopy are in compliance with those 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 only staff that can operate the x-ray equipment are the physicians and our cardiovascular technologists (CVTs) who are also radiologic technologists. They must complete a 6-course didactic curriculum that is required by the standards set by the Cleveland Clinic. After the successful completion of this material, they are given machine-specific training. Only then can they be considered competent to “step on fluoroscopy” and teach new staff, such as incoming yearly fellows or new attending physicians. They also become our unit experts in regards to operating and troubleshooting x-ray related issues.

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

There are several ways we protect our staff members from radiation exposure. Our physicians wear lead goggles and there is a lead barrier consisting of a drape and movable shield for added protection. All our staff, of course, wears lead tops and aprons. We stress the rule of maintaining a safe distance without compromising the care of the patient, especially during long cases. The physicians will routinely come off of fluoroscopy if there are any patient needs that have to be addressed at the bedside. We also have mobile shields that we can place at the left side of the bed. We have modified our x-ray settings to minimize radiation to the patients and published some important research papers on this subject.^2,3

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

The Cleveland Clinic has been and remains on the cutting edge as far as new technology being used in invasive cardiac medicine today. We have multiple vendors in the lab daily and they keep the staff up to date on emerging technologies, including advances in and uses of peripheral, structural, and interventional techniques and equipment. We encourage trials of new devices and have a specific process in place for these trials, which involves supply chain management and proper documentation of evaluation. 

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

As we all know, communication is the key to success. Without communication, the lab would fail. In our lab, we have monthly staff meetings that cover the high-level information that the lab needs, such as human resources policy changes or other enterprise information needing updating. The cath lab also has daily 0700am huddles that are led by the charge nurse, assistant nurse manager, or nurse manager. This information is focused more on day-to-day issues. Huddles are also the time for staff to voice any concerns about any process or department. We also have several communication boards in the scrub room. These boards talk about the STEMI process along with posting recent STEMI times for door-to-balloon or door-to-door-to-balloon times. There are also scheduling boards that have the staff schedule and when the next schedule will be posted, along with when the schedule will be pulled. The last group of boards is in our break room. These boards are employee engagement boards featuring the employee of the month along with employee birthday boards. Electronic communication boards are used in our lab to monitor patient flow between prep/recovery and the main cath lab.

Who pulls sheaths post procedure? 

Diagnostic sheaths are either closed with a closure device or pulled post procedure in the prep/recovery area or in the procedure room. Post intervention sheaths are either closed with a closure device or pulled post procedure in the prep/recovery area. With increasing radial access, sheath burden has decreased. Patients with sheaths that remain in post interventional procedures later in the day will be admitted to the hospital. These sheaths will be pulled after the results of a partial thromboplastin time (PTT) test by the in-house night shift staff. All intensive care unit (ICU) patients who have had procedures and sheaths that remain in place will return to the ICU. Depending on the time of day, these sheaths will be pulled by the ICU fellow or night shift staff if available. Once a cath lab staff member has successfully pulled ten sheaths without issues, that team member is competent to perform the task independently. 

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

All to-come inpatients are prepped in the prep/recovery area. All in-house patients come to the prep/recovery area before entering the cath lab. All ICU patients come directly to the cath lab suite. Sheaths removed in the prep/recovery area are pulled by RNs. If a sheath needs to be removed in the cath lab suite, an RN or CVT may be responsible for removal of the sheath. Prep/recovery pulls 90-93% of the arterial sheaths the cath lab sends to them.

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

The growth of cath labs is in structural and peripheral cases. It is clear that these fields are expanding, and with the atrial appendage occlusion and mitral valve replacement technologies, the field will grow even further. Awareness of peripheral vascular disease and expanding minimally invasive treatment options with growing expertise is making this field emerge as another major area of growth for us.

Is your lab involved in clinical research?

Research is a major focus in the cath lab. We are involved in randomized trials of coronary, peripheral, and structural interventions. We also have registries of our own patients that provide another opportunity for investigations. We also encourage and perform site-initiated research projects. For several years, our cath lab attendings have published more than 100 manuscripts each year.

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

Our most recent D2B median time from Q1 2015 is 43 minutes. We have achieved these best practices of D2B times <90 minutes with rapid feedback and recognition reporting of each STEMI patient, along with a diligent team of caregivers that attend a weekly STEMI huddle where a comprehensive review of each STEMI patient is completed. The same team meets once a month to discuss current month and quarterly American College of Cardiology National Data Registry (ACC-NCDR) CathPCI D2B outcomes. The Heart and Vascular Institute (HVI) has made tremendous developments in ensuring optimal outcomes with D2B times <90 minutes for our patients by developing close collaboration with our local emergency medical services (EMS), allowing emergency department (ED) physician STEMI activation, instituting an ED bypass system that allows EMS to bypass the ED and directly transport patients to the cath lab, and sustaining a 24/7 staffed cath lab, the first in northeast Ohio.                                                                                                                                 The dynamic teams involved in providing world-class care to our patients consist of our HVI chief quality officer, Emergency Services Institute (ESI) quality officer, section head of invasive cardiology, interventional cardiologists, HVI and ESI quality directors, HVI assistant nursing director, cath lab and ED nurse managers, critical care transport, pharmacy, and the quality facilitator for registries and reporting.  

Who transports the STEMI patient to the cath lab?

From the in-house ED, the ED nursing and/or medic team transports patients to the cath lab. A cardiology fellow and/or ED resident will also accompany the patient to the cath lab. When the ED bypass system is used, EMS will directly transport the patient to the cath lab. There are no off hours in our lab, since we are staffed 24/7/365. For in-house STEMIs, the nursing staff brings them down to the cath lab. Out-of-house STEMIs are flown in or come by critical care transport to the cath lab. 

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

All STEMI cases during the hours of 7am-7pm that arrive to the ED are taken to the lab.  The STEMI patient may be brought to the room of the on-call physician or to another open lab. If the two above options are not available, a back-up lab will be utilized and staff pulled to take care of the patient. On the off shift, there are only two people in-house, with the third staff member reporting in from home. If a STEMI patient arrives during an ongoing case, that patient will go to the cardiovascular ICU (CICU) until the team is available to take the patient to the lab. If the current case is close to completion, one team member, with the help of the Cardiac Medical Emergency Team (CMET), will be utilized to take the patient directly to the lab.

What quality measures are practiced in your cath lab?

Patients are able to review a number of metrics and outcomes related to quality, safety and patient experience on Medicare.gov’s Hospital Compare website. This enables patients to make an informed decision about where to seek care. Preventing hospital-acquired infections, avoiding and preventing harm to patients, advancing a safety culture, developing and implementing care coordination, improving clinical practices to drive outcomes, and delivering timely, efficient, effective, and equitable care across the continuum of care are safety and quality strategies across our organization. Applying evidence-based standards, maintaining volume standards, and consistent tracking of outcomes and complications are fundamental metrics tracked in our cardiac catherization lab.  

The quality director serves as a leadership role to collaborate in the development and implementation of plans to drive improvement. Local owners and support resources from the cardiac cath lab implement and sustain the improvement activities.

Are you recording fluoroscopy times/dosages? 

During each case, radiation exposures are displayed on the syngo imaging monitor (Siemens Healthcare). The staff member monitoring the case can update the team at regular intervals with real-time radiation exposure time and dosages. If the exposure level exceeds 5 Gy, an alarm notifies the monitor person, who then notifies the team, and especially the attending physician, that 5 Gy has been reached. If a patient’s radiation dosage exceeds 5 Gy during a case, the cardiology fellow provides follow-up teaching regarding possible complications that could occur due to an exposure of 5 Gy or more. In the rare instance that a patient reaches a dose of 10 Gy or higher, they are also given instructions regarding aftercare, but are also followed and monitored during their hospital stay for possible complications related to radiation exposure. 

After each case, the Sensis system (Siemens Healthcare) automatically captures and calculates the total dosage. Dosages are monitored and recorded daily in a detailed fluoroscopy log that we submit to our radiation safety committee on a quarterly basis. Each cath film has a log of cine runs with amount of radiation used and can be easily accessed.

Who documents medication administration during the case?

All medication documentation is completed by the monitor staff member. This may be either an RN or a CVT.

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

We have a structured reporting system (syngo-based) that is customized for our use. We have been using these databases for several years. The cath reports are done as soon as the catheterization is finished and then finalized in the next few days.

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

Yes, the Heart and Vascular Institute participates in the ACC-NCDR CathPCI Registry, as well as ICD, Impact, and the Society of Thoracic Surgeons (STS)/ACC Transcatheter Valve Therapy (TVT) and STS Adult Cardiac registries.

How are new employees oriented and trained at your facility? 

Our team has implemented a unique, individualized orientation process that spans 18 months. The new staff member goes through a traditional orientation process that lasts 12 weeks, during which they are paired with an experienced preceptor. During this time period, the new staff member becomes acclimated to the lab. They are first introduced to diagnostic orientation. This allows the new staff member to become familiar with the cath lab’s processes, equipment, routine, and personnel. Diagnostic orientation typically lasts for 6 weeks. The new staff member then goes through another 6 weeks of interventional orientation, where they are introduced to more advanced theories such as stents, balloons, assist devices, STEMIs, etc.

After the completion of the 12-week orientation process, the new staff member is then counted in staffing, becoming an independently functioning staff member. From the period of 12 weeks to 1 year, they are typically paired with our more experienced cath lab staff until they feel completely comfortable in the unit. During this time, they participate in any and all of the types of cases done at the Clinic. At 12 months, they are again paired with an experienced structural heart preceptor, where they will focus on learning advanced structural theory including TAVRs, PFOs, paravalvular leak closures, and so on. After 3 months, they will spend an additional 3 months with a peripheral preceptor, and learn theories and procedures related to functioning independently in our peripheral diagnostic and interventional cases. We, as a team, decided on this process, because it allows new staff members learn and grow at a reasonable pace that fosters successful learning.

During the orientation process, the new staff member will meet weekly with the lab educator and the manager to make sure everyone is on the same page. The educator is also in the lab to assist with education such as advanced cardiac life support/basic life support (ACLS/BLS) as well as different technologies that are in the lab.

What continuing education opportunities are provided to staff members?

We provide our staff with multiple continuing education unit (CEU) opportunities. In cooperation with our equipment vendors, we have been able to provide excellent, high-level educational opportunities relating to advanced cardiac concepts. We also provide opportunities to our staff to go off-site to get super user training in order to become resources for the team.

How do you handle vendor visits to your lab? 

1. The vendor process in our lab is very specific. 
2. Vendors must be VendorMated.
3. Representatives must wear orange scrubs.
4.  They must sign in the office whenever they are in the lab.
5. They are required to make an appointment with the manager in order to introduce themselves and explain the reason for their visit.
6. We have a table set up outside the lab specifically for representatives. This decreases the chance for clutter in the labs.
7. Vendors need to schedule at least 4 hours a month for staff education. If they do not, they will not be allowed in the lab.

How is staff competency evaluated? 

We have recently reviewed this issue and made some significant changes. We now have the equipment-specific vendors in the lab and available for teaching at least once a month. This gives our staff an opportunity to discuss issues, answer any questions they have regarding issues, and stay current with the latest technology as it becomes available. Also, the educator will assist in in-services to help make sure all staff is competent with all technology that is in our lab. We have unit-specific checklists for all technologies. When this checklist is completed, the staff is considered expert. 

Does your lab have a clinical ladder? 

The Cleveland Clinic has a clinical stepladder for all RNs that provides the opportunity for our staff to be recognized for accomplishments and education that goes above and beyond the required unit-specific requirements. RNs can move up to the next step annually by meeting criteria set forth by the Clinic. We highly encourage our staff to apply for the opportunity to participate in the clinical ladder program and make every effort to assist them in successfully submitting the required criteria material. We have seen a steady increase in RNs taking advantage of the career ladder. The career ladder has helped transform the cath lab by encouraging higher staff engagement. 

How does your lab handle call time for staff members? 

On-call is a maximum of 2 twelve-hour shifts in a 4-week period. Each team is comprised of a minumum of two RNs and a CVT, or three RNs. Of note, 2 call team members are in-house staff, so only one person comes from home. On-call team members are expected to arrive to the lab between 30-45 minutes from the activation of the page. Our rapid response team covers the lab until our third staff member arrives, which solidifies our teamwork philosophy and gives us the ability to take care of our STEMIs in a rapid manner.

Do you have flextime or multiple shifts? 

No flextime is utilized in the lab. Staff members either work 2 eight-hour and 2 twelve-hour shifts per week, or 3 twelve-hour shifts per week.

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

The OR is located 2 floors directly above the cath lab. The emergency department is located in a different building, but is connected by walkways. It is a 4- to 5-minute walk from the ED to the lab.

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

We have seen some decline in stable coronary artery disease patients for coronary interventions. However, patients with acute MI, non ST-elevation MI, and complex coronary artery disease have increased in volume. There is a large increase in patients with aortic stenosis referred for TAVR. Our peripheral vascular disease volume is primarily from obstructive disease and is comprised of a large number of patients with critical limb ischemia. We have also seen an increase in this volume.

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

1.    STEMI program: The Cleveland Clinic has in-house staff 24/7/365. We have had D2B times in the low 20-minute range as a result. 

2.    Average first patient start times are in the 90% range.

3.    Room turnaround times are around 16.1 minutes.

4.    We have the ability to perform wide range of complex procedures safely and effectively.

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 Cleveland Clinic has been ranked as number one for treatment of cardiovascular diseases by U.S. News & World Report for the last 21 consecutive years. All workers in the cath lab, from technologists to nurses to fellows to attendings, are all very proud of this ranking and work hard to maintain our status. Passionate staff makes this cath lab a unique and pleasurable place to work. 

References

1. Kapadia SR, Svensson LG, Roselli E, Schoenhagen P, Popovic Z, Alfirevic A, et al. Single center TAVR experience with a focus on the prevention and management of catastrophic complications. Catheter Cardiovasc Interv. 2014 Nov 1; 84(5): 834-842. doi: 10.1002/ccd.25356.
2. Agarwal S, Parashar A, Ellis SG, Heupler FA Jr, Lau E, Tuzcu EM, Kapadia SR. Measures to reduce radiation in a modern cardiac catheterization laboratory. Circ Cardiovasc Interv. 2014 Aug; 7(4): 447-455. doi: 10.1161/ CIRCINTERVENTIONS.114.001499.
3. Agarwal S, Parashar A, Bajaj NS, Khan I, Ahmad I, Heupler FA Jr, Bunte M, Modi DK, Tuzcu EM, Kapadia SR. Relationship of beam angulation and radiation exposure in the cardiac catheterization laboratory. JACC Cardiovasc Interv. 2014 May; 7(5): 558-566. doi: 10.1016/j.jcin.2013.12.203.

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? 

Group risk-adjusted outcomes and case appropriateness are reviewed quarterly via the ACC-NCDR registry. Areas of concern are identified by the leadership, drill-down analyses performed as needed, and an action plan developed. Appropriate use criteria (AUC) data are supplemented by quantitative coronary analysis (QCA) from our Core Lab in conjunction with fractional flow reserve (FFR) data. Follow-up outcomes are then carefully reviewed for improvement. Numerous staff-specific, risk-adjusted outcomes (e.g. death, myocardial infarction, blood product usage, contrast-induced nephropathy) are tracked annually and on an as-needed basis. Similar processes for structural interventional cases have just been developed, and are under development for peripheral interventions. Major adverse outcomes are reviewed at a monthly morbidity and mortality conference or weekly cath conferences. Detailed processes to review product utilization in the catheterization laboratory on a per-staff basis are also reviewed.

The NCDR Institutional Outcomes Report provides us with the ability to trend performance data, benchmark outcomes, identify any potential areas of opportunity, and serve as a foundation to initiate quality improvement discussions with key stakeholders. With our current practice of weekly data submissions, we have to ability to stay up-to-date on key metrics such as door-to-balloon times, procedural complications, discharge medication compliance, monitor appropriateness of percutaneous coronary intervention, and more with the use of the NCDR online dashboard.

We routinely discuss these data in our staff meeting. We also have a dashboard that lets us see individual data. We are proactive in maintaining excellent outcomes. NCDR data are useful for benchmarking purposes.

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

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?

Several staff members have obtained the RCIS credential, which was supported by prep classes and physicians. We continually encourage all cath staff to obtain RCIS education, which is not required at this time. If the x-ray technologists achieve the RCIS, they will be moved to a higher pay grade. We also have many RNs who hold and/or are going on for their BSN and also MSNs in nurse practitioner, education, or business disciplines.

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? 

Yes, the nurses, technologists and physicians are involved. We have leadership roles at all levels in different organizations. Some of the organizations where we are very active include the American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, and the ACC-NCDR.

CVIL Vision: To achieve excellence in health care through ongoing education, research, integrity, dedication and teamwork. 

CVIL Mission: The Cardiovascular and Interventional Radiology labs are committed to providing competent and compassionate patient-centered care with integrity and trust.

Tell us about your facility and the Cardiovascular Interventional Lab (CVIL).

Tampa General Hospital (TGH) is a 1,018-bed private, not-for-profit, level I trauma center in west central Florida. Tampa General offers a variety of services, including a children’s medical center and state-verified regional burn center, and is one of the busiest adult solid organ transplant centers in the country. The facility serves a dozen counties with a population in excess of 4 million. TGH is a certified comprehensive stroke center, a cardiovascular and orthopedic center, and is the region’s safety net hospital. Tampa General Hospital is the primary teaching hospital for the University of South Florida (USF) Health Morsani College of Medicine.  

TGH’s Cardiovascular Interventional Lab (CVIL) consists of four cardiac catheterization labs, two electrophysiology (EP) labs and six interventional radiology (IR) labs, including two neuro-interventional labs.  The CVIL cares for more than 11,000 patients a year and has a staff of 90 that includes registered nurses (RNs), registered radiology technologists (RT[R]s), registered cardiovascular invasive specialists (CVISs and RCISs), nurse practitioners (ARNPs), physician assistants (PAs), management team, transporters, and an administrative assistant. The average length of employment for the department is greater than 4 years.

How is TGH’s Cardiovascular Center Unique?

The CVIL employs a multidisciplinary approach. Cardiologists, interventional radiologists, vascular surgeons, and neuro-interventionists work collaboratively to perform a multitude of procedures. Our center has the ability to perform procedures in a timely manner while maintaining the capability to provide emergent care for the critically ill. 

What procedures are performed in your Cardiovascular Center (CVC)?

The CVC offers both inpatient and outpatient services, including diagnostic and interventional procedures. Our cardiovascular procedures include: ST-elevation myocardial infarction (STEMI) interventions, right and left heart catheterizations, heart biopsies, and septal closures. Percutaneous coronary interventions include balloon angioplasty and stenting. The EP lab performs ventricular tachycardia, atrial fibrillation and atrial flutter ablations, pacemaker implants, and device changes. IR procedures include dialysis access plus fistulagrams, embolizations, transarterial chemoembolization (TACE), biopsies, nephrostomy tubes, biliary tubes and Y-90s. Neuro-interventionalists treat strokes and perform aneurysm treatments including coilings, stent placements, and flow diverters (including the Pipeline Embolization Device [Medtronic], Surpass Streamline Flow Diverter [Stryker], and Flow Re-Direction Endoluminal Device [FRED] [MicroVention]), as well as carotid stenting and arteriovenous malformation (AVM) embolizations.

Does your lab have a hybrid room?

Our hybrid room is equipped to perform transcatheter aortic valve replacements (TAVRs) and placenta accreta procedures. The hybrid room is in the cardiovascular surgical department, only a few steps away from the CVIL. Cath lab staff collaborates with the TAVR team in every TAVR case. The cath lab has a designated TAVR team consisting of two CVISs, one RN, and one team leader. In addition, the team performs endografts, “snorkels” for endovascular aneurysm repair (EVAR), and stents for aortic aneurysms.  

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

Approximately 42 percent of our interventional cardiologists use radial access, while the interventional radiologists use a variety of arterial access methods, including radial access. Physicians have performed 388 radial access procedures in the CVIL thus far in 2015.

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

We have several new products, including:

• Optical coherence tomography (OCT) is used in the cardiac cath lab to verify proper stent placement. 
• Thrombix (Vascular Solutions), a powerful hemostatic dressing, has been initiated in the cath lab for temporary control of moderate to severe, post-sheath, removal bleeding.  
• ViewMate ultrasound (St. Jude Medical) is used in EP for advanced, real-time, intra-cardiac echo imaging. 
• AngioVac (AngioDynamics) is used in IR procedures that require evacuation of large fresh thrombus through a cardiac perfusion flow pump. 
• Flow diverters, including the Pipeline, Surpass and FRED, are being used in neuro IR to repair aneurysms.

Who manages your lab?

The management team reports to a senior vice president, the medical directors for EP, cath lab, and IR, and an administrative director. We employ a synergistic approach that involves the clinical nurse manager of the CVIL and a business manager. We also have a frontline management team of six staff that includes an IR team leader and nurse clinician, cath lab team leader, cath lab nurse clinician, EP nurse clinician, and a unit-based educator. The CVIL management team recently added a shared governance council structured with five departmental- based committees. 

The CVIL clinical nurse manager has over fourteen years of nursing experience with ten years of management.  She has been in her current position for more than a year. This nurse manager has received awards including: Leadership of the Month February 2010 and Nurse Manager of the Year 2010, and recently completed AONE Fellowship. The nurse manager has completed her master’s degree in nursing and is currently enrolled in the Doctorate in Nursing Program (DNP). She previously led different nursing units at TGH and has a cardiac and transplant background. The nurse manager is accountable to the senior VP of Cardiovascular Services and the director of imaging, CV Center, and Cancer Center. 

The CVIL business manager has a master’s degree in hospital administration and has served the department for more than three years. Responsibilities include planning and procurement of material components to minimize obsolescence and overstock situations while achieving maximum customer service levels. He is responsible for the management of material inventory levels to ensure that equipment and supplies are available when needed to satisfy department requirements. The business manager also develops and implements budgets, prepares reports for senior management, and ensures the department meets financial goals. He collaborates with the nurse manager and evaluates employee performance.  

All seven management team members of the CVIL were promoted from existing staff. The daily operations are a collaboration of staff, clinicians, team leaders, the educator, and the nurse manager. The IR and cath lab team leaders have been in their positions for more than 10 years. Each member of the management team has had extensive training and preceptorship with another experienced clinician, team leader, or unit-based educator. The management team meets twice a year for a strategic planning. The meeting is designed to set goals and to make new plans and/or modify existing ones. Additionally, the chair of the shared governance council attends these meetings and is very involved in strategic planning. Each member of the management team sponsors one of the unit-based shared governance committees. The CVIL shared governance council consists of the Recruitment and Retention Committee, Safety/Quality Control Committee, Patient Satisfaction Committee, Efficiency, and the Education Committee.  

Who scrubs, who circulates, and who monitors? 

CVIS staff members are cross-trained to monitor and scrub on a variety of cases. The RNs circulate and monitor patients. The RNs and CVIS are trained to operate the EP lab stimulator. In the IR labs, the IR technologist (IRT) circulates and scrubs, while the RN is responsible for sedating and monitoring the patient. Some staff members are cross-trained to work in more than one area in the CVIL.

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

CVIS are trained to change the angles in our labs. The fluoroscope is controlled by physicians who are licensed and certified by the National Radiological Commission (NRC). For IR procedures, the IRTs obtain angles for the procedures and are certified to operate fluoroscopy.

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

All staff and physicians are fitted and assigned a lead apron, including a thyroid shield. All lead items are inspected annually, dated, and coded to allow for identification. If compromised, the lead is removed from use. Protective lead eyeglasses, lead drapes, and free-standing lead shields are available to staff and physicians.  Radiation badges are assigned to each staff member and are monitored monthly for radiation doses. Staff receives required annual training on radiation safety.

How does your lab communicate information to staff and physicians?

Departmental communication is dynamic and provided through a variety of methods, including written notes, meetings, and in lectures. Our unit-based educator, clinicians, and team leaders distribute information through email, which is reinforced in weekly meetings. Bi-monthly staff meetings focus on departmental goals and highlight ongoing areas of improvement. Our clinical unit-based educator updates and provides current information regarding education and safety concerns. Minutes from the shared governance meetings are posted on the department website.

The three medical directors meet monthly with the management team and senior leadership. The meetings serve as an open forum for decision making and information sharing. Most physicians serving the CVIL and all three medical directors receive a weekly e-mail titled “Friday Updates”, containing a brief summary of the weekly face-to-face meeting, important announcements, quality data, and lessons learned. 

Who pulls sheaths post procedure?

When procedures are completed, sheaths are removed by an IRT, CVIS, or nurse, using manual pressure. It is common practice for the CVIL physician to use a closure device for sheath removal to reduce recovery time and aid in patient comfort. Sheaths may also be left in place and patients sent to our post-procedure recovery rooms for care. The post-procedure areas have highly trained intensive care unit (ICU) nurses that are qualified to remove the sheaths and assess for signs of complications.

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

Patients are prepped in the 47-bed pre-and post-procedure area. Once the procedure is complete, the patient returns to this area for recovery. Most outpatients are discharged home on the same day after their interventional procedure following the appropriate recovery time. 

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

Inventory is managed by the CVIL business manager, as well as by three dedicated inventory specialists. We use Qsight (Owens & Minor), an electronic inventory control system which interfaces with EPIC, our electronic medical record (EMR), and McKesson system. This system increases traceability using lot numbers, expiration dates and product recalls, which increases patient safety, reduces inventory, and limits supplies to a just-in-time basis. During a case, the product is opened and then immediately scanned, which impacts par levels and ordering status. The CVIL (IR and cath lab) have a combined inventory.

The CVIL utilizes a value analysis model to evaluate new products and implement cost-saving initiatives. The CVIL has its own committee, but can refer large-scale items to an executive committee if necessary. 

How do you handle vendor visits to your lab?

Vendors may request an appointment through RepConnect (Medical Rep Connect), a computer-based calendar. Some vendors will pre-schedule with a particular physician for a case and in those instances, the vendors deal directly with the physicians. Before going into any labs, vendors must check in with the business operations manager, change into appropriate scrubs, and have their credentials verified. Vendors are required to wear proper identification at all times, and follow hospital policies and procedures. 

Has your lab recently expanded in size?

In 2008, the CVIL expanded from 8 to 12 rooms, and added the hybrid OR. 

Is your lab involved in clinical research?

TGH is affiliated with the University Of South Florida Morsani College Of Medicine. Currently, the cath lab has several research projects:

• ABSORB III – a bio-absorbable stent (Abbott Vascular);
• ABSORB Imaging – bio-    absorbable stent with intravascular ultrasound (IVUS)/OCT;
• ABSORB IV – bio-absorbable stent with a computed tomography (CT) scan post-placement;
• CAIN – IVUS of the vessels to correlate progression of carotid disease with coronary artery disease (Canadian Atherosclerosis Imaging Network);
• SYMPLICITY HTN-3 – renal denervation for patients with uncontrolled hypertension (Medtronic);
• COAPT – mitral valve clip study for percutaneous mitral valve repair (Abbott Vascular).

The IR lab has the following research studies underway: 

• BEST – embolization for prostates;
• TGH BHP – embolization for prostates larger than 90 grams;
• HIQ – embolization of liver tumors;
• ACE – coiling of aneurysms;
• Penumbra 3D stroke trial (Penumbra);
• SCENT – Surpass device for aneurysms (Stryker)
• PREMIER – Pipeline device for aneurysms (Medtronic).

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

The average D2B time in 2014 was 64 minutes. The target time for D2B is less than 90 minutes. From door to electrocardiogram (ECG), the goal is less than 10 minutes. From door to decision, the goal is less than 15 minutes. From cath lab door to actual time when the procedure begins, the goal is 10 minutes. The emergency department (ED) STEMI doctor on call and the cath lab staff work collaboratively to achieve these goals.  

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

During regular and off hours, STEMI patients are transported by two staff members, one of whom must be a registered nurse or physician. All the patients are transported on a cardiac monitor with defibrillator.

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

If a STEMI occurs during regular business hours, the first available cath lab would accommodate the STEMI. The staff at the main control desk assigns cath lab cases keeping the need for emergent caths and STEMIs in mind. Procedure assignments are placed so that there is always a lab available for emergencies. In case of multiple emergencies and STEMIs resulting in all labs doing procedures, the patient will be taken to the next available CV surgical room. 

If a STEMI occurs during off hours when the call team is already on a case, the call team will request an additional team. If it is not possible to get an extra complete team, the rapid response team assists with monitoring, turnover, and transport. 

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

We have implemented staggered shifts to align staffing with peak volumes. This evidence-based process has decreased overtime. We recently switched to the Qsight inventory system, which has helped streamline inventory and cut waste by $1.5 million. We also analyzed patient schedules and workflow, and reinforced prompt staff arrival times and attendance. All together, the CVIL reduced operating costs by 6% last year.

Tell us about the quality control (QC)/quality assurance (QA) measures practiced in your lab.

We continually monitor STEMI times to adhere to the American College of Cardiology Guidelines, and stroke times to retain our National Stroke Certification. 

Time-out audits ensure all the safety steps are being followed before a procedure is started. We monitor hand hygiene when staff enter and exit the procedural rooms. We also perform random chart audits to ensure compliance with benchmarking and regulatory agencies.  

The unit-based quality and safety committee recently revised the Peer Audit Tool, which is utilized by all staff members. Peer Audit Tool compliance is monitored by the management team. The data from the peer audit is posted on the department quality bulletin board. Areas in need of improvement are discussed at committee meetings and communicated to all staff members.

Are you recording fluoroscopy times/dosages?

We record total minutes in Air Karma and in the cath report. 

Who documents medication administration during the case?

The RN is responsible for documenting medications given during the procedure in the EMR.

How are new employees oriented and trained at your facility?

All new employees receive an orientation to their work area prior to the delivery of patient care or performance of new job functions. A detailed orientation tool is used and an experienced team member is chosen as a preceptor to work with the employee and monitor progress towards their training goals. Orientation starts with a full day of on-boarding activities provided by the organizational development department. Clinical orientation includes safe patient handling and electronic medical record training. A unit-based educator provides new hires with a unit-specific orientation during the first week. New staff will provide copies of licenses and certifications, and review both the unit and divisional orientation booklets, followed by a department tour. A competency-based orientation (CBO) evaluation is provided to every new staff member. Staff documents validation of competencies on this form as learning competencies are completed. We also utilize an orientation progress record to monitor individual progress and identify learning goals. The length of orientation is based on the employee’s level of knowledge and experience. The manager or unit-based educator conducts formal/informal new employee onboarding meetings to get feedback regarding orientation. The goal of each meeting is to determine if new staff feel welcomed and are receiving proper orientation/training. 

What continuing education opportunities are provided to staff members?

Continuing education is provided to all levels of staff and in various settings around the hospital. Education is also provided at the division and unit level. These include monthly department continuing education unit (CEU) presentations, in which the speakers are staff physicians, volunteer clinical ladder nurses, advanced registries, CVISs, and IRTs. Staff members are encouraged to attend the annual Cardiovascular Symposium and hospital-based, instructor-led training classes. Most of our mandatory education programs are provided electronically. Mindlab is our electronic education software that awards continuing education credits upon successful completion of modules. Tampa General also offers Continuing Education (CE) Direct. CE Direct provides online, nationally accredited, and Florida-required CE courses, webinars, and certification review modules for access at work or home.

Tampa General offers all full- and part-time employees tuition assistance for continuing education. Full-time employees may receive up to $16,000 towards continuing education, and part-time employees up to $8,000. TGH also sponsors selected IRTs, CVISs, and nurses for attendance at national conferences and professional organization meetings every year.

How is staff competency evaluated?

Our organizational development department plans and implements educational programs based on assessments of employees’ learning needs, using adult learning theory. In addition, an online survey is sent out to all clinical employees to assess each individual’s learning needs. The TGH Competency Assessment Program (CAP) assesses job-related skills, and addresses changes in practice, policy and knowledge. CAPS is used to assess, validate, and document job performance competencies for clinical and non-clinical staff. Unit-specific CAPs are identified through low-volume, high-risk cases, quality improvement data, incident reports, staff feedback and direct observation. CAPS were designed to improve patient care outcomes.

Does your lab have clinical ladder?

Clinical nurses working in our labs are eligible to participate in the RN clinical ladder program. The program was developed in 1999. The ladder recognizes and rewards the application of clinical nursing expertise in direct patient care. Eligibility requirements must be met to submit an application. Nurses can apply for one of the four ladder levels, based on meeting specific criteria. A paid hourly differential is attached to the clinical ladder levels, ranging from 4% to 16% of the base hourly wage. Clinical ladder nurses must meet renewal criteria every two years, and re-apply at that time in order to continue or raise their clinical ladder level. 

Our IRTs and CVISs have a similar professional development matrix. The matrix has three levels: entry level I, staff level II, senior level III. The levels are based on education, certification, experience, and specific skill sets. Unlike clinical ladder nurses, the IRTs and CVISs do not need to renew their level every 2 years. Advanced certification in their given specialties is required to stay on their current levels. This is considered a promotion for our IRTs and CVISs.

How does your lab handle call time for staff members?

Call is mandatory for all staff members and is evenly distributed. Staff members are permitted to exchange shifts with manager approval.

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

All team members are expected to arrive to the cath lab within 30 minutes for STEMIs and 45 minutes for in-house emergencies. The IR lab on call staff is expected to arrive within an hour for strokes and emergent IR procedures.

Do you have flexible or multiple shifts?

With staggered shifts, the first shift begins at 07:00, the on-call staff follows at 07:30, and the stay-late teams come in at 08:00. Typically, the first cases begin at 08:00 and last cases finish at 18:00. The labs operate 5 days a week. There is one call team in the cath lab 24/7 and one on-call team for IR Monday through Friday. On the weekends, there are two on-call teams to cover stroke and trauma in IR.

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

The CVIL has seen an increase in volume in the past few years. Cardiac patients appear to be getting younger, with a far greater percentage of coronary artery disease. The number of cardiomyopathy cases has also increased. TGH is one of the nation’s busiest transplant centers, so there is an increased need for performing biopsies. EP studies and ablations used to treat abnormal heart rhythms or arrhythmias have also increased due to the rise in heart disease.

The IR labs have noted an increase in dialysis patients who have complications from long-term dialysis. Other procedures such as embolization and stroke interventions have markedly increased.

Is there a problem or challenge your lab has faced?

Door-to-device times for STEMI and stroke will always be a challenge. Many elements beyond our control, such as weather and traffic, can be very challenging. Together with the shared governance council and the various committees, including quality, education and efficiency committees, we continually strive to identify ways to meet target times to achieve desired patient outcomes.  

Has your lab recently undergone a national accrediting agency inspection?

TGH has undergone the following agency inspections: The Joint Commission, Magnet re-designation, Comprehensive Stroke Center status, and Society of Cardiovascular Patient Care Heart Failure accreditation.  

What’s special about your city or general regional area in comparison to the rest of the United States? How does it affect your CV lab “culture”?

For almost 80 years, Tampa General Hospital has been a source of pride to residents of Hillsborough and surrounding counties. Located on Davis Islands in the city of Tampa, TGH is easily accessible to the entire region via interstates 75 and 4, and a variety of surface roads. Warm winters, access to the Gulf of Mexico, and a thriving economy make the west coast of Florida popular for companies looking to relocate, as well as retirees. 

Our partnership with the University of South Florida sets us apart from all other local hospitals. We are the region’s safety net hospital, whose mission is to provide excellent and compassionate health care to the residents of west central Florida, from the simplest to the most complex medical services. 

The geographic location and the diverse patient population drive the CVIL to create a unique culture where interventional cardiology, electrophysiology, vascular, and neurology are combined. We are integrated, sharing supplies, resources, and staff.  

Read an excerpt about the pulmonary embolism program with Samuel A. Shube, MD, Tampa General Hospital, Tampa, Florida.

Can you tell us about pulmonary embolism and the evolution of treatment?

Normally, the body makes and breaks down clots at the same rate. Something changes that equilibrium, whether it is medications that make people prone to clotting, cancer, which also makes people prone to clotting, immobility, or injury to the vessel. On the dissolution side, the body makes tPA endogenously in the cells of the inner lining of the blood vessel. Essentially, something throws that equilibrium off and now the patient makes clots, which can migrate to the lungs and become a pulmonary embolus. Categories of PE include minor, submassive, and massive. A majority of pulmonary emboli, around 55%, are minor, meaning that it could be anything from subclinical, a tiny clot no one notices but is caught on a CT scan, to somebody that comes in with a little chest pain that resolves by the time anybody looks at it. Submassive is the intermediate category. Patients are very symptomatic, short of breath, and they have a large clot burden. They may show signs of right heart strain. Their labs are abnormal, but they are hemodynamically stable. Massive PE patients, the smallest category, present in cardiogenic shock and have high mortality. 

Unless you are in a major medical institution, the standard treatment all over the world is to give heparin, a blood thinner that does nothing to dissolve blood clots, but prevents clot progression. Before heparin is administered, clots are being made faster than the body can dissolve them. If you decrease that level of production by giving heparin, then the body can now dissolve the clots. The trouble is that over time, clots, even while they are dissolving, will age. They turn from acute to subacute to chronic, and during that process, the body reabsorbs the water out of the clot, and it becomes more cellular and solid. It is harder to dissolve or even break up mechanically, and by the time a clot is chronic, there is no effective treatment. 

The EKOS procedure (EkoSonic Endovascular System, EKOS Corporation) is one of the latest advances in treatment and it involves the use of tPA through a multi side-hole infusion catheter with an ultrasound wire through the center. The ultrasound works to push tPA out further into the surface of the clot. Since tPA works on the surface area of the clot, the more clot that is bathed in it, the better it works. The EKOS ultrasound also vibrates at the resonant frequency of fibrin. You know how a singer hits a certain note and then a glass will vibrate until it breaks? The note being sung is the resonant frequency of that glass. Everything has its own resonant frequency, and the EKOS ultrasound vibrates at the resonant frequency of fibrin, which in addition to pushing the tPA out into the clot, causes the fibrin strands to vibrate apart. This allows for the use of significantly less tPA. In the old days, when they gave tPA through an IV (and they still do it in some places), they would give 50 mg bolus of tPA and then a second 50mg aliquot either over 1 or 2 hours with a side effect of a high chance of bleeding. Yes, it would help dissolve clot, but it would also dissolve clot if someone had bleeding from the colon (diverticulitis). If somebody had a kidney stone, recent trauma, recent surgery, a tumor in the brain that nobody knew was there — all those things could start to bleed as well. The incidence of complications with peripheral tPA was high because the dose was high. Also, because the tPA only treats the small surface of the clot in contact with the open vessel, this method also didn’t dissolve clot as well as it could. The next development was the use of a multi side-hole infusion catheter, offering a lower dose of tPA and better result than tPA administered peripherally, because it treated more surface area of the clot. The EKOS procedure is the next advancement. It allows us to obtain much more effective lysis of the clot much faster, with lower doses of tPA. It is also safer, with less bleeding. We started doing the EKOS procedure in bypass grafts, thrombosed arteries and veins, and then began using it for other clots, becoming involved in some of the PE trials. Overall, our cases number more than 600 and we have treated well over 200 PE cases with the EKOS procedure. We treat over 24 hours, using 24 to 36mg of tPA, depending on time and clot burden. We try to do it overnight. If we are starting at 8pm or if the patient is really sick, we may give a bolus through each side first. If we are starting at 8am, we may not give a bolus. Once the treatment is done, patients are usually discharged within a few days. After we completed our first 75 PE cases, we reviewed our results, which were very good, with zero complications. We were able to significantly decrease thrombus load and decrease pulmonary artery pressures almost uniformly across the board. 

Do you have an organized clot program at Tampa General Hospital?

Yes. We saw how good the results were in treating pulmonary embolus with the EKOS procedure and decided to start a pulmonary embolus program with the emergency department (ED). We have given multiple lectures and grand rounds, and emphasized that we would take care of everything. If a patient came in with chest pain and shortness of breath, the ED would do the workup and that would include a computed tomography angiography (CTA) and labs: BNP, troponins, d-dimer, etc. We primarily use a CT scan of the chest. We can estimate the burden of clot and estimate the right heart strain. We also use the BNP; the others are only tiebreakers if we have questions. If anything is abnormal, then the ED calls us, and in the beginning of our program, whoever was there at the time would go down and evaluate the patient immediately. If the patient was a good candidate for the EKOS procedure, then we would have the patient sent up to the interventional radiology (IR) suite and we would do the procedure. At the same time, we wanted to include our pulmonary critical care colleagues, so we would call them and have them involved as well. Our challenges included encountering some people who weren’t really familiar with EKOS or who were afraid of complications associated with tPA. Now that our program is more established, the protocol is that the patient comes in, the ED clinically suspects PE, and they order a CTA and BNPs. We look at the CTA, look at the labs, and if warranted, then they send the patient to us and we do the EKOS procedure. We consult pulmonary and critical care, who come to see the patient. The patient is usually admitted to the ICU, we follow them to discharge, and see them for follow-up in clinic.

The EKOS procedure is performed in the IR lab?

IR has 6 rooms, and we are adding one more. During the day, 3 of our rooms have full-time anesthesiologists as well. We are well versed in handling these patients. Our cardiovascular center actually has 12 rooms. Six are IR and right across the hall, 6 rooms are cardiology. We are under the same umbrella, but we work separately. We do help each other when needed. 

What do you see as the future of the PE program?

It is growing. For the last 5 or 6 years, the EKOS procedure has been the only advanced treatment for pulmonary embolus. Three months ago, we had a case that could have been tragic. It was a woman in her forties who was a single mom and a grandmother. She had fractured her ankle and ended up with a massive pulmonary embolus. She had a code blue, was dead, and was brought back. The ED brought her right to us per our protocol. In general, people put the EKOS system in and leave it overnight, because it is a small dose administered over 24 hours. The drawback is that someone who is critically ill with a massive pulmonary embolus may not survive that long. In this case, faced with a patient who coded already, we called cardiothoracic surgery for a surgical embolectomy. They declined, feeling that she might not survive it. Since we already had her on our table, we said, okay, this is our only choice, and put in the EKOS catheters. Three days later, she went home. We saw her in clinic and she was still in a wheelchair because her ankle was in a cast, but she said she felt back to baseline. We saw her at follow-up twice in clinic. She is doing great.

People are realizing now that pulmonary embolus may not be a death sentence; it can be treated and people are working on different ways to treat it. But EKOS was really the first modern treatment. There are other things coming on the market now that are also going to be useful. Two are mechanical suction embolectomies: AngioVac (AngioDynamics) and CAT 8 (Penumbra). As with EKOS, the AngioVac was first approved for IVC and lower extremity veins, and it is not approved for pulmonary embolus or intracardiac use. The first dozen cases that we did with the AngioVac were all IVC and iliac veins, and we recently did a case with an intracardiac thrombus, with excellent results. We have done three of those cases thus far, and may end up using it for pulmonary embolus at some point as well. I don’t think AngioVac is going to replace EKOS. It is a different tool. The EKOS system does not damage the red blood cells at all, it can clear clot completely or almost completely, and reduces the pressures down to normal or near normal — all of which is great, but it works overnight. In a patient with a major pulmonary embolus, their heart is straining because the pulmonary arteries are blocked with clot. Basically, the heart is pumping against a brick wall. In some massive PE patients, the heart may just get tired and give out before the brick wall dissolves, so time is an issue with these patients. EKOS has started a trial (OPTALYSE PE) where they are reevaluating patients after treatment at 8 hours, 6 hours, and 4 hours. Perhaps we will find out that the patients don’t need to have the system in place overnight. 

Any final thoughts?

The EKOS procedure is the newest standard for thrombolysis. We have used it in not only arteries and veins, but in transplant livers where the portal vein thromboses and the transplant liver is going to die. We will place the catheter via transhepatic access through the liver into the portal vein and do thrombolysis overnight, dissolving the clot completely and saving the liver. The EKOS procedure is not approved by the FDA for liver transplants. But if the patient is going to die, you have to do something. And it works well. 

Disclosure: Dr. Shube reports no conflicts of interest regarding the content herein.

Dr. Samuel Shube can be contacted at zipmont@mindspring.com.

Tell us about your cath lab.

Carolinas HealthCare System Northeast has more than 4,200 employees that provide services through an extensive inpatient and outpatient network, including Jeff Gordon Children’s Hospital, Hayes Family Center, and Batte Cancer Center. Cardiology services are provided by the Sanger Heart and Vascular Institute. We are a primary percutaneous coronary intervention (PCI) center as well as a tertiary referral hospital for ST-elevation myocardial infarction (STEMI).

The cardiac catheterization/electrophysiology (EP) department consists of 3 labs: 2 cardiac cath labs, one of which is primarily a vascular lab, and 1 EP lab. We have a 13-bed pre/post procedure outpatient unit where we prep and recover all of our outpatients. We also perform outpatient and inpatient cardioversions (DCCV), and transesophogeal echocardiograms (TEE).

Our lab consists of 13 registered nurses (RNs), 4 registered cardiovascular invasive specialists (RCISs), 1 registered cardiac electrophysiology specialist (RCES), 1 registered radiologic technologist (RT[R]), and 1 care partner. Expertise in the department ranges from 2-25 years. We have a total of 12 cardiologists from Sanger Heart and Vascular Institute that perform procedures in the department. There are 3 interventional cardiologists and one vascular interventionalist. 

What procedures do you perform? 

We perform a variety of procedures in the department. The following procedures are performed in the cardiac cath, EP, and vascular labs: 

• Left and right diagnostic catheterization;
• Percutaneous coronary intervention (PCI), which may include the use of intravascular ultrasound (IVUS), fractional flow reserve (FFR), instant wave-free ratio (iFR) (Volcano Corporation), AngioJet (Boston Scientific);
• Hemodynamic support with Impella (Abiomed);
• Device implants, intra-aortic balloon pump (IABP);
• Optical coherence tomography (OCT);
• CorPath robotic-assisted PCI (Corindus Vascular Robotics);
• Pericardiocentesis;
• Electrophysiology procedures/ablations;
• Permanent pacemaker (PPM), loop recorders;
• Implantable cardioverter defibrillators (ICDs);
• Biventricular (BiV)-ICD and BiV-PPM;
• Diagnostic peripherial angiograms;
• Vascular stents, venous studies, inferior vena cava (IVC) filter placement, atherectomy;
• Carotid stents, endovascular aneurysm repair (EVAR);
• Thrombolysis.

Is your lab planning a hybrid room in the future? 

Yes, we are planning a hybrid room in the near future.

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

We have a surgical backup team available 24/7. Our cardiovascular operating room (CVOR) is conveniently located adjunct to our cath labs.

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

Interventional cardiologists regularly utilize radial access for diagnostic and interventional procedures. Overall for the last year, our percentage for transradial interventional procedures was 60%. However, we expect that number to continue to rise due to an increase in the number of STEMI cases performed via radial access. 

Who manages your cath lab? 

The manager of the cath and EP lab is Gina Young, BSN, RN-BC. She has been a nurse since 1992 and came to the cath lab in 1999, so she holds over 20 years of nursing experience, 17 of those in the cath lab. She is responsible for day-to-day operations of the lab. Dr. Kevin Kruse, interventional cardiologist, serves as the medical director and has been with the hospital for over 20 years. They work collaboratively to set quality standards and optimize patient care. 

What percentage of your diagnostic caths is normal? 

Approximately 20% of our diagnostic caths have non-obstructive coronary artery disease (CAD).

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

We provide cross training in our lab. The scrub role is performed by RCISs, RCESs, RNs and RT(R)s. RNs are assigned to the circulating role. The monitor role is shared by all staff members. We have a dedicated group of 3 staff members that work primarily in the EP lab; however, all 3 members are cross-trained to work in the cath lab, and cath lab staff is trained to work in the EP lab. Ablation procedures are always performed by the EP staff. We encourage all staff that work in the cath lab to become RCIS-certified and it is a requirement for all technologists. 

Are there licensure laws in your state for fluoroscopy? 

North Carolina has no state or local laws requiring licensing for operation of x-ray equipment. However, we strongly support efforts that would be instrumental in working to create laws requiring licensure for operating radiation-emitting equipment, such as the Consumer Assurance of Radiologic Excellence (CARE) Bill.

Since we have no state licensing laws, all staff members that scrub can perform positioning, panning, setting up views, and utilizing the fluoro pedal in our procedure rooms, under the direct supervision of the physician.

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

We use the standard ALARA (As Low As Reasonable Achievable) principle to minimize radiation. Minimizing time and maximizing distance is our aim. Lead-lined vests, skirts, thyroid collars, and eyeglasses are routinely used. We also use low-dose fluoroscopy and cineangiography for imaging, 15 frames per second and a fluoro-save for interventional procedures. No-brainer lead-lined hats, pelvic shielding to reduce scatter for radial cases, and long extension tubing for contrast injecting are utilized. Additionally, we use a Mavig swing table drape shield, a hanging Mavig facial shield and a portable chat ’em up screen for additional shielding (Figure 2). We also have recently been using the RaySafe radiation protection system to give real-time feedback on radiation exposure. The Corindus CorPath Vascular Robotic System offers the benefit of a radiation-shielded cockpit for coronary interventions. We receive monthly reports from our hospital’s radiation safety committee if we exceed radiation exposure limits set up for the purposes of monitoring safety.

Can you tell us more about some of the new equipment recently introduced at your lab? Why have you chosen to implement these new technologies? 

We have instituted the use of the Corindus CorPath Vascular Robotic System, which has a radiation-shielded cockpit for coronary interventions. The RaySafe radiation protection system, which provides real-time feedback on radiation exposure, has also been recently implemented. We have also begun the regular use of our chat ’em up radiation protection screen, which is placed to the right side of the patient and to the left of the physician in order to limit the radiation exposure during LAO (left anterior oblique) shots, when the camera is closest to the staff. It was noted with the use of the RaySafe System that the highest radiation exposure was with LAO shots and with interventions working in the LAO projection. Use of a 48cm extension tube in place of the usual 24cm tubing allows for more distance between the technologist and the camera during contrast injection in interventions. All of these interventions have been undertaken with an eye towards reducing radiation and improving safety for the physicians and staff. 

We have recently implemented the use of iFR software from Volcano Corporation to evaluate the severity of baseline lesions by angiography. We utilize the hybrid strategy and defer treatment with an iFR >0.93, and revascularize in those lesions with an iFR <0.86. Lesions in the gray zone (0.86-0.93) require adenosine administration. We have eliminated the use of adenosine in approximately 70% of our cases. This has allowed for improved procedure times, reduced cost with adenosine, and improved patient outcomes.

How have physicians and staff reacted to the introduction of the CorPath System? 

The physicians have been very positive with the introduction of the CorPath Robotic System. It allows a significant reduction in radiation exposure for the primary operator, as documented by previous studies, with the use of the radiation-shielded cockpit (95% reduction). It allows for the ability to do coronary interventions without having to wear heavy lead vests and skirts, thus providing a more ergonomically friendly work environment. It allows for better visualization of the coronary arteries, as the screen is less than 10 inches in front of the operator. The system also allows more precise measurements and balloon/stent positioning via sub-millimeter controlled movements with the robotic device. 

The staff has been very favorably influenced by our use of the CorPath Robotic System. It has enhanced their skill sets in regards to loading wires, balloon, and stents. It has had them become more actively involved in the cases and improved their confidence. Staff morale has been boosted as well as overall catheterization lab teamwork. Additionally, the CorPath Robotic System has caused them to become more acutely aware of radiation safety issues and more actively involved in factors aimed at reducing exposure for the entire catheterization lab team. The introduction of the robotic system influenced us all to be more acutely aware of radiation safety. 

How does your lab communicate information to staff and physicians? 

We implemented Managing for Daily Improvement (MDI) huddles to strengthen communication among our team. The entire staff attended training on Lean Basics to assure they were knowledgeable about the concepts on communication and group decision-making, really creating an environment for a change. The huddle is a time for the staff to bring forward ideas for improvement, equipment issues, any concerns, and to recognize the team for the work being done. Through the MDI huddles, departmental metrics are chosen and results are reported daily for continuous improvement. We have a monthly meeting with staff members and physicians. Any new products or medications are introduced by vendor representatives. Cath lab leadership attends several monthly meetings to discuss quality and any operational issues. The physicians and staff attended TeamSTEPPS training (via the Agency for Healthcare Research and Quality [AHRQ]) to improve communication and promote patient and staff safety. Teamwork is very important to our lab.

How is coding and coding education handled in your lab? 

Procedures and supplies are entered into our cath lab documentation system (Merge), and through an interface, are sent to our billing system for daily charges. A physician and procedure report is created, and once it is electronically signed, it goes into the EMR. Coding reviews the documentation to ensure charges match. Two staff members are responsible for reconciling procedure charges each day for our cath labs, and the manager is the final check. The coding department applies the diagnosis codes according to the physician’s report, the case report, and any other supporting documentation available in the EMR.

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

All cath lab staff is trained to pull sheaths. Nursing staff on our cardiac units is also trained to pull sheaths. Per our policy, staff must show competency to pull 3 sheaths, and are proctored by either cath lab staff or a preceptor. All radial sheaths are removed by the physician post procedure and TR Bands (Terumo Interventional Systems) are utilized. A competency has been developed for removing TR Bands and again, employees must be proctored before signing the competency.

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

We have a 13-bay pre/post procedure area where all of our outpatients are prepped and recovered. If the patient is admitted to the hospital, they are placed on the Cardiovascular Intermittent Care Unit (CVIMC), Progressive Coronary Care Unit (PCCU), or the Acute Coronary Care Unit (ACCU). Angio-Seal (St. Jude Medical) is the closure device used most often in our lab, but we do have a variety of devices available. 

How is inventory managed at your cath lab? 

Inventory is managed in our cath lab by the team leader and manager. We have a new cath lab system that records all supplies used during each case, and at the end of the day, a report is generated that is used to order daily supplies. The supplies are ordered using the materials management system and the replenishment arrives to the lab within 1-3 days. The cath lab inventory system is used to maintain par levels within the lab and is used as a cost management system for fiscal inventory.

Is your cath lab expanding in size and patient volume? 

Yes, we are growing at a rate of between 5 to 10% each year in cath volumes.

Is your lab involved in clinical research? 

Carolinas HealthCare System Northeast and the Sanger Heart and Vascular Institute, along with our Clinical Research Department, is very active in clinical research. We are involved in device trials related to electrophysiology and coronary intervention, as well as pharmaceutical trials that are site-specific and some are multi-campus trials. The PRECISION Registry is a multicenter post-market registry for the evaluation of the safety and effectiveness of the CorPath System in PCIs. Currently, 122 participants have been enrolled at our facility. The staff exposure to X-ray during PCI: CorPath vs. Manual Observational Study is also currently enrolling patients who are randomized in the cath lab with a current enrollment of 27 participants in part “A” of the study and seven (7) participants in part “B”. The ABSORB IV study also randomizes participants in our cath lab. The ABSORB IV Study is assessing the safety and effectiveness of treatment of coronary blockages with a bioresorbable vascular scaffold system (BVS, Abbott Vascular) vs a metallic drug-eluting stent. ABSORB IV is a multi-site study that includes Carolinas Medical Center, Carolinas Healthcare System (CHS)-Pineville, and CHS-Northeast. We recently completed the EVERA MRI Study of the first FDA-approved MRI-safe ICD. An upcoming study is called BASELINE, sponsored by Google Life Sciences. This study extensively characterizes participants at baseline serially using a battery of clinical, imaging, physiometric, and molecular tools/testing. The study will enroll approximately 2000 patients with cardiovascular disease. We are also in the pre-approval process of a Phase III study of a new pharmaceutical treatment in subjects with acute coronary syndrome.

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

Carolinas HealthCare System Northeast is a regional PCI center providing STEMI care for Cabarrus and surrounding counties. We are part of American Heart Association’s Mission: Lifeline, and have been working on improving STEMI care for many years. We have been awarded the Quality Achievement award as a Mission: Lifeline STEMI receiving center and have achieved gold plus recognition. We partner with our Cabarrus, Stanly, and Rowan County EMS agencies to bring best practices to the overall care for our patients. Our average D2B time is 48 minutes, which is within the top 10th percentile of the country. We have a highly engaged team of individuals who work to keep this initiative a high priority.

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

STEMI patients who present via the ED are transported to the cath lab by the ED staff. Patients who present by EMS bypass the ED during regular hours and are transported directly to the cath lab. Carolinas HealthCare System Northeast partnered with our local EMS agency to implement cellular ECG transmissions to the physicians’ handheld smart phones. This allows the physician to view the ECG in the field and make the decision whether to bring the patient to the cath 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 presents in the ED and we have a patient on the cath table, we usually complete the diagnostic procedure and take the patient off of the table. If they require an intervention, we bring them back after the STEMI. If we are in the middle of an intervention, the interventional procedure is completed.

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

There is a Cardiac PEPS team, a collaborative team that looks at pricing, contracting, and equipment, that works directly with materials management, the cath labs across the system, and contracts to look for opportunities for cost savings. Most recently, through this work, we have seen considerable savings by limiting the number of vendors within our lab. Initiatives involving standardizing hemostasis devices, vascular products, and implantable devices contracts will be the focus in 2016.

What quality control/quality assurance measures are practiced in your cath lab? 

Quality data from the National Cardiovascular Data Registries (NCDR) (PCI, ICD, and ACTION) are shared in a monthly Cardiovascular Quality Committee. This multidisciplinary team meets to review areas for improvement to help achieve goals and performance outcomes. 

Who documents medication administration during the case? 

The RN administers medications during the procedure and documents in the cath lab hemodynamic system. They are responsible for moderate sedation and complete a yearly competency to ensure safe medication administration.

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

In August 2015, a new Merge cath lab hemodynamic system was installed in our cath and EP labs. This system has a standard report, which flows directly to into our EMR once signed. The report is viewable before the patient leaves the cath lab, allowing for better communication to other healthcare providers. The Merge Healthcare system is used across our primary enterprise, making it a seamless approach to cath lab reporting. 

What has been the impact of your hospital’s commitment to radiation safety in the cath lab? 

Our hospital’s commitment to radiation safety has allowed for further education of staff about the significance of occupational hazards and safety procedures. It has brought an appreciation by the staff for the hospital’s commitment to human capital and the value of its employees to the greater mission. It is understood that providing for safety and prolonging the working careers of healthcare providers will lead to improvement in the care of our patients while providing for cost-effective efficient treatments. We are fortunate to work in a hospital system that acknowledges the value that an experienced healthcare team brings to the care of our patients.

How are new employees oriented and trained at your facility? 

New employees go through at least a 6-week orientation program. They are assigned a preceptor and she/he takes care of all of their educational needs. Weekly meetings with the new employee, the preceptor, and leadership occur to determine any needs of the new employee.

What continuing education opportunities are provided to staff members? 

Each staff member has around $1500.00 dollars of educational assistance money available for continuing education each year. There are in-services provided by the vendors for new equipment and once a year, we have a skills day. The day is devoted to training staff on all of the equipment in the lab that may be used for patient care. This keeps the staff knowledgeable about new equipment and changes in the current equipment. All staff members are required to complete a series of modules for the hospital for continuing education credit. The staff is eligible to attend national conferences and is encouraged to do so. It requires an application to the manager of the department with some requirements upon return. 

How do you handle vendor visits to your lab? 

We have a vendor policy in place that specifies how often vendors are allowed in the department. They must check in with Reptrax to obtain an ID badge that is dated for the specific date they are in the department. Some equipment representatives are allowed in the control room (determined by the procedure being performed) and others must remain in a designated area.

How is staff competency evaluated? 

Staff competency is evaluated on an annual basis. We have an annual “education day” for the cath lab to validate those procedure skills that are identified as high risk and low volume. Staff is required to complete ACE modules as well as online “NEXT” learning modules.

Does your lab have a clinical ladder? 

Yes. We currently have a clinical ladder for the nurses and the clinical invasive specialist. The nurses are able to apply for the Professional Nurse-Clinical Advanced Program through nursing services within our system. There are 3 levels they can achieve by completing an application and a portfolio of work. There is a monetary increase with each level achieved. The clinical specialists have a clinical ladder as well that requires steps to complete. There is also a monetary increase that in added to the base pay. Each clinical ladder step requires some approvals on what projects are allowed and the staff member must be in good standing.

How does your lab handle call time for staff members? 

Each team member is assigned 6-10 call days a month. This includes their weekend rotation, which for the cardiovascular specialists, is every fifth, and for the nurse, it is every fourth. The call team consists of 1 cardiovascular specialist, 1 nurse, and 1 cardiovascular specialist or nurse. The team is available 24/7 for emergency calls. 

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

All of our staff is expected to respond to the hospital within 30 minutes. It is a requirement of employment that you are able to arrive within that specified time frame.

Do you have flextime or multiple shifts? 

We do have multiple shifts in the department. Most employees work 10-hour shifts; however, we have some employees doing 12- and 8-hour shifts as well. Our pre and post procedure area is open until 7pm.

Has your lab recently undergone a national accrediting agency inspection? 

We just had our triennial Joint Commission survey in June 2015. The cath lab was visited by the surveyor and the staff were questioned on post procedure education regarding moderate sedation, lead storage, and radiation safety. We highlighted the Corindus CorPath 200 Robotic System and the use of the RaySafe trial, since we are looking at both staff and physician safety. The survey went well. The only recommendation we received pertained to the way we stored our lead aprons. To bring our lab in compliance with the Joint Commission standard, we purchased lead hangers and removed the pegs.

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

The cath lab is located on the second floor of our hospital. There has been a lot of work to determine the best path especially for the STEMI transport. There is a back elevator adjacent to the Emergency Care Center and then a hallway directly into the cath lab suite. The cath labs are located next to the cardiovascular operating rooms. 

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

We have seen an increase of radial access. We have had a decline in usage of glycoprotein IIb/IIIa inhibitors as well as the IABP. We have documented the appropriate use criteria (AUC) for our elective interventional procedures.

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

We utilize the Corindus CorPath Robotic PCI System for many of our interventional procedures. At this time, we are the only hospital in North Carolina to have this innovative system. We also provide same-day discharge for outpatient PCI procedures. Our discharge rate is greater than 90%. We have also partnered with the local EMS agency on ECG transmission from the field. The ECG is sent to each physician’s phone, which allows for quicker diagnosis and an earlier deployment of the cath team. We utilized this technology to bypass the ED and go straight to the cath lab, saving time. 

Is there a problem or challenge your lab has faced? 

One of the challenges we have faced is maintaining our quality measures at 100% with aspirin, statin, and beta blocker given at discharge. We have implemented several measures as a reminder to the physicians and nurses. We monitor these measures and report them in our quality meetings.

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”? 

Carolina HealthCare System Northeast is the only hospital within Cabarrus County, and is located approximately 20 miles east of Charlotte. We are fortunate to have great entertainment close by, such as the Charlotte Motor Speedway, home to Nascar Motor Sports. We are also just minutes away from Bank of America Stadium, home of the NFL Carolina Panthers. We are centrally located in North Carolina and it is only a short drive to the Blue Ridge Mountains or to the Outer Banks area. We are the PCI receiving center for surrounding rural counties and partner with local EMS to provide care. Most of our staff lives within Cabarrus County, which can help create a small-town feel. The staff delivers a great patient experience based on individual patient care needs. 

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 report data to the ACC-NCDR registries to benchmark our performance to like-size organizations and nationally. This data is reported monthly at our Cardiovascular Quality Meeting identifying opportunities for improvement.  

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?  

All cardiovascular invasive specialists are required to obtain the RCIS certification within one year of employment. There are 3 levels for the cardiovascular invasive specialist job code, entry level, level 1 and level 2. The entry-level position is a non-registered cardiovascular invasive specialist, level 1 is a registered cardiovascular specialist, and the third level allows a registered cardiovascular invasive specialist to progress through the clinical ladder track. There is a salary increase with each level of progression.  

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?   

The members of our team are involved in several professional organizations.  All of the staff has membership in the SICP.

Tell us about your cath lab.

The cardiac cath lab at Stamford Hospital consists of 1 director, 1 nurse manager, 1 clinical coordinator, 5 technologists, 2 advanced practice registered nurses (APRN), 1 physician assistant (PA), 1 scheduler, 1 unit coordinator, and 20 RNs. We have 3 labs. One lab is designated for electrophysiology (EP) studies and ablations, and device implants, one lab is for cardiac catheterization procedures, and one lab is for vascular interventional radiology procedures. We have dedicated staff for both EP and cardiac procedures. Our nurses have a variety of credentials: we have bachelor degree nurses, associate degree nurses, and a diploma nurse. We have staff members that have been working in this lab for over 15 years.

What procedures are performed in your cath lab? 

A variety of procedures are performed on a daily basis, including but not limited to: diagnostic heart caths, with possible angioplasty and stenting, chronic total occlusions (CTOs), ST-elevation myocardial infarctions (STEMIs), lower extremity angiograms with interventions, pacemaker/implantable cardiac defibrillator (ICD) implants, paravalvular leak repair, balloon aortic valvuloplasty (BAVs), transcatheter aortic valve replacement (TAVR), CardioMEMS implant (St. Jude Medical), EP studies with various ablations, pericardiocentesis, temporary pacemaker insertions, transesophageal echocardiograms (TEEs),g Impella insertions (Abiomed), Rotoblator (Boston Scientific), intra-aortic balloon pump (IABP) insertions, cardioversions, convergent ablations, and LINQ insertions (Medtronic). Approximately 35 procedures are performed in our lab each week.

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

We do have a hybrid operating room (OR) that was recently built to perform these procedures. We performed our first TAVR procedure in April 2015 and continue to grow this service. At this time, we have completed 17 TAVR procedures.

What percentage of your diagnostic caths is normal?

Approximately 60% of our heart caths are normal.

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

Radial access is utilized in approximately 80-90% of our cases.

Who manages your cath lab?

We have 1 director and 1 nurse manger managing our cath lab.

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

We do not have cross training in our cath lab. However we are looking into this route. Currently, our technologists scrub with the cardiologist, 1 RN circulates, and 1 RN monitors each case. 

Which personnel can operate the x-ray equipment in your cath lab? 

In the state of Connecticut, only the physician or the technologist can use the fluoroscopy. Similarly, in our cath lab, only the physician or the technologist can operate the x-ray equipment. This includes positioning the C-arm, panning the table, changing the angles, and stepping on the fluoro pedal.

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

We are provided with lead aprons, thyroid shields, stand up and rolling lead shields, dosimetry monitors that are read monthly, and we have routine check of lead aprons under fluoro. We also have a radiation safety officer who oversees the radiology department.

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

We have been using new radial compression devices. We currently have 3 vendors for stents and balloons. We have an optical coherence tomography (OCT) system and the Impella device. We also have been implanting CardioMEMS devices to monitor pulmonary artery pressures to prevent/reduce heart failure hospitalizations. Our staff is independent using all of these technologies. Both the Impella and OCT systems have representatives who have been very helpful and available for any questions.

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

In our lab, our manager communicates via email and monthly staff meetings, which are usually attended by our physician director and nursing director. Occasionally, we will have “huddles” for important announcements. 

How is coding and coding education handled in your lab?

We have a lead technologist who handles coding and billing. Prior to each case, we have the ability to scan all equipment used, which is then printed for billing purposes at the end of the case.

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

All of our technologists, our physician assistant, and our nurse practitioners have the ability to pull sheaths, both diagnostic as well as interventional. The EP nurses have also completed competencies to pull venous sheaths. In many cases, we do utilize a closure device, placed by the physician at the end of the procedure. The physician, PA, or APRN will work with our technologists to teach them the proper process for pulling sheaths. Staff is required to pull a certain amount of sheaths supervised before they are “signed off”.

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

Our patients come to our holding room prior to each procedure (with the exception of the STEMI patients, who go directly to the lab from the emergency department [ED]). In the holding room, the patients are prepped and screened by 2 RNs, the APRN or PA, and are also seen by the physician before going into the lab. Post procedure, if the sheath is still in place, we will keep the patient in the holding room, monitored by one RN, until the sheath is pulled.  

How is inventory managed at your cath lab? 

Our lead technologist manages and performs the purchasing of our supplies, which is overseen by our manager and director. We scan all equipment for each case, which generates a detailed inventory report.

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

From fiscal years 2013 and 2014, our volume has increased by 23%. In 2015, we were targeted to do 787 procedures, and we actually completed 851 procedures. A new hospital is currently under construction and on schedule to open in late summer 2016. Our expanded Heart & Vascular Institute will have 2 EP rooms and 3 cardiac cath rooms. At that time, the non-invasive cardiac procedures, such as TEEs and cardioversions, will be managed separately from the invasive team by the cardiology department.

Is your lab involved in clinical research?

At times, we have patients who are involved in a clinical research study through their private physicians. We are currently in the process of developing our first nursing clinical research project for same-day radial access cardiac cath discharge. At this time we have completed 3 with great success, as we only began this past December.

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

Our average D2B time was 62 minutes in the last quarter of 2014. We have been 100% compliant for D2B time for 17 quarters. Our STEMI team is extremely diligent. We are always here within the 30-minute timeframe; however, most of the time we are here well before the 30-minute timeframe. 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?

Our STEMI patients are brought from the emergency room with the ED physician or the intensive care unit (ICU) resident, who will accompany the patient to the cath lab along with the ED nurse and the hospital resource nurse. At times, the STEMI physician will make a determination to bring the patient directly to the cath lab and bypass the emergency room.

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

During regular hours, another cath lab team will set up in another room to do the STEMI. During off hours, if our call team is in a procedure, they will contact the nursing supervisor to facilitate the next STEMI patient getting to the room. The nursing supervisor and resource nurse will need to help transport patient out of the lab in order to get in the next patient. The call team will work quickly to finish the procedure in order to see to the next patient.

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

We scan equipment for every case and most physicians are very diligent about not using excess equipment. Our lead technologist works with the vendors to achieve quality control and utilization in an effort to contain costs. We have implemented quantity purchases for devices to decrease cost. We have also created staggered shifts to keep labor costs down.

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

We do daily room and equipment checks, and monthly QC checks to ensure QA. We monitor first case start time, cost per case, universal protocol, pain assessment, and use a pre-op checklist to ensure high quality, safe patient care. We also do antibiotic timing for device implants.

Are you recording fluoroscopy times/dosages? 

We document fluoroscopy dosages in our lab-documenting program for each case. It also is documented in our national registry information. 

Who documents medication administration during the case?

During each case, the RN monitoring will document medication administration.  After the procedure, the physician and both RNs will electronically approve the entire report.

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

Our physicians dictate after each procedure via telephone, which is then typed by a service within the hospital. They also dictate using a structured reporting tool that is contained in our documenting system.

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

We currently use the ACC-NCDR to report cardiac cath procedures. We also use the NCDR-ICD registry for any implants.

How does your cath lab compete for patients? 

We maintain our patient population through physician referrals. Additionally, we are a member of the New York-Presbyterian Healthcare System and an affiliate of the Columbia University College of Physician & Surgeons. We also get patients via word of mouth from other patients. We are the only hospital in Lower Fairfield County with the ability to perform elective angioplasty and stenting, which increases our patient population. 

How are new employees oriented and trained at your facility?

New employees complete an 8- to 12-week orientation where they are partnered with a seasoned cath lab nurse. During this orientation process, we have a competency program where steps are checked and reviewed with the orientee, preceptor, and manager on a weekly basis. We provide a 6-8 week shadow STEMI call period.

What continuing education opportunities are provided to staff?

We have monthly education by vendors and representatives for products and equipment. We also complete a yearly competency hands-on program specialized to our unit and our equipment. At times, outside education opportunities are provided by vendors. Each year, we have money set aside in our budget for staff to attend national and local conferences.

How do you handle vendor visits to your lab? 

Vendors are required to sign in with materials management, provided a photo ID badge, and sign in with security. Vendors coordinate with our unit coordinator and lead technologist to plan visits on certain available days.

How is staff competency evaluated?

Staff competency is evaluated each year by performance reviews with our manager. We also have modules to complete on the computer on an annual basis, along with an annual hands-on competency program. 

Does your lab have a clinical ladder?

We do have a clinical ladder within our hospital. It is a hospital-wide nursing program designed to engage nurses in expanding and improving their professional development.

How does your lab handle call time for staff members? 

During off hours, we have 2 RNs and 1 technologist on call. Off hours include 5pm-7am, the weekend hours, as well as holidays.

Do you have flextime or multiple shifts?

We do have flexible shifts to accommodate our patient population. These include 6:30am-4:30pm, 7am-5pm, 8am-6pm, and 7am-8pm.

Has your lab recently undergone a national accrediting agency inspection? 

Our lab has not undergone any national accrediting agency inspection. We are currently looking into national accreditation. We are subject to routine visits from The Joint Commission and the Department of Health, as are many other facilities. Our hospital recently applied for Magnet status with a site visit planned for early February 2016.

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

Our cath lab is currently on the ground floor, down the hall from the emergency room. The operating room is currently on the second floor, directly above the cath lab. However, with the advent of the new hospital, this layout will change.

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

One trend we have seen in our procedures includes the change from femoral access with no closure device to radial access with the use of compression devices. This has made it more comfortable and safer for the patient, and can expedite a faster discharge time. In regard to our patient population, we have been seeing an aging population who need interventions.

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

The staff in our cath lab is very close knit. We are like a family. Everyone gets along; we even get together outside of work regularly. We share lots of laughs and good times. Our staff is consistently working towards the best interest of the patient, as well as the safety of our patients.

Is there a problem or challenge your lab has faced?

One challenge our lab has faced is regarding on-time starts. We collected data that included patient arrival time, patient prep time, and physician arrival time. We presented this data to the staff and physicians. We have made some previsions regarding room turnover and patient prep practices, and have since had much better results. We went from 0% compliance for on-time start in 12/2013 to 60-70% compliance in 12/2014. We are currently at 100% compliance for on-time start over the past 2 months.

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”?

Lower Fairfield County is a highly populated area. We are the only hospital in Lower Fairfield County that provides elective angioplasty. There are many large corporations in Lower Fairfield County that bring people from outside areas to work, thus increasing our population, especially during the week. 

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 rise upon passing the exam?

Our lab currently does not require clinical staff members to take the registry exam for the RCIS. We do have one technologist and one RN with the RCIS certification. The RCIS credential is something we are currently looking into for our lab and there are additional people who are interested in getting this certification. Our manager will reimburse staff for the cost of the exam if a passing grade is achieved. 

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 organization?   

Our manager and clinical coordinator are members of the Society for Cardiovascular Angiography and Interventions (SCAI).

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

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

We use the NCDR Outcome Reports to drive QI initiatives such as cardiac rehab referrals. Over the past year, our cath lab operations group has been revamped as an operational working group. The data coordinator brings back the information gathered to improve our measures regarding cardiac rehab referrals and we are now at over 90%. 

Tell us about your facility and cath lab.

WakeMed is a 919-bed, private, not-for-profit health care system based in Raleigh, North Carolina. It operates two acute care hospitals (WakeMed Raleigh Campus and WakeMed Cary Hospital), a women’s hospital (WakeMed North Family Health & Women’s Hospital), a physical rehabilitation hospital, three healthplexes (WakeMed Apex, WakeMed Brier Creek and WakeMed Garner), a home health agency, two outpatient facilities, four collaborative outpatient rehabilitation programs located inside area YMCAs, and WakeMed Physician Practices, a multi-specialty physician practice. WakeMed is a leader in both Wake County and North Carolina in developing innovative services to meet the needs of the community and region. 

WakeMed is one of the state’s largest providers of comprehensive cardiothoracic and vascular services. The hub of cardiac services at WakeMed Raleigh Campus is the WakeMed Heart Center. This facility, physically connected to the main hospital, first opened in 1998 and underwent expansion and renovation in 2005. The layout of the Heart Center allows patients to register, see their cardiologist in their offices, and have non-invasive cardiovascular tests and invasive cardiac, peripheral and neuro procedures performed all under one roof. If an overnight stay is required prior to or following a specific procedure or test, patients and their families have the option of spending the night in the full-service hotel located on the top floor of the Heart Center.

Other services unique to WakeMed that bring added value to the communities we serve include: 

• Wake County’s only Level I Trauma Center as designated by the North Carolina Office of Emergency Medical Services;
• Chest Pain Centers accreditation by The Society of Cardiovascular Patient Care;
• Primary Stroke Centers certified by The Joint Commission;
• The Heart Center Conference Center, a 5,000-square foot facility with meeting rooms for conferences and symposia, with state-of-the-art capabilities for streaming video directly from the cardiac catheterizations labs and operating rooms to the conference center.  WakeMed physicians frequently present findings from research, as well as host experts in cardiovascular disease treatment and management for local physicians and health care professionals;
• On-site 24/7 invasive cardiology staff to expedite all emergent procedures in the cath lab.

Who manages your cath lab?

The Invasive Cardiology management team consists of a department manager (Kim Wooten RN, BSN, RCIS), three cath lab supervisors (Kristy Whitley, BSN, RN, RCIS, Mike Turner, RT[R], RCIS, and Hollie Boswell, MHA, RCIS), and one electrophysiology (EP) supervisor (Jeannine Volles, BSN, RN, RCIS).

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

The Invasive Cardiology Department at WakeMed Health and Hospitals consists of 11 procedure rooms, which include cardiac catheterization labs, a hybrid room, and EP procedure rooms. Five of the coronary procedure rooms are equipped to perform complex peripheral vascular and neurovascular procedures. The hybrid room is also used for structural heart and complex endovascular procedures. Our newest procedure room is equipped to perform coronary, peripheral vascular, and complex EP procedures such as complex ablations.  

The staff within our department consists of 59 cardiovascular specialists (CVS), three secretaries, one scheduler, and two cath lab assistants. The cardiovascular specialist or CVS title encompasses multiple modalities, consisting of 25 registered nurses (RNs), 20 radiologic technologists (RT[R]s), 8 emergency medical technicians-paramedics (EMT-Ps), 3 registered respiratory therapists (RRT) and 3 registered cardiovascular invasive specialists (RCISs), although all 59 of our CVS staff are RCIS certified in addition to any credentials they may hold.

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

Our cardiovascular specialists, which include nurses, radiology technologists, paramedics, and respiratory therapists, are cross-trained to function in all three roles (monitor, scrub and circulate). They have all achieved the RCIS credential, in addition to their primary credentials.

What procedures are performed at your facility? 

Our facility performs coronary, peripheral vascular, and neurovascular diagnostic and interventional procedures. Our coronary procedures include left heart and right heart catheterizations from multiple access sites (femoral, brachial and transradial). Percutaneous coronary interventional (PCI) procedures include intravascular ultrasound, fractional flow reserve (FFR), embolic protection devices, mechanical and manual thrombectomy procedures, and insertion of intra-aortic balloon pumps and Impella (Abiomed) ventricular assist devices.  We also perform complex chronic total occlusion interventions using both the antegrade and retrograde techniques.

Peripheral vascular procedures performed include atherectomy (Jetstream [Boston Scientific], Diamondback [CSI], TurboHawk [Medtronic]), drug-coated balloons, EkoSonic (EKOS Corporation), stenting and mechanical thrombectomy (AngioJet [Boston Scientific]). We are also using the tibiopedal arterial minimally invasive retrograde revascularization (TAMI technique) for critical limb ischemia (CLI). 

Our neurovascular procedures include carotid/intracerebral angiography and interventions.  Interventions performed include stroke, aneurysm coiling, arteriovenous malformation (AVM) and arteriovenous fistula (AVF) embolizations and stenting (Pipeline [Medtronic]).

Electrophysiology procedures are also occasionally done within the invasive cardiology procedure rooms, but are most commonly performed in our EP procedure rooms. 

We perform transcatheter aortic valve replacement (TAVR) procedures, MitraClip (Abbott Vascular) procedures, endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) in our hybrid procedure room.

Can you share more about your TAVR experience?

Our TAVR program began in March 2013. We perform all our cases in our hybrid procedure room in our invasive cardiology department. We have performed a total of 93 cases over the past two years.  

Do interventional radiologists and cardiologists perform procedures in the same area?

The peripheral procedures that are performed within our department are performed by interventional cardiologists, vascular surgeons and one neurosurgeon. We do not have interventional radiologists that work in our department.

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

Our D2B times are consistently less than 50 minutes for 100% of Code STEMI (ST-elevation myocardial infarction) patients. We average less than 90 minutes for first medical contact to balloon/device time. We were awarded the Mission Lifeline Silver Award in 2015 for consistently following the American Heart Association’s treatment guidelines for four consecutive quarters, meeting performance standards and measures for STEMI care.

WakeMed initiated a Code STEMI process in March 2006 to facilitate improving the door-to-balloon (D2B) times. The process involves early identification through the Wake County Emergency Medical Services (EMS) system. The paramedics in the field are trained to recognize criteria for ST elevation. They utilize Bluetooth technology to transmit electrocardiograms (EKGs) directly to the emergency room and the cath lab prior to arrival with the patient for confirmation. Once confirmed, the emergency department (ED) physician can activate the internal Code STEMI response. 

The response team consists of a cardiac care unit (CCU) rapid response nurse, the clinical administrator, the physician assistant/nurse practitioner (PA/NP) for the cardiology practice on call, and the in-house cath lab staff. The Code STEMI response team assists the ED staff in facilitating and expediting transport of the patient to the cath lab.

Before the initiation of the Code STEMI response process, our average D2B time was 120 minutes. In January 2008, the invasive cardiology department implemented 24/7 cath lab staffing. This staffing is made up of a full-time, 4-member team and was developed to further improve the Code STEMI response time.  

As a backup to the 24/7 staffing, our department maintains an on-call team to respond if multiple emergent procedures occur. The on-call team for our department has a 30-minute response time for arrival to the cath lab when called to duty.

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

The Code STEMI response team (critical care RN, respiratory therapist, house clinician, NP/PA) in collaboration with members of the cath lab team will transport the patient to the cath lab during both regular and after-hours operations.  

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

The department on-call team has a 30-minute response time. We do not routinely have an attending cardiologist on-site; however, PA/NPs affiliated with the physician practices are on-site 24 hours a day. 

How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?

Radiation protection is an important part of our day-to-day operations and our department has implemented several radiation safety measures. All staff and physicians are monitored utilizing radiation badges. These badges are exchanged monthly and readings are available to staff. In addition to monitoring badges, all staff and physicians are provided with personal lead aprons and lead glasses. Radiation badge audits are performed monthly on staff and physicians by a departmental radiation safety committee to verify that monitoring devices and protective equipment are being utilized appropriately.

Within the peripheral vascular rooms, additional lead shielding has also been added to both sides of the procedure table to include table shielding and hanging lead shields. This provides additional protection for staff regardless of access site.  

Can you describe the system(s) you utilize and how they work in cath lab daily life?

Our hospital system switched to EPIC for our electronic medical records (EMR) last year. Our department uses the cardiology module of EPIC, known as CUPID. We use CUPID for scheduling and documentation of our procedures. However, we still use the GE Mac-Labs system for hemodynamic monitoring. We use Lawson (Lawson Software) for our inventory system, which interfaces with the CUPID EMR system. 

Who documents medication administration during the case?

For every case, we have an assigned documenter. The role of the documenter is to monitor vitals and record all procedure and medication events. Using CUPID, the documenter is able to record the physician order, dosage, route, indication and medication administrator in the procedural event log.

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

Inventory is managed through our Lawson system using a bar code system for scanning inventory into the procedure log, which replenishes inventory (generates a purchase order) based on par levels set once the item is scanned/used during a procedure. Products are selected through a department/hospital product review committee, which consists of physicians, clinicians, and a strategic sourcing contract specialist. The strategic sourcing contract specialist works with department management to purchasing equipment and supplies, and negotiates pricing contracts. 

How do you handle vendor visits to your lab? 

 All appointments and visits are handled through the strategic sourcing contract specialist and all vendors must be compliant with all immunizations, mandatory education, and HIPAA (Health Insurance Portability and Accountability Act). These requirements are managed through our Reptrax vendor credentialing system. Vendors are not allowed on the hospital premises without an appointment and must wear their Reptrax badge at all times while on the premises. Vendors are not allowed in procedure rooms unless invited in by a physician and must wear hospital-issued scrubs. 

How are new employees oriented and trained at your facility? 

The orientation process for new employees usually takes up from 3 to 6 months. Each employee is given an orientation manual (that provides didactic explanations of procedures, equipment, anatomy and medications) and is assigned with a preceptor who has worked in the lab for a minimum of two years for hands-on experience. The orientee is trained in each of the three roles (monitor, scrub and circulate). Each role, on average, takes 4 to 6 weeks for complete training.  Each employee must complete competency checklists, and have the approval of their preceptor, educator and management prior to completion of a role. For employees entering with cath lab experience, the same process is utilized; however, the orientation time frame is usually shorter.  Performance assessments are completed at the stages of 30 days, 60 days, and 90 days to assess the progress and needs of the new employee. 

Our educators also have access to a simulation lab that can be utilized in the teaching of new staff and students on coronary and carotid procedures.

Every employee must be credentialed as an RN, EMT-P, RRT, RCIS, or RT in order to work in the lab. Our staff is also required to have basic life support (BLS) on hire, advanced cardiac life support (ACLS) within 3 months of employment, and obtain the National Institutes of Health Stroke Scale certification (NIHSS). The registered cardiovascular invasive specialist credential (RCIS) is required within 2 years.

What continuing education opportunities are provided to staff members?

WakeMed’s professional development of staff is supported through various continuing education opportunities. Opportunities include:  tuition reimbursement, an on-site RN to BSN program, an on-site BSN to MSN program, Masters in Health Administration and Masters in Business Administration programs, WakeMed’s Leadership Academy, and WakeMed Foundation grants and scholarships for skills development.  

Within our department, we provide monthly in-services on medications, equipment and anatomy that assist with obtaining continuing education for our staff. Our staff also has annual blitz check-offs that include staff and vendor education on frequently and infrequently utilized devices. 

Programs are also offered from our Area Health Education Center (AHEC) organization that include but are not limited to: RCIS review seminars, cardiac symposiums, and stroke symposiums.  

As part of our department’s employee evaluation, every CVS is required to obtain a minimum of 15 continuing education units (CEUs) annually. 

Does your lab have a clinical ladder? 

Our facility does have a professional development program that is available to staff after one year of employment (6 months if prior cath lab experience) within the department. Staff is required to fulfill a standard set of requirements that include technical skill check-offs/experience, education of other staff/peers, community involvement, and leadership components. There are three levels of progression: CVS I, CVS II, and CVS III. 

Our department also offers a professional development program for our team leaders as well, with requirements containing more leadership expectations.

How does your lab handle call time for staff members? 

Our call team consists of 4 staff members, all of whom are cross-trained and RCIS-credentialed to staff every role needed. This team is utilized for situations in which there are multiple emergencies. Our in-house team is the primary response team for emergencies after hours.

Do you have flextime or multiple shifts? 

With 24/7 operations, our department can perform elective and emergent procedures at any time, including weekends and holidays. If additional staff is needed, there is an on-call team that is available. Currently our department consists of multiple shifts for 24-hour coverage. We have staff that work 8-hour shifts, 10-hour shifts, and 12-hour shifts. There is also staff that is scheduled to work night shifts and weekend shifts. 

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

The OR and the cath lab are both located on the second floor of the hospital. These departments are separated only by the critical care units and critical care family waiting room. Our ED is located on the first floor of the hospital directly below the critical care units.

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

The current trend in our department is an increase in complex procedures. We are performing an increased number of hybrid procedures, as well as complex peripheral vascular and EP procedures.  

How do you see your cardiac catheterization laboratory changing over the next decade? 

Integration of multiple modalities has been key to the growth of our cardiovascular program. Peripheral vascular intervention is a rapidly growing market as we progress towards more CLI and hybrid procedures. We anticipate progressing as a regional stroke center utilizing mechanical intervention. Planning for future expansion and renovation projects will be geared toward additional multi-purpose procedure rooms for flexibility to perform heart caths, EP and peripheral vascular procedures.  

What do you consider unique and/or innovative about your cath lab and staff?

Several items make our lab unique and innovative:

• Fully cross-trained staff: What this means for our patients and staff is that each staff member can contribute to a procedure or emergency in every way possible to take exceptional care of our patients’ well-being.  
• 24/7 staffing: We are proud that our department can provide patients with full-time, 24-hour staffing coverage. We employ a 4-member team during off hours (nights and weekends) to allow for quick emergency coverage and availability for elective procedure completion beyond regular lab hours. This coverage has reduced the amount of staff callback and has reduced the Code STEMI D2B times.
• Stroke and carotid interventional program: Our department has performed carotid interventions since October 2003 and is currently one of the few cath labs developing interventional stroke programs in the nation.   
• NIH Stroke Scale certified: Our department prides itself in the fact that 100% of our staff is NIH Stroke Scale certified. As our department moves into the field of stroke intervention, it was felt that our staff needed to have the knowledge to best support and treat our patients. 

WakeMed Awards & Accolades:

• Magnet Designated facility by the American Nurses Credentialing Center
• Blue Distinction Center+ for Cardiac Care by Blue Cross and Blue Shield of North Carolina
• American College of Cardiology’s NCDR ACTION Registry–GWTG Platinum Performance Achievement Award for 2015
• American Heart Association’s Mission: Lifeline® Receiving Center – SILVER Plus Level Recognition Award
• 2015 Get With the Guidelines Heart Failure Gold-Plus Quality Achievement Award
• WakeMed Raleigh Campus was rated “High Performing in Heart Bypass Surgery and Heart Failure” and WakeMed Cary Hospital was rated “High Performing for Heart Failure” by U.S. News & World Report

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 Outcome Reports in both our physician quality committee as well as our department QI committee.

A question 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?

We take pride that the majority of our staff is recognized as RCIS certified. We require new staff to obtain the RCIS credential within 2 years of hire. WakeMed makes every effort to help each employee achieve this through RCIS exam review and exam reimbursements. The RCIS is recognized in our progression ladder process for advancing to a CVS III.

Tell us about your facility and cath lab.

Houston Heart Institute (HHI) is a 17,000-square-foot facility with four procedural rooms and 12 recovery bays. We have one dedicated cardiac room, one combo room where we do cardiac, peripheral and device procedures, and we also have an electrophysiology (EP) lab. We have 12 registered nurses (RNs), two registered cardiovascular invasive specialist (RCIS) technologists, and three radiologic technologists (RTs) trained to scrub. We have one cardiovascular (CV) technologist whose specialty is post cath groin management. Approximately 70 percent of the current staff has been with us since the inception of the program in 2010. 

What procedures are performed in your cath lab?

The following are procedures that will be routinely performed in the cardiac cath cab, within C-PORT trial (Cardiovascular Patient Outcomes Research Team) guidelines where applicable:     

• Left heart cath: 30-45/week
• Right heart cath: 2-3/week
• Electrical cardioversion
• Transesophageal echocardiogram (TEE)
• Angioplasty
• Percutaneous coronary intervention (PCI): average 8-10/week
• Abdominal aortography with or without runoff
• Permanent pacemaker
• Temporary pacemaker
• Intra-aortic balloon pump (IABP)
• Pericardiocentesis
• Thrombectomy
• Peripheral transluminal angioplasty with and without stent placement
• Intravascular ultrasound (IVUS)
• Fractional flow reserve (FFR)
• Loop recorder
• Renal angiography selective (unilateral or bilateral)
• External pacing
• Fluoroscopy 

You mentioned C-PORT guidelines. Does your cath lab perform primary angioplasty without surgical backup on site? 

HHI does perform primary angioplasty without surgical backup. Our tertiary partner is located 20 minutes north and we have a transfer agreement with them to accept our patients. We also own our Emergency Medical Services (EMS) service and have protocols in place to expedite transfers from HHI to our tertiary partner very quickly. Since we operate under C-PORT guidelines, we report our outcomes to the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR). Within the registry, hospitals in the 90th percentile have a mean time of transfer from emergency department (ED) arrival at the transferring facility to ED arrival at the receiving facility of 48 minutes, which is very good. The mean time of transfer for HHI is 29 minutes. Our staff takes their work very seriously and we are very proud of that metric.

Can you tell us more about the start of your interventional program in 2010?

Prior to 2010, HHI was a one-lab, diagnostic-only cath lab with non-invasive cardiology and a cardiac rehab department. We deployed our first stent on October 12, 2010. Since that time, we expanded by building two new state-of-the-art cath labs outfitted with Siemens Artis Q and Artis zee x-ray equipment. We also converted our old cath lab to an EP lab. Our echo department achieved IAC (Intersocietal Accreditation Commission) accreditation in 2015 and is the only echo department in a 50-mile radius to have such accreditation. We also recently submitted our application for ACE (Accreditation for Cardiovascular Excellence) accreditation for PCI. We would be only the third cath lab in Georgia to have this accreditation.

Our cath volume has grown; however, we feel — like most areas nationwide — that growth in heart caths will be flat or decreasing over the next few years. Our greatest area of growth has been in devices. Our peripheral volume is also growing, and we are working hard to build that program, because it reflects a huge need in our area. Also, our EP program is new, so we are still in the early building stages of that service line. We have come a long way in a short time.  

Who manages your cath lab? 

Scott Cole, RN, is our manager for Invasive Cardiology. Brandy Hill, RN, is the assistant nurse manager.    

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

We encourage our nurses to train to scrub, and currently one RN is actively being trained to do so. Naturally, it will be accomplished over time. We have RCIS and RT staff that scrub. The nurses circulate. All RCISs, RTs, and RNs may monitor. 

What percentage of your diagnostic caths is normal?

We have struggled at times with this metric. On our last ACC report, we had a 62 percent “clear cath” rate. We have gone from 17 percent or so to 62 percent since we started in 2010. We now have in place several measures to lower this percentage, including more accurate documentation. We expect to improve, and be more consistent and in line with what is expected.

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

We have four physicians that perform radial approaches. Radial access has been slow to take hold here, but all our physicians recognize the advantages of going radial. 

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

All staff, technologists and RNs, takes an occupational radiation exposure learning session and competency test annually. All staff and physicians wear lead aprons, thyroid shields, and eye protection. All staff wears dosimetry badges and reviews their readings monthly.

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

After a recent expansion, we have Siemens Artis Q and Artis Zee x-ray equipment. We purchased two integrated Volcano systems for FFR and IVUS fairly recently. We have started using the Medtronic percutaneous loop recorder, and we also recently purchased a vein finder device to aid in intravenous starts on patients with hard-to-find veins.

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

We utilize our vendors to a great extent for doing lunch and learns, as well as occasional after-work dinner meetings to discuss new technology and products. We occasionally have a staff member research a new product and do a presentation for staff. 

How is coding and coding education handled in your lab? 

Coding is performed in our coding department within medical records.

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

All of our clinical staff is trained to pull sheaths AND manage groins. We believe pulling a sheath is standard practice for all our clinical staff, but managing a challenging groin takes much more skill. We have a post cath groin management team of two people that rounds on all our patients and rotates call 24/7. They also make post discharge calls to our patients to see if there have been any issues or concerns from the patient since discharge. The staff making up this team can be a RN, RCIS, RT, or our CV technologist. It has been a tremendous resource for the floor and intensive care unit nurses, and demonstrates the dedication our people have to delivery of very high quality care for our patients. We have a very vigorous training program undergone by all new clinical staff, consisting of printed literature and instruction on all aspects of groin management. We ultimately require 10 independent successful pulls to be checked off in orientation and then 5 yearly on competencies. 

Where are patients prepped and recovered post sheath removal? 

Our patients are prepped in our 12-bay recovery area. We have two types of vascular closure devices and one access device available, but primarily use Angio-Seal (St. Jude Medical). Manual pull and closure device patients both go back to cath recovery. Angio-Seal patients are recovered for a minimum of 30 minutes and transferred to our cardiovascular floor or to ICU. Manual pull patients have their sheath pulled in cath recovery by either our CV technologist or other clinical staff that have been trained in groin management. After transfer, all our patients are rounded on twice a day by our CV technologist or another staff member trained in groin management. Of course, if the floor nurse has any concerns over the groin, we encourage them to call for help — the post cath groin team is available as a resource to them 24/7. As a safety measure, we make post discharge follow-up calls to check on the groin. We recognize the critical nature of this component of care and the post cath groin management team is an example of how dedicated our staff is to patient safety.   

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

We use the SpaceTrax inventory management system (Stanley Healthcare) in interventional radiology and in HHI. Through the use of this system, staff can see what items are common to both areas and manage inventory par levels accordingly. We were able to achieve a 38 percent decrease in supply cost per procedure in the first 18 months of use. Supplies are ordered by Katie Graham, RT. Katie does a great job of utilizing SpaceTrax to its fullest extent. She has been very successful in establishing appropriate par levels and in getting our needed supplies here quickly.   

Is your lab involved in clinical research?

Not at this time.

Can you share information about your lab’s door-to-balloon (D2B) times and structure of your ST-elevation myocardial infarction (STEMI) program?  

Door-to-balloon time is a critical metric with regard to positive outcomes for the patient. Working with Francis Peed, RN, Director of Critical Care and ED, and David Borghelli, Director of EMS, we developed a process that begins in the field with EMS. Our medics receive excellent training in ECG interpretation and will obtain an electrocardiogram (ECG) on site. If the ECG indicates a STEMI or if it is questionable, they transmit it to the ED physician, who can direct them to the cath lab, bypassing the ED. At the same time the ED physician makes that call, the ECG is sent by secure e-mail to the cardiologist on call, who will verify the need to go to the cath lab or wave them off. For patients that arrive by patient office visit (POV), our criteria for an ECG in less than 10 minutes are: 30 years old or older, and pain above the umbilicus. The national standard is 15 minutes; however, we felt we could do it in 10 or less, and we consistently achieve this goal. We monitor this closely, and meet monthly with EMS and ED leadership to review these times, which are presented on a spreadsheet. Many factors dictate D2B times. STEMIs can present in a number of ways that might not be identified quickly. But by being as diligent as is humanly possible on the front end, we eliminate as many of those variables as we can. Our EMS and ED staff has done a tremendous job of getting these patients to the cath lab as quickly as possible. Our median time for immediate PCI for STEMI patients, as reported on our last ACC report, was 62 minutes. Ideally, we would like to drop this number down to 50 minutes within the next year.     

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

For regular hours and off hours, we require two members of the STEMI call team to transport these patients. One must be an RN. 

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

Appropriate triage is the first step. In the case of an STEMI being intra-procedural and a second STEMI presenting, the teamwork between the ED nurses, house supervisor, and the rapid response nurse is employed. The ED physician will discuss further treatment in addition to the ED protocols in place with the interventional cardiologist.

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

The SpaceTrax inventory control system has been a big help in managing inventory, which reduces cost. Our hospital joined SCSS, a large purchasing group, and that has also helped us reduce cost.                                 

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

We have several QA measures in place within HHI. We have 100 percent physician review of all STEMI cases. We have monthly meetings to review every STEMI case for procedural hiccups — a measure that has proven to be very effective. We have quarterly cath conferences that are open to everyone in the hospital and offer CMEs for the physicians that attend. We also have monthly morbidity and mortality conferences with the physicians. 

Are you recording fluoroscopy times/dosages? 

Fluoroscopy times/dosages are recorded using our recording systems and entered in the procedure report. 

Who documents medication administration during the case? 

The monitoring technologist enters all meds given during the case and the RN signs off on the report at the end of the case. We also have a Pyxis medication-dispensing machine (Becton, Dickinson and Company) in our procedure rooms.

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

Our hospital is working with Duke University to establish a FastSTEMI program. We have partnered with the three other facilities in our area that offer PCI to accomplish this. We are fortunate to be the only healthcare system within our community. Our objective is to get patients in our area to the nearest PCI center as quickly as possible and to establish protocols for treating STEMI patients in the ED in rural hospitals until patients can be transported to a PCI center.

How are new employees oriented and trained at your facility?

New employees are placed with one of our two preceptors. Their preceptor or team leader provides intense training on all the equipment and will ultimately check them off on a competency worksheet. Orientation and training includes medication administration, circulator role, recorder role, primary recovery room nurse, and post cath groin management. It is a progressive approach to training where the new employee is primarily exposed to one area for a certain amount of time or until they demonstrate competency, and then they move to the next area. Midway through what is typically a three-month training period, new employees go on “buddy call” with their assigned team. This approach allows us to transition new staff members from their previous experience into the unique world of cath lab patient care. 

How do you handle vendor visits to your lab? 

Vendors can be a huge asset to our staff in terms of training and education, and we deeply appreciate what they do. We have to manage their access to the lab, however, to prevent too many from being here at once. Vendor access is managed by Brandy Hill, RN, assistant nurse manager for invasive cardiology. Brandy will typically allow one vendor a day to sign in through Vendormate in our supply chain department. They are allowed in the cath lab at the request of the physician that is working at the time, but are not given free access to the lab. Otherwise, vendors are asked to set up in one of the break rooms. Device representatives have been issued hospital badges.

How is staff competency evaluated?  

Standard nursing competencies are done by our hospital education department yearly, but competencies specific to the cath lab are done yearly by the cath lab manager and assistant nurse manager by demonstration.

How does your lab handle call time for staff members?

HHI has five call teams of four people. There are three RNs and a technologist per team. Obviously with five teams, each team will have one day of call a week and on a rotation, the Friday team covers Friday, Saturday, and Sunday.

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

All members of the STEMI team, including the physicians, are required to be on site within 30 minutes.

Do you have flextime or multiple shifts? 

We do not currently have multiple shifts, but we do have the ability to flex on the occasion that the call team gets caught up all night or if the late stay team works more than 12 hours, which happens frequently.

Has your lab recently undergone a national accrediting agency inspection?

We are extremely proud to report that we have been granted provisional accreditation by ACE. This is something that we worked very hard at and it was a very rigorous process, but very well worth it!  It is very challenging, but it is our belief that to do your best, you must constantly challenge everything you do, as well as each other. It is not enough to know that you have a great program and staff ­— you have to demonstrate that fact to the world. We think we have a world-class program and staff here at HHI, but we recognize that we have struggles just like every other program. We don’t want to hide from the areas in which we are weak — we want to identify them and work together to find a solution. We sought ACE accreditation because we feel their organization will challenge us to be the best, support us on our journey, and help us in areas where we need it most. We welcome their feedback and appreciate their investment in our continuous learning. Their standards are very high and it is a very rigorous process to achieve accreditation from them. We feel it provides legitimacy to our program and validation to our belief in the quality of our program and people. It certainly demonstrates to our community our level of dedication to high quality care for our patients and families. We highly recommend accreditation for anyone thinking about pursuing it.    

As a part of the ACE accreditation process, we undertook an evaluation of structured reporting software. We are now going through the approval process internally to purchase the software we chose (ProVation MD, ProVation Medical).  

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

From the door nearest to the cath lab, it is 69 steps and two automatic double doors to the emergency department. 

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

We have seen a trend toward younger people in their early to mid-30’s having STEMIs.

What is unique about your cath lab and staff?

It is unique to have a staff of men and women as eager and willing to provide the best care to our patients and also to provide the best service possible to our physicians. I have never worked with a group as dedicated and determined as this one. If a physician requests an earlier than usual start time, it is accommodated without question, every time. Regardless of the time, we do not put restriction on numbers of cases or start times — staff will come back 24/7 for any reason. I have seen this staff identify patients at high risk for re-bleed and spend the entire night to assure the safety of the patient. It is not uncommon for us to get a request over the weekend for a permanent pacemaker. We cannot utilize the STEMI team in this case, but frequently the call team will call everyone else on all the call teams to ask if they can come in to do the procedure. While we cannot guarantee we will be successful in finding staff to agree to return after hours when not on call, there is not an instance I am aware of that the need wasn’t met. These are things that are certainly not mandated (it would be very difficult, if not impossible, to mandate that), but this team takes it on themselves to go the extra mile. I could cite many examples of this level of dedication. This is something that can’t be taught and this staff consistently steps up to a higher level.  

Is there a challenge your lab has faced? 

The biggest challenge we encountered was getting past the old culture of only having a diagnostic cath lab and the reluctance of people to accept that change. Another challenge was getting past the fact that we do not offer surgical backup. Both are legitimate concerns and people have a right to their opinion, but both of these were monstrous obstacles for us to face. Our approach was to simply recognize and understand these concerns and to not try to minimize them. Our solution was a two-step program: education and performance. Much of our early efforts revolved around educating everyone in the hospital and the public on why it is safe to perform this procedure without surgical backup. We were able to speak at community events and with civic organizations, and educate people about our new processes, as well as share some of our successes. We used the C-PORT findings as well as follow-up studies from C-PORT to our advantage, and that is about all we could do early on, but we knew we had the facts on our side. Our message was simply that we understand completely why people were apprehensive, but C-PORT proved the safety of the procedure and our people will not let you down. All it took was time. The staff proved themselves many times over to be more than equal to the task. There will always be the naysayers, but at this point, I think it is safe to say we won the battle decisively by the outstanding work done in the ED, HHI, and post nursing care. 

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 fortunate in our region to have two other outstanding hospitals with great cardiovascular programs. The unique thing for us at HHI is that south of our hospital is a vast, rural geographical area with a large population, but it is almost two hours to the next PCI facility. This makes us a very valuable resource for all of those people, because now they have faster and easier access to this life-saving procedure. 

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?

This report is a very valuable tool. We use it extensively to help identify trends that might indicate that our processes are not being followed. We review each report with leadership and the medical director of the PCI program. We review our report one standard at the time, identify areas that need improvement, and develop an action plan to resolve the issue. Our quality department is very helpful in investigating any issues and recommending changes. 

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

We do encourage our staff to obtain the RCIS credential. Some of our staff are currently preparing to take the registry 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 are members of VHA Georgia (now known as Vizient MidSouth) and that association has been invaluable to us. It is a great way to network with others in the area and exchange ideas.

Ray Jones, RN, Associate Director of Cardiovascular Services, can be contacted at lrjones@hhc.org.

Tell us about your facility and cath lab.

The Frankel Cardiovascular Center has 4 cardiac catheterization laboratories that are used for a variety of coronary, peripheral and structural procedures. These labs complement the 2 hybrid rooms we use in the OR suite and the 5 electrophysiology rooms. In addition, the Cardiac Procedures Unit has started construction on our hybrid OR suite, to be completed in early 2017. Our labs are staffed with 14 registered cardiovascular invasive specialist (RCIS)-certified technologists and 12 registered nurses (RNs). We also have interventional cardiology fellows, as well as interventional cardiology and heart failure attending physicians.

What procedures are performed at your lab? 

Our lab is a full-service interventional cardiology procedural area. We perform a myriad of routine and complex hemodynamic studies in addition to percutaneous coronary and peripheral interventions. We implant left and right percutaneous ventricular assist devices and also perform a full spectrum of structural heart procedures, including procedures on both native and bio-prosthetic valves and paravalvular leak closures.

Can you share more about your experience with transcatheter aortic valve replacement (TAVR)?  

We currently perform 4 to 6 TAVR procedures per week. Our cases take place in both the cardiac catheterization laboratory and in the hybrid rooms in the OR suite. As of January 2016, we have successfully performed over 700 implant cases, and are slated to do over 200 more by the end of 2016. We implant a variety of TAVR devices, including the Medtronic CoreValve Classic and the CoreValve Evolut, along with the Edwards Sapien XT and Edwards Sapien 3 devices. We also participate in the trial utilizing the Boston Scientific Lotus Valve.  

Who manages your cath lab? 

Stanley Chetcuti, MD, is our cath lab medical director. Janice Norville, MSN, MSBA, RN, is our director of clinical operations. Colleen Lucier, BS, RCIS is our technologist supervisor and Sheryl Wagner, BSN, RN, and Joshua Barsaleau, BSN, RN, are our nursing supervisors.

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

Our first-year and third-year cardiology fellows and our fourth-year interventional cardiology fellows scrub. Our cath lab technologists primarily monitor and circulate in our cases. The technologists will scrub assist when a fellow isn’t available and a dedicated group of technologists have received intensive training and education on the correct preparation and loading of all TAVR devices. This team will first assist scrub during all TAVR procedures. Our cath lab nurses document vitals, medications and assist in circulating.

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 attending physicians, interventional cardiology fellows and cath lab technologists are competent to operate the x-ray equipment, but it is usually our fellows and attendings that operate the fluoro pedals.

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

We carefully monitor and track dosimeter badge use and dosimeter readings every month. We fluoro all protective radiation apparel annually to validate integrity. After integrity is ascertained, we label each piece of apparel accordingly. We also complete a yearly competency on radiation safety and ALARA (as low as [is] reasonably achievable). As of December 2015, we have a real-time monitor for the lab that allows us to instantaneously monitor each individual’s exposure and make the appropriate changes in practice.

What percentage of your diagnostic caths are normal?

Approximately 20% of our diagnostic caths have normal coronary arteries. Many of these cases are sent to the lab for hemodynamic studies or as part of a pre-operative evaluation.

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

All our physicians perform radial artery procedures with some preferring this as their main access site. Some of the attendings perform 75% of their interventions through the radial artery.

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

New devices in our lab include the TandemHeart ProTek Duo (CardiacAssist) and the coronary CSI Diamondback orbital atherectomy device. New equipment to the lab includes drug-coated peripheral balloons, structural heart devices, and chronic total occlusion (CTO) platforms.

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

For daily cases, we have a charge nurse and cath tech lead that communicate the flow of the day to the labs. New equipment education and maintaining yearly competencies are handled by Chuck Hobkirk, BSN, who is the nurse educator, and Katie Della Mora, RCIS, the technical educator.

How is coding and coding education handled in your lab? 

A dedicated coding and billing team communicate directly with physicians and staff to educate and advise on the latest changes in coding and billing practices. 

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

We have a designated team of sheath pullers who pull post diagnostic and interventional procedures. The Sheath Pulling Team is also responsible for the removal of all intra-aortic balloons and sheaths up to a 14 French.  

A sheath puller must be supervised for 15 arterial and venous sheath pulls, and 5 intra-aortic balloons. During the evaluation period, the trainee must demonstrate the core competencies of sheath pulling, which includes proper technique and achieving successful hemostasis. Once competency is achieved, they can pull sheaths independently and participate in the on-call process.  

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

We have a designated prep and recovery area on our unit. We use a variety of techniques to achieve hemostasis, including manual pressure, compression devices, and vascular closure devices. Post procedure, our patients are transported to the recovery area within our unit. The recovery area is staffed by a team of registered nurses and sheath pullers. All of our patients will receive care until they are ready to be discharged home or they will be admitted to another department for any care that requires a length of stay twenty-four hours or greater.

How is inventory managed at your cath lab? 

Marlon Bird is the supervisor of the supply chain in the Cardiac Procedures Unit and manages the unit inventory control process along with the unit inventory control analysts. All our equipment is scanned through our Internet-based program during the procedure by the monitoring technologist and reviewed for re-ordering by our inventory control analysts.

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

Yes, and we continue to look for opportunities to expand. Our expansion includes construction of our hybrid OR suite. We also completed the design and implementation of a state-of-the-art cath lab in December 2015.

Is your lab involved in clinical research?

Yes. One ongoing research study we are involved in is the TIMI 60 (LATITUDE) trial. Past studies that we have participated in include the RESOLUTE Study and the PRE-DETERMINE Study: Biologic Markers and Sudden Cardiac Death. We also collected data in trials utilizing the TandemHeart and Impella devices: (THEME) and USpella. We also participated in a peripheral trial called MGVS Phase I in Peripheral Arterial Disease. As an implanting hospital for CoreValve Evolut, Boston Scientific Lotus, and the Edwards Sapien 3, all data we capture during our TAVR procedures are submitted to the TVT Registry.

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 is 90 minutes or less. We have regular acute myocardial infarction (AMI) meetings with Emergency Medical Services (EMS) and the emergency department (ED) as part of an ongoing quality assurance and improvement program. We also gather data for the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

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

Our ED staff and our interventional cardiology fellow transport all our AMI patients to the cath lab.

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

If we are near the end of our first AMI, we have an emergency room nurse and a cardiology fellow transport the second AMI to a secondary cath lab. Upon patient arrival, a member of the AMI team will join the emergency room nurse and the cardiology fellow to prep the patient and to prepare the second lab. The Coronary Care Unit charge nurse helps transition the first AMI to their unit for continuation of care. 

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

We have implemented multiple LEAN projects to maximize efficiency in our labs while eliminating waste. Our most successful LEAN project to date is our TAVR project that earned us the title of Exemplar status in our institutional Quality Month. The TAVR LEAN project helped us increase our TAVR implants from 2 to 5 during one normal business day.  

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

Our physicians use Lumedx cardiovascular information systems (a structured reporting tool) to generate all of our interventional documents. 

What quality control measures are practiced in your cath lab?

We have quality control measures on all our devices and equipment through our clinical engineering department. All procedural data is reported into multiple state and national registries (ACC-NCDR, BMC2, PVI, TVT). Quarterly morbidity and mortality conferences occur where open discussion of cases is encouraged. These conferences have participation from members including our physicians, fellows, nurse practitioners, physician assistants, registered nurses, and technologists. Our lab’s outcomes are also reported in an institutional dashboard.

Both BMC2 PCI and ACC-NCDR CathPCI are used to drive quality improvement (QI) initiatives. Our computing technology department has mapped Lumedx. This mapping pulls all ACC-NCDR data fields from history and physicals, as well procedural reports. Lumedx then filters the information to databases where our QI teams review the information for accuracy and completeness before sending it to the ACC-NCDR.

Are you recording fluoroscopy times/dosages? 

Yes, we record fluoroscopy results after each case and the information populates into our electronic medical records. We capture the dose area product, air kerma data and fluoro times. We have standard parameters outlined by our radiation safety health physicist. Any values that fall outside these parameters get reported to the attending physicians and supervisors so that they can follow up accordingly with the patient.

Who documents medication administration during the case?

Our registered nurses document medication administration into the electronic medical record during cases.

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

We collaborate regularly with area physicians, responding to every referral within twenty-four business hours. 

How are new employees oriented and trained at your facility? 

All new employees go through a standard orientation process with a preceptor. Before each standard orientation is complete, every new employee must demonstrate competency for their supervisor and educational specialist on a standard list of duties and devices. 

What continuing education opportunities are provided to staff members?

We have weekly educational conferences led by the attendings and fellows. We also have quarterly morbidity and mortality conferences. Vendors and our educational specialist provide regular in-servicing opportunities as well. Our unit also funds for three team members to attend a national interventional cardiology conference each year. 

How do you handle vendor visits to your lab? 

Vendor visits are by appointment only. Each vendor must be registered with Vendormate, which is a national vendor logging system. As part of the appointment, Vendormate generates a badge that must be worn by the vendor, including the time of the appointment, and who the appointment is with, preventing the vendor from wandering from one unit to another. Vendormate also helps the institution track vendor compliance with mandatory completion of HIPAA forms, immunization screening, and an assortment of other compliance concerns.  

How is staff competency evaluated? 

After the standard orientation process has been successfully completed, each team member receives annual performance evaluations. In the completion of the annual evaluation, hospital- and job-specific expectations must be met. Supervisory, physician and peer feedback are all used to verify the hospital- and job-specific performance expectations. In addition, standard competencies on all low-volume, high-risk procedures are completed annually in a mock simulation by our supervisor and our educational specialist.  

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

Our staff has a 30-minute response time. Team members are offered call rooms to stay in-house if they choose to do so. The call team consists of two registered technologists, one registered nurse, one interventional cardiology fellow, and an interventional cardiology attending.

Do you have flextime or multiple shifts? 

We have 8-, 10- and 12-hour shifts.

Has your lab recently undergone a national accrediting agency inspection?

We have recently undergone inspection by Centers for Medicare & Medicaid Services (CMS). Make sure to have a well-documented and standard institutional process for tracking and confirming the integrity of all radiation protection apparel. 

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

The operating rooms are two floors above our unit. The ED is located in the main hospital, with clear signs and a secure, low-traffic hallway that leads directly to the cath lab.

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

Our patient population is getting older. We are seeing more non-STEMIs compared to STEMIs, and our rate of restenosis has been decreasing. We have also seen a surge of structural heart procedures and interventions on chronic total occlusions.

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

All of our technologists have received their RCIS credentialing. 

Our TAVR implanting physicians have given our registered technologists the unique opportunity to take the lead in the prepping of all our TAVR procedural implants. 

We practice Patient Family Centered Care (PFCC) where the family and the patient participate in the care process. The patients collaborate with our team of specialists to create a care plan that meets their individual needs.

We have a state-of-the-art waiting area that provides family members with updated information on the status of each patient’s location while maintaining confidentiality. Our waiting area also has a unit host that answers questions, provides information, and directs families as needed. 

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 centered in a diversified cultural area, which allows us to treat a variety of patient populations. Our cath lab consists of a team of physicians, nurses and technologists that strive to always be the leaders and the best. 

The authors can be contacted via Megan Kennison, RCIS, at mkenniso@med.umich.edu.

Tell us about your cath lab.

We have a three-lab facility that is supported by a dedicated four-bay pre and post area as well as our radial lounge. Our staging area employs four RNs. We have two registry nurses who are cross-trained to work in the lab as well as our pre and post area. Our lab employs 10 staff members. All of our staff are RNs with the exception of our two radiologic technologists (RT[R])s. Our staff has a diverse mixture of experience ranging from 2 to 27 years in the cath lab.

What procedures are performed in your cath lab? 

We perform between 50 and 75 cases a week. Our lab provides a variety of services, including right and left heart caths, percutaneous coronary interventions (PCIs) including chronic total occlusions (CTOs), pulmonary hypertension studies, Impella (Abiomed) insertion, cardiac device pacemaker/implantable cardioverter-defibrillators (ICDs), transesophageal echocardiography (TEE), cardioversion, LINQ loop recorder (Medtronic), tilt tables, electrophysiology studies with ablation, and left atrial appendage (LAA) closure with the LARIAT Suture Delivery Device (SentreHeart, Inc.).

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

Our facility has an overall radial access utilization rate of 65% and our radial access utilization rate for interventions, including ST-elevation myocardial infarction (STEMI), is 90%. Devang Desai, MD, FACC, FSCAI, heads our Radial Access Training Program with Terumo and performs more than 95% of his cases via the radial artery. Our training program invites physicians from across the country to receive a one-day medical license in the state of Nevada and receive hands-on experience/training in radial access. Secondary to our high use of radial access, we have one of the few dedicated prep and recovery radial lounges on the west coast. Our radial lounge consists of four pods that each host one patient and visitor as well as a separate locker/changing room for patients. Patients are remotely cardiac monitored and equipped with a pulse oximeter. 

Can you tell us about your plans to incorporate transcatheter aortic valve replacement (TAVR) procedures at your hospital?

We just finished a yearlong expansion project that included the construction of a hybrid room. We have started utilizing the room for non-TAVR cases to acclimate ourselves to the new room and train on the new equipment. We do not yet have a start date for TAVR, since we are still in the beginning stages.

How long did it take to plan and build the hybrid room?

Planning was the longest part of this process and took well over a year. Construction of the lab took 8 months. We staged construction so that our other two labs could remain functional during the build.

What are some of the important elements of your hybrid room?

Our hybrid room is a low-fluoro room and has cut radiation exposure by a third.

Is the hybrid room located in the cath lab area or the OR? 

Our hybrid room is located in the cath lab and is under cath lab management.

Do you have advice for readers who may be adding a hybrid room to their lab?

Our greatest challenge in this process was/is changing from a procedural area to a surgical area.  We now have a red line in the cath lab and that has required practice changes for the cath lab staff, physicians, housekeeping, and ancillary staff.  Structural heart technology is new to our lab and devising a schedule for all employees to receive training and practice has been crucial to success.   

Who manages your cath lab? 

Our manager, Jenna Beadell, RN, PCCRN, is on-site in the cath lab Monday through Thursday. On a daily basis, Jenna designates a staff member from the cath lab and one from our pre and post area to disseminate information and collaborate to manage the flow of patients.

Who scrubs, who circulates and who monitors?

Our nursing staff is cross-trained in all positions and rotates every case to minimize radiation exposure and maintain competency in all roles. The only function our RT(R)s do not perform is medication administration. Allowing nurses to perform in all roles has led to an increase in job satisfaction, resulting in a low turnover rate.

Are there licensure laws in your state for fluoroscopy?

Yes, Nevada has extensive licensing laws covering limitation of useful beam, activation of the tube, exposure rate limits, barrier rate limits, indication of potential, current, source-skin distance, mobile fluoroscopes, and control of scattered radiation. 

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 entire staff positions the image intensifier (II), pans the table and changes the angles.  Only our licensed diagnostic/interventional cardiologists and RT(R)s step on the fluoro pedal.

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

All staff has their own fitted lead and eyewear that is checked regularly. Radiation badges are worn by all staff members and monitored for excessive exposure. Every case we rotate circulator, monitor, and scrub to minimize the amount of exposure to any one staff member. We also emphasize radiation safety and follow ALARA (as low as reasonably achievable) standards. Our new equipment includes the RaySafe i2 dosimetry system (Fluke Biomedical), so we will be able to identify unnecessary exposure in real time.

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

We have recently introduced optical coherence tomography (St. Jude Medical), pressure monitored ablation, cryoablation (Medtronic), LARIAT (SentreHeart), S-ICD (Boston Scientific), and LINQ (Medtronic).

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

Our manager holds biweekly meetings with Devang Desai, MD, FACC, FSCAI, physician director of the cath lab, and emails the physicians regularly with updates, including a STEMI synopsis/STATS with every case. Our physicians meet quarterly with the hospital representatives and Lisa Pistone, RN, BSN, MBA, CNML, Director of Cardiovascular Services, at our Cardiology/STEMI meetings. The physicians hold a monthly cath conference with the staff where education/case studies can be presented. Our manager communicates with staff during a daily huddle and staff meetings are scheduled when a topic requiring more time needs to be discussed. 

What is your percentage of normal diagnostic caths?

25.2%.

How is coding and coding education handled in your lab? 

Peggy Lee, RN, is one of our cath lab RNs who works closely with the hospital’s coding department. She educates the cath lab staff annually on coding changes and updates. 

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

Sheaths are pulled in the lab or the staging recovery area. Staff in both areas are certified to pull sheaths. Prior to being signed off, the trainee observes and is educated on sheath removal in the cath lab. The trainee is then observed pulling a sheath and holding manual pressure or placing the TR Band (Terumo) on radial cases. Observations are continued until the trainee is signed off with a passing score, and feels comfortable and confident in their ability to maintain hemostasis.

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

Patients are prepped and recovered in our pre and post staging area, as well as in our radial lounge. For femoral diagnostic cases using 4 French, manual pressure is the primary method used for homeostasis, and can occur in the lab or in our pre and post area. To aid in hemostasis for femoral cases utilizing larger than a 4 French size, our staff is certified in the placement of the Angio-Seal closure device (St. Jude Medical). Unfortunately, the Nevada Nurse Practice Act prohibits RNs from placing stitches, so the Perclose device is only placed by RT(R)s and physicians. For radial access cases, we employ the TR Band with a wrist splint to maintain visual access of the site while neutralizing the wrist. 

How is inventory managed at your cath lab? 

Supply utilization is tracked during each case and documented in the Mac-Lab (GE Healthcare). Trent Foust, one of our cath lab RNs, runs a supply report, then places orders through the hospital’s purchasing department so that a par level of supplies is maintained.

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

In January of 2013, Saint Mary’s expanded their cardiology service line, recruiting several of the area’s leading cardiologists. The new cardiology team led to cath lab volumes nearly tripling. We maintained steady growth in 2014 and 2015. 

Is your lab involved in clinical research?

Yes, Saint Mary’s has a growing cardiac research program, with several trials involving the cath lab and its patient population.

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

We achieved this goal by adopting the goal of a 60-minute door-to-balloon time. Our year to date average is 40 minutes door-to-balloon. We worked with and educated the emergency department (ED) staff as well as our Emergency Medical Service (EMS) partner REMSA, creating a Code Cardiac protocol and providing/reviewing times for every case. We are registered with Mission: Lifeline and are cycle IV Chest Pain Center certified with PCI. In September 2015, we received the Mission: Lifeline Receiving Center Silver award for our first medical contact to reperfusion times.

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

The Code Cardiac team, comprised of an ED RN, ED tech and Critical Care RN transport our STEMI patients during regular and off hours.

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

Our facility has several contingencies for this situation. If the current procedure can be finished without causing a delay of care, it is finished while the STEMI patient is brought to the staging area and prepped. If the current procedure cannot be finished without causing a delay of care and can safely be postponed, access is maintained and the patient is monitored in the staging area until the STEMI procedure can be completed. In the situation where our team is already in an emergent case, thrombolytics are utilized and PCI is performed at a later time. 

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

After extensive market and price structure research of the northern Nevada and California areas, Saint Mary’s implemented capitated pricing. Our lab is open to all vendors and products as long as they are willing to comply with the capitated pricing, which is evaluated annually. We have also encouraged stewardship for all our staff in trying to minimize costs where possible and appropriate. Our hospital uses a front line, staff-driven approach to process change. Using a combination of Lean and Six Sigma tools, we improved our patient experience, wait times, and flow of patients into the cath lab. These process changes led to faster turnaround times, and decreased physician and patient wait times, giving us the ability to perform more cases in a day.

What quality control/quality assurance measures are practiced in your cath lab?

We recently implemented the use of an outpatient cardiac cath indication form. This form is filled out by the ordering physician and efficiently communicates medical history as well as cardiac presentation to aid interventional cardiologists in decision-making for the appropriate use of PCI.   

Are you recording fluoroscopy times/dosages? 

We document fluoroscopy times and dosages at the end of each case on a radiation report. Some of our physicians utilize this report in their procedure dictations.

Who documents medication administration during the case?

The circulating position documents medication administration during the case and staff can receive assistance from the monitor in situations where multiple time-sensitive drugs are being started or titrated. To ensure accuracy in documentation, closed loop communication is used and the procedure report is reviewed by both parties before it is signed.

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

Our physicians dictate their reports. We have implemented Vincari, a program for surgical structured reporting designed to increase accuracy and ease dictation while meeting ICD-10 regulatory requirements. The report becomes immediately available in the electronic medical record.

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

Our lab is involved in the ACC-NCDR Cath/PCI, ICD, and ACTION-GWTG registries. We also collect and submit for the STS Adult Cardiac registry.

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

We have formed an alliance with our EMS, REMSA and Truckee Meadows Fire Department. We support both agencies with cardiac education. Education is formally provided most months by Devang Desai, MD, FACC, FSCAI, covering topics such as STEMI, 12-lead EKG, and arrhythmias.  

Our lab provides an observation day along with CEUs for RNs, EMTs, paramedics and dispatch personnel. REMSA attends our quarterly STEMI meetings and has a standing agenda time allotted to them. We have two-way sharing with REMSA so that STEMI times can be easily tracked between entities. The collaborative working process we have in place has established a relationship that has doubled the number of cardiac patients we see.

We have a secondary alliance with rural hospitals in our area, including Susanville, California, Redding, California, and Yerrington, Nevada. These hospitals are supported by our cardiologists who hold clinics there monthly and see patients.  

How do you handle vendor visits to your lab?

Vendors contact our manager, Jenna Beadell, RN, PCCRN, who schedules specific days in the cath lab that are then put on our calendar.

How are new employees oriented and trained at your facility? 

Our facility has its own hospital orientation and competencies that must be completed within 30 days of being hired. The cath lab allots 90 days for a new employee to complete unit-specific competencies. An employee new to the cath lab can expect a formal, six-month orientation process. During the formal orientation process, the employee becomes the fourth member of the team during the day and on-call schedule. New employees are assigned a preceptor and they follow their preceptor during the day as they rotate from role to role. Our employees learn all roles simultaneously (circulator, scrub/x-ray, and monitor). We have found that performing each role every day prevents knowledge loss that was occurring when roles were taught separately over two-week increments. We incorporate mock cases into the orientation as well as a sim lab for practice.  

What continuing education opportunities are provided to staff members?

We have a very active and growing electrophysiology (EP) program, and have sent our staff to several conferences of their choosing and supported them in the registered cardiac electrophysiology specialist (RCES) certification process. We have weekly vendor-supported education and the hospital provides all RN staff with 24 paid CEUs annually. 

How is staff competency evaluated?

New employees are evaluated at 30 days, 90 days, and annually. After the first year, evaluations are performed annually. Our lab holds an annual skills day where high-risk, low-volume procedures are reviewed and performed. 

Does your lab have a clinical ladder? 

No, but Saint Mary’s is currently investigating reestablishing its clinical ladder.    

How does your lab handle call time for staff members? 

Our call team is comprised of three members, one of which is required to be an RN. Our staff is on call two nights a week, one to two weekends a month, and two holidays a year. Anyone wanting to take an extra call is permitted, as is trading or swapping days.  

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

Our facility has a 30-minute response time mandate for all call positions.

Do you have flextime or multiple shifts? 

We have flextime shifts.

Has your lab recently undergone a national accrediting agency inspection? 

We recently underwent Chest Pain Center with PCI and Mission: Lifeline accreditations. Even though some of these accreditations seem solely cardiac- or cath lab-focused, we found that the process involved the entire hospital. We needed involvement and participation not only from clinical departments like ED, telemetry, and the critical care unit (CCU), but also non-clinical departments like outpatient offices, marketing, outreach, and environmental services. The accrediting process also caused us to work closely and develop our relationship with our EMS provider, REMSA.   

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

Our lab is located on the fifth floor directly next to the cardiac OR and cardiac intensive care unit. Our ED is located directly under us on the first floor.

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

Improved medical management has led us to see patients later in the disease process, resulting in more complex cases. The use of drugs such as methamphetamines has increased the number of patients we see with pulmonary hypertension and patients in need of cardiac devices, while decreasing the mean age of our patients.     

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

We are associated with Joseph Stevenson, DO, FACC, Associate Clinical Professor at the University of Nevada Medical School. Dr. Stevenson operates the only full-service pulmonary hypertension (PH) clinic in the state of Nevada, including prostacyclins. We are in the process of becoming a certified center of excellence for PH. We are integrated into a progressive medical model where patients diagnosed with PH have applications for medication submitted within 24 hours of their right heart cath and are taking their medication within seven to ten days of diagnosis. We are part of a unique education process involving physician patient counseling. Patients also receive videos to educate themselves and their families on PH. Additionally, we host a PH support group every four months at the hospital.

Is there a problem or challenge your lab has faced? 

When the cardiology group came to Saint Mary’s in 2013, they brought expectations of how the lab would function and perform. At the same time, they exponentially increased our case load. In a very short period of time, we had to cut our turnaround time in half while training the lab staff to function in new roles. Our pre and post area was instrumental in decreasing our turnaround times, transporting patients to and from different areas of the hospital and prepping them, and pulling sheaths as needed. The staff showed great enthusiasm toward the cardiologists and had a willingness to learn. Our cardiology group volunteered to hold a monthly cath conference primarily led by our interventional physicians Frank Carrea, MD, FACC, Devang Desai, MD, FACC, FSCAI, and Eric Drummer, MD, FACC, where educational needs could be addressed and training could be provided to the staff by the cardiologist they would be working with. We had to deal with some growing pains, but the process has elevated our lab and staff to a new level of excellence and instilled a desire to continue improvement.

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 population of Nevada as a whole has led our state to be categorized as frontier land. Reno is a cosmopolitan area, but we service over a 300-mile area that is mostly rural. Our cath lab is a microcosm of the area we serve. We have employees that live rurally on farms, some with young families living in the suburbs, and others live the cosmopolitan life. Despite the diverse lifestyles, we all live within 25 minutes of the hospital.

A question 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?

Our staff is not required to take the exam, but we highly encourage and incentivize them to do so. We financially support educational classes and employees receive an annual bonus upon passing the exam. We currently have several RNs working on obtaining their RCIS: Trent Foust, RN, and Mike Hagstrand, RN, while Jeremy Shea, RN, and Nichole Gocke, RN, are both working toward the RCES.

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?

The NCDR Outcome Report is presented at monthly meetings with cath lab and cardiology representation. We have used this report to identify several QI initiatives. Our most recent process change was with cardiac rehab referrals. With the use of the Outcome Report and the drill-down feature, we were able to identify a patient population that was frequently missed for cardiac rehab. After educating our physicians and improving documentation, we had a compliance increase from 48 percent to 85 percent, and are continuing to improve. With the use of the outcomes report, we identified several areas that appeared to be under-reporting on the pre-procedural status of our outpatients. As a result, we implemented an outpatient cardiac cath indication form. The use of this form has improved the accuracy and quality of the data we collect and submit. 

Our extensive participation in clinical research trials allows our patients to have access to advanced therapies that otherwise might not be available for many years. In addition to performing these advanced treatments, we help develop them. Research by our physicians has been recognized by organizations such as the American Heart Association (AHA), the American College of Cardiology (ACC), and the National Institutes of Health. In fact, one of our cardiologists, Sidney C. Smith, MD, is a past president of the American Heart Association.

Our catheterization department has 2 dedicated adult procedural suites and 1 dedicated pediatric cath suite, 1 shared cath/electrophysiology (EP) suite, and 1 hybrid/operating room (OR) lab shared with surgical services and used for transcatheter aortic valve replacement (TAVR) procedures. We have a diverse staff, both professionally and culturally. We have 31 staff members: 3 registered cardiovascular invasive specialists (RCISs), 5 registered radiologic technologists (RT[R]s), 1 cardiovascular technologist (CVT), 18 registered nurses (RNs), 1 inventory manager, 1 procedure flow coordinator, 1 administrative assistant, 1 administrative coordinator, 1 coder, 2 RNs to coordinate scheduling, and 1 quality and organizational excellence analyst.

What procedures are performed in your cath lab?

In our adult cath labs, we perform the full spectrum of complex coronary and peripheral diagnostic and interventional procedures, including right heart catheterizations, right ventricular biopsies, peripheral vascular procedures, TAVR, valvuloplasty including aortic, mitral, and pulmonary, complex higher risk (and indicated) patients (CHIP), chronic total occlusions (CTOs), orbital and rotational atherectomy, physiological assessment of lesion significance using fractional flow reserve (FFR) (both wire- and catheter-based), intracoronary imaging using intravascular ultrasound (IVUS) and optical coherence tomography (OCT), and left ventricular (LV) hemodynamic support.

In the pediatric cath lab, we perform diagnostic right and left heart catheterizations, valvuloplasty including aortic, pulmonary, and conduit, pulmonary arterial angioplasty and/or stenting, congenital diagnostic catheterization procedures, atrial septal defect (ASD), patent ductus arteriosus (PDA), patent foramen ovale (PFO) and ventricular septal defect (VSD) closures, aortic angiography, coarctation angioplasty and/or stenting, and transcatheter pulmonic valve (TPV) replacement (Melody, Medtronic).

UNC Heart & Vascular has seen a significant growth in structural heart interventions under the leadership of co-directors John Vavalle, MD, MHS, FACC, and Thomas Caranasos, MD. Our TAVR team consists of cardiothoracic surgeons, interventional cardiologists, cardiac anesthesiologists, cardiac radiologists, and cath lab and OR staff. The procedure is performed in both the hospital surgical hybrid OR suites as well as in the cath lab. We have performed TAVR cases via femoral, subclavian, and apical approaches. We have also performed the first suprasternal-approach TAVR in the world. On the pediatric side, our Melody valve team has performed a significant number of Melody valve procedures.

Tell us about the availability of surgical backup.

Surgical backup is available 24/7 for both our adult and pediatric patient population, emergent and otherwise. The University of North Carolina at Chapel Hill is home to UNC Hospitals’ American College of Surgeons (ACS)-verified Level I Trauma Center. In addition, UNC Hospitals’ North Carolina Children’s Hospital has been verified by the ACS as a Level I pediatric trauma center, the highest verification offered by the ACS Committee on Trauma. It is the first hospital in the Triangle (a geographic area in North Carolina with companies and universities committed to high levels of research), and one of only two in the entire state, to receive ACS recognition for having the highest level of expertise in treating critically injured children.

How many of your diagnostic caths are normal?  

Approximately 20% of our diagnostic procedures at UNC demonstrate “normal” coronary arteries. The balance (80%) require medical management, intervention (percutaneous coronary intervention [PCI]) and/or coronary artery bypass graft surgery (CABG). 

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

We have seen a significant increase in transradial procedures. All of our faculty perform transradial interventions, and over half of our interventionalists are “radial first” operators that routinely perform complex coronary interventions, including primary PCI for ST-elevation myocardial infarction (STEMI), CTOs, and high-risk cases via the radial approach. We also routinely perform our right heart catheterizations via an antecubital vein.

Who manages your cath lab?

Prashant Kaul, MD, FACC, FSCAI, is the Director of the Cardiac Catheterization Laboratory and Interventional Cardiology, and George A. “Rick” Stouffer, III, MD, FACC, FSCAI, is Chief of the Division of Cardiology. Cathy Rege, RN, MS, is Director of Cardiac Services and Brenda McClure, RN, BSN, is Manager of Invasive Cardiology Laboratory.

Who scrubs, circulates, and monitors?

In each procedure room, we have 1 nurse and 2 cardiovascular (CV) technologists or cath lab specialists per case. Our drug administration policy is that only RNs administer sedation/medications, so the RN in the lab circulates, and the technologists/specialists scrub and monitor during the procedures. There currently are 2 cath RNs who are also trained to monitor. We have cath lab staff who are cross-trained in the pediatric cath lab, EP staff who are cross-trained in the adult cath lab, cath lab staff who are cross-trained in the EP lab, and cath lab nurses, specialists, and technologists who support pre and post procedure. All staff in the cath lab work together to load patients on the table, monitor/assess patient vitals, pull sheaths, hold pressure, and assist the physicians as needed.

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

UNC’s radiation policy states that RT(R)s, CVTs, and RCISs may perform fluoro and serial radiographic imaging under the immediate supervision of a physician. This includes positioning the image intensifier, panning the table, camera angulation, fluoro pedal, and manual switch operation (e.g. peripheral run-offs). The primary operators of the fluoro pedal in our cath labs are the interventional attending and cardiology fellow. All staff that operates fluoro must demonstrate annual competency by meeting all requirements of the competency checklist developed by our radiation safety officer. All staff must successfully complete an online module on radiation safety on an annual basis.

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

Lead aprons, radiation eye protection, additional shielding, and Radpads are provided in the cath suites to all staff. Dosimeters are provided and monitored monthly. The adult labs are equipped with Philips DoseAware, which provides real-time feedback on scattered x-ray dose so the staff can change their behavior if necessary, taking secondary shielding or distance precautions during the case. Several years ago, we decreased our frame rate for both fluoroscopy and cineangiography from 15 frames to 7.5 frames per second. This simple intervention allowed us to reduce our overall radiation dose by 40%.

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

As a leading academic medical facility, we are fortunate to be regularly invited to participate in clinical trials for new and cutting-edge technologies. We were the world’s number-one enrolling site in the Volcano Corporation-sponsored ADVISE II trial using the new Instant Wave-Free Ratio (iFR) physiology assessment and continue to use the technology in clinical practice. We routinely use St. Jude Medical’s OCT, CSI orbital atherectomy, peripheral drug-coated balloons, and CrossBoss and Stingray devices (Boston Scientific) for CTO cases. We are implanting the MitraClip (Abbott Vascular), CardioMEMS (St. Jude Medical), and the Watchman left atrial appendage closure device (Boston Scientific).

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

We use the SharePoint website, which provides a central storage and collaboration space for documents, information, and ideas. It is how we collaborate, communicate and “meet”. Through the site, we: 1) coordinate projects, calendars, and schedules; 2) discuss ideas and review documents or proposals; and 3) share information and keep in touch with each other. We also have monthly staff meetings with peer presentations. Regular supplier and vendor inservices keep us current and competent with equipment, techniques, and medications. 

How is coding and coding education handled in the lab?

We have a dedicated coder in the department who reviews all charting for accuracy, and to confirm all procedures and equipment used have been captured. Weekly, ongoing feedback to cath lab staff keeps all staff apprised of changes in coding/charting, and reduces incorrect documentation and billing. A revenue and usage report is checked weekly to ensure all charges are crossing correctly. The coder checks the work queues in our electronic medical record (EPIC) to make sure all charges are addressed appropriately.

Who pulls the sheaths post procedure?

Fellow physicians, cath lab nurses, and specialists/technologists may remove femoral sheaths, including pre/post holding nursing staff. All staff must pull 10 sheaths under supervision in order to achieve competency. Once they have demonstrated competency, they may pull sheaths unsupervised. As a result of our increasing radial access, more hemostasis bands are being used. Typically, the interventional attending or fellow will remove the radial sheath and apply the radial compression device. In the pediatric cath lab, manual pressure is the standard. Sheaths are pulled by the pediatric interventional cardiologist and pressure is held by cath lab staff.

Where are patients prepped and recovered, post sheath removal? 

All patients (adult and pediatric) are prepped, have sheaths pulled, and are recovered in the holding area of the cardiac cath lab. Due to the growing number of radial procedures, fewer cases are being done via the femoral approach. We use manual pressure in the majority of femoral cases to achieve hemostasis, but also use Mynx (Cardinal Health), Perclose (Abbott  Vascular) and Angio-Seal (St. Jude Medical) devices in select cases. Patients are recovered in the cath lab holding area or on their inpatient unit. Holding nurses or unit nurses take responsibility for post PCI care, involving interventional fellows and attendings as needed.

How is inventory managed at your cath lab?

Britt Oldham, our inventory manager, monitors procedure room and stock room par levels, expiration dates, and unique equipment requirements. He communicates regularly with physicians, lab staff, and the cath lab manager to ensure that equipment needs are met and appropriate inventory is ordered. Lab staff also plays a role in inventory stocking. Vendors meet with the cath lab manager before bringing a product into the department. All contracts must go through purchasing before any equipment can be brought into the institution.

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

We have had a steady growth in cath lab volume each year over the last 5 years. We have seen growth in coronary, peripheral, and structural cases. We have had to increase our capabilities by maximizing the resources currently available. We share lab space with the OR where we perform our TAVR and MitraClip procedures, and also share lab space with EP, where we have the ability to perform right heart and minor diagnostic procedures. We are currently completely renovating an existing cath lab that will become a shared lab for both EP and cardiac cath procedures. The lab will feature state-of-the art Philips equipment in line with our 5 existing cath lab suites (after the renovation, we will have 6 cath lab suites). This lab will be a welcome addition to support our growing volume and is expected to be ready in September 2016.

Is your lab involved in clinical research?

We have been actively involved in multiple site-based and investigator-initiated clinical trials and research studies, including:

• NORDICA (Novel Biomarkers for Risk Prediction of Contrast-Induced Acute Kidney Injury Post Coronary Angiography); 
• FAME 3 (A Comparison of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in Patients With Multivessel Coronary Artery Disease); 
• TRYTON (Prospective, Single Blind, Randomized Controlled Study to Evaluate the Safety & Effectiveness of Tryton Side Branch Stent Used With DES Treatment of de Novo Bifurcation Lesions in MB & SB in Native Coronaries); 
• RADIANCE-HTN (A Study of the ReCor Medical Paradise System in Clinical Hypertension); 
• SYMPLICITY (Renal Denervation in Patients With Uncontrolled Hypertension); 
• ADVISE II (iFR, ADenosine Vasodilator Independent Stenosis Evaluation II); 
• and SAFE-PCI (efficacy and feasibility of transradial vs transfemoral approach in women), among others. We have a clinical trials team with 5 clinical research coordinators and a clinical trials supervisor.

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

We are recipients of the AHA Mission: Lifeline Gold Plus Receiving Award in recognition of outstanding treatment of STEMI patients. This award is given to centers that are able to demonstrate a composite score of at least 85% on quality and performance metrics for STEMI systems of care, for at least 24 consecutive months. This award is the third Gold Receiving Award from AHA Mission: Lifeline for the UNC Medical Center. Our median time from arrival to primary PCI for the last 12 months was 38 minutes for patients presenting directly to UNC. For patients transferred from other non-PCI capable facilities, our median time from arrival at the referral facility to primary PCI at UNC was 94 minutes. We have a multi-disciplinary committee that meets monthly and includes representatives from Emergency Medical Services (EMS), the emergency department (ED), the cath lab, and administrative leadership. Every STEMI case is reviewed and there is ongoing quality improvement.

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

STEMI patients are transported to the cath lab by the ED staff and a cardiology fellow during all hours. When a STEMI patient is brought directly to UNC via EMS, a 12-lead electrocardiogram (ECG) is transmitted from the field via the LIFENET alert system. Patients often bypass the ED and are brought directly to the cardiac cath lab. For patients presenting to the ED or who are brought to us by Carolina Air Care (CAC) air ambulance (UNC’s critical care transport system), there is direct communication between the ED or CAC, and the cardiology fellow and/or the interventional cardiologist. The patient is then transported to the cath lab by the ED or CAC staff and cardiology fellow.

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

An assessment is made by the interventional cardiology attending of the expected delay to treatment of the second patient. If we are able to treat the patient and meet our quality time metrics, we will hold the patient in an ED room and stabilize the patient under the supervision of a senior cardiology fellow and with nursing assistance from our cardiac intensive care team before we bring the patient to the cath lab. If we are not able to treat the second patient in a timely fashion due to the team being busy with another patient, we have a system in place to either administer thrombolytic therapy or transfer the patient to another hospital within the area depending on the time of symptom onset, although we have never had to do this.

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

UNC Health Care System has 9 hospital locations across the state of North Carolina, with more than 30,000 employees and revenues of more than $3.2 billion. Despite our rapid growth and strong financial health, UNC Health Care is not immune from downward reimbursement pressures facing the health care providers in our state and throughout the country. Thus, the executive board has instituted “Carolina Value”, a system-wide initiative to improve our operational efficiency, enhance the quality of our system processes, and strengthen our financial stability. One of the objectives is the “streamlining and simplifying of our processes,” which includes utilizing the purchasing power of our 9 hospital locations to get best vendor pricing. In addition, cath lab management monitors daily staff worked hours to minimize overtime expense. 

We believe quality is no longer a metric that can be discussed in isolation without an assessment of cost. In order to define value in the cath lab (quality per unit cost), we have created a dashboard that reports quality and cost, with granular data to the individual operator and case level. We aim to bring increased value by increasing quality and decreasing cost. With the help of the dashboard, we are able to review data on a monthly basis to guide physicians towards high quality, low cost procedures.

What quality control measures are practiced in your cath lab?

We have a monthly meeting of the interdisciplinary STEMI team that reviews STEMI monthly and aggregate data, acute myocardial infarction (AMI) Core Measure compliance, outreach, and accreditation updates. We have a separate monthly cath lab quality meeting for continuous quality improvement that is attended by all cath lab faculty and includes case reviews for all PCI procedures that may be outliers. We review appropriate use criteria for all PCI procedures and perform peer review of any procedures that may be listed as “rarely appropriate”, as well as any cases deemed to be process outliers or with unexpected patient outcomes. In addition to our AHA Mission: Lifeline Gold Plus Receiving award, we have also received the Platinum Performance Achievement Award from the NCDR ACTION Registry-Get With The Guidelines (GWTG). We are also accredited by the Society of Cardiovascular Patient Care (SCPC) as a Chest Pain Center with PCI.

Who documents medication administration during the case?

The staff member in the monitor role documents all events during the case, including medication administration, fluoroscopy times, and radiation dose. In addition, the nurse charts all medications administered during the procedure in the EPIC system.

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

Our physicians use a customized standardized structured procedure report within the EPIC EMR system that we have developed ourselves. It includes still angiographic images from the procedure. Data can be input either manually using pull-down menus or dictated using the Dragon dictation system. Registry data for the National Cardiovascular Data Registry (NCDR) is uploaded using the Lumedx system. We participate in the ACTION-GWTG, CathPCI, and IMPACT registries.  

How are patients referred to your facility from within your 9-hospital network? 

Through our Open Access physician referral service, created by the UNC Center for Heart & Vascular Care, we coordinate all admissions and transfers through a single phone call. We guarantee immediate acceptance for patients. Designed for the convenience of our referring physicians and their staff, the Open Access service also facilitates consultation and collaboration with our team of Heart & Vascular physicians. Our Open Access vision is to simplify the process for our referring providers and ultimately offer easy access for patients to the world-class Heart & Vascular resources at UNC Health Care.

How are new employees oriented and trained at your facility?

A new employee is paired with a preceptor and follows their schedule exactly. If they are assigned to the cath lab procedure room, they will take call with the preceptor only after they have been in the role for 4 to 6 weeks. They will take call with their preceptor for another 4 weeks, but this can vary, depending on their prior experience. If they are orienting to the holding area, they are usually in orientation for 6 to 8 weeks. Each new employee is given an orientation that includes the mission statement, policies and procedures, and competency checklists.

How do you handle vendor visits to your lab?

UNC Health Care allows staff personnel to interface with outside vendor representatives in order to provide staff with required training for new devices and equipment. Each vendor must check in through the Reptrax system in the hospital lobby. Vendor representatives must have a previously scheduled appointment. Representatives are not allowed to be in any patient care area. An exception is made only for prearranged appointments with a member of the medical staff. The hospital issues a temporary badge to each representative that must be prominently displayed during the visit, along with their own identification tag showing their name and company. Sales representatives arrive just prior to their appointment and depart immediately after. 

How is staff competency evaluated? 

We hold an annual mandatory skills day where competency with all equipment used in the lab is reviewed. This usually takes place on a Saturday morning to prevent interruption in case volume. Vendors come in and review all equipment. Staff assists in the education as well. Vendors are also brought in at least once a year to assist in competency with equipment such as the Impella (Abiomed) and intra-aortic balloon pump (IABP).

We also have a regular inservice event that provides education on new equipment and procedures. Our physicians, fellows, peers, and vendors present pertinent hemodynamic, anatomical, and technical information. UNC also has numerous continuing education (Con Ed) symposiums. In addition, staff is chosen to attend regional conferences such as the Pediatric and Adult Interventional Cardiac Symposium (PICS-AICS).  

Does your lab have a clinical ladder?

We have a clinical ladder for nurses. They start out as a Clinical Nurse II and can work up to a Clinical Nurse IV with administrative functions.

How does your lab handle on-call? 

Our department manager generates a 4-week schedule. Most call team members have the responsibility to cover approximately 7 call days in that 4-week schedule, including 1 weekend. The staff mix is 2 specialists/technologists to 1 registered nurse. In addition, there is a fellow and an attending physician on call. All call team members are expected to be in the lab, in scrubs, and ready for the STEMI in less than 30 minutes.

Do you have flextime or multiple shifts?

We do have 3 staff members who work 8-hour shifts and 5 staff members who work 10-hour shifts. The 8-hour staff rotates working a week of 10-hour shifts in order to make sure that there is enough staff to keep 2 labs open until 5:30 pm daily. The holding staff work 12-hour shifts.

Has your lab recently undergone a national accrediting agency inspection?

We were inspected by the Joint Commission in November 2014 and passed our inspection with no infractions. During a time-out procedure it is very important that all staff are paying attention and are not doing anything else but being involved in the time out. The patient should also be involved in the time out.

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

The cath lab is located down the hall from the OR, but at the opposite end of the hospital from the ED.

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

We have seen a trend towards older and sicker patients. Consequently, we are treating patients with more complex coronary and valvular disease who are often not surgical candidates. 

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

The staff is very motivated to learn a new skill or procedure. They enjoy learning about structural heart procedures in the adult and pediatric lab, and being involved in these procedures. They also enjoy the comradery with the fellows.

We have started a same-day discharge program for select PCI cases, overseen by our team of advanced practice providers, who facilitate the discharge and follow-up on these patients. This has been a source of great satisfaction for our patients and their families.

Is there a problem or challenge your lab has faced? 

The hospital is often on critical bed status and as a result, we had a very difficult time getting beds for our patients, so we started a night shift in our holding area last year. We care for patients overnight and discharge them the following morning. This allowed us to free up a hospital bed and provide continuity of care for our patients within the cath lab. This has also allowed the hospital to take more Open Access patients referred from outside facilities and place them in beds on nursing units. 

This has been in place since September 2015, and we have received many accolades from patients and their family members. Having a night shift in our holding area has also improved staff satisfaction, because they know that when they are scheduled to go home at 7:30 pm, they will be actually be able to leave on time. In the past, they had to stay until the patient was assigned a bed, no matter how late it was. 

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 located in Chapel Hill, North Carolina, and are part of the famed “Research Triangle.” Many people transfer in and out of this area on a constant basis. When we have position openings, people from all over the United States apply due to spouses being transferred or their desire to move closer to the coast. We are only 2½ hours from the Atlantic Ocean and to the west are mountains. Our area is a very desirable one for many people. 

Questions from the Society of Invasive Cardiovascular Specialists (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?

No, we do not require the RCIS, and there is no incentive or bonus for taking the exam. We do have the Wes Todd educational system (www.westodd.com) on the computers in the lab for those who would like to pursue this route. 

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?

A number of our staff members are SICP members.

The authors can be contacted at pkaul@med.unc.edu or at brenda.mcclure@unchealth.unc.edu.

Tell us about your cath lab.

The cath lab at Jupiter Medical Center opened in March 2011 and has grown exponentially ever since. The lab has been doing emergent ST-elevation myocardial infarction (STEMI) since June 2014 and elective percutaneous coronary intervention (PCI) since November 2014. We also perform diagnostic and interventional peripheral procedures, pacemaker/defibrillator implants, and loop recorder implant/explant on an inpatient and outpatient basis. There are 10 full-time team members who handle our pre, intra, and post procedural care. Our department shares a space with the cardiology department, so most of our cath lab nursing team has been cross-trained to perform transesophageal echocardiography (TEE)/cardioversion, tilt table tests, and stress tests. We are fortunate to be located in Jupiter, Florida, just north of West Palm Beach. The community has a close relationship with the hospital and has been very active in developing all service lines. The hospital was actually built based on demand and with support from the local community in the 1970’s. We are a not-for-profit 327-bed regional medical center consisting of 207 private acute-care hospital beds and 120 long-term care, sub-acute rehabilitation, and hospice beds. We provide a broad range of services with specialty concentrations in cardiology, oncology, imaging, orthopedics and spine, digestive health, emergency services, lung and thoracic, women’s health, weight management, and men’s health. In February 2016, we opened the De George pediatric inpatient unit.

The hospital and cath lab continue to receive support through generous donations from the surrounding community. The cath lab owes its existence to the support of the Jupiter community, and the dedication and vision of our senior leadership team, led by CEO John Couris, the board of directors, and our team members. Our cardiology department, which includes the cath lab, is ranked in the 90th percentile for likelihood to recommend for Palm Beach and Martin Counties.

In order to grow our cardiology program, Jupiter Medical Center recently entered into an exciting partnership with Mount Sinai Heart New York. We are working toward beginning an open heart program within the next two years and are increasing steadily in volume to accomplish that goal. 

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

The department consists of 2 cardiac cath labs (Room 1 is a Philips FD10 and Room 2 is a Philips Allura FD20), and there are 10 holding beds for pre and post recovery. Presently, there are 10 total team members during the off-season and supplemental seasonal employees are hired for our winter season. We have 4 registered nurses (RNs) and 4 cardiovascular technologist (CVT) team members. Since our lab has only been open for elective PCI since November 2014, most of the team has been employed here for less than 2 years. The majority of our team has been working in a cath lab for greater than 20 years.

What procedures are performed in your cath lab? 

Procedures performed in our lab include diagnostic right and left cardiac catheterizations, intravascular ultrasound (IVUS), fractional flow reserve (FFR), optical coherence tomography (OCT), PCI, and peripheral diagnostic and interventional procedures. We also implant pacemakers, defibrillators, and loop recorders. We have seen tremendous growth in the past year and presently perform an average of 15-20 procedures per week.

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

Yes, we have been performing primary angioplasty without surgical backup on site since June 2014. At the present time, we have performed over 400 PCI cases. 

How many of your diagnostic caths are normal?

According to our data obtained from National Cardiovascular Data Registry (NCDR), at least 40.2% have non-obstructive coronary artery disease (CAD) not requiring PCI.

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

Our physicians use radial access 40-50% of the time.

Who manages your cath lab? 

Our day-to-day operations are overseen by the assistant clinical manager, Sara Gelo, RN, BSN, CVRN-BC, who reports directly to the director of the cardiovascular service line, Barbara Lamia, RN, MSN, CCRN.

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

Because of the size of our team, cross-training is a necessity. We have 4 CVTs who scrub and monitor. All RN team members are cross-training to circulate and monitor. 

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

Most of our physicians pan the table, change angles, and fluoro during the procedures. Our scrub staff (CVT or RN) is also trained to pan and move the table as needed during the case. We work with a dozen physicians, and everyone has a different workflow. Our team is capable of accommodating the preferences of the physicians. It truly is a collaborative effort between the interventionalist and the scrub person, which makes for an engaging and rewarding work environment.

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

We have a radiation safety officer for the hospital. A radiation committee oversees our practice, and monitors the safety of team members and patients. Quarterly meetings keep everyone current with the safest recommendations. X-ray badges are worn by all team members and physicians. Logs are reviewed by the safety officer. A quarterly report is kept in the lab so that everyone can see their own dose amounts. Vendors also give radiation safety lectures.

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

We were excited to bring St. Jude Medical’s OCT technology into our lab, which allows us to be prepared for new advancements (i.e., bioresorbable stent technology). We recently added ceiling-mounted, zero-gravity lead protection systems (CFI Medical, a TIDI Products Company) to both rooms in response to physician requests. We are in the process of training team members and physicians. As our program grows, we look forward to expanding our peripheral vascular procedures and our use of drug-eluting balloons. 

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

Communication is important in any cath lab. We communicate by having monthly team meetings, emails, and quarterly town hall meetings, which are led by our CEO. The unit-based council sets up “lunch and learns” to communicate changes within the industry. The goals of our facility are displayed on our organizational action plan board, which is updated quarterly. There are quarterly division of cardiology meetings to keep physicians abreast of any new information and changes.

How is coding and coding education handled in your lab? 

We have an excellent relationship with our billers and coders. We work as a team to update and maintain our procedure charges. We have successfully implemented our ICD-10 conversion. Ana Balensiefer, CVT, handles the Charge Master. She informs the cath lab team members of any updates. 

Charges are entered in the Horizon Cardiology Hemodynamic billing module (McKesson) and all CPT codes are attached to the charges. Procedure charges are entered at the completion of cases and reviewed the next morning for accuracy. If a modifier needs to be added, Ana works with the coders to complete the chart.

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

All team members are trained and competent to pull sheaths, and during business hours, sheaths are pulled by the cath lab team. After hours, we are currently training intensive care unit (ICU) and progressive care unit (PCU) team members to pull sheaths and manage TR Bands (Terumo) in order to improve patient flow and experience, and allow the call team to leave upon completion of the procedure.

All new team members are trained by first watching videos on how to pull sheaths or remove a TR Band. Next, they observe the procedure being performed, and then they must demonstrate competency before they are allowed to proceed without supervision. 

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

Patients are prepped and recovered in our 10-bed cath holding area during business hours. Emergency cases usually are recovered in the ICU. We use vascular closure devices and manually remove sheaths. 

How is inventory managed at your cath lab? 

We use a combination of Horizon Cardiology Inventory modules and manual counting to manage our supplies. Ana is primarily in charge of reordering supplies and maintaining vendor relationships, but a group effort is required to check expiration dates and supply levels.

We have a large consignment inventory for our coronary interventional needs. We work with Boston Scientific and Abbott to allow for physician preferences and requirements. Jupiter Medical Center is part of the SCMA Alliance (a regional purchasing organization). We use products that the alliance has approved. We stock, order, and adjust our par levels as needed. We are fortunate to work with an outstanding materials management department, and enjoy an excellent working relationship with our buyers and vendors.

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

In 2011, the lab opened, and only offered diagnostic caths and implants. In 2014, Jupiter Medical Center started performing emergent and elective PCI. Due to our growth, volume has increased 177% since 2014. We anticipate further growth and expansion of our program. 

Is your lab involved in clinical research?

Not at the present time. We are presently working through our affiliation with Mount Sinai Heart New York. We hope to participate as our program expands.

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? 

Jupiter Medical Center’s D2B median time is currently at 59 minutes. We have collaborated in setting up a protocol in transmitting electrocardiograms (EKGs) via Lifenet (Physio Control) from emergency medical services (EMS) to the emergency department (ED). The ED physician will determine if it is a ST-elevation myocardial infarction (STEMI) and contacts the interventionalist on call. The call team is notified by the nursing supervisor by phone and must respond within 30 minutes.

The ED, cath lab, ICU and telemetry floor directors/managers meet bi-monthly with the medical directors of the ED, cath lab, and the Mount Sinai Heart New York Program. All STEMI cases are presented for D2B or door-to-door (D2D) time. We review our quarterly reports from the American College of Cardiology’s NCDR PCI registry at each meeting. Accomplishments and areas of opportunity are discussed. Changes are put into effect immediately in order to continually work on improvements in the program.

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

The cath lab RN will go to the ED, receive a hand-off report, and transport the patient back to the cath lab on one of our monitor/defibrillators. Depending on patient situation, another cath lab team member, respiratory therapist, or the ED RN will assist with patient transport. This process is used 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?

After being notified of the STEMI by the ED or the nursing supervisor, the STEMI will take precedence over elective procedures. We make every effort to have two teams available during regular hours for this reason. After 5 pm, we make every attempt to limit elective procedures in order to have the call team available for STEMI patients. 

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

Being part of the SCMA Alliance is our best measure for containing costs, as they are able to negotiate the best contract prices. We carry most of our supply on consignment and work closely with our physicians to only carry what they prefer to use to avoid product sitting on our shelves. Every team member is mindful of waste and checks expiration dates, rotates, and stocks supplies as needed. In order to control costs and curb waste, ordering supplies is limited to 2 people. The facility works with MedAssets and Truven Health Analytics to manage labor productivity.

What quality control/quality assurance measures are practiced in your cath lab?

Quality and safety are a huge priority for our cath lab. We are diligent with hand hygiene, minimizing contrast utilization, radiation safety, accurate point-of-care testing, “time outs” and universal protocol. Our implants follow the operating room standards, and include the need for accurate instrument and sponge counts before and after procedures.

Are you recording fluoroscopy times/dosages? 

This is a mandatory field for our hemodynamic report for each patient. We also report on a quarterly basis to our radiation safety officer.

Who documents medication administration during the case?

Medication administration is documented primarily by the RN administering medication in the room. The recorder does assist in the medication administration documentation during emergent cases, which is then reviewed by the RN. 

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

We have a reporting system through the McKesson Cardiology monitoring system. Most of the cardiologists utilize the structured report; others will still dictate their report.

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

We submit to the ACC-NCDR’s PCI registry and the Implantable Cardioverter Defibrillator (ICD) registry.

How does your cath lab compete for patients? 

Jupiter Medical Center provides the world-class care that you would find at a large institution, with the concierge-style, individualized care you’d expect from a community hospital. We know our patients have a choice, and we have been told time and time again by our patients that they specifically choose to come to Jupiter Medical Center, even when coming from surrounding counties. 

Our partnership with Mount Sinai Heart in New York is another unique aspect of the cath lab. It allows our physicians to access the resources of a world-renowned institution and research facility to deliver the best possible care to our patients. This also allows our patients a choice to receive care at Mount Sinai Heart in New York. Locally, we have transfer agreements in place with a facility that has an on-site open heart program.

How are new employees oriented and trained at your facility? 

Our new employees undergo didactic and practical orientation. We have developed a manual to aid in the training of our new team members. The time period of the orientation is individualized on new employee’s needs. The entire team is involved in training of new team members. 

What continuing education opportunities are provided to staff members?

There is ongoing continuing education presented to the team in a variety of ways. Hospital classes and seminars are offered through our education department. Vendors provide seminars in the area all year long. Three team members attended last summer’s Cardiac Symposium at Mount Sinai in New York City. The team has access to modules on our HealthStream educational site, as well as many CEU opportunities through CE Direct. Our physicians are always happy to educate cath lab team members.

How do you handle vendor visits to your lab? 

Vendors make appointments to visit the lab and sign in through the materials management department.

How is staff competency evaluated? 

Our yearly employee education is managed online through HealthStream. Unit-specific competencies are done peer-to-peer through verbal instruction and return demonstration.

Does your lab have a clinical ladder? 

At the present time, the clinical ladder program is available to RNs only. As our lab grows, our goal is to implement the program to all team members.

How does your lab handle call time for staff members? 

There is no particular mix of credentials. It is a 4-person team consisting of RN and CVT personnel. Since there is a small team who supports the 24/7 requirements of call, there are many combinations.

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

The team is required to report to the hospital within 30 minutes of receiving a call from the nursing supervisor. We do not use a paging system.

Do you have flextime or multiple shifts? 

At Jupiter Medical Center, we have a team arrive at 0600 and a second team at 0700. We will flex and start call early during slower times. We look on a day-to-day basis to ascertain the next day’s caseload. All team members are flexible to meet the next day’s demands. During the busier months of our winter season, we stagger the 2 shifts to accommodate the longer days.

Has your lab recently undergone a national accrediting agency inspection? 

The Joint Commission visited Jupiter Medical Center in July 2015. The surveyors were very complimentary on our lab and our progress. Our recommendations are to always be prepared. Follow the guidelines made by the surveyors and stay abreast of recommendations made by your quality department. Implement changes as soon as you are made aware of them and there will be no surprises.

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

The OR is on the second floor. The cath lab procedural areas are on the first floor, adjacent to the ED. We are located close to 3 elevators and are able to move from floor to floor fairly rapidly, which will benefit us when we begin our open heart program. Currently, open heart surgery is not available at Jupiter Medical Center. We are striving to obtain state approval within the next two years. 

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

In terms of population, Jupiter, Florida, is fairly homogenous. Our patient population is primarily composed of a mix of seasonal and annual patients who tend to be 50 and older. As a lab, we do a fairly even mix of in and outpatient procedures, with diagnostic or interventional cardiac catheterization procedures being the bulk of our volume. We have seen more local physicians start to prefer radial access, and in accordance with evidence-based practice, use FFR, IVUS, or OCT to determine interventional necessity. 

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

Our cath lab does pre-cath, procedure, and post-cath care. We are comprised of 8 cath lab team members, 2 other RNs and a few per diem team members who help during busy times. Because of the small team, and proximity to our cardiology procedural area and interventional radiology department, our team’s skill set is diversified, and we collaborate between departments to share team members and resources. 

Is there a problem or challenge your lab has faced? 

Our challenge has been developing and implementing our program without on-site open heart surgery. We have addressed it by having an experienced, dedicated team and excellent outcomes. All of our cardiologists are self-employed private practice physicians. We have worked continually to show them that our approach to quality drives us to be the best. We are becoming very busy and growing daily, but we remain focused on quality. This has helped us to become recognized for excellence by our physicians and the community.

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”?

Jupiter, Florida is located in northern Palm Beach County. It is an idyllic waterfront community located less than 2.5 miles from the Atlantic Ocean and is known for its iconic red lighthouse that was built in the 1860s. In the winter season, the average temperature is 70 to 80 degrees Fahrenheit. The area becomes very busy around November, due to the seasonal population arriving from all over to retreat for the winter. 

Something unique about this community in particular is its overwhelming support for the medical center and our presence in the community. Jupiter Medical Center is also unique for its upstream thinking in regards to community health, and it dedicates many resources to the community to detect conditions such as heart disease, breast cancer, and diabetes, and works hard to keep patients with chronic health problems out of the ED. Resources such as the wellness bus, cardiac risk screenings by our cardiac nurse navigator, outpatient clinics in several residential developments, urgent care centers, frequent health fairs, and a presence at the local Mandel Jewish Community Center allow Jupiter residents to access world-class care without ever needing to step foot in the hospital. There are also exciting partnerships beyond Mount Sinai Heart New York with Nicklaus Children’s Hospital, the Mandel Jewish Community Center, and the Joe Namath Neurological Research Institute, which afford Jupiter residents comprehensive care from birth through their golden years. The hospital truly collaborates with and advocates for the health of the community. 

The authors can be contacted via Barbara Lamia, RN, MSN, at barbara.lamia@jupitermed.com.

Questions from the Society of Invasive Cardiovascular Specialists (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?

Since we are a new program, at this time, we have not required our team members to be credentialed. Our team members with the RCIS credential currently do not receive compensation for this certification.

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 the present 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?

In the past 2 quarters, our volume has increased. Having a larger volume of patients has allowed us to review our results in order to identify trends and benchmark ourselves. We will be using Q3 results to drive QI initiatives moving forward.

Mount Sinai Heart New York’s Partnership with Jupiter Medical Center

Talking with Samin K. Sharma, MD, FSCAI, FACC, Director, Clinical & Interventional Cardiology, President, Mount Sinai Heart Network, Dean, International Clinical Affiliations, Zena & Michael A. Wiener Professor of Medicine, The Mount Sinai Hospital, New York, New York.

Can you tell us about the partnership?

Mount Sinai Heart New York’s affiliation with Jupiter Medical Center started a few years ago, with a single purpose — providing the best patient care and research in south Florida. Mount Sinai has many affiliations with other countries, but outside of the boroughs of New York, Jupiter Medical Center is our first trans-state affiliation for cardiology services. Jupiter Medical Center is a reputable center with excellent, experienced cardiologists, but there are a few complex diseases that cannot be taken care of there, such as complex coronary interventions, transcatheter aortic valve replacement (TAVR), and cardiac surgeries. The ultimate goal is to empower Jupiter Medical Center to have the cardiac surgical program on site at the local level. Also, under our affiliation, Jupiter physicians have visited us frequently and their cath lab staff attended our Nurse and Technologist education sessions at our annual symposium in June 2016. It has been very useful. The goal is to improve knowledge and participation in research, and extend all the clinical care available at Mount Sinai Hospital, and they are on the right track.

Your lab is well known for establishing protocols. Have those also been shared with Jupiter Medical Center?

Yes, Mount Sinai’s protocols are also being extended to Jupiter Medical Center. They get the benefit of academically and clinically tested protocols to improve patient care and also identify patients who need advanced care. Jupiter Medical Center now offers a clear-cut referral pattern to Mount Sinai Hospital for advanced care. At Mount Sinai, we have access to Jupiter Medical Center patients’ electronic medical records. Jupiter physicians refer patients needing advanced care to Mount Sinai New York, and they also can look at the patient’s record, angiogram, anything being done here. It is a great step. We have found that unless a formal relationship has been established, patients are reluctant to pursue advanced care outside their locality. But if a system has been created, patients are much more receptive to travel for advanced care, and this has been proven in the last 2 years of our relationship. Patients seen at Jupiter Medical Center who require advanced care are now routinely coming to Mount Sinai New York. Also, many of our patients who also live in Florida are being taken care of by Jupiter Medical Center doctors. 

Any final thoughts?

Eradication of cardiac disease may be an impossible goal, but at Mount Sinai, we are seeking to improve cardiac care globally. Our relationship with Jupiter Medical Center is one step toward this goal. Mount Sinai has been a leading center in providing care to the patients in New York State, and now we are branching out nationally, as well as globally. This process has accelerated recently under leadership of our network president, Dr. Arthur Klein, and we are considering how we can go further to improve relationships with both patients and medical centers in offering global cardiovascular care. 

Tell us about the cardiovascular service line and the cath labs at ProHealth Care.

The service line is a multidisciplinary group that includes cardiologists, interventional radiologists, hospitalists, emergency room physicians, family practice, nurse practitioners, finance, marketing, diagnostics areas, billing and coding, materials management, and other ancillary support staff and departments. The overarching goal of the service line is to engage key stakeholders around cardiac services, to inform and deliver on the strategic vision of the organization, drive out variation, and enhance access to care, resulting in exceptional clinical care, and improved patient throughput and satisfaction, as well as increasing market share.  

The interventional department at ProHealth Care consists of services at 3 geographic locations with over 40 staff and support personnel. Waukesha Memorial Hospital is our main site, which consists of a dedicated electrophysiology (EP) lab (that can also perform cath procedures), 2 cath labs, a hybrid operating room (OR) suite, an 8-bed holding area, and 2 interventional radiology (IR) suites. Oconomowoc Memorial Hospital has 1 cath lab and 1 IR suite. ProHealth Care’s new Cancer Center location also has an IR suite and a 4-bed holding area.  

Staff is a mixture of registered nurses (RNs), radiologic technologists (RTs), registered cardiovascular invasive specialists (RCISs), and other licensed professionals. Our staff members are a very loyal group, with well over half having at least 10 years of tenure with ProHealth Care.

What procedures are performed in your cath lab? 

We perform a variety of procedures: advanced diagnostic and interventional EP exams, including a-fib ablations, cardiac rhythm management services such as pacemakers, defibrillators, loop recorders, and CardioMEMS implants (St. Jude Medical), transcatheter aortic valve replacements (TAVRs), atrial septal defect (ASD) closures, laser lead extractions, diagnostic and interventional catheterizations, transesophageal echocardiograms, tilt table tests, and dobutamine stress echos, IR procedures such as central lines, peripheral angiography and interventions, acute stroke treatments, and radiofrequency ablations. Across this spectrum, we perform well over 100 procedures/week.

Can you share your experience with TAVR? 

We started performing TAVR procedures in September 2015; to date, we have done 20 procedures. By creating a multidisciplinary team and utilizing a team-based approach, our program was able to integrate TAVR procedures into the current case mix in an efficient and effective manner. The team is made up of cardiothoracic surgeons, interventional cardiologists, a dedicated cardiac anesthesiologist, dedicated radiologists for imaging, cath lab RNs and technologists, OR RNs and technicians, and support staff, as well as a valve clinic coordinator.

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

At Waukesha Memorial Hospital, we have full surgical backup. However, we do not have on-site surgical backup at Oconomowoc Memorial Hospital; numerous processes have been integrated that allow us to perform interventions in a safe and effective manner at this location.

Who manages your cath lab?

An outstanding group of individuals form the leadership team and manage the Interventional Services department at ProHealth Care. The team consists of the cardiovascular service line administrator, a manager, 2 team leads, 3 nursing care coordinators, and an educator. Weekly leadership meetings focus on training, education, cross training, project management, and day-to-day operations, as well many other factors that affect our environment.  

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

Currently, our RTs and RCISs scrub and monitor procedures. RNs circulate, provide patient care and monitor, and some RNs also scrub procedures. We are striving for cross-functionality across all of our modalities to include the cath lab, holding room, and IR.  

Who documents medication administration during the case?  

The administration of medications is documented by the circulating RN in the patient’s electronic medical record (EMR).

What percentage of your diagnostic caths is normal?  

By American College of Cardiology (ACC) standards, approximately 25-30% may be categorized “within normal limits”.

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

We have multiple physicians who utilize the radial approach. Radial procedures have had a positive impact on patient satisfaction and throughput. The key to transitioning from a femoral approach to a radial approach has been education and training for physicians and staff members.

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

We do have physicians who will access the pedal artery when appropriate.

Are there licensure laws in your state for fluoroscopy? 

There are laws regarding fluoroscopy in Wisconsin. Currently, technologists can pan and move the table, while the physician steps on the pedal that creates the radiation.  

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

Safe and effective radiation protection, monitoring, and reporting are a vital aspect of our services. Staff and physicians are educated annually concerning radiation safety and are continually monitored regarding dosage. The organization has recently acquired a GE product called “Dosewatch” in which we can track and trend the amount of radiation delivered during specific exams. It adds another tool to our arsenal in an effort to protect our patients and staff from excessive radiation doses.

Fluoroscopy times and dosages are recorded, trended and reported to our radiation safety committee. We have an RT who tracks, monitors, reports, and consults with our physicist to ensure we are proactive in the management of radiation doses. 

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

If a patient receives a higher dose than normal, the occurrence is registered in our incident tracking system. We notify the physician, who in turn notifies and examines the patient for any possible injuries. All information/data is then documented in the EMR and the incident tracking system. The patient will receive a form notification follow-up through their physician in conjunction with the physicist, compliance officer, and patient safety officer.

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

Recent equipment, device and product additions to the ProHealth Care’s repertoire include CardioMEMS implantation, TAVR procedures, and laser lead removals. We are currently upgrading our hemodynamic system, replacing our inventory management system, and upgrading our PACS system to integrate structured reporting. We have chosen the Medstreaming PAC’s system for echo, vascular and cath lab. We are also upgrading and integrating our Philips Witt hemodynamic monitoring system. Both of these systems will tie into our Lawson POU inventory management system as well as our EPIC medical record.

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

The service line model utilized by ProHealth Care offers numerous opportunities for effective communication across a wide spectrum of individuals, departments, committees, and physician practices. Our program communication comes through the Service Line Executive Committee, with additional sub-committees on patient experience, clinical practice, TAVR, credentialing, EP, clinical informatics, and quality improvement projects. We have monthly cardiology division meetings, and monthly departmental staff and educational meetings, as well as numerous other meetings in which the staff, physicians, and ancillary personal participate in education and improvement initiatives.  

ProHealth utilizes a shared governance model that focuses on quality, education, and clinical practice. We have shared decision-making between staff, administration, and providers. 

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

Cath lab staff, holding room staff, telemetry staff, intensive care unit (ICU) staff, and Heart Care Unit staff can pull sheaths. We have a detailed competency that all staff must accomplish successfully prior to pulling sheaths independently.

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

Cath lab patients are prepped and recovered in the cath lab holding room. Physicians deploy closure devices in the cath lab. Patients who leave the lab with their sheaths will have them manually removed in a variety of clinical settings.

How is coding and coding education handled in your lab?

CPT codes are updated twice a year, during the budget and at the beginning of each calendar year when changes occur. The cath lab has a detailed process for reviewing procedure codes and supply changes for each exam.  We have a dedicated individual who oversees the coding and subsequent education of the staff.

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

We have a value analysis team. This is a committee that includes cath lab leadership, staff, service line leadership, and materials management personnel. They continually work to increase/create effective materials management solutions that meet the needs of the clinicians and are fiscally responsible. We are in the process of transitioning to a new inventory management system. The cath lab works in conjunction with materials management on major equipment acquisitions. Currently our cath lab and IR staff order, receive, and put away our supplies.

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

Our hybrid OR/cath lab suite opened in August 2013 and we recently integrated an off-site cancer center into our organization.

Is your lab involved in clinical research?  

Currently we have 4 ongoing research trials in which we are participating.

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 current D2B times are 58.42 minutes for Waukesha Memorial Hospital and 57.61 minutes for Oconomowoc Memorial Hospital. We are working on cath lab accreditation as well as Chest Pain Center accreditation and participation in a national database. 

How does your lab handle call times for staff members?  

The call team consists of 2 technologists and 2 RNs. The call team covers both Waukesha Memorial Hospital and Oconomowoc Memorial Hospital. 

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

Staff has 30 minutes to come in to the hospital.

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

We are incredibly lucky to have outstanding emergency departments (ED) that will not only transport a patient to the cath lab, but will also stay and help with the management of the patient until the entire on-call staff and cardiologist have arrived.  

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

While it is a rare experience, our process is to send out a group page/notification message that denotes the urgent need for a second team. In the last year and a half, we have used the process and the response has been positive and very timely.

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

In conjunction with our Lawson point of use inventory management system, we are participating in a project to reduce our “owned” inventory and utilize consignment opportunities more. We have worked to adjust our scheduled work hours (8- and 12-hour shifts) in an effort to be more effective and efficient in regards to our patient throughput and in addressing late procedures. We also work closely with our materials management department in an effort to strictly adhere to any contractual savings we may realize as part of a large buying group.

What quality assurance measures are practiced in your cath lab? 

ProHealth Care utilizes a shared governance model, which focuses on three areas: clinical practice, education, and quality. Data concerning core measures, outcomes, and appropriate use, as well as various other pertinent data, is monitored, trended, and discussed in an effort to improve patient care, outcomes, and throughput.

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

Currently, we are not utilizing structured reporting; however, in an effort to integrate structured reporting into our processes, we are upgrading our current hemodynamic and PACS systems. 

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

Yes. Right now, we are only collecting PCI data; however, with our planned PACS and hemo system upgrades, we will expand our database to include diagnostic procedures.  

How are you populating the registry data records?

Currently forms are created and abstracted by staff from the quality services department. Registered nurses in the quality department are abstracting charts from the EMR. Future practice will integrate this process into the cath lab.

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

We compete with several large systems in the greater Milwaukee area based upon quality, timeliness, access, and clinical outcomes. We are currently number one in the market with a share in the high 40s. At this time, our cardiothoracic surgery program is a partnership between ProHealth Care and IU Health, which is based in Indianapolis.  

How do you handle vendor visits to your lab?  

Vendors are either invited or they inquire about opportunities to visit the labs. All vendors are required to wear appropriate and current vendor badges. All new products go through a rigorous process that involves our new technology committee. The process is very detailed and each supply is examined based upon clinical effectiveness and fiscal responsibility. Vendors meet with the director of cardiology and the VP of materials management quarterly.

How are new employees oriented and trained at your facility?

We are incredibly lucky to have a dedicated educator who creates a very detailed orientation process based upon the new employee’s education and experience. The process entails a detailed overview/guide, weekly meetings, tests, updates, hands-on, and classroom training. New staff is assigned a preceptor for clinical rotations, and the preceptor works with our employee and educator to ensure a seamless onboard and training process for new staff.  

What continuing education opportunities are provided to staff members?  

Staff members are provided with multiple educational opportunities per month. There are sessions offered by industry representatives, our educator, and the organization. Computerized programs are also available.  

How is staff competency evaluated?

Competencies are evaluated through observation, education/training/in-servicing, and testing. The organization has computer-based learning modules (CBLs), and the interventional departments have multiple learning resources and assessment processes to evaluate and assess the cognitive and physical skills associated with various clinical competencies.

Does your lab have a clinical ladder?

The clinical advancement program recognizes the expertise of nurses who make a difference at the bedside and provides them a pathway to grow professionally in their practice. The clinical ladder is comprised of 4 levels and is grounded in the Benner Model of Skill Acquisition model. Nurses are advanced in the program as they develop their skill in 4 domains of practice: clinical knowledge and decision-making, caring, collaboration, and leadership. Nurses seeking advancement are evaluated by a panel of their peers who evaluate the data they provide regarding their practice in the 4 domains.

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

We have no physical bottlenecks or limitations; however, we are challenged with gaps in the schedule during the workday, and the associated staffing and productivity challenges. 

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

Our staffing model is a combination of differing length shifts with staggered start and finish times. We flex our staff to meet the needs of the service line and make every effort to cross train. We work on quality and accreditation processes during slow times.

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

The cath lab is located between the ED and the OR. Our hybrid room connects the OR and the cath lab, while the ED is approximately 40 feet down the hall.

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

For cardiac procedures we have seen a slight downturn; however, in other areas we have seen growth.

What is unique or innovative about your lab and staff?  

Staff at PHC demonstrates a genuine concern for the welfare of each and every patient. We have a spirit of cooperation and understanding, and value the knowledge, skills, and talents of our staff. We have the right mix of staff to create an environment that fosters community.  

Is there a problem or challenge your lab has faced? 

For several years, we struggled and searched for a strong manager and at the end of 2014, we found one, using a national search firm. Our manager, a RCIS with over 25 years of experience, started about a year ago. 

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”?

The Milwaukee area has a strong relationship with physicians and physician groups; many independent providers only practice at ProHealth Care. Waukesha County, outside of Milwaukee, is about halfway between Milwaukee and Madison giving us that entire geography to enjoy. We can be in downtown Milwaukee in 25 minutes and enjoy everything that the city offers. Summer is a great time to be in our cities, with all the different festivals that we can enjoy, as well as outside music concerts. 

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?

At this time, it is not required. If staff chooses to takes the exam and pass, the exam is paid for. They also receive a bonus.

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?

Yes, we have several team members who are very active in several societies.

A QUESTION FROM THE AMERICAN COLLEGE OF CARDIOLOGY’S NATIONAL CARDIOVASCULAR DATA REGISTRY:

How do you use the NCDR outcomes report to drive QI initiatives at your facility?

We are currently working on our documentation and data abstraction practices concerning appropriate use criteria. The basic premise for the improvement is to become proactive/concurrent in our documentation and data abstraction processes versus retrospective. We also hope to better understand and address variances in the documentation process.