Crittenton Hospital Medical Center

Author(s): 

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?

The number of procedures performed has grown steadily over the last five years. We are hoping this trend continues in the future. The cardiologists are actively involved in public outreach programs in three counties to educate communities and hopefully increase patient population. In addition, Dr. Samer Kazziha is currently training in atrial septal defect (ASD)/patent foramen ovale (PFO) percutaneous procedures to draw in a new patient population.

Do you have a hybrid cath lab, or are you planning to build one?

No, not at this time.

Is your lab involved in clinical research?

Yes, Crittenton Medical Center has several research projects, all coordinated by Elias Boueiri. Our lab was the top enroller in the nation for the ICE T-TIMI 49 study using tenecteplase, and the IC TITAN TIMI 47 study involving abciximab. Both involved intracoronary injections of the drug or a placebo in STEMI patients. These studies are completed, but we are still following up with patients.

Currently, we are involved in the following trials:

  • The VERDICT study (Vascular Evaluation for Revascularization: Defining the Indications for Coronary Therapy: A Pilot Study) involving FFR and IVUS;
  • The CHOICE and SAPHIRE studies involving patients who undergo carotid stenting;
  • The Endeavor Study, in which we are trialing zotarolimus-eluting stents specifically designed for small blood vessels. 

We are in the follow-up stage of the Xience V drug-eluting stent study (Abbott). Also, we participated in research using bivalirudin and the Mynx closure device in patients undergoing percutaneous coronary intervention procedures. Soon there will be an article published on the results of this research.

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

Fortunately, we have had no cath lab-related complications requiring emergent cardiac surgery. Although this is not a cath lab-related complication, we did have a patient present with a severe aortic dissection. Surgical repair was performed for the first time at our facility. This was accomplished by our new thoracic cardiovascular surgeon, Alvise F. Bernabei, MD, FACS, FACC. Normally, this patient would have been airlifted to the University of Michigan for surgical repair. We are happy to report that this patient is doing very well.

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? 

Average door-to-balloon time for our facility is 50.5 minutes. Crittenton Medical Center has made efforts to lower our D2B times by implementing the following changes:

  • Electrocardiograms are transmitted directly from the field and the call team is activated sooner;
  • One page through an outside service now contacts the whole cath lab team; 
  • Decreased call response time from 45 minutes to 30 minutes, with some call team members moving closer to the hospital and others staying in-house while on call; 
  • An in-house STEMI team was formed utilizing cardiovascular intensive care unit and emergency room nurses to prepare the lab and the patient while the call team is en route to the hospital. 

By making these adjustments, we have decreased our D2B time by 27 minutes in the last two years. The American Heart Association’s Mission: Lifeline was also initiated in our facility in May 2011.

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

The STEMI team, which consists of 1 ER RN, 1 ER tech, and 1 cardiovascular NP, will take the patient to the lab. If the patient is an inpatient, 2 RNs will transport the patient.

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

The STEMI always takes first priority. We rarely face this issue, but the few times that we have, we called in a second team.

What other modalities do you use to verify stenosis?

To verify stenosis in the cath lab, we utilize IVUS and FFR. We are the number-one user in our region of IVUS and FFR. We just completed data collection for the FAAST Registry by Volcano Corporation. The purpose of this study was to gather data on how long it takes to utilize the FFR wire during a procedure.

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

Costs are contained through aggressive negotiations with vendors and bulk buys to reduce cost. We emphasize cost effectiveness by practicing evidenced-based medicine and utilizing clinically proven technology, using only essentials in our daily operations. Currently, 90% of our cases are performed via the radial approach, which decreases patient length of stay and is a tremendous saving to the patient, the hospital, and insurance companies. Patients who have undergone a diagnostic heart cath are usually discharged in 2 hours and those undergoing a low-risk PCI usually go home in 8 hours.

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

Daily quality control is done on all medical equipment in our cath lab. Medications and the crash cart are checked on a monthly basis for expiration dates. We follow (Joint Commission) standards. As a quality measure, we follow D2B times, average length of stay on cath lab patients, hematomas, and the Perfect Care Score for heart failure patients. 

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

Yes, we use the NCDR CathPCI Registry, NCDR ICD Registry, and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) Registry.

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

Crittenton Hospital Medical Center has formed emergency medical services (EMS) alliances to bring cardiac patients in through the emergency department (ED). Also, our hospital has provided the necessary equipment to the local 9-1-1 agencies, allowing ECGs to be transmitted directly to the ED before the patient arrives. 

We have a once-a-month public outreach program that educates the community about cardiovascular health in-house, with a team of Crittenton physicians rotating the lectures.  Also, our executive director Dr. Kazziha gives public presentations on cardiovascular health in a three-county radius.  

How are new employees oriented and trained at your facility?

New employees are orientated by the hospital and trained by a senior staff member in the lab. All of our staff members have more than a year’s experience in the lab, and most have over twenty years of cath lab or critical care experience. We have employees with previous ICU, ER, EMS, stress testing, cardiac rehab, and medical armed services backgrounds. We require RN and/or RCIS licensure/registry for our staff.  

What continuing education opportunities are provided to staff members?

Yearly, we provide a cardiovascular symposium that is open to the surrounding medical community, 9-1-1 agencies, and schools. There is no cost to attend the symposium and it provides 6 CEUs/CMEs. Our hospital provides on-site basic life support (BLS) and advanced life support (ACLS) training. Quarterly, our vendors/clinical presenters provide inservices with CEUs for cath lab staff. Often staff members are sent off site to train for new equipment and are provided credits for doing so. Any mandatory training is offered as a continuing education opportunity through the hospital.

How do you handle vendor visits to your lab?

Our hospital uses the Vendormate system (Atlanta, Georgia) to provide badges to our vendors. All vendors must go through our cath lab coordinator to schedule days in the lab. If what the vendor represents pertains to the case, they are allowed in the procedure room. High-volume and contracted vendors have set lab days.

How is staff competency evaluated? 

Staff competencies are performed, assessed, and checked off by senior staff members on a yearly basis. 

Does your lab have a clinical ladder?

We do not have a clinical ladder. However, all staff members have additional job duties or projects in the lab, including learning new equipment, and researching and participating in registries. Some staff is trained as a resource for specific equipment. 

How does your lab handle call time for staff members?

Our clinical coordinator organizes the call schedule and makes it available to the staff a month ahead of time. Staff is allowed to make changes to the schedule to accommodate their personal lives. This makes for a great work-life balance. We have a three-person call team that has to include at least one nurse.

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

All members of the call team must arrive at the hospital within 30 minutes, including the cardiologist.

Do you have flextime or multiple shifts?

We have 8-, 10- and 12-hour shifts.

Has your lab recently undergone a national accrediting agency inspection?

Yes, we obtained accreditation as a Chest Pain Center with PCI through the Society of Chest Pain Centers in October of 2010. We would suggest keeping very good statistics over several years, specifically, showing an improvement in D2B times. Present a program data collection and analysis system (PDCAS) to highlight process improvements and show how they were obtained. Also recommended would be algorithms or flow charts to show your facility’s process from door to cath lab, and how you streamline that process to improve flow.

In 2010, the Joint Commission made an inspection visit to our facility. Our focus in the cath lab was on labeling all fluids on and off the sterile field, time outs, airway assessments, and conscious sedation.

We are currently working on our Heart Failure accreditation through the Society of Chest Pain Centers and anticipate obtaining this by the end of 2011.

We are a registered transradial center. Currently, we are seeking to become a training center.

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

We are conveniently located through a set of double doors to both the ED and the OR.

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

Our cath lab is seeing more cardiac intervention done with 5 French guiding catheters via radial access, more vascular procedures for below-the-knee arterial disease in patients with non-healing ulcers; less patients presenting with acute myocardial infarction than noted in past years, and more patients seeking earlier attention for symptoms of angina. The economy has affected this trend recently, due to insurance issues.

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

Our team is made up of highly qualified professional staff members. This team is unique in its ability to problem solve and get along well. We are all dedicated to providing excellent patient care. New procedures and changes are welcomed by team members as process improvements.  

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

The region surrounding Crittenton Hospital Medical Center is, for the most part, well educated and health conscious. We have noticed a drop in the acute cardiac care setting as the community responds to educational programs encouraging them to seek out preventative care.

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

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

The RCIS is required for all CVTs hiring into our lab. Our RNs do not receive incentive bonus or raise upon passing the exam.

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

Our radiologic technologist belongs to the American Society of Radiological Technologists (ASRT). One of our RCISs belongs to the SICP and one RN belongs to the ACC.

The authors can be contacted via Laura Allen at heartsaverx3@hotmail.com.

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