Susquehanna Heart Center

Author(s): 

David R. Rothrock, BS, RCIS

What is the size of your cath lab facility and number of staff members?

Susquehanna Health System presently has two cardiac cath labs, both capable of diagnostic and interventional cases. Our clinical staff includes six RNs, five cardiovascular technologists (RCIS) and an LPN. In addition, the staffing complement includes an inventory technician, a data clerk and a database applications analyst. A Cardiovascular Service Line educator/RN focuses on the department’s educational needs. Staff members’ years of service range from 1 year to 30 years.

What types of procedures are performed at your facility? Does your lab perform peripheral interventions?

Our cath lab is a full-service, 24/7 adult lab that offers diagnostic and therapeutic interventions. In addition, we insert permanent pacemakers and plans are in place for an electrophysiology laboratory. Interventional procedures include plain old balloon angioplasty (POBA), bare metal stents (BMS), drug-eluting stents (DES), thrombectomy, rotational atherectomy (RCA), directional coronary atherectomy (DCA), intravascular ultrasound (IVUS) and intra-aortic balloon pump (IABP). The number and type of procedures varies each day, with an average of 35-40 procedures per week. Currently we are not performing peripheral interventions in the cath lab.

Does your cath lab perform primary angioplasty with or without surgical backup? If with surgical backup, how is it scheduled?

Primary angioplasty is available 24/7. There are cardiac surgeons available for our patients at all times. They are in-house during the day and on-call during off hours. Only patients that are considered high risk are prescheduled with the OR and cardiac surgeon. The operating room and cardiac surgeons receive a copy of the scheduled elective cases.

What procedures do you perform on an outpatient basis?

Diagnostic catheterizations and pacemaker battery changes are the only invasive procedures we currently perform on an outpatient basis.

What percentage of your patients is female? What percentage of all patients is obese?

Approximately 35-40% of our patient population is female. Sixty percent of our patients are more than 25 pounds overweight.

What percentage of your diagnostic cath patients goes on to have an interventional procedure?

Approximately 30%.

Who manages your cath lab?

David R. Rothrock BS, RCIS, FSICP. David was one of the original members of the cath lab when it opened in 1975. Presently he is Manager of Cardiology Services, which includes Invasive and Non-Invasive services

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

All clinical staff members are required to maintain competency in at least two of the three roles. The Cardiovascular Technologists scrub, the RNs circulate, and everyone is competent in the monitoring role. We currently have one staff RN that performs all three roles.

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

No - we do currently employee any radiology technologists. Our standard is to have a physician present whenever the radiology equipment is being used.

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? Please specify according to the actions listed.

In our lab, the scrub staff member is responsible for positioning the II and panning the table during the exposures. This is under the direct supervision of the physician who is actually stepping on the fluoro pedal.

Does your lab have a clinical ladder?

Presently we do not have a cath lab-specific clinical ladder, but there are opportunities for advancement. The first is an RN Resource Clinician who is responsible for core staff education/competencies and mentoring less experienced RNs on patient care functions within the lab. The second position is an operational supervisor that spends half of his/her time performing patient care and the remainder on supervisory tasks, such as staff assignments, coordinating patient flow, miscellaneous daily operations and physician communication. In addition, the Cardiovascular Services educator is a career option for the cath lab staff. Both the Resource Clinician and Cardiovascular Services educator are part of the patient care professional career ladder that exists throughout the hospital system.

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

In 2003, our device list expanded to include drug-eluting stents. Currently, we are exclusively using Boston Scientific’s Taxus stent (Maple Grove, MN). In 2004, we added the FilterWire EX from Boston Scientific, as well as the next generation of Guardwire from Medtronic. During the last several months we have started to use Abbott Vascular’s MIRACLEbros and Confianza wires (Redwood City, CA) for chronic total occlusions.

Can you discuss your cath lab systems?

In 2002, we opened a new room and observation area, and our Health System has gone completely digital since that time. At that same time, we also performed an image chain upgrade in the second room so we could offer the same generation of digital imagery throughout. GE (Waukesha, WI) is the manufacturer of our radiology and digital systems. Also in 2002, we purchased Witt physiological monitors (Melbourne, FL) for both rooms. These monitors are interfaced with our hospital information system and our Lumedx Apollo database (Oakland, CA). These interfaces have allowed decreased data entry, automated our billing process, improved inventory control and allowed for in-depth analysis of device utilization.

How does your lab handle hemostasis?

We have been using the SyvekPatch® (Marine Polymer Technologies, Danvers, MA) since 2003 and St. Jude Medical’s Angio-Seal (Minnetonka, MN) since 2004. One or the other of these devices is used approximately 30% of the time, including PTCA cases this is driven by physician preference. Diagnostic sheaths are pulled either in the room or in the observation area, depending on patient comfort, staffing and caseload. All clinical staff is trained and competent in manual sheath removal and hemostasis. If the sheaths are not removed in the room, interventional patients are transferred to ICU with the sheaths in place. The cath lab staff is responsible for manually removing the sheaths after the ACT is within normal limits.

Does your lab have a hematoma policy?

Yes. Our policy carefully outlines higher risk situations when additional digital pressure is recommended. We attribute a low rate of site complications to this process. Presently every interventional patient is formally monitored for site complications as one of our ongoing Performance Improvement indicators.

How is inventory managed at your cath lab?

Our staff includes an inventory technician who works evenings and is responsible for stocking and ordering of all supplies. This includes the monitoring of interventional device levels through our cardiology database. With the extensive list of ever-changing PTCA devices, having one person responsible has improved our inventory process. Essentially all interventional devices are on consignment - thus avoiding tying up significant operational dollars.

How is coding and coding education handled in your lab? How is coding communication handled with the billing dept.?

The Cath Lab Chargemaster includes the HCPT codes that are hard wired to the procedure charges. The monitor staff member enters all charges in the Witt system, at the time of the procedure. After each case, the charges are reviewed for billing accuracy. The Witt physiological monitor system allows for once-daily batch transmission of all charges directly into the hospital billing system. This works very well for us and has been operationally problem free.

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

Although our geographic referral pattern has been relatively static from a growth perspective, our volumes have been growing slowly over the last five years. In addition, the patient age, acuity and co-morbidity factors have been increasing. We expect both of these trends to continue as interventional techniques and devices improve and the patient population ages. In 2002, we constructed a new room and observation area directly adjacent to our other cath lab. As a result, our operational efficiency has significantly improved. Moreover, it has allowed us to increase cases without increasing staffing. Pending the recruitment of an electrophysiology cardiologist, we plan to open an electrophysiology lab in 2006 or 2007.

Is your lab involved in clinical research?

We are currently not involved in any research projects.

Does your lab perform elective cardiac interventions?

Yes. The majority of our cases are scheduled as elective diagnostic catheterizations with possible therapeutic intervention.

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

Yes both were related to the being unable to cross highly calcified lesions with the coronary wire and/or balloon. One patient was an acute myocardial infarction and the other was an elective case. Both patients had successful emergent CABG without complications.

What other modalities do you use to verify stenosis? Are you using physiology for lesion assessment?

None at this time, however the Radi PressureWire (Wilmington, MA) to measure functional lesion assessment is being considered.

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

For PTCA and pacemaker supplies, primary vendor contracts have been negotiated to achieve the best prices for the dollar volumes involved. The devices under these contracts are all on consignment. The cardiologists have been supportive of the process and preferentially using the preferred devices whenever possible. The key to the physicians’ support is their ability and freedom to go outside the preferred contract either when a device is needed for the patient’s unique clinical presentation or the technical considerations of specific cases.

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

We have extensive daily protocols in place to assure the functionality of all patient care electrical equipment before procedures are started. The point-of-care equipment (glucometer and ACT) is subject to the Laboratory CAP standards and is tested daily with quality controls to assure accuracy. All staff is required to maintain yearly competencies on high-risk or low-volume procedures/equipment. We actively participate in our system’s extensive Continuous Quality Improvement programs, with at least two active clinical Performance Improvement indicators. Through this program, we are required to develop specific action plans whenever our indicators fall outside of established thresholds of performance benchmarks. Ongoing monitoring occurs to document the outcome of interventions intended to improve the process. We also do extensive closed chart reviews looking for JCAHO, Department of Health or other regulatory documentation requirements.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

Williamsport is located in a relatively rural area in north central Pennsylvania and therefore, geographically, competition is limited. The closest full-service adult lab is located approximately 45 minutes away. We differentiate ourselves from other healthcare providers by exceeding our customers’ expectations and following our system’s simple creed: Courtesy, Attentiveness, Responsiveness, and Empathy (CARE).

Susquehanna Health System was formed in 1994 with the alliance of three hospitals. The alliance was created to contain costs and to limit duplication of services across the region. It is important to understand that this was (and is) a voluntary alliance and not a merger. We agreed to function as one institution, but still exist separately. Because of our success as an alliance, we frequently entertain interviews and visits from other hospitals from across the country. Our stated mission is to improve the health status of the communities we serve through high-quality, compassionate, accessible and cost-effective care.

How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab?

The orientation plan is individualized to meet new employees’ educational needs. New employees hired without prior experience receive an intensive, full-time, 3-6 month orientation. Each orientee is paired with an experienced team member who precepts them clinically, provides didactic material, mentors them in system/ departmental expectations and is available for questions. These employees document their procedures and accomplishments, and are given daily feedback on their performance, both verbally and in writing. Frequent meetings occur with the orientee, preceptor and Cardiovascular Service Line educator to review progress and address outstanding items. The cath lab management team participates in these meetings as needed. Experienced new employees have a similar but accelerated orientation. All nurses are required to have a valid license in the state of Pennsylvania. The Cardiovascular Technologists are required to have successfully passed the RCIS certification. The RNs are also required to pass the RCIS certification within three years of hire. All clinical staff is BLS- and ACLS-certified.

What types of continuing education opportunities are provided to staff?

There are multiple opportunities for education, and the staff has not found it difficult to obtain enough educational hours to meet the requirements for a RCIS or RN. Within the lab, there is a monthly education hour. This is supplemented periodically by vendor inservices for new devices or drugs. System-wide education also occurs for global topics affecting all staff. On a rotating basis, two of the clinical staff have the opportunity to attend the TCT (Transcatheter Cardiovascular Therapeutics) meeting in September/October. Multiple staff members have also attended the Cath Lab Digest Regional Seminars when they are held in Philadelphia.

How do you handle vendor visits?

System policy specifies that vendor/drug representatives check in with Purchasing before entering the department. In addition, they are required to schedule an appointment with the cath lab manager and present at the schedule office upon arrival. New representatives are required to have a Life Safety orientation to the lab, as well as HIPAA education/review. Vendors have signed Business Partner HIPAA contracts with the Health System. They are required wear to a badge with their name and company and are restricted to the office area, unless providing staff and/or physician education.

How is staff competency evaluated?

The Cardiovascular Services Educator coordinates annual competency for high-risk or low-volume procedures. He/she uses various techniques for the assessment, such as individual demonstration of the skill, self-learning packets, group discussions and written tests. The cardiologists and cath lab leadership team also observe staff daily to assess their individual skills.

Does your lab utilize any alternative therapies?

At present, we are not utilizing any alternative therapy 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? Do you have flextime or multiple shifts?

All clinical staff is required to take call on a rotating basis. One of the staff RN currently is responsible for building the call schedule. She has been able to coordinate everyone’s needs into a workable schedule. Currently call time is usually broken into 2 or 3-day increments and ends when staff arrives for scheduled or unscheduled cases. We have four people on call at all times, typically two RNs and two RCISs. There are multiple staggered start times, with the non-call staff arriving at 07:00 or 07:30 and the call staff between 08:00 and 10:00.

What trends do you see emerging in the practice of invasive cardiology?

Catheter-based interventional devices will continue to improve. This will lead to an increase in the number and complexity of interventional procedures. The age and acuity of patients will also continue to increase. There will be economic pressure from CMS and insurance companies to control cost and decrease the average length of stay. It is likely that one of the emerging modalities in either MRI or CT scan will replace at least a portion of the diagnostic cases. This will be more than offset by the increase in interventional cases.

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

Our hospital and Health System has been accredited by JCAHO for many years. We were inspected in 2001 and 2004, and received a 3-year accreditation status. The cath lab passed without any deficiencies both times.

Where is your cath lab located in relation to the OR department, ER, & radiology departments?

The cath labs are located directly between our medical ICU and the Cardiovascular Surgical Unit (CVSU). The OR is at the end of the hallway. The ER is located three floors below, with Radiology one floor above the ER. The heliport is on the roof, two floors above. We believe that we have an ideal central location.

Please share with readers what you consider unique or innovative about your cath lab and its staff.

The entire staff is one big family. We will do anything for each other, including covering shifts and call. We joke and poke fun with each other like brothers and sisters, but we have a lot of fun doing it and the time passes quickly. Our patients sense the familiarity of staff and comment frequently about it.

Is there a problem or challenge your lab has faced? How was it addressed?

Maintaining full staffing is an ongoing challenge; the demands of on-call responsibilities are significant with a small staff. This is compounded by the employment opportunities outside the cath lab for RNs and the local and national shortage of Cardiovascular Technologists and RNs. Educational support for two of our Cardiovascular Technologists is an example of a tool used to retain valuable staff members. It also reflects one of many staff retention and recruitment initiatives that contributed to Susquehanna Health System’s designation as an Employer of Choice in March 2005. This prestigious honor is presented only to organizations dedicated to a higher level of employee relations that results in increased employee satisfaction and workforce stability. Only one percent of hospitals in the nation operate at the level required for this designation. SHS was honored because 92.5% of employees surveyed find that patient care services are never postponed due to insufficient staffing. For this same question, the average of the six other hospitals and Health Systems that are designated as an Employer of Choice scored 68.3%, while all other healthcare organizations average only 58.6%. Numbers such as this signify the emphasis SHS employees place on patient care.

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?

Williamsport is located in the Susquehanna Valley on the bank of the Susquehanna River in north central Pennsylvania. It is beautiful country, with many wonderful opportunities for outdoor sports and recreation. The nine-county referral area that we serve consists of mostly farms, woodland and scattered small towns. In many of our referral counties, white tail deer outnumber the residents! Williamsport is by far the largest city within 50 miles. Each summer, Williamsport reaches the international news media as the site and home of Little League Baseball World Series. During the two weeks of the Series, the population in our area triples.

SICP QUESTIONS:

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?

The cardiovascular technologists are required to pass the RCIS examination before they are hired. The RN clinical staff is required to pass the test within three years of employment in the lab. Currently there is no monetary inventive in place to pass the exam.

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?

The manager is a SICP fellow and the RN Resource Clinician is a member of SICP and ACVP.

David Rothrock can be contacted at drothrock@shscares.org

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