Little Rock Cardiology Clinic, P.A. Cardiac Catherization Laboratory

Author(s): 

Jonathan Clopton, PhD, LRT(R), RCIS, Cath Lab Manager

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

Little Rock Cardiology Clinic, P. A. is a physician owned and operated clinic that provides multiple cardiac diagnostic services. The clinic is comprised of twelve cardiologists and one internal medicine physician. Services include: nuclear medicine, laboratory, radiology, echo, and most recently, cardiac catheterization laboratory. The cardiac cath lab is the first freestanding outpatient cath labs in the state of Arkansas, and was built with the vision of making the patients feel comfortable when undergoing a diagnostic invasive procedure such as a cardiac catheterization or peripheral angiography.

The idea of building a cath lab was further driven by the results of the CREDO study (Clopidogrel for Reduction of Events During Observation, Bristol-Myers Squibb & Sanofi-Synthelabo, 2002).

The cardiac catheterization department is staffed with 8 full-time employees and 4 PRN employees:

FTE: 3 BSN, RN (2 of which are currently working toward their MS); 1 BA, RN; 1 RN; 1 BS, LRT(R), CV; 1 LRT(R); and 1 receptionist

PRN: 1 BSN, RN; 2 RN, LT; and 1 RN

The pre/post procedure care is performed by 3 RNs and the cath labs are staffed with 2 RNs and 2 LRT(R).

What types of procedures are performed at your facility?

We have two equipped cath labs, in which, we perform approximately 50 cases per 4-day work week. We do diagnostic right and left heart catheterizations along with imaging of the bypass grafts and internal mammary arteries. We also perform diagnostic peripheral angiography. Currently, we do not do cardiac or peripheral interventions.

What percentage of your patients are female?

Our case mix consists of 50% female patients.

What percentage of your diagnostic cath patients go on to have an interventional procedure?

Approximately 32% of our patients go on to have a percutaneous coronary interventional procedure, while approximately 12% of our patients are referred for coronary artery bypass grafting.

Who manages your lab?

The cath lab is managed by Jonathan Clopton. His educational background consists of a PhD in Health Administration, a MS in Radiologic Administration, a BS in Radiography, and he is also a Registered Cardiovascular Invasive Specialist (RCIS). He is responsible for the day-to-day operation of the cardiac cath labs, along with fiscal management and resource utilization. He also develops strategies to improve financial performance for assigned departments, including expenses, revenues, efficiency, and productivity.

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

Yes, cross-training is encouraged in the cath labs. RNs are the only team members that administer narcotics. All cath lab staff is required to maintain current ACLS and BLS certifications. All pre and post procedure care is performed by RNs that are ACLS and BLS certified. We have also found that for diagnostic procedures, a procedure can safely be performed by two staff members, including one scrub LRT(R) and one RN that circulates and monitors.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

No, to the best of my knowledge, the state of Arkansas allows individuals holding the state licensure to perform procedures using ionizing radiation as long as it is under direct supervision of a physician. In Arkansas, a radiologic technologist can obtain a state license after passing their national registry. A state license can also be obtained by individuals that have passed the RCIS (registered cardiovascular invasive specialist) registry from CCI (Cardiovascular Credentialing International). There are those individuals in the state that were able to take advantage of the grandfather period and get grandfathered in as an LT (licensed technologist). This was a wonderful opportunity for those individuals. Having a Arkansas state license as an LT allows individuals with a non-radiation background an opportunity to continue performing their job duties in a specific department, such as a RN scrubbing in the cath lab.

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

Routinely, the scrub will position the II, pan the table and change the angles, and the cardiologist will step on the flouro pedal.

Does your lab have a clinical ladder?

We do not have a clinical ladder at this time.

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

Our first cath lab opened in February of 2003 and our second cath lab opened in December of 2003, both with all new GE equipment (GE Medical Systems, Waukesha, WI). We have two GE LC+ single plane digital cath labs with flat panel monitors and two GE MacLab® 7000 hemodynamic systems. Each patient is continuously monitored by a GE Dash® 2000 hemodynamic monitor, which is linked to both of the nurses’ stations. We have two GE imaging review stations, one CRSPC and one DDS; at this time, archival is maintained on CD.

We also have two ACIST CMS systems (ACIST Medical Systems, Inc., A Bracco Company, Eden Prairie, MN) which we have found to increase our overall procedure efficiency and to more accurately manage the patients' contrast dose. We have also found the ACIST CMS multiple dose system to greatly reduce the overall turnaround time between procedures when compared to the single dose system. By using the ACIST CMS multiple dose system we have reduced our contrast waste; thus increasing our profit margin.

How is coding and coding education handled in your lab?

As most managers would probably agree, understanding the value of accurate coding is important. It is important to have experienced, registered coders stay current on all the frequent updates that occur in coding. An attempt is made to attend as many coding educational opportunities as possible to maintain compliancy in our coding practices.

It is important to have an excellent relationship between the cath lab and the billing department, which we have worked hard to establish. One way we found to improve communication between the cath lab and the billing department was to allow the individuals coding to spend some time in the cath lab, seeing procedures and interacting with the cath lab staff.

It is also important that the cath lab staff have an opportunity to sit down with the registered coder and learn proper coding mechanics. It is essential to overcome the educational barriers that exist between the two departments. This also establishes a foundation and a sense of appreciation between the two departments.

How does your lab handle hemostasis?

One of the unique things about our cath lab is that we follow a 4 and 5 French policy on our left heart catheterization and diagnostic peripheral angiography procedures. This enables manual pressure to be applied for approximately 10 minutes, followed by a minimum of one hour of monitoring prior to discharge. Routinely following the diagnostic catheterization, the patient returns to their room, at which time the sheath is removed. The patient will be instructed to lie flat on their back with the affected extremity extended for 30 minutes. At this time, the patient’s head will be elevated 40-45 degrees or to a comfortable level for the patient. The patient will remain inclined for 30 minutes, during which time they will be offered something to eat and drink. One hour following sheath removal, if their puncture site is stable, the patient will be assisted to the restroom. Following the patient’s restroom visit, the patient will be allowed to change into their own clothing and will receive their discharge orders. All of the patients are escorted to their means of transportation. We do not use closure devices.

Does your lab have a hematoma management policy?

We have a quality assurance program in place to properly document and track any hematomas.

How is inventory managed at your cath lab?

Our cath lab has an individual budget. The ordering of supplies is primarily done by a strong cooperative effort among all the staff. The cath lab manager is responsible for approving all purchases.

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

Our cath lab department was initially built with the expectation of expanding to a second lab as census increases. The second lab was completed in December of 2003. Our future plans are to implement an archival network in conjunction with an electronic medical records system.

Our cardiology practice is on the fore front of modern technology. In February of 2005, we will be completing our newest addition a CTA department. We are installing a Siemens 64 multi-slice CT scanner (Siemens Medical Systems, Malvern, PA) with primary focus on cardiac and peripheral imaging. We are excited about the opportunity to provide our patients with the most cutting-edge technology available on the market.

Is your lab involved in clinical research?

At the time this information was submitted, we are looking into performing some diagnostic clinical research. We are also in the process of performing a conscious sedation study.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

No.

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

Negotiations were made during the development process to get the best quality products. As in most cases, volume plays a major role in product pricing. We purchase the majority of our supplies using a Group Purchasing Organization (GPO). Strong efforts are made to maintain close par levels.

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

We have a continuing quality assurance/quality control program with daily and monthly checks.

We perform point-of-care testing. Fluoro times are documented to monitor for the prevalence of radiation burns. We make a courtesy follow-up phone call to every patient after their procedure to answer any questions or concerns they may have.

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

Our cath lab competes for patients based on physician referral patterns and insurance alliances that have been established with larger healthcare networks. Being a freestanding clinic, we have made agreements with area hospitals in the event of an emergency.

How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab?

We have developed and implemented an orientation program for new employees. The program will provide the new employee with an orientation of sufficient scope and duration to inform the new employee about his/her responsibilities. A preceptor is assigned and will direct the orientation phase, consisting of 4-5 weeks or individualized on person's experience. BLS and ACLS are required. Our cath lab team consists of: RNs, RTs and one RCIS.

What type of continuing education opportunities are provided to staff members?

Little Rock Cardiology Clinic, P. A. offers recertification for BLS and ACLS annually. Vendors are always helpful in providing educational opportunities to receive CEUs on new products. Efforts are being made to send staff members to national meetings annually.

How do you handle vendor visits?

All vendors are requested to make appointments to visit the cath lab. Some of our vendors wear name badges, but it is not required. There are typically no time restraints placed on vendor visits.

How is staff competency evaluated?

We have established a specific set of requirements for each job description. These requirements are then evaluated by the cath lab manager annually, but monitored daily.

Does your lab utilize any alternative therapies (such as guided imagery, etc.)?

Typically, patients are very anxious about having an invasive procedure such as a cardiac catheterization. It is important for the cath lab team to provide a calm and soothing environment for the patient during their procedure. We have found that with the use of music most patients are more relaxed during the procedure. The patient has the choice on what type of music they would like to listen to.

How does your lab handle staff scheduling?

We are open 7:00 am to 5:00 pm, Tuesday through Friday. Being an outpatient facility, there is no need for call at this time. There is a rotation system in place for staff members to stay late when patients are required to stay past 5:00 pm. Staff members rarely have to stay late, which nowadays in cath lab world is atypical.

What trends do you see emerging in the practice of invasive cardiology?

One of the trends in invasive cardiology over the next several years will be the implementation of freestanding outpatient cath labs. There is a growing interest in the development of outpatient catheterization labs across the nation. There is also a great deal of literature suggesting that medicated stents are the way of the future, and it will be interesting to see how this could potentially change the way invasive cardiology patients are treated. One non-invasive diagnostic tool that is emerging is Computerized Tomography Angiography (CTA), which could be very useful in the years to come.

Has your lab undergone JCAHO inspection in the past three years?

No, we are in the process of applying for accreditation through the AAAHC (Accreditation Association of Ambulatory Health Care).

Please tell the readers what you consider unique or innovative about your cath lab.

We are blessed to have the opportunity to work with such a skilled group of cardiologists. The cardiologists treat each employee as a team member. Something rather innovative is that the scrub gains access for the cardiologist, which makes the cardiologist much more efficient.

In an attempt to increase the efficiency of patient care, the monitor role will type the cardiologist's interpretation of the procedure from a dictation template, which once completed and signed, is faxed to the referring physician. With each of the team members knowing their roles, there is a better understanding of teamwork.

Our cardiac catheterization laboratory has been designated as a Center of Excellence by Bracco Diagnostics Inc. and ACIST (Princeton, NJ). Obtaining a designation as a Center of Excellence means many things. It means a place that Bracco Diagnostics Inc. and ACIST can use as a show site for current and future customers. It also means that Bracco Diagnostic Inc. and ACIST believe that through our practice patterns that our facility is at the forefront of modern technology and a leader in performing diagnostic invasive cardiology.

Is there a problem or challenge your lab has faced?

In starting any new program, there are many hurdles. As most managers would agree, the most important quality of any program, especially a new program, is its ability to hire experienced, competent staff that can work well together. One of our initial challenges was establishing a level of confidence in patient safety issues related to performing diagnostic cardiac catheterization in a non-hospital environment. The issue of patient safety was addressed by hiring competent staff that had diagnostic and interventional cath lab experience, along with being BLS and ACLS certified. The confidence in patient safety issues has evolved as our volume has increased.

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

Little Rock is the capital of Arkansas, and is located on the banks of the Arkansas River. It is home to several corporations and a few minor league sports teams. We recently experienced the opening of the Clinton Presidential Library. Little Rock is a city that has a lot to offer anyone, from night life lovers to the adventurous outdoor types. To the west of Little Rock are the Ozark Mountains, and to the east, you will find the crop lands of Arkansas. Many of our patients are from small rural communities, which present a lot of diversity from various socioeconomic backgrounds.

Author Jonathan Clopton can be contacted at: jclopton@lrcardiology.com

Comments

i need to know more about post heparin management,post pci regarding sheath removal

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