Kresge Cardiovascular Catheterization Laboratory, Frederik Meijer Heart & Vascular Institute, Spectrum Health

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Author(s): 

Ryan D. Madder, MD; David Wohns, MD, Medical Director Kresge Cardiac Cath Labs & Interventional Cardiology; Anne Beekman, BSN, RN, Manager Kresge Cardiac Cath Labs; Lynn Hanson; Diane Ivy Grand Rapids, Michigan

 

Tell us about your cath lab.

The Kresge Cardiovascular Catheterization Laboratory at the Frederik Meijer Heart & Vascular Institute has six adult catheterization labs and three electrophysiology (EP) labs. Our 56 staff members have varying credentials, including cardiovascular technologist (CVT), three of which have obtained their registered cardiovascular invasive specialist (RCIS) credential, registered nurse (RN), and radiologic technologist (RT). Staff averages 12 years of experience in the cath lab.

What procedures are performed at your cath lab?

We perform diagnostic catheterizations, percutaneous coronary intervention (PCI) (elective, primary, and high-risk interventions), biopsies, peripheral diagnostics and interventions, and advanced circulatory support procedures. We perform 6,061 cardiac and peripheral procedures per year.

 

Does your cath lab perform primary angioplasty without surgical backup on site?

No, we have open-heart surgery available on site.

Is your cath lab performing transcatheter aortic valve replacement (TAVR)?

We are involved in the Medtronic CoreValve trial here at Spectrum Health. The procedures are done in a hybrid OR room with a combined team of cath lab and OR staff.  We do recognize the need to develop more space for hybrid procedures and are working together as a system to determine if that will be in the OR, cath lab, or both.

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

Yes, some operators use the radial approach for all cases, even ST-elevation myocardial infarction (STEMI) work. Overall, we see about 30 percent of our coronary work done via radial access.

What percentage of your diagnostic caths are normal? 

Thirty-seven percent of our diagnostic caths are normal.

Does your lab have cross-training? 

Yes, staff works in other specialized teams such as pediatrics, peripheral, TAVR and EP. Most staff members seem to like the variety of performing all the roles. 

In the cath lab, one RN will be circulating and sometimes a second circulator will be a technologist. The majority of RNs scrub diagnostic and interventions, but a few do not scrub interventions.

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

No, it is not a requirement at our facility.

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?

Physicians perform all these activities in our lab.

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

We provide the basic protection such as lead aprons. We also have ZeroGravity systems (CFI Medical Solutions), generally worn by the operator. The cath lab is represented by a staff member in the hospital-wide radiation safety committee. This committee reviews staff and patient dose exposure. It also reviews policy related to radiation and helps educate on best practice.

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

We continue to see growth in advanced intracoronary imaging devices for coronary work.  Fractional flow reserve (FFR), intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared spectroscopy are common tools used in the rooms. Another area of considerable growth has been the technology around advanced circulatory support. We have considerable experience with Impella (Abiomed), TandemHeart (CardiacAssist), and CentriMag (Thoratec) for patients in cardiogenic shock and for supporting high-risk coronary interventions. We also provide cooling protocols for patients presenting to the lab after cardiac arrest.

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

We have several ways to communicate to the team. One of the most effective groups has been an interventional sub committee that meets monthly. This has been a very effective way to involve physicians in both clinical and business decisions. We also hold a weekly case conference, monthly blinded review of routine work done in the lab, quality meetings for acute MI, and division and staff meetings monthly.  If we are implementing a focused change, this is often handled with in-lab education for staff and physicians.

How is coding and coding education handled in your lab?

We do not offer coding education for the staff, but do get documentation feedback from the coders and adjust our documentation tools accordingly.

Where are patients prepped and recovered?

Patients are prepped in our prep and recovery unit. This unit has 24 private rooms and is staffed by nurses and technologists. Once the sheath is removed, manual pressure is the most common way we manage the site. We do see closure devices, but they are more commonly used with interventional cases.

Who pulls sheaths post procedure, both post intervention and diagnostic cases?

All radial sheaths are pulled in the room. Other lines are removed in the 24-bed pre and recovery area, or on the inpatient cardiac unit. Generally, our sheaths are pulled by technologists. Staff receives an eight-hour class on sheath removal and then must be signed off on a minimum of 10 pulls to be independent.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

Our inventory is managed with Pyxis machines (CareFusion). The machines are able to track pars, product turns, expiration dates, drop charges directly to our charge master, and create purchasing requests. The system is managed by our equipment coordinator, Kathy Flynn, and she is assisted by Bob Karam from the supply chain team.

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

Our coronary work has declined. However, that decline has been offset by growing needs in EP.

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? Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance?

Our average D2B time is 53 minutes. We are doing several things to continue to reduce these times. We currently staff the cath lab 24/7 Monday am to Friday pm. We then staff an on-call system for the weekends. We use logs so staff can clearly see any step that exceeds our time goal. We also have staff members on our acute MI quality team, so we can continue to coordinate our efforts with the emergency room (ER). We currently participate in AHA’s Mission: Lifeline. Denise Busman is the clinical nurse specialist for the lab, participates in the National Science Advisory Task Force, and is on the Michigan Lifeline Steering Committee.

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?

We staff the cath lab Monday from 6 am to Friday 8 pm with an in-house team. The remaining weekend hours are staffed by an on-call team. The team consists of two RNs and two CVTs.  

How long has your 24-hour coverage during the week been in place?

We have had it for the past five years. The staff loves it. The reduced call time and reduction of staff shortages after a busy night have been tremendous positives for everyone. We saw benefits in safety for the staff from reduced fatigue, reduced turnover of staff, elimination of next-day schedule disruptions and increased staff satisfaction for the day team. Other benefits the night shift adds are well stocked and organized rooms, reviewing of documents for quality and charging, equipment checks, and support for other floors in the hospital with site or sheath questions during the off shifts.

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

Thirty minutes.

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

The ER and emergency medical services (EMS) transport the patient to the cath lab during both regular and off hours.

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

We have four staff on call, so one person will go and open up another room. We use the in-patient areas to help with transport. We are actively working on creating a second back-up STEMI team. Even though the volume of STEMI is stable, the length and complexity of STEMI cases is creating greater risk of a competing need.

Do you have flextime or multiple shifts?

Yes, we offer 8-, 10-, and 12-hour shifts.

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

With the growth of radials, we saw an increase in table resets. We redesigned the process of opening equipment, requiring a confirmation regarding access site from the proceduralist prior to opening product, and have created a savings of about 38K per year. We also implemented a product review at the end of the case to validate accurate charges. This double check is new, so we are not sure of the results yet.

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

Like other labs, we follow many quality control tasks to ensure the equipment is current and ready to use. For quality assurance, we focus on activities that are shown to enhance safety. Examples are audits of labeling on the sterile table, procedural time outs, handoffs between departments, and practicing safety behaviors such as double checks. Although these actions seem simple, consistent monitoring, in our experience, is the only way to hardwire the behavior.


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