Manatee Memorial Hospital

Author(s): 

Srinivas Iyengar, MD, Clinical Attending, Bradenton Cardiology Center; Paula Jefferson, RN, BSN, Director, Manatee Heart & Vascular Center; Bradenton, Florida

Tell us about your cath lab.

The Manatee Heart & Vascular Center has one coronary lab, two coronary/peripheral labs, an electrophysiology (EP) lab and a 12-bed holding area for pre/post cath. Staff includes 10
registered nurses (RNs), 6 cardiovascular technologists (CVTs), and 1 radiologic technologist (RT). Experience level ranges from a minimum of one year to 15 years, with a mean experience level of 5 years. Approximately 32 physicians use our interventional labs.

We have 4 Philips labs (Philips Healthcare, Bothell, Wash.). The Philips Allura FD 20 cardiovascular lab utilizes state-of-the-art flat-panel digital detector technology, which provides excellent image resolution. The EP/ablation lab utilizes the EnSite NavX Navigation & Visualization Technology (St. Jude Medical, Minnetonka, Minn.), which facilitates
procedures by creating realistic cardiac chamber sizes and guiding precise catheter movement. Intravascular ultrasound (iLab, Boston Scientific, Natick, Mass.) is also available in each room as well.

Technology (St. Jude Medical, Minnetonka, Minn.), which facilitates procedures by creating realistic cardiac chamber sizes and guiding precise catheter movement. Intravascular ultrasound (iLab, Boston Scientific, Natick, Mass.) is also available in each room as well.

What procedures are performed at your cath lab?

We do diagnostic cardiac caths, percutaneous coronary interventions (PCIs), peripheral angiograms, peripheral percutaneous transluminal angioplasty (PTA)/stent/atherectomy, inferior vena cava (IVC) filters, EP procedures [implantable cardiac defibrillators (ICDs), pacemakers, ablations], and endovascular abdominal aortic aneurysm (AAA) repairs (EVAR, or endovascular aneurysm repair). Surgical backup is available for all emergencies.

On average, the lab is performing 20-30 cardiac caths per week, 10-12 EP procedures, and 10-15 peripheral procedures. In 2009, we performed:

• >1400 total heart caths;

• >600 PCIs;

• >460 peripheral interventions;

• >430 EP procedures.

Since the opening of our new heart center in June of 2009, in the last seventeen months, we have performed >200 EP ablations (including atrial fibrillation/atrial flutter/ventricular tachycardia (v tach)), >750 peripheral PTA/stents (both lower extremity and carotid), and >75 EVARs.

Who manages your cath lab?

Paula Jefferson, RN, BSN, is director of the Manatee Heart & Vascular Center, Nancy Vilomar, RN, MBA, MSN is the nurse manager, and Sheri Sanford, RN, is supervisor.

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

All staff is cross-trained to do all jobs. All team members scrub, nurses circulate, and all team members monitor, based on staff mix.

How many diagnostic cath patients go on to have an interventional procedure and how many are normal?

Using a four-quarter data collection summary, 66% of our diagnostic cath procedures required intervention. Non-obstructive disease was found in 32%.

What percentage of your patients is female?

Twenty-three percent (23%) of our patients are female.

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

Yes, Dr. Iyengar. He utilizes a standard micropuncture needle/kit for initial access. Then a Terumo hydrophilic 6 French (F) sheath is introduced into the artery. A cocktail of 200 micrograms of NTG and 2000 U of heparin is given slowly through the sheath.
Use of radial access for interventions has been actively been used for the last 15 months. Post procedure, patients will have a radial band placed by lab staff while in the lab, which is then slowly unbuckled at 20 minute intervals in the holding bay by the holding bay RNs.

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

Only physicians are permitted to operate fluoro during 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?

Physicians step on the pedal, and all team members are trained in other areas.

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

We have annual education for all team members and dose monitoring.

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

We have regular committee and staff meetings, i.e., there are CCU, chest pain, congestive heart failure, and stroke committees, which report to medical executive staff and the nurse executive committee. There are regular staff meetings and educational forums provided by vendors and education staff.

How is coding and coding education handled in your lab?

It is a shared responsibility between the cath lab and medical records.

Where are patients prepped and recovered, and how does your lab handle hemostasis?

Patients are prepped and recovered in our pre and post holding area, a 12-unit area adjacent to the cath lab. We utilize all types of closure devices [Perclose (Abbott Vascular, Redwood
City, Ca.), Starclose (Abbott), Angio-Seal (St. Jude Medical), Mynx (AccessClosure, Inc., Mountainview, Ca.) and perform manual compression. The staff is trained and competent in recognizing issues related to post-cath possible complications and their manifestations.

What is your lab’s hematoma management policy?

We use close observation with a collaborative effort and review with physicians.

How is inventory managed at your cath lab?

This is also a shared responsibility between the cath lab and purchasing department. Our inventory management system is SpaceTrax (InnerSpace Corporation, Grand Rapids, Mich.).

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

The hospital recently built a new heart and vascular center. It is 17,000 square feet and includes 3 cath labs, 1 EP lab, a 12-bed pre and post holding area, a procedure room for transesophageal echocardiograms (TEEs) and cardioversions, an echo department, nuclear medicine, a conference room with closed circuit viewing of procedures in the cath labs (a 52-inch HD screen) and a large waiting room.

Do you have a hybrid cath lab?

We have a lab specifically designed with the Philips Allura FD 20 imaging equipment. This lab also contains air-flow ventilation consistent with current OR practices and standards. Additionally, a mobile GE anesthesia unit (Waukesha, Wisc.) is available and is readily employed with full backing of the hospital anesthesia department.

Is your lab involved in clinical research?

Yes, Dr. Iyengar and Dr. Gino Sedillo are both involved in research. Currently, both the OSPREY trial (Terumo) and SUPRERA trial (IDEV Technologies) are ongoing [both trials are examining the use of bare-metal stent technology in superficial femoral artery (SFA) disease].

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

We had two patients requiring emergent surgery in the past year.

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?

Using data compiled from the year 2009, our average D2B time is 65 minutes. Direct EKG transmission from emergency medical services (EMS) to the emergency room (ER) physician has saved time and allowed, occasionally, direct transport to the cath lab. Our ER team has put together a ST-elevation myocardial infarction (STEMI) Alert box. When opened, it contains needed meds and flow sheets. This allows for prompt patient treatment, along with accurate event recording. After hours, our on-call staff is alerted by a one-call paging system. There is also a dedicated procedure room equipped and ready for the incoming emergency. We are currently registered with the American Heart Association’s Mission: Lifeline.

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

We are part of a group purchasing organization (GPO), do bulk purchases and have sole-source vendors.

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

All complications are monitored and trended. The Chest Pain Committee monitors all STEMIs. We do submit to the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) and the ACTION-Get With The Guidelines (GWTG) Registry.

How does your cath lab compete for patients?

We do advertisements in all media, community outreach, and direct marketing to physicians and the community.

What continuing education opportunities are provided to staff members?

We do a monthly “lunch and learn,” offering CEUs to staff.

How do you handle vendor visits to your lab?

All vendors must be registered with Status Blue (Marietta, Georgia) and get a badge in the lobby before going to any work areas. Vendors are not allowed unless they have a scheduled appointment or case.

How is staff competency evaluated?

Staff is evaluated annually for performance with competency based orientation. Continuing education and in-services are ongoing.

Does your lab have a clinical ladder?

No.

How does your lab handle call time for staff members?

We have three team members on call 24/7, and at least one member is an RN. All team members are expected to arrive within 30 minutes of being paged.

Do you have flex time or multiple shifts?

Staff is flexed as needed.

Has your lab has undergone a Joint Commission inspection in the past three years?

Yes, the last Joint Commission survey was two years ago. We are in constant Joint Commission preparedness. National Patient Safety Goals are evident throughout our practice.

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

The elevators to the OR are located adjacent to the cath lab. The emergency room is on the same floor.

How do you see your cardiac catheterization laboratory changing over the next few years?

We expect to expand our service line to offer percutaneous cardiac valves and more extensive neuro-interventional procedures.

Is there a problem or challenge your lab has faced?

Currently, with our new heart and vascular center, we have had no major issues regarding safety or equipment. Staffing has remained consistent and physician relationships collegial.

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”?

Florida, and specifically, Bradenton, is known to have a large retiree population, and with this group also comes a number of patients with established CAD/PVD. This places us in a unique position to aggressively address advanced cardiac/vascular disease on a daily basis, with the latest cutting-edge technology.

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

1. 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?

No.

2. 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?

We have staff and management team members involved with the American College of Cardiology, Chest Pain Society, American Heart Association, and Florida Organizations of Nurse Executives.

New! A question from the National Cardiovascular Data Registry:

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

Outcomes reports are reviewed at Chest Pain Committee meetings with collaborative practices to improve processes and indicators. PCI performance measures and data quality metrics are all reviewed. Recommendations for process and quality improvement are discussed. The Chest Pain Coordinator tracks and trends variances concurrently for improvement.

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The authors can be contacted at Paula.Jefferson@mmhhs.com
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