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

Our Methodist site consists of 4 procedure rooms: 2 cardiac labs (diagnostic and interventional), 1 electrophysiology (EP) lab, and 1 hybrid peripheral suite. The Proctor Community site has 2 cardiac labs (diagnostic and interventional) and 1 peripheral lab that is shared with the interventional radiology department. Pekin Hospital has 1 lab that performs diagnostic-only cardiac angiograms, and diagnostic and interventional peripheral studies. All 3 facilities have a pre and post recovery unit.

Our physician staff consists of 9 cardiologists, 1 cardiovascular surgeon, 1 independent cardiologist, 3 vascular surgeons, and 1 independent vascular surgeon. Cath lab staff includes 4 full-time critical care registered nurses (CCRNs), 4 PRN RNs, and 9 radiologic technologists (RT[R]s).

Our staffing longevity is from 1-25 years of service IN the cath lab. We recently added up our years of service at Methodist (this includes our open-heart team). It was over 600 years.

All of our team members work in cardiac, peripheral, and implant procedures. Four of these team members work in the EP lab. Pre and post recovery is staffed with 3 RNs, who are part of the surgical prep and recovery department. We have 1 chaplain who assists daily with family updates and our patients’ religious needs. We also have 1 dedicated certified coder.

What procedures are performed in your cath lab? 

We have a vast array of cardiac procedures, including left and right heart catheterizations, and utilize fractional flow reserve (FFR), intravascular ultrasound (IVUS), intra-aortic balloon pumps (IABPs), Rotablator (Boston Scientific), and Impella (Abiomed). We also perform chronic total occlusion (CTO) procedures and stenting. Peripheral diagnostic and interventional procedures involve atherectomy, ELGs, hybrid procedures, carotid stenting, IVUS, radiofrequency (RF) ablations, fistula diagnosis, and interventions. Our implants include permanent pacemakers, implantable cardioverter defibrillators (ICDs), biventricular ICDs, and the Micra (Medtronic). Our EP team performs radiofrequency ablation of atrial fibrillation/flutter, ventricular tachycardia (VT), and premature ventricular contractions (PVCs), as well as cryoablation of supraventricular tachycardia (SVT). Some of our team also participates with the peripherally inserted central catheter (PICC) team. The PICC team consist of an all-RN team from both cath lab and open heart staff, and covers the Proctor and Methodist campuses.

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

The Methodist cath lab performs complex coronary and peripheral procedures with surgical staff backup on site. Methodist has 2 operating rooms and 24-hour coverage. The Proctor cath lab performs basic coronary and peripheral procedures. Pekin Hospital performs diagnostic coronary procedures only, but also does basic interventions for peripherals. Pekin and Proctor have an OR unit, but not open heart or vascular surgery. Critical patients are transferred to Methodist via Advanced Medical Transport (AMT) ambulance services.

What is your rate of normal diagnostic catheterizations? 

The average rate of normal diagnostic caths is 1000 a year.

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

Yes, there are 3 coronary physicians who routinely gain radial access for ST-elevation myocardial infarction (STEMI) and non-STEMI procedures. Radial procedures are performed on 45% of our coronary percutaneous coronary intervention (PCI) cases and approximately 65% of diagnostic cases.

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

All of our vascular surgeons and 1 interventional cardiologist will obtain pedal access as needed for complex vascular cases. These are usually ultrasound and/or Doppler guided.

Who manages your cath lab?

Alexander Adler, MD, FACC, FHFSA, is our medical director. He is board-certified in internal medicine, cardiovascular disease, and heart failure transplantation. Tina Miller, RN, MSN, MBA, NEA-BC, is the Executive Director of Cardiovascular Integrated Services. Shannon Glover, RN, BSN, manages the cath labs, except for the Pekin campus. She also manages open heart at Methodist and the care unit at the Proctor campus, as well as the PICC team for both campuses. She is overseeing and consulting for the Pekin campus at this time, which is currently going through UnityPoint Health integration.

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

RT(R)s routinely rotate between scrubbing and monitoring roles. RNs mostly circulate. Our patient care team will always have 1 RN and 1 RT(R) to scrub, and 1 of either license to monitor.

Are there license laws in your state for fluoroscopy?

Yes, the state of Illinois has a government body called the Illinois Emergency Management Agency (IEMA). Illinois law states only licensed personnel can operate radiologic imaging equipment.

Certified RT(R)s must complete 24 hours of continuing education biannually in order to maintain licensing.

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

The RT(R)s and physicians.

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

The hospital has a governing Radiation Safety Committee and Radiation Safety officer. There is 1 quality control RT(R) that maintains badge and exposure reporting. She oversees the radiation equipment testing by a physicist, and tracks lead aprons and their annual testing for Methodist and Proctor campuses. We also have a dedicated RT(R) who serves on the committee and assists her in the cath labs for lead testing. 

New team members are fitted for wraparound aprons, thyroid shielding, lead glasses, and protective hats, if wanted. Sterile RadPads (Worldwide Innovations & Technologies, Inc.) are provided on all cases. The Pekin cath lab has a senior RT(R) who handles radiation protection for that campus. All staff that work in our area are expected to do a yearly NetLearning competency test on ALARA (“as low as reasonably achievable”).

How is coding and coding education handled in your lab?

We have charge forms geared to each procedure and a dedicated coder. She performs coding for cath lab and open-heart procedures at Methodist and Proctor. She has 19 years of coding experience and is a certified professional coder (CPC) through the AAPC, with 18 required hours of continuing education per year. She does a presentation every year at a staff meeting to update or clarify coding issues. We are certainly fortunate to have her. 

Who pulls the sheaths post procedure, for both interventions and diagnostic procedures?

The RT(R)s, nurses, and physicians pull for diagnostic and intervention. There is mandated observation by senior personnel for new staff for their first 5 sheath pulls. They are then able to pull sheaths themselves. All nurses and scrub RT(R)s are trained on closure devices and post procedure care. Outpatients are transferred to our recovery area. Inpatients are transferred to the cardiovascular intensive care unit (CVICU) or to our step down cardiac unit, where staff is trained on access management. Closure devices are deployed by the physicians. Manual pulling can be done in the lab or the patient can be taken to another patient care area for pulling. It depends on caseload volume and needed procedure flow.

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

We have instantaneous wave-free ratio (iFR, Philips), Aquamantys bipolar sealers (Medtronic), Resolute Onyx stents (Medtronic), Surfacer (Bluegrass Vascular Technologies), the leadless pacemaker Micra (Medtronic), and the Impella (Abiomed). We have just completed a new state-of-the-art EP lab that is using an esophageal temp probe (Circa Scientific) and EnSite Precision Cardiac Mapping System (Abbott).

The SpaceTRAX inventory system (Stanley Healthcare) was added to the Proctor campus for better inventory control. A new Witt hemodynamic monitoring system (Philips) was also installed at Proctor in order to standardize procedure documentation and increase staff competency. Stryker reprocessing has been added to the cath lab for EP catheters.

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

Our coder performs two roles. One is coding and the second role is answering phones. Daily, we have a rotating “board runner”. They communicate case changes and delays to physicians and cath lab staff. Both people keep procedure flow going for all 3 campuses.

The department manager makes case assignments the day before and posts them, so people know which campus to go to and the cases they will be doing for the day.

Our cases are posted on a large board in our main hallway, with color coding of the physicians. This is another way of keeping physicians and staff updated for add-ons and time changes.

Our manager sends daily emails (huddle notes), and organizes monthly staff meetings and quarterly meetings, including 1 meeting for the RNs, 1 for RT(R)s, 1 for open heart, and one for the care unit. She also attends a monthly physician meeting.

We have “reminders” put on flip chart paper and posted inside our bathroom stalls.

Our break room has multiple dry erase boards and bulletin boards on every wall that are geared specifically to certain topics, e.g., engagement, wellness classes at our gym, birthdays, and our favorite, THE POT LUCK!

Our monthly meetings include guest speakers and vendors. It is a time we also receive policy reviews or updates. Most staff members serve on a hospital committee or project and will share updates regarding their assignment.

How is inventory managed at your cath lab? 

SpaceTRAX is our electronic inventory management tool at UPH Methodist and Proctor (Figure 5). It shows us inventory usage, physician procedure costs, expired product, and what should be reordered. All staff are trained at different tiers for SpaceTRAX utilization.

There are 4 team members at the Methodist and Proctor campuses that will receive product from the warehouse, check it into SpaceTRAX, and put it away. There are 3 requesters who can initiate equipment purchases under our manager’s supervision. They also do this in between patient care assignments. It is a constant, never-ending process in our lab.

Methodist has a central supply department that handles daily miscellaneous supply stocking: syringes, saline, etc. This is also being initiated at Proctor. Pekin is currently manually counting supplies, but looking to purchase SpaceTRAX in 2018.

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

All three campuses have a prep and recovery area that is skilled and specific to the cath lab. It is staffed with RNs that are trained to address our patients’ specific needs. They perform:

• Prep: start an IV, shave, dress, consent, check for current labs, and history & physical;
• Post care: sheath pulling, monitoring access site, patient and family education, and discharge;

Cardioversions, loop recorder insertions, and transesophageal echocardiograms (TEEs) are also performed in this unit.

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

The Methodist campus now has 2 EP labs; a new cath/EP lab was just completed. The new lab has allowed us to increase our efficiency and better serve our patient population by being able to perform 2 ablations a day. We are currently integrating with Pekin Hospital and its cath lab.

Is your lab involved in clinical research?

The Methodist campus is participating in the Surfacer Research Study (Evaluation of the Surfacer System Approach to Central Venous Access).

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

Our average D2B time is 72 minutes at Methodist. Proctor is 78 minutes. All of Pekin’s STEMI patients are transferred to Methodist by paramedics, so they are included in the Methodist time window for transfers.

When patients present in the emergency department (ED) with chest pain, an electrocardiogram (EKG) is done within 10 minutes. There are 3 cath lab call personnel and 1 STEMI physician on call 24/7. Labs are drawn in the ED, and an IV and drugs started. The patient is then transported directly to the cath lab. The city’s emergency medical services (EMS) personnel are able to communicate with the ED and send an EKG for suspected STEMIs. This allows for calling/paging the call team and beginning room/procedure preparedness for the patient’s arrival.

A STEMI task committee meets monthly, and reviews fallouts and ways to improve times. We are working on an internal D2B time of 60 minutes to increase proficiency. We are also registered with the American Heart Association’s Mission: Lifeline.

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

STEMI patients are transferred by ED staff and we are given handoff information.

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

The cath lab has everyone’s phone numbers posted. If need be, volunteers are asked to come in and given shift bonus for their time. When absolutely necessary, a patient procedure will be abandoned and moved to the CVICU, or their staff will come and stay with a patient so the STEMI can be addressed. If we know late or long procedures are going to run after hours, a volunteer backup call team for STEMIs is implemented. This happens infrequently.

What measures has your cath lab implemented to reduce costs?

We utilize our electronic system’s information for par levels. We will share products among the three campuses to reduce “overall” spending  due to caseload variances. Our inventory requesters review individual  items for discontinuing or par level reduction monthly when reviewing expiration and reordering reports. We have been able to shift some items to consignment instead of owned. Contracted bulk buys have been used when possible that allow us a reduction in dollars spent or will allow for needed equipment inclusion. Being part of a larger, 9-hospital unit helps us to work with vendors to reduce unit prices. Also, the ACIST CVi contrast injection system is utilized in most of our procedures by several physicians. This can also be set up for low viscosity mixes. Our expired product is donated to third-world organizations.

What quality control measures are practiced in your cath lab?

There are monthly acute MI/STEMI data review meetings that review fallouts. Also, there are quarterly cath PCI reviews with physicians on their data. There are audits performed on all complications and reviews are done with physicians as needed.

How are you recording fluoroscopy times and doses?

We have dose timing tracked on all our units. This is transposed to our patient procedure report.

Any dose that is in excess of 5Gy is reported by the RN into our RL Solutions software, and a radiation oncology nurse and next caregiver are notified. The patient is followed up at 2, 4, 6, 8, and 12 weeks. These cases are reviewed by our radiation safety officer and at risk management meetings. The operating physician is notified every 5 minutes and when they reach 3Gy. Dosing and time are displayed on procedure monitors at all times.

How do you determine contrast dose delivered to the patient during angiographic procedures?

The ACIST CVi injector gives us an exact amount. If low viscosity contrast media is used, the ACIST amount is times 0.7. Colored syringes and labeling stickers are used on the sterile field to help staff keep track of hand injections. Manual eyeballing is used for manifold procedures.

Are you tracking the incidence of contrast-induced acute kidney injury in patients?

Pre-procedure labs must be done within 30 days of the angiogram and rehydration is scheduled if necessary. Doses are documented in the patient procedure report and the operating physicians state the amount in their dictation. Physicians define patient care and follow-up. This data is also tracked in the National Cardiovascular Data Registry (NCDR) CathPCI registry per provider.

Who documents medication administration during the case?

The RN documents in the monitoring system during the case. This is shared with the next caregiver for their handoff forms.

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

The structured tool is available for them, but our operators dictate their procedure report. They also chart an immediate post procedure note in Epic.

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

Yes, we participate in the NCDR CathPCI registry. This data self-populates through the Philips hemodynamic system. We have 3 data abstractors focused on registry data, and their focus is divided as follows: the NCDR ICD Registry: 1 abstractor; NCDR Peripheral Vascular Intervention (PVI) Registry: 1 abstractor; NCDR AFib Registry: 1 abstractor – done by analytics dept; and CathPCI Registry: 3 abstractors. We also participate in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) Registry and the NCDR ACTION Registry (now the Chest Pain – MI Registry), and those are handled by our analytics department.

How are new employees oriented and trained at your facility?

New staff have a week of hospital orientation that includes policies and expected standards and values. In the department, new employees have a mentor/call buddy for 90 days for basic skills. They meet with our manager frequently to discuss orientation needs, progress, and goal setting. Everyone is sent to ECG, basic life support (BLS), and advanced cardiovascular life support (ACLS) classes. We have a large orientation manual for each license that is read by each new employee. It is up to the manager if longer orientation time is needed.

How is staff competency evaluated?

All staff have yearly competencies and review their job description. Our manager gives everyone a yearly job performance evaluation that is also attached to their pay increase. She uses staff and physician input, as well as her own observation. We also have computer-based training required through NetLearning that must be met. There are yearly comps on equipment and procedures. We review our ACLS practices, defibrillators, and so on.

What continuing education opportunities are provided to staff?

Continuing education is done by vendors for new equipment and supplies. Quarterly inservices are done by vendors on more infrequent supplies like the Impella, Rotablator, etc., to keep current the wide range of skills needed by staff. Staff is also sent to symposiums and conferences to enhance their job knowledge. American Society of Radiologic Technologists (ASRT) membership is provided to keep our CEUs for RT(R)s. Physicians, other hospital representatives, and vendors attend monthly staff meetings and share information on devices and topics such as right heart catheterizations, etc.

How do you handle vendor visits to your lab?

Vendors are required to schedule time in advance. They must meet RepTrax requirements and wear the badge at all times. They are also expected to wear a red surgical hat. If a vendor is invited by a physician to come for a procedure, this is also acceptable.

Do you require your clinical staff to take the registry exam for the registered cardiovascular invasive specialist (RCIS) credential? Does staff receive an incentive bonus or raise on passing the exam?

No, all staff must be licensed, but it can be RN or RT(R). We do have a RT(R) who took the RCIS exam and passed. The RCIS review and test is paid for by Methodist.

Tell us about your department’s physical space.

We have limited square footage. We have remodeled and upgraded our x-ray equipment in 3 of our 4 rooms at Methodist and 1 room at Pekin over the last 5 years. These procedure rooms are improved, but we have met a lot of physical limitations. We also share our work area with 2 open-heart rooms. Between the cath lab and open-heart supplies, we need more storage space. We are very landlocked at this time.

How does your cath lab handle call time for staff members?

We have 1 call team for everything, everywhere. It is 1 RN and 2 RT(R)s. Staff chose this instead of 2 call teams to improve their work/life balance. Their call can be hectic, but they have more off time. This has not impacted patient care. There is 1 STEMI call doctor, so they are hectic together. Staff typically have 1 set weekday call and 1 weekend a month. The call team has 30 minutes to arrive after being paged.

Do staff members have any little or big particular perks that you might like to share?

Staff has paid ASRT membership. Self-scheduling is allowed as long as cases are covered. Paid time off (PTO) is not required for low census, but is still an option. We have flexibility with appointments and family obligations, such as changing hours to fit with work/life balance. There are monthly birthday and work anniversary celebrations. We receive recognition if we are mentioned by name on a patient survey at staff meetings. Our manager will also celebrate above and beyond efforts with our peers. She is also able to give “shout-outs” recognizing staff and other department members at intra-department manager meetings. Team-building parties are scheduled off campus twice a year with our greater work family, including the CVICU and step down unit.

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

Most staff work four to five 8-hour shifts a week. Two RT(R)s work four 10-hour shifts.

During low census, the manager will post “things to do” such as checking expirations, NetLearning, comps, room cleaning, etc. There is an option to go home early. Several staff have additional duties: inventory, PACS, and NCDR data collection. They always have something to do.

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

Our manager participates in Association of periOperative Registered Nurses (AORN) and is a Society for Cardiovascular Angiography and Interventions (SCAI) member.

Has your lab recently undergone a national accrediting agency inspection?

Yes, we underwent Joint Commission accreditation in 2017 and Illinois Department of Public Health (IDPH) in 2017.

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

We are using different access sites: radial, pedal, brachial, subclavian, antegrade, and cut downs. Many of our patients have more than 1 co-morbidity. We do a lot of abdominal aortic aneurysm (AAA) grafts. The Midwest diet, manufacturing, and farming exposure risks impact certain population groups. Our EP procedures have expanded in the last 5 years and this has increased our EP caseload.

Is there a problem or challenge your lab has faced?

Yes, construction woes and physician shortages (we have only 1 cardiovascular surgeon and 2 interventional cardiologists). We always have staffing holes due to medical reasons or vacations. There is not enough equipment storage space, and we have some older equipment that is or will be needing updating.

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

The Methodist work area was designed to keep cardiac care close together. Two open-heart suites share our immediate work space. Our progressive unit and CVICU are directly beyond our double-entry doors. Our prep/recovery area is 1 floor above us. The Methodist ED is in the same hospital wing, but 2 floors down. We have a “code blue” elevator that accommodates rapid transportation. The Proctor ED is on the same floor as the cath lab, and they do not have open-heart backup on campus. The patient is transferred to the appropriate facility. The Pekin ED and cath lab are on the same floor.

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

There has been a combined effort among physicians, anesthesia, scheduling, and staff schedules to accomplish a workflow that better meets case volume needs. For example, some doctors have blocked scheduling days/times. Staff themselves developed 1 call team between the Methodist and Proctor cath labs. This decreased their call hours, decreased call pay to the hospital, and gave staff satisfaction because of fewer individual call days per month. This also increased productivity and decreased overall labor cost. Some of our open-heart RNs have cross-trained to circulate cases in the cath lab to help with staffing holes.

Our staff has a wide age range, from the mid 20s to the mid 60s. We trialed 10-hour days for staff. The four people who trialed it have stated it is the best thing they have ever done. They like the work-life balance it offers and this schedule has also decreased the overtime budget, since they are on regular time to finish cases that run after hours. Their days off are alternated, so there are four full teams to cover. Some staff trialed going from an 80-hour pay period to a 72- or 64-hour pay period in order to have a day off, decrease burnout, and improve work-life balance. Every staff member who made that change has not gone back to their previous hours. PRN people are utilized for staff openings. Our manager considers the use of PRNs to be a wonderful option, because they are not here all the time, they are always happy, and being content keeps them competent as well. Our manager is very approachable in regard to trying new ideas and new ways of doing things that “have always been done this way”. She believes “happy staff = happy patients”.

What is special about your city or general regional area in comparison to the rest of the United States?

Peoria is a river city in central Illinois. It is set along the Illinois River with a population of 115,000 people. It was settled in 1680 by French explorers. We are home to Caterpillar, Inc., and local colleges, including Bradley University, Illinois Central College, and Midstate Technical Institute. Our city council has developed a warehouse district that has a museum, concerts, restaurants, night entertainment, and a baseball diamond. It is along the waterfront and hosts many festivals year round. There is a St. Jude research facility at another institution. The region has several wineries, craft distilleries, and a wildlife state park. The river is used for recreation and transportation of goods. There is also a replicate paddle boat that offers cruises. The Paradise casino also resides on the river. Peoria is an industrial city surrounded by smaller communities and farmland. It has a lot to offer fishermen and hunters, and has lots of other outside activities. There are a lot of smaller communities to live in if you don’t like the city life. There is a large 4th of July fireworks display sponsored by UnityPoint Health - Methodist. We are only a couple of hours from Chicago, St. Louis, and our state capital, Springfield, all offering even more cultural and sports activities close by. Peoria is also the home of Richard Pryor, Dan Fogelberg, Gary Richrath (REO), Sam Kinison, Jim Thome, Shaun Livingston, and Bob Michel.

A note from author Sally Weiman, RT(R):“I have worked in the cath lab for almost 20 years. Our technology has changed! Smaller catheters, leadless pacemakers, transcatheter aortic valve replacement (TAVR), digital processing — it is fascinating when you think about it. I have loved the victories. It makes you feel like a rock star. I still remember the name of the first patient we lost. My team cried with her family. The cath lab really is a calling, a service to humanity, a gift to our community. I am proud to be a part of it.” 

Kevin Tobin, RN, RCIS, Manager Heart and Vascular Center, can be contacted at kevin.tobin@ahn.org

NSUH uses a mix of registered nurses (RNs) (38), radiologic technologists (RTs) (11) and cardiovascular technologists (CVTs) (10) to staff the department daily. The recovery suite is open 6:00am–9:30pm and the cath labs are open 7:30am–8:00pm, Monday through Friday.  Saturday is an abbreviated schedule, 6:00am–4:00pm.

As a teaching hospital, NSUH has interventional fellows that assist in the preparation of patients, as well as scrub into procedures. In addition, nurse practitioners (NPs) (6) and patient care assistants (PCAs) (4) are staffed in our recovery suite or peri-procedural area. Some of our staff has been employed in the cath lab for over 20 years.

As a Magnet-designated hospital, professional development is supported and recognized. Seventy-three percent of RNs have a bachelor of science in nursing (BSN), 76% are certified, and 50% are on the clinical ladder. A clinical ladder was recently instituted for the cardiac technologists.

What procedures are performed in your cath lab?  

Our lab performs a variety of interesting procedures. Most frequently performed are left heart catheterization, right heart catheterization, percutaneous coronary interventions (PCIs), biopsies, and peripheral angioplasties. Our lab also performs coronary brachytherapy, atrial septal defect (ASD) closures, aortic valvuloplasty, mitral clips, inferior vena cava (IVC) placement/retrievals, and transcatheter aortic valve replacement (TAVR). Intravascular ultrasound (IVUS), optical coherence tomography (OCT), fractional flow reserve (FFR), orbital atherectomy, Rotablator (Boston Scientific), and laser are also available. Over a one-week period, our lab performs approximately 150 left heart catheterizations, 8 TAVRs, 7 peripheral angioplasties, and 60 PCIs.

Can you share more about your experience with TAVR? 

The NSUH TAVR program has grown with tremendous success since 2011. In our first year, 11 procedures were performed in our facility. This year, we are on target to hit 300. Much of the success has been as a result of the collaboration between the cath lab and operating room (OR) staff to turn around the hybrid room (Siemens) more efficiently. Since the program’s inception, we have seen a decrease in the number of permanent pacemakers (PPMs) required post procedure, a decrease in the amount of paravavular leakage, and a decrease in the number of peripheral vascular complications. The procedure has also moved to a more non-invasive process, using conscious sedation and transthoracic echocardiograms (TTE). New developments in valve technology, a decrease in sheath size, and the ability to recapture and reposition valves allow us to provide the best possible outcome for our patients.    

What is your percentage of normal diagnostic caths? 

Our normal cath rate is about 38%. This is based on the New York State Department of Health definition that any single or multiple lesions of <50% stenosis are normal. Heart function and valve disease are reported separately. Approximately one-third of our diagnostic procedures advance to PCI.

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

A large majority of our staff physicians use the radial approach as their primary choice for access. This results in about 60% of the cases being performed via this approach. If a complex procedure is planned (chronic total occlusion [CTO], high-risk PCI with Impella [Abiomed], etc.), multiple access sites are considered, including femoral. 

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

Yes, our vascular interventionalists use pedal artery access when needed.

Who manages your cath lab? 

Dr. Loukas Boutis is the medical director. Dorothy Veron, RN, is the director of patient care services for invasive and non-invasive cardiology, as well as the cardiac short stay unit (CSSU). Rachael Haddock, RN, is the nurse manager of the cath lab, EP lab, and recovery suite. Dawn Zioba, RN, is the assistant nurse manager. Michael Kleinschmidt, LRT, is supervisor of the invasive cardiovascular technologists (RT[R]s and CVTs).
Do you have cross-training? Who scrubs, who circulates and who monitors? 

Nursing is responsible for circulating and technologists are responsible for monitoring. The interventional fellows program has provided the scrub assist for the physicians and it had not been necessary for staff to perform scrub responsibilities during cases until recently. We have now started cross-training the technologists to scrub. Currently, they scrub into peripheral cases and by 2019, they will be trained to scrub cardiac cases.    

Are there licensure laws in your state for fluoroscopy? 

Yes, as per New York State Department of Health regulation, other than the physician, a licensed radiologic technologist is the only staff able to turn on, test, and utilize fluoroscopy. In our lab, the physicians step on the pedal and maneuver the fluoroscopy system during the procedure. Physicians, nurses, and technologists maintain competency to work in an area that uses ionizing radiation. 

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

We practice as low as reasonably achievable (ALARA) for radiation protection. All of our designated lab staff are provided with lead kilts, vests, and thyroid collars. Lead glasses are used by physicians and fellows, and are available to anyone else who chooses to use them.  Some of the physicians have started using lead head gear for additional protection. All personnel in the procedure rooms wear personal dosimetry. Exposure levels are available to staff monthly. Anyone exceeding limits receives re-education from the hospital radiation safety officer. The supervisor of technologists is responsible for the visual and manual inspection of all lead twice a year. Any lead suspected of being in poor condition undergoes a fluoro inspection.  Color-coded discs are attached to lead that can be scanned in order to easily identify lead for inspection and electronic record keeping.

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

One of the newest devices that has been introduced into our lab is extracorporeal membrane oxygenation (ECMO). This is placed in conjunction with cardiothoracic surgery and perfusionists. We are proud to say that our lab was the first in New York State to place a RP Impella. We currently use the 2.5, CP, and RP Impella devices. With our active clinical research program, we utilize numerous novel stents and other devices that are not yet FDA approved.

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

Communication is essential to stay current with additions and changes that are constant in interventional cardiology. It remains a struggle, but monthly meetings, email, briefs, and huddles are used to communicate information. The service line has a quarterly meeting that is attended by quality coordinators, as well as physicians from the six Northwell centers performing PCI.

How is coding and coding education handled in your lab? 

Coding is handled by certified coders in a central business office. When there are questions regarding a particular case, they speak directly with the physician to clarify. In addition to reviewing all procedural and equipment usage reports, our coders provide ongoing coding education to the physicians in order to ensure documentation comprehensively reflects patient acuity and procedures done.

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

Diagnostic and interventional femoral sheaths are pulled primarily by the RNs and NPs. They must perform 10 sheath pulls under direct supervision of a preceptor before being deemed competent to perform sheath removal independently. The quality department tracks and trends outcomes. Adverse bleeding events are discussed for possible re-education opportunities. Large-bore sheaths (>10 French) are pulled by physicians or fellows.

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

Patients are prepped and recovered in a 22-bed peri-procedural area, the recovery suite. An additional 20 beds located in the CSSU, adjacent to the recovery suite, can be used to prep transfer patients and recover patients who are staying overnight.  

All radial sheaths are pulled immediately post procedure in the lab by the performing physician or fellow, and hemostasis is obtained via a radial band. The radial band is removed after 1-2 hours while in the recovery suite or CSSU. Occasionally, patients are recovered from sedation and sent back to their in-patient room with sheaths or a radial band. In this situation, the NP will remove the sheath/band while the patient is on the telemetry unit. The same competency process is followed before a clinician may remove a radial band. Only about 7% of cases receive a vascular closure device to achieve hemostasis.

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

We have a procurement specialist designated to do the ordering and stocking for the supply room. Supplies are ordered based on a usage report that is run daily from Mac-Lab (DMS). A visual inventory is conducted weekly to ensure par levels are maintained. A system procurement department supports the department with new product acquisition.

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

In 2015, Northwell Health integrated two nearby high-volume, high-quality cath labs into one center of excellence. This was the beginning of the Heart Hospital at NSUH, formed in 2017, and a heart transplant program.

Is your lab involved in clinical research? 

NSUH maintains a very active role in the clinical research arena and is usually one of the top enrolling sites. Some of the interventional cardiology trials include: 

• COBRA REDUCE, a blind clinical trial to assess superiority of dual antiplatelet therapy (DAPT) over drug-eluting stents (DES) plus 3 or 6 months of DAPT; 
• Onyx, an open-label, multicenter trial to assess the safety and efficacy of the Resolute Onyx  stent for the treatment of lesions in coronary arteries amenable to treatment with a Resolute Onyx 4.5 mm – 5.0 mm stent;
• SAFE STEMI, a single-blind clinical trial examining the effectiveness of zotarolimus-eluting stents for radial PCI in STEMI and the benefits of iFR-guided complete revascularization vs infarct-only revascularization. 
•  The peripheral program at NSUH is the third-largest randomizer in the country for the ROX Hypertension Study, an interventional vascular therapy for uncontrolled hypertension.  
• The CONFIDENCE trial uses a dual-layer nitinol micromesh carotid artery stent (Roadsaver, Terumo) for sustained embolic protection.      

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 overall time is 59 minutes. We also track the times when the cath lab is open (51 minutes) and closed (67 minutes). Over the past 5 years, the D2B workgroup has made significant improvement in the overall time (72 to 59 minutes and the cath lab closed time (75 to 67 minutes). We have a monthly, interdisciplinary D2B workgroup meeting that includes leadership, physicians, and nurses from the cath lab, emergency department (ED), cardiac care unit (CCU), quality, and data registry. Guests are invited as we address ideas to improve times. We have addressed several data points: door-to-electrocardiogram (EKG), on-call team activation, and facilitating transport of the patient to cath lab anticipating team arrival. The ED re-educated staff on signs/symptoms that require immediate EKG, created “Code EKG” in the ED to prioritize the need for an EKG, and specified an ED attending to expedite the EKG read and ST-elevation myocardial infarction (STEMI) activation. The process of activating the on-call team via cell phones changed to a universal page system. The cardiology fellow and off-shift assistant nurse manager for cardiology coordinate the transport of the patient to the cath lab, no longer waiting for the team to arrive in the ED to initiate transport. If the cath lab is open, the cardiology fellow and ED staff bring the patient directly to the prepared procedure room. Our community emergency medical services (EMS) is largely supported by volunteer fire/rescue departments. Ambulances are not universally equipped with EKG transmission ability or all staffed with advanced medical technicians (AMTs).

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

EMS transports STEMI patients from referring facilities directly to the lab. In-house STEMI patients are transported by the cardiology fellow and a member of the rapid response team. 

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

The members of the on-call team grew to include 2 RNs and 2 technologists as patient acuity, activations, and technology needs increased. If the team is involved with a procedure when a second STEMI is activated, one technologist will set up a second room. In this situation, the on-call physician will use medical judgment to decide the best plan of care for the patient. There is a second on-call physician available, but this option has rarely been used. 

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

Evidence-based practice is used to guide use of products and medications. As a large healthcare system, product costs are negotiated for all 6 cath labs to contain costs. The use of bivalirudin has significantly decreased over the past few years, specifically during radial PCI. Additionally, the use of a more expensive contrast agent is limited to specific cases, generally peripheral.

What quality control measures are practiced in your cath lab?

We provide individual patient data to the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) and New York State Department of Health databases. Quality outcomes are monitored and reported monthly at our quality meeting. In addition to D2B times, acute kidney injury rates, bleeding incidents, mortality and morbidities are discussed.

How do you determine contrast dose delivered to the patient during an angiographic procedure? 

Our physicians use a power injector during the procedure and the amount of contrast can be read on the injector. The contrast dose is reported to the technologist at the end of the case for documentation. Target maximum volume of contrast is noted at the beginning of the case using 3x the patient’s creatinine clearance (CrCl). We are currently trialing the DyeVert system (Osprey Medical) with chronic kidney disease patients to evaluate patient outcome and cost benefits.

Are you tracking the incidence of contrast-induced acute kidney injury in patients? 

Our NCDR data is tracked by the registry nurses and the incidence of acute kidney injury (AKI) is discussed at the monthly quality meeting. Recently, a decision was made to standardize hydration practices for patients.

How are you recording fluoroscopy times/dosages? 

After a procedure is completed, a form is placed in the patient’s chart containing the total amount of fluoroscopy time, as well as the cumulative dose area product (DAP). The DAP has been shown to correlate well with the total energy imparted to the patient, which is related to the effective dose and overall cancer risk. Any dose over 5,000 mGy is documented and brought to the attention of the physician and nurse. The physician discusses it with the patient and the nurse educates the patient.

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

Any patient receiving extended fluoro (>5,000 mGy) receives education, verbal and written, regarding signs and symptoms of exposure. The patient receives a follow-up phone call from the cath lab assistant nurse manager after 3 weeks to evaluate any adverse reaction.  

Who documents medication administration during the case?

Electronic documentation is used by the monitoring technologist to document all aspects of the case: equipment, medication, and procedures. The physician verbally orders the medication, the nurse repeats back and administers the medication, and the technologist documents it. At the end of the procedure, the physician, nurse, and technologist review the documentation for accuracy and all sign the printed report.

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

Our physicians currently use GE Centricity (GE Healthcare) as their reporting tool.

How are you populating outside registry data records? 

The service line supports a team of nurses trained to extract data specifically for registry reporting. The two registries (ACC-NCDR and New York State Department of Health) look at data differently. The nurses attend annual conferences to stay current on reporting requirements.  The nurses are physically located off site, and review charts electronically and complete registry forms by hand.

How does your cath lab compete for patients? 

NSUH is part of the Northwell Health System and collaboration agreements to enhance clinical services and operation efficiencies are addressed through corporate negotiations.   

How are new employees oriented and trained at your facility? 

Northwell Health begins the onboarding process with a system orientation called “Beginnings”. The system president and CEO attends each orientation personally to introduce himself, as well as the mission and vision of the organization. The next day, new hires attend site orientation at their respective hospital. The following day, they begin orientation on their unit. Nursing education utilizes education pathways to ensure basic competencies are met.

What continuing education opportunities are provided to staff members?

Professional growth is encouraged. Nurses can take advantage of an on-site MSN program in leadership or education. There is also a NP program that the health system conducts in conjunction with a local university. An MBA or MHA is available through the same university.  All degree programs are either reduced rate, free, or supported with some tuition reimbursement. Certification programs are provided on site and those who successfully complete the exam are reimbursed. Our nurses and technologists are able to receive an annual stipend for program registration and continuing education time each year. Four times a year, a cath lab education day is organized by the nurse educator on a Saturday. Lectures are conducted by vendors, physicians, and staff. In addition, there are numerous continuing education programs available through nursing education on a variety of topics throughout the year. We often receive complimentary attendance at local conferences at which our physicians are presenting. Once a year, the physicians provide the opportunity for three staff to attend a national conference, usually the ACC Scientific Sessions or the Transcatheter Cardiovascular Therapeutics (TCT) meeting.

How do you handle vendor visits to your lab? 

Vendors are limited to scheduled visits each month, made with our procurement representative. NSUH utilizes a third-party credentialing agency, RepTrax, to ensure representatives meet health screening, competency, and HIPAA requirements set by the health system. Vendors enter the building through staff entrance, where they sign in via a vending machine that issues a daily pass and paper scrubs necessary for their visit. The pass is worn across the chest and visually expires after 8 hours of activation.    

How is staff competency evaluated? 

Staff competency is evaluated annually and topics are chosen on the basis of risk and volume.  Validation methods can be direct or indirect observation, simulation, or testing. The invasive cardiology staff educator (.6 FTE) works with several departments to develop ongoing competency assessment tools. Nursing education supports the cath lab for critical care assessment skills (EKG, intra-aortic balloon pump [IABP], Impella, hemodynamics, etc.), and peri-op services supports initial competency training on aseptic technique, phase I/II recovery, and malignant hyperthermia. Competency skills specific to the cath lab are developed with the support of nursing education (sheath removal, radial band removal, preparation and use of manifold, etc.).

Does your lab have a clinical ladder? 

There is a clinical ladder for nurses, technologists and PCAs. Each has a similar foundation of elements: service excellence, quality, leadership, research, and education. Each applicant selects categories with associated point values to achieve their desired level (1, 2, 3). Portfolios are evaluated by a committee of peers, educators, and leadership for validation. Clinical ladder recognition must be submitted each year for renewal. There is a financial reward associated with the clinical ladder level achieved.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

To work as a technologist in our lab, you must obtain either RCIS or CI credentials within the first 18 months of hire. There is no incentive bonus or raise upon passing the exam, as it is required. Those in the department prior to 2014 are not required to do so. Nurses are encouraged, but not required, to achieve national certification through a nursing leadership organization recognized by Magnet. They do receive an annual certification stipend. Technologists and nurses can use certification to receive clinical ladder points in the element of education.  

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

Since integration and the increased volume, the physical space of the recovery suite has presented difficulties with throughput. The CSSU was opened at the same time and has helped with movement through the department, but does not solve the bottleneck completely. By the end of 2018, we will see 5 beds added to CSSU to help facilitate throughput.

What do you like about the physical space in which you work? 

Our newest room has a sleek look, including ambient lighting. Last year, with our input, our staff lounge was cosmetically remodeled. The largest refrigerator was installed to accommodate the staff’s biggest wish.

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

Two RNs and two technologists are scheduled for call. This model was requested by staff to recognize the increased acuity and technology demands of the patients. If it has been a difficult call schedule, they are granted sleep time.

How does your lab schedule team members for call? 

Call time is distributed equally to staff members. They are then permitted to ‘give it away’, down to a minimum number of hours, based on their full-time employment status. Staff with more than 15 years of service in this cath lab are not required to take call.

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

The call team is expected to arrive within 30 minutes of activation. The use of the universal page has significantly improved arrival times.  

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

Our lab uses part-time, full-time, and per diem staff. The earliest shift starts at 6:00 am and the latest shift begins at 11:00 am. Our technologists mainly work 10-hour shifts, and nurses vary from 8-, 10-, and 12-hour shifts. Leadership huddles the day before to determine if the staffing schedule requires adjustment. When there are lower volume days or we finish early, paid time off is offered. In preparation of inclement weather, staffing is always reviewed to make sure we meet patient needs as well as the safety of the staff.

Can you share any staff perks? 

NSUH celebrates all staff with many recognition programs and celebration days: nurses’ week, radiology week; certified nurse day, the DAISY Award program, an employee BBQ, a holiday celebration for employee children, etc. There is an employee recognition program where anyone can nominate any employee with recognition points. Once approved by their leader, those recognized can use points to purchase gift cards, entertainment, or merchandise. There is free parking for staff.  When on call, staff can park in reserved parking closer to the hospital.

Has your lab recently undergone a national accrediting agency inspection? 

In March 2018, NSUH successfully completed a Magnet Survey. The cath lab played an important role, as the success of the D2B workgroup was featured as a successful interdisciplinary initiative.

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

With the growing number of heart failure patients, our hospital has increased resources to serve this population. A new Cardiomyopathy Clinic was instituted about 3 years ago and programs have sprouted from this initiative. The use of cardiopulmonary exercise testing (CPET), CardioMEMS (Abbott) to track high-risk patients, left ventricular assist devices (LVADs) as destination or bridge therapy, ECMO, and the heart transplant program all developed out of the clinical needs of this population. As a result of the heart transplant program, with 10 transplants completed in the past 6 months, we have seen a tremendous increase in cardiac biopsies.

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

Our cath lab is never lacking for something exciting and new to learn. The latest and most advanced treatments, including MitraClip (Abbott Vascular), Watchman (Boston Scientific), extracorporeal membrane oxygenation (ECMO), left ventricular assist devices (LVAD), and heart transplants, have all been added over the last 4 years. We are the only hospital on Long Island performing heart transplant and coronary brachytherapy. Within the past 2 months, we introduced the DyeVert Plus System to help in the reduction of AKI rates.

Is there a problem or challenge your lab has faced? 

The staff are encouraged to participate in the Collaborative Care Council for Invasive Cardiology. This is a self-governance committee run by two staff members. Currently, the co-chairs are two cath lab nurses. Leadership, including physician and nursing, attend the meetings to listen and provide answers or address concerns requiring follow-up. Cath lab staff specifically addressed the number of staff on call and requested additional nursing help. The request was escalated to the chief nursing officer, who approved the request.

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”?

NSUH is located on the north shore of Long Island. The communities it serves are local; however, with the addition of niche procedures and cardiologists from other parts of the country, we are seeing more patients who fly in from other states.

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?

• PCI Task Force (quarterly system meeting inviting physicians, department leadership, quality nurses, data extractors, service line leadership from all 6 cath labs).
• Communicate with quality department to set thresholds for outcome reporting.
• Quarterly meetings with department chair to review quality metrics negatively impacting Northshore’s performance.
• Complications negatively affecting outcomes metrics are reported monthly for peer review at cath conference.
• Weekly meetings with RNs performing data abstraction, regarding understanding of and compliance  with NCDR guidelines.
• Communication with in-service providers regarding documentation requirements. 

The authors can be contacted via Dorothy L. Veron, MSN, RN, NEA-BC, Director, Patient Care Services, Cardiology, at dveron@northwell.edu.

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

Our cath labs are shared between interventional cardiology and electrophysiology (EP). Our department has a 20-bay pre/post unit, three cath lab procedure rooms, and utilizes a hybrid OR room as necessary. One room is a dedicated cardiac suite, one room can be used for coronary or specials, and our third room (shared with EP) is a single-plane room that can also be used for structural heart procedures. We employ 15 staff members, including four registered nurses (RNs), three radiologic technologists (RTs), six registered cardiovascular invasive specialists (RCISs), 1 registered cardiac electrophysiology specialist (RCES), and 1 lab coordinator. Staff experience ranges from a modest 20-plus years to new orientees that just began their cath lab adventure a month ago. The doors to the NH PMC Cardiac Cath Lab first opened in 1985. We have been offering our services for over 33 years. 

What procedures are performed in your cath lab?  

The NH PMC Cath Lab is a combination cardiac and special procedures unit. Our coronary work involves diagnostic and interventional procedures, including chronic total occlusions (CTOs). We also perform peripheral vascular procedures, including upper and lower extremity angiograms and interventions, abdominal angiograms and stents, patent foramen ovale (PFO) closures, use of the EkoSonic Endovascular System (BTG), chronic limb ischemic (CLI) procedures, Watchman (Boston Scientific) procedures, laser therapy, transcatheter aortic valve replacement (TAVR), and MitraClip (Abbott Vascular) transcatheter mitral valve repair (TMVR).

Can you share your experience with structural heart procedures?

The NH PMC Cath Lab has a hybrid OR suite with an Artis zee system (Siemens Healthineers), and is staffed with a combination of cath lab and OR staff members. We performed our first TAVR in November 2011 and have since performed over 350 cases. The program was initially birthed and nurtured by Dr. Richard Jacoby, Jeff Kittle, RN, BSN, RCIS (Cardiac Cath Lab Manager), Barry Horsey, RCIS, and now-retired interventional cardiologist Dr. Akinyele Aluko, all of whom underwent training at the Cleveland Clinic. After Dr. Aluko’s retirement from our organization in 2016, Dr. Oluseun Olukayode Alli became Novant Health’s structural heart specialist and director.

The NH PMC Cath Lab has a robust MitraClip program in conjunction with structural procedures such as atrial septal defect (ASD) closures and PFO closures, along with thriving Watchman procedure volumes. We are also able to do less common procedures like perivalvular leak closures.

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

All nine of our interventional cardiologists adopted radial access about five years ago. Transradial access can be utilized for diagnostic, interventional, and acute (ST-elevation myocardial infarction [STEMI]) cases, unless a limiting factor is present. 

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

Yes, pedal access is obtained by four of our interventional cardiologists and vascular surgeons, when necessary. NH PMC Cath Lab undertakes a high volume of complex peripheral cases.

Who manages your cath lab? 

Genteal Pelzer, MHA, NE-BC, is the director of invasive and non-invasive cardiology. Jeff Kittle, RN, BSN, RCIS, is the manager of invasive and non-invasive cardiology, and Ruben Filimonczuk, RCES, AS-PMD, CCEMT-P, is supervisor of invasive cardiology (cardiac cath and EP labs).

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

Yes. RNs can be cross-trained to the scrub position, but primarily circulate, with our technologists monitoring and scrubbing. Currently, only nurses have the capacity to dispense and administer medications.

Are there licensure laws in your state for fluoroscopy?

All technologists/nurses run the fluoroscopic equipment under the direction of the physician. North Carolina has a radiation control agency responsible for regulating radiation-producing equipment and materials used for medical, industrial, and energy purposes. The agency may or may not be responsible for regulating medical imaging and radiation therapy professionals. The NH radiation safety officer is responsible for the quality management program in radiation protection and for maintaining all state, federal and accreditation standards, regulations, and laws.

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

The physicians primarily operate the x-ray equipment while technologists tend to inject contrast, but not always. Staff who moves to NH from other facilities with “panning” experience are a big asset in assisting physicians. At NH PMC, where a high volume of complex cases are performed, collaborative efforts and experiences are invaluable to ensure a successful outcome for all our patients. Our cath lab values a team approach. 

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

The staff is provided with lead aprons and lead glasses. All staff is required to wear dosimetry badges that are analyzed quarterly. Protection is also provided by means of lead shielding, Radpads (Worldwide Innovations & Technologies, Inc.), and education on radiation safety and internal radiation protection initiatives.

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

The cath lab works with a large variety of technology and equipment, including Jetstream (Boston Scientific), AngioJet (Boston Scientific), TurboHawk (Medtronic), intra-cardiac echocardiography (ICE), intra-aortic balloon pumps, Impella – CP & RP (Abiomed), Ekos (BTG), Diamondback 360 (coronary and peripheral) (CSI), ACIST CVi contrast injection system, laser therapy, Rotablator (Boston Scientific), intravascular ultrasound (IVUS) with the multi-modality platform for fractional flow reserve and diastolic fractional flow reserve (dFFR) (Philips Volcano), Watchman procedures, MitraClip procedures, PFO closure procedures, TAVR and TMVR procedures, TandemHeart procedures (LivaNova), CardioMEMS (St. Jude Medical) insertion, and various closure devices such as Angio-Seal (Terumo), Mynx (Cardinal Health), Perclose (Abbott Vascular), and the TR Band (Terumo). This year, we introduced the HD-IVUS in conjunction with the Comet FFR wire (Boston Scientific) and Wolverine cutting balloon (Boston Scientific).    

How does your lab communicate information to staff and physicians?

We have weekly huddles, monthly staff meetings, internal email, educational in-services, and cardiac cath conferences for staff and physicians.

How is coding and coding education handled in your lab? 

All coding is handled through our corporate coding department. A designated cath lab charge specialist mediates all information between staff, physicians, and the hospital’s chargemaster department, which in turn handles all coding for the cardiac cath lab department. 

Who pulls the sheaths post procedure? 

After completing required NH PMC cardiac cath lab competencies, registered technologists and nurses are qualified to apply manual pressure and pull sheaths. Sheath removal may, at times, need to be performed by nursing staff from adjacent units. The nursing staff from these units are trained under the same competencies as the cardiac cath lab staff. 

Patients who have had their radial artery accessed are managed with radial bands (TR Band) applied by the scrub individual prior to patient leaving the cath lab. Perclose, Angio-Seal, and Mynx are utilized for those patients that have undergone a femoral approach and are deployed by the interventional cardiologist.

How is inventory managed at your cath lab? 

A designated operating room coordinator (ORC) for supply chain is responsible for ordering and maintaining par levels on a daily basis. Inventory for the cath lab is done annually in December and the ORC is responsible for ensuring their area is in order. Corporate finance will audit the manual count of the entire department, allowing minimal counting errors. Inventory and storage remain dynamic challenges.

Is your lab involved in clinical research? 

NH PMC Heart & Vascular Institute is a leader in national and international cardiovascular research. Our exceptional doctors and coordinators have allowed us to become a top-performing cardiovascular investigative site and participate in many pivotal trials. Currently, we are participating in the following studies:

• Xience 90 – Short Dual Antiplatelet Therapy (DAPT) Study
• LEADERS-FREE: polymer-free drug-eluting stent study, short DAPT
• COPPER-A: occlusion perfusion catheter (OPC) for optimal delivery of paclitaxel for the prevention of endovascular restenosis ­— above and below the knee
• We are a future trial site for TAVR and TMVR research studies.

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

Median door-to-device timing is 51 minutes for non-transfer patients (national benchmark is 60 minutes) and 79 minutes for transfer-in patients (national benchmark 106 minutes) for PMC as of Q1 2018. (Source: American College of Cardiology’s National Cardiovascular Data Registry [ACC-NCDR] CathPCI registry).

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

PMC participates in AHA Mission: Lifeline, and the ACC-NCDR Chest Pain-Myocardial Infarction (MI) national registry (formerly ACTION) award performance programs. PMC has received the highest award levels for both these programs since their recognition programs began: 

• Mission:Lifeline STEMI receiving facility – Gold Plus Level;
• ACTION registry MI performance – Platinum Level.

Who transports the STEMI patient to the cath lab?

Patient transport is facilitated by emergency medical services (EMS) directly to the cath lab. If the patient was first brought to the emergency department (ED), the ED nurse transports to the cath lab. If the patient is in-house, team members from all units may work together to assist in transporting 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?

The STEMI on-call physician, ED physician, and the cath lab team triage patients if a second room, team, and physician are not available. If necessary, the patient on the table will be moved and held in the recovery area temporarily until their case can be completed. Our team leaders have also reached out to other members NOT on call to ask for volunteers to help mend the situation.

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

Our designated ORC in the cath lab supply area is dedicated and meticulous. The ORC has several initiatives that have been instituted to help reduce cost:  

1.    Any balloon or stent that does not cross the lesion gets full replacement from the vendor FREE;

2.    Anything that can be consigned is consigned;

3.    Vendors check their stock to ensure products don’t expire;

4.    Cath lab team also helps to check expiration dates;

5.    ORC keeps the physicians informed of upcoming expired products so these products can be used or removed from the par level;

6.    ORC checks balloons and stents every day to ensure she doesn’t need to order (because of the “no-cross” free exchange, she may have balloons/stents coming in);

7.    Management consistently seeks out cost-saving initiatives.    

What quality control measures are practiced in your cath lab?

There are many elements to an effective quality control plan, including setting a quality control schedule, educating staff on the value of the program, training staff to perform tasks, and maintaining records for verification. Quality control allows optimal delivery of patient care, and promotes stewardship of the limited resources available in the modern healthcare environment. An effective quality control program establishes uniform standards of excellence, and enables the staff to understand the value of the processes and practices that are involved to create and maintain it. At Novant Health Presbyterian Medical Center, each day begins with reviewing and updating the schedule, opening the labs, making sure they are properly supplied, and performing comprehensive quality control. Quality control is a foundational concept that we adhere to in order to promote patient and staff safety. We verify that the lab’s equipment works properly, and that we are compliant with industry- and regulatory-based standards of excellence. The equipment that needs to be “QC’d” includes the Avoximeter and Hemochron (Accriva Diagnostics), defibrillator, emergency equipment, fluoroscopic and imaging systems, personal protection equipment, climate control, medical gasses, personal lead, and any procedural equipment necessary to perform patient care.

How do you determine contrast dose delivered to the patient during an angiographic procedure?

In 1976, the Cockcroft Gault (CG) formula was developed to predict creatinine clearance (CrCl) based upon the serum creatinine (SCr) alone versus formal creatinine clearance, which requires additional measurement of urine creatinine in a timed urine collection. Since then, the CG formula has become a common method to estimate renal function, as it is widely available, relatively quick, and inexpensive. It certainly provides a quick estimate of creatinine clearance that may be helpful in determining the appropriate dosages of nephrotoxic drugs (iodinated contrast) or drugs that reply on renal excretion. Therefore, we determine the amount of contrast delivered to our patients based on the CG formula.

Are you tracking the incidence of contrast-induced acute kidney injury in patients? 

Yes, we track acute kidney injury (AKI) events, based on the NCDR definition. Our process includes:

• If patients are identified during scheduling (office labs or if in-house, unit staff) as at-risk of an AKI event pre percutaneous coronary intervention (PCI), the physician decides on cancellation or how to better prepare patient for the procedure.
• If an AKI event occurs, an established subcommittee drills down each event and determines if anything could have been done differently (contrast amount, pre-procedure hydration, etc.) The committee attempts to determine if the event is related to anything in the process or structure of care that may have impacted the outcome.
• Every AKI event is identified as soon as possible, and feedback via email is given directly to the cardiologist with the patient history/factors and lab results.

How are you recording fluoroscopy times/dosages? 

The American College of Radiology-Society of Interventional Radiology (ACR–SIR) Practice Guideline for the Reporting and Archiving of Interventional Radiology Procedures recommends that radiation dose data be recorded in the final report for all fluoroscopically-guided procedures and that, if possible, all radiation dose data recorded by the fluoroscopy unit should be transferred and archived with the images from the procedure. We currently use our Mac-Lab system (GE Healthcare) and Epic to document the fluoroscopy time (unit: minutes) used during each procedure and the amount of radiation dose absorbed (cumulative air kerma [CAK], unit: milligray [mGy]).

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

A record of the investigation(s) are kept for a minimum of two years. There are adequate guidelines provided to the users of fluoroscopic x-ray equipment that satisfies the regulatory standards under clinical use conditions. The radiation safety department reviews exposures on a regular basis that are in accordance with the ALARA (As Low As Reasonably Achievable) policy and procedure. If an incident is reported, then an incident report is filed. The radiation safety officer reviews the case and a follow-up is completed by the radiation safety officer according to hospital policy. However, with radiation exposures greater than 5Gy, it is the responsibility of the NH radiation safety officer to notify the patient.

Who documents medication administration during the case?

Medications are documented in both the patient’s electronic medical record (Epic) by the administering nurse and in the Mac-Lab report, which is done by all staff members, but is verified by the nurse.

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

Physicians perform their dictation using structured reporting tools like Centricity (GE Healthcare) or PowerScribe 360 (Nuance).

In which registries do you participate?

PMC participates in several ACC-NCDR registries:

1.    CathPCI;

2.    Chest Pain-MI (previously ACTION);

3.    Implantable Cardioverter Defibrillator (ICD);

4.    Left Atrial Appendage Occlusion (LAAO);

5.    TAVR (Society of Thoracic Surgeons [STS]/ACC Transcatheter Valve Therapy [TVT] Registry); 

6.    Under consideration for participation: Vascular (Peripheral Vascular Intervention [PVI]).

PMC out-of-hospital cardiac arrest data is entered into the Cardiac Arrest Registry to Enhance Survival (CARES) national registry. We also participate in American Heart Association – Get With The Guidelines (GWTG) Coronary Artery Disease (CAD) Registry; for 2018, we are exporting files from ACC-NCDR Chest Pain-MI registry and uploading into GWTG-CAD for our Mission:Lifeline MI initiative.

How are you populating registry data records?

Currently, we retrieve this information and enter it into our databases manually. Clinical improvement analysts abstract, enter, validate, and analyze all registry data. There are future plans to automate and populate fields wherever possible. Depending on the registry, we either enter into a third-party vendor or use direct entry into the national registry database. The source of all data entered is the patient’s chart. We do utilize the procedure event logs and dictation to complete cath lab-based fields. 

How does your cath lab compete for patients? 

Novant Health is a four-state integrated network of physician clinics, outpatient facilities, and hospitals that delivers a seamless and convenient healthcare experience to our communities. The Novant Health network consists of more than 1,500 physicians and over 28,000 employees that provide care at over 580 locations, including 14 medical centers and hundreds of outpatient facilities and physician clinics. Headquartered in Winston-Salem, North Carolina, Novant Health serves more than 4 million patients annually. By bringing together world-class technology and clinicians to provide quality care, we are committed to creating a healthcare experience that is simpler, more convenient, and more affordable, so patients can focus on getting better and staying healthy. Novant Health, in conjunction with Carolinas Medical Center (now Atrium) and the Mecklenburg County Health Department, decided to collaborate and focus on the public health priority areas within Mecklenburg County. This collaboration was driven by innovative organizational leadership, and the comparison of social determinant data to patient data and outcomes. They also identified physician leadership in organizations working to improve community health.

How are new employees oriented and trained at your facility?

All employees initially undergo an entire week of our organization’s corporate orientation program prior to going to their designated units. Once the new employees arrive at the cardiac cath lab, the new member is paired with an elected staff member who is a certified proctor. They are then mentored for 90 days or until the proctor deems the new recruit ready to function independently in the unit.

Senior cath lab nurse Emily Luna has helped direct the program and streamline the training for new cath lab recruits. A portion of this training takes place in various cardiovascular units such as the coronary care unit (CCU), intensive care unit (ICU), EP lab, etc., given the fact that becoming a cardiac cath lab nurse specialist entails rigorous post-licensure training and clinical experience. For those nurse candidates who lack clinical experience, our program allows the new nurse recruit to obtain the needed background. Rose Servido serves as our primary liaison and proctor for training our cardiovascular and radiologic technologist students from Central Piedmont Community College during their clinical rotations.

What continuing education opportunities are provided to staff members?

Education is an integral part of what we do, given the numerous devices, evolving technology, new staff, and new procedures introduced into the lab, and continues to be an ongoing process (as it should). Increased education is certainly a tool, one that leads to increased skill levels, which in turn also increases physician confidence in staff. We at NH PMC Cardiac Cath Lab work closely with various company representatives who graciously provide in-services and educational opportunities for all staff members to also obtain CEUs. Once per quarter, our physicians also provide an educational opportunity by taking our staff to dinner and simultaneously providing an in-service on various topics or procedures performed within our lab. 

How do you handle vendor visits to your lab? 

Vendors must schedule visits with the inventory coordinator (the ORC in the cardiac cath lab) who oversees this task. The hospital has a check-in system (Vendormate) for the vendor each time they visit, which logs them in and produces a visitor badge for that day. The number of vendors each day is controlled in order to avoid disrupting the care provided to our patients.

How is staff competency evaluated? 

New initiatives are currently being put into action for a bi-annual skills fair conducted yearly that evaluates each individual’s competency for various skills, device usage, and applications. The skills fair is a week-long process with various representatives reviewing and refreshing team members on the application of devices with hands-on setup and preparation. Each team member carries a packet containing check-off sheets for each station, and will go through each station completing the hands-on review and being signed off. Examples include intra-aortic balloon pumps (IABPs), sheath pulling, AngioJet, IVUS, etc. 

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

All cardiovascular technologists working in the cath or EP lab are required to have the RCIS or RCES prior to becoming an employee at Novant Health. Radiologic technologists are required to obtain the Cardiovascular Interventional Radiography (CV) credential within 2 years of employment. Nursing staff has the option of whether to obtain the RCIS/RCES credential(s).

What do you like about the physical space in which you work? 

All cath lab rooms are located to one side of a long hallway. Coincidently, Unit Coordinator Wendy Ballentine’s station is located opposite of the cardiac cath lab rooms in order to maintain a visual on progress of all procedures, ensuring the seamless workflow of the lab. The manager’s office is on the far end of the hallway and the supervisor’s office is on other end of the hallway. All patients coming for procedures enter and exit through only one set of secured doors, admissible by employees with badge access.   

How does your lab schedule team members for call?

Team members self-schedule themselves for call. Our scheduler (Rose Servidio) determines how many days each team member needs to take and each individual then signs up. The order in which people sign up rotates each cycle so everyone gets a chance to eventually pick first. Once team members pick call, the scheduler assigns late days, being mindful of the days each individual picked for call and tries not to assign a late day on a post call day. The schedule also ensures that people are not assigned call or late on the days which the team members are scheduled off. 

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

Call team credential mix is one nurse with 2 technologists.

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

The team has a 30-minute response time. In light of the Charlotte traffic due to the large influx of people that have relocated to this city, our current door-to-balloon time performance testifies to our team’s commitment.

Do staff members have perks that you might like to share? 

Recruiting and retaining top talent has a lot to do with the benefits and incentives offered by the company/organization. Today, it can be difficult to discern what it is that really attracts employees, and then what continues to motivate them once they have been hired. At NH PMC Cardiac Cath Lab, we recognize hard work and efforts put forth by our incredible team. Some perks we have implemented are:

1.    Education and development opportunities – paid conferences, symposiums and seminars;

2.    Yearly performance bonus;

3.    Proctor pay – additional pay for experienced proctors overseeing the training of new employees;

4.    Self-scheduling for call rotation;

5.    Extended lunches – a relaxed lunch can go a long way in order to face the rest of the day;

6.    Free parking – this can be a “biggie” – many large facilities/ organizations charge their own people to park…yikes!

Has your lab recently undergone a national accrediting agency inspection? 

NH PMC Cardiac Cath Lab has an ongoing system to maintain our proficiency for unannounced Joint Commission inspections. Our hospital last went through Joint Commission accreditation in 2017. Advice that our cath lab has to offer: 

1)    Avoid errors committed in the TIME-OUT procedure:

a.    Time-outs occurring before all staff members are ready or before prep and drape occurs;

b.    Performing time-outs without full participation of all the staff involved;

c.    Lack of senior leadership engagement in the time-out;

d.    Staff feeling passive or inattentive to time-out process;

e.    Inconsistent organizational focus on patient safety;

f.    Distractions or rushed time-outs.

^*Needless to say that the Joint Commission underscores the crucial need for effective preoperative communication and planning for surgical teams.

2)    Focus on narcotics control (waste/count procedures and documentation, and how long it is kept and where).

3)    Radiation monitoring and annual lead apron checks (ensure documentation).

4)    Maintain staff educational records, and proof of licensure and certifications.

5)    Initial and ongoing competency checks (documentation within the department and in human resources).

6)    Be knowledgeable of the conscious sedation policy and training.

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

Peripheral work and the growth of structural heart procedures has become a focus and means of volume growth for us. The PFO program commenced 16 years ago under the direction of Dr. Akinyele O. Aluko and we have performed 528 PFO cases to date. 

We started our MitraClip program in 2014 and performed our first case in December 2014. To date, we have performed about 108 cases. 

Our Watchman program started in 2016 with the first case done in November 2016. To date, we have completed 49 cases. Currently, we have one physician who is trained and performing these cases, Dr. Oluseun Alli.

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

Our cardiac cath lab nursing staff comes from a variety of backgrounds: emergency care, intensive care, cardiac telemetry, step down, and med surg. Our technologists come from just as diverse a background, from 20-plus years of experience in the cath lab to new graduates from our local cardiovascular program. This brings a robust and dynamic view of patient care and treatment.  

We are also a primary training site for Central Piedmont Community College (CPCC) students in the Cardiovascular and Radiology Technology program here in Charlotte, North Carolina. The CPCC students are proctored by our senior technologists and nurses, allowing them to gain hands-on experience in order to enhance their learning and education. 

Is there a problem or challenge your lab has faced? 

In today’s competitive market for cardiovascular services, job opportunities within the specialty have increased as a result of nationwide program growth. Staff retention should always be considered of major importance to hospital and service line leaders. Industry estimates reveal that the increased expenses for recruitment and relocation of new staff, overtime rates to ensure adequate coverage during the hiring process, the costs of temporary/agency staff, as well as the costs associated with training the new team members can easily exceed $25,000 for every new hire. While these expenses can be quantified, it is much more difficult to assess the impact of vacancy and turnover on the organization as a whole in terms of the morale and job satisfaction of the existing staff. Furthermore, unhappy employees are typically under-productive, which can translate into operational inefficiencies, higher care delivery costs, and decreased patient satisfaction scores. NH PMC Cardiac Cath Lab designed a retention plan to help with this issue, starting with our leadership:

1.    Leaders need to have a high investment in “retention”;

2.    Using core members, build a council to help develop retention strategies; this in itself “tightens” the bonds with stable members;

3.    Choose the right person for the job – avoid the “turnstile to turnover”;

4.    Treat your employees like extended family – be kind to one another;

5.    Get your employees to understand the vision, mission and values of the organization. Frankly, most formal mission statements fail to embody adequate amperage to grab the attention of a workforce. At Novant Health, we go beyond the vison, mission and values of the organization and include “Our People” and “Our Promise”. 

    Our People Credo states, 

    “We are an inclusive team of purpose-driven people inspired and united by our passion to care for each other, our patients, and our communities”. This is not a slogan. Our People Credo articulates a unifying vision that aligns the organization’s engagement initiatives, patient-centered goals, and overall mission.

     Our Promise says, 

    “We are making your healthcare experience remarkable. We will bring you world-class clinicians, care and technology – when and where you need them. We are reinventing the healthcare experience to be simpler, more convenient and more affordable, so that you can focus on getting better and staying healthy”.

    Novant Health is the transformation in healthcare! How can you not want to work for an organization with such a deep commitment to their patients, employees and communities?

6.    Focus on the end result that the organization produces, not just the tasks individuals perform. The member of the housekeeping staff who contributes to a remarkable guest experience is more engaged than the one who just cleans hotel rooms.

7.    As a leader…stand behind the vision, mission and values – practice what you preach.

8.    Recognition, in various forms, is a very powerful retention tool.

9.    Have fun! Remember this is your extended family. Go to dinner together.

10.    Strong retention strategies become strong recruitment advantages.

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”?

Charlotte is a region that is equal parts old-fashioned southern charm and high-energy cosmopolitan bustle. You’ll still hear “y’all” dropped into casual conversation, but Charlotte is a metro area on the rise, and has its own culture, culinary sophistication, and unique feel that’s making it a more enticing place for people from all over the world to settle down. This melting pot effect makes Charlotte an easy area to become a part of. As the influx of growth continues with its diversity of people, you can often hear from a true Charlottean, “You’re not from here”? Well, neither are most people you’ll meet.

Charlotte has become a place filled with new restaurants to try and events that attract people from all over. It’s a standalone destination area now, no longer living in the shadows of Atlanta or Charleston, South Carolina. Though Charlotte has evolved significantly in the past decade, the transformation is only continuing, as evidenced by the numerous construction cranes across the skyline.

New census numbers released in May show that Charlotte is the 17th largest city in the country and the third fastest growing city across the nation.

You’ll frequently hear the word “manageable” used to describe Charlotte. Its climate is more manageable than Florida’s climate, and its housing prices and living expenses are more manageable than those of other major cities. Charlotte is a vibrant city that has something for everyone, allowing us to attract the best and the brightest.

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?

Each Best Practice Team is driven by a national registry population. We set goals (usually top 10%) and report to our teams regularly. This information drives where we wish/need to focus. 

We provide regular case feedback and have regular case review meetings with all teams, including EMS. Benefits of participating in quality improvement initiatives and national registries:

• Elevates use of data
• Promotes consistency of reporting
• Promotes exchange of information/tools
• Learn from other sites
• Share best practices
• Friendly competition (corporate-wide, regional, and national)
• Provides a collaborative effort toward change
• Provides communication with senior management
• Provides benchmarks and comparison data
• Provides a voice in changing/growth of registries 

Acknowledgments. A special thank you to:

Dr. Michael Miller and Brian Harkey, for lending their talents in photography and granting us these wonderful pictures. 

Rosanne Short and Alyson Flood, for their time and assistance with not only gathering needed data, but walking us through it. 

What procedures are performed in your cath lab?  

We routinely perform right and left heart caths and percutaneous coronary intervention, along with the use of intravascular ultrasound (IVUS), instantaneous wave-free ratio (iFR), fractional flow reserve (FFR), intra-aortic balloon pump (IABP), Impella (Abiomed), and Rotablators (Boston Scientific) as needed for our cases. We also perform pericardiocentesis and temporary pacemakers. Our EP lab performs all types of ablation procedures, and places pacemakers and implantable cardioverter defibrillators (ICDs), as well as biventricular ICDs. With the addition of our structural heart program, we have expanded services and are performing transcatheter aortic valve replacement (TAVRs) as well as valvuloplasty, atrial septal defect (ASD) closure, pulmonary embolism (PE) treatment with the EKOS system (BTG), and laser lead extractions. In our recovery area, we routinely perform transesophageal echocardiograms (TEEs), cardioversions, tilt table tests, and loop recorders, as well as teaching for upcoming procedures. 

Can you share your lab’s experience with TAVR?   

We have been performing TAVR procedures since January of 2017. Our hybrid OR was a new space that was built on an open rooftop and is 1064 square feet. We had considered combining two smaller ORs into one, but the size and shape would have been too limiting. We performed 24 TAVR procedures in 2017 and 30 thus far in 2018, using the Sapien 3 (Edwards Lifesciences) and Evolut R valve (Medtronic). We also use the ACIST system for our TAVR procedures. The ability to keep a pressure showing with minimal breaks for injections has been very helpful. We have 3 dedicated cath lab staff (2 RNs and 1 technologist) with 3 additional cath lab-trained team members that assist with the TAVRs. We work alongside our skilled cardiothoracic OR team for these cases. 

What is your percentage of normal diagnostic caths?  

Our percentage of normal caths is 39%, lower than the national average.

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

All of our physicians are performing radial access for elective cases, unless the patient’s anatomy directs us to the femoral site. We routinely perform an Allen’s test on all cath patients. 

Who manages your cath lab? 

Our cath lab manager is Linwood Williams, RT(R). Linwood has been with SRMH in the cath lab since 2010. Along with managing the unit, Linwood takes call 1 weekend a month and 1 day a week. Competency is held to the highest standard at SRMH.

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

Our interventional technologists scrub all cases; they are responsible for using the ACIST injection system, panning the table, controlling the x-ray equipment, and assisting the physician. Our RNs circulate, assess, and monitor all cases. We have 3 technologists that have cross-trained to monitor some cases when the need arises.

Are there licensure laws in your state for fluoroscopy? 

Per Virginia law: A physician assistant working under the supervision of a licensed doctor of medicine is authorized to use fluoroscopy for guidance of diagnostic and therapeutic procedures provided such activity is specified in his protocol and he has met the following qualifications. 1. Completion of a least 40 hrs. of structures didactic educational instruction and at least 40 hrs. of supervised clinical experience as set in the Fluoroscopy Educational Framework for the PA created by the American Academy of Physician Assistants (ASRT) and  successful passage of the American Registry of Radiologic Technologists. (ARRT) Fluoroscopy Exam. 

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 interventional technologists are very knowledgeable and talented. They are trained to operate the x-ray equipment, pan the table, work the c-arm to change the angles, and set up and control the ACIST injection system. 

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

All staff receive inservices on radiation protection yearly and are monitored monthly. The technologists and physicians are very observant of safe practices and will pause for the RN to finish administering meds or assessing the patient before stepping on the x-ray pedal. We routinely evaluate lower fluoroscopy rates to determine if the loss of quality is low enough as to not affect safety. The EP lab has been using low fluoro rates for several years now and has seen a marked reduction in x-ray exposure. The EP lab also utilizes the Zero-Gravity radiation cabin (Biotronik) during ablations, which has greatly reduced the exposure to the physician and technologist.

What are some of the new devices recently introduced at your lab? 

We use the Synergy (Boston Scientific) and Onyx (Medtronic) stents primarily. We have added Penumbra and EKOS for PE treatment. We have a new ultrasound intra-cardiac echo (ICE) system that is shared by the labs. We have started to perform laser lead extraction with our new laser. We are using and have become very skilled at Impella and Rotablator procedures.  

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

Email is probably overused, so rounding and weekly Friday morning updates are very important to disseminate info that needs to be communicated quickly. This information is reinforced at the monthly department and staff meetings. Our director provides a weekly newsletter with updates for the department. 

How is coding and coding education handled in your lab? 

Any coding questions go to the manager who then has access to both electronic systems and trained coders to assist him.

Who pulls the sheaths post procedure? 

For cardiac cath procedures, most femoral sites are closed mechanically by the physician before the patient leaves the table, using Angio-Seal (Terumo), Starclose (Abbott Vascular) or Perclose (Abbott Vascular). The cardiac technologist pulls the radial sheaths while the patient is still on the table and applies a TR Band (Terumo). Venous sheaths and a small number of femoral arterial sheaths go to our pre/post holding area, where they are pulled by either a technologist or RN. All RNs and technologists are trained to pull arterial and venous sheaths, with the requirement of 10 supervised pulls to become competent and proficient.

Where are patients prepped and recovered post sheath removal? 

Outpatients are prepped and recovered in the cath lab holding area. Inpatients briefly come to the holding area for a check-in and an assessment by a RN. Post procedure, inpatients stay 15-120 minutes in our holding area, depending on their floor assignment and level of care needed. Outpatients are recovered and discharged home if patients are stable. Unstable patients or patients with special needs are admitted to the hospital for further monitoring. 

How is inventory managed at your cath lab? 

Our cath lab has 2 technologists that manage the supplies and equipment, as well as monitoring for expiration dates. Each technologist that scrubs the case orders the interventional equipment used in their case. 

Is your lab involved in clinical research? 

Not currently, although we have, in the past, been involved in trials.

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

From the latest American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)/CathPCI Registry, our D2B time is 54 minutes. First medical contact-to-balloon time is 73 minutes.   We have a very collaborative relationship with EMS and share each field ST-elevation myocardial infarction (STEMI) with EMS to help improve first medical contact to balloon times. We are registered with the American Heart Association’s Mission:Lifeline and also participate in the Virginia Heart Attack Coalition.

Who transports the STEMI patient to the cath lab?  

The cath lab RNs go to the emergency department (ED) or inpatient floor, and bring the patient back to the lab, with assistance from the ED/floor RNs. 

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

Everyone gets the STEMI pages, on call or not. This team is so dedicated to the patients and to their teammates, that if second STEMI is called, people drop what they are doing and begin calling in to see if they are needed. This has occurred twice in the past few months and there was no delay in patient treatment. If a secondary team is not available, SRMH protocol is to use tPA in the ED; however, this has not had to be utilized.

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

Being part of a larger system does give an advantage on pricing and the ability to shuttle short-dated product to other facilities. We take part in bulk purchases that have given a significant savings. Staff  are very cognizant of their time and normally leave when the work is done.

What quality assurance measures are practiced in your cath lab?  

A cardiac scorecard is reviewed with the physicians at a monthly heart council meeting. This scorecard covers many of the quality indicators on the CathPCI and Chest Pain MI registries.

Are you recording fluoroscopy times and dosages? 

Both are recorded in both our hemodynamic system and in our electronic medical record.

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

We notify our safety officer if fluoroscopy time exceeds 45 minutes per case. If high exposure is noted, the physician in charge of the case will be notified and the patient is followed by our safety officer. This high exposure is reported to the patient by the physician. 

Who documents medication administration during the case? 

The circulating RN is in charge of all medication administration and Epic documentation in the cath lab. The monitoring RN is in charge of documenting the medications in our hemodynamic system. 

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

Our physicians utilize Dragon software (Dragon Systems) to dictate directly into our EMR.

Can you tell us about your cath lab’s participation in the ACC-NCDR or any other outside data collection registry?  

We have participated in the NCDR registry since approximately 2006. We also participate in Mission:Lifeline, the Society of Thoracic Surgeons (STS) database, and the Vascular Quality Initiative (VQI) Vascular Ultrasound Registry. 

How are you populating the registry data records? 

The RN begins the data sheet as they check the patients in, but a dedicated abstractor completes the data gathering process. Data are sent to the NCDR registry through Armus (Armus Corporation).

How does your cath lab compete for patients?

We are the only hospital facility within 30 miles, as well as the only hospital with an open heart program/surgical back-up within 60 miles. We market new procedures through advertising and outreach.

How are new employees oriented and trained at your facility? 

New staff have a 2-3 month orientation period before taking STEMI call. They are assigned a mentor/preceptor who is primarily responsible for ensuring the training is complete and accurate. 

What continuing education opportunities are provided to staff members? 

Our hospital participates in a clinical ladder program that encourages continuing education. Our RNs are eligible to participate in the hospital clinical ladder program, which goes from Level 1 (new hires) up to Level 5. We also utilize vendor training and education via the local chapter of Alliance of Cardiovascular Professionals (ACVP), and our cardiologists are very proactive and schedule monthly cath conferences. Staff also participates in national conferences. 

How do you handle vendor visits to your lab? 

Vendors must check in through Vendormate and wear the badge that is given to them. Vendors are only allowed in the cath lab when they have a new product to launch or their assistance is requested. Lunches or gifts are not allowed.

How is staff competency evaluated? 

We perform yearly competencies for electrocardiogram (ECG), IABP, Code Blue scenarios, devices, Rotablator, etc.

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

Our hospital is new as of 2010. We have a beautiful facility. The major limitation is a lack of storage as we expand services.

How does your lab handle call time for staff members? 

We have 4 set teams of 2 RNs and 1 technologist. Each team has a set day of the week for call and rotates every 4th weekend. Depending on the schedule and time of “call-in”, every effort is made to let the call person leave early or arrive late. 

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

The call team is expected to be here within 30 minutes. 

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

Our staff all work 10-hour shifts, 7:00am-5:30pm. During slow periods, inventory is cleaned up and online training is completed. Medication audits are performed. Some staff float to other units, but many go home during slow times. We have designated “late” people if cases or recoveries run past scheduled shift. We have instituted 12-hour staff to accommodate late recoveries.

Has your lab recently undergone a national accrediting agency inspection? 

Yes, we just finished our yearly DNV survey (Det Norske Veritas Healthcare), with very favorable remarks. 

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

We are located about a minute walk down the hallway from the ED. We have an elevator adjacent to the cath lab suites that opens directly into the OR suites.

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

We are performing more complex PCIs, normally staging procedures to ensure that the patient and families understand the risk. Our right heart volume has increased as the cardiologists are working closely with Pulmonology and our Critical Care Unit. A distressing trend that we see among patients is the increased number of STEMI patients driving themselves to the ED in order to avoid an ambulance expense. 

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

Our team is unique due to their focus on safety. They have been given a toolkit for safety and all are comfortable using it. They respectfully challenge physicians and management when they find an issue. The physicians have come to respect this culture and accept questions about procedures or orders graciously.

Is there a problem or challenge your lab has faced? 

The first several months of 2016 brought several large-scale changes for our teams. New EP software was installed, a cath lab system was upgraded, a hemodynamic system changed, and we began using a brand-new electronic medical record (EMR). Careful planning and staff involvement were keys to success. More recently, our hospital has dealt with nursing shortages and we have had to hold cath/ EP patients in our holding area for extended periods of time. We have addressed this shortage by increasing several staff members to work 12-hour shifts to allow for patients having to stay more than 4 hours post procedure. This has also allowed us to increase our staff by 2 extra employees. 

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”?  

Harrisonburg is part college town and part farming community. We have 48 different languages spoken in the service area of the hospital. There are many cultures represented, and we make every effort so that everyone is treated with dignity and respect.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

Prior to our merger with a larger system, the RCIS was not required. We have a great deal of respect for all of the professions in the cath lab and do not see how one credential in particular holds any more weight than the others. 

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

We are involved with the ACVP and the Virginia Heart Attack Coalition (VHAC).

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?  

We had always utilized the outcomes report for a QI measuring stick. We now have a corporate scorecard that is based strongly around the outcomes report and is visible to upper administration.

The authors can be contacted via Linwood N. Williams, RT(R), Manager, Invasive Cardiovascular, at Lnwilli1@sentara.com.