Advances in Simulation Training for Cath Lab Staff

Simantha in the SimSuite Center at St. Luke’s Episcopal Hospital. The screen to the far right lets the participants choose sheaths, catheters, size of interventional supplies and medications.
From left to right: SimSuite Clinical Education Specialist Emily Conner RN, Herman Massad RT(R)(CT), Christine Weisinger, RT(R)(CT) and Shannon Moti RT student.

Emily Conner, RN, SimSuite Clinical Education Specialist

Percutaneous interventional approaches for the treatment of vascular disease have become more common. As catheter-based technology advances, physicians are preparing to perform an increased volume of percutaneous alternatives to surgery. Hospital administrators, directors, department managers, risk managers and clinical educators have all questioned the appropriate method for training staff on new procedures, new products and the delivery of care for patients undergoing these procedures. Simulation training has it all covered.

Teaching, as well as learning a new procedure, can be challenging for the entire team. Performing the procedure for the first time on a real patient can be deleterious if the operator has not undergone proper training or proctoring. Pre-case jitters can lead to mistakes that can ultimately compromise the quality of patient care delivery.

Our number-one priority is the delivery of safe patient care, states Lynne Jones RN, RCIS, Cardiac Cath Lab Director at Tomball Regional Hospital. Lynne also serves as President-elect for the Society of Invasive Cardiovascular Professionals (SICP). She and her staff had the opportunity to attend an exclusive training event at the SimSuite ® Education Center within St. Luke’s Episcopal Hospital, home of the Texas Heart Institute in Houston, Texas. A didactic lecture was offered, but the advantage of hands-on training with the simulators served as the most effective teaching tool. Staff members took on the physician role while a clinical education specialist from SimSuite served as an assistant. Attendees were challenged with such adverse events as vasospasm, inability to cross a guidewire and stroke. The experience of simulation not only provides a hands-on opportunity to facilitate an intervention, but it also requires the participant to use cognitive skills in regard to patient care in the interventional setting. When adverse events occur, the participant must choose the appropriate treatment options to manage the patient. The lifelike simulator gives a patient response unique to the treatment selected, medication dosage and the route of administration. Simulation is a safe way to be exposed to adverse events that commonly occur during catheter-based procedures. Participants have the ability to plan and implement their treatment options along with assessing the response to the treatment selected. Simulation also requires the operator to choose the appropriate sheath, guide catheter, guidewire, dilatation balloon, stent and contrast type. Participants also selectively cannulate vessels and advance guidewires through tortuosity. The simulator gives the user the feel for crossing a tight lesion and dealing with possible complications such as dissection.

This new program is known as the Carotid T2 Program (Medical Simulation Corporation [MSC], Denver, Colorado) and is specifically designed to address two complex needs in today’s hospital: to train staff that support physicians performing carotid artery stenting and to offer a platform to train-the-trainers, enabling a hospital to establish a skills-competency program for every team member providing care to patients undergoing carotid artery stenting. Dr. Subbarao Myla, Medical Director, CV Research & Vascular Intervention, at Hoag Memorial Hospital, and Course Director for the Carotid T2 Carotid Team Training with Medical Simulation Corporation, notes, Carotid Team Training is an integral part of success for a carotid stenting program. Regardless of physician experience, superbly trained cath lab nurses and technologists are essential for a safe and state-of-the-art interventional team focused on delivering consistently superior results every time, ensuring successful patient outcomes. A well-trained cath lab staff will ultimately differentiate themselves as the safe haven for both the expert and novice interventionalist performing carotid stenting procedures.

The mission of the Carotid T2 program is to improve and support staff confidence for pre-, intra-, and post-procedure management of patients undergoing carotid stent placement.

Not only should the interventional lab nurses and technologists be trained in carotid artery stenting, but the entire team should be involved. Participation in this training should also include staff in cath lab recovery, telemetry, interventional lab nurses and techs, neuro ICU, and CCU, states Jones. As the need for percutaneous procedures increases, smaller cities and suburban hospitals will require training for physicians and their invasive teams. Many vascular surgeons are now training in catheter-based procedures, leading operating room staff, who are challenged with managing a patient who is awake and undergoing a percutaneous procedure. It is quite a change of practice for operating room nurses and scrub technicians who are used to open cavity and general anesthesia procedures. Chanah King, RN, Coordinator of Vascular Surgery at the University of Texas Medical Branch in Galveston, also attended the exclusive training event in Houston. She will be responsible for facilitating a smooth transition for her operating room staff from traditional surgical interventions to percutaneous interventions.

The simulation was great because it brought up a lot of questions and also gives you a greater appreciation of what the doctor is doing, King commented. Being able to anticipate the next step of the physician will allay staff fears of appearing unprepared or undereducated. The operating room staff ran cases on the simulator in which the patient responded to sensations and treatment given. Patient feedback is something unique to the catheter-based procedures; the patient is not generally anesthetized. This is just another skill the staff was able to initially face and become familiar with while working with simulated cases. Simulation training is bridging the gap in training diverse team members on new procedures and state-of-the-art technology.

Training at the SimSuite requires a pre-procedure report, followed by simulation, and closes with post-procedure questions and the development of treatment plans. The cases are presented in a SimSuite that looks like a real cath lab. The patient, represented by the realistic Simantha ®, presents like a real patient in the cath lab who is prepped and draped. Femoral access has already been obtained for the operator. Contrast type, catheter selection, and guidewire selection must be chosen before the participant can begin. As catheters are advanced, the realistic effect that physicians feel is simulated to give the participant a feeling of what to expect on a real patient. Calcified lesions and thrombus are just part of the courseware. A hemodynamic system above the patient displays ECG and pressure waveforms along with the noninvasive blood pressure and oxygen saturation. The pressure waveforms are continuously presented and responsive to pharmacology adjuncts, patient condition and the participant’s clinical decisions for treatment. Medications given during the simulation will have an effect on the patient’s status according to the type, dosage and route. A virtual balloon pump can also be initiated on a patient with a real augmented waveform on the hemodynamic system. The patient occasionally has a complaint or comment during the procedure to reinforce the realism of patient care and may be directly correlated to complications or changes in status. Adverse events in a variety of cases require the operator to use critical thinking skills to develop a differential diagnosis or change the therapy being delivered. The simulated cases focus on angiography and intervention for coronary arteries, renal arteries, iliac arteries and carotid arteries. Catheter and wire changes can be done virtually or through exchange to demonstrate the technique commonly used in delicate catheter-based procedures. Guidewires frequently require steering to land in the appropriate vessel, giving the participant the opportunity to face the challenge of hard-to-wire lesions.

I’m not one for classes; I’m more of a hands-on type of person. I really like the simulations and the faculty was great, says Marc Llamas, RT(R)(VI) of Bayshore Medical Center in Pasadena, Texas.

Why such an investment in simulation training for catheter-based procedures? Traditional surgical procedures are now finding their way into invasive procedure labs, cath labs and operating rooms. Simulation decreases the learning curve, and provides an environment in which a bad decision will not compromise patient care. Simulation also teaches new skill sets for new products as they enter the market. Nurses and technologists get hands-on practice with the device and learn how to use it as a physician would, allowing the participant to better understand the procedure and to be prepared for his or her role when the patient is on the table. It really gives the staff an appreciation of what the doctor is actually doing, notes Lynne Jones.

Simulated cases aren’t just for coronary and peripheral catheter-based work. Development in open-chambered procedures and complex medical devices is underway. To aid in the training of catheter-based professionals, there are seven dedicated SimSuites in the United States located in various regions around the country to make access to a SimSuite Education Center convenient for most hospitals. The Carotid T2 program is offered for carotid team training for facilities nationwide. There will always be a place in the education of clinicians for theory and understanding of the treatment of disease processes. Simulation is proving to be an invaluable educational tool for hands-on reality-based training without risk or harm to patients.

For more information, log onto If you would like to provide input into a forum discussing your facility’s carotid stenting program, please email


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