Crittenton Hospital Medical Center

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Sherie Bland, RN, Laura Allen, RCIS, CCT, Rochester, Michigan

Can you tell us about your cath lab?

Crittenton Hospital Medical Center is a not-for-profit community hospital with 248 licensed beds. Crittenton is one of a few independent community hospitals left in Southeastern Michigan, with a strong commitment to providing service excellence and compassionate care at a community level. We have a strategic partnership with the University of Michigan for cardiothoracic surgical services. Our facility’s cath lab has a swing lab, a special procedures/electrophysiology (EP) lab, and a stand-alone multipurpose lab. We especially like our swing lab. It is a cost-effective way to keep physicians moving from case to case. The stand-alone multipurpose lab is our newest lab, and it has intravascular ultrasound on the procedure table and in the control room. Having this option makes it operator-friendly for all staff members. This lab also has Artis Zee x-ray equipment by Siemens (Malvern, Penn.). It has a large flat-panel image intensifier that allows us to image bilateral extremities, while simultaneously reducing the amount of exposure. 

In our cath lab, we have 15 staff members: 1 cardiac cath lab manager, 5 registered nurses (RNs), 5 registered cardiovascular invasive specialists (RCISs), 1 cardiovascular technologist (CVT), 1 registered radiologic technologist (RT[R])/RCIS, 1 RT(R)(M)(CV), and 1 Cath Lab Coordinator/RT(R). Our prep/recovery area consists of 1 nurse practitioner (NP), 1 physician assistant (PA), 6 RNs and a secretary.  The majority of our staff has been employed here 5 years or longer, and many of the staff members possess 30 years or more of experience in their field. Our team of physicians includes interventional cardiologists, diagnostic cardiologists, interventional radiologists, vascular surgeons, and electrophysiologists.

What procedures are done at your lab? 

In our cath lab, we perform cardiac diagnostic and interventional procedures, pericardiocentesis, device implants, peripheral vascular diagnostic and interventional procedures (including carotids), and interventional radiology procedures (including percutaneous nephrostomy tube placement, percutaneous transhepatic cholangiogram, ureteral stenting, arterio-venous [AV] fistula grams with angioplasty, foreign body retrieval, dialysis catheter insertion, and pulmonary angiograms). We utilize intravascular ultrasound (IVUS)/fractional flow reserve (FFR)/coronary flow reserve (CFR), AngioJet (Medrad Interventional, Indianola, Penn.), thrombectomy devices, intra-aortic balloon pumps (IABPs), and Impella (Abiomed, Danvers, Mass.) for cardiac procedures, along with percutaneous coronary transluminal angioplasty (PTCA) and stenting. For peripheral procedures, we use the Silverhawk/Turbohawk (ev3 Endovascular, Inc., Plymouth, Minn.), AngioJet, self-expandable stents, thrombectomy devices, and the Pioneer Plus ultrasound transducer and percutaneous catheter (Medtronic, Minneapolis, Minn.). Our implanted devices include permanent pacemakers, automatic internal cardiac defibrillators (AICDs), bi-ventricular ICDs, and loop recorders. 

The EP lab is capable of diagnostic EP studies, mapping, and ablations. Transesophageal echocardiograms (TEEs) and cardioversions are performed in our prep/recovery area.

Our facility performs an average of 156 cases per week, including the TEEs and cardioversions.

Does your cath lab perform primary angioplasty with surgical backup on site?

Yes, at our facility we have two cardiothoracic surgeons, Frank Fazzalari, MD, MBA, FACS, and Alvise F. Bernabei, MD, FACS, FACC. Surgical backup is always available on site, 24/7.

What percentage of your patients is female? 

Females make up approximately 40% of our patient population.

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

Sixty-five to 70% of our procedures turn into interventions. 

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

Samer Kazziha, MD, FACC, established our radial program in November of 2010. Upon the completion of 100 successful cases by Dr. Kazziha, some of our other physicians started using radial access on their patients as well. We are in the process of having our facility registered as an official radial program center. Also, we have begun gaining radial access on our stable ST-elevation myocardial infarction (STEMI) patients. Currently 80% of our procedures are being performed by radial access. Recently, Dr.Kazziha successfully performed an abdominal aorta and lower extremity runoff using the radial approach.

Who manages your cath lab?

Jill Griffin, RN, nurse manager, oversees our daily operations and contributes to our lab with many years of experience working in the lab. The Executive Medical Director of the Cardiovascular Services is Samer Kazziha, MD, FACC. The Director of Interventional Cardiology is Zakwan Majoub, MD, FACC.

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

Yes, we do have cross training. Our lab is made up of RNs, RCISs, RT(R)s, and a CVT. All of our staff is trained on the hemodynamic monitoring system and in circulating. However, only the nurses give the medications in the circulating role. The RCISs, RTs, and our CVT all scrub.

Who documents medication administration during the case?

The circulating RN documents medications as they administer them.

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

No, we do not always have an RT present during the procedures.

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

The scrub tech is trained to operate all aspects of x-ray equipment. Physician preference will determine how the scrub tech operates. Typically, when we are working with the cardiologists, they operate the fluoro pedals, and when working with the radiologists or the vascular surgeons, they typically like the scrub tech to manage the pedals.

Are you recording fluoroscopy times/dosages?

The fluoroscopy times are recorded in the Mac-Lab system (GE Medical, Waukesha, Wisc.) and the dosages are recorded in the Siemens exam system.

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

All staff in lab is required to wear radiation badges and is monitored on a monthly basis. Badge readings are reviewed to look for any trends of increased exposure. Lead aprons are monitored annually. Incoming staff is educated on radiation protection.

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

Recently, we upgraded to the latest version of the AngioJet. We also upgraded our IVUS equipment and software, and have an integrated IVUS unit mounted on the procedure table in our new multipurpose lab. Our multipurpose lab also houses the Siemens Artis Zee x-ray equipment, and as noted, our swing lab is equipped with Axiom Artis x-ray equipment. In our EP lab, we utilize the Carto EP navigation system by Biosense Webster (Diamond Bar, Calif.). The Impella left ventricular assist device has been recently added to our lab to assist in high-risk procedures.

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

We have monthly cath lab staff meetings including our physicians, NPs, and PAs. The staff attends the mortality and morbidity conference on a bimonthly basis, presented by the physicians, where our most difficult cases are presented and critiqued for quality assurance. We are very fortunate to have a team that communicates well on a daily basis to problem solve and implement new ideas. Our executive medical director presents cardiovascular service line meetings to communicate with administration and hospital physicians on a bi-monthly basis.

How is coding and coding education handled in your lab?

Our cath lab coordinator, Suzie Barterian, manages our department coding. She is responsible for attending health information management (HIM) educational classes to stay current with all coding updates.

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

As part of our cath lab, we have a prep/recovery unit. For most of our patients, hemostasis is achieved in the lab post procedure with closure devices (Perclose [Abbott Vascular, Redwood City, Calif.] and Mynx [AccessClosure, Inc., Mountain View, Calif.]) for femoral access. For radial access, we utilize TR Bands (Terumo Medical, Somerset, New Jersey) to assist in hemostasis. The scrub tech deploys the closure and assist devices. Manual sheath pulls are done by the nurses in the prep/recovery area or in the unit where the patient originated. Rarely, sheaths are pulled in the cath lab.

What is your lab’s hematoma management policy?

Since beginning our radial program, groin complications have not been an issue.

Although performing radial access has decreased groin complications and length of stay, we do have hematoma guidelines that we follow should complications develop. Standard protocol for our facility is to apply pressure to the site, reduce the hematoma, measure and document the size of the hematoma, outline the borders to watch for growth, notify the NP/PA/attending physician, standing orders for lab work, and use of the FemoStop (St. Jude Medical, Minnetonka, Minn.) device. During this process, standard policy is to monitor vital signs, have atropine available, and evaluate the groin every five minutes. If the sheaths are still in the patient, manual pressure is applied directly to hematoma and we assess with attending physician the need to stop anticoagulants or remove the sheath.  Once hemostasis is achieved, the policy is to recheck the groin and vital signs every ½ hour x6 and when necessary.

How is inventory managed at your cath lab?

Inventory is managed by the QSight Inventory Management System (Owens & Minor, Mechanicsville, Virginia). The data is entered by the cath lab coordinator. The coordinator, with the approval of the manager and the executive director, handles the purchasing of equipment and supplies.

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

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