What type of procedures are performed at your facility?
A variety of procedures are performed on approximately 125 adult patients per week. Procedures include angioplasty, stenting, AngioJet® thrombectomy (Possis Medical, Inc., Minneapolis, MN) and Export Aspiration Catheter (Medtronic, Minneapolis, MN), iLab Intravascular Ultrasound (IVUS) (Boston Scientific, Maple Grove, MN), FilterWire (Boston Scientific, Natick, MA), PolarCath (CryoVascular Systems, Inc./Boston Scientific), SmartWire Pressure System (Volcano Therapeutics, Inc., Rancho Cordova, CA), directional coronary atherectomy (DCA), Rotablator (Boston Scientific), temporary pacemaker insertion (TPM), permanent pacemaker (PPM), intra-cardiac defibrillator (ICD), pericardiocentesis and intra-aortic balloon pump (IABP) insertion. Routinely, renal and iliac stenting, with occasional stenting of the superficial femoral artery (SFA) and subclavian arteries is performed. A carotid angiography and stenting program was recently launched in our lab.
Does your cath lab perform primary angioplasty with surgical backup?
Surgical backup is available at all times. The on-call cardiovascular (CV) physician and surgical team are readily available on nights and weekends.
What procedures do you perform on an outpatient basis?
All cath lab procedures, as needed, are performed on an outpatient basis; however, inpatients who require our services are also treated.
What percentage of your patients are female?
Women comprise 38% of our patient population.
What percentage of your diagnostic cath patients go on to have an interventional procedure?
Thirty-one percent of our diagnostic left heart caths will have an intervention.
Who manages your cath lab?
Patricia Bailey, RN, BSN, manages the cath lab. She has 15 years of experience in our lab. Our clinical coordinator is Sandy Tigue, RN, BSN. Dr. Warren L. Strickland, III, MD, FACC serves as medical diretor.
Do you have cross-training? Who scrubs, who circulates and who monitors?
RNs scrub, monitor, and circulate. RTs scrub (pan the camera and table) and circulate. When using a three-person team consisting of two RNs and one RT, the two RNs trade between the scrub and monitor/circulate position; when we have one RN and two RTs, the RN monitors, one RT scrubs and the other RT pans.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
Yes, the RNs are not trained to operate the fluoroscopy equipment, thus an RT must be present.
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 RT operates the equipment and pans the table. The physician, or at his designation, the scrub person, uses the fluoro/cine pedal from the scrub side of the table.
Does your lab have a clinical ladder?
All new employees start out as a Cardiac Cath Technologist I. With documented competencies and experience, they can advance to a Tech II. To become a Tech III, there are additional requirements, such as teaching a class.
What are some of the new equipment, devices and products introduced at your lab lately?
We are using the Polar Cath (CryoVascular Systems/Boston Scientific) cryoplasty system. For carotid stenting procedures, we are using the Rapid Exchange Carotid Stent System and Embolic Protection System (Abbott Vascular Devices, Redwood City, CA).
Can you describe the system(s) you utilize and how they work in cath lab daily life?
Three of our cardiac labs are equipped with Medical Imaging Solutions (New Orleans, LA), provided through Southeast Imaging (North Little Rock, AR). Our other two labs are scheduled to be updated in 2006. Out of the five labs, the first lab was upgraded to the Axiom Artis dTC (Siemens Medical Solutions, Malvern, PA) large flat detector. The second lab is currently being installed with an Axiom Artis dTC dedicated cardiac flat detector. The remaining three labs are scheduled for upgrades to flat detector technology (also Axiom Artis dTC) at the rate of one per year for the next three years. We use the PICOM archival system by ScImage (ScImage, Inc. Los Altos, CA). Hemodynamic and event log recording are done with the Witt Calysto Series IV System (Melbourne, FL). Our scheduling is done under the OR framework in the Eclipsys 7000 Series System (Eclipsys Corp., Boca Raton, FL). To further modernize our department, we are considering the addition of the dual-source Siemens CT scanner.
How is coding and coding education handled in your lab?
Currently at Huntsville Hospital, our materials management staff enters procedural codes through the SIS by utilizing a patient charge sheet completed by clinical staff and the physician at the time of procedure. This information is communicated with the appropriate personnel in patient accounting and medical records to insure that coding and billing are accurate. However, we are currently awaiting a Witt Transcription Interface upgrade that will allow the physician to transcribe the procedure at the end of the case, and this will communicate with the proper departments to generate patient procedure charges.
How does your lab handle hemostasis?
Hemostasis is usually a matter of physician preference. We have several physicians who regularly close the arterial site using Angio-Seal (St. Jude Medical, Minnetonka, MN) after visual verification with femoral angiography. Other physicians prefer hemostasis by either manual or C-clamp pressure. D-Stat (Vascular Solutions, Maple Grove, MN) and FemoStop® Plus (Radi Medical Systems, Wilmington, DE) are also utilized. Sheaths are pulled in the recovery unit by a multi-disciplinary tech or an RN.
Does your lab have a hematoma management policy?
Hematomas are handled immediately with either manual pressure or a FemoStop Plus. Residual hematomas of greater than 3 cm are reported to the hematoma nurse, who starts data collection for quality assurance purposes.
How is inventory managed at your cath lab?
Huntsville Hospital utilizes SIS (Surgical Information Systems, Alpharetta, GA) and Lawson (St. Paul, MN) for its in-house communication, patient scheduling, billing and inventory control. Our department employs two full-time materials management staff members, one RN and one RT. Their responsibilities include:
Maintaining current par levels
Identifying par level need changes
Replacement of expired products
Coordinating all purchase requisitions for daily supplies
Participating in all supply contract negotiations
Helping in labs when needed
Supplies utilized during procedures are entered each day by the materials management staff into SIS, which interfaces with Lawson to generate an itemized patient bill, deducts from our inventory and orders supplies according to par levels.
When physicians express interest in new products, our materials management staff is responsible for completing the New Product Request Form, which contains all pertinent information related to justification and costs, and presenting it to the Clinical Operations Committee. This approach has proven to be successful for Huntsville Hospital.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
We have three cardiology groups that utilize our cath labs: Alabama Cardiology, Huntsville Cardiovascular Clinic and The Heart Center. The Heart Center, our primary cardiology group of 28 physicians, has privileges at six smaller facilities in northern Alabama and south-central Tennessee, from which we receive numerous transfer patients and outpatient referrals. Our total number of cases has increased as well as the acuity levels.
Is your lab involved in clinical research?
We have participated in several studies and are currently involved with the ENDEAVOR stent study and the REVERSE ICD study with chronic heart failure (CHF) patients.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
Our emergency CABG rate is approximately .06%.
What other modalities do you use to verify stenosis?
The iLab (Boston Scientific) or the SmartWire are occasionally used to assess difficult stenotic lesions. Our labs are also equipped to diagram and compute lesions in stenotic vessels, but our physicians are highly experienced in interventional cardiology and are able to make those decisions without aid in the great majority of cases.
What measures has your cath lab implemented in order to cut or contain costs?
Our entire staff is very cost-conscious, including our medical director. The cath lab manager, materials manager, purchasing director and medical director, working together, have a maximum purchase price allowed to insure best price. If the company does not agree to these terms, their inventory is removed from the hospital. With this in place, along with a just-in-time (JIT) warehouse, and a well-trained staff that doesn’t open a product until it is ready to be utilized, we have seen a significant reduction in costs.
What type of quality control/quality assurance measures are practiced in your cath lab?
Hematomas, handwashing and physician documentation are three quality assurance measures that are practiced. All interventions are reviewed with data collected and quantified.
In March of 2005, the Heart Alert Program was initiated at Huntsville Hospital. ST-segment elevation in suspected myocardial infarction (MI) patients, diagnosed in the field by EMT personnel or in the hospital, sets a rapid-response sequence in motion. This 24-hour-a-day program involves a dedicated ER team, pharmacy, respiratory, the house supervisor, cardiologists and the cath lab. The goal initially was to have the door-to-device (balloon or stent) time less than 90 minutes. The goal now is to have this time less than 60 minutes. The average time for the last quarter of 2005 was 68 minutes.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
We have a strong presence in the area as the largest hospital in north Alabama and the primary hospital for The Heart Center, a group of 28 cardiologists who maintain offices at a number of facilities throughout north Alabama and southern Tennessee. We receive referrals from all of these facilities.
How are new employees oriented and trained at your facility?
Employees from outside the hospital system receive a general hospital orientation first. They also take a test to assess their basic cardiac knowledge. All new employees receive a cath lab orientation from our education coordinator, who schedules classes on an as-needed basis and assists the preceptor in skills and knowledge assessment. Each employee is precepted one-on-one by selected, experienced personnel for at least 120 days or until they are proficient in the scrub/monitor or scrub/tech position. Each employee is provided a copy of The Cardiac Catheterization Handbook by Morton Kern, MD and is encouraged to read it. Current state licensure/ ARRT is required.
What type of continuing education opportunities are provided to staff members?
The hospital has a variety of classes and seminars available to staff hospital-wide. The cath lab has monthly inservices sponsored by vendors and hospital personnel. They are held from 7 to 8 am one Wednesday per month, and cases start later that day. There is also a yearly cardiology conference organized by The Heart Center. All of our cath lab RTs and RNs are required to be ACLS-certified. These classes are provided by the hospital.
How do you handle vendor visits to your lab?
Product and pharmaceutical representatives are welcome to visit by appointment through our materials manager. Due to HIPAA guidelines, we require the representatives to follow corporate compliance policies and sign in with the pharmacy or purchasing department in order to pick up a vendor identification badge before entering the lab. Vendors are only allowed in the procedure rooms by physician invitation.
How is staff competency evaluated?
Staff competency is evaluated first at the 30-, 60- and 90-day periods during their probationary period, then annually unless a problem is noted during the interim. Evaluations are prepared and presented by the clinical coordinator and the manager.
Does your lab utilize any alternative therapies (such as guided imagery, etc.)?
We use no alternative therapies, though many members of our staff are adept at using empathetic touch and speech to calm and reassure our patients.
How does your lab handle call time for staff members?
The cath lab day shift staff is scheduled for call four times per month, which includes weeknights and a weekend (S-S) rotation approximately every 6“8 weeks. The evening shift is scheduled weekend call every 6“8 weeks. All cath lab personnel are scheduled for call one holiday per year. Call personnel are required to live within 30 minutes of the hospital or sleep on the premises while on call.
What trends do you see emerging in the practice of invasive cardiology?
An increase in the amount of multiple vessel stentings/staged procedures as opposed to sending these patients to surgery has been observed. We are also performing more peripheral procedures, such as carotid, superior femoral artery and aortic stenting in our labs.
Has your lab undergone a JCAHO inspection in the past three years?
Our hospital passed the JCAHO inspection in November 2005 and the cath lab did very well. The staff emphasis was on handwashing, time-out and charting details. The environmental emphasis was on clean/uncluttered work areas and in moving supplies from boxes to plastic bins. We also participate in unscheduled in-house surveys similar to JCAHO to assure continual compliance.
Where is your cath lab located in relation to the OR department, ER and radiology departments?
The cath lab is located on the third floor of the hospital with the OR located on the first floor. The ER and radiology are located on the ground floor.
Please tell the readers what you consider unique or innovative about your cath lab and its staff.
The physicians in The Heart Center group are divided into specialties. There are eight dedicated interventional cardiologists, three of whom are scheduled to work in the lab daily.
We have a dedicated team of people, from environmental services staff to physicians, who have care and respect for one another, and enjoy working together. Social events, such as the annual Christmas party or cosmic bowling, provide another way to get to know one another. One team leader devised a star award certificate that can be given to a staff member who does something special. Usually a piece of chocolate is affixed to the award. We consider the cath lab to be the best hospital department in which to be associated. Our staff is proud of the humanitarian contributions made to our patients within the hospital setting.
Is there a problem or challenge your lab has faced?
We have been faced with increasing callbacks, causing a burden on those call people who are scheduled to work the next day and staff in general. An additional call burden was realized when our facility switched to a primary PCI methodology, requiring even more callbacks. An informal phone interview was conducted by one of our RNs, who contacted comparable size/volume cath labs by searching an informal list of regional cath labs that we had on hand. Our interview consisted of questions like: what is your average call back per month, do you receive additional call pay, and are your employees scheduled to work the day following call. After compiling data, the ultimate result was incentive pay for those taking call and the creation of a night shift position in order to have an RN in-house at all times to respond to the after-hour cath lab procedures. One of our experienced RNs accepted the position. This change has resulted in reduced number of required call slots per month, as well as improved response time for off-hour door-to-balloon time. We have utilized this position by adding such duties as: validating current H & P of outpatients scheduled for the next day, reviewing inpatient charts for completion of all requirements for the procedure and taking appropriate action based on findings, reviewing labs and graft reports, assisting in maintaining adequate inventory in the department, and providing C-arm coverage for procedures in the unit as needed. The completion of duties by the cath lab night shift nurse prepares for the upcoming day and assures the prompt, seamless start of each day’s schedule.
What’s special about your city or general regional areas in comparison to the rest of the U.S.?
Huntsville, nicknamed The Rocket City, is located in north central Alabama in the foothills of the beautiful Appalachian Mountains. It is home to Redstone Arsenal and the Marshall Space Flight Center, which support a large high-tech, professional population. Huntsville Hospital is the largest non-governmental employer in the area. The Arsenal is home to the U.S. Space and Rocket Center, the top tourist attraction in Alabama. Its Space Camp program draws adults and children from all over the world. Other area attractions include numerous museums and historical sites; minor league and college sports teams; community music, theater, and dance leagues; touring Broadway shows, and big name concerts. This is small-town living with big-city amenities.
The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:
Do you require clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus/raise upon passing the exam?
The RCIS certification is not a requirement; however, we offer a 5% raise to the clinical staff that pass the exam. We currently have one RT who has received RCIS certification.
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 manager, Patricia Bailey, belongs to the SICP.
Patricia Bailey can be contacted at firstname.lastname@example.org