The Salem Hospital cath lab shines with its award-winning care, low employee turnover and new state-of- the-art facilities. Located in Salem, Oregon, the Salem Cardiovascular Center cath lab at Salem Hospital serves more than 360,000 people in a two-county region, and still more from the Pacific coast to the Cascade Mountains.

Tell us about your cath lab.

   The cath lab completed a move last year to a new $220-million patient care tower. The cath labs are now 30 percent larger and have convenient overhead booms so medical teams can move about easily with the latest in technology at their disposal.

   We have seven rooms that are 650 square feet each. All rooms are multi-purpose and can be used for almost any procedure. Included are two electrophysiology (EP) rooms, two cardiac cath labs, one vascular studies room, one outpatient cardiac cath lab and one combination cath lab/OR room — the hybrid suite. We also have 14 beds in the prep and recovery unit designated for cath lab patients.

   Our outpatient cath lab handles diagnostic cardiology and diagnostic vascular procedures. The hybrid suite is predominately used by vascular surgeons, who combine vascular surgery and angiographic procedures. We often schedule abdominal aortic aneurysm (AAA) stents and arteriovenous (AV) fistula revisions in the hybrid suite. For example, by doing our AAA stent grafts via the femoral artery in the combination cath lab/OR room, we can go from a closed procedure directly into an open procedure without needing to move the patient if a complication arises.

   Staffing the cath lab are ten registered nurses (RNs), 16 radiologic technologists, one unit clerk, one scheduler, and one charge capture specialist. Because we have expanded in the last five years, we have newly hired team members along with a majority of dedicated staff who have been with us on average more than 18 years, with one team member going on 30+ years.

What procedures are performed at your cath lab?

   On average, we perform 15–25 cardiac or interventional procedures per day and 125 per week. Salem Hospital’s cath lab services include right and left heart catheterizations, assessment and diagnosis of pulmonary hypertension with drug reactive testing, lesion assessment using intravascular ultrasound (IVUS), and pressure wire. Our interventional procedures include percutaneous transluminal coronary angioplasty (PTCA) and stent placement, thrombectomy using aspiration catheters, use of distal protection devices, pericardiocentesis, temporary pacer insertion and balloon pump therapy.

   We also have an active EP lab where we do EP studies and ablations with 3D mapping, as well as place implantable cardiac defibrillator (ICDs), biventricular ICDs, and pacers.

   Our interventional radiology lab handles arteriovenous (AV) shunt angiograms with PTA and declots, chest tube placement, intravenous cholangiogram (IVC) filter placement, aorta-grams with runoffs, tunnel cath placement and repair, temporary dialysis catheter placement, Port-a-Cath (Smiths Medical, Dublin, OH) placement, peripherally inserted central catheter (PICC) lines, nephrostomy tubes, ureteral stents, renal angiograms and stents, peripheral angiograms and stents, atherectomies using Silverhawk (ev3, Inc., Plymouth, MN) and Diamondback (Cardiovascular Systems, Inc., St. Paul, MN) devices, tissue plasminogen activator (tPA) infusion therapy for peripheral vascular disease (PVD) and clots, cerebral angiograms, carotid stents, G and J tube placements, cholangiograms and tube placement, uterine embolizations, and embolization procedures that include coiling, AAA stent grafts and AV fistula revisions.

   Last year, we celebrated 20 years of performing open-heart surgeries and currently complete more than 400 a year.

Does your cath lab perform primary angioplasty with surgical backup on site?

   Yes. Although Salem Hospital has a highly experienced cath lab team, we do not perform primary angioplasty without surgical backup readily available. If there is a complication during regular cath lab hours, we have an in-house surgical team on site. We have an on-call team available 24/7 for after-hour emergent cases.

What percentage of your patients is female?

   This year and for the past five years, 43 percent of our patients are female.

What percentage of your diagnostic cath patients goes on to have an interventional procedure and what percentage of your diagnostic caths are normal (i.e. disease-free)?

   About 35 percent of our diagnostic catheterization patients undergo a percutaneous coronary intervention (PCI) and about ten percent go on to have open-heart surgery. That results in approximately 55 percent of our diagnostic catheterization patients being normal.

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

   No, not routinely, but we are seeing an increase in radial artery access.

Who manages your cath lab?

   Bryan Sprague, RT(R) is our cath lab supervisor. He was an RT(R) for 20 years in the Salem Hospital cath lab prior to becoming the lab supervisor. Our lead tech is Rocky Faren, RT(R), RCIS, and Katina Hatzantonis, RN, is our lead nurse. Lori James-Nielsen, RN, is our director of cardiovascular services. Lori has worked in the cath lab and also helped start the electrophysiology program.

Do you have cross-training?

   Yes. Our technologists scrub, control and circulate with each case. RNs circulate, sedate and monitor, but currently do not scrub in with the physician.

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

   Currently, we use two RT(R)s for all fluoroscopic procedures — one to scrub and one to control the x-ray.

Which personnel can operate the x-ray equipment in your cath lab?

   Only RT(R)s or physicians are allowed to operate x-ray equipment, such as panning, positioning the table and stepping on the flouro pedal.

How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?

   To reduce our radiation exposure, we use lead aprons, RadPads (Worldwide Innovations & Technologies, Inc., Kansas City, KS) and lead shielding. In addition, Salem Hospital employs a radiation safety officer who checks equipment and monitors radiation exposure of staff, physicians and patients.

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

   When we designed the new space, we furnished the cath and EP labs with state-of-the-art equipment. Our community has been taken care of quite well, in part due to the excellent equipment and new products we have. We were the second hospital in the country to receive the Philips AD20 x-ray machine (Bothell, WA). Most recently, we had intravascular ultrasound (IVUS) and pressure wire monitoring integrated into our systems for ready, tableside access.

Can you describe the systems you utilize to organize staff and communicate necessary information?

   We have several means of communication at the lab. Our specialty practice team (SPT) concentrates on patient satisfaction and best-practices projects. The SPT discusses ideas for improvement and shares those ideas with other staff members. Recently, the SPT educated all hospital departments on sheath pulling best practices, with the goal of being more consistent hospital-wide.

   We also have monthly staff meetings, education events and a Journal Club intranet site, where we share recently published research and articles.

How is coding and coding education handled in your lab?

   We have a full-time coding specialist, Chris Bryan, who reviews our cases, does the coding for patient procedures, conducts current procedural terminology (CPT) code reviews and educates the team on coding. She is a resource for our physicians and interfaces with our Health Information Management department. If Chris sees an issue, she brings it to our staff meeting for education and discussion.

How does your lab handle hemostasis?

   Patients are closely monitored for hemostasis in our prep and post-surgical recovery area. This system provides consistent groin management and prevents patients from multiple transfers. In most cases, we use a C-clamp to stop bleeding from a sheath pull. However, our technique is always based on an individual’s anatomy, anxiety level, comfort level and their ability to comply with extremity restriction. In certain cases, we use manual pressure or FemoStop (St. Jude Medical, Minnetonka, MN).

What is your lab’s hematoma management policy?

   Our policy is to hold manual pressure and mark the edges of hematoma for further monitoring. Occasionally, we will use FemoStop for additional protection. All complications are monitored and tracked through the American College of Cardiology’s CathPCI registry.

How is inventory managed at your cath lab?

   The cath labs at Salem Hospital are equipped with a workstation where the RN or RT(R) scans any product being used into our Intellishelf Supply System (McKesson Automation, Cranberry Township, PA) for billing and reordering purposes. Armed with the information from the McKesson system, Wayne Amende, RT(R), manages all inventory purchases and restocking of supplies. Wayne’s 30+ years of knowledge and experience in Salem Hospital’s cath lab make him a valuable resource for us. The McKessson system automatically interfaces with EPIC, our hospital computer system, and populates the patient bill eliminating manual entry.

Has your cath lab recently expanded?

   Yes. In 2009, we completed and moved into our new tower. We increased from three 450-square-foot rooms to seven rooms averaging 650 square feet in our new space. Every staff member in the cath lab was given the opportunity to offer input and review the blueprints. The end result is a beautiful, state-of-the-art space with large rooms and the latest technology. Our local population continues to grow, so the new space has enabled us to meet the needs of our growing patient volume and expanding physician practices. We believe the space will continue to meet our needs and growth expectations well into the future.

   Our staff has increased as well to meet our growing patient volume. In the last two years, we have hired six new RT(R)s, and we currently have job openings for two more RT(R)s. We have also doubled our nursing staff in the last five years.

Is your lab involved in clinical research?

   Yes. Currently, we are participating in the SAPPHIRE carotid stent trial and a Cordis Cypher trial. In the Cordis Cypher trial, we are working with Raghu Kamineni, MD, medical director of interventional cardiology and acute myocardial infarction at Salem Hospital, and Maziar Azadpour, MD, cardiologist, in recording details of interventions requiring the use of a stent.

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?

   Our average DTB time is 65 minutes and 97 percent of the time we beat the national average of 90 minutes or less.

   We have an Acute Myocardial Infraction (AMI) committee that is devoted to continued improvement on our DTB time and other cardiac issues. Dr. Raghu Kamineni, chair of the committee, is instrumental in team member collaboration. In addition to Dr. Kamineni, cath lab medical director, the AMI team includes nurses, physicians, the emergency department and EMTs. We recently initiated a field activation trial for AMIs where EMTs in the field, with one call, can activate our on-call cardiologist, our on-call cath lab team, our ER and our nurse administrative coordinator (NAC). With instant notification at the same time, teams are ready to go prior to a patient’s arrival, which should bring down our DTB times even further.

   We also have direct access to the ER from the cath lab via an elevator. We work well with the ER team in that our nurses help the ER staff prep patients in the ER while the rest of the cath lab staff is getting the room and equipment ready for the patient. This helps us get patients in and complete their procedure even more quickly.

What other modalities do you use to verify stenosis?

   We currently use IVUS and pressure wire/FFR measurements to further measure borderline or suspected lesions. With physiology, we can see lipid pools or calcification. These assessments provide us with the lesion pathology, so we know how to best treat it.

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

   We are implementing a few programs to help contain costs. Currently, we use consignment agreements on some equipment. In addition, we verify equipment or product use with the physician before opening packages. Finally, we work closely with supply chain services for cost efficiencies.

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

   Our lab works on Best Practice projects monthly, such as the recent, hospital-wide sheath pull standardization and competency project. We talk with experts and other hospitals on what is best for our patients based on available data and hospital statistics.

   Before a case starts, we write all pertinent information about the patient and his/her treatment on a board. This documents all the equipment and information specific to the patient’s condition. That way anyone who treats the patient knows exactly what we are doing. We also have a post-procedure pause to assure any issues in patient care are addressed and to account for all equipment, data entry and documentation at the end of the case.

All of our staff and physicians have participated in Communication and Teamwork training. The purpose of this training is to mitigate human error by creating a culture where it is safe to “speak up” if there are questions about a procedure or thoughts on how to maintain quality control for our patients. This training also resulted in the development of hand-off tools and checklists that are used by all on a regular basis. Additionally, we are currently members of the American College of Cardiology and participate in the Internal Cardiac Defibrillator and Cath PCI registries. The information gathered by these registries provides a “standard of practice” benchmark, which we meet with our patients.

How does your cath lab compete for patients?

   First, we promote our rankings and positive outcomes. Salem Hospital has received five-star ratings for coronary bypass surgery four years in a row (2007–2010) and for treatment of heart attack three years in a row (2008-2010) by HealthGrades^®, a healthcare ratings company. These ratings mean Salem Hospital has “better than expected” outcomes in these areas.

   Second, we have applied for Magnet designation. We have submitted hundreds of pages of documentation and are hoping for a site visit to occur this summer. We hope to receive designation by the end of this year. Magnet status will help us continue to attract high-level physicians and staff. It will reflect the strength and quality of our nursing team, patient outcomes and low staff turnover.

   We focus our efforts on patient satisfaction and assuring we provide very good care to each of our patients and family members.

   We also reach out to help educate outlying hospitals on patient care. We have good working relationships with the community hospitals in our area. Many of the more rural hospitals transfer critical cardiac patients to our facility for care. Salem Hospital ER is the fifth busiest in the nation per capita and the busiest in the state. Because of our location in Oregon, hospitals from as far as 100+ miles to the east and a 50-mile radius to the west, north and south, will send patients to us. Because most of the community hospitals don’t have the ability to handle the more critical cases, we educate those hospitals on the medications and prep patients need to safely transfer them here.

How are new employees oriented and trained at your facility?

   All new RNs and RT(R)s undergo a three-month on-the-job training program, which includes balloon pump, hemodynamic, advanced cardiac life support (ACLS) and cardiac rhythm training.

   We have amazing staff retention. Five of our employees have worked together for more than 15 years.

   In the last year, we had significant growth in our case load and we contracted with two traveling RT(R)s for three months to meet demand. At the
end of the three-month contract, we renewed their contracts due to the sustained growth. At the end of the second contract term, both Salem Hospital and the RT(R)s made the relationship permanent. In addition, we just hired a new RN.

   To work in the Salem Hospital cath lab, you must be an RT(R) or an RN. Our RT(R)s are required to have their x- ray technologist certification. In addition, Oregon law requires RT(R)s to have both their ARRT and OBRT license. We currently have two positions open and are looking for experienced RT(R)s who have their ACLS and hemodynamics certifications. In addition, we like our RT(R)s to have completed the critical care class.

What types of continuing education opportunities are provided to staff members?

   Salem Hospital provides in-house, ongoing training opportunities such as our recent Code 99 practice and various online educational opportunities. Salem Hospital also encourages us to attend medical conferences and participate in further education opportunities, such as college courses and additional certifications. The hospital offers a reimbursement program for expenses associated with continued education.

   Additionally, we have our monthly education day, called Late Start Thursday, and our intranet Journal Club where we submit pertinent journal articles and research for everyone to review. Recent topics at our Late Start Thursday meetings include pulmonary hypertension, atherectomy procedures, and a presentation on balloon pumps.

How is staff competency evaluated?

   Our cath lab supervisor, Bryan Sprague, provides annual evaluations of skills and competencies in medications, procedures and equipment. Input from co-workers is encouraged. In addition to our department evaluation, all employees must meet a list of required hospital competencies.

Does your lab have a clinical ladder?

   Our technologists are given the opportunity to grow from Tech 1 to Tech II based on years of experience and advanced certification in areas like registered cardiovascular invasive specialist (RCIS), registered vascular specialist (RVS) and registered cardiac electrophysiology specialist (RCES). We encourage continued education.

   The hospital has established a professional excellence reward system as well. Our APEX (Acknowledging Professional Excellence) program rewards employees for achievements throughout the year. Points are earned for activities that correspond to our core commitments, such as professional growth, volunteer work, or contributing best practices or patient satisfaction ideas. Points are reviewed at each annual evaluation. Applications are reviewed by the APEX review team and awards are based upon number of points accumulated. Financial reward is based on the level of education and professional certification.

Does your lab utilize any alternative therapies (such as guided imagery, etc.)?

   We offer music to our patients and provide an iPod in every room. We provide warming blankets and positioning changes for all our patients.

How does your lab handle call time for staff members?

   Nurses are asked to cover one call weekend per month and one night during the week. Techs are asked to do one weekend per month and one to two nights during the week. Due to our experienced staff, we do not require a particular mix other than requiring four team members — two techs, one nurse, and the fourth person being either a nurse or a tech.

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

   On acute pages, call team members must arrive within 20 minutes of being paged. Physicians are not always on-site, but are also required to arrive within 20 minutes of paging.

Do you have flex time or multiple shifts?

   Yes, we do. Staff members are scheduled for four ten-hour shifts each week. Shifts start as early as 6:30 am and our last scheduled shift ends at 6:30 pm.

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

   Yes. To stay on top of correct procedures, our lead tech hands out a mock survey to one staff member every day. The survey has a list of Joint Commission questions on correct procedures, hand washing, etc. This way we are preparing for the highest level of care on a daily basis.

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

   Our cath lab is located right next to the OR and has direct elevator access to the ED, which is one floor below us. The hybrid OR room, which was designed with our needs in mind, is just across the hallway from the main cath lab. Transfers between these departments are efficient.

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

   We expect continued growth in our vascular and EP caseloads. We also think that advancements in technology, equipment and medications over the next five years will result in industry-wide changes on how patients are treated. We believe the result will be fewer open procedures with more percutaneous valve replacements. The cath lab will be the driving force behind these changes. Patients will spend less time in the hospital due to an increase in less invasive, outpatient procedures, and the cath lab will be able to handle a larger caseload.

What is unique or innovative about your cath lab and staff?

   One thing that sets us apart is our space and equipment. With the move to our new facility a year ago, cath lab patients enjoy top-of-the-line, new equipment. The rooms are large and designed to make everyone’s job easier and the patient more comfortable.

   Our staff is more like a family than co-workers. We are friendly, professional, bring humor to the workplace and truly enjoy working together. We are a very integrated team. As a result, we have minimal turnover and our patients benefit from our highly experienced staff.

   The collaborative effort and teamwork between our nursing and RT(R) staff is demonstrated through our shared decision-making model and SPT. The value of teamwork is evidenced in our cath lab, as well as throughout our organization. We recognize the importance of the entire team and collaboration of nursing and all providers and sub-specialties. Many of our SPTs also have physician involvement, including our cath lab medical director, Raghu Kamineni, MD.

Is there a problem or challenge your lab has faced?

   The biggest challenge we have faced was the transition and physical move into our new space a year ago. We have recently also had multiple changes with physicians and group practices. We addressed this by focusing on what was most important — our patients. Our goal is to continue increasing patient satisfaction scores as we meet our community’s continued growth.

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”?

   Oregon is a beautiful state with environmental diversity. Salem benefits from its central location. Salem is in the heart of Oregon’s nationally renowned wine country. Salem is located two to three hours from Central Oregon’s high desert amenities (skiing, hiking, rock climbing, fishing, rafting, etc.) and is an hour drive from the Oregon coast.

   Most people who live in Oregon embrace its natural beauty and its many outdoor opportunities. Our staff is all quite active and “out- doorsy.” Depending on our interests, we may hike, hunt, fish or golf together. The culture here is very much a family atmosphere. We are a cohesive unit, which makes people enjoy working here. We often plan team-building activities, such as this summer’s ropes course adventure.

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

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?

   It is not required, but is strongly encouraged. The hospital offers full reimbursement for certification costs, and staff members earn points toward their APEX bonus for earning their RCIS. In addition, the hospital awards a $1,000 incentive bonus for obtaining RCIS certification.

Is your clinical and/or managerial team members involved with any professional organizations that sup- port the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

   Cath lab supervisor Bryan Sprague is part of NW Cath Lab Managers. The organization meets once a year to discuss policies, procedures, staffing issues and other cath lab topics. He takes one other person from the department with him to the conference. Other professional organizations in which various team members are involved include the EP Society, Oregon Society of Radiology Technologists (OSRT), RCIS, and PCNA (Preventative Cardiovascular Nurses Association).

   Rocky Faren, lead radiologic technologist, cath lab. Rocky, who joined Salem Hospital in 1987, is a lead technologist in the cath lab. He specializes in both cardiac and vascular interventions. Rocky earned an associate’s degree in radiology from the School of Radiology at Memorial Hospital in Colorado Springs, CO. He is a registered radiologic technologist and a registered cardiovascular invasive specialist (RCIS). Rocky is the current Magnet champion for the cath lab. He was the first technologist in the department to scrub AAA grafts and carotid stents. Rocky can be contacted at rocky.faren@salemhealth.org

Nancy Leach, registered nurse, cath lab. Nancy has worked as a nurse at Salem Hospital since 1987. She has become a specialist and leader in the cath lab, serving as co-chairman of the lab’s Specialty Practice Team. Nancy earned an associate degree in nursing from Chemeketa Community College in Salem. She worked for several years in the hos- pital’s Intermediate Care Unit and is a member of the hospital’s Practice Council and Magnet Champions.
Nancy can be contacted at nancy.leach@salemhealth.org