Saint Joseph's Hospital Cardiac Cath Lab

Author(s): 

Deryck Yarde, RN, BSN, CCRN, Manager, Cardiac Cath Lab,
Haleh Eskandari, RN, MSN, CCRN, RCIS, Clinical Educator, Cardiac Cath Lab, Atlanta, Georgia

What is the size of your cath lab facility and number of staff members? Our cath lab consists of seven cath lab suites, including one peripheral lab, two dedicated electrophysiology (EP) labs and one electrophysiology (EP)/cath lab, and one biopsy lab. We have 11 registered nurses (RNs), 14 cardiovascular technologists (CVTs), two radiology technologists (RTs), and four registered invasive cardiovascular specialists (RCISs). We also have 1 educator and two transporters. Two RNs also hold RCIS and CCRN credentials. We have several staff members with 10-15 years of experience in Saint Joseph’s Cath Lab. We also have two nurses in orientation.

What types of procedures are performed at your facility? Our cath lab performs diagnostic and interventional procedures. Diagnostic procedures include right and left heart catheterization, Swan-Ganz insertion, coronary and peripheral intravascular ultrasound, WaveWire™ (Volcano Therapeutics, Inc., Rancho Cordova, CA), carotid arteriograms, peripheral arteriograms and runoffs. Interventional procedures include coronary and peripheral angioplasty and stent implantation, rotational atherectomy, directional atherectomy, intra-aortic balloon pump (IABP) insertion, and thrombectomy. We also perform cardiac biopsies pre and post transplant (including fresh transplants), and tilt table tests. We perform approximately 201 procedures per week, including peripheral procedures. Our peripheral volume in 2007 was 430 patients.

Does your cath lab perform primary angioplasty with surgical backup? Our cath lab performs primary angioplasty with surgical back up. The cardiothoracic OR receives daily schedules from the cath lab and they are aware of the number of procedures that are scheduled in the cath lab. If there is an emergency situation and the patient requires immediate surgery, the surgeon will arrange to have the OR receive the patient emergently.

What procedures do you perform on an outpatient basis? All diagnostic caths, biopsies (except for fresh transplants), diagnostic and interventional peripheral procedures (except carotid stent patients).

What percentage of your patients are female? In 2007, 33% of patients were female.

What percentage of your diagnostic cath patients go on to have an interventional procedure and what percentage of your diagnostic caths are normal? In 2007, 19% of patients who came in as cath/possible PCI had an intervention done. Eight percent of diagnostic caths were normal.

Who manages your cath lab? The manager of the cath lab is Deryck Yarde, RN, BSN, CCRN. He has 19 years of nursing experience and nine years of cath lab experience. Deryck reports to Tony Petrillo, RN, Director of Invasive and Non-Invasive Cardiology.

Do you have cross-training? Who scrubs, who circulates and who monitors? All staff are cross-trained to perform all roles. We do have several newer CVTs who only perform monitoring and scrubbing, but the goal is to have all staff able to perform all three roles.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No, an RT does not have to be present in the room for all fluoroscopic procedures.

Which personnel can operate the x-ray equipment in your cath lab? All personnel can operate the x-ray equipment in our cath lab, i.e., position the II, pan the table, change angles, and step on the fluoro pedal.

How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day? Our physicians wear lead, most wear lead glasses and some use added lead arm sleeve to protect the long bone of the arm closest to the x-ray source. Each room has a lead shield hung from the ceiling to cover the image intensifier/flat detector and lead aprons that hang from the table to cover the x-ray source. Also all staff and physician use radiation badges, monitored monthly by the hospital-wide and department radiation safety officers. If there is too much exposure, the staff or physician will receive a letter and have to meet with the Hospital Radiation Safety Officer to go over ways to decrease radiation exposure. The radiation badge reports are posted in the staff lounge and provided to the physicians. The staff is required to take a radiation safety test annually as part of their credentialing process. The cath labs are inspected each year by an outside company to measure the amount of x-ray produced by the C-arm. All lead aprons are inspected bi-annually to assure that they are in working condition and any found to have cracks or holes are replaced as needed.

If your lab performs peripheral interventions, what disciplines are involved? Do interventional radiologists and cardiologists perform procedures in the same area? Cardiologists perform both coronary and peripheral interventions. We do have vascular surgeons who perform peripheral procedures in the cath lab. Interventional radiologists perform their procedures in the special procedure department.

What are some of the new equipment, devices and products introduced at your lab lately? We have just upgraded our intravascular (IVUS) machines to Volcano’s newest IVUS platform with Virtual Histology. We also have started to do atrial septal defect (ASD) (Amplatzer, AGA Medical Corp., Minneapolis, MN) and patent foramen ovale (PFO) closures (CardioSeal, NMT Medical, Boston, MA). We have the NOGA cardiac mapping system (Biosense Webster, Johnson & Johnson Corp, Diamond Bar, CA) installed to assist with research for chronic end-stage chest pain.

Can you describe the system(s) you utilize and how they work in cath lab daily life? We have six Philips (Bothell, WA) digital cath labs and one (1) Siemens (Malvern, PA) lab. One of the Philips rooms is primarily a peripheral room with a 15” image intensifier and digital subtraction. Other labs are able to accommodate renals and iliacs when subtraction is not required.

How is coding and coding education handled in your lab? Our cath lab has a product specialist, Chuck Naylor, who handles charge capture and coding. He communicates with the finance department for all coding-related issues. All new product information is sent to coding specialist to have a service code assigned and placed on the Charge Master. The coding specialists will then notify Chuck, who will put the new equipment or procedure on the charge sheet. The charge sheet is periodically updated to add or remove any procedure or equipment.

How does your lab handle hemostasis? Patients are either transferred to our Admission Receiving Unit (ARU)/ Discharge Recovery Unit (DRU) or to telemetry beds in the hospital. Both manual and mechanical compression is used for sheath removal, and we use the D-Stat hemostatic patch (Vascular Solutions, Minneapolis, MN) in combination with manual and mechanical pressure. If the patients are transferred to the ARU, the nurses who receive the patients are responsible for sheath removal, which is performed either by the nurse or the patient care technicians. We also have two sheath pullers who are responsible for sheath removal post procedure if the patient is transferred to an inpatient bed. We also use Angio-Seal (St. Jude Medical, Minnetonka, MN), Perclose Proglide (Abbott Vascular Devices, Redwood City, CA) and Starclose (Abbott Vascular) following the procedures for vascular closure.

What is your lab’s hematoma management policy? We do not have a set hematoma management policy; we strive not to have any hematomas following sheath removal! We do have sheath pullers for the whole house who have been trained extensively by our ARU/DRU staff and the clinical educator for safe and effective sheath removal, as well as to free the nurses on the floors to provide better patient care.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Product specialist Chuck Naylor is in charge of inventory management. We have a manual system of ordering, which will be changed to an automated inventory management system (Lawson, St. Paul, MN) in 2008. Chuck handles purchasing of equipment and supplies with the approval of the department director, Tony Petrillo, RN.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future? We have recently added a new biplane EP lab, which can double as a cath lab, and we are redoing the other two EP labs. We have also recently added 17 beds to our ARU/DRU department.

Is your lab involved in clinical research? Yes. The Saint Joseph’s Research Institute (SJRI) is very active in pre-clinical and clinical cardiovascular research. Nicolas Chronos, MD, the President/CEO of SJRI, is an invasive cardiologist who practices in our cath lab. Dr. Chronos actively recruits new studies.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Unfortunately, yes. Our patient population is high risk with multiple comorbidities.

Can you share your lab’s average door-to-balloon (DTB) times and some of the ways employees at your facility have worked together to keep DTB times under the mandated 90 minutes? For the year 2007, 84% of the patients who came in with a ST-elevation myocardial infarction (STEMI) diagnosis had interventions done under 90 minutes. Average DTB time is 69 minutes. When the patient is brought in the emergency room (ER) with active suspicious cardiac symptoms, an ECG is performed within 5 minutes of arrival. Some of the EMS ambulances are equipped with 12-lead ECG which can be transmitted to the ER prior to the patient’s arrival. The ER physician activates the cath lab team as soon as a STEMI is identified, using a one-call paging system. All cath lab staff carry a pager individually assigned to them by the hospital which is included in this one-call system. The manager and clinical educator also carry pagers included in this system. The ER physician then pages the interventionalist on call to accept the patient. If it is during off hours, the cath lab staff is required to respond within 30 minutes of the page.

What other modalities do you use to verify stenosis? We use Volcano IVUS with Virtual Histology and WaveMap to further assess stenosis. It does not affect cash flow since it is bundled in our procedure cost.

What measures has your cath lab implemented in order to cut or contain costs? We have gone to one vendor for our cath packs, drapes and gowns. We have established par levels for each interventional product available.

What type of quality control/quality assurance measures are practiced in your cath lab? We run quality control on the Hemochron ACT machines and the whole blood oximeter daily. We have performance improvement initiatives regarding room turnaround time, wait times, expired products, DTB times, medication administration and documentation.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Atlanta has a very competitive market. We have the state-of-art x-ray equipment and technology to keep our physicians committed to bringing their patients to our cath lab. As Atlanta’s only Magnet hospital, we provide high-quality nursing care for all of our patients on a daily basis, which keeps patients coming back to Saint Joseph’s Hospital when need arises.

How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? Each new employee, RN or CVT, goes through 90 days of orientation. This includes didactic and hands-on training. The didactic portion of the orientation covers coronary anatomy and angulations, hemodynamics, pharmacology, medication calculation, radiation safety, ECG rhythm recognition and 12-lead interpretation, patient assessment and cardiovascular disease states. The new employees are required to complete this didactic portion and take a comprehensive test to assess their grasp of the theory. They will then be paired with a preceptor who will train the employee in scrub, monitor and circulating roles. All staff member must be BLS- and ACLS-certified. CCRN and RCIS certification is strongly recommended.

What type of continuing education opportunities are provided to staff members? There are many forms of continuing education available to the staff. There are vendor-sponsored in-services in the cath lab, and the hospital provides free online CEU opportunities. Staff are encouraged to attend conferences.

How do you handle vendor visits to your lab? We are revising our vendor policy at this time. The vendors are allowed in the cath lab only on their assigned days, unless requested by the physician for the use of specific equipment, such as peripheral or carotid interventions.

How is staff competency evaluated? All staff are required to take yearly competency tests developed by the clinical educator and must attend a credentialing session in which they are required to demonstrate competency in performing sheath pull, IV insertion, equipment use, codes, and pacemakers and special equipment used in the cath lab (such as Rotablator [Boston Scientific, Natick, MA], AngioJet [Possis Medical, Inc., Minneapolis, MN], IVUS, ComboMap and IABP).

Does your lab have a clinical ladder? Our cath lab has a clinical ladder system that mirrors the hospital’s clinical ladder. There are three levels in this system: Level I is the base level where every employee is hired in. They are required to maintain 12 hours of continuing education per year, and assist in data collection for performance improvement and quality analysis processes. Level II is the middle level, in which the staff member is required to maintain 18 hours of continuing education, participate or lead a performance improvement project, and provide an inservice for the staff (includes presentations, equipment review, or instructor in the Credentialing Day). Level III is the highest level, in which the staff member is required to hold a certification (either RCIS or CCRN). They are also required to maintain 24 hours of continuing education, lead a comprehensive performance improvement project, and provide two inservices for the staff. A level III staff is considered a mentor and resource for the staff, is required to be competent and proficient in the performance of all three roles, and must be able to expertly utilize all equipment in the cath lab.

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? We have three staff members on call each day and on the weekend. This must include one RN. The other two staff members may be CVTs or RNs. If there are two CVTs, one must be able to circulate. Our call schedule is nine weeks, and the amount of days each staff has to be on call varies due to staffing. We have self-scheduling for call. The staff gets paid $4/hr for carrying the pager when on call. If they come in to do a case, they are paid time and half, plus one hour drive time and case incentive.

Within what time period are call team members expected to arrive to the lab after being paged? Our goal is to have two staff members in the lab 30 minutes from time the STEMI page is initiated. There is no attending cardiologist on call after hours. They are expected to arrive when they are paged.

Do you have flex time or multiple shifts? Our shifts consist of 8-hour, 10-hour and 12-hour shifts.

Does your cath lab do electives on weekends and or holidays? We do not do elective cases on weekends or holidays. We do, however, perform many emergency procedures on weekends and holidays.

Has your lab has undergone a Joint Commission on Accreditation of Healthcare Organizations Inspection (The Joint Commission) in the past three years?We were inspected by The Joint Commission in June of 2006. Our recommendation is to keep the cath lab clutter-free, and make sure that all medications are secured properly. Also, make sure that Time Out is done correctly, and two patient identifiers is used for each patient.

What do you find challenging regarding your department’s physical layout? The cath lab is too spread out, and we have one lab which is very small.

Where is your cath lab located in relation to the OR and ER? We are across the hall from the OR and down the hall from the ER.

What trends do you see emerging in the practice of invasive cardiology? The emergence of new drug-eluting stents (DES) will hopefully lower the price on the existing DES. We see a decrease in the number of patients making repeat visits to the cath lab because of the emphasis on preventative cardiology, especially the increased length of anti-platelet therapy to decrease late stent thrombosis. Patients are also savvier regarding their care, ask more questions and are more involved.

What do you consider unique or innovative about your cath lab and staff? What is unique about our cath lab is the cohesive relationship between CVTs and RNs. There is no division between them; they perform the same jobs and they work as a team to care for our patients. We have been involved in live cases with the Transcatheter Cardiovascular Therapeutics (TCT) meeting and American College of Cardiology Scientific Sessions. We are always on the forefront of new technology, and our physicians are extremely skilled and talented in their care of patients.

Is there a problem or challenge your lab has faced? The opening of new open heart programs and C-Port programs (facilities that perform interventional procedures without having surgical backup at the hospital) has somewhat decreased our census. But we rely on Saint Joseph’s stellar 125-year reputation of excellent and compassionate care of our patients.

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”? Atlanta is home to many exciting opportunities for work and play. This is why it is sometimes called the “Capital of the South.” It is also very culturally diverse since there are people of many different ethnic backgrounds. It is the birthplace of the civil rights movement, and home to the Martin Luther King Jr. Center. We have the world’s largest aquarium; many cultural events such as the Atlanta ballet and symphony; the Fabulous Fox Theater; Georgia Youth Symphony Orchestra; professional sporting teams such as Atlanta Falcons, Atlanta Braves and Atlanta Hawks and now the WNBA Atlanta Dream. We have many top-notch colleges and universities in the area. We host the annual Peachtree Road Race on July 4th. If outdoors is what you are looking for, you can spend the day at the Stone Mountain Park and watch the fabulous Laser Show where Elvis dances across the mountain! There are also many parks and nature preserves such as Calloway Gardens, Atlanta Botanical Gardens and Piedmont Park. If you are a fan of hiking, the beautiful north Georgia mountains are a fabulous place to spend the weekend, and explore the outdoors in the clean, crisp weather. You can ride the Blue Ridge scenic railroad on the 26-mile scenic mountain from Taccoa River to McCaysville to Copperhill, Tennessee, where you can get out and shop for unique arts and crafts. This makes our cath lab very culturally diverse and helps us understand the intricacies of caring for patients who may be of different cultures. It also makes for a wonderful potluck!

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)? Do staff receive an incentive bonus or a raise upon passing the exam? We are starting to require clinical staff to take the registry exam for RCIS. To help them accomplish this, senior staff is conducting RCIS review on the weekend for all interested staff. All registered staff will receive a raise upon passing the exam.

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 several staff that are members of SICP.

 

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