Saint Joseph's Hospital Cardiac Cath Lab

(From left to right) Front row: Feneca Carter, RCIS, Aazam Bayat, CVT, Les Evans, RT(R)(CV). Second row: Greg Messina, RN, BSN, RCIS, Dr. Lieppe, Victoria Silva, CVT, Clarence Pinkston, RN, Alan Bauer, CVT, Greg Holtz RT(R)(CV).
EmmyLou Mercado, RN, BSN, CCRN.
Beth Collins, RN, BSN, CCRN and Tara Hicks, RCIS.
Mike Robinson, Cardiac Aide.
Deryck Yarde, RN, BSN, CCRN, Cath Lab Manager.
Some of our Admission Recovery Unit staff. Seated, from left to right: Joan Stultz, RN, Gloria Morandarte, RN manager, Gail O’Neill, Unit Secretary. Second row, seated: Lynda Michaels, RN, Regina Freeman, CVT,  Novlette Henry-Small, RN,  Back row: Elain
Dr. Marc Unterman, explaining the findings of the case to the patient.  Yvonne Love, our most senior CVT, is assisting.
Dr. Jack Chen.Dr. Jack Chen performing a catheterization via the radial artery. Greg Messina, RN, BSN, RCIS, assisting.
Dr. Aman Kakkar, happy to be working in the cath lab.
Marilyn Norman, CVT, up to no good, as usual!
I love my job!
Cath Lab Scheduling Specialists Carol Forts and Valerie White.
Admission Recovery Unit staff hard at work.
(From left to right) Front row: Yvonne Love, CVT, Dr. Marc Unterman, Molly Emmanuel, CVT, Dr. Mike Lipsitt, Kim Vriend, RN, Gary Goff, CVT. Second row: Victoria Silva, CVT, Alan Bauer, CVT, Greg Messina, RN, BSN, RCIS, Carol Best, CVT, Tiffany Williamson,
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.


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